JP6820528B2 - Electronic medical record system - Google Patents

Description

The present invention relates to an electronic medical record system that manages clinical disease names input to electronic medical records and the like.

When a doctor examines a patient, it is required to record the result of the examination such as what kind of drug was prescribed, what kind of treatment was taken, what kind of disease name, etc. in an electronic medical record. .. When a doctor records a disease name in an electronic medical record, since the electronic medical record is a record of a medical examination, it is originally required to record the disease name that actually reflects the patient's condition.

The information recorded in the electronic medical record is roughly divided into "medical record description" information and "ordering" information. The information in the "medical record" is the information when the doctor examined the patient, and generally, the chief complaint, current medical history, medical history, oral medication, etc. heard from the patient, as well as the result of the examination by the doctor, It includes information such as the name of the clinical disease determined, findings, and course. In addition, "ordering" information is information on the contents of instructions given to medical staff such as nurses and pharmacists by doctors, such as treatments and tests for patients, and prescription drugs. The treatment and examination for this patient is the implementation treatment, and the information on the drug to be prescribed is the implementation prescription. The chief complaint is a complaint of symptoms by a patient, and the current medical history is information indicating when and how the chief complaint started and how it has progressed, and is information accompanying the chief complaint. .. Findings are information that indicates the views of the doctor who examined the patient, progress is information that indicates what kind of treatment or prescription was given to the patient, and medical history is the patient's past medical history. Yes, oral medications indicate the medications that patients are taking on a regular basis.

In Japan, it is common to have medical insurance. In insurance medical treatment, the name of the insurance disease corresponding to the treatment and prescription is recorded, and the medical fee is billed based on the treatment, prescription, and insurance disease name. This medical fee billing is made based on the information of "ordering" in the electronic medical record. Therefore, in the "ordering" information of the electronic medical record, there is an input field for the purpose of recording the insurance disease name, and the doctor must record the insurance disease name there. As a result, the name of the patient's disease for which a record is surely recorded on the electronic medical record becomes this insurance disease name.

However, this insurance disease name is far from "a disease name that accurately reflects the patient's condition (clinical disease name)" (a disease name that the doctor recalled to be optimal for the patient's condition and included in the medical record). There are also many.

For example, when a doctor prescribes an analgesic drug to an outpatient, regardless of the actual patient's disease name (clinical disease name), it is covered by insurance, so all the insurance disease names are recorded as "backache" or an electrocardiogram. Regardless of the clinical disease name, "arrhythmia" is recorded as an insurance disease name in all the patients examined.

In addition, in the case of a patient with a long course, the insurance disease name corresponding to each treatment or examination is recorded in the electronic medical record, so that the insurance disease name may exceed 100 disease names. Therefore, it is not easy to immediately determine which is the clinical disease name that is the actual disease name of the patient just by looking at the list of insurance disease names written in the electronic medical record.

On the other hand, from the doctor's point of view, it is sufficient to know the clinical disease name for the patient's examination, so the patient's clinical disease name is in the doctor's memory or in the free text of "medical record description" in the electronic medical record. It is enough if it is recorded as a memorandum inside. For this reason, the list of disease names (clinical disease names) is often not properly recorded on electronic medical records.

This is specifically shown in FIGS. 9 and 10. FIG. 9A is an example of a part of the record described in the medical record of the electronic medical record for a certain patient. FIG. 9B is an example of an implementation treatment and / or an implementation prescription (hereinafter referred to as “implementation treatment / implementation prescription”) recorded in the ordering information of the electronic medical record of FIG. 9A. Further, FIG. 10 is a table showing disease names (indication disease names) to which insurance medical treatment can be applied to the implementation treatment / implementation prescription. The performed treatment indicates the treatment or test performed on the patient, and the performed prescription indicates the drug prescribed to the patient. The unit price for insurance medical treatment is set for each treatment / prescription, and is the information that is the basis for claiming medical fees.

As mentioned above, in Japan, it is premised that insurance medical treatment is performed, so the doctor will appropriately select the name of the disease from among the names of the indicated diseases according to the treatments and prescriptions that the doctor has given to the patient. Insurance disease name) will be selected and recorded. Therefore, in the case of the patient shown in FIG. 9, although the disease name "shingles" is clinically the main disease name, on the record of the actual electronic medical record, the electrocardiogram and chest X-ray are used as the treatment / prescription. Since each test was performed and Loxonin tablets, Baltrex, and Methicobal were prescribed, for each treatment / prescription, "arrhythmia suspected", "pneumonia suspected", "chest pain", "shingles", "shingles" "Vitamin B12 deficiency" etc. will be recorded as the name of the insurance disease. Therefore, even a doctor cannot immediately determine that the patient's main clinical disease name is "shingles" just by looking at this insurance disease name, and if there is only a list of insurance disease names, there is nothing in medical research. It is not useful information.

If you check in detail the part of the free text in the information in the medical record of the electronic medical record (Fig. 9), you can understand that shingles is in mind, but unless you do that, you will be able to understand the name of the clinical disease. difficult.

In this way, it is not easy to infer an appropriate clinical disease name from the information on insurance disease names, treatments, and prescriptions that are structured and accumulated in electronic medical records, and in order to know the clinical disease names, medical treatment of electronic medical records It is necessary to read back the information in the medical record in detail.

