Electronic Patient Record
From diorama to paperless office: EPRs and their different forms
Introduction
ChipSoft is an innovative Dutch software house, established in 1986 and
supplier of its own CIS, developed in-house, since 1994. In 2001, ChipSoft
marked a new era with the introduction and implementation of the ChipSoft
Electronic Care Information System (CS-ECIS). From the
very beginning, ChipSoft has focused exclusively on the computerization of care
institutions, which is why ChipSoft has a thorough knowledge of the
computerization of business processes in health care.
ChipSoft is the market leader in the computerization of a number of business
processes in health care (which include operating room management, invoicing and
patient data management). In the Electronic Patient Record (EPR) field, ChipSoft
has had a functionality available for years for patient oriented consultation of
the available sources of information in the hospital and the registration of
record data. The approach for consulting these sources of information can be
configured in a way appropriate for the positions.
The developments in information and communication technology in general are
very fast moving. Many developments in information and communication technology
are also noticeable in the health care sector. The EPR, integrated outpatient
and inpatient logistics and order management are the most striking changes.
Within the care sector, ChipSoft observes in the main an increasing demand for
flexible and user-friendly software that is, depending on the business
processes, scalable and configurable. The rapid technological developments and
the ICT developments within health care have motivated ChipSoft to design an
information system on the basis of a model that combines all that is good at
present with all the possibilities that are foreseeable for the future. In doing
this, ChipSoft has developed functionality that can meet the computerization
demands made by the care sector now and in the future.
The ChipSoft CS-ECIS is dedicated to supporting the entire treatment and care
process. ChipSoft recognizes the importance of the increasingly process oriented
working methods within hospital structures and has focused primarily on this
with the development of its software. Overview and accessibility are key words.
The entire care process from A to Z is subdivided into functionality that can be
built into a flexible application based on the work process. The patient is
central in the ChipSoft CS-ECIS. The underlying theme of the CS-ECIS is to
present the entire care and treatment procedure that a patient undergoes as a
clear and workable package. From registration to first appointment, from
admission to operation, from discharge to invoicing.
ChipSoft is committed to the development of software for care institutions
and the supply of a Care Information System (CS-ECIS) that is as complete as
possible and, in doing so, produce an Electronic Patient Record that is as
comprehensive as possible.
Integration and configuration
In ChipSoft’s vision of the Electronic Care Information System (CS-ECIS),
data must be accessible from every location in the hospital (of course dependent
on the authorizations of the individual care provider). The open system that
ChipSoft has developed for this purpose is characterized by the presence of
independent objects, which allow for separate processes. This form of
programming (known as object-oriented programming) has the major advantage that
the independent components of the CS-ECIS can make use of each other’s
functionality and logic.
In using, amongst others, HL-7 standards, ChipSoft ensures good mutual
communication between medical systems and with administrative systems. This
communication takes place through the COMEZ, the communication server developed
by ChipSoft. The communication server provides the links between all the
subsystems inside the hospital. COMEZ is suitable for all protocols used in
medical software and can support multiple protocols simultaneously.
A single user interface
The CS-ECIS has ‘one face’ for the system users. This means that
everyone works in the same basic screen, in which users recognize their work
process using the functionalities made available to them. Of course, many
different lay-outs are possible in the basic screen.
Configurable
The basic screen can be designed in various ways. Using the extensive
authorization structure, rights can be issued in various ways through profiles
and groups.
In addition, ‘buttons’ can be created at the top of the screen that form
“shortcut keys” to specific functions. This could be for writing out a standard
prescription or a link to another doctor’s diary.
It is also possible to lay out a screen yourself and set up functionalities
in fixed positions. The working screens to be created this way are known as the
compiled worksheets in the CS-ECIS. The functionalities in a compiled worksheet
can be tailored exactly to the care provider’s needs. This lay-out shows,
amongst other things, the surgery overview, the DTC registration and viewing
various information “sources”. The ‘EPR dashboard’ on the lower left shows the
user - at a glance - which information is available for the patient.
Context sensitivity
The CS-ECIS is equipped with context sensitivity. This means that
when a patient has been selected, the CS-ECIS knows what information is
available about this patient. Because the patient is presented in context, all
sorts of functionalities for this patient can be accessed, without the patient
having to be selected again.
User rights and access
CS-ECIS has an extensive authorization structure, which ensures that all
rights can be protected at a detailed level. In general, rights are issued based
on the user’s job profile.
Every user is given a unique user name and unique password with which they
can log on to the application. In the so-called profiles management, it is
indicated which functionalities can be started for each user or each user group.
Within the maintenance module Ziscon, rights can subsequently be issued to each
user (or user group). These rights and profiles work according to the principle
of succession, which means that users can be added to an authorization group
with a minimum of effort and that they automatically receive the rights of this
group.
The system is equipped with a method for fast logging in and off, so that
users can start up a required functionality with a minimum of effort. It is also
possible to start up ChipSoft applications simultaneously with another
application in the background based on a single sign-on.
