Electronic medical records system

• US 20020046346A1
• Filed: 10/03/2001
• Published: 04/18/2002
• Est. Priority Date: 09/27/1996
• Status: Abandoned Application

• Current Assignee: Jae A. Evans
• Original Assignee: Jae A. Evans
• Inventors: Evans, Jae A.
• Application Number:
  US09/970,506
• Publication Number:
  US 20020046346A1
• Time in Patent Office: Days
• US Class Current: 713/200
• 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 20/10 relating to drugs or medications, e.g. for ensuring correct administration to patients
• CPC Class Codes: G16H 40/67 for remote operation
• CPC Class Codes: G16H 50/70 for mining of medical data, e.g. analysing previous cases of other patients
• CPC Class Codes: G16H 80/00 ICT specially adapted for facilitating communication between medical practitioners or patients, e.g. for collaborative diagnosis, therapy or health monitoring
• CPC Class Codes: Y10S 707/99931 Database or file accessing
• CPC Class Codes: Y10S 707/99933 Query processing, i.e. searching

Abstract

A medical records system that creates and maintains all patient data electronically. The system captures patient data, such as patient complaints, lab orders, medications, diagnoses, and procedures, at its source at the time of entry using a graphical user interface having touch screens. Using pen-based portable computers with wireless connections to a computer network, authorized healthcare providers can access, analyze, update and electronically annotate patient data even while other providers are using the same patient record. The system likewise permits instant, sophisticated analysis of patient data to identify relationships among the data considered. Moreover, the system includes the capability to access reference databases for consultation regarding allergies, medication interactions and practice guidelines. The system also includes the capability to incorporate legacy data, such as paper files and mainframe data, for a patient.

Claims

1. A medical records system, comprising:

a point of care system to capture patient data at a point of care wherein the point of care system comprises;

a patient data capture to enter information provided by a patient;

a clinical data capture, in data communication with the patient data capture, to enter clinical data for the patient;

an encounter data capture, in data communication with the patient data capture, to enter diagnoses and procedures administered to the patient;

progress notes, in data communication with the patient data capture, the clinical data capture and the encounter data capture, to enter information related to changes in the patient'"'"'s condition;

a patient data repository, in communication with the point of care system and with external systems, to store and organize the patient data for access by the point of care system;

a medication data capture, in data communication with the patient data capture and the progress notes, to enter medication information for the patient; and

a practice guideline for reference to accepted medical practices, wherein the practice guideline communicates with the patient data capture, the clinical data capture, the progress notes and the encounter data capture.

2. A medical records system, comprising:

a point of care system to capture patient data at a point of care; and

a patient data repository, in communication with the point of care system and with external systems, to store and organize the patient data for access by the point of care system, wherein the patient data repository comprises;

a patient locator having a patient identifier;

a data manager, in communication with the patient locator, to organize patient data for storage and retrieval using the patient identifier;

a data interface, in communication with the data manager, to transmit patient data to external systems and to receive patient data from the external systems;

a cache, in communication with the data manager, to temporarily store the patient data for retrieval, wherein the cache is located on a server computer, and wherein the cache is distributed across a computer network; and

a data archive, in communication with the cache, to permanently store the patient data.

3. The medical records system of claim 2, wherein the data archive comprises a jukebox having at least one storage device.

4. The medical records system of claim 3, wherein the at least one storage device is a recordable optical disk.

5. The medical records system of claim 3, wherein the at least one storage device is a magnetic disk drive.

6. The medical records system of claim 2, wherein the data interface comprises:

a communication interface to send and receive patient data from external systems;

an interface manager, in communication with the communication interface, to set the communication interface for either transmission or receipt of the patient data from the external systems; and

a data handler, in communication with the interface manager and with the communication interface, to convert selected patient data into a selected data format.

7. A medical records system comprising:

a point of care system to capture patient data at a point of care wherein the patient data includes clinical data and progress notes;

a patient data repository, in communication with the point of care system and with external systems, to store and organize the patient data for access by the point of care system; and

a reference database in communication with the point of care system, wherein the reference database comprises;

a diagnosis module having diagnosis codes indicative of a condition of a patient;

a procedure module, in communication with the diagnosis module, having procedure codes indicative of a treatment to administer to the patient; and

a medication manager, in communication with the diagnosis module and with the procedure module, having information on medication to administer to the patient.

8. A medical records system comprising:

a point of care system to capture patient data at a point of care;

a patient data repository, in communication with the point of care system and with external systems, to store and organize the patient data for access by the point of care systems; and

a legacy data system in communication with the patient data repository, wherein the legacy data system comprises;

a data source having patient data, wherein the data source comprises physical data, and wherein the data source comprises a computer network having electronically stored patient data; and

a converter, in communication with the data source, to convert the patient data into a selected format for transfer to the patient data repository.

9. The medical records system of claim 8, wherein the converter comprises a scanner.

10. A medical records system, comprising:

a point of care system to capture patient data at a point of care wherein the point of care system provides for annotation of the patient data, wherein the annotation acknowledges review of the patient data, and wherein the annotation includes instructions for patient care; and

a patient data repository, in communication with the point of care system and with external systems, to store and organize the patient data for access by the point of care system.

11. The medical records system of claim 10, wherein the annotation indicates approval.

13. The method of claim 12, wherein evaluating the patient data comprises consulting a diagnosis module to review diagnosis information.

14. The method of claim 12, further comprising prescribing a medication.

15. The method of claim 14, wherein prescribing a medication comprises consulting a medication manager to review medication information.

16. The method of claim 12, further comprising administering a treatment.

17. The method of claim 16, wherein administering a treatment comprises consulting a procedure module to review procedures to administer the treatment.

19. The method of claim 18, further comprising delivering the patient data when the patient data is located in the cache.

20. The method of claim 18, further comprising:

moving the patient data from the data archive when the patient data is not located in the cache; and

delivering the patient data.

12. A method of using an electronic medical records system, comprising:

capturing patient data electronically at the point of care;

organizing the patient data so as to form a patient record;

filing the patient record;

retrieving the patient record to access the patient data for use in the care of a patient, wherein retrieving the patient record includes annotating the patient data; and

evaluating the patient data so as to make a diagnosis.

18. A method of retrieving patient data in an electronic medical records system having a patient data repository, comprising:

obtaining a patient identifier;

locating a patient record corresponding to the patient identifier in the patient data repository, wherein the patient data repository includes a cache and a data archive;

determining the location of the patient data within the patient record; and

delivering the patient data.

21. A method of communicating with an external source having an interface to an electronic medical records system, comprising:

finding an interface for the external source;

connecting to the external source using the interface; and

converting patient data for transfer between the external source and the electronic medical records system, wherein converting patient data for transfer comprises converting patient data for transfer from the electronic medical records system to the external source, and wherein converting patient data for transfer also comprises converting patient data for transfer from the external source to the electronic medical records system.

22. A program storage device storing instructions that when executed perform the method, comprising:

capturing patient data electronically at the point of care;

organizing the patient data so as to form a patient record;

filing the patient record; and

retrieving the patient record to access the patient data for use in the care of a patient.