Abstract:
A system of creating and maintaining medical records provides a central monitoring system for a patient-care facility. The system can include a real-time medical charting interface for consistent and objective patient data entry and logging the time identification of patient data entry. The interface can display real-time objective data and can include a first menu of first charting categories; a second menu populated with keywords based upon the charting category selected from the first menu; and a third menu populated with values for the keyword selected from the second menu. The menus can be concurrently presented for data entry allowing efficient charting of the patient&#39;s condition. Patient data can be digitized to be distributed on a network.

Description:
BACKGROUND OF THE INVENTION  
       [0001]     Manual data capture in the medical field has, in the past, been known to suffer shortcomings. Thus, computer-based patient record data collection systems have been proposed to solve certain of the manual data capture shortcomings. Yet the ease of use of such systems and their limited utility is often cited as the major stumbling block to computer-based patient record adoption. Current computer-based patient record systems can be too complicated, too restrictive, or too slow to be used effectively by many caregivers. Some computer-based patient record systems may require that the time-constrained caregivers learn separate operating methods or may require training on the computer systems to obtain adequate results from the system. Further, not all necessary patient information may be available through a single interface.  
         [0002]     Known computer-based patient record systems fall into several categories including those that focus on capturing structured data through the use of pick lists, those that rely on text generated by dictation and/or automated speech recognition, and those that attempt to combine both methods. There can be limitations for each known system. Some known systems use a point-and-click input method for data entry into structured data computer forms. Some systems allow for dictation of free text and subsequent transcription. Many systems require extensive training of the caregivers, the computer system, or both. Thus, known systems for the capture of the necessary data can be cumbersome and can slow office production.  
         [0003]     Thus, there remains a need for a computer-based patient record system which requires little to no training on the part of the caregivers and is fast, accurate, and conveniently usable, and which provides all necessary patient data to the user. A system for generating medical charts should desirably be fast enough to be real time or near real time (hereinafter simply referred to as “real time”) in order to allow for review of the data intake and possible decision support during the time the patient is in need, especially in such fields as perinatal care. Further, the system should desirably effectively utilize the captured data to reduce costs within, and provide information about, the medical care delivery system. Time spent by healthcare personnel generating, analyzing, and retrieving a patient&#39;s records should desirably be reduced. Errors in record generation and data retrieval should desirably be reduced.  
       SUMMARY OF THE INVENTION  
       [0004]     The present invention provides solutions to the above discussed shortcomings in the known art. The present invention recognizes that, within a discipline, the vocabulary may be limited and segmented into indentifiable and objective groupings. Thus, the present invention may utilize such limitations and segmentations of vocabularies to provide objective, consistent, quick, and efficient charting. The present invention can further provide data entry uniformity leading to better medical practice through the enforcement of objective criteria in the data gathering process.  
         [0005]     In one aspect of the present invention the data capture is effectively addressed by allowing the caregivers to follow a set of categories, keywords and values expressed as details in drop down menus which are automatically called up and populated by the preceding choice of the caregiver who is doing the charting. The present invention can reduce or eliminate training by creating a menu driven system for accurately and quickly standardizing and recording care-giving routines including diagnostic data gathering. Desirably, the system can be used throughout the care-giving process to maintain consistency and objectivity. Data capture for a medical chart can be addressed through a combination of electronic monitoring equipment and caregiver observations recorded in a patient chart. Each mode of data can be captured digitally and combined in manners efficacious to the treatment of the patient. Desirably the system can provide detailed records of the care-giving process, including time of patient monitoring and care and the identification of the caregiver.  
