US20060212452A1

US20060212452A1 - System and method for remotely inputting and retrieving records and generating reports

Info

Publication number: US20060212452A1
Application number: US11/083,865
Authority: US
Inventors: Louis Cornacchia
Original assignee: Individual
Current assignee: Individual
Priority date: 2005-03-18
Filing date: 2005-03-18
Publication date: 2006-09-21
Also published as: WO2006101770A2; US7725479B2; US7877683B2; WO2006101770A3; US20070033174A1; US20070033033A1; US20070038948A1

Abstract

A computer-based system and method is provided for remotely accessing stored record and remotely inputting data, comprising: accessing by a user a record stored remotely in a database via an electronic network; displaying a portion of the accessed record as at least one hypertext page, the hypertext page comprising pre-filled text, at least one selectable hyperlinked object, and a box for receiving information input by the user, wherein the information input by the user is by a combination of voice dictation and one of pointing, clicking, or typing; and sending the information input by the user over the electronic network to be stored as part of the record in the database. The electronic network is one of a local area network and the internet.

Description

BACKGROUND OF THE INVENTION

1. Technical Field
The present invention relates to an electronic storage and retrieval system and method for remotely inputting data and records and for generating reports; specifically, an electronic storage and retrieval system and method for facilitating interactive computer and dictation input of data and records and to automatically generate reports.
2. Discussion of Related Art
It has been the practice of professionals, such as doctors, lawyers, and engineers to personally record pertinent information on a subject patient, client, or matter so that professional services performed and data pertinent to the subject are documented. The documented information can be in many different forms, such as a patient database with patient demographic and clinical data, an engineer's report on the structural conditions of a building, or an invoice for professional services performed. In many instances, the professional memorializes the pertinent data contemporaneously as services are performed, such as by handwritten notes or by dictation into a voice recorder, and the information is subsequently gathered for an office staff personnel to enter into a report. Many reports are standardized as forms and the gathered information is filled into the form for efficient reporting. For example, in the case of a physician examining a patient, clinical information for a patient is developed during discussions with and the physical examination of a patient. The physician makes dictation or writes the clinical information observed during the examination and the forms and notes are typically later entered by a medical staff in the physician's office. Likewise, an engineer may be inspecting a building and dictates his observations on the conditions of the building and a building inspection report can be generated by filling in a form-like report with standard pre-filled text on general building condition, supplemented by contemporaneous information using the recorded dictation.
In the case of patient information and report, a patient is typically required to complete a questionnaire which discloses personal information about a patient, including background medical information and pre-existing medical conditions. The questionnaire may also establish a patient's current medical condition. A patient's history file is opened and contains the completed questionnaire along with other documents.
As part of the physical examination, the physician makes a determination as to the medical condition of a patient and this is generally referred to as the patient diagnosis. Also, the physician makes a determination as to how a diagnosed medical condition is to be treated medically and this is generally referred to as a patient treatment plan. The information derived from the examination is also referred to as clinical information.
When a patient is examined by a physician, the results of the physical examination or clinical information are typically recorded by the physician entering the information manually onto a form which is then placed in the patient's history file. Also, it is common practice for the healthcare professional to make hand notes during the patient's physical examination. The hand notes are later used by the physician for personally dictating a patient's report. The dictation is then transcribed, reviewed and signed by the physician who conducted the patient's physical examination.
The practice of dictating and transcribing is widely used to record information in the medical and other fields. Physicians have been increasingly burdened by the need to document every encounter with patients. Physicians must record information about each patient's office visit, diagnosis, suggested treatment and prescription given. In addition to recording patient's information, physicians must fill out forms for submission to insurance companies and provide information to regulatory agencies. Physicians spend a significant portion of their work day gathering and dictating the needed information for each record or form. Further, a physician must maintain a staff to transcribe the information into reports and fill out required forms.
Additionally, as many medical offices operating under health maintenance organization (HMO) oversight are required to audit the examination notes of medical professionals for consistency and trends in diagnosis and treatment, the lack of computerized databases for monitoring and updating clinical examination data and the time consuming process of re-transcribing and editing paper charts into a computer database can complicate this auditing process.
There are a number of medical history documentation systems known in the art which are intended to more efficiently and effectively gather and/or document medical information of a patient. Some examples of medical documentation systems are provided below.
U.S. Pat. No. 4,428,733 discloses an information gathering system used for obtaining medical information from a patient. The system has one or more question sheets bearing a set of questions, usually medical questions written in the language of the patient. A separate answer sheet is provided, upon which the patient provides answers the questions. The answer sheet has information concerning each possible answer. A mechanism is preferably provided for positioning and holding the answer sheet in a predetermined position relative to the question sheets to enable the patient to see the information on the answer sheet as well as the questions.
U.S. Pat. No. 3,913,118 discloses a process and apparatus for accurately recording medical and personal information obtained from a medical patient or a prescription customer. This process and apparatus expedited accounting and bookkeeping procedures related to the medical treatment or transcription services furnished the patient or customer. A transparent matrix has pre-printed thereon in permanent ink portion of a form for recording information to be submitted for payment to a medical program for professional services rendered to the patient or member of the program. The matrix also includes a means forming a pocket thereon for receiving and holding an identification card or other information bearing form, such as a prescription order or the like.
U.S. Pat. No. 4,991,091 discloses a self-contained apparatus used personally by a physician during patient examination. The apparatus is battery operated and can be programmed to alter or modify examination information or produce a permanent record of examination results. The apparatus includes a pen board which includes microprocessor based controller with internal memory having prestored thereon sets of specific examination indicia which are displayed by liquid crystal displays (“LCDs”). The patient's name is displayed on an LCD. Associated with the specific examination indicia are one or more light emitting diodes (“LEDs”) and corresponding bar codes which represent permanently pre-printed indicia representations.
General information diagnosis categories are identified by suitable words such as “Vital Signs”. Also, LEDs and bar codes are provided for general examination and treatment categories such as, for example, “Chemistry Profile.” The bar codes are used with a light pen for optically identifying the corresponding category and the LED adjacent to each category indicia are illuminated for indicating the category selected by the physician. The controller includes suitable memory for storing patient examination information, for controlled programming of the operating panel and for down loading data to a central computer. A light pen provides input to a microcontroller to manipulate scanning in one or more bar code panels. The concept is based on the examining physician personally using the pen board, light pen and microprocessor during the examination procedure to record medical information.
U.S. Pat. No. 5,267,155 describes a document generation system which automates the documentation process in the medical field. The system provides a computer-based documentation system incorporating a retrievable database with a menu driver and graphic window environment. The documentation system utilizes previously defined document templates or “boiler-plates” to manage Patient Reports and includes user interface for use in selecting phrases to be inserted in the template.
The system contemplates that the physician personally conducts a patient examination and either generates personal notes which the physician can use later for dictation or the physician personally fills out a checklist. In this manner, the physician reports of the patient examination can vary for each patient. The input for the report is prepared directly by the physician and can contain any number of variable responses. Each variable response may include different options, such as options on a menu of a computer. The physician can then personally modify and customize the report document throughout by inserting words into the generated document with the use of an integrated word processor. When the physician personally completes a checklist, another individual can generated the desired document from information checked off by the physician on the checklist.
U.S. Pat. No. 6,026,363 discloses a medical history documentation system and method for recording information relating to at least one of a designed patient's current medical condition, a physical examination, a diagnosis and a treatment plan. The system includes a recording member having a plurality of discrete recording sections formed thereon programmed for recording information relating to the patient. The encoded indicia is communicated by a first person to a second person during a physical examination of the patient by the first person. An input member is used by the second person for recording medical information in the form of predetermined encoded indicia in applicable discrete recording sections of the recording member. A transcriber having a plurality of report section templates is used. Each report section template corresponds to a discrete recording section. Each of the report section templates comprise a plurality of optional text variable segment each of which are assigned to a selected one of the predetermined encoded indicia. The transcriber is operative to decode each one of the predetermined encoded indicia recorded on the recording member. An imaging device responsive to the transcriber prepares a patient's report specific to the designated patient.
Despite the advances in the art, there is a need for a system and method for facilitating interactive dictation of data and records and to automatically generate reports. A need also exists for a system and method of managing medical records for concurrently recording patient history and/or examination notes, if so desired, during patient examination. A further need exists to have a system and method of managing medical records in which the physician may document (e.g., by dictating or transcribing) the medical information by voice dictation over a global electronic network.
It is an aspect of the present invention to provide a comprehensive system and method of managing records, such as medical records, in which the system, through a voice driven, voice entry interactive mechanism, facilitates the medical professional to input information and to generate a report.
It is another aspect of the present invention to provide a system and method for managing medical records through a computer program that provides for specific pre-encoded indicia of medical information, such as medical codes, basis for billing, symptoms, standard phrases and templates that are physician specific.
It is another aspect of the present invention to provide for a system and method for managing medical records in which the computer program used provides for patient specific data.
It is another aspect of the present invention to provide for a system and method for managing medical records in which the computer program provides a basis for editorial using voice input.
It is another aspect of the present invention to provide for a system and method for managing medical records in which the system associated therewith provides a basis for generating reports and in various desirable forms.
It is another aspect of the present invention to provide for a system and method for managing medical records in which the system associated therewith is transmitted through the internet and the data input can be based on voice dictation, text input or by point and click mechanism.
These and other aspects of the invention will be apparent to those skilled in the art from the following detailed description of the invention, the accompanying drawing and the appended claims.