Currently, regional medical records that share patient information among multiple hospitals in the region and PHR (Personal Health Record) projects are being carried out, but the clinical disease name is not recorded as explicit information in the electronic medical records, or Since it is recorded only as a memo, in these systems, in addition to the patient's own personal information, the prescribed medicines and treatments, the contents of the test results, etc. are only shared, which is essentially the most important medical treatment. Information on clinical disease names is not shared. This is because, due to the above-mentioned circumstances, even if the insurance disease name is shared, it is almost meaningless for grasping the patient's medical condition, and the clinical disease name is often not explicitly recorded in the electronic medical record. Based on the reason.

In this way, in the conventional electronic medical record, the insurance disease name is the center, and the clinical disease name is not provided with an input field to be explicitly recorded, and is treated as a secondary treatment. Of course, the insurance disease name is an indispensable disease name when claiming medical fees in insurance medical treatment, so from the viewpoint of medical fee billing, it is important information on the electronic medical record and must be recorded. However, it is natural that clinical disease names are important from the viewpoints of clinical work and medical research, and from the viewpoint of sharing disease name information on a regional or individual basis.

As described above, although the management of clinical disease names is essentially required in electronic medical records, the actual electronic medical record system does not provide an input field for clinical disease names. Therefore, for example, as in Non-Patent Document 1 below, an attempt is made to describe a clinical disease name in an electronic medical record.

Nikkei Digital Health, "Electronic problem list as the core of cooperation information", [online], Internet <URL: https://tech.nikkeibp.co.jp/dm/atcl/event/15/062600168/072300004 /? ST = health & P = 3 ＞

Even in an electronic medical record system provided with a column for managing clinical disease names as in Non-Patent Document 1 described above, it is essential to record the insurance disease name in order to claim medical fees for insurance medical treatment. Therefore, in addition to the input of the insurance disease name, the clinical disease name (“problem list” in Non-Patent Document 1) is input. The clinical disease name can be managed by using this system, but on the other hand, the doctor who inputs the electronic medical record must input both the insurance disease name and the clinical disease name. However, since the insurance disease name is recorded in the input field for the disease name that is essential for the electronic medical record, it is complicated for a busy doctor who performs clinical work to input the clinical disease name in addition to the insurance disease name. Is. In particular, it is extremely complicated for doctors who examine patients in the emergency or acute phase who are competing for one second. Therefore, in the case of a system that forces such double input, the problem that information is not sufficiently collected naturally occurs. For this reason, general electronic medical records do not have a clinical disease name input field in addition to the essential insurance disease name input field.

In addition, young doctors and medical clerks may enter the name of the insurance disease, but this can only be done by a medical institution with well-equipped personnel and systems, and not necessarily at any medical institution. In addition, government agencies require that the records of insurance disease names and their management be performed by doctors.

In this way, when requesting a doctor to record a clinical disease name using an electronic medical record system, in order to manage the clinical disease name for information sharing, etc., an input field for the clinical disease name is provided in the electronic medical record system, and the clinical disease name is input there. Will be asked from the doctor. However, since it is necessary to input the insurance disease name, which is essential information for medical fee billing in insurance medical treatment, it is necessary to input both the insurance disease name and the clinical disease name in the end. It imposes a double burden on the doctor.

As another method, it is possible to infer the clinical disease name from the recorded treatment / prescription and insurance disease name. However, it is only speculation and does not always match the clinical disease name that doctors have in mind. In particular, guessing the name of a clinical disease that affects the life and health of a patient may affect the life and health of the patient if the guess is incorrect.

In view of the above problems, the present inventor has invented the electronic medical record system of the present invention.

The first invention is an electronic medical record system, which includes an electronic medical record information input reception processing unit that accepts input of a patient's clinical disease name and an implementation treatment and / or an implementation prescription, the clinical disease name, the implementation treatment, and /. Alternatively, it has an insurance disease name processing unit that executes a process of presenting an insurance disease name using an implementation prescription and an indication disease name, and the insurance disease name processing unit has an indication disease name of the implementation treatment and / or an implementation prescription. It is determined whether or not the standardized clinical disease name corresponding to the clinical disease name is included, and if it is determined that the standardized clinical disease name is included, the standardized clinical disease name is presented as an insurance disease name and is not included. If, further, it is determined whether the indication disease name has a disease name that satisfies the predetermined condition regarding the relationship with the standardized clinical disease name, and it is determined that there is a disease name that satisfies the predetermined condition. An electronic medical record system that presents the disease name as an insurance disease name or a candidate for an insurance disease name, and presents the indication disease name as a candidate for an insurance disease name or an insurance disease name when it is determined that there is no disease name that satisfies the predetermined conditions. Is.

With the configuration as in the present invention, it is possible to manage important clinical disease names from the viewpoint of clinical work and medical research with an electronic medical record system. On the other hand, important insurance disease names from the viewpoint of claiming medical fees for insurance medical treatment can be presented using clinical disease names, treatment / implementation prescriptions, and indications, without imposing the burden of inputting insurance disease names on doctors. it can.

When the clinical disease name is included as the indication disease name of the implementation treatment / prescription, the insurance disease name can be presented based on the clinical disease name by performing the treatment of the present invention.

