U.S. patent application number 17/124757 was filed with the patent office on 2021-04-08 for clinical structured reporting.
The applicant listed for this patent is CLICKVIEW CORPORATION. Invention is credited to David A. Martinez, David K. Martinez.
Application Number | 20210104303 17/124757 |
Document ID | / |
Family ID | 1000005290107 |
Filed Date | 2021-04-08 |
View All Diagrams
United States Patent
Application |
20210104303 |
Kind Code |
A1 |
Martinez; David A. ; et
al. |
April 8, 2021 |
CLINICAL STRUCTURED REPORTING
Abstract
Systems and methods for generating clinical structured reports,
allowing users to indicate findings from a medical examination
without having to enter normal findings. In one aspect, a user
selects a clinical structured report template for a particular type
of medical examination. A default clinical structured report based
on the template, and comprising normal findings for the medical
examination type, is presented to the user. The user modifies one
or more of the normal findings to indicate abnormal findings. A
clinical structured report is generated, based on the default
normal findings and the abnormal findings received from the user.
The report is stored in a database or sent to one or more
recipients over a network. In one aspect, the normal findings
comprise text data. In another aspect, the normal findings comprise
plots, graphs, diagrams, or other types of data. In one aspect, the
system provides for multi-language support and translations. In one
aspect, the clinical structured report is used to generate billing
information. In one aspect, the clinical structured report is
generated by a computer aided diagnosis tool.
Inventors: |
Martinez; David A.;
(Kentifield, CA) ; Martinez; David K.; (San
Francisco, CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
CLICKVIEW CORPORATION |
San Francisco |
CA |
US |
|
|
Family ID: |
1000005290107 |
Appl. No.: |
17/124757 |
Filed: |
December 17, 2020 |
Related U.S. Patent Documents
|
|
|
|
|
|
Application
Number |
Filing Date |
Patent Number |
|
|
12276174 |
Nov 21, 2008 |
10872683 |
|
|
17124757 |
|
|
|
|
60989797 |
Nov 21, 2007 |
|
|
|
Current U.S.
Class: |
1/1 |
Current CPC
Class: |
G16H 10/00 20180101;
G16H 80/00 20180101 |
International
Class: |
G16H 10/00 20060101
G16H010/00; G16H 80/00 20060101 G16H080/00 |
Claims
1. A method of automatically generating clinical structured reports
based on clinical structured report templates, the method
implemented by one or more report management computing devices, the
method comprising: providing a clinical structured report template
for a medical examination based on a received user selection input
of the medical examination, the clinical structured report template
associated with medical data comprising medical examination data
points for the selected medical examination, wherein the clinical
structured report template is automatically pre-populated with
default normal data points corresponding to the medical examination
data points; receiving one or more abnormal data points related to
one or more of the medical examination data points based on the
medical examination of a patient; automatically generating a
clinical structured report based on the clinical structured report
template, wherein the generated clinical structured report includes
modifications to one or more of the automatically pre-populated
default normal data points in the clinical structured report
template based on the abnormal data points; and generating and
outputting executable instructions for a graphical user interface
display of the clinical structured report.
2. The method of claim 1 further comprising: providing a default
collection of abnormal data points; and receiving the one or more
abnormal data points based on another received user selection input
from the default collection of abnormal data points.
3. The method of claim 1 further comprising: providing visually
highlighting of the modifications to one or more of the
automatically pre-populated default normal data points in the
clinical structured report template based on the abnormal data
points on the graphical user interface.
4. The method of claim 1, wherein the clinical structured report
further comprises additional data related to the medical
examination, wherein the additional data comprises one or more of
image data, audio data, or video data related to the medical
examination, or data points corresponding to prior medical
examination data from a prior medical examination of the patient
displayed on the graphical user interface.
5. The method of claim 1 further comprising: distributing the
clinical structured report to one or more remote recipients over a
network.
6. The method of claim 1 further comprising: generating an
automated billing statement based on the clinical structured
report.
7. The method of claim 1, wherein the one or more abnormal data
points related to one or more of the medical examination data
points based on the medical examination are received based on a
user interaction with the graphical user interface.
