Physician and clinical documentation specialist workflow integration

• US 9,916,420 B2
• Filed: 06/18/2013
• Issued: 03/13/2018
• 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: Cardoza, Timothy, Flanagan, James R., Boyer, Brian P.
• Primary Examiner(s): KANAAN, MAROUN P
• Application Number:
  US13/921,038
• Publication Number:
  US 20130297348A1
• Time in Patent Office: 1,729 Days
• Field of Search: 705 2, 705 3
• CPC Class Codes: G10L 15/1822 Parsing for meaning understanding
• CPC Class Codes: G10L 15/26 Speech to text systems G10L15/08 takes precedence
• CPC Class Codes: G10L 2015/221 Announcement of recognition results
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records
• CPC Class Codes: G16H 10/65 stored on portable record carriers, e.g. on smartcards, RFID tags or CD
• CPC Class Codes: G16H 15/00 ICT specially adapted for medical reports, e.g. generation or transmission thereof
• CPC Class Codes: G16H 40/20 for the management or administration of healthcare resources or facilities, e.g. managing hospital staff or surgery rooms

Abstract

A medical documentation system and a CDI system may be linked together, or integrated, so there is a tie between the two systems that allows for a much more efficient and effective CDI process. In one disclosed embodiment, a CDI system receives from a medical documentation system a structured data set including at least some information relating to one or more medical facts the medical documentation system automatically extracted from text documenting a patient encounter.

Claims

1. A method for use with a Clinical Documentation Improvement (CDI) system implemented via at least one first processor and processing medical documentation input at least in part by a clinician, the CDI system configured to communicate with a medical documentation system that also processes the medical documentation and is implemented via at least one second processor, wherein the CDI system includes a user interface by which to present the medical documentation to a CDI specialist and receive from the CDI specialist new information to include in the medical documentation to clarify the medical documentation and to receive from the CDI specialist identification of opportunities for clarification of the medical documentation, the CDI specialist being a human user of the CDI system, and wherein the medical documentation system implemented via the at least one processor analyzes text included in the medical documentation to extract medical facts expressed in the medical documentation and identify opportunities for clarification of the medical documentation, the method comprising:

with the CDI system implemented via the at least one processor,

receiving from the medical documentation system a structured data set including at least some information relating to one or more medical facts and including information indicating that the medical documentation system automatically extracted the one or more medical facts from text documenting a patient encounter, wherein the information related to the one or more medical facts comprises a first medical fact and a first confidence score produced by the medical documentation system indicating a confidence of the medical documentation system that the first medical fact was accurately extracted from the text documenting the patient encounter, the information relating to one or more medical facts further comprising at least one clarification request generated by the medical documentation system, the at least one clarification request requesting clarification regarding at least the first medical fact of the one or more medical facts and/or regarding at least a portion of the text documenting the patient encounter;

in response to determining that the first confidence score is below a first threshold,

prompting a user of the CDI system regarding the at least one clarification request;

receiving from the user of the CDI system, in response to the prompt regarding the at least one clarification request, at least one input providing clarification regarding the first medical fact and/or the at least the portion of the text documenting the patient encounter; and

in response to receiving the at least one input, transmitting a clarification response to the medical documentation system addressing the at least one clarification request, the clarification response comprising an indication of whether to prompt the clinician regarding the at least one clarification request.

2. The method of claim 1, further comprising an act of:

with the CDI system, transmitting a request to the medical documentation system that causes the medical documentation system to transmit the structured data set to the CDI system.

3. The method of claim 2, wherein the request transmitted by the CDI system comprises a call to an API of the medical documentation system.

4. The method of claim 1, wherein transmitting the clarification response comprising the indication of whether to prompt the clinician comprises instructing the medical documentation system not to prompt a clinician regarding the at least one clarification request.

5. The method of claim 1, wherein transmitting the clarification response comprising the indication of whether to prompt the clinician comprises instructing the medical documentation system to prompt a clinician regarding the at least one clarification request.

6. The method of claim 5, wherein instructing the medical documentation system to prompt the clinician comprises identifying an urgency with which the medical documentation system is to prompt the clinician.

7. The method of claim 1, further comprising an act of:

(b) receiving, at the CDI system from a user of the CDI system, a request for clarification of at least a portion of a medical record; and

(c) transmitting, with the CDI system, at least one second clarification request to the medical documentation system, the at least one second clarification request identifying the at least the portion of the medical record.

8. The method of claim 1, wherein the at least one first processor and the at least one second processor are the same at least one processor.

