WO2018092145A1 - Procédé mis en œuvre par ordinateur permettant de créer ou de mettre à jour des dossiers médicaux - Google Patents

Procédé mis en œuvre par ordinateur permettant de créer ou de mettre à jour des dossiers médicaux Download PDF

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Publication number
WO2018092145A1
WO2018092145A1 PCT/IL2017/051264 IL2017051264W WO2018092145A1 WO 2018092145 A1 WO2018092145 A1 WO 2018092145A1 IL 2017051264 W IL2017051264 W IL 2017051264W WO 2018092145 A1 WO2018092145 A1 WO 2018092145A1
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WO
WIPO (PCT)
Prior art keywords
patient
medical condition
medical
clinical term
emr
Prior art date
Application number
PCT/IL2017/051264
Other languages
English (en)
Inventor
Tatyana DUBIZHANSKY
Original Assignee
Assuta Medical Centers Ltd
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.)
Filing date
Publication date
Application filed by Assuta Medical Centers Ltd filed Critical Assuta Medical Centers Ltd
Publication of WO2018092145A1 publication Critical patent/WO2018092145A1/fr

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Classifications

    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q30/00—Commerce
    • G06Q30/04—Billing or invoicing
    • 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
    • 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
    • G16H15/00—ICT specially adapted for medical reports, e.g. generation or transmission thereof

