Electronic patient record documentation with push and pull of data to and from database

• US 8,321,241 B1
• Filed: 05/31/2005
• Issued: 11/27/2012
• Est. Priority Date: 05/31/2005
• Status: Active Grant

• Current Assignee: Allscripts Software LLC (Veradigm, Inc.)
• Original Assignee: Allscripts Software LLC (Veradigm, Inc.)
• Inventors: Mansour, Richard P., Mullehhour, Lori, Loch, Ellen, Barige, Sash, Downs, Tyler, Mitchel, David H., Ipock, Jason C., Kasargod, Shiva
• Primary Examiner(s): Najarian, Lena
• Assistant Examiner(s): SEOH, MINNAH L
• Application Number:
  US11/142,060
• Time in Patent Office: 2,737 Days
• Field of Search: 705 2- 3
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A medical records software apparatus and method is described that allows a clinician, e.g., nurse or doctor, to combine entry of new patient orders, prescriptions, flowsheet observations, etc. into the documentation process or workflow. A documentation user interface is provided that pulls patient data from a database into the display. The user can select on the user interface a category of a patient record, e.g., Significant Events or Orders, view or edit prior entries in the database in these categories, and add additional documentation for that category. The documentation is written or pushed to two areas of the database, one devoted to patient documentation and a second area corresponding to the selected category, e.g., Orders. The method and apparatus improves workflow efficiency and promotes a smooth transition from the thought process of the clinician to the ordering or prescription process, without the need for changing venues or screen displays to both enter documentation and enter the order or new prescription.

Claims

1. A medical records information apparatus for use with a networked database storing data of patients in electronic patient records, comprising:

(a) a computing device having a processor and a machine readable medium containing machine readable code for performing a computer implemented method and executable by the processor of the computing device,

(b) wherein the computing device is configured for network communications with the networked database for accessing data from and storing data in the networked database, and

(c) wherein the computer implemented method comprises the steps of,

(i) providing a user interface including,

(A) one or more user interface areas configured to allow for creation of a structured note representing clinical documentation of a patient, and

(B) one or more user interface areas configured to allow for selection, during the creation of the structured note, of one or more categories of medical data for which data associated with patients is stored in the networked database,

(ii) receiving, via the user interface provided in said step (i), a selection of one or more of the categories of medical data,

(iii) accessing data that has been previously stored in the networked database, that is associated with a patient for which a structured note representing clinical documentation is being created, and that corresponds to the one or more categories of medical data of the selection of said step (ii),

(iv) presenting, during the creation of the structured note via the user interface, the data accessed from the networked database in said step (iii),

(v) receiving, via the user interface provided in step (i), input for creating the structured note, the structured note including medical information associated with the one or more categories of medical data of the selection of said step (ii),

(vi) in response to user input, storing in the networked database the structured note as a part of a clinical documentation stored in the electronic patient record of the patient, and

(vii) in conjunction with the storing of the structured note in said step (vi), automatically storing in the networked database, as a part of the electronic patient record of the patient, information from the structured note in a second area of the electronic patient record, the second area being determined based on predetermined system administrator settings and the one or more categories of medical data of the selection of said step (ii).

2. The apparatus of claim 1, wherein the one or more categories of medical data comprises at least one of the following predetermined categories:

health issues, past medical history, outpatient medications, prescriptions, orders, care providers, significant events, allergies, patient problems, and flowsheet observations.

3. The apparatus of claim 1, wherein the user interface provides a first display area displaying categories of medical data corresponding to a plurality of fields in the electronic patient record, and wherein the selection of one of the fields pulls one or more rows of data from the electronic patient record into a user interface area for display.

4. The apparatus of claim 1, wherein the computing device is configured for network communications with the networked database over the Internet.

5. The apparatus of claim 1, wherein the computing device is configured for network communications with the networked database over a local area network at a medical facility.

