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SIL EMR Requirements 0.0.2 documentation »

1. Product: Billing and back office

Billings and payments are the two functions that have the greatest influence on cash flow. In healthcare, like in any other business, ‘cash is king’. Every healthcare enterprise wants to make more revenue, collect all of that revenue, minimize purchasing spend and pay suppliers at the last ‘polite’ moment.

1.1. Theme: Registration and visits

This is the entry point for all clinical and administrative processes.

1.1.1. Epic: Patient registration

Instead of providing separate registration experiences e.g quick registration for emergency rooms and ‘normal’ registration for other settings, this design will target a streamlined patient registration function that can be used in all settings.

The important fields should be clustered at the top of the page - so that a time pressed department can opt to fill in the important ones first and add the rest later.

Note

The assigned patient numbers should be unique network-wide. One suggestion is for them to be namespaced alphanumerics that have at least 16 characters, a mix of letters and numbers. The designers of this numbering scheme should however be humane; the numbers should be easy to “chunk” into working memory.

Note

The Master Patient Index should provide a way in which related patients ( e.g mother and baby or siblings ) are cross-referenced.

The MPI should support merging of patient records.

Note

The complete history of a patient record’s changes should be maintained.

1.1.1.1. Story: Find existing patient record

The focus here should be on providing search that is of sufficiently high quality - high enough that the users almost never have to rely on the ‘Advanced Search’.

The search should tolerate common errors ( transpositions, translations, ommissions ) etc, tolerate alternate spellings ( British vs. American ) and support transliterated Arabic names ( e.g Mohammed vs Mohamad vs Muhamed ).

The available search fields include:

patient names ( surname, first name, middle name )

date of birth / age

gender

unique patient identifier / medical record number

alias

father’s or mother’s name - useful for neonates

identification document number

phone number

location e.g room or bed

visit number

visit date

admission date

admitting physician

discharge date

family linkage e.g son of

Many of these are more suited to the ‘Advanced Search’ function. We should strive to implement default search so that it is good enough to obviate the need for these most of the time.

The patients list should be sorted in reverse chronological order by default.

Listing 1.1 Find an existing patient via full text search

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Feature: Find existing patient record
    The system should support multiple patient search criteria, including:
    names, partial names, historical names e.g maiden names, identification
    numbers e.g National ID or passport number, medical record / patient
    numbers, visit / encounter numbers e.g IP / OP number and insurance
    numbers e.g NHIF or private insurance member numbers.

    The search should be tolerant of simple spelling mistakes e.g
    translocations, transpositions, translations, alternate spellings
    ( American vs British spellings ), common abbreviations ( e.g. 'Bill' for
    'William' ) etc. A partial name should work as well as a full name, even if
    the order of the names is reversed.

    The multi-location nature of the enterprise ( e.g a multi-branch healthcare
    chain ) should not matter - a patient registered in one branch should have
    their record available in any other branch.

    Scenario: Search for a patient record from a patient list
        Given that I am logged in as "a <POS> user>"
        And I navigate to the "<POS>" home page
        And I navigate to the "Patients" listing
        And I click on the search box
        When I type at least three characters of the "<field>" of a patient
            that exists
        Then I should see records that match the "<field>" on the patient
        listing, with each listing entry showing the name, patient number,
        identification number, date of birth, gender and current patient queue,
        a patient photo, visit status, preauthorization status and copay status
        And I should get fewer and better matches as I type more
        And the patient list should be sorted in reverse chronological order by
            default

        Examples:
            | POS       | field                                     |
            | Triage    | name                                      |
            | Triage    | historical name e.g maiden name           |
            | Triage    | patient record number                     |
            | Triage    | identification number e.g national ID     |
            | Triage    | insurance number e.g NHIF or member number|
            | Triage    | visit number ( IP or OP )                 |
            | Pharmacy  | name                                      |
            | Pharmacy  | historical name e.g maiden name           |
            | Pharmacy  | patient record number                     |
            | Pharmacy  | identification number e.g national ID     |
            | Pharmacy  | insurance number e.g NHIF or member number|
            | Pharmacy  | visit number ( IP or OP )                 |
            | Lab       | name                                      |
            | Lab       | historical name e.g maiden name           |
            | Lab       | patient record number                     |
            | Lab       | identification number e.g national ID     |
            | Lab       | insurance number e.g NHIF or member number|
            | Lab       | visit number ( IP or OP )                 |
            | Radiology | name                                      |
            | Radiology | historical name e.g maiden name           |
            | Radiology | patient record number                     |
            | Radiology | identification number e.g national ID     |
            | Radiology | insurance number e.g NHIF or member number|
            | Radiology | visit number ( IP or OP )                 |
            | Blood bank| name                                      |
            | Blood bank| historical name e.g maiden name           |
            | Blood bank| patient record number                     |
            | Blood bank| identification number e.g national ID     |
            | Blood bank| insurance number e.g NHIF or member number|
            | Blood bank| visit number ( IP or OP )                 |

        And I should be able to open an editing view to edit patient
            registration details
        And I should see a start visit button for patients with no ongoing
            visit
        And I should see a link / button to the current visit for patients with
            and ongoing visit

    Scenario: Advanced patient search
        If ordinary search returns too many hits, the user may resort to
        filtering the search results.

        Given that I am logged in as "a <POS> user>"
        And I navigate to the "<POS>" home page
        And I navigate to the "Patients" listing
        And I click on the search box
        When I type at least three characters of the "<field>" of a patient
            that exists
        And I click on the filter area of the list view
        And I constrain my search results by entering values into these field:
            | Field                 |
            | Gender                |
            | Age or date of birth  |
            | Phone number          |
            | Email address         |
            | Postal address        |
            | Last visit date       |
        Then I should see records that match the "<field>" on the patient
        listing and the constraining filter, with each listing entry showing
        the name, patient number, identification number, date of birth, gender
        and current patient queue, a patient photo, visit status,
        pre-authorization status and copay status
        And I should get fewer and better matches as I type more

        Examples:
            | POS       | field                                     |
            | Triage    | name                                      |
            | Triage    | historical name e.g maiden name           |
            | Triage    | patient record number                     |
            | Triage    | identification number e.g national ID     |
            | Triage    | insurance number e.g NHIF or member number|
            | Triage    | visit number ( IP or OP )                 |
            | Pharmacy  | name                                      |
            | Pharmacy  | historical name e.g maiden name           |
            | Pharmacy  | patient record number                     |
            | Pharmacy  | identification number e.g national ID     |
            | Pharmacy  | insurance number e.g NHIF or member number|
            | Pharmacy  | visit number ( IP or OP )                 |
            | Lab       | name                                      |
            | Lab       | historical name e.g maiden name           |
            | Lab       | patient record number                     |
            | Lab       | identification number e.g national ID     |
            | Lab       | insurance number e.g NHIF or member number|
            | Lab       | visit number ( IP or OP )                 |
            | Radiology | name                                      |
            | Radiology | historical name e.g maiden name           |
            | Radiology | patient record number                     |
            | Radiology | identification number e.g national ID     |
            | Radiology | insurance number e.g NHIF or member number|
            | Radiology | visit number ( IP or OP )                 |
            | Blood bank| name                                      |
            | Blood bank| historical name e.g maiden name           |
            | Blood bank| patient record number                     |
            | Blood bank| identification number e.g national ID     |
            | Blood bank| insurance number e.g NHIF or member number|
            | Blood bank| visit number ( IP or OP )                 |

        And I should be able to open an editing view to edit patient
            registration details
        And I should see a start visit button for patients with no ongoing
            visit
        And I should see a link / button to the current visit for patients with
            and ongoing visit

1.1.1.2. Story: Full patient registration

Listing 1.2 Full / standard patient registration at the front desk

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Feature: Full' patient registration
    This will be the patient registration path that will be followed in
    settings that are not severely time constrained e.g at a registration desk
    for regular outpatients.

    Background:
        Given that I am logged in as a 'registration desk' user
        And I click on the 'Front Desk' main navigation link

    Scenario: Register a patient with no prior system record ( first timer )
        If the patient is a new born baby that has not been named yet, they
        will initially be registered under by prefixing their mother's name
        with 'Baby '. These records will be edited later.

        This form will also serve as a quick registration form. In a quick
        registration scenario, the optional fields will be left unfilled. It
        should be possible to fill in the form in 'quick registration mode'
        in 15 seconds ( verified by user testing ).

        Given that I have logged in and navigated to the front desk
        And I navigate to the "Patients" listing
        And I click on "Add New Patient"
        When I fill in the following unique data
          | field           | explanation                                   |
          | title           | Title of address e.g Mr, Dr ( optional ).     |
          | name            | Name: family, give and middle components      |
          | photo           | A photograph of the patient ( optional )      |
          | aliases         | e.g maiden names, old names ( optional )      |
          | father's name   | ( optional )                                  |
          | mother's name   | ( optional ) might include her maiden name    |
          | gender          | Administrative gender                         |
          | sex             | Birth sex ( optional, hidden by default )     |
          | birth date      | Date of birth, **can be estimated**           |
          | ID documents    | e.g ID or passport; can be more than one      |
          | Guardian's ID   | For minors                                    |
          | nationality     |                                               |
          | marital status  | Civil / marital status ( optional )           |
          | religion        |                                               |
          | telephone no(s) | Current phone contacts ( optional )           |
          | email(s)        | Current email contacts ( optional )           |
          | addresses       | Postal and physical addresses ( optional )    |
          | residence       | Country -> street and door ( optional )       |
          | next of kin     | Names, relationship, phone, residence         |
          | payment method  | Default payment method ( optional )           |
          | payment details | e.g NHIF, insurance details ( optional )      |
          | occupation      | ( optional )                                  |
          | employer        | ( optional )                                  |
          | notes           | ( optional ) free text                        |
          | guarantors      | Full name, address, phone number ( optional ) |
          | referred by     | Doctor or institution; name and contacts      |
        And click on "Save Patient"
        Then I should see a "Patient added" success message
        And a patient record number should be assigned automatically
        And I should be redirected to the patient listing
            with the new patient's record showing on top

    Scenario: Trigger validation errors when registering a patient
        Validation errors should display as soon as the field is 'blurred'.
        They should also inactivate the "Save Patient" button. The user should
        not have to wait for a failed server side "save" to be informed of
        validation errors.

        It should not be possible to save a patient record without any of the
        mandatory fields.

        Given that I have logged in and navigated to the front desk
        And I navigate to the "Patients" listing
        And I click on "Add New Patient"
        When I fill in wrong / non-existent values for each of these fields:
          | field           | explanation                                   |
          | title           | Title of address e.g Mr, Dr, Prof.            |
          | name            | Name: family, give and middle components      |
          | gender          | Administrative gender                         |
          | sex             | Birth sex                                     |
          | birth date      | Date of birth, **can be estimated**           |
          | ID documents    | e.g ID or passport; can be more than one      |
          | photo           | A photograph of the patient                   |
          | telecom(s)      | Current phone and email contacts              |
          | addresses       | Postal and physical addresses                 |
          | marital status  | Civil / marital status                        |
          | contacts        | Family or emergency contacts e.g guardians    |
          | payment method  | Default payment method e.g insurance          |
          | payment details | e.g NHIF number, insurance details            |
        Then I should see a field-specific validation message for each value
        And the "Save Patient" button should be inactive

    Scenario: Attempt registration of a patient who already **has** a record
        The government issued ID documents are used to identify 'true
        duplicates'.

        This de-duplication should work across an entire organization e.g every
        branch in a multi-branch hospital.

        Given that I have logged in and navigated to the front desk
        And I navigate to the "Patients" listing
        And I click on "Add New Patient"
        When I fill in the following data, with an existing ID type & number
          | field           | explanation                                   |
          | title           | Title of address e.g Mr, Dr, Prof.            |
          | name            | Name: family, give and middle components      |
          | gender          | Administrative gender                         |
          | sex             | Birth sex                                     |
          | birth date      | Date of birth, **can be estimated**           |
          | ID documents    | e.g ID or passport; can be more than one      |
          | photo           | A photograph of the patient                   |
          | telecom(s)      | Current phone and email contacts              |
          | addresses       | Postal and physical addresses                 |
          | marital status  | Civil / marital status                        |
          | contacts        | Family or emergency contacts e.g guardians    |
          | payment method  | Default payment method e.g insurance          |
          | payment details | e.g NHIF number, insurance details            |
        And click on "Save Patient"
        Then I should see a "Patient already exists" error message
        And I should be prompted to click through to the existing record
        And I should be able to edit the existing patient record

    Scenario: Attempt registration of a patient who **might** have an existing
        record. The combination of name, gender, sex and birth date
        is used to provide a 'potential duplicate' warning.

        This de-duplication should work across an entire organization e.g every
        branch in a multi-branch hospital.

        Given that I have logged in and navigated to the front desk
        And I navigate to the "Patients" listing
        And I click on "Add New Patient"
        When I fill in the following data, with an existing ID type & number
          | field           | explanation                                   |
          | title           | Title of address e.g Mr, Dr, Prof.            |
          | name            | Name: family, give and middle components      |
          | gender          | Administrative gender                         |
          | sex             | Birth sex                                     |
          | birth date      | Date of birth, **can be estimated**           |
          | ID documents    | e.g ID or passport; can be more than one      |
          | photo           | A photograph of the patient                   |
          | telecom(s)      | Current phone and email contacts              |
          | addresses       | Postal and physical addresses                 |
          | marital status  | Civil / marital status                        |
          | contacts        | Family or emergency contacts e.g guardians    |
          | payment method  | Default payment method e.g insurance          |
          | payment details | e.g NHIF number, insurance details            |
        And click on "Save Patient"
        Then I should see a "Did you mean to update ..." warning message
        And I should be prompted to navigate to the existing record OR save
        And I should be able to navigate to editing the existing record
        And I should be able to click "Save" and get a success message

    Scenario: Cancel a patient registration
        It should be possible to abort a patient registration at any time

        Given that I have logged in and navigated to the front desk
        And I navigate to the "Patients" listing
        And I click on "Add New Patient"
        When I click on the "Cancel" button
        Then I should be navigated back to the patient list

    Scenario: Register a John Doe in the emergency room
        A 'John Doe' or 'Jane Doe' is a patient - usually an unconscious
        emergency - about whom little or nothing is known. They still need to
        have a patient record created in order for treatment to proceed.

        Given that I have logged in and navigated to the front desk
        And I navigate to the "Patients" listing
        And I click on "Register Emergency Patient ( John Doe )"
        Then I should be prompted to enter as plain text descriptive and
            context information e.g scars, eye color or other unique descriptions
        And I should be able to click "OK" and get a confirmation message
        And I should be navigated back to the patient listing, with the new
            record appearing near the top

1.1.1.3. Story: Edit patient record

Listing 1.3 Edit patient record

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Feature: Find existing patient record
    Patient details e.g contacts change, and they need to be kept up to date.

    Scenario: Open but do not edit a patient record
        When navigating away from a patient record that is not "dirty", the
        user should not be presented with any prompts.

        Given that I am logged in as "a front desk user>"
        And I navigate to the patient listing
        And I 'Search for a patient record from a patient list'
        And I select a single patient record by clicking "Edit Details"
        And I see an editing form with the patient's details shown
        When I click on "Cancel Editing"
        Then I should be navigated back to the patients listing

    Scenario: Edit an existing patient record
        Any patient record that is retrieved can be updated. This includes
        John/Jane doe patients and infants initially registered under a
        'placeholder' name.

        Given that I am logged in as "a front desk user>"
        And I navigate to the patient listing
        And I 'Search for a patient record from a patient list'
        And I select a single patient record by clicking
        And I see an editing form with the patient's details shown
        When I change any value on the form
        Then I should see a visual indication that the form is 'dirty'
        When I click "Update Patient Details"
        Then I should see a "Patient details updated" success message
        And I should be navigated back to the patient listing

    Scenario: Navigating away from a "dirty" record and discarding
        When attempting to navigate away from a "dirty" record, a user should
        be prompted to save or discard. If they choose to discard, they should
        be navigated back to the patient listing with no further prompting.

        Given that I am logged in as "a front desk user>"
        And I navigate to the patient listing
        And I 'Search for a patient record from a patient list'
        And I select a single patient record by clicking "Edit Details"
        And I see an editing form with the patient's details shown
        And I make some changes to the patient record
        When I click on "Cancel Editing"
        Then I should be prompted to "Save" or "Discard" the changes
        And I click on "Discard"
        Then I should be navigated back to the patients listing

    Scenario: Navigating away from a "dirty" record and saving
        When attempting to navigate away from a "dirty" record, a user should
        be prompted to save or discard. If they choose to save, the changes
        should be saved.

        Given that I am logged in as "a front desk user>"
        And I navigate to the patient listing
        And I 'Search for a patient record from a patient list'
        And I select a single patient record by clicking "Edit Details"
        And I see an editing form with the patient's details shown
        And I make some changes to the patient record
        When I click on "Cancel Editing"
        Then I should be prompted to "Save" or "Discard" the changes
        And I click on "Save"
        Then I should see a success confirmation message
        And I should be navigated back to the patients listing

    Scenario: Trigger validation errors with invalid edits
        When an invalid edit is made, the error should be fed back in a field
        specific manner right away. The "Update Patient Details" button should
        also be disabled.

        Given that I am logged in as "a front desk user>"
        And I navigate to the patient listing
        And I 'Search for a patient record from a patient list'
        And I select a single patient record by clicking
        And I see an editing form with the patient's details shown
        And I make some invalid change to any of these fields:
          | field           | explanation                                   |
          | title           | Title of address e.g Mr, Dr, Prof.            |
          | name            | Name: family, give and middle components      |
          | gender          | Administrative gender                         |
          | sex             | Birth sex                                     |
          | birth date      | Date of birth, **can be estimated**           |
          | ID documents    | e.g ID or passport; can be more than one      |
          | photo           | A photograph of the patient                   |
          | telecom(s)      | Current phone and email contacts              |
          | addresses       | Postal and physical addresses                 |
          | marital status  | Civil / marital status                        |
          | contacts        | Family or emergency contacts e.g guardians    |
          | payment method  | Default payment method e.g insurance          |
          | payment details | e.g NHIF number, insurance details            |
        Then I should see a field-specific error message next to the field
        And the "Update Patient Details" button should be disabled

1.1.2. Epic: Visit start

Every billing and clinical action is tied to a visit.

1.1.2.1. Story: Start out-patient cash visit

Listing 1.4 Starting cash visits

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Feature: Start a visit for a cash patient
    For cash patient, a deposit or consultation fee is often ( but not always )
    needed up-front.

