JP2003337860A - Medical record entry system, medical record entry method, computer program, recording medium for computer program, medical record entry simulation system - Google Patents

Abstract

<P>PROBLEM TO BE SOLVED: To provide a medical record entry system, a medical record entry method, a computer program, a recording medium for the computer program, and a medical record entry simulation system for realizing the entry of medical treatment records in electronic medical records without interrupting the thinking of a doctor who gives a medical treatment or using any keyboard. <P>SOLUTION: When facts to be written in electronic medical records are uttered by a doctor 3c, the voice signals of the uttered voice are transmitted via a microphone 3c, a doctor's side personal computer 3d, the Internet communication network 2, and a server device 6a to an entry operator side personal computer 9c, and reproduced from the speaker 9b. Then, a medical records entry operator 9a who listens to the reproduced voice converts it into character information by a keyboard, and writes it in an electronic medical records part 6a after the doctor 3c is made to confirm it. <P>COPYRIGHT: (C)2004,JPO

Description

Detailed Description of the Invention

[0001]

BACKGROUND OF THE INVENTION 1. Field of the Invention The present invention relates to a medical chart writing system, a medical chart writing method, a computer program, a recording medium for a computer program, and a medical chart writing simulation system, and in particular, a doctor gives a medical chart while performing medical treatment such as examination of a patient. The present invention relates to a configuration for entering predetermined items by a simple operation.

[0002]

2. Description of the Related Art Conventionally, doctors have summarized medical progress and results in medical charts while or after conducting medical examinations, reading of inspection data, treatments, diagnoses, prescriptions of medicines, etc. Then, it was recorded and saved so that this medical practice could be traced at a later date. Although these medical records have traditionally been in the form of handwritten documents recorded by handwritten characters on a paper medium, on the other hand, according to the progress of IT (Information Technology) technology which is spreading to various places in society. Thus, an “electronic medical record” that electronically records and stores the above medical records is also being used gradually.

In the following, a well-known material, "Home Care Medici", a magazine published by Medical Tribune Co., Ltd.
ne ”2002 February p. 40, what does the above-mentioned“ electronic medical record ”refer to, and what kind of conditions can be treated as a conventional paper medical record? Is explained as follows.

That is, "First of all, regarding the printing / description of medical records on a paper chart by using a word processor or a personal computer, if the responsibility of the doctors who made them is clear,
There has been no particular problem than before. In other words, the former Ministry of Health is 63
On May 6, 2012, each prefecture was notified that "how to write medical records, etc." and the above method was approved. However, this is not a so-called electronic medical record. This is because the point of an electronic medical record is to record and store information as a medical record on an electronic medium instead of paper.

As a standard for storing medical records in electronic media or the like, that is, as a standard for completely using electronic medical records instead of paper medical records, the former Ministry of Health and Welfare
On 22nd of March, we issued a notice to each prefectural governor saying "About storing medical records in electronic media". Incidentally, the term "electronic medium" used here includes not only a medium such as a floppy disk (registered trademark) or an optical disk that can be exchanged and carried around, but also a hard disk and the computer itself.

The standard for electronic medical records presented by the former Ministry of Health and Welfare is
To ensure (1) authenticity, (2) readability, and (3) preservability.

[0007] That is, (1) authenticity is to prevent false input, rewriting, deletion, etc. due to intentional or negligence, and to clarify the responsibility of preparation, and (2) readability is medical record. The contents such as can be printed out as needed and can be easily read with the naked eye. (3) Preservation means that the authenticity and readability described above are ensured and the data is restored within the preservation period specified by law. It is possible to save in a possible state.

As a major premise of (1) authenticity, (2) readability, and (3) storability, which are the standards of the electronic medical record described above, the electronic medical record records and stores digital information from the beginning. Need to save.

For example, even if a conventional medical chart handwritten on paper is read by a scanner and converted into a digital image, it is not recognized as an electronic medical chart. This is because what was originally analog was just digitized. From the viewpoint of the above-mentioned three criteria, this can be interpreted as the fact that the authenticity is not ensured in the process of digitizing the analog one.

The electronic medical record needs to be stored for 5 years like the paper medical record (medical record). Therefore, the physical durability of the electronic medium is required. For example, if you continue to use one floppy disk for 5 years,
Have difficulty. If the floppy disk is stored in a place with high humidity, mold may grow on the surface of the disk and it may not be usable after 5 years.

Therefore, it can be said that it is essential to copy (back up) the data to another electronic medium in consideration of the possibility that the data will be lost during the storage period due to an accident or the like. In this case, if the digital information is copied, the same thing as the original data will be completed. In that sense as well, electronic medical records need to store information that is digital from the beginning.

By the way, it is up to the doctor (self-responsibility) to judge whether or not the above three criteria of the electronic medical record are satisfied.
You can go in. Although the three standards are seemingly strict, it is possible to judge at their own risk whether or not they are cleared. Therefore, the above notification of the Ministry of Health and Welfare can be considered as part of deregulation.

