Software Technology for System to create structured and database information from verbal input.

Invented by Michael F. Stefanchik, John G. Mathe, Robin L. Scott, Steven W. Loper, Christopher S. Krueger, Robert H. Groves, VERBAL WORLD Inc

The VERBAL WORLD Inc invention works as follows

Background for System to create structured and database information from verbal input.

Verbal information is one of the most inefficient ways to capture data. Verbal and perhaps dictated information can have multiple meanings, making it difficult to capture data in structured format. One example is the medical environment. This environment may be one where the need is urgent (e.g. to treat a patient who has a potentially fatal condition). It can also present one in which the structure and format of the information can vary from that of insurance billing to that of the need for immediate correlation. The professional may not have the time or ability to manually enter the data. Bioterrorism is now a real threat. Although the attack technology was simple, the devastating consequences have been extensive and severe. It is now clear that terrorist attacks can’t be stopped completely. The rapid collection, sharing, and response to bioterrorist attacks is our best weapon. This process is dependent upon accurate, comprehensive, and rapid data capture.

In just one instance, it is clear that healthcare in general, and physician practices in particular have not kept up with the rapid technological advances in data capture and management technology. All stakeholders, from patients to providers, are affected as a result. The vast majority of doctors have not adopted technology solutions. They are mainly small, independent groups that focus on patient interaction, with little patience for high-tech solutions. However, it is clear that this market is fragmented and waiting for a solution.

Medical doctors are often quoted as losing money at a rate of up $60,000 per doctor per year due to the complexity of a reimbursement program that forces them to choose between millions of possible codes in order to be paid. The government’s stern eye and threat of criminal and monetary penalties if physicians over-charge for their services are the main drivers of revenue loss. The paper nightmare that is managing paper files at hospitals and doctor practices across the country means that fragments of patient data are hidden in paper files. This results in tens to millions of dollars being wasted each year. This puzzle is still unsolved. Why? Understanding physician culture and mechanics is the key to understanding why. Doctors are aware they have a problem, and in pain. The pain of the proposed solutions has been more severe than the pain from the problem.

The problem’s scope can be understood when we realize that doctors are only one type of service provider who is impossible to accommodate. Many service providers see clients or patients non-stop, from the moment they arrive at their office until they leave. They work 60 hour weeks and are focused on the client or patient. This includes interacting with the client or patient, assessing their problems and offering solutions. The practice of medicine, like many other services, is a relationship-based, interpretive, and interpersonal endeavor. The art of medicine is just as important as the science that is applied. The physician must then document his impressions, plan and thoughts after each encounter. He also needs to justify his reasoning in legal documents. There is little time for this because there are so many patients to see, it’s difficult to complete the task. The vast majority of doctors must then dictate the outcomes of each encounter. This can be done quickly, and often with very few hours to review or edit before the next patient encounter. Physicians cannot and will not learn new data entry methods that are more difficult and time-consuming. Today, less than 5% of physicians use electronic medical records. They cannot use pen charts, keyboards or uneditable voice recognition programs. Instead, they rely on an existing transcriber system and a somewhat haphazard code solution to document and justify every encounter. This service is available at a reasonable cost to physicians, and they are happy to learn coding and documentation. They are people-oriented and not technology-oriented. It is possible and desirable to have this aspect of healthcare managed by someone else. Many people mistakenly believe that if they create a data repository and give physicians a screen, keyboard, or drop list, doctors will flock to them in large numbers. These technologically advanced solutions are available now, but they’ve been mostly ignored or abandoned quickly. It is too difficult to get in.

The provider will need service as part the data capture solution. Technology alone is not enough. Doctors and other medical professionals often need local service. They or their staff can call them and hold them accountable. Someone who doesn’t hide behind bureaucracy but is available and willing to take on the risks of the relationship. Today, in medical applications, the local medical transcriber fills the roll to create edited paper documents. Medical transcriptionists mirror the healthcare industry. They are often small and fragmented but accountable local shops that serve physician needs. They also have a need. They know technology will eventually replace them but they don’t know when. The transcriptionist, but not their clients, realizes that the paper documents they provide are only a partial solution to the doctor’s needs. Their careers and livelihoods are at risk, but they realize that they don’t have the resources or time to solve all of their clients’ problems. The same goes for coding solutions. Although they are aware that there are problems with doctors, professional coders do not have the resources or insight to address them all.

One of the issues in sharing information is that healthcare and physician practices have not kept up with the rapid advancements in data management and capture technology. Our public health surveillance system’s primary problem is the inefficient sharing of data between public facilities and between them. This includes both the public system and private practitioners as well as between the private hospitals and clinics. The Senate Appropriations Committee requested and received a status report regarding public health infrastructure in September 1999. This document identifies the importance of data and information systems as a key need. The Health Alert Network was made a priority by both the Centers for Disease Control and the Secretary of Department of Health and Human Services. The HAN was created to achieve the goals and recommendations of the status report. The following is one of the three main goals:

?Goal number 2: Robust information and data systems GOAL – Each health department will have the ability to electronically access and share up-to-date information on public health and emergency alerts. This will allow them to monitor the health of their communities and help in the detection and treatment of a new public health problem.

