Patient Care


Chapter 1 Introduction to Patient Care Using SMS Application

Patients travel longer distances for the opinion of consultant which is not possible either due to patient situation or due to distances. Enhancement of health care in different locations and other remote areas can be achieved using mobile phone applications [1].

1.1 Problem Statement

Development of mobile communication networks playing an important part in the enhancement of a mobile medicine. Patient Care Using SMS Application represents a feasible solution of patient care such as text messaging and booking appointments using mobile phones, which are best aspects of mobile medicine. The main idea is improve patient access to healthcare; encouraging patient’s to use mobile health application and supporting people with long term conditions [5].

1.2 Objectives

Incredible growth of mobile communication and recognition of new generation Wireless protocols has initiated the advance SMS based medical applications. Following that facts Patient care using SMS based application for mobile application for patient is good solution [5 6]. * To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis-à-vis Exchange Server etc * Main aim of this application is to achieve “greater quality communication between GPs and consultants using mobile medicine, which will results in enhancement of patient’s care “[5 6].

1.3 Scope

The goal of Patient Care Using SMS Application is based on two major conditions. First, is to achieve proficient means to exchange message between General Practitioners and consultants’ care have to be provided. The second is sufficient exchange of patient’s information have to be provided. Additionally, privacy of communication and stored information has to be guaranteed. Both ethical and technical aspects are equally important [7].

1.4 Existing Systems

The existing system of treatment consists of two different systems. They are as follows: * Traditional or manual system * Online application

1.4.1 Traditional or Manual system

The present system of treatment consists of manually consulting a doctor by taking prior appointment or else registering at that instant of time, waiting to get register themselves and then consulting the doctor which is a time consuming process. Drawbacks

* Time consuming * Patient need to stand in long queues to make appointments * Patients not follow prescription directions once they leave the surgery or hospital. Research has showed that more than 50 percent of patients not follow the management advised by their doctors may be due to lack of time and interest.

1.4.2 Online System

Online application is also available where the user is provided a login and password through which he can access the website, make appointments, clarify their queries etc. The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5]. The online systems are discussed below are: * EMIS * VISION System EMIS System

EMIS® stands for Egton Medical Information Systems Limited. EMIS provides a service that enables you access to your healthcare online [9]. After registering with the surgery, patients are able to book or cancel their appointments with the doctor. Patient can also request repeat prescription, send messages to their practice and update personal information – if practice has set up these features online [10]. This example has been explained in detailed in chapter 2.

1.5.2 Example 2: Vision System

Vision [14] is the most famous system in use UK, within the GPs sector today, due to its market leading features, functionalities and first class support from INPS. There are currently more than 1,800 GP practices which are using Vision system across the UK each day. “Vision system version 3 is fully RFA 99 acquiescent, includes, support for the encryptedEDIFACT pathology v1.1 message, MIQUEST and DTS. The Vision application is stable, proven and reliable. The strong product-base has allowed other features such as advanced-scanning, PDA’s support and incorporated voice dictations as well as extension to core functionality such as XML based clinical-messaging, allowing integrations with third party systems” [14]. In this project we are more concentrating on EMIS rather than Vision system.

Key Features

Messaging Incorporated External system Appointments Consultation Manager Problem Orientated Views Community Caseload Search and Reporting 7. Clinical Audit Vision and the National Applications [14] Few of the above features are explain below [14]:

1. Messaging

This system offers unparallel flexibility with the wider health community via its highly supple and adaptable in-built messaging and web-services. These allow patient’s data from number of external sources including the NHS Spine or local CPR’s to be easily accessed and used within Vision, supporting the requirements of the NHS IT-strategy. Vision also manages a range of clinical messages from third party systems to support the patient care as follows: * Choose and Book Referral’s (electronic booking) * E- Discharge Summaries * Radiology reports and Encrypted pathology reports * OOH Summaries With a powerful XML event and messaging engine, Vision is designed to ensure the performance of new messages require no changes to the core Vision product. In a single, clear and simple interface, all message types are managed.

2. Incorporated External System

In the Vision tabbed views, external web enabled application can now be well-established, allow access patient information from number of sources to be seamlessly from the Vision desktop. The patient is automatically recognised in the target system, when the required data is passed to the third-party application. For integration into the patient record when required, important data may also be written back to Vision

3. Patients Appointments

This Vision system allows user full access to the appointment screen. “Using session templates developed by the practice” the appointment books are defined in advance. The view of appointment book can be defined by user: all significant doctors and other Healthcare professionals can be added or deleted as requirements. To denote, each slots can be assigned in different colours. As the patients arrives at reception, enters the doctor’s room or leave the surgery, their status is recorded. Our evaluations are based on EMIS system, its features and limitation which have been explained in later chapters.

1.5 Thesis Organisation

In chapter 1 we have explained Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages. The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. This chapter 3 gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained. In the chapter 4 we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter. The chapter 5 focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions. The chapter 6 is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained. Advance system and its features are discussed in this chapter 7. Waterfall Model’s activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations. The chapter 8 explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter.

Chapter 2 Egton Medical Information Systems

EMIS® and ‘EMIS intellectual technology’ are trading names of “Egton Medical Information Systems Limited”. EMIS had begun 18 years ago in a rural area dispensing practice in Egton near Whitby in North Yorkshire [11]. EMIS® head-offices are based in Leeds, including Development and Support departments. Training for general practices is localised and headed by Provincial Operations Directors [11].

2.1 Practice Care System Enterprise

Due to the growing number of EPRs held in both GP and Secondary Care, the requirement for a whole EHR has never been greater. The EMIS’s Primary Care System Enterprise edition for PCTs has been designed to meet all the challenges. EMIS PCS will maintain the patient information at many levels and ease safe access 24/7 by the wider health care-community [11]. PCS Enterprise for PCTs has been designed with capability of future technological and keeping development in mind, such as sharing data between General Practices. This includes GP to GP records transfer and inter-operability between in- and OOH PCSs. Using a HL7 Version 3 the patient data is transferred between dedicated health care systems directly [11].

2.2 An overview of PCS Enterprise

This edition has been designed to develop EMIS’ provision of an absolute system solution for primary care. The system is scalable, multi-practice, and multi disciplinary with shared EPRs and seamless data exchange. This system is based on three-tier architecture, while utilising MS Dot Net technologies, this system has the flexibility to increase numerous clients with its ability to scale to thousands of instantaneous user connections [11]. EMIS Primary Care System Enterprise edition is designed to meet GP needs as closely as possible, while supporting specialties related to medicine. See in 2.1 below gives the overview of PCS Enterprise system:

2.3 EMIS Primary Care System Practice edition

Health information system plays an important role in how practice operates. The good and right clinical system can help to save practice valuable time, assist in practice management and ultimately lead to improved patient care. The EMIS PCS Practice edition has been designed to meet GP needs, combining functionality with simplicity of use [11].

Key features of EMIS PCS

* Complete patient record management * Quick and good prescribing * Formulary managements * Incorporated consultation mode * Incorporated appointments * Mentor Library * Integrated with MS Word support * User defined templates * Drug Explorer

2.4 EMIS LV Version 5.2

In the PCS market, EMIS Live Version [11] is the main text based medical system. Approximately 5000 GP’s currently using EMIS LV system (which is shown below) in the UK. The system offers GP’s consultation mode option, medical record, search and reports option, prescription and booking appointments.

2.5 Population Manager

This system enables General Practices to effortlessly meet the requirement of the new GMS Contract. Population Manager [11] has a set of more than 160 searches that extract the data require for the new Contracts and present it in an understandable format. It also contains a set of specially designed templates to help speedy and standardised information entry. Population manager is an incorporated part of EMIS LV system.

2.6 Version 5.2 features

This is the most recent release of EMIS LV. This LV offers users the following key features [11]:

2.6.1 MS Word incorporation

Patient data is easily transferred between EMIS system and MS Word enabling the clinician or staff to create patient related letters in MS Word easily. To create consultation references for simple retrieval, documents are created in MS Word which is saved back into EMIS.

2.6.2 Referral template for Cancer patient’s

If cancer is suspected GPs requires produce and fax or e-mail suspected cancer referrals within 24 hours of seeing the patient (this is according to the NHS Plan). These patients have to be seen by the Hospital Trust within 2 weeks; hence these referrals are named as “two week rule referrals”. EMIS has included a suite of MS Word templates for each cancer type into EMIS LV5.2.

2.6.3 Electronic Insurance reports

One of the most common and time taking medical information requests for GP’s is the PMA form for the claim companies. A familiar format for General Practitioner Report has been decided and computer-based reports (eGPR) are accepted by insurers. The electronic GPR can be generating within the EMIS system, integrating all related patient information. The eGPR template is installed by default in this system.