8. A report management computing device, comprising memory
comprising programmed instructions stored thereon and one or more
processors configured to execute the stored programmed instructions
to: provide a clinical structured report template for a medical
examination based on a received user selection input of the medical
examination, the clinical structured report template associated
with medical data comprising medical examination data points for
the selected medical examination, wherein the clinical structured
report template is automatically pre-populated with default normal
data points corresponding to the medical examination data points;
receive one or more abnormal data points related to one or more of
the medical examination data points based on the medical
examination of a patient; automatically generate a clinical
structured report based on the clinical structured report template,
wherein the generated clinical structured report includes
modifications to one or more of the automatically pre-populated
default normal data points in the clinical structured report
template based on the abnormal data points; and, generate and
output executable instructions for a graphical user interface
display of the clinical structured report.
9. The device of claim 8, wherein the processors are further
configured to be capable of executing the stored programmed
instructions to: provide a default collection of abnormal data
points; and receive the one or more abnormal data points based on
another received user selection input from the default collection
of abnormal data points.
10. The device of claim 8, wherein the processors are further
configured to be capable of executing the stored programmed
instructions to: provide visually highlighting the modifications to
one or more of the automatically pre-populated default normal data
points in the clinical structured report template based on the
abnormal data points on the graphical user interface.
11. The device of claim 8, wherein the clinical structured report
further comprises additional data related to the medical
examination, wherein the additional data comprises one or more of
image data, audio data, or video data related to the medical
examination, or data points corresponding to prior medical
examination data from a prior medical examination of the patient
displayed on the graphical user interface.
12. The device of claim 8, wherein the processors are further
configured to be capable of executing the stored programmed
instructions to: distribute the clinical structured report to one
or more remote recipients over a network.
13. The device of claim 8, wherein the processors are further
configured to be capable of executing the stored programmed
instructions to: generate an automated billing statement based on
the clinical structured report.
14. The device of claim 8, wherein the one or more abnormal data
points related to one or more of the medical examination data
points based on the medical examination are received based on a
user interaction with the graphical user interface.
15. A non-transitory computer readable medium having stored thereon
instructions for automatically generating clinical structured
reports based on clinical structured report templates comprising
executable code that, when executed by one or more processors,
causes the processors to: provide a clinical structured report
template for a medical examination based on a received user
selection input of the medical examination, the clinical structured
report template associated with medical data comprising medical
examination data points for the selected medical examination,
wherein the clinical structured report template is automatically
pre-populated with default normal data points corresponding to the
medical examination data points; receive one or more abnormal data
points related to one or more of the medical examination data
points based on the medical examination of a patient; automatically
generate a clinical structured report based on the clinical
structured report template, wherein the generated clinical
structured report includes modifications to one or more of the
automatically pre-populated default normal data points in the
clinical structured report template based on the abnormal data
points; and generate and output executable instructions for a
graphical user interface display of the clinical structured
report.
16. The non-transitory computer readable medium of claim 15,
wherein the executable code, when executed by the processors
further causes the processors to: provide a default collection of
abnormal data points; and receive the one or more abnormal data
points based on another received user selection input from the
default collection of abnormal data points.
17. The non-transitory computer readable medium of claim 15,
wherein the executable code, when executed by the processors
further causes the processors to: provide visually highlighting of
the modifications to one or more of the automatically pre-populated
default normal data points in the clinical structured report
template based on the abnormal data points on the graphical user
interface.
18. The non-transitory computer readable medium of claim 15,
wherein the clinical structured report further comprises additional
data related to the medical examination, wherein the additional
data comprises one or more of image data, audio data, or video data
related to the medical examination, or data points corresponding to
prior medical examination data from a prior medical examination of
the patient displayed on the graphical user interface.
19. The non-transitory computer readable medium of claim 15,
wherein the executable code, when executed by the processors
further causes the processors to: distribute the clinical
structured report to one or more remote recipients over a
network.
20. The non-transitory computer readable medium of claim 15,
wherein the executable code, when executed by the processors
further causes the processors to: generate an automated billing
statement based on the clinical structured report.
21. The non-transitory computer readable medium of claim 15,
wherein the one or more abnormal data points related to one or more
of the medical examination data points based on the medical
examination are received based on a user interaction with the
graphical user interface.
Description
[0001] This application is a continuation of Ser. No. 12/276,174
filed Nov. 21, 2008 which claims priority to U.S. Provisional
Patent Application No. 60/989,797 filed on Nov. 21, 2007.
FIELD
[0002] The present invention generally relates to document
generation, and in particular to creating a clinical structured
report.
