CA2325205A1

CA2325205A1 - Computerized risk management module for medical diagnosis

Info

Publication number: CA2325205A1
Application number: CA002325205A
Authority: CA
Inventors: Daniel Joseph Sullivan
Original assignee: Individual
Current assignee: Individual
Priority date: 2000-11-02
Filing date: 2000-11-02
Publication date: 2002-05-02
Also published as: AU2002225838A1; WO2002037389A9; US7197492B2; CA2427636A1; WO2002037389A1; US20020077865A1

Abstract

Apparatus and a method are provided for improving the medical care of patients. The apparatus includes an input device, a medical risk database, a data processor, and a communication device. Data entered in the input device, usually by a health care professional, defines a patient data record. The medical risk database associates certain patient data entered into the data record, which increases the risk of a missed medical care opportunity, with additional medical care to address the risk. The communication device responds to the identification of patient data presenting a medical risk by communicating to a health care professional additional medical care selected to identify and take advantage of a medical care opportunity.

Description

Attorney Docket No. 001400 COMPUTERIZED RISK MANAGEMENT MODULE
FOR MEDICAL DIAGNOSIS
FIELD OF THE INVENTION
This invention generally relates to apparatus and methods for improving medical care. ("Medical care" is broadly defined here to include both medical diagnosis and therapeutic treatment of a patient.) This invention relates more particularly to such apparatus and methods that can be used by a health care professional to avoid making the kinds of professional mistakes that can lead to a significant risk of medical errors, patient injury and legal liability.

BACKGROUND OF THE INVENTION
"Health care professionals" is used broadly here to refer to anyone who participates in the diagnosis or treatment of medical problems. For example, medical doctors, dentists, nurses, nurse-practitioners, medical technologists, physical therapists, and other health workers that assist in examination of patients, diagnosis, or treatment are all included by this term.
A health care professional diagnoses an illness by collecting and evaluating information about the patient, then determining what disease or condition best fits the information. The information gathered from the patient usually is processed to reach a diagnosis by using a protocol learned during the professional's professional training and modified and updated by his or her medical experience. The protocol is an ordered process by which a health care professional ascertains information that allows the professional to rule out possible diseases until enough information is gathered to eliminate all but the diagnosed condition. Alternatively, the protocol may end when an appropriate treatment is identified. Recently, medical associations, health maintenance organizations, and hospitals, among others, have prescribed protocols.
Employed health care professionals in particular are often subject to mandated protocols.
One problem in the field of medicine is how to improve diagnostic protocols to take into account advances in medical knowledge. A related problem is how to ensure that health care professionals update their skills to take advantage of advances in medical knowledge. Still another problem is how to expedite the diagnosis and treatment of certain conditions that should be treated quickly, so treatment can begin soon enough to be most effective.
U.S. Patent No. 6,095,973 discloses a data processing system and method for evaluating the treatment of chest pain patients in a medical facility.
U.S. Patent No. 6,029,138 discloses a decision support system for the selection of a diagnostic test or therapeutic intervention, which are both called ''studies" in that patent.
U.S. Patent No. 4,857,713 discloses a program for reducing hospital errors in the delivery of medications, goods, services or procedures in patient treatment.
U.S. Patent No. 5,732,397 describes an automated system for use in decision-making processes which is said to improve the quality and consistency of decisions made.
U.S. Patent No. x,772,585 discloses a common user interface to allow different 1 S medical personnel access to centralized files regarding patients.
U.S. Patent No. 5,832,450 describes an electronic medical record system that stores data about individual patient encounters in a convenient form.
U.S. Patent No. 5,845,255 describes an electronic prescription creation system for physician use that includes an adverse indication review and online access to comprehensive drug information including scientific literature.

U.S. Patent No. x,911,132 discloses diagnosing and treating patient diseases using a epidemiological database containing medical, personal or epidemiological data relevant to a presented set of symptoms, test results, a diagnosis, etc.
U.S. Patent No. 5,915,240 discloses a context-sensitive medical lookup reference computer system for accessing medical information over a network.
U.S. Patent No. x,924,074 discloses a medical records system that is said to create and maintain all patient data electronically.
U.S. Patent No. 5,953,704 discloses a system in which a user inputs information related to the health condition of an individual.
U.S. Patent No. 6,022,315 discloses a system and method for providing computerized, knowledge-based medical diagnostic and treatment advice to the general public over a telephone network or a computer network.
There is currently a need in the medical field for a system that communicates to a health care professional carrying out a diagnosis that a certain symptom, combination of symptoms, or other patient information recorded by the physician is associated with an increased risk of a missed medical care opportunity leading to a less favorable patient outcome. (A ''medical care opportunity" is defined as an opportunity to correctly or more quickly diagnose or treat the patient's condition and thus provide a better patient outcome.) Further, there is also a need in the medical field for an apparatus communicate to the health care professional special steps to take to avoid the missed medical care opportunity.

