Method and system for automated medical records processing

• US 7,624,027 B1
• Filed: 10/24/2003
• Issued: 11/24/2009
• Est. Priority Date: 10/29/2002
• Status: Active Grant

• Current Assignee: Practice Velocity
• Original Assignee: Practice Velocity
• Inventors: Stern, David E., Koehler, John J., Pearson, Wayne R.
• Primary Examiner(s): Gilligan; C. Luke
• Assistant Examiner(s): NGUYEN, TRAN N
• Application Number:
  US10/692,976
• Time in Patent Office: 2,223 Days
• Field of Search: 705/2
• US Class Current: 705/2
• 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
• CPC Class Codes: G16H 70/00 ICT specially adapted for the handling or processing of medical references

Abstract

A method and system for automated medical records processing. The method and system includes plural paper and electronic templates specifically designed such that they reduce the complexity of collecting patient encounter information and help generate the appropriate number and type medical codes for a specific type of medical practice when processed. The method and system also includes processing applications that allow easy and automated collection, processing, displaying and recording of medical codes (e.g., diagnosis codes, billing codes, insurance codes, etc.). The medical codes and other types of processed patient encounter information are displayed in real-time on electronic templates immediately after a patient encounter.

Claims

1. A method of processing medical records, comprising:

(a) creating on a network device with one or more processors and one or more associated databases, one or more different medical templates capable of being used to enter information from an encounter with a patient, wherein the one more medical templates comprise a plurality of data fields comprising;

(i) patient history data;

(ii) patient physical condition data;

(iii) summary information;

(iv) existing patient history information; and

(v) complexity risk coding information;

(b) printing the one or more different medical templates on paper forms;

(c) entering patient encounter information from a patent encounter into the plurality of data fields by writing on the paper forms with a writing utensil, thereby creating completed paper forms;

(d) scanning the completed paper forms into the network device;

(e) digitizing the completed paper forms by;

(i) identifying from the network device a plurality of locations of data fields on the completed paper forms; and

(ii) performing optical character recognition on the network device on data created with the writing utensil at each of the plurality of identified locations of the data fields;

(f) aggregating the recognized data into an electronic patient medical record and storing the electronic patient medical record on the network device; and

(g) determining on the network device with the stored electronic patient medical record for the patient encounter represented by the paper forms;

(i) medical and billing codes;

(ii) legal compliance for medical treatment provided to the patient during the patient encounter;

(iii) an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter;

(iv) a physician practice profile by aggregating data for a particular physician; and

(v) data for use in research studies.

2. The method of claim 1 further comprising:

generating a plurality of electronic medical templates in real-time using the determined medical and billing codes; and

utilizing in real-time the generated plurality of electronic medical templates and the stored electronic medical record by displaying the generated plurality of electronic medical templates and the stored electronic medical record on a graphical user interface (GUI) on the network device.

3. The method of claim 2 wherein the one or more generated electronic templates include one or more of an electronic invoice template, and electronic medical record template, a chief compliant template, a diagnosis template, a nurse template, a review template, or provider template.

4. The method of claim 2 wherein the generating step includes:

creating a coding summary of the one or more medical and billing codes generated from the stored electronic patient medical record; and

attaching the created coding summary to the stored electronic patient medical record, wherein the coding summary can be used to verify that the proper medical codes where generated from the patient.

5. The method of claim 2 further comprising:

selecting a generated electronic medical information template on the network device;

generating automatically one or more additional electronic medical information templates based on the selected generated electronic medical information template and the stored electronic medical record, wherein the one or more additional electronic information templates including additional electronic medical information templates for medical personnel, the patient or a health-care provider.

6. The method of claim 1 wherein the one or more printed paper forms include a limited number of check-boxes specifically selected for a specific type of medical practice, wherein the limited number of check boxes reduce a risk associated with making a complex medical decision by allowing only a single check box for each level of risk, wherein digitizing the plurality of check-boxes generates an appropriate number and type of medical and billing codes for the specific type of medical practice including complexity risk coding information for the specific type of medical practice.