Even if the clinical disease name is not included as an indication disease name, if a disease name related to the clinical disease name is included as an indication disease name, it may be used as an insurance disease name. As a result, it is possible to avoid pointing out deficiencies in the examination of medical fee billing.

If the disease name related to the clinical disease name is not included as the indication disease name, it is necessary to present the insurance disease name from the indication disease name as before. Therefore, it is advisable to carry out the processing of the present invention.

In the above invention, the insurance disease name processing unit uses natural language analysis to determine whether or not there is a disease name that satisfies a predetermined condition for relevance by using the unified code of the clinical disease name and the unified code of the indication disease name. Determine if there is a disease name that satisfies the prescribed condition for relevance, determine whether there is a disease name that satisfies the prescribed condition for relevance using the distance of the disease name pair, or information on the relationship between disease names. It can be configured like an electronic medical record system that uses one or more of the determination processes of determining whether there is a disease name that satisfies a predetermined condition for relevance by referring to.

There are various methods for determining the relationship between the clinical disease name and the indication disease name. For example, the determination process of the present invention can be used.

In the above-described invention, the insurance disease name processing unit displays the determined insurance disease name on a computer operated by a doctor, and requests approval of the insurance disease name for the treatment and / or prescription, as in an electronic medical record system. Can be configured.

If there are multiple candidates for the specified insurance disease name, it is necessary to specify them as one. Therefore, it is advisable to display the candidates on a computer operated by a medical worker such as a doctor or a medical office worker and accept the selection. In particular, by displaying it on a computer operated by a medical office worker, the burden on medical staff such as doctors can be reduced. In addition, the name of the insurance disease has been specified by the medical office staff in the past, but in that case, since the medical office staff does not have specialized knowledge about medical care, the appropriate insurance disease name is specified. In some cases it wasn't. However, as in the present invention, by presenting candidates for insurance disease names using clinical disease names, treatments / prescriptions, and indications, and then selecting insurance disease names, there is no specialized knowledge regarding medical treatment. Even a medical office worker can increase the possibility of appropriately identifying the name of an insurance disease.

In the above-described invention, the insurance disease name processing unit displays the determined insurance disease name on a computer operated by a doctor, and requests approval of the insurance disease name for the treatment and / or prescription, as in an electronic medical record system. Can be configured.

In the above-described invention, the electronic medical record system receives approval of the insurance disease name for the implementation treatment and / or the implementation prescription from a computer operated by a doctor, and when the approval is received, the insurance disease name for the implementation treatment and / or the implementation prescription. It can be configured like an electronic medical record system having an approval reception processing unit, which is determined as.

The final decision on the name of the insurance disease is required by a doctor. Therefore, it is preferable to configure the invention as in these inventions.

In the above-described invention, the electronic medical record system can be configured like an electronic medical record system provided with an input field for the clinical disease name.

In order to properly manage clinical disease names with electronic medical records, it is preferable to provide an input field for clinical disease names in the electronic medical records. This makes it possible to appropriately manage clinical disease names in electronic medical records.

In the above-described invention, when the clinical disease name is text-input, the electronic medical record system refers to a collation dictionary storage unit that stores the standard notation and notation pattern of the disease name based on the input clinical disease name. It can be configured like an electronic medical record system having a standardized processing unit that changes the clinical disease name to a standard notation.

Various methods such as text input, pull-down menu or search from the master can be used to input the clinical disease name. And the least burdensome for doctors who perform clinical work is text input that can be freely input. However, in the case of text input, the notation of the disease name often differs depending on the doctor. Therefore, by performing the processing of the present invention, the text-entered clinical disease name can be changed to the standard notation and used for the specific processing of the insurance disease name.

The first invention can be realized by loading the program of the present invention into a computer and executing it. That is, the computer uses the electronic medical record information input reception processing unit that accepts the input of the patient's clinical disease name and the action treatment and / or the action prescription, the clinical disease name, the action treatment and / or the action prescription, and the indication disease name. It is an electronic medical record program that functions as an insurance disease name processing unit that executes a process of presenting an insurance disease name by using the insurance disease name processing unit, and the insurance disease name processing unit is used for the indication of the treatment and / or the prescription for the clinical disease. It is determined whether the corresponding standardized clinical disease name is included, and if it is determined that it is included, the standardized clinical disease name is presented as an insurance disease name, and if it is determined that it is not included, it is determined. Furthermore, it is determined whether or not the indication disease name has a disease name that satisfies the predetermined condition regarding the relationship with the standardized clinical disease name, and if it is determined that the disease name satisfies the predetermined condition, the disease name is insured. This is an electronic medical record program that presents a disease name or an insurance disease name as a candidate, and if it is determined that there is no disease name that satisfies the predetermined conditions, the indication disease name is presented as an insurance disease name or an insurance disease name candidate .

By using the electronic medical record system of the present invention, the doctor only needs to input the clinical disease name, so that the electronic medical record system can manage important clinical disease names from the viewpoint of clinical work and medical research. On the other hand, important insurance disease names from the viewpoint of claiming medical fees for insurance medical treatment can be presented based on the clinical disease name, treatment / implementation prescription, and indication disease name, so that the burden of inputting the insurance disease name is not imposed on the doctor. it can.

