Generation of codified electronic medical records by processing clinician commentary

• US 7,853,446 B2
• Filed: 05/02/2006
• Issued: 12/14/2010
• Est. Priority Date: 05/02/2006
• Status: Expired due to Fees

• Current Assignee: LinkedIn Corporation (Microsoft Corporation)
• Original Assignee: International Business Machines Corporation
• Inventors: Toohey, James J., Allard, David J., Szabo, Robert M.
• Primary Examiner(s): Hong; Stephen S
• Assistant Examiner(s): YANG, I CHAN
• Application Number:
  US11/381,141
• Publication Number:
  US 20070260977A1
• Time in Patent Office: 1,687 Days
• Field of Search: 715/230, 715/231, 705/2, 704/9
• US Class Current: 704/9
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A method and system for generating codified electronic records. A textual commentary can be received from a user and, in real time, the textual commentary can be analyzed to identify a plurality of codes that potentially correlate to the textual commentary. The identified codes then can be presented to the user in real time. A first user input can be received to select at least one of the identified codes, and the selected code can be added to an electronic record.

Claims

1. A method for generating a codified electronic record using a computer comprising an output device, the method comprising:

receiving, within the computer, a textual commentary from a clinician, wherein the clinician is a source of the textual commentary;

responsive to receiving the textual commentary from the clinician, and in real time, analyzing the textual commentary to identify a plurality of codes that potentially correlate to the textual commentary, wherein analyzing the textual commentary comprises;

maintaining a code acceptance history of identified codes previously accepted by the clinician on a per clinician basis, wherein within the code acceptance history, each code is correlated with an attribute identified within the textual commentary; and

selecting the plurality of codes, at least in part, according to the code acceptance history, wherein one or more identified codes previously accepted by the clinician and correlated to a particular textual commentary attribute are selected when the textual commentary corresponding to the particular textual commentary attribute is received and analyzed;

presenting the identified codes to the clinician through the output device;

responsive to presenting the identified codes, receiving a first clinician input selecting at least one of the identified codes presented via the output device; and

adding the selected code to the electronic record responsive to receiving the first clinician input.

2. The method of claim 1, further comprising receiving a second clinician input to initiate at least one operation on the selected code, the operation selected from the group consisting of accepting, changing, refining, negating, and deleting the selected code.

3. The method of claim 1, wherein:

analyzing the textual commentary further comprises applying at least one text processing technique to identify at least one attribute contained in the textual commentary; and

identifying the plurality of codes comprises determining codes that correlate to the identified attribute.

4. The method of claim 1, wherein the output device is a display, the method further comprising selectively enabling the display according to proximity of an authorized clinician to the display.

5. The method of claim 1, wherein the plurality of the identified codes are selected from a plurality of coding schemes, and at least one of the plurality of coding schemes is selected from the group consisting of current procedural terminology (CPT) coding, diagnostic coding, symptom coding and prescription coding.

6. The method of claim 1, wherein receiving the textual commentary comprises receiving at least one form of commentary selected from the group consisting of a spoken utterance, typed text and hand scribed text.

7. The method of claim 1, wherein presenting the identified codes comprises presenting the identified codes in a hierarchical order.

8. The method of claim 1, further comprising:

identifying an annotation that potentially correlates to the textual commentary; and

presenting the annotation to the clinician.

9. The method of claim 8, further comprising receiving a second user clinician input selecting the annotation and initiating at least one operation on the selected annotation, the operation selected from the group consisting of accepting, changing, refining, negating, and deleting the selected annotation.

19. The method of claim 1, wherein:

the identified codes are presented to the clinician via the output device, and the identified codes are presented in a list from which the clinician selects at least one of the identified codes that is to be added to the electronic record;

receiving the first clinician input selecting at least one of the identified codes comprises selecting at least one of the identified codes that is presented in the list; and

the identified codes in the list that were not selected by the clinician are not added to the electronic record.

