Patent Application Titled “System And Method For The Recording Of Patient Notes” Published Online (USPTO 20190172559)

2019 JUN 24 (NewsRx) -- By a News Reporter-Staff News Editor at Insurance Daily News -- According to news reporting originating from Washington, D.C., by NewsRx journalists, a patent application by the inventors Cane, Daniel (Boynton Beach, FL); Sherling, Michael (Boca Raton, FL), filed on February 6, 2019, was made available online on June 6, 2019.

The assignee for this patent application is Modernizing Medicine Inc. (Boca Raton, Florida, United States).

Reporters obtained the following quote from the background information supplied by the inventors: “Studies have shown that physicians spend 45% of their time outside of the examination room. A good deal of that time is spent filling out paperwork, such as patient notes and billing documentation. It takes the average physician two minutes to dictate a note. Even computer-literate clinicians take four minutes to record a note using standard electronic medical records software. Therefore, the act of completing a patient record is time consuming.

“In addition to the patient health aspects of record keeping, record keeping also has an economic aspect. Payment depends in part on record keeping. For example, the physician must confirm that the correct treatment codes are entered, and that various other required documentation is in place.

“Because of these complicated billing requirements, some physicians under-code their billing information. Because these physicians are concerned that mistakes in billing entries might lead to an audit, these physicians will under-code or claim to have done less work than they what was actually performed to avoid missing something in the required documentation.

“Conversely, physicians may mistakenly over-code. This occurs when the physician appropriately codes for a certain level visit based on what has occurred during the visit but because he or she has forgotten to enter key components of documentation. The Centers for Medicare and Medicaid Services (‘CMS’) treats this as an over-code. As far as CMS is concerned, if the documentation is not correct, the examination or procedure did not occur.

“The issue then is that note taking and diagnosis session related documentation by a physician is time consuming, fraught with errors and inefficient. To relieve these issues a number of systems exist that provide template patient records into which physicians enter data on the computer. In general, these systems barely reduce the time it takes for a physician to enter a note into the medical record of a patient.

“What is needed is an intelligent system that will enter data with minimal physician interaction. The present invention addresses this need.”

In addition to obtaining background information on this patent application, NewsRx editors also obtained the inventors’ summary information for this patent application: “In one aspect, the present invention relates generally to a system for recording patient notes by a physician. In one embodiment, the system includes a server comprising: a database; an input module constructed to receive data input from a user, a display module to display notes and note options; and an adaptive notes generation module in communication with the database, the input module and the display module, the adaptive notes generation module receiving input data from the input module and the database and in response to the input data from the input module and the database, automatically generating a plurality of notes and note options. In one embodiment, patient notes can include any diagnosis, insurer, or other patient related data of interest to a physician relative to their practice.

“In another embodiment, the notes and note options are medical domain specific. In yet another embodiment, current input from the user modifies subsequent notes and note options automatically generated by the adaptive notes generation module. In still yet another embodiment, clinician preferences learned by the notes generation module modifies the notes and note options automatically generated by the adaptive notes generation module. In another embodiment, the frequency of clinician use determines clinician preferences automatically generated by the system. In yet another embodiment, the system includes one or more of a billing module, a laboratory module and a prescription module.

“In one embodiment, the system includes a client computer system in communication with the server input module and the server display module. In another embodiment, the client computer system is keyboardless. In yet another embodiment, the input module and the display module are in communication and permit input from the client using a graphical display. In one embodiment, the system automatically generates a treatment plan in response to input data and database data. In another embodiment, the treatment plan is modifiable by a clinician. In still yet another embodiment, the graphical display produces graphical changes by rollover.

“In another aspect, the invention relates to a method of recording patient notes by a clinician. In one embodiment, the method includes the steps of: providing an input screen; inputting data; accessing a database to obtain patient data in response to data input to the input screen; and generating domain specific notes and note options in response to patient data and input to the input screen.

“In another embodiment, the method includes the step of modifying the generation of domain specific notes and note options in response to subsequent input. In yet another embodiment, the method includes the step of modifying notes and note options in response to subsequent input further comprises modifying notes and note options in response to clinician preferences. In still yet another embodiment, the method includes modifying the notes and note options in response to clinician preference according to frequency of clinician use. In another embodiment, the method of the system automatically generates a treatment plan in response to the data input and the patient data on the database. In yet another embodiment, the treatment plan is modifiable by a user. In another embodiment, the data input by a user is entered in response a prompt generated in response to metadata associated with an output graphic.

