Medical Report Template System for Automatic Billing Code Embedding
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Solution Overview
Problem
Current medical report generation and coding processes are cumbersome, lengthy, and expensive due to manual or semi-automatic methods, which are prone to errors and suffer from a shortage of trained medical coders, hindering efficient and accurate automatic billing and data management in healthcare.
Innovation Solution
A computer-assisted method and system that selects electronic templates suited to a patient's condition, automatically enters personal and condition data, and uses speech recognition to embed code data into medical reports, leveraging existing hospital information systems and imaging data for accurate and efficient coding.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If manual or semi-automatic coding methods are used, then medical reports can be generated, but the process becomes cumbersome, lengthy, and expensive with high error rates
Solution Approach 1:
The system performs preliminary actions by automatically populating the medical report template with patient data, condition information, and pre-stored medical text passages before the coding process begins. This preliminary population reduces the amount of manual work required during the actual report generation and coding phases, thereby improving productivity and reducing time loss.
Solution Approach 2:
The system enables self-service by automatically generating code data from the populated medical report content without requiring extensive manual intervention from trained coders. The automatic coding functionality allows the system to serve itself in the coding process, significantly reducing the time and resources needed for manual coding operations.
2Reliability
If manual coding by trained professionals is used, then accurate coding can be achieved, but resource constraints and shortage of trained medical coders become problematic
Solution Approach 1:
The system introduces an intermediary automated coding component that acts as a mediator between the medical report content and the final coded output. This intermediary automatically extracts relevant information from the populated report and generates appropriate code data, maintaining coding accuracy while reducing reliance on scarce human resources. The intermediary handles the complex coding logic, keeping the overall system manageable.
3Productivity
If speech recognition systems are used to transcribe dictated reports, then report generation is accelerated, but manual correction and checking are still required increasing time consumption
Solution Approach 1:
The system performs preliminary actions by pre-storing accurate medical text passages and condition information in databases before the dictation process. When the physician dictates the report, these pre-stored passages are automatically integrated into the report template, reducing the need for manual correction of transcribed text and thereby reducing correction time while maintaining high dictation speed.
Data Source
AI summary
A method and a system for generating, with the assistance of a computer system (12), a medical report (18) suitable for automatic billing, where an electronic template (39) suited for a specific patient's condition is selected out of a plurality of given electronic templates stored in storage means (15); personal data of the specific patient's and previously stored in storage means (11) are automatically entered into the selected electronic template; and medical report text passages and instructions are entered into the selected template by dictating and using a speech recognition system (13); additionally, condition data are automatically entered on the basis of condition information as far as stored in storage means (7) into the selected template, and code data associated with these condition information are automatically embedded in the selected template; and when entering medical report text passages, at least one predetermined voice macro stored in the storage means (16) together with code data embedded therein is called in; the code data thus embedded in the medical report (18) being applicable when coding the medical report for automatic billing.