WO2000065485A2 - Systeme, procede et dispositif de codage de renseignements medicaux avec codes exemplaires - Google Patents

Systeme, procede et dispositif de codage de renseignements medicaux avec codes exemplaires Download PDF

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Publication number
WO2000065485A2
WO2000065485A2 PCT/US2000/011571 US0011571W WO0065485A2 WO 2000065485 A2 WO2000065485 A2 WO 2000065485A2 US 0011571 W US0011571 W US 0011571W WO 0065485 A2 WO0065485 A2 WO 0065485A2
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WIPO (PCT)
Prior art keywords
medical information
patient
segment
coding
given
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PCT/US2000/011571
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English (en)
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WO2000065485A3 (fr
Inventor
William Ernest Rutherford
Jennifer Bennett
Daniel Popp
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Physicians Information Exchange, Inc.
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
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Publication date
Application filed by Physicians Information Exchange, Inc. filed Critical Physicians Information Exchange, Inc.
Priority to EP00931970A priority Critical patent/EP1204936A2/fr
Priority to AU49768/00A priority patent/AU4976800A/en
Priority to IL14615600A priority patent/IL146156A0/xx
Priority to CA002371401A priority patent/CA2371401A1/fr
Publication of WO2000065485A2 publication Critical patent/WO2000065485A2/fr
Publication of WO2000065485A3 publication Critical patent/WO2000065485A3/fr

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    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H70/00—ICT specially adapted for the handling or processing of medical references
    • G16H70/20—ICT specially adapted for the handling or processing of medical references relating to practices or guidelines
    • G—PHYSICS
    • G16—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR SPECIFIC APPLICATION FIELDS
    • G16H—HEALTHCARE INFORMATICS, i.e. INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR THE HANDLING OR PROCESSING OF MEDICAL OR HEALTHCARE DATA
    • G16H10/00—ICT specially adapted for the handling or processing of patient-related medical or healthcare data
    • G16H10/60—ICT specially adapted for the handling or processing of patient-related medical or healthcare data for patient-specific data, e.g. for electronic patient records

