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TRANSCRIPT
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Summer Training
In
Fresco Informatics
(April 9 - May 31, 2012)
Requirement Gathering and Functional Requirement specifications for
Physiotherapy specific EHR
Dr. Manish Jain (PT)
Post-graduate Programme in Hospital & Health Management,
New Delhi
2011-13
International Institute of Health Management Research, New Delhi
2012
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ACKNOWLEDGEMENT
I owe a great many things to a great many people who helped me and supported me during
the summer training.
I wish to express my deep sense of gratitude to Mr. Ahimanikya Satapathy, Founder & CEO,
for giving me the opportunity to do my Summer Training at Fresco Informatics. He was very
kind enough to spare his valuable time and provide me suggestions regarding the study to be
undertaken.
I hereby take this opportunity to thank, Mrs. Asha Satapathy, Founder, Fresco Informatics for
her valuable guidance & advice. Her willingness to motivate me contributed tremendously to
my project.
My special thanks to Business Analyst Saurabh Leekha and Dr. Shirin Saini for their
guidance, support, interest, involvement and encouragement and for being a source of
inspiration and timely guidance during the training period.
My sincere acknowledgement goes to Professor Indrajit Bhattacharya for his kind
assistance and support throughout my summer training.
Finally, I would like to show my greatest appreciation to my colleagues and family for their
tremendous support and cooperation while working on this project.
The guidance and support received from all the members who contributed was vital for the
success of the project. I am grateful to them for their constant support and guidance.
Thank You
Dr. Manish Jain (PT)
PGDHHM, IIHMR, New Delhi
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CERIFICATE
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FEEDBACK FORM
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TABLE OF CONTENTS
S. No. CONTENT Page
Number
A Acronyms 7
B Executive Summary 9
C Introduction 11
Organization Profile 10
About the project 12
Project Objectives 13
Requirement gathering 15
Background of project development 16
Software Development Life Cycle (SDLC) 17
Software Development Model at Fresco 18
Programming Language used at Fresco 20
D Methodology and Tools used 23
Methodology Used 23
Steps followed at Fresco 24
Tools Used 25
Stages Covered 26
E Observations 29
Workflow 29
Consultation Process 31
F Findings and Recommendations 33
Findings 33
Recommendations 37
G Conclusion 41
H Case Study 42
I References 52
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S. No. CONTENT Page
Number
J List of Figures
Figure 1: Scrum Model of Software Development 18
Figure 2: Workflow of Consultation Process at a
Physiotherapy Centre 30
Figure 3: Number of Patients, Physiotherapists and staff 33
Figure 4: Time Spent for Assessment and Treatment 34
Figure 5: Conducting Assessment 34
Figure 6: Working with Computer & Internet 35
Figure 7: Willing to adopt a Computerized System 35
Figure 8: Features they want in the system 36
Figure 9: Snapshot of Login Screen Specification 37
Figure 10: Snapshot of Appointment Screen Specification 38
Figure 11: Snapshot of Physiotherapist profile Specifications 39
Figure 12: Snapshots of the Consultation Module Specifications 40
K Annexure 54
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ACRONYMS/ ABBREVIATIONS
EHR: Electronic Health Record
EPR: Electronic Patient Record
EMR: Electronic Medical Record
SDLC: Software Development Life Cycle
SOAP: Subjective Objective Assessment Plan
SOA: Service Oriented Architecture
WOA: Web Oriented Architecture
SODA: Service Oriented Development Architecture
ESB: Enterprise Service Bus
MPI: Message Passing Interface
HMS: Hospital Management System
CDLL: Common Development and Distribution License
GPL: General Public License
SDO: Standard Development Organization
ISO: International Standards Organization
OSI: Open Systems Interconnection
HL7: Health Level Seven
CCD: Continuity of Care Document
CDA: Clinical Document Architecture
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RIM: Reference Information Model
SNOMED: Systematized Nomenclature of Medicine
LOINC: Logical Observation Identifiers Names and Codes
CCR: Continuity of Care Record
JVM: Java Virtual Machine
WORA: Write Once, Run Anywhere
JRE: Java Runtime Environment
API: Application Programming Interface
GUI: Graphic User Interface
HTML: Hypertext Markup Language
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EXECUTIVE SUMMARY
Indian healthcare enterprises are beginning to embark on their ―digitization cycle and have
a long way to go before they can match the level in the developed countries. Integration of
Information Technology is not only useful for only large hospital setups but also other
clinical setups like physiotherapy clinics which play an important role in healthcare sector.
An electronic health record (EHR) is an evolving concept defined as a systematic
collection of electronic health information about individual patients or populations. It is a
record in digital format that is theoretically capable of being shared across different health
care settings. In some cases this sharing can occur by way of network-connected enterprise-
wide information systems and other information networks or exchanges. EHRs may include a
range of data, including demographics, medical history, medication and allergies,
immunization status, laboratory test results, radiology images, vital signs, personal stats like
age and weight, and billing information.