BRIEF SUT~VIARY OF THE INVENTION
One aspect of the invention is apparatus for improving the medical care of patients. The apparatus includes an input device, a medical risk database, a data processor, and a communication device.
The input device can be any device that is useful for entering medical data presented by a patient. Data entered in the input device defines a patient data record.
The medical risk database associates certain patient data, which increases the risk of a missed medical care opportunity, with additional medical care. The additional medical care is predetermined action that reduces the risk of a missed medical care opportunity, despite the presentation of the patient data.
The data processor is programmed to compare the patient data record with the medical risk database. This comparison is carried out to identify patient data in the record that increases the risk of a missed medical care opportunity.
The communication device responds to the identification of patient data that increases the risk of a missed medical care opportunity. The communication device responds by communicating to a health care professional additional medical care. The additional medical care is selected to reduce the risk of a missed medical care opportunity.

Another aspect of the invention is an interactive method a health care professional can use for avoiding medical risk while the health care professional is providing medical care to a patient.
The health care professional records medical data presented by the patient in a data storage device, forming data records.
The health care professional has access to a medical risk database maintained on a data storage medium. The database associates certain medical data with additional medical care. The certain medical data is data that increases the risk of a missed medical care opportunity. The additional medical care is something that can be done to reduce the risk of a missed medical care opportunity, despite the presentation of the certain medical data.
A data processor is used to compare the medical data presented by the patient with the medical data in the medical risk database to identify whether medical data presented by the patient is associated with a risk of missed medical care opportunity.
1 S If medical information presented by the patient is associated with a risk of missed medical care opportunity, information about additional medical care that would reduce the risk of a missed medical care opportunity is presented to the health care professional.
Another aspect of the invention is a red-light green-light prompting system that suggests or prompts the health care provider to include the important or critical elements of documentation of a patient's particular medical condition in the medical record. This component of the invention contains some aspects of simple medical logic. For example, the critical elements of documentation for a patient with a laceration are not known until the specific location of the laceration is known. Once the health care provider indicates the location of the laceration, the red-light green-light S prompts then appear at the appropriate locations in the templated medical record.
Prompting systems other than a red-light green-light system can be used.
Another aspect of the invention is immediate electronic access to critical information behind a "key information" icon, at various points throughout the many templates. For example in the shoulder injury template, in the physical exam section for the shoulder, there are three key information icons containing the following information: 1 ) the anatomy of the shoulder; 2) the vascular anatomy of the arm; and 3) the nerve distribution of the arm in a dermatome map. This information is currently available in textbooks, on the Internet, or in policy and protocols. The key information icons make this critical information immediately accessible as the health care provider creates the medical record.
Another aspect of the program is the use of the red-light, green-light system, and a drop down list of acute life threatening emergencies, utilized by the triage nurse to identify, expedite and prioritize patients with these special conditions. This part of the invention contains a special warning to notify the physician and charge nurse in the emergency department. Other types of prompting or warning systems may be used.

BRIEF DESCRIPTION OF THE DRAWINGS
Other objects and advantages of the invention will become apparent upon reading the following detailed description and upon reference to the drawings in which:
Figure 1 is a schematic view of one example of a medical charting system suitable for carrying out the present invention.
Figure 2 shows a portion of an exemplary medical diagnostic template for use with the system of Figure 1 when diagnosing chest pain.
Figure 3 is similar to Figure 2, but shows the template modified to display an activated medical risk icon when an entry is made on the template that the patient has chest pain radiating to the back.
Figure 4 is a pop-up legend presented by the system when the activated medical risk icon is queried to determine the nature of the medical risk.
Figure ~ is an illustration of a screen display of the chest pain electronic medical record template with the red-light, green-light prompts all red.
Figure 6 is an illustration of a screen display of the chest pain electronic medical record template with the red-light, green-light prompts all turned green.
Figures 7 and 8 are the results of a medical research study published in the Supplement to Annals of Emergency Medicine ACEP Research Forum, October 23-23, 2000. Figures 7 and Figure 8 demonstrate compliance with S historical elements of the chest pain evaluation using dictated medical records (Figure 8) and the electronic medical record with red-light green-light prompting.
Figure 9 is an illustration of a screen display of the history section of the electronic medical record laceration template physical examination of the extremity before the health care provider indicates that the laceration involves the hand, ~avrist, ankle or foot.
Figure 10 is an illustration of a screen display of the electronic medical record laceration template physical examination of the extremity before the health care provider indicates that the laceration involves the hand wrist, ankle or foot.
Figure 11 is an illustration of a screen display of the electronic medical record laceration template physical examination of the extremity after the health care provider indicates that the laceration involves the hand wrist, ankle or foot.
Figure 12 is an illustration of a screen display of electronic medical record laceration template physical examination of the extremity showing the information icons as they would appear to a user of the program.
Figure 13 is an illustration of a screen display demonstrating the use of the red-light, green light system to prompt the practitioner to consider the possible differential diagnosis and risk factors for a particular presentation. This figure shows three of the possible high risk diagnoses in the chest pain patient on the "Risk Factor"
line. These include 1) Coronary Artery Disease (CAD) 2) Thoracic Aortic Dissection (TAD) and 3) Pulmonary Embolism (PE).