Definitions

  • the invention relates to coding medical records and more particularly to a system and a method managing such records in a dynamic manner with a minimal risk of coding error which enables clinical data exchange for the sake of promotion of medical treatment quality, account management in the health system, medical researches and regulatory reporting system.
  • the main task of medical coders is to review clinical statements and assign standard codes such as CPT®, ICD-10-CM, and HCPCS Level II classification systems.
  • Medical billers process and follow up on claims sent to health insurance companies for reimbursement of services rendered by a healthcare provider.
  • the medical coder and medical biller may be the same person or may work with each other to ensure invoices are paid properly.
  • the coder checks the patient's medical record (i.e., the transcription of the doctor's notes, ordered laboratory tests, requested imaging studies, and other sources) to verify the work that was done.
  • US 20150039330 discloses an episode builder which is a web-based computer application and its associated architecture that allow health care professionals to define and describe episodes of care.
  • the episode builder provides a tool for describing an episode of care so that the health care professional can create and modify episodes for a variety of purposes.
  • the episode builder includes a configurable and extensive code set management system, a suite of display panels that define the episodes themselves based upon the code sets, and a means to export the episode definition tables created to be used as inputs into an analytic program or a claims adjudication engine.
  • Many categories of the abovementioned medical classification systems include the codes attributed to a group of diseases which are classified as "others". In other words, one code is attributed to a plurality of diseases which brings incertitude between medical billers and medical insurance companies.
  • the aforesaid method comprises the steps of: (a) providing a computer system comprising: (i) a processor; (ii) memory configured for storing electronic medical records (EMR) concerning medical services provided by the healthcare organization; and (iii) a graphic user interface configured for displaying a categorized Classification of Diseases and Related Health Problems, searching a relevant medical condition and a coded clinical term thereof and selecting thereof; (b) querying a patient's personal EMR stored in the memory by inputting a patient's ID or creating if the personal EMR does not exist; (c) establishing a diagnosis and a concomitant treatment characterizing the medical condition of the patient; (d) searching the coded clinical term relevant to the medical condition of the patient within the categorized Classification of Diseases and Related Health Problems; (e) selecting the relevant coded clinical term if the coded clinical term is uniquely
  • Another object of the invention is to provide a computer-implemented system for creating or updating medical records associated with patient's encounter with a healthcare organization.
  • the aforesaid system comprises: (a) a processor; (b) memory configured for storing electronic medical records (EMR) concerning medical services provided by the healthcare organization; and (c) a graphic user interface configured for displaying a categorized Classification of Diseases and Related Health Problems, searching a relevant medical condition and a coded clinical term thereof and selecting thereof.
  • EMR electronic medical records
  • the processor is preprogrammed for: (a) displaying a patient's personal EMR stored in the memory in response to a corresponding query by means of inputting a patient's ID or creating if the personal EMR does not exist; (b) displaying categorized Classification of Diseases and Related Health Problems such that the coded clinical term relevant to the medical condition of the patient is selectable; (c) saving the relevant coded clinical term in the personal EMR if the coded clinical term is uniquely attributable to the medical condition of the patient and saving the coded clinical term.
  • Figure is a flowchart of a computer-implemented method of creating or updating medical records associated with patient's encounter with a healthcare organization.
  • a system for implementing the abovementioned method comprises a processor; (ii) memory configured for storing electronic medical records (EMR) concerning medical services provided by the healthcare organization; and (iii) a graphic user interface configured (GUI) for displaying a categorized Classification of Diseases and Related Health Problems, searching a relevant medical condition and a code thereof and selecting thereof.
  • EMR electronic medical records
  • GUI graphic user interface
  • a diagnosis and/or concomitant treatment characterizing a medical condition of a patient is established (step 130).
  • a health care worker for example a doctor, carries out a search of coded clinical terms suitable to the medical condition of the patient by means of the system GUI (step 140).
  • the method 100 is bifurcated at step 150 according to the stipulation if the obtained coded clinical term is uniquely attributable to the medical condition of the patient or not.
  • the health care worker selects the relevant coded clinical term (step 160) and saves it in the personal EMR( step 170).
  • the health care worker saves a descriptor of the medical condition in a form of free text in the personal EMR (step 180). Then, the saved free-text descriptor is analyzed by a medical record clerk (step 190), who assigns an additional code uniquely attributable to the medical condition (step 200). The additional code is also saved in the personal EMR (step 210). It should be appreciated that that the present invention is also directed to facilitating big data management in order to identify the same condition among different patients by means of identical coded clinical terms.
  • the computer-implemented system for creating or updating medical records associated with patient's encounter with a healthcare organization is preprogrammed for (a) displaying a patient's personal EMR stored in the memory; (b) displaying categorized Classification of Diseases and Related Health Problems; (c) saving the relevant code in the personal EMR.
  • the computer-implemented system is configured for (a) saving the medical condition in a form of a free text in the personal EMR if no code is uniquely attributable to the medical condition of the patient; (b) assigning an additional code uniquely attributable to the medical condition of the patient by a medical statistics clerk after analyzing the free text; and saving the additional code in the personal EMR.
  • a computer-implemented method of creating or updating medical records associated with patient's encounter with a healthcare organization comprises the steps of: (a) providing a computer system comprising: (i) a processor; (ii) memory configured for storing electronic medical records (EMR) concerning medical services provided by the healthcare organization; and (iii) a graphic user interface configured for displaying a categorized Classification of Diseases and Related Health Problems, searching a relevant medical condition and a code thereof and selecting thereof; (b) querying a patient's personal EMR stored in the memory by inputting a patient's ID or creating if the personal EMR does not exist; (c) establishing a diagnosis and a concomitant treatment characterizing the medical condition of the patient; (d) searching the coded clinical term relevant to the medical condition of the patient within the categorized Classification of Diseases and Related Health Problems; (e) selecting the relevant code if the code is uniquely attributable to the medical condition of the
  • a computer-implemented system for creating or updating medical records associated with patient's encounter with a healthcare organization comprises: (a) a processor; (b) memory configured for storing electronic medical records (EMR) concerning medical services provided by the healthcare organization; and (c) a graphic user interface configured for displaying a categorized Classification of Diseases and Related Health Problems, searching a relevant medical condition and a code thereof and selecting thereof.
  • EMR electronic medical records
  • the processor is preprogrammed for: (a) displaying a patient's personal EMR stored in the memory in response to a corresponding query by means of inputting a patient's ID or creating if the personal EMR does not exist; (b) displaying categorized Classification of Diseases and Related Health Problems such that the code relevant to the medical condition of the patient is selectable; (c) saving the relevant code in the personal EMR if the code is uniquely attributable to the medical condition of the patient and saving the code.

