[Gnumed-devel] Anticoagulation project and larger planning issues

[J Busser]

I now have a computer (Windows XP) set up for the nurses. It makes 
them independent of the secretary's computer which had been their 
means of getting lab results, which are however still being printed 
on paper (the entire workflow is still paper based).

My larger interest is in seeing if I can move a couple of pieces 
together. My "district" has 2200 doctors of whom 65% are estimated to 
have little or no EMR functionality. Most of these do have a computer 
on which a secretary does scheduling and billing, and some have 
internet access for on-line resources.

The local district strategic planning committee believes that a set 
of very basic modules
- patient identification (even if just "fed" from an appointment 
manager / biller)
- lab results handling
- medication management

would be a very good starting point for many people, it would be a 
tremendous help while staying compatible with an otherwise largely 
paper practice.

OSCAR, while having some management issues, is still in place locally 
so has a head start. I believe Gnumed's technical & clinical design 
are better but, to warrant consideration, Gnumed must *at least* fit 
it into the basic frame above. I was hoping my anticoagulation 
project could be a demonstration platform.

@ Horst, the above is partly FYI but to what extent does OSCAR's work 
with drugref put OSCAR significantly ("even further") ahead of Gnumed 
or could gnumed redeploy what OSCAR is doing with little added work 
perhaps especially using a browser?

@ Karsten & others, would it take a full-time programmer more than a 
month to develop gnumed to the extent I need? Should a programmer 
from a developed country cost much more than $50 Can/Aus (30 euros) 
per hour? (Not twice that, I hope!!!)

EMR needs for an anticoagulation clinic:
========================

input new patient from the keyboard,
detect / warn if duplicate patient about to be created
find patient
edit current demographic information
input health issue(s)
        indication for anticoagulation
        target intensity (INR 2.5-3.5)
input medications (warfarin & maybe a low molecular weight heparin 
(LMWH) e.g. tinzaparin)
input soaP
        set date for next lab_request
	identify lab_request status (needed/printed/submitted vs 
standing order)
establish connection to lab to fetch lab data
fetch data (LOINC)
populate gnumed test_type table with any "new" combinations of
        organisation/code/coding_system
notify users that new lab data is available
import data into staging table
        match to patients (since Canada uses no lab_request id) :-(
        if lab_request originated from the clinic
                offer that encounter/episode as the one to link
        elif originated from some other provider
                create dummy encounter/episode "unrequested test results"
        update the following for actual requests +- unrequested test results
                update lab_request_id (internal to the lab)
                update lab_rxd_when (specimen date/time received)
                update results_reported_when (was the report generated)
                update request_status (final, preliminary, partial)
                update is_pending
transfer data into test_results
assign fk_reviewer
permit manual entry of lab results that did not arrive by way of the 
electronic interface

next, the following must be identifiable and must support a good work flow:
- for test results outside of range
        instruction obtained from doctor
        input medication change (including "no change")
        - capture the change as "as nurse user xx" for "authorizing Doctor yy"
        soaP entry references medication change and next lab_request
        patient notified & notification status is captured
        (might we want notification_status in test_results?)
        test results outside of range are marked as having been dealt with
        for all these, set reviewed_by_clinician boolean "TRUE"
- for test results within range
        soaP entry specifies per-protocol next lab_request
        patient notified & notification status is captured
        test results within range are marked as having been dealt with
        for all these, set reviewed_by_clinician boolean "TRUE"
- for overdue requests having lab_rxd_when is NULL
        patient is contacted / reminded / SoaP captured
        existing lab_request is CANCELLED
        new lab_request is entered (or should existing be modified?)
        overdue requests are marked as having been dealt with

optionally / Stage 2
- support appointments for those requiring bridging injections of LMWH
- data export / reporting tools