Vision
With the ChipSoft Electronic Patient Record, all patient related data can be
integrally managed. The ChipSoft EPR should not really be considered as a
‘separate’ module, but instead as a flexible configurable information system
that does not just form a source of information for the care provider, but can
also offer optimum support in the primary care process.
In ChipSoft’s vision, the EPR does not exist. An EPR is not an application
that can be bought, but an EPR is created when data relating to a patient are
collected from different systems. An EPR has to be more than just a ‘diorama’.
Being able to consult data that have been recorded in different systems is a
first step. However, to end up with a comprehensive patient record, the care
provider must be able to record data as well. This could include anamnesis, test
data, medication orders and all correspondence related to a patient. These
registrations should be able to follow structured patterns (so-called ‘order
explosions’), which means that the registrations result from the primary
logistic process of the care treatment. For quite some time now, ChipSoft has
offered the functionality for initiating registrations on the basis of treatment
protocols. It has also been possible for some time to record data in patient
records in a structured or unstructured manner.
In addition, an EPR will have to contain different data for a medical
specialist than for a nurse. Where the doctor, in the case of medication for
example, will be interested in having an easy way to prescribe complex
medication schedules, a nurse will prefer to see the medication round list in
the EPR screen.
Due to the modular construction of the CS-ECIS, an EPR can be designed to
meet the wishes of the end user. An EPR for a medical specialist is usually
constructed of the following components:
- Required care and referral data
- Case history and diagnosis data
- Clinical (admission and OR) data
- Progress data
- Medication information
- Laboratory results (Chemical Pathology, Microbiology, etc.)
- Radiology results and images
- Medical correspondence
- DTC data
- Special examinations
Many variations of the above summary are possible depending on the position
and role of the care provider who is given access to the patient’s information.
Why an Electronic Patient Record?
From the very beginning of electronic patient records, intensive research has
been done into the effects of electronic record forming on the patient’s care
process and the care providers involved.
Based on research literature and endorsed by care providers who use the
ChipSoft EPR, the following effects of working with electronic records are
discernable.
- Quality of the information
The structured recording of data (for example using a ‘question and answer’
game) increases the completeness of the recorded data. By employing precoded
answers, the accuracy of the recorded information is increased.
- Access to the information
Electronic data recording simplifies the access to the data. Access to the
record is not linked to a physical location. More than one person can view a
record at any one time and the information in the record can be approached
from different angles.
- Quality of the care
The structured protocoled registration of patient data provides better
insight into a patient’s status. Electronic record forming can simplify the
multidisciplinary exchange of knowledge about a patient, which can lead to,
amongst other things, a reduction in the number of double examinations.
- Decision support
Through the improved access to more structurally recorded information, EPRs
can be increasingly used to support decision forming related to the
patient’s care process. Notifications and warnings guide the care provider,
for example, when deciding whether or not to prescribe certain medication,
or to request a particular examination.
- Data protection
Through making data available electronically instead of in paper form, the
access to the information can be better coordinated and guarded. Where in
the case of a paper record, access to a record is either given or not, in an
electronic environment access can be protected at the data source. It is
also possible to relate the request of patient data to the treatment
relationship that exists between the person requesting the data and the
patient.
- Research and management information
All electronically recorded information can ultimately be extracted for
research purposes or management information. The relationship between for
example the registered diagnosis and the treatment a patient received can be
investigated. Reports can also be compiled from the recorded data, which
contribute to an insight into the effectiveness of the care process.
Ultimately, optimum insight into the medical history and current patient
situation is established. This benefits both care providers and patients. They
do not need to carry their own data around with them, a once-only input of data
prevents the same question from being asked in different places. Once data have
been entered, they can be requested immediately anywhere by both doctors and
nursing staff.
To allow the EPR to function as optimally as possible, it is essential that
all parties within the institution feel committed to the integrated recording of
data. Once the intrinsic care reporting has taken on a consistent form, the
information system yields tremendous results. Not only in the eventual time
saving that can be made, but also in the prevention of unnecessary searching for
data and thumbing through records.
On the road to Evidence Based Medicine
Consistent and protocoled reporting in the EPR will noticeably
improve the quality of registration even in the early stages after
implementation. Relating medical treatment to, for example, a diagnosis made is
also simplified, because in the EPR the cause and effect relationships are
monitored. Ultimately, the EPR is an important step on the road to Evidence
Based Medicine.
Access to the EPR
To simplify the accessibility of the information recorded relating to the
patient, ChipSoft has opted for providing access to the EPR in many different
ways.
The different approaches for gaining patient information are summarized below:
- Patient number
After selecting the patient number, the EPR is opened for the selected
patient. Patient number selection can be simplified by the use of, for
example, bar code readers.
- Outpatients’ surgery list, radiology work list,
functional diagnostics department
The EPR can be approached from the outpatients’ appointments diary. This can
be from a diary in an outpatient department, the functional diagnostics
department, the radiology department or the physiotherapy department. When
working from the outpatients’ appointment diary, separate patient selection
is unnecessary; the care provider need only select the patient from the
diary. The diary can also be ‘browsed’, in which case the EPR fills in the
currently selected patient’s data.