2.6.4 Scanning and attachments

This module enables to scan corresponding or images and attaches them directly to a patient’s record in consultation mode. These documents are instantly available during consultation.

2.7 EMIS Clinical Communication Modules

The following Clinical Communication Modules are available with EMIS LV5.2, providing links with Secondary Care [11]. 1 Online Referrals with Booked Admissions 2 Electronic Referrals 3 Incoming Reports including Electronic Discharges 4 Online Results Ordering With an approved list of suppliers this Clinical Communication Modules work. Using the common set of messaging standards currently being developed by the National Design Authority, links to other suppliers will become available, an arm of the National Programme for IT in the NHS. For this reason that EMIS are not progressing, with the further testing of links with other suppliers using proprietary messaging standards. The Clinical Communication Modules are explained below [11]:

2.7.1 Online Referrals and booked admissions

Traditionally referring patients from doctors at general practices to hospital or Secondary Care consultants has been a paper based with its problems of delays (slowness) and occasional loss. The EMIS Online Referrals with Booked Admissions module enable us to create a referral on a Secondary Care website using protocols created by Secondary Care consultants, adding patient demographics and clinical information and in some cases booking an appointment. Requirements: Each EMIS practice must have: * EMIS LV 5.2 * NHS Net connectivity * Router access for EMIS * Version 2 clinical terms (5 byte Read Codes) The Secondary Care Provider will need: * An EMIS approved website

2.7.2 Electronic Referrals

This module enables us to create a referral letter within EMIS LV and transmit it electronically to a secondary care consultant [11]. The way electronic referrals work You can use MS-Word Integration in EMIS LV to create a referral letter. When you save the referral letter, you are prompted to link with EDI for an electronic transmission: answer ‘Yes’ and the referral letter is placed in the Communications outbox (CO, OD). From here, you can check the letter before authorising the transmission. When you have authorised the transmission, you can either send the referral letter immediately or wait until the next scheduled transmission. Upon receiving the referral letter, the secondary care software system will transmit an acknowledgement that you can view within the EMIS Communications screen. Requirements Each EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS Support * SMTP or DTS mailbox * MS-Word Integration The secondary care provider will need: * SMTP or DTS mailbox * Suitable software capable of sending and receiving XML messages and acknowledgements * SMTP/DTS and EDI code addresses of the practices involved – the trust should obtain these from the health authority or national tracking database

2.7.3 Incoming Reports including electronic discharges

Use this information sheet to give you an overview of the Incoming Reports module and the requirements to get you started. The communication of patient information from out of hour’s services and secondary care used to be paper system, which has been unmanageable and untrustworthy with discharge notes being illegible, incomplete and often late in delivery. The paper-based system replaced by Incoming Reports module which receives electronic discharge notes or other patient related reports from an OOH service or a secondary care provider [11]. How does the Incoming Reports module work? Incoming Reports is a one-way process whereby the out of hours service or secondary care provider sends a message containing the incoming report to EMIS LV. However, EMIS LV will send an acknowledgement of receipt back to the provider. When EMIS LV receives a report, it is matched to the correct patient and placed on a list ready for viewing, and then filing. If EMIS LV cannot match a report to a patient automatically, you can match a patient manually. When viewing a report, you can match the clinical information in the report to clinical terms before you file it. You can link a report to a past consultation (for example, the consultation during which the original referral was made) or create a new consultation specifically for the report. You can view filed incoming reports using the *RL function in Consultation Mode.


To use Incoming Reports, an EMIS practice must have: * EMIS LV 5.2 * NHSnet connectivity * Router access for EMIS * A DTS address To use Incoming Reports, a secondary care provider must have: * A DTS address. * The DTS addresses and EDI? codes for all required practices – this information is available from the health authority or from the national tracking database. * Software to create and send XML messages and receive acknowledgements

2.7.4 Online Test Ordering

Requesting and processing pathology samples were traditionally paper-based systems, with their inherent problems of slowness and occasional loss of information. Pathology labs can now provide web-enabled IT systems to produce a far more efficient and streamlined service. The EMIS Online Test Ordering module, available for EMIS PCS and EMIS LV systems, enables GPs, via a secure NHSnet connection, to access the pathology lab and exchange information regarding requests, samples and results [11]. Online Test Ordering can be access from Consultation Mode or Medical Record, and then access the website of a compatible laboratory. The current patient’s demographic and GP details are transferred to the laboratory system when you request the required tests. After you have ordered the tests, the test information is transferred to your EMIS system and filed in the patient’s record. At this point, you can continue with other work or take the test sample(s). When you take a sample, you can print a bar-coded label to attach to the sample, ready to send to the lab. Use the Online Test Ordering menu options to monitor the progress of the sample and view the results as soon as they are available, although you will still receive the results through the Clinical EDI or Pathology Links modules, as before [11].


Each EMIS practice must have: * EMIS LV 5.2 or EMIS PCS * NHSnet connectivity * Router access for EMIS * Version 2 clinical terms (5-byte Read codes) Support issues The overall Online Test Ordering process relies on different services and software all working in conjunction with each other: the EMIS software, the laboratory website and the NHSnet network. Unless a problem occurs with the EMIS software, EMIS is improbable to be able to resolve issues with the two areas; therefore, the secondary care trust and/or the practice should ensure that support facilities are in place for these eventualities.

2.8 Storage area network (SAN)

Using the highest industry standard storage area network (SAN) configuration EMIS data centres are run [11], on which EMIS stores data [Detail explanation in later chapter].

Chapter Summary

The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements.

Chapter 3 Drawbacks of Online systems

Although online application provides many services the challenges associated with are given below. All the drawbacks are explained taking EMIS as an example.

3.1 Patient Record

¨ Time required to put all relevant information onto system ¨ Possible security issues ¨ Doctor can focus too much on patient information onscreen which could intimidate the patient ¨ Scanning and entry of data is more time consuming. Important information lost can when overlooking the record. ¨ Medical record print-outs are frequently of poor quality and difficult to understand necessary information ¨ In spite of using EPR, Paper records need to be kept back or scanned material become unmanageable. ¨ Often using computer and paper records together will make patient data look very difficult. ¨ Currently between GPs there is no electronic transfer as it is due to having a risk of data lost and duplication of data[16]

3.2 Appointments

¨ Patients have to be checked into appointment system by receptionist ¨ Problematic if patient’s can’t read, or unable to view sign (e.g. blind people)

3.3 Prescriptions

¨ Relies on drug information being up to date ¨ Aptitude of doctor in using computer effectively ¨ Some times doctors issue hand written prescription; they may not be available on computer. The acute and repeat prescribing registers can make it more confused. Printouts of Pharmacy still required [16].

3.4 Email

¨ Relies on doctor checking their mail daily ¨ Troublesome patients abusing the system ¨ Hospital letters not emailed (would be preferred)

3.5 Security issues

¨ Doctors have to go to bother of signing on and off EMIS ¨ Forgetting passwords ¨ Passwords can be troublesome, staff or anyone can abused or swapped it, if they are lost the system can be absolutely in-operable ¨ Leaving computer on ¨ Locum doctors ¨ Experts are need to show computer frauds and misuse [16]

3.6 Internet connection

¨ Continuous internet connection required ¨ The problem with online application is we cannot access from remote areas, compulsory web connection should be there and we cannot get alerts [4, 5].

3.7 Backup

¨ System backed up every night onto tape ¨ Two copies:- – Fireproof safe – Remote location

3.8 Read codes

Maintenance of enormous clinical expressions or codes is very complex, and the Read Codes present many challenges. In addition, structure of controlled terminologies has been learned about the principle because of the structure of the earlier versions. Version 3, the existing read code systems have been design keeping in mind the previous, simple versions, and to achieve forward compatibility [17]. The problems associated in steps in read coding the medical problems are explain below in s step 1 and step2 The Read Codes are used for many purposes such as clinical audit, searches, source allocation, and for the making of central government statistical returns. Problems arise from different uses and from the different views of Healthcare professional. [17]. Statistical classifications like ICD and OPCS4 may cause inconvenience so they are cross map. Version 2 with its diagonal section closely mirrors ICD9, even though this doesn’t always reflect a clinician’s view, and correct hierarchy placement of a concept according to ICD9 rules may appear anomalous to a clinician. Besides this Version 2 initial aim is for a code, with its preferred term and it offers a single cross-map to these classifications, and its and all its synonyms, to map correctly to ICD9 [17]. Version 3 came with its directed acyclic graph structure, greater synonym purity, and much easy cross-mapping design, incorporating default maps and alternative maps, avoids the previous version limitations. However this came with other possible problems. Therefore, the two processes, authoring and mapping are closely incorporated [17].

