Method and apparatus for analyzing patient medical records

• US 8,326,653 B2
• Filed: 03/04/2003
• Issued: 12/04/2012
• Est. Priority Date: 03/04/2003
• Status: Active Grant

• Current Assignee: Microsoft Technology Licensing LLC (Microsoft Corporation)
• Original Assignee: Nuance Communications, Inc. (Microsoft Corporation)
• Inventors: Gottlieb, Meir, Gottlieb, Sheldon H., Weisz, Gabriel
• Primary Examiner(s): Dunham, Jason
• Assistant Examiner(s): MISIASZEK, AMBER ALTSCHUL
• Application Number:
  US10/378,748
• Publication Number:
  US 20040176979A1
• Time in Patent Office: 3,563 Days
• Field of Search: 705 2- 4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/02 Banking, e.g. interest calculation or account maintenance credit or loans G06Q40/03
• CPC Class Codes: G16H 10/20 for electronic clinical trials or questionnaires
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof

Abstract

A medical form is marked by a clinician during a patient/clinician encounter to generate a record with information related to a current complaint. The form is partitioned into several regions related to patient history, examination and medical decision, respectively. The form is automatically analyzed and using the locations of the marks on the form and a predetermined set of rules, a billing code is generated. The billing code determines the fee to be paid to the clinician or health provider.

Claims

1. An apparatus for generating a medical billing code from a populated form resulting from a patient/clinician encounter, said populated form having locations with marks, each mark having a respective content indicative of either information obtained by the clinician during the encounter about the patient or a physical condition of the patient, said marks being made by the clinician, comprising:

a detector, comprising at least one processor, adapted to detect marks on said form, within predetermined zones defined thereon; and

an analyzer, comprising the at least one processor, adapted to generate a medical billing code based on said number of zones with marks detected on said form and a predetermined set of rules, wherein said rules are independent on the content of the markings at the respective locations.

2. The apparatus of claim 1 wherein said form is hard-copy form and said detector includes a scanner that scans said hard-copy form.

3. The apparatus of claim 1 wherein said detector includes an electronic data collection device adapted to generate an image of said form and wherein said data collection device is adapted to detect said marks as they are entered on said electronic data collection device.

4. The apparatus of claim 3 wherein said electronic data collection device is a tablet PC.

5. The apparatus of claim 1 wherein each zone has respective locations and marks made at least at some of said locations, and wherein analyzer counts the number of marks in each zone, generates a respective parameter and operates said preselected set of rules on said parameters to generate said billing code.

6. The apparatus of claim 5 wherein said parameter is selected by said analyzer based on the complexity of a task performed by the clinician, said task being associated with the respective zone of said form.

7. The apparatus of claim 1, wherein said analyzer assigns a classification for each zone and determines said billing code by evaluating the classifications of said zones.

8. The apparatus of claim 7 wherein said zones include at least one zone dedicated to one of the patient'"'"'s history of present illness, review of systems and past, family and social history.

9. The apparatus of claim 1 wherein the form includes at least one zone, said zone including several regions, each region including at least one subregion and reflecting the examination of one of a body organ and organ system of a patient, wherein said analyzer assigns a respective parameter for each region depending on how many subregions have markings, and wherein said analyzer further assigns said billing code based on the parameters from said regions.

10. A method of generating a billing code for an encounter between a patient and a healthcare provider, wherein during the encounter, the healthcare provider populates a form defining a history zone, an examination zone and a prognosis zone by making entries in several subdivisions within the respective zones, each entry indicating some information or patient condition as determined or obtained by the clinician, said method comprising:

using at least one processor, analyzing each zone to determine how much effort has the clinician spent in examining the patient during the respective zone, wherein at least in one zone, said analyzing includes counting the number of subdivisions within said one zone that have entries;

using the at least one processor, assigning a parameter to each zone based on said analysis, wherein in for at least one of said zone, said step of assigning is dependent on the number of subdivisions within that zone in which there are entries made by the clinician each said parameter being completely independent of any information associated with the entries in the respective zone;

using the at least one processor, generating a classification for said encounter indicative of the complexity of the encounter based on the parameters assigned to each zone; and

using the at least one processor, assigning a billing code for the encounter based on said classification.

11. The method of claim 10 wherein said form further includes an identification zone with information identifying the patient, further comprising verifying the information in said identification zone before analyzing the remaining zones.

12. The method of claim 10 wherein said form includes a history zone, an examination zone and a medical decision zone.

13. The method of claim 12 wherein said history zone and said examination zone are each designated as being one of problem focused, expanded problem focused, detailed and comprehensive.

14. The method of claim 12 wherein said medical decision zone is designated as being one of straight forward, low complexity, moderate complexity and high complexity indicating the complexity of the diagnosis performed by the healthcare provider.

15. A method of generating a billing code for an encounter between a patient and a healthcare provider, wherein during the encounter, the healthcare provider populates a form defining a history zone, an examination zone and a prognosis zone by making entries in the respective zones, each entry indicating some information or patient condition as determined or obtained by the clinician, said method comprising:

using at least one processor, analyzing each zone to determine how much effort has the clinician spent in examining the patient during the respective zone;

using the at least one processor, assigning a parameter to each zone based on said analysis, wherein in for at least one of said zone, said step of assigning includes determining the number of entries made by the clinician in the respective zone, each said parameter being completely independent of any information associated with the entries in the respective zone;

using the at least one processor, generating a classification for said encounter indicative of the complexity of the encounter based on the parameters assigned to each zone; and

using the at least one processor, assigning a billing code for the encounter based on said classification;

wherein said form includes a history zone, an examination zone and a medical decision zone, said history zone and said examination zone are each designated said respective parameter as being one of problem focused, expanded problem focused, detailed and comprehensive; and

wherein the parameter for said medical decision zone is designated as being one of straight forward, low complexity, moderate complexity and high complexity indicating the complexity of the diagnosis performed by the healthcare provider.