JP7535242B2 - Electronic medical record system, processing method and program for electronic medical record system - Google Patents

Description

The present invention relates to an electronic medical record system, a processing method for the electronic medical record system, and a program.

Electronic medical record systems are widely used in hospitals and other medical institutions to manage medical records such as consultation records, examination records, and nursing records (for example, Patent Documents 1 and 2). Electronic medical records are required to record necessary information regarding medical treatment in accordance with the three principles of "authenticity," "readability," and "storability," as specified in Form 1 of Article 22 of the Regulations for Insurance Medical Institutions and Insurance Medical Care Personnel (Ministry of Health and Welfare Ordinance No. 15 of 1957).

In addition, electronic medical record systems record information in SOAP format. In SOAP format, information is recorded in four categories: subjective information (S), objective information (O), assessment (A), and plan (P).

JP 2010-277550 A JP 2006-338522 A

However, while typical electronic medical record systems are designed to meet the three principles mentioned above, the items recorded vary from one electronic medical record system to another. As a result, even among medical professionals, it is difficult to collect and integrate data from different electronic medical record systems and efficiently manage medical records.

In order to collect as much information as possible in electronic medical records and ensure the accuracy of the contents, it is desirable for as many medical professionals as possible (doctors, nurses, pharmacists, etc.) as possible to be able to view, input, and share information in the electronic medical record system. In addition, it is considered desirable for patients and other recipients of medical care to be able to check whether their complaints of symptoms are accurately reflected in the electronic medical record, both for the patient's sake and to ensure the accuracy of the electronic medical record.

Therefore, there is a need to build an electronic medical record system that can be used by a wide variety of users, including patients.

The present invention was made in consideration of the above circumstances, and aims to provide an electronic medical record system that can display appropriate information according to the user's attributes.

The electronic medical record system according to one aspect of the present invention comprises an information management device having a medical information database in which patient medical information is stored, and a user terminal device configured to be accessible to the information management device via a network and displaying the patient medical information stored in the medical information database, the information management device selecting items of the patient's medical record that are permitted to be displayed according to the attributes of the user operating the user terminal device.

In one aspect of the present invention, a processing method for an electronic medical record system includes an information management device having a medical information database in which patient medical information is stored, and a user terminal device configured to be accessible to the information management device via a network and displaying the patient medical information stored in the medical information database, the information management device determines the attributes of a user operating the user terminal device, and selects items of the patient's medical record that are permitted to be displayed according to the attributes of the user.

The program according to one aspect of the present invention is an electronic medical record system that includes an information management device configured as a computer having a medical information database in which patient medical information is stored, and a user terminal device that is configured to be accessible to the information management device via a network and displays the patient medical information stored in the medical information database. The program causes the information management device to execute a process of determining the attributes of a user operating the user terminal device, and a process of selecting items of the patient's medical record that are allowed to be displayed according to the attributes of the user.

The present invention provides an electronic medical record system that can display appropriate information according to the user's attributes.

1 is a diagram illustrating a schematic configuration of an electronic medical record system according to a first embodiment. FIG. FIG. 2 is a diagram showing a display example of an electronic medical record according to the first embodiment; FIG. 2 is a diagram illustrating an example of a hardware configuration of a terminal device, a server, and a user terminal device. 1 is a diagram illustrating a schematic configuration of an information management device according to a first embodiment; FIG. 2 is a diagram illustrating a configuration of a user terminal device according to the first embodiment; 1 is a sequence diagram of the operation of the electronic medical record system according to the first embodiment. FIG. FIG. 13 is a diagram showing an example of a display of an electronic medical record when viewed by a medical recipient. FIG. 13 is a diagram showing an example of the display of an electronic medical record for a medical provider when the items viewable by a medical recipient are restricted. FIG. 13 is a diagram showing an example of the display of an electronic medical record for a medical recipient when viewing items for the medical recipient are restricted. A diagram showing a schematic configuration of an electronic medical record system according to a second embodiment. FIG. 10 is a diagram illustrating an example of an input form for a question message. FIG. 13 is a diagram illustrating an example of a question thread. FIG. 10 is a diagram illustrating an example of an input form for a reply message. FIG. 13 is a diagram showing an example display of an electronic medical record system having a function for sending messages from a medical recipient to a medical provider. FIG. 13 is a diagram showing an example of a display screen of an electronic medical record system according to a fourth embodiment. 13 is a diagram showing a schematic configuration of an electronic medical record system in the case where a medical history is read from another database and integrated into a medical information database. FIG. A diagram showing a schematic configuration of a modified example of an electronic medical record system according to the fourth embodiment. FIG. 13 is a diagram showing an example of a display screen of an electronic medical record system according to a fifth embodiment.

