Advanced Point-of-Care Clinical Information Solutions and Services
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Advanced Point-of-Care Clinical Information Solutions and Services |
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medEntry is an on-line encounter system and the primary method with which clinicians interact with patient information. Clinicians and staff use the medEntry system to enter information, review patient information, histories, issue orders/prescriptions (medOrder) and interact with other professionals using our integrated Clinical Messaging system.
medEntry applications are designed to automate the process of obtaining, storing and searching all types of clinical data in a highly secure, codified and structured medical record data warehouse. The system provides several methods to add information from other sources (other ancillary systems, email, lab results, free text notes, etc.). This information is then available for immediate care needs, billing, reporting, analysis and research.
The encounter system is designed to be customized to match each customer's unique needs through the use of a table-driven design using a data dictionary. These provide the ability to rapidly prototype new documents or customize existing encounter documents.
The system supports Problem-Oriented, Time-Oriented, and Source-Oriented medical record/chart views. Designed in cooperation with leading clinicians and medical informatics experts the system is based on a "signs and symptoms" approach - SOAP (Symptoms, Objectives, Assessments & Plans).
Conceptual Overview of Information Integration
Information obtained in the encounter process, from transcriptions and/or from other ancillary systems are permanently stored in the medDataSafe data base management system via the medIntegrator HL7 interface(s). This information is then immediately accessible through medEntry specialty applications, medSummary and/or by using the medAnalyze decision support tools.
The system is intuitively easy to use and learn. The system has been designed with leading medical practitioners to emulate the natural work-flow of key clinical specialties. The organization of each medEncounter specialty screen-set is optimized for that specialty. Using graphical menu capabilities in an internet browser, users point and click using a keyboard/mouse on the menu-driven screens to access or enter information. Information is entered into the system by using structured fields and accommodates clinician notes by providing the capability of entering free-text notes everywhere to supplement the structured data selections. Drop down menus and search capabilities allow convenient, rapid access to records and information including search by ID number, code, patient record number, part of a name (or drug name), or sound-like (soundex) searches. The drop-down and pop-up style windows also have safe-guards with reminders and alerts for context-sensitive prompting and key information. Information contained in a patient record may be copied forward from a past encounter to help rapidly complete a current encounter.
medEncounter has multi-layer security. Access to the system and to patient medical records is highly restricted to authorized users using various means including the typical username/password conventions. Each username is associated with certain levels of security privileges ranging from the privilege to only view a record, only view a set of records, or view certain fields within specific records. Another user may be able to write information into certain patient's records but only view other patient's records - not change any information. Thus, as an example, a doctor can have complete access to view and change that doctor's assigned patient records but may only be able to view another doctor's patient records - or view just allergies in the record. Security is taken down to the individual data-item level within a record in addition to overall records. Even system administrators are restricted to what can be accessed. Providers can access the system from a hospital system or a remote system. Intranet, Internet and other remote access is controlled using Virtual Private Network (VPN) and 128-bit Secure Socket Layer (SSL) encryption technology.
Once information is saved in the system it is available to all authorized users in the clinical environment and other medical staff - including referring physicians. Electronic signatures are used to denote final documentation. This digital signature is built using key features including: message integrity, user authentication and non-repudiation concepts. Once information is saved it cannot be deleted but new information or revised information can be appended in the record and shown as the current information. Clinicians and other authorized users can update a patient's medical record and the system will automatically archive and produce an audit trail of all changes. A record that has been appended has a special notation showing it is changed and will allow navigation to the previous record entries. This supports HIPAA compliance as well as providing a useful history of changes.
Key Features:
medEncounter was originally deployed in 1983 as THERESA and is still in use at Grady Health System (GHS) in Atlanta, Georgia under the THERESA brand. medEncounter builds on the success and quality of THERESA. The system is design for very rapid response times and scales to accommodate hundreds of interactive users or multiple sites simultaneously. Click HERE to view additional THERESA information.
medEntry specialty modules are a series of encounter screens, forms and menus that are customized for each medical specialty. Since each medical specialty requires different information in a different order each medEntry specialty module reflects the unique needs of the medical specialty. Thus the Medicine specialty module is different than the Obstetrics specialty module. All modules have the same basic profile and same operational characteristics so learning one module provides knowledge of using the entire system. There are certain key elements included with all specialty modules including: consistent menu bars/buttons, comprehensive patient Problem List, Master Summary (medSummary), Physician's Assessment, free text Notes, Patient History, Drug and Allergies list, prior visits, incorporation of other data (e.g. lab results, scanned pages), reminders, protocols and other features.
Clinicians utilize the Microsoft Internet Explorer, Mozilla Firefox or Apple Safari browser to access all applications. Screens and menus are designed with windows-style drop-down/pop-up type windows and operate with a mouse and/or keyboard. All screens are designed using a global data dictionary so all modules operate consistently from application to application. The system can also be accessed using a tablet PC or laptop - including secure wireless networks and soon with a Windows CE-based PDA. Access is granted through secure channels typically using a Virtual Private Network (VPN) and encryption.
Example medEntry Patient Encounter Application Documents
medEncounter applications are designed to make it easy to enter information directly or via transcription or dictation. Clinicians may elect to enter information directly into the encounter system, dictate or make written notes that will be transcribed into the system through our transcription link. All information is kept in a secure central permanent information repository. System security is multi-layered down to the individual data element. Users authorized in the system can view only the information allowed. Thus a clinician may be able to see and write information only about their set of patients and yet another clinician or staff member can only view specified information about those patients - not change the records.
MsdC's system approach provides existing off-the-shelf medical specialty application modules as the starting point for customizing a system for your needs. Each module can be further customized per customer requirements while maintaining full data integrity and system conventions. MsdC has taken the science and art of creating custom screens and menus to a new level by using the system's data dictionary and our table-driven design. These allow for rapid editing and creation of new screens, menus and forms. MsdC provides very high quality applications and support for all custom designs. Maintaining application availability and complete data integrity are key design elements.
medEncounter applications operate in a natural-workflow and interactive information-rich environment. In order to organize and create a single global view of the patient, related information from other applications (e.g. pharmacy data, lab tests, etc.) are integrated into the central patient information record (typically using HL7 standards). Depending on the type of billing codes needed some form such as ICD-9 or CPT codes are automatically generated and are linked to the clinical billing system thus capturing all billing information and increasing the bill rate. MsdC does not provide medical billing systems but links the system into existing systems. We work with our customers to integrate their chosen billing system as a part of the overall system solution.
Information obtained in the encounter process and from other ancillary systems is permanently stored in the medDataSafe data base management system and can be accessed through a medEncounter Specialty module or by using the decision support tools of the medAnalyze application. During the encounter process a clinician may issues orders for prescriptions, lab tests etc. using a third party system or medOrder. There are times when only a view of summary information is required and medSummary may be used in conjunction with medEntry or may be used standalone. When viewing information with medSummary edits cannot be made.
Key Benefits
List of Existing medEncounter Modules
NOTE: Combinations of the following can be used to create other specialty modules.
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Clinicians
use the system through modularized patient encounter
screen sets that are customized for each medical
specialty's unique workflow. Use of a Graphical
User Interface (GUI) with "windows-style"
mouse/keyboard interaction provides a user-friendly
environment so clinicians can be more productive.
These computer application screen sets are structured
smart documents that follow the natural flow
of the medical specialty utilizing an ergonomic style
document format. They contain menus that allow
rapid and secure access to all patient information
through convenient and intuitive screens and
windows-style menus. They are dynamic
since the screens and menu options expand on-demand
so that clinicians may add additional information
on-the-fly 
medEntry Specialty Modules