Figure 14 is an illustration of a screen display demonstrating that the practitioner has turned the red-lights green, thus having considered the differential diagnosis.
Figure 15 is an illustration of a screen display of the electronic medical record shoulder injury template prior to clicking on the key information icon for shoulder anatomy.
Figure 16 is an illustration of a screen display of the electronic medical record shoulder injury template after clicking on the key information icon for shoulder anatomy.

DETAILED DESCRIPTION OF THE INVENTION
While the invention will be described in connection with one or more embodiments, it will be understood that the invention is not limited to those embodiments. On the contrary, the invention includes all alternatives, modifications, and equivalents as may be included within the spirit and scope of the appended claims.
The present inventors have discovered a previously overlooked source of information from which appropriate diagnostic protocols can be developed: the results of medical malpractice claims. Each malpractice claim represents a decision made by a patient that his or her medical care was not appropriate and harmed him or her.
For example, a course prepared by inventor Daniel J. Sullivan, M.D., J.D., High-Risk Acute Care: The Failure to Diagnose (1998) identifies missed medical diagnoses as the principal cause of most malpractice suits. A missed medical diagnosis is defined here to include either the wrong diagnosis or a delayed diagnosis that leads to a materially worse patient outcome. This conclusion was reached by studying over medical malpractice suits to determine what caused the alleged malpractice and what could be done to avoid the alleged malpractice. High-Risk Acute Care: The Failure to Diagnose ( 1998) is incorporated here by reference.
Data about medical malpractice claims has limited scientific value because the data is strongly influenced by non-medical factors. These factors include the differences among the jurors and judges involved in different cases, how credible, worthy, or attractive the plaintiff, the physician, and other parties and witnesses may appear to be, and the skill of the respective lawyers. Other factors include differences in the laws of different states and the common unavailability of data for many claims, particularly claims that are resolved by private settlement instead of by public judgment.
The outcome of cases that proceed to trial depends on whether jurors agree that the care given to the plaintiff that led to the filing of the lawsuit was appropriate.
The amount of damage awarded to a successful plaintiff reflects the jury's impression of how much worse the patient outcome was economically, compared to what it should have been. By putting a dollar value on the harm suffered by the plaintiff, a jury verdict reflects how much importance should be attached to the alleged error in patient care. Again, the medical or scientific communities do not commonly gather this information. It can only be obtained from litigation results.
Despite its limited scientific value, information obtained by studying medical malpractice claims is vitally important to improve diagnostic protocols.
Medical malpractice claim experience largely reflects the attitudes of nonscientific, untrained, 1 ~ ordinary people. Such people have no connection with the scientific or medical worlds.
The information they provide is not reflected in the usual diagnostic protocols, but often should be.
The present invention is not limited to information derived from medical malpractice claims. Any source of the required information, such as clinical experience, scientific experimentation, or the opinions of expert health care professionals is contemplated to be useful here.

One embodiment of the invention is the medical charting system 10 shown in Figure 1. The system 10 generally includes an input device 12, a medical risk database 14, a data processor 16, a communication device 18, and a data link 20.
The input device 12 can be any device that is useful for entering medical data presented by a patient. Data entered in the input device defines a patient data record.
One suitable input device is a cursor-moving device. A cursor moving device can be a pointing device such as a mouse, a track ball, a touchpad, a joystick, a voice-activated cursor directing program, a touch screen that moves a cursor responsive to finger or stylus placement or movement on the screen, etc.
Another suitable input device is a text entry device. A text entry device can be a keyboard for directly entering alphanumeric characters or other information directly. A
non-alphanumeric keyboard can also be used, for example, a keyboard that has programmed keys directly representing the answers to medical questions indicative of medical information. A text entry device can be a text-generating device that converts spoken or handwritten words or characters into text entries. Two examples of text generating devices are a dictation program and the stylus and tablet of a personal digital assistant. Another suitable text entry device is a scanner for reading or copying alphanumeric text, a bar code, or other indicia.
Another type of input device contemplated here is a mechanism for transmitting data to the system 10 from a medical instrument. Examples of suitable medical instruments are an electrocardiograph, an electroencephalogram (EEG), a blood pressure measuring instrument, a pulse monitor, a thermometer, a laboratory machine, an intravenous drug administration monitor, or any others.
Yet another type of input device contemplated here is a communication device allowing a patient to enter data on his or her own patient record. It is advisable to identify the information so entered as coming from the patient, and to limit access of the patient so only appropriate portions of the patient record, such as the portion input by the patient, can be accessed by the patient, and so pertinent information cannot be erased or changed by the patient after it is entered.
Even another type of input device contemplated here is a magnetic strip reader for extracting information from a card carned by the patient, such as medical information that could be recorded on a patient-carried emergency medical information card or insurance card.
Still another type of input device contemplated here is a communication link between preexisting patient records and the medical charting system 10, as for communicating medical history or previous medical treatment information.
Yet another type of input device contemplated here is a communication device adapted to allow for entry of patient information by the attending physician or other medical personnel from the patient's bedside. Such a communication device could be a hand-held computer or the like. It is also contemplated that patient information could be input into the system 10 through a sound input device, such as a microphone or the like, by the attending physician or other medical personnel vocally. Such an embodiment would eliminate the need to input the patient data into the system 10, thereby permitting the physician to treat the patient and input the patient data simultaneously.
The input device is used to input information about a patient. The information is stored as a patient data record 22. Examples are given below of patient record data that is pertinent to determining medical risks.
The patient data record 22 is physically embodied as data stored in any suitable medium. Suitable media include a hard drive, a floppy drive, a tape drive, a magnetic strip (as is often found on a credit card), or any other magnetic medium.
Other suitable media include a CD, the internal memory of a computer, information written on paper or in microfiche form (either readable by a computer or by a physician), or in any other form, without limitation. The data in the patient data record 22 can be digital or analog data in text, numerical, graphic, audible, or any other form perceivable by a health care professional.
1 S The patient data record 22 can be physically stored anywhere. For example, the patient data record 22 can be located in a drive of a portable computer, such as a notebook computer or a personal digital assistant, also providing the input device 12, data processor 16, and communication device 18 for the system. This could be a self contained system carried by a health care professional and used for medical charting.
Alternatively, the patient data record 22 can reside in a remote drive, computer, or server, as shown in Figure l, and be accessed via a data link 20.