Read/SNOMED Codes

Read/SNOMED codes are used by the doctors at hospitals because medical records in future can be transferred through GP2GP links. “Unlike the principal of Linnaean classification of species in the 19th Century, James Read brings in an international categorization of medical activity to contain disease names, operations and procedures. The main aim of this classification was to allow easy transfer of data between GPs, hospital and PCTs and easy to use by clinical staff, administrators and planners” [24]. Read codes has been explained more clearly in chapter 4.

3.9 GP2GP Record transfer

The experience of the GP2GP record transfer and the clinical involvement are explained this section.

3.9.1 The underlying principle for electronic GP-GP record transfer

The vast majority of UK GPs (greater than 96 percent) are computerised in some way or other. A sizeable proportion of these practices use their computer systems for recording patient record information in whole or in part [33]. This results from a variety of causes whose main headings are: * Patient records that are an unpredictable mix between paper and electronic. * The net effect of the above is to place difficulties on new practices in identifying salient information in transferred records and in incorporating that information within the new record. This is to known to have significant (but un-quantified) resource implications for practices. There is also widespread anecdotal evidence of resulting adverse effects on patient care. The rationale for the electronic transfer of records is therefore: * As a support for electronic records in general practice and their general benefits in terms of decision support and audit/governance abilities. * To obviate the need, as far as possible, for re-keying of paper-based information for new patients and thus reduce resource implications * To reduce the risks to patients arising from the transfer of confusing records.

3.9.2 The nature of electronic GP-GP record transfer

Electronic patient record systems in general practice in England are provided by the commercial sector. At the time of writing this annex to the Good Practice Guidelines, eleven different commercial suppliers are known to be involved in this provision. In simple terms is that it is a common convention for the representation of [33]: * Record encounters; what constitutes a single transaction with the record like a doctor’s consultation, a letter received from hospital or outside, an examination result etc * Names for these encounters; e.g. home visit, * Headings within these encounters * Complex clinical constructs * Read code mappings; such medication codes sets * Codes and associated text * Major modifiers of clinical meaning

3.9.3 The Problems of electronic GP-GP record transfer

There are four particular aspects of current GP-GP records where the transfer process of that record information needs to be supported by additional rules or processes if fully safe and usable records are to be reconstituted on receiving systems and are explain below [33].

Medication information

There are currently three different coding schemes for the representation of medication information on GP systems. The principal reasons for failure to reach 100% reliability are: * The multiple coding schemes used and * Failure of previous code mapping exercises (see chapter 5 on data transfer).

3.10 The Problem Oriented Medical Record (PMOR)

Electronic health records (EHR) are more used in UK General Practice despite continuing improbability about its legality and admissibility. The transfer of electronic record is currently in demand by the practices when the patient moves i.e. GP2GP transfer. The EHR implementations differ from a simple sequential list of medical concepts in an out of date coding system to sophisticated Problem Oriented Medical Records (POMR) [31].

3.10.1 Limitations of the PO Medical Record

The limitations of POMR are explain below [31] * It is very easy to pick up but very difficult to maintain. * In the strict way of the word not all headings are ‘problems’. For example, the heading of ‘Immunisation’ is used usually to indicate where all the entries related to a immunization history may be found. * Many different problems may be discussed within a single consultation * To check scanned documents is very difficult especially when patient record is too big * Problems are frequently linked in a fundamental way. * The PO Medical Record only gives a basic measure of the state of a problem. * Different clinicians, view the clinical record, required different information from the medical record as well as with different views. * Some of problems are complex and they are difficult to read. Those records which have few entries are conversely are easy to read, hence POMR is meant to avoid comes to the fore again. Though POMR have above limitation but it is a popular medium for data entry and viewing, there is indeed room for enhancement and progress [31].

3.11 Other Disadvantages

* Typing skills required for doctors and other clinicians. They are using ever more abbreviations and acronyms. * Many screen need to be changes to find results and mouse activity * Information can be hidden as only the information requested is * Viewing screen generally takes longer time than scanning visually * In busy practices information fatigue can easily occurs and while entering all telephone data slows doctors as they practice defensive medicine * Information and data quality depends on the software using and user skills * Patients see the doctor as computer centred [16]

Chapter Summary

This chapter gives brief overview of problems associated with online medical systems with examples. Problems of online medical system such as internet connection, email, prescription, Electronic Patient records and read codes are explained.

Chapter 4 Patient Medical Records & Read Codes

“A medical record, health record, or medical chart is an organized record of a patient’s medical history and care”. The term ‘Medical record’ is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient’s health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal [22]. A medical record consists of the following: * Demographics * Medical history * Surgical history * Obstetric history * Medications and medical allergies * Family history * Social history * Habits * Immunization history * Growth chart and developmental history A medical record provides a written account of a patient’s complete medical history. A whole draft of legislation, standards and guidance on what has become known as ‘Information Governance’ has been produced in the last few years to cover issues of access, confidentiality and disclosure [21].

4.1 Traditional Patient or Medical Records

Traditionally, patient records have been written on paper and kept in thick envelopes which classically divided into useful sections either alphabetically or using patient numbers, with new information added to each section ascending or descending order as the patient experiences new medical issues. Active problem records are generally housed at the clinical site, but past records (e.g., those of the dead or the patient who have more than one record) are often kept in different location or facilities [22].

Problem of Paper based system

Though paper-based records have been in continuation for centuries and their gradual substitute by computer-based records has been slowly underway for over twenty years in healthcare systems. The main problems with the manual records are security, if lost cant be recovered, time consuming. Even computerised information systems have not achieved the same degree of penetration in healthcare as that seen in other sectors such as finance, transport and the manufacturing and retail industries. Those EMR (Electronic Medical Record) systems that have been implemented however have been used mainly for administrative rather than clinical purposes [20].

4.2 Paperless Practices

With the help of system providers many GPs are developing into paperless practices, which have a completely incorporated Windows-based system including access to full EMRs [15]. “Improvements in information flow technologies, supportive national and local policies, as well as a motivated practice and a local champion with good management skills have contributed to the successful integration of computers. These improvements have subsequently moved many general practices forward towards becoming paperless. Hospital’s are not making improvements as general practices in their IT infrastructures” [16] The reason why the hospital or the GPs that prevents or discourages doctors from migrating towards becoming absolutely paperless is generally the restricted and uncoordinated development of Information Technology (IT) within [19].

4.2.1 The reason General practices become paperless

There has been a relentless move with computerisation of practices towards paperless clinical records and paperless practice activity generally. Good quality electronic records, generally, can be used to prompt [19]: * patient care can be improve * Better management of patient care between GP and secondary care * monitoring of the health of populations will improve * Research based on primary care improves

4.2.2 Advantages and disadvantages of paperless practice

Computerisation has traditionally been seen as enabling improvements in the quality of care given by a practice. A variety of advantages and disadvantages have been cited [19].


* problems such as delay when transferring paper records and loss or misplacement of paper records envelopes can be overcome * Time saving and convenient * It allows information sharing more easily, the practice can reduces internal paper flows using email and intranet communication * Provides better security and confidentiality * Using electronic patient records, data quality can be achieve * Provides more efficient and effective consultations * collecting/retrieving exact information becomes easy * Provides transparency of patient data


* Data security is still remain an issue * managing and scanning documents have proved difficult * Staff training required and lack of IT principles for GP staff * Problems such as data backup and sharing information externally between practices * using Data Protection Act patient may view notes which can have considerable workload implications

4.2.3 Migration towards a paperless Hospital

There are several different document-related activities that can be analysed for investigating the practical implications of migrating towards a paperless organisation. Data entry into electronic format by consultants using the preoperative risk assessment PRA form is tiresome and an additional activity that is required purely for reasons outside the local concerns of the medical professional [19]


* reduce costs of storage space * Up to date data and aggregation of data with online access * reducing redundant form filling by providing link to a centralised data store thereby * data access and retrieval is relatively easy compared to paper notes, and those generated by different hospitals * Allow consultants remote access to information


* Paper record is more flexible, portable and available i.e. PRA forms * Computer based systems are more structured with constrained interfaces * Data inputting via keyboards * Problems such of screen size, viewing angles and the ability to share multiple documents simultaneously by people in the similar room However, due to poor system design and poor investment means that hospital doctors do not use computers.

4.3 Electronic patient records

“An EPR is generally a computerized lawful health record created in hospital and doctor’s surgery that delivers care”[23]. Electronic Patient Records (EPRs) are the recommended format promoted by the NHS information strategy, the National Service Frameworks, and the NHS plan. EPRs aim to improve patient care, improve the communication and coordination of care between primary and secondary health care services, monitor the health of populations, and undertake primary care research [19]. An Electronic patient record consists of following: * Demographics * Consultations * Present and past problems * Test results * Immunisation record * Allergies record * Attachments (scanned letters from hospital or other secondary care) * Current and past drugs list * Family history * Due diary entries

4.4 Clinical codes

Clinical codes play an important in General Practices today. All the data of patient is read coded which helps in doing patient searches and audit trails. Whilst adequate for primary care, the clinical code system does have its limitations in the wider environment of the integrated care record, and SNOMED CT (Systemised Nomenclature of Medicine) has been selected as the standard terminology scheme for the National Programme for IT (NPfIT, see below) [20].

