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Web Based Electronic Medical Records & Medical Practice Management System

A web based Electronic Medical Records (EMR) & Medical practice Management system.

The software intended to be develop is an online web based Medical Practice Management system intended to computerize the clinic and provide a seam less integration of its various processes.

The application should facilitate input, storage, transfer and retrieval of medical information within a practice and enables interfacing with other data providers outside the practice.

The application aims to expedite record keeping processes and enable doctors to retrieve and input Patient Data, Medical Data, Analysis Reports etc., anywhere and anytime from a PC. Also the application should provide electronic capabilities for routine tasks related to clinical data( Such as Patient Registration, Search for Patient Transcription, imaging, Messaging and Prescription writing, Staging of Cancer, Suggestion of Relevant Regimens based upon Staging, as well as a wireless point-of-care solution for Doctors in the examination room.

EMR Workflow

Modules Overview:

1. Patient Registration and Appointment Scheduling

Patient will be registered with the system through a Nurse/ front office / doctor.

2. Patient Demographics

Capture all the patient preliminary details, such as

o Personal Information
o Correspondence details
o History of the Patient
o Social Background
o Insurance Details
o Family History
o Family Medical History
o Allergies and Operations
o Education details

3. Patient Chart

Patient chart includes complaints, diagnosis, vitals, prescribed tests, current medications, drug allergies, past surgeries and clinical reminders details will be displayed. Also patient name, sex, age, date of last visit and patient related menu will be displayed. A patient related menu option includes chart, subjective, plan, order, assessment, others, super bill and mark as seen.

4. Physical Examination

List of items for a New Physical Exam will be displayed and by default General details form will be displayed for capturing the details. New Physical Exam can be made for a patient includes general details, eyes, ears, etc details list will be displayed.

5. Review of System

If any Clinical Trials information available, the doctor refers to it including the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info.

Review all the previous hospitalization, reports before starting the treatment.

6. Diagnosis, Staging and Chemotherapy

The doctor uses the proposed software from the point where he diagnoses the patient and determines the cancer type. The software will be used from then onwards as under:

o ICD Code Master
o Diagnosis Process based on ICD
o Staging
o Stage Grouping
o Medicine for Chemotherapy
o Chemo Order Generation
o Flow Sheet for Chemo Cycle

Based on all the above inputs the doctor diagnoses the patient and understands the problem. This leads to determining the Cancer Stage.

In case there has been and Clinical Trials information the doctor refers to it including the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Based on all this information the doctor writes a prescription and doctor's note and enter the relevant details with the charge capture form.

In case the patient requires Chemotherapy the doctor schedules the next appointment for him with a nurse and the relevant procedures have to be followed.

7. E-Prescription

Displays all previous prescriptions (if exists) with date and edit links for a particular patient. If no prescription exists, i.e., the patient is a new patient doctor will create a new prescription.

8. Doctor Notes

Doctor can able to enter notes regarding patient, after physical testing and diagnosis. And a doctor/nurse can also view the list of all doctor notes created for a patient

9. Nurses Notes

List of regimens prescribed to a patient by the doctor will be displayed to a nurse to select regimen for capturing other details. Nurses can provide other treatment apart from regimen treatment by phone.

The nurse initiates the chemotherapy process and maintains a detail of medication and IV access for the patient. This process ends with Charge Capture based on ICD Codes and subsequent Scheduling for next appointment.

o Nurse will get the relevant patient chart.
o Views the Chemo Schedule and description.
o Updates the chemo order sheet and creates the nurses notes.
o Closes the 'chemo day' after the chemo has been completed.
o Views the nurse's report/notes.
o Closes the 'Chemo' after all the chemo days have been closed

10. Laboratory Management

This is used to capture tests information under special diagnosis. If tests are already prescribed for a patient by a doctor, then page will be displayed with existing data and can be captured other new tests otherwise new page will be displayed for input, new prescribed tests will be captured and shown back with captured data.

11. Others

o Demo Project Codes
o Other Scanned Documents
o Spell checker
o Audit Trail
o Phone Call board

12. Billing Management

The software shall not deal with the billing module and if required shall only have an integration with the existing Billing Management System

13. Reports

o Patient Registrations
o Patient Visits
o Diagnosis-Location
o Diagnosis-Cancer
o Doctor Visits

The above reports will be presented in a graphical representation (Bar and pie chart) for the respective data captured in the application.