Below, an embodiment of the present invention will be described with reference to the drawings. In each drawing, the same elements are given the same reference numerals, and duplicate explanations will be omitted as necessary.

First embodiment
A description will be given of an electronic medical record system according to embodiment 1. The electronic medical record system according to embodiment 1 is configured so that medical information stored in a server can be viewed by a terminal via a network.

Figure 1 shows a schematic diagram of an electronic medical record system 100 according to the first embodiment. The electronic medical record system 100 is configured to include an information management device 110 and a plurality of user terminal devices 120 that are communicatively connected via a network 130.

The information management device 110 is configured as hardware that manages medical information, including electronic medical records, of multiple patients. In FIG. 1, the information management device 110 has a terminal device 111 that has the function of inputting, changing, and displaying medical information in the electronic medical records, and a server 112 that manages the information that constitutes the electronic medical records.

The server 112 stores a medical information database (medical information DB) 20 that records the medical information of multiple patients. The medical information database 20 stores various types of medical information, such as progress notes that record the so-called medical history constituting an electronic medical record, problem notes that record the history of illnesses and injuries for each patient, and nursing records that record the nursing care plan for the patient and the patient's condition. Of these, progress notes are generally written in SOAP format. Details of the SOAP format will be described later.

In FIG. 1, the information management device 110 is described as having a terminal device 111 and a server 112, but the information management device 110 may be configured as a computer such as a PC that executes a program to input, change, and display medical information and manage the medical information.

The information management device 110 and the multiple user terminal devices 120 can be connected to the network 130 by either wired or wireless communication. The network 130 can be a variety of networks, such as a LAN (Local Area Network), a VPN (Virtual Private Network), or a cloud service.

The user terminal device 120 is configured to execute a program and access the information management device 110 to input, change, and display desired medical information. The user terminal device 120 is installed in a location where it can be operated not only by users who provide medical care, such as doctors, nurses, and laboratory technicians (hereinafter also referred to as medical providers), but also by users who receive medical care, such as patients and their families (hereinafter also referred to as medical recipients). Users can view electronic medical records by operating the user terminal device 120 to access the information management device 110.

Specifically, the user terminal device 120 accepts an operation from the user to display the medical information of a specific patient, requests the information management device 110 to access the medical information, and displays the medical information sent from the information management device 110. Furthermore, when the user operates the user terminal device 120 to add or modify item contents to the medical information displayed on the user terminal device 120, the changed medical information is sent to the information management device 110 and rewritten. The rewritten medical information is stored in the medical information database 20. Furthermore, when new medical information is input by the user terminal device 120, it is sent to the information management device 110, and the information management device 110 associates it with each patient and stores it in the medical information database 20.

Here, we will explain the SOAP format. The SOAP format includes four items: S (Subjective), O (Objective), A (Assessment), and P (Plan). S (Subjective) is subjective information, and refers to information based on the subjective opinion of the subject, such as symptoms reported by the patient. O (Objective) is objective information, and refers to information obtained from examinations and tests on the patient, such as diagnostic images and vital signs, that objectively indicate the subject's condition. A (Assessment) refers to information that indicates a comprehensive evaluation, such as a diagnosis made by a doctor based on S (Subjective, subjective information) and O (Objective, objective information). P (Plan, plan and policy) refers to information that indicates actions such as plans and policies for treatment, surgery, medication, and lifestyle guidance for the patient, which are decided by the doctor based on A (Assessment, evaluation).

Figure 2 shows an example of the display of an electronic medical record according to the first embodiment. In Figure 2, item names are arranged in columns and events are arranged in rows in chronological order. The items arranged from left to right are date and time, importance, Title/Problem (item name), Subjective/Data (S, subjective information), Objective/Data (O, objective information), Assessment/Data (A, evaluation), and Plan/Action (P, plan, policy). In this example, as shown in the third, fifth, and eighth lines from the top, SOAP items can be merged as necessary. Note that the display of the electronic medical record shown in Figure 2 is intended for medical providers, who will be described later, and medical providers can enter information for each item as necessary.

