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Summer Training

In

Fresco Informatics

(April 9 - May 31, 2012)

Requirement Gathering and Functional Requirement specifications for

Physiotherapy specific EHR

Dr. Manish Jain (PT)

Post-graduate Programme in Hospital & Health Management,

New Delhi

2011-13

International Institute of Health Management Research, New Delhi

2012

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ACKNOWLEDGEMENT

I owe a great many things to a great many people who helped me and supported me during

the summer training.

I wish to express my deep sense of gratitude to Mr. Ahimanikya Satapathy, Founder & CEO,

for giving me the opportunity to do my Summer Training at Fresco Informatics. He was very

kind enough to spare his valuable time and provide me suggestions regarding the study to be

undertaken.

I hereby take this opportunity to thank, Mrs. Asha Satapathy, Founder, Fresco Informatics for

her valuable guidance & advice. Her willingness to motivate me contributed tremendously to

my project.

My special thanks to Business Analyst Saurabh Leekha and Dr. Shirin Saini for their

guidance, support, interest, involvement and encouragement and for being a source of

inspiration and timely guidance during the training period.

My sincere acknowledgement goes to Professor Indrajit Bhattacharya for his kind

assistance and support throughout my summer training.

Finally, I would like to show my greatest appreciation to my colleagues and family for their

tremendous support and cooperation while working on this project.

The guidance and support received from all the members who contributed was vital for the

success of the project. I am grateful to them for their constant support and guidance.

Thank You

Dr. Manish Jain (PT)

PGDHHM, IIHMR, New Delhi

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CERIFICATE

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FEEDBACK FORM

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TABLE OF CONTENTS

S. No. CONTENT Page

Number

A Acronyms 7

B Executive Summary 9

C Introduction 11

Organization Profile 10

About the project 12

Project Objectives 13

Requirement gathering 15

Background of project development 16

Software Development Life Cycle (SDLC) 17

Software Development Model at Fresco 18

Programming Language used at Fresco 20

D Methodology and Tools used 23

Methodology Used 23

Steps followed at Fresco 24

Tools Used 25

Stages Covered 26

E Observations 29

Workflow 29

Consultation Process 31

F Findings and Recommendations 33

Findings 33

Recommendations 37

G Conclusion 41

H Case Study 42

I References 52

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S. No. CONTENT Page

Number

J List of Figures

Figure 1: Scrum Model of Software Development 18

Figure 2: Workflow of Consultation Process at a

Physiotherapy Centre 30

Figure 3: Number of Patients, Physiotherapists and staff 33

Figure 4: Time Spent for Assessment and Treatment 34

Figure 5: Conducting Assessment 34

Figure 6: Working with Computer & Internet 35

Figure 7: Willing to adopt a Computerized System 35

Figure 8: Features they want in the system 36

Figure 9: Snapshot of Login Screen Specification 37

Figure 10: Snapshot of Appointment Screen Specification 38

Figure 11: Snapshot of Physiotherapist profile Specifications 39

Figure 12: Snapshots of the Consultation Module Specifications 40

K Annexure 54

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ACRONYMS/ ABBREVIATIONS

EHR: Electronic Health Record

EPR: Electronic Patient Record

EMR: Electronic Medical Record

SDLC: Software Development Life Cycle

SOAP: Subjective Objective Assessment Plan

SOA: Service Oriented Architecture

WOA: Web Oriented Architecture

SODA: Service Oriented Development Architecture

ESB: Enterprise Service Bus

MPI: Message Passing Interface

HMS: Hospital Management System

CDLL: Common Development and Distribution License

GPL: General Public License

SDO: Standard Development Organization

ISO: International Standards Organization

OSI: Open Systems Interconnection

HL7: Health Level Seven

CCD: Continuity of Care Document

CDA: Clinical Document Architecture

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RIM: Reference Information Model

SNOMED: Systematized Nomenclature of Medicine

LOINC: Logical Observation Identifiers Names and Codes

CCR: Continuity of Care Record

JVM: Java Virtual Machine

WORA: Write Once, Run Anywhere

JRE: Java Runtime Environment

API: Application Programming Interface

GUI: Graphic User Interface

HTML: Hypertext Markup Language

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EXECUTIVE SUMMARY

Indian healthcare enterprises are beginning to embark on their ―digitization cycle and have

a long way to go before they can match the level in the developed countries. Integration of

Information Technology is not only useful for only large hospital setups but also other

clinical setups like physiotherapy clinics which play an important role in healthcare sector.

An electronic health record (EHR) is an evolving concept defined as a systematic

collection of electronic health information about individual patients or populations. It is a

record in digital format that is theoretically capable of being shared across different health

care settings. In some cases this sharing can occur by way of network-connected enterprise-

wide information systems and other information networks or exchanges. EHRs may include a

range of data, including demographics, medical history, medication and allergies,

immunization status, laboratory test results, radiology images, vital signs, personal stats like

age and weight, and billing information.

The terms EHR, EPR (electronic patient record) and EMR (electronic medical record) are

often used interchangeably, although differences between them can be defined. The EMR

can, for example, be defined as the patient record created in hospitals and ambulatory

environments, and which can serve as a data source for the EHR. It is important to note that

an EHR is generated and maintained within an institution, such as a hospital, integrated

delivery network, clinic, or physician office, to give patients, physicians and other health care

providers, employers, and payers or insurers access to a patient's medical records across

facilities.

Objectives

1. Gather requirements for a consultation module for a Physiotherapy specific EHR.

2. On the basis of the gathered requirements develop the Functional documents module

which describes the features to be included in the consultation module.

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Project Plan

1. Understanding the complete requirements through requirement gathering process

2. Assessing and understanding the existing workflow

3. Finding the Gaps and areas of improvement

4. Preparation of functional specification documents

Conclusion

There is no magical wand, no one answer, no perfect approach method or technique to

requirements gathering. Developing a good requirements document is about giving your

project the best chance of success. To do so, you must reduce the risk of common mistakes

that arise from a lack of communication or understanding. Keep this in mind as you gather

your requirements, and the documentation — and project as a whole — will have the best

chance of success.

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INTRODUCTION

Organization Profile

Fresco Informatics provides extensive range of enterprise computing solutions, consulting

services and technology products for the ever-changing world of business. The goal is to

exceed the expectations of every client by offering outstanding customer service, increased

flexibility, and greater value, thus optimizing system functionality and improving operation

efficiency.