SUMMARY OF THE INVENTION

A computer-based system and method is provided for remotely accessing stored record and remotely inputting data, comprising: accessing by a user a record stored remotely in a database via an electronic network; displaying a portion of the accessed record as at least one hypertext page, the hypertext page comprising pre-filled text, at least one selectable hyperlinked object, and a box for receiving information input by the user, wherein the information input by the user is by a combination of voice dictation and one of pointing, clicking, or typing; and sending the information input by the user over the electronic network to be stored as part of the record in the database. The electronic network is one of a local area network and the internet.
One aspect of the invention is a computer-based method for managing medical records through electronic network, the method comprises: accessing a database; compiling and updating a patient medical data comprising at least one of patient medical history and patient physical examination in the database; and dictating a medical report based on the patient medical data.
Another aspect of the invention is a computer-based method for managing medical records and dictating medical records through the internet, the method comprises: accessing a dedicated database in the electronic network; and dictating a medical report.
Yet another aspect of the invention is a computer-based method for dictating medical information through a electronic network, the method comprises: accessing a dedicated database in the electronic network, the database capable of recognizing voice and textual data; and dictating medical information on the database.
Yet another aspect of the invention is a computer-based system capable for dictating medical information through the internet interface, the system comprises: a central computer network interface comprising inputting, storing and retrieving means for electronic database files, a coordination means for coordinating input electronic signals for storing and retrieving data in the electronic database filed, and a memory means for maintaining data in the electronic database files; a network server means that is in communication with the central computer network interface; and a user work station that is in communication with the network server.
The aspects of the present invention will become apparent from the following detailed description of illustrated embodiments thereof, which is to be read in connection with the accompanying drawings.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows a computer network suitable for use in accordance with an embodiment of the present invention.
FIG. 1A shows an exemplary process in speaker identification/authentication according to an embodiment of the invention.
FIG. 2 shows the access page of the user to log into the database in accordance with an embodiment of the present invention.
FIG. 2A shows an exemplary emergency access process according to an embodiment of the present invention.
FIG. 3 shows the Physician Greetings page to allow the user to select one of several locations for which the user accesses the database in accordance with an embodiment of the present invention.
FIG. 4 shows the Scheduling Page for a specific location to enable the user to review patient scheduling in the selected location in accordance with an embodiment of the present invention.
FIG. 5 shows the Dictate All page that allows the user to dictate medical information in accordance with an embodiment of the present invention.
FIG. 5A shows an HPI page.
FIG. 6 shows the Prefix Phrase page to allow the user to pre-record commonly used phrases to facilitate in the dictation process in accordance with an embodiment of the present invention.
FIG. 7 shows the Demographics page that allows the user to review the demographics of a patient while dictating a report in accordance with an embodiment of the present invention.
FIG. 8 shows the Dictate Correspondence page that allows the user to dictate a report directing the correspondence to others in accordance with an embodiment of the present invention.
FIG. 9 is a Report page summarizing the medical information of a patient in accordance with an embodiment of the present invention.
FIG. 10 shows the Medical Record Screen page that provides the user with several ways of searching a patient's medical record in accordance with an embodiment of the present invention.
FIG. 11 shows the Accounting Setting page that provides the user with options for setting up the account in accordance with an embodiment of the present invention.
FIG. 12 shows an exemplary voice transcription page accessible from the Transcription Portal.

DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS

According to an embodiment of the present invention, a new method and apparatus is provided for facilitating entry of records by either point, click, or type with computer interfaces, or by voice dictation, or by a combination of point, click, type, and dictate. The entry of records is stored in an electronic database. The entry of records can be communicated over an electronic network. The illustrative embodiments are explained herein for entry, documentation, and reporting of medical records, but one skilled in the art readily appreciates that the system and method can be applicable for other professional or commercial services and reports.
FIG. 1 provides a computer network system in accordance with an embodiment of the present invention. In FIG. 1, the computer network system 10 comprises a central server 20, which includes a central controller 22, memory 36, various software modules including a voice processing unit 24, a speaker identification unit 26, and word processing/transcription unit 28. Each software module may include associated cache memory to facilitate direct and speedy access to corresponding stored templates or data. For example, the voice processing unit 24 includes speech recognition capability to facilitate recognition of voice input by a user over a network (described below). The associated memory may store the user's pre-recorded (or templated) words and phrases to facilitate the voice recognition process. The speaker identification unit 26 is used to identify users seeking entry into the system. The word processing/transcription unit 28, along with template files 30, transcribes entries of medical information from voice into text. The template files 30 may store pages of templates accessible through the network from a browser at the user's computer terminal 52. The memory 36 stores executable codes executable by central controller 22 to perform processes including accessing records from memory and storing data including data usable by the central server 20 to communicate with subscriber users, subscriber authentication data, medical records, etc.
A network server 40 includes modules to facilitate access to/from the central server 20 to computers/servers connected to the network. The network server modules interface the servers using local area network (LAN) protocol in a LAN environment or, preferably uses internet protocol (IP) to interface the client stations/servers to the central server 20 over a global electronic network such as the Internet.
Generally, the user work station 52, which, for example, includes a computer CPU fitted with software for connection with the user server 50. The use of a user server 50 is optional (as shown by the dashed lines) if the user work station 52 is equipped with the interfacing tools compatible with that of the network server 40. The user computer work station 52 may be a fixed or portable personal computer equipped with a computer screen, a keyboard, a microphone and/or a camera, software modules for browsing hypertext or hypermedia pages, a set of computer speakers and a computer mouse.
Data or information can be input into the central server 20 from the user's computer work station 52 over the Internet without software specially made for the central server 20. Specific software that may be needed from time to time can be downloaded from the central server 20 and installed at the user's station 52. For example, security software for user identification or authentication can be loaded at the user's station and used to ensure the user is a registered subscriber.
According to an aspect of the present invention, the speaker identification unit 26 serves to identify specific users, such as a physician or healthcare worker, to access the patient database file stored in memory 36. FIG. 1A shows an exemplary process for user identification according to an embodiment of the present invention. When a user accesses the URL for accessing the medical system (e.g., www.medicasystem.com), the user is presented with a home page having a user sign-on area (see FIG. 2). The user enters its pre-registered user login name and password (step 1000). The central server 20 compares the sign-on entries against its subscriber database with the stored pre-registered information and if the sign-on information matches (step 1010), the user information stored in the memory 36 specific to the sign-on data is retrieved. The user is prompted to speak a random phrase into its microphone (step 1020). The spoken phrase is received by the central server 20 and the voice processing unit 24 parses the received voice information and performs biometric analysis against voice information previously collected from this user (step 1040). If the biometric analysis returns with a high percentage match, the user is identified and authenticated (step 1050) and the user gains access to the system. If the biometric analysis returns with a negative match, the user is asked to repeat the login procedure. An alternative process to identify the speaker may dispense with the login name and password entry (e.g., the speaker skipping onto the speak phrase portion) if the biometric analysis returns with a very high percentage (e.g., 99%) match.
A commercially available software such as VoiceID, from Pronexus can be used for the speaker identification process.
The voice identification system can be used to authorize the user emergency access from remote locations and allow only certain individuals whose voice has been specifically identified by the voice identification database to access. With a random phrase access basis, access to the patient database file is not possible through a recording device, which is, merely re-transmitting a person's voice, unlike other speaker identification that ordinarily would have allowed the user access to the patient database file, from a recording device without the correct combination of words. Only specific words identified by the voice identification program 30 would allow access in this embodiment.
A presently preferred embodiment is typically operated in a medical clinic environment where the user (medical practitioners and staff) requires access to various types of information previously recorded about existing patients and also requires the ability to add new patients to the clinic's files. Every user having access to the central computer network system 10 can access specific patient databases based on the above-described speaker identification database, and different levels of data access can be granted to different users.
Henceforth, the description to pages corresponds to pages displayable using a web browser or other medium to display hypertext or hypermedia pages, as shown in some of the figures later in this application. Some pages are a part of the template files, and serves as the basis for the patient database entry and report system. That is, the web pages have customized features that have been prearranged for the user. For example, the page may contain a designated space on the page to allow the user to enter information on the patient's current status. The file may contain a space to view previous entries (“persistent data”) for reviewing the history of the patient's status. The file may contain a set of boxes for the user to check (by point-and-click mechanism) with regard to medical conditions like low back pain, neck pain, double vision, headaches, etc. Although the forms shown in the drawings are applicable to patient records accessed by health care professionals as illustrations, the forms can be made applicable to other professions or services by changing the content of the forms. One ordinary skilled in the art can readily appreciate that the form features usable by any professional include the presentation to the user of forms with areas of pre-filled information and areas for filling in, in most cases interactively, information which is contemporaneous, such as patient examination data, building inspection data, billing information, etc., as the exam, inspection, or billing is occurring. Preferably, the user may enter information into the form and thus the database through one or more combination of voice, type, or point-and-click mechanism.