    This story depends upon the patient registration and patient search stories
    i.e. you must have found or registered a patient and clicked on their record

    Scenario: Start an outpatient visit for a cash patient, payment received
        Given that I am viewing a single patient's record
        And I have selected the type of visit e.g emergency, routine, ambulance
        And I have selected the 'Queue' where the patient will go next
        And I have selected 'Cash' as the visit payment method
        And I select the initial service e.g consultation, a lab test
        And I receive the amount that the system indicates as due
        When I click on "Start Visit"
        Then a receipt should be sent to the printer automatically
        And I should see a "Visit Started" confirmation message
        And I should be navigated back to the active visits list
        And the visit should get a visit number auto-assigned

    Scenario: Start an outpatient visit for a cash patient, payment not received
        The system will not stop visits from being started with no payment,
        because that can become a blocker in emergency scenarios. The design
        should however make payment information very easy to spot, so that the
        staff member operating the front-desk always has enough information to
        make a good judgement.

        Given that I am viewing a single patient's record
        And I have selected the type of visit e.g emergency, routine, ambulance
        And I have selected the 'Queue' where the patient will go next
        And I have selected 'Cash' as the visit payment method
        And I select the initial service e.g consultation, a lab test
        When I click on "Start Visit"
        Then I should see a "Visit Started" confirmation message
        And I should be navigated back to the active visits list
        And the visit should get a visit number auto-assigned
        And the balance / amount owed should show on the visits listing

    Scenario: Receive non-service cash payment e.g copay or deposit
        This scenario **does not supersede the dedicated billing scenarios**.

        Given that I am viewing a single patient's billing record
        And I have selected the type of visit e.g emergency, routine, ambulance
        And I have selected the 'Queue' where the patient will go next
        And I click on 'Receive Payment' to open a payment form
        When I enter the amount to be received
        And indicate what it is received for e.g deposit, copay
        And click on 'Record Payment'
        Then the system should print a receipt
        And the payment status shown on the patient banner should update

1.1.2.2. Story: Start out-patient insurance visit

Listing 1.5 Starting insurance visits

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Feature: Start Insurance Visit
    Scenario: Start a visit for an insurance patient ,first time to use insurance
        In order for this story to stay this 'simple', we will have to develop
        a mechanism by which all insurance customers - EDI and non EDI - are
        pre-registered. Non EDI customers can be pre-registered by uploading of
        Excel files. This particular scenario will need to be a little permissive
        i.e it should not prevent a user from starting a visit merely because
        there is no eligibility information. This edge case will typically arise
        in two circumstances: customers of foreign insurance companies and
        beneficiaries added since the last 'update' of beneficiary information.

        Given that I am viewing a single patient's record
        And I have selected 'Insurance' as the visit payment method
        And I have entered insurance details - company, scheme, member number
        And I have clicked on "Check Eligibility"
        And I have examined the eligibility breakdown that shows
        And the patient has valid insurance
        And I have selected the type of visit e.g emergency, routine, ambulance
        And I have selected the 'Queue' where the patient will go next
        And I can see an "Eligibility checked" message
        When I click on "Start Visit"
        Then I should see a "Visit Started" confirmation message
        And I should be navigated back to the active visits list
        And the visit should get a visit number auto-assigned

    Scenario: Should not look up insurance eligibility, for cash patients
        Given that I am viewing a single cash patient's billing record
        When I examine the patient 'banner' on top
        Then I should not see a "View Eligibility" button

    Scenario: Should not start a visit for a patient with invalid insurance
        Given that I am viewing a single patient's record
        And I have selected 'Insurance' as the visit payment method
        And I have entered insurance details - company, scheme, member number
        And I have clicked on "Check Eligibility"
        And I have examined the eligibility breakdown that shows
        And the patient **does not** have valid insurance
        Then the "Start Visit" button should be inactivated
        And I should see a message "Please select another payment method.
            The indicated insurance is not valid."

1.1.2.3. Story: Start out-patient credit visit

Listing 1.6 Starting credit visits

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Feature: Start a visit for a credit patient
    The tricky part of this implementation will be determining that a
    patient is a valid scheme member AND the scheme is valid AND they
    are eligible for care under the visit type indicated.

    The 'credit schemes' envisioned by this are things like employer managed
    medical schemes.

    This story depends upon the patient registration and patient search stories
    i.e. you must have found or registered a patient and clicked on their record

    Scenario: Start an outpatient visit for a credit patient successfully
        Given that I am viewing a single patient's record
        And I have selected 'Credit' as the visit payment method
        And I have selected the type of visit e.g emergency, routine, ambulance
        And I have selected the credit scheme to use from a shortlist
        And I can see a "Credit Eligibility Confirmed" message on the screen
        And I have selected the 'Queue' where the patient will go next
        When I click on "Start Visit"
        Then I should see a "Visit Started" confirmation message
        And I should be navigated back to the active visits list
        And the visit should get a visit number auto-assigned

    Scenario: Fail to start a visit for an ineligible credit patient
        Given that I am viewing a single patient's record
        And I have selected 'Credit' as the visit payment method
        And I have selected the type of visit e.g emergency, routine, ambulance
        And the patient is not pre-registered for credit
        Then I should not see a credit scheme shortlist to pick from
        And the "Start Visit" button should be disabled
        And I should see a "Patient not found in credit scheme" message

1.1.2.4. Story: Start capitation credit visit

Listing 1.7 Starting capitation visits

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Feature: Start a visit for a capitation patient
    The tricky part of this implementation will be determining that a
    patient is a valid capitation member AND the scheme is valid AND they
    are eligible for care under the visit type indicated.

    This story depends upon the patient registration and patient search stories
    i.e. you must have found or registered a patient and clicked on their record

    Scenario: Start an outpatient visit for a capitation patient successfully
        Given that I am viewing a single patient's record
        And I have selected 'Capitation' as the visit payment method
        And I have selected the type of visit e.g emergency, routine, ambulance
        And I have selected the 'Queue' where the patient will go next
        And I have selected the capitation scheme to use from a shortlist
        And I can see a "Capitation Eligibility Confirmed" message on the screen
        When I click on "Start Visit"
        Then I should see a "Visit Started" confirmation message
        And I should be navigated back to the active visits list
        And the visit should get a visit number auto-assigned

    Scenario: Fail to start a visit for an ineligible capitation patient
        Given that I am viewing a single patient's record
        And I have selected 'Capitation' as the visit payment method
        And I have selected the type of visit e.g emergency, routine, ambulance
        And I have selected the 'Queue' where the patient will go next
        And the patient is not pre-registered for capitation
        Then I should not see a capitation scheme shortlist to pick from
        And the "Start Visit" button should be disabled
        And I should see a "Patient not found in capitation scheme" message

1.1.2.5. Story: Access the visits listing and individual visit pages

Listing 1.8 Visits listing and individual visits pages

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Feature: Visits listing and visit detail page
    All clinical and billing activities are tied in to a visit. It follows then
    that this listing should be available from all clinical and billing points
    of service. Key status information ( e.g preauth status, copay status and
    visit status ) should be shown as highly visible 'badges'.

    Scenario: Navigate to the visits listing
        The visits listing will show "Active Visits" by default, but allow the
        user to navigate to visits in other statuses via a tab mechanism.

        Given that I am logged in as a <Role> worker
        When I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        Then I should see a listing of visits for my location and department

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: View the patient's billing information by opening the visit
        Given that I am logged in as a <Role> worker
        And I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        Then I should see a listing of visits for my location and department
        When I click on a visit to open it
        Then I should see a page relevant patient billing information
            | Type              | Explanation                               |
            | Copays            | Amount or percentage due per visit        |
            | Insurers          | One or more insurers                      |
            | Eligibility       | An always accessible eligibility lookup   |
            | Capitation m.ship | Membership in capitation scheme(s)        |
            | Credit scheme     | Membership in capitation scheme(s)        |
            | Preauthorizations | All visit-linked preauths and their status|
            | Preauth status    | A status badge with current preauth status|
            | Charges           | A summary of amount owing and breakdown   |
            | Statements        | A detailed entry of every charge, by visit|
            | Adjustments       | e.g account credits, writedowns           |
            | Payments          | By invoice and visit                      |
            | Prepayments       | e.g pre-paid delivery packages            |
            | Deposits          | e.g cash deposits                         |
        And I should see a note recommending the next logical action e.g to
            pay a deposit or to seek eligibility
        And I should see a clear indication of the need or lack of need for a
            copay

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: Cannot start a visit for a patient with an ongoing visit
        Inpatient visits will be closed upon discharge or transfer. Out-patient
        visits will be closed after a **configured** time period. A sensible
        default for this time period is 48 hours. After due consideration, it
        is the author's opinion that a "Close Visit" function would add
        complexity without a significant gain in utility.

        Given that I am logged in as a <Role> worker
        And I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        Then I should see a listing of visits for my location and department
        When I click on a visit to open it
        Then I should see a page relevant patient billing information
        And there should be no "Start Visit" button

1.1.2.6. Story: Receive payments

Listing 1.9 Payments receipts in visit

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Feature: Patient billing and payments

    Scenario: Determine that a copay is due and not paid
        Given that I am logged in as a <Role> worker
        And I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        And Isee a listing of visits for my location and department
        And I click on a visit to open it
        Given that I am viewing a single insurance patient's billing record
        And the patient's plan needs a copay
        And the patient has not paid the copay
        Then I should see a "COPAY NOT RECEIVED" badge
        And the "Start Visit" button should be disabled

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: Determine that a copay is due and paid
        Given that I am logged in as a <Role> worker
        And I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        And Isee a listing of visits for my location and department
        And I click on a visit to open it
        And I see a page with relevant patient billing information
        And the patient's plan needs a copay
        And the patient has paid it
        When I look at the patient 'banner' on top
        Then I should see a muted 'COPAY RECEIVED' badge
        And I should be able to click on the 'Start Visit' button

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: Print and reprint patient's receipt
        Given that I am logged in as a <Role> worker
        And I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        And Isee a listing of visits for my location and department
        And I click on a visit to open it
        And I see a page with relevant patient billing information
        And I see a listing of the patient's most recent payments
        And I click on any paymen
        Then I should see the payment details
        And I should see a "Print Receipt" button
        When I click on the "Print Receipt" button
        Then the receipt should be sent to the printer

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

1.1.2.7. Story: Pre-authorizations

Listing 1.10 Preauthorization

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Feature: Preauthorizations
    Pre-authorization requests are needed for some classes of visits ( e.g all
    inpatient ) and on the basis of payer specific business rules ( e.g all
    visits with an expected charge above KES 10,000 ). The design goal here is
    to get the system to do most of the heavy lifting in answering the question
    "Do we need a pre-authorization for this patient?"

    Scenario: Show pre-authorization status when it is relevant
        In this scenario, the user opens a 'visit sheet'. The need for a
        pre-auth request should be communicated in a prominent 'badge' on a
        'banner' that brings together all relevant visit information.

        Given that I am logged in as a <Role> worker
        When I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        And I click on a visit that should require preauthorization e.g inpatient
        Then I should see a page that summarizes that visit's information
        And I should be see a "Pre-authorization Status" section in its banner
        And I should see a "Pre-authorization needed" badge in that section
        And I should see a "Request pre-authorization" button next to that badge

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: Do not show a pre-authorization section when it is not needed
        Given that I am logged in as a <Role> worker
        When I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        And I click on a visit that should NOT require preauthorization
        Then I should see a page that summarizes that visit's information
        And I should NOT be see a "Pre-authorization Status" section

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: View preauth status from the patient listing
        Given that I am logged in as a <Role> worker
        When I click on <Role> in the main navigation
        And I click on "Patients"
        And I find the patients of interest by typing into the search box
        Then I should see a pre-authorization status badge for each patient
            that has or needs pre-authorization

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: View preauth status from the visit listing
        Given that I am logged in as a <Role> worker
        When I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        And I find a specific visit by typing into the search box
        Then I should see a pre-authorization status badge in each visit
            that has or needs pre-authorization

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: Request pre-authorization, for insurance patients
        Given that I am logged in as a <Role> worker
        When I click on <Role> in the main navigation
        And I click on "Visits" in the secondary navigation
        And I click on a visit that should require preauthorization e.g inpatient
        Then I should see a page that summarizes that visit's information
        And I should be see a "Pre-authorization Status" section in its banner
        And I should see a "Pre-authorization needed" badge in that section
        And I should see a "Request pre-authorization" button next to that badge
        When I click on "Request Pre-authorization"
        Then I should see a pre-authorization request form
        And the form should have pre-filled with all details already present in
            the visit
        And I should edit and fill out the rest of the form
        And I should press "Submit"
        And I should see a "Pre-authorization request sent" message
        And I should be navigated back to the visits listing

        Examples:
            |Role                                                           |
            |Registration                                                   |
            |Triage                                                         |
            |Pharmacy                                                       |
            |Radiology                                                      |
            |Lab                                                            |

    Scenario: Receive notification of pre-authorization approval
        Given that I am logged in
        And I had previously entered a request for pre-authorization
        When a pre-authorization is approved
        Then I should get a notification in the application notification area
        And I should also get a native notification on my device
        And I should be able to click on the notification to view the preauth

    Scenario: Receive notification of pre-authorization rejection
        Given that I am logged in
        And I had previously entered a request for pre-authorization
        When a pre-authorization is rejected
        Then I should get a notification in the application notification area
        And I should also get a native notification on my device
        And I should be able to click on the notification to view the preauth

    Scenario: Receive notification of pre-authorization clarification request
        Given that I am logged in
        And I had previously entered a request for pre-authorization
        When a pre-authorization clarification is requested
        Then I should get a notification in the application notification area
        And I should also get a native notification on my device
        And I should be able to click on the notification to respond to the request

    Scenario: View preauth status from the patient listing
        Given that I am logged in as a front-/ corporate- / admissions- worker
        When I access the patient listing
        Then I should see pre-authorization status badges for every patient
        And patients with recent activity should appear at the top of the list

    Scenario: View preauth status from the visits listing
        Given that I am logged in as a front-/ corporate- / admissions- worker
        When I access the patient listing
        Then I should see pre-authorization status badges for every patient
        And patients with recent activity should appear at the top of the list

    Scenario: Determine a patient's preauth status
        Given that I am viewing a single insurance patient's billing record
        And the patient has a pre-authorization request(s)
        When I look at the patient 'banner' on top
        Then I should see a summary of the status of the pre-auth requests
        And I should be able to click on each request to view it in full

1.2. Theme: Purchasing

This covers routine purchasing and acquisition of assets.

1.2.1. Epic: Purchasing

This is focused on ‘routine purchasing’ i.e purchasing of supplies that are re-sold or used as direct inputs in service delivery. Purchasing may be centralized ( in a purchasing department ) or decentralized ( with each service delivery department carrying out part or all of the process ).

All purchasing documents go through a maker-checker ( issuer / approver ) cycle.

Note

As a:

purchasing or stores employee

I need to:

set up vendors

set up payment terms

set up product information. In healthcare, product information might include specialized data fields e.g for Pharmacy, it includes: generic names, stock codes, strengths, units of issue e.g tablet or vial, unit pack sizes, manufacturer information, storage requirements, supplier, product categories, notes, category, storage instructions, dosing information etc

product status - active, obsolete, phased out, expired

define maximum and minimum reorder levels and critical stock levels

define minimum and maximum stock cover days

checking of back-orders, with deactivation after a time threshold

automatic rounding off the the nearest pack size during reorder

issue purchase orders, which derive from requisitions / requests

split orders between different suppliers

receive goods deliveries - noting batch numbers and expiries at this stage

note delivery details e.g vehicle number and driver when receiving goods

check the goods deliveries before accepting them into the store(s) and issuing a goods receipt note

receiving donations

accepting promotional stocks and prizes

return goods that are not accepted - before or after they are stocked

transfer goods to other stores, at cost

enter invoices. While entering invoices, I expect discounts and due dates to be computed automatically, on the basis of payment terms. When accessing invoice listings, I should be able to sort or filter invoices by vendor, date etc. Potentially duplicated invoices should be flagged. An invoice may be assigned to a future accounting date.

set up recurring invoices, for recurring vendor payments

enter credit and debit memos

make payments against purchase invoices, with the ability to: apply account credits to future purchases, pay in full or in part and add or remove vendor invoices from payment schedules. Potentially duplicated payments should be flagged as should payments to vendors who owe us money ( from credits or as customers ).

generate vendor statements that can be used to reconcile their accounts

access a dashboard that has: listings of invoices that are due for payment, aging analyses, cash requirements projections

access the following reports: inventory by store, low inventory, slow moving inventory, batch and expiry tracking, purchases by vendor

alert / flag when ordering items that are already in stock

highlight the last supplier of an item and the price paid

support requisitions with: current stock, stock cover days, lead time, forecasts

requests for quotation

1.3. Theme: Billing

This write-up is to be read in conjunction with the positive ID specifications.

1.3.1. Epic: Billing dashboard

The billing dashboard should focus on the most important and actionable bits of summary information.

Note

As a:

billing manager

I need to:

quickly analyze receivables - aging, days in accounts receivable by insurance group / provider / visit type / diagnosis etc, aggregate days in accounts receivable

quicly analyze denials, by reason, payer, condition, procedure etc

access top n lists - service / procedure, payer etc

quickly analyze revenue - by procedure, by payer, by diagnosis

have access to a dashboard that tracks all my claims by status e.g paid, pending, late, returned, re-submitted

view the audit trail of all transactions

view current cash availability

forecast cash sources against cash users

track follow-up conversations e.g in collections

1.3.2. Epic: Preauthorizations

As an employee at any point of service that needs pre-authorization e.g the admissions desk, I need to be able to requests and track pre-authorizations.

Note

As a:

point of service staff member

I need to:

be able to request pre-authorization - both elective and emergency preauths

be notified when a pre-authorization changes status e.g is approved or rejected, so that I can inform waiting patients and move the process along

be able to respond to clarification requests on pre-authorizations

be able to check on the status of any pre-authorization and have a simple dashboard that gives visibility into the status of all preauthorizations that are in flight

1.3.3. Epic: Cashiering

This feature covers both cash and credit invoices - what we’d conventionally call ‘tills’ or ‘pay points’.

Note

As a:

cashier

I need to:

be able to log in to my own cashiering ‘site’, with its own cash drawer, receipt etc

have my own shift, with a ‘day book report’ that is produced at the end

post payments singly and in batch

access cash balancing reports, within and at the end of a shift

accept MPESA payments

accept card and other electronic payments

show a warning if a customer payment will put the customer account into credit

1.3.4. Epic: Billing back-office

As a billing clerk, I need to quickly distinguish tasks that need special attention. For each patient, the operating analogy is that of a ‘cockpit’ that is focused on a single patient’s billing. The activities described here should be designed for ‘a world with EDI’ and ‘a world without EDI’.