Definitions

  • the present invention relates to a medical record and healthcare information coding scheme and method, particularly to a system for providing physicians the ability to record data in a natural language format and extract finely granular information about treatments, conditions and outcomes .
  • ICD International Classification of Diseases
  • ICD-9 CM codes are now required by Medicare on each ⁇ Part-B' claim submitted by physicians .
  • the structure of the coding scheme contains a number that can indicate a disease process or phrase describing a disease process . Without exception, the descriptive phrase cannot be changed in any way, so the when a coded number related to a phrase is selected, it is an all or none situation. It is possible to make the code slightly more finely granular by adding modifiers, but there is a limit to the degree of specificity that may be achieved.
  • ICD-9 is limited to three codes: 599.7 Hematuria, 788.41 Urinary Frequency, and 789.07 Abdominal pain, generalized. There is no mechanism to record the very basic clinical information of how long the condition has existed, how often the hematuria occurs, or even the location of the abdominal pain.
  • CPT Current Procedural Terminology
  • SNOMED has been in use since the late 1970s and was designed for pathological classification.
  • SNOMED RT Reference Terminology
  • the latest version, SNOMED RT (Reference Terminology) is organized in a multi-axial and hierarchical manner.
  • the different axes allow for the coding of various aspects of a situation such as the disease, functions, body parts or regions, occupations, and drugs.
  • the hierarchical organization of the terms and the use of modifiers allows for varying degrees of detail to be encoded at the same time, i.e., from a specific disease description be able to identify more general conditions such as the disease category, the affected body system, and possibly the disease cause.
  • the missing piece in SNOMED RT and all the other coding schemes is that there is no way to apply context to the information being coded and there is no specific way to store the information in a database such that it can be queried and analyzed in a sophisticated manner.
  • the present invention is a system, methodology and apparatus for encoding medical information about a patient that can serve as a basis for supporting applications ranging from a medical records system to a data warehouse containing medical history information.
  • the encoded information pertains to an individual patient, their medical history, conditions, treatment and other related information.
  • FIGURE 1 illustrates an exemplary configuration of database interconnections for correlating a variety of distributed medical data about a particular patient
  • FIGURE 2 illustrates an exemplary interface whereby a user may access information from databases, such as the configuration shown in FIGURE 1, to determine and hierarchically relate segments with a variety of attributes pursuant to the teachings of the present invention
  • FIGURE 3 illustrates a table or database containing functionality therein for converting and cross- referencing a variety of conventional coding schemes into the preferred coding scheme of the present invention
  • FIGURE 4 illustrates a preferred configuration of segment values pursuant to the teachings of the present invention
  • FIGURE 5 represents an exemplary list of associations between segment names and abbreviated codes therefor pursuant to a preferred embodiment of the present invention
  • FIGURE 6 illustrates exemplary steps utilized in designing a code form pursuant to the principles of the present invention
  • FIGURE 7 illustrates an exemplary interface for accessing and modifying controls pursuant to the present invention
  • FIGURE 8 illustrates a further exemplary interface for accessing and modifying attributes and controls pursuant to the teachings of the present invention
  • FIGURE 9 illustrates a preferred methodology for applying codes produced in accordance with the present invention to a particular term
  • FIGURE 10 illustrates a preferred methodology for utilizing the coded arrangement of the present invention to obtain a variety of information about a given patient
  • FIGURE 11 illustrates an exemplary configuration of a computer system whereupon the principles of the present invention may be implemented and utilized.
  • the PIE coding scheme preferably includes a collection of segments that contain multiple terms. These segments are utilized in such a way as to essentially code medical information about a single patient and individual encounters .
  • the PIE codes are preferably integrated into a Specialized Entry Tool (SET) and are hierarchical, as described in more detail hereinbelow.
  • the hierarchy is created by coding forms, controls, and attributes that are linked. The highest order of the hierarchy is on the form, next the control, and last the attribute.
  • the codes are linked together to represent a fact or piece of information about a patient. Terms can modify other terms.
  • Modifiers are indicated by indenting the term under the one being modifying, becoming, in essence, a child of the term being modified and, as such, represents a hierarchy within a hierarchy.
  • One of the advantages of this coding scheme is that a value/type can modify a term and specify variation. For example, using the aforementioned situation, a patient presents to the physician with urinary frequency for the past three days associated with abdominal pain in the supra pubic region and occasional hematuria .
  • the PIE code would be : Note Section: Chief complaint Body System: GU Problem/finding: frequency Value/type: urinary
  • the PIE Coding Scheme allows the clinical team to collect a set of facts about a patient. These facts collectively provide a picture of the condition of the patient and their medical history.
