System and Method for Problem List Reconciliation with Care Plan Generation in an Electronic Medical Record

Abstract

A method for generating orders for a care plan through a problem list in an electronic medical record or an electronic health record includes the steps of mapping, using a computer, entries in a problem list with a respective concept in an interface terminology, analyzing, by a computer, each mapped entry to determine related problem list entries, grouping related entries into one or more categories, and aggregating a plurality of care plans relevant to one of the categories. Care plans may include medications and labs, and each care plan entry also may be coded with an external terminology, such as RxNorm or LOINC.

Description

[0001]This application is a continuation of U.S. application Ser. No. 14 / 530,727, filed Nov. 1, 2014, which claims priority to U.S. provisional application 61 / 943,109, filed Feb. 21, 2014, which is incorporated herein by reference.BACKGROUND OF THE INVENTION[0002]Patient electronic medical records (EMRs) are used to store a patient's medical history in one location. EMRs permit more complete recordkeeping, which may lead to improved patient care, as healthcare professionals may be able to quickly and thoroughly review the patient's previous and current medical conditions in one location. EMRs also may facilitate portability of healthcare records.[0003]As computer use has become more prevalent, electronic health records or electronic medical records (EHRs or EMRs) have become the industry standard for documenting patient care. Industry initiatives and government legislation have facilitated EHR implementation and use. Most notable among them is the Health Information Technology for E...

AI Technical Summary

Benefits of technology

This approach provides a clearer, prioritized view of patient problems, reducing information overload and improving clinical decision-making by categorizing and ranking problems based on clinical relevance and severity, and facilitating the identification of actionable care plans.

Problems solved by technology

While EHRs aggregate patient information into a single location, they may suffer from information overload.

Every time the patient indicates that he or she has a problem, that problem may get added to the patient list, causing the list to grow.

Over time, this list may contain many entries, including duplicate problems, inaccurate problems, and outdated or resolved problems.

Similarly, because the problem list includes all of the patient's stated problems, it may contain information that, while current and unique, may not be that useful to the practitioner, particularly when the practitioner is a specialist.

At the same time, the problems that actually are most useful to the practitioner may be overlooked or otherwise missed when the practitioner is reviewing the entire problem list.

In addition, while one of the benefits of an EMR is record portability, difficulties may arise when problem lists from multiple sources are combined, particularly if those lists come from different types or formats of EMRs, or contain problems that are represented within multiple different reference vocabularies.

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