Method and system for generating a medical report and computer program product therefor

Abstract

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.

1 .- 15 . (canceled) 
     
     
         16 . A method for generating a medical report, said method comprising:
 associating a preliminary set of medical billing codes with the medical report for a patient during generation of the medical report;   identifying one or more first medical billing codes from one or more sources to which medical billing codes are linked;   updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes to obtain an updated preliminary set of medical billing codes; and   generating a processed set of medical billing codes that is at least a subset of the updated preliminary set of medical billing codes, wherein generating the processed set comprises:
 for at least one medical billing code of the updated preliminary set of medical billing codes, generating a determination of whether to retain the at least one medical billing code in the medical report, wherein generating a determination of whether to retain the at least one medical billing code comprises:
 determining whether the at least one medical billing code represents at least one ambiguity in the updated preliminary set of medical billing codes, 
 in response to a determination that the at least one medical billing code represents at least one ambiguity, determining whether the at least one ambiguity can be resolved based on data associated with the patient, and 
 in response to a determination that the at least one ambiguity can be resolved, resolving the at least one ambiguity using the data associated with the patient. 
 
   
     
     
         17 . The method of  claim 16 , wherein the one or more sources comprises one or more medical images, and identifying one or more first medical billing codes from the one or more sources comprises:
 identifying from data associated with the one or more medical images, the one or more first medical billing codes linked to the one or more medical images.   
     
     
         18 . The method of  claim 17 , wherein updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes comprises:
 adding the one or more first medical billing codes identified from data associated with the one or more medical image to the preliminary set of medical billing codes.   
     
     
         19 . The method of  claim 16 , wherein the one or more sources comprises at least one voice macro, and identifying one or more first medical billing codes from the one or more sources comprises:
 identifying the one or more first medical billing codes from the at least one voice macro that includes the medical billing codes.   
     
     
         20 . The method of  claim 19 , wherein updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes comprises:
 automatically transferring, upon invoking the voice macro, the one or more first medical billing codes from the voice macro to the medical report by embedding the one or more first medical billing codes from the voice macro in the medical report.   
     
     
         21 . The method of  claim 20 , wherein embedding the one or more first medical billing codes from the voice macro in the medical report comprises embedding the one or more first medical billing codes in the medical report as hidden tags. 
     
     
         22 . The method of  claim 21 , wherein embedding the one or more first medical billing codes in the medical report as hidden tags comprises embedding the one or more first medical billing codes such that the one or more first medical billing codes embedded in the medical report are not visible when the medical report is presented to a clinician in a display. 
     
     
         23 . The method of  claim 16 , wherein resolving the at least one ambiguity using the data associated with the patient comprises resolving the at least one ambiguity based, at least in part, on previously stored personal data associated with the patient. 
     
     
         24 . The method of  claim 16 , wherein resolving the at least one ambiguity using the data associated with the patient comprises resolving the at least one ambiguity based, at least in part, on previously stored condition information associated with the patient. 
     
     
         25 . The method of  claim 16 , wherein resolving the at least one ambiguity using the data associated with the patient comprises resolving the at least one ambiguity based, at least in part, on medical examination information associated with the patient. 
     
     
         26 . A system comprising:
 at least one processor; and   at least one storage device storing executable instructions that, when executed by the at least one processor, cause the at least one processor to perform a method comprising:
 associating a preliminary set of medical billing codes with the medical report for a patient during generation of the medical report; 
 identifying one or more first medical billing codes from one or more sources to which medical billing codes are linked; 
 updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes to obtain an updated preliminary set of medical billing codes; and 
 generating a processed set of medical billing codes that is at least a subset of the updated preliminary set of medical billing codes, wherein generating the processed set comprises:
 for at least one medical billing code of the updated preliminary set of medical billing codes, generating a determination of whether to retain the at least one medical billing code in the medical report, wherein generating a determination of whether to retain the at least one medical billing code comprises:
 determining whether the at least one medical billing code represents at least one ambiguity in the updated preliminary set of medical billing codes, 
 in response to a determination that the at least one medical billing code represents at least one ambiguity, determining whether the at least one ambiguity can be resolved based on data associated with the patient, and 
 in response to a determination that the at least one ambiguity can be resolved, resolving the at least one ambiguity using the data associated with the patient. 
 
 
   
     
     
         27 . The method of  claim 26 , wherein the one or more sources comprises one or more medical images, and identifying one or more first medical billing codes from the one or more sources comprises:
 identifying from data associated with the one or more medical images, the one or more first medical billing codes linked to the one or more medical images.   
     
     
         28 . The method of  claim 27 , wherein updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes comprises:
 adding the one or more first medical billing codes identified from data associated with the one or more medical image to the preliminary set of medical billing codes.   
     
     
         29 . The method of  claim 26 , wherein the one or more sources comprises at least one voice macro, and identifying one or more first medical billing codes from the one or more sources comprises:
 identifying the one or more first medical billing codes from the at least one voice macro that includes the medical billing codes.   
     
     
         30 . The method of  claim 29 , wherein updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes comprises:
 automatically transferring, upon invoking the voice macro, the one or more first medical billing codes from the voice macro to the medical report by embedding the one or more first medical billing codes from the voice macro in the medical report.   
     
     
         31 . The method of  claim 30 , wherein embedding the one or more first medical billing codes from the voice macro in the medical report comprises embedding the one or more first medical billing codes in the medical report as hidden tags. 
     
     
         32 . The method of  claim 26 , wherein resolving the at least one ambiguity using the data associated with the patient comprises resolving the at least one ambiguity based, at least in part, on previously stored personal data associated with the patient. 
     
     
         33 . The method of  claim 26 , wherein resolving the at least one ambiguity using the data associated with the patient comprises resolving the at least one ambiguity based, at least in part, on previously stored condition information associated with the patient. 
     
     
         34 . The method of  claim 26 , wherein resolving the at least one ambiguity using the data associated with the patient comprises resolving the at least one ambiguity based, at least in part, on medical examination information associated with the patient. 
     
     
         35 . A non-transitory computer-readable storage medium encoded with a plurality of computer-executable instructions that, when executed by at least one processor, cause the at least one processor to perform a method comprising:
 associating a preliminary set of medical billing codes with the medical report for a patient during generation of the medical report;   identifying one or more first medical billing codes from one or more sources to which medical billing codes are linked;   updating the preliminary set of medical billing codes by adding the one or more first medical billing codes to the preliminary set of medical billing codes to obtain an updated preliminary set of medical billing codes; and   generating a processed set of medical billing codes that is at least a subset of the updated preliminary set of medical billing codes, wherein generating the processed set comprises:
 for at least one medical billing code of the updated preliminary set of medical billing codes, generating a determination of whether to retain the at least one medical billing code in the medical report, wherein generating a determination of whether to retain the at least one medical billing code comprises:
 determining whether the at least one medical billing code represents at least one ambiguity in the updated preliminary set of medical billing codes, 
 in response to a determination that the at least one medical billing code represents at least one ambiguity, determining whether the at least one ambiguity can be resolved based on data associated with the patient, and 
 in response to a determination that the at least one ambiguity can be resolved, resolving the at least one ambiguity using the data associated with the patient.