Standards and Guidelines for Electronic Medical Record Systems in ...

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4.3. System has the capability to receive clinical documentation and notes via a standard MOH HL7 interface. 4.4. System has the capability to capture vital signs data. At minimum, the system collects height, weight, pulse rate, respiratory rate, blood pressure, BMI (calculated), and MUAC for children. 4.5. System has the capability to capture and edit health data regarding the patient’s current health status, including (as applicable): chief complaint, onset and duration of symptoms, physical examination findings, diagnosis, performed/planned laboratory procedure, medications prescribed, patient education, non-drug prescriptions such as exercise and diet plans, and follow-up plans, including dates of next visit. 4.6. System enables the documentation and tracking of referrals between care providers or healthcare organizations. The following information is captured for every referral: reason for referral, date, referring provider and referred-to provider 4.7. System applies security controls to clinical notes to ensure that data cannot be deleted or altered except within the current session and by an authorized user. The only exception to this is that if an entry clerk has made an error transcribing paper clinical notes into the system, a correction may be allowed subsequently by an authorized user. The correction including the original text will be visible to anyone subsequently viewing the notes. 4.8. System supports the capability to collect the minimum data elements defined by the associated clinical practice guidelines, e.g. minimum data elements for HIV care, TB care. H H H H H H 5. Problem Lists 5.1. System creates, maintains and reports all active problems associated with the patient. H 5.2. System provides a problem status (active, inactive) for each shown problem. H 5.3. When capturing problem information, the system captures at minimum: H diagnosis/problem date(s), and the severity of illness. 5.4. System provides the ability to maintain a coded list of problems/diagnoses. H 6. Clinical Practice Guidelines (CPG) 6.1. System includes and maintains evidence-based Clinical Guidelines (for diseases such as H HIV, TB, and Malaria) published and maintained by credible sources such as the MOH, NASCOP, Malaria and TB program. The guidelines incorporate alerts and reminders. 6.2. System includes decision support prompts to support clinical guidelines and protocols. H 6.3. System has the capability to allow revision of clinical practice guidelines. H Standards and Guidelines for Electronic Medical Records Systems in Kenya 23
6.4. System allows the provider or other authorized user to override any or all parts of the guideline. System is able to collect exceptions for NOT following the guidelines including reasons for overriding and details of provider. H 7. Prevention 7.1. System has the capability to display health prevention prompts on the summary L display. The prompts must be dynamic and take into account sex, age, and chronic conditions. 7.2. System includes a patient tracking and reminder capability (for patient follow-up). H 7.3. System includes the incorporation of immunization protocols: H 7.3.1. For children as per Kenya Extended Programme for Immunization (KEPI) schedule. H 7.3.2. Captures and shows immunization due dates. H 8. Patient Education 8.1. System has the capability to create, review, update, and delete patient education plans L and materials as defined by disease programs such as NASCOP, The Division of Leprosy, TB and Lung Disease (DLTLD), and Malaria. 8.2. System has the capability to create, review, update, or delete patient education materials. L 9. Results 9.1. System has the capability to manage, and present current and historical test results to H appropriate clinical personnel for review, with the ability to filter and compare results with previous tests. 9.2. System is capable of receiving test results from laboratory and radiology (imaging results). H 9.3. Laboratory and radiology results are received via a standard MOH HL7 interface. L 9.4. When displaying results, the system, at a minimum, displays the patient name, date and H time of order, and date and time results were last updated. 9.5. System uses visual cues to highlight abnormal results. H 9.6. System allows the provider to comment on received lab results, or allows data entry H personnel to capture comments on results. 10. Medication and Immunization Management 10.1. System creates prescriptions or other medication orders with detail adequate for correct filling and administration, and captures the identity of the prescriber. At minimum, system should capture: the name of the drug, the dose and frequency of administration. H Standards and Guidelines for Electronic Medical Records Systems in Kenya 24
Page 1 and 2: Ministry of Medical Services Minist
Page 4 and 5: Acknowledgements This initial publi
Page 6 and 7: Change Management Process .........
Page 8 and 9: Architecture Enterprise Architectur
Page 10 and 11: and without the ability to share pa
Page 12 and 13: Purpose of this document This docum
Page 14 and 15: Globally, several organizations hav
Page 16 and 17: will be reviewed by the technical w
Page 18 and 19: Section Introduction The section de
Page 20 and 21: The above listed documentation requ
Page 22 and 23: Clinical Decision Support This refe
Page 24 and 25: H = Requirements. These items tare
Page 28 and 29: 10.2. System has the capability of
Page 30 and 31: 16. Children’s Health 16.1. Syste
Page 32 and 33: The recommendations in this section
Page 34 and 35: Backup Backup is the procedure for
Page 36 and 37: Case Example: Building an EMR syste
Page 38 and 39: o Date medically eligible to start
Page 40 and 41: o Height o Blood pressure o BMI Whe
Page 42 and 43: · Form 711 - Cross-sectional quart
Page 44 and 45: Section Introduction Within the hea
Page 46 and 47: Data Transmission Protocols There a
Page 48 and 49: i. EMR systems ii. Patient Identifi
Page 50 and 51: Summary Primary Actor Secondary Act
Page 52 and 53: Use Case Title Summary Primary Acto
Page 54 and 55: Business Rules Pre-condition(s) Cor
Page 56 and 57: Section Introduction The implementa
Page 58 and 59: Requirements 1. Servers and worksta
Page 60 and 61: informatics skills in order to effe
Page 62 and 63: competencies will be of greater use
Page 64 and 65: esponsible for utilizing the inform
Page 66 and 67: expertise, this cadre is also likel
Page 68 and 69: Data Quality and Confidentiality Id
Page 70 and 71: Demonstrate use of mouse functions
Page 72 and 73: Health facility management plays a
Page 74 and 75: A locally stored backup log should
Page 76 and 77:
· User related issues could also b
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Upgrade Scheduling The EMR system n
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Monitoring is an ongoing, continuou
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down these alerts on a notification
Page 84 and 85:
Hardware requirements Other infrast
Page 86 and 87:
System Costs, Ownership and Sustain
Page 88 and 89:
their health records upon request o
Page 90 and 91:
A. Sample EMR Implementation Plan E
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deployment of the EMR (i.e. change
Page 94 and 95:
C. EMR Readiness Assessment Checkli
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Is there a computer at each point o
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D. Security Policy Template Documen
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1.9 Employees shall not access, sto
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E. Information Asset Inventory Name
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G. Sample Service Level Agreement T
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• Determine appropriate incident
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H. Sample EMR Monitoring and Evalua
Page 110 and 111:
Strongly agree Agree Disagree Stron
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Functional areas Attributes Compone
Page 114 and 115:
Functional areas Attributes Compone
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