Methods and apparatus for updating text in clinical documentation

• US 8,738,403 B2
• Filed: 02/18/2011
• Issued: 05/27/2014
• Est. Priority Date: 02/18/2011
• Status: Active Grant

• Current Assignee: Microsoft Technology Licensing LLC (Microsoft Corporation)
• Original Assignee: Nuance Communications, Inc. (Microsoft Corporation)
• Inventors: Flanagan, James R., Montyne, Frank, Decraene, David, Van der Vloet, Joeri, Raedemaeker, Johan, Casella dos Santos, Mariana, Holvoet, Marnix
• Primary Examiner(s): Sereboff, Neal
• Assistant Examiner(s): KANAAN, MAROUN P
• Application Number:
  US13/030,964
• Publication Number:
  US 20120215557A1
• Time in Patent Office: 1,194 Days
• Field of Search: 705/2, 705/3
• US Class Current: 705/3
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• 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

Abstract

Based on a free-form narration of a patient encounter provided by a clinician, it may be determined that one or more clinical facts could possibly be ascertained from the patient encounter. One or more options corresponding to the one or more clinical facts may be provided to a user. A selection of a first option of the one or more options may be received from the user. The first option may correspond to a first fact of the one or more clinical facts. A textual representation of the free-form narration may be updated to identify the first fact as having been ascertained from the patient encounter.

Claims

1. A method comprising:

processing a free-form narration of a patient encounter provided by a clinician, using a natural language understanding engine implemented by one or more processors, to identify one or more options corresponding respectively to one or more clinical facts that could be extracted from the free-form narration of the patient encounter, the processing comprising

analyzing the free-form narration to identify a set of one or more features of at least a portion of the free-form narration,

correlating the set of features to one or more abstract semantic concepts, and

generating computer-readable data that expresses the one or more abstract semantic concepts as the one or more clinical facts that could be extracted from the free-form narration;

providing to a user the one or more options corresponding to the one or more clinical facts corresponding to the one or more abstract semantic concepts identified from the processing of the free-form narration;

receiving from the user a selection of a first option of the one or more options, the first option corresponding to a first fact of the one or more clinical facts; and

updating a textual representation of the free-form narration, using at least one processor, to identify the first fact as having been ascertained from the patient encounter.

2. The method of claim 1, wherein the providing comprises providing a visual listing of the one or more options.

3. The method of claim 1, wherein the providing comprises providing an audio listing of the one or more options.

4. The method of claim 1, wherein the receiving comprises receiving a spoken selection of the first option.

5. The method of claim 1, wherein the receiving comprises receiving manual input selecting the first option.

6. The method of claim 1, wherein the first fact is a more specific version of a second fact specified in the free-form narration as having been ascertained from the patient encounter.

7. The method of claim 1, wherein the providing comprises providing disambiguating options among facts.

8. The method of claim 1, wherein the first fact is implied by a combination of two or more facts specified in the free-form narration as having been ascertained from the patient encounter.

9. The method of claim 1, wherein the updating comprises generating natural language text corresponding to the first fact, and adding the generated text to a textual representation of the free-form narration.

10. The method of claim 9, wherein the updating further comprises:

identifying a section heading in the textual representation of the free-form narration that corresponds to the first fact; and

adding the generated text to a section of the textual representation of the free-form narration corresponding to the identified section heading.

11. The method of claim 9, wherein the updating further comprises adding the generated text to a location, in the textual representation of the free-form narration, specified by the user.

12. The method of claim 11, wherein the updating further comprises adjusting the generated text in accordance with the location specified by the user.

13. The method of claim 1, wherein the user is the clinician.

14. The method of claim 1, wherein the user is a person other than the clinician, and wherein the method further comprises prompting the clinician to approve the user'"'"'s selection of the first option.

15. The method of claim 1, wherein the updating is performed automatically.

16. Apparatus comprising:

at least one processor; and

a memory storing processor-executable instructions that, when executed by the at least one processor, perform a method comprising;

processing a free-form narration of a patient encounter provided by a clinician, using natural language understanding, to identify one or more options corresponding respectively to one or more clinical facts that could be extracted from the free-form narration of the patient encounter, the processing comprising

analyzing the free-form narration to identify a set of one or more features of at least a portion of the free-form narration,

correlating the set of features to one or more abstract semantic concepts, and

generating computer-readable data that expresses the one or more abstract semantic concepts as the one or more clinical facts that could be extracted from the free-form narration;

providing to a user the one or more options corresponding to the one or more clinical facts corresponding to the one or more abstract semantic concepts identified from the processing of the free-form narration;

receiving from the user a selection of a first option of the one or more options, the first option corresponding to a first fact of the one or more clinical facts; and

updating a textual representation of the free-form narration to identify the first fact as having been ascertained from the patient encounter.