Fresco Informatics associates are distinguished by their functional and technical expertise

combined with their hands-on experience, thereby ensuring that the clients receive the most

effective and professional service. Fresco Informatics brings in a fresh and innovative

approach to software products and services. Software systems are agile and hence

requirements continue to evolve throughout the life of the software system. Need of the hour

is an adaptive and collaborative approach to software development. Hence Fresco chooses to

follow agile practices like scrum.

Fresco team experts in the Open source and closed source enterprise technologies and

products build over SOA, WOA and SODA. The team has contributed significantly to

various open source initiatives such as Project Mural, Open ESB and Glassfish.

Open ESB is a Java based open source enterprise service bus. Open ESB can be used as a

platform for both Enterprise Application Integration and SOA. Open ESB is built on open

standards. Oracle, after acquiring Sun Microsystems, has cancelled corporate sponsorship of

this project. Community development on Open ESB continues, organized

by LogiCoy and Pymma Consulting.

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Glassfish is an open-source application server project started by Sun Microsystems for

the Java EE platform and now sponsored by Oracle Corporation. The supported version is

called Oracle Glassfish Server. Glassfish is free software, dual-licensed under two free

software licenses: the Common Development and Distribution License (CDDL) and

the GNU General Public License (GPL) with the class path exception.

Project Mural is an attempt to build an ecosystem to solve such data management problems.

Leveraging NetBeans, Glassfish and Open ESB communities, Project Mural aims to provide

a platform to power various transformational initiatives like:

Customer Data Integration

Product Information Management

Building data services for SOA Initiatives

Powering enterprise mashups

Fresco EHR and MPI product suites empower and enable physician practices to provide

effective and integrated care delivery. Fresco Informatics delivers the next generation of

clinical care information systems solutions built upon best-of-breed and best-in-class

healthcare software. The Fresco Informatics solution creates a foundation for heterogeneous

communication amongst healthcare providers throughout the hospital as well as all

caregivers within the Hospital Network.

About the Project

The project was concerning the development of a Physiotherapy specific EHR. My role

involved finding the requirements through the process of requirement gathering from

prospective clients and preparation of functional requirement document for the development

of consultation module that can facilitate workflow at any physiotherapy clinic and helps to

increase the efficiency and quality of procedures to achieve high patient satisfaction by

reducing the patient waiting time and providing higher quality of patient care.

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What is Physiotherapy?

Physiotherapy means physiotherapeutic system of medicine which includes examination,

treatment, advice and instructions to any person preparatory to or for the purpose of or in

connection with movement dysfunction, bodily malfunction, physical disorder, disability,

healing and pain from trauma and disease, physical and mental conditions using physical

agents including exercise, mobilization, manipulation, mechanical and electrotherapy,

activity and devices or diagnosis, treatment and prevention.

There are various specialties covered under it like:

1. Orthopedic

2. Neurological

3. Sports

4. Cardiovascular & Pulmonary

5. Pediatric

6. Geriatric

7. Women Health

8. Many more

Project Objectives

1. It will help the Physiotherapy clinic to have a whole range of data in comprehensive

form.

2. A good Functional Requirement Document clearly states the objective of the project

and defines its scope, to clarify what the project does and does not cover.

Rationale

To enhance health care delivery quality, to facilitate clinical data exchange and retrieval and

maintain confidentiality of the patient records and reduce patient waiting time and thus

enhance the patient satisfaction.

HL7 is an ANSI-accredited Standard Development Organization (SDO) operating in the

healthcare arena. • It is a non-profit organization made up of volunteers – providers,

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customers, vendors, government, etc. HL7 is an acronym for Health Level Seven – Seven

represents the highest, or “application,” level of the International Standards Organization

(ISO) communications model for Open Systems Interconnection (OSI) networks.

HL7 provides standards for interoperability that improve care delivery, optimize workflow,

reduce ambiguity and enhance knowledge transfer among all of our stakeholders, including

healthcare providers, government agencies, the vendor community, fellow SDOs and

patients. In all of their processes they exhibit timeliness, scientific rigor and technical

expertise without compromising transparency, accountability, practicality, or willingness to

put the needs of stakeholders first.

The Continuity of Care Document (CCD) specification is an XML-based markup standard

intended to specify the encoding, structure and semantics of a patient summary clinical

document for exchange.

The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA)

standard. The CDA specifies that the content of the document consists of a mandatory textual

part (which ensures human interpretation of the document contents) and optional structured

parts (for software processing). The structured part is based on the HL7 Reference

Information Model (RIM) and provides a framework for referring to concepts from coding

systems such as from SNOMED and LOINC.

The patient summary contains a core data set of the most relevant administrative,

demographic, and clinical information facts about a patient's healthcare, covering one or

more healthcare encounters. It provides a means for one healthcare practitioner, system, or

setting to aggregate all of the pertinent data about a patient and forward it to another

practitioner, system, or setting to support the continuity of care. Its primary use case is to

provide a snapshot in time containing the pertinent clinical, demographic, and administrative

data for a specific patient.

The CCR (Continuity of Care Record) standard is a patient health summary standard. It is

a way to create flexible documents that contain the most relevant and timely core health

information about a patient, and to send these electronically from one caregiver to another. It

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contains various sections such as patient demographics, insurance information, diagnoses and

problem list, medications, allergies and care plan. These represent a "snapshot" of a patient's

health data that can be useful or possibly lifesaving, if available at the time of clinical

encounter. The ASTM CCR standard is designed to permit easy creation by a physician using

an electronic health record (EHR) system at the end of an encounter.

Because it is expressed in the standard data interchange language known as XML, a CCR can

potentially be created, read and interpreted by any EHR or EMR software application. A

CCR can also be exported in other formats, such as PDF and Office Open XML (Microsoft

Word 2007 format).

Requirement gathering

Getting the requirements right – and getting the right requirements – can mean the difference

between a successful project – one that satisfies the needs of its users and is delivered on-

time and on-budget – and one that fails. It should come as no surprise that effective

requirements gathering involves much more than asking business users what they want and

need. It is a complex process that involves users and system designers in a collaborative

effort that explores both functional requirements and the new possibilities that technology

offers.

