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IMPACT©

Intelligent Medical Patient Record And Coding Tool

E.Papazissis

The problem with medical records

What information must a doctor collect and report during or shortly after a patient consultation?

  • Medical history; past and present.
  • Clinical findings.
  • Procedures and treatment.
  • Directions.

This is the patient's medical record concerning the specific consultation.

Let's suppose that a patient visits the same or different doctors 2-3 times a year and every time the doctor keeps just a few lines of notes. As time goes on, this patient's file becomes quite big.

Let's suppose again that in one of these consultations the patient mentioned an important event like drug allergy. Unfortunately such a serious information concerning a potentially life threatening situation, which is most likely to recur, is lost amongst less important notes. The only possibility one has to come accross this information, is to carefully go through the entire file.

However, a doctor rarely has the time to read such a big file line to line. Thus important elements of patients' records are frequently overlooked, which is potentially hazardous to their health.

This is a sample of a good electronic patient file. It perfectly incorporates in the same screen images, bio-signals, graphs, sound, video and text. The text on this screen concerns a specific consultation. Although the file has been improved to a sophisticated environment, where a lot of miscelaneous information can be easily accessed instantaneously, the problem persists: Important information may be lost in thousands of text lines.

Now let's go to another example: A doctor reports: "Palpable abdominal mass". This information is insufficient to make someone else completely realize what the doctor really palpated. Additional characteristics have to be reported like:

  • Where was the mass localized?
  • What was its diameter?
  • Was it tender or not?
  • Was it fixated to the surrounding tissues or mobile?
  • Was it firm or soft?
  • Did it have smooth or irregular edges and surface?

Consequently complete phrases such as: "Palpable mass, localized in the right iliac fossa, hard, non tender, non mobile with an irregular edge, of 4-6 cm diameter", give almost the entire information.

Also normal findings are frequently quite as important as abnormal ones. For instance, when a doctor suspects acute bowel obstruction, the presence of normal bowel sounds, practically rulles out the diagnosis.

However absence of this normal finding from the medical record does not necessarily mean that the doctor heared normal bowel sounds. It may mean one of the following:

  1. The patients abdomen was regularly examined and bowel sounds were detected as normal.
  2. The doctor did not auscultate the patient's abdomen.
  3. Auscultation was performed but the doctor was uncertain of the findings.

This is why a complete medical record, apart from abnormal findings, must include all those pathological clinical signs which were looked for and not found (e.g. absence of neck stiffness reducing the likelihood of meningitis) as well as all those physiological and anatomical features which were searched for and found with confidence (e.g. thyroid gland palpated as normal or first and second heart sounds clearly audible and distinct).

Nevertheless, apart from records that conscientious students keep, in order to get good marks, such detailed records are not usually met because:

  1. Almost nobody has the time to write so much.
  2. Almost nobody would have the time to go through such vast records. That means that even if all of this information was kept, it would be practically useless.

There is only one case in which this material would be really useful: If every piece of information would be coded. Coded information can be classified, sorted, searched for, correlated and recalled in various ways. E.g. If the information "penicillin allergy" was coded, the system could be programmed so that if someone prescribed a ß-lactam antibiotic it would prompt a message such as: "CAUTION: This patient is allergic to penicillin!".

But how could a coding system include all these billions of different combinations and be user-friendly at the same time? So much so, that a doctor can easily and quickly reduce the entire information acquired during a patient consultation into codes within the limited time available?

IMPACT©

IMPACT includes:

  • Code-elements for symptoms and clinical findings
  • Code-elements for areas of surface anatomy and the physical cavities of the human body.
  • Code-elements for commonly used expressions to describe normal examination findings like "On inspection of the abdomen there is no distention, presence of ectopic pulses, protrusion of intra-abdominal mass, presence of hernia or dialated superficial veins".
  • Code-elements for clinical proceedures (e.g. 2055 means "urinary catheter", 56 means "placed", 57 means "removed" and 54 means "found properly positioned").

When the user selects a code-element, the system provides assistance by guiding him/her to the next group of code-elements out of which he/she has to make the next selection. This way code-elements develop into strings that represent whole sentences of medical records. These strings called IMPACT-codes build-up to whole records.

E.g. The code 05-04-01-04-2 means "pain which started 5 hours ago and continued up until one hour ago in the same intensity".

The code 700-86-31-25-06-7-046-00-3-057-00 means "Intolerable pain, zoster-like, which does not improve in any position of the body, it is not altered by respiration, it is affected by coughing, is localized over the epigastrium and reflects to the back".

Similarly the code 130-21-0504-01-5-048-001 means "A palpable firm mass with an irregular edge and irregular surface, non-tender, with a maximum diameter of 5-10 centimeters is localized in the region right of the umbilicus".

Codes of ICD-10 can also be used as code-elements in IMPACT, for instance to describe events in past history.

 

Advantages of IMPACT®

  • Only a few minutes are needed by a doctor to select proper code-elements and develop IMPACT codes regarding a patient's consultation. The result will be 2-3 pages of a well-written and comprehensive text.
  • The information in its entirety is coded.
  • The whole record can be instantaneously reproduced in different languages.
  • Automatic translation of complete medical records allows supervision of health services from a distance and telemedicine between different language speaking parties.
  • This system provides all essential prerequisites for building systems to ensure prevention of medical mistakes.

For further information about IMPACT, please CONTACT US

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