It is a block diagram which shows typically an example of the whole processing function of the electronic medical record system of this invention. It is a conceptual diagram which shows typically an example of the hardware composition of the computer in which the electronic medical record system of this invention functions. It is a flowchart which shows typically an example of the whole processing process of the electronic medical record system of this invention. It is a flowchart which shows typically an example of the processing process of the insurance disease name processing in the electronic medical record system of this invention. It is a figure which shows an example of a part of the record of an electronic medical record. It is a figure which shows an example of the collation dictionary storage part. It is a figure which shows an example of the indication disease name memory part. It is a figure which shows an example of the electronic medical record input by a doctor. It is a figure which shows an example of the conventional electronic medical record. This is an example of a table showing the names of indications for the treatment / prescription.

An example of the overall processing function of the electronic medical record system 1 of the present invention is shown in the block diagram of FIG. Further, FIG. 2 shows an example of the hardware configuration of the computer that realizes the electronic medical record system 1 of the present invention.

The electronic medical record system 1 uses a management terminal 2 and an input person terminal 3. The management terminal 2 is a computer that executes processing in the electronic medical record system 1, and the input person terminal 3 is a medical worker such as a doctor or a nurse who inputs information into the electronic medical record, as well as medical office work in charge of processing related to insurance medical treatment. It is a computer used by the person in charge.

The computer used in the electronic chart system 1 includes an arithmetic unit 70 such as a CPU that executes arithmetic processing of a program, a storage device 71 such as a RAM or a hard disk that stores information, a display device 72 such as a display (screen), and a keyboard. It has an input device 73 such as a pointing device (mouse, ten-key, etc.), and a communication device 74 that transmits / receives the processing result of the arithmetic unit 70 and the information stored in the storage device 71 via a network such as the Internet or LAN. There is. Each function (each means) realized on the computer is executed when the means (program, module, etc.) for executing the process is read into the arithmetic unit 70. When the information stored in the storage device 71 is used in the processing, each function reads the corresponding information from the storage device 71 and appropriately uses the read information for the processing in the arithmetic unit 70. Further, although the management terminal 2 and the input person terminal 3 of FIG. 1 are realized by one computer, the functions may be distributed and arranged on a plurality of computers. Computers include various information processing devices such as servers, personal computers, and workstations. It may also be in the so-called cloud format.

When the computer includes a touch panel display, the display device 72 and the input device 73 may be integrally configured. Touch panel displays are often used, for example, in portable communication terminals such as tablet computers and smartphones, but are not limited thereto. The computer may also be capable of voice input. In this case, the voice uttered by a medical worker such as a doctor or a medical office worker is collected by a predetermined microphone (sound collector), converted into text, and text is input to the corresponding location.

The touch panel display is a device in which the functions of the display device 72 and the input device 73 are integrated in that input can be performed directly on the display with a predetermined input device (such as a pen for a touch panel) or a finger.

Each means in the present invention has only a logical distinction in its function, and may form the same area physically or substantially.

The management terminal 2 includes an electronic medical record information input reception processing unit 20, an electronic medical record information storage unit 21, a standardization processing unit 22, a collation dictionary storage unit 23, an adaptive disease name storage unit 24, an insurance disease name processing unit 25, and an approval reception processing unit 26. Have.

The electronic medical record information input reception processing unit 20 receives input of information to be recorded in the electronic medical record when the doctor examines the patient from the input person terminal 3. Input may be accepted at the time of emergency or acute examination. The electronic medical record information is preferably information recorded as an electronic medical record, but is not limited to this, and includes, for example, information according to a general method of writing an outpatient record for the first visit. The electronic medical record information input reception processing unit 20 may accept the input of the text in which the voice input information is converted into text, in addition to accepting the input by the keyboard.

The electronic medical record information input reception processing unit 20 accepts the information to be recorded in the electronic medical record as described above, but at least the clinical disease name and the information on the treatment / prescription to be performed may be received.

The treatments and prescriptions in the "ordering" information are the basic information for claiming medical fees for insurance medical treatment. Therefore, a national standard code (receipt computer processing code) is assigned to all treatments and prescriptions, and unit prices are also set. Therefore, the input method by the pull-down menu or the search from the master is adopted for the implementation treatment / implementation prescription to be input as the information of "ordering" in the electronic medical record.

In addition, input fields are provided as appropriate for the information in the "medical record description". In the electronic medical record system 1 of the present invention, it is preferable that at least an input field for "clinical disease name" is provided, and the input field accepts input by text, pull-down menu, or search by the master. If the clinical disease name input field is not provided, the clinical disease name may be specified by using a technique such as natural language analysis from the information described in the medical record in the electronic medical record.

In the electronic medical record information input reception processing unit 20, in addition to the selection and approval operation of the insurance disease name candidate in the insurance disease name processing unit 25 described later, the doctor directly inputs the insurance disease name (input other than correction and approval). It may be configured not to be accepted.

The electronic medical record information storage unit 21 stores the electronic medical record information received by the electronic medical record information input reception processing unit 20. An example of electronic medical record information is shown in FIG. In FIG. 5 (a), the clinical disease name is entered in the input field for the clinical disease name in the electronic medical record, in FIG. 5 (b), the treatment / prescription for ordering information is shown, and in FIG. 5 (c), the chief complaint other than the above. It shows the state in which information such as the current medical history, findings, and progress has been entered. The storage of electronic medical record information is not limited to this, and may be arbitrary.