The great challenge of the requirements process is finding a way to uncover and capture the

needs of the business and communicate those needs to a software development team in a

language and style that facilitates the software design process, producing a result that

precisely solves the business problem. All too often the requirements process begins with a

few key questions about the business need, and then quickly moves to discussions about parts

of the technology solution.

Requirement gathering is usually the first part of any software product. This stage starts

while thinking about developing software. This phase, involves meeting customers or

prospective customers, analyzing market requirements and features that are in demand. In

this stage, people who have direct contact with the customers do most of the work. These

people talk to customers & try to understand what they need. A comprehensive

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understanding of the customer‘s needs & writing down the features of the proposed software

are the keys to success in this phase.

Advantages

It provides:

1. A succinct requirement specification for management purpose.

2. A statement of key objectives-a cardinal point specification”.

3. A description of the environment in which the system will work.

4. Background information and references to other relevant material.

5. Information on various design constraints.

Types of requirement gathering

1. Shadowing- Observing the end user and understanding about the manual process of

how they are doing in their environment.

2. Interviewing- It includes interviewing the end user or business owner with a set of

questionnaire.

3. Focus group- It involves involving everyone in a meeting to discuss on requirements.

4. Survey- It involves conducting a survey with a set of questions and options & set it to

the end-user or clients and analyzes the information from it.

5. User instruction- One has to do the work the end-user is doing and follow his

instructions to complete the task.

6. Prototyping- Create a prototype of requirement or information in the form of photos

or physical things.

Background of the project/project development

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Software development is a complicated process comprising many stages. Each stage requires

a lot of paperwork and documentation in addition to the development and planning process.

The term "software development" may be used to refer to the activity of computer

programming, which is the process of writing and maintaining the source code, but in a

broader sense of the term it includes all that is involved between the conception of the

desired software through to the final manifestation of the software, ideally in a planned and

structured process.

Any software which needs to be developed irrespective of the purpose whether for clinical or

administrative or programming purpose goes through the same set of steps or life cycle

which is grouped as software development life cycle.

Software development lifecycle (SDLC)

The software development life cycle (SDLC) can be considered to be the oldest formalized

methodology for building information systems. The main idea of the SDLC has been "to

pursue the development of information systems in a very deliberate, structured and

methodical way, requiring each stage of the life cycle from inception of the idea to delivery

of the final system, to be carried out in rigidly and sequentially within the context of the

framework being applied.

The software development life cycle, or development process, is a structure imposed on the

development of a software product. It typically covers all aspects of the development,

starting from the identification (capture) of the customer‘s (or end user‘s) requirements,

through the implementation of the code, to product deployment and maintenance of the

system in the field. A software development methodology is a framework that is used to

structure, plan, and control the process of developing an information system - this includes

the pre-definition of specific deliverables and artifacts that are created and completed by a

project team to develop or maintain an application.

Each software development project has to go through the following stages:

1. Requirement gathering

2. Writing functional specifications

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3. Creating architecture and design documents

4. Implementation and coding

5. Testing and quality assurance

6. Software release

7. Documentation

8. Support and new features

There may be many additional steps and stages depending upon the nature of the software

product. My project covered the initial part or stages of the software development life cycle.

Software Development Model used at Fresco Informatics

The Software Development Method which is being used at Fresco Informatics is

scrum which is an iterative and incremental agile software development method for

managing software projects and product or application development.

Figure 1: Scrum Model of Software Development

Scrum contains sets of methods and predefined roles. The main roles in Scrum are:

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1. The "Scrum Master", who ensures the process is followed, removes impediments, and

protects the Development Team from disruption

2. The "Product Owner", who represents the stakeholders and the business

3. The "Development Team", a cross-functional, self-organizing team who do the actual

analysis, design, implementation, testing, etc.

Sprint

A sprint is the basic unit of development in Scrum. Sprints last between one week and one

month, and are a "time boxed" (i.e. restricted to a specific duration) effort of a constant

length.

Each sprint is preceded by a planning meeting, where the tasks for the sprint are identified

and an estimated commitment for the sprint goal is made, and followed by a review or

retrospective meeting, where the progress is reviewed and lessons for the next sprint are

identified.

During each sprint, the team creates finished portions of a product. The set of features that go

into a sprint come from the product backlog, which is a prioritized list of requirements.

Which backlog items go into the sprint is determined during the sprint planning meeting.

During this meeting, the Product Owner informs the team of the items in the product backlog

that he or she wants completed (the ones with the highest priority). The team then determines

how much of this they can commit to complete during the next sprint, and records this in the

sprint backlog. During a sprint, no one is allowed to change the sprint backlog, which means

that the requirements are frozen for that sprint. Development is time boxed such that the

sprint must end on time; if requirements are not completed for any reason they are left out

and returned to the product backlog. After a sprint is completed, the team demonstrates how

to use the software.

Scrum enables the creation of self-organizing teams by encouraging co-location of all team

members, and verbal communication between all team members and disciplines in the

project.

A key principle of Scrum is its recognition that during a project the customers can change

their minds about what they want and need (often called requirements churn), and that

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unpredicted challenges cannot be easily addressed in a traditional predictive or planned

manner. As such, Scrum adopts an empirical approach—accepting that the problem cannot

be fully understood or defined, focusing instead on maximizing the team’s ability to deliver

quickly and respond to emerging requirements.

Like other agile development methodologies, Scrum can be implemented through a wide

range of tools. Many companies use universal tools, such as spreadsheets to build and

maintain artifacts such as the sprint backlog. There are also open-source and proprietary

packages dedicated to management of products under the Scrum process. Other organizations

implement Scrum without the use of any tools, and maintain their artifacts in hard-copy

forms such as paper, whiteboards, and sticky notes.

Programming Language used at Fresco Informatics

The programming language used at Fresco Informatics is JAVA. Java is a programming

language originally developed by James Gosling at Sun Microsystems (which has

since merged into Oracle Corporation) and released in 1995 as a core component of Sun

Microsystems' Java platform. Java applications are typically compiled to byte code (class

file) that can run on any Java Virtual Machine (JVM) regardless of computer architecture.