BACKGROUND
[0003] In many industries, such as the healthcare industry,
technicians or specialists evaluate data and generate written
reports to be utilized by others in providing a service or product.
Other individuals refer to the written reports to provide the
appropriate service or product to the consumer. The process of
creating the written reports, however, is a time-consuming and
expensive process.
[0004] For example, radiologists diagnose diseases by analyzing
radiological images and generate written reports describing their
findings. One technology available to such specialists is the use
of dictation systems, such as a Dictaphone. The tapes are picked up
by transcriptionists and taken off-site for transcription.
Approximately 24-48 hours later, the transcribed reports are
returned to the radiologist for corrections. The marked reports are
picked up by the transcriptionists and taken off-site for
correction. The radiologists and the transcriptionists continue in
this manner until all corrections have been incorporated into the
transcribed report. Finally, the radiologist signs the corrected
reports, and the corrected reports are made available for
distribution via runners, who typically hand-carry the corrected
reports to the requesting physicians.
[0005] Technologies such as fax and e-mail have eliminated the step
of physically picking up the reports, thus, decreasing the amount
of time required to produce the corrected reports. These
technologies, however, fail to significantly impact the timeliness
of the production of such reports.
[0006] Tele-transcription systems reduce the dictation and
transcription time because the systems allow radiologists to pick
up an ordinary phone and dial into a dictation system provider and
report their cases. These systems eliminate the runners and cut
transcription turnaround time significantly, to about 12-24 hours.
Corrections to the reports, however, are still time-consuming.
[0007] Some systems utilize voice recognition technology in an
attempt to reduce the dictation/transcription time. These voice
recognition systems, however, have to be trained to each speaker's
specific voice recognition patterns, and the accuracy rates are too
low for many applications, including radiology in which an accuracy
rate of 95% is not acceptable.
[0008] Corrections in many of these systems are even more
cumbersome, and the systems are expensive. Although the voice
recognition system provides many advantages, such as the electronic
distribution of reports, the disadvantages discussed above limit
its usefulness.
[0009] Another technology available to such specialists is the use
of electronic data entry systems, such as those utilizing
hierarchical input nodes, similar to those mechanisms employed by
programs such as Microsoft Corporation's Windows Explorer program.
Such systems require a user to select a parent node, the selection
of which displays several child nodes. The user selects a child
node, which may, in turn open up several other nodes. The parent
node may describe general parts of the anatomy. The child node may
describe sub-parts of the anatomy. The user thus searches through
the node tree to find the appropriate node and selects that node.
The selection of this node prompts the system to add a text to the
report. Such techniques have several shortcomings in the medical
context. For example, such hierarchical trees can be very large and
complex. A user is forced to search through the entire tree to find
the desired node, or to select through several hierarchies to find
the desired node. Further, the user goes through the process of
selecting a node for each line of the report that the user wants to
generate. Such a system is both time-consuming and can be
confusing, as a user not familiar with the layout of the nodal
hierarchy will have to search the entire hierarchy for the desired
selection.
[0010] Other systems employ a combination of node selection and
voice recognition to generate radiology reports. Users of such
systems select a single node to generate a normal report, and use
voice recognition technology to dictate a report with a finding of
a medical abnormality. Such a system is prone to the same errors
previously described with respect to voice recognition
technology.
[0011] The systems described generally begin with a blank report.
The user populates the report by adding material to the blank
report. Medical reports are required to contain significant amounts
of detail for medical billing practices (particularly promulgated
by the insurance industry). This is true even if the report denotes
normal or healthy findings. Statistically, a significant proportion
of medical reports, particularly radiology reports, are normal.
Thus, systems that begin with a blank report for the user to
populate with normal as well as abnormal findings are both costly
and time-consuming for an industry where the significant proportion
of such reports are normal and contain similar text and values.
[0012] The systems described are also plain text reports, and the
consumer of that report must read carefully through the report in
order to discern whether the report discloses any medical
abnormalities. Such a system is prone to errors in fast-paced
environments, 15 where a medical abnormality thus reported may be
overlooked.
[0013] Furthermore, the systems described generally do not provide
the reports in an electronic form that enables a user to search
across reports and create reports based on the content of a
plurality of previously completed reports. Rather, the systems
generally only provide the ability to search for specific strings
of text contained within a report.
[0014] Therefore, the present invention advances the art by
providing an improved technique that allows users to generate
clinical reports.