When the clinical disease name input as a part of the electronic medical record information is text input, the standardization processing unit 22 executes a standardization process of changing to the standard notation by referring to the collation dictionary storage unit 23 described later. ..

That is, when the standardization processing unit 22 is input as a text in the clinical disease name, the standardization processing unit 22 refers to the collation dictionary storage unit 23 described later for the disease name, and if there is a character string matching the notation pattern, the standardization processing unit 22 is predetermined. Add or change the standard notation to the standard notation, and add standard code etc. to unify the notation.

The collation dictionary storage unit 23 stores the standard notation, code, and notation pattern for the disease name. FIG. 6 shows an example of the collation dictionary storage unit 23 for the disease name. The collation dictionary storage unit 23 of FIG. 6 shows a case where the standard disease name, the ICD code (international standard code), the disease name conversion code (domestic general-purpose medical record code), and the notation pattern of the disease name are stored in association with each other.

The indication disease name storage unit 24 stores the implemented treatment / implementation prescription and the disease name (indication disease name) for which the remuneration can be claimed in the insurance medical treatment for the implementation treatment / implementation prescription. FIG. 7 schematically shows an example of the adaptive disease name memory unit 24. In FIG. 7, "arrhythmia", "angina", etc. are associated with "arrhythmia", "angina", etc. as indications for "electrocardiogram" as an implementation treatment, and "backache", "backache", "backache", "backache" as indications for "loxonin tablets" as an implementation prescription It shows that "upper respiratory tract inflammation" etc. are associated. The indication disease name at this time corresponds to the receipt computer processing code common throughout the country, and is associated with the standard disease name, ICD code, etc. through this.

The insurance disease name processing unit 25 presents the insurance disease name for the treatment / implementation prescription performed by the doctor using at least one of the clinical disease name, the treatment / implementation prescription, and the indication disease name corresponding to the implementation treatment / prescription. Then, the recording process is executed.

First, the insurance disease name processing unit 25 refers to the adaptive disease name storage unit 24 for each of the treatments / prescriptions recorded as information on the “ordering” of the electronic medical record, and the clinical disease name of the electronic medical record (which is standardized). Determine whether the clinical disease name) is included in the indication disease name corresponding to the treatment / prescription. If it is included, the clinical disease name will be used as the insurance disease name for the treatment / prescription.

If the clinical disease name is not included in the indications corresponding to the treatment / prescription, the disease name highly related to the clinical disease name is included in the indications corresponding to the treatment / prescription. If it is included, the name of the disease with high relevance is selected as a candidate for the insurance disease name. If there are multiple highly related disease names, all of them may be candidates for insurance disease names, or the most relevant disease names may be candidates for insurance disease names. If the indication disease name does not include a disease name that is highly related to the clinical disease name, the indication disease name corresponding to the treatment / prescription is extracted from the indication disease name storage unit 24, and the disease name is used as the insurance disease name. Make it a candidate.

Then, the candidate insurance disease name is displayed and presented on the input person terminal 3 operated by a medical worker such as a doctor or a medical office worker, and which disease name is selected as the insurance disease name is accepted. The name of the disease for which the selection has been accepted shall be the name of the insurance disease for the relevant treatment / prescription.

Such processing is performed for all the actions / prescriptions to be performed in the electronic medical record information.

When the above processing is executed for all the treatments / prescriptions, the insurance disease name recorded as the treatments / prescriptions is displayed and presented to the input person terminal 3 operated by the doctor at a predetermined timing. ..

Various treatment methods can be used to determine whether or not the disease name is highly related to the clinical disease name. For example, there is a method of calculating and comparing the similarity between the ICD code corresponding to the clinical disease name and the ICD code corresponding to the indication disease name. Since the ICD code indicates a major classification, a middle classification, and a minor classification from the preceding digit, it can be determined whether or not the relevance is high according to the similarity of the ICD code. When the similarity of the ICD code is equal to or higher than the predetermined threshold value, it can be determined to be a highly relevant disease name, and when it is less than the predetermined threshold value, it can be determined to be a less relevant disease name.

Further, since the ICD code is defined in a hierarchical structure as described above, the similarity may be determined in the order of major classification, middle classification, and minor classification. In other words, the former indication disease name is more related to the indication disease name that matches in the major classification and the middle classification and differs only in the minor classification, and the indication disease name that matches the major classification but differs in the middle classification and the minor classification. It can be judged that the sex is high.

In addition to the method using the ICD code in this way, a method of determining similar words by combining morphological analysis and a natural language vectorization method (for example, word2vec), and a disease name pair based on the expertise of medical professionals such as doctors. It is possible, but not limited to, a method of manually quantifying the distance, or associating the relationships between disease names in advance.

It is also included that the insurance disease name processing unit 25 described above performs processing using a unified code such as an ICD code, a disease name conversion code, and a receipt computer processing code.

