Generation of codified electronic medical records by processing clinician commentary

A method and system for generating codified electronic records. A textual commentary can be received from a user and, in real time, the textual commentary can be analyzed to identify a plurality of codes that potentially correlate to the textual commentary. The identified codes then can be presented to the user in real time. A first user input can be received to select at least one of the identified codes, and the selected code can be added to an electronic record.

BACKGROUND

1. Field of the Invention

The present invention relates to electronic record systems and, more particularly, to devices that generate codified electronic records.

2. Description of the Related Art

The Institute of Medicine has reported that approximately 100,000 deaths occur per year in the United States due to preventable medical errors. This, in part, is the reason for a massive world wide effort to move to electronic health record (EHR) systems. Some EHR systems do exist today; however, such systems are not integrated in a manner that allows efficient sharing of medical records between medical facilities. Further, existing EHR systems do not capture a level of detail required to automatically analyze patient data.

Another obstacle hindering widespread implementation of EHR systems is that such systems do not seamlessly integrate with current medical practices. For instance, clinicians usually are trained to dictate a patient condition into a recorder using a textual commentary that interweaves potential and excluded diagnosis with positive and negative indications in a run-on sentence format. Such sentence structure normally exceeds the trusted ability of standard computerized text analysis tools. Thus, automated analysis of text currently is not a viable option. Instead, a medical transcription service is used to subsequently transcribe the dictation into a text document that can be stored in the clinician's office with other patient records. The transcribed text typically does not contain medical codes that are compliant with EHR systems, however. Moreover, medical transcription is labor intensive, time consuming, and error prone.

It therefore would be beneficial to provide a system for documenting patient information that is both accurate and efficient.

SUMMARY OF THE INVENTION

The present invention provides method(s), system(s), and apparatus relating to generation of codified electronic records. One embodiment of the present invention can include receiving, within a computer, a textual commentary from a user. The user can be a clinician that is the source of the textual commentary. The method can include, responsive to receiving the textual commentary and in real time, analyzing the textual commentary to identify a plurality of codes that potentially correlate to the textual commentary and presenting the identified codes to the user through an output device. A first user input can be received to select at least one of the identified codes presented via the output device responsive to presenting the identified codes, and the selected code can be added to an electronic record responsive to receiving the first user input.

Another embodiment of the present invention can include receiving, within a computer, a textual commentary from a user, wherein the user is a clinician and source of the textual commentary. The method can include, responsive to receiving the textual commentary and in real time, analyzing the textual commentary to identify a first plurality of codes that potentially correlate to the textual commentary and presenting the first plurality of codes to the user through an output device. Responsive to presenting the first plurality of codes, at least a first user input can be received to select at least one code from the first plurality of codes presented on the output device and at least one operation can be initiated on the selected code. A second plurality of codes can be presented to the user reflecting changes caused by the operation on the selected code via the output device responsive to receiving the at least a first user input. The second plurality of codes can be added to the electronic record.

Yet another embodiment of the present invention can include a machine readable storage being programmed to cause a machine to perform the various steps and/or functions described herein.

DETAILED DESCRIPTION OF THE INVENTION

The embodiments disclosed herein relate to a method and a system for generating codified electronic records in an intuitive manner that is both accurate and efficient. In particular, the system can receive a textual commentary from a user and, in real time, analyze the commentary and present to the user codes and other data that correlate to information communicated in the commentary. The codes and data can be presented hierarchically via an intuitive interface that allows results to be quickly accepted, changed, refined, negated, or deleted by the user. The system also can allow the user to indicate and/or change priority of the codes and data. Primary and secondary considerations also can be indicated or changed. Accordingly, the present invention can aid clinicians in their generation of electronic health records.

FIG. 1is a block diagram depicting a system100for generating codified electronic records in accordance with an embodiment of the present invention. The system100can include a textual input device105that receives textual commentary110from a user and forwards the textual commentary110to a record generation system115. The textual commentary110can be entered, for example, as one or more spoken utterances, typed text, hand scribed text, or entered in any other suitable manner. For instance, the textual input device105can include an audio transducer (e.g. a microphone), a keyboard, a keypad, an electronic writing tablet, a scanner or any other device which can be used by a user to enter textual commentary110. The textual commentary110can be propagated to the record generation system115via a wired or a wireless communication link. In one wireless arrangement, the textual input device can transmit the textual commentary110in accordance with the Bluetooth protocol or the IEEE 802.11 protocol. Nonetheless, any suitable wireless and/or wired communication protocol(s) can be used and the invention is not limited in this regard.

In an arrangement in which the textual commentary110is entered as spoken utterances, a speech recognition application can be used to convert the spoken utterances to text. The speech recognition application can be instantiated on the textual input device105, in which case the textual commentary110can be transmitted as text to the record generation system115, or the speech recognition application can be instantiated on the record generation system115, in which case the textual commentary110can be transmitted as audio data.

