Data Sheet SW Ishmed Basis

®i.s.h.med basis (Basic Medical Record) Data Sheet Table of Contents Solution Definition .............................................. 4 Smart UI Initiative ..................................................... 4 Performance Features ........................................ 5 i.s.h.med basis (07600997) ...................................... 5 Medication Orders ...................................................... 14 Progress Entries......................................................... 14 Medical Services ........................................................ 14 Nursing Services ........................................................ 15 Administrative Services .............................................. 15 Chart ......................................................................... 15 Effects on Existing Data.............................................. 15 Intended Use ................................................................ 5 Health Problem ....................................................... 15 Basic Data Administration......................................... 5 Clinical Order .......................................................... 16 Base Items ................................................................... 6 Categories.................................................................... 6 Material Consumption ................................................... 6 Employees (Business Partners) .................................... 7 Definition of Order Types ............................................ 16 Clinical Order and Appointment Management.............. 17 Process Acceleration and Comfort Functions .............. 17 Implementation Support ........................................... 7 Clinical Work Station ................................................ 7 Patient Record / Patient Organizer ........................... 9 Administrative and Clinical Object Types (Content of Record) ...................................................... 9 Arrangement with Help of Aspects................................. 9 Screen Areas of the Record .......................................... 9 Patient Organizer Functionality.................................... 10 Patient Groups (Smart UI) ........................................... 10 Selection Dialog.......................................................... 10 Views and Displays..................................................... 10 Filters ......................................................................... 11 Graphical Plan ............................................................ 11 Patient Profile (Smart UI)........................................ 11 Patient Header ........................................................... 11 Compact Patient Header ............................................. 12 Task Management (Licensed) ..................................... 12 Applications ................................................................ 12 Patient Record (Smart UI) ...................................... 13 Parameterized Medical Documents (PMD) .................. 14 Examinations.............................................................. 14 Diagnoses .................................................................. 14 Vital Signs .................................................................. 14 Lab Values ................................................................. 14 Data Sheet i.s.h.med basis Page 2 of 35 Service Ordering (Smart UI) .................................... 17 Medical Service Management ................................. 18 Plan Services ............................................................. 18 Document Services .................................................... 18 Appointment Management and Planning ................. 19 Planning Grid ............................................................. 20 Quota-Based Planning................................................ 22 Configuration and Functionality ................................... 23 Clinical Documentation ........................................... 23 Parameterized Medical Documentation ................... 23 Definition of PMD Types ............................................. 23 PMD and SAP Document Management....................... 24 Usage Scenarios ........................................................ 24 Document Creation .................................................... 25 Subdocuments ........................................................... 25 Security, Release and Versioning ............................... 25 Special Indicators ....................................................... 25 Editing Documents ..................................................... 25 Deleting Documents ................................................... 26 Handling of Documents, Lists and Mass Processing Functions ........................................ 26 Findings Inbox............................................................ 26 Dispatch Control......................................................... 26 Document Communication.......................................... 27 Communication with External Systems ................... 27 Message Communication Infrastructure (MCI) ............. 27 Archive Connection..................................................... 27 Diagnosis and Case Processing ............................. 28 DRG and Other Billing Systems.............................. 28 Clinical Case Processing ............................................ 29 Cancel ................................................................... 29 Accident Number.................................................... 29 Outpatient Clinic and Service Facilities ................... 29 Calling Patients .......................................................... 29 Outpatient Treatment .................................................. 29 Outpatient Clinic Folder (Part of SAP ACM – Licensed Product from SAP) ....................................... 30 Treatment Sequence .................................................. 30 Ending Outpatient Treatment ...................................... 30 Application Logging ................................................ 30 Employee Responsible ........................................... 30 Enhancement Framework....................................... 31 Allergy Documentation ........................................... 31 Basic Data.................................................................. 31 Functionality ............................................................... 31 Examination and Laboratory Results ...................... 31 Clinical Evaluations / Statistics ............................... 32 Prerequisites for Implementation .................... 33 Modules ................................................................. 33 Integration .............................................................. 33 HANA ......................................................................... 33 System ................................................................... 33 Smart UI ..................................................................... 33 Other Prerequisites ................................................ 34 Data Sheet i.s.h.med basis Page 3 of 35 Applications incl.s.Patient groups (my care unit incl. The architecture of Smart UI consists of three pillars: · Overview .med occupancy management can also be used without i. service facilities and care units for communication. tasks and patient record) · Activity .Solution Definition i. i. Smart UI Initiative i.h. new developments and functionality Fig.med basis Page 4 of 35 .med SAP 6. graphical overview. the service request.h.s.med basis) is the core component of i.0 EHP 6 provides the first elements which resulted from the Smart UI initiative.h.med (exception: i.med and contains the most important basis and cross-sectional functions in outpatient clinics.s. dynamic filters and tasks) · Patient-specific work .s. These basic functions include the clinical work station.med basis contains the electronic patient record and is the basis for further modules of i.h.s.med SAP 6.h.h.med architecture (the relevant components are flagged with Smart UI).s. appointment planning and parameterizable electronic documents.basis (i.s. Furthermore.h.s. 1: Overview of the i.h.s.h. the redesign of the i.s. planning and documentation in hospitals.h.s.med basis).h.med und SAP components Data Sheet i.0 EHP 6 .Patient profile (overview of the patient. · Reduction of outlay for implementation and training Basic Data Administration i. clinical orders). The functions for adapting i.s.med to the specific administrative and organizational requirements.med basis (07600997) Intended Use i. The entered and displayed patient information includes administrative and medical data (findings.h. cancellation reasons.g.s. units of measurement.e. as well as those in clinical enhancements to the functionality of SAP Patient Management (licensed product from SAP) with two levels of system maintenance and master data management.med basis Page 5 of 35 . some of which are continual.s.h. IMG activities) are intended for IT specialists.med is also intended to enable access to data from third party systems.h. on the other hand basic tabular data. etc. i.s. Data Sheet i.s.med is intended for use by specialist medical staff that enter or call patient information for the purpose of planning. physician’s orders. is maintained here.h.s. The clinical basic data includes content such as the service master data (and clinical enhancements). input helps for attributing diagnoses. some of which are initial. for example. can generally be divided into: · Customizing · Basic Data Administration On one hand customizing includes individual parameters at system and institution level.med (i.s. medical and nursing care.h. These maintenance procedures.h.med is equipped for the use of various clinical functions and modules. reason codes. customizing. which as a rule remains constant over long periods of time. e.h.Performance Features The components under the umbrella term Smart UI which become available with EHP6 have the following aims: · Reduction of barriers for new users who are not yet familiar with the application · Drastic reduction in operational steps for routine workflows · Faster construction of mental models for the patient’s situation · Direct access to relevant information · Cross-sectional navigation · Flexible support in resolution of medical problems i. supporting and documenting clinical. who adapt i. · Depending on the type.h. such as steps of a clinical pathway. There are two methods of material consumption documentation: · Material consumption documentation without integration into SAP ERP Materials Management MM (licensed product from SAP): A prerequisite for this method is that materials have been created as services of the material type in service basic data administration. ‘plants’ must be configured and assigned either for each care unit (organizational unit = OU) or. In addition to the configuration functions described in this service description for the individual applications / processes (such as.s. are regulated using the usual attributes in the service master. such as medically better legible labels. at least. · Base items are used by various modules which are based on i. medical services.document categories and their structure and much more.g. diagnoses.med. · Using the semantics of the preset content.h. once per institution. for example OU-related hit lists. The MM article masters have additional medical attributes assigned within basic data management. Different proposal lists can be used to simplify documentation. task of a situation in the documentation work station).) the following data. transactions. controlling. · Material consumption documentation with integration in SAP ERP Materials Management MM is available if SAP MM is used in an institution. Material documentation based on SAP MM optionally enables the automatic posting from the . clinical orders. whereby servicerelated proposals are also supported. etc. requests. Categories Categories represent a way of classifying executed actions. URLs.s. · In i. progress entries. most of this basic data is connected to the SAP transport system (licensed product from SAP) so that formatting and quality assurance