Analysis and Requirements Document for the creation of a Medical Information System Copyright (c) 1999-2002. Daniel L. Johnson, Christian Heller, Karsten Hilbert, William R. Gilchrist, The Res Medicinae developers et al. All rights reserved. Permission is granted to copy, distribute and/or modify this document under the terms of the GNU Free Documentation License, Version 1.1 or any later version published by the Free Software Foundation; with no Invariant Sections, with no Front-Cover Texts and with no Back-Cover Texts. A copy of the license is included in the section entitled "GNU Free Documentation License". http://www.resmedicinae.org - Information in Medicine - $RCSfile: analysis.txt,v $ @see http://resmedicinae.sourceforge.net/model/analysis/index.html @version $Revision: 1.5 $ $Date: 2002/11/24 14:35:37 $ $Author: chrissy $ @author Daniel L. Johnson @author William R. Gilchrist @author resmedicinae-deutsch@lists.sourceforge.net @author Dr. Roland Colberg @author Dr. J. Fischer joachim_fischer@web.de @author Priv.-Doz. Dr. P. Hahn @author Christian Heller @author Karsten Hilbert @author Dr. Bernd Heller @author Magdalena Heller @author Jörg M. Sigle joerg.sigle@jsigle.com @author Jürgen Saucke jsaucke@t-online.de @author Dr. Winfried Behrendt @author Dr. med. Andreas Streller @author Dr. med. Michael Elisat @author Dr. med. Gerhard Bauer Preface _______ A common effort of many enthusiasts working in the areas of Medicine, Informatics, public institutions and companies. Based in part on the Open-Source Medical Information Management (Quick Quack) http://lorenzo.uwstout.edu/QQMIM/medicalfreesource.html of Daniel L. Johnson . Created under the great support of the readers of the mailing list. Contents ________ 1 Introduction 2 Basic Concepts 2.1 Program Control 2.2 Program Elements 2.x Other Concepts 3 Standard Use Cases (Functionality in Detail) 3.1 Get Patient Data 3.1 Get an Overview 3.x Patient Data at a Doctor's visit (at the Patient's home) 3.2 Medical Documentation 3.2.1 Model 3.2.1 Administrative Patient Data 3.2.1 Continuous Documentation during a visit (at the Doctor) 3.2.2 Topologic/Genealogic 3.2.3 Document Archive 3.2.4 Diagnose 3.2.5 Therapise 3.3 Print Forms 3.4 Use Laboratory Data 3.4.1 Presentation 3.4.2 Saving 3.4.3 Import 3.4.4 Export 3.4.5 Miscellaneous 3.5 Plan Tasks/Time 3.6 Prescribe things 3.7 Edit Text (Doctor's Letters etc.) 3.8 Create Statistics 3.9 Communicate 3.10 Billing 3.11 Use Devices 3.12 Backup Data 3.13 Consider Security Aspects 3.14 Unsorted 4 Special Doctor's Use Cases 4.1 Dentist 4.2 "Eye" (?) Doctor 5 Additional Use Cases 5.1 Use external Services 5.2 Use external Programs 5.3 Use commercial Programs 5.4 Use HDTF (CORBAmed) Services 5.5 Clinic/Hospital 6 Introduction Strategy 6.1 Presumptions (?) for Acceptance 6.2 Order of Development 6.3 Possibilities for Market Introduction 6.4 Partnerships 7 Hardware Infrastructure 8 Questions & Answers 9 Directories 9.1 Abbreviations 9.2 Figures 9.3 Tables 9.4 Sources (Literatur etc.) 10 Appendices 10.1 GNU Free Documentation License 1 Introduction ______________ Paul Rodriguez _____________________________________ > Subject: Re: [Gnumed-devel] Should I switch to Gnumed? > From: Paul =?ISO-8859-1?Q?Rodr=EDguez?= > To: Karsten Hilbert > Cc: GNUmed list > Date: 29 Apr 2002 11:08:03 -0400 > > I apologize for having taken my time with this, and I appreciate the > friendly help you have given me with this matter. > > Some time ago, I asked about transferring the practice management > software at the office for which I work to Free Software.  I was asked > to describe our situation in more detail and also to explain in detail > what our specific needs were. > > > Our Requirements to implement Free Software > > We are an optometrist's private practice in the United States.  We have > become increasingly dissatisfied with the current proprietary system > which we are currently using.  This closed system is currently very > expensive, but more importantly we do not feel we have control over the > data that is essential for the smooth running of our office.  We > currently use a proprietary practice management system called RLI.  As > it currently stands, we are on a forced upgrade track every couple of > years.  If we do not continue to upgrade, the company ceases to support > our product.  In addition, we pay for their services on a monthly basis, > if we do not pay at the end of the month, or there is a problem on their > end with the electronic billing (as has already happened) we cease to > have access to all of our electronic patient records.   If the company > changes their terms, or goes out of business, we will experience great > difficulties we cannot currently afford. > > In addition, this program is only available for Windows.  We are trying > to move all of our software to Linux and Free Software.  For issues of > long-term stability we feel it is necessary to have control of our own > systems and patient information.  We are looking for a cheaper solution > which can meet our needs, give us more control of our practice (over the > long run), and embrace and support Free Software. > > 1) > Our current database of patient information, currently part of a > proprietary program called RLI, needs to be transferred to an open > database format.  (Such as SQL.)  This information includes patient > names, addresses, birth dates, medical history, > medical/insurance/demographic codes, and recall dates. > > To this database we would like to add information about past and future > appointments > and scheduling, and also be able to cross-link patients with family > members. > > 2) > In addition, we need a scheduling program to manage appointments.  This > program needs access to certain information in the patient database > (previous and future appointments, family members, and contact > information).  When scheduling an appointment for a patient, the program > needs to be able to display when the patient's last appointment was and > when their next one is scheduled.  There also needs to be a convenient > way to access the patient's contact information, and if necessary or > appropriate, the contact information of their closest relatives. > Perhaps a simple middle or right click on a patients name (or a > mouse-over) would display their phone number, and a small menu with > members of their immediate family with corresponding phone numbers.  The > program needs to automatically print a list of patients who missed the > day's appointments and print a recall label for each of these patients > which we'll affix to a postcard.  (We'll need templates for the > labels.) > > The scheduling program will be run on a separate computer from the > database.  Ideally there would be a way to restrict what information > from the database is accessible to the scheduling program.  The program > should automatically be able to access a patient's appointment history, > contact information (and immediate family's contact information), and > future appointments (and perhaps insurance and payment information) but > not medical history. > > 3) > We need to be able to easily print out a superbill to give to the > patient and a way of keeping track of when and how much a patient has > paid and consequently, how much the patient owes.   We also need a way > of printing out an invoice to mail to the patient. > > 4) > One of the most potentially difficult and important things is to be able > to send an electronic insurance claim via a direct modem connection to a > clearinghouse.  Our clearinghouse is currently WebMD as they have an > exclusive contract with Aetna (and possibly Blue Cross Blue Shield > soon).  WebMD accepts claims forms in either print image or NFS format. > The form that needs to be sent is form #1500.  Some of the insurance > companies we deal with are: > Medicare > Medicaid > PHS > Aetna > Empire Blue Cross Blue Shield > Blue Cross Blue Shield > AmeriHealth > Oxford Health Plans > > > 5) > Once we have this system set up, we need to automatically print out > labels to send recall letters and birthday cards to patients twice a > month.  This requires a label template and for a program to display a > notice to the user to insert the appropriate labels in the printer. > > 6) > One other automated task that needs to be set up is the weekly backup of > the database and/or entire system.  Ideally, I'd like for this to be > done on CD-ROM.  A program would be needed to prompt the user to insert > a CD and how to label it.  CD-RW is another viable option (perhaps a set > that can be recycled every few months). > > 7) > We also need a set of templates to use for writing letters to patients. > Right now we are using both Abiword and OpenOffice.org, but there are > certain aspects of OpenOffice.org that may perhaps make it more > appropriate for our environment.  What is needed is the ability to > select a patient from the database and choose to open one of a list of > pre-written letters in a word processor, and have the program insert the > patient's information in the appropriate spaces. David Guest ________________________________ I have been thinking about Richard's interface during the week and his lecture made me focus on what was my main activity during the patient encounter. For me, as a GP in private consulting rooms, it is clinical data capture using a keyboard and manipulating the data while accessing already collected information such as previous consultations, investigations and other doctors' notes and correspondence. I prefer to record my data items one after the other in a left justified vertical column. This means I need a tall but not very wide vertical column to record and display the current encounter data. (Say 40% of the screen width). For access to the other data I need a summary of all previously recorded items (e.g. investigations, old notes, correspondence) and a display window for the items that I select from the summary. So, in essence this is a three window screen, with the middle and right windows being accessed by hot keys and icons as per Richard's interface. Hopefully there is still room to squeeze in his scratch pad and Reminders windows. I also liked the way his patients' id window only took up one line at the top of the screen. Horst Herb __________ Functionality: - a spreadsheet like panel (horizontal days of week, vertical time slots) displays the names of people who made an appointment at a specific time. - To enter a patient, one clicks into the vacant time slot, and enters as many characters of the surname +/- given names as one likes, plus optionally a sequence of "+" characters. Once enter is pressed or the cell looses it's focus, the cell contents are parsed for surname fraction and, if existing, given names fraction. The database is then searched for patients with matching criteria. If only one is found, it is pre-selected in an otherwise empty selection, accepted by "enter key" and entered into the cell.  