The approval acceptance processing unit 26 receives the operation of approving the insurance disease name, which is displayed on the input person terminal 3 operated by the doctor and recorded as the implementation treatment / implementation prescription, in the insurance disease name processing unit 25. By accepting the approval operation, it is recorded in the electronic medical record information storage unit 21 as a confirmed insurance disease name for the implementation treatment / implementation prescription. In addition, determining the name of the insurance disease for the treatment / prescription means that the medical fee statement (receipt) is prepared based on the contents.

Next, an example of the processing process of the electronic medical record system 1 of the present invention will be described with reference to the flowcharts of FIGS. 3 and 4.

When the doctor examines the patient, the chief complaint, current medical history, findings, course, etc. are input as the information of the "medical record description" of the electronic medical record system 1, and the clinical disease name is input in the clinical disease name input field. This input may be a text input, a pull-down menu, or a search from the master. In the case of text input, the doctor can freely input, and in the case of search from the pull-down menu or master, the selection is made from the disease names stored in advance. In the case of input by a pull-down menu or a search from the master, the input disease name is a standardized notation of the standard disease name, and is associated with an ICD code, a disease name conversion code, a receipt computer processing code, and the like.

In addition, the doctor inputs information on the treatment to be performed and the prescription to be performed on the patient as the information on the "ordering" of the electronic medical record system 1. The action / prescription entered here will be entered by searching from the pull-down menu or the master.

The electronic medical record information input in this way, particularly the clinical disease name, the treatment / prescription information, is received by the electronic medical record information input reception processing unit 20 (S100), and the electronic medical record is used as a part of the electronic medical record information. It is stored in the information storage unit 21 (S110). It is assumed that the electronic medical record information input here is shown in FIG.

In the electronic medical record information of FIG. 8, the clinical disease name "suspected VZV infection" is text-entered in the input field of the clinical disease name (FIG. 8 (a)), and "electrocardiogram" is used as an implementation procedure of the ordering information. , "Chest X-ray", "Loxonin tablets", "Baltrex", "Meticovar" are entered as the implementation prescription (Fig. 8 (b)), and information such as chief complaint, current medical history, findings, progress is entered as text. (Fig. 8 (c)). When entering the clinical disease name in text, the ICD code, disease name conversion code, and receipt computer processing code cannot be specified because the clinical disease name is not standardized, and are left blank. In the case of input by pull-down menu or search in the master, the standardized clinical disease name is recorded from the beginning, so the ICD code, disease name conversion code, and receipt computer processing code are also recorded from the beginning (without undergoing standardization processing). Will be done.

When text input is accepted for the clinical disease name, or when the ICD code, disease name conversion code, and receipt computer processing code are not recorded (S110), the standardization processing unit 22 stores the collation dictionary based on the text input clinical disease name. By referring to Part 23, a standard disease name that matches the notation pattern (exact match or partial match), a corresponding unified code, for example, an ICD code, a disease name conversion code, and a receipt computer processing code are specified. A standardization process for changing the notation is executed (S120). For example, in the case of FIG. 8A, since the text "VZV infection suspected" is input as the clinical disease name, the standardization processing unit 22 matches the input clinical disease name "VZV infection suspected" with the notation pattern of the collation dictionary storage unit 23. Collate with. Then, since "VZV infection" matches the notation pattern of the standard disease name "shingles", the clinical disease name is "shingles", the ICD code is "B029", the disease name conversion code is "KE2D", and the receipt computer processing code is specified. Then, the notation of the clinical disease name is changed and stored in the electronic medical record information storage unit 21. That is, it is updated as electronic medical record information as shown in FIG. When the disease name input to the clinical disease name is standardized in the standardization processing unit 22, a flag indicating the standardization may be stored in the electronic medical record information storage unit 21, or the display may be performed on the electronic medical record. .. At this time, in addition to changing the display mode such as changing the color of the input field for the clinical disease name or changing the font, a message may be notified or a sound may be output. If the clinical disease name whose notation has been changed by the standardization processing unit 22 is incorrect, the correction input may be accepted.

When the clinical disease name is searched from the pull-down menu or the master instead of text input, the standardized disease name, ICD code, and disease name conversion code are attached, so the standardization process does not have to be executed. In this case, it will be recorded as shown in FIG. 5A from the beginning.

After the clinical disease name is recorded as electronic medical record information with the standardized disease name as described above, the insurance disease name processing unit 25 executes the insurance disease name processing (S130).

First, the insurance disease name processing unit 25 identifies the clinical disease name (standardized clinical disease name) recorded in the electronic medical record information and each action / treatment / prescription recorded as the ordering information of the electronic medical record. In the case of FIG. 5, “shingles” is specified as the clinical disease name, and “electrocardiogram”, “chest radiograph”, “loxonnin tablet”, “valtrex”, and “methicobal” are specified as the treatment / prescription.

Then, the indication disease name memory unit 24 is referred to for the “electrocardiogram” as the implementation treatment / implementation prescription, and it is determined whether or not “shingles” is included as the indication disease name (S200). Since it is not included here, it is next determined whether the disease name highly related to the clinical disease name “shingles” includes the indication disease name of “electrocardiogram” (S210). Here, the indications for "electrocardiogram" are "arrhythmia suspected", "angina", etc., and since these are not highly related to "shingles", insurance for "electrocardiogram" as an implementation treatment / prescription Candidates for disease names are "suspected arrhythmia" and "angina", which are indications for "electrocardiogram" (S230). The insurance disease name processing unit 25 inputs the insurance disease name candidates selected in this way by the input person terminal 3 (a medical worker such as a doctor or a medical office worker who performs paperwork related to medical fee billing for insurance medical treatment). It is displayed on the person terminal 3) and the selection of the insurance disease name is accepted (S250). For example, accept the selection of "suspected arrhythmia".