         [0006]     Medical chart generation for a particular area of care, e.g., perinatal care, generally follows a set pattern. For example, there can be a fairly standard list of categories for caregiver activity. Each activity category will have a characteristic vocabulary defined by keywords. Within the context of each keyword a variety of defined values will exist which must be charted. For example, the context of perinatal assessment will have a characteristic diagnostic category such as Uterine Contractions (UC) Evaluation. Selection of the UC diagnostic category on a first menu of an I/O charting interface by a user, i.e., caregiver, at a workstation will call up a second menu of a characteristic list of details, or symptom keywords, dealing specifically with UC assessment, e.g., contraction intensity. Selection of the contraction intensity symptom keyword will call up a third menu of a characteristic list of value categorizations, be it types, ranges, or the like, e.g., in the case of contractions, from absent through strong. Selection and charting may thus be done very efficiently on an I/O device with light pen, touch pad, mouse or the like. Desirably each of the category, keyword, and value entry menus remain accessible on one screen of the I/O interface for providing the caregiver easy accessibility and awareness of the charting functions.  
         [0007]     In some embodiments the category selection may pertain to the entire care-giving process including admitting and discharge of the patient. Desirably, each section of the charting function may be arranged for ease of use, such as by frequency of occurrence or use of the category or keyword or value. The charting functions may further be arranged to accommodate, and be updated to account for, changes in legal and/or medical standards. Intelligent selection and arrangement of the category, keyword, and value menus can provide broad charting functionality while capturing all necessary details of the care-giving.  
         [0008]     Once the data is captured electronically and digitized it can be distributed for availability throughout the system such as by a connection through a network switch to various servers and peripherals, including the I/O interfaces used for charting. 
     
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       [0009]      FIG. 1  is a schematic illustration of a perinatal patient monitoring system according to one embodiment of the present invention.  
         [0010]      FIG. 2  illustrates aspects of the charting function of one embodiment of the present invention.  
         [0011]      FIG. 3  illustrates aspects of the charting function of one embodiment of the present invention.  
         [0012]      FIG. 4  illustrates aspects of the charting function of one embodiment of the present invention. 
     
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS  
       [0013]     Discussion of the sections or parts of the exemplary embodiment will be given herein with respect to specific functional tasks or task groupings that are in some cases arbitrarily assigned to the specific sections for explanatory purposes. It will be appreciated by the person having ordinary skill in the art that a system according to the present invention may be arranged in a variety of ways, or that functional tasks may be grouped according to other nomenclature or architecture than is used herein without doing violence to the spirit of the present invention.  
         [0014]     Referencing  FIG. 1 , a medical chart generating system  11  is shown. The system  11  is shown in the exemplary form of a perinatal patient monitoring environment although it will be realized by the person having ordinary skill in the art that other applications are readily adaptable to, and can exist within, the spirit of the present invention. In general, the system  11  can include a data management section  13  including a database  15  containing a roster of patients and further including a fixed, i.e., nondynamic, data storage device such as the optical server  16  connected to the system  11  through a network switch  22  and having redundant optical drives, collectively  18 . Database management and applications may be obtained through a database/applications server  20  connected to the system  11  through the network switch  22 . Peripherals for remote access to the system  11 , such as a modem  24  for sending patient data and receiving remote diagnostics from offsite monitors or physicians may further be connected to the database/applications server  20 .  
         [0015]     The system  11  can further include the functionality of a bedside workstation  17  enabling the entry or selection, or both, (hereinafter simply referred to as “entry,” “entering” and forms thereof) of a patient record from the roster and having an interactive, real-time medical charting I/O interface accessed through the workstation  17  as illustrated by the component keyboard  19  and screen  21 . The workstation  17  may accept direct or indirect input from various patient monitoring devices such as a non-invasive blood pressure monitor  23  or a fetal monitor  25 .  
         [0016]     The system  11  can further include the functionality of a surveillance section  26  whereby patient data may also be gathered without direct access to a workstation  17  through the use of a data acquisition unit  27  which may, e.g., be constructed and arranged to accept analog signals from a plurality of fetal monitors, collectively  29 , and digitize the signals before providing them to a surveillance server  31  for further availability in the system  11  such as by the illustrated connection through the network switch  22 . Alternatively, the fetal monitors may directly output data in digital form. One example of such further availability is illustrated by providing the data from fetal monitors  29  to a multiplexing video processor  33  which provides signals for display of the fetal monitor data to display screens, collectively  35 , located remotely from the patient and fetal monitor  29 , such as at nurses stations or doctor lounges, or the like.  