The terms EHR, EPR (electronic patient record) and EMR (electronic medical record) are
often used interchangeably, although differences between them can be defined. The EMR
can, for example, be defined as the patient record created in hospitals and ambulatory
environments, and which can serve as a data source for the EHR. It is important to note that
an EHR is generated and maintained within an institution, such as a hospital, integrated
delivery network, clinic, or physician office, to give patients, physicians and other health care
providers, employers, and payers or insurers access to a patient's medical records across
facilities.
Objectives
1. Gather requirements for a consultation module for a Physiotherapy specific EHR.
2. On the basis of the gathered requirements develop the Functional documents module
which describes the features to be included in the consultation module.
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Project Plan
1. Understanding the complete requirements through requirement gathering process
2. Assessing and understanding the existing workflow
3. Finding the Gaps and areas of improvement
4. Preparation of functional specification documents
Conclusion
There is no magical wand, no one answer, no perfect approach method or technique to
requirements gathering. Developing a good requirements document is about giving your
project the best chance of success. To do so, you must reduce the risk of common mistakes
that arise from a lack of communication or understanding. Keep this in mind as you gather
your requirements, and the documentation — and project as a whole — will have the best
chance of success.
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INTRODUCTION
Organization Profile
Fresco Informatics provides extensive range of enterprise computing solutions, consulting
services and technology products for the ever-changing world of business. The goal is to
exceed the expectations of every client by offering outstanding customer service, increased
flexibility, and greater value, thus optimizing system functionality and improving operation
efficiency.
Fresco Informatics associates are distinguished by their functional and technical expertise
combined with their hands-on experience, thereby ensuring that the clients receive the most
effective and professional service. Fresco Informatics brings in a fresh and innovative
approach to software products and services. Software systems are agile and hence
requirements continue to evolve throughout the life of the software system. Need of the hour
is an adaptive and collaborative approach to software development. Hence Fresco chooses to
follow agile practices like scrum.
Fresco team experts in the Open source and closed source enterprise technologies and
products build over SOA, WOA and SODA. The team has contributed significantly to
various open source initiatives such as Project Mural, Open ESB and Glassfish.
Open ESB is a Java based open source enterprise service bus. Open ESB can be used as a
platform for both Enterprise Application Integration and SOA. Open ESB is built on open
standards. Oracle, after acquiring Sun Microsystems, has cancelled corporate sponsorship of
this project. Community development on Open ESB continues, organized
by LogiCoy and Pymma Consulting.
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Glassfish is an open-source application server project started by Sun Microsystems for
the Java EE platform and now sponsored by Oracle Corporation. The supported version is
called Oracle Glassfish Server. Glassfish is free software, dual-licensed under two free
software licenses: the Common Development and Distribution License (CDDL) and
the GNU General Public License (GPL) with the class path exception.
Project Mural is an attempt to build an ecosystem to solve such data management problems.
Leveraging NetBeans, Glassfish and Open ESB communities, Project Mural aims to provide
a platform to power various transformational initiatives like:
Customer Data Integration
Product Information Management
Building data services for SOA Initiatives
Powering enterprise mashups
Fresco EHR and MPI product suites empower and enable physician practices to provide
effective and integrated care delivery. Fresco Informatics delivers the next generation of
clinical care information systems solutions built upon best-of-breed and best-in-class
healthcare software. The Fresco Informatics solution creates a foundation for heterogeneous
communication amongst healthcare providers throughout the hospital as well as all
caregivers within the Hospital Network.
About the Project
The project was concerning the development of a Physiotherapy specific EHR. My role
involved finding the requirements through the process of requirement gathering from
prospective clients and preparation of functional requirement document for the development
of consultation module that can facilitate workflow at any physiotherapy clinic and helps to
increase the efficiency and quality of procedures to achieve high patient satisfaction by
reducing the patient waiting time and providing higher quality of patient care.
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What is Physiotherapy?
Physiotherapy means physiotherapeutic system of medicine which includes examination,
treatment, advice and instructions to any person preparatory to or for the purpose of or in
connection with movement dysfunction, bodily malfunction, physical disorder, disability,
healing and pain from trauma and disease, physical and mental conditions using physical
agents including exercise, mobilization, manipulation, mechanical and electrotherapy,
activity and devices or diagnosis, treatment and prevention.
There are various specialties covered under it like:
1. Orthopedic
2. Neurological
3. Sports
4. Cardiovascular & Pulmonary
5. Pediatric
6. Geriatric
7. Women Health
8. Many more
Project Objectives
1. It will help the Physiotherapy clinic to have a whole range of data in comprehensive
form.
2. A good Functional Requirement Document clearly states the objective of the project
and defines its scope, to clarify what the project does and does not cover.
Rationale
To enhance health care delivery quality, to facilitate clinical data exchange and retrieval and
maintain confidentiality of the patient records and reduce patient waiting time and thus
enhance the patient satisfaction.
HL7 is an ANSI-accredited Standard Development Organization (SDO) operating in the
healthcare arena. • It is a non-profit organization made up of volunteers – providers,
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customers, vendors, government, etc. HL7 is an acronym for Health Level Seven – Seven
represents the highest, or “application,” level of the International Standards Organization
(ISO) communications model for Open Systems Interconnection (OSI) networks.