6. The apparatus of claim 1, wherein the computing device is a handheld computing device.

7. The apparatus of claim 1, wherein the computing device is a workstation.

8. The apparatus of claim 1, wherein the user interface that is provided in said step (i) comprises a plurality of tabbed user interface areas.

9. The apparatus of claim 1, wherein said step (vi) is performed upon selection of a user interface element representing user instruction to save the structured note to the networked database.

10. The apparatus of claim 9, wherein the user interface element is a button.

11. The apparatus of claim 1, wherein said step (vii) comprises pushing data from the structured note to one or more fields of the electronic patient records other than a documentation field where clinical documentation is stored.

12. A computer implemented method for storing information regarding a patient in a database in the form of an electronic patient record, comprising the computer implemented steps of:

(a) presenting via an electronic display of a computing platform, to a health care practitioner during a patient visit by the patient, a user interface including,

(i) one or more user interface areas configured to allow for creation, by the health care practitioner during the patient visit, of a structured note representing clinical documentation associated with the patient, and

(ii) one or more user interface areas configured to allow for selection, by the health care practitioner during the creation of the structured note, of one or more categories of medical data for which data associated with patients is stored,

(b) receiving, from the health care practitioner via the user interface of the computing platform presented in said step (a), a selection of one or more of the categories of medical data,

(c) accessing data that has been previously stored, that is associated with the patient of the visit, and that corresponds one or more categories of medical data of the selection of said step (b),

(d) presenting, to the health care practitioner, during the creation of the structured note via the user interface, the data accessed in said step (c),

(e) receiving, from the health care practitioner via the computing platform, input for creating the structured note, the structured note including medical information associated with the one or more categories of medical data of the selection of said step (b),

(f) in response to user input by the health care practitioner, storing, in the database as a part of a clinical documentation stored in an electronic patient record of the patient, the structured note, and

(g) in conjunction with the storing of the structured note in said step (f), automatically storing by one or more processors, in the database as a part of the electronic patient record of the patient, information from the structured note in a second area of the electronic patient record, the second area determined based on predetermined system administrator settings and the one or more categories of medical data of the selection of said step (b).

13. The computer implemented method of claim 12, wherein the user interface provides a first display area displaying categories of medical data corresponding to a plurality of fields in the electronic patient record, and wherein the selection of one of the fields pulls one or more rows of data from the electronic patient record into a user interface area for display.

14. The computer implemented method of claim 12, wherein the electronic patient record comprises rows and columns of data;

wherein the method comprises selecting, from a menu of categories of medical data corresponding to a plurality of separate locations in the electronic patient record, a field for which to add documentation regarding the patient;

wherein the selection of the field pulls one or more rows of data from the electronic patient record into the user interface for display, at least in part, on the user interface; and

wherein the documentation entered via the user interface regarding a selected categories of medical data is pushed to both the location of the electronic patient record directed to clinical documentation and to the location in the electronic patient record directed to the selected categories of medical data.

15. The computer implemented method of claim 12, wherein the user interface that is provided in said step (a) comprises a plurality of tabbed user interface areas.

16. The computer implemented method of claim 12, wherein said step (g) comprises pushing data from the structured note to one or more fields of the electronic patient records other than a documentation field where clinical documentation is stored.

17. A medical records information system comprising:

(a) a database storing patient data, and

(b) a plurality of user computing devices operatively connected to the database for reading data from and writing data to the database, each user computing device comprising a processing unit, a memory, and a display,

(c) wherein the memory of each user computing device contains machine readable instructions executable by the processing unit for performing a computer implemented method comprising the steps of,

(i) providing,

(A) one or more user interface areas configured to allow for creation of a structured note representing clinical documentation of a patient, and

(B) one or more user interface areas configured to allow for selection, during the creation of the structured note, of one or more categories of medical data for which data associated with patients is stored in the database,

(ii) receiving, via the user interface areas provided in said step (i), a selection of one or more of the categories of medical data,

