Computerized method and system for coding-based navigation

• US 8,082,280 B2
• Filed: 10/29/2004
• Issued: 12/20/2011
• Est. Priority Date: 10/29/2004
• Status: Active Grant

• Current Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Original Assignee: Cerner Innovation, Inc. (Oracle Corporation)
• Inventors: Compton, David L., Eaton, James D. Jr., Matarrese, Paula S., Nair, Manikandan
• Primary Examiner(s): Vu, Bai D.
• Application Number:
  US10/977,983
• Publication Number:
  US 20060106795A1
• Time in Patent Office: 2,608 Days
• Field of Search: None
• US Class Current: 707/805
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

Computerized methods and systems for professional evaluation and management coding of a patient visit based upon documentation are provided. Such methods and systems increase efficiency and enhance the quality of clinician documentation by permitting automatic coding as a byproduct of documentation and eliminating the necessity for an after-the-fact check of the patient'"'"'s chart to ensure appropriate documentation. Computerized methods and systems for navigating to a portion of an electronic record, e.g., an electronic medical record, based upon professional evaluation and management coding are also provided, as is the automatic insertion of document content where necessary.

Claims

1. One or more computer-storage media having instructions embodied thereon for performing a method for navigating to a portion of an electronic record based upon coding, the method comprising:

receiving an input identifying a reason for a patient visit;

based on the reason for the patient visit, identifying a plurality of evaluation and management (E&

M) coding components, wherein each E&

M coding component includes a plurality of elements for E&

M coding;

displaying each E&

M coding component, wherein each E&

M coding component is associated with;

(i) a first numerical value representing a quantity of elements associated with the E&

M coding component that have been documented in a patient'"'"'s electronic record, wherein the first numerical value is used to determine a current E&

M coding level; and

(ii) a second numerical value representing a quantity of undocumented elements associated with the E&

M coding component that remain undocumented in the patient'"'"'s electronic record and are required to achieve a typical E&

M coding level, wherein the typical E&

M coding level is based on the reason for the patient visit;

receiving a user selection of a selectable indicator associated with one of the first numerical value, the second numerical value, the current E&

M coding level, or the typical E&

M coding level, wherein each of the first numerical value, the second numerical value, the current E&

M coding level, and the typical E&

M coding level are associated with one of the E&

M coding components;

in response to receiving the selection of the selectable indicator, displaying the plurality of elements for E&

M coding associated with the E&

M coding component indicated by the selectable indicator, wherein the displayed plurality of elements for E&

M coding includes both elements that have been documented in the patient'"'"'s electronic record and elements that have not been documented in the patient'"'"'s electronic record;

receiving a second user selection of one of the plurality of elements;

referencing a data store that includes the portion of the patient'"'"'s electronic record;

determining if content is present in the patient'"'"'s electronic record that is associated with the selected one of the plurality of elements; and

incident to determining that associated content is present in the patient'"'"'s electronic record, simultaneously displaying the associated content in the patient'"'"'s electronic record, each of the plurality of elements for E&

M coding a patient visit, and the selected one of the plurality of elements corresponding with the associated content, wherein the selected one of the plurality of elements corresponding with the associated content is associated with a completion indicator indicating that the element has been documented in the patient'"'"'s electronic record.

2. The media of claim 1, wherein if it is determined that no content is present in the electronic record that is associated with the one of the plurality of elements, the method further comprises displaying an indication that no associated content is present.

3. The media of claim 1, wherein if it is determined that no content is present in the electronic record that is associated with the one of the plurality of elements, the method further comprises displaying a user-selectable option to insert content into the electronic record.

4. The media of claim 3, further comprising:

receiving user input indicating content is to be inserted into the electronic record; and

directing the user to the portion of an electronic record associated with the one of the plurality of elements so that content may be inserted.

5. The media of claim 4, further comprising inserting content into the portion of the electronic record associated with the one of the plurality of elements and storing the inserted content in the data store in association with the portion of the electronic record.

6. The media of claim 5, wherein the content inserted into the portion of the electronic record associated with the one of the plurality of elements includes a portion which is at least partially pre-established.

7. The media of claim 6, further comprising receiving user input indicative of personalization of the portion of the content which is at least partially pre-established.

8. A computer system embodied on one or more computer storage media having computer-executable instructions embodied thereon for navigating to a portion of an electronic record based upon coding, the computer system comprising:

a first receiving module for receiving an input identifying a reason for a patient visit;

an identifying module for identifying a plurality of evaluation and management (E&

M) coding components, wherein each E&

M coding component includes a plurality of elements for E&

M coding;

a first display module for displaying each E&

M coding component, wherein each E&

M coding component is associated with;

(i) a first numerical value representing a quantity of elements associated with the E&

M coding component that have been documented a patient'"'"'s electronic record, wherein the first numerical value is used to determine a current E&

M coding level; and

(ii) a second numerical value representing a quantity of undocumented elements associated with the E&

M coding component that remain undocumented in the patient'"'"'s electronic record and are required to achieve a typical E&

M coding level, wherein the typical E&

M coding level is based on the reason for the patient visit; and

a second receiving module for receiving a user selection of a selectable indicator associated with one of the first numerical value, the second numerical value, the current E&

M coding level, or the typical E&

M coding level, wherein each of the first numerical value, the second numerical value, the current E&

M coding level, and the typical E&

M coding level are associated with one of the E&

M coding components;

a second display module for displaying the plurality of elements for E&

M coding associated with the E&

M coding component indicated by the selectable indicator, wherein the displayed plurality of elements for E&

M coding includes both elements that have been documented in the patient'"'"'s electronic record and elements that have not been documented in the patient'"'"'s electronic record;

a third receiving module for receiving a user selection of one of the plurality of elements; and

if content is present in the patient'"'"'s electronic record that is associated with the one of the plurality of elements, a third display module for simultaneously displaying the associated content, each of the plurality of elements for E&

M coding a patient visit, and the one of the plurality of elements corresponding to the associated content, wherein the one of the plurality of elements corresponding to the associated content is associated with a completion indicator indicating that the one of the plurality of elements has been documented in the patient'"'"'s electronic record.

9. The computer system of claim 8, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, the computer system further comprises a fourth display module for displaying an indication that no associated content is present.

10. The computer system of claim 8, wherein if no content is present in the electronic record that is associated with the one of the plurality of elements, a fifth display module for displaying a user-selectable option to insert content into the electronic record.

11. The computer system of claim 10, further comprising:

a fourth receiving module for receiving user input indicating content is to be inserted into the electronic record; and

a directing module for directing the user to a portion of the electronic record associated with the one of the plurality of elements so that content may be inserted.

12. The computer system of claim 11, further comprising an insertion module for inserting content into the portion of the electronic record associated with the one of the plurality of elements.

13. The computer system of claim 12, wherein the content inserted into the portion of the electronic record associated with the one of the plurality of elements includes a portion which is at least partially pre-established.

14. The computer system of claim 13, further comprising a fifth receiving module for receiving user input indicative of personalization of the portion of the content which is at least partially pre-established.