Recommendation 5, ensure that all health department have high-speed internet access by 2010, and that they use standard protocols for data collection and transport. This will allow them to exchange information that is secure and confidential and connects with federal, state and local data systems.

Recommendation 6″: All health departments should have instant online access to the most current public health guidelines, medical data, treatment guidelines, and information about the effectiveness of public-health interventions by 2010.

Recommendation 7″: “By 2010, ensure that all departments of health have the ability to transmit and receive sensitive information via secure electronic networks and to broadcast emergency alerts to hospitals, medical centers and universities as well as local public health agencies and systems.

As for the medical application, it is clear that these goals must be reached to leverage the currently available technology and protect public health. However, the September 2001 events make it clear that while a state-by-state fragmented approach may get us to 2010 but we don’t have the luxury of time. It is urgent and clear that we must address this threat in the next few months, not years. These important recommendations and the health alert network have not adequately addressed a critical component of the electronic chain. Providers in the field need to be able to capture accurate and successful data, both private and public. The vast majority of doctors, who function independently, have not yet adopted technology solutions. They are focused on patient interaction and patient treatment and keep up with the rapid advancements in medical knowledge. They have little patience or time for high-tech solutions. Inaccessible paper files at hospitals and doctor practices across the country hide fragments of patient data. This paper nightmare is costing us tens to millions of dollars. We also lose literally billions of dollars because we are unable to capture vital information and quickly find out about public health, treatment efficacy, and health trends. It is impossible to manage information if it is not captured. It cannot be managed. Then care cannot be improved optimally. This simple logic has profound implications on the ability to respond to bioterrorist threats and for overall public safety and health.

The invention is conceptually possible to be understood from many perspectives. Understanding that these details are not limited, it is possible to understand the invention from four perspectives. A CE or other personal computer capability recorder object, functionality for precision code through software and the like, and a separate CE, or other personal computing ability, such as an active-synch portal station. File transfer protocols, such as electronic signatures, can also be used in medical applications. You can use each of these aspects separately, or combine them with other aspects to create an overall system.

The invention could be viewed from a data creation perspective as potentially including a data tag engine or other functionality. It may also include functionality for parsing data to data. An application for dealing digitally with workflow streams such as one for a medical transcriptionist, or another such user. A HIPAA compliant electronic notes security transfer system. Each of these elements can be used individually or combined with other aspects to create an overall system.

In addition to this, the invention may also be understood through an information flow or access perspective, by reference to a digital streaming, an Internet access database, automated patient information services, or an interactive portal-based knowledge transfer system. Each of these aspects may be used individually or combined with other aspects to create an overall system.

Capturing the data is the first step in solving the problem. The invention contains elements that tap into the huge amount of data and information that is dictated every minute in every office in America into a portable tape recorder. The invention allows for the creation of both coding and a checklist. It does this by placing custom templates on the screen of a handheld device, such as a pocket computer. The invention allows for direct dictation. The invention allows dictation directly?into? A network of independent transcriptionists in your area can be used (in most cases, it could be the physician who is using the template). The structured data can then be accessed via the internet and plugged into the appropriate fields while the doctor is editing or transcribing the note. This is possible, surprisingly, with minimal effort and without any difficulty. The transcriptionist sees this as an opportunity to solve a problem for their clients and save their career. They no longer have to drive to the practice to pick up tapes. Because the technology interfaces seamlessly with practice management software, they don’t have to deal with the hassle of matching demographic information to tapes. The data (code, for instance) can now be shaped, captured and structured in one seamless step that does not increase the cost of the physician or decrease the compensation for the transcriptionist. The technology can also be used to save time and money for the doctor or another person (using customized macros), to reduce the burden of inaccessible, fragmented patient data, and to collect the information in a secure website accessible via any Internet portal. The invention also allows for interfaces with existing systems by using an XML model, semi-automation and leveraging. One embodiment allows wireless remote handheld units to function as information and data portals.

The hand-held data entry device is able to record any type of pertinent data such as ICD-9 or CPT codes information, disease surveillance data, lab data, history, or physical examination data. The system can be used to record data in a portable, voice-driven manner. It also allows for the creation and structuring of templates and checklists. This makes it easy to use and has a flat learning curve. Data can also be stored securely in an XML format in a central database where it can be aggregated to meet a variety of purposes. The template model allows any entity to download checklists and templates from the internet to help shape data entry so that only the most important data elements are captured and tagged. The solution can be used in both directions. You can send customized templates via the internet to any hand-held data entry device. They can also receive updates, health alerts and relevant templates in real time. This dramatically reduces the information cycle. Remote sites can be connected via radio wireless technology to the central data processing repository.

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