Again referring to patient data for illustration, the type of input criteria on each page of the patient database entry and report system is specific for each user. Although a user may choose to select one or more pages that are pre-filled or pre-arranged, the type of information for entry into the file may be modified for the user by the host. For example, the user may enter data using a voice input device, a computer mouse or a keyboard. The data may be left as a digitally stored voice data or translated into textual data from the stored voice data. The date, name, and other voice-recognizable information may be translated into text.
In one preferred embodiment, the user accesses the patient databases though a specific internet address or URL. FIG. 2 shows an embodiment of the access page 210. The webpage presents several selectable entries, such as Physician Portal 240, Patient Portal 250, New Physician Account Portal 260, New Patient Account 265, Transcription Portal 270, New Transcription Account 275, Apply for transcription directorship button 285, or Emergency Access 290. In this access page, optional other information may be provided. For example, company identification, like company logo 280, may be provided. In another embodiment, other forms of advertisement may be provided as an on-screen display prior to displaying a page.
In an embodiment, the user identified in the login entry 220 may be locked out from further use if the user enters the incorrect password assigned to the user in the password entry 220 for a fixed number of attempts, after which time access may be allowed only by an administrator of the main computer network system 10, preferably by resetting the password. Depending on the administrator, the user may be required to set a different password in resetting the password. Also, the administrator may require the password to be of a specific length, and it may be case-sensitive, or it may include both numbers and alphabets.
Even with the correct login entry and password entry, the user may be authorized to access only certain databases, depending upon the associated login/password entries.
The Physician Portal 240 provides the database containing the page that the user requires to view patient information and to dictate (and transcribe) patient information. The Patient Portal 250 provides a database that a patient may access at a work station 52 in the physician's office or a separate location so that the patient can provide preliminary (demographic) information. Such information may include personal data and description of medical symptoms to allow the physician to access this patient information prior to examination or treatment. The level of security and the basis for entering the Patient Portal 250 is dependent on the user's requirement. The Transcription Portal 270, New Transcription Account 275, and Apply for transcription directorship button 285 are selected and portals accessed by professional transcribers to retrieve voice records to transcribe, to set up an account as a registered transcriber to transcribe the voice records in exchange for fee, or to apply for further transcription services.
FIG. 2A shows an exemplary emergency access process according to an embodiment of the present invention. A subscriber accesses the portal by clicking on the Emergency Access portal button on the portal selection page after sign-on (step 2010). A form is presented for the user to enter demographic data such as patient ID, name, date of birth and residence and a space for the user to describe the emergency and provide location of access and contact information for the hospital. User is presented with a “Send by Secure Mail” button, which upon clicking by the user, the entered information is sent to an emergency attendant EA (step 2020). The EA receives the information and checks it against the stored patient database (step 2030), if there is a match, the EA contacts the hospital using the contact information in the mailed message. The physician treating the patient requiring emergency aid is given a temporary login and temporary password (step 2040) to gain access to the central server and database (step 2050). If there is no match to the patient records, the user is returned to the login page to try entry again. It is contemplated that subscribers or patients of subscribers whose records are stored in the database are given a custom emergency card for the users to carry. The card indicates the url or the web address of the record system and notification on the card to access the url in an emergency.
FIG. 3 provides a Physician Greetings page 310 dedicated to a specific user after the user selects the Physician Portal 270. This dedicated Physician Greeting page recognizes the users by the login entry 220, and provided its identification by name as provided in block 320. The user may access the computer network system 10 from one of several user work stations 50. Through a location/office dropdown menu tab 330, the user chooses one of several locations from where the user is working. The choice of location/office in conjunction with entering the Dictate Report 340 entry will lead the user to a page shown in FIG. 4. The location/office is specific, for example, to various offices or clinics that the user examines patients. A separate Sign Off 459 entry button enables the user to sign off and return to the previous Physician Greetings page 310.
FIG. 4 is the Scheduling Page 410 specific for a given location/office. This page enables the user to gain an overview on the patients. Various patient information are provided on this page including Patient Name 420, Dictation ID 422 that is specific to each session, Provider Name 424, and User Name 426.
The Location/Office Identification 430 is prominently provided. Specific to each patient is the patient's Problem Type 432 that can be chosen through a dropdown menu. The category of Problem Type may include General, Cardiologic, ED-Head Injury, Neurological, Orthopedic, Rheumatoid and Urologic. The choice of the category in the Problem Type dropdown menu may be changed in accordance to a pre-set menu chosen by the user.
The Report Type 434 is chosen from a dropdown menu. The category of Report Type includes Consultation (H+P), Narrative, Discharge and Operative. The choice of the category in the Report Type 434 dropdown menu may be changed in accordance to a pre-set menu chosen by the user. After the Report Type 434 drop down menu is chosen, the GO button 436 enables the user to proceed to the next page of the chosen Report Type 434.
Other information relating to the patient is also provided in this Scheduling Page 410, including identification of the primary physician in Primary MD 440, the referring physician in Referring MD 442, and the patient's insurance company in Insurance 444.
