Procedure Reporting System

The Procedure Reporting System provides clinical users with the ability to document any type of clinical procedure. It is fully integrated with the JHMI Electronic Patient Record (EPR); using EPR as the source for patient, encounter, and referring MD information; and automatically adding clinical procedure documents to the EPR as they are created. As by-products of the procedure documentation process; professional fee charges and hospital charges are automatically generated and delivered to the appropriate patient billing systems; and, the procedure reports are automatically delivered to referring physicians via fax. By its integration the system eliminates many, currently disconnected, manual processes such as transcription, hospital charge entry, and professional fee charge entry. Data is captured at a very detailed level for all procedures and can easily be extended to include data specific to an individual procedure. The resulting database provide an ideal data source for management reporting, process analysis, and clinical research. Initially developed for the Department of Cardiology the system has been constructed in a modular fashion which will allow it to be adapted, at low cost, for any procedure oriented specialty area. Each specialty will inherit all the common functions and integration provided by tlte base application while still providing each specialty with complete control over the detailed data specific to their own procedures. Description (Set) Virtually all data entered into the system is validated either against a dictionary of allowed values (for coded items, or categorical variables) or a numeric range. In the case of numeric values both an "allowable range" and a "warning range" may be specified in the system dictionaries. In addition to checking the validity of individual items, the system also checks for validity in relation to the values already entered in otIler fields. These "cross field rules" are also dictionary driven, and like other validity checks may reject a value or give the user an "overridable" warning. Data Entry Validation occurs in three stages: 1. field mask (i.e. is the entry really a date, decimal number, or character string?) 2. is the field value itself valid (i.e. is a number in the allowed or warning range; or, is a categorical value one of the allowed choices?) 3. does the value violate any rule in relation to another value (is the systolic blood pressure higher than the diastolic blood pressure?) The dynamic behavior of the user interface, based upon context, is used extensively throughout the application. As is the ability of the user to expand the application's behavior beyond the context defined default. To facilitate rapid keyboard entry the user is never "forced" into any fonn of pick list. Valid data can be entered by simple "type" and "TAB" (often with automatic typing completion). The flow of data entry is only interrupted if the data entered is invalid, or if the user "selects" a drop down. Report content can be generated in multiple output fonnats including plain text (for transmission to our text oriented legacy data stores), "pretty print" (proportionally spaced, multiple fonts and attributes), PDF, RTF and HTML. In this system all common elements (such as patient, procedures performed, basic case infonnation, staff, medications, pre and post case vitals) are in typical subject oriented SQL tables and hence are easily reported in a common way across all cases. Similarly all procedure detail information is stored in typical subject oriented SQL tables (one or more for each procedure) and are easily reported by procedure. Only Observations are stored in "meta-data" driven tables. For data mining and reporting, measurement data would need to be "rotated" into a more typical SQL structure for easy access. Proposed Use (Set) Provide an "expandable" application which: -includes system integration with core institutional systems (modularly replaceable for different environments) -includes common components relevant to all procedures (Staff, Medications, basic Case information, etc.) -includes "meta-data" components for procedure related observations and measurements, which allow tailored functionality without coding allows individual procedure specific components to be seamlessly incorporated (with whatever data collection fimctionality the specific procedure requires) is configurable to serve a wide variety of procedure reporting medical specialties The overall objective was to provide a core application and infrastructure, which integrated with existing hospital infonnation systems, and which was configurable for any procedure reporting medical specialty witIl minimal additional coding. The application records detailed procedure and observation specific data, expanding its data entry GUI as needed.

Inventor(s): Coltri, Alan

Type of Offer: Licensing

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