Java is a general-purpose, concurrent, class-based, object-oriented language that is

specifically designed to have as few implementation dependencies as possible. It is intended

to let application developers "write once, run anywhere" (WORA), meaning that code that

runs on one platform does not need to be recompiled to run on another. Java is currently one

of the most popular programming languages in use, particularly for client-server web

applications, with a reported 10 million users.

One characteristic of Java is portability, which means that computer programs written in the

Java language must run similarly on any hardware/operating-system platform. This is

achieved by compiling the Java language code to an intermediate representation called Java

byte code, instead of directly to platform-specific machine code. Java byte code instructions

are analogous to machine code, but are intended to be interpreted by a virtual machine (VM)

written specifically for the host hardware. End-users commonly use a Java Runtime

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Environment (JRE) installed on their own machine for standalone Java applications, or in a

Web browser for Java applets.

A Java virtual machine is software that is implemented on virtual and non-virtual hardware

and on standard operating systems. A JVM provides an environment in which Java byte code

can be executed, enabling such features as automated exception handling, which

provides root-cause debugging information for every software error (exception), independent

of the source code. A JVM is distributed along with a set of standard class libraries that

implement the Java application programming interface (API). Appropriate APIs bundled

together with JVM form the Java Runtime Environment (JRE).

JVMs are available for many hardware and software platforms. The use of the same byte

code for all JVMs on all platforms allows Java to be described as a write once, run

anywhere programming language, versus write once, compile anywhere, which describes

cross-platform compiled languages. Thus, the JVM is a crucial component of the Java

platform.

The syntax of Java is largely derived from C++. Unlike C++, which combines the syntax for

structured, generic, and object-oriented programming, Java was built almost exclusively as

an object-oriented language. All code is written inside a class, and everything is an object,

with the exception of the primitive data types (integers, floating-point numbers, Boolean

values, and characters), which are not classes for performance reasons.

Unlike C++, Java does not support operator overloading or multiple inheritance for classes.

This simplifies the language and aids in preventing potential errors and anti-pattern design.

Java uses similar commenting methods to C++. There are three different styles of comments:

a single line style marked with two slashes (//), a multiple line style opened with /* and

closed with*/, and the Javadoc commenting style opened with /** and closed with */. The

Javadoc style of commenting allows the user to run the Javadoc executable to compile

documentation for the program.

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Here is an example of JAVA program code for a sentence such as “Development of Doc

Engage”:

public class DocApp{

public static void main(String args[]){

System.out.println("Development of Doc Engage");

}

}

The Graphic User Interface (GUI) being used at Fresco Informatics is HTML5. HTML5 is

a markup language for structuring and presenting content for the World Wide Web, and is a

core technology of the Internet originally proposed by Opera Software. Its core aims have

been to improve the language with support for the latest multimedia while keeping it easily

readable by humans and consistently understood by computers and devices (web

browsers, parsers, etc.). HTML5 is intended to subsume not only HTML 4, but XHTML 1

and DOM Level 2 HTML as well.

Following its immediate predecessors HTML 4.01 and XHTML 1.1, HTML5 is a response to

the observation that the HTML and XHTML in common use on the World Wide Web are a

mixture of features introduced by various specifications, along with those introduced by

software products such as web browsers, those established by common practice, and the

many syntax errors in existing web documents. It is also an attempt to define a single markup

language that can be written in either HTML or XHTML syntax. It includes detailed

processing models to encourage more interoperable implementations; it extends, improves

and rationalizes the markup available for documents, and introduces markup and application

programming interfaces (APIs) for complex web applications.

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METHODOLOGY AND TOOLS USED

Study Type- Questionnaire based Study

Sample size- 50 Respondents

Sample included- Working Physiotherapists

Method Used- Survey and Interviewing individuals

Data Type- Primary

Tools Used for Functional specifications- MS Word, and Microsoft Visio

Tool Used for Evaluation of Responses- SPSS 16.0

Requirement gathering for the Physiotherapy Specific EHR involved conducting a survey

and visit to a renowned Physiotherapy centre in Bangalore, Karnataka. The survey conducted

was an online survey which was a semi structured one to get an idea of the features to be

included in the EHR for physiotherapists. The visit to the physiotherapy centre involved

understanding the current workflow and features of assessment of patients done by

physiotherapists over there along with interview of the physiotherapists working over there.

The studied involved a sample of 50 respondents which included currently practicing

physiotherapists out of which 45 were from the online survey and 5 were from the visit to the

physiotherapy centre.

The requirement gathering tools which I used were survey and interviews.

After carrying out the above procedures I did a gap analysis of existing features of the

assessment procedure being followed by physiotherapists and found out the features which

should be included in the EHR. According to the gap founds I recommended the features

required in the EHR for Physiotherapists.

These features were listed down in some specific formats called the Functional Documents

that can be understood by the technical team (Software Engineers) while developing the

EHR. The tools used to prepare the Functional documents were Microsoft word and

Microsoft Visio.

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Steps followed at Fresco Informatics

It begins by leading a meeting session to capture high-level business goals and project vision.

IT staff and business users/analyst participate. Business goals and project vision are the

guideposts of the requirements process. One cannot expect to deliver the right solution at the

right time if they do not know the vision and goals of the solution.

Steps involved in development of software

Preliminary investigation or analysis

Specification and requirement analysis

Design or architecture

Development or coding

Testing and documentation

Implementation or deployment

Maintenance

Steps covered by me-

1. Preliminary investigation or analysis - This is the task of extracting the

requirements from users and gauging the feasibility of the project. Project sponsors

usually know what they want but often have incomplete, ambiguous or contradictory

requirements. It is the job of software developers and project managers to steer them

in the right direction and to clarify the requirements. Upper management, both in it

and the sponsoring department, should determine if the project has business value to

the organization and if there are sufficient resources to complete the project as

requested.

2. Specification and requirement analysis - This step can vary a lot depending on the

formality, size, and scope of the project and the methodology used in an organization.

In general, it involves taking the requirements and describing them in a way

meaningful to programmers. In your average business application this usually is a

mapping between the user requirements and a description of the functionality to be

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coded into a program, such as a screen that displays current inventory or a report that

has this month's sales figures.