4.4.1 The National programme for Information Technology

The UK Government’s vision is to establish, an NHS information technology system which will be able to communicate within itself through its agency connecting for Health (transfer of information between GPs, the hospital sector and community services), with external agencies such as social services, and with health services globally [20]. To deliver the objectives, several components need to be in place, the most significant of which are explained below [20]: * N3 the National Network allows secure connection * GP to GP transfer allow transfer electronic transfer of patient records * NHS Care Records facility securely accessible by the patient * Choose and Book Referrals- patients select their choice of hospital and can make their appointment * Electronic Prescription Service- enables GPs to electronic transfer of prescriptions dispensers · The National Health Service Spine – It is the National database which stores each patient’s complete medical record. Detailed information from NHS number to past problems The NHS Spine has been shown below in the . The represents how NHS spine is connected to secondary and primary care system.

4.5 Electronic Patient Record stands Lawful Alone

From October 2000 it became lawful that GPs can keep only electronic patient records, i.e. the whole idea is to become paperless. As patient data is very sensitive, GPs and hospitals follow rules and regulation according to Data Protection act. More steps are taken to safeguard patient information which otherwise can be misuse. As Electronic Patient Records is easily accessible there are many advantages and disadvantages associated with it. Few are discussed below in Table 4.1 [24].

Table 4.1: pros and cons of the EPR



All the data can be easily found. Typing skills required which makes doctors as computer centric and many are using ever more abbreviations and acronyms. Patient data can be easily reached and confidential, of staff and level of use carefully controlled. People can misuse passwords, which can be troublesome or swapped which will make system can be completely inoperable. No filing required which save staff time from filing. It is time consumable as its take more time for scanning letters and data entry. Identifiable staff or clinician enter encounter date and time. Necessary patient information print-outs often of deprived quality and unclear. Drugs prescribed can be accurately recorded which will includes date, amounts of repeats and staff initial issuing medication. The patient may get confused due to current and repeat medication Results can be displayed easily and BP readings that can be in tabulated or graph form. To view different results can sometimes only be found by many screen changes and mouse activity. Data is back up every day this made records more secure. Paper records are also need to be kept Patient data is more easily transferable by email, patient card or disc so risk of loss or misuse of data Many GPs sill do not transfer records using GP2GP links Data Quality of record can be high if data is entered accurately. Data Quality depends on the skills of the user and the software Due to patient summaries and drugs warnings can be easily displayed safer prescribing is possible Read codes can be used for clinical purpose which make Doctor or clinician life easy. Sometime many codes are meaningless.

4.6 The main Clinical Risk areas of EPR

There are numerous areas of risk of patient records. The two main risks are * Inability to transmit patient data between GPs * restriction of the PC screen for viewing patient data The other few clinical risks are discussed below [24]:

4.6.1 GP to GP Transfer

The risks associated in transferring the information using GP2GP links are as follows: * Different surgeries use different computer systems which are not inter compatible, due to which transfer patient records does not takes place accordingly. * As many patient moves from place to place and get register each time. Sending their medical summary to each practice practically not possible due to due to cost. When the record is reached to the practise it goes on computer manually which need trained staff. * From the above problems it may leads to some of the data loss and time consuming

4.6.2 Viewing Notes quickly

Viewing notes quickly leads to Information Fatigue. Just as traditional notes are impossible, enormous patient data is more difficult manage can’t view in one go and going back to previous screen is also difficult. It quicker to scan all hospitals letter, when doctors try to locate for the particular letter it takes time, he might miss important information.

4.6.3 Problems in Clinical Negligence

Using computer in GPs is giving many problems for those who are working in clinical negligence. It is important for the staff to know what information may be obtainable, recognising and understanding that the standard of practice has been changed and finding new solutions to old issues, makes knowledge of the EPR vital for clinical negligence lawyers [24].

4.6.4 The patient’s complete Record

Solicitors now request the whole record of patient and also they need to be told which software is being used at the practice and to what extent the system is being used by the practice. Already cases have arisen when a paper record was not entered on a computer system and was negligently overlooked.

4.7 New solutions to old issues

There are few well known issues in medical negligence and those are presented differently below [24].

4.7.1 Which notes practitioner is responsible to see for

When doctor is doing or writing series of consultations it has frequently been necessary to give opinion as to which of the previous consultations a practitioner would have read or considered. With the paper record, a doctor is more likely to have read the penultimate consultation if it was on the same page and less likely if a crucial consultation occurred some entries back in the record. In general, when an entry is made immediately below another, the preceding entry cannot be overlooked.

4.7.2 Notes has been modified or not

There are many risks associated with paper based records such as suspicious handwriting and changes ink for fraud entries. The computer record can more easily be altered or misuse can easily send via email or copied to pen drive but it leaves an audit trail.

4.7.3 Different Computer have Different Style

To some extent using a computer in the practices may look easy but there are chances of errors. Doctors and other healthcare professionals may get confused due to these problems. The LV5 version of EMIS for example encourages a separate entry for History, Examination, Comment and Problem, whereas some systems allow the doctor to enter the entire consultation under one free text area which, although quicker, is less likely to produce a safe structured entry. The former will be more likely to provide a sound defence. I have no doubt that within ten years some systems will be identified as much more liable to medical accident as others [24].

4.7.4 Automated Warnings

* Computers not only keep records of discussion with patient, but they also provide automated warnings about medicine, annual alerts such as diabetes review, asthma review and in some situation a GP has to ignore a warning in order to print the patient prescription. * Some programmes such NHS sponsored SCRIPT or PRODIGY will prompt medicine choices in certain * Systems like British National Formulary and Electronic MIMS advice such as Mentor can all be installed [24].

4.7.5 Length and Accountability of Doctor’s Consultations

Presently with many systems such as EMIS it is possible to find out patient arrival time, waited for doctor to see and how long doctor has spent time with patient. Most clinical negligence lawyers are aware with this information and this is useful for deciding whether a systematic opinion has been made [24].

4.7.6 The Doctor as Typist

* It is now essential for doctors to have typing skills otherwise they will spend more time in data entry and patient have to wait * It is not possible that Medical school train doctors each system in use and some doctors will be working with systems with which they are unknown. * Additional training required to train doctors and health care professional. Without full training the possible for locum doctors to error is greatly enhanced [24].

4.7.7 Out of Hours Services

Patients these days prefers to be see nurse practitioners at a Walk in clinic or centre, or duty doctors at a Primary Care’s OOH centre and before doing so they have to go through a triaged by a message handler, doctor or nurse at triage or attended to by a paramedic [24].

Chapter Summary

In this chapter we have focussed on Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed in this chapter.

Chapter 5 Read Codes and Its Challenges

In the early 1980s hierarchically-arranged Read Codes are controlled clinical vocabulary and it mainly consists of three maintained description of various complexities. The read codes are updated quarterly as they are dynamic in response to user requests which includes clinicians in both General Practices and PCT’s, System suppliers and advice from a group of expert healthcare professionals. The progress of codes content within versions creates tensions between different users and uses of coded medical data. In-house processes, outside interactions and new structural characteristics are implemented by the NHS Centre for Coding and Classification (NHSCCC) for user interactive continuation of the Read Codes is described [13]. The Codes are dynamic medical terminology; they are updated in order to release on a quarterly basis for medical terms and monthly basis for drugs and appliances. The release gap supports stability for the need of quick response to feedback and also reduces problem to the users. The revise process is difficult by the need to concurrently maintain three separate versions that remain in active use: the early four byte set, Version 2, and Version 3. Even though they support migration to Version 3, the essential upgrades to hardware and software are expensive, and there is responsibility to ensure that older versions are supported [13]. Even though the formal classifications need stability over a period of time to allow continuity in data aggregation, a maintained vocabulary for the compilation of clinical data needs to be dynamic. The updates of frequency and mechanisms will differ in response to a number of factors: in particular, size, design purpose, ownership, and available resources. For ex: the revision of annual ICD-9-CM are in printed and electronic formats, but the UML Meta thesaurus is issued annually on CD-ROM, and SNOMED International has enlarged its frequency of electronic updates [13]. The three versions are as follows [13] * The Four Byte set * Five Byte Set * Version 3

5.1 The Four Byte Set

In the early 1980’s the read codes were first introduced to keep a summary record of clinical and clerical data for the Surgeries. These were introduced to record patient’s clinical summary and administrative data for General Practice. “The Four-character alpha-numeric code decides position of term in a hierarchy is called as the The Four Byte Set. It is divided in to two delimited text files, file 1 one contain fields for the read codes and the thirty character preferred term (For Ex: F682.| Sensorineural deafness) and the second contains four character keywords and synonyms, for ex: F682.| Sensorineural deafness| SENS and F682.| Nerve deafness| NERV). Even though the easy code-dependant structure is attractive to both users and developers there are quite resulting problems persist”. Advantages * It has simple code-dependant structure * This version attractive to users and developers Disadvantages * Simple structures but resulting in numerous problems * Compare to 4 Byte set, Version 2 has shorter terms and keys * Multiple parentages are not supported, leading to either partial classification or to replication [13].