can take place on upstream systems. Individual materials or entire hierarchy trees are assigned to OUs via specific catalog and material proposal maintenance.med documentation objects (such as orders. also exists: Base Items Base items create the connection between the process-supporting objects of various applications (such as the steps of clinical pathways or the tasks in the care unit (ward) work station or surgery work station) and the individual i.med. call document in change mode as the repeat action). order types.h.). Data Sheet i. etc.h. base items also define the actions which should happen to the assigned object.med basis Page 6 of 35 documents.med. Billing. material entry.s.s. treatment pathways. base items enable extensive semantic presetting of the relevant object in i.med base items are supported for: Administrative services. To be able to use this form of material documentation. Material Consumption i. medication orders. surgery times. before this data is explicitly used productively. which simplify the documentation at the time of the performance.med provides options for posting material consumption on a patient-related basis (specifically: with a case or movement or service reference) or with reference to documented services (in surgery or at service facilities).h. document categories. form printing. surgical documentation. textual orders. which is used in various components of i. procedures. for example the exact specification of an entire order profile for a certain step within a clinical pathway. Depending on the recommended implementation scenarios. problems.s.s. complications. etc. and therefore being able to evaluate these specifically.s. documents. Medical services can therefore be assigned to service-dependent material proposals. for example. create a specific document as the initial action. team entry. · Base items are defined by the object which assigns them to a specific process step (pathways step. business add-ins (BAdI). as soon as the concerned calling process step is triggered for the first time or a repeated time (e.h.h. for team documentation within surgeries or at service facilities. Person-related billing steps.s.med basis Page 7 of 35 .med (see below).) and service-dependent task proposals enables a targeted documentation range at the time the service is performed. etc. etc. Employees (Business Partner) Implementation Support Implementation support is used to transport customizing data (e. assistant. · Tasks and employees can be connected if qualifications are determined as connectors. Depending on the object category in the foreground (patients. a correct assignment of the entered employee to an OU is necessary. orders.Import Wizard On the target system the content selected for installation in the selected installation package can be revised.g. documents. Clinical Work Station The clinical work station is the central organizational instrument for administrative and medical issues. can be interrupted.g.s. Due to their content.s.s. Data is transferred once from a named source into a specific system. for example.h. in case of extensive packages.s. for documentation.med surgery). several of these view types are jointly managed by SAP Patient Management (licensed product from SAP) and i. Typically it represents the start transaction of the medical user and is therefore often the first screen with which the user is presented in the HIS. MTRA.Export Wizard · Customizing . This assignment is made using the position reference. service description i. surgeon. for example.g.h. · The definition of tasks (e. Content which already exists in the target system can be adapted using different display and processing methods. for example. The two most important components of this function are offered in the ‘Customizing Transfer Manager’: · Depending on customizing.) special view types are provided.stock with optional immediate triggering of corresponding ordering and purchasing processes as well as patient-related billing of consumed materials using stored administrative service keys. Shift plans or shift times are not explicitly managed with this tool. · Customizing . · Country-specific versions: The assignment of employees to services controls the transfer of defined documented employee references into the administrative system. team entry can be filled at the time of planning (e. The employees maintained in the system can be offered. XML files are the technical basis for this data transfer. order types for the clinical order) and parameterized documents (PMD) in a system landscape. Data Sheet i.med. team documentation offers employees. · For the documentation of the employee responsible for specific actions in the clinical system i. can be based on this.med systems of the same release state. of a surgery) and then supports the process (see. Employees are business partner as far as the SAP ERP system is concerned (licensed product from SAP).h.h. via various configuration functions. Data is transferred via any media between independent i.h. The installation process and the processing of the content to be installed can be done in sessions and. As a preliminary step to the actual documentation. according to defined tasks and any assigned qualifications. The clinical work station displays content . An extendable list of favorites is available for calling other transactions without a reference to the objects displayed in the list.g. The views of the clinical work station enable automatic refreshing with a definable time interval. Many cells in the display area of the clinical work station enable hotspots for calling specific processing functions. .h. In the resulting sequence of views the user can navigate back step-by-step. In these views the allocation of a room or bed via drag & drop is supported.med is supported by various module-related documentation work station (see relevant descriptions). with regard to the columns to be displayed.g. Content is sometimes displayed directly via icons. The view types of the clinical work station provide the entry points to processing functions. which are sensible in the context of the view type.s. The specific functionality is dependent on the licensed components. This offer is made in the navigation area. A specific view of the clinical work station is defined by: · The view type (e. Data Sheet i. The user can personalize supplied layouts as well as the default layout. Columns can be fixed for horizontal scrolling.med basis: · Occupancy · Arrivals · Departures · Clinical Orders · Documents · Outpatient Clinic / Service Facility · Medical Controlling · Preregistrations · Appointment Planning The user himself can adapt the clinical work station at runtime.s. The clinical work station can be enhanced with the help of the enhancement framework with content to be displayed and functions. The Occupancy and Arrivals or Departures view types can be displayed simultaneously. their width. the sort order: Layout variant · The functionality: Function variant The clinical work station enables the design of specific worklists each with the suitable functionality which can therefore be adapted to the requirements of a specific work situation or role. which display a role-based grouping of views adapted to the specific work context. orders which are pending confirmation) · The layout of the list. Functions can be grouped for better clarity.depending on the definition of the view .h. The clinical work station can be operated using function keys. A view can be called transferring a specific patient or a selection of objects from another view.med basis Page 8 of 35 Patient-specific working in i. This call is possible using drag & relate.h.for all patients in an overview and is therefore suitable for triggering individual functions. which can be shown or hidden at runtime in order to make room for the actual list.The following view types are available in i. The selection behavior in the clinical work station can be controlled individually by showing or hiding a row selection button. A return to presettings is supported. The clinical work station is presented to the user in the form of work environments. depending on his authorizations (for example concerning data selection). Documents or Orders) · The data quantity to be displayed: Selection variant (e.s. months.licensed product from SAP).h.med the patient organizer represents the patient’s electronic record.g.s.) The display class can be used to define. as a separate aspect of the record. at the time of configuring the system. etc. Document category settings are also taken into account.g. the shape which is presented. In case of a tree display the following grouping options are supported: · Case · Time (days. involved employees. PDF view of a document. a parameterized medical document when the record is called.g.Patient Record / Patient Organizer In i. descriptive text. Data Sheet i. · Procedures Screen Areas of the Record · Medical records · Range of aspects · Country-specific version NL: DBC (DiagnoseBehandeling-Combinaties) · Navigation structure (tree or list) · Medication orders · Outpatient notes (if SAP ACM is in use – licensed product from SAP) · Treatment pathways · Time grid A call can branch directly into the patient administration function (Clinical Process Builder from SAP Patient Management . documents). quarters or years) · Clinical orders · Object type (e. all discharge summaries) · Requests · Health problem · Diagnoses · Documents · Services · Appointments and movements · Surgeries · Way in which details on entries of the record are displayed The Patient Appointments is a special version which can be called in i.s. weeks. which was created in other institutions (as a rule hospitals of a network or chain) in the same client. for example. etc.s.med from various places.) · Detail screen (e.g. The patient organizer can optionally also be used for all institutions and can therefore display content (e.g.h. Arrangement with Help of Aspects An aspect is defined by: · Content which is compiled in a selection variant (view) · Structure of its navigation component (e. tree display with various grouping criteria and several levels or a list display). in order to gain an overview. XML formatting of an order.med basis Page 9 of 35 · Detailed information on the selected object (e.h. . time stamp of an object. It is used to gain information and enables both a specific search for suspected or known content as well as a largely non-specific glance through the patient’s medical history. Administrative and Clinical Object Types (Content of Record) The patient header includes an indication of the patient’s documented risk factors and enables the call of the corresponding detail documentation. · Room view: The system displays the building units (e. Patients who have not been allocated a bed / bed location / room. allergies. · Generic functions · General functions are also offered in a general function toolbar. provide particularly relevant medical information. risk factors) on patient cards.).Patient Organizer Functionality · Call.g. the clinician receives an overview of the patients in his area of responsibility. existing objects can be changed and canceled. · Department · If the patient search is called first. My patient groups means that a user can quickly call patient groups he has configured himself. Selection Dialog · The patient viewer is integrated into the versions of the patient-specific documentation work stations (DWS). whereby here it is also possible to control which aspect should be displayed in the patient viewer by defining info items. The clinician receives information concerning what is going on in his area of responsibility. · User-specific patient groups can be saved (my patient groups). etc. and what needs to be done. are displayed separately. rooms and beds) for each selected treatment / nursing organizational unit (e. which are composed of individual inpatient and outpatient patient contact. The following selection criteria are available: · Treatment / nursing organizational unit · Current date · Days back (for discharged patients) Individual patient groups can be composed using the following criteria: · The patient organizer (not the patient viewer) offers basic functions for processing the displayed objects. The size of the card determines the quantity of displayed information. Certain