Tools Used

1. Microsoft Word

Microsoft Word is a commercial word processor designed by Microsoft. It was first released

in 1983 under the name Multi-Tool Word for Xenix systems. Subsequent versions were later

written for several other platforms including IBM PCs running DOS (1983), the Apple

Macintosh (1984), the AT&T UNIX PC (1985), Atari ST (1986), SCO UNIX, OS/2, and

Microsoft Windows (1989). It is a component of the Microsoft Office software system; it is

also sold as a standalone product and included in Microsoft Works Suite. The current

versions are Microsoft Word 2010 for Windows and 2011 for Mac.

Microsoft word was used to make a detailed Requirement Document describing the each

feature for what it‘ll be used, so that it can be well and clearly understood by the technical

team.

2. Microsoft Visio

Microsoft Visio (formerly known as Microsoft Office Visio), is a commercial diagramming

program for Microsoft Windows that uses vector graphics to create diagrams. Microsoft

Visio is a powerful drawing and diagramming application. It allows the user to create a

variety of diagrams and technical drawings either from scratch or with the aid of templates.

By using a visual format as opposed to relying on words and numbers, complex information

can be communicated effectively in a clear and concise fashion to the target audience. As a

result, understanding is enhanced and outcomes are improved.

Once an individual has learned how to use Microsoft Visio software, their skills can be put to

use in a variety of ways. For example, in a business environment, Microsoft Visio can be

used to display workflow diagrams and business processes. Organization charts can be used

by HR managers to illustrate the position of employees within a company or project

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managers can create timelines to visualize how a particular task is progressing. Financial

planners can analyze market trends using charts and graphs or IT professionals can use

network diagrams to assist in the creation of complex systems. Building plans can be

designed to illustrate the office floor plan, the layout of security systems and emergency exit

routes. Furthermore, Microsoft Visio can also have applications in the home environment.

3. SPSS 16.0

SPSS (Statistical Package for the Social Sciences) was released in its first version in 1968.

SPSS is among the most widely used programs for statistical analysis in social science. It is

used by market researchers, health researchers, survey companies, government, education

researchers, marketing organizations and others. In addition to statistical analysis, data

management (case selection, file reshaping, creating derived data) and data documentation

(a metadata dictionary is stored in the data file) are features of the base software.

In SPSS frequency count was used to analyze the responses received from the survey

conducted among working physiotherapists.

Stages covered at Fresco Informatics

The steps of software development which were covered by me at Fresco Informatics are:

1. Preliminary investigation or analysis

2. Specification and requirement analysis

At Fresco Informatics the above mentioned steps were covered in two major stages:

1. Requirement gathering & gap analysis (Both steps preliminary investigation and

requirement gathering was covered under this step)

This phase is actually a base for the whole development effort. If the base is not laid

correctly, the product will not find a place in the market. If you develop a very good software

product which is not required in the market, it does not matter how well you build it.

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Requirements gathering techniques provide project team members with a choice of methods

for eliciting needs or requirements from stakeholders and for validating requirements with

stakeholders. Certain techniques are appropriate in gathering stakeholder needs, while other

techniques are most helpful in defining high-level and detailed requirements, or validating

detailed requirements with the stakeholders.

This phase was very important for the development of physiotherapy EHR. It included the

conducting survey among working physiotherapists, visit to a physiotherapy centre and using

the various techniques of requirement gathering process viz. surveys, interviewing and

prototyping for understanding the process of assessment and assessing the requirements and

features that could be included in the EHR.

Gap analysis

In business and economics, gap analysis is a tool that helps companies compares actual

performance with potential performance. At its core are two questions: "where are we?" and

"where do we want to be?. I studied the existing workflow of patient assessment by

physiotherapists and found the Gaps, listed them down that we can add the features as per the

requirement of the patient assessment recording that can be fulfilled by Physiotherapy EHR

that we are planning to develop. This reveals areas that can be improved and properly

utilized. Gap analysis involves determining, documenting, and approving the variance

between business requirements and current capabilities

This stage of requirement gathering and gap analysis included a one week study at the day

care centre which involved observational and analytical study with the help of questioners.

2. Documentation of functional requirements (This included the specification of the

requirements)

After understanding the requirements of the prospective client and the process of patient

assessment the functional requirements were interpreted and written so that it can be

conveyed to and understood by the technical team.

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Discussing the many ways in which requirements can be gathered can end up in a heated and

impractical debate. The short answer is that you should gather requirements using whichever

method works for you. Whether you prefer a written document, screen diagrams, prototyping

or use cases the most important outcome is that the people who need to understand the

requirements can do so. If the people that form the project team (client, stakeholders,

designers, developers) are happy with the format, that‘s half the battle won.

Functional specifications may consist of one or more documents. Functional specification

documents show the behavior or functionality of a software product on an abstract level.

Assuming the product is a black box, the functional specifications define its input/output

behavior. Functional specifications are based upon the product requirements documentation

put forward by people who have contact with the end-user of the product or the customers.

The art of writing requirements takes great skill and, like writing code, the end result is

usually cleaner and more consistent if you have understood and interpreted or conveyed the

requirements of the software in an eligible way to the technical team. It‘s a matter of

balancing the need for a thorough understanding of the project domain (i.e. the client‘s

business) against understanding the process of software development.

During this phase the requirements we got by visiting the day care center were documented

into certain formats that can be well understood by the technical team. The formats

included:-

A detailed functional document in word format mentioning the functional

specifications and technical complexity of a feature.

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OBSERVATIONS

After conducting the requirement gathering process, the following observations and findings

were made:

Workflow

It was found that the workflow at any physiotherapy setup involves a particular set of

procedures once the patient comes to the clinic for the treatment:

Patient arrives at the clinic and comes to the front office desk

The patient undergoes registration

Patient is attended by the physiotherapist

Patient undergoes the process of consultation where his assessment is done under the

SOAP note plan

The treatment protocol of the patient is decided

The patient undergoes treatment

Treatment protocol of the patient is recorded in the SOAP note

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Figure 2: Workflow of Consultation Process at a Physiotherapy Centre

Page | 31

Consultation Process

The consultation process of a patient by a physiotherapist is done under the SOAP note

which is divided into 4 parts:

Subjective

Objective

Assessment/ Analysis

Plan

Subjective

The subjective part of the SOAP note is where you write what your patient has to say about

his or her current condition. Initially is the patient's Chief Complaint, or CC. This is a very

brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization.