  • a patient fact table 100 would tie together the various values of the segments for each individual fact, e.g., a body location table 110, a body system table 120, a procedure table 130, a problem table 140, a drug table 150 and a demographics table 160.
  • Patient fact table 100 along with the segment tables discussed in more detail hereinbelow, can then be queried for sets of facts that satisfy a certain criteria. The resulting set of the query can then be analyzed further.
  • Each fact would also have an associated date and time so studies of effects or changes over time can also be done in an efficient manner. Collection of Medical Information and History
  • the contents of any data warehouse are accumulated from sources other than the data warehouse itself.
  • the data sources can be an automated medical records system, transcripts of physician notes or other suitable sources.
  • None of the existing medical record systems provide for the collection of information in such a manner as to allow significant queries to be made. They typically allow for searching for individual or sets of records based on a certain characteristic or keyword, but do not provide any analysis capabilities across sets of records. As any health professional knows, this capability is needed to obtain meaningful results from a large enough sampling so that it is statistically significant.
  • PIE codes apply only to data entered using SET. That is PIERS Specialized Entry Tools. The code is embedded into this Specialized Entry Tool at the time that the tools are created. The tools are created using the SET Authoring and occur as follows: The data to be entered is chosen by selecting a node on a tree. That node has a corresponding form, the form has controls on it and there are attributes associated with these controls. The form has PIE codes, the control has PIE codes and the attributes have PIE codes . They all link together in a hierarchical manner, that is, attributes inherit the code of the control and the controls inherit the code of the forms. Each of the codes associated with the form, control and attributes are all made up of PIE codes that are segments and terms.
  • the coding scheme preferably includes 13 segments presently labeled as problems/findings, general, subject, note section, body system, methods, units, descriptor, value/type, body part, aspect, procedure, and drugs.
  • Segment problems/findings generally are those things that are coded in standard ICD-9 codes. They relate to diagnoses, findings, and symptoms.
  • the general segment refers to a broad category such as infectious disease, bacterial disease, viral disease, malignant disease, carcinoma, etc. Terms within the subject segment include nouns, verbs, and gerunds.
  • Encoded data that uses other coding schemes will be handled by looking up the meaning of the encoded data and processing it as a textual input or cross-referencing a table to locate the appropriate PIE Code.
  • FIGURE 3 A representation of a cross reference table, generally designated by the reference numeral 300, is illustrated in FIGURE 3.
  • the table 300 includes mapping functionality for mapping conventional codes, e.g., ICD-9, ICD-10, CPT, NOMESCO, FDB, SNOMED, UMLS and HCPCS to the PIE codes of the present invention.
  • a segment table generally designated by the reference numeral 400, includes a segment columns portion 410 and a segment rows portion 420 for marked elements.
  • 'upper left chest' are terms in the Body Location and aspects segments.
  • “Left” and “Upper” are terms in the aspect segment. This allows a search for problems in the chest, left chest, and upper left chest to obtain meaningful results.
  • the PIE Coding Scheme is being referred to as a 'multi-segmental mark-up code' .
  • 13 segments consisting of the following: Problems/Findings, Subjects, Note Sections, Body Systems, Methods, Units, Descriptors, Value/Type, Body Parts, Locations, Tests, Procedures, and Drugs.
  • the Segment Table is preferably composed of Segment Columns and Rows of 'marked' terms.
  • the 'mark' associated with each Term uniquely identifies the Term as belonging to that particular segment.
  • FIGURE 5 A table of currently preferred pairings is shown in FIGURE 5 where an identifying mark within mark column 510 is uniquely paired with a particular segment within segment column 520. It should be understood that by so abbreviating the designations for segments in this protocol countless trillions of data bytes would be saved in the medical databases employing the principles of the present invention.
  • Each Segment has a 'mark' and each Segment has many Terms.
  • Each Term is uniquely identified by its 'mark' that indicates the Segment that it belongs to as noted above .
  • a Term may belong to more than one Segment and its uniqueness is guaranteed by its 'mark' .
  • the use of the word 'mark-up' when referring to codes is abstractly similar although not identical to its meaning when referring to 'mark-up languages' .
  • a PIE Code can be made up of a single 'marked Term' or a combination of 'marked Terms' .
  • the Pie Code is composed of a combination of 'marked Terms'
  • each 'marked Term' will be separated from the others by its 'mark' .
  • the PIE codes are used to code various parts of the medical record such as chief complaint, present illness, past history, physical examination, impression, plan, etc. They are also used to code procedures. Each section of the record has a Note Section that identifies which part of the record contains the data. This allows clinicians to know if a blood pressure is part of the present illness, past illness or part of the family history.
  • a flow chart 600 outlines a methodology for sketching a form pursuant to PIE coding.
  • step 610) and a decision made as to which items to include therein (step 615) .