facts (e. · List view: In this view the patients are displayed in a tabular form. In the form of patient cards or alternatively a list. Patient Groups (Smart UI) The patient groups (Smart UI) are a graphic alternative to the occupancy view of the clinical work station.g. access to the patient organizer clearly using filters or the display can be restricted using these filters. the patient organizer can be called directly via a transaction (from the SAP menu. In an optically pleasing form and with a variable degree of detailing. · Department · New objects can be created. · Processing functions The patient groups selection dialog enables the quick and easy determination of patients. depending on the current work context.) or specific tasks which must be executed (currently: service orderings which must be processed) can be highlighted Data Sheet i.h.med basis Page 10 of 35 · Treatment / nursing organizational unit Views and Displays Various views and displays are available for the display of patient information: · Card view: The system displays the name of the patient as well as important information (e.s. the call of the cumulative lab findings. care units) with the allocated patients in a graphical scheme. · The patient organizer can be called from various views of the clinical work station for a specific patient. The user can choose between five different patient card sizes. birthdate. gender. for example. etc.g. to simplify work on specific groups of patients. .g. upcoming surgeries. these patient groups. ) The graphical plan is the main component of the Department Display and the Room Display.) Data Sheet i. · Risk factors (the patient header indicates whether risk factors exist for the patient and. Based on the number of occupied beds the system also displays the degree of occupancy of a care unit which contains beds.g. · Sex For a selected patient the graphical plan displays the allocated organizational unit and building units.med task management) Graphical Plan The patient profile contains the following components: · Patient header · Tasks · Applications · Patient record with clinical information (reading.g.med basis Page 11 of 35 · Age · Birthdate . how many. care units) with their building units (e. A large patient card can be displayed for each patient who occupies a bed with a click of the mouse. The labeling and the sequence of the filter can be determined in customizing. rooms and beds) and the allocated patients for each selected departmental organizational unit (e.h. The user can also implement own filters in the system.s. Filters Filters can be used to restrict the determined patient group according to various criteria. · Planned Discharge (a planned discharge exists) The patients who satisfy the filter criteria are highlighted in the overall list of the determined patients. writing) Patient Header The patient header contains the following data for the identification and the case of the patient: · Patient ID · Name of the patient (the name appears as follows: name prefix last name first name.g.: In case of multiple occupancy of a bed the system displays the number of patients on the bed icon.g. In the List Display and the Card Display the system displays the graphical plan next to the listed patients. as well as the suppression of the display of filters. The Tasks Exist filter displays all patients. · Surgery Tomorrow (a clinical order of the Surgery type exists for tomorrow) Patient Profile (Smart UI) · Today’s Labs (a lab document exists which was created today) The patient profile can be used to easily and quickly view and process the medical documentation of a patient via an intuitive user interface (Smart UI).h. surgery). The system separately displays patients who have not been allocated a bed / bed location / room. e. patients who do not satisfy the filter criteria can be hidden. A click on the entry opens the list of entered risk factors. are displayed separately. The name and case number of the occupying patients can be found in the tooltip of a bed icon. Patients who have not been allocated a bed / bed location / room. for which at least one task exists for the Physician occupational group (license prerequisite: i. Filtered patients are highlighted in the graphical plan. The name affix and title do not appear.· Department view: The system graphically displays the subordinate treatment / nursing organizational units (e. if so.s. The following information is displayed in the compact patient header: · Patient ID · Name of the patient (name prefix last name. how many. · Assigned care unit (ward) · Main diagnosis / diagnoses (if a hospital main diagnosis exists. If the movement status is set to inactive stay.s. · Length of Stay indicator (country version Austria: no display) The tasks for a patient are displayed in two lists: · Department · Tasks of all occupational groups · Room / bed · Tasks for the user's occupational group · Indicator for private patient · Attending physician .this is only displayed if a surgery appointment exists.med task management component displays the currently outstanding tasks for the occupational group of the user and also for all occupational groups in tabular form. A click on the entry opens a list of entered allergies. Applications Compact Patient Header For the applications within Smart UI (e. discharge.g. service ordering) a compact patient header is available. The user can process the tasks of his occupational group directly from the list. first name) · Age · Sex · Birthdate · Risk factors · Allergies · VIP indicator (icon) · Care unit · Patient Deceased (icon) · Case number · Case type .med task management). if so.) The information on allergies is taken from the allergy documentation. If this is a provisional or preregistered patient. planned admission.s. which is displayed in the upper area of applications in Smart UI.if an attending physician has been defined for the corresponding departmental stay. nothing is displayed. the diagnoses here are transferred from the clinical order. Task Management (Licensed) The i.h.) patients. it disappears from the list of outstanding tasks. Once a task has been completed. · Admission date · Number of days pre / post-op . In all other cases.) is made visible by icons in the patient header. Currently the clinical order and service ordering are connected to task management.s.h.outpatient or inpatient · Case number · Status of movement (e. he is displayed here. etc. The following applications are available: · Call Medical Record List Data Sheet i. The tasks in the patient profile are a licensed component (i.· Allergies (the patient header indicates whether allergies exist for the patient and. absence. outpatient visit. this is displayed.h. Other tasks can be displayed using BAdIs. to guarantee a unique assignment of applications to Under the Hit List application up to 10 quick links are available for directly choosing the applications which are selected most frequently. Diagnoses Exist is displayed and a click on the entry opens the list of entered diagnoses.med basis Page 12 of 35 .g. h.med vital signs license) · Plan Vital Signs (prerequisite: i. . Client-specific functions can also be integrated.s.h. The patient record enables the user to call processing functions directly via the object.med medication license) · Enter Vital Signs (prerequisite: i.g.This application is only available in the country version Austria.s. · Patient Appointments · Plan Appointment · Enter Progress Entry (prerequisite: i. The mechanisms in i.· Edit Allergies · Edit Diagnoses The applications component is configurable. This means the patient record itself does not offer the option of searching for patients or toggling to another patient.med Smart Chart (licensed) is part of the patient record · Edit Procedures · Edit Risk Factors · Service+Diagnosis Fast Entry .licensed) (property of the patient profile) · Create Case and Surgery · Medical Service Processing · Outstanding Patient Items · Create Surgery · Edit Patient Master Data · Display Patient Master Data · Case and time period selection · Page navigation (property of the patient profile) · i. The patient record is only integrated into the patient profile and is available within the NetWeaver Business Client (NWBC). etc.s. · Create Document · Edit Delivery Data · Call Case Overview Patient Record (Smart UI) · Create Clinical Order The patient record is part of the patient profile.g.s. in other cases the classic processing functions are called.h. dialogs.s.h.).h.h.s.h. In cases where Smart UI components are available for displaying and processing objects (e.med are used to process objects (applications.s.med medication license) · Display of additional information in so-called pop-in areas for specific objects · Medication: Create Emergency Event (prerequisite: i.med medication license) · Full screen option for being able to use the entire display area for a component (e. documents and services).med vital signs license) Data Sheet i.med Smart Chart .h.s.s.s. service ordering) these are used. for i. Functions can be hidden or grouped according to your own criteria.h. The following elements characterize the operation of the patient record (Smart UI): · Order Service · Configurable layout (property of the patient profile) · Enter Service · One-Click-Action for frequently required functions · Subsequently Enter Service · Call of full screen detail screens · Edit Medication (prerequisite: i. interactive chart.h.med progress documentation license) · Create Medication Order (prerequisite: i.med basis Page 13 of 35 The patient record provides the option of editing objects and creating new objects (e.g. s. The functions which were previously available in the Medication component are used for the other actions. in the patient organizer) can be used for diagnoses in the patient record. The Create function which was previously available in i.med (e. · Cancel Examinations The following actions are available: · Create · Change · Cancel Examinations can be ordered in i. which were created with the old application can only be displayed in the new patient record once migration has been executed.h. Progress Entries The following actions are available: · Create · Cancel The following actions are available: Within the patient record only the new application for entering progress entries can be used.Actions which refer to an existing object (e. Parameterized Medical Documents (PMD) Lab Values The following actions are available: The Create action is available for lab values.g.h.med (e.h.s. This action can be used to create a request to the lab.h. · Create Diagnoses · Change · Release · Cancel Data Sheet i.g.med both with the clinical order component in the SAP GUI as well as with the service ordering function within Smart UI. · Create · Change Medication Orders · Release The following actions are available: · Create Version · Create · Cancel · Change The functions which were previously available in i.med (e.s.s.med basis Page 14 of 35 . change. · Create Medical Services · Change The following actions are available: · The functions which were previously available in i. The system displays the clinical orders in the Examinations component of the patient record. cancel) can be executed as a one-click action.g.g. in the patient organizer) can be used for vital signs. Progress entries.h.s. in the patient organizer) can be used for documents in the patient record. The Change action uses the detail dialog which is available in the Medication component. Vital Signs All functions and objects are downwards compatible with the applications in the SAP GUI. in the patient organizer) can be used for nursing services in the patient record. It specifies the reason for the contact with the healthcare institution.s.h. e. developed for Smart UI. As a rule health problems are managed in special catalogs.h. A health problem represents the parentheses around various content. Chart The i.med basis Page 15 of 35 The following content of the record can be grouped on a problem-specific basis: · Visits · Appointments · Medication orders · Clinical orders · Outpatient notes · Documents . so that Data Sheet i.med. but can also follow freely selectable semantics in i.med (e. · Service Entry · Subsequent Service Entry · Medical Service Entry (you can specify a configuration here) · Service+Diagnosis Fast Entry (only available