If this is the first time a physiotherapist is seeing a patient, he will take a History of Present

Illness, or HPI. This describes the patient's current condition in narrative form. The history or

states of experienced symptoms are recorded in the patient's own words. It will include all

pertinent and negative symptoms under review of body systems. Pertinent medical history,

family history, and social history, along with any treatment taken, is also recorded.

Subsequent visits for the same problem briefly summarize the History of Present Illness

(HPI), treatments, outcomes and follow-ups.

Objective

The "objective" part includes all the measurements that you've obtained from your client.

This includes features like vital signs, manual muscle testing measurements, joint range of

motion measurements, etc .

The specific physiotherapy treatments are also included in the objective part of your SOAP

note. The treatments provided should be specific enough so as another PT can provide

treatment if the treating physiotherapist is out for the day. The treatment should include the

specific weight, repetitions, intensity and duration whenever applicable.

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Assessment/ Analysis

This is where the physiotherapist impression regarding patient's current situation since his or

her last visit. This may also include the physiotherapist's perspective on whether a particular

treatment will be continued or modified according to client's needs.

Plan

In the SOAP plan part, the physiotherapist writes the plans for the client's next physiotherapy

visit. This may include the objectives, treatments, progression parameters, and precautions.

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FINDINGS AND RECOMENDATIONS

FINDINGS

An online survey was conducted to find out the requirements among working

physiotherapists regarding various aspects for developing an EMR for them along

with a visit to physiotherapy centre in Bangalore, Karnataka.

Responses of 50 working physiotherapists were recorded and analyzed using SPSS.

Number of patients coming to the clinic per day: 30

Number of physiotherapists at the clinic: 4

Number of attendants at the clinic: 3

Figure 3: Number of Patients, Physiotherapists and staff

Average time spent in initial assessment: 20 minutes

Average time spent in treatment of the patient: 40 min

30

4 3 0

5

10

15

20

25

30

35

Number of patients coming to the clinic

per day

Number of Physiotherapists at the

clinic

Number of attendants and other staff at the

clinic

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Figure 4: Time Spent for Assessment and Treatment

63% of the physiotherapists conduct their assessment of the patient before the start of

treatment while 33% of the physiotherapists conduct their assessment both before and

during the course of treatment.

Figure 5: Conducting Assessment

Most of the physiotherapists said that patient history taking and examinations

consumed their maximum amount of time in the assessment of the patient. While in

the treatment part of the patient manual therapy, exercises and modality application

consumed their maximum amount of time.

Most of the physiotherapists utilize their in between treatment time to:

20

40

0

10

20

30

40

50

Assessment Treatment

Time spent (in Minutes)

63%

4%

33%

Conducting Assessment

Before start of treatment

During course of treatment

Both

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Update and complete patient records

Treat other patients

Discus the case with the patients and other colleagues

80% of the physiotherapists found themselves easy working with the computer and

internet while only 6% of them found it difficult.

Figure 6: Working with Computer & Internet

95% of the physiotherapists expressed their willingness to adopt the computerized

system of maintaining the patient records.

Figure 7: Willing to adopt a Computerized System

80%

14% 6%

Working with Computer & Internet

Easy

Modearte

Difficult

95%

5%

Willing to adopt a computerized patient record system

YES

NO

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Out of the above 88% wanted to have features in their record system which should

include:

Patient demographic details

Patient history (present, past, medical)

Observations made by you (E.g.: posture, body type, facial expression, etc.)

Examinations done by you (E.g.: Range of motion, MMT, special tests done,

etc.)

Treatment given to the patient

Patient prognosis

Others wanted to have all the features mentioned above excluding the patient

prognosis part.

Figure 8: Features they want in the system

88%

12%

Features they want in the system

Patient Demographic details, History, Obseravations, Examinations, Treatment, Prognosis

All excpet the prognosis part

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RECOMMENDATIONS

Physiotherapist signup and login

The physiotherapist will sign up into the system filling all his details and hence will be

registered with the system where later he can sign up through his user name and password.

Advantages

Physiotherapist will have access to the full database

Time saving for accessing and viewing records

Can store all his data in a single place where his data can remain secure

Figure 9: Snapshot of Login Screen Specifications

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Patient Registration and Appointment Scheduling

Patients can be registered into the system as the book an appointment with the

physiotherapist and their appointment can be scheduled according to the time slot available.

Advantages

Time saving

Lowers regular expenditure of stationary

Lowers patient waiting time

Creates authenticity of patient records

It create fast backup

It has less error

It reduces space

Helps to maintain centralized data

Environmental friendliness

Figure 10: Snapshot of Appointment Screen Specification

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Physiotherapist Profile

In it the physiotherapist can have various features like:

List of his patients

List of consultants with whom he is connected

Is able to manage his staff access to the system

Advantages

Easier access and view of the database

Ability to monitor and control access of other staff to the system

Figure 11: Snapshot of Physiotherapist profile Specifications

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Patient consultation

The consultation of the patient should follow the SOAP note protocol where systematic

capturing of information can take place so that no details of the patient are missed out and

proper and effective treatment of the patient will take place.

Advantages

Increase efficiency of physiotherapist

Physiotherapist spends less time recording the details manually

Completeness of patient assessment

All the patient information can be accessed easily and much faster

Recording and storage of information can take place in a more systematic and easier

way

Figure 12: Snapshots of the Consultation Module Specifications

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CONCLUSION

Requirement gathering, functional documentation and designing architecture of any software

based on the priorities from the end user‘s perspective is an essential part of a software

development project as understanding what a project will deliver is critical to its success.

Also, we can conclude that development of physiotherapy specific EHR is very important to

facilitate paperless operations at a physiotherapy clinic which in turn will increase efficiency

and quality of the treatment being administered thus resulting in patient satisfaction. This will

overall result in improved profitability for the physiotherapists.

Recommendations for requirement Gathering

To be successful at requirement gathering and to give your project an increased likelihood of

success follows the given rules:-

Don‘t‘assume you know what the customer wants, ask.

Involve the user from the start

Ensure requirements are specific, realistic and measurable.

Create a clear specification document.

Avoid duplication of requirements in a functional document.

Create a prototype if necessary to confirm or refine the customers‘requirements.