7. The method of claim 6 wherein digitizing the plurality of check-boxes includes generating:

a plurality of HX data fields including patient history information;

a plurality of PX data fields including patient physical condition information;

a plurality of CX data fields including complexity risk information; and

one or more E/M data fields including evaluation and management codes, wherein the generated one or more E/M data fields include summary information obtained by aggregating information from the HX, PX and CX data fields.

8. The method of claim 1 further comprising a computer readable medium having stored therein instructions for causing one or more processors to execute the steps of the method.

9. The method of claim 1 wherein the determined medical and billing codes include one or more of Evaluation and Management codes (“

E/Ms”

) codes, Current Procedural Terminology (“

CPTs”

) codes, Health Care Financing Administration Common Procedural Coding System (“

HCPCS”

) codes, International Classification of Diseases 9^th Edition Clinical Modification (“

ICD-9”

) codes or International Classification of Diseases 10^th Edition Clinical Modification (“

ICD-10”

) codes.

10. The method of claim 1 wherein determining step includes:

determining historical information, physical examination information, complexity information, patient status information, patient demographic information, diagnosis information, clinical procedure information and supply information from the stored electronic medical record on the network device.

11. The method of claim 1 further comprising:

generating automatically one or more medical and billing codes using historical, physical complexity of medical decision making information, patient status information, patient demographic information, diagnosis information, clinical procedure information, treatment information and supply information collected from the stored patient medical record.

12. The method of claim 1 further comprising verifying in real-time the stored patient medical record via the scanned completed paper forms.

13. The method of claim 1 wherein the determined medical and billing codes include one or more medical codes specifically generated for a new patient or one or more medical codes specifically generated for an existing patient.

14. The method of claim 1 wherein complexity risk coding information helps eliminate an amount and complexity of patient data to be collected and a number of diagnostic options to be considered during the patient encounter thereby reducing a risk associated with making a complex medical decision and limiting an amount and complexity of patient data to be processed and reviewed.

15. A system for processing medical records on a plurality of network devices each with one or more processors, comprising in combination:

a first network device for;

creating one or more different medical templates capable of being used to enter patient encounter information, wherein the one or more medical templates comprises a plurality of data fields comprising;

(i) patient history data;

(ii) patient physical condition data;

(iii) summary information;

(iv) existing patient history information;

(v) complexity risk coding information;

printing on the first network device the one or more different medical templates on paper forms;

entering patient encounter information from a patent encounter into the plurality of data fields by writing on the paper forms with a writing utensil, thereby creating completed paper forms;

a second network device with one or more associated databases for;

scanning the completed paper forms;

digitizing the completed paper forms by;

(i) identifying from the network device a plurality of locations of data fields on the completed paper forms;

(ii) performing optical character recognition on the second network device on data created with the writing utensil at each of the plurality of identified locations of the data fields;

aggregating the recognized data into an electronic patient medical record and storing the electronic patient medical record on the second network device;

determining on the second network device with the stored electronic patient medical record for the patient encounter represented by the paper forms;

(i) medical and billing codes;

(ii) legal compliance for medical treatment provided to the patient during the patient encounter;

(iii) an appropriateness of care based on the stored patient data and the medical treatment provided during the patient encounter;

(iv) a physician practice profile by aggregating data for a particular physician; and

(v) data for use in research studies;

generating one or more electronic templates from the stored electronic medical record on the second network device; and

displaying the scanned paper forms, the stored electronic medical record and the generated one or more electronic templates on a graphical user interface (GUI) on the second network device.

16. The system of claim 15 wherein the determined medical and billing codes include one or more of Evaluation and Management codes (“

E/Ms”

) codes, Current Procedural Terminology (“

CPTs”

) codes, Health Care Financing Administration Common Procedural Coding System (“

HCPCS”

) codes International Classification of Diseases 9^th Edition Clinical Modification (“

ICD-9”

) codes or International Classification of Diseases 10^th Edition Clinical Modification (“

ICD-10”

) codes.

17. The system of claim 15 wherein the one or more generated electronic templates include one or more of an electronic invoice template, and electronic medical record template, a chief compliant template, a diagnosis template, a nurse template, a review template, or provider template.