Financial ‘class codes’ on patient accounts are things like ‘ensuite’, ‘private’ etc.

Note

As a:

billing clerk

I need to:

have quick access to a worklist ( alternative names: task list, queue )

be able to hold ( suspend processing of ) bills that need some special action e.g a consultation with my boss, a confirmation etc

be able to access a listing of held bills and a simple summary of the status of held / pending / processed bills for a particular day

easily send out payment reminders for both individuals and corporate payers

be able to look up a patient’s insurance eligibility - for those from EDI linked payers - at any moment

have access to patient summary clinical information ( discharge summary, problem list )

be able to view all the billings and payments on a patient’s account. This includes deposits, charges, adjustments, corrections and refunds.

have quick and obvious access to patients’ deductibles / copayment obligations and whether they have been met or not

be able to see a patient’s insurance details and look up eligibility on demand ( a patient may be on multiple insurance schemes )

be able to generate an interim invoice for a patient with an active inpatient or outpatient visit on demand

access a queue of requests for interim bills from insurance care managers ( from the payer portal ) then review and respond ( accept / reject ) those requests; for the ones that I accept, an interim bill is automatically sent to the requester

be able to consolidate bills at the end of a patient’s stay to produce a ‘super bill’; this consolidated bill may be grouped by department

make adjustments on patient bill

support multiple prices e.g by patient type, insurance

support percentage discounts and allowances for third party contracts e.g volume and prompt payment discounts

get alerts when patient cover is about to be depleted

enter price and description for miscellaneous charges

entry of late charges - with different cut off periods

produce daily and monthly later charge reports

be able to generate a final bill for a patient whose visit has been completed e.g a discharged patient; the patient’s bill may be printed in summary or detailed form

be able to reprint any final bill on demand

be able to process a cash refund for a patient who is billed less than their deposit

be able to split a bill between the patient and their insurer / employer / sponsor

be able to generate a split bill for a second payer

be able to support rebilling for late charges and changes in financial class after billing

be able to retroactively change financial class and rebil

be able to post a supplementary bill to a patient e.g posting charges to the patient post-discharge, even after the late charge threshold

be able to generate and print or send a patient statement

be able to bill guarantors or family

be able to view prominent flags / warnings for patients who may present collection problems

be able to submit claims via EDI

be able to group invoices destined for a specific payer, generate cover sheets and dispatch them in bulk , batch and dispach them ( dispatch paper claims )

be able to track the status of all claims, including denials, those that need additional information, low pay claims etc

be able to respond to requests for clarification on claims and effect the necessary claims edits

be notified via the claims section of my message inbox when a claim changes status e.g is paid, there is an incoming remittance advice etc

be able to enter non EDI remittance advices manually

billing for non-patient accounts e.g guest beds

batch printing of bills

print free format text messages on all bills in a financial class

each bill has the following:

header: patient name, guarantor name and address, date and type of bill ( interim or final ), hospital service, physician(s), financial class, admit and discharge diagnosis, visit diagnosis for outpatients ( including ICD 10 code )

lines: service code, date, description, quantity, amount, total

a bill may have a summary ( grouping ) of charges

a bill may have comments

collections - standard form letters on demand e.g for 30 day old accounts, 60 day old accounts etc

aging of undispatched claims

generate reminder letters for overdue invoices

write off small remaining balances based on user defined tolerance

The ‘conveyor belt’ analogy is a good one, for billing clerks. Keep the belt movin’.

1.3.5. Epic: Aged trial balance

Note

As an:

accounting user

I need to:

print an aged trial balance, with account number, name, dates of service and last statement

include number of statements, last payment date and amount, current credits

print separate aged trial balance for inpatient and outpatient

sort the aged trial balance by patient last name, descending order of account balance, financial class, bill date, guarantor, age,

compare aging trial balance in summary or at the detail level

print aged trial balance summary with multiple aging categories, showing amounts and percentages

user definable aging

generate aging by activity date, due date, effective date etc

manage dispute items

generate guarantor aged trial balance

generate doctor aged trial balance

1.3.6. Epic: Hospital administered schemes

This includes the like of internally managed staff schemes and employer credit schemes.

Note

As a:

billing administrator

I need to:

set up the following details for principal members:

name

gender

age

ID no / passport number

contact details - address, telephone, email

photo

date of employment ( optional )

payroll number

division

department

cover limit

entitlement

exclusions

auto-generated hospital patient number ( pre-registration )

set up the following details for dependants:

name

gender

age

contact details i.e address, telephone number, email

ID no / passport number

photo

auto-generated hospital patient number ( pre-registration )

add dependants

remove dependants

control validity / expiry

set cover limits, entitlements and exclusions

1.3.7. Epic: Corporate Schemes

Note

As a:

billing administrator

I need to:

open and close corporate accounts: each with a code, start date, end date

auto-suspend corporate accounts on end date

activate or inactivate corporate accounts

define if an account uses a medical benefit management system e.g biometrics

define the scope of cover: outpatient vs inpatient, maternity, optical, dental

define max. credit limit

warn the user if the credit limit is reached

maintain exclusions

manage services that need pre-authorization

manage copay details: may be linked to specific benefits, and be amount or percentage

manage contact persons

attach reference documents

list exclusions ( coded )

define active, suspended, terminated entitlements, with dates

define panel of doctors

real time beneficiary database

corporate basic details: name, addresses, email, contact person, internal account manager

status management: active, inactive, pending, merged, unavailable

define the scope of the contract: open ended or specified

indicate bank guarantee and deposit status

manage deposits

1.3.8. Epic: Billing setup

This includes price-list setup along with setup of prepaid schemes and capitation.

Note

As a:

billing administrator

I need to:

be able to set up a ‘charge master’ with all billable items

be able to associate a single item with multiple codes e.g a billing code, a LOINC code for lab services, a drug code for a medication

be able to package multiple items and services together as a single billing item ( package billing )

be able to set up multiple prices with different effective times for each billable item

create prepaid schemes - including setting up limits, members and dependants. Prepaid scheme beneficiaries are registered as patients.

create capitation schemes - with limits, members and dependants Capitation scheme members are registered as patients.

Scheme and capitation setup will need to be a maker-checker process.

1.3.9. Epic: Managing consultants and locums

External doctors ( specialist and non specialist ) present special payment allocation challenges for hospitals.

Locum doctors need to be paid on a regular ( e.g monthly ) basis for service rendered and hours worked. External specialists often ‘pass their bills through’ the hospital.

Note

As a:

clinic or hospital manager

I need to:

enroll specialists into our panel

enroll locum doctors ( who are paid by the hour and a fee for select services ) into our panel

allocate payments to specialists - with those that derive from insurance being paid when the claims are paid and those that derive from cash billings being paid on a schedule

compute and pay locum doctors dues on a schedule

deduct the appropriate withholding taxes from all payments

link specialists, locums and full-time resources to queues, workflows, rooms etc

Because:

the hospitals service delivery is influenced by the quality of the relationship with our doctors - both internal and external

These external doctors should also be ‘schedulable resources’.

1.3.10. Epic: Printing

It should be easy to print pixel perfect output e.g lab reports, even from tablets or phones. It should not involve the usual ‘download PDF, open PDF, print’ cycle, or the poor precision of in-browser printing. The implementers should evaluate Google Cloud Printing and similar solutions. The ‘printers’ in question might be very varied - from a departmental copy printer to a little label printer.

Note

As a:

user ( any user )

I need to:

be able to click ‘Print’ and print any transaction or output document that I have access to e.g a patient invoice or a patient’s visit summary

be able to easily choose from a selection of printers

1.3.10.1. Scenario: Send a patient bill to the printer

Patient bills are some of the most frequently printed documents in a hospital setting.

Note

Given:

that I am logged in to the system

And:

I want to print a patient bill

When:

I click on an easy to locate print button / icon / control

And:

Select the printer from the pop over / pop up dialog that results

Then:

The document should be sent to the selected printer

And:

Print with the precision I expect / as it looks on the screen / with proper headers, page numbers etc

The ‘big deal’ here is the combination of pixel-perfect printing, mobility and simplicity. Stock browser printing does not cut it.

© Copyright 2016, Savannah Informatics Limited.

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SIL EMR Requirements 0.0.2 documentation »

2. Product: Ambulatory Clinical

This product focuses on the needs of outpatient clinical care settings. It meets a subset of the needs of larger hospitals and healhcare chains.

Patient care is multi-disciplinary. The circle of care for a patient may involve doctors, nurses, clinical support staff e.g admissions clerks, case managers, payors, guarantors, pharmacists and others. This multidisciplinary role setup is made harder by the need to balance between access and confidentiality - what does each party need to know in order to do their job? This is made even tougher by the need for mobility.

Note

Information Security

This guide assumes that there shall be fine grained role based access control. The permissions used shall be granular, so that is shall be possible to grant or deny access to any screen or section of a screen. It shall also be possible to grant view only rights.

Access shall be restricted on the basis of:

user groups

user types

individual patient charts

locations e.g nursing floors, clinics

patient type e.g VIP, confidential patients

a combination of all of the above

Logged in sessions shall be timed out after 10 minutes. The user shall be locked out from further login attempts after three incorrect login attempts. Each lockout shall be an hour long.

All entries shall be time stamped and audit trailed.

The system will need to support secure logon - with hardware tokens.

Note

Online Help

The system should embed online ‘help’ and first-use tutorials.

For clinical services, the need to design for high distraction environments and for task efficiency is paramount. Many of the existing products have failed to gain adoption in clinical settings in part because they are perceived to be more cumbersome than paper.

2.1. Theme: Scheduling

The scheduler will be available to administrative staff ( e.g registration clerks ), clinical staff ( e.g doctors and nurses ) and even to patients themselves.

This feature should work for both single clinics and large multi-site healthcare businesses. For a multi-site operation, the calendar should be synchronized enterprise-wide.

A medium- to large- provider will typically have many concurrently scheduled routine clinics e.g paediatric, antenatal, postnatal, family health, diabetes, chest, well baby, child welfare, immunization, lamaze etc. There will also be a sizable number of specialist clinics e.g neurosurgical, obstetric, cardiology, neurology etc

2.1.1. Epic: Booking appointments

Most bookings will be done by administrative or nursing staff. It should still be possible to individual providers to book their own appointments.

The business goal for scheduling is to increase schedule density. Every missed appointment is a double revenue loss - an opportunity cost loss and a direct loss. In order to succeed at this, the scheduler needs to recognize that appointments are not all the same; some appointments e.g a specialist second opinion consultation take a long time; other appointments e.g a routine post-surgery checkup could take a shorter time.

The scheduling implementation should be “network aware” i.e it should be possible to book appointments at other in-network facilities or in other departments.

Note

As a:

user

I need to:

schedule physicians, technicians, radiologists, rooms, equipment etc; one appointment can have multiple exams or procedures scheduled

capture patient name, contacts, date, time and requesting doctor when ordering for investigations or procedures

check for conflicts when scheduling staff; factoring in preparation time and procedure duration; this also includes flagging patients who have been flagged for multiple exams at the same time

automatically finding the next available time slot for inpatient / outpatient

enter orders when scheduling appointments. This requires a link between the appointment screen and the patient record.

view existing schedules and appointments on a calendar; color coding shall be used to identify specific providers, and augmented with initials. For example - it should be easy to discern which physicians and rooms are available to take appointment times in certain slots. Clicking on an appointment in the calendar should show the appointment details.

view a schedule of all appointments by patient - over a specified date range

in a multi-location healthcare network, see only the appointments for providers within my facility

drag and drop appointments

send reminders to patients, with configurable time frames. These reminders can be emailed, sent by text message or even printed. All patient communications are tracked - as part of the patient’s record.

transfer appointments between resource schedules, singly or in bulk e.g from one doctor to another

view and edit my own schedule

be able to opt in / opt out of viewing specific calendars e.g to see a particular clinic’s calendar and not see other clinics’ calendars; this means that I can view multiple provider schedules

print a specific resource ( e.g doctor, theater, CT scan machine )’s schedule / appointment list; also able to filter printed schedule by appointment type

print daily department schedules for inpatients and outpatients

print patient schedules for exams and procedures on demand

print provider schedules on demand

print a schedule of all appointments by date

print a schedule of appointments by time

print a schedule of appointments by nursing station

print transport request slips based on schedule needs e.g trolleys, wheel chair

print transport cards with notices, data, equipment required for transport, patient location, condition, comments

print notices with hospital registration number, patients name, date of birth, physician, patient ID and date of procedure

print no-show, exam canellation, unauthorized, scheduled, completed, cancelled appintment analyses

add appointments for a specific date and time

get notified of appointment conflicts / overlaps when scheduling; with proper authorization, I should be able to forcefully override conflict warnings or availability warnings

add multiple resources in a single appointment e.g multiple doctors in a single appointment slot

ability to schedule multiple patients for an appointment e.g group therapy

add a note with each new appointment; this note can be a comment or instruction

search for appointments using e.g the patient number, doctor, day of week, time of day; exclude days or time frames from search; exclude resources from search

register a patient on the fly when creating appointments for a walk in patient; before adding a new patient, search to see if the patient is already registered. Where data on a patient already exists ( e.g data from previous visits ), the system should use that data to pre-fill slots / make suggestions

update demographic and payment information in the patient record while scheduling; this could also include applying flags to the patient record e.g VIP, Debt Default Risk etc

look up eligibility when registering a patient or searching for an appointment

search for an appointment slot on the basis of a patient’s availabilty ( search within defined date / time bounds ); schedule the patient for the next available time slot

assign priorities to appointments e.g urgent

display a color coded calendar view of appointments

allow cancellation of appointments - with the need to specify the reason for cancellation; the system may have a predefined pick list of reasons for cancellation

send cancellation notices

send follow-up questionnaires after appointments

allow recurring appointments to be both added and removed

different appointment profiles e.g a profile for back pain, fever, well child, well woman,. Each appointment profile is linked to a color coded appointment type and may be associated with a duration, consent forms, a chief complaint and a billing code. Different appointment profiles may be associated with different patient instructions.

maintain a wait list of patients waiting for an appointment; in the event of a cancellation, it should be straight forward to move a patient from the wait list to the newly freed slot. The wait list includes a call back number, priority and appointment type. It also has: hospital registration number, patient number, patient name, ID/Passport, referring physician, attending physician, patient status ( inpatient, outpatient ), diagnostic procedure

access a list of all patients needing to be rescheduled, in the event of a resource becoming unavailable; this list should include contact details so that I can contact the patients

authorized users can overbook, in order to cover for the possibility that some appointments will be no shows or to take advantage of time freed from appointments that take a shorter duration of time

determine visually whether the patient to whom an appointment relates has arrived, been seen or departed ( appointment status )

create a sequence of appointments - that could recur at a regular interval or have an irregular interval between them. These future appointments can be scheduled up to a year in advance; the system should help with the creation of a best fit schedule in this case. The system should support business rules that constrain the spacing between the appointments e.g prevening them from being spaced less than <x> days apart or indicating how many in the series are left

track arrival times, exam or procedure begin / end times and departure times

handle no shows - generate a no show list for each day, transfer no show appointments to a waitlist and generate no show letters / emails

schedule future investigation orders or prescriptions e.g scheduling a sequence of HbA1c tests for a diabetic patient on long term follow up

schedule multiple services per day for a single patient, with automatic generation of best-fit schedule and options

scheduling groups e.g therapy groups

attach free form notes to ‘reason for visit’ codes

enter special instructions into schedules

configurable limit for the number of times a physician can be scheduled for a procedure

logic e.g cancellation of orders also causes cancellation of the scheduled review with the doctor

link to insurance eligibility

link to pre-authorization when required: prevent finalization before approval

link and print patient preparation instructions e.g diet instructions for scheduled exam

enter and display transport requests - patient, transport mode etc

substitute staff, equipment and resources, with system suggestions

monitor and switch resources in an emergency

appointment search by ID / Passport, appointment number, cell number, name, phonetic search

display schedules by patient, room, procedure, staff, consultants, department, location

color code based on status e.g confirmed, paid, booked etc

Because:

I need to get maximum value from available resource hours while also providing good customer service ( low and predicatable wait times )

2.1.2. Epic: Setting up schedules

These features describe the ‘back-office’ maitenance of scheduling e.g creating schedules for schedulable resources, availability rotas etc

Schedules can be created for many kinds of ‘resources’ in healthcare - people ( e.g doctors, nurses, pharmacists etc ), machines ( e.g MRI and CT scan machines ), locations ( e.g rooms ) etc.

Note

As a:

user with administrative rights ( could be departmental administrative rights )

I need to:

be able to create new schedules for resources under my administration

be able to establish availability time blocks, with the ability to determine how many appointments are fit into a single appointment block

block non working hours e.g vacations or hours during which the office practice is closed ( this can also be seen as defining office start and end times )

define different appointment types, with each appointment type having different time lengths

for equipment schedules, block periods of non-availability due to maintenance

define templates for the notes that accompany appointments

link resources to locations e.g link an ultrasound machine to a particular consulting room

place resources in resource groups

customize reminder profiles and messages e.g email a week before the appointment, call a fortnight before the appointment, SMS a day before the appointment ( all with customizable messages )

scheduling logic e.g diabetics should not be scheduled at mealtime

Because:

every department needs its own custom schedule

2.2. Theme: The patient record

An individual patient’s record shall be accessed via a dashboard that ‘brings together’ all of a single patient’s clinical records.

Clinical and billing information should be displayed in reverse chronological order by default; more recent events are of greater interest than remote ones.

All patient records shall be accessed via the same interface, whether current or historical. “Archiving” is a back-end level concern that should be auto-managed.

The coded sections of each patient record shall use the following terminologies:

ICD-10 ( provisional and final diagnoses )

ICD-O ( oncology )

LOINC ( investigation orders and results )

SNOMED ( the detail of the clinical record itself )

In addition to having SMART apps for custom templates, custom visualizations etc, the system should support an arbitrary number of custom print templates.

2.2.1. Epic: Patient dashboard

An analogy: this is the ‘cockpit’ of the clinical part of the EMR. Some EMRs - mostly American - call this the ‘face sheet’.