  • An iterative process is then commenced to determine first (step 620) whether another item is to be included: if yes, control transfers to step 625 where the user places the correct field on the form; otherwise, control transfers to finished (step 640) .
  • step 630 a determination is made (step 630) whether the item requires PIE encoding: if yes, a PIE encoding occurs (step 635) , and in either event control transfers to box 620 to ascertain whether item entry is complete.
  • An exemplary control form, generally designated by reference numeral 700, for item insertion is shown in FIGURE 7, wherein a node and tree structure is illustrated.
  • a given node i.e., a CC node 720
  • a group of pre- created control selections are illustrated within design tool portion 730, and a button control portion 740 selected therein. This selection activates a control portion 750 and deactivates another portion 760, as illustrated.
  • an attributes and codes form is generally designated by the reference numeral 800 in FIGURE 8.
  • a node and tree structure 810 includes a highlighted node 820, i.e., Right Upper Lobe, therein.
  • a design tool portion 820 and a Right Upper Lobe control portion 830 having a variety of proposed attributes therein, e.g., a percussion portion 840 and an auscultation portion 850, the latter of which is illustrated in a highlighted position.
  • a PIE code portion 870 the highlighted portion (auscultation) is designated as the method and a note as to insertion point is associated therewith in a subordinate, indented fashion.
  • FIGURE 9 there is shown a methodology, generally designated by the reference numeral 900, for coding a term pursuant to the teachings of the present invention.
  • a determination is made as to the most important part of the term. An iterative process is then entered
  • step 915 to determine whether any additional segments are to be evaluated: if yes, the next segment is selected
  • step 920 and a further determination made whether there is an element within the segment that should be part of the code (step 925), if yes, the element is added (step 920).
  • control reverts to step 925, if not, control reverts back to step 915.
  • step 915) a determination is then made (step 935) to determine if any of the segments describing the term can be more completely described and whether there is another segment that can be described in more detail (step 940) : if yes, the current segment is utilized to limit the definition of the current term (step 945) and control transferred back to step 910; otherwise, the item is fully coded (step 950) and permanently saved (step 955) prior to finishing (step 960) .
  • FIGURE 10 there is illustrated a methodology, generally designated by the reference numeral 1000, for reviewing and testing a coded tree according to the present invention.
  • a user logs onto Applicant's PIERS system, opens a patient file, goes into a SET runtime and opens an existing SET tree (step 1010) .
  • Selection of a first node (step 1015) within the tree causes a tree object to give the tree a control identification to load (step 1020) , whereupon the database is accessed (step 1025) , particularly, the child control for this control.
  • the associated PIE codes for the respective child control (s) are retrieved (step 1030) and all the obtained information from the database is retrieved: database information, PIE codes, patient ID, date, etc. (step 1035) .
  • the user can then modify or otherwise choose various functions and controls (step 1040) , additions/deletions (step 1045) mode, storage (step 1050) and a determination whether the user has then selected another node: if yes, control reverts back to step 1020; otherwise, the routine finishes (step 1060) .
  • Attribute a characteristic or quality describing data gathered during a patient encounter
  • Control a data entry box or tool used to record patient encounter data into a form.
  • a control may be items such as an edit box, a check box, a single or multi select list box, a numeric, time or temperature keypad, graphic control, or a clear or select button, etc.
  • Form an organized combination, arrangement or style of controls and attributes used to record data about a patient encounter
  • Graphic Control a data entry box containing some type of graphical image used to record patient encounter findings
  • Hot Spot a specific area or trouble spot marked on a graphic control
  • the basic codes required for a Form are: A Procedure Segment is required if the data entry tool is for a procedure.
  • a Body System and or a Body Part should be on each form although this is not necessary when dealing with a general form such as Chief complaint . Both should be included whenever possible.
  • a Problem/Finding is used to denote an Attribute and is typically the starting point for coding a present illness.
  • An Insertion Point is used to indicate the level (hierarchical) that the first term of the control will reference. Insertion Points are removed when the hierarchy is connected. Edit boxes do not require insertion points.
  • a Value Point is similar to an Insertion Point, but it is not removed. The Value Point assigns a number to an edit box to denote the term to which it applies.
  • Each form requires a Note Segment: Present Illness.
  • the present illness note segment requires a body system and a problem/finding.
  • the common Controls on the Present Illness use the following Segments, all of which are Descriptors: Onset, Duration, Frequency Pattern, Relieved by, Associated with, Exacerbated by, Progression and sometimes Quantity, Color, Character, Mode of Onset, Mode of Resolution, Severity, Location, and Radiation.
  • Each Control also requires an Insertion Point.
  • the Attributes on the Controls in Present Illness are mostly Value/Types and Subjects although the Segments Body Parts and Aspects are used to reference parts of the body. Numbers are also Value/Types and are used to denote days, weeks, etc.