In the above judgment, a "commentary regarding storage of medical records and the like in an electronic medium" by the Medical Information System Development Center of Japan, etc. can be referred to. It is an explanation.

By using an electronic medical record which satisfies the above-mentioned conditions and is regarded as equivalent to the traditional medical record of a paper medium,
As a typical configuration from the past for a doctor to record medical treatment, a personal computer (hereinafter referred to as a personal computer) placed under the doctor who performs the medical treatment, and an electronic medical record entry built in this personal computer It is a system whose main elements are an electronic (including electromagnetic) recording medium, which is a means for embodying a computer program for use and an electronic medical record.

That is, when the doctor examines the patient in the examination room, the result of the examination is the contents of the inquiry, the state and progress of the patient,
In order to enter various findings, treatment plans, etc. in the chart, enter the results of these examinations as characters using the keyboard attached to the above PC, and also see and display the display screen of the monitor attached to this PC. When it is confirmed that the written character string is the same as the result of the medical examination that the user tried to write in the medical chart, the character string is confirmed by performing a predetermined confirming operation, and these character strings are recorded, for example, on an electronic (including magnetic) recording medium. Is recorded on a floppy disk (registered trademark). As a result, this floppy disk is created as an electronic medical record. Further, the character string on which the above-mentioned confirming operation is performed is recorded in a recording means embodied by a hard disk drive device via a network connected to this personal computer, and this recording means may be used as an electronic medical record. The electronic medical chart entry computer program described above may be a dedicated computer program developed for the purpose of filling in an electronic medical chart,
Alternatively, a configuration using a general-purpose word processor program, a spreadsheet application program, or a database application program is also possible.

[0016]

As described above, an electronic medical record, which is a medium for electronically storing medical records,
Also, by using an electronic medical record writing / reading system for recording in this electronic medical record or for reading out the record already recorded in the electronic medical record, the medical record can be saved more reliably and the backup record can also be obtained. It can be easily executed, and the space for storage can be limited, and a medical fee statement (receipt) can be created using the information in the medical record recorded in such an electronic medical record, or online. It is possible to easily reuse the medical record such as using the medical record, and it is possible to improve the convenience in the whole medical work.

However, in the configuration related to the entry of the electronic medical record according to the configuration of the prior art, there are still unsolved essential problems as described below.

(First Problem) That is, the first problem of the conventional electronic medical record entry configuration is that the entry operation operates an information device such as a personal computer, and a doctor who feels inconvenience in operating the information device, The operation of filling in an electronic medical record by using such a structure naturally feels inconvenient, and as a result, the spread of the electronic medical record is hindered.

At present, IT devices represented by personal computers have spread in various places in society, and IT such as office work processing in enterprises has become popular.
It is unthinkable to do without equipment, and it has been reported that more than 30% of households have personal computers.
However, it should be noted that these information devices have only become popular with the general public in the last 10 years or so. Originally, in Japan, which is a kanji culture area, unlike the United States and Europe, keyboard input methods represented by typewriters were not widely used in society. Therefore, it has been pointed out that there are strict layers of resistance and inconvenience in using keyboard means as input means for characters, and in particular, elderly people often feel great resistance to operating a personal computer.

Needless to say, the doctors who practice at clinics have a large proportion of elderly people. Therefore, a large proportion of those who feel resistance to inputting characters using a keyboard occupy a large proportion. Many doctors hesitate to introduce electronic medical charts to the public, which may hinder the spread of electronic medical charts.

(Second Problem) The second problem of the conventional electronic medical record entry configuration is that the operation of entering the electronic medical record interrupts the doctor's thinking, which hinders the efficient and reliable execution of medical care. There is a risk of doing this.

A publicly known material, which is a home page on the World Wide Web, "is a principle of" while doing medical treatment ""
(Http://www.jmcnet.co.jp/siron/siron3.html) has the following description considering the above problems.

That is, "For example, recalling a typical medical treatment scene using a conventional traditional paper chart, first of all, there is a patient to be examined in front of the doctor, and on the desk of the doctor. Shows the above-mentioned paper chart, examination result sheet, referrals from other doctors, charts of patients awaiting medical examination, and the like, and the abdominal roentgen and abdominal CT are posted on Schaukasten.

While diagnosing the patient, the doctor also looks at the X-ray, refers to the test results, confirms the contents of the letter of referral, and also performs thinking work regarding the diagnosis and the test.

Further, the doctor refers to the test result again while writing on the medical chart of the paper, asks a supplementary question to the patient while seeing the referral letter, and verifies whether the diagnostic result given is correct. In addition, the number of other outpatients is checked to adjust the clinical process of today's outpatient clinic.

That is, the doctor starts the diagnosis process while inquiring about the patient and writing the medical record, and while advancing the diagnosis process while taking various findings and re-taking the inquiry if necessary, In some cases, we are proceeding to make a treatment plan. In this way, medical care activities are always carried out in the process of "while",
It is clear that if this "while" is divided, the efficiency becomes poor.