5.2 Version 2

Both Four Byte Set and Five Byte Set have cross-mappings to other classifications, including OPCS4, ICD9, ICD10, the British National Formulary (BNF), and the Anatomic and Therapeutic Chemical Classification Index (ATC).Version 2 is the most widely used format because of the Five Byte Set [13]. The Five Byte Set consists of two files, they are one file contains the five-character code for the notion and the preferred term of up to 198-characters and additional fields for mappings to formal classifications (Table 4.1). “Another file contains all the terms that can describe a concept, such as the preferred term and synonyms. Another field holds a two-digit term code that flags a term as preferred (00) or synonymous (11, 12, 13, etc.)”. Each record has a field that may hold a term key of up to 10 characters to facilitate searching. Advantages and Disadvantages of Version 2 * Most widely used because of Five Byte Set * Simple and meaningful * Version 2 is not flexible

5.3 Version 3

In 1994 Version 3 structure, “a link-based directed acyclic graph hierarchy was introduced which has complex structure includes meaningless identifiers (see 5.1), a prototype table to maintain semantic definition and attachment of qualifying detail, and a more sophisticated cross-mapping scheme”. Furthermore, Version 3 concept also is flagged with a status, enabling extraction of different sets of codes for specific purposes and additional functions as discussed below. Current codes form the core of usable clinical concepts within Version 3, whereas codes flagged as optional are not deemed clinically useful by the SWGs and can be filtered out if desired. Two additional status flags allow preliminary new development of the Thesaurus to be tested without affecting existing users. Finally, there are experimental concepts, accessible only to in-house authors at the NHSCCC, and allowing preliminary exploration of different options. The features of the three versions are compared in Table 5.1. In order to facilitate inter-version compatibility, current work aims to incorporate all Four Byte and Version 2 codes into Version 3, thus making Version 3 a “superset” of all versions (see 5.2). Any concept or term added to an earlier version must, therefore, now be added Version 3, and a record must be entered in appropriate inter-version mapping tables.

5.3.1 Read/SNOMED Codes

Read/SNOMED codes are used to classify medical activity and offer to be the means by which patient’s clinical records will in future be transferred from one GP to another GP. In 19th Century, James Read produced an international classification called Linnaean classification of species of medical activity to include illness names, operations and procedures. The aim was to allow easy transfer of information between GPs, hospital and tertiary care and be easy to use by healthcare profession, clinical staff and planners [24]. * Coding is good only if the user has good knowledge of it and knows the best way to use it. Most of the doctors use the Read/SNOMED Code as computer system in use allows and insists on coding each consultation. * Coding has made obligatory in all practices, as locum does not have much knowledge of each system in use in this sense the code can prejudice and doctor may enter wrong code. * Coding is easy for some conditions but the more complex for the other. It is reliable and useful once users have good knowledge of how to use it.

5.4 Read Codes Maintenance

Although Read Version 3 has become standard clinical coding system within the NHS, earlier versions remain in widespread use and need ongoing maintenance. Their fixed code-dependent hierarchies, however, limit maintenance to a relatively small number of additions and corrections. Read codes are maintained by two processes, internal process and external interaction [13].

5.6 Advantages of Read code

* An electronic medical (clinical) record for individual patients * Read Codes are used for recording clinical and administrativeinformation such as codes dealing with registration, certification claims and other patient related information * Allow Quick search and Audit trails for quarterly and yearly reports, auditing major and chronic disease for most practices (patient medical summaries) * Rapid data entry using clinical read codes can be performed. Read codes make data entry as accurate, complete, timely and accessible * The 2 types of description for Read codes one is ‘Preferred’ term only one per Read code (like enter P in the Read code browser and user will get list of options) * The other is ‘Synonymous’ term – there may be numerous for one code (say if you enter G30 Read code browser it will give user with number of options such as Heart attack, Coronary thrombosis,Cardiac rupture – MI)

5.7 Disadvantages of Read codes

Training * All the medical staff and doctors need training to avoid errors * Cost and time for training Maintenance Every quarterly most of the codes are change

Chapter Summary

This chapter focuses on Read codes and its structures. In this chapter 3 versions of read codes are explain with examples. Maintenance of read codes i.e. internal process and external interaction and hierarchy has been explained with s. The example case study represents the limitations associated with 3 versions, its results and solutions. Evaluation: Though version 3 comes with its flexible directed acyclic graph hierarchy, greater synonym purity, and more flexible cross-mapping scheme, incorporating default and alternative maps, avoids these limitations. This flexibility, however, allows other potential problems

Chapter 6 Database and Its Structure

Providing patients the top quality service is the main aim of UK government’s healthcare programme, and in 2005 connecting for Health programme strategies came into operation, which support this goal of healthcare programme. Electronic patient records offer a rapid, consistent, and protected method of sharing patient data [25]. The National Health System employs the country’s good solutions to sustain this programme of healthcare reform. EMIS is based in Leeds, one of the leading companies in UK. “An IT supplier in primary healthcare, the company already hosting more than 39 million patient records within and around 60 percent of the country’s doctors use it as well” [25]. Example: Data transfer within PCT (Primary Care Trust) The below 6.1 explains how data transfer takes place within the PCT. Patient records is accessed by hospitals, pharmacy, Out of ours service and the surgery. Its also shows that where patient records are kept in order to access them whenever required. Its also represent data transfer between surgery and Spine. According to Sheavills “Gp’s can utilise their time (even a 30 second) to view patient records as they don’t have wait for screens to get refresh as that is not acceptable in this environment.” Sheavills says that has always been a challenge to achieving that performance over a network the scale of the NHS. “It hasn’t easy to attain sub-second systems. People have always been a negotiation between usability and speed. But due to Microsoft latest release products this changed.” [26]

6.1 Solution

EMIS Web suite has been redeveloped to take the advantage of latest-released of Microsoft technologies including the Windows Server 2008 Enterprise operating system and the Microsoft Visual Studio 2008 development system. EMIS firmly believes that these Microsoft technologies provide the high levels of performance and scalability that meet and exceed industry all needs. EMIS have design database in such a way to accept upgrades in future. Patient database is designed as shown in 6.2 (The database model of EMIS is shown below in the 6.2). Where patient variable are defined in order meet the NHS requirements. The shows patient class relationship with hospitals, staff at GPs or hospital and Insurance companies. In other way it shows that hospital and insurance company have limited access to patient data [26].

6.2 Scalable and Secure Database

Microsoft SQL Server 2005 database environment support EMIS Web now with a view to improve to SQL Server 2008 (see 6.3). It offers EMIS the different levels of performance clinicians need regardless of the total number of patient numbers and NHS by means of the technology. Using SQL Server tools such EMIS Web is providing scalable, secure database applications. EMIS is using it to distribute patient records in real time between all surgeries [26]. SQL Server Service Broker offers excellent security, by using secure Service Broker services and routes millions of patient medical records are transferred between distributed databases each day [26].

6.3 Better Patient Support using Sub-Second Transactions

Today with added usability that suits clinicians’ needs across all fields EMIS Web match the speed of text-based systems. The new EMIS Web solution now offers “very good speed of service that exceeds NHS requirements but the using previous ASP.NET version doctors and patients need to wait as it used to take longer time for screens refreshed” [26]. The new version offers speed which is very best from the previous version and it ensure all the transactions are now at least sub-second—a full second faster than the previous version. As a result, doctors can make use of their time with patients not as computer centric. Using the latest technologies EMIS has created an excellent user experience across its big database network and data centres which hold around 39 million patient records and medical records information about more than 100 terabytes” [26].

6.4 Secure Solutions Protect Patient Interests

EMIS Web has the tools to protect processes and stop security breaches or loss of patient information. According to Sheavills [26], “features from Microsoft technologies such as Windows Communication Foundation in Visual Studio 2008 deliver both system scalability and data security which has become possible. Few organisations have already taken this on or they have succeeded,” he says. “EMIS Web is successful because of the use of the right technologies for the job, which contain Windows Communication Foundation and SQL Server Service Broker. He says that there are no other technologies that allow distributing the amount of data EMIS distributing between databases securely.”