in the country version Austria) Nursing Services The following actions are available: · Create · Change · Release · Cancel · The functions which were previously available in i. Effects on Existing Data For inpatient progress notes. regardless of its administrative assignment. migration must be executed.g. WONCA. The health problem is currently only significant in an outpatient scenario (prerequisite is SAP ACM – licensed product from SAP).s.h. predominantly where primary care is provided in so-called primary care centers.s.med Smart Chart (licensed). nursing notes and outpatient notes.h. is displayed in the new patient record. Administrative Services The following actions are available: · Create · Change Health Problem A health problem comprises all symptoms of a patient which require medical care.s. The health problem is supported in the following modules / components: · Clinical Process Builder (SAP Patient Management component – licensed product from SAP) · Patient organizer · Documentation work station in SAP Ambulatory Care Management for Healthcare (ACM – licensed product from SAP) · Release · Cancel · The Maintain Services function (transaction NL10) from SAP Patient Management (licensed product from SAP) is still used for administrative services.One of the following four service entry options can be determined in customizing for entering or processing medical services: these are converted into the new progress entry format and can be displayed in the progress entries of the new patient record.g. The clinical order is not intended for the detailed organization of work within a care unit or outpatient operations. surgery) or an employee. it is possible to define required entry fields.g. Clinical orders can have a reference to a case. medical objects are assigned to a health problem in the patient organizer. the reference to a real patient is not necessary. If preregistrations exist for a patient at the time of admission.med basis Page 16 of 35 Definition of Order Types · An order type consists of clinical order components. · Clinical order components are assigned either to the order header and apply to all order items contained within the order. for reasons of downward compatibility remains available in the system. or are assigned to the individual order item and enable the mapping of semantics which are predefined for a specific order situation (e. Several clinical orders can be created using collective entry. Clinical Order The clinical order is the tool for ordering examinations. · An order type (or in case of the grouping of several orders. A clinical order is used to organize diagnostics and therapy. in particular when several departments or the transition from the care unit to the outpatient clinic / service facility / surgery are involved.g. · In the order components which are assigned to an order type. it enables the mapping of workflows and role distributions both for the order initiator (e. The optional i. This assignment is made when the ordered services are confirmed. The clinical order represents the recommended technology for ordering and replaces the historical functionality (service request) which. but is no longer described here. This enables a labor-saving procedure in case of a large number of similar orders.s. · The use of an order type is assigned to specific order initiators (in the form of OUs) at the time of definition.s. depending on the order status. at the latest. but this is not mandatory. . A clinical order can also be entered as a preregistration with provisional data. this is freely definable. these can be assigned to the case.It is possible to call information with a reference to one or more health problems in the patient organizer. The clinical order refers to the information transfer and workflow design between the order initiator and the order fillers within an institution. · Order types can offer a range of orderable services.med connectivity module (07601086) enables the inbound and outbound communication of clinical orders and therefore the connection of third party systems. For this purpose the system offers an overview of objects which are not yet assigned to a health problem. treatments and surgeries as well as for planning inpatient admissions.g.h. alternatively the request for services which are possible with a specific order type depends on the service range of the addressed OU. an order item) follows a defined status profile. such as the ordering of daily routine examinations for all patients of an intensive care unit. special content for a radiology order or a surgery). Furthermore. Special display options are available for this.h. Generally. A clinical order (or an order item) is addressed to an organizational unit (outpatient clinic. · An order type is addressed to one or more order fillers determined at the time of definition. This means that documentation in accordance with the purpose of the order type is possible. service facility. the radiology service facility). With its status concept. Data Sheet i. the care unit) as well as the order fillers (e. determined at the time of definition. Individual order items can also be actively detached from a case. · Depending on the planning authority (can the ordering facility allocate appointments in the ordered facility itself) the allocation of appointments for order items or individual services is possible directly from the order. Order templates which have been defined for the clinical order or in SAP GUI. · If the process begins with the allocation of an appointment (e. For services which are addressed to different order fillers. These can then be individually planned.h. when the patient arrives at the service facility). Services which have been requested with service ordering can be processed in the clinical order.med pathways modules.e. Service ordering uses an easy-to-use user interface (Smart UI) which enables users to order services simply and quickly. The clinical order remains for complex cases. can be re-used. The system bundles the services in one order. The clinical order in the SAP GUI and service ordering can be used in parallel.Clinical Order and Appointment Management (See also section under Appointment Management and Planning) · An order item can include an appointment template. Order templates can be used in service ordering. requestable services from the service ranges of various order fillers can be selected and ordered in one step. further information can be entered in a detail view (for example a comment or the localization). · Services can also be ordered on a cyclical basis. appointments cannot . · Furthermore.g. A click on an icon in the service row is all that is required to select a service. which contain at least one service and only one item.med ward and i. Data Sheet i.s.med basis Page 17 of 35 An appointment template can also be created for a service ordering order. Service ordering is based on the technical concept of the clinical order.h. the system creates individual orders. · Several order items can be compiled in one order template as an order profile and simply called together. Following selection of the desired services. This indicates a desired date or provides information on when the ordered action should take place. Clinical orders can also be called for processing from service ordering. Service ordering is determined with the following parameters: · Order filler from the order filler group · One or more services from the service range of the order filler · Possible selection of another order filler and selection of one or more services In service ordering. Process Acceleration and Comfort Functions · The data required for an order item can be preset in template management. However. or were ordered with different order types. previous selection of an entry is not necessary for this.s. The clinical order also remains available. One or more services to be ordered can be created with service ordering. if they are of the same order type and are addressed to the same order filler.h. predefined order templates can be used via the basis items in the versions of the documentation work station: in the i. Service Ordering (Smart UI) One-click actions are available in icon form for actions for processing orders. Frequently used services can be selected from a personalized favorites list. Individual services are generated for each ordered service according to the cycle assigned. · This appointment template supports appointment planning at the ordered facility. during telephone contact) the definite order can also be entered during the existing appointment (i.s. This defines which services can be performed at which organizational unit. or common proposal values are provided by the system. · At different times in the service planning and documentation process the documentation of the planned procedures (also multiple) can be ‘replaced’.s. refined or specified. release. Service ordering orders cannot be flagged as preregistrations.s.med is activated.h. · The service documentation process follows a defined status profile.med is generally based on the same service master and corresponding basic data management as SAP Patient Management (licensed product from SAP).h. whereby the setting of each individual status (service performance.h. to a large extent. such as the requestable departmental and nursing OU. LKF in Austria) at the time that a medical service is released. Plan Services · Services are planned when an appointment is allocated for a service (or for an order item which comprises several services ordered from the same order filler). In service ordering there is currently no function for canceling orders. depending on the process. · Cyclical services are services of the same service type.g. Medical services are documented in the i. · Depending on the user parameters set. In order to be able to cancel a service ordering order. At the time a service is performed.e. etc. Service orders from the new service ordering are managed in the system as individual orders with one order item each.s.currently be planned in service ordering. A service is mandatory for service ordering. When i. DRG in Germany) or administrative services (e. billing-technical replacement is offered. you can call the SAP GUI cancellation dialog for the order concerned from service ordering.s.med transactions. to create the actual billing services in a semi-automatic procedure. Document Services · Performed services are documented either after they have been ordered or explicitly by the facility performing the service. step means the same individual services are generated according to the cycle attributes. Data Sheet i. services which are not a result of ordering are documented either via entry of (and possible searching for) service codes or the call of the service hit list. services can be flagged as requestable and / or performable. Furthermore the service range at the time of ordering is also influenced by the order type definition and the hit list settings (see also Clinical Order). To support the ordering process accordingly.h. · The definition or assignment of a cycle for a service and a manual or automated generation · Services can be grouped into service groups for the following purposes: · A cycle can be assigned to ordered services.med basis Page 18 of 35 . generally with a reference to the service range. Medical Service Management i. i.) is. The attributes relevant for the specific handling in the service billing or controlling area. configurable. · In this definition cycle represents a regular or irregular iteration regulation. the service master is enhanced with additional attributes. Appointment planning is possible at the service facility. · Country-specific version: Depending on the country the system can automatically create procedures (e. See also under Appointment Management and Planning. · The individual services created within the generation step then represent the basis for an optional definite appointment planning step and can be documented or confirmed individually in this form.g. are defined via parameters. med surgery .s.07601003) as well as in the care unit and service facility views of the clinical work station.h.).h. e.s. i. quota-based planning) · Various functions Planning with i. The (optional) range of target services is presented.h. surgeries) and services.In i.h.med