As described above, in the daily medical care activities in which "while" is performed, by performing the character input operation using the keyboard, as in the conventional electronic medical record entry described above. The “while” disruption that occurs greatly impedes the efficiency of medical treatment by doctors. In particular, it is impossible to practice the above-mentioned "while" in a discontinuous work in the writing operation of the electronic medical record (character input by the keyboard is repeated intermittently). On the other hand, in the conventional traditional paper chart, the above continuity is maintained, so there is no such concern.

To carry out a busy outpatient work, such "while" work is necessary and actually effective. In addition, what a doctor is doing "while doing" has a great meaning to keep the psychological distance from the patient as much as possible.

On the other hand, regardless of whether he wants or not, there is anxious patient information in the doctor's head, and he or she is pulling this information regardless of whether he is conscious or unconscious and he is conducting medical treatment. . In order to support such a doctor's behavior pattern, it is necessary to assist the above-mentioned "while", and for that purpose, it is necessary to ensure consistency, continuity, and listability. Is described. "

As described above, in the conventional configuration in which the characters are input using the keyboard to fill in the electronic medical chart, there is a risk of interrupting the doctor's thinking and hindering efficient medical treatment. There was a risk that it would hinder the spread of electronic medical records.

Further, none of the configurations proposed hitherto for solving the above-mentioned first and second problems is an essential solution.

That is, in order to avoid a character input operation using a keyboard, a mouse is provided, and the mouse is operated to perform a click operation of a button on the display screen and a selection operation from a pull-down menu on the display screen. A configuration has been proposed in which an attempt is made to fill out an electronic medical record.
However, medical charts are often described based on doctors' thought processes and empirical rules, and in some cases are not necessarily logical. Therefore, there is a possibility that sufficient description cannot be made only by the operation of selectively inputting characters using the mouse.

Alternatively, as another configuration, a configuration is possible in which a dedicated operator who performs character input operation using the above-mentioned keyboard is arranged in the examination room, and the operator inputs the content uttered by the doctor. To be However, the description of the medical record has a high degree of medical knowledge, and therefore the above operator also needs to be a skilled person having a high degree of medical knowledge. However, it takes a great deal of money to always assign such a skilled person to a medical institution as a full-time employee, and it is difficult to establish such a medically economically.

The present invention has been made in view of the above situation, and is particularly a medical chart entry system for a doctor to enter predetermined matters in a medical chart while performing a medical examination. While collecting the voice of the prescribed matter uttered, converting it into a voice signal and transmitting it via the communication path, and the voice signal transmitted is received via the communication path, The reproducing means to be reproduced below, the character information inputting means for the chart entry operator who listens to the reproduced utterance voice to input and operate the listened predetermined information as character information, and the character information input operation. A writing means for writing to a predetermined electronic medical chart means is provided, and when a doctor executes an utterance, transmission of an audio signal, reproduction of an uttered voice, input operation of character information, and writing of character information are immediately performed. By the medical record entry system characterized by being configured so as to be line,
Even those who feel inconvenience or resistance to keyboard operation can easily perform input operations without feeling inconvenience or resistance, and to ensure consistency, continuity, and list of medical treatment without interrupting the doctor's thinking in medical treatment. The present invention aims to provide a medical chart writing system, a medical chart writing method, a computer program, a recording medium for a computer program, and a medical chart writing simulation system which can promote further spread of electronic medical charts.

[0035]

In order to solve the above problems, the present invention provides a medical record entry system, a medical record entry method, a computer program, and a computer program record having the following configurations (1) to (13). Provide a media and chart entry simulation system.

(1) A medical record entry system for a doctor to enter a predetermined item in a medical record while performing a medical examination action, which collects a voice of the predetermined item uttered by the doctor while performing a medical examination action and outputs a voice. Sound collecting means for converting into a signal and transmitting it via a communication path; reproducing means for receiving the transmitted voice signal via the communication path and reproducing it under a predetermined chart writing operator; The character information inputting means for the medical record entry operator who has listened to the uttered speech to input the predetermined information that has been listened to as the character information, and the character information input and written to the predetermined electronic medical chart means. Writing means, and when the doctor executes the utterance, transmission of the voice signal, reproduction of the uttered voice, input operation of the character information, and writing of the character information are performed. A medical record entry system characterized by being configured so that it can be executed immediately.

(2) Display means for displaying the character information input by using the character information input means so that the doctor can visually recognize it, and the character information displayed by the display means for the electronic medical chart means. It is characterized by comprising: selection means for the doctor to select whether or not to write, and the writing means writes only the character information selected by the selection means to the electronic medical chart means ( 1)
The medical record entry system described in.

(3) The sound collecting means is a plurality of sound collecting means arranged under the plurality of doctors, respectively, and the reproducing means is arranged under a plurality of the chart input workers. Any one of the plurality of reproducing means, which is a plurality of reproducing means, is connected to the communication path, and once receives the audio signal output from any one of the plurality of sound collecting means. The medical chart entry system according to (1) or (2), further comprising a server unit for selectively transmitting to the.