When the selection of the insurance disease name is accepted in this way, the treatment for the "chest X-ray" as the next treatment / prescription is executed in the same manner as described above (S260). Regarding "chest radiograph" as an implementation treatment / prescription, the clinical disease name "shingles" is not included in the indication disease name (S200), and there is no highly relevant indication disease name (S210). Therefore, the indications of "chest X-ray" such as "suspected pneumonia" and "heart failure" are selected as candidates for insurance disease names (S230), displayed on the input person terminal 3 and accepted for selection of insurance disease names (S250). For example, accept the selection of "suspected pneumonia".

The treatment for the "loxonnin tablet" as the next action / prescription is carried out in the same manner as described above (S260). Although the clinical disease name "shingles" is not included in the indications for "loxonnin tablets" as the treatment / prescription (S200), "neuralgia" is highly related to "shingles" among the indications. It is included as the name of the disease (shingles has a pathological condition called postherpetic neuralgia, and shingles causes neuralgia) (S210). Therefore, "neuralgia" is set as a candidate for the insurance disease name of "Loxonin tablets" as the implementation treatment / prescription (S240), and the insurance disease name processing unit 25 sets it as the input person terminal 3 (preferably the input person terminal 3 operated by a doctor). ), And accepts the selection of insurance disease name (S250).

The processing for "Valtrex" as the next implementation treatment / implementation prescription is executed in the same manner as described above (S260). About "Valtrex" as an implementation treatment / prescription Since the clinical disease name "shingles" is included in the indication disease name (S200), the insurance disease name for "Valtrex" as an implementation treatment / implementation prescription is "shingles". (S220).

The processing for "Valtrex" as the next implementation treatment / implementation prescription is executed in the same manner as described above (S260). About "Valtrex" as an implementation treatment / prescription Since the clinical disease name "shingles" is included in the indication disease name (S200), the insurance disease name for "Valtrex" as an implementation treatment / implementation prescription is "shingles". (S220).

The treatment for "Meticovar" as the next implementation treatment / implementation prescription is executed in the same manner as described above (S260). Although the clinical disease name "shingles" is not included in the indications for "methicobal" as the treatment / prescription (S200), "peripheral neuropathy" is included as a highly relevant disease name among the indications. (S210). Therefore, "peripheral neuropathy" is designated as a candidate for the insurance disease name of "Mechicovar" as the implementation treatment / prescription (S240), and the insurance disease name processing unit 25 sets it as the input person terminal 3 (preferably the input person terminal operated by a doctor). Display in 3) and accept the selection of insurance disease name (S250).

When the insurance disease name is set for all the implemented treatments / prescriptions as described above (S260), it is recorded as an implemented treatment / implemented prescription for the input person terminal 3 operated by the doctor at a predetermined timing. Display the name of the insurance disease to be covered. That is, "arrhythmia suspected" as the insurance disease name of the implementation treatment / implementation prescription "ECG", "pneumonia suspected" as the insurance disease name of the implementation treatment / implementation prescription "chest X-ray", and "loxonnin tablet" as the insurance disease name of the implementation treatment / implementation prescription "Loxonin Tablets". "Neuralgia", "herpes zoster" as the insurance disease name of the treatment / implementation prescription "Baltrex", and "peripheral neuropathy" as the insurance disease name of the treatment / implementation prescription "Meticovar" are displayed.

In this way, the approval reception processing unit 26 accepts the implementation treatment / prescription and the corresponding insurance disease name from the input person terminal 3 operated by the doctor (S140). Then, based on the approval information received by the approval reception processing unit 26, it is recorded in the electronic medical record information storage unit 21 as an insurance disease name for the implementation treatment / implementation prescription (S150).

By executing the above processing, only the clinical disease name can be entered when inputting to the electronic medical record at the time of the patient's examination, and the insurance disease name is recorded at any time such as after the examination. be able to. In addition, regarding the selection of the insurance disease name based on the clinical disease name executed by the insurance disease name processing unit 25, the medical office staff, not the doctor, performs the selection operation, and the doctor performs the final approval process. Doctors will no longer have to record both clinical disease names and insurance disease names. The approval process at this time is operated by the doctor at a predetermined timing such as the timing when the doctor logs in to the electronic medical record system 1 based on the identification information of the doctor who entered the electronic medical record recorded in the electronic medical record information. This can be done by causing the input person terminal 3 to display that there is an insurance disease name that requires approval.

In the above processing, the case where the insurance disease name processing unit 25 identifies the insurance disease name or its candidate for the implemented treatment / implemented prescription and displays it on the input person terminal 3 is shown. However, the clinical disease name, the implemented treatment / implemented prescription, and the indicated disease name are shown. May be displayed on the input person terminal 3 to accept the input by the pull-down menu of the insurance disease name or the search by the master.