ward – 10415867).med is either day-specific (determination of the planned date only) or timespecific. See also Medical Documentation. the service group can also be broken down into one or more other services. orders and services are processed.med surgery (07601003) the ’anchor service’ is the reference point. · The medical service entry offers the hit list. Data Sheet i. · For the medical service documentation there is an optional alternative dialog application available. a surgery. if no valid visit has been documented in the service-performing OU on the day concerned.s.med is integrated into the processing functions and work stations in which preregistrations. Depending on the settings made.med also shares the preregistration based on the clinical order with SAP Patient Management (licensed product from SAP). · By flagging in the service master the user can determine that an ordered service group must be replaced at the time of performance. at the latest at the time of performance. the system automatically creates this reference and can also create a new visit.h. Appointment Management and Planning i. regions.h. Parameterized Medical Documentation · Material consumption documentation · Team documentation . · Mapping of semantic groups according to clientspecific definitions. an inpatient admission. to accelerate the documentation process and attach dependent documentation steps (material documentation. This means the specific semantic characteristic of the service entry dialog can be adapted specifically to certain work situations (see also i.med basis Page 19 of 35 · Favorite lists are supported. Using appointment management the planning of outpatient or inpatient treatment processes is continuously possible: . which enables a semantically preset and highly configurable documentation via corresponding customizing (see also base items). · This medical service entry is available in-place in the documentation work stations (see also i.med enhances the appointment management available in SAP Patient Management (licensed product from SAP) with: · The reference between appointments and orders (specific order items. · Graphical user interfaces (planning grid and dayspecific. · Services represent a possible reference level for: · Medical documents and medical records.s. whereby multiple references are possible.· Navigation support or grouping characteristic in the hit list · Simplified ordering · Documentation of a performable service group.s. etc. team documentation. detailed information on services and the actual input area in table form in one dialog. these are defined via the base item. However. e.h. · Medical services must receive a reference to a movement (an outpatient visit.s. Appointment management in i.10415867 and i.med ward .h.h.g. · The layout of the entry dialog as well as the function range can be configured. servicerelated documents) to an entire group.s.s.s. as long as these are assigned to the range of the performing organizational unit.g. each treatment or departmental OU. · i.s.s. which enables the modification of appointments. · The individual appointments resulting from a multi-appointment are saved as an appointment series. with the addition of a deadline: This is the time up until which the orders to be planned must be received. · i.s.h. · An overview of the planned appointments is available in the form of appointment lists. service facility and outpatient clinic organization and surgery scheduling.med basis Page 20 of 35 (provisional or actual) patient and a planning object (= calendar column at organizational unit. · i. such as examinations at service facilities · Support of the admission process for preregistered patients · Creation of the case reference · The connection between an order item and an appointment can be made in both directions: Planning of an ordered procedure or subsequent documentation of an order for an appointment which was entered previously · Appointment planning is oriented towards (optional) appointment templates: Specification of a desired date and time within ordering.s. · Preregistration of inpatient admission including pre-entry of important content for the automatic presetting of the administrative data on the patient · Management of waiting lists according to definable criteria with the possibility of specifying priorities and taking patient’s wishes into consideration · Planning of preoperative procedures.h. It is integrated into all planning functions.h.h. · Configuration functions · The planning grid is based on the OU structure of SAP Patient Management (licensed product from SAP) and the planning objects defined at room level or on an employee-related basis. attending physician (if entered in the visit appointment). consideration of this content during the appointment search and planning at the service facility · The appointment template tool in clinical ordering also supports multi-appointments. These can be used to determine time or content dependencies or sequences for several items of a clinical order.med can be created both stand-alone with a reference to one or more services or also for order items without services.· Entry of a preregistration for a treatment process under optional specification of only rudimentary patient data and then without the necessary case reference.med shares the categorization of plannable slots with so-called scheduling types as well as the definition of the opening times of plannable facilities / employees with SAP Patient Management and the planning tools offered there. ordering. room or employee level) · Patient-related appointment series can be planned (such as a series of appointments at various OUs).g.h.s. Planning Grid The planning grid is a graphical tool optionally installed with the SAP GUI. · Appointments in i.med enhances the planning object definition offered by SAP Patient Management.med provides an enhanced version of the MED Appointment Calendar from SAP Patient Management (licensed product from SAP) which can be called for the patients at all necessary places (e. · Appointments are always valid for the entire institution and generally have a reference to a Data Sheet i. These can be configured for each patient. · The MED Patient Calendar is technically a decoupled display variant of the patient organizer and is subject to its configuration functions. via additional attributes and OU-specific settings. for the display of planned services). . Day-specific appointments are classified as colliding with other appointments of the patient on the same day. Outpatient Clinic / Service Facility view type of the clinical work station) when one or more ordered services or order items are transferred. The joint data and function base enables the parallel use of various planning tools (each with a different extent and focus).med basis Page 21 of 35 · The objects transferred for appointment planning when the grid is called are displayed in a configurable work list. public holidays) should be displayed or not.g. · The display is determined in variants when the tool is configured. · Clients can adapt the labeling of planning grid slots which are plannable and those which have already been planned using a BAdI. that a specific service facility generally plans its own ordered services. regardless of the OU in which they will take place. for example at the hub of a service facility for processing telephone appointment enquiries. A grouping option. This also includes the decision concerning whether days without time slots (such as weekends. to help the user to avoid content or time-related collisions. of the rooms of an organizational unit (e. · Parameters can be used to control whether the dialog-supported appointment search. · This planning authority can be supplemented or further restricted by authorized users at runtime. · The planning grid supports a zoom-in for the incremental optimization of the display concerning the range of detailed information on one hand. for example. · During appointment planning for a specific ordered procedure all other appointments allocated to the patient concerned are also displayed in the planning grid. the evening scheduling of appointments for the next day at service facilities is supported.in order to be taken into account for the appointment planning of the following work day. · The planning grid can be operated on a standalone basis. e. · The planning authority controls which planning OU may allocate which appointments at a specific plannable OU (a specific planning object). and the overview display on the other. This ensures. · The variant which is used when the planning grid is initially presented depends on the user-specific settings as well as the context or process in which it is called. Furthermore.s. · Functions · Display of the time slot in variant form which controls which calendar strips (planning objects) should be offered simultaneously and whether this display should be day-specific or timespecific. · The planning grid can be called from a clinical order or an overview display of order items or services (e. Subsequent changes can only be made with special authorizations.g.h. but still provides selected order placers with defined time periods on a self-service basis. · The system can optionally also warn of timerelated collisions. the planning grid or the SAP Patient Management planning tool should be used.g. it can be determined that the entry of a change reason is obligatory in case of subsequent changes. The appointments of the patient are included in this warning. . Data Sheet i. For example. as long as this is presented in the active display variant. treatment rooms of an outpatient clinic or image-rendering devices of a modality type) is available using tab pages. From this overview the user can navigate directly to any appointments which have already been planned. · Completed plans can be released (preferably during surgery planning) and are subject to versioning in case of subsequent enhancement or modification. In the latter case. Quota-Based Planning If appointments. should not yet be planned as time-specific in the long-term. · The planning grid also offers the appointment search offered in other. · Within the planning grid appointments can be rescheduled or the duration changed using drag & drop. which is specifiable for each OU. for surgeries. · In the planning grid users can plan on a timespecific basis. · The planning grid is subject to the general appointment management settings as far as the overbooking of appointments is concerned.h. · The planning grid also visualizes group appointments and supports the filling of these. the labeling of the free slots in the calendar including their duration. i.med.). This means that a targeted search for free slots with suitable content is possible. system settings are taken into account. for example if a resource is suddenly unavailable. a previously booked patient appointment can be used as a template. · The planning grid supports the collective processing of appointments.e. at different OUs) for one patient in one work step. radiology). physician or examination device (e. The appointment search (see also service description SAP Patient Management – licensed product from SAP) supports the use of predefined search patterns. · In order to comfortably be able to create repeat appointments. etc. · In order to be able to quickly reschedule several appointments. This is particularly suitable for planning admission appointments or surgeries and should be used for the resource type which is currently critical.