Integrated medical software system
View Patent ↗A medical management system is provided that integrates all aspects of healthcare provider practice management and managed care, including schedule management, patient registration, insurance information, EMR and billing and collections. The system integrates a central framework module, a scheduling module, a registration module, an account management module and an electronic record module to provide a seamless exchange of information. A clinical module provides template builder which allows the users to define a customized template. The custom and standard templates are used by a document builder to generate documents, such as progress notes and H&P notes, which are retained in the patient's electronic chart. The progress note template allows the clinician to record a patient encounter by presenting the clinician with predefined sections and sentences that are easily completed by the clinician during or after the patient encounter. The templates and documents generated are designed to closely resemble a paper chart. Information gathered during patient scheduling and triage are referenced to pre-populate the templates to avoid having the clinician entering redundant information. The documents are relied upon to automatically generate patient superbills and electronic requests are sent to a claims clearinghouse.
1. A template builder building a custom template that will be used by a health care provider to generate an electronic document for a patient during a subsequent encounter with the patient, the template builder comprising:
means for a user to select a type of electronic document that will be generated from the custom template during the subsequent encounter with the patient, the type of electronic document selected defining one or more predefined sections that will be built in the custom template; and
means for building one or more predefined sections in the custom template that is configured for the user to draft and/or select one or more sentences in at least one of the one or more predefined sections and that is configured for the user to define and/or select one or more fields for completing at least one of the one or more sentences,
wherein one or more fields include at least one of a default control type that is subsequently and automatically populated with the patient information during the encounter with the patient, an input box that creates a point in a sentence where data can subsequently be manually input by the user during the encounter with the patient, and a select list that creates a list of different options that can subsequently be chosen by the user as text for completing at least one of the one or more sentences during the encounter with the patient.
2. The template builder of claim 1 , wherein the one or more predefined sections are based on a clinical document architecture (CDA) defined by Health Level 7(HL7).
3. The template builder of claim 1 , wherein
the user can select at least one of the one or more sentences by topic from one or more predefined sentences; and
elements of the one or more predefined sentences that are required to submit a patient bill for payment are denoted by a different color.
4. The template builder of claim 1 , wherein
the electronic document built for the patient is built with an electronic date/time stamp that corresponds to the date and time of the encounter with the patient.
5. The template builder of claim 1 , further comprising
means for the user to define and/or select one or more body systems and one or more symptoms related to each body system in at least one of the one or more predefined sections,
wherein the user can subsequently choose from the defined and/or selected one or more body systems and one or more symptoms during the encounter with the patient to identify specific symptoms to which the patient admits.
6. The template builder of claim 5 , wherein
each of the one or more symptoms defined will be available for selection in subsequent template building operations performed with the template builder.
7. The template builder of claim 5 , further comprising
means for the user to configure one or more worksheets or checklists in at least one of the one or more predefined sections for performing a physical examination of the one or more body systems during the encounter with the patient, the one or more worksheets or checklists being configured to include one or more findings associated with each of the body systems being examined and being available to subsequently be chosen by the user during the encounter with the patient.
8. The template builder of claim 7 , further comprising
means for the user to select and/or locate and select one or more diagnoses in at least one of the one or more predefined sections, the selected and/or located and selected one or more diagnoses being associated with the one or more findings and being available to subsequently be chosen by the user during the encounter with the patient.
9. The template builder of claim 8 , further comprising
means for a user to define and/or select one or more plans for treating the patient in at least one of the one or more predefined sections, the defined and/or selected one or more plans for treating the patient corresponding to the one or more diagnoses and being available to subsequently be chosen by the user during the encounter with the patient.
10. The template builder of claim 9 , further comprising
means for a user to define and/or select one or more chief complaints in at least one of the one or more predefined sections,
wherein the user can subsequently choose from the defined and/or selected one or more chief complaints during the encounter with the patient, and
wherein the one or more sentences drafted and/or selected, the one or more body systems and one or more symptoms defined and/or selected, the one or more worksheets or checklists configured, the one or more diagnoses selected and/or located and selected, and the one or more plans for treating the patient defined and/or selected each relate to the one or more chief complaints defined and/or selected.
11. The template builder of claim 9 , wherein
at least one of the one or more findings, the one or more diagnoses, and the one or more plans for treating the patient is automatically associated with one or more of Evaluation and Management (E/M) coding, International Code of Diseases (ICD) coding, Current Procedural Terminology (CPT) coding, and HCFA Common Procedure Coding System (HCPCS) coding.
12. The template builder of claim 11 , further comprising
means for automatically generating an electronic superbill for billing the patient at checkout and for electronically filtering and sorting insurance claims using the one or more of ICD coding, CPT coding, and HCPCS coding.