Priorities the functionalities in specification document keeping in mind the technical

complexity and end user demand.

Mistake one should avoid-

Not prioritizing the User requirements, for example “must have”, “should have”,

“could have” and “would have”

Lacking a clear understanding and making assumptions rather than asking

Page | 42

CASE STUDY

FEEDBACK AND EVALUATION OF A HMS

(HOSPITAL MANAGEMENT SYSTEM) IN A

PHYSIOTHERAPY HOSPITAL IN

BANGALORE

Page | 43

INTRODUCTION

A hospital consists of various organizational units with differing tasks for various types of

healthcare professionals. Since integrated care should be the aim, a high degree of ability has

to be reached. This requires intensive internal communication among organizational units

and healthcare professionals as well as external communication (e.g. to insurance

organizations, general practitioners, etc.). The hospital is itself a system, in which human

beings and machines carry out specific actions following established rules. Accordingly we

can say that the hospital’s system for communicating and processing information, i.e. the

hospital management system (HMS), is that socio-technical subsystem of a hospital which

allows this ability by presenting information at the right time, in the right place to the right

people So, modern computer-based information processing tools, legacy systems, and still

paper-based records, forms etc. exist side by side as part of a HMS.

Hospital management systems are large, complex computer systems designed to help manage

the information needs of a hospital. They are tools for interdepartmental and

intradepartmental use (Linda Roussel, Russell C. Swansburg and Richard J. Swanburg,

2005). Hospital Management System (HMS) is vital to decision making and plays a crucial

role in the success of the organization. Computerization of the medical records and

documentation has resulted in efficient data management and information dissemination for

the users. Managers, Clinicians and other healthcare workers can now access the information

without delay or errors.

Hospital Visited

RECOUP, established in 2001, is located in India, and has a hospital and 6 clinics in

Bangalore and 1 each in New Delhi, Ghaziabad, Patna, Hyderabad and Thrissur (Kerala).

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RECOUP's mission is to maintain its position as one the world’s topmost

centres for Repetitive Strain Injury (RSI), other Musculoskeletal Disorders (MSD),

Ergonomics and Childhood Disabilities.

Dr. Deepak Sharan, Consultant in Orthopaedics, Rehabilitation and Ergonomics, heads

RECOUP. Dr. Sharan has supplemented 21 years of International clinical experience in

Musculoskeletal Rehabilitation with qualifications in Biomechanics, Ergonomics,

Orthopaedic Engineering, and Rehabilitation Technology. Dr. Sharan, described as a

"cult figure in the world of RSI" by the Wall Street Journal, is an advisor on RSI and

Cerebral Palsy to the Govt. of India.

RECOUP has a multi-disciplinary team of over 150 highly trained, qualified, experienced

and reputed Physicians and Rehabilitation Professionals.

HMS being Used

HealthObject ™ is a health care application of Idea Object which is a Chennai based

company. HealthObject ™ seamlessly combines the traditional healthcare clinical and

administrative functionality with the latest trends in community networking. It enables to

create local healthcare community involving patients, clinics, hospitals, labs, scan

Page | 45

centres, pharmacies become partners or community members in the application and

provide efficient care for the patient.

HealthObject ™ is a rich internet application comprising of three main components

highlighted below, with all the three of them operating on the same data repository.

HealthObject ™ Core: The application that provides comprehensive administrative and

clinical functionality used by doctors, administrators and other care providers. It supports

management of uniform processes and practices in a multi location and multi-specialty

care setting. HealthObject ™ Core application is offered in the following services:

Clinics Service

Hospitals Service

Lab and Pharmacy Service

Optical Service

Patient Portal: An online web portal through which the patients can login in a secure

manner and view their medical records such as prescriptions, lab results, discharge summary,

etc. The patient can search of clinics and doctors and schedule appointments online.

DisplayObject: A digital information signage which can be set up in the reception / waiting

area / lobby though which the clinic / hospital can display slide shows comprising of

facilities offered, awards received, disease awareness, patient education, appointments,

doctors availability, etc. The display panel can pull-in real-time information asuch as next

appointment, doctors holidays, etc and display them.

The product is built using enterprise class architecture and frameworks using the latest

Microsoft .Net 3.5 technologies.

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METHODOLGY

Meetings with the users of this software at RECOUP Hospital were conducted to take

their feedback on HealthObject.

The users of HealthObject whose responses were recorded and analysed were:

Doctors

Physiotherapists

Front Office Staff

System Administrators

Separate discussions were conducted with all the users to record their feedback and

experience of using HealthObject. All of their views, opinions and responses were noted

down and evaluated.

Page | 47

OBSERVATIONS

The software has been used by RECOUP for its hospital and 6 clinics in Bangalore only at

present. They have been using it for the past one year. The one thing which came out quite

evidently after reviewing the feedback of all the users was that they had an opinion that the

software is not user friendly at all.

Technical Details

Technology being used: Microsoft .Net 3.5

Database being used: SQL Server

Various issues and drawbacks were identified after discussion with all the users as they had

to face problem due to it as it was affecting the overall functioning of the hospital and

disturbing the workflow.

The various issues and drawbacks which were identified in the software are:

Integration issues

The most major issue and drawback which they face while using the software is the

integration issue of the software as it is not centralized. A patient coming and registered at

one of their centre cannot be viewed as a registered patient at other centre and hence the

patient has to undergo the process of registration all over again.

The doctors and physiotherapists are not able to see the patient records and details who are

visiting other centres as the system is not centralized.

Data Entry Issues

There is no specific template for recording patient assessment for the doctor and all the entry

has to be made by the doctor through typing only. The mode of all the data entry is in free

text form where a blank prescription note is displayed on the screen where he enters all the

details by typing only. This was found to be a major reason for the doctors being irritated by

the software and reporting it to be not at all user friendly.

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Backend Issues

These were many issues at the backend of the software due to which work had been

interrupted many times also which were being reported to the system administrator:

1. At times doctors and physiotherapists reported to them of the software not working

properly when they are entering details in it

2. Users of the software often report of problem in accessing and signing up in the

system and that need resetting the password again

3. The billing department also reports of discrepancies in the bill with wrong units being

billed or a particular treatment being billed multiple times.

4. At times it does not show the payments of the patient being made in advance on the

landing page and the billing desk has to go into billing details to check for it.