- Inpatients
The EPR can be approached from the current, historic or future ward
occupancy. When working from the ward, separate patient selection is
unnecessary; the care provider need only select the patient from the ward
block.
- Personal patient lists
A care provider can put patients on a personal patient list. This personal
patient list can be approached in the same way as the outpatient or clinical
lists. This functionality is used, for example, to follow patients who are
participating in a trial.
- Inbox
Care provider can send orders (actions) for patients to other departments or
care providers inside or outside the care institute. Using their Inbox, care
providers are informed about the status of all the outstanding orders for
patients in their care. From the Inbox, the selected patient’s entire
Electronic Patient Record can be accessed.
Forms of patient information presentation
Once a patient has been selected in the Electronic Patient Record, all the
available sources in the EPR will fill up with information related to this
patient. Sources of information can be consulted through the EPR dashboard and
through the tabs that can be included in a worksheet.
EPR dashboard
Green colored ‘notice board pins’ will appear for each source of
information containing information pertaining to the selected patient. The EPR
dashboard always provides direct insight into the information available about a
patient.
Information requested through the EPR dashboard is always presented full
screen. After closing the screen, the user returns to the original screen.
Tabs
If the EPR tab lay-out has been selected, the tabs will be filled
with information related to the patient.
When approaching information through the tabs, only the right-hand side of
the screen is used and the work context (for example the appointments diary)
remains visible in the middle of the screen. In addition, it is possible to
enlarge part of the screen and subsequently reduce it again.
A worksheet shows three different angles for viewing patient information. All
the underlying (ECIS) functionalities can be approached directly. From the
medication tab, for example, a prescription can be written, and from the
diagnosis list a new diagnosis can be added. New appointments can also be made
immediately for the patient concerned. In all cases, work is started from the
worksheet and the care provider does not need to perform extra tasks to initiate
other functionalities.
As stated, the EPR does not exist in ChipSoft’s vision. There are many
imaginable appearances for the Electronic Patient Record, varying from a diorama
to view a small amount of data, to the lay-out of a completely digital record to
achieve paperless operational management. ChipSoft offers functionality to
support all possible EPR appearances.
In the categorization of EPRs, various systematics can be applied. EPRs can,
for instance, be classified by their degree of registration intensity. A lay-out
can also be selected depending on the degree of support of the workflow. Other
lay-outs can, for example, have a bearing on the degree to which the EPRs are
focused on one care provider, have a multidisciplinary lay-out or be deployable
transmurally. ChipSoft is able to support any form of lay-out. We offer EPRs
solely for reference functionality and EPRs that can replace paper records.
ChipSoft’s EPRs are mono-disciplinary, multi-disciplinary and can be deployed
transmurally. We are also able to support the care provider’s complete workflow
from the record.
To choose a lay-out, three options are discussed in this chapter:
- The EPR as a diorama for information.
- The EPR as the basis for the registration of logistic care actions.
- The EPR as the cornerstone for protocol driven treatment and the
registration of domain specific information.
The following paragraphs will describe the possible lay-out of the
aforementioned EPR forms. Considering the modular character of the ChipSoft ECIS
and the way in which the ECIS can integrate with third party systems, none of
the descriptions will be complete or exclusive.
The EPR as diorama
The EPR as diorama offers the possibility of consulting all the registered
patient related information. This can be information that is stored in ChipSoft
modules, but also information from other sources. ChipSoft does not supply
modules for chemical pathology, medical microbiology or pathology, but it is
able to display this data from decentralized laboratory systems in the ChipSoft
EPR. Software interfaces with the ‘external’ systems Labosys, Glims, TDLims,
Molus and Palga have, for instance, been created.
Data can be displayed through the EPR dashboard. All the sources of
information that a care provider is authorized for are visible in the EPR
dashboard.
The active (selected) patient is put into the context in the EPR. This means
that all sorts of procedures (registration) related to this patient can be
carried out without having to reselect the patient. The active patient is stated
at the top of the EPR dashboard (in this example Ms. L. Visser).
The green ‘notice board pins’ indicate if information is available for the
selected patient from different sources of data. By clicking on the notice board
pins, the information from the specific information source is displayed.
Paragraph 3.2 gives an example of a medication list that has been selected from
the EPR dashboard.
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| Figure: EPR dashboard. |
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Information that is stored behind the notice board pins in the EPR dashboard,
can also be included in tabs. Which tabs are made available to a care provider,
can be preset. The example below displays an EPR with an outpatient (surgery
diary) entrance, in which the tab with laboratory data has been brought to the
foreground.
The philosophy behind both the EPR dashboard and including information on
tabs, is that all the necessary information is a maximum of one click away from
a care provider.
To meet the wish to be able to view all the data stored in the electronic
record chronologically (to be a match for the familiarity of thumbing through a
paper record), it is possible to request an overview with all the registered
information regarding a patient. From this chronological record, users can click
through to the actual registration that is the basis of the record entry.