10. A method for generating a codified electronic record using a computer comprising an output device, the method comprising:

receiving, within the computer, a textual commentary from a clinician, wherein the clinician is a source of the textual commentary;

responsive to receiving the textual commentary and in real time, analyzing the textual commentary to identify a first plurality of codes that potentially correlate to the textual commentary, wherein analyzing the textual commentary comprises;

maintaining a code acceptance history of identified codes previously accepted by the clinician on a per clinician basis, wherein within the code acceptance history, each code is correlated with an attribute identified within the textual commentary; and

selecting the plurality of codes, at least in part, according to the code acceptance history, wherein one or more identified codes previously accepted by the clinician and correlated to a particular textual commentary attribute are selected when the textual commentary corresponding to the particular textual commentary attribute is received and analyzed;

presenting the first plurality of codes to the clinician through the output device;

responsive to presenting the first plurality of codes, receiving at least a first clinician input to select at least one code from the first plurality of codes presented via the output device and initiating at least one operation on the selected code;

responsive to receiving the at least a first clinician input, presenting, via the output device, a second plurality of codes to the clinician reflecting changes caused by the operation on the selected code; and

adding the second plurality of codes to the electronic record.

11. The method of claim 10, wherein the operation is selected from the group consisting of accepting, changing, refining, negating, and deleting the selected code.

20. The method of claim 10, wherein:

the identified codes are presented to the clinician via the output device, and the identified codes are presented in a list from which the clinician selects at least one of the identified codes that is to be added to the electronic record;

receiving the first clinician input selecting at least one of the identified codes comprises selecting at least one of the identified codes that is presented in the list; and

the identified codes in the list that were not selected by the clinician are not added to the electronic record.

12. A machine readable storage, having stored thereon a computer program having a plurality of code sections executable by a machine for causing the machine to perform the steps of:

receiving a textual commentary from a clinician, wherein the clinician is a source of the textual commentary;

responsive to receiving the textual commentary and in real time, analyzing the textual commentary to identify a plurality of codes that potentially correlate to the textual commentary, wherein analyzing the textual commentary comprises;

maintaining a code acceptance history of identified codes previously accepted by the clinician on a per clinician basis, wherein within the code acceptance history, each code is correlated with an attribute identified within the textual commentary; and

selecting the plurality of codes, at least in part, according to the code acceptance history, wherein one or more identified codes previously accepted by the clinician and correlated to a particular textual commentary attribute are selected when the textual commentary corresponding to the particular textual commentary attribute is received and analyzed;

presenting the identified codes to the clinician;

responsive to presenting the identified codes, receiving a first clinician input selecting at least one of the identified codes; and

adding the selected code to an electronic record responsive to the first clinician input.

13. The machine readable storage of claim 12, further causing the machine to perform the step of receiving a second clinician input to initiate at least one operation on the selected code, the operation selected from the group consisting of accepting, changing, refining, negating, and deleting the selected code.

14. The machine readable storage of claim 12, wherein:

analyzing the textual commentary further comprises applying at least one text processing technique to identify at least one attribute contained in the textual commentary; and

identifying the plurality of codes comprises determining codes that correlate to the identified attribute.

15. The machine readable storage of claim 12, further comprising selectively enabling a display according to proximity of an authorized clinician to the display.

16. The machine readable storage of claim 12, wherein the plurality of the identified codes are selected from a plurality of coding schemes, and at least one of the plurality of coding schemes is selected from the group consisting of current procedural terminology (CPT) coding, diagnostic coding, symptom coding and prescription coding.

17. The machine readable storage of claim 12 wherein receiving the textual commentary comprises receiving at least one form of commentary selected from the group consisting of a spoken utterance, typed text and hand scribed text.

18. The machine readable storage of claim 12, further causing the machine to perform the steps of:

identifying an annotation that potentially correlates to the textual commentary; and

presenting the annotation to the clinician.

21. The machine readable storage of claim 12, wherein:

the identified codes are presented to the clinician via the output device, and the identified codes are presented in a list from which the clinician selects at least one of the identified codes that is to be added to the electronic record;

receiving the first clinician input selecting at least one of the identified codes comprises selecting at least one of the identified codes that is presented in the list; and

the identified codes in the list that were not selected by the clinician are not added to the electronic record.