SUMMARY
[0015] Systems and methods for generating clinical structured
reports, allowing users to indicate findings from a medical
examination without having to enter normal findings. In one aspect,
a user selects a clinical structured report template for a
particular type of medical examination. A default clinical
structured report based on the template, and comprising normal
findings for the medical examination type, is presented to the
user. The user modifies one or more of the normal findings to
indicate abnormal findings. A clinical structured report is
generated, based on the default normal findings and the abnormal
findings received from the user. The report is stored in a database
or sent to one or more recipients over a network. In one aspect,
the normal findings comprise text data. In another aspect, the
normal findings comprise plots, graphs, diagrams, or other types of
data.
[0016] In one embodiment, the system provides for multi-language
support and translations. In one embodiment, the clinical
structured report is used to generate billing information. In one
embodiment, the clinical structured report is generated by a
computer aided diagnosis tool.
BRIEF DESCRIPTION OF DRAWINGS
[0017] Referring now to the drawings in which like reference
numbers represent corresponding parts throughout:
[0018] FIG. 1 illustrates a system for creating and managing
clinical structured reports, in accordance with an embodiment of
the present invention.
[0019] FIG. 1A is a flow diagram illustrating the process of
generating a clinical structured report, in accordance with one
embodiment of the present invention.
[0020] FIG. 2 illustrate example portions of an initial clinical
structured report, in accordance with an embodiment of the present
invention.
[0021] FIGS. 3 and 4 illustrate example user interfaces for
creating a clinical structured report, in accordance with an
embodiment of the present invention.
[0022] FIGS. 5A-5F illustrate different views of one particular
example of a structured clinical report.
[0023] FIG. 6 illustrates a clinical structured report created in
accordance with an embodiment of the present invention.
Specifically, the figure illustrates further user interface
elements for selecting or specifying an abnormality.
[0024] FIG. 7 illustrates a completed clinical structured report in
accordance with an embodiment of the present invention.
[0025] FIGS. 8-10 illustrate user interface elements for modifying
a template for an example clinical structured report in accordance
with an embodiment of the present invention. FIG. 8 illustrates the
choice of various templates for a set of example clinical
structured reports according to embodiments of the present
invention. FIG. 9 illustrates the consequence of selecting a
template of a clinical structured report of FIG. 8, in accordance
with an embodiment of the present invention. FIG. 10 illustrates
the consequence of selecting a template of a clinical structured
report of FIG. 9, as well as the ability to edit the standard
normal templates of the clinical structured report in accordance
with embodiments of the present invention.
DETAILED DESCRIPTION
[0026] In the following description, for purposes of explanation,
numerous specific details are set forth in order to provide a
thorough understanding of the invention. It will be apparent,
however, to one skilled in the art that the invention can be
practiced without these specific details.
[0027] It is further noted that, unless otherwise indicated, all
functions described herein may be performed by either hardware or
software, or some combination thereof. In a preferred embodiment,
however, the functions are performed by a processor such as a
computer or an electronic data processor in accordance with code
such as computer program code, software, and/or integrated circuits
that are coded to perform such functions, unless otherwise
indicated.
[0028] Reference in this specification to "one embodiment" or "an
embodiment" means that a particular feature, structure, or
characteristic described in connection with the embodiment is
included in at least one embodiment of the invention. The
appearances of the phrase "in one embodiment" in various places in
the specification are not necessarily all referring to the same
embodiment, nor are separate or alternative embodiments mutually
exclusive of other embodiments. Moreover, various features are
described which may be exhibited by some embodiments and not by
others. Similarly, various requirements are described which may be
requirements for some embodiments but not other embodiments.
[0029] As employed herein, the term "patient" shall mean a living
member of the animal kingdom including human beings
[0030] The present invention provides a method for generating a
clinical structured report. As one of ordinary skill in the art
will appreciate, the present invention applies to any area in which
a report is to be generated for use by other individuals or groups.
For example, an embodiment of the present invention may be utilized
in radiological, toxicological, pharmaceutical, other healthcare
specialties, or the like. For illustrative purposes only, however,
the following description generally provides examples specific to
one or more types of reports, such as radiology and reports
generated by radiologists, radiology technicians, or other
radiology support staff.