Key Features:

1) Patient Registration & Appointment Scheduling
2) Patient Demographics
3) Patient Chart
4) Physical Examination
5) Review Of Systems
6) MRI
7) HPI
8) Diagnosis, Cancer Staging and Chemotherapy
9) E-Prescription
10) Doctor Notes
11) Nurses Notes
12) Laboratory Management
13) Others
14) Billing Management
15) Reports
16) Admin Module

1) Patient Registration & Appointment Scheduling:

Patient registration can be done in two ways:

1. Through Appointment Scheduling
2. Registration by visit.
Patient will be registered with the system through a Nurse/ front office / doctor. If a patient booked an appointment on a particular date, the front office will have a provision to track the patient physical arrival status.

2) Patient Demographics

Capture all the patient preliminary details, such as

The sub functionalities of this feature are as follows:

a. Personal details
b. Insurance Details
c. Social history details.
d. Medical history details.
e. Family history details.
f. Family medical history details.
g. Surgical history details.
h. Hospitalization details.
i. Correspondence details.
j. Chief complaint(s) details.
k. Drug allergies details.
l. Current medication(s) details.
m. Discontinued medication(s) details.
n. Vitals details will be captured and can update date wise.
o. Women Only - Women related information will be captured (like Number of
Pregnancies and Number of Children born etc). This is exclusively for women only.
p. HIPAA - A provision to upload HIPAA related docs.

Update existing details.

3) Patient Chart

a. Display Patient Chart
b. Display, Add and Modify Complaints details
c. Display, Add and Modify Diagnosis details
d. Display, Add and Modify Vitals details
e. Display, Add and Modify Prescribed Tests details
f. Display, Add and Modify Current Medications details
g. Display, Add and Modify Drug Allergies details
h. Displaying different details of a patient as a report
i. Display, Add and Modify Past Surgeries details
j. Display, Add and Modify Clinical Reminders details
k. Display, Add and Modify Flow sheet details
l. Display, Add and Modify Template for referral note details
m. Display, Add and Modify Template for letter details
n. Display, Add and Modify Tumor Marker details
o. Display, Add and Modify PT/INR details
p. Display, Add and Modify Diagnostic test details
4) Physical Examination

i. The sub functionalities of this feature are:

a. General details
b. Central Line details
c. Skin details
d. Head and Face details
e. Eyes details
f. Ears details
g. Nose and Nasopharynx details
h. Neck details
i. Lymph Nodes details
j. Musculoskeletal Details
k. Genitalia
l. Rectal
m. Breast
n. Cardiovascular details
o. Respiratory details
p. Abdomen details
q. Extremities details
r. Neurological details

ii. Display list of report(s) created for a particular patient date wise
iii. Display individual report.
iv. Update existing report details.
v. Delete existing report(s) details.

5) Review of System

i. Capture the following details

a. General details
b. Eyes details
c. Cardiovascular details
d. Genitourinary details
e. Musculoskeletal details
f. Skin details
g. Psychiatric details
h. Endocrine details
i. Respiratory details
j. Ear, Nose, Mouth and Throat details
k. Gastrointestinal details
l. Breasts details
m. Neurological details
n. Hematological/Lymphatic details
o. Chest Details
ii. Display list of report(s) created for a particular patient date wise
iii. Display individual report.
iv. Update existing report details.
iv. Delete existing report(s) details.

6) MRI Details

i. Capture MRI details

ii. Display list of report(s) created for a particular patient date wise
iii. Display individual report.
iv. Update existing report details.
iv. Delete existing report(s) details.

7) HPI

a. General HPI or HPI details and can view past HPI details date wise.
b. Lung Cancer HPI details.
c. Colon HPI details.
d. Breast HPI details.

8) Diagnosis, Cancer Staging and Chemotherapy

The doctor uses the proposed software from the point where he diagnoses the patient and determines the cancer type. The software will be used from then onwards as under:

• ICD Code Master
• Diagnosis Process based on ICD
• Staging
• Stage Grouping
• Medicine for Chemotherapy
• Chemo Order Generation
• Flow Sheet for Chemo Cycle

Based on all the above inputs the doctor diagnoses the patient and understands the problem. This leads to determining the Cancer Stage.

In case there has been any Clinical Trials information the doctor refers to it including the drug information Charts, Lab Reports, Chemo Order generation, Clinical Trials Info. Based on all this information the doctor writes a prescription and doctor's note and enter the relevant details with the charge capture form.