The Scheduling Page 410 provides a set of dropdown menus (450, 452, 454, 456, 457, 458 and 459) that enables the user to access other pages. In a preferred embodiment, the Dictation 450 dropdown menu provides hyperlink to pages for New Dictation, Today's Dictation, and Show Full Dictation. The Medical Record 452 dropdown menu provides hyperlink to pages for Synchronize (to synchronize entries), New/Add Patients, and Medical Record List. The Account Info 454 drop down menu provides hyperlink to Doctor's Address Book, Account Status, Billing Info and Account Setting. The Message 456 drop down menu provides hyperlink to New Message, Delete, Read Add and Read Unread Message. Other entries also include News 457, Help 458 and Sign Off 459 buttons. These dropdown menus are operable by point-and-click (and in some cases, point-click-and-drag mechanism).
The Scheduling Page 410 includes a number of hyperlinked objects which upon selection by clicking by the user, links to other pages for documenting patient medical history and physical examination. Various hyperlinked objects are located on the left column of the Scheduling Page. In this particular embodiment, the hyperlink Dictate All 460, enables the user to access a page for dictation, and Show Report enables the user to access a summary page. Other hyperlinks in this column are directed to patent medical history 462 and physical examination 470. For example, The hyperlinks under the Medical History 462 category includes Prefix phrase 464, Demographics 466, CC, HPI, Meds, Allergy, PMed HX, PSurg HX, Fam HX, Soc HX, Hospitalizations, Handedness and ROS. The hyperlinks under Physical Exam 470 includes VS, HEENT, Chest, Abdomen, Extremities, Back, Mentation, Speech, Summary, Assessment, Plan 472, Suffix Phrase 474 and Correspondence 476. For further illustrations, each of the hyperlinks to Dictate All 460, Prefix phrase 464, Demographics 466, Plan 472, Suffix Phrase 474 and Correspondence 476 will be discussed in a separate figure below. The hyperlink enables the user to access a separate page in the patient file database, which the user accesses using a point-and-click mechanism. For each page, the user may input data at a dialogue box presented on the page, using one of or a combination of text data, voice data captured by the microphone, or a video file captured by the camera and/or point-and-click mechanism to record information relating to the patient's medical history and physical examination.
Individualize information in the Scheduling Page 410 include information on each patient. The personal information 490 include the patient's full name, date of birth, time of appointment, dictation ID to access and document medical informational data, indication of the completeness of the patient's documentation, and an indication of the chief complaint of the patient. The user may click on the name of the patient in 490, which also serves as a hyperlink to further general identification information including Patient Name 420, Dictation ID 422, Provider Name 424, User Name 426, Primary MD 490, Referring MD 442 and Insurance 444. It should also be noted that all of the hyperlinks in the left column, specifically, Dictate All 460, Show Report 468 and all the hyperlinks under Medical History 462 and Physical Exam 470 are directed to the specific patient as identified in the Patient Name 420. To access the hyperlink pages to another patient, the user clicks on the name of another patient in the personal information 490 section.
This Scheduling Page 410, as well as any other pages, may also contain a space for advertisement 498. Specifically targeted advertisements are placed in pages of the specific template files to enable the user to consider its products and services.
FIG. 5 provides a page that the user accesses through hyperlinked objects on the left column of the page. The hyperlinks are the same as those from the Scheduling Page 410 for the same patient in FIG. 4. This enables the user to input medical data in the form of medical history or physical examination in accordance with specific topics. The user may input data under one patient's Demographics 466 page by clicking on the hyperlink associated with the data that the user desires to input or modify. By doing so, the user can move back and forth through various pages under the specific patient's Medical History and Physical Examination files and input medical data.
The user can access the Dictate All page by clicking on the Dictate all hyperlink 460. In this Dictate All page, the user may effect dictation of medical information directly through the internet and store the information in the central file memory 36. FIG. 5 provides a number of recording management buttons accessible through the computer mouse. The play button 530 allows the user to listen to the recorded documentation. The stop button 532 stops the playback or recording process. The rewind button 534 and forward button 536 move the recorded document in a reverse or forward direction. The sound button 540 enables sounding or muting the recorded document. The volume button 542 enables the user to change the volume output of the recorded documentation. The recordation button 544 allows the user to record the document. Recordation is preferably performed by voice dictation. If the media to be played or recorded is video, a media player having functions such as the Media Player x or the RealNetwork player can be used.
Dictation Recordation identification 550 provides identification of the dictation recording along with the identification of the user who dictated the recording and the date of recordation. The Recordation identification is preferably entered by text. Here, it is shown that the record is entered by voice in combination with typing.
According to one embodiment of the invention, the functions of the voice processing unit 24 can be implemented by use of the VoiceXML Websphere studio, commercially available from IBM Corp. Voice over IP (VoIP) technology can also be employed to communicate the voice information from the user to the central server.
In another embodiment, the user performs dictation of medical information data through the internet. To facilitate the user's dictation, the user may access other patient medical files (or pages), which in the present case, may be the medical history or physical examination status. As the user dictates the information, the information is then transcribed into textual data. In the Dictate all page shown in FIG. 5, it is contemplated that the user/physician dictates portions or an entire patient record, including demographic and clinical information for the patient. The dictate all page is thus useful for use in generation of a complete report without segregation. A more efficient or HIPM compliant record entry method can be entered by use of the HPI page, selectable from the HPI button on the left column of FIG. 5. The HPI page is shown in FIG. 5A. It can be seen that the physician can select from one of ‘Voice Recording’, ‘Previous Entry’, ‘Type Text’, or ‘Standard Phrases’ to input clinical data. The selection of ‘Previous Entry’ will access from the database the previously entered information on this patient. This data is the ‘persistent’ data such as the information from the last examination, the previous prescription or diagnosis, etc. The ‘Standard Phrases’ button will cause the doctor constant or patient constant or pre-filled information to be accessed and presented to the user. The “Voice Recording’ selection will bring up the voice player as shown in FIG. 5 for interactive voice dictation entry. The ‘Type Text’ button selection opens a dialogue box for entry of clinical information, in this case, patient complaint information as shown in FIG. 5A. Thus, FIG. 5A shows again the use of interactive point, click, or type, in combination of voice entry of records.