[0031] As will be discussed in greater detail below, an embodiment
of the invention allows a user to generate clinical structured
reports from a default template pre-filled to show normal radiology
findings. For example, the radiologist or user can use and access
an embodiment of the invention on a computer to generate a
radiology report. An embodiment of the invention displays a default
template showing descriptions or values indicative of normal
radiology findings to the user. The normal values describe names
and normal characteristics of both the general and specific anatomy
that is the subject of the radiology report.
[0032] A user interface displays the default report and includes
one or more user interface elements for confirming the values shown
in the default report. Such a confirmation generates a report
showing that general and specific anatomy exhibit normal
characteristics. The user interface also displays one or more user
interface elements for allowing users to indicate that some of the
findings in the radiology exam at hand indicate one or more
abnormalities (hereinafter also referred to as abnormal findings).
Such a selection will preferably prompt the user to input the
specifics of the abnormality, for example via one or more drop down
menus or optionally through manual entry of the details of the
abnormality. In one embodiment, the normal findings comprise text
data. In other embodiments, the normal findings may also comprise
plots, graphs, diagrams, or other types of data.
[0033] Referring to FIG. 1 of the drawings, the reference numeral
100 generally designates a reporting system, which embodies
features of the present invention. Generally, the reporting system
100 comprises one or more interface devices 102, such as computers,
cell phones, appliances, personal digital assistants (PDAs),
television systems, etc. The interface device 102 preferably
includes a processor, one or more data communications devices
(e.g., modems, network interfaces, etc.), a monitor (e.g., CRT, LCD
display, etc.), and one or more input devices (e.g., a mouse and/or
a keyboard). It is envisioned that attached to the client computer
may be other devices such as random-access memory (RAM), read-only
memory (ROM), a video card, bus interfaces, printers, and the like.
The interface device 102 is configured to allow a user 103 to enter
data regarding observations that user 103 has made regarding a
subject, patient, or image (not shown). For the purposes of
describing the invention, user 103 will have the same meaning as
"user" or "users".
[0034] Optionally, the interface device 102 is coupled to a server
101. The server 101 is preferably coupled to a database 104, which
receives, stores, and sends data generated by one or more users.
Database 104 also receives, stores, and sends default or modified
templates that are used to generate clinical structured reports, in
accordance with an embodiment of the present invention. Changes to
the templates stored in database 104 are reflected in the generated
reports. The server 101 is preferably a server accessible via an
internal network to enable sharing of templates, generated data,
and reports. Optionally, server 101 is also accessible via an
external network, such as the Internet, to which the interface
device 102 couples via a communications link, such as a TCP/IP
communications link, a wireless communications link, or the like.
The present embodiments allow for single user as well as multi user
configurations. One or more users may be interacting with the
system concurrently or sequentially when performing tasks such as
viewing a report, filling a report, modifying a report or template
or interacting with a system in any other way as described
herein.
[0035] FIG. 1A is a flow diagram illustrating the process of
generating a clinical structured report, in accordance with one
embodiment of the present invention. At step 151, a user selects a
report for a medical examination. At step 152, a user interface is
presented to the user, the user interface indicating the selected
report and initialized from a template comprising pre-filled values
denoting normal findings for the selected medical exam. An example
portion of such an initial report user interface is shown in FIG.
2, illustrating a portion of an example report for a medical exam
of the liver and spleen as the report evolves according to the
various steps of FIG. 1A. While the example report shown in FIG. 2
is generated from an exemplary template with pre-filled values
denoting a normal medical exam of the liver and spleen, it is
understood that this represents an exemplary embodiment and that
reports for other medical exams can be generated in a similar
manner.
[0036] At step 153, the user may modify the presented report user
interface, which indicates pre-filled normal findings, in order to
indicate actual findings from an actual medical exam. The user may
do this, for example, by electing to edit the comments, as shown in
the user interface 201a of FIG. 2. User interface 201b shows what
is displayed to the user upon clicking an exemplary "Edit Comment"
button of user interface 201a. Upon completion of the edit, the
user may save the edited comment, for example by clicking a "Save
Comment" button on the user interface of user interface 201b, upon
which server 101 stores the edited comments into database 104,
reflecting the actual medical findings as indicated and saved by
the user. Upon storage of the actual findings, a user interface
201c is displayed to the user, presenting the user's modifications.
For illustrative purposes, this is shown in user interface 201c of
FIG. 2 using the phrase "MORE COMMENTS ADDED."
