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

• US 8,566,123 B2
• Filed: 09/15/2012
• Issued: 10/22/2013
• 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, Downs, Tyler, Mitchel, David H., Ipock, Jason C., Kasargod, Shiva, Barige, Sash
• Primary Examiner(s): SEOH, MINNAH L
• Application Number:
  US13/621,119
• Publication Number:
  US 20130080190A1
• Time in Patent Office: 402 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.

Claims

1. An information apparatus for use with a networked database, 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, the processor being configured to perform the implemented method,

(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 documentation, 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 for which data 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,

(iii) accessing data that has been previously stored in the networked database, that is associated with a patient for which a structured note representing documentation is being created, and that corresponds to the one or more categories 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 information associated with the one or more categories 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 documentation stored in a record for 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 record for the patient, information from the structured note in a second area of the record, the second area being determined based on predetermined system administrator settings and the one or more categories of the selection of said step (ii).

2. The apparatus of claim 1, wherein the one or more categories 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 corresponding to a plurality of fields in an 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.

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 said step (vi) is performed upon selection of a user interface element representing user instruction to save the structured note to the networked database.

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

10. 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, a user interface including,

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

(ii) one or more user interface areas configured to allow for selection of one or more categories for which data associated with patients is stored,

(b) receiving, via the user interface of the computing platform presented in said step (a), a selection of one or more of the categories,

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

(d) presenting, via the computing platform, the data accessed in said step (c),

(e) receiving, via the computer platform, input for creating the structured note, the structured note including information associated with the one or more categories of the selection of said step (b),

(f) in response to user input, storing the structured note in the database as a part of an electronic patient record of the patient, and

(g) in conjunction with the storing of the structured note in said step (f), automatically storing by one or more processors 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 the selection of said step (b).

11. The computer implemented method of claim 10, wherein the user interface provides a first display area displaying categories 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 on the computing platform.

12. The computer implemented method of claim 10, wherein the electronic patient record comprises rows and columns of data;

wherein the method comprises selecting, from a menu of categories 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 a user interface for display of data therefrom on the computing platform; and

wherein the documentation entered via the computing platform regarding a selected category 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 category.

13. 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.

14. An 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 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,

(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 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 information associated with the one or more categories 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 pertaining to the patient, information from the structured note as part of one or more categories determined based on predetermined system administrator settings and the one or more categories of the selection of said step (ii).

15. The system of claim 14, wherein one or more of the user computing devices is configured for network communications with the networked database over the Internet.

16. The system of claim 14, wherein one or more of the user computing devices is configured for network communications with the networked database over a local area network.

17. The system of claim 14, wherein one or more of the user computing devices comprises a handheld computing device.

18. The system of claim 14, wherein one or more of the user computing devices comprises a workstation.

19. The system of claim 14, 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.

20. The system of claim 14, 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.