Next, an example of the hardware configuration of the terminal device 111, the server 112, and the user terminal device 120 will be described. FIG. 3 shows a schematic example of the hardware configuration of the terminal device 111, the server 112, and the user terminal device 120. The terminal device 111, the server 112, and the user terminal device 120 can be realized by a computer 10 such as a dedicated computer or a personal computer (PC). Note that the computer does not need to be physically single, and may be multiple when performing distributed processing. Furthermore, when the information management device 110 is configured by a single computer, the information management device 110 may have the configuration shown in FIG. 3.

As shown in FIG. 3, computer 10 has a CPU (Central Processing Unit) 11, ROM (Read Only Memory) 12, RAM (Random Access Memory) 13, storage unit 14, and communication interface 15, which are interconnected via bus 16. Note that we will not explain the OS software for operating the computer, but it goes without saying that computer 10 operates based on the OS software.

The CPU 11 executes various processes in accordance with various programs stored in the ROM 12 or various programs loaded from the storage unit 14 to the RAM 13, for example, processes in the information management device 110 or the user terminal device 120 described below in this embodiment. The RAM 13 may also store data necessary for the CPU 11 to execute various processes as appropriate.

The storage unit 14 is configured as a storage device such as a hard disk or SSD (Solid State Disk). The CPU 11 can write data to the storage unit 14 and read data from the storage unit 14 as appropriate.

The communication interface (I/F) 15 is configured as a communication means such as a modem or terminal adapter that connects the computer 10 (i.e., the server 112 and the user terminal device 120) to the network 130. The communication I/F 15 communicates via the network 130, transmits data provided by the CPU 11, and transfers data received from the communication partner to the CPU 11, the RAM 13, and the storage unit 14. The communication I/F 15 also performs communication processing of analog or digital signals between other devices.

An input unit 17 and an output unit 18 may be connected to the bus 16. The input unit 17 may be configured as an input device, such as a device operated by a user, such as a keyboard or a mouse, or a sensor or a microphone. The output unit 18 may be configured as an output device, such as a display device, such as an LCD (Liquid Crystal Display), and audio equipment, such as headphones or speakers.

In addition, an external storage device 19 may be connected to the bus 16 as needed. As the external storage device 19, various types of storage devices such as a magnetic disk, an optical disk, a flexible disk, and a semiconductor memory can be used. The computer 10 can read information from the external storage device 19 and write information to the external storage device 19 as needed.

Next, the configuration and operation of the electronic medical record system 100 will be specifically described. FIG. 4 shows a schematic configuration of an information management device 110 according to the first embodiment. The information management device 110 has a login authentication unit 1, a display item determination unit 2, an access permission unit 3, and a medical information database (also referred to as a medical information DB) 20.

The login authentication unit 1, the display item determination unit 2, the access permission unit 3, and the medical information database 20 are realized by the hardware configuration of the terminal device 111 and the server 112 of the information management device 110. The medical information database 20 is stored in, for example, the storage unit 14. For example, the processing by the login authentication unit 1, the display item determination unit 2, and the access permission unit 3 is realized by the CPU 11 in both or one of the terminal device 111 and the server 112 reading and executing a program stored in the storage unit 14, and by referring to the medical information database 20. The terminal device 111 can also be used as a user terminal device 120, which will be described later.

Figure 5 shows a schematic configuration of the user terminal device 120 according to the first embodiment. The user terminal device 120 has a login request unit 4, a display information acquisition unit 5, and a display unit 6. The login request unit 4, the display information acquisition unit 5, and the display unit 6 are realized by the hardware configuration of the user terminal device 120. The processing of the login request unit 4 and the display information acquisition unit 5 is realized, for example, by the CPU 11 reading and executing a program stored in the memory unit 14 or the like.

Next, the operation of the electronic medical record system 100 according to the first embodiment will be described. FIG. 6 shows a sequence diagram of the operation of the electronic medical record system 100 according to the first embodiment.

Step S11
A user who wishes to view an electronic medical record operates the user terminal device 120 to input a user ID and password, or to log in to the electronic medical record system 100 using various authentication techniques such as fingerprint authentication and face authentication. As a result, the login request unit 4 transmits a login request REQ to the information management device 110 via the network 130.

Step S12
When the login authentication unit 1 receives the login request REQ, it refers to the user authentication information included in the login request REQ and judges whether the user indicated by the user authentication information is a registered user. If the user is a registered user, the login is permitted, and otherwise the login is rejected.