(4) The server unit temporarily stores the doctor information based on the doctor information previously given to each of the plurality of doctors and the medical chart input worker information previously given to each of the plurality of medical chart input workers. The medical chart entry system according to (3), characterized in that a reproducing means for transmitting the received voice signal is selected.

(5) The medical record entry system according to (4), wherein the doctor information and the medical record input operator information include information on a medical care subject to which the medical care action belongs.

(6) The doctor information includes information on the degree of difficulty of inputting the character information by listening to the speech uttered by the doctor, and the medical chart input operator information includes the character information. The medical record entry system according to (4) or (5), characterized in that it includes information on the skill level of the medical record input operator in the input operation.

(7) The connection time when the sound collecting means is connected to the communication path and is capable of transmitting the audio signal, and the reproducing means is connected to the communication path and is capable of receiving the audio signal. At least one of the connection time, the number of characters of the character information written in the electronic medical record unit by the writing unit, and the number of words included in the character information written in the electronic medical record unit by the writing unit. Accordingly, the chart entry system according to any one of (3) to (6), further comprising a billing unit that performs billing calculation for the doctor.

(8) Connection time during which the reproducing means is connected to the communication path and is capable of receiving the audio signal, the number of characters of the character information written by the writing means in the electronic medical chart means, and the writing The means includes a reward calculation means for performing a reward calculation for the chart input worker according to at least one of the number of words included in the character information written in the electronic chart means. The medical record entry system according to any one of (3) to (7).

(9) A medical record entry method for a doctor to enter predetermined items in a medical record while performing medical treatment,
The sound collecting means collects the voice of the predetermined matter uttered by the doctor while performing medical treatment, converts the voice into a voice signal and transmits the voice signal through a communication path, and the reproducing means transmits the transmitted voice. A reproduction step of receiving a signal via the communication path and reproducing it under a predetermined charter operator, and a character information generating means, an input operation of the charter operator who has listened to the reproduced speech sound. According to, a generation step of generating the predetermined item heard by the medical record entry operator as character information, and a writing means, a writing step of writing the generated character information in a predetermined electronic medical chart means, Moreover, when the doctor executes the utterance, the transmitting step, the reproducing step, the generating step, and the writing step are configured to be immediately executable. Medical record entry method, characterized in that it was.

(10) A computer program for causing a computer and / or a computer system to execute each step of the medical record entry method described in (9).

(11) A computer program recording medium in which a computer program for causing a computer and / or a computer system to execute each step of the medical record entry method described in (9).

(12) A medical chart writing simulation system for automatically generating information on the degree of difficulty of the work in the medical chart writing system described in (6), wherein a speech voice uttered by a doctor while performing medical treatment is voiced. First trial transmitting means for converting into a signal and transmitting it via a communication path, receiving the transmitted voice signal, and comparing the words contained in this voice signal with a reference word table stored in advance. Based on the above, a medical record entry simulation system comprising: a difficulty level information generating means for automatically generating information on the difficulty level of the work related to the doctor.

(13) A chart writing simulation system for automatically generating information on the proficiency level of the work in the chart writing system described in (6), wherein the chart input operator performs the character information input operation work. Second trial transmitting means for transmitting a trial voice signal for trial through a communication path, and receiving the transmitted trial voice signal,
Trial reproduction means for reproducing as a trial sound, trial character information generation means for generating trial character information according to an input operation of the chart input operator who listened to the reproduced trial sound, and the generated trial Character information is compared with character information included in the trial voice signal, and skill level information generation means for automatically generating skill level information of the work related to the chart input operator according to the comparison result. A medical record entry simulation system characterized by having.

[0049]

BEST MODE FOR CARRYING OUT THE INVENTION An electronic medical chart writing system and an electronic medical chart writing simulation system, which are preferred examples according to an embodiment of the present invention, will be described below with reference to FIG. FIG. 1 is a block diagram of the electronic medical record entry system of this embodiment.

[Configuration of Electronic Medical Record Writing System] As shown in the configuration diagram of FIG. 1, the electronic medical chart writing system of the present embodiment has a medical institution such as a medical clinic (first medical institution 3, second medical institution). 4, third medical institution 5), electronic medical record preservation institution
6, chart filling worker's house (first chart writing worker's house 7,
Each of the following components arranged in the second medical chart writing worker's house 8 and the third medical chart writing worker's house 9) and the Internet communication network 2 interconnecting these components are provided.

The first medical institution 3, the second medical institution 4, and the third medical institution 5 have the same essential parts, and therefore the description of the first medical institution 3 will be omitted. And the first medical record entry worker's house mentioned above.
7, each of the second medical chart writing worker's house 8 and the third medical chart writing worker's house 9 are common in their essential parts.
This will be represented by the explanation of the third medical chart entry worker's house 9.

First, in the first medical institution 3, the outpatient 3a
Is to be treated by a doctor 3c, such as a medical examination, and the first medical institution 3 has a doctor-side personal computer (hereinafter referred to as a doctor-side personal computer) 3d and a microphone 3c connected to the doctor-side personal computer 3d. It has.