17. The apparatus of claim 16, wherein the providing comprises providing a visual listing of the one or more options.

18. The apparatus of claim 16, wherein the providing comprises providing an audio listing of the one or more options.

19. The apparatus of claim 16, wherein the receiving comprises receiving a spoken selection of the first option.

20. The apparatus of claim 16, wherein the receiving comprises receiving manual input selecting the first option.

21. The apparatus of claim 16, wherein the first fact is a more specific version of a second fact specified in the free-form narration as having been ascertained from the patient encounter.

22. The apparatus of claim 16, wherein the providing comprises providing disambiguating options among facts.

23. The apparatus of claim 16, wherein the first fact is implied by a combination of two or more facts specified in the free-form narration as having been ascertained from the patient encounter.

24. The apparatus of claim 16, wherein the updating comprises generating natural language text corresponding to the first fact, and adding the generated text to a textual representation of the free-form narration.

25. The apparatus of claim 24, wherein the updating further comprises:

identifying a section heading in the textual representation of the free-form narration that corresponds to the first fact; and

adding the generated text to a section of the textual representation of the free-form narration corresponding to the identified section heading.

26. The apparatus of claim 24, wherein the updating further comprises adding the generated text to a location, in the textual representation of the free-form narration, specified by the user.

27. The apparatus of claim 26, wherein the updating further comprises adjusting the generated text in accordance with the location specified by the user.

28. The apparatus of claim 16, wherein the user is the clinician.

29. The apparatus of claim 16, wherein the user is a person other than the clinician, and wherein the method further comprises prompting the clinician to approve the user'"'"'s selection of the first option.

30. The apparatus of claim 16, wherein the updating is performed automatically.

31. At least one non-transitory computer-readable storage medium encoded with a plurality of computer-executable instructions that, when executed, perform a method comprising:

processing a free-form narration of a patient encounter provided by a clinician, using natural language understanding, to identify one or more options corresponding respectively to one or more clinical facts that could be extracted from the free-form narration of the patient encounter, the processing comprising

analyzing the free-form narration to identify a set of one or more features of at least a portion of the free-form narration,

correlating the set of features to one or more abstract semantic concepts, and

generating computer-readable data that expresses the one or more abstract semantic concepts as the one or more clinical facts that could be extracted from the free-form narration;

providing to a user the one or more options corresponding to the one or more clinical facts corresponding to the one or more abstract semantic concepts identified from the processing of the free-form narration;

receiving from the user a selection of a first option of the one or more options, the first option corresponding to a first fact of the one or more clinical facts; and

updating a textual representation of the free-form narration to identify the first fact as having been ascertained from the patient encounter.

32. The at least one computer-readable storage medium of claim 31, wherein the providing comprises providing a visual listing of the one or more options.

33. The at least one computer-readable storage medium of claim 31, wherein the providing comprises providing an audio listing of the one or more options.

34. The at least one computer-readable storage medium of claim 31, wherein the receiving comprises receiving a spoken selection of the first option.

35. The at least one computer-readable storage medium of claim 31, wherein the receiving comprises receiving manual input selecting the first option.

36. The at least one computer-readable storage medium of claim 31, wherein the first fact is a more specific version of a second fact specified in the free-form narration as having been ascertained from the patient encounter.

37. The at least one computer-readable storage medium of claim 31, wherein the providing comprises providing disambiguating options among facts.

38. The at least one computer-readable storage medium of claim 31, wherein the first fact is implied by a combination of two or more facts specified in the free-form narration as having been ascertained from the patient encounter.

39. The at least one computer-readable storage medium of claim 31, wherein the updating comprises generating natural language text corresponding to the first fact, and adding the generated text to a textual representation of the free-form narration.

40. The at least one computer-readable storage medium of claim 39, wherein the updating further comprises:

identifying a section heading in the textual representation of the free-form narration that corresponds to the first fact; and

adding the generated text to a section of the textual representation of the free-form narration corresponding to the identified section heading.

41. The at least one computer-readable storage medium of claim 39, wherein the updating further comprises adding the generated text to a location, in the textual representation of the free-form narration, specified by the user.

42. The at least one computer-readable storage medium of claim 41, wherein the updating further comprises adjusting the generated text in accordance with the location specified by the user.

43. The at least one computer-readable storage medium of claim 31, wherein the user is the clinician.

44. The at least one computer-readable storage medium of claim 31, wherein the user is a person other than the clinician, and wherein the method further comprises prompting the clinician to approve the user'"'"'s selection of the first option.

45. The at least one computer-readable storage medium of claim 31, wherein the updating is performed automatically.