[0037] Alternatively, the user may choose to cancel the most recent
edits, for example by clicking on a "Cancel" button as shown in
interface 201b, upon which time the original user interface 201a is
displayed to the user again. Alternatively, the user may choose to
reset the presented user interface according to the pre-filled
normal findings of the particular medical report template, for
example by clicking on the "Reset" button as shown as shown in
interface 201b, upon which time the Server 101 retrieves the normal
findings from database 104 (or from a cache) and presents them once
again as in user interface 201a.
[0038] Still referring to FIG. 2, the user may also interact with
user interface 201a in a more structured fashion in order to denote
an abnormality, for example by clicking the "Check for Abnormal"
checkbox. The server 101 may then present to the user a more
structured interface, for example such as interface 201d of FIG. 2,
prompting the user to input further information regarding the
abnormality. The server 101 and database 104 may be configured to
present any suitable interface for entering abnormal findings, as
appropriate for the particular medical report and as depending on
any other relevant factors. The user may interact with user
interface 201d to indicate one or more abnormal findings, and may
then save the findings, for example by clicking on a "Save Comment"
button as shown in 201d. Thereupon, the server 101 saves the
findings, and subsequently presents a user interface indicating the
user's findings in text form, such as shown in interface 201e. The
user may continue to interact with user interface 201e to refine
the next form of the findings, for example to add more comments.
When done, the user may click on "Save Comments" to save the edits,
whereupon the server 101 may present user interface 201f to the
user indicating the user's edited findings. At this point, the user
may indicate completion, or the user may alternatively further
interact with interface 201f to "Edit Comments" (going back to
201e) or choose "Reset" (going back to 201d).
[0039] FIGS. 3 and 4 illustrate the process of accessing a template
for a clinical structured report in accordance with an embodiment
of the present invention. FIG. 3 illustrates a general patient file
that user 103 may access via a database or through a network. User
103 selects "Create a New Exam" in order to initiate the creation
of a new clinical structured report for the selected patient. FIG.
4 illustrates a consequence of selecting "Create a New Exam" in
FIG. 3. FIG. 4 illustrates the retrieval or entry of the details of
the patient's examination, the details being optionally retrieved
from commonly utilized hospital network systems such as Hospital
Information Systems (HIS), Radiology Information Systems (RIS),
Picture Archiving Communications Systems (PACS), or other suitable
system.
[0040] The clinical structured report comprises of one or more
sections to indicate normal clinical or medical findings, and
preferably one or more sections containing patient identifying
information. FIGS. 5A-5C illustrate different views of one
particular example of a structured clinical report (as indicated by
the scroll bar on the right). The example report shown is a
radiology report, and has sections 501a, 501b, 501c, 501d, 501e,
501f, 501g, and so on (best seen in FIG. 5B). As described above,
these sections are pre-filled from a normal radiology template in
order to indicate normal radiology findings. Preferably, these
findings describe both the general and specific anatomy of the
radiology subject, though the individual sections need not
necessarily correspond directly to only one named part of the
subject's anatomy. For example, report 501 is a CT Scan of the
Brain/Head, the sections 501a through 501f (best seen in FIG. 5B)
are found within the general anatomical description "Intracranial,"
referring to the general intracranial portions of the Brain/Head.
However, in the particular example best seen in FIG. 5B, sections
501a through 501f (best seen in FIG. 5B) comprise descriptions of
those specific portions of anatomy, and descriptions of the normal
characteristics of those anatomies. For example, section 501a
indicates "Cerebral Hemispheres" and includes a description of
medically or clinically normal cerebral hemispheres.
[0041] Referring to FIG. 5C, to produce a radiology report
indicating no abnormalities, user 103 interacts with an element of
the user interface, for example by clicking on "Click Here to
Validate". Thus, a detailed report is produced by minimal
interaction with the user, in this particular example via one
click. This system is desirable for hospitals, where a significant
proportion of reports are normal, as it drastically reduces the
production time for documents and reduces errors associated with
voice recognition technology. Furthermore, it promotes linguistic
and visual uniformity of medical reports.
[0042] To produce a report indicating the presence of
abnormalities, user 103 may disaffirm the report by interacting
with an element of the user interface, for example by clicking a
box under the heading "Check for Abnormal" (the heading is best
seen in FIG. 5A). A selection of "Abnormal" prompts the user 103 to
enter further information about the abnormality into the report.