The doctor's personal computer 3d is connected to the internet communication network 2 and the speech of the doctor 3c is sent to the third medical chart entry worker's house 9 side via the internet communication network 2 according to the following procedure. This is a configuration for transmitting information and for the doctor 3c to confirm the character information to be entered in the electronic medical chart, which is sent from the third medical chart entry work company house 9 side. Therefore, the doctor-side personal computer 3d is realized by assembling a general-purpose personal computer with a dedicated computer program for the electronic medical chart entry system. The operation accompanying the execution of this dedicated computer program will be described later in detail.

The microphone 3c collects the utterance voice uttered by the doctor 3c to fill in the electronic medical record and transmits it as a voice signal to the doctor side personal computer 3d. The microphone 3c may use a built-in microphone built in the doctor-side personal computer 3d.

Further, in the electronic medical record storage facility 6, a server device 6a is arranged so that information signals can be transmitted and received between it and the Internet communication network 2.

The server device 6a has an electronic medical record unit and an input / output unit (neither is shown) inside. The electronic medical chart unit and the input / output unit may be software configurations realized by a computer program installed in the server device 6a.

The electronic medical chart section is a recording medium for recording and holding predetermined items to be described in the medical chart by an electronic (including magnetic and optical) method, and is realized by a hard disk drive device, for example.

The input / output unit is (1) information writing / reading control to / from the electronic medical record unit,
(2) Relay control of information transmission / reception between each medical institution 3,4,5 and each medical chart entry worker's home 7,8,9, (3) When a call to start writing an electronic medical record is received from a medical institution In addition, control to select the optimal medical chart entry worker, (4) control to calculate the charge for the electronic medical chart entry work request to the medical institution, (5) to the medical chart entry worker who contracted the electronic medical chart entry work It is for controlling the reward calculation.

It should be noted that the above-mentioned server device 6a is a medical institution 3,4,
Although it is located in the electronic medical record storage organization 6 outside the server 5, a confidentiality agreement, a maintenance contract, etc. are concluded between each medical institution 3, 4, 5 and the electronic medical record storage organization 6, and the server Since the recorded contents of the device 6a and the electronic medical record part inside thereof are stored under the responsibility of each medical institution 3,4,5, the information recorded in this electronic medical record part is the same as a normal paper medical record. It has authenticity. On the other hand, it goes without saying that the server device 6a may be arranged inside each of the medical institutions 3, 4, 5.

[Items to be Described in Electronic Medical Record] The items to be described in the electronic medical record (electronic medical record unit in the server device 6a) included in the system of this embodiment are the same as those in the conventional paper medical record. There is no restriction by doing.

That is, the matters to be described in the conventional paper medical record and also in the electronic medical record of this embodiment are as follows.
(1) Medical record basic items-address, name, sex, age, health insurance information, consultation history, etc. of the person who received medical treatment, (2) basic medical items-disease name, major symptoms, interview results, various findings (examination findings) ,
Examination findings), treatment plan, treatment method (prescription and treatment), patient guidance content, explanation content, medical treatment date, and others.

The electronic medical record used in this embodiment to describe each of the above items is a document file of electronic data configured by the following paging, for example.

(1) First page-chart cover-Address, name, age, gender, health insurance information, risk information (history of allergies, infection risk), disease name, disease name outcome, etc. of the person who received medical treatment.

(2) 2nd page-Medical record items at the first visit-
Basic information about the patient's condition (life history, social history, family history, medical history, allergies, infectious disease, patient's chief complaint, current medical history)
Such.

(3) Page 3 No. 2 Paper (patient records over time, described in chronological order)-(3-
1) Rightmost column-Date, (3-2) Central column (patient medical record)
(Often SOAP (Subjective, Objective, Assessm
ent, Plan) format) Various findings, various evaluations,
Diagnosis progress record, guidance record, treatment-related description, (3-3) rightmost column (mainly instruction book) -medication instruction, inspection instruction, treatment instruction,
Test results, nursing records, instruction implementation information, etc.

(4) 4th page-insurance score description field.

Of course, it is possible to construct the electronic medical chart in a format different from the above.

[Operation of Electronic Medical Record System] Next, the operation executed by this system in order to actually write a medical record using the electronic medical record writing system having the configuration shown in FIG. 1 described above will be described.

(1-Patient visit and entry of basic items) When the patient 3a visits the medical institution 3 and performs the reception procedure,
In the case of the first medical examination, the clerical staff of the medical institution 3 or the nursing staff listen to the contents of the above-mentioned first page to second page, and the listened contents are designated input means (keyboard by the clerical staff or the nursing staff). It is input as character information using a personal computer having a section) and recorded in the electronic medical chart of this patient 3a newly created in the electronic medical chart section in the server device 6a.

(2-Start of medical treatment and establishment of communication channel) Next,
When it is the turn for the patient to be examined, the patient 3a enters the examination room and faces the doctor 3c. The doctor 3c operates the doctor-side personal computer 3d to make a call for connection to the server device 6a in order to fill in the electronic medical chart while examining the patient 3a.

