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Method and system for automated medical records processing

  • US 8,606,594 B2
  • Filed: 11/20/2009
  • Issued: 12/10/2013
  • Est. Priority Date: 10/29/2002
  • Status: Active Grant
First Claim
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1. A method for automated processing of medical information, comprising:

  • generating dynamically via a first application on a first network device with one or more processors, one or more different electronic medical templates on the first network device, wherein the one or more different electronic medical templates are periodically and dynamically updated on the first network device via a communications network via a second application on a second network device with one or more processors and one or more associated databases;

    creating dynamically via the first application in the one more different medical templates a plurality of data fields stored in a non-transitory computer readable medium on the first network device comprising;

    patient history data comprising at least past medical, family, social history (“

    PMSFH”

    ), allergies and medications,patient physical condition data comprising at least a chief complaint and vital signs,medical summary information comprising at least a review of present systems (“

    ROS”

    ) and type of exam information,existing patient history information comprising at least a history of present illness (“

    HPI”

    ), andcomplexity risk information comprising at least diagnosis (“

    DX”

    ) or treatment options and a plurality of risk (“

    RISK”

    ) information;

    accepting patient encounter information via a graphical user interface (GUI) via the first application from a patent encounter into the plurality of created data fields on the one or more different electronic medical templates, thereby creating a completed electronic form for the patient encounter;

    generating from the first application a plurality of summary information matrixes in the non-transitory computer readable medium on the first network device,the plurality of summary information matrixes including;

    a historical information (HX) matrix, a patient examination (PX) matrix and a complexity risk (CX) information matrix,wherein the HX information matrix includes a plurality of matrix information elements comprising;

    a chief complaint (“

    CC”

    ), history of present illness (“

    HPI”

    ), past medical, family, social history information (“

    PFMSH”

    ) elements or review of system (“

    ROS”

    ) information elements,wherein the PX information matrix includes a plurality of matrix information elements comprising;

    (“

    PF”

    ) exam information for a general exam;

    an expanded problem focused exam (“

    EXPF”

    ) a detailed exam (“

    DET”

    ) or comprehensive exam (“

    COMP”

    ) information elements, andwherein the CX information matrix includes a plurality of matrix information elements comprising;

    diagnosis (“

    DX”

    ) or treatment options information elements including a straight forward (“

    SF”

    ) diagnosis, low risk (“

    LOW”

    ) number of diagnosis, a moderate number of (“

    MOD”

    ) diagnosis or a high (“

    HIGH”

    ) number of diagnosis and a plurality of risk (“

    RISK”

    ) information elements including straight forward (“

    SF”

    ) risk information, low risk (“

    LOW”

    ) information, moderate risk (“

    MOD”

    ) information or high risk (“

    HIGH”

    ) information;

    aggregating medical data from the plurality of data fields on the completed electronic form and storing the aggregated medical data from the first application on the first network device in real-time, wherein the aggregated medical data is aggregated into the plurality of summary information matrixes stored in the non-transitory computer readable medium on the first network device associated with the completed medical form;

    calculating from the first application a plurality of medical and billing codes and a plurality of risk codes with selected ones of the plurality of matrix information elements from each of the plurality of summary information matrixes including the aggregated medical data accepted from the patient encounter;

    creating automatically a new electronic medical record with a plurality of information fields in real-time via the first application on the first network with the aggregated medical data, the plurality of summary information matrixes, the calculated plurality of medical and billing codes and the calculated plurality of risk codes and a plurality of other summary medical information including;

    one or more medical and billing code modifiers,legal compliance for medical treatment provided to a patient during the patient encounter,an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter,a physician practice profile by aggregating data for a particular physician,an amount of time spent during the patient encounter;

    complexity risk information,laboratory and diagnostic test results completed during the patient encounter,data for use in research studies, andbilling and invoice data;

    providing in real-time the created new electronic medical record via the first application on the first network device for display on the GUI, thereby providing a complete 360 degree view of medical, complexity risk, billing, insurance and other information collected and generated from the patient encounter;

    categorizing and limiting via the first application a selected number of medical diagnoses or medical management options in the created new electronic medical record, thereby reducing a medical risk and complexity associated with the patient encounter;

    calculating a risk complexity value for the patient encounter from the categorized and limited created new electronic medical record;

    extracting in real-time from the first application selected ones of elements from the categorized and limited created new electronic medical record and creating a summary information matrix for the patient encounter, wherein the summary information matrix limits an amount and complexity of patient data to be reviewed and a number of diagnostic options to be considered for the patient encounter;

    displaying in real-time via the first application on the first network device via the GUI electronic information generated from the created summary information matrix and extracted from the categorized and limited created new electronic medical record and the calculated risk complexity value in one or more different colors than are used to display other electronic information from the created electronic medical record, thereby further reducing the medical risk associated with making a medical decision for the patient encounter using the displayed created summary information matrix; and

    generating in real-time from the first application a patient invoice for the patient encounter via the categorized and limited created new electronic medical record and the one or more generated medical and billing codes for immediate presentation to the patient after the patient encounter, thereby reducing a risk and complexity associated with insurance billing and reducing a risk and complexity associated with collecting immediate payment from the patient after the patient encounter.

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