Different from the Dictate All page shown in FIG. 5, this page records only the clinical portion of the record. It is contemplated that the patient's demographic data is already or separately entered, preferably by the patient or by staff member. The patient demographic data is separately stored in a different file from the patient's clinical data. The system uses reference coding, such as a patient's ID number, to link the demographic and the clinical data and to maintain patient's identity confidential, for example, if a patient's record is accessed or sent using the patient's ID number, the demographic and clinical data are accessed and transmitted separately. A combined patient demographic and clinical data is accessible only if the patient's name and other identification information set by the system is entered. Such use makes entry of data secure, cost efficient, and HIPAA complaint.
The clinical information input can be made in segmented portions, each segmented portion can be entered by different users, such as one segment input by a physician and another segment input by another health care provider or physician. The segmented portions are linked to the patient by the index such as the patient's ID. Each segmented portion can be retrieved, displayed, or input separately, independent of other segments, or in combination with other segmented portions. Preferably, the segmented portions are organized into corresponding sections and subsections, as further shown as described below.
FIG. 6 provides a Prefix Phrase 610 page that the user pre-records prefix phrases particular to the user. This page is accessed through the hyperlink on the left column of the Scheduling Page 410 for the same patient in FIG. 4, and the hyperlink is the same for each page of the database for each patient. Patient identification as described in FIG. 4 is also found in this page, and is not described herein.
The Prefix Phrase 610 page allows the user to record certain prefix phrases that are commonly used by the user to facilitate dictation. Box 650 provides the dictation document that the user transcribes. For example, the user may transcribe a medical data entry by voice dictation using the dictation method as described for FIG. 5 through the use of the set of Dictate Text 660 commands. Previously recorded information, or ‘persistent’ data is found in the Previously Entered Text 670 box. The user may use the previously entered text to facilitate the present dictation if persistent data is useful to the present dictation by checking box 672. Alternatively, the user may transcribe medical information by typing the text of the transcription into text box 674 and checking the add text box 680. The Your Standard Phrases box 682 lists all of the commonly used text that the user uses in transcribing medical information. The user's dictation can be facilitated by viewing the user's standard phrases in the Your Standard Phrases box 682 onto the transcription text in box 650. The Normal button 654 reverts the text to a normal text without the use of prefix phrases. After the user transcribed the medical information by dictation and/or text input, the user submits the report for recordation to the Central File Memory 36. Alternatively, the user may quit the page before, during or after transcription without submitting the report for recordation to the Central File Memory 36 by selecting the close button 692.
FIG. 7 provides a Demographics 710 page that the user pre-records demographic information of the patient. This page is accessed through the hyperlink on the left column of the Scheduling Page 410 for the same patient in FIG. 4, and the hyperlink is the same for each page of the database for each patient.
In one embodiment, selected patient information data that the patient entered from the Patient's portal 250 can be transferred to this Demographics page. The user may modify the demographics information that the patients entered.
This Demographics page enables the user to view the demographics of the patient while transcribing the medical report. Dictation is effected through a set of command buttons 720, which is the same as 660 in FIG. 6 and legend numbers 530, 532, 534, 536, 540 and 544 in FIG. 5. The demographic information includes the date of service 730, location of service 732, billing information 734, and identification and address information of the patient 736, 738, 740, 742, and 744. Information relating to the patient's primary physician is in Primary MD box 746 and information relating to the patient's referring physician is in Referring MD box 750. Address Book buttons 748 and 752 provides a list of pre-recorded names of physician so that the user may view, insert or modify as needed. Other patient data includes Marital Status checkboxes 750, and employment information in the set of check and text boxes 760.
Another added feature in this Demographics page is the photograph of the patient 724. The feature of this photograph enables the user to upload a picture of the patient onto a designated space in the Demographics page. This can be done by prompting the user with an ‘Attach Image’ button (not shown). Upon selection, the user can attach an image file, such as JPEG or TIFF and press SEND. Image files in digitized versions of medical images such as xray photos can also be stored in the patient records using the ‘Attach Image’ button. Further, a recorded video, for example, for showing an injury can also be uploaded to the patient records. The central server 20 places the image onto the designated space upon receipt of the image file. This particular feature is of importance to the user as the user may see numerous patients in the course of a day's schedule. The picture of the patient will help jug the user's memory of the user's experience with the patient during the patient's examination.
The Type Text box 762 allows the user to input textual information and the Your Standard Phrases box 764 allows the user to visualize his standard phrases used in dictating the patient's medical information.
According to a preferred embodiment of the present invention, a user has access to a voice activated program to dictate information over the internet interface, and at the same time, has access to the patient's medical information (including, for example, the patient's medical history and physical examination). Accordingly, the pages under the title Medical History and Physical Examination have the same hyperlink on the left column of each page so that the user may visually review all of these information available over the computer screen and interactively dictating in front of the same computer screen. The user can see different pages of the medical information using the hyperlinks, while at the same time dictating (and subsequently transcribing) a medical report.
FIG. 8 shows a Dictate Correspondence page 810, which is accessible through the hyperlink on the left column of the page, and the hyperlinks are the same for each patient. As discussed earlier, many of the patient information (such as 420, 422, 424, 426, 440 442 and 444) are the same in each page that is specific to that patient. Additionally, the left column containing hyperlinks to other pages for the same patient are also the same to facilitate the user to move from one page to another for the same patient.