If multiple entries match, a list box drops down from the cell with the cursor at the first entry. Cursor+enter selects, tab escapes into the "new patient" entry dialogue. If one or more '+' characters are found following the name fractions, the appointment time is increased in fixed increments. The increments are defined in each doctor's preferences. The spread sheet greys out time slots where the doctor is not available buy default (like free afternoons), but allows to override this (receptionist still can enter data into the greyed section). It colour codes the column representing the current day, and the "selected" day as well. A combo box above the spread sheet widget displays the doctors name. By selecting another doctor, the spreadsheet displays that doctors schedule. A container widget hosts as many of these schedule widgets as doctors are working in the practice. A top row with buttons allows to quickly jump between days, weeks and months ahead; a "calendar" button pops up a calendar for convenient date selection. As the calendar is not needed that often, I decided not to waste screen real estate with it by default (can be overridden, and calendar dispayed left hand / right hand/top/bottom of schedules I have yet to write an overview widget which displays all appointments of all doctors for a given time span at once David Guest ________________________________ I like the automatic generation of the notes with the word wheel as you describe below... except for history taking. My problem with it is that it forces you down a previously determined track even if it is your own individual track. My approach is to let the patient spill out their history in their own unstructured way and then go back and expand on certain points. I touch type and try to eyeball the patient as they give the initial history. It is prefererable to keep symptoms at one per line to aid adding new items, annotating existing items and moving the data around. I have added the history component from one of my typical consultations as an addendum. The dashed lines are the annotation of the initial symptom and are added on the second and subsequent runs through the history. My patients almost always have two problems and often up to four or five. I have played around with the best way of recording the data in these multi-problem consultations and do not have a perfect answer. I think encapsulating each problem in its own section of the page is the best approach. I prefer [S1O1A1P1; S2O2AOP2] to [S1S2O1O2A1A2P1P2]) but use a line of tildes as a demarcator on the first run through the history. My preference is still for a three window approach, 40% width is sufficient for my note taking as mentioned but I agree that the 60% width is necessary for displaying other data for the reasons you state below. My difficulty is placing the third box so that I can see the summary items of the information that I am seeking, whether they be correspondence, pathology or previous notes. I _do not_ want to obscure my current consultation screen or reduce width of the "Detail info" display window. As a first draft my preferences are: |---------------------------|   |----------------------------------------------------| | Short patient id line     |   |  Scratch Pad                                       | |---------------------------|   |                                                    |                                 |----------------------------------------------------| |---------------------------|   |   Warnings /  Reminders                            | |                           |   |----------------------------------------------------| |                           |      Ico|Ico|Ico|Ico|Ico|Ico|Ico|Ico |                           |   |----------------------------------------------------| |    Current                |   |   Summary screen                                   | |    consultation           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |----------------------------------------------------| |                           | |                           |   |----------------------------------------------------| |                           |   |      Detail info                                   | |                           |   |      Display screen                                | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |                           |   |                                                    | |---------------------------|   |----------------------------------------------------| I am not a great believer in the value of voice dictation or video taping the consultation. My notes are a summary of the consultation not a re-enactment. (It was only barely sufficiently interesting the first time through.) I agree that one day computers will record all this information, lay it out neatly, make the diagnosis and prescribe the correct