(iii) accessing data that has been previously stored in the database, that is associated with a patient for which a structured note representing clinical documentation is being created, and that corresponds to the one or more categories of medical data of the selection of said step (ii),

(iv) presenting, during the creation of the structured note via the user interface areas provided in said step (i), the data accessed from the database in said step (iii),

(v) receiving, via the user interface areas provided in step (i), input for creating the structured note, the structured note including medical information associated with the one or more categories of medical data of the selection of said step (ii),

(vi) in response to user input, storing in the database the structured note as a part of clinical documentation of the patient stored in the database, and

(vii) in conjunction with the storing in said step (vi) of the structured note in the database as a part of clinical documentation of the patient, further automatically storing in the database, as additional data of the patient, information from the structured note as part of one or more categories of medical data determined based on predetermined system administrator settings and the one or more categories of medical data of the selection of said step (ii).

18. The system of claim 17, wherein the system is installed at a medical enterprise and one or more of the user computing devices comprise workstations at the medical enterprise.

19. The system of claim 17, wherein one or more of the user computing devices is configured for network communications with the networked database over the Internet.

20. The system of claim 17, wherein one or more of the user computing devices is configured for network communications with the networked database over a local area network.

21. The system of claim 17, wherein one or more of the user computing devices comprises a handheld computing device.

22. The system of claim 17, wherein one or more of the user computing devices comprises a workstation.

23. The system of claim 17, wherein said step (vi) is performed upon selection of a user interface element representing user instruction to save the structured note to the networked database.

24. The system of claim 17, wherein said step (vii) comprises pushing data from the structured note to one or more fields of an electronic patient record other than a documentation field where clinical documentation is stored in the electronic patient record.

25. A medical records information system of a medical facility, comprising:

(a) a database server and an associated database in which electronic patient records are stored,

(b) a plurality of workstations operatively connected to the database server for exchanging data with the database server including accessing data in electronic patient records stored in the database and writing data to electronic patient records stored in the database, each workstation comprising a processing unit, a memory, and a display,

(c) a plurality of handheld computing devices operatively connected to the database server for exchanging data with the database server including accessing data in electronic patient records stored in the database and writing data to electronic patient records stored in the database, each workstation comprising a processing unit, a memory, and a display,

(d) wherein the memory of each workstation and each handheld computing device contains machine readable instructions executable by the respective processing unit for performing a computer implemented method comprising the steps of,

(i) providing,

(A) one or more user interface areas configured to allow for creation of a structured note representing clinical documentation of a patient, and

(B) one or more user interface areas configured to allow for selection, during the creation of the structured note, of one or more categories of medical data for which data associated with patients is stored in the one or more databases,

(ii) receiving, via the user interface areas provided in said step (i), a selection of one or more of the categories of medical data,

(iii) accessing data that has been previously stored in the database as part of an electronic patient record of a patient for which a structured note representing clinical documentation is being created, and that corresponds to the one or more categories of medical data of the selection of said step (ii), by communicating with the database server,

(iv) presenting, during the creation of the structured note via the user interface areas provided in said step (i), the data accessed from the database in said step (iii),

(v) receiving, via the user interface areas provided in step (i), input for creating the structured note, the structured note including medical information associated with the one or more categories of medical data of the selection of said step (ii), and

(vi) by communicating with the database server,

(A) storing in the database the structured note as a part of clinical documentation in the electronic patient record of the patient, and

(B) in conjunction with the storing in said step (vi)(A) of the structured note in the database as a part of clinical documentation in the electronic patient record of the patient, storing in the database, as additional data of the electronic patient record of the patient, information from the structured note as part of one or more categories of medical data determined based on predetermined system administrator settings and the one or more categories of medical data of the selection of said step (ii),

(C) wherein said step (vi)(A) is done in response to receipt of user input representative of a user command to save the structured note, and

(D) wherein said step (vi)(B) is done automatically as a consequence of the storing of the structured note as part of clinical documentation of the electronic patient record of the patient in the database.