         [0017]     Patient management functionality may further be provided by non-bedside workstations  37 ,  39  located remotely from the patient and located, e.g., at a nurses station and a medical records review station, respectively, and connected to the system  11  through the network switch  22 . It will be noted that peripherals, such as the fax modem  41 , secondary display screen  43 , and printer  45  connected to the workstation  37 , and the optical drive  47  connected to workstation  39 , may be provided within the system  11 , as necessary or desired. Likewise, a variety of peripherals for remote communications including the output or the input of data, such as a printer  49 , internet firewall  51 , web server  53 , and wireless communications apparatuses, collectively  55 , may be located throughout the system  11  and be provided with access to system resources through the network switch  22 .  
         [0018]     The database  15  may be controlled by a database management program such as a commercial SQL software package, e.g., MICROSOFT SQL 2000, and can provide the ability to manage the data through applications such as the .NETREPORTINGTOOL from ScriptLogic Corporation of Boca Raton, Fla., for notes charting. Further, once data has been transformed into any XML format it can be easily pushed and pulled into various other applications, including MICROSOFT OFFICE applications or the like. Appropriate computer hardware and software for the given system installation will be understood to be within the ordinary skill in the art.  
         [0019]     The database/applications server  20  includes an Application Server software module for transaction processing and which is the access point for all data and communication to process, validate, approve, and log all requested transactions with the database from client workstations. A patient manager software module will provide a user interface for the management of patient data. Each entry or action of the care-giving process can be logged and/or charted with a time stamp and caregiver identification. Desirably, system access and user identification may be controlled through a secure login procedure such as a private password or the like. A communication software module within the database/applications server  20  allows all applications to communicate with the database/applications server  20 . An optical server software module will manage the optical server  16 , the optical disks  18 , and the archived information thereon including status and repair of the optical storage disks and associated indexing. It will be understood that optical disks are merely representative of a fixed data storage medium and that the fixed data storage functionality is not limited to optical disks.  
         [0020]     Within the appropriate computer hardware comprising the bedside workstation  17  and the patient management workstation  37  will be the appropriate communications software module, a forms software module, as further discussed below with respect to  FIG. 2 , a digital interface manager software module to allow the digital capture of objective fetal and maternal information, and a surveillance manager software module which allows the display of patient or fetal trace strip chart information and a patient status information display in the form of a board showing the status of multiple patients within the healthcare facility.  
         [0021]     Within the appropriate computer hardware comprising the surveillance server  31 , the surveillance manager software module will also allow the display of fetal monitor trace information in a real time format and display of the patient status board on any connected display device and will further provide audible alerts of system malfunction or patient distress if necessary. A monitor I/O software module within the surveillance server  31  will gather fetal monitor information from the data acquisition unit  27  and forward the information to database/applications server  20  for storage until the data is archived. The data acquisition unit  27  may function as an amplifier, data sampler, A/D converter, and computer interface, as necessary. A corresponding communication software module within the surveillance server  31  will allow applications to communicate back to the database/applications server  20 .  
         [0022]     Remote access to the system  11  may be obtained through the Internet by either of browser based access or application based access and may utilize virtual private networks or secure web site access. The web server  53  may likewise include the appropriate patient manager software module and communication software module for the database/applications server  20  and further include a surveillance manager software module for the display of patient or fetal trace strip chart information and status board information.  