6.5 Internationally Recognised Systems Support NHS Needs

Using EMIS the patient records are accessible to the wider healthcare community, including secondary care and hospital outpatient clinics, district nurses, child healthcare clinic, social services, and departments such as dermatology. “Using the correct content and security settings which are found in Windows Communication Foundation, the common patient medical record can be accessible among a larger number of healthcare organisations to significantly improve standards of patient care,” says Sheavills [26].

6.6 Cutting-Edge Technologies Support

EMIS works together with Connecting for Health of NHS, and holds important responsibilities as a qualified supplier of software to the NHS. The objective of EMIS is to make patient data available wherever it’s required. It also works with around 30 other partners that design and develop software components for healthcare. Sheavills says “We are proud that the EMIS Web product suite is interoperable with standard industry technologies,” [26]. EMIS with new technologies support involved with a number of national government projects such as GP2GP patient records transfers choose and book, and electronic prescription transfers. “We work closely with Microsoft development teams to bring new healthcare solutions and also improve existing ones,” says Sheavills [26].

6.7 SQL Server 2008

SQL Server 2008 with Windows Server 2008 and Visual Studio 2008 provide a protected and reliable foundation for creating and organizing most demanding applications. “Combined product offers advanced security technology, enhanced management and Web tools, flexible virtualisation technology to optimise your infrastructure, and also access to relevant information throughout the organisation” [26].

6.7.1 Storage area network (SAN)

SAN is the abbreviation of “Storage Area Network”. Using the highest industry standard (SAN) configuration EMIS data centres are run [11], on which EMIS stores patient’s data. The SAN is a huge array of disks which replicate all patient records to a second SAN at a different location. When patient data is stored at the first location, a copy of that same patient data is saved at the same time at a second location as it is added or changed (see 6.4). Must there be a problem at Other SAN benefits: * Data is written rapidly to cache memory i.e. enhanced performance on SAN infrastructure. * Provides maximum data integrity and safety * Provides online upgrades for disk space and also performance tuning as a result the system doesn’t have to be taken down for necessary upgrades * to maximise performance faster backup time over SAN fabric is provided * instant data copying to secondary location so as to improve business stability * external connections by means of N3 * as well as this, there is a separate tape backup procedure [11]

6.8 A shared Patient record for General Practices

General Practices can to access their patient’s data as usual, sitting in centre in a secure Enterprise environment or on servers at the practice (see 6.5). If the second option is chosen then the GPs patient information will be mirrored in EMIS Web, using data streaming process of EMIS. “Community clinicians will also submit patient information to the central EMIS Web database, enabling General Practices to access patient data recorded by other healthcare professionals” [11]. Example: EMIS Database at GP surgery

6.9 Patient record is shared between healthcare professionals

Clinicians or healthcare professionals providing care outside of the practices will have access to a summary of the EPR so as to have accurate data and patient health chart. Healthcare professional at secondary care record information which patient’s GP accessed. These secondary care professional using advanced EMIS Web functionality read code data, with user interfaces tailored specifically for each role, together with appropriate templates and Read/ SNOMED codes. In context and in real time, this is enabled by interoperability – systems exchanging data securely, [11].

6.10 EMIS Web Interoperability

additional IT functionality are provided to EMIS users, EMIS systems interoperate with a wide range of third party GP IT suppliers, to offer products and services such as incorporated ECG readings software and document management. EMIS Web interoperability also facilitates patient services such as EMIS Access online appointment booking etc [11].

6.10.1 EMIS Drug Database

* Part of the EMIS clinical product supporting prescribing and dispensing within Primary Care * Comprehensive (covering primary care prescribing) * Up to date (Team of operators and efficient EMIS patch mechanism) * Accurate drug knowledgebase (including BNF data) [27]

6.10.2 Current EMIS Database

* Lists all currently available UK licensed products including Drug Tariff of England & Wales * Each preparation description : approved name + form +strength e.g. ‘Amoxicillin’ + ‘Tablets’ + ‘500 mg’ * This allows grouping under approved names or within the EMIS Drug Groups (similar to BNF hierarchy) * Each supported by constituents (also coded) * Considerable number of attributes for prescribing and dispensing [27]

6.10.3 EMIS Database Maintenance

* Database managed by qualified team. Application allows rapid updating. * New data requests are added to the central database and can be placed on the distribution update system (EMIS Patch) within 8 hours. * Within 48 hours 75% of sites will have a new addition or other field property change (GV & PCS 100% in 24 hours) * Approximately 15,000 GP’s collect update within 7 working days [27]

Chapter Summary

This chapter is about EMIS database, i.e. patient database and focuses on its usability and security. It explains structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained. Evaluation or Opinion: Presently there are no major problems associated with Database but in future they can be arise due to increase in number of patients or may be due to more people trying to access the same record at same time. It is going to slow down the speed to view the record.

Chapter 7 Advance System Implementation

We are going deal with few problems of existing system by developing mobile medicine application i.e., Patient care using SMS application. This enables user to access their records from remote areas, they may not have to travel for longer distance for requesting the repeat prescription and it is less time consuming. Patients can get their lab reports through mobile. ‘Patient Care Using SMS Application’ helps in mobile health promotion, using wireless technology assisting healthcare providers to improve the health of patients. This application helps in improving easy patient access to healthcare, enabling large number of people with personalized mobile health support and supporting people with long term health problems [32]. There are many benefits for GPs using mobile computing, especially in a big practice, although at present very a small number of practices make use of this technology. The Windows 95 has brought the opportunity of remote access capabilities [32].

7.1 Reasons for SMS Application

* Present system of medical treatment is a time consuming process as people need to travel for simple reasons like requesting repeat prescriptions, booking appointments etc. * Getting the lab-reports instantly is not possible in this system. Some of the benefits or main features associated with it are as follows:

7.2 Main Features

* Text Messaging * Requesting repeat prescription * Update personnel details * Patient record access * Automated Appointment Reminder * Viewing available doctors at your surgery

7.2.1 Text Messaging

The text messaging service aims to reduce patient’s non-attendance to booked doctor appointments by giving people timely reminders so that it can used for patient in urgent needs. This service will also be used for informing patients about crucial NHS services such as diabetes or cancer screening and immunization. This text messaging service aim is to provide support for health campaigns such as ‘cervical smear test’, ‘Diabetes Review’ and also help decrease number of DNAs (Did Not Attend by patient), by automated appointment reminders. Text messaging through mobile phones is fast, cost effective and private. It is easier to recall and easier to respond unlike email which need to be connected to internet.

7.2.2 Request repeat prescriptions

Patients can request repeat prescriptions through mobile – the surgery verifies it and replies via EMIS Access or present system suppliers. The patient only needs to make one trip to the surgery to pick up their prescription. You may also be able to request repeat medication from your mobile without travelling to surgery. From the searches made on their General Practice system, GP can send a text message asking patients to reply via text message if they smoke or not. Patients who receive this text can reply via text their answer, received by the surgery as an email to a designated surgery email address. All patients who are acknowledged as smokers can then be sent an another text message inviting them to Smoking Cessation clinic for support and advice.

7.2.3 Update personal details

Patients can update their basic information such as change of address, surname or telephone number. The surgery will be notified of any changes to be authorised

7.2.4 Patient Record Access

Allows patients to securely view a summary of their medical history from any PC with a live internet connection – whether in the UK or abroad.

7.2.5 Viewing available doctors

Patients can view available doctors, nurses and other health care professionals at surgery and their availability.

7.2.6 Automated Appointment Reminder

Automated Reminders can helps to decrease the number of DNAs (Did not attend) at GP, by automated appointment reminders. Annual review reminders can be send to patients such Diabetic, Asthma, COPD, CVD, CKD, smear, and immunisation. Appointment reminders texts can be sent to patients at a pre-defined time before the hospital visit, which considerably reduce the number of DNAs.

7.3 Structure of Advance system

The 6.1 explains the structure of SMS application i.e. how patients interacts with their the server at surgery

7.4 Systems Development Life Cycle (SDLC)

To develop Patient care using SMS Application we have used Software Development Life Cycle. In this project we have “Classic Life Cycle Model or water fall model, because waterfall model is the basic model and it is an easy compare to the other systems development life cycle model for software engineering”. It has different aim for each stage of development system. The SDLC method consists of the following phases [34]: From 6.3 the classic life cycle paradigm encompasses the following activities [34]:

7.4.1 System Engineering and Modelling

For the existence of software in any entity system is the basic and very critical requirement. So if the system is not in place, the system should be engineered and put in place. To extract the maximum output, in some cases, the system should be re-engineered and spruced up. Once the ideal system is tuned, the development team studies the software requirement for the system.

7.4.2 Software Requirement Analysis

This phase is also known as feasibility study as we understand or analyses the requirements of the software project. In this phase, the development team visits the customer and analyses their system requirements. They investigate the need for possible software automation in the given system. By the end of this phase, the team furnishes a document that holds the different specific recommendations for the system. The document also includes the personnel assignments, expenses, plan schedule, and goal dates.