Note

As a:

clinical user

I need to access a patient summary dashboard that:

puts the patient’s allergies in prominent view; it should be easy to capture or edit allergy information from here

places vitals - recent vitals and trends from past vitals - in view. Key vitals include: weight, height, BMI, BP, temperature, head circumference ( paediatric ), oxygen saturation, pulse, respiration rate, head circumference ( paediatric ), mean upper arm circumference ( paediatric ) and pain scales. The paediatric measurements are usually plotted against percentile charts. Vital signs that are out of range should be flagged. Future iterations might consider capturing vitals directly from bedside monitors.

access flow sheets that plot vitals and other numeric observations over time; the flow sheets should also include graph / chart views

places the patient’s diagnoses or problem list in prominent view. Diagnoses can be primary or secondary, confirmed or presumed. Problems can have different chronicities ( e.g acute, chronic ) linked to them. Problems can also be active or inactive - with the possibility of reactivating previously inactivated problems.

provides access to a patient’s medication list

allows sticky notes and flags and search tags to be placed on individual patient records

allows patient records to be marked as confidential e.g staff records, HIV patients etc

allows patient demise information to be recorded quickly

allows click through to the detailed patient record - where full information line notes, orders, results, reports, assessments, medications etc can be found

can be exported or printed e.g for purposes of communication with colleagues who are not able to constantly check the EMR

can be sorted or grouped in different ways e.g reverse chronological, chronological, by problem, by discipline etc

shows the practitioners who have worked with a patient before

allows click through to the patient’s billing, claim and scheduling / appointments information

allows me to capture charges e.g for procedures and have the charges appear in the patient bill

capture dietary orders and restrictions

record consents, authorizations and directives

2.2.2. Epic: Detailed patient chart

All documentation in the patient record is automatically user and date-time stamped. One patient may be assigned to multiple physicians, nurses etc

A patient chart may have flags e.g Do Not Resuscitate.

Note

The system shall provide input-time decision support e.g checking diagnoses against gender and age, checking procedures against diagnoses, checking that dates make chronological sense e.g discharge after admission etc.

It should also support authoring and entry of Clinical Practice Guidelines, and ship with well known CPGs.

Note

As a:

clinical user

I need to:

access templates related to the patient’s chief complaint and my specialty

have automatic expansion of abbreviations in the clinical templates

I should be able to see all of the patient’s notes, test orders and results, medications, observations ( including vitals ) etc

I should be able to write triage notes - these are clinical notes that will be a mix of structured and unstructured input, and that may be augmented by diagrams e.g annotated anatomical drawings. When entering these notes, I expect to have time saving conveniences e.g macros, voice input, templates etc. The triage nurse may conduct a review of systems, in addition to ‘the usual’ vitals.

enter coded but readable clinical notes. Clinical notes sections include the history of present illness, medical history, family history, social history, review of systems, physical exam, assessment, plan, billing, medications and allergies. This also includes consultation notes from ancillary professions e.g nutritionists, physiotherapists, speech therapists, psychologists, counsellors, social workers etc

I should be able to enter additional notes ( with all appropriate input acceleration conveniences e.g voice input, macros, templates ). All notes should be signed / authenticated by the author and time stamped. These notes could be doctors notes or nursing assessments.

I should be able to enter a plan of care

I should be able to manually enter vital signs. Abnormal vital signs should be flagged.

The system should be able to read vital signs directly from point of care monitors

I should be able to examine vitals and numeric observations ( e.g lab results ) on flow sheets

I should be able to see a graphical representation of the data that is on the flow sheets

I should be able to place orders for assessments e.g imaging and lab tests. The orders or order sets suggested by the system should correlate with the patient’s complaints.

I should be able to prescribe medicines electronically. I expect the system to help me with dosage calculations, interaction checking ( drug-drug, drug-allergy, drug-disease ), duplicate therapy checks, disease contraindication checks, formulary checks, dosage checks ( by age, weight, disease ) etc

input and output tracking - with tracking and charting on flowsheets

quickly enter progress / update notes for follow up patients ( both inpatient and outpatient )

quickly enter assessments e.g a nutritionists or physiotherapists assessments

carry out medication reconciliation ( see ‘Inspired EHRs’ for a good treatment of this subject )

track adverse reactions

copy previous notes when making updates

sign, lock and unlock clinical notes. Every unlock or modification needs to have a reason indicated. All changes appear in the audit log.

view and export or print the patient record - in full or in part - on demand; this could be a nursing sheet, a referral file etc. Some of the sections that could be printed include: current demographic information, current insurance information, current allergies list, current medication list, radiology reports and images, scanned documents e.g scanned consent forms etc

access patient specific plans of care

prescribe special or normal diets for patients

add attachments e.g scanned documents to the patient chart

get contextual access to decision support resources

capture temporary addresses for emergency patients

store risk factors

social history - marital status, occupation, religious preference, socioeconomic status, native language, translator needed ( Y/N )

linking to family member records

genograms

health surveys

measures of functional level

capture patient referral and consultation information

problem oriented progress notes

accounting for valuables

notifications for medico-legal e.g trauma, accidents, rape, brough in dead, gunshot wounds

2.3. Theme: CPOE

Computerized ordering covers the domains of pharmacy, lab ( pathology, microbiology, hematology etc ), radiology / imaging, diet, nursing care, procedures ( e.g specialized assessments ), physiotherapy, occupational herapy, catering, transport, theater etc

Orders share the following characteristics:

time and user stamped

‘signed’ by the ordering clinician or on behalf of the ordering clinician

Some orders ( e.g those entered by medical students ) may need verification before they are fulfilled.

Results share the following characteristics:

time and user stamped

‘signed’ by the issuer

patient name

hospital number

date and time of order

date and time results were last updated

alerts for changes / amendments

test name

visual cues for abnormal results

It should be possible to define custom result templates.

2.3.1. Epic: Medication orders

The CPOE system should support the following types of orders: medication, chemotherapy, large volume IVs, alternating IVs, total parenteral nutrition, piggyback IVs, compound medications, standing orders, medication protocols, medications with different strengths combined, medications from home etc

Note

As a:

doctor, nurse, clinical officer

I need:

to view the patient record as I make orders e.g ordering side by side with the patient chart ( see Practice Fusion for a good implementation ); current test results and vitals should be visible

enter orders that include:

all the essential elements of a ‘sig’ e.g route, dose, duration, administration time / frequency, IV volume, drip rates, additives etc

a link to the visit and the patient

date and time

diagnosis / episode summary

medication(s) - trade name and generic name

indication(s) - selected from the patient chart

status

priority e.g routine, STAT, now, morning, timed

route

frequency

start

duration / end

treatment goal

instructions for the patient

free text comments for nurses and pharmacists

signed by or signed on behalf

name, designation, location and contacts of prescriber

flow rates for IV meds

dose

quantity

expiry or validity

enter medication orders, including one time doses - with the system interacting with a formulary service to help me:

check for duplicate orders - by class, generic ingredient etc

check that a medication is on the approved formulary

check for age / gender / disease conflicts e.g medications contraindicated in children below a particular age, medications contraindicated in pregnancy, medications contraindicated in kidney or liver failure

calculate normal dosages - based on age, height, weight, body surface area etc

calculate dosages for patients with reduced or increased needs e.g in renal failure, hepatic failure

check for interactions - drug to drug, allergy, drug to disease, contraindicationes etc. Interactions should have severity levels. It should be possible to override an interaction warning - with a signed note needed for all moderate or severe interactions.

check for dose limits - by height, weight, body surface area etc

cumulative dose alerts e.g for chemotherapy

work out tapered dosing and alternate day dosing schedules

calculate number of dispensing units e.g number of tablets to dispense

check against lab test results

integrate suggestions for less expensive generic alternatives

view formulary information within the context of ordering

display cost information as part of the order template

flag special orders for additional review e.g chemotherapy orders

define order associated messages e.g drug is a restricted antibiotic that needs infectious disease approval

generate an alert if an “on hold” item has been on hold for a while

facilitate review of all on-hold items at a time interval

define intervals at which on hold orders must be reviewed

resume held orders

discontinue orders - based on stop dates/times, expiration; with reason

flag orders due for renewal

view stock availability within the context of ordering

mark orders that need review e.g Pharmacist review

view overridden alerts clearly in order summary

maintain favorite medication lists that can be edited on the fly

create custom alert rules. CDS alerts can match what the patient has or what the patient does not have. They contain the following elements:

ID

Description

Age range ( optional )

Gender ( optional )

Race and ethnicity ( optional )

Problems ( diagnostic codes )

Medications ( codes )

Allergies ( codes )

Lab results ( codes )

Active or inactive

A contextual label

overidden alerts visible on order

have order suggestions - brought up by diagnostic, age or gender triggers

mark relevant orders as refillable, and get alerts when a refill is needed

mark orders as discharge orders - mamaging the transition from inpatient to outpatient

do conditional ordering

renewal of flagged patient orders

create future dated orders - will be dispensed or administered when die

send prescriptions to the pharmacy; drugs from one order can be sent to more than one pharmacy e.g due to availability or payer restrictions. The following is the minimum information that should be printed on a prescription:

prescriber name and department

prescription date

prescription number

medication prescribed

product name

strength

form for medicine e.g tablet, capsule, injection, suspension

quantity

dosage ( dose, frequency, duration, regimen )

route of administration

instructions for use

any other relevant information e. gprgnancy status

patient name

medical record number

sex

height

weight

mark preferred Pharmacies

print prescriptions for manual transmission / email prescriptions

record continuing over the counter or outpatient medications

track all changes or additions to orders - visually highlighted in the patient’s medication list

orders for surgical supplies by theater staff / anaesthesiologists

request for documentation when prescribing controlled medications

scanning of hard copy prescriptions

change drug brand when doing refills

detect early refills e.g for suspected overuse

2.3.2. Epic: Investigation orders

Investigation orders include lab, imaging, clinical assessment ( e.g speech assessment ) etc

Note

As a:

ward nurse or doctor

lab employee ( lab clerk )

I need to:

enter investigation orders. A proper investigation order has similar elements to those listed for a prescription before.

ordering provider

send to ( internal or external lab )

order date

free text notes

priority

status

internal comments / free text notes

specimen collected - on lab or on site

bill to ( patient, third party, facility )

patient instructions

diagnoses ( one or more, coded in ICD 10 or SNOMED )

location of the patient

be able to order any test or panel from LOINC, and also custom tests / panels

have the system check for - and flag - duplicate orders; there should be a prompt to verify or cancel the duplicate

override duplicate order warnings with a reason

charge for tests - with the ability to handle multiple pricing schemes, prevent charges for redraws, place multiple charges per test and add comments

enter no charge tests

sign orders; with the ability for a junior provider to enter orders on behalf of a senior e.g verbal orders and sign on behalf of

have order suggestions - brought up by diagnostic ( ICD 10 and SNOMED ), age or gender triggers, results of previous tests etc

have flags from medical necessity checks e.g orders which do not correspond to the primary diagnosis

view the patient record, including current test results and vital signs in the context of ordering

print a patient’s orders - current, discontinued; chronological and reverse order

view previous results on the order screen, with abnormal results clearly flagged; these orders could be summarized on a flowsheet or a 24 hour panel

assign priorities to orders

suspend, reinstate, cancel or amend existing orders - with automatic credit for cancelled tests

pick from community and custom / practice level order sets

save favorite order sets

create user order sets - linked to diagnoses, specialties, patient events, facilities, departments, clinical pathways etc

copy and edit order sets; changes should be highlighted and tracked

print orders e.g for sharing with external labs

print specimen labels

send orders - in whole or in part, even split - to diagnostic partners

mark favorite diagnostic partners e.g favorite labs

alerts for time bound diagnostics e.g glucose tolerance tests, cortisol levels etc

warnings and reports for uncollected orders

alert on patient discharge of orders needing action or completion

2.3.3. Epic: Imaging orders

Note

As an:

imaging employee

I need to:

enter orders that are linked to imaging appointments

support emergency order entry ( name, age, sex, reason for order, physician name ) to expedite examination followed by full registration including insurance information at a later time

each order has: patient details, medical record number, ordering doctor’s, details, diagnosis, exam type, isolation type, reason for ordering, patient current condition e.g pregnancy, patient allergies, date and time ordered, free text or coded comments

prevent use of abbreviations in order entry - known error sources

automatically require scheduling for some orders

entry and charging of backdated orders e.g after downtime

display procedure description at order entry for verification

rank procedures by priority when multiple procedures are ordered for the same visit

assign unique exam numbers to each order; which will also appear in bar coded form when printed

assign priorities to orders e.g STAT, urgent, routine

place multiple exams in a single order for a patient

match orders with associated procedures, tests or preparations

notify the ordering physician and the nursing department of preparation procedures or instructions regarding a test during order entry

display and print order-associated preparation procedures

modify orders wwith comments - by authorized personnel

cancel orders - specific orders, orders for a date/time range, all orders; supply a reason

notify ordering unit of order cancellation

retrieval of orders by: order number, date range, order status, patient, ordering physician, department ( most recent orders first )

perform the following checks on orders:

checks for conflicts e.g pregnancy

checks for duplication

checks for allergies - contrast interactions

checks for proper exam sequence

checks for previous exams e.g Barium

check for patient having another order in a similar modality for the day

2.4. Theme: Radiology

This chapter focuses on features that are unique to radiology.

2.4.1. Epic: Radiologists’ and radiographers’ dashboards

Note

As a:

radiologist or radiographer

I need to:

view a list of all scheduled exams, with exam status and the ability to filter by radiologist / radiographer, room, modality, order time, exam time etc

track patients through the radiology department

track patient check-in and departure times, exam start and stop, rooms, name, results report start and sop

show status of exams: scheduled, imaging done, dictated, transcribed, authenticated, sent etc

split ordered exams into more than one exam request

view a log of completed exams

view unsigned reports under my name

track waiting and turnaround times; by mnitoring arrival times, exam times and departure times

view my workload and colleagues’ workloads; organized by modality and procedure

print schedules by room, radiologist, technician, nursing station, department, equipment, patient etc

click through to patient records, which include a log of their current and past orders

alerts for patients who have staid for longer than the normal waiting time

receipts and tracking of films from outside entities e.g other hospitals

tracking of film movement using bar codes

2.4.2. Epic: Capturing the radiology exam

All exam notes are user and date/time stamped. In imaging, more than one radiographer / radiologist may be involved in a single exam.

Note

As a:

radiologist or radiographer

I need to:

work through a pre-examination checklist that also includes consent

access the patient’s full medical record

scanning and attachment of documents

display information to technologists: special instructions, equipment needed, number of repeats

enter imaging reports using reporting templates that: support rich text formatting, have spell checking and can auto-populate demographic data. Some of these reports may be predefined e.g reports for normal findings

enter comments, diagnostic codes in results

use graphical templates ( schematics, diagrams )

support a workflow that has transcriptionists enter dictated reports

document adverse incidents

review reports e.g in a maker-checker workflow

electronically sign reports and send them to the correct department e.g the requesting department

preview and print reports

record supplies used, decrement stocks and charge for the supplies

charge patients for the procedures - with the ability to apply relevant discounts

record charges from independent radiologists

perform retakes ( repeat exams ) without charging the patient

automatically update order status after entering results

track follow-up for abnormal results

support transcription workflows: with word processing, spell checking, glossary, medical dictionary

support batch reporting: by physician, medical record number, modality, patient location etc

automatic printing and sending of stat reports to remote sites

remote reporting

dictation

voice recognition

co-reporting

notify nursing of abnormal results or emergencies

capture preliminary and final report timestamps

replace preliminary report with final report when ready

attachment of addenda to the final report

listing of reports, filterable by patient, MRN, sex, age, test, location etc

printing of final reports after approval

listing of reports pending final approval

on-demand re-printing of patient reports

retrieve reports by: radiologist, transcriptionist

release or restriction of unverified or un-approved reports

link multiple procedures to one report

alerts to patients and ordering doctors

2.4.3. Epic: Image management

The ‘party trick’ here is the integration of PACS into a teleradiology ecosystem. The images that can be shared over PACS run the full gamut of imaging modalities - from echosonographs to ECGs; from angiographic images to MRIs; from endoscopic images to CT scans.

Note

As a:

radiographer or radiologist

I need to:

track the locations of all films

print labels for films and jackets

interface with PACS to view images online and link reports to images

receive images from local and remote PACS

2.4.4. Epic: Imaging operations management

Note

As a:

team leader in an imaging department

I need to:

set up the schedule - designate times when staff, rooms, equipment etc are not available

manage equipment maintenance schedules

get alerts on expired films

track quality control data e.g number of repeats and reasons for repeat

analyze workload / utilization - by exam type, patient type, radiologist, technician, requester, department, equipment / device etc

monitor inventory levels - with auto-restock notifications when supplies fall below a user specified threshold

monitor departmental financial performance at a summary level

The implementation will need to be benchmarked against a commercial RIS/PACS e.g the Philips eXtended Internet Radiology Information System ( XIRIS )

2.5. Theme: Laboratory

The domain of laboratory medicine includes:

hematology and blood transfusion

clinical pathology - with histopathology and cytology

clinical chemistry / biochemistry - includes serology

special chemistry - applies elaborate techniques e.g electrophoresis, immunoassays etc

microbiology - including TB

Some hospitals may place the blood transfusion department under the lab, while run it as an independent department. However the administrative setup is done - there will always be an intimate interplay between the laboratory and the blood transfusion unit e.g screening of all blood donations.

Within a lab, there are multiple roles. A partial list includes:

clients or patients - who may need to access results online in a patient portal

clerks - front desk administrators who handle sample receipt, billing etc

analysts - technical lab staff

supervisors - review results before publishing

regulatory inspectors

system administrators

The domain is regulated by a variety of standards, with ISO 17025 being one of the more important ones.

2.5.1. Epic: Laboratory user dashboard

The laboratory user dashboard is focused on ‘task visibility’.

Standard access control usually prevents analysts from seeing patient identification details, and clerks from seeing results.

Note

As a:

laboratory user

I need to:

have visibility into my worklist; this includes my pending tasks

have visibility into my colleagues worklists

filter or sort the worklist by patient

see a summary of incomplete orders, abnormal results, recent activity, consult status ec

see my scheduled / recurring tasks e.g recording observations on a blood culture daily

print or share/send any worklist on demand

transfer a case to a colleague’s queue - for additional consultation or to balance workload

allocate pending tasks to myself / colleagues

reschedule pending tasks

track instrument workloads

track turnaround times

assign priorities to worklist items

2.5.2. Epic: Investigation sample collection

Investigation samples may be collected in the clinical areas - wards, clinics, casualty etc - or at the lab itself. The samples may also be collected by laboratory staff or by clinical staff.