The medical risk database 14 associates certain patient data, which increases the risk of a missed medical care opportunity, with additional medical care. The additional medical care is predetermined action that reduces the risk. Examples of the information in the medical risk database 14 are provided below.
The medical risk database 14 is physically embodied as data stored in any suitable medium. Suitable magnetic media include a hard drive, a floppy drive, a tape drive, a magnetic strip such as the type often found on a credit card, or any other magnetic medium. Other suitable media include a CD, the internal memory of a computer, information recorded in paper or microfiche form (either readable by a computer or by a physician), or in any other form. The data in the medical risk database 14 can be digital or analog data in text, numerical, graphic, audible, or other perceivable form. 'The media in which the medical risk database and patient data record can be stored can be the same medium or different media. Either of them can be stored in more than one place or in more than one medium. In a simple embodiment, the database 14 can be built into the template 24 shown in Figure 2 below, so entering certain patient data can prompt the presentation of a message that certain medical action is recommended.
The medical risk database 14 can be physically located anywhere. For example, the medical risk database 14 can be located in a drive of a notebook computer or personal digital assistant also providing the input device 12, data processor 16, and communication device 18 for the system. Alternatively, the medical risk database 14 can reside in a remote drive or computer, as shown in Figure 1, and be accessed via a data link 20. It likewise can be either network based or Internet based.
The medical risk database 14 can be updated to reflect recent medical or legal experience. The updated database can be updated by providing a subscription CD
or Internet download service, by updating a central database that is accessed by many health care professionals, or by any other effective method.
The data processor 16 is programmed to compare the patient data record 22 with the medical risk database 14. This comparison is carried out to identify patient data in the record 22 that increases the risk of a missed medical care opportunity.
The data processor 16 can have any suitable form or configuration. It can be a dedicated microprocessor, a programmed general-purpose computer, or any other mechanical or electronic processing device. In a simple form of the system, the data processor can be used simply to update the display to present a communication, responsive to the entry of certain patient data.
The communication device 18 is any type of device that communicates to a health care professional the presence of an increased medical risk, based on the identification by the data processor of information in the patient data record 22 that increases the risk of a missed medical care opportunity. The communication device 18 responds by communicating to a health care professional proposed additional medical care. The additional medical care is selected to reduce the risk of a missed medical care opportunity.

One suitable embodiment of the communication device 18, illustrated in Figure l, is a video display operatively connected to the data processor 16 to display an indication of appropriate additional medical care. Another suitable embodiment of the communication device 18 is an alarm providing a signal perceptible to a health care ~ professional. The alarm can be a visible warning, like a symbol on a graphical display or a warning light. The alarm can be an audible warning. The alarm can be a tactile warning, such as a signal sent to a vibrating pager, cellular telephone, or personal digital assistant worn or carned by the health care professional. The alarm can also be presented remotely, as to another health care professional who can attend to the alarm condition. In various embodiments, the alarm can be presented locally only, remotely only, or both locally and remotely.
The alarm can be arranged to ordinarily be selectively perceptible to a health care professional and not to the patient. For example, it can be presented as a visual display on a terminal screen that is selectively viewable from one angle, presented 1 S toward the health care professional, and not from another angle where the patient's eyes are positioned.
The alarm can be encoded, to avoid alarming a patient who happens to encounter it. For example, it can be presented as a non-threatening icon on a visual display or a non-threatening sound. For another example, it can be made to appear or sound like something ordinary in the medical environment, such as an innocuous page on a public address system that is known only to the health care professional to relate to patient data being entered.
The data link 20 can be any means of communication of voice, data, or visual information now known or developed in the future. For example, the link 20 can be a telephone line, an Internet communication pathway (such as a telephone modem link, a dedicated link, a cable modem link, or a satellite link), computer wiring in a hospital or medical office, or any other communication path.
Another aspect of the invention is an interactive method a health care professional can use for avoiding medical risk while the health care professional is providing medical care to a patient.
The health care professional records medical data presented by the patient in a data storage device, forming a patient data record 22.
The health care professional has access to a medical risk database 14 maintained on a data storage medium. The database 14 associates certain medical data in the patient data record 22 with additional medical care. The health care professional uses a data processor 16 to compare the medical data presented by the patient data record 22 with the medical data in the medical risk database 14 to identify whether medical data presented by the patient is associated with a risk of missed medical care opportunity. If so, information about additional medical care that would reduce the risk of a missed medical care opportunity is presented to the attending medical health care professional.