9. An apparatus comprising:

at least one processor; and

at least one storage medium having encoded thereon executable instructions that, when executed by the at least one processor, cause the at least one processor to carry out a method for use with a Clinical Documentation Improvement (CDI) system implemented via the at least one processor and processing medical documentation input at least in part by a clinician, the CDI system configured to communicate with a medical documentation system that also processes the medical documentation and is implemented via at least one second processor, wherein the CDI system includes a user interface by which to present the medical documentation to a CDI specialist and receive from the CDI specialist new information to include in the medical documentation to clarify the medical documentation and to receive from the CDI specialist identification of opportunities for clarification of the medical documentation, the CDI specialist being a human user of the CDI system, and wherein the medical documentation system implemented via the at least one processor analyzes text included in the medical documentation to extract medical facts expressed in the medical documentation and identify opportunities for clarification of the medical documentation, the method comprising;

with the CDI system,

receiving from the medical documentation system a structured data set including at least some information relating to one or more medical facts and including information indicating that the medical documentation system automatically extracted the one or more medical facts from text documenting a patient encounter, wherein the information related to the one or more medical facts comprises a first medical fact and a first confidence score produced by the medical documentation system indicating a confidence of the medical documentation system that the first medical fact was accurately extracted from the text documenting the patient encounter, the information relating to one or more medical facts further comprising at least one clarification request generated by the medical documentation system, the at least one clarification request requesting clarification regarding at least the first medical fact of the one or more medical facts and/or regarding at least a portion of the text documenting the patient encounter;

in response to determining that the first confidence score is below a first threshold,

prompting a user of the CDI system regarding the at least one clarification request;

receiving from the user of the CDI system, in response to the prompt regarding the at least one clarification request, at least one input providing clarification regarding the first medical fact and/or the at least the portion of the text documenting the patient encounter; and

in response to receiving the at least one input, transmitting a clarification response to the medical documentation system addressing the at least one clarification request, the clarification response comprising an indication of whether to prompt the clinician regarding the at least one clarification request.

10. The CDI system of claim 9, wherein the method comprises, with the CDI system, transmitting a request to the medical documentation system that causes the medical documentation system to transmit the structured data set to the CDI system.

11. The CDI system of claim 10, wherein transmitting the request comprises making a call to an API of the medical documentation system.

12. The CDI system of claim 9, wherein the receiving comprises receiving at least one clarification request generated by the medical documentation system as at least a part of the structured data set.

13. The CDI system of claim 9, wherein the method comprises, with the CDI system, transmitting a clarification request to the medical documentation system concerning the one or more automatically extracted medical facts.

14. At least one non-transitory, computer-readable medium having a plurality of instructions encoded thereon which, when executed by at least one processor, cause the at least one processor to carry out a method for use with a Clinical Documentation Improvement (CDI) system implemented via the at least one processor and processing medical documentation input at least in part by a clinician, the CDI system configured to communicate with a medical documentation system that also processes the medical documentation and is implemented via at least one second processor, wherein the CDI system includes a user interface by which to present the medical documentation to a CDI specialist and receive from the CDI specialist new information to include in the medical documentation to clarify the medical documentation and to receive from the CDI specialist identification of opportunities for clarification of the medical documentation, the CDI specialist being a human user of the CDI system, and wherein the medical documentation system implemented via the at least one processor analyzes text included in the medical documentation to extract medical facts expressed in the medical documentation and identify opportunities for clarification of the medical documentation, the method comprising:

with the CDI system,

receiving from the medical documentation system a structured data set including at least some information relating to one or more medical facts and including information indicating that the medical documentation system automatically extracted the one or more medical facts from text documenting a patient encounter, wherein the information related to the one or more medical facts comprises a first medical fact and a first confidence score produced by the medical documentation system indicating a confidence of the medical documentation system that the first medical fact was accurately extracted from the text documenting the patient encounter, the information relating to one or more medical facts further comprising at least one clarification request generated by the medical documentation system, the at least one clarification request requesting clarification regarding at least the first medical fact of the one or more medical facts and/or regarding at least a portion of the text documenting the patient encounter;

in response to determining that the first confidence score is below a first threshold,

prompting a user of the CDI system regarding the at least one clarification request;

receiving from the user of the CDI system, in response to the prompt regarding the at least one clarification request, at least one input providing clarification regarding the first medical fact and/or the at least the portion of the text documenting the patient encounter; and

in response to receiving the at least one input, transmitting a clarification response to the medical documentation system addressing the at least one clarification request, the clarification response comprising an indication of whether to prompt the clinician regarding the at least one clarification request.

15. The computer-readable medium of claim 14, wherein the method further comprises, with the CDI system, transmitting a request to the medical documentation system that causes the medical documentation system to transmit the structured data set to the CDI system.

16. The computer-readable medium claim 15, wherein transmitting the request comprises making a call to an API of the medical documentation system.

17. The computer-readable medium of claim 14, wherein the method further comprises, with the CDI system, transmitting a clarification request to the medical documentation system concerning the one or more automatically extracted medical facts.