This Dictate Correspondence page 810 facilitates the dictation process. The user may dictate correspondence for reporting to physicians and other requesters. Features in this page include automated report of the dictated document as well as the use of templated cover letters. The user may use the automated feature by clicking on the Automated box 822 in conjunction with each of the templated cover letters by clicking the box corresponding to the Correspondence Standard Cover Letter A, B or C, which is designated as 824, 826 and 828, respectively. The standard cover letters are pre-recorded by the user or others. The standardize letter may contain boiler-plate content to facilitate the user in reporting to physicians and other requesters. To use the standard cover letters, the user checks the Automated box 822 and one of the box associated with the correspondence cover letters, i.e., 824, 826 or 828. The user supplements the text in the correspondence by entering textual data in the Typed Text box 830 or dictating using the set of buttons 840. Alternatively, the user types a new cover letter in the Typed Text box 830 or dictating using the set of buttons 840. The voice recognition program automatically transcribes the voice data to textual data in the Types Text box 830, which the user can edit using either entering textual data into Types Text box 830 or dictating using the set of buttons 840.
The Dictate Correspondence 820 page also facilitates the transmission of the correspondence. The user chooses the recipient of the correspondence by checking the boxes associated with the patient's Primary MD, Referring MD, and others at the user's choosing. For example, the user directing the correspondence to the primary physician checks off the Primary MD box 850 and input the Dictation ID number (or MSID) in MSID box 852. The user chooses the mode of transmission using fax, E-Mail or Mail in the set of boxes 854. Similarly, the user directs the correspondence to the referring physician by checking off Referring MD box 860, inputting the Dictation ID number (or MSID) in the set of boxes 862. The user may transmit the correspondence to others by checking off Provider Name button 870, inputting the MSID in 872 and selecting the mode of transmission using boxes 874. These commands are performed by the point-and-click mechanism using the computer pointer or mouse. Address Book box 880 provides a list of pre-recorded physician addresses. These reports may be provided on a regularly scheduled basis or at a period chosen by the user.
To ensure complete record-keeping of all transmitted records, Audit Trail section 890 provide information of previously transmitted correspondence, that is listed by name of physician, document identification number, date/time of transmission, and the action taken.
The user may also dictate correspondence to other service providers and health/managed care insurance companies. Hyperlinks through this page have pre-recorded medical/medical insurance codes and billing information, such as basis for billing, symptoms, standard phrases and other templates for the physician's use. One of the more time consuming tasks that the physician faces is the billing and collection process. The hyperlinks to this and/or other dedicated pages will facilitate the user in submitting billing statements for collection. Various medical service codes are part of the pre-recorded web page forms to allow the user to input data in conjunction to the billing and collection process.
Referring to FIG. 9, the user accesses the Report 910 page by entering the Show Report hyperlink 468. This hyperlink, and similar hyperlinks, is patient specific and is found on the left column in each page specific to the patient. The Report 910 page provides a summary of the input generated from each page of the medical history and physical examination hyperlinks. For example, the Demographics 940 section provides the data entered from the Demographics page 710 (see FIG. 7). Similarly other medical history sections, such as Chief Complaints (CC) 950 section and HPI 960 sections, provide the same information as each of the respective pages. The user can access the Demographics page 710, CC page and HPI page by entering through Demographics hyperlink 940, Chief Complaints hyperlink 950 and HPI hyperlink 962, respectively. Voice data 962 logo refers to the input being provided by voice activated dictation. Other report sections corresponding to the hyperlinks under the heading Medical History and Physical Examination are also provided in the summary, but not described herein.
The entire Report 910 may be downloaded to various readable forms. Operation 920 enables the user to download the Report page 910 into the PDF format, and operation 930 enables the user to download the Report page 910 into the Word format.
FIG. 10 shows a page from the Medical Record Screen page 1010. This page enables the user to search patient medical records by a number of search criteria in the Search section 1020. The search criteria includes searching by last name 1030, by the patient's social security number 1032, by MSID 1034 and by the patient's date of birth 1036. The Search Results 1044 provides the Patient Name 1040, the Date of Service 1042, the Reporting Type 1046 and the patient's Problem Type 1048.
FIG. 11 shows the Account Setting 1110 specific for the user subscribing to the system of the present invention. Setting the account will serve as a basis of the type of information to which the user has access and the type of medical data input, retrieval and reporting that the user can perform.
The user chooses the Download Options 1120 in various forms including Word Format 1122, Text Format 1124, PDF Format 1128 and Doctation Format 1128. Correspondence Options 1130 includes a choice of E-mail 1132, Mail 1134, Fax 1136 and DocMail (through membership) 1138. The Report Transmission Option 1140 includes delivery by E-mail 1142. These categories and the corresponding options are merely one embodiment; various other embodiments are possible and contemplated by this invention.
The account setup for a particular user also includes the List of Places of Service 1150, Specialties and board certification status 1152, Information about training ad service of practice 1154, Cost of referring MD 1156, Default Text for Operative Procedure codes and finding services 1160 and Template Setup 1162.
By properly setting up the account, the user has access to numerous search and reporting criteria at the user's choosing, as well as the level of services that the user chooses to subscribe.
FIG. 12 shows an exemplary voice transcription page accessible from the Transcription Portal (270 of FIG. 2). This page is intended for access by the registered transcriber. A list of transcribed files 1210 is presented on the page for the transcriber should she wishes to access one of the files. A Foot Pedal Set Up button 1220 is available for the transcriber to actuate the voice record as by use of a foot pedal. The transcriber can access a voice file by entering the file name in box 1230. Player 1240 is available to play, pause, or stop the voice record as it is being played. The transcriber enters the text in the Type Text box as she listens to the voice record. Upon completion, the transcriber selects the Select button and the transcribed text is submitted for storage.
Having thus described exemplary embodiments of the interactive dictation, click, point, and type remote entry system and method, it is to be understood that although the record entries and reporting are described above using medical/patient records, the system and method is applicable to other fields where record documentation benefits from remote entry and reports automatically generated. Thus, the invention defined by the appended claims is not to be limited by particular details set forth in the above description of exemplary embodiments, as many apparent variations thereof are possible without departing from the spirit or scope of the invention as hereafter claimed.