medication. At that point the doctor will be superfluous. Unfortunately that will also be the day that the patient is superfluous. Richard Terry _____________ *History* continuing abdo pain headaches - frontal, mild, constant, paracetamol helps poor sleeping - dozes for an hour - wakes repeatedly through the night - will stay awake for 1-3 hours each time -- now sleeping in separate room to wife - tired in morning - slight improvement in late afternoon edgy, cannot relax - only feels good when out doing heavy manual work in garden generally unwell last six months seen by Dr W. gastroscopy - mild distal oesophagitis last Monday colonoscopy 3 weeks ago - haemorrhoids, few pelvic diverticulae Karsten Hilbert _______________ Given that an episode based structure is implemented our multi-problem encounter would become an multi-episode encounter. Now, either during typing or during rearranging the typed notes I want to be able to hit to change the episode for the current logical block. Logical blocks are S/O/A/P or whatever system one uses. Logical blocks also would be notes taken previously (like before doing the sonography) and now during the same encounter. However, if I then attach the same episode to them notes of the same type (SOAP) will be grouped into one logical block except if they are separated by a configurable amount of time (the patient came in the morning with subacute Appendicitis and came back in the late afternoon after deterioration). An example: Patient with abdominal pain. Tells me "pain, steady, not really convulsive although at times worsening, no throwing up, since yesternight" I type that and attach the episode "subacute appendicitis" as my working diagnosis. This is now a logical block. I then do the physical and write down my findings. They are another logical entity because of being of a different type (O vs. S). Then the patient says "Ah, doctor, I _did_ throw up once this morning. I forgot about that." I'll type that and _right now_ it is a logical block separate from the first "S" notes logical block. However, when I change notes type again (or leave the record or whatever) it will be grouped with the first "S" notes logical block since the data was captured during the same encounter AND I didn't change episodes. Then the patient remembers that his left ankle is still bothering him at times due to that last-years fracture which prompts me to type some more notes after selecting the appropriate old (or creating a new if non-existant) episode by just typing . "S" notes logical blocks for this episode need to remain logically separate from the "S" notes of the "subacute append." episode. I need to be able to switch episodes quite at will. Now, if the patient returns in the evening for deterioration of the abdominal pain (don't take me up on the medical side here - he did throw up in the moring already :-))  I will reselect the old episode (the one selected last in the morning should be autoselected) and type a few more notes and, say, a referral letter. Those notes, even if of type "S" and belonging to the same episode as in the moring should remain a separate logical block since it effectively is a different patient-encounter. Another approach would be to cycle through existing episodes for this patient upon hitting . On wrapping around a field for typing a new episode name is offered. Am I making any sense here ? I do see your point about not using the word wheel for "S" notes. 9 Directories _____________ 9.1 Abbreviations _________________ CIAS - Clinical Imaging Access Service der HDTF COAS - Clinical Observation and Access Service der HDTF GNU - "GNU's Not UNIX" Rekursives Akronym, welches als Name fuer ein freies UNIX, basierend auf dem Linux Kernel, gewaehlt wurde. HDTF - Healthcare Domain Task Force (CORBAmed) der OMG JSP - "Java Server Pages" HTML Seiten, die Java Programmcode enthalten. Vor ihrer Anzeige werden die JSP Seiten durch ein Interpreter Programm gelesen und in reines HTML umgewandelt. Mit Hilfe von JSP koennen Applikationen eine plattformunabhaengige Web Oberflaeche erhalten und sind damit ueber WebBrowser bedienbar. Als Alternative zu diesen Web basierten Oberflaechen gibt es herkoemmliche stand alone Applikationen, also Programme, die eigenstaendig gestartet und ausgefuehrt werden und ihre Oberflaeche mitbringen. Siehe hierzu "Swing". OMG - Object Management Group http://www.omg.org PIDS - Person Identification Service der HDTF RAD - Resource Access Decision Service der HDTF Swing - Bezeichnung einer Quelltextbibliothek der Sprache Java fuer die Oberflaechenprogrammierung. Dient dem Erstellen von Oberflaechen fuer stand alone Applikationen. W3C - World Wide Web Consortium http://www.w3.org 9.2 Figures ___________ 9.3 Tables __________ 9.4 Sources (Literature etc.) _____________________________ OIO Project Library http://www.txoutcome.org QuickQuack Requirements (Website) 10 Appendices _____________ 10.1 GNU Free Documentation License ___________________________________ Version 1.1, March 2000 Copyright (C) 2000 Free Software Foundation, Inc. 59 Temple Place, Suite 330, Boston, MA 02111-1307, USA Everyone is permitted to copy and distribute verbatim copies of this license document, but changing it is not allowed. 0. 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