5. At times the doctors and physiotherapists see that the date of birth, gender and area

location of the patient has changed when they open the patient records to make

further addition to the patient assessment note.

6. Sometimes the system does not save the data which the doctor has entered into the

system and hence the doctor has to enter all the data again which was not saved.

7. Data entered into the system has been reported for errors and mismatch at multiple

occasions.

8. Another issue which they are facing is a problem with the email and SMS alert

service of theirs. The system does not send SMS and emails at the same time and

often they are long delays in receiving either of them (more commonly seen in case of

email delays).

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DISCUSSION

The evaluation of responses gave us an insight about the functioning of HealthObject and the

various issues which its users have to face while working on it. The major problem which is

associated with HealthObject is it not being centralized and hence it is not able to connect all

the centers within Bangalore. Along with this provision of no specific templates for recording

patient assessment and doctors having to do most of the recording by typing only has made

the users more resistant to adopting it. All the backend issues with HealthObject have only

invited more complains and problems only from the users.

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RECOMMENDATIONS

The following points are recommended for rectification in HealthObject to make it function

properly and suit RECOUP’s needs:

Centralization of the system is very essential as it is a multi-location establishment

and hence access to records of all places should be available to the users so that we

can save the patient time and improve delivery of services

Specific templates for recording of patient assessment need to be formulated as

doctors will only adopt the system when they will feel that their workload is being

reduced with the help of the system. At present as the doctors have to enter all the

data through typing only they are not comfortable using it.

The backend of the software needs to be rectified for all the bugs and errors which are

affecting and interrupting the workflow at present. A proper backend of the system

will only ensure proper functioning of the software.

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CONCLUSION

A properly functioning HMS is very essential to make it user friendly which will ultimately

help in increasing the adoption rate of EMR achieve our goal of integrating healthcare and

information technology. Therefore proper steps need to be carried out to ensure that we

present to the users a system which is user friendly and suited to their needs and

requirements.

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REFERENCES

http://en.wikipedia.org/wiki/Electronic_health_record (Accessed on Date: 10/5/2012)

www.frescoinformatics.com (Accessed on Date: 10/5/2012)

www.physiotherapyindia.org (Accessed on Date: 10/5/2012)

http://en.wikipedia.org/wiki/Physical_therapy#Specialty_areas (Accessed on Date:

10/5/2012)

http://en.wikipedia.org/wiki/Agile_Modeling (Accessed on Date: 10/5/2012)

http://en.wikipedia.org/wiki/Scrum_(development) (Accessed on Date: 11/5/2012)

http://en.wikipedia.org/wiki/SOAP_note (Accessed on Date: 12/5/2012)

http://www.physiotherapynotes.com/2011/03/parts-physiotherapy-soap-notes.html

(Accessed on Date: 12/5/2012)

www.scribd.com/doc/5195326/PPT-on-SDLC-Models (Accessed on Date:

15/5/2012)

http://www.outsource2india.com/software/RequirementAnalysis.asp (Accessed on

Date: 16/5/2012)

Douglas Havelka and Sooun Lee (2002), Critical success factors for information

requirements gathering, Information Strategy: The Executive's Journal, Summer

Issue, Page- 98-105

www.himss.org/content/files/Amb_EHR_Implemention081507.pdf (Accessed on

Date: 13/5/2012)

itsupportcorona.weebly.com/.../emr-implementation-convert-paper-charts Accessed

on Date: 13/5/2012)

Into-electronic-format.html (Accessed on Date: 13/5/2012)

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www.informationmanagementcompare.com/.../1121-Electronic-Medical- Records-

EMR-Implementation (Accessed on Date: 13/5/2012)

Winter, B. Brigl, T. Wendt (2003), Modeling Hospital Information Systems (Part 1): The

Revised Three-layer Graph-based Meta Model 3LGM2

http://www.recoup.in/jcms/index.php (Accessed on Date: 30/5/2012)

http://www.ideaobject.com/products.html (Accessed on Date: 30/5/2012)

Gunter, T.D. and Terry, N.P. 2005 The Emergence of National Electronic Health

Record Architectures in the United States and Australia: Models, Costs, and

Questions in J Med Internet Res 7(1)

Habib JL. EHRs, meaningful use, and a model EMR.Drug Benefit Trends. May

2010;22(4):99-101

Patrick Kierkegaard (2011) Electronic health record: Wiring Europe’s healthcare,

Computer Law & Security Review, Volume 27, Issue 5, September 2011, Pages 503-

515

Schwaber, Ken (1 February 2004). Agile Project Management with

SCRUM. Microsoft Press ISBN 978-0-7356-1993-7

Gauthier, Alexandre (August 17th, 2011). "What is scrum"

Sprint, Planning (January-February 2009) (html). Sprint Planning Rules Retrieved

2009-03-30

Sutherland, Jeff (2004-10). "Agile Development: Lessons learned from the first

Scrum" (PDF). Retrieved 2008-09-26.

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ANNEXURE

Page | 55

QUESTIONNAIRE FOR REQUIREMENT GATHERING

Physiotherapist’s Name:

Name of the Clinic:

Clinic’s Address:

No. of Physiotherapists at the clinic:

No. of Attendants and other staff at the clinic:

1. How many patients come to your clinic per day?

2. What is average time you spend per patient in initial assessment?

3. What is average time you spend per patient in treatment?

4. When do you conduct the full assessment of the patient?

• Before starting the treatment

• During the course of treatment

• Both

5. Which areas of assessment consume your maximum amount of time?

6. Which areas of treatment consume your maximum amount of time?

7. How do you utilize the time when you do not have to be continuously present with

the patient? (E.g.: when you have put the patient on a modality for 10-15 min)

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8. How do you find yourself working with computer & internet?

• Easy

• Moderate

• Difficult

9. Do you wish to have a computerized patient record system to be installed at your

clinic enabling you in faster workflow?

Yes

No

10. If yes, then what all features of the assessment and treatment do you wish to have in

this system?

Patient demographic details

Patient history (present, past, medical)

Observations made by you (E.g.: posture, body type, facial expression, etc.)

Examinations done by you (E.g.: Range of motion, MMT, special tests done,

etc.)

Treatment given to the patient

Patient prognosis

All of the above