· The planning grid offers comfortable options for storing day-related notes on planning objects (calendar columns). whereby both the default time spans stored in the service master (for the service duration as well as for planning objectrelated preparation and follow-up times) as well as the stored scheduling types (as a proposal value when planning visit appointments without a service reference) are taken into account. rescheduled or canceled.s. with which appointment blocks can be changed. or as a service-based appointment search.s. non-graphical tools both in SAP Patient Management (licensed product from SAP) and i.g. as well as the consideration of priorities. the specification of certain temporal dependencies between appointments and the consideration of patient preferences. in order to be able to map an on call appointment confirmation. · Users can also plan on a day-specific basis in the planning grid.h.s. in order to inform the planning staff of any room and / or day-specific peculiarities (e. congresses.h. Data Sheet i.g. .g. the planning grid can also be printed out. e. but are oriented towards defined available quotas. the planning grid offers a collective processing function. either based on scheduling types. In the same step it is also possible to specify the actual treatment room. via drag & drop).g. and visualizes the time slot proposed by the appointment search either in color in the planning grid or presents the hits in a list for supplementing.g. a separate tool is available.med the system searches for appointments depending on a parameter. · When certain restricting parameters and formatting defaults are specified. · Refinement of planning: Appointments which were initially planned as day-specific (perhaps at a coordinating facility or an OU superordinate to a group of modalities or rooms) can subsequently be scheduled as time-specific (e.med basis Page 22 of 35 which assign specific scheduling types to defined services. In this way several appointments can therefore be planned (e. employee absences. · In i. g. These are technically stored as group services. · A document category represents the parentheses around any number of documentation elements. A specific display appearance is assigned to each documentation element at the time of definition: the end result is a document category as a form.s. surgery or treatment room quotas. etc.h.med occupancy management (10415841) is available. for example) the content of a PMD is saved in database tables. content of nursing process documentation.h. service types are defined. Microsoft Word) · Display – document categories for the visualization of XML data or PDF files · Progress entries – module-specific versions of continuous.med basis of in enhanced SAP Patient Management objects (licensed product from SAP). for example at service facilities. is visualized in color. Configuration and Functionality · In order to be able to plan on a quota-related basis. · The state of a day’s booking.Optional: For planning admission appointments including approximate lengths of stay for the optimization of capacity in care units containing beds (see also in interdisciplinary units) the component i.med modules and are further described there.h. etc. These versions are licensed with certain Data Sheet i. for example.s. mostly categorizable documentation. Parameterized Medical Documentation The parameterized medical documentation (PMD) enables the structured documentation of patient-related information. Examples: Diagnoses. · For faster navigation the day-specific planning tool displays an overview of days which have already been planned. This enables the targeted formatting of different visualizations and printouts as well as the specific access to stored content for the purpose of summarizing (e.h.med. . The supplied sample documents can be copied and enhanced with the definition of document categories in i. Existing form components are available for this. compiling the findings of a discharge summary) or evaluations. medical services. · For each day the administrator defines the maximum number of services which can be planned for each category. · The actual medical services are assigned to these defined service types.) · Special documentation objects . Unlike in text documents (such as Microsoft Word. Clinical Documentation The clinical documentation consists of: · Documents · Parameterized Medical Documentation (PMD) · Office documents (e.s.g. in relation to its quotabased time slots.h. It is used to create findings.s.s. (Examples: Nursing progress notes. progress documentation. to create discharge summaries and for transferring data from third party systems.med basis Page 23 of 35 i. Documentation elements are the granular component of a document category. · The user interface of the day-specific planning function enables the simultaneous visualization of admission quotas and. · Categories can be oriented towards typically rough average durations of surgeries. Definition of PMD Types · Parameterized medical documents are based on document categories. vital signs.h.s.This includes all content for which a specific documentation option exists in one of the modules supplied with i. allergies.med basic data maintenance. in i. whereby transfer structures. · The structure of a document category can. as well as the process logic are. In Process à Dictated à Written à Corrected à Released). there are also special elements available. · The generation of the necessary database tables for a document category. via the versioning of its master data. can be semiautomatically provided in the document category design. at the level of one of the named optional reference points. It is possible to generate several parameterized medical documents (PMD) at once.h.· Documentation elements can be used individually or in groups in any number of document category definitions.med or from third party applications or which can be used to integrate special functions. be adapted to modified content requirements. the layout of which can be processed with standard SAP means. As standard print forms are designed using SAP script (licensed product from SAP). which are used to integrate data from other application areas of i. The latter determines the status profile which applies to a filled document (e. · Printing can be formatted with various technologies.s. . The correct display of historical documents of the same category is guaranteed. the screen layout is determined and special process logic is enhanced via user exits. an initial form is generated using the defined structures of a document category. A separate ADS (Adobe server) must be available.med basis Page 24 of 35 · Movement(s) · During the definition of a document category you can also define whether it is permissible to create more than one document of the same document category. automated. · The way the instances of a document of this document category behave during case archiving and case revision is regulated at document category level.g. for example. · When designing print forms with SAP script. · A connection to Adobe printing is available. · Patient (mandatory) · The way the instances of a document of this document category behave during document dispatch is regulated at document category level.h. · Tools simplify the targeted productive use and distribution of document category definitions. for example via the assignment of a document category to a document type. the status profile and archiving functionality from there. Usage Scenarios · The (minimum) reference points which a document instance which uses this document category should have are determined when the document category is defined. · Case · The definition process of a document category is supported in a separate work station.s. · Process-relevant settings are determined at document category level. · External data modules (for example for integrating diagnoses. etc. · As well as documentation elements in the form of input-ready form fields. including the naming of supplementary database content. · Service(s) Data Sheet i. PMD and SAP Document Management PMD uses the SAP document management system (licensed product from SAP) and takes. This is where the structure is defined.) · Link elements (such as an html control for integrating intranet or internet resources) · Pushbuttons · Content of link elements and simple display fields is not stored as document content. to a large extent. This is determined in the master data of the document type.· Documents are therefore used in particular in the following scenarios: · Often corresponding determination logic is available for the proposal values of other content. · Discharge summaries (with a reference to an inpatient case) Subdocuments · Outpatient clinic reports (with a reference to an outpatient visit) Several separate documents (of different categories) can be logically connected under one joint document number as subdocuments. Generally it is possible to create a document almost anywhere in the application. · If changes or enhancements are made to a document after it has been released. However. the one with the highest priority (defined in the master data) is displayed. · Employee responsible · Reference points · Application and storage path (in Office documents and document references) The presetting of this document management data is based on proposal lists in Customizing.s. At the end of each status profile there is a release status. Editing Documents · The presetting of the fields of a document is logically determined at the time the document category is defined. This is managed as the primary version to be displayed once the document has been released again. a version number · Document date and time (in service-related documents this relates to the confirmation time of the performed service) · A document runs through the pre-defined status logic of its assigned document type. This release status represents the applicational protection of the document against later changes. The content of a released document version remains stored in the database. a task in a patient-related work station. regardless of versioning. · Furthermore it is possible to track each save process of a document.med basis Page 25 of 35 · If a document has one or more special indicators. earlier versions can be accessed at any time. a new version of the document must be created.h. known context. in change documents. · Documenting OU Special Indicators · Brief text which describes the document content · An instance of a PMD can have special indicators in the form of text or icons. Depending on the currently available context information the user is prompted to enter or select data. One or more services in a service view in the clinical work station can be the starting point for the creation of a document or. . where applicable. A document is not released with a real digital signature. This presetting is usually executed when the document is created or after field updates. Release and Versioning Document Creation A document is often created from a specific. · Organ examination findings. such as radiology findings (with a reference to one or more services) Security. for example. · Selection of the document category · Allocation of a document number and. The presetting can also be actively triggered when the document is filled. · Service-related document category assignments · OU-related document category assignments Data Sheet i. Lists and Mass Processing Functions Documents can be displayed or edited using: · A version of the Documents view type of the clinical work station · The Prefindings Viewer link element in PMD · The patient organizer is to directly inform the user of new clinical documents which are available either generally or specifically for him. .