Examples of Associations in the Medical Risk Database Examples 1-5 presented in tables at the end of this specification are examples of associations between patient data, increased medical risk, and one or more proposed medical responses that can optionally be made by the medical risk database 14.
Two examples of proposed medical responses are diagnostic steps, as shown in several of the examples, or treatment steps, shown for example in the Neck Pain table of Example 2.
The associations presented here are merely exemplary. A skilled health care professional who is familiar with the present disclosure and investigates medical liability results can readily find additional or alternative associations of the same type, useful for addressing the same or other medical conditions. Medical risk information is available from Daniel J. Sullivan, M.D., J.D., High-Risk Acute Care: The Failure to Diagnose ( 1998). This publication is incorporated by reference. A medical risk database incorporated in the PulseCheck~ medical charting system is commercially available from IBEX Systems Group, Ltd. sometimes known as IBEX Healthdata Systems, 5600 N. River Road, Suite 150, Rosemont, IL 60018. The templates and medical risk data of the PulseCheck~ medical charting system are incorporated by reference here. Other templates, medical risk data and medical charting systems can be used.
No representation is made that a health care professional should always follow the proposed advice, since it is not wise to rely solely on a preprogrammed database, unassisted by the judgment of a health care professional. The purpose of the medical risk database is simply to provide timely information to the health care professional that identifies and addresses a risk as it is presented.
Communication of Medical Risk Figure 2 shows a portion of an exemplary diagnostic template 24 that can be displayed on the communication device 18 when diagnosing a patient who complains of chest pain. This template 24, as with each template, includes a plurality of template sections. Each subsection 25 includes a plurality of queries 26, each relating to an observable patient medical condition (i.e.: whether the patient is vomiting, is nauseated, has chest pain). A query could be presented in the form of a checkable box (as with the query indicated as reference numeral 26a. Each query 26 includes a query heading 27 which identifies the patient medical condition for which the user is to input information. In the preferred embodiment, each query 26 includes a plurality of preselected observations (noted below) which the user can select. Each subsection also includes a plurality of qualifying statements, indicated generally as 26a, each having a checkable box. These qualifying statements can be selected by the user to narrow or further describe the information input by the user into the relevant query 26.
The template 24 as shown in FIG. 2 is in its initial condition, before a health care professional begins to respond to questions raised by the template or before the health care professional begins to input information into the queries 26. For example, the template 24 includes a query 26 to determine whether the chest pain is radiating toward the back. If not, ''none'' is marked by placing the cursor 28 on the "none"
legend 30 for that answer and activating the choice (as by clicking a mouse button, if the cursor is moved by a mouse). The communication device 18 then displays that answer and the user is free to move on to other questions.
If the health care professional determines that the patient has chest pain radiating toward the back, "yes" is marked by placing the cursor 28 on the "to back"
legend 32 for that answer and activating the choice. Other choices not shown in Figure 2 are accessed by operating a scrolling button 34. Responsive to that answer, an icon 36 indicative of an increased medical risk is presented on the communication device 18.
This icon 36 is displayed in Figure 3, and is a fire-shaped, brightly colored icon that contrasts by its larger size and brighter red and orange colors with other indicia on the template 24. The icon 36 is also visible in Figure 2, but is muted in color in Figure 2 because it is not activated. The icon 36 is present in muted form before it is activated so a health care professional will not overlook the inquiry that activates the icon 36 when necessary.
Upon activation of the icon 36, the health care professional can click on or otherwise query the icon 36. This might be done to find out what medical risk is presented or what additional medical care is necessary to reduce the medical risk resulting when the chest pain presented by the patient is radiating toward the back.