All collections are user and date/time stamped. These ‘stamps’ must be displayed everywhere the sample is displayed.

For quantitative tests ( e.g an electrolyte asseay ), the input worksheet closely resembles a spreadsheet. For semi-quantitative tests ( e.g culture and sensitivity in microbiology ), the results are entered using a mix of pre-defined pick-lists and free text comments. For purely qualititive results ( e.g reporting on the morphology of a blood film ), the system should provide the same template driven input mechanisms available to doctors.

Note

As a:

lab or clinical user

I need to:

access a sample collection worklist that I can sort and filter by test type, test, technologist, time etc. The collection list includes the test name, code, priority, accession number, patient allergies, comments, scheduled draw time, sample size, tube type, patient location and associated practitioner(s)

merge items from multiple worklists into a new worklist

generate collection labels - with bar and QR codes - and print them

access a log of pending collections

access a log of uncollected specimens, with alerts for overdue collections

have auto assigned accession numbers for each sample. These numbers shall be bar and QR coded on sample labels

view payment status before sample collection; charge tests that are uncharged and require payment for cash patients before tests

register samples with the following information:

number / ID

requester

collection date/time

type e.g blood, urie, serum, stool, semen, CSF, sputum, pus, synovial fluid, slit skin, pleural fluid, pericardial fluid, peritoneal fluid, QA test samples, others

source - IPD, OPD, emergency, sub center, community program

priority

a special mark for outbreak specimens

get flags / warnings when sample types are linked to the wrong tests

issue sample receipts for accepted samples; with the ability to print

track the chain of custody of every sample; a sample could be in the following statuses - pending, sampled, preserved, received, assigned, cancelled, to be verified, verified, invalid, published

support partitioning and storage of samples

reject samples - with reasons picked from a predefined picklist and plain text reasons; an alert should be sent back to the responsible practitioner(s) for action

register and track specimens in batch

2.5.3. Epic: Investigation results entry

Laboratory results can be entered manually or captured directly from analyzers. For the manual entry scenarios, design so that the results can be entered in multiple passes.

The system should provide rich text editing for qualitative reports e.g pathology reports.

Note

As a:

lab analyst

I need to:

enter results via test type specific worksheets. Worksheets are spreadsheet like and should support configurable automatic calculations, rouding and adjustment factors. They should also support graphing / visualization. Results may be quantitative, semi-quantititative or qualitative. Quantitative results have values, units, reference ranges, flags [ high / low / critical high / critical low / normal ] and comments. Large changes / deltas in a test series should be flagged.

export worksheets to Excel

import worksheet data from Excel

add comments at the worksheet level or for individual entries

attach versioned documents to results e.g images, MS word reports etc

edit results on unsaved worksheets; no editing after the worksheet is processed

fill a worksheet in via a bidirectional link to lab equipment

publish results ( could be access controlled in a maker-checker setup )

retract or invalidate results

send alerts to practitioners for panic values

mark some results as classified and control access to named people e.g VIP patient results, HIV

preview and print / send / email results; the requester and requesting department should get automatic alerts

2.5.4. Epic: Laboratory operations management

Note

As a:

lab manager

I need to:

manage equipment maintenance schedules

track expiry dates and inventory for culture media, regents, stains and other laboratory supplies

keep track of licensing inspections and reinspections

access quality control information - including non-conformities, PT and IQA results

keep track of quality documents - SOPs, instrument calibration certificates, certificates of analysis, QC reports, reference specifications etc

analyze workload - by analyst, instrument, procedure, diagnosis etc

do case management - disease tracking, trend analysis etc

generate surveillance reports - e.g notifiable positive test results

2.6. Theme: Clinical dashboards

Each clinical worker ( e.g nurse, doctor ) shall have their own individually customizable dashboard. This dashboard is focused solely on their own tasks. Each practitioner can work in multiple stations e.g multiple nursing desks or wards for nurses, multiple consulting rooms or wards for doctors.

Note

The messaging system shall send notifications to these points of service whenever there is a new unit of work e.g notifications to pharmacy when there is a new prescription or a newly discharged patient who needs discharge meds and inpatient drug returns

When the number of patients in a point-of-service queue exceeds a set threshold, an alert should be generated. This condition should also be displayed prominently on the dashboard.

The dashboards should clearly distinguish ‘information that is new to me’ from ‘information that I have already seen before’. This should occur on a user by user basis.

2.6.1. Epic: My messages

Messaging - between care team members, between the care team and the patient, between provider and payers etc - shall be the backbone of ‘care coordination’ and ‘telemedicine’.

If you want a mental metaphor, think ‘a secure / confidential Slack for Healthcare’ and you’ll not be far off. The system shall support the following kinds of messaging:

communication between care providers in the same healthcare organization or practice

communication between care providers and patients

communication between care providers in different organizations e,g in referrals

communication with payers

communiation with service providers e.g labs, imaging centers

This is literally the ‘backbone’ or care coordination and telemedicine ( repetition for emphasis ). We cannot afford to do this in a half-assed manner.

The user should be able to opt in to desktop and background push ( service worker ) based alerts.

Note

As a:

clinical or administrative user

I need to:

communicate with my colleagues e.g primary care physician to specialist

communicate with the patient

communicate with service providers e.g labs and imaging centers that we work with, sending post discharge communication to post-acute care centers

communicate with partners e.g referral centers that we collaborate with

communicate with payers e.g insurers and employers

conduct televisits, with access to voice, video, text and image communication modalities

access a log of all patient specific communications ( e.g teleconsultation notes ) in the patient chart

record charges for teleconsultations, where applicable

Because:

I need to pass on important patient care information - information that is safety or outcome critical

I need to pass on scheduling information - which will help me attain high utilization levels and increased revenue

I need to get important updates as soon as they are available e.g when an insurer authorizes an admission and my patient is waiting

I need to get life-saving information as quickly as I can e.g a patient with lab results that should prompt immediate life saving interventions

2.6.1.1. Scenario: Receive lab results update

This scenario is merely representative; the same thing could be said of any time critical update e.g an incoming insurance approval / rejection, an incoming referral from a lower level health facility etc

Note

Given:

that I am logged in to the system

And:

the lab ( internal or external ) posts results for a patient under my care

When:

I look at any open application window, I should be able to see an alert and visual indication of my new messages

And:

upon clicking on the message indication

Then:

I should be able to access the message

I should have be able to reply to a message thread, in the same way that I am accustomed to doing on Google Hangous, Slack, WhatsApp, Facebook etc

I should be able to link a patient in for context or view the record of the patient that has already been linked in for context

And:

interact with its contents

The main ‘metaphor’ going on here is the ‘rich inbox’. It is not enough to see a message, it should be possible to act on it, right from the inbox.

2.6.1.2. Scenario: Task inbox

With all the messages that need action flying around, the ‘task specific inbox’ is a key metaphor. For example: here are all the claims that need to be reviewed, here are all the imaging reports that need to be reviewed etc

Note

Given:

that I am logged in to the system

And:

I have any screen open

When:

I look at the top of the screen, I should be able to see a clear indication of what tasks I have pending, including a sense of how many new tasks of each category I have

And:

Upon clicking on any task type

Then:

I should be able to view further detail on the task

I should be able to click on a shortcut that takes me to the relevant task window e.g to review the results if the task is to review lab results

And:

the number of pending tasks should decrease automatically whenever I interact with a task e.g act on a pre-authorization that needed review

This task inbox is complicated by the fact that tasks may be shared between several individuals in a group.

2.6.1.3. Scenario: Contact support from within the product

For a SAAS product, support cannot afford to be ‘distant’ or ‘remote’.

The system shall provide a constant ( permanent in the user interface ) mechanism to access help ( the knowledge base ) and contact human support. The user interface design shall also focus on ‘teaching’, esp. for the first use interfaces or new users.

Note

Given:

that I am logged in to the system

And:

I have a question or need help with a system task

When:

I look at the bottom of the screen

And:

Click on the support button / popup / link

Then:

I should be able to initiate a chat session ( text, audio or video ) with a support person

And:

Get help with my question or problem

2.6.1.4. Scenario: Access online help

The system should provide guidance each time the user accesses an unfamiliar page. This help should be contextually relevant.

Note

Given:

that I am logged in to the system

And:

I have accessed a page that I am not familiar with

When:

I look at the bottom of the screen

And:

Click on the help icon / popup / link / icon

Then:

I should be able to access simple guidance that is relevant to the screen that I am on

And:

Use the information so gained to complete my task

2.6.1.5. Scenario: Setup wizard

We should strive to avoid a ‘blank’ experience on first setup.

Note

Given:

that I am a new user logged in to the system

And:

I have not completed my system setup

When:

I access the default / home page

And:

Interact with the dashboard

Then:

I should see an indication of how far I have gone with my setup / onboarding

I should be able to access setup / onboarding information

I should be able to click on a shortcut to the next step on my setup / onboarding

And:

I should be guided gently to complete my orientation / onboarding / setup

One thing that may not be obvious when reading the scenario above - it is user / role specific.

2.6.2. Epic: Triage dashboard

‘Triage’ is the name given to the clinical process of assessing incoming patients and separating them into different queues based on the urgency with which they need to be attended to. In common practice, ‘triage nurses’ also collect vital signs and document the chief complaint / presenting problem.

In a typical outpatient department / casualty, the triage nurses manage the flow of patients and staff. They ‘make the call’ on which patients are so sick the need to be seen NOW and which patients can wait for their turn on the queue.

In order for an emergency room to offer an acceptable standard of care, the staff should have continous visibility over the status and location of all patients.

The patient display should be color coded e.g by urgency and waiting time. It is not just patients that are tracked - providers ( e.g nurses and doctors ) are also tracked. This tracking interface should be mobile friendly, so that it can be used from tablets and other portable displays.

Note

As a:

emergency room worker ( nurse, doctor, adminisrator, records employee etc )

I need to:

capture code and time of triage; triage codes can be customized

see a color coded display of all patient and provider locations that is updated in real time. This display should be graphical. It should be easy to filter e.g status of all patients with imaging orders, bed requests etc

see a clear indication of patient wait times, with patients that have not been attended to for longer than a departmentally defined task duration threshold clearly flagged

see a clear indication of patients awaiting attention or transfer to other departments

see notifications of incoming results, patients awaiting triage etc. In addition to notifications, there should be a permanently visible task inbox / queue. Results that are flagged as critical or abnormal should be clearly marked.

filter or sort my patient location dashboard by patient type, diagnosis, triage status, provider and arrival mode

have visibility into ambulance status for both own and third party ambulances

enter and receive notifications of remotely entered requests

book patients for ambulance services

book multiple patients for the same ambulance e.g for transfers

cancellation of ambulance bookings

capture requirements when booking ambulances e.g mechanical ventilation

charging for ambulances e.g on distance / mileage

show where ambulance booking was made from

booking outsourced ambulances; tracking and reporting

ambulance logs - driver, patient,

ambulance inventory e.g ventilators

update vitals and other data prior to arrival; requests pre-arrival

dispatch ambulances

record arrival of ambulances

track ambulances

Because:

I need to keep the patients / tasks moving; prompt visibility into delays will allow me to intervene in time`

I need to filter the large volume of information that I get, and opt in to what I need only

I should be able to respond promptly to urgent or critical results - it could save lives

Note

Given:

that I am a logged in triage nurse

And:

I am at the triage ‘dashboard’ or home page

When:

I look at my summary / dashboard

Then:

I should be able to see the queue of patients awaiting triage

I should be able to prioritize patients on the basis of of their acutity level

I should be able to see the queues ( with color coded statuses ) for the patients that I have already triaged and e.g. sent to a specific consulting room

I should be able to see the queue of patients awaiting re-consults e.g after lab results are in, and the status of their pending tests

I should be able to move patients around between queues

I should be able to remove patients from the queue e.g patients who have already left

I should be able to assign patients in specific rooms to particular care providers e.g to particular doctors or nurses

I should be able to see a particular doctor or nurse’s ( or other care team member’s ) queue

I should be able to manage observation rooms for outpatients

2.6.2.1. Story: Triage

Listing 2.1 Triage

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Feature: Triage
    Triage controls the flow of patients. The primary roles are: prioritization,
    observation of vitals and 'pre-clerking' ( updating the problem list and
    performing a routine review of systems ).

    Every entry made here is date/time- and user- stamped. The identity of the
    user that last updated it and the exact time of that event MUST always be
    shown.

    The complaints search box should have "predictive" or "learning" behavior
    i.e common conditions in the local practice / hospital and for the patient
    should be suggested before less common ones.

    Background: Find a visit through the listing of active visits
        Given that I am logged in via the triage role
        And I navigate to the "Active Visits" queue
        When I type into the search box any of the following:
            | field         | explanation                                   |
            | name          | any of the patient's name or a fragment of it |
            | visit number  | a full or partial visit number                |
            | patient number| a full or partial visit number                |
            | priority      | triage priority status                        |
        Then I should see a filtered list of visits that match the query
        And the list should become more specific as I type more
        And I should be able to click on one of the visits to see the patient's
            face sheet

    Scenario: Add a complaint
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing complaint(s) if any
        Then I should see an "Add Complaint" control
        When I click on "Add complaint"
        And type a complaint name or fragment into the search box that appears
        Then the search box should show matches for the typed input
        And I should be able to select one match
        And The selected match should then appear in the patient's problem list

    Scenario: Dismiss the complaint form
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing complaint(s) if any
        Then I should see an "Add Complaint" control
        When I click on "Add complaint"
        Then I click on the "X" or "Cancel" controls
        Then the form should dismiss and I should be taken back to the patient
            face sheet

    Scenario: Remove a complaint
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing complaint(s) if any
        And I should see a "Remove" button next to each complaint
        When I click on the "Remove" button
        Then the complaint should be removed from the "Active Complaints" list
        And added to the "Inactive Complaints" list

    Scenario: Record vitals successfully
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing vital signs for the visit in a
            tabular 'flowsheet' and graphical form
        And I should see a "Note New Vitals" button
        When I click on the "Note New Vitals" button
        Then I should see a form that allows me to input vitals
        And I should be able to fill in the form with normal values and click
            "Save Vitals"
        And I should see a "Vitals Saved" success message
        And I should be navigated back to the patient's face sheet

    Scenario: Record vitals that are abnormal but feasible
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing vital signs for the visit in a
            tabular 'flowsheet' and graphical form
        And I should see a "Note New Vitals" button
        When I click on the "Note New Vitals" button
        Then I should see a form that allows me to input vitals
        And I should be able to fill in the form with abnormal values and click
            "Save Vitals"
        And I should see a "Vitals Saved" success message
        And I should be navigated back to the patient's face sheet
        And I should see the abnormal values clearly flagged on the
            color coded flowsheet

    Scenario: Record vitals that are incompatible with life
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing vital signs for the visit in a
            tabular 'flowsheet' and graphical form
        And I should see a "Note New Vitals" button
        When I click on the "Note New Vitals" button
        Then I should see a form that allows me to input vitals
        And I should be able to fill in the form with infeasible values and click
            "Save Vitals"
        And I should see an on-screen prompt that highlights the infeasible
            values
        And the "Save Vitals" button should be disabled until those values are
            corrected

    Scenario: Dismiss the vitals form
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing complaint(s) if any
        Then I should see an "Note New Vitals" button
        When I click on "Note New Vitals"
        Then I click on the "X" or "Cancel" controls
        Then the form should dismiss and I should be taken back to the patient
            face sheet

    Scenario: Record the review of systems
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing review of systems
        And I should see a "Review of systems" button
        When I click on the "Review of systems" button
        Then I should see a checklist style form that allows me to input ROS
            responses
        And I should be able to fill in the form and click "Save Vitals"
        And I should see a "Review of Systems Saved" success message
        And I should be navigated back to the patient's face sheet

    Scenario: Dismiss the review of systems form
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's existing review of systems
        And I should see a "Review of systems" button
        When I click on the "Review of systems" button
        Then I should see a checklist style form that allows me to input ROS
            responses
        Then I click on the "X" or "Cancel" controls
        Then the form should dismiss and I should be taken back to the patient
            face sheet

    Scenario: Assign a priority to the patient
        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's color-coded current "Priority" in the
            patient banner
        When I click on the priority badge
        Then I should see a pop up control with a listing of priorities
        When I click on a new priority
        Then the new priority should immediately show on the patient banner
        And the new priority should be seen when I navigate back to the visit
            listing

    Scenario: Assign the patient to a queue
        Queue are one of the primary constructs of the EMR workflow. Queues are
        attached to resources e.g doctors, consulting rooms, diagnostic machine
        etc ( any schedulable resource ).

        Some queues will be unconstrained / unbounded in size e.g orders
        awaiting processing at a lab. Some queues will be limited in capacity
        e.g patients assigned to an observation room.

        Given that I have opened a single patient's visit / face sheet
        Then I should see the patient's color-coded current "Queue" in the
            patient banner
        When I click on the queue badge
        Then I should see a pop up control with a listing of downstream queues
        When I click on a new queue
        Then the new queue should immediately show on the patient banner
        And the new queue should be seen when I navigate back to the visit
            listing

2.6.3. Epic: Doctors’ and nurses dashboard

This dashboard should be mobile friendly - the ability to access and update the EMR when on the go or in between shifts is an important efficiency booster.

Clinical templates allow us to strike a balance between detail and user convenience. They can be thought of as ‘documentation accelerators’.

Templates contain rich text formatting within them. They may also support keyboard shortcuts ( see Practice Fusion for a good example in practice ). They can take many forms, for example:

a checklist for review of systems

orthopaedic charts

dental charts

growth charts - CDC, WHO

psychiatry - DSM 4 and global assessment of functioning

diabetic patient insulin history tracking

standardized wound description templates e.g templates that describe wound appearance and drainage

immunization records - schedule, consent, refusal with reasons etc

obstetric history forms - recording e.g foetal heart rates, fundal heights, weight, urinalysis, blood pressure, notification dates - EDD, scheduled delivery, date to start ART etc, auto calculation of EDD from LMP or ultrasound EGA etc

Clinical templates will be a common ongoing customization. We should design a ‘plugin’ architecture for templates. We might want to take a good look at SMART on FHIR. The practitioner portal will include this functionality.