Step S13
The display item determination unit 2 refers to the attributes of users who have been permitted to log in and are included in the medical information database 20, and selects and determines the items of medical information included in the medical information database 20. The electronic medical record system 100 according to this embodiment is configured to allow not only medical providers, such as doctors and nurses, who provide medical care, but also medical recipients, such as patients and their families, to view medical information.

For example, when the medical provider mentioned above views the electronic medical record, it is desirable for them to be able to view all of the SOAP in order to provide an accurate diagnosis and treatment.

On the other hand, when medical recipients view electronic medical records, not only will they be unable to interpret O (Objective) and A (Assessment), which require medical expertise to interpret, even if they are disclosed, but there is also a risk of misunderstanding based on inaccurate knowledge. For this reason, it may be desirable to adopt a policy of disclosing only S (Subjective) and A (Assessment), and not disclosing O (Objective) and P (Plan), to medical recipients.

In this case, by viewing S (Subjective information), the medical recipient can check whether the medical provider accurately recognizes the symptoms and other information that the medical recipient has reported. This is useful for the medical recipient in that it allows the medical provider to confirm the state of understanding of the patient's main complaint, which was not possible before. In addition, by viewing A (Assessment), the medical recipient can understand the patient's health condition at any time. Generally, notifications from medical providers such as doctors to medical recipients such as patients are almost always given verbally, but by viewing the electronic medical record, the medical recipient can check the patient's health condition at any time. In addition, even if the diagnosis is changed according to the progress of the medical treatment, the medical recipient can check the change in a timely manner.

Step S14
The access permission unit 3 transmits, for example, an access permission PER to the user terminal device 120, and permits access to data of an item selected based on the user attributes from among the medical information contained in the medical information database 20.

Step S15
The display information acquisition unit 5 of the user terminal device 120 acquires data of the items for which access is permitted, from among the SOAP data.

Step S16
The display unit 6 displays items for which access is permitted based on the data acquired by the display information acquisition unit 5. If the person who logs in is a medical provider, the screen shown in Fig. 2 is displayed. If the person who logs in is a medical recipient, only S (Subjective) and A (Assessment) of SOAP are displayed on the display screen shown in Fig. 2. Fig. 7 shows an example of the display of the electronic medical record when viewed by a medical recipient.

As described above, the electronic medical record system 100 makes it possible to appropriately display the necessary items contained in the electronic medical record according to the attributes of the user viewing the electronic medical record.

In the above explanation, the items that medical care recipients can view are S (Subjective information) and A (Assessment), but these may include information that should not be made available for viewing by medical care recipients. For example, S (Subjective information) may include information that the patient does not want his/her family to view, at his/her own request. Also, for example, A (Assessment) may include information that may upset the patient if conveyed to him/her, such as a diagnosis of a serious illness such as cancer, or information at an intermediate suspicion level that has not yet been definitively diagnosed. In such cases, it is desirable to exclude some or all of S (Subjective information) and A (Assessment) from the information that medical care recipients can view.

In this case, when entering information into the electronic medical record, the healthcare provider can exclude information that should not be made available for viewing by the healthcare recipient from being viewed by specifying the S (Subjective) and A (Assessment) items that should not be disclosed to the healthcare recipient. Figure 8 shows an example of the display of an electronic medical record for healthcare providers when restricting the items that can be viewed by the healthcare recipient. In this example, check boxes are displayed in the lower right corner of each input field for S (Subjective) and A (Assessment) for each event (each row). The healthcare provider who enters information can keep the information in the checked field private by clicking and checking the check box of the input field that should not be disclosed to the healthcare recipient. In Figure 8, A (Assessment) in the first row from the top is checked, and the contents of this field will not be disclosed to the healthcare recipient.

Figure 9 shows an example of the display of an electronic medical record for a medical recipient when the items that can be viewed by the medical recipient are restricted. In this case, compared to Figure 7, it can be seen that the A (Assessment) column in the first row from the top is left blank. As explained above with reference to Figures 8 and 9, it is possible to selectively provide necessary information for viewing by the medical recipient.

Here, the items to be kept private are S (Subjective information) and A (Assessment), but it is also possible to make it possible to select whether to make public or private for SOAP and some or all of the other items.

For the sake of simplicity, we have described electronic medical records as users of healthcare providers and recipients, but users of electronic medical records may be further subdivided.

For example, healthcare providers may be divided into doctors, nurses, and other healthcare providers, and the items that can be viewed and entered may be specified for each. In addition, the items that can be viewed and entered may be restricted between healthcare providers in a similar manner to that described with reference to Figures 8 and 9.