This query causes an additional care legend or message to be presented on the communication device 18, such as the pop-up legend 38 shown as Figure 4:
"Recommendation: Consider the diagnosis of Thoracic Aortic Dissection (TAD).
Measure bilateral arm blood pressure, if possible. Look at the X-ray specifically for signs of TAD (e.g. abnormal aortic contour, widening or mediastinum, deviation of the trachea or mainstem bronchi). Document your observations." Thus, additional diagnostic steps are recommended to evaluate whether a TAD is present. The health care professional also is strongly encouraged to document his observations so the fact that the possibility of a TAD was thoroughly and quickly evaluated can be verified.
The medical risk raised by the symptom of chest pain radiating toward the back is that a TAD will be missed, as this is a condition that sometimes is not found quickly enough when a chest pain complaint is evaluated. This fact was ascertained by reviewing the scientific medical literature and the results of malpractice actions in which liability was found because a TAD allegedly should have been diagnosed soon enough to avoid further complications, but was not.
This medical risk has two components. One component is that a health care professional must recognize the possibility of a TAD very rapidly to reach the best possible patient outcome.
The other component is that, even if the health care professional quickly recognizes and properly evaluates the possibility of a TAD, but rules it out as inconsistent with other diagnostic indications, the pertinent facts must be documented in the patient's chart immediately. Even if the patient's condition has been properly evaluated as ruling out a TAD, an anomalous TAD could exist that would not have been recognized by even a skilled physician. Alternatively, the patient might not be suffering from a TAD initially, but may develop this condition shortly after the diagnosis that no TAD is present. If the symptoms presented by the patient at the time of diagnosis are properly and quickly evaluated and documented, the best possible care has been given, and the health care professional will be able to show this fact by reference to the patient's chart.
The present invention addresses the need to quickly evaluate and document TAD in a patient presenting chest pain that radiates to the back. The template responds to the selection of this characterization of the chest pain immediately by presenting a distinctive and unusual warning, here the fire icon 36, that additional diagnostic work is necessary to rule out an increased medical risk of a TAD in this instance. This information is presented only when it is needed, so if this condition is not presented there is no need to alarm or distract the medical health professional by presenting this information.
The present invention works equally well to signal the need for additional care, whether diagnostic or therapeutic, when other conditions posing an increased medical risk are presented.

Red-Light Green-Light Prompting Insurance company data and the scientific medical literature clearly indicate that poor medical record documentation, inadequate history taking and inadequate physical examinations are among the leading causes of medical errors, patient injuries and medical malpractice lawsuits. This part of the invention is designed to prompt health care practitioners to address factors in the history and physical examination that are critical to documenting a complete medical record, identifying important factors in the patient's history and physical examination, reduction in medical errors and resulting medical malpractice lawsuits.
The factors deemed critical to medical record documentation have been identified through an investigation by Daniel J. Sullivan, M.D., J.D., FACEP, into the scientific medical literature (multiple publications in the ED Legal Letter), and an analysis of over 100 malpractice lawsuits published in Dr. Sullivan's High Risk Acute Care: The Failure to Diagnose, noted herein above.
As noted above and as shown in Figures 2, 3, S and 6, each template 24 includes a plurality of queries 26. Each query 26 includes a red light prompt 52 and a green light prompt 54. The program displays or highlights the red light prompt 52 (as shown in FIG. 2) when no input has been entered into the query 26 by the user.
However, then the user inputs information into the query 26, the program displays or highlights the green light prompt 54. The prompts 52, 54 provide a visual display indicating to the user whether information has been observed or collected and input in the system 10. The red light prompts 54 and the green light prompts 52 form a red-light, green-light system. Other types of prompts are possible.
After the user has finished completing all of the relevant templates 24, the program generates a report indicating whether a user input information into each query 26 (even if such information indicates that no observations were present or observable for a particular condition). Thereby providing a record and a report which can later be used for assessments, teaching, litigation, etc. regarding what actions were specifically taken by the user, and whether certain observations were made.
The red-light, green-light system are merely prompts, they are not mandatory.
However, use of these prompts in a research setting, has led to an unprecedented level of documentation as demonstrated through the published, juried, scientific publication of Supplement to Annals of Emergency Medicine, October 2000 Volume 36 Number 4, Abstract # 216 entitled "On-Line Risk Management Combined With Template-Based Charting Improves the Documentation of Key Historical Data in Patients Presenting With Chest Pain". (See, Appendix A hereto).
In addition, the use of the electronic template format allows the application of medical logic. It is impossible to know what factors in the history and physical examination are essential in patient care without some initial input from the practitioner. Once the practitioner begins entering information, the risk program responds by allowing previously invisible red-lights, green lights to become visible.
See the following examples:
' Template User Input ~ System ' i Red-light, green light, previously invisible now lights up next to I
bilateral blood pressures in the I cardiovascular examination.
Thus, ' I

' ~ the practitioner measures i bilateral Practitioner indicatesblood pressures, documents that the j chest pain radiates result, specifically looking to the for and back. (see reference documenting the examination number for a Chest Pain 56 in Figure 7) Thoracic Aortic Dissection.

