Patent Application
20080077443
The accompanying drawings, which are incorporated in and constitute a part of the specification, illustrate presently preferred embodiments of the invention, and together with the general description given above and the detailed description of the preferred embodiments given below, serve to explain the principles of the invention. As shown throughout the drawings, like reference numerals designate like or corresponding parts in the various figures.
In describing the present invention, reference is made to the drawings, wherein reference numerals designate like or corresponding parts
Reference is now made to
The relationships between the various applications and databases are such that the medical record viewer is a data base viewing system that lets the coder/medical record reader look at the medical records stored in the medical record data base. This relationship consists of a request for certain pages of the record and then the organization of that data for display. There, of course, can be other more complicated functions if desired. The primary relationship of the coding system is that it may include its own library of codes and coding rules, and its store of the codes created for each coded patient medical record. This data could be stored in the medical record data base also and, even if the codes are stored separately, they may also be stored as part of the complete medical record in the medical data base. Thus the coding system is connected via the audit application to the medical records application and is also connected to the coding data base. The audit application needs to be able to know when a code was entered in the coding system and to save its own copy of the code as well as some reference to the portion(s) of the medical record that were employed to justify the code assignment. That is why the audit application is connected to the coding system and part of the reason the audit system is connected to the medical record system. When the audit process happens, the audit software needs a way to tell the medical record system to fetch and display the part of the record associated with the code. The communication of this command, as well as the ability to display the markers or other form of highlighting, is the another reason the audit application is connected to the medical record application.
Reference is now made to
The medical record viewing application 24 may be any of a number of various applications, which allows a display on a screen of medical records associated with a patient. The particular record portion being displayed at 30 are progress notes by a doctor. A series of tabs 32, 34, 36, 38, 4042 and 43 allow the coder or auditor using the system to display different portions of the medical record. A visible marker, here flags, have been placed on the progress note comment field stating, “patient has Viral Pneumonia” The flagging of this portion is denoted by a starting flag 44 and an ending flag 46, such that the beginning and ending of the particular portion is flagged for later utilization. The portion is also show as being highlighted.
The second application, the coding capture application 26, allows the coder (or auditor, should the auditor be using the system) to apply various codes to the medical record. For example, a primary diagnosis code is available for entry at field 48 showing “480.9 viral pneumonia NOS”, a secondary diagnosis code is available at field 50, as well as various procedure codes for entry at fields 52, 54 and 56. NOS stands for “Not Otherwise Specified.” The codes that are entered are based on information obtained by the coder or auditor from information displayed on the screen 23 by the medical records viewing application 24. At a subsequent point in time, an audit can be conducted of the coding of the medical record. The auditor may implement this by bringing up the medical record through the viewing application 24 for a particular record or a portion of a record such as the progress notes to be audited for proper coding. The auditor can bring up the appropriate medical record either with the visible marking and/or the associated codes in plain view or hidden on the medical record being reviewed.
The audit tracking application 28 allows capture at 58 of the various codes that have been entered by the original coder, as well as the associated medical record portions for the particular code, as denoted by the various flags. For example, if a primary diagnosis at field 48 is a code for “patient has viral pneumonia,” that code at field 48 would be related to the patient record progress note portion flagged at 44 through 46. The same is true in connection with the secondary codes and the various procedure codes that may be applied to any portion of the medical record.
When an auditor is recoding a patient record, the auditor has an option, as previously noted, to either view the portion that is associated with a particular code by clicking the screen cursor 27 on the screen button VIEW 60 or, if desired, to hide that information at by clicking the cursor 27 on the screen button HIDE 62 so as to re-code without seeing how original codes were applied by the coder. When auditing a record, the auditor can look at the previously assigned codes, and if the auditor selects any code, such as with cursor 27, the medical record viewing system will reveal the page and markers that go with that code.