  • Problem/Findings are also used to denote Attributes. When coding Attributes for the Present Illness, the highest level starts with the Problem/Finding, and then the other Segments follow and modify the Problem/Finding. If there is no Problem/Finding then the Subject is next followed by the Body Part and then the Aspect. If a phrase ends in the word disease or syndrome then the Problem/Finding is listed as a compound phrase and does not need modifiers. Subjects are modified by Value/Type segments. Body Part is modified by Aspect.
  • the form always needs a Note Segment of Review of Systems, which also requires a Body System and Insertion Point.
  • the Body System Segment may be the first part of a Control if multiple body systems are included on the same form. In the latter case only one Insertion Point may be on the form and all of the other information is at the beginning of each control . That is the body system information is repeated on each Control when it is not on the form. If the Control has multiple Attributes that are not common then the Body System Segment must be repeated at the beginning of each Attribute since is was not referenced at the control level .
  • hematuria Descriptors are used to clarify Attributes: For example painful hematuria could be coded as : Problem/Finding: hematuria Descriptor: associated with
  • the form must always have a Note Segment: Physical Exam, Body System, and the Body Part.
  • the Insertion Point must modify the Body Part. If the Body Part Segment is not included on the form it should be the first Segment on the control. The remainder of the Segments fall in the order appropriate for modifiers.
  • Descriptors are categories; i.e. 'caused by' and 'secondary to' are descriptors and are also synonyms •
  • the 'subject' segment includes nouns, verbs, and gerunds .
  • the segment 'value/type' includes modifiers, numbers, prepositions.
  • the 'unit' segment refers to units of measure.
  • a unit has a value associated with it; i.e. unit: day, value/type: three.
  • daily is a value/type that does not have an associated number.
  • Muscles are entered as compound terms and are Body Parts .
  • the segment 'Body part' refers to parts of the body that can be removed. Exceptions are chest wall, back, and abdomen. Bronchoaleveoli and alveolus are examples of body parts .
  • Body parts that are adjectives should be used as the noun form, i.e. testicles for testicular and scrotum for scrotal .
  • Location is an element of the segment 'descriptor' .
  • Left upper quadrant, left lower quadrant are coded as LUQ and LLQ in the 'aspect' segment.
  • inner outer we will make inner outer a modifier of the quadrants. That breaks them down into smaller more finely granular codes .
  • Duodenum, cecum, and ileum are body parts not aspects of the colon or small bowel. • The 'body part' segment does not have plural terms for parts of the body that are limited to two. For example, to code legs, we will code leg, right, and left. On the other hand, when there are many multiples of body parts or whatever, we will have plurals of the terms. An example is vein and veins.
  • Tracts and ducts are areas that are aspects.
  • Body system gastrointestinal, Aspect tract. Urinary tract would be coded
  • Body system GU, Aspect: tract,
  • Aspect urinary. Urinary tract infection would be coded, Problem: infection, Body system: GU, Aspect: tract, Aspect: urinary.
  • the 'method' segment refers to laboratory methods, methods of examination such as inspection, palpation, percussion etc. , and any other procedural method.
  • the 'note' segment refers to parts of the medical note such as CC, PI, PHx etc.
  • the 'Problem' segment is composed of diagnoses, symptoms and findings. Examples are, headache, nausea, diabetes mellitus and essential hypertension. They would be coded as, Problem: headache, Problem: nausea, Problem: diabetes, Value/type: mellitus, and Problem: hypertension, Value/type: essential. Examples compound terms are, Bartter's syndrome or Cushing's disease. They are coded, Problem: Bartter's syndrome and, Problem: Cushing's disease. Problems that end with syndrome and disease are always compound. Chronic Obstructive Lung Disease is coded Problem: Chronic Obstructive Lung Disease. The acronym COPD is a synonym.
  • the 'Procedure' segment is reserved for any procedure that exists in the CPT code. Tests, assays and biopsies are in the 'procedure' segment and are considered the same as diseases and syndromes under the 'problem' segment; that is, they are legitimate compound terms by the fact that it says test, assay or biopsy.
  • the 'Drug' segment is reserved for drugs in the MediSpan database .
  • the general segment refers to general categories such as, infectious disease, malignant disease, genetic and, congenital disease. This is comparable to the 'isa' in SnoMed RT.
  • o Unit grade, stage, etc.
  • FIGURE 11 there is illustrated a computer system 1100 upon which a user may access, input and modify patient information pursuant to the teachings of the present invention.
  • the computer system 1100 is interconnected with other computers, e.g., computer 1105, via an intranet or the Internet, generally designated by the reference numeral 1110.
  • a mouse 1115, a keyboard 1120 and other devices, e.g., a scanner, transcriber or other device, generally designated by the reference numeral 1125, may receive or transmit information to/from the computer system 1100.
  • the computer system 1100 may comprise a conventional desktop unit, a portable PC or be a portable device configured to implement the teachings of the instant invention.
  • Databases 1100A and 1105A, as well as other memory storage systems, may be employed to store, distributed or local, the information pertaining to a given patient.