On the right-hand side of the chronological record, all the existing sources
of information for the selected patient are displayed. Through selecting or not
selecting sources of information, the record can be ‘tailor-made’ for a specific
care provider.
It is possible to record all sorts of structured patient related
registrations in the EPR. For example, case history registration or the
registration of repeat outpatient visits (more information regarding this
‘digital record registration’ can be found in chapter 12).
This information can be viewed from the EPR diorama functionality. Templates
can be used to indicate which information must be displayed on the tab and if
certain information should be ‘highlighted’ with color coding.
The integration of PACS images and other photo (X-ray) or film material is
also possible in the CS-ECIS. From the Electronic Patient Record, it is possible
summon a patient’s radiology images. Integration takes place through a web
viewer interface. Integration with images from, for example, gastro-enterology
can also take place this way.
Figure: Integration of radiology images in the EPR.
The EPR as the basis for the registration of logistic care actions
The EPR as a diorama offers many functionalities for a care provider and is a
suitable solution in situations in which the care provider is not responsible
for the registration of patient data. However, the registration of patient
related information is increasingly shifting to ‘the source’, which means that
the care provider who performs a procedure also records it. A significant
incentive for the digital registration of patient related data by the care
provider is created by the obligations concerning DTC registration.
ChipSoft has opted for all the patient related registrations to take place
from the Electronic Patient Record. These registrations can have a bearing on
registering a DTC, putting a patient on a waiting list, requesting laboratory
tests or radiology examinations for a patient, booking a repeat outpatient
appointment, prescribing outpatients’ or inpatients’ medication, etc. Through
making registration possible from the EPR, and allowing the registrations to
enter the EPR workflow logically, we hope to keep the registration threshold and
registration pressure for the care provider as low as possible.
Below is a brief summary describing the registration functionality that can
be included in a ChipSoft EPR. The summary is not complete, but is indicative.
The description of the registration possibilities is based on a situation in
which the ChipSoft HIS (Hospital Information System) is also in use. However,
from the EPR registrations it is also possible to supply third party systems or
to place registration components from external systems on the EPR desktop.
- DTC registration
From the ChipSoft EPR, Diagnosis Treatment Combinations can be recorded.
Behind the scenes, the recorded DTCs are checked against the current
regulations. Registration of DTCs usually takes place from the EPR’s main
screen (the central section). If a patient is, for example, selected in the
surgery diary, the DTC can simply be added. When ‘browsing’ the diary, it is
also immediately visible if a DTC has been registered for a patient, without
actually having to open the DTC registration. More information regarding DTC
registration is included in chapter 8.
- Patient notes
The care provider can record unstructured (free text) patient notes. These
notes can be kept ‘private’, but can also be made available to the
department, partnership or the entire hospital. More information regarding
patient notes is included in chapter 6.
- Medication
From the EPR, patient medication can be prescribed or terminated. Medication
can be prescribed for both inpatients and outpatients. In each situation,
the relevant formula and observations are indicated. Of course, a patient’s
medication profile and the medication actually dispensed is always visible.
- Medical correspondence
Medical correspondence can be created from the EPR. Based on predefined
templates, the letters can be automatically filled with all sorts of
recorded data from the ECIS.
- Outpatient check-up appointments
From the EPR, the care provider can make a check-up appointment for an
outpatient or for an inpatient who is being discharged from a ward. By
employing appointment protocols that are issued to certain care providers,
all the appointment parameters will be filled automatically. T
- Waiting list registration
From the EPR, whether or not based on a treatment protocol, the care
provider can put a patient immediately on the waiting list for an operation
and/or an admission. Based on predefined treatment protocols, admission and
operation related data are automatically filled. Chapter 7 will discuss in
more detail the manner in which the logistic care processes for a patient
can be steered and followed from the EPR.
The examples above indicate how a care provider can enter all sorts of
patient (care process) related registrations in the Electronic Patient Record.
The summary is not conclusive, but provides an image of the way in which an EPR
can migrate from a diorama functionality to an EPR that supports the care
provider during the care process.
The EPR as the cornerstone for protocol driven treatment and reporting: on
the road to paperless records
Discussions about the Electronic Patient Record often focus on EPRs that are
able to support the logistic treatment process and on EPRs that are capable of
completely replacing paper records. ChipSoft also offers the possibility of
laying out the ChipSoft EPR in such a way that all registrations from the paper
record can be replaced with a digital equivalent.
In daily practice, a paper record consists of many different data carriers. A
record for a patient whose kidney has been removed will at least contain the
following data:
- Referral letter from the general practitioner
- Outpatient case history from the internist, the nephrologist and the
surgeon
- Outpatient check-up data from all the specialists involved
- Laboratory results
- Radiology reports
- Medication prescriptions
- Pre-operative screening data
- Admission data, admission and discharge correspondence
- Operation data, operation report
- Progress data
- Nursing procedure data
- Etc.
