Automated code feedback system
A computer system automatically generates and provides real-time feedback to a healthcare provider about a selected Evaluation and Management (E/M) level to assign to a patient encounter. The system provides the feedback while the healthcare provider is creating the clinical note that documents the patient encounter. The system may also automatically generate and suggest E/M levels to the healthcare provider for approval by the healthcare provider while the healthcare provider is creating the clinical note.
1. A method performed by at least one computer processor executing computer program instructions stored on at least one non-transitory computer-readable medium, the method comprising:
(1) at an audio capture component:
(1) (a) capturing speech of a healthcare provider and speech of a patient;
(1) (b) producing an audio signal representing the speech of the healthcare provider and the speech of the patient;
(2) at an automatic speech recognition/natural language understanding (ASR/NLU) component, generating, based on a first portion of the audio signal, a first data structure containing: (a) a first text within a document, the first text representing a first speech of the healthcare provider and a first speech of the patient; (b) a first concept; and (c) a first association between the first text and the first concept;
(3) at a code generator module, after (2) and before (4):
(3) (a) generating a first code automatically based on the first text and the first concept; and
(3) (b) incorporating the first code into the document;
(4) after (2) and (3) and before (5), at the automatic speech recognition/natural language understanding (ASR/NLU) component, generating, based on a second portion of the audio signal, a second data structure containing: (a) a second text within the document, the second text representing a second speech of the healthcare provider and a second speech of the patient; (b) a second concept; and (c) a second association between the second text and the second concept; and
(5) at the code generator module, after (2), (3), and (4):
(5) (a) generating a second code automatically based on the second text and the second concept; and
(5) (b) incorporating the second code into the document.
2. The method of claim 1 , wherein the first code comprises an evaluation and management (E/M) code.
3. A non-transitory computer-readable medium comprising computer program instructions executable by at least one computer processor to perform a method, the method comprising:
(1) at an audio capture component:
(1) (a) capturing speech of a healthcare provider and speech of a patient;
(1) (b) producing an audio signal representing the speech of the healthcare provider and the speech of the patient;
(2) at an automatic speech recognition/natural language understanding (ASR/NLU) component, generating, based on a first portion of the audio signal, a first data structure containing: (a) a first text within a document, the first text representing a first speech of the healthcare provider and a first speech of the patient; (b) a first concept; and (c) a first association between the first text and the first concept;
(3) at a code generator module, after (2) and before (4):
(3) (a) generating a first code automatically based on the first text and the first concept; and
(3) (b) incorporating the first code into the document;
(4) after (2) and (3) and before (5), at the automatic speech recognition/natural language understanding (ASR/NLU) component, generating, based on a second portion of the audio signal, a second data structure containing: (a) a second text within the document, the second text representing a second speech of the healthcare provider and a second speech of the patient; (b) a second concept; and (c) a second association between the second text and the second concept; and
(5) at the code generator module, after (2), (3), and (4):
(5) (a) generating a second code automatically based on the second text and the second concept; and
(5) (b) incorporating the second code into the document.
4. The non-transitory computer-readable medium of claim 3 , wherein the first code comprises an evaluation and management (E/M) code.