The record generation system115can include a text processor120that processes the textual commentary110in real time. As used herein, the term “real time” means a level of processing responsiveness that a user senses as sufficiently immediate or that enables the processor to keep up with some external process. The text processor120can include text analysis routines that analyze the textual commentary110and identify at least one attribute contained therein. The attribute can be, for example, information that is conveyed in the textual commentary110, such as an observation, complaint, sign, symptom, diagnosis, drug, and/or procedure. To identify the attribute, the text analysis routines can perform a sequence of processing steps. For instance, the routines can perform tokenization (including abbreviations, spelling, acronyms), sentence segmentation, part-of-speech assignment, named-entity identification, phrasal parsing, sentential parsing, semantic interpretation, lexical normalization, discourse interpretation, template filling, merging and/or any other suitable text processing techniques. Such routines can be integrated into a text analysis framework, for example the Unified Information Management Architecture (UIMA) as provided by International Business Machines of Armonk, N.Y., and specifically optimized to recognize medical terminology.

The text processor120then can associate the attributes contained in the textual commentary110with appropriate codes selected from one or more chosen coding schemes. As used herein, the term “code” means a grouping of one or more characters that has been defined to correlate to one or more attributes. In one embodiment, the coding schemes can be medical coding schemes, for instance current procedural terminology (CPT), diagnostic coding, symptom coding and prescription coding. Still, other coding schemes can be used and the invention is not limited in this regard.

Selection of the codes can be trainable. For example, the record generation system115can maintain a history of codes that have been previously accepted for a particular attribute that has been contained in previous textual commentaries. Such history then can be referenced when selecting codes with which to associate that attribute when the attribute is contained in the textual commentary110. Each code that is selected can be weighted based on the relative frequency that the code has been accepted as indicated in the code history. Such weighting can be indicated when the codes are presented to the user.

In one aspect of the invention, the code selection history can be user specific. For instance, code acceptance records can be maintained for each user. Thus, by way of example, if one user tends to use a particular utterance when referring to a particular diagnosis, the text processor120will have a high probability at selecting the appropriate diagnostic codes.

The codes and code acceptance history records can be retrieved from a data repository125. The data repository125can include, for example, one or more data tables126that correlate attributes with appropriate codes. Such codes and attributes can be automatically updated to insure that the codes and attributes contained in the data repository125are current, accurate and complete. The data tables126also can indicate the code acceptance history. In one arrangement, one or more data tables126can be provided for each of the coding schemes that may be used.

The data repository125also can include one or more data tables127that store annotations. The annotations can be used to describe the attributes contained in the textual commentary110and/or describe the selected codes. As with the codes, the annotations can be automatically selected by the text processor120in real time. In one arrangement, annotators that use the annotations can be trained using suitable training data. Annotators can be a specifically relevant type of code that is selected, for example a code correlating to an observation, complaint, sign, symptom, diagnosis, drug and/or procedure. The annotations also may include dictionaries, specialized vocabularies, terminology, abbreviations and/or ontologies for each of these. Nonetheless, other types of annotations can be used and the invention is not limited in this regard. The annotators can be updated to insure that the annotations contained in the data repository125are current, accurate and complete.

The attributes identified in the textual commentary110, as well as the codes selected by the annotators, and other information, such as primary and/or secondary considerations, can be forwarded to a presentation device140for presentation to the user. In one arrangement, the textual input device105and the presentation device140can be integrated into a single device or system. Alternatively, the textual input device105and presentation device140can be separate devices or systems. Hereinafter, codes, annotations and other information are collectively referred to as codes/information130. The codes/information130can be propagated from the record generation system115to the presentation device140via a wired or a wireless communication link. As noted, any suitable communication protocol(s) can be used.

The user can interface with the presentation device140to scan, modify and confirm the analysis of the textual commentary110represented by the codes/information130. The presentation device140can include, for example, an audio transducer (e.g. a loudspeaker), a display and/or any other device suitable for presenting the codes/information130to the user. In one aspect of the invention, the codes/information130can be presented to the user in a hierarchical order. Such order can be based, at least in part, on code acceptance history, user preferences, code classifications, or any other suitable parameter.

In an arrangement in which the presentation device140comprises an audio transducer, the codes/information130can be audibly presented to the user. For instance, the codes/information130can be propagated as text to the presentation device140, in which case a text-to-speech application can be instantiated on the presentation device140, or the codes/information130can be transmitted to the presentation device140as audio data, in which case a text-to-speech application can be instantiated on the record generation system115. The user can be prompted to utter selections145into the textual input device105to select particular ones of the codes/information130and accept, change, refine, negate, or delete such selections. The hierarchical order of the codes/information130also can be changed by the user in the same manner. Updated codes/information can be audibly presented to the user reflecting changes to the codes/information130originally presented. The process can repeat until the user accepts the codes/information130as presented.