FIG. 6 shows an example user interface for accepting such
information from user 103. In one embodiment, the prompt includes a
series of one or more check boxes and/or drop-down menus with
pre-filled portions of text. Once the user 103 indicates his
selections, the selections are assembled into a data structure
indicating a paragraph or other structure for storage in database
104.
[0043] Alternatively, the user interface may include a text box (as
seen in FIGS. 5C, 5D, and 5E, section 502), which the user 103 can
modify with any desired text.
[0044] Alternatively, for either a normal or abnormal report, user
can modify the pre-existing template through entry into a text box
(as shown in FIG. 5F, section 501a).
[0045] Referring to FIG. 7, optionally the clinical structured
report thus produced comprises visual cues such as highlights or
flags of any fields marked as abnormal. In one embodiment, such
visual cues appear at the various stages of producing the report.
For example, the parts of the report shown in FIG. 7 denoting an
abnormality may be highlighted with visual cues. As another
example, the parts of the working report shown in FIGS. 5D and 6
denoting the abnormality may be highlighted as well. Further, the
report may be generated on a screen or other suitable electronic
display, in a paper printout, in an electronic document, on a
storage medium, or in any other suitable format. Inclusion of
visual cues is advantageous, especially in a fast-paced environment
where abnormalities may be overlooked or need to be called out
visually for additional convenience or safety.
[0046] A user may customize an existing template or create a new
template. FIGS. 8, 9, and 10 illustrate the process of such
customization. FIG. 8 illustrates the starting point for the
customization of an existing template for an example abdominal
exam. User 103 selects one of the template reports to modify, for
example by clicking on it. Optionally, once user 103 selects the
template, the user is presented to a user interface for selecting
from one or more specific sub-templates, for example such as shown
in FIG. 9. In the example shown, user 103 selects from one or more
specific sub-templates in the menu on the left hand side of the
screen.
[0047] Optionally, once user 103 selects a sub-template, the user
is presented with an interface, such as the screen shown in FIG.
10, showing a modifiable template. The modifiable template
comprises one or more sections, shown here as sections 1001a and
1001b, which will allow the user to pre-fill values for both normal
and abnormal radiological reports, thereby defining the
template.
[0048] While the above embodiments have been described generally
with respect to normal and abnormal findings that are represented
in text form, it is an advantageous aspect that the clinical
structured reports may optionally comprise non text data, such as
data plots, diagrams, images, etc., as will be presently
described.
[0049] For example, in a medical ultrasound examination of an
obstetrical patient, an ultrasound operator may measure one or more
fetal biometrics. For example, the ultrasound operator may measure
the size of certain elements of the fetal anatomy, such as the
head, abdomen, extremities, etc. This ultrasound image data is then
transferred from the ultrasound equipment into a database, such as
database 104 or other database, as part of the patient's record
(i.e. the mother, in this case). Such ultrasound image data often
represents a significant portion of the patient's periodic
ultrasound examination results. The system 100 may be configured to
apply one or more mathematical computations (such as regressions,
standard deviations, etc.) for fetal growth, as are known in the
art, to the data stored in the database 104. For example, such
computations may be applied to the fetal age, fetal weight, or to
other data gathered from the examination. Results of such
computations may then serve as statistical data points which can be
correlated with the various dates of the periodic ultrasound
examinations which are generally performed throughout the
pregnancy. For example, such data points may be tracked graphically
as serial data points plotted on a trend line to display progress
of normal or abnormal fetal growth. A clinical structured report,
as described herein, may comprise pre-filled graphical
representations based on normal data points that are indicative of
normal fetal growth, and which are part of an obstetrical
ultrasound examination template stored on database 104. The actual
data produced by the examination may then be used to juxtapose the
actual findings against normal findings, in order to determine
abnormalities or deviations from norm (if any). Optionally, and as
also described above, abnormal data may be color coded or otherwise
visually highlighted for display.