The previous paragraphs have already shown that using the ChipSoft EPR
functionality can make a large number of these data carriers available in
digital form. For example, examination results, operation reports and admission
and discharge letters. However, to be able to also record the case history data,
consultation data and any other structured and unstructured information, the
need arose for a registration tool that could be laid out flexibly.
In addition, there is an increasing demand for patient related procedures to
be set out in protocols using predefined treatment trajectories. All patient
related consultations, examinations, registrations, discussions, and
measurements to be carried out can be ‘predicted’ in advance based on the
patient’s diagnosis.
Finally, to achieve a completely digital record, it will have to be possible
to transfer the data supplied by external third parties to the digital
environment.
The ChipSoft products that facilitate completely digital, protocol guided
record forming are described briefly below.
- Digital Record Registration
The module CS-Digital Record Registration offers optimum support in the
structured recording of various data that are generated during a patient’s
care process. The recorded data can be recycled in the medical
correspondence and, for example, form the basis for research into certain
clinical pictures. Other ECIS functionalities can be summoned from the
digital record registration. This facilitates the initiation of follow-up
actions based on certain registered data in the record registration.
- Medical and administrative orders
From the EPR, supported by treatment protocols, all sorts of patient related
orders can be generated. This way, the care provider can place an order for
a radiology examination, a laboratory test or an ECG, but he/she can also
‘order’ the patient for an oncology discussion. Nursing orders regarding,
for example, performing measurements, can be given from the EPR. The EPR
informs a care provider about the status of all the orders they have given.
- Multimedia applications
To make the digital record complete, it is necessary to include, for
example, referral letters from the general practitioner and the patient’s
X-rays or disorder photographs in the record. Chapter 13 discusses the ways
in which these documents and images can be integrated in the EPR.
In modern care institutions, large volumes of data circulate, which are
generated by a large number of more or less integrated departments. These data
must be made available for the user from different angles, whereby the time
element is an important factor.
The ChipSoft module CS-Info provides insight into all the available patient
related data from a single screen. CS-Info ensures mutual contact between the
various data islands in the hospital, such as the patient registration, the
various functional diagnostics departments, the outpatient departments, the
pharmacy and the laboratory. CS-Info is therefore seen as the first step on the
road to a completely electronic record.
CS-Info does away with the need for setting up a central data management and
central reporting system, which means that, in addition to controlling costs,
higher quality of care and more intensive patient care can be achieved.
Using CS-Info, the following data can, for example, be retrieved:
- Appointments (historic and future)
- Answers based on structured questionnaires
- Diagnoses and complications
- DTCs
- Medical correspondence
- Medication prescriptions
- Operation data and reports
- Admission data
- Patient notes
- Radiology data and reports
- A&E registrations
- Chemical Pathology results
- Medical Microbiology results
- Pathology results
- Isotope results
- Outstanding orders
- Procedures
- …
The active (selected) patient is put into the context in the EPR. This means
that all sorts of procedures (registration) related to this patient can be
carried out without having to reselect the patient. Indications (green notice
board pins) on the EPR dashboard show if information for the selected patient is
available from the different data sources. By clicking on the notice board pins
or the description of the data source, the data from this specific source are
displayed.
Information that is stored behind the notice board pins in the EPR dashboard,
can also be included in tabs. Which tab can be made available to a care
provider, can be preset.
Interfaces
An interface can facilitate the retrieval of data from third party
systems. ChipSoft already has years of experience in creating interfaces with
third party systems. Interfaces have not just been created with all the
available Hospital Information Systems in the Netherlands, but also with many
department systems and medical equipment. Software interfaces have, for
instance, been created with the ‘external’ systems Labosys, Glims, TDLims, Molus
and Palga.
These interfaces can be implemented using both the Health Level 7 protocol (if
available) and the external system supplier’s protocol.
Security
It goes without saying that the protection and personal nature of the
data has been taken into account. In the CS-Info configuration module, it can be
determined for each individual user which data should or should not be
available.
Patient notes can be recorded in the Electronic Patient Record. These notes
can be given different accessibility levels:
- Personal notes
Notes are only displayed to the person who recorded them in the Electronic
Patient Record.
- Research group / specialist group notes
Notes can be made available to the research group or the specialist group to
which the user making the notes belongs.
- Public notes
Notes can be made available to all the users in the care institution.
All sorts of logistic care actions can be supported from the Electronic
Patient Record. For example making appointments and putting patients on the
waiting list for Admission or OR.
Logistic care actions can be supported from the EPR in various ways.
-
 Firstly,
the care provider’s worksheet can be laid out in such a way that all sorts
of patient related procedures can be initiated with a single click. In the
‘outlook’ bar to the left of the screen, buttons can be created (shortcut
keys) for the most common procedures. These shortcut keys can be deployed
flexibly. For example, an ophthalmologist will not need an on-screen
shortcut key for a laboratory test request, while this is essential for an
internist.
See adjacent example for a surgeon. The care provider can, for example, open a
worksheet from the visible shortcut keys, a case history can be registered,
a single or combinatory appointment can be made or a patient can be placed
on the waiting list. Behind the different tabs (Patient, OR, Admission, etc)
there are other shortcut keys. The care provider’s workflow can be
intelligently supported through the intelligent lay-out of tabs with
relevant shortcut keys.