For example, medical recipients may be divided into the patient himself/herself and the patient's family, and items that can be viewed and entered may be specified for each.

Embodiment 2
The electronic medical record system 100 according to the first embodiment is intended for viewing electronic medical records, but if it were possible to ask questions about specific items in the electronic medical record system, answer the questions, or express opinions, it would be possible to further improve the usefulness of the electronic medical record system. Therefore, in the second embodiment, an electronic medical record system 200 will be described, which adds a function for sending messages between medical providers to the electronic medical record system 100 according to the first embodiment.

Figure 10 shows a schematic configuration of an electronic medical record system 200 according to the second embodiment. The electronic medical record system 200 has a configuration in which the user terminal device 120 of the electronic medical record system 100 according to the first embodiment is replaced with a user terminal device 220. The user terminal device 220 has a configuration in which a message sending unit 7 is added to the user terminal device 120. The questions and answers described below are sent by the message sending unit 7 of the user terminal device 220.

In this embodiment, as an example of a message transmission function, a message transmission function between medical providers will be described. When examining and treating a patient, a wide variety of medical providers are generally involved, such as doctors, pharmacists, nurses, clinical laboratory technicians, physical therapists, and occupational therapists. It is also conceivable that the same patient may be examined at different medical institutions. In this case, each medical provider belonging to each medical institution will view the electronic medical record written in SOAP format and input information as necessary. At this time, it is expected that detailed information may be difficult to understand just by viewing the electronic medical record, so it is desirable to be able to ask questions to the person who entered the information into the electronic medical record and receive an answer.

The following describes how a questioner sends a question. Figure 11 shows a schematic example of a question message input form. When the questioner clicks, for example, on a specific line or item on the screen shown in Figure 2, the question message input form shown in Figure 11 is displayed in a separate frame or window on the same screen. The questioner (for example, a doctor belonging to another medical institution) enters a question in the question input field and performs a send process, whereby the question regarding the selected event or item is linked to a question thread, which will be described later. When a question is entered, an email is sent to the person in charge of the event or item (for example, the doctor in charge), notifying them that the question has been sent, for example.

The person in charge of the event or item receives the notification and logs into the electronic medical record system, and can view the question thread by, for example, clicking on the event or item. FIG. 12 shows an example of a question thread. By clicking on a question that the person in charge should answer among the questions displayed in the question thread shown in FIG. 12, an answer input form for inputting an answer to that question is displayed in a separate frame or window on the same screen. FIG. 13 shows an example of an input form for an answer message. The person in charge enters an answer in the answer input field and performs a send process, so that the answer is linked to the question thread. When the answer is entered, an email is sent to the questioner, for example, notifying the questioner that the answer has been sent. This allows the questioner to receive an answer to the question from the person in charge.

The viewing of the above-mentioned questions and answers may be limited to the parties, the questioner and the answerer, or may be made public to medical providers other than the parties. In addition, whether or not the questions and answers are to be made public to medical providers other than the parties may be specified by checking check boxes provided in the question input field and answer input field. It goes without saying that the method of specification is not limited to this.

As described above, this configuration allows medical providers to ask and answer questions about medical records. This makes it easier for different medical institutions and medical providers to communicate with each other and share information about patients' medical records.

Embodiment 3
In the second embodiment, an electronic medical record system with a function for transmitting messages between medical providers was described, but it is also possible that a medical recipient may wish to express an opinion about the description in the electronic medical record. In the third embodiment, an electronic medical record system with a function for transmitting messages between a medical recipient and a medical provider is described, in addition to the electronic medical record system 100 in the first embodiment. The configuration of the electronic medical record system in this embodiment is the same as that of the electronic medical record system 200 in the second embodiment, and messages are transmitted by the message transmission unit 7 of the user terminal device 220.

In the above embodiment, it has been described that the medical recipient only views S (Subjective) and A (Assessment) in the SOAP. However, when a patient views the electronic medical record system, due to misunderstanding or the like, there may be a difference between the explanation the patient gave to the medical provider about the symptoms and the content entered by the medical provider in the S (Subjective) column. In addition, medical terms that are difficult for the medical recipient to understand may be used for the A (Assessment) item. In such cases, it is desirable for the medical recipient to be able to give the medical provider their opinion on the contents of S (Subjective) or ask questions about A (Assessment).