[0050] As another example, a clinical structured report for a blood
flow examination may comprise one or more anatomical images,
diagrams, line drawings, etc., of blood vessels, and may indicate
blood flow, for example blood velocity and direction. For instance,
for a patient suffering from stenosis of arteries (e.g. in the neck
or other part of the body), a Doppler ultrasound examination as
part of a carotid vascular examination may measure the flow of
blood in the carotid artery, with the ultrasound measurements
helping to determine a degree of narrowing of the affected blood
vessel lumen. Therefore, a template for such a clinical structured
report may comprise an image, diagram, line drawing, or other
representation of the artery, indicating normal findings for such
an examination (such as normal ranges for blood flow, normal blood
flow ratios, etc.). During or after the medical examination, the
system 100 would allow a user to simply confirm normal findings, or
to indicate abnormal findings by drawing onto (e.g. with a computer
drawing tool), or by otherwise interacting with, the diagram in
order to indicate the obtained data, such as the measured blood
flow through the stenosis. As with the above embodiment, this
allows the user to indicate abnormal findings of the examination
without having to also enter all the normal findings. Optionally,
the system 100 may also be configured apply mathematical equations
in order to arrive at blood flow ratios (as known in the art) in
order to determine the significance of the stenosis. As with the
above embodiments, template images, graphs, plots, diagrams, etc.
may be used in a wide variety of structured medical report
templates for a variety of medical examinations.
[0051] As another example, a clinical structured report may
comprise one or more anatomical images, diagrams, line drawings,
etc., of a region of anatomy, such as the brain or other organ,
indicating normal ranges for the size or other characteristics of
the region or organ. This allows a user of system 100 to indicate
any abnormal findings of a medical examination into a clinical
structured report. For example, the user may indicate an abnormal
size or other characteristic of the region, or draw and indicate a
size or other characteristics of an abnormal mass found in the
region, for example by using a drawing tool to draw onto the
provided diagram, or by choosing from one or more abnormal
selections, etc.
[0052] Optionally, the present embodiments also comprise
multi-language capabilities. For example, the user interface may
allow the user to dynamically select among a plurality of supported
languages (such as English, Spanish, German, French, etc.) and
dynamically modify the user interface to present the normal
findings, as well as the abnormal findings, in the user selected
language. In such an embodiment, the default template would store
the normal findings, as well as the collection of available
abnormal findings, in the supported languages so they can be
presented accordingly upon the user's language selection.
Optionally, the system may be configured to receive normal and
abnormal findings from the user in one language, and present and/or
report them in another language. For example, the user interface
may allow the findings to be entered in Spanish (or in any other
supported language), and the system may then display and/or store
the report in English (or in any other language). In such
embodiments, the normal and abnormal findings stored in report
templates may be pre-translated (i.e., "canned`), and the system
may optionally provide for on-the-fly translations and/or
post-process translations.
[0053] Optionally, the clinical structured report may comprise
links or other resource identifiers to supplementary data. The
server 101 may use such links or resource identifiers to assemble
the supplementary data into the report for presentation to the
user. For example, the report may contain a reproduction of one or
more radiology exam images or a link to such images (not shown),
audio files from the exam, video files from the exam, or other
supplementary data. Such supplementary data may reside in database
104, a separate storage system, a network resource, or
elsewhere.
[0054] Optionally, the server 101 distributes the clinical
structured report via a public or private network such as the
Internet. For example, the server may e-mail the report from one
user to another, or distribute it in any other common fashion as
should be obvious to one of ordinary skill in the art.
[0055] In another embodiment of the invention, the clinical
structured report is electronically transmitted to a portable
wireless device. For example, the report, along with any images or
other data it may contain, may be transmitted to a mobile device
(such as a mobile phone, laptop computer, handheld device, etc.),
where it may or may not be modified by a user.
[0056] Optionally, the generation of the clinical structured report
triggers generation of billing information. For example, after the
generation of a report, the server may generate a bill or invoice
for the examining physician's services, and send the bill or
invoice to the appropriate recipient or submit it electronically
according to a billing protocol.
[0057] Optionally, the clinical structured report is automatically
generated by a computer-aided diagnostic tool. For example, a
software program, or a combination of software and hardware
elements, may study data or images obtained from clinical exams or
tests residing on the database, on a network resource, or
elsewhere. Once the software program identifies any medical
abnormalities, or lack thereof, the reports of the present
embodiments may be used to communicate any diagnoses, along with
findings from such exams. A report thus created may be affirmed or
disaffirmed by a reviewing physician.
[0058] While the above is a complete description of the preferred
embodiments of the invention, various alternatives, modifications,
and equivalents may be used. Therefore, the above description
should not be taken as limiting the scope of the invention which is
defined by the appended claims.
* * * * *