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Medical Records Web |
- Comprehensive patient's data set
- Detailed clinic workflow
- Detailed doctor records
- Global data and standards integration (ICD-10/11, ICHI, ATC/DDD, NDC, CPT, HCPS ...)
- Social Security Administrations and Health Care Funds integration
- Clinic individual settings & existing data integration
- Flexible doctor interface
- Powerful analytic
- ...
Simplified solution schema:
Patient Data
Locations
Record
- Date
- Country
- City
- District
- ...
Occupations
Record
- Date
- Description
- ISCO 08
- ...
Symptoms
Record
- Date
- Description
- Measure
- ICD-10/11
- ...
Tests
Record
- Date
- Description
- ICHI
- CPT
- ...
Indications
Record
- Date
- Temp.,press,...
- Value
- ...
Clinic Workflow
Medical Case (previous)
Medical Case (Clinic visit, doctor in charge assigning, ...)
Doctor's Record
Visit / Patients Round / Ambulance / ... other events
- Patient's data adding/updating
- Preliminary diagnosis establishing
- Tests assigning
- Diagnosis confirmation
- Treatment assigning
- Treatment results analyzing
- Discharging/ transmittal
- Treatment changing
- ...
- CPT
←←←←←←←←
Diagnosis 1 (ICD-10/11) |
Diagnosis 2 (ICD-10/11) |
Diagnosis n (ICD-10/11) |
Session
in-patient/
out-patient
Surgery
- Date
- Description
- ICHI
- CPT
- ...
Procedure
- Date
- Description
- Doses
- ICHI
- CPT
- ...
Medicines
- Date
- Description
- Doses
- ATC/DDD
- CPT
- ...
↓
↑
↓
↑
Medical Records staff
Referrals handling, Billing, MSA withdrawing, ...
Doctor's interface standards:
Main challenge - don't busy doctor with typing, but provide entering most of analytic data.
Most of objects of patient's data and treatment process contain three level of information (at least):
- Free style description (of quolities, symptoms, tests, diagnosis, medicaments, ...)
- MRW (Merical Records Web) previously entered matching descriptions (list). "This clinic" or "World" options available to search.
- Global data matching objects (list) (ICD-10/11, ICHI, ATC/DDD, CPT, ...).
Doctor can select valid objects from matching/suggested (selected and unselected will be kept).
Clinic settings allow defining "Selection required", "Select later" or "Optionally" options individually for each data source (MRW, ICD-10/11, ICHI, ATC/DDD, CPT, ...). In the first case doctor should select items in matching lists during record entering. In the second case doctor may open record later and make selections, or may delegate to other staff handling doctor's record later and making selections from matching lists. In the third case selection can be omited.
Clinic individual adjustments
- Structure
- Personnel
- Information secure, visibility/accessibility from outside
- Global sources data selection requirements ("Required" status for diagnosis(ICD-10/11), treatments(ICHI), medicines(ATC/DDD), ...
- CPT prices
- ...
Social Security Administration & Health Care Funds integration
- Patients sharing by SSN
- MSA online withdrawing (clinic invoices)
- Invoices to patient and Health Care Fund (NHI copayment)
- Referrals handling
- ...