Web-Based Form With Embedded Knowledge Base For Medical Imaging Documentation
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Solution Overview
Problem
Current electronic medical record systems lack efficient tools for documenting imaging findings and generating standard, searchable imaging documentation, leading to confusion, high costs, and administrative burdens for physicians.
Innovation Solution
A method and platform for creating web-based forms that incorporate an embedded knowledge base, guiding users through a decision tree to ensure accurate and complete documentation of medical imaging findings and compliance with ICD-10 coding standards.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Ease of manufacture
If current electronic medical record systems use templated pick-lists for documenting imaging findings, then the system implementation is simpler and costs are lower, but the documentation becomes too simple creating confusion among users and lacks standard nomenclature
Solution Approach 1:
The system segments the imaging documentation process into multiple hierarchical levels: examination type selection, anatomical region selection, finding categories, and specific findings. This segmentation allows the system to maintain simplicity in implementation while providing structured guidance that reduces user confusion and ensures standard nomenclature through progressive disclosure of options.
Solution Approach 2:
The system performs preliminary actions by pre-configuring the decision tree with standard nomenclature and ICD-10 coding mappings before the physician uses the system. The knowledge base is pre-loaded with clinical guidelines and coding standards, so physicians receive automated guidance without needing to learn complex systems or worry about coding accuracy.
2Reliability
If radiological software provides comprehensive templated studies for imaging documentation, then the documentation standardization is improved, but hardware, software and support become expensive
Solution Approach 1:
The system achieves universality by building a single web-based platform that handles multiple functions: imaging documentation, ICD-10 coding, clinical guidelines integration, and quality measure tracking. This multi-functional approach eliminates the need for separate expensive specialized software systems while maintaining comprehensive standardization through the unified decision tree architecture.
Solution Approach 2:
The patent replaces complex mechanical/electronic EMR systems with a web-based platform accessible through standard browsers. This substitution reduces hardware requirements and software complexity while maintaining documentation standardization through the knowledge base and decision tree, which are implemented as software logic rather than complex hardware systems.
3Measurement precision
If physicians customize and learn complex imaging documentation systems, then the documentation accuracy is improved, but physicians lack time to customize and learn the system
Solution Approach 1:
The system implements self-service by automatically generating the documentation and coding based on the physician's selections in the decision tree. The knowledge base automatically maps selections to standard nomenclature and ICD-10 codes, and the system automatically tracks quality measures and generates reports, eliminating the need for physicians to manually customize or learn complex coding rules.
Solution Approach 2:
The system provides continuous feedback to physicians during the documentation process through the decision tree, showing what selections have been made, what information is still needed, and automatically updating the documentation as progress is made. This feedback mechanism ensures documentation accuracy while saving time by guiding physicians through only the necessary steps rather than requiring them to learn entire complex systems.
4Quantity of substance
If imaging documentation systems include multiple windows and detailed options, then the documentation completeness is improved, but screens become too busy and multiple windows open at any given time
Solution Approach 1:
The system implements dynamics through the decision tree interface, where the number and visibility of options change dynamically based on previous selections. As physicians navigate through the tree, the system dynamically adjusts which fields are visible, which options are available, and how much detail is displayed, ensuring documentation completeness while preventing screen clutter by showing only relevant information at each step.
Solution Approach 2:
The segmentation of the documentation process into sequential decision tree steps ensures that only one section of the form is visible at a time, with related options grouped together. This segmentation maintains documentation completeness by systematically working through all required elements while keeping the screen simple and focused, avoiding the need for multiple windows or overly busy interfaces.
Data Source
AI summary
A web-based platform for guiding a user's encounter with a patient and for generating a medical record of the encounter. The web-based platform comprises a processor in communication with an output display device and an input user interface, a knowledge base. The processor outputs information to the output display device, accesses the knowledge base, and receives information from the input user interface. The output display device requests patient information in response to presented successive prompts for patient medical information. The prompts are responsive to the knowledge base and to prior responses to prior prompts as entered through the input user interface. The output display device presents a patient medical condition report based on responses to requests and prompts. ICD codes are included within the knowledge base and included within the patient medical condition report. The codes are determined, as applicable, as each prompt and response is entered.