- The support of logistic care transactions can take place from the Digital
Record Registration; the care provider is guided to a procedure to be
performed based on questions. For example: the diagnosis ‘appendectomy’
automatically leads to an icon in the Digital Record Registration and the
patient is subsequently placed on the waiting list for admission and OR.
- It is also possible to initiate part of the order communication from the
Digital Record Registration, where, for example, on the grounds of a
registered diagnosis, a number of protocol driven order explosions take
place. For example: based on the diagnosis ‘Appendectomy’, the necessary
laboratory tests and radiology examinations are automatically ordered.
CS-Episode is a CS-ECIS module with which it is possible to record the
patient care process in the form of a Diagnosis Treatment Combination (DTC). The
recording of DTCs is at present a statutory obligation. Each patient treatment
must be able to be linked to a registered DTC. A DTC consists of 4 standard
components: the type of care, the required care, the diagnosis and the
treatment. It is only obligatory to register the type of care and the diagnosis.
The use of the required care and the treatment is left to the discretion of the
scientific bodies.
How does CS-Episode work?
A DTC is usually registered through a so-called ‘mobile screen’,
which is linked to an outpatients’ surgery diary. Of course, in many cases, the
care provider will perform the registration from the EPR.
The input of DTCs is intuitive and user-friendly in nature. The screens have
different input options; direct entry of codes, scroll lists and even graphic
display of the profile lists are standard functionalities. And as is the case
for all CS-ECIS modules, input with both mouse and keyboard are possible.
In addition to the registration of a new DTC, it is also possible to close
DTCs, to make DTCs ‘chronic’, to record deterioration of condition and other
treatments.
Most important features
In addition to the registration of DTCs, reporting is an important
component. CS-Episode uses the built-in Report Builder for this purpose. This
module offers extensive options for displaying, creating and even recording
data. For extensive questions and counting options, the so-called overview
generator can be used.
CS-Document is a total solution for the
management, routing and archiving of correspondence, reports and forms.
CS-Document can be used throughout the care institution. For example, you can
generate and register letters and medical reports.
How does CS-Document work?
Templates can be created using CS-Document (in an integrated
Microsoft Word environment). Using these templates, information that is recorded
in the CS-ECIS can be integrated in the correspondence. For example, data
regarding the patient, the patient’s appointment at the care institution and the
admission of the patient. By recycling the recorded information, standard
correspondence can be processed more efficiently. After the generation of a
document on the basis of the standard template content, unexpected sources of
data not included in the template can still be added.
Most important features
CS-Document lends itself excellently for the standardization of
reporting within a specialist group or a care institution. Through the
integration of the already registered data, great efficiency can be achieved in
the work processes related to medical reporting. When writing an operation
report, for example, inputting the operation number can generate a large part of
the operation report automatically. Various data that are already known (name
and address data), or are recorded in OR (operation procedure data), can be
integrated in the operation report.
If data have not been included based on the standard letter template, but are
still relevant, they can be added.
Once a document has been drawn up, it is saved automatically and can be
archived and routed. CS-Document takes care of the saving and archiving of
documents itself. Documents can be routed to a printer, but also to a fax,
e-mail or sent by EDI.
CS-Document lends itself excellently for a phased implementation; you can
begin with setting up the medical correspondence for each specialism and
subsequently widen the implementation within the institution at your own pace.
Applications in the EPR
In the EPR, the outpatient letter corresponding with, for instance, a
case history registration can be initiated and sent to your own secretarial
department for further processing.
Directly from the main screen, the overview screen provides insight into the
content of the particular document, so that a care provider who is looking for
specific information need not open all the letters. It is also possible to save
information brochures in CS-Document with for example an explanation of a
particular operation. These information brochures can be addressed personally to
the patient or his or her parents / carers. The EPR shows which information
brochures were issued to a patient.
The ChipSoft medication prescription system, CS-Medication, includes both
outpatient and clinical prescription options. The same functionality is used for
the prescription of medication for both outpatients and inpatients. The angle
for outpatient prescriptions or viewing a medication list is usually the
doctor’s surgery. Clinical prescriptions are usually started from the patient
admissions overview for a doctor or specialism.
Outpatient prescription takes place from the patient’s treatment process.
Patients are easy to select from the appointments list and medication can
subsequently be prescribed.
Outpatient prescriptions
Medication can be prescribed in various ways:
- Shortcut keys
Functionalities can be created for prescriptions that are frequently
prescribed, which can then be selected directly from the left-hand side of
the screen. The frequency of use and standard dosage are already linked to
these prescriptions.
- Setting protocols
All medication that is prescribed in an institution or specialism can be
protocoled and, for example, be linked to a diagnosis or policy (so for a
migraine, a standard combined prescription can be defined). Protocols can
also relate to a particular medication dosage, with a dispensation period to
be set linked to it. Protocols are included in CS-Medication as PMOs
(Predefined Medication Orders) and PCMOs (Predefined Combinatory Medication
Orders).