· Interactive data transfer from other documents of the same patient. · The dispatch control has its own logging. Parameterized documents can be displayed as follows: · Structured as in the entry dialog · As PDF · With an XML scheme (three are available) · With an XML scheme enhanced by the client Furthermore a preview of the printout is available which follows the formatting logic stored at the time of definition. i. deleted documents remain available for display.med basis Page 26 of 35 The dispatch control in document management determines which (external) recipients should receive a document and how. · The specific logic of the findings inbox can be adapted to special requirements using the enhancement framework. but excluded from display by the setting of a deletion indicator.s. Dispatch Control The individual overviews each use their own special variant concept and have their own procedure for personalization or integration into the role concept. data which has been saved is not physically deleted. · In dispatch control the document recipients are selected.h. Its goal Data Sheet i. · In i.s. The Documents view type of the clinical work station provides a corresponding determination logic for documents which is generally oriented towards the current departmental or nursing assignment of the patient. · (See also: à Case Archiving) Handling of Documents. · Country-specific version AT: A dispatch function (EDIVKA) to insurance providers is available. Findings Inbox This function represents the postal inbox of a care unit / outpatient clinic or a physician for internal documents. · With corresponding authorization. e-mail. business workplace.h.h.med connectivity (07601086) license is necessary. Deleting Documents · In accordance with SAP standards. · During the status conversion a log text can optionally be entered. fax. · In the overview list corresponding icons indicate whether the logged on user has already read the document concerned or whether another user has already read the document. · The configuration of dispatch control is connected to the document category. the reading of a document means the conscious confirmation of a document which is technically mapped using the document’s status profile. web service. created in the same healthcare institution.s. Note: For the email and web service dispatch routes an i.med there is a report for the physical removal of deleted documents from the database. · Here. · Documents can be dispatched by post.e. med objects are provided in additional modules or can be configured in projects. Archive Connection · For the outbound and inbound (= viewing) communication with archive systems i. · When transferring lab findings. Furthermore it is important to specifically call certain individual parameters or parameter groups in specific treatment situations. The connection to the archive Data Sheet i. formatting and tracking of incoming and outgoing message flows. or also be able to use for presetting (e.h. HTTP. Document content can be imported to i. the processing status. The message communication infrastructure consists of the configurator. the archiving of documents runs in the background for users. findings or image material in a 3rd party RIS). etc.g. The system displays how many messages it should process for a communication process.h. where applicable.s.s. for example.s. cockpit and monitor components.s. Configurator – You can use the configurator to set up a communication process consisting of a start connector.s. the patient organizer and the various other views of clinical documents is positioned as a registry (directory) and. transformer and end connector for a defined communication scenario.med basis Page 27 of 35 . a lab order created in i.h. how many messages it has successfully processed and how many it was not possible to process. file. CWS.s.s. These components offer you functions for the configuration.h.med.g. The following functionalities are supported: · Findings transfer via HCM or message communication infrastructure (MCI) · Transfer of document references: Synchronous document transfer (BAPI) or asynchronous transfer via batch input · Special case – lab documents: · i. cumulative findings. i. PMD connectors) and standard transformers are available for the configuration.med as the clinical system with its record.med uses the standardized SAP technology Archive Link. A range of standard connectors (e. The system displays additional details. which uses special logic for the data handling and display (print preview.h. in the form of a cumulative display.e. as a repository (storage) of all clinical documents originating in a healthcare institution for a patient. i. The specific messages for importing / exporting i.med does not take on the role of an archive (see also Archive Connection). Communication with External Systems Message Communication Infrastructure (MCI) The message communication infrastructure supports the implementation of communication processes with external systems in i.Document Communication i. · As a rule.med can be referenced.h.g. · Lab data is saved by i.med transfers lab findings in a standardized structured form.h. RFC. but are more often called in trend / progress.h.med in a document category supplied especially for this.s.h. the start of processing and the end of processing of a message. The message communication infrastructure provides a standard implementation model for this. because lab findings are rarely individual results.). Cockpit – You use the cockpit to receive an overview of the defined communication processes.s. Monitor – You use the monitor to receive information on individual messages of a communication process. order forms for the radiology department).med (e. lab findings) or references to external documents managed (e.g.h.s. · Diagnosing person Generally. on a patient and case-related basis. · Diagnosis type (referral diagnosis. It is seamlessly integrated into all i.s. hospital main diagnosis).s. Note: A special license (Add-On Archiving Connector Imp/Ex – 07601193) is required for the connection to SHA (licensed product). a case can receive a case status.med for diagnosis coding: Only a few selected functional details are listed here. · Multi-case diagnosis · Secondary diagnosis · Lock indicator (flagging of clinical diagnoses to prevent the administrative access to a diagnosis) · DRG information (country-specific. Germany) Additional diagnosis information Diagnosis and Case Processing · Diagnosis date / time From an administrative point of view the basic medical documentation is essential and is provided by SAP Patient Management (licensed product from SAP). a corresponding interface is available in SAP Patient Management (licensed product from SAP) for the connection of external coding systems or DRG groupers. cause of death. A mandatory reference to specific movements of a case (e.h. outpatient visits to service facilities or surgeries) can be enforced by the system via customizing. procedures and certain other casedependent data SAP Patient Management (licensed product from SAP) provides a country-specific work station. · Localization · Diagnostic certainty · Diagnostic supplement (see also clinical information such as Status After…) Data Sheet i. Additionally.h. diagnoses are always documented for the case. treatment diagnosis) and diagnosis class (admission.med clinical applications concerned. department main diagnosis. surgery.subject to license) offers the option of prompting for a digital signature when a document is transferred to the archive system.med basis Page 28 of 35 · Hit list · Hierarchic catalog · OU diagnosis hit list · External diagnosis coding DRG and Other Billing Systems Country-specific characteristic: For processing diagnoses. which compiles the processing of the respective data.g. · Keyword catalog (multi-axial catalog) Diagnoses can have attributes according to specific criteria.system Soarian Health Archive (SHA . some of which are mandatory at specific times depending on (sometimes country-specific) customizing. · Comment · Number of surgeries (number of surgeries which have been carried out due to a specific diagnosis with an inpatient stay) Several aids are available in SAP Patient Management (licensed product from SAP) and i. e.g.s. which also has a department-specific characteristic. discharge. in . A complete service description of the basic medical documentation is contained within the documentation on SAP Patient Management (licensed product from SAP). · Diagnosis catalog To support the documentation process both by medical staff as well as by any special documentalists or coding directors..h. · The number of calls is logged and can be viewed in the clinical work station.h. Accident Number Country-specific characteristic AT: In the country version Austria SAP Patient Management (licensed product from SAP) and i. medication orders and events) are taken into account in an accordingly plausible way. which document categories are offered directly on pushbuttons) can be configured using customizing.med offer the option of compounding outpatient and inpatient treatments with a so-called accident number.g. the service entry and requesting of further facilities in the planned treatment process is supported in the form of a simple patient-related work station. corrections to an object assignment result during an admission or when the wrong case was selected. · The offered functions. Cancel i. . LKF data) is also provided.s. · Via the assignment to a movement in SAP Patient Management (licensed product from SAP) objects in i.s.med offers a standard cancellation dialog for its own objects as well as those which are jointly managed with SAP Patient Management (licensed product from SAP). Most of the objects connected to this visit are automatically moved with the visit. · An accident number indicates a specific treatment context and is actively created during the initial Data Sheet i. · A patient who does not react can automatically be deferred. Outpatient Treatment · The quick creation of documentation. The consistency of data objects which are dependent on each other is automatically guaranteed.a processing environment.s.med basis Page 29 of 35 patient contact for this treatment context within patient administration. If specific dependencies do not permit the cancellation of a certain object. This cancellation dialog helps the user to recognize dependencies between data scheduled for cancellation and other documentation objects of the same patient.med radiology) enable special filtering or grouping of the record content. Outpatient Clinic and Service Facilities Calling Patients · Following the administrative admission of a patient (SAP Patient Management – licensed product from SAP) i. including the respective semantics (e. Here.h. in a service facility.h.h.h.s.s.s. · The patient history and the prefindings aspect of the patient organizer (i. for example. the user is informed in the cancellation dialog. documents. the call of an externally connecting DRG grouping software (DE) or online scoring (AT. This function is used when. Clinical Case Processing Visits can be moved from one case to another using case revision.med supports calls into the treatment room. radiology objects.s.h. · Note: Alternatively.h. for example. for most of the functions provided here SAP Ambulatory Care Management for Healthcare (ACM – licensed product from SAP) (10178675) provides a patient-related work station based on the documentation work station.med objects (clinical orders.med receive an implicit connection with this treatment context. The various i. to organize the necessary treatment steps across several facilities (the patient’s actual visit) Ending Outpatient Treatment When a patient is deregistered at the end of an outpatient visit i. Data Sheet i. from a master data point of view.med can inform of the correct completion of the service documentation. · When using i. It also enables a check of the effectivity of the configured authorization system and the selective checking of the adherence to organizational regulations. · The steps of a treatment sequence can be called or supplemented in a separate treat screen. even if the entry is enforced by the system.h.h.s.med basis Page 30 of 35 Employee Responsible In many actions in i.h. · Treatment sequences can be planned in advance. corresponds to the business partner in SAP ERP (licensed product from SAP).h.s. This is a personal abbreviation which. The entry of an employee responsible serves processorganizational and documentational purposes and does not correspond to a digital signature. · Medication events (i. If desired. · The next planned step of a treatment sequence is called using a simple forward function. Case and movement references are optional and are configured in customizing.med medication) · A treatment sequence is the order of the datatechnically connected outpatient visits. Several variants are available in customizing for this. which identifies the specific employee.med without ACM outpatient clinic folders and individual entries (notes) are created in the patient organizer. user-specific or patient-related logs are created. with which one or more notes of an outpatient clinic folder can be printed.med offers the option of determining treatment sequences.med it is necessary to enter the employee responsible. Application Logging Application logging can be used to log all access to the patient record and specific actions regarding individual objects. .s.s. · Documents · Patient record · Clinical orders Treatment Sequence · Medication orders (i. The following is connected to application logging: · A print function is available for outpatient notes. Application logging supports a healthcare institution