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  • Business, Economics & Management (AREA)
  • Engineering & Computer Science (AREA)
  • Development Economics (AREA)
  • General Health & Medical Sciences (AREA)
  • Medical Informatics (AREA)
  • Primary Health Care (AREA)
  • Public Health (AREA)
  • Epidemiology (AREA)
  • Health & Medical Sciences (AREA)
  • Finance (AREA)
  • Economics (AREA)
  • Accounting & Taxation (AREA)
  • Marketing (AREA)
  • Strategic Management (AREA)
  • Physics & Mathematics (AREA)
  • General Business, Economics & Management (AREA)
  • General Physics & Mathematics (AREA)
  • Theoretical Computer Science (AREA)
  • Medical Treatment And Welfare Office Work (AREA)

Abstract

L'invention concerne un procédé mis en œuvre par ordinateur permettant de créer ou de mettre à jour des dossiers médicaux associés à la visite d'un patient auprès d'un organisme de soins de santé, ledit procédé consistant à : (a) consulter l'EMR personnel d'un patient; établir un diagnostic et un traitement concomitant; (b) rechercher un terme clinique codé pertinent pour ledit état pathologique dudit patient dans ladite classification des maladies par catégorie; (c) sélectionner le terme clinique codé pertinent si ledit terme clinique codé est attribuable uniquement audit état pathologique dudit patient et enregistrer ledit code dans ledit EMR personnel. Si aucun terme clinique codé n'est attribuable uniquement audit état pathologique dudit patient, ledit état pathologique est enregistré sous la forme d'un texte libre dans ledit EMR personnel. Le texte libre est analysé par un commis aux dossiers médicaux qui attribue un terme clinique codé supplémentaire pouvant être attribué uniquement audit état pathologique dudit patient.
PCT/IL2017/051264 2016-11-21 2017-11-20 Procédé mis en œuvre par ordinateur permettant de créer ou de mettre à jour des dossiers médicaux WO2018092145A1 (fr)

Applications Claiming Priority (2)

Application Number Priority Date Filing Date Title
US201662424585P 2016-11-21 2016-11-21
US62/424,585 2016-11-21

Publications (1)

Publication Number Publication Date
WO2018092145A1 true WO2018092145A1 (fr) 2018-05-24

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PCT/IL2017/051264 WO2018092145A1 (fr) 2016-11-21 2017-11-20 Procédé mis en œuvre par ordinateur permettant de créer ou de mettre à jour des dossiers médicaux

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Cited By (1)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN110471941A (zh) * 2019-08-12 2019-11-19 贵州医渡云技术有限公司 自动定位判断依据的方法、装置及电子设备

Citations (3)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US7725330B2 (en) * 2002-12-03 2010-05-25 Siemens Medical Solutions Usa, Inc. Systems and methods for automated extraction and processing of billing information in patient records
US20150356647A1 (en) * 2014-06-04 2015-12-10 Nuance Communications, Inc. User and engine code handling in medical coding system
US20170323060A1 (en) * 2016-05-04 2017-11-09 Nuance Communications, Inc. User interfaces for medical documentation system utilizing automated natural language understanding

Patent Citations (3)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US7725330B2 (en) * 2002-12-03 2010-05-25 Siemens Medical Solutions Usa, Inc. Systems and methods for automated extraction and processing of billing information in patient records
US20150356647A1 (en) * 2014-06-04 2015-12-10 Nuance Communications, Inc. User and engine code handling in medical coding system
US20170323060A1 (en) * 2016-05-04 2017-11-09 Nuance Communications, Inc. User interfaces for medical documentation system utilizing automated natural language understanding

Cited By (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN110471941A (zh) * 2019-08-12 2019-11-19 贵州医渡云技术有限公司 自动定位判断依据的方法、装置及电子设备
CN110471941B (zh) * 2019-08-12 2020-10-02 贵州医渡云技术有限公司 自动定位判断依据的方法、装置及电子设备

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