Claims

1. A computer-based method for remotely accessing stored record and remotely inputting data, comprising:

accessing by a user a record stored remotely in a database via an electronic network;

displaying a portion of the accessed record as at least one hypertext page, the hypertext page comprising pre-filled text, at least one selectable hyperlinked object, and a box for receiving information input by the user, wherein the information input by the user is by a combination of voice dictation and one of pointing, clicking, or typing; and

sending the information input by the user over the electronic network to be stored as part of the record in the database.

2. The computer-based method of claim 1, wherein the electronic network is one of a local area network and the internet.

3. The computer-based method of claim 1, further including authenticating a user as a registered subscriber before access to the database is granted.

4. The computer-based method of claim 3, wherein said authenticating is by speaker identification.

5. The computer-based method of claim 1, wherein the pre-filled text is preinstalled templates of a form.

6. The computer-based method of claim 1, wherein selection of the at least one hyperlinked object links the user to a media player for playing or recording a media file including at least one of voice and video.

7. The computer-based method of claim 1, wherein selection of the at least one hyperlinked object links the user to an object having persistent data previously input by a user.

8. The computer-based method of claim 1, wherein the information input by voice dictation is stored as a media file.

9. The computer-based method of claim 8, wherein the media file is accessible by a transcriber subscriber over the electronic network, and the media file is audibly presented to the transcriber subscriber.

10. The computer-based method of claim 1, wherein the database comprises patient medical records, each patient record comprises demographic patient information and clinical patient information.

11. The computer-based method of claim 10, wherein the demographic patient information indexed to a specific patient is input by a first user and the clinical patient information indexed to the specific patient is input by a second user.

12. The computer-based method of claim 10, wherein the clinical patient information comprises segmented portions, each segmented portion corresponding to a section or a subsection, and each segmented portion is separately retrievable from the record independent of other segmented portions.

13. The computer-based method of claim 10, wherein the clinical patient information comprises segmented portions, each segmented portion is input by a different user.

14. The computer-based method of claim 11, wherein the demographic patient information and the clinical patient information indexed to a specific patient are stored in separate files.

15. The computer-based method of claim 1, wherein the step of displaying the hypertext page includes displaying media files including video.

16. A computer-based method for accessing stored records and receiving inputs to the records remotely from a user, comprising:

receiving a request from a user via an electronic network to access a record stored in a database;

retrieving the record and forwarding at least a portion of the record for display by the user as at least one hypertext page, the hypertext page comprising pre-filled text, at least one selectable hyperlinked object, and a box for receiving information to be input by the user, wherein the information input by the user is by a combination of voice dictation and one of pointing, clicking, or typing; and

receiving the information input by the user over the electronic network and storing the information input by the user as part of the record in the database.

17. The computer-based method of claim 16, wherein the electronic network is one of a local area network and the internet.

18. The computer-based method of claim 16, further including authenticating a user as a registered subscriber before access to the database is granted.

19. The computer-based method of claim 18, wherein said authenticating is by speaker identification.

20. The computer-based method of claim 16, wherein the pre-filled text is preinstalled templates of a form.

21. The computer-based method of claim 16, wherein upon receipt of a selection of the at least one hyperlinked object, a media player is presented to the user for playing or recording a media file including at least one of voice and video.

22. The computer-based method of claim 16, wherein upon receipt of a selection of the at least one hyperlinked object, the user is presented with an object having persistent data previously input by a user.

23. The computer-based method of claim 16, wherein the information input by voice dictation is stored as a media file.

24. The computer-based method of claim 23, wherein the media file is accessible by a transcriber subscriber over the electronic network, and the media file is audibly presented to the transcriber subscriber.

25. The computer-based method of claim 16, wherein the database comprises patient medical records, each patient record comprises demographic patient information and clinical patient information.

26. The computer-based method of claim 25, wherein the demographic patient information indexed to a specific patient is input by a first user and the clinical patient information indexed to the specific patient is input by a second user.

27. The computer-based method of claim 25, wherein the clinical patient information comprises segmented portions, each segmented portion corresponding to a section or a subsection, and each segmented portion is separately retrievable from the record independent of other segmented portions.

28. The computer-based method of claim 25, wherein the clinical patient information comprises segmented portions, each segmented portion is presented to a different user for input.

29. The computer-based method of claim 25, wherein the demographic patient information and the clinical patient information indexed to a specific patient are stored in segregated portions of the record.

30. The computer-based method of claim 16, wherein the step of presenting the hypertext page includes presenting media files including video for playing or recording by the user.

31. A computer-based system for retrieving records and inputting data to the records, comprising:

a server having a controller and a memory, the memory for storing a database of records and for storing executable codes, the executable codes are executed by the controller for performing method steps, the method steps including:

receiving a request from a user via an electronic network to access a record stored in the database;