in enhancing its authorization concept to satisfy privacy guidelines in national and regional law.Outpatient Clinic Folder (Part of SAP ACM – Licensed Product from SAP) · The outpatient clinic folder helps to clearly display individual unstructured information on outpatient visits in the form of outpatient notes. · An outpatient note has at least a patient reference. · The date and time reference preset for an individual outpatient note is configured in customizing. Optionally it is also possible to assign such a responsible employee / business partner to an SAP user in the master data.s.med medication) In the outpatient environment i. · The treatment sequence is used particularly during the organization of accident outpatient clinics and emergency admissions.h.h. The documentation of an employee responsible is not connected with the entry of a password or another check based on possession or knowledge. which can subsequently be evaluated.h. depending on the configured definition.s.s. Data Sheet i. which are called at precisely defined times in a process.s.h.s.h.med offers extensive possibilities for completely integrating and enhancing special cases or requests which exceed the boundaries of the supplied standard functionality. This represents the first step on the path to the comprehensive documentation of categorized risks or hazard potential for the patient or those which the patient himself causes. These programming interfaces.h. · If the documentation of allergies is used for the connection of external checking systems in medication.h.med supplies adequate functionality for the typical standard processes of outpatient and inpatient activity. · Allergen Allergy Documentation · Assessment (documented allergies of the patient which are considered to be particularly critical.h. · All allergy documentation can be integrated into the situations of the inpatient documentation work stations as a task. offer the option of implementing project-specific enhancements. which can be used immediately following correspondding customizing within an implementation project. · Documentation of individual allergies of the patient under specification of certain attributes: · More modern technology with generally the same aim exists in an extensive library of BAdIs. · Determine documentation status of allergy documentation: · Have enquiries been made? · Were these successfully completed? · The system differentiates between information which has not yet been queried and the fact that the patient does not know of any allergies at the time of the enquiry.s. value lists must be stored in corresponding customizing tables for the attributing options listed below during documentation. Examination and Laboratory Results The results of lab examinations have a special position in clinical operations. are highlighted in display) In addition to the SAP Patient Management risk factors (licensed product from SAP) and as the first level in their replacement.med offers a documentation function especially for allergies in Release 6. i. the content of the allergen catalog (typically allergy groups) must be discussed with the supplier of the checking service.Enhancement Framework Functionality i. allergies are documented on a patientspecific basis. The visualization of the results of such examinations is rarely order-related and only partially expected in individual findings. Furthermore.med basis Page 31 of 35 · Allergy type · Certainty (reliability of information) · Reactions and their severity (several reactions can be documented for each allergen) · The status of the allergy documentation can be displayed as a column in various patient-related views of the clinical work station. · The allergy documentation can be called directly if the patient search is integrated.05. Two technologies are available for this: · Older parts of i. i.med’s basic catalog maintenance. · Generally.s. i. This then leads directly to the allergy documentation via a hotspot. · In addition to the allergens.s.h. Basic Data · The allergen catalog for the allergy documentation is a special separate catalog category in i.h.s.med therefore offers several cumulative displays for lab .med offer so-called user exits.s. Alternatively.s. time period. · There are various print formats available. which are integrated into the patient-related views of the clinical work station. as well as in the patient organizer and in the ward work station. specific lab parameters or parameter groups).m.health (see corresponding data sheet). nuclear medicine lab).med basis Page 32 of 35 · Evaluations of clinical documentation (countryspecific characteristic: In Germany flat rates per case and procedure surcharges) More specific evaluation options are available in i. chemical lab.s. · The cumulative findings can be provided for calling in several versions. Data Sheet i. including a collective printing function for each care unit / ward or for each institution. in its pivot-like display. transport list) · It is also possible to display lab values for all the patients of a ward / care unit. surgery work station) and also stand-alone as an alternative to the other display options.c.h. an overview of the lab values of a patient or case.h.med basis provides reports in the following categories: · Master data overviews · Services (evaluations using visits or treatments per day. which can be printed as a background job. · Various filter functions are available (case. such as when different lab information systems supply information to i. to the tabular display of lab parameters. Clinical Evaluations / Statistics i.h.findings.g. other graphical formatting is also available: · Active-X – component for use on Windows platforms: This enhances the above-described functionality with a trend display for a number of lab parameters and offers optimization options in the grid. for example when new findings are received.s. This is available as part of the clinical overview in versions of the documentation work station (ward work station. optionally also for multiple institutions. · Web dynpro components for the formatting of lab results.med (e. . or in addition. · Users can scroll through findings individually or in blocks. · The cumulative findings of lab results provides. · A restriction to only pathological values is supported. h. RAM.h. This technology can be run with the hardware which is usual for i.med SAP 6. diagnoses.s.h. services. etc.med progress documentation data sheet).med Basic Medical Record license package (10402193 or 10402294). · The SAP GUI including the i.h.h. · SAP Netweaver Business Client (NWBC) 4.med is understood as a clinical information system in combination with SAP Patient Management (licensed product from SAP).s.h.med Named Users (10402192) · Generally. but also appointments.med can be technically run on the hardware which is necessary for SAP Patient Management.med-specific planning grid component is either used exclusively as the client application or. · License and installation of SAP Patient Management (IS-H) (10178662) All i. the Netweaver Business Client.0 for Desktop or higher Implementing HANA requires an implementation project with SAP and other partners.h. etc.med can be used with HANA database technology from SAP.s. However. possible server clusters.) (see also SAP note number 1517664). · Microsoft Silverlight Version 4 or higher (for the patient groups and Smart Chart components) Data Sheet i.h.med.30 or higher HANA · SAP Netweaver 7. preregistrations. database systems. Within this project it is necessary to procure licenses and configure applications.s. etc.Prerequisites for Implementation Modules System i.med basis Page 33 of 35 · Prerequisites for the use of WebDynpro technology .h.h.s.med basis. We recommend the scaling of this concerning CPU performance.s. This integration immediately makes functionality from other ERP components available in i. · Adobe Document Services (ADS) are used for the form-based processing of business data.s.s.s. In this integration there is generally no data or functional redundancy.s.med. The systems both jointly use the central datasets (such as patients. in accordance with the foreseeable system load (number of users. These run on a Java application server (see also i. in addition. The materials management (MM) content is accessed directly. are the same as those for SAP ERP Release 6.med modules and departmental solutions are based on i. etc.).0 EHP 6 basis is part of the i.h.0 SAP EHP3 SPS 05 or higher i. i.s. cases.h. etc. the online service portal and the upgrade and error correction processes. Integration · The supported operating system platforms. Furthermore the hardware in use is checked and adapted through optimization. Prerequisites for this package are: · Licenses for i.h.0. the integration also concerns the technical components such as the transport system.s. Smart UI (see also SAP note number 1782982) The following recommendations apply for the use of Smart UI components: · SAP GUI for Windows 7.s. i. g.g. 19” (TFT) with a resolution of 1280*1024 pixels (minimum) · IT network: At least 1 GBit/s network speed on client Other Prerequisites · Once a year the client must provide voluntary information on license-relevant audits (number of users.g.The following recommendations apply for a Smart UI infrastructure: · ABAP application server Hardware – Server: · CPU: 2x Xeon E5-2680 v2 · RAM: 512 GB RAM · Model: e.med basis Page 34 of 35 · Services are required for productive use (some can be executed by the client). if terminal servers are used (e.g.g.h. HP DL360p G8 · Work station – local NWBC installation or terminal server (e. Data Sheet i.s.8 GHz · RAM: 64 GB RAM · HDD: 2x 200GB SSD as RAID-1 · Model: e.x) Hardware – Client: · CPU: Core i5 · RAM: 8 GB RAM · Graphic: Separate graphic card · Monitor: e. In the license contract Cerner expressly reserves the right to perform license audits. CITRIX) Hardware – Terminal server: · CPU: 2x E5-2680 v2 10-Core 2. . Citrix XenDesktop 7. number of patients treated each year). HP BL460c G8 · Additionally.g. 22“ (TFT) with a resolution of 1920*1080 pixels (recommendation) e. cerner. i. All personal and patient data displayed in Software Screenshots or Contact otherwise in this document are imaginary. Thus all requested specifications and options are to be defined individually in the contract. Original images always lose a certain amount of detail when reproduced.h. Cerner reserves the right to modify the design. Screenshots were created on Cerner owned systems for the purpose of presentation. or to replace clinical judgment or responsibilities. individual cases. MO 64117 / USA This document contains Cerner confidential and/or proprietary information belonging to Cerner Corporation and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of Cerner. All Cerner trademarks and logos are owned by Cerner. Cerner Corporation / 2800 Rockcreek Pkwy / Kansas City. Healthcare professionals should always refer to the primary information source before making any clinical diagnostic plan or treatment. packaging.The information in this document contains general technical descriptions of specifications and options as well as standard and About Cerner optional features which do not always have to be present in We’re continuously building on our foundation of intelligent solutions for the health care industry.0 EHP 6 basis en. clinical diagnostic. and/or therapeutic purposes. and operational needs of organizations of every size.med is not intended to be used for monitoring.s. Corp. All other brand or product names are trademarks or registered marks of their respective owners. Any technical data contained in this document may vary within defined tolerances. Documentation supplied to Cerner by third parties and included with this documentation is not warranted for accuracy or completeness. specifications and options described herein without prior notice.com . SAP and other SAP products and services mentioned herein as well as their respective logos are trademarks or registered trademarks of SAP SE in Germany and in several other countries. Data Sheet SW ishmed SAP 6. Our technologies connect people and systems and our wide range of services support the clinical. financial.docx Page 35 of 35 Released Date: 03/15 Cerner Health Services Deutschland GmbH Karl-Zucker-Straße 18 91052 Erlangen Germany www.