Note

As a:

doctor or nurse

I need my dashboard to:

access a personalized calendar that has my appointments and tasks, and can be toggled between day / week / month or agenda views; the schedule should include the reason for visit and symptoms documented during the intake process

book new appointments; scheduling patients by time, type of appointment, location etc

cancel appointments

confirm or remind patients of appointment times via automated email, text and phone notifications

add reminders that are not tied to appointment slots

add and view tasks / TODOs, also not tied to appointment slots

be able to opt in to email / mobile push / SMS reminders and set the times when the reminders are sent

be able to opt in to daily agenda emails and set the time when the emails are sent

able to access ( and search, filter, sort ) listings of my patients

click through to each patient’s detailed patient record

view orders and results / reports for each patient

view pending medication refills and refill / cancel

write and send prescriptions

show me my patients - name, contacts, emergency contacts, medical history, demographic and diagnostic data, current orders, current results, images

show me my worklist - with the ability to export or print on demand

show me my urgent tasks and priority items e.g unacknowledged results, unsigned documents, incomplete tasks; new tasks should be flagged

show a quicklist of procedures to be performed during a shift

provide easy access to specimen collection lists, with the ability to rapidly print bar coded labels

allow me to prioritize the tasks on my worklist

alert me when there are overdue tasks

alert me when there are new tasks

show me a list of my patients, with those that I have interacted with recently appearing earlier in the list

allow me to click through and see my patients medical records - with their medications, history, orders, results, images etc - along with the ability to edit and input new clinical notes. The actions that can be performed on each patient record are defined in further detail in a ‘My patients’ feature below.

access theatre lists for patients under my care and monitor progress across pre-operative checklists ( that work towards transfer to operating theaters )

show me alerts for incoming investigation reports and results that need review

request consults and view the status of pending consults

allow me to click through to the patient tracking and bed board pages

enter charges for ward and clinic procedures

process birth and death notifications

browse a template library that is organized by specialty and has featured templates, template preview and ratings

create custom templates or custom template sections and link them to the appropriate sections of the patient chart. The template builder should provide at least the following field types: short text fields, yes/no fields ( always generate text ), on/off fields ( generate text only if off ), single selects, multiple selects, diagrams, fractions, headers, sub-headers and blank fields / spacers

create custom templates by saving notes as a template ( placeholders or variables? )

sharing templates with specific users

2.6.4. Epic: Dispensing dashboard

In addition to dispensing medications - for inpatients and outpatients - many hospital pharmacies also maintain a poison information center.

Note

As a:

pharmacist, pharmaceutical technologist or nurse with a dispensing role

I need to:

view a worklist - medications pending dispense, filterable by station or pharmacy; the patient should be cleared from the worklist only when fully dispensed

dispensing statuses: not atended, in processing, ready for dispensing, partially dispensed, dispensed

listing of patients waiting at various locations / pharmacies

distinguish between inpatient and outpatient orders

process discharge drugs - returns of inpatient medicines, issuance of discharge medicines

get alerts on new location when a patient is transferred / moved

perform price checks ( quotations ) without the need to register the patient in advance

management of pre-packaged kits / packages

produce Patient Information Leaflets

record patient arrival at the counter and departure after dispensing

monitor turnaround times from receiving orders to final dispensation

show average waiting time at the display monitor

clearly identify orders that need a Pharmacists’ review

print labels. General labels should contain the following information:

name of the patient

name of the medicine ( generic and trade )

strength

form of medicine e.g tablet, capsule, injection, suspension

expiry date

quantity

instructions for use e.g avoid alcohol

dispensing date

storage requirements

name of the dispensing facility and department

IV labels have the following additional information:

start time

solution and volume

time to run

drip rate

initials of the pharmacist or technician that compounded the solution

administration insructions

Label types are:

inpatient

outpatient

discharge

pack

reprinting of labels, as necessary

ISMP ( Institute of Safe Medication ) compliant labels

generate and print compounding worksheets: preparer, checker, components used, manufacturers, lot numbers, expiration date, volume, weight

automatic pricing of compound items, including the compounding fee

susbstitute generic drugs - except where there is a do not substitute order

dispense a prescription in full or in part

charge dispensing fees

print prescriptions for medications not dispensed e.g to send to third party pharmacy

place prescriptions on hold ( with a comment )

acknowledge / ignore alerts

2.6.5. Epic: Medication administration dashboard

Note

As a:

ward nurse or doctor

I need to:

access a medication administration list; printable for easier communication during handovers. It includes: patient, drug, dose, age, cart filler name / cart checker name, total units dispensed

access a summary area that includes a renewal notice list, expired treatment list, alerts on patients who missed medications and medication errors

be warned about potential interactions e.g drug-drug, drug-allergy, drug-food, duplicate drug; I can override warnings by writing an note that is prominently displayed on the patient record

be notified of abnormal lab results or vitals prior to medication administration

be able to check medication labels against patient wrist bands

place orders on hold

receive notice of orders that are near expiry

document why a medication was not administered

add administration notes to the medication adminisration record

record adverse drug reactions

synchronize the medication administration list with a dispensing system

automatically decrease inventory during cart filling

print a specific patient’s medication administration record on demand

© Copyright 2016, Savannah Informatics Limited.

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SIL EMR Requirements 0.0.2 documentation »

3. Product: Inpatient clinical

Patient care is multi-disciplinary. The circle of care for a patient may involve doctors, nurses, clinical support staff e.g admissions clerks, case managers, payors, guarantors, pharmacists and others. This multidisciplinary role setup is made harder by the need to balance between access and confidentiality - what does each party need to know in order to do their job? This is made even tougher by the need for mobility.

Note

Information Security

This guide assumes that there shall be fine grained role based access control. The permissions used shall be granular, so that is shall be possible to grant or deny access to any screen or section of a screen. It shall also be possible to grant view only rights.

Access shall be restricted on the basis of:

user groups

user types

individual patient charts

locations e.g nursing floors, clinics

patient type e.g VIP, confidential patients

a combination of all of the above

Logged in sessions shall be timed out after 10 minutes. The user shall be locked out from further login attempts after three incorrect login attempts. Each lockout shall be an hour long.

All entries shall be time stamped and audit trailed.

The system will need to support secure logon - with hardware tokens.

Note

Online Help

The system should embed online ‘help’ and first-use tutorials.

For clinical services, the need to design for high distraction environments and for task efficiency is paramount. Many of the existing products have failed to gain adoption in clinical settings in part because they are perceived to be more cumbersome than paper.

3.1. Theme: Scheduling

The scheduler will be available to administrative staff ( e.g registration clerks ), clinical staff ( e.g doctors and nurses ) and even to patients themselves.

This feature should work for both single clinics and large multi-site healthcare businesses. For a multi-site operation, the calendar should be synchronized enterprise-wide.

A medium- to large- provider will typically have many concurrently scheduled routine clinics e.g paediatric, antenatal, postnatal, family health, diabetes, chest, well baby, child welfare, immunization, lamaze etc. There will also be a sizable number of specialist clinics e.g neurosurgical, obstetric, cardiology, neurology etc

3.1.1. Epic: Operating room ( theater ) scheduling

This, too, can operate in a centralized or decentralized manner.

Some departments that are not classically thought of as ‘surgical’ e.g cardiac catheterization, interventional radiology and endoscopy will use scheduling facilities that are similar to what is described for operating rooms.

Preference cards for surgical and anaesthetic staff define the supplies needed for each case.

Note

As a:

user with OR scheduling duties e.g surgeon, theatre nurse, ward doctor

I need to:

view daily and weekly schedules by operating room, department, surgeon, anaesthesiologist, patient etc

capture the following scheduling data: patient name, age, gender, ward and bed number, medical record number, contact details, diagnosis / indication, planned operation / procedure, surgeon, booking date and time, name of scheduler, estimated time of surgery, anaesthetist / anaesthesiologist, type of anaesthesia, assisting surgeon(s), scrub nurse, special requirements, known allergies, comorbidities, physician, special requirements e.g implants

scheduling of recovery locations

shift start times automatically when surgeries are added

swap cases - individual or entire rooms - without reentry of data

automatically shift start times when cases are cancelled

speed scheduling - next five available conflict free time slots

scheduling of multiple procedures for the same patient cases

scheduling of multiple procedure and multiple surgeons for one case

re-sequence the cases in the final list, as necessary

surgeon’s verification of the operating list before it starts

color coded status of the operating list - provisional, verified, final

printing of operating lists

transfer patients from one surgeon to another

online waiting list and reservations, with priorities

standard turnover and setup times per case - added to case duration

manually override standard turnover or setup time per case

automatically use surgeon’s average case time when scheduling a case

OR status whiteboard

book slots - with the following conveniences:

drag and drop rescheduling e.g swapping cases between rooms

automatically locating the next available time slot

wait lists

ability to select durations based on the case, surgeon etc

moving cases between surgeons and operating rooms e.g due to schedule changes

cancelling or holding cases, with reasons indicated

free text notes for bookings - comments for OR staff

automatic checks for resource conflicts

override conflict checks and availability block conflicts - with a reason given

associate bookings with orders

A booking may involve multiple surgeons and multiple rooms ( e.g OR and recovery )

edit bookings

manage equipment availability / unavailability

schedule equipment for use in surgeries

manage operating rooms e.g set rooms aside for specific procedures

define availability blocks for surgeons, rooms, anaesthesiologists, support staff ( scrub nurses etc )

define surgeon preferences - allergies ( e.g allergies to latex ), hand size, handedness ( left or right )

reschedule e.g because an emergency operation took precedence over the scheduled operations ( common occurrence )

reschedule cases that have not started within a defined threshold e.g 30 min

reactivate a cancelled case, with retrieval of all previous data

surgical packages - with the ability to charge for extra items and theatre time

3.2. Theme: The patient record

An individual patient’s record shall be accessed via a dashboard that ‘brings together’ all of a single patient’s clinical records.

Clinical and billing information should be displayed in reverse chronological order by default; more recent events are of greater interest than remote ones.

All patient records shall be accessed via the same interface, whether current or historical. “Archiving” is a back-end level concern that should be auto-managed.

The coded sections of each patient record shall use the following terminologies:

ICD-10 ( provisional and final diagnoses )

ICD-O ( oncology )

LOINC ( investigation orders and results )

SNOMED ( the detail of the clinical record itself )

In addition to having SMART apps for custom templates, custom visualizations etc, the system should support an arbitrary number of custom print templates.

3.2.1. Epic: Care plans

Plans of care range from medication or procedure plans to lifestyle interventions. Many of these plans of care will be multi-disciplinary e.g involving physiotherapists, occupational therapists and speech therapists.

Nursing care plans might include risk factors, signs and symptoms, outcome criteria, nursing interventions and discharge criteria.

Note

As a:

clinical user

I need to:

define individualized plans of care - that might be multi-disciplinary. The system should assist this process by providing critical pathway guidance and decision support

document care goals and outcomes

define acuity levels and early warning signs - track, filter by patient / nursing unit, date, shift, care level

edit or discontinue all or part of any plan of care

note target dates for interventions on care plans

access previous plans

record interventions ( date, practitioner, intervention notes )

assessment at variu=ous stages depending on condition and level of nursing care e.g on admission, on change of condition, post-op, every 24 hours, on discharge etc

reminders, checklists and planning documents

standard care plans - linked to diagnosis

define nursing checklists e.g change of shift, nursing round, pre-op

alerts for planned care when the time elapses

fluid chart automated cumulative balances

free text entry of non-standard care plans

nursing progress notes and observations; progress notes may be SOAPIER - Subjective, Objective, Analysis, Plan, Intervention, Evaluation and Review

entry of all medical equipment that has been connected to the patient

define and support patient call system

define high priority patients

chaplaincy service requests, alerts, request list, notes, follow up ( pre-supposes capture of patient religion )

shift handover summary

print care summaries for patients

print active care plans by patient

3.2.2. Epic: Operating room documentation

Operating room documentation is multidisciplinary. There are surgeons, surgeons’ assistants, anaesthesiologists, various nursing roles...

Note

As a:

operating room nurse or doctor

I need to:

access the complete patient record

work through pre-operative checklists - consent, investigations, blood requests, pre-anasethesia checks etc

enter pre-, intra- and post- operative documentation using templates. This includes text, outcomes, anaesthetic medications, implants, explants, items used, medication administration record, transfusion administration record, pre-operative diagnosis, post-operative diagnosis, indications, specimens, complications, findings, notes etc

anaesthetic documentation includes: anaesthesiologist, start and stop times, anaesthesia types and agents, complication codes, free text

add addenda to documentation that has already been finalized

register specimens and dispatch them to the relevant labs

track usage of consumables and services and submit charges to billing as they are added; this also updates floor inventories. Bar code scanning or similar methods could be used.

track implants and explants - for purposes of tracking in the event of a recall

3.2.3. Epic: Peri-operative care

Note

As a:

operating room nurse or doctor

anaesthesiologist or anaesthetist

I need to:

access the complete patient record

generate and print patient collection cards

record the exit of the patient from the ward / department and notify theater

verify the pre-op checklist

admit, acknowledge and document patient arrival in the holding bay, OR, recovery bay and checkout ( with bar code scanning )

support verification of patient identity and procedure to be performed

validate the identity of the patient by scanning the bar code

record the start time of reach avigity - patient arrival, administration of anaesthesia, start of surgery etc

color coded tracking display: checked in, awaiting procedure, procedure in progress, procedure completed, in recovery, checked out

cancellation, with reasons

WHO surgical checklist

peri-operative data:

pre-op and post-op diagnosis

time in and time out

delay time and reason

allergies

meds and/or IV, dose, time

prep performed

pre-op and post-op free text notes

type of anaesthesia and anaesthesia agents

X-ray takens

implant log data e.g serial number, lot number, size

specimen data

blood loss

assistant surgeon(s) name

circulator nurse(s) name

scrub nurse(s) name

start and stop times for anaesthesia

start and stop times for surgery

complications

specimen dispatch list

consistent and organ disposal

requirements per procedure ( basket ) - to request from theater store

interface with CSSD for sets

return of unused supplies

documentation in death registry

3.3. Theme: CPOE

Computerized ordering covers the domains of pharmacy, lab ( pathology, microbiology, hematology etc ), radiology / imaging, diet, nursing care, procedures ( e.g specialized assessments ), physiotherapy, occupational herapy, catering, transport, theater etc

Orders share the following characteristics:

time and user stamped

‘signed’ by the ordering clinician or on behalf of the ordering clinician

Some orders ( e.g those entered by medical students ) may need verification before they are fulfilled.

Results share the following characteristics:

time and user stamped

‘signed’ by the issuer

patient name

hospital number

date and time of order

date and time results were last updated

alerts for changes / amendments

test name

visual cues for abnormal results

It should be possible to define custom result templates.

3.3.1. Epic: Patient diet orders

Diet orders could be entered by nursing staff, kitchen staff or clinical staff.

Note

As a:

nurse, kitchen staff member or clinical staff member

I need to:

prescribe diet for inpatients, outpatients, visitors, hospital staff etc

record patient specific diet preferences, which should be displayed to anyone involved in making or modifying diet orders

easily prescribe special diets e.g cardiac diet, normal diet, diabetic diet, renal diet

prescribe therapeutic diets e.g total parenteral nutrition, tube feeding or supplemental feeding

view meal requests, by day and mealtime

cancel meal requests manually; the completion of a discharge process or the recording of a patient demise should trigger auto-cancellation

view ingredients and calorie values for any available meal

3.3.2. Epic: Blood orders

Orders for blood can come from any of the clinical areas.

Note

As a:

doctor or nurse

I need to:

make requests for blood or blood products for my patients. Each request indicates: reason, urgency, patient’s blood and rhesus types, patient location, date needed, location needed etc

receive notifications on availability / non-availability and issuance of requested blood / blood products

perform electronic specimen cross-matching

3.4. Theme: Admissions, discharges and transfers

This set of features covers both ‘conventional’ (e.g surgical, medical, paediatric and specialized wards ) and short stay ( e.g day surgery, some endoscopy and some in-vitro fertilization ) admissions.

Every ward will be set up with: name, status, number of beds, specialty and gender. Rooms will have varied occupancy - single, double, ward bed, deluxe, suite etc. They will also have different charges. Beds will have different status codes e.g occupied, available, reserved, empty etc.

3.4.1. Epic: Real time bed board

The bed board is a real-time graphical representation of bed availability / status across the healthcare enterprise. It is the digital world equivalent of the traditional whiteboard that is often found near the nursing desk in hospitals - only better, by being realtime and hospital / enterprise wide.

The bed board shall be visible from every point of care that participates in the admission, discharge and transfer processes.

Note

As a:

user with an admissions role ( e.g admissions clerk, nurse )

I need to:

have access to a realtime bed board that shows patient names, patient numbers, visit (IP) numbers, age, status, type, gender, bed typem insurance information, clincial needs ( e.g oxygen or isolation ), expected length of stay / discharge date, leave of absence status, confidentiality status, admitting diagnosis and location

be able to filter the bed board by department, ward, room, patient type etc

be able to generate a printable patient census on demand, filterably by ward, nursing station, practitioner, expected discharge date etc

be able to view the bed status of other facilities in the enterprise

be able to distinguish occupied from unoccupied beds

be able to distinguish admitted patients from others in patient listings e.g by a bed icon

be able to quickly see unoccupied beds, and the corresponding wards / rooms

be able to block out periods of time when beds are unavailable; these periods will have lower and upper date / time bounds

be able to predict bed shortages

be able to track a single patient’s movements during their stay

be able to quickly access pending transfers, discharges, emergency registrations, demises etc

be able to set up custom floor plans and designate certain beds as being for certain patients e.g gender specific rooms / beds, beds for infectious disease patients etc

be able to set aside beds / rooms for observation patients; these rooms could potentially be billed by the hour

be able to generate an interim bill for any patient that is currently admitted, right from the bed board

produce and in-patient therapeutic procedures list

Because:

I need to be able to give my patients quick and accurate answers as I guide them through the admission process

I need to have accurate patient censuses at shift handover times

I need to quickly access information on bed status at other in-network hospitals when I am planning a referral or admission there

I need to be forewarned on impending bed shortages so that alternative arrangements can be made

I need to eliminate time wastages from placing patients in beds that are not usable e.g in a room that is undergoing maintenance

I need to be able to adapt to developments in my hospital e.g a new ward / wing, an outbreak that causes an improptu isolation ward to be set up etc

3.4.2. Epic: Outpatient ‘discharge’

This is the case for most patients - all who needed simple outpatient care or even mere reassurance.

‘Discharge’ from the emergency room could involve:

sending the patient home / back into the community ( the traditional meaning of discharge )

sending the patient to a ward ( admission to hospital for further care )

sending the patent to another facility for further care ( usually called referral )

The details of these three ‘modes’ of discharge are covered in the sections of this document that deal with ADT ( Admision - Discharge - Transfer ).

