WK1PROJP1HALLA

REQUIREMENTS
DOCUMENT
Health First EMR
September, 2013

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Revision Sheet
Release No.
1
2

Date
09/07/2013
09/08/2013

Revision Description
Group Requirements document posted in Group Area
Requirements document and 3NF entities added- Aaron Hall

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TABLE OF CONTENTS

1.
1.1
1.2
1.3

GENERAL INFORMATION
Purpose
Scope
Acronym and Abbreviation

2. CURRENT SYSTEM SUMMARY

3. REQUIREMENTS

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1.0

GENERAL INFORMATION

1.1

Purpose

Describe the purpose of the Requirements Document.

The purpose of this document is to define requirements for designing and implementing an electronic
medical record system for Health First. The document presents a summary of the current system,
challenges associated with the current system, and the requirements associated with the project. The goals
for the project are:
-

1.2

Improve patient safety quality of care through better access to information.

Improve the accuracy and fairness of medical billing practices.
Transition the practice management of Health First from an inefficient paper based system to an
electronic system utilizing database management and custom designed applications for interfacing
with clinical data.

Scope

Describe the scope of the Requirements Document as it relates to the project.

The scope of this document is to identify current business rules, processes and data requirements which will
be incorporated into the new database system.
-

1.3

Define information necessary to design the database structure

Define requirements for unique patients identification within the system
Define requirements for provider/physician identification
Define practice management processes and functional requirements to support operations

Acronyms and Abbreviations

DOB date of birth

SSN social security number
PIN Provider Identifier Number
BPI Blood pressure
BMI Body mass index
OP Outpatient
IP Inpatient

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2.0

CURRENT SYSTEM SUMMARY

Provide information of the current existing system. Any flaws if the system has.
Health First currently utilizes a paper-based system for medical records. Services are provided by an array
of physicians including visiting and residential staff. Residential staff assist visiting specialists in providing
care to admitted patients. Rooms are allocated by day, use, and physician. Patient point of entry is through
the outpatient department where information about reason for visit, requested physician, medical history,
pathology tests reports and payer is collected via paper forms. Once complete, patients hand in the forms
and pay the consultant charge for the visit, patients are assigned to rooms to receive care, and all
information is updated in the chart.
Flaws of the current system:
- Care delivery is managed via paper charts and forms which create inefficiencies in the areas of
availability of information, and practice management.
- Patient identification is complicated- information spread across multiple forms- and patient safety
is a concern when charts are incomplete.
- Paper system may generate errors in delivery of care associated with medications.
- Scheduling of rooms and staff is a manual process and information associated with the schedule
may be subject to data integrity issues.

3.0

REQUIREMENTS

Health First needs an electronic health record for storing patient, clinical, and employee data. The system
must be able to:
Track room assignments by department and physician.
Track patient/physician relationships.
Assign unique patient IDs for tracking patient information.
Handle scheduling for appointments.
Manage billing for private pay and 3rd party payers
Protect access to clinical data based on employee role
Track and manage physician credentials and associated fees by role
Manage staff-to-staff relationships (residents/specialists)
Data requirements grid is below:

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Patient identity management

1. SSN
2. Name- First, Last, initial
3. Address
4. DOB
5. Gender
Electonic Clinical Record
1. Record ID number
2. Payer ID number
3. Vitals
4. Medications
5. Lab results
6. Services Provided/History
Employee Records
1. Empolyee ID
2. Employee Name
3. Employee PIN
4. Job Code/Description
5. Employee Pay Rates
Services Provided
1. Service Date
2. Patient information
3. Provider information
4. Types of services provided
5. Fee for service
6. Diagnosis
Department Information
1. Department ID
2. Department Description
Room Information
1. Room Number
2. Room Description
Payer Information
1. Payer ID number
2. Payer description/name
3. Payer fee structure

First, last and middle initial

Number, Street, City, Zipcode
Male, Female, other

BPI, Weigth, Height, Pulse, BMI, Respitory rate, Temperature, Pain

Scale
List of medication history and current meds

Fist Last and Middle Initial

Unique provider id number
Identify specification
varies by provider

Employees associated

Reason for treatment

OP, IP, etc.

Defining what services are associated with which rooms

Defined by procedure codes and credentials

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ENTITIES
PATIENT
PAT_ID PAT_SOCIAL PAT_FNAME PAT_LNAME PAT_INITIAL PAT_DOB PAT_GENDER PAT_ADDRESS PAT_CITY PAT_ZIP
RECORD
REC_ID
PAYER_ID
HIST_REC_ID
VITALS_REC_ID
MEDI_REC_ID
LAB_REC_ID
SERV_ID
SERVICES
SERV_ID
SERV_DATE
PAT_ID
ASSGN_ID
SERV_DESCRIPTION SERV_DIAGNOSIS SERV_FEE
EMPLOYEE
EMP_ID
EMP_FNAME EMP_LNAME EMP_INITIAL EMP_ADDRESS EMP_CITY
EMP_ZIP
EMP_PIN
JOB_CODE
JOB
JOB_CODE
JOB_DESCRIPTION
JOB_PAYRATE
ASSIGNMENT
ASSGN_ID
ASSGN_DATE
ROOM_NUMBER
EMP_ID
DEPT_ID
PAYER
PAYER_ID
PAYER_DESC
PAYER_ADDRESS
PAYER_CITY
PAYER_ZIP
ROOM
ROOM_NUMBER
ROOM_DESCRIPTION
DEPARTMENT
DEPT_ID
DEPT_DESCRIPTION
VITAL
VITAL_REC_ID

LAB
LAB_REC_ID
MEDICATION
MEDI_REC_ID
HISTORY
HIST_REC_ID

PAT_ID

VITAL_DATE

VITAL_BPI

VITAL_HEARTRATE

LAB_DESCRIPTION

LAB_RESULT

MEDI_NAME

MEDI_DATE

HIST_TYPE

VITAL_TEMP

VITAL_HEIGHT

MEDI_FORMULARY

HIST_DESCRIPTION

VITAL_WEIGHT

VITAL_BMI

VITAL_RESRATE

REC_ID

VITAL_PAINLVL