7.4.3 Product Perspective

To design and develop a WAP enabled wireless applications that will enhance the feature of mobile device by incorporating the features of a digital diary. The application should be able to get integrated with the existing application vis-à-vis Exchange Server, Outlook Address Book, Lotus etc. The application should be able to start and maintain a minimal WAP session and connect to the data server, query and fetch the required information as submitted by the user. The application should be designed in such a way that it should be inline with the functions of a Hospital.

Product functions

* The main tasks involved in this project are, * Maintaining the databases for surgeries and patients by administrator * Registering through web or manually accordingly. * Getting the services as registered user and non registered user. * Sending SMS and getting prescription, making appointments, getting lab reports, viewing the doctors schedules are the services. * Displaying the Prescription, lab reports, doctors schedule for the login patients.

7.4.4 System Design Phase

In this phase the software’s overall structure is defined. In the software development cycle Analysis stage and Design phases are very important because any problem in the design phase could be very costly to resolve in the later stages of the life cycle due to which developer take more care during this phase. Elements of System Analysis: There are 4 basic elements of System analysis, they are 1. Outputs 2. Inputs: The essential elements of Inputs are bulletAccuracy of data bulletTimeliness bulletProper format bulletEconomy. 3. Files 4. Process

7.4.5 Architectural Design

“This part of document is producing the solution to the problem given in the SRS document. In this design we transform the ideas into detailed implementation description, with the goal of satisfying the software requirements”. The design is having two parts. 1. Conceptual design 2. Technical design 1. Conceptual design In this the software system is this part of document is producing the solution to the problem given in the SRS document. In this stage we transform the ideas into detailed implementation description with the goal of satisfying the software requirements. From 7.1 which structure of advance system the conceptual design has been designed ( 7.4) 2. Technical design This part of document which is Technical Design will describe the structural design which represents the data and program components that are necessary to make a computer-based system. For this proposed system Service Oriented Architecture best suits.

WAP gate way:

7.4.6 Generating Code

In this period, design will be translate into a machine-readable form. Code generation can be accomplished without many problems if the design is performed in a detailed manner. Debuggers, Interpreters, and Compilers are the programming tools which are used to generate the code. Programming languages like Java and Dot Net are used for coding.

7.4.7 Testing

The software program testing begins once the code is generated. Different testing tools and methods are which are available in the market.

7.4.8 Maintenance Of developed system

Once software is delivered to the customer, it will definitely get modify. There are many reasons for the change of the product or software. Changes in system might occur due to some unexpected input values. Software Design phase is concerned with identifying, data streams, specifying relationships with those functions, maintaining a record of design decisions and providing a plan for the implementation stage.

7.4.9 Software Integration and testing

The test and integration phase really begins at project inception and overlaps with analysis, design, coding and unit testing. The software acceptance test will be done concurrently with the development of Software Requirement Specifications. So the net effect of the reviews and documents at strategic points in the SWDLC gives the appearance of a waterfall like process to an SWDLC model.

7.5 UI-Design-Unified Modelling Language

“Unified Modeling Language is used to design Use case, class diagrams and sequential diagrams. UML using object oriented notations has been implemented by the Grady Booch, James Rumbaugh, Ivar Jacobson, and the Rational Software Corporation” [35]. The following are the diagrams which has been design for this project using UML language

7.5.1 Use-case diagrams

Based on 7.1 the has been designed. 7.7 represents the use case for the user where user can perform the following operations: * Login * Find the doctors available * Send the request for medicine or prescription * Checking lab reports * Make appointments * Log out Note: The same operations have been explained using class diagram, sequence and activity diagr

7.6 Data Flow Diagrams

Data flow diagrams of this application are shown below:

Chapter Summary

Advance system and its features are discussed in this chapter. Waterfall Model’s activities have been explained. The structure of advance system with s is discussed in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations. Using dataflow diagrams and ER diagrams application’s operations have been explained. The application database views have been shown.

Chapter 8 Advance System Requirements and Specification

The problems of present system have been discussed in chapter from 3. Problems such as database back up, passwords etc have been discussed. The limitations discussed below are of EMIS system.

8.1 User Characteristics of system

The main users of the system are various hospitals like general, corporate hospitals. To whom the service creation framework facilitates the creation of various business applications like sending SMS system, hospital management through mobiles etc.

8.2 General Constraints

The medical System can run using WINDOWS XP or WINDOWS 2003 professional server.

8.3 Specification Requirements

The specification requirements are divided into two. They are as follows:

8.3.1 External Interface Requirements

User Interface

In this development all functions are completed through web portal and mobile browser.

Hardware Interface

WIFI AND GPRS ENABLED DEVICES: Examples of such devices include PDA (Personal Digital Assistant), Laptop, Mobiles.

Software Interface

DATABASE: We have used SQL Server 2005 for this dissertation to store patient records and staff details [36]. APACHE TOMCAT: It is the Servlet container that is used in the certified Reference Implementation for the Java Server Pages and Java Servlet technologies. The Java Servlet and Java Server Pages specifications are developed by Sun under the Java Community Process [37]. JSP: JSP is designed for mobile phones with more memory and permanent power sources.

Communication Interface

GPRS TECHNOLOGY: “General packet radio service is a service that allows users to send and receive messages through IP based protocol”. This is Packet switched network transmission. The protocol used here is WAP and HTTP.

8.4 Functional Requirements

In this functional capabilities of the system are described. They are as follows: Input Adding departments, doctor’s details, schedules, and lab reports is at the administration side. Registering according to package and then login to use the services available for that package Output Displaying the doctor’s details, prescriptions, lab reports, time schedules etc Displaying all these at the administration side for modifications

8.5 Performance Requirements

The system should send the patients text messages for the prescriptions and it should display the available doctors list provided by the server located in the hospital in mobile interface. Design Constraints It specifies all the constraints imposed on design.

8.6 Hardware Requirements

Pentium Processor : Pentium 4 1.4 Keyboard : 101 Standards RAM : 128 MB CD Drive : 52 Bits Floppy Disk : 1.44 MB Hard Disk : 160 Giga Byte

8.7 Software Requirements

Operating System : Windows 2003 server/XP Server. Front end : WML, JSP Back end : MS SQL Server. Design Tools : Front page 2000 Other Application : Tomcat Web Server/BEA Web Logic Server/Smart Trust Simulator/Open wave SDK 6.2.2 Technologies Used Operating System : Windows XP RAD Tools : Front Page 2000 Web Server : Tomcat Web Server Front End : JSP Database : MS SQL Server. Scripting : WML Scripts Acceptance criteria Before accepting the system the developer must demonstrate that the system works on the course data.

8.8 Other Non-Functional Requirements

SECURITY REQUIREMENTS: Security can be provided during connection, by using authentication process. They are of two types: 1. open system authentication and 2. Shared key authentication. Some of the technologies which I am using this project is explained below: 8.9 About Operating Systems An operating system is defined as “a program which controls the execution of programs and acts as an interface between the user and the computer hardware”. The main reason for developing these operating systems is to get some useful services from this OS. An operating having three objectives or performing three functions [41]: · Convenience · Efficiency · Ability to evolve The hardware and software that are used in providing applications to user can be viewed in a layered, or hierarchical, fashion. End User: “The user of the application is called end user and generally is not concerned with the computer’s architecture. Thus the end user views a computer system in terms of an application”. That application can be expressed in a programming language and is developed by an application programmer [41].

8.10 About Languages used

The following programming languages has been used in this project

8.10.1 Java Server Pages

The language used application is Java, in which JSP are used to design the application. WAP technology for mobile communication is used and Scripting language is Servlets “Java Server Pages (JSP) is developed by Sun Microsystems allow server side development. JSP files are like HTML files only with special Tags consisting of Java source code which provide the dynamic content”[40]. The following 7.1 shows the distinctive Web server where different clients connecting through the Internet to Web server. As shown below the Web server is running on UNIX platform and is the popular tomcat server These technologies were known as Common Gateway Interface server side applications. Active Server Pages allow HTML developers to easily provide dynamic content supported as standard by Microsoft’s free Web Server, Internet Information Server (IIS). Java Server Pages is the equivalent from Sun Microsystems. The following diagram 7.2 shows a web server supports JSP files which is connected to a database [40] Why to use Java Server Pages JSP is simple to learn and in standard and way developers can design web sites and applications quickly. JSP is based on Java which an object-oriented language. JSP offers a strong platform for web development [40]. Reasons to use Java JSPs are Multi-platform By using JavaBeans and EJB Components can be reuse [40] Advantages of Java This is multi platform based as JSP file from one platform can be moved to another platform, web server or JSP Servlet engine see the below 8.3 [40]. Java Server Pages architecture On top of SUN Microsystems’ Servlet technology Java Server Pages are built as shown in below. These Java Server Pages tags contain Java code with JSP file extension .jsp. JSP is first time slower when it fis accessed because first JSP engine parses the file and after parsing Java Servlet source file. After that it compiles the source file into a class file which takes time. After this the compiled Servlet is executed and is as a result returns faster [40].

