Data processing: financial – business practice – management – or co – Automated electrical financial or business practice or... – Health care management
Reexamination Certificate
1998-02-26
2001-09-11
Kemper, M. (Department: 2165)
Data processing: financial, business practice, management, or co
Automated electrical financial or business practice or...
Health care management
C705S002000
Reexamination Certificate
active
06289316
ABSTRACT:
BACKGROUND OF THE INVENTION
1. Field of the Invention
The present invention generally relates to Clinical Information Systems (CIS) and, more particularly, to computer implementation of Progress Notes (PNs) in an electronic patient chart.
2. Background Description
A patient's medical chart is a complex collection of all the relevant “facts” relating to the patient's health. This raw data can be quite voluminous, and this has led to efforts to manage the data with a computer rather than with paper. But just keeping track of the data is not enough, to be useful and illuminating to the health care professional, the data must be organized in familiar and predictable ways.
There is no universal standard for the organization of a medical chart, be it paper or electronic. However, certain paradigms have evolved in modern medical practice using the paper chart. These can serve as the starting point for the level of standardization which the computerized patient record demands. Two organizing principles stand out as useful approaches for making patient data more informative: clinical histories and Progress Notes (PNs).
“Clinical Histories” denote the grouping of patient data by its type, independent of the context in which the data was recorded. Refinements can include further sub-classification and sorting. For example, a medication history includes all medication data, but not laboratory data, even though certain medications may have been prescribed based on the results of certain laboratory tests. The medication history may be grouped by drug and sorted by date to make it more readable. Observe that it is only because the reader associates certain drugs with certain medical conditions that the medication history is useful for understanding the patient's problems and treatment. When several histories are considered together (e.g., medications, laboratory tests, procedures, family history, allergies), the experienced clinician can piece together a more complete picture of the patient's condition. The completeness of the record and the skill of the clinician combine to make the historical, data-centered view of the chart a useful clinical tool.
But the clinicians, and the health care enterprise, want more information. They want the context in which the data was generated. This context includes the relationships between medical facts and the thought processes involved in investigating, diagnosing, and treating medical conditions. The “Progress Note” or PN is the vehicle for capturing that context. In practice, the degree of structure evident in Progress Notes spans the continuum from unstructured stream-of-consciousness text, to highly structured machine-readable forms. Although most Progress Notes exhibit neither of these extremes, the reason for the polarization is clear: the content must be both expressive and searchable. A common approach is to record information as labeled, stylized, free text, optimized for visual scanning by clinicians, in one place, and selectively code certain information, optimized for processing by data analysts, in another place. With this scheme, neither the clinician nor the analyst has easy access to the complete picture.
SUMMARY OF THE INVENTION
It is therefore an object of the present invention to provide computer implemented method for generating and storing a medical chart which is expressive, searchable, and facilitates both data-centered (historical) and process-centered (contextual) views.
According to the invention, there is provided a computer implemented method for generating Progress Notes (PNs) in a Clinical Information System (CIS). The Progress Notes function of this invention is designed around the following key points:
1. All medical data entered into the chart should be part of a Progress Note, independent of their use elsewhere in the chart. The intent is to always preserve the context in which events occur.
2. Progress Notes should support both business and clinical analysis by storing data in coded form, while providing medically familiar textual documentation.
3. Progress Notes should allow for entries by multiple authors without sacrificing individual accountability. This behavior should support both the common physician
urse office visit scenario as well as the broader team approach to treatment.
4. Progress Notes should allow useful documentation patterns to be captured and later applied, with suitable modification, in similar clinical situations. The goal is to facilitate ease of use, reduce time spent entering data, and provide a framework for protocol definition and management.
The model implemented by the invention addresses each of these points. The following description of the preferred embodiment of the invention defines layers of data organization used for Progress Notes (PNs), exposes the structure of the principle PN components and describes their behavior within, and effect on, the PN. The Progress Notes as implemented by the invention are readable, easily understood, complete, accurate and concise. They are also flexible enough to logically convey to others what happened during an encounter, e.g., the chain of events during the visit, as well as guaranteeing full accountability for documented material, e.g., who recorded the information and when it was recorded.
REFERENCES:
patent: 5077666 (1991-12-01), Brimm et al.
patent: 5265010 (1993-11-01), Evans-Paganelli et al.
patent: 5924074 (1999-07-01), Evans
patent: 5946659 (1999-08-01), Lancelot et al.
patent: 2296468 (1996-07-01), None
Song et al. “A Cognitive Model for the Implementation of Medical Problem Lists” Proceedings of the First Congress on Computational Medicine, Public Health and Biotechnology, 1994.*
Poon et al. “Pen-Ivory: The Design and Evaluation of a Pen-Based Computer System for Structured Data Entry” Section on Medical Informatics, No Date.
Aghili Houtan
Mushlin Richard A.
Rose Jeffrey S.
Williams Rose
International Business Machines - Corporation
Kemper M.
McGuireWoods
Percello Louis J.
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