Note

As a:

emergency room clinical worker ( doctor, nurse )

I need to:

be able to discharge a patient who only needed outpatient care once their care plan has been implemented

print discharge instructions that the patient can take home with them. These discharge instructions can be customized for each patient, by picking relevant instructions from the patient’s record. The system should provide for multiple customizable discharge templates.

generate a discharge prescription and send it to the Pharmacy

schedule a follow up appointment

generate a return to work or school letter for the patient on request

generate a patient survey and send it to the patient portal

Because:

most patients who come to the emergency room will be discharged home in a matter of hours

patients who get clear instructions on discharge do better / follow their treatment plan better

most patients will be discharged with an prescription for home drugs

some patients may need to come back, esp. if we have decided on ‘empiric therapy’ ( treat on a presumed diagnosis, not a definitive / confirmed diagnosis )

some patients will need to get a doctors’ letter for their workplace and school

This feature interacts heavily with billing - the discharge cannot be completed unless the patients bill is settled or all the details needed to claim it from a corporate payer ( insurer / employer ) are captured.

3.4.3. Epic: Admissions

The pre-admission process is focused on information capture.

Admissions can be triggered from several points of care e.g A&E, theater, clinics etc. It follows then that these features will be exposed to multiple user roles.

There should be continuity between the emergency room and the inpatient departments i.e the same patient record should be used after the patient is admitted.

Note

As a:

user with admission responsibilities e.g an admissions clerk or a nurse

emergency room clinical worker ( doctor, nurse )

I need to:

view a queue of patients awaiting admission / admission requests

be able to request an admission for the patient

view ward / room / bed availability

request pre-authorization for insured patients that need admission

have instant access to the billing status of each patient in my queue

be able to send patients to the billing clerk’s queue for the payment of their deposits

be stopped by the system from re-admitting a patient whose previous bill is not settled

be stopped by the system from allocating a bed for a cash patient whose deposit is not paid

capture all vital information for patients who are due to be admitted. This information includes room preferences e.g ‘Prefers Standard Room’ / ‘Prefers Private Room’. It might also involve updating the existing patient record

admission data includes: date and time, medical record number, admitting physician, attending physician, admitting diagnosis, last inpatient date, text, primary and secondary insurance, VIP status,

verify eligibility for insured patients and obtain a pre-authorization where one is needed

reserve a room for a patient that is going through the pre-admission process; this could be a room or bed that is currently occupied but can be reasonably expected to be available at the time the admission completes

pre-admission reservation number

assign an inpatient number at the start of the pre-admission process

enter clinical notes

enter orders e.g lab and medication orders

access a listing of pre-admitted patients that can be filtered by date and time, location etc

cancel a pre-admission process

reschedule / change the target admission time for a pre-admitted patient

admit newborns

Because:

capturing all the information up-front will lead to a smoother admissions process

insurance authorizations usually take time; it is best if they are done early

rooms can be scarce or ephemeral in a busy hospital; I need to reserve it in order to be reasonably sure that my patient will get a room

the inpatient number is used to tie together the patient’s inpatient records, including any orders that may be made in the pre-admission period

the patient could already be under active management e.g in the emergency department, hence the need for ongoing clinical notes

it is essential to have visibility into the pre-admission queue / workload, for optimization and planning

pre-admissions can be aborted e.g in the event of a patient’s demise

pre-admissions can be delayed, e.g in the case of an elective surgical procedure that is moved to another date after a surgeon’s or anaesthetists’ review

for most patients, the admission process starts at the casualty / emergency department

I need to be able to deal with the two most common hold ups in the process: ward / room / bed availaibility and billing problems

I need to quickly advice my patient - or my caregiver - on whether they need to go through billing first OR on the status of their insurance pre-authorizations

I need the system to help me avoid errors that could cause revenue leakage

3.4.4. Epic: Assigning a bed to a patient

The ward / bed / room assignment has billing implications; for example, private suites are more expensive than shared standard rooms, per day. Some patients may have high end insurance that entitles them to expensive rooms; others might only be able to afford cheaper ones.

This is the last step in the ‘admission’ process - it is the point at which the whole admission ‘crystallizes’.

Note

As a:

user with admissions responsibilities ( admissions clerk or nurse )

I need to:

assign a bed to a patient, based on their preferences and ability to pay ( deposit paid, insurance category )

be able to charge a lower rate to a patient who is placed in an expensive room / bed because of lack of availability of cheaper rooms / beds

be able to assign confidential / VIP status to certain patients; their records get sealed for access by only a select ( named ) list of caregivers

print patient labels

enter the expected length of stay - which can be used to give alerts when the patient is near the end of that lenght of stay

assign a patient to an overflow bed if their assigned room / bed is occupied

alert porters and ward staff when a patient needs to be transported to the ward

admit a newly born baby to the mother’s bed; the baby should be able to get their own record and inpatient number later

rely on the system to check for conflicts for me e.g prevent me from assigning a female patient to a male bed

be able to overrride system conflict warnings ( with a reason kept on record )

be able to transfer patients between wards and beds, noting the reason for transfer each time. The transfers may or may not trigger new rates.

be able to swap patients between two beds

assign beds to observation patients - who are not actually in-patients

transitioning patients from observation to inpatient and v. versa

Because:

it is my job to meet patients’ needs as well as I can

I need to solve emergent problems e.g temporary capacity problems that can be worked around by admitting some patients into more expensive rooms without prejudice to the patient

I need to communicate efficiently with ward staff and porters

I need to be able to correct errors or undo temporary choices that were made due to capacity challenges

I need to be able to make judgement calls e.g in times of emergencies such as outbreaks, when a female room could be used for male patients or vice versa

3.4.5. Epic: Discharge from inpatient or day case admission

This feature’s scope runs from discharge planning to post=discharge actions e.g housekeeping.

The discharge process is one of the processes that is most commonly ‘broken’ in today’s healthcare settings. The norm is for it to be a disorganized mess, with the patients / caregivers tossed between offices and taking hours for what should be a routine process.

Note

As a:

user with discharge responsibilities ( e.g discharge clerk or nurse )

I need to:

receive relevant ( to my location or job station ) discharge planning alerts based on expected discharge dates

receive confirmed discharge alerts after the doctors make the discharge decision; these include information on the discharge e.g doctor , reason ( normal, against medical advice, absconded, demise ), dischage diagnosis, date and time of discharge, clinical discharge notes / summary

be able to view pending discharges by nursing station

be able to work through a discharge checklist - nursing actions, patient / billing actions, discharge medications and equipment, post-discharge care instructions e.g wound dressings

customize discharge checklists / discharge plans - by patient, diagnosis, surgery, physician

be able to process unused drug returns from the patient

be able to cancel undone investigations and have them removed from the patient bill

automatically discontinue inpatient medications upon discharge

be able to schedule follow up appointments

be able to cancel the discharge and notify relevant departments ( e,g Pharmacy, kitchen, lab, ward nursing desks ) of the cancelled discharge

be able to notify housekeeping after the discharge - to prepare the bed for another patient

be able to notify other relevant departments e.g cancel kitchen orders

be able to re-admit patients whose discharge is rescinded before they leave the ward

be able to initiate a ‘leave of absence’ - essentially a ‘soft discharge’ where the patient is sent elsewhere ( e.g ICU ) but is expected back

be able to view a summary of the discharge queue / pending workload, by station

print patient discharge instructions - educational and functional e.g drug monographs

send patient post-discharge surveys to the patient portal

handle death notifications

handle discharge against medical advise

Because:

the process will be more efficient if all involved parties have advance information

if I can see the points at which a discharge process has stalled, I can make targeted interventions

the post-discharge care process is as important as the intra-hospital care process; I need to set my patients up for success by equiping them with the right information and scheduling follow-on appointments

housekeeping need to turn the bed around quickly so that another patient can be admitted into the same bed

a discharge may be cancelled because of emergent clinical or administrative problems

other departments e.g the kitchen may need to adjust their workplans as a result of the discharge

3.4.6. Epic: Refer the patient to another facility

These referrals occur for these common reasons:

the patient is unable to pay e.g referral from an expensive private hospital to a public facility

the level of care needed is unavailable e.g referral from a smaller hospital to a teaching and referral hospital

Note

As a:

emergency room clinical worker ( doctor, nurse )

ward nurse or ADT officer

I need to:

be able to discharge and transfer a patient to another facility

generate discharge / transfer notes - containing clinical information picked from the patient’s record

view billing status, so that I can advice the patient or their care givers accordingly - e.g. to clear their bill

Because:

we commonly transfer patients who need more specialized care

we commonly transfer patients who are unable to pay, after delivering the legally mandated emergency care

The referral information could be printed ( common case in our context ) or sent via a health information exchange ( what we are building towards ).

3.4.7. Epic: Automatic charges

In a hospital, there are a lot of automatically added charge items e.g charging for inpatient beds each day, automatically charging for every test that is ordered etc

Even though these charges are automatic, there still needs to be some level of human oversight.

Note

As a:

billing user

I need to:

see room and bed charges that have been calculated automatically every day

see charges that have been added as a result of provider orders or nursing activities

see charges that have been added as a result of a workflow step e.g a standard admissions charge

see automatically calculated rebates e.g NHIF bed rebate

with authority ( maker - checker ), remove or reverse charges

Because:

adding these routine charges or rebates manually would quickly overwhelm the billing team

3.5. Theme: Blood Bank

The blood bank supports inpatient, surgical and emergency departments.

3.5.1. Epic: Blood bank dashboard

Note

As a:

blood bank employee with coordination duties

I need to:

access listings of blood requests for clinicians

enter manual requests ( request that come as paper instead of ‘online’ )

be notified when a new request is received via CPOE

prioritize requests for blood e.g higher priority for surgical emergencies

conduct cross-matching for incoming patient requests

issue blood and blood products to fill requests

accept returns of unused blood that is in restockable condition

perform transfusion reaction workups

see a patient’s blood bank history when ordering

Because:

responding quickly to blood requests can save lives

3.5.2. Epic: Donor register

Note

As a:

blood bank employee with donor registration duties

I need to:

maintain a donor register - which will have, among other details, contact details, donor types ( patient / relative / autologous / platelets etc ), donor vitals, donor lab readings e.g Haemoglobin, donor notes, donation history etc. The donor register will allow for search by blood group, gender, date of birth etc. For each donor, track name, sex, date of birth, marital status, contacts, occupation, blood group, blood type, antibody profile, donation dates, comments

link to donor medical history

display donors full history of donations, tests, results

consent for donors

mark permanently deferred donors e.g due to sero status

mark temporary deferral e.g weight, age, menses, time lapse period

warn the user during registration if the user is on a deferral list

generate an alert when a donor attempts to donate while deferred

trace all recipients of a particular donor

trace all donors of a particular recipient

recall donors who are due for next donation via automatic notification

list of regular donors for rare blood groups

track minimum / maximum donation levels and generate alerts when necessary

support donor inquiries

generate birthday / anniversary new year/ Christmas wishes for donors and reminders for next donation

Because:

the blood bank needs to have accurate information for emergency blood outreach

donor tracking information will help the department plan blood drives

3.5.3. Epic: Handling blood donations

Note

As a:

blood bank employee with blood donation duties

I need to:

receive donations - with the ability to maintain bleeding data, blood bag data, blood bag expiry, amounts drawn, time in and out

tag blood bags with RFID tags and bar codes; the bar codes should be ISBT 128

conduct standard tests on donated blood, as per national guidelines e.g BP, HB, weight, temp, pulse

conduct rhesus typing and antibody screening on donated blood

process donated blood - in whole or separated form - into bar coded blood bags

dispose of unacceptable blood

carry out repacking

carry out aliquoting / pooling

scanning and printing of ISBT128 labels

maintain an audit trail of all processes from the vein of the donor to the recipient

manage autologous and directed donations

link directed and autologous donations to the intended recipient even if the intended recipient is not yet registered

screening and compatibility tests

phlebotomy - facilitate sample collectionn and processing

entry of phlebotomy information, including start and end

track specimens through transport, receipt, testing, storage, testing, final disposition

generate bar coded labels and collection lists

log specimens into storage and quickly locate them by rack, position and refrigerator when additional testing is required

provide a list of specimens to be discarded according to a lab defined retention period

entry of blood bag types and lot numbers

antibody, antigen and serology specimens

capture and provide reagent log details e.g lot number, batch number, expiry date and manufacturer

quarantine non-conforming blood and blood components

quarantine products from prior doations wtih HIV , HEP C HBV, syphilis

all tests on a donated unit must be completed before transfer to stock inventory

generate and print black and white ABO/Rh labels on demand

notify donors of test results

authorized override of cross-match restrictions in emergencies

Because:

blood donations are the primary way in which the blood bank receives ‘new stock’

3.5.4. Epic: Management of blood and blood product inventory

Note

As a:

blood bank employee with supervisory duties

I need to:

access inventory information for blood and blood products

track each blood product from donation through receipt into inventory, testing, modification, transfers to other facilities and final disposition

be alerted on reorder levels

be alerted on critical / panic levels

be able to reserve blood / blood products for anticipated uses

access donation and screening reports

be able to receive blood and blood products from other centers

Because:

avoiding stockouts helps avoid unnecessarily suffering or death

3.5.5. Epic: Blood Component Preparation

Examples of blood components are fresh frozen plasma, packed red cells, platelets, cryoprecipitate etc

Note

As a:

blood bank user

I need to:

support blood component preparation: capture the date of preparation, date of expiry, storage of each component, link to donor profile

track deviations and unexpected events during manufacture of a finished product

generate a list of donor units waiting to be label verified

maintain a reference table of blood components and batch products with label bar codes

print color coded ABO labels ( O - Blue, A - Yellow, B - Pink, AB - White )

automatically update the donor / patient records once test results are reviewed and verified

3.5.6. Blood storage and distribution

Note

As a:

blood bank user

I need to:

capture the following information for each individual unit: donation number, ABO and RhD group, component code, expiry date, expiry time

allow entry of the component information above by scanning of the bar codes

allow the following component characteristics to be retained against each component: antigen typing, CMV antibody status, gamma / X-ray irradiation, Hb S status, high titre flags, volume, comments

allow the system to generate an alert if freezing time requirements are not met for cryoprecipitate

ability of the system to generate an alert if a unit of blood is not leukoreduced within the appropriate time frame

ability of the system to provide component inventor control, processing and tracking

manage and automatically update inventory based on donated units and units issued

prompt for the following before issuance of units: identity of the individual collecting the units, patient’s MRN, destination of the unit, barcodes of the units

mark specific units that should not be used

modify expiration date and time for products

allow expiration date to be overridden with proper clearance

track expiry dates and manage issuance of units based on this

track expiry dates of units in stock and generate an alert when about to expire

generate a list of units in order of remaining shelf time for any unit type and ABO group

record unit movements, including transfer between reserved and unreserved stock, transfer to and from satellite refrigerators, issus to users, transfers to other departments

return of unused products

recall of units, with reasons

log the amount of time a unit was out of the blood bank for returns and recalls; alert if above policy threshold

recall, with reasons

prevent dispense of incompatible blood and components

match needs to units e.g patients who need irradiated or antigen negative blood

allow emergency issue

automatic cancellation for discharged patients

display patient specific blood bank info: units held for the patient, current specimen status, ABO/Rh, antibodies and antigens, transfusion needs, current testing status / results, current order status, transfusion reactions

reports:

daily transfusion log

units received by donor

units issued per patient based on component type and blood group

cross match requests - by location, diagnosis, doctor etc

transfusion reactions

disposition

donor units ready to be label-verified

stock

request and demand

expired blood products

reserved, recalled, returned units

3.6. Theme: Support services

3.6.1. Epic: Kitchen management

The kitchen contributes directly to patient care, especially for inpatients. It is also a significant cost and revenue center - making it relevant to overall profitability.

Large hospital kitchens may want to conform to ISO 22005.

Note

As a:

kitchen supervisor

I need to:

define different menus: regular, renal, low cholesterol, diabetic, light and gastric, children’s ( above 9 months ), children’s ( below 9 months ), toddler;s menu, a la carte, special diet request, kitchen feed, banqueting

access listings of patient meal requests for each meal - with the ability to group similar meal requests together for easier use in meal production planning; this list includes: patient age, physician, diet type, isolation indicator, current diet order and effective date, diet order history, food allergies, preferences, date last seen by dietician, next visit with dietitican, nutritional assessment score, dietitian comments, NPO status

define site specific recipes - portion sizes, preparation area and time, equipment and serving utensils, recipe category, ingredients, directions for preparation, nutritional values etc

define multiple meal and menu cycles, including planning for holidays

forecast meal demands

access a diet cancellation report for each meal - e.g for patients who have been discharged or passed on. This information should also be updated in the listing of meal requests

prepare meal distribution lists - for each meal, it should be clear where it is to be delivered, to whom and when. The meals should be accompanied by delivery labels / slips. These slips may be referred to as diet cards or tray tickets.

access a dashboard / reports with the following information: analysis of served meals, additional meals, cost per meal, tube feeding cost, supplemental feeding cost, staffing etc

manage inventory and cost of raw ingredients; forecast, requisition, purchase, receive, issue

access a late admission report / dashboard and notifications - with meal requests arising from admissions that occur close to meal time

support group ordering e.g meals ordered for seminars

document and communicate drug-food interaction

3.6.2. Epic: Housekeeping management

The housekeeping team cleans and maintains all public and private areas. Some cleaning tasks are scheduled e.g low traffic public areas may be cleaned daily. Some cleaning tasks are performed on demand e.g cleaning spillages in high traffic patient areas or cleaning a room after its occupant is discharged. Sometimes a location may be cleaned on both schedules - every room is cleaned daily, regardless of whether the occupant is discharged or not.

Note

As a:

housekeeping supervisor

I need to:

maintain schedules for day to day housekeeping activities e.g routine cleaning

receive notifications for new tasks e.g post-discharge cleaning. These notifications may be from automated events e.g post discharge hooks. They may also be entered manually by nursing staff.

manually enter and allocate requests for ad-hoc cleaning

have a dashboard that shows all of the workload, staff and locations in a manner that is easy to process

maintain cleaning supplies inventory - requisitions, receipts, issues, stock reports etc

monitor task completion for staff under me

update task status for staff under me e.g when rooms are cleaned

mark locations that need prolonged housekeeping work ( e.g wards that are temporarily closed for fumigation ) as unavailable

3.6.3. Epic: Management of central sterile services

CSSD coordinates the cleaning / disinfection / sterilization of hospital linen and reusable equipment e.g surgical packs

Note

As a:

CSSD supervisor

I need to:

define the CSSD store, with items, sets and packs

define instruments and consumables in each pack

maintain inventory

charge user departments for consumption

generate and print bar code labels for items: name, expiry data, batch number, department / specialty

autoclaving schedule for all equipment and items

recognize items consumed in patient care and mark them as due for stelilization

request for sterilization from outside services

alerts at CSSD for items due from various points of service

alerts for items whose expiry date is due for resterilization

capture broken and lost items

recall issued items / packs / sets from the user department

billing for sterilization services

loaning of equipment to points of consumption

planned preventative maintenance

receive contaminated items from wards, outpatient departments and theaters

exchange those items with clean or sterile ones

prepare work lists, segregated by sterilization method

transfer cleaned items to wards, outpatient or surgical departments

send items to external cleaning agencies

receive back items from external cleaning agencies

access a dashboard / reports with inventory, location and transaction information

3.6.4. Epic: Biomedical equipment maintenance

Equipment maintenance may be scheduled or ad hoc.

