Physician and clinical documentation specialist workflow integration

Patent metadata

Field	Value
Publication number	US-9679107-B2
Application number	US-201313921014-A
Country	US
Kind code	B2
Filing date	Jun 18, 2013
Priority date	Feb 18, 2011
Publication date	Jun 13, 2017
Grant date	Jun 13, 2017

Abstract

A medical documentation system and a CDI system may be linked together, or integrated, so there is a tie between the two systems that allows for a much more efficient and effective CDI process. In one disclosed embodiment, a medical documentation system transmits to a CDI system a structured data set including at least some information relating to one or more medical facts the medical documentation system automatically extracted from text documenting a patient encounter.

First claim

What is claimed is:

1. A method for use with a medical documentation system implemented via at least one processor and processing medical documentation input at least in part by a clinician, the medical documentation system configured to communicate with a Clinical Documentation Improvement (CDI) system that also processes the medical documentation, wherein the medical documentation system implemented via the at least one processor analyzes text included in the medical documentation to extract medical facts expressed in the medical documentation and identify opportunities for clarification of the medical documentation, and wherein the CDI system includes a user interface by which to present the medical documentation to a CDI specialist and receive from the CDI specialist new information to include in the medical documentation to clarify the medical documentation and to receive from the CDI specialist identification of opportunities for clarification of the medical documentation, the CDI specialist being a human user of the CDI system, the method comprising:
with the medical documentation system implemented via the at least one processor,
for each fact of at least one medical fact extracted by the medical documentation system from text of the medical documentation documenting a patient encounter between a patient and the clinician,
evaluating a confidence score for the fact indicating a confidence of themedical documentation system that the fact was correctly extracted from the medical documentation system; and
selecting, with the medical documentation system and based at least in part on a result of the evaluating, whether to transmit the fact to the CDI system for review by the CDI specialist or to communicate the fact to a clinician for review; and

in response to selecting to transmit one or more medical facts to the CDI system, transmitting to the CDI system a structured data set including at least some information relating to the one or more medical facts and including information indicating that the medical documentation system automatically extracted the one or more medical facts from the text documenting the patient encounter.

2. The method of claim 1 , wherein the method further comprises:
receiving, at the medical documentation system and from the CDI system, a request for information produced by the medical documentation system; and
transmitting the structured data set in response to receiving the request from the CDI system.

3. The method of claim 2 , wherein receiving the request from the CDI system comprises receiving the request via an API of the medical documentation system.

4. The method of claim 1 , wherein transmitting the structured data set comprises transmitting at least one clarification request generated by the medical documentation system, the at least one clarification request requesting clarification regarding at least one first medical fact of the one or more medical facts that the medical documentation selected to transmit to the CDI system for review and/or regarding at least a portion of the text documenting the patient encounter from which the at least one first medical fact was extracted by the medical documentation system.

5. The method of claim 4 , further comprising an act of:
with the medical documentation system, receiving a clarification response from the CDI system addressing the at least one clarification request.

6. The method of claim 5 , further comprising an act of:
with the medical documentation system, storing information identifying that the clarification request is addressed in response to receiving the clarification response from the CDI system.

7. The method of claim 1 , further comprising acts of:
with the medical documentation system, receiving a clarification request from the CDI system concerning the one or more automatically extracted medical facts; and
with the medical documentation system, communicating the clarification request to a clinician via the same user interface that is used to communicate to the clinician clarification requests automatically generated by the medical documentation system.

8. The method of claim 4 , further comprising:
receiving, with the medical documentation system, an instruction from the CDI system to prompt a clinician regarding the at least one clarification request.

9. The method of claim 8 , wherein:
receiving the instruction comprises receiving an indication of an urgency with which to prompt the clinician; and
the method further comprises prompting the clinician in accordance with the urgency.

10. The method of claim 9 , wherein communicating the first clarification request via the same user interface in a manner different from a manner in which the second clarification request is communicated to the clinician via the same user interface comprising communicating via the same user interface that the first clarification request originated from the CDI system and the second clarification request originated from the medical documentation system.

11. The method of claim 6 , wherein storing the information identifying that the clarification request is addressed comprises storing information indicating that a clinician does not need to be prompted regarding the clarification request.

12. The method of claim 7 , wherein:
the clarification request received from the CDI system is a first clarification request;
the method further comprises, with the medical documentation system, generating a second clarification request; and
communicating the first clarification request to the clinician via the same user interface comprises communicating the first clarification request via the same user interface in a manner different from a manner in which the second clarification request is communicated to the clinician via the same user interface.

13. An apparatus comprising:
at least one processor; and
at least one storage medium having encoded thereon executable instructions that, when executed by the at least one processor, cause the at least one processor to carry out a method for use with a medical documentation system implemented via the at least one processor and processing medical documentation input at least in part by a clinician, the medical documentation system configured to communicate with a Clinical Documentation Improvement (CDI) system that also processes the medical documentation, wherein the CDI system includes a user interface by which to present the medical documentation to a CDI specialist and receive from the CDI specialist new information to include in the medical documentation to clarify the medical documentation and to receive from the CDI specialist identification of opportunities for clarification of the medical documentation, the CDI specialist being a human user of the CDI system, the method comprising:
with the medical documentation system,
for each fact of at least one medical fact extracted by the medical documentation system from text of the medical documentation documenting a patient encounter between a patient and the clinician,
evaluating a confidence score for the fact indicating a confidence of the medical documentation system that the fact was correctly extracted from the medical documentation system; and
selecting, with the medical documentation system and based at least in part on a result of the evaluating, whether to transmit the fact to the CDI system for review by the CDI specialist or to communicate the fact to a clinician for review; and

in response to selecting to transmit one or more medical facts to the CDI system, transmitting to the CDI system a structured data set including at least some information relating to th

Assignees

• Nuance Communications Inc

Inventors

• Cardoza Timothy
• Flanagan James R
• Boyer Brian P

Classifications

• G10L15/26

  Speech to text systems (G10L15/08 takes precedence) · CPC title

• G10L15/1822

  Parsing for meaning understanding · CPC title

• G10L2015/221

  Announcement of recognition results · CPC title

• G06Q50/24

  Physics · mapped topic

• G06F19/322 Primary

  Physics · mapped topic