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  • Health & Medical Sciences (AREA)
  • Bioethics (AREA)
  • Engineering & Computer Science (AREA)
  • Epidemiology (AREA)
  • General Health & Medical Sciences (AREA)
  • Medical Informatics (AREA)
  • Primary Health Care (AREA)
  • Public Health (AREA)
  • Medical Treatment And Welfare Office Work (AREA)

Abstract

L'invention concerne un système, un procédé et un dispositif de codage de renseignements médicaux concernant un patient, pouvant servir de base pour supporter des applications allant d'un système de dossiers médicaux à un dépôt de données contenant des informations sur les antécédents médicaux. Les renseignements codés concernent un patient donné, ses antécédents médicaux, ses pathologies, ses traitements et d'autres informations pertinentes.
PCT/US2000/011571 1999-04-27 2000-04-27 Systeme, procede et dispositif de codage de renseignements medicaux avec codes exemplaires WO2000065485A2 (fr)

Priority Applications (4)

Application Number Priority Date Filing Date Title
EP00931970A EP1204936A2 (fr) 1999-04-27 2000-04-27 Systeme, procede et dispositif de codage de renseignements medicaux avec codes exemplaires
AU49768/00A AU4976800A (en) 1999-04-27 2000-04-27 System, method and apparatus for encoding medical information with exemplary codes
IL14615600A IL146156A0 (en) 1999-04-27 2000-04-27 System, method and apparatus for encoding medical information with exemplary codes
CA002371401A CA2371401A1 (fr) 1999-04-27 2000-04-27 Systeme, procede et dispositif de codage de renseignements medicaux avec codes exemplaires

Applications Claiming Priority (4)

Application Number Priority Date Filing Date Title
US13127599P 1999-04-27 1999-04-27
US60/131,275 1999-04-27
US16739399P 1999-11-24 1999-11-24
US60/167,393 1999-11-24

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WO2000065485A3 WO2000065485A3 (fr) 2002-02-21

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Cited By (2)

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WO2003034274A1 (fr) * 2001-10-18 2003-04-24 Yeong Kuang Oon Systeme et procede d'enregistrement ameliore des transactions medicales
WO2020046790A1 (fr) * 2018-08-26 2020-03-05 Haemonetics Corporation Système et procédé d'obtention à distance d'informations de donneur

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US5845253A (en) * 1994-08-24 1998-12-01 Rensimer Enterprises, Ltd. System and method for recording patient-history data about on-going physician care procedures

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Cited By (4)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
WO2003034274A1 (fr) * 2001-10-18 2003-04-24 Yeong Kuang Oon Systeme et procede d'enregistrement ameliore des transactions medicales
US7555425B2 (en) 2001-10-18 2009-06-30 Oon Yeong K System and method of improved recording of medical transactions
WO2020046790A1 (fr) * 2018-08-26 2020-03-05 Haemonetics Corporation Système et procédé d'obtention à distance d'informations de donneur
CN112789681A (zh) * 2018-08-26 2021-05-11 美国血液技术公司 用于远程获得捐献者信息的系统和方法

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EP1204936A2 (fr) 2002-05-15
AU4976800A (en) 2000-11-10
IL146156A0 (en) 2002-07-25
WO2000065485A3 (fr) 2002-02-21

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