Red-lights, green-lights previously ' I invisible in the extremity examination now light up. If the ' injury is in the extremity, critical il documentation includes ~ examination of the pulses, distal ~I Practitioner indicates in the I~ Laceration histo that the laceration neurologic system and tendons.
~' ' Template ~ involves an extremity. (see figures 10 through 12) The red-light, green light prompts 52, 54 also assist the practitioner in considering the differential diagnosis. In the typical patient medical presentation, the patient first states a problem. Based upon this problem, or chief complaint, the practitioner then considers a list of possible diagnoses, called the differential diagnosis.
This list of possible diagnoses guides the practitioner as to what questions to ask, what organ systems to evaluate, and which diagnostic tests to order. The prompts 52, 54 assist the practitioner in considering the diagnoses, which are prone to being missed, or a particularly high-risk to the patient (i.e.: family history of certain illnesses, hypertension, etc.). The differential diagnosis each have a drop down list of risk factors 62, allowing the physician a method for immediate recall of difficult to remember historical items.
This function is demonstrated in Figure 13 and 14. Figure 13 is an illustration of the risk factor section 25 of a template 24 as it would appear prior to entry of information in the queries 26. As shown in Figure 14, upon selection of a risk factor in the first query, indicated as reference numeral 72, the system 10 highlights that query's green light prompt 54, and displays the fire icon 36 indicating to the user that a missed care opportunity may be present. Upon selection of the icon 36 by the user, a pop-up legend 38 (as illustrated in Figure 4) appears indicating other observations, which should be performed by the health care provider. As noted above, the recommended observations are derived from prior occasions where a health care provider made an incorrect diagnosis because of the lack of additional observations by the health care provider.
Key Information Icons Medical Practice is complex. Practitioners must remember or refer to a reference for a wide range of information. In actual practice, it is not possible to remember for an entire career, long lists of nerves with their specific function, long lists of tendons and how to test them, trauma scoring, croup scoring, Apgar scoring for the newborn, new standards of care and too many other lists, scores and other items to mention.
The simple fact is that practitioners need immediate reference to large amounts of diverse information that is often not immediately available in text, or on line. In addition, the busy practitioner seldom has time for looking up reference information.
As shown in FIG. 10, 11 and 12, based upon research and practice, the program provides immediate access via key information icons 58 to lists of critical information, anatomical drawings, scores of various kinds, updates on standards of care, tendon identification and testing. This information may be stored within the system 10, or may be accessed via the Internet or a Local Access Network (LAN) or the like.
Further, this information may be graphical or textual.
Figure 15 is a screen display illustrating a subsection 25 of the shoulder injury.
There are four key information icons 58 in the gray area labeled "extremity examination". The practitioner can place a cursor or touch mechanism over the labeled icons 58 and with a single click, the program will provide an information icon screen display 74 which demonstrates the anatomy of the shoulder (see Figure 16).
Thus, the practitioner has immediate access to information, which simply may not be available in many medical settings.
Immediate Identification of High Risk Diagnoses When patients present to an emergency department with a medical problem, in most cases, they first see a nurse in an area outside of the department, called triage.
Triage is the sorting of patients by severity of illness. There are several diagnoses which are so acute, that intervention must be immediate or the patient may suffer severe injury. It is critical that the staff in triage recognize this small group of acute emergencies and communicates this to the appropriate individuals, such as the physician on duty in the emergency department or the charge nurse. The group of diagnoses includes such things as the following: chest pain in a patient over 35 years of age; a patient presenting a cold pulse-less extremity; a child under 2 months of age with a fever, etc.
This invention provides the triage nurse with an electronic template, which includes a drop down list of these high risk acute presentations. That part of the template contains a red-light, green-light prompt in order to obtain a high level of compliance with the use of this function. If the nurse chooses one of these high risk diagnoses, the program immediately pops up a warning indicating that immediate notification of the physician or charge nurse must occur. In this fashion, the combination of the red-light, green-light prompt and the high risk list assists the nurse in quickly identifying the acute emergencies and making the patient a high priority for treatment in the emergency department. Other types of prompts can be used.

Example 1: Abdominal Pain Patient Data Medical Risk Proposed Response the patient is A pregnant patient Perform an ultrasound pregnant suffering study from abdominal pain of the fetus and surrounding may have an ectopic pregnancy,maternal tissue.

which is not necessarily determinable by physical examination and may be misdiagnosed as another condition.

woman of child Patients reporting Test for pregnancy bearing information age with abdominalinconsistent with pregnancy, pain such as abstinence from intercourse, recent menstruation, or the use of contraceptives often are nonetheless pregnant.
When a pregnant person presents abdominal pain, the diagnosis of (cont' d) ectopic pregnancy should be considered.

sudden onset of A vascular event that Test for a vascular requires event abdominal pain quick treatment, such as abdominal aortic aneurysm (AAA), may have occurred.

AAA is often overlooked, as it can be difficult to diagnose.

Example I: Abdominal Pain Patient Data Medical Risk Proposed Response The patient's An AAA, which requiresTest for AAA

abdominal pain quick treatment, may radiates have to the back or occurred.
to the flank.