Figure 14 shows an example of the display of an electronic medical record system having a message transmission function from a medical recipient to a medical provider. Figure 14 shows a case where a medical recipient (e.g., a patient) sends a message to a medical provider (e.g., a doctor in charge) regarding S (Subjective, subjective information) of "medical examination article 036", which is the event in the second row from the top. When the medical recipient clicks on the S (Subjective, subjective information) column of "medical examination article 036", for example, a message input column is displayed in a separate frame or window on the same screen, as shown in the lower left of Figure 14. The medical recipient can send a message regarding the description in the S (Subjective, subjective information) column of "medical examination article 036" by inputting a question in the message input column and performing a transmission process. When the message is sent, an e-mail is sent to the medical provider (e.g., a doctor in charge) who entered information in the S (Subjective, subjective information) column of "medical examination article 036", for example, notifying that the message has been sent. The healthcare provider who filled in the S (Subjective) field of "Consultation Note 036" is notified and logs into the electronic medical record system. For example, they can view the contents of the message sent by clicking on the S (Subjective) item of "Consultation Note 036."

The viewing of the above-mentioned sent message may be limited to the medical recipient and the medical provider related to the target field of the sent message, or may be made public to medical recipients and medical providers other than the parties. In addition, whether or not the sent message is to be made public to people other than the parties may be specified by checking a checkbox provided in the sent message input field. It goes without saying that the method of specification is not limited to this.

In this embodiment, as in embodiment 2, a function for sending replies to sent messages may also be provided. In this case, a message thread similar to the question thread in embodiment 2 may be provided, and replies to sent messages may be sent. Needless to say, the decision as to whether or not to make replies public can be made in the same way as for sent messages.

As described above, with this configuration, if a medical recipient has an opinion or question about medical information, he or she can send a message to the medical provider.

In a typical electronic medical record system, a medical recipient cannot view an electronic medical record and give opinions or ask questions about the contents of the record. In contrast, according to the electronic medical record system of this embodiment, a medical recipient can give opinions or ask questions about specific items to a medical provider, thereby improving the contents of the electronic medical record to make them more appropriate, and aligning the understanding of the contents between the two parties. This makes it possible to perform examinations and treatments using electronic medical records more effectively and appropriately.

Fourth embodiment
In the above embodiment, medical information is recorded in the electronic medical record in the SOAP format, but the medical information may include items other than the SOAP format. In this embodiment, a case will be described in which the electronic medical record includes disease name and medication history information in addition to the SOAP format.

Figure 15 shows an example of a display screen of the electronic medical record system according to the fourth embodiment. Figure 15 shows the display screen when the user is a medical provider. As shown in Figure 15, the name of the disease and medical history (medication history) determined by the attending physician are displayed in the column to the right of the SOAP.

The SOAP, disease name, and medication history may be input sequentially by the medical provider, and this information may be integrated and stored in the medical information database 20. In this case, this can be realized by adding display items for the electronic medical record to an electronic medical record system having a configuration similar to that of the above-mentioned embodiment.

On the other hand, for example, if the medication history is stored in another database, the electronic medical record system may read the medication history from the other database and integrate it with the medical information database 20. Figure 16 shows a schematic configuration of an electronic medical record system 400 when the medication history is read from the other database and integrated into the medical information database. The electronic medical record system 400 has a configuration in which the information management device 110 of the electronic medical record system 100 according to the first embodiment is replaced with an information management device 410. The information management device 410 has a configuration in which a medication history acquisition unit 8 and a medication history integration unit 9 are added to the information management device 110.

The medication history acquisition unit 8 accesses an external database to acquire the necessary medication history information. The medication history integration unit 9 links the acquired medication history to events and items included in the corresponding medical information, integrates the medication history information with the medical information, and stores it in the medical information database 20.

As described above, even if medication history information is stored in an external database, the medication history information can be easily integrated into the medical information database 20 and the medication history can be displayed by the electronic medical record system.

It is also possible to obtain items included in SOAP, such as S (Subjective information), disease name, and medication history, from the medical information database 20 and classify the correlation between S (Subjective information), disease name, and medication history by machine learning the correlation between them.

Figure 17 shows a schematic configuration of an electronic medical record system 401, which is a modified example of the electronic medical record system 400 according to the fourth embodiment. The electronic medical record system 401 has a configuration in which the information management device 410 of the electronic medical record system 400 is replaced with an information management device 411. The information management device 411 has a configuration in which a machine learning unit 30 is added to the information management device 410.