The codes/information130also can be visually presented to the user via a display. For example, the codes/information130can be presented on a handheld portable display. In another arrangement the codes/information130can be presented on a wall mounted display or a display attached to a patient bed. For example, the record generation system115can be configured to communicate with a plurality of displays, each of which is in a different location, and one or more of such displays can be activated when their use is desired.

In another example, a proximity detector can be implemented to activate a particular display140when an authorized user is detected within an area served by the display. For instance, the textual input device105can communicate an authorization signal to activate the display140when the textual input device105is located within an area in which the display140can be viewed. Further, the textual input device105can communicate an identifier for a particular user session with which the textual input device105is associated, and the identifier can be used by the display140to become associated with that user session. For instance, the display140can send a session request to the record generation system115. Notwithstanding, display selection can be implemented in any other suitable manner and the invention is not limited in this regard.

The display can include a graphical user interface (GUI) for presenting the codes/information130to the user. The GUI can include, for example, a touch screen or cursor to navigate the GUI and to receive user selections150. The user selections150can be processed to select particular ones of the codes/information130and accept, change, refine, negate, or delete such selections, or to change the hierarchical order in which the codes/information130are presented. User selections145generated from spoken utterances also can be received from the textual input device105. In response to the user selections145,150, updated codes/information can be presented to the user on the display reflecting changes to the codes/information130originally presented. The process can repeat until the user accepts the codes/information130as presented.

Once the user has accepted the codes/information130, a record formatter155can add the codes/information130into a codified record160. The codified record160then can be forwarded to a record repository165. The record repository165can be a component of the record generation system115, or be communicatively linked to the record generation system115in a suitable manner. The record repository165can provide access to the codified record160for purposes of treatment, diagnosis, billing, filling of prescriptions, or any other desired purposes.

FIG. 2is a flow chart illustrating a method200of generating codified electronic records in accordance with another embodiment of the present invention. In step205, a textual commentary can be received from a user. In step210, the textual commentary can be analyzed in real time to identify a plurality of codes, annotations and/or other information (hereinafter codes/information) correlating to attributes contained in the textual commentary. In step215, the identified codes/information can be presented to the user, also in real time.

Referring to decision box220, if a user acceptance of the presented codes/information is received, the process can continue to step255and the codes/information can be added to an electronic record. If, however, the user does not accept the codes/information, the process can continue to decision box step225. If the user does not reject all of the presented codes/information, the process can proceed to step230and a user input can be received to change, refine, negate, or delete the selected codes/information, or to change the hierarchical order in which they are presented. The process then can proceed to step215and the updated codes, annotations and/or other information can be presented to the user. The process can continue until the user accepts the codes, annotations and/or other information as presented.

Referring again to decision box225, if the user rejects all presented codes/information, the method can proceed to decision box235. If the user requests a longer list of codes/information, additional codes/information can be identified, as shown in step240, and presented to the user in step215. If, however, the user does not request a longer list, the method can continue to decision box245. If a manual code entry is received from the user, additional codes/information correlating to the manual code entry can be identified in step250and presented to the user in step215. If a manual code entry is not received, the process can proceed to step215and the originally identified code/information can again be presented.

The present invention can be realized in hardware, software, or a combination of hardware and software. The present invention can be realized in a centralized fashion in one computer system or in a distributed fashion where different elements are spread across several interconnected computer systems. Any kind of computer system or other apparatus adapted for carrying out the methods described herein is suited. A typical combination of hardware and software can be a general-purpose computer system with a computer program that, when being loaded and executed, controls the computer system such that it carries out the methods described herein. The present invention also can be embedded in a computer program product, which comprises all the features enabling the implementation of the methods described herein, and which when loaded in a computer system is able to carry out these methods.

The terms “computer program”, “software”, “application”, variants and/or combinations thereof, in the present context, mean any expression, in any language, code or notation, of a set of instructions intended to cause a system having an information processing capability to perform a particular function either directly or after either or both of the following: a) conversion to another language, code or notation; b) reproduction in a different material form. For example, a computer program can include, but is not limited to, a subroutine, a function, a procedure, an object method, an object implementation, an executable application, an applet, a servlet, a source code, an object code, a shared library/dynamic load library and/or other sequence of instructions designed for execution on a computer system.

The terms “a” and “an”, as used herein, are defined as one or more than one. The term “plurality”, as used herein, is defined as two or more than two. The term “another”, as used herein, is defined as at least a second or more. The terms “including” and/or “having”, as used herein, are defined as comprising, i.e. open language.