- Medication list
Prescription is also possible from the medication list (an overview of the
patient’s active medication). It can be adjusted, so that the care provider
can look at all the patient’s medication, or just what they as care provider
have prescribed. In addition, it is possible to provide insight into planned
and stopped patient medication. CS-Medication remembers how each user last
looked at the medication list.
Medication prescriptions can be stopped or postponed at any moment. When
stopping medication, a reason for stopping can be given, which means that, for
example, patient allergies can be recorded directly.
Insight into medication profile
The patient record always shows which medication the patient is
using, and which complaints have been registered for the patient. Conflicts with
already prescribed medication and conflicts with the patient’s complaints are
automatically pointed out.
Doctors can also create a list with prescriptions that they often prescribe.
These individual ‘favorites lists’ simplify issuing prescriptions. When ‘writing
out’ a prescription, it can be recorded in a single action that a prescription
must be added to the care provider’s favorites list.
Clinical prescriptions
From the wards, prescriptions can be issued using the same
functionality as is in use for outpatient prescriptions, only the entry to the
EPR is laid out differently in the clinical setting.
Administration registration
The prescribed medication for inpatients is approved after it has
been prescribed and subsequently ends up on the rounds list for the appropriate
departments. A rounds list is available for each department. The departments’
various round times can be set in the system.
To ensure that the registration of the medication administered to the patient
is as complete as possible, medication administered to the patient adhoc can be
recorded. To provide insight into all the medication that has been administered,
an overview of all the administered and planned medication for a patient can be
displayed. The administration registration can also take place from this patient
oriented screen. Postponed medication and the reason why the administration was
postponed can also be viewed.
In the CS-ECIS, all the patient’s logistic processes are supported and
medical procedures can be recorded comprehensively. CS-Order Communication
‘ties’ all registrations and logistic actions to each other. Using CS-Order
Communication, registrations and processes can be recorded as tasks and these
tasks can be presented on a work list for specific care providers.
The ultimate aim of the order communication is to make the progress of the
patient treatment process more transparent. Important pillars are certainty to
ensure that a task has been carried out and that there is proper feedback of the
performance.
Order initiation
In the ChipSoft EPR, the term ‘order’ is a collective name for all
sorts of actions, whether or not related to a specific patient. Below are a
number of example orders that can be initiated from the EPR:
- a request for a laboratory test, a radiology examination or an examination
in the functional diagnostics department;
- the registration of a patient for an oncology discussion;
- blood pressure measurement in an x-frequency for the period the patient is
admitted;
- a consultation by a colleague care provider;
- the request of a record from another care institute;
- …..
It is helpful for the care provider if during the patient treatment process
(part of) the order communication is initiated automatically based on a
particular diagnosis or treatment. This can occur from the digital record
registration as a logical result of the policy that is deployed for the patient.
To be able to issue orders effectively, it is important to think carefully
about which roles are active within the care institution. In the case of order
communication, it is not desirable in most cases to assign an order to a
specific care provider or department. For example, orders sent to the nursing
staff. For the implementation of the order, it is not relevant which nurse
accepts and implements the order. It is important that an order arrives with a
group (the role) of nurses in a specific department.
Monitoring an order
Outstanding patient orders can be monitored in the EPR. The
outstanding orders can be viewed on a tab in the care provider’s worksheet. If
the receiving department accepts the order or reports it done, the status of the
order changes. A quick view rapid access at the bottom right-hand side of the
screen provides insight into an order’s content. This prevents unnecessary
searching for a specific order.
The status of the order is reported back to the care provider through the
‘Inbox’. The ‘Inbox’ shows clearly which orders have been issued by the care
provider. Acceptances and check-offs for the order also return to the Inbox. In
the tab ‘Reports’, the care provider can see directly the findings for their own
orders. This information can also be found on the individual tabs for the
laboratory, radiology, etc. An advantage of the ‘reports’ functionality is that
all the tests and results of examinations initiated by the care provider are
collected and clearly displayed in one place. This provides a direct and
improved view of the patient’s treatment status.
Order appropriation
Users who belong to a role (a user group) can appropriate orders that
have been assigned to the role concerned. Patient oriented appropriation can
also occur; in a single action, all the orders for a patient that are intended
for a role of which a user is part, can be included in the care provider’s own
action list. This creates a work list for the nurse. This work list can be
displayed on screen, with the tabs for patient status underneath.
Orders can also be assigned from a role to other users of that role. This
way, a team leader can, for example, distribute orders amongst the personnel
present in the department.
Using the ChipSoft module CS-Digital Record Registration, it is possible to
record patient related information in a structured and intelligent manner.
CS-Digital Record Registration offers optimum support in the structured
recording of various data, which are generated during a patient’s care process.
This can be information related to an appointment, admission or course of
treatment, but also substantive medical information and information about the
patient’s clinical picture.