The machine learning unit 30 reads S (Subjective information), disease name, and medication history for each event of a specific patient from the medical information database 20, and performs machine learning on these, for example, by unsupervised learning, making it possible to learn the correlation between S (Subjective information), disease name, and medication history. The learned correlation is stored in a separately provided database, and can be used, for example, to predict disease name, medication, etc. according to S (Subjective information).

Note that in this embodiment, the integration of disease name and medication history has been described as an example, but it goes without saying that other items may also be integrated into SOAP.

Fifth embodiment
Next, an electronic medical record system according to the fifth embodiment will be described. The electronic medical record system according to the fifth embodiment is configured to have a function for a medical provider who inputs information into the electronic medical record to input information indicating a patient's condition or mood by linking it to S (Subjective information).

Figure 18 shows an example of the display screen of the electronic medical record system according to the fifth embodiment. As shown in Figure 18, a frame containing five stars is displayed below the S (Subjective) column of each event (each row). In the initial state, all five stars are displayed in white, and a healthcare provider who enters information in the S (Subjective) column can change a star to a solid black star by clicking on it. This makes it possible to evaluate the patient's condition and mood, i.e., the healthcare provider's impressions, on a five-point scale depending on the number of solid black stars.

As described above, with this configuration, by adding a means for inputting the medical provider's impressions of the patient's condition and mood to S (Subjective information), it becomes possible to easily record the impressions received by medical providers such as doctors during examinations. This allows a person who later views the electronic medical record to understand the information from the patient recorded in the S (Subjective information) column and the medical provider's judgment regarding this information, and to interpret the entries in the S (Subjective information) column.

In this embodiment, the case where the medical provider inputs his/her impressions about S (subjective information) has been described as an example, but it goes without saying that the medical provider may also be configured to input his/her impressions about items other than OAP or SOAP.

In addition, in this embodiment, an example has been described in which the medical provider's impressions are input as a five-point rating, but the rating may be any rating other than five, or may be a text listing other than a rating scale.

Other embodiments The present invention is not limited to the above-mentioned embodiments, and can be modified as appropriate without departing from the spirit of the present invention. For example, in the fourth embodiment, in a configuration similar to that of the electronic medical record system 100 according to the first embodiment, it has been described that items other than SOAP, such as disease name and medication history, are integrated into the medical information of a patient, but this is merely an example. It goes without saying that items other than SOAP, such as disease name and medication history, may be integrated into the medical information of a patient in a configuration similar to that of the electronic medical record system according to the second, third, or fifth embodiment.

In the fourth embodiment, a medical history acquisition unit 8 and a medical history integration unit 9 are added to the information management device 110 of the electronic medical record system 100 according to the first embodiment to integrate items other than SOAP, such as disease name and medical history, into the patient's medical information. However, this is merely an example. It goes without saying that a medical history acquisition unit 8 and a medical history integration unit 9 may be added to the electronic medical record system according to the second, third, or fifth embodiment to integrate items other than SOAP, such as disease name and medical history, into the patient's medical information.

In the fourth embodiment, a machine learning unit 30 is provided in the information management device to learn the correlations between items of medical information by machine learning. However, it goes without saying that a machine learning unit 30 may be provided in the information management device of the electronic medical record system according to the first, second, third, and fifth embodiments to learn the correlations between items of medical information by machine learning in a similar manner.

In the fifth embodiment, a configuration in which a medical provider inputs impressions into specific items in the electronic medical record system according to the first embodiment has been described. However, it goes without saying that the electronic medical record systems according to the second to fourth embodiments may also be configured so that a medical provider inputs impressions into specific items.

In the above embodiment, the present invention has been described mainly as a hardware configuration, but the present invention is not limited to this, and any process can be realized by having a CPU (Central Processing Unit) execute a computer program. In this case, the computer program can be stored using various types of non-transitory computer readable medium and supplied to the computer. Non-transitory computer readable medium includes various types of tangible storage medium. Examples of non-transitory computer-readable media include magnetic recording media (e.g., flexible disks, magnetic tapes, hard disk drives), magneto-optical recording media (e.g., magneto-optical disks), CD-ROMs (Read Only Memory), CD-Rs, CD-R/Ws, and semiconductor memories (e.g., mask ROMs, PROMs (Programmable ROMs), EPROMs (Erasable PROMs), flash ROMs, and RAMs (random access memories)). The program may also be provided to the computer by various types of transient computer-readable media. Examples of transient computer-readable media include electrical signals, optical signals, and electromagnetic waves. The transient computer-readable medium can provide the program to the computer via a wired communication path such as an electric wire or optical fiber, or via a wireless communication path.