The above processing is only an example, and the processing process can be changed as appropriate. For example, after receiving the selection of the insurance disease name candidate for the implementation treatment / implementation prescription from the input person terminal 3, the next implementation treatment / implementation prescription is processed, but the insurance disease name for all the implementation treatment / implementation prescription is performed first. After specifying the above or the candidates for the insurance disease name, they can be collectively displayed on the input person terminal 3 and configured to accept the selection of the insurance disease name.

By using the electronic medical record system 1 of the present invention, the doctor only needs to input the clinical disease name, so that the electronic medical record system 1 can manage important clinical disease names from the viewpoint of clinical work and medical research. .. On the other hand, important insurance disease names from the viewpoint of claiming medical fees for insurance medical treatment can be presented based on the clinical disease name, treatment / implementation prescription, and indication disease name, so that the burden of inputting the insurance disease name is not imposed on the doctor. it can.

1: Electronic medical record system 2: Management terminal 3: Inputter terminal 20: Electronic medical record information input reception processing unit 21: Electronic medical record information storage unit 22: Standardization processing unit 23: Collation dictionary storage unit 24: Adaptive disease name storage unit 25: Insurance Disease name processing unit 26: Approval reception processing unit 70: Computing device 71: Storage device 72: Display device 73: Input device 74: Communication device

Claims (8)

It is an electronic medical record system
An electronic medical record information input reception processing unit that accepts input of the patient's clinical disease name and the treatment and / or prescription to be performed,
It has the insurance disease name processing unit that executes the process of presenting the insurance disease name using the clinical disease name, the implementation treatment and / or the implementation prescription, and the indication disease name .
The insurance disease name processing department
It is determined whether the indications for the treatment and / or the prescription include the standardized clinical disease name corresponding to the clinical disease name.
If it is determined that it is included, the standardized clinical disease name is presented as an insurance disease name.
When it is determined that the disease is not included, it is further determined whether or not the indication disease name satisfies the predetermined condition regarding the relationship with the standardized clinical disease name.
If it is determined that there is a disease name that satisfies the above-mentioned predetermined conditions, the disease name is presented as an insurance disease name or a candidate for an insurance disease name.
If it is determined that there is no disease name that satisfies the predetermined conditions, the indication disease name is presented as an insurance disease name or a candidate for an insurance disease name.
An electronic medical record system characterized by this. The insurance disease name processing department
Use the standardized unified code for clinical disease names and the unified code for adaptive disease names to determine whether there is a disease name that satisfies the prescribed conditions for relevance, and use natural language analysis to satisfy the prescribed conditions for relevance. Determining if there is a disease name, determining if there is a disease name that satisfies the prescribed condition for relevance using the distance of the disease name pair, or predetermining the relevance by referring to the information on the relevance between disease names. Use one or more of the determination processes to determine if there is a disease name that satisfies the conditions.
The electronic medical record system according to claim 1 . The insurance disease name processing department
The determined insurance disease name candidate is displayed on a computer operated by a medical worker or a medical office worker, and selection of an insurance disease name for the treatment and / or prescription is accepted.
The electronic medical record system according to claim 1 or 2 , wherein the electronic medical record system is characterized in that. The insurance disease name processing department
The determined insurance disease name is displayed on a computer operated by a doctor, and approval of the insurance disease name for the treatment and / or prescription is requested.
Electronic medical record system according to any of claims 1 to 3, characterized in that. The electronic medical record system is
The approval reception processing unit, which accepts the approval of the insurance disease name for the implementation treatment and / or the implementation prescription from the computer operated by the doctor, and when the approval is accepted, determines the insurance disease name for the implementation treatment and / or the implementation prescription.
The electronic medical record system according to any one of claims 1 to 4 , wherein the electronic medical record system is characterized by having. The electronic medical record system is
It has an input field for the clinical disease name.
The electronic medical record system according to any one of claims 1 to 5 , characterized in that. The electronic medical record system is
When the clinical disease name is entered as text, the clinical disease name is changed to the standard notation by referring to the collation dictionary storage unit that stores the standard notation and notation pattern of the disease name based on the entered clinical disease name. Standardization processing unit,
The electronic medical record system according to any one of claims 1 to 6 , wherein the electronic medical record system is characterized by having. Computer,
Electronic medical record information input reception processing unit that accepts input of the patient's clinical disease name and the treatment and / or prescription.
An electronic medical record program that functions as an insurance disease name processing unit that executes a process of presenting an insurance disease name using the clinical disease name, the treatment and / or prescription, and an indication disease name .
The insurance disease name processing department
It is determined whether the indications for the treatment and / or the prescription include the standardized clinical disease name corresponding to the clinical disease name.
If it is determined that it is included, the standardized clinical disease name is presented as an insurance disease name.
When it is determined that the disease is not included, it is further determined whether or not the indication disease name satisfies the predetermined condition regarding the relationship with the standardized clinical disease name.
If it is determined that there is a disease name that satisfies the above-mentioned predetermined conditions, the disease name is presented as an insurance disease name or a candidate for an insurance disease name.
If it is determined that there is no disease name that satisfies the predetermined conditions, the indication disease name is presented as an insurance disease name or a candidate for an insurance disease name.
An electronic medical record program characterized by this.

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