Just as the care provider can make notes about a patient or a patient’s
treatment in a paper record, it will have to be possible for the care provider
to record the information in the digital record registration. The so-called
registration ‘at source’ offers the possibility of recording data as completely
as possible with as little interference as possible.
Patient information is often recorded more than once by different care
providers. For example, case history registration or the recording of social
data, such as information regarding the patient’s home-life situation. Through
the use of digital record registration, it is possible to record this data only
once and to subsequently make it available to other care providers. This
prevents duplication and discrepancies in the registration and it aids direct
understanding of the patient’s situation.
To record data digitally, digital forms are often used which cover a
particular area of the treatment process. Data that is registered in one form at
any one time, can be recycled in another form at any other time. Many of the
record data form an important basis for the medical correspondence about the
patient. Through the integration between CS-Digital Record Registration and
CS-Document, it is possible to automatically transfer all the data that have
been recorded digitally to the medical correspondence.
Digital registration
CS-Digital Record Registration is based on the question and answer
principle. The care provider is lead through the registration in a structured
manner.Depending on the answers given, so-called triggers determine the route
through the predefined questions. Important questions can consequently no longer
be forgotten. Imagine for example a situation where the question ‘Do you smoke?’
is answered with a ‘Yes’. This answer automatically leads to the follow-up
question ‘How much do you smoke?’. If the initial question is answered with a
‘No’, the follow-up question will not be displayed to the care provider. This
keeps the registration uncluttered and brief, in case of few particulars.
The digital record registration supports the care provider’s workflow
wherever possible. It can also be used to steer the patient’s treatment process.
It is possible, for example, to issue a request for performing supplementary
examinations from the digital record registration. It is also possible to let
the registration automatically produce an icon, based on a particular policy,
for the prescription of medication or for the recording of a Diagnosis Treatment
Combination.
The history of the recorded patient information can always be reused and
supplemented, so that duplicative input of data becomes a thing of the past.
During the registration of patient data in the record, the right-hand side of
the screen can be unfolded as shown in the example below. This enables fast
registration. In the top column on the right, the patient’s history is shown, if
any, as an answer to the active question. The central column displays the
recently given answers to the active question. The lower column is for recording
standard answers, which can be pre-entered in the system. During registration,
patient history answers, recent answers and standard answers can be simply
inserted in the form. This will limit the registration pressure on the care
provider as far as possible.
Everything that can normally be registered in paper patient records, must of
course also be able to be recorded in digital records. Images and diagrams can
be included, for instance, when a particular question is answered with a certain
value. The care provider can draw on these images, so that, for example, the
narrowing of a blood vessel can be indicated.
Consulting digitally recorded data
When recording patient related data digitally, it becomes important
how these digital data are presented to care providers later on. There are
different ways of viewing digitally recorded information. Templates can be made
from the digital recordings, which present the information in a predefined
manner. Users can opt to view all the information or look at parts of the
digital record registration. For example, in the case of a patient who has been
receiving treatment for a while, the policy and medication are often focused on,
while in the case of a ‘fresh’ patient the case history data are of great
importance. The templates can be included in the doctors’ worksheets. The
example below shows a summary template for cardiological case history.
CS-MultiMedia is the module for linking scanned records and other files to
information in the CS-ECIS. The arrival of CS-MultiMedia marks the last step to
complete paperless availability of all patient related information.
It is possible, for example, to include the midwife’s referral letter in a
patient’s gynecology record, to include the radiology referral or a patient’s
X-rays or a photo of a physical characteristic of the patient. Data carriers can
be linked to a patient number, but can also attached to an event, for example to
a patient’s appointment. The actual storage of scanned documents, images and
such like can take place both in or outside ECIS.
Documents can be scanned, after which they are linked to a patient number or
an event (for example an appointment). It is also possible to summon the
scanning of documents from the user’s workflow. For example, if the patient
reports to the radiography department’s reception and the patient is placed in
the waiting room in CS-X-ray, the system asks if a referral letter must be
scanned at that moment. The scanned document is subsequently automatically
linked to the patient and the appointment.
It is also possible to store images on the file server and to lay a link in
the ECIS between the patient and a file on a particular disk. The example below
shows a radiological X-ray. It is also possible to link photos from, for
example, dermatology (allergies) or plastic surgery to patients or appointments.
Figure: Images stored in the ECIS
The implementation of an Electronic Patient Record seldom takes place in a
so-called ‘big bang’ scenario. AN EPR is often realized bit by bit by connecting
new functionalities to an existing configuration.
Although the introduction of an EPR has immediate benefits for a care
provider, there will be many obstacles that have to be overcome. After all, not
every advantage of electronic record forming is immediately apparent, and
electronic reporting will, certainly initially, require a lot of effort and
motivation from the care provider. During the implementation process,
considerable commitment will be required from the care providers who eventually
have to work with the Electronic Patient Record. Not only for increasing the
support, but also for transferring domain specific knowledge that will have to
be translated into digital reporting possibilities.
ChipSoft has considerable experience in the implementation of (parts of)
Electronic Patient Records and is able to supervise and guide the implementation
process within a care institution professionally.
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