The server device 6a having received the above-mentioned call first analyzes the code included in the call, finds out that the call is made by the doctor 3c, and calculates the charge to the doctor 3c. The timer for performing is started, the electronic medical chart of the patient 3a is read from the electronic medical chart unit, and transferred to the doctor side personal computer 3d.

Further, the server device 6a reads out the information of the medical department to which the doctor 3d belongs from the memory of the input / output unit, and learns that it is mainly specialized in orthopedics, particularly bone diseases, and as a result, , Orthopedics, especially those who are skilled in chart writing regarding bone diseases, and who are skilled in charting and who are currently in standby (see below) Read from the memory and the corresponding person is the third chart entry worker
Know that it is 9a. Therefore, the server device 6a is the third
The personal computer 9c on the worker's side in the chart worker's home 9
To the doctor's computer if you get a reply to the request,
A communication path is established between the 3d, the server device 6a, and the personal computer 9c on the entry worker side so that the electronic chart entry work can be executed.

Here, it is preferable that the medical record entry operator is an experienced medical worker such as a nurse who once retired after working at a hospital. Using this system, these experienced people can perform electronic medical record entry work at home, so valuable ability,
It is important to make effective use of experience and contribute to medical care in general. These chart entry operators connect the entry operator's personal computer to the server device 6a at a predetermined time in a standby state according to a predetermined schedule table,
The work form may be such that the electronic medical record entry work can be performed at any time, or the personal computer of the self-explanation worker can be installed on the server device 6a at any time desired by the medical record entry worker.
It is also possible to disconnect the standby state by connecting this to the standby state and disconnecting this connection when another purpose occurs. On the server device 6a side, all the personal computers on the entry worker side connected to itself are known, and it is possible to select the worker having the most suitable specialty from the entry workers currently in the standby state.

Further, the input / output unit of the server device 6a measures the time during which each personal computer for the data entry operator is connected to the server device 6a and is in the standby state. Based on the measured time, the corresponding medical record entry work is performed. The reward to the person. Alternatively, this reward calculation can be calculated according to the number of characters and the number of words in the electronic medical record entry work described later in detail.

Further, although the chart entry worker has a high degree of specialization, the human rights cost can be kept relatively low because of the convenience of being able to work at home at a desired time, and one chart entry worker can Since it is not dedicated to all doctors, but only when a large number of doctors make a request contact, the work can be performed by a small number of chart entry workers, which also reduces costs. I can.

(3-Speech of entry and reproduction of speech)
Next, the doctor 3c sees the display screen of the doctor's personal computer 3d on which the transferred electronic medical record data of the patient 3a is displayed, knows the information of the patient 3a necessary for medical treatment, and performs a medical examination. . While or after the medical examination, utter a matter to be described in the electronic medical record, for example, "medical prescription, Bonard 10 mg". Doctor using keyboard etc.
Since the 3c does not need to perform character input work, the doctor's 3c thinking can be performed smoothly and efficiently without interruption of the thinking regarding the medical treatment.

The uttered voice is collected by the microphone 3c and converted into a voice signal, and the doctor side personal computer 3d, the internet communication network 2, the server device 6a, the internet communication network.
After being passed through 2, the data is delivered to the personal computer 9c on the input operator side. The voice signal is delivered in packets, and immediately after the utterance, in real time. Input operator's computer
The voice signal reaching 9c is reproduced by the speaker 9b, and the utterance voice "Yakuzashohou, Bonarujumigurumimu" is emitted so that the chart entry worker 9a can listen.

(4-Generation of Character Information and Filling in Electronic Chart) Chart writing operator 9a who listens to the above speech
Is able to understand that the utterance "Bonaru" contained in the above-mentioned utterance is a drug "Bonard" that exerts an effect on osteoporosis, because of its high degree of expertise. Then, using the keyboard attached to the personal computer 9a on the entry operator side, input "medicine prescription, Bonard 10 mg" to execute the transmission procedure. According to this procedure, the character information input and operated as described above is packetized and reaches the doctor side personal computer 3d via the input operator side personal computer 9c, the internet communication network 2, the server device 6a and the internet communication network 2.

The doctor's personal computer 3d displays the arrived character information "medicine prescription, Bonard 10 mg" on the attached display screen. Doctor 3c sees the above text information displayed,
If the item is the same as the item for which the user has made an input instruction, the user performs a final selection operation. Then, the input / output unit performs an execution operation so that this character information is written in the electronic medical record unit in the server device 6a.

On the other hand, when the character information different from the item designated by the doctor 3c is displayed, the doctor 3c executes the correction request operation. This correction request signal is displayed on the display screen of the personal computer 9c on the entry operator side, so that the chart entry operator 9a inputs character information again to correct the error, or the doctor 3c speaks again. By doing so, it is possible to prompt an input operation of correct character information.