8.10.2 Wireless Mark up Language

“WML is based on XML, is a content format for devices that implement the WAP specification, such as mobile phones, and preceded the use of other mark up languages now used with WAP, such as XHTML and even standard” [39]. WML is similar to HTML and provides navigational support, inputting data, hyperlinks, text and image presentation, and simple forms and we have used WML in our dissertation [39].

8.11 Introduction to web applications

HTTP is used by the browsers to communicate with the web servers. In place of browser we and develop our own programs using Socket API to communicate with a web server.

8.11.1 TOMCAT

Tomcat home is a directory in which TOMCAT is installed [37]. Ex: C:TomcatTomcat5.0 (most it look like C: jakarta-tomcat-5.0.19/jakartatomcat- 5.0.19 when you extracted zip file to C drive) Starting and Stopping Tomcat [37] To start Tomcat run Tomcat_Homebinstartup.bat To stop Tomcat run Tomcat_Homebinshutdown.bat Tomcat requires the location in which java is installed for this we need to add set

8.12 Wireless Application Protocol

The Wireless Application Protocol was designed to show internet-contents on wireless users, like cell phones. “Wireless Mark-up Language is the language used to create pages which can be displayed in a WAP browser”[38].

8.12.1 WAP Architecture

WAP is an open, worldwide specification which allows mobile phone user’s to access and interacts with information and services instantly [38]. Through handheld devices such as cell phone, the users can access to Internet using WAP. Wireless Application Protocol Gateways acting as a link between the cellular phone world and the Internet [38].

8.12.2 WAP Server

WAP Server is just a normal web server and a WAP gateway-type device built into one. WAP content is servable from any normal web server. While focussing on WAP security, the WAP server can help plug some few holes which are unplugged in the WAP environment [38].

8.12.3 SMS Gateway

Short Messaging Capability in the shortest time SMS – Short Message Service “SMS is the facility which allow user to send and receive text messages from and to mobile phones. The text can include of an alphanumeric characters, words, numbers, or combination”. Every short message can be up to 160 characters in length but new mobile phone allow more that 160 characters these days [38].

Advantages of SMS

* SMS is an inexpensive method of communication. * 160 characters take up as much room as a one-second-voice call. * Messages are delivered immediately when the recipient’s phone is turned on. * Messages get stored and delivered later if the recipient’s phone is not on. * Like e-mail, they can also be reviewed or stored in your phone for as long as you wish.

8.13 Open wave SDK 6.6.6

“This is a Windows-based application that is user can use it to test how your wireless applications work with Open wave Mobile Browser 6.2.2 and Open wave Mobile Messaging client. The SDK features a mobile phone simulator, which includes the same browser code as is embedded in real mobile phones. It also includes sample code and a generic phone configuration file, or “skin,” that represents an idealized mobile phone”.

8.14 Database: The SQL Language

“The SQL language and relational database systems based on it are one of the most important foundation technologies in the computer industry today”. Today, a number of database products support SQL language. We have used SQL language in our project because of it simple structure and security [36].

8.14.1 Database Structure

The SQL1 standard specified a simple structure for the contents of a database, shown in 7.7. Each user of the database has a collection of tables that are owned by that user. Virtually all major DBMS products support this scheme, although some (particularly those focused on special-purpose or embedded applications or personal computer usage) do not support the concept of table ownership. In these systems all of the tables in a database are part of one large collection [36]. Although different brands of SQL-based database management systems provide the same structure within a single database, there is wide variation in how they organize and structure the various databases on a particular computer system. Some brands assume a single, system-wide database that stores all of the data on that system. Other DBMS brands support multiple databases on a single computer, with each database identified by name. Still other DBMS brands support multiple databases within the context of the computer’s directory system [36]. These variations don’t change the way you use SQL to access the data within a database. However, they do affect the way you organize your data—for example do you mix order processing and accounting data in one database or do you divide it into two databases? They also affect the way you initially gain access to the database—for example, if there are multiple databases, you need to tell the DBMS which one you want to use. To illustrate how various DBMS brands deal with these issues, suppose the sample database were expanded to support a payroll and an accounting application, in addition to the order processing tasks it now supports [36].

Chapter Summary

This chapter explains the SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Openwave SDK and its functions are discussed in this chapter.

Chapter 9 Output and Evaluation

In this chapter we are going to discuss about problems associate with EMIS system and few limitations.

9.1 Output Screens

The output screens are as shown and explained below. There are web based application screen shots.

9.2 Database connection and design 9.2.2 Creating Database and tables

Now to create database Open SQL server management

9.3 EMIS System Problems and Limitations

Approximately 5000 GP’s currently using EMIS LV system in the UK. The below are the few problems and limitation associated with it.

9.3.1 System Crash

The system need to be updated time to time, otherwise it leads to system crash or break down. For which special team of people required for maintenance of the system. If system gets break down doctors can not do anything until it gets solved or else later data has to be enter manually.

9.3.2 Smart Cards and Passwords failures

Clinical staff needs to log on to EMIS system using their smart cards for doing prescriptions and GP2GP transfer. If system is not upgraded time to time it doesn’t allow user to logon. If passwords are lost anyone can abuse or swapped it and the system can be absolutely in-operable.

9.3.3 Do not support Latest version of MS Office tools

All the referrals are done using MS Word 93-2003 version, upgrades leads to problems. If you try to upgrade system does not function properly either become too slow or completely stop.

9.3.4 Reboot Requires

All the patient records are saved on main server. Staff accesses the data from network folder. Very frequently it does not allow user to access the files saved on network folder, and then reboot requires.

9.3.5 GP to GP Transfer

Different surgeries use different computer systems which are not inter compatible, due to which transfer patient records does not takes place accordingly. Some of the records are reached proper format and some do not.

9.3.6 Read Codes

The read codes are updated quarterly which makes clinical staff and doctor’s life difficult. Other limitations of read codes are discussed in chapter 5.

9.3 Proposed systems outcomes

The objectives discussed chapter 1 and chapter 7 have been achieved. The below screen shots are some of the objectives achieved in this application. Few of the features of the application are * Text Messaging * Requesting repeat prescription * Patient record access * Automated Appointment Reminder * Viewing available doctors at your surgery

9.3.1 Simulator outputs

Chapter Summary

In this chapter we have discuss about limitations of EMIS system and its problems. Database Views are explained and all the tables associated with this application are discussed. The outputs screens of the SMS applications are designed are shown in this chapter.

Chapter 10


Patient Care Using SMS Application operations will be possible by using WAP technology and all devices having SMS service. It is expected that the organizations buying this Software may tweak and adopt there scripts, for their further implementation. It is believed that the SMS based medical application Software will quicken the latest Soft- Ware technology integrates in companies WAP technology works as a tool to send the request and getting information about medicines and doctors and etc. In this dissertation we have discussed about Patient care using SMS application and its aim, objectives and scope. The existing systems such as manual and online systems are briefly explained in this chapter along with it features and disadvantages. The chapter 2 explains EMIS system and its features. Features of EMIS explained in this chapter with examples, their functionality and requirements. The problems associated with online medical systems with examples are explained such as online medical system such as internet connection, email, prescription; Electronic Patient records and read codes are explained. We have also discussed about Patient Records and how they are managed at General Practices and hospitals. The traditional paper based practices and its limitations have been explained with examples. The paper less practices and its pros have been explained and the reasons why practice should follow this have explained with examples. The advantages and disadvantages of Electronic patient records with s and examples are discussed. EMIS database, i.e. patient database and focuses on its usability and security has been discussed with its structure of database and its solutions. Secure Patient data transfer within the PCT has been explained. Storage Area Network is used by EMIS to store patient records. How the GPs and other Healthcare Professional access patient records has been explained. Advance system and its features are discussed. Waterfall Model’s activities have been explained. The structure of advance system with s is discussed in detail in this chapter. The conceptual and technical design of this project has been briefly explained. UML language is used in this project to represent user and admin operations. SMS system requirements such as Specification requirements, Functional requirements, Performance requirements, and hardware and software requirements are discussed in this project. About operating system and languages used in this projects are discussed in this chapter. Wireless application protocol architecture and WAP server are explained using diagrams. Database requirements and its uses are explained using diagrams. Open wave SDK and its functions are discussed in this chapter.

Future Enhancement

The future enhancement of this project is: this application can be implemented with audio. The features of this application can be enhanced using new future technologies.

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Patient Care. (2017, Jun 26). Retrieved June 25, 2021 , from

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