         [0023]     Referencing  FIG. 2 , an interactive, real-time medical charting I/O interface  57  for a user, i.e., caregiver, accessed through a workstation, e.g.,  21  ( FIG. 1 ), is shown. Operationally, a touch screen, mouse, light pen, or the like may be used to chart a patient&#39;s condition through use of the interactive interface  57 . It will be appreciated that a workstation  21  may in some instances be substantially equivalent to all the functionalities of an I/O interface for the system  11 . The interface  57  includes a selectable first menu  59  having a plurality of first details, e.g., care-giving activities or patient condition categories. A second menu  61  is provided with second details  66 , i.e., keywords relevant to the first menu category, such as keywords defining the patient condition or symptoms. A third menu  65  with third details  68 , i.e. values, defining or quantifying the selected second detail  67  from the second menu  61  is provided. The second menu  61  appears and is automatically populated upon selection of the first detail  63  from the first menu  59 . The third menu  65  appears and is automatically populated upon selection of the second detail  63  from the second menu  61 .  
         [0024]     In  FIG. 2 , a diagnostic category, i.e., first detail  63 , of “UC (uterine contraction) Evaluation” is selected from the first menu  59  by the caregiver. The second menu  61  then appears on the graphic interface  57  pre-populated with selectable keywords, i.e., second details  66 , related to the category of “UC Evaluation”  67 . In the illustrated case, the detail  67  of “UC Eval” is selected by the caregiver and the third menu  65  then appears on the graphic interface  57  pre-populated with selectable third details  68 , i.e., intensity values representing a standard evaluation scale related to a UC Eval, for selection by the caregiver to complete a UC charting. Time of entry and caregiver identification for any or all parts of the charting and/or caregiver activity can be automatically date-stamped in real-time into the computerized medical chart compiled from all patient details or data gathered by the system. Further, a window  69  showing additional data, here a real-time fetal monitor strip chart trace  71 , can be displayed simultaneously with the charting menus  59 ,  61 ,  65  selected by the caregiver.  
         [0025]     In  FIG. 3 , a category, i.e., first detail  75 , of “Resuscitation” is selected from the first menu  77  by the caregiver. The second menu  79  then appears on the graphic interface  57  pre-populated with selectable keywords, i.e., second details  81 , related to the category of Resuscitation  75 . In the illustrated case, the detail  83  of “Stabilization” is selected by the caregiver and the third menu  85  then appears on the graphic interface  57  pre-populated with selectable third details  87 , i.e., values representing a standard list of care-giving activities related to a Stabilization, for selection by the caregiver to complete a Resuscitation charting. Time of entry and caregiver identification for any or all parts of the charting activity can be automatically recorded in real-time into the computerized medical chart compiled from all patient details or data gathered by the system.  
         [0026]     In  FIG. 4 , a category, i.e., first detail  87 , of “Medications” is selected from the first menu  89  by the caregiver. The second menu  91 , shown in an unexpanded state, then appears on the graphic interface  57  pre-populated with selectable keywords, i.e., second details, related to the category of Medications  87 . In the illustrated case, the caregiver has selected the detail  93  of “Blood Products” from the second menu  91  and the third menu  95  has appeared on the graphic interface  57  pre-populated with a plurality of selectable value menus including the medication name  97 , the value amount  98  and units  99  of the medication, the rate of administration  101 , the site of the administration  103 , and the route of the administration  105 , which have been charted by the caregiver.  
         [0027]     In each instance all selectable menus remain accessible and visible on the I/O device, or graphic interface  57  for efficient charting and switching between or among menus. The present invention thus provides a means of quickly and efficiently creating a medical chart and supplying the chart information to a variety of locations and functionalities throughout the system.  
         [0028]     The person having ordinary skill in the art will appreciate that there has been described an exemplary embodiment. It will recognized that many of the functionalities described herein can be accomplished by a variety of computer hardware, firmware, and software; methods and apparatus within the scope of the present invention. Having thus described the present invention, it will be appreciated that many variations thereon will occur to the artisan upon an understanding of the present invention, which is therefore to be limited only by the appended claims.