By repeating the input operation as described above, the doctor 3c can fill in the electronic medical record without interrupting the thinking concerning the medical treatment, so that the medical treatment efficiency is improved and the character input operation is performed by using the keyboard. Since even a doctor who feels discomfort in performing the procedure can fill in the medical record without feeling this distress, it is possible to remove the factor of popularization of the electronic medical record in the present embodiment.

(5-End of Electronic Medical Record Entry) After the above-described operation is repeated, when an item to be entered in the electronic medical record is entered, the doctor 3c performs a predetermined ending operation. Then, the end signal reaches the input / output unit of the server device 6a from the doctor side personal computer 3d through the internet communication network 2. The input / output unit stops the above-mentioned timer for billing, generates billing information for this session, and makes it available for issuing a bill. In addition, the input / output unit is the doctor's computer 3
d, disconnecting and opening the communication path to the internet communication network 2, server device 6a, internet communication network 2, input operator side personal computer 9c to make it ready for the next session, and a series of electronic medical chart entry procedures finish.

As a method for calculating the charge to the doctor, in addition to the connection time of the doctor side personal computer 3d described above, the connection time of the input operator side personal computer 9c, the number of characters of the items entered in the electronic medical chart, and the same number of words are used. The charging calculation may be performed based on this.

(Electronic Medical Record Entry Simulation System) The electronic medical record entry system of the present embodiment described above holds the specialized area of the doctor as data in advance, and selects a medical record entry operator having the same specialty to make sure medical record entry. The point that the work can be carried out is as described above.

On the other hand, as a point to select an optimum operator for writing a medical record, in addition to the matching of specialties, the doctor side receives the utterance and generates the character information (level of specialization, etc.). ), Etc., similarly, on the side of the chart entry operator, there is a degree of proficiency in the work of listening to the utterance of the doctor and generating character information (high degree of specialization, etc.).

To measure these difficulty levels and proficiency levels,
It may be considered that a specialized evaluator evaluates the actual work of writing the chart, but on the other hand, by partially changing the configuration using the system of this embodiment, the evaluation is automatically performed without human intervention. The configuration can be easily realized.

That is, first, in the first medical record entry simulation system for measuring (evaluating) the difficulty level on the doctor side, a difficulty level evaluation device (not shown) connected to the Internet communication network 2 is provided, and the same procedure as above is performed. The difficulty level evaluation device that has received the utterance voice uttered in step 1 refers to a word table prepared in advance, and determines the degree of expertise of this doctor from the vocabulary of words included in the utterance of this doctor. It is possible to evaluate and use this to measure the degree of difficulty.

Similarly, the second medical chart writing simulation system for measuring (evaluating) the skill level of the medical chart writing operator has a test signal transmitting device (not shown) connected to the Internet communication network 2, A test voice based on the test voice signal emitted from this test signal transmitting device is emitted from the speaker of the chart entry worker's house in the same procedure as above, and the chart entry worker who is evaluated receives the text information. The input operation is performed, and the character information is returned to the test signal transmitting device. The test signal transmitting device that received the reply compares the character information included in the original test voice signal with the character information included in the above reply signal, and evaluates according to the degree of agreement. You can measure the degree.

[0089]

As described above, the present invention is a medical record entry system for a doctor to enter a predetermined item in a medical record while performing a medical examination, and a voice of the predetermined item spoken by the doctor while performing the medical examination is recorded. Sound collecting means for collecting sound, converting it into a voice signal and transmitting it via a communication path, and reproducing means for receiving the transmitted voice signal via the communication path and reproducing it under a predetermined chart writing operator. A character information inputting means for a medical record entry operator who listens to the reproduced utterance voice to input the listened predetermined information as character information, and a writing for writing the input operated character information to a predetermined electronic medical chart means It is configured such that when the doctor performs a utterance, the voice signal transmission, the reproduction of the utterance voice, the input operation of the character information, and the writing of the character information can be immediately executed. Special By adopting a medical record entry system, even those who feel inconvenience and resistance to keyboard operation can easily perform input operations without feeling inconvenience and resistance, and consistency of medical care without interrupting thinking of doctors in medical practice , Continuity and listability can be secured,
As a result, it is possible to provide a medical chart writing system, a medical chart writing method, a computer program, a recording medium for a computer program, and a medical chart writing simulation system that promote the further spread of electronic medical charts.

[Brief description of drawings]

FIG. 1 is a configuration diagram of an electronic medical record entry system which is a preferred example of an embodiment of the present invention.