In case the patient requires Chemotherapy the doctor schedules the next appointment for him with a nurse and the relevant procedures have to be followed.

a. Doctors can view diagnosis report.
b. Doctors can create diagnosis by selecting ICD Code and Disease Name.
c. Capture ICD Code, histology details, histological grade and residual tumor
grade details.
d. Define the stage and capture stage details.
e. Doctors can see all the existing regimens.
f. Doctors can create blank regimen or related regimens with cancer type or
ICD Code and capture the details of regimen.

9) E-Prescription

Displays all previous prescriptions (if exists) with date and edit links for a particular patient. If no prescription exists, i.e., the doctor will create a new prescription.

a. Doctors can maintain common prescription list.
b. Doctors can maintain common drug(s) list.
c. Doctor can generate a new prescription or generate prescription with an
existing common prescription.
d. Doctor can update or delete an existing prescription(s) for a particular patient.
e. Doctor can have a preview, print and fax the entire prescription.
f. Doctor will have glance of chief complaints, cancer type, stage and current
medication(s) and discontinued medication(s) details at the time of giving a
new prescription or updating prescription.
g. Doctor will have a facility search for selecting the drug(s).

10) Doctor Notes

Doctor can able to enter notes regarding patient, after physical testing and diagnosis. And a doctor/nurse can also view the list of all doctor notes created for a patient

a. Doctors have a facility to view list of doctor notes as a report created for a
particular patient.
b. Doctors have a facility to view particular doctor note created for a particular
patient
c. Doctors can update exiting doctor note created for a particular patient.
d. Doctors can delete exiting doctor notes created for a particular patient.
e. Doctors can create new note on patient last visits containing the details of
HPI, history and plan.
f. Doctor can create a new note with an existing doctor note for a particular
patient.
g. Doctor can have facility to search referral doctors list and can add them to
doctor note.
h. Displaying different details of a patient as a report
i. Including different details of a patient in a particular doctor note
j. Modifying different details of a patient in a particular doctor note
k. Doctor's note can be print and fax.

11) Nurse Notes

List of regimens prescribed to a patient by the doctor will be displayed to a nurse, to select regimen for capturing other details. Nurses can provide other treatment apart from regimen treatment by phone.

1) Clicks on the Patient ID to get the patient chart relevant to the nurse.
2) Views the Chemo Schedule and description.
3) Updates the chemo order sheet and creates the nurses notes.
4) Closes the 'chemo day' after the chemo has been completed.
5) Views the nurse's report/notes.

Closes the 'Chemo' after all the chemo days have been closed

a. Nurse can view all the regimens prescribed by the doctor to a patient.
b. Nurse can select regimen to view treatment schedule for that particular
regimen to a patient.
c. Nurse can select a day in treatment schedule cycle and required data will be
captured for regimen.
d. Nurse can make a note under Non ChemoMedicine, Chemotherapy, Pump,
Phlebotomy, Antibiotic, Hydration, Hormone Injection, Antiemetics, Laboratory
and Paracentesis.
e. Nurse can close or open a day in a cycle for particular regimen.
f. Nurse can close or open a cycle or chemo cycle for particular regimen.
g. Nurses can provide non chemo other medicine at hospital or on phone.
h. Nurse can view cycle report to a particular regimen for a particular patient.

12) Laboratory Management

This is used to capture tests information under special diagnosis. If tests are already prescribed for a patient by a doctor, then page will be displayed with existing data and can be captured other new tests, otherwise new page will be displayed for input, new prescribed tests will be captured and shown back with captured data.

a. Doctors can order In-house or Out-House lab tests under Laboratory, Special
Diagnosis, CT scan, Radiology, Respiratory, Physiotherapy, Nuclear Meds,
Ultrasound and Miscellaneous Orders for a particular patient.
b. Doctors can cancel the tests which were ordered previously for a particular
patient.
c. Doctors can view pending, completed and seen tests for a particular patient.
d. Doctors or Lab Person can upload In-house or Out-house tests information
which were undergone present or past by the patient.
e. Clinical Reminders can be captured, modified and displayed.
f. Doctor or Lab person can view today's tests by patient name or test name.

13) Others:

a. Capture Patient Other Scanned documents & Modify or Edit Patient Other Scanned documents
b. Demo Project Codes - Here the diagnosis related data will be mapped with the Insurance according to the given gcodes
c. Capture, Modify and Display Patient Educational information on diseases
d. Capture, Modify and Display Patient Medication log
e. Capture, Modify and Display Pathology
f. Display Patient Diagnosis flow sheet according to the patient visits.
g. Capture, Modify and Display Bone marrow biopsy
h. Capture, Modify and Display Phlebotomy
i. Capture, Modify and Display Paracentesis
j. Phone Call board - Where the nurse/front office/doctor can attend and prescribe a suitable solution to a patient through phone call. All these details will be captured.
k. Mark as Seen - Doctor can mark the patient consultation status as seen for the day.
l. Spell Checker - Using this feature, the user can perform the spell check with the related forms.
m. Audi trail - Captures Doctor Visits on patient including IP address, visit time stamp and navigation information on patient records.