“In another aspect, the invention relates to a medium including an executable program, the executable program. In one embodiment, the method includes the steps of providing an input screen on a computer system; inputting data to the computer system; accessing a database on the computer system to obtain patient data in response to data input to the input screen; and generating domain specific notes and note options in response to patient data and input to the input screen.”

The claims supplied by the inventors are:

“1-20. (canceled)

“21. A system for recording patient information by a user and automatically generating patient notes for a clinician, the system comprising: a server comprising: a database comprising clinician preference data, patient data, and metadata; an input module constructed to receive data input from the user and store it as patient data in the database; a display module to display notes, note options and reports; and an adaptive notes generation module in communication with the database, the input module and the display module, the adaptive notes generation module receiving input data from the user through the input module and provider preference data, patient data, and metadata from the database and in response to the input data from the input module and the clinician preference data, patient data, and metadata from the database, automatically generating a plurality of notes, note options, and reports using adaptive learning in response to clinician preference data, patient data, and metadata, wherein data is input and stored as objects that are interpretable by the adaptive notes generation module to generate a natural language structured display of the clinician’s preferences in response to the metadata of each datum.

“22. The system of claim 21 wherein the notes and note options are medical domain specific.

“23. The system of claim 21 wherein current input from a user modifies subsequent notes and note options automatically generated by the adaptive notes generation module.

“24. The system of claim 23 wherein past clinician preferences learned by the adaptive notes generation module modifies the notes and note options automatically generated by the adaptive notes generation module.

“25. The system of claim 24 wherein the frequency of clinician use of a past clinical preference determines the clinician preferences automatically generated by the system.

“26. The system of claim 21 further comprising at least one of a billing module, a prescription module, and a lab module.

“27. The system of claim 21 further comprising a client computer system in communication with the server input module and the server display module.

“28. The system of claim 27 wherein the client computer system is keyboardless.

“29. The system of claim 28 wherein the input module and the display module are in communication and permit input from the client computer system using a graphical display.

“30. The system of claim 29 wherein the graphical display produces graphical changes by rollover.

“31. The system of claim 21 wherein the system automatically generates a treatment plan in response to input data and database clinician preference data, patient data, and metadata.

“32. The system of claim 31 wherein the treatment plan is modifiable by a clinician.

“33. A method of recording patient information by a user and generating patient notes by an automated system for a clinician, the method comprising the steps of: providing an input screen on a computer system; inputting clinician preference data, patient data, and metadata to the computer system, wherein clinician preference data, patient data, and metadata is input and stored as objects that are interpretable by an adaptive notes generation module to enable a structured display of the clinician’s preferences; accessing a database on the computer system to obtain patient data in response to data input to the input screen; and generating domain specific structured natural language notes, note options and reports in response to patient data, and past clinician preferences and metadata for each datum.

“34. The method of claim 33 further comprising the step of modifying the generation of domain specific notes and note options in response to subsequent input.

“35. The method of claim 34 wherein the step of modifying notes and note options in response to subsequent input further comprises modifying notes and note options in response to past clinician preferences.

“36. The method of claim 35 wherein the notes and note options are modified in response to a spat clinician preference according to frequency of clinician use.

“37. The method of claim 21 further comprising automatically generating a treatment plan in response to the data input and the patient data on the database.

“38. The method of claim 37 wherein the treatment plan is modifiable by a user.

“39. The method of claim 21 wherein the data input by a user is entered in response a prompt generated in response to metadata associated with an output graphic.

“40. The system of claim 21 wherein the adaptive notes generation module determines what metadata is necessary for the adaptive notes generation module to perform its function and if that metadata is missing, notifies the clinician as to the problem.

“41. The system of claim 21 wherein the adaptive notes generation module determines what graphical user interface to use in response to patient data.

“42. The system of claim 21 wherein the adaptive notes generation module determines what drug to prescribe in response to patient data.

“43. The system of claim 21 wherein the adaptive notes generation module generates a plurality of entry options as a hierarchy of clinician preferences and determines a hierarchy by a response to a previous entry in the hierarchy.”

For more information, see this patent application: Cane, Daniel; Sherling, Michael. System And Method For The Recording Of Patient Notes. Filed February 6, 2019 and posted June 6, 2019. Patent URL: http://appft.uspto.gov/netacgi/nph-Parser?Sect1=PTO1&Sect2=HITOFF&d=PG01&p=1&u=%2Fnetahtml%2FPTO%2Fsrchnum.html&r=1&f=G&l=50&s1=%2220190172559%22.PGNR.&OS=DN/20190172559&RS=DN/20190172559

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