[Explanation of symbols]

1 Electronic chart writing system (chart writing system) 2 Internet communication network (communication path) 3 First medical institution 3a Patient 3b Doctor 3c Microphone (sound collecting means) 3d Doctor's personal computer (sound collecting means, display means) 6 Electronic chart Preservation organization 6a Server device (server part, electronic chart means, writing means) 9 Electronic chart entry house 9a Electronic chart entry operator (chart entry operator) 9b Speaker (playback means) 9c Writing person side personal computer (character information input) Means, playback means)

Claims (13)

[Claims] 1. A medical record entry system for a doctor to enter a predetermined item in a medical record while performing a medical examination, wherein a voice signal of the predetermined item uttered by the doctor while performing the medical examination is collected to obtain a voice signal. Sound collecting means for converting to and transmitting via a communication path, and receiving the transmitted audio signal via the communication path,
Reproduction means for reproducing under a predetermined chart record operator, and character information input for the chart record operator who listens to the reproduced speech sound to input and operate the predetermined matter that is heard as character information. Means and writing means for writing the input-operated character information in a predetermined electronic medical chart means, and when the doctor executes the utterance, transmission of the voice signal, reproduction of the uttered voice, and A medical record entry system, which is configured such that an operation of inputting character information and a writing of the character information can be executed immediately. 2. Display means for displaying character information input and operated using the character information input means so that the doctor can visually recognize it, and writing the character information displayed by the display means into the electronic medical chart means. Selection means for the doctor to select whether or not, and the writing means writes only the character information selected by the selection means to the electronic medical chart means. The chart entry system described in 1. 3. The sound collecting unit is a plurality of sound collecting units respectively arranged under the plurality of doctors, and the reproducing unit is a plurality of reproductions arranged respectively under the plurality of medical record input workers. Means and connecting to the communication path,
It is characterized by further comprising a server unit for temporarily receiving the audio signal output from any one of the plurality of sound collecting means and selectively transmitting the received audio signal to any one of the plurality of reproducing means. The medical record entry system according to claim 1 or 2. 4. The server unit, based on doctor information previously given to each of the plurality of doctors and medical record input operator information previously given to each of the plurality of medical chart input workers, receives the temporary reception. 4. The medical chart entry system according to claim 3, wherein a reproducing means for transmitting the generated audio signal is selected. 5. The medical chart entry system according to claim 4, wherein the doctor information and the medical chart input operator information include information on a medical treatment subject to which the medical treatment action belongs. 6. The doctor information includes information on the degree of difficulty of an operation of inputting and operating the character information by listening to a speech uttered by the doctor, and the medical chart input operator information inputs the character information. 5. The information including the skill level of the chart input operator in the operation to be operated is included.
Alternatively, the medical record entry system according to claim 5. 7. A connection time during which the sound collecting means is connected to the communication path and is capable of transmitting the audio signal, and a connection time during which the reproducing means is connected to the communication path and is capable of receiving the audio signal. Depending on the amount of time, at least one of the number of characters of the character information written in the electronic medical record unit by the writing unit, and the number of words included in the character information written in the electronic medical record unit by the writing unit. The medical chart entry system according to any one of claims 3 to 6, further comprising: a billing unit that performs billing calculation for the doctor. 8. A connection time during which the reproducing unit is connected to the communication path and is capable of receiving the audio signal, the number of characters of character information written by the writing unit into the electronic medical chart unit, and the writing unit. Is provided with a reward calculation means for performing a reward calculation for the chart input worker according to at least one of the number of words included in the character information written in the electronic chart means. The medical record entry system according to any one of claims 3 to 7. 9. A medical record entry method for a doctor to enter a predetermined item in a medical record while performing a medical examination, wherein the sound collecting means collects a voice of the predetermined item uttered by the doctor while performing the medical examination. A transmitting step of sounding, converting into a voice signal and transmitting the voice signal via a communication path; and a reproducing means receiving the transmitted voice signal via the communication path and reproducing the voice signal under a predetermined charter operator. The reproducing step and the character information generating means generate, as character information, the predetermined item heard by the medical chart writing operator in response to an input operation of the medical chart writing operator who has listened to the reproduced speech. And a writing step in which the writing means writes the generated character information in a predetermined electronic medical chart means, and when the doctor executes the utterance, the transmission scan is performed. -Up and, and the regeneration step, said generating step, medical record entry method, characterized in that said writing step is configured to immediately executable. 10. A computer program for causing a computer and / or a computer system to execute each step of the medical record entry method according to claim 9. 11. A computer program recording medium in which a computer program for causing a computer and / or a computer system to execute each step of the medical record writing method according to claim 9. 12. A medical chart writing simulation system for automatically generating information on the difficulty level of the work in the medical chart writing system according to claim 6, wherein a voice signal is a uttered voice uttered by a doctor while performing medical treatment. A first trial transmitting means for converting to and transmitting via a communication path, receiving the transmitted voice signal, and comparing the words contained in this voice signal with a reference word table stored in advance. Based on the difficulty level information generating means for automatically generating information on the difficulty level of the work of the doctor. 13. A chart writing simulation system for automatically generating information on the proficiency level of the work in the chart writing system according to claim 6, wherein the chart input operator tries the character information input operation work. For transmitting a trial voice signal for communication via a communication path
Trial transmission means, trial reproduction means for receiving the transmitted trial voice signal and reproducing it as trial voice, and trial according to the input operation of the chart input operator who listened to the reproduced trial voice. Trial character information generating means for generating character information, and the generated trial character information is compared with the character information included in the trial voice signal, according to the comparison result, the medical chart input operator A medical record entry simulation system, comprising: a proficiency level information generating means for automatically generating the proficiency level information of the work.