14) Billing Management

The system should provide the billing information, which needs to be integrated with the third party billing software.

Capture the following details

a. Primary focus of visit charges
b. Practice Guideline Adherence charges.
c. Current Disease State charges.
d. Office services charges.
e. Out patient initial consultation charges.
f. Prolonged services charges.
g. Miscellaneous charges.
h. Non-chemotherapy Injections charges.
i. Chemotherapy Injections charges.
j. Non-chemotherapy drugs charges.
k. Chemo Administration charges.
l. Chemotherapy drugs charges.
m. Laboratory services charges.
n. New Consultation charges.
o. Confirmatory Consultation charges.
p. Emergency Department Service charges.
q. Initial Hospital Care charges.
r. Initial Observation Care < 8 hrs charges.
s. Initial Observation Care > 8 hrs charges.
t. Subsequent Hospital Care charges.
u. Follow up Consultation charges.
v. Chemo drug charges will be automatically added to the super bill.
ii. Update existing details.
iii. Display super bill for all charges.

Note: The software shall not deal with the billing module and if required shall only have an integration with the existing Billing Management System. It will facilitate all the required inputs/information to the billing software.

15) Reports

a. Patient Registrations
b. Patient Visits
c. Diagnosis-Location
d. Diagnosis-Cancer
e. Doctor Visits

The above reports will be presented in a graphical representation (Bar and pie chart) for the respective data captured in the application.

16) Admin Control Panel

I. Office Admin details

1. Capture the following details

a. Appointment Type details.

Appointment type details include appointment type and description will be
captured.

b. Clinic details.

Clinic details include clinic name, street line1, street line2, city, state, zip, country,
work phone and other phone will be captured.

c. Pharmacy details.

Pharmacy details include pharmacy name, contact person, address1, address2, zip,
phone1, phone2, email, fax1, fax2, registration id, open time, close time and round
clock will be captured.

d. Holiday details.

Holiday details include holiday name, start date, end date, day, recursive and
creation date will be captured.

e. Employee category details.

Employee Category details include employee category name and remarks will be
captured.

f. Employee Master details.

Employee Master details include salutation, title, first name, middle name, last
name, date of birth, sex, ssn, marital status, photograph, address1, address2,
city, state, zip, email, home, work, other phone, cell, username, password, role,
superior and employee category will be captured.

g. Custom Scheduler details.

Custom Scheduler details include clinic name, start time, end time, default interval and custom interval will be captured.

h. Employee Leave/Vacation details.

Leave details include employee name, from date, to date, start time and end time will be captured.

i. Referral doctor details.

Referral Doctor Details include doctor name, hospital name, hospital phone, doctor phone and classification will be captured.

j. Doctor clinic details.

Doctor Clinic details include clinic name, employee name, from date time, to date time, recursive date, start date, from day time, to day time, recurrent day, end date and terminated will be captured.

2. Update existing details.
3. Delete the existing details

II. Diagnosis Management details

1. Capture the following details
a. Residual Tumor Grade details.
b. Histological details.
c. Histological Grade details.
d. ICD Code details.
e. ICD Histology details.
2. Update existing details.
3. Delete the existing details

III. Staging Treatment details

1. Capture the following details
a. Chemo drug code details.
b. Antiemetics details.
c. TNM details.
d. Regimen details.
e. Admin code details.
f. Drug code details.
2. Update existing details.
3. Delete the existing details

IV. Orders details

1. Capture the following details
a. MRI Part details.
b. Test details.
2. Update existing details.
3. Delete the existing details

V. Super Bill details

1. Capture the following details
a. Super Bill Header details.
b. Super Bill Data details.
2. Update existing details.
3. Delete the existing details

VI. Flow sheet details

1. Capture the following details
a. Flow sheet details.
2. Update existing details.
3. Delete the existing details

VII. Demo Project

1. Capture the following details
a. Section details.
b. Cancer Type details.
c. GCode details.
d. ICD & GCode mapping details.
2. Update existing details.
3. Delete the existing details

regards,
Dr Tom

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