Note

As a:

maintenance supervisor

I need to:

maintain an equipment-location register, with each piece of equipment uniquely coded

manage a maintenance schedule

receive alerts for ad-hoc maintenance requests

allocate staff for maintenance tasks / issue job cards

manage external annual maintenance contracts

request maintenance work from external maintenance partner

manage warranties - including warranty work job cards

manage equipment availability for scheduling

3.6.5. Epic: Morgue management

Note

As a:

morgue manager

I need to:

receive bodies - from own hospital and from outside sources ( admission )

register deaths - including issuance of relevant legal documents

charge morgue fees - including preservation fees

manage preservations - work lists

manage post-mortems - including entry of post-mortem reports

manage morgue discharge and body collection

access reports on unclaimed bodies

dispose off unclaimed bodies - following the due legal process

This particular feature should be designed in a ‘bare bones’ manner.

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4. Product: Network, mobility and telemedicine

Good analytics demands a very different mindset from operational system design. Slade clinical analytics shall be offered as a companion product.

Some of the portals that are likely to be in the backlog are:

a supplier portal

an employer portal

4.1. Theme:Patient Portal

4.1.1. Epic: Patient portal enrollment

There are two ‘paths’ to patient portal enrollment: self enrollment and enrollment via a provider’s invitation.

Note

As a:

patient

I need to:

receive portal invitations from providers

respond to invitations from providers, with email and date of birth verification; if I already had an account on the provider portal, a new one should not be created

enroll myself into the provider portal, without an invitation

set up my preferred providers and practitioners

reset my own password

update my own profile e.g contact details

enroll dependants / family members e.g children

pre-register myself and share demographic data with the hospital

The ‘dependants’ functionality is likely to be very tricky, esp. when it comes to privacy and confidentiality angles.

4.1.2. Epic: Patient calendar

This calendar is focused on a single patient’s health related schedule, tasks and reminders. These may be linked to different providers or practitioners.

Note

As a:

patient

I need to:

view my own appointments; both those sourced from in-network provider EMRs and those that I input myself

toggle between day, week, month and agenda views ( the agenda view has compressed appointments, reminders and tasks )

add appointments - noting locations, times, people as needed and color coding them as needed

opt in to appointment reminders, with the ability to choose the method of communication and timing

receive billing, preventive and follow up care reminders

receive chronic disease management plan linked reminders e.g reminder to a diabetic to do their blood sugars

request appointments - check availability, receive confirmation on booking

communicate with providers to request appointments for those that have no enabled online appointment booking

4.1.3. Epic: Patient medical profile

The ‘medical profile’ brings together information about a patient’s health that they are entitled to from all in-network healthcare providers.

The health log allows patients to log their own observations - manually or via connected devices - and share them on an opt-in basis with their providers and practitioners.

The patient portal can be used to deliver targeted and relevant health information to patients e.g pregnancy related information to female patients who are currently pregnant.

Note

As a:

patient

I need to:

view a log of my past medical visits

view my chronic problems

view and update my allergies

view and update my family and personal medical history

view and update current and previous medications; both those sourced from connected EMRs and those that I input myself; when updating medications, I should be able to note the names, reason for medication, times / dates / doses, who prescribed etc. Over the counter medications should be part of this.

view and update my immunization history

view the detail of each visit - with the detail including tests, results, discharge / visit summaries, medications, discharge information packets etc

view and update my bio-data ( including weight, height etc )

maintain a log of my health issues

share my health log with specific providers - when I choose to

connnect my fitness tracker or mobile devices to my health log for personal fitness tracking

access relevant health related articles and education resources e.g videos, infographics etc

access fitness calculators

access treatment guidance and symptom checkers

4.1.4. Epic: Cover information

This includes: visibility into insurance, employer benefits, health savings plans etc

As written, this focuses largely on the needs of insurance customers.

Note

As a:

patient

I need to:

access clear information on my insurance cover - including validity, packages, benefits, exclusions, rider packages, provider panels, dependants etc

view a timeline of visits, claims and preauthorizations that have been linked to my cover

click through to detail on visits, claims and preauthorizations

receive notifications whenever there are changes in my cover or new visits, claims and preauthorizations

4.1.5. Epic: Communicating with my providers and practitioners

Telemedicine is ‘woven into’ the communications infrastructure. Some of the telemedicine services may be billable.

Note

As a:

patient

I need to:

access and filter / search through listings of providers and practitioners; with those that I have dealt with in the past or added to my ‘preferred’ lists being easier to find

exchange secure messages with the care team via threaded messages and a rich inbox. These messages should be routed to the correct team / team members e.g refill requests go to doctors, billing questions go to billing staff e.g

requesting prescriptions or refills

sharing documents or images with the provider / practitioner

sharing my health history and/or health log with the provider / practitioner

make voice calls via the patient portal to the provider / practitioner

make video calls via the patient poral to the provider / practitioner

capture images with my mobile device camera and share them with the provider / practitioner

control my presence / availability

respond to requests from the provider e.g filling in questionnaires, filling in practice forms, self check-in

request or schedule appointments

receive alerts when there are results or reports awaiting review in the portal; the provider / practitioner should be alerted when they are reviewed

receive clear information on what charges are due, for what services

be able to pay online via card or mobile money

be able to opt to pay on arrival for services delivered in person

4.2. Theme: Practitioner Portal

The practitioner portal provides access to the ‘Clinical Workers Dashboard’ ( described before in other features ) and to the records of patients that the practitioner in question has interacted with.

The remote visits features that are part of the ‘main EMR’ will also be enabled here.

4.2.1. Epic: Practitioner portal sign up

Practitioners can self-enroll in the practitioner portal. They can also be enrolled by invitation from collaborating hospitals.

It is important to note that a practitioner may be working in more than one clinic or hospital.

Note

As a:

practitioner e.g doctor, dentist, counselling psychologist, physiotherapist etc

I need to:

be able to enroll myself in the practitioner portal ( self service )

enroll by responding to an email invitation from a provider ( hospital, clinic etc ) that I work with

set up the providers that I work at e.g the hospitals where I have admitting rights

set up the locations at those providers that I work at

set up my preferences e.g e-Consultation

Because:

for the portal to be useful, it needs to reflect the fact that I might be working at more than one provider at the same time e.g on a locum basis at multiple facilities

I need targeted information e.g for locations that I care about

4.2.2. Epic: Manage my own profile as a practitioner

An individual provider has complete control over what appears in their profile. This profile may be shown in public listing pages and in the patient portal.

Note

As a:

practitioner

I need to:

add, view and edit my basic details e.g name, license information, locations of practice, contacts, about me ( descriptive text ), specialty or specialties, affiliations ( professional and hospital affiliations ), availability ( hours, days and locations ) ec

view my ratings and reviews from patients and engage with the reviewers ( reputation management )

view and update my practice listing as seen on the patient portal and other practice marketing tools

4.2.3. Epic: Find locums

Locums are temporary positions - often filled on an ad-hoc basis by younger practitioners - that pay by the hour or a fraction of specified billable items e.g consultations, procedures etc

Finding locums is presently a ‘human’ process. A locum finder is likely to be a ‘hook’ for younger doctors.

Note

As a:

practitioner

I need to:

set up my locum settings - specialties, preferred providers, hours, days, locations etc

browse through upcoming locums, auto-filtered by my preferences e.g my hours and days of availability, preferred providers, preferred towns / locations etc

receive notifications of locums that match my preferences

click through to the detail of any locum - view the provider, desription, duration

skip locums that do not interest me and apply to positions that interest me

receive notifications of accepted / declined applications

4.2.4. Epic: My billings

As a provider - especially one that has multiple locums and e.g admitting rights in multiple hospitals - I want to have a single unified view of my billings.

Note

As a:

provider

I need to:

access a unified cross-provider listings of my billings, sorted by date with more recent ones first

filter or sort the billings list by date range, provider etc

click through to detailed invoices

add and send invoices - linked to specific patients and visits - to providers e.g to charge for my consultations fees after discharging a patient

4.2.5. Epic: My televisits

The practitioner portal and EMR will offer the ‘supply end’ of telemedicine. It is important to note that teleconsultations will not be just patient-provider, but also provider-provider.

Note

As a:

practitioner

I need to:

browse and search through the contacts of providers and patients that I can communicate with

manage my availability / presence e.g available, busy, do not disturb, unavailable between specified dates and times etc

communicate via text ( threaded chat ) with patients and colleagues

communicate via voice ( IP voice call ) with patients and colleagues

communicate via video ( browser or mobile based video call ) with patients and colleagues

use my phone cameras to capture still images that can be sent to patients or colleagues

charge for televisits - where applicable

access all my communications via a rich and smart inbox

4.3. Theme: Payer portal

4.3.1. Epic: Case Management

Note

As a:

case manager at a payer

I need to:

access real time admissions information for beneficiaries from my company for the providers that are on the Slade network

access real time discharge information from beneficiaries from my company for the providers on the Slade network

easily request and receive interim bills for inpatient beneficiaries from my company

receive and respond to pre-authorization requests from network providers

update pre-authorizations with new information e.g revised limits

access incoming claims from an online interface

request and receive clarifications on claims

Because:

I need to monitor utilization in realtime, to manage risks

I need to communicate efficiently with providers in our panel in order to shorten claims assessment times, even for claims with potential problems

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5. Product: Informed decisions

Good analytics demands a very different mindset from operational system design. Slade clinical analytics shall be offered as a companion product.

5.1. Theme: Reporting

One of our project goals is to facilitate ‘informed decisions’ in healthcare.

5.1.1. Epic: Clinical analytics

The mix of summaries and reports that a single user sees shall be determined by a mix of access control ( what they are allowed to see ) and opt-in controls ( what they want to see ).

Note

As a:

clinical analytics user

I need to perform the following analyses:

identification of patients that need care management e.g high risk, chronic disease, frequent flyers, high utilization

alerts and listings of notifiable conditions e.g those that should be reported under Kenya IDSR guidelines

case mix analyses e.g case mix by physician, case mix by department, workload by surgeon etc

volume analyses e.g outpatients by service and department, top N diagnoses, top N procedures

length of stay analyses for inpatients

clinical study eligibility and recruitment - calling up matching patient records from the registry

patient satisfaction analyses - informed by patient surveys

drug and device recalls

service utilization trends

adverse outcomes analysis - mortality reviews, surgical morbidity, adverse drug reactions, medication interactions, allergic reactions, medication errors etc

network referral analysis, including network leakage reports for out of network referrals

operating room utilization analysis - activity, overruns, delayed cases, rescheduling, cancellations, requests etc

monthly, quarterly and annual surgical volume reports

surgical supplies utilization

surgical equipment maintenance and downtime

turnaround times from support services e.g CSSD, blood bank, maintenance

drug utlization statistics - by drug, class, physician, service, location, diagnosis etc

issuance and usage of controlled substances - by patient, department, date, location etc

inpatient, outpatient and emergency department abstracts

DRGs - before, during and after inpatient stay

case mix analysis based on DRGs

retrieve patient demographic data and diagnoses

productivity - work completed, time spent

birth log

death log

generate DHIS 2 reports

age standardized death rates e.g 0-5 years, 5 - 10 years

reporting trends e.g total admissions, bed occupancy over a user define period

5.1.2. Epic: Hospital reporting

This covers administrative-style hospital reporting

Note

As a:

hospital administration user

I need to perform the following analyses:

workload and utilization e.g by theatres, nursing staff etc

end of shift reports

statististical reports on casualties, attendance and admission from A&E

turnaround times, by point of service

daily ( midnight ) ward statistical report: name of the ward, actual vs occupied capacity for each room type, admissions, discharges, transfers in, transfers out, deaths, vacant / available beds, turnover per bed, average length of stay, patient days

daily ( midnight ) clinic activity report: clinic name, number of new patients for the day, number of old patients for the day, total number of patients ( new / old / reviews ) seen for the day

daily ( midnight ) admissions statistics: analyzed by admitting department, specialty, department, hospital, doctor etc ( in aggregage and listing )

running monthly report generated daily: day, total admissions, average length of stay, deaths, percentage bed occupancy, bed turnover interval, total patients seen at A&E, percentage of A&E admissions, cumulative and average statistics

monthly morbidity summary sheet from MOH for children under 5 - disease, day of the month, cases reported for each day, cumulative cases for the month to date, total cases reported each day for all diseases, gender of patients, new or existing / old case

monthly morbidity summary sheet from MOH for patients over 5 yrs- disease, day of the month, cases reported for each day, cumulative cases for the month to date, total cases reported each day for all diseases, gender of patients, new or existing / old case

inpatient statistics: specialty, admissions ( admissions under 5, admissions over 5, paroles, occupied bed days - cash and NHIF, well ), discharges, average length of stay, patient days, turnover per bed, deaths, abscondees, beds - authorized and actual, cots - authorized and actual

maternity services statistics - normal deliveries, caesarean deliveries, breech deliveries, assisted vaginal deliveries - vacuum and forceps, born before arrival ( BBA ), maternal deaths, audited maternal deaths, live births, still births, neonatal deaths, low birth weight babies ( under 2500gms ), total new born discharges, date of birth, time of birth, infant mortality, perinatal mortality, immunization schedules and coverage ( in pediatrics ), child growth and malnutrition

surgical statistical reports - minor surgeries by type, emergencies by type. cold cases, circimcision, major surgeries by type

ICD-10 statistics: injury cases, sports injury among children and adults, general accident statistics, cancer incidence rates, mortality rates, patient survival rates, incidences of vaccine preventable diseases, infectious disease statistics, communicable disease statistics. tropical diseases, non-communicable diseases, child health related diagnoses e.g acute respiratory infections, HIV/AIDS, Asthma, sexually transmitted diseases, other diseases e.g TB, causes of health, causes of infant death, suicide statistics, blindness and deafness, mental health

disease control and prevention statistics

clinical service visit statistics by department, days on list by unit and treating doctor, elective admissions, actual time of procedure vs planned, cancellations with reason

waiting list survey for different time periods or services / procedures

services scheduled, cancelled, completed etc by department

patints on waiting list

days on list by unit and treating doctor

elective admissions report

nursing reports:

KPIs, training, special procedures, patient satisfaction

critical patients from wards

occupancy report

discharge summary report

duty rotas and allocation

incidents

patient complaints

discharge against medical advice

admissions

sick off

readmissions within a month

readmissions to CCU

readmissions after outpatient visit

unplanned CCU admission

unanticipated cardiac arrests

unexpected medical outcomes

unexpected surgical outcomes

unexpected anaesthetic outcomes

unexpected obsteric outcomes

maternal deaths

fetal deaths

neonatal deaths

surgical REDOs

priority patients e.g VIP, critically ill, long stay, major surgery

medication errors

near misses

self extubations

failure to rescue cardiac arrests

property loss

missed diagnosis

declined intervention

missed radiological diagnosis

laboratory incidences

finance indidences

ADT incidences e.g insurance fraud

security incidences

physical medicine incidences

food handlers report

catering hygiene

clinical audits

5.1.3. Epic: Pharmacy reporting

Note

As a:

pharmacy adminisrator

I need to perform the following analyses:

billing summaries, by patient, date, drugs etc

medication summaries, by patient

drug usage / utilization

goods in transit

revenue analysis

drug pricing

controlled substances

statistics: most used drugs, slow moving drugs, workload, stock usage, departmental usage

items above maximum stock level

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6. Backlog

This work is not scheduled. There are no immediate plans to schedule it.

6.1. Theme: Asset Register

This covers routine purchasing and acquisition of assets.

6.1.1. Epic: Asset Register

The asset register tracks assets - e.g expensive clinical equipment - and their cost, depreciation, maintenance, insurance, improvements, sale, retirement, writing off etc. It interacts with the balance sheet ( assets appear on the balance sheet ). Some assets are ‘devices’ in the FHIR sense.

Note

As a:

asset manager

I need to:

maintain an asset register that tracks asset names, location, descriptions, costs, tag and serial numbers, purchase dates, in service dates, depreciation methods, book lifes, disposal methods, disposal dates, salvage values, vendors and vendor invoices, purchase order numbers, property types, funding types and old vs new indicators

place assets in categories e.g buildings, leasehold improvements, medical equipment, furniture and fittings, other equipment, motor vehicles

asset sub-categories

define asset types as: Tangible - Fixed, Tangible - Moveable, Intangible

access historical asset data, even that relating to retired assets

record asset acquisitions

record asset sales or disposals

transfer assets between organizations and locations

track leased assets

manage lease payments

retire assets

record asset improvement costs

reinstate retired assets

view depreciation - by time period, life to date etc

maintain warranty information

change operating status e.g out of service

issue work orders for warranty and non warranty maitenance

6.2. Theme: Voice support

This covers routine purchasing and acquisition of assets.

6.2.1. Epic: Dictation of clinical notes

Clinical voice recognition shall be used in order to make clinical notetaking less cumbersome, especially on mobile platforms.

The dictation feature will be appreciated most by busy clinical workers e.g doctors, radiologists, pathologists, nurses and lab technicians.

Note

As a:

clinical user ( e.g doctor, nurse, pathologist, lab technician )

I need to:

dictate notes using my voice on my computer and on my mobile devices

Because:

my workload is high - I need speed

I want to be able to make notes as I wait or move around

6.2.1.1. Scenario: Dictating Pathology Reports

This scenario is merely representative; there will be dozens of scenarios in which voice input applies.

Note

Given:

a completed pathology investigation that I wish to report, as a pathologist

And:

a voice capable device e.g my phone, tablet or laptop

When:

I click or tap on the microphone icon

And:

dictate into the device

Then:

text that is at least 95% accurate is entered into the template, with potential spelling errors highlighted / underlined

And:

I am able to correct the few errors and quickly save the completed report

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