REFERENCE SIGNS LIST 1 Login authentication unit 2 Display item determination unit 3 Access permission unit 4 Login request unit 5 Display information acquisition unit 6 Display unit 7 Message transmission unit 8 Medication history acquisition unit 9 Medication history integration unit 10 Computer 11 CPU
12 ROM
13 RAM
14 Storage unit 15 Communication interface 16 Bus 17 Input unit 18 Output unit 19 Storage device 20 Medical information database 30 Machine learning unit 100, 200, 400, 401 Electronic medical record system 110, 210, 410, 411 Information management device 111 Terminal device 112 Server 120, 220 User terminal device 130 Network

Claims (13)

An information management device having a medical information database in which medical information of patients is stored;
a user terminal device configured to be able to access the information management device via a network and displaying the medical information of patients stored in the medical information database;
The medical information of the patient is described in a SOAP format consisting of S (Subjective) indicating subjective information, O (Objective) indicating objective information, A (Assessment) indicating evaluation, and P (Plan) indicating plan and policy,
the information management device selects an item of the SOAP that is permitted to be displayed according to an attribute of a user who operates the user terminal device;
Electronic medical record system. the information management device permits display of all of the SOAP when the user operating the user terminal device is a medical provider, and permits display of some of the items of the SOAP when the user operating the user terminal device is a medical recipient;
The electronic medical record system according to claim 1 . the information management device permits display of S and A in SOAP when the user operating the user terminal device is a medical care recipient;
The electronic medical record system according to claim 2 . A medical provider can input medical information of a patient by operating the user terminal device;
The input medical information is stored in the medical information database.
4. An electronic medical record system according to claim 1 . When inputting medical information of a patient, the medical provider can specify descriptions that are permitted to be displayed and descriptions that are not permitted to be displayed for each item that is permitted to be displayed when the user operating the user terminal device is a medical recipient.
The electronic medical record system according to claim 4 . A healthcare provider who inputs medical information of a patient can specify, when inputting the medical information of a patient, descriptions that are permitted to be displayed by the other healthcare provider and descriptions that are not permitted to be displayed by the other healthcare provider for each item that is permitted to be displayed when a user operating the user terminal device is another healthcare provider.
6. An electronic medical record system according to claim 4 or 5 . A user who operates the user terminal device can send a message to a healthcare provider who has input each item of the displayed medical information of the patient.
7. An electronic medical record system according to claim 4 . A healthcare provider who receives the message can transmit a reply message to the person who transmitted the message by operating a user terminal device.
The electronic medical record system according to claim 7 . The medical information includes items other than SOAP,
The information management device is configured to perform machine learning to learn correlations between a part or all of the SOAP and a part or all of the items other than the SOAP.
9. An electronic medical record system according to any one of claims 1 to 8 . The items other than the SOAP are the patient's disease name and medical history.
The electronic medical record system according to claim 9 . When entering a patient's medical information, the healthcare provider can enter their impressions of S.
11. An electronic medical record system according to any one of claims 1 to 10 . An electronic medical record system including an information management device having a medical information database in which medical information of patients is stored, and a user terminal device configured to be able to access the information management device via a network and display the medical information of patients stored in the medical information database,
The medical information of the patient is described in a SOAP format consisting of S (Subjective) indicating subjective information, O (Objective) indicating objective information, A (Assessment) indicating evaluation, and P (Plan) indicating plan and policy,
By the information management device,
determining an attribute of a user who operates the user terminal device;
selecting an item of the SOAP that is permitted to be displayed according to the attributes of the user;
How to process electronic medical records systems. An electronic medical record system including an information management device configured by a computer having a medical information database in which medical information of patients is stored, and a user terminal device configured to be able to access the information management device via a network and display the medical information of patients stored in the medical information database,
The medical information of the patient is described in a SOAP format consisting of S (Subjective) indicating subjective information, O (Objective) indicating objective information, A (Assessment) indicating evaluation, and P (Plan) indicating plan and policy,
A process of determining attributes of a user who operates the user terminal device;
A process of selecting items of the SOAP that are permitted to be displayed according to the attributes of the user;
causing the information management device to execute the above steps;
program.

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