Example 2: Neck Pain Patient Data Medical Risk Proposed Response Blunt spine injuryIn a number of cases,Blunt spine injury less is treated than eight hours liability has been with high dose before found the time of diagnosis.because the patient methylprednisolone was if diagnosed with a spinaltreatment is begun cord within eight injury several hours hours of the injury.
(but The fewer than eight hours)literature does not after demonstrate the injury, but any benefit beyond eight methylprednisolone hours.

treatment to reverse 30 mg/kg bolus the effects of spinal administered IV over cord injury was not started early15 min.
enough to improve the patient45 min. pause outcome. Maintenance infusion 5.4 mg/kg/hr for 23 hours The patient is The intoxication may Liberal ordering of mask the trauma intoxicated with the effects of cervicalC-Spine series is spinal alcohol or other cord injury or renderrecommended in this the setting.

intoxicants. patient unable or unwilling to cooperate.

(cont' d) Example 2: Neck Pain Patient Data Medical Risk Proposed Response Neck pain, but Spinal cord injuries Don't rely solely on no do radiologic (i.e.not always coincide the absence of radiological bone) with abnormality in spine damage visible abnormality and of the x- on x- present ray and no apparentrays or stable neurologicalneurological symptoms.
Look neurological changes. Transient carefully at EMT (emergency changes.

neurologic changes medical technician) may and occur before the emergencynursing notes relating back to department visit, and the time of the injury.
not be present in the emergencyIf there is prior evidence of a department. Spinal neurologic sign or Cord symptom, Injury Without Radiologicalneurosurgical consultation, a Abnormality (SCIWORA) period of observation or is often very difficulthospital admission to are diagnose, sometimes recommended.
with catastrophic results.

Example 3: Chest Pain Patient Data Medical Risk Proposed Response Chest Pain RadiatingThis is a characteristicConsider the diagnosis to of TAD

Measure bilateral arm the Back symptom of Thoracic Aortic blood pressure, if possible.

Dissection (TAD), . Look at the x-ray which is often missed in diagnosisspecifically for signs of TAD (e.g. abnormal aortic because it often contour, widening or resembles other, less-criticalmediastinum, deviation of the trachea or mainstem conditions. TAD mustbronchi).
be quickly diagnosed Document your and observations.

treated to avoid death.

Chest pain PLUS: Where chest pain Do one of the following:
is the only One major risk clinically apparent Obtain cardiology symptom factor of an acute myocardialconsultation (smoking, infarction (AMI), . Observation status that to hypertension, diagnosis is often rule out myocardial diabetes, family prematurely ruled infarction out in history (Hx), favor of other possible. Admit high conditions (often due to cholesterol) or coinciding symptoms of A history of lesser problems, like coronary artery (cont'd) disease indigestion) and the patient is discharged. This delayed or missed diagnosis frequently results in death of the patient.

Example 4: Headache Patient Data Medical Risk Proposed Response This is reported This is a two-step risk.(1) Order a non-infused as First, a CT

the worst headachevery bad headache may of the head to rule be out a of the patient's caused by a subarachnoidsubarachnoid entire life. hemorrhage. Even thoughhemorrhage.
few severe headaches are (2) Proceed with caused by lumbar a subarachnoid hemorrhage,puncture even if the the CT of patient outcome is poorthe head is read unless as negative the condition is quicklyfor bleeding.

diagnosed and treated.

Second, even if a 4'h generation CT of the head is carried out, sometimes it will not be read as showing bleeding when the patient in fact has a subarachnoid hemorrhage.

Example 5: Testicular Pain Patient Data Medical Risk Proposed Response Abdominal pain, Torsion of the Consider torsion in the but no testicle differential testicular pain is a difficult diagnosis.
diagnosis, and is often missed, as often the patient's site of discomfort is in the abdomen, rather than the testicles.

sudden onset of Sudden onset of Immediately consider the pain severe diagnosis pain should rule of torsion testicle out epididymitis, but often does not. Torsion testicle must be immediately diagnosed, since salvage of the testicle is only highly probable within six hours of the onset of pain.

The foregoing description of an embodiment of the invention has been presented for purposes of illustration and description, and is not intended to be exhaustive or to limit the invention to the precise form disclosed. The description was selected to best explain the principles of the invention and practical application of these principles to enable others skilled in the art to best utilize the invention in various embodiments and various modifications as are suited to the particular use contemplated. It is intended that the scope of the invention not be limited by the specification, but be defined by the claims as set forth below.

Claims

What is claimed is:

1. Apparatus for improving the medical care of patients, comprising:
A. an input device for entering medical data presented by a patient, the data defining a patient data record;
B. a medical risk database that associates:
i. certain patient data in said patient data record that increases the risk of a missed medical care opportunity, with ii. additional medical care that would reduce the risk of a missed medical care opportunity, despite the presentation of said certain patient data;
C. a data processor programmed to compare said patient data record with said medical risk database to identify patient data in said record that increases the risk of a missed medical care opportunity;
D. a communication device, responsive to the identification of patient data that increases the risk of a missed medical care opportunity, that communicates additional medical care that will reduce the risk of a missed medical care opportunity.