Reference is now made to
Reference is now made to
The message sent to the medical record at 92 enables the particular portion of the medical record associated with the selected code to be displayed for review by the auditor depending whether the VIEW button 60 or HIDE button 62 has been activated. The auditor may agree or disagree with a particular code selection for the portion displayed. At block 95, the system can provide for the auditor to make note of the agreement or disagreement, to make note of different codes that may be selected, or codes that may be deleted, and/or an explanation for the action taken. In this way, the subsequent re-auditing process, should that occur, allows for a further refinement of the coding and auditing of the particular medical record being processed. The system has thus allowed the coding and storing of audit trail information to facilitate subsequent audits and to enhance the effectiveness of the coding of medical records and the subsequent auditing of those records. The audit information (comments, deleted codes, added codes and the like as well as auditor data such as time stamp, auditor identification, digital signature are at 97 entered and loaded into the database. The system then returns to the input to decision box 90.
In operation, the coder reviews the medical record. When the coder finds the critical passages in the patient documentation, they can capture the codes in a coding system. This puts a visible marking onto the imaged or electronic medical record. The coder moves the flag to exact location of the source documentation that supports the code and attaches it by clicking, drag and drop or other computer interaction. If the coder needs to visibly mark multiple passages from the document, they can get additional flags or other forms of marking for a code by instantiating additional marking and placing them in the pertinent locations. Multiple code marking for a passage may be noted such as by a superscript number and stored for subsequent retrieval with the visibly marked medical record region.
While the medical record is presented to the coder in electronic form, the electronic form can be an imaged medical record, or can be a database electronic medical record data. Paper aspects of the medical records can be scanned and stored as electronic medical records where desired so as to be available for use with the system.
When the coder makes the coding keystrokes, the coding software captures the codes and a flag or mark would appear in the view of the imaging or digital medical record system. The coder moves the flag to the data or region of the imaged medical record that substantiates the assigned code. These flag locations (data references), the actual medical code assigned, and possibly other aspects of the coders activity such as time stamps and coder identification, are stored in the database of the medical record.
Placing the mark or flag in the digital medical record or imaged medical record can be done by enabling the coder to click and drag a screen cursor over a region to highlight a passage, click on a specific datum, and/or place a flag near or on a region for association. Any method can be employed that makes it plain which data or region of the medical record is to substantiate the medical code assigned. The imaged or digital medical record system allows any data or any region of any image to be flagged by a coder. Where necessary, existing imaged or digital medical record system can be modified to provide this functionality. The coder and/or auditor can mark overlapping but different regions of a medical record with multiple codes assigned if desired.
The information of the code, the flag, the region size, its location on the page, and/or other meta data, is be stored with the image in the image record database and become part of the permanent medical record storage. If desired, a digital signature of the coder and/or auditor can be also employed. This is analogous to the placement of a physician's digital signature near a passage that was transcribed or documented without the legally required authorizing handwritten signature.
When the audit of a medical record takes place, the medical record can reveal to the audit coder where in the medical record the substantiating evidence for a code is located. For instance, by selecting a code, the digital medical data or imaged medical record region flagged by the original coder would be brought into view. If multiple locations were indicated a list of links would be provided and the auditor could examine each or as desired as necessary due to regulation or procedure. The auditing process could thus be done, for example, on specific codes, over a great number of records, without the need to review each record in its entirety. The full coding of a record could be reviewed without needing to read the entire medical record.
When the auditor recodes the medical record, the audit coder may choose to operate the system in different modes of operation. The audit coder may choose to turn off the display of the coder's document flags until the system or auditor determines if there is a disparity in the coding assignment. The audit coder may then choose to turn on the flags to understand what the first coder was looking at when the first coder assigned codes. This mode of operation of the system can be also utilized as a training tool. In this utilization as a training tool the student can code a series of exercises or examination medical records, already coded by an expert or instructor. When the student has completed the coding, they can reveal the expert coding, as well as see where in the medical record the expert or instructor coder found the supporting documentation for the assignment of the codes. When utilized in the audit mode, the auditor might also turn on the coders flags and review a number of similar records, to see what documentation is referenced for the assignment of the same or similar codes in each chart.
While the present invention has been disclosed and described with reference to a single embodiment thereof, it will be apparent, as noted above, that variations and modifications may be made therein. It is, thus, intended in the following claims to cover each variation and modification that falls within the true spirit and scope of the present invention.