13. A method for building a custom template that will be used by a health care provider to generate an electronic document for a patient, the method being embodied on a computer readable medium and executed by a processor to perform steps comprising:
having a user to select a type of electronic document that will be generated from the custom template during the subsequent encounter with the patient, the type of electronic document selected defining one or more predefined sections that will be built in the custom template; and
having the user building one or more predefined sections in the custom template by having the user draft and/or select one or more sentences in at least one of the one or more predefined sections and by having the user to define and/or select one or more fields for completing at least one of the one or more sentences,
wherein one or more fields include at least one of a default control type that is subsequently and automatically populated with the patient information during the encounter with the patient, an input box that creates a point in a sentence where data can subsequently be manually input by the user during the encounter with the patient, and a select list that creates a list of different options that can subsequently be chosen by the user as text for completing at least one of the one or more sentences during the encounter with the patient.
14. The method of claim 13 , wherein
the user can select at least one of the one or more sentences by topic from one or more predefined sentences; and
elements of the one or more predefined sentences that are required to submit a patient bill for payment are denoted by a different color.
15. The method of claim 13 , wherein
the electronic document built for the patient is built with an electronic date/time stamp that corresponds to the date and time of the encounter with the patient.
16. The method of claim 13 , further comprising the step of
having the user define and/or select one or more body systems and one or more symptoms related to each body system in at least one of the one or more predefined sections,
wherein the user can subsequently choose from the defined and/or selected one or more body systems and one or more symptoms during the encounter with the patient to identify specific symptoms to which the patient admits.
17. The method of claim 16 , wherein
each of the one or more symptoms defined will be available for selection in subsequent template building operations performed with the template builder.
18. The method of claim 16 , further comprising the step of
having the user configure one or more worksheets or checklists in at least one of the one or more predefined sections for performing a physical examination of the one or more body systems during the encounter with the patient, the one or more worksheets or checklists being configured to include one or more findings associated with each of the body systems being examined and being available to subsequently be chosen by the user during the encounter with the patient.
19. The method of claim 18 , further comprising the step of
having the user select and/or locate and select one or more diagnoses in at least one of the one or more predefined sections, the selected and/or located and selected one or more diagnoses being associated with the one or more findings and being available to subsequently be chosen by the user during the encounter with the patient.
20. The method of claim 19 , further comprising the step of
having the user define and/or select one or more plans for treating the patient in at least one of the one or more predefined sections, the defined and/or selected one or more plans for treating the patient corresponding to the one or more diagnoses and being available to subsequently be chosen by the user during the encounter with the patient.
21. The method of claim 20 , further comprising the step of
having the user define and/or select one or more chief complaints in at least one of the one or more predefined sections,
wherein the user can subsequently choose from the defined and/or selected one or more chief complaints during the encounter with the patient, and
wherein the one or more sentences drafted and/or selected, the one or more body systems and one or more symptoms defined and/or selected, the one or more worksheets or checklists configured, the one or more diagnoses selected and/or located and selected, and the one or more plans for treating the patient defined and/or selected each relate to the one or more chief complaints defined and/or selected.
22. The method of claim 19 , wherein
at least one of the one or more findings, the one or more diagnoses, and the one or more plans for treating the patient is automatically associated with one or more of Evaluation and Management (E/M) coding, International Code of Diseases (ICD) coding, Current Procedural Terminology (CPT) coding, and HCFA Common Procedure Coding System (HCPCS) coding.
23. The method of claim 22 , further comprising the step of
automatically generating an electronic superbill for billing the patient at checkout and for electronically filtering and sorting insurance claims using the one or more of ICD coding, CPT coding, and HCPCS coding.
24. A template builder building a custom template that will be used by a health care provider to generate an electronic document for a patient during a subsequent encounter with the patient, the template builder comprising:
a chief complaint component for a user to define one or more chief complaints in a chief complaint section of the custom template;
a history of illness component for the user to draft and/or select one or more sentences and for the user define and/or select one or more fields for completing at least one of the one or more sentences in a history of illness section of the custom template, the one or more fields including at least one of a default control type that is subsequently and automatically populated with patient information during the subsequent encounter with the patient, an input box that creates a point in a sentence where data can be manually input by the user during the subsequent encounter with the patient, and a select list that creates a list of different options that can be chosen by the physician as text for completing at least one of the one or more sentences during the subsequent encounter with the patient;
a review of systems component for the user to define and/or select one or more body systems associated with the chief complaint and one or more symptoms related to each body system in a review of systems section of the custom template, the one or more body systems and one or more symptoms being available to be chosen by the user during the encounter with the patient to identify specific symptoms to which the patient admits;
a physical examination component for the user to configure one or more worksheets or checklists for performing a physical examination of the one or more body systems associated with the chief complaint in a physical examination section of the custom template, the one or more worksheets or checklists being configured to include one or more findings associated with each of the body systems being examined from which the user can subsequently choose during the encounter with the patient;
an assessment component for the user to locate and select one or more diagnoses associated with the one or more findings in an assessment section of the custom template the user being able to choose from one or more diagnoses during the subsequent encounter with the patient; and
a plan component for a user to define one or more plans for treating the patient corresponding to the one or more diagnoses in an plan section of the custom template the user being able to choose from one or more plans during the subsequent encounter with the patient
wherein the chief complaint section, the history of illness section, the review of systems section, the physical examination section, the assessment section, and the plan section are compiled by the template builder to generate the electronic progress note that will be used by the user during the subsequent encounter with the patient.