HL7 provides standards for interoperability that improve care delivery, optimize workflow,
reduce ambiguity and enhance knowledge transfer among all of our stakeholders, including
healthcare providers, government agencies, the vendor community, fellow SDOs and
patients. In all of their processes they exhibit timeliness, scientific rigor and technical
expertise without compromising transparency, accountability, practicality, or willingness to
put the needs of stakeholders first.
The Continuity of Care Document (CCD) specification is an XML-based markup standard
intended to specify the encoding, structure and semantics of a patient summary clinical
document for exchange.
The CCD specification is a constraint on the HL7 Clinical Document Architecture (CDA)
standard. The CDA specifies that the content of the document consists of a mandatory textual
part (which ensures human interpretation of the document contents) and optional structured
parts (for software processing). The structured part is based on the HL7 Reference
Information Model (RIM) and provides a framework for referring to concepts from coding
systems such as from SNOMED and LOINC.
The patient summary contains a core data set of the most relevant administrative,
demographic, and clinical information facts about a patient's healthcare, covering one or
more healthcare encounters. It provides a means for one healthcare practitioner, system, or
setting to aggregate all of the pertinent data about a patient and forward it to another
practitioner, system, or setting to support the continuity of care. Its primary use case is to
provide a snapshot in time containing the pertinent clinical, demographic, and administrative
data for a specific patient.
The CCR (Continuity of Care Record) standard is a patient health summary standard. It is
a way to create flexible documents that contain the most relevant and timely core health
information about a patient, and to send these electronically from one caregiver to another. It
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contains various sections such as patient demographics, insurance information, diagnoses and
problem list, medications, allergies and care plan. These represent a "snapshot" of a patient's
health data that can be useful or possibly lifesaving, if available at the time of clinical
encounter. The ASTM CCR standard is designed to permit easy creation by a physician using
an electronic health record (EHR) system at the end of an encounter.
Because it is expressed in the standard data interchange language known as XML, a CCR can
potentially be created, read and interpreted by any EHR or EMR software application. A
CCR can also be exported in other formats, such as PDF and Office Open XML (Microsoft
Word 2007 format).
Requirement gathering
Getting the requirements right – and getting the right requirements – can mean the difference
between a successful project – one that satisfies the needs of its users and is delivered on-
time and on-budget – and one that fails. It should come as no surprise that effective
requirements gathering involves much more than asking business users what they want and
need. It is a complex process that involves users and system designers in a collaborative
effort that explores both functional requirements and the new possibilities that technology
offers.
The great challenge of the requirements process is finding a way to uncover and capture the
needs of the business and communicate those needs to a software development team in a
language and style that facilitates the software design process, producing a result that
precisely solves the business problem. All too often the requirements process begins with a
few key questions about the business need, and then quickly moves to discussions about parts
of the technology solution.
Requirement gathering is usually the first part of any software product. This stage starts
while thinking about developing software. This phase, involves meeting customers or
prospective customers, analyzing market requirements and features that are in demand. In
this stage, people who have direct contact with the customers do most of the work. These
people talk to customers & try to understand what they need. A comprehensive
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understanding of the customer‘s needs & writing down the features of the proposed software
are the keys to success in this phase.
Advantages
It provides:
1. A succinct requirement specification for management purpose.
2. A statement of key objectives-a cardinal point specification”.
3. A description of the environment in which the system will work.
4. Background information and references to other relevant material.
5. Information on various design constraints.
Types of requirement gathering
1. Shadowing- Observing the end user and understanding about the manual process of
how they are doing in their environment.
2. Interviewing- It includes interviewing the end user or business owner with a set of
questionnaire.
3. Focus group- It involves involving everyone in a meeting to discuss on requirements.
4. Survey- It involves conducting a survey with a set of questions and options & set it to
the end-user or clients and analyzes the information from it.
5. User instruction- One has to do the work the end-user is doing and follow his
instructions to complete the task.
6. Prototyping- Create a prototype of requirement or information in the form of photos
or physical things.
Background of the project/project development
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Software development is a complicated process comprising many stages. Each stage requires
a lot of paperwork and documentation in addition to the development and planning process.
The term "software development" may be used to refer to the activity of computer
programming, which is the process of writing and maintaining the source code, but in a
broader sense of the term it includes all that is involved between the conception of the
desired software through to the final manifestation of the software, ideally in a planned and
structured process.
Any software which needs to be developed irrespective of the purpose whether for clinical or
administrative or programming purpose goes through the same set of steps or life cycle
which is grouped as software development life cycle.
Software development lifecycle (SDLC)
The software development life cycle (SDLC) can be considered to be the oldest formalized
methodology for building information systems. The main idea of the SDLC has been "to
pursue the development of information systems in a very deliberate, structured and
methodical way, requiring each stage of the life cycle from inception of the idea to delivery
of the final system, to be carried out in rigidly and sequentially within the context of the
framework being applied.
The software development life cycle, or development process, is a structure imposed on the
development of a software product. It typically covers all aspects of the development,
starting from the identification (capture) of the customer‘s (or end user‘s) requirements,
through the implementation of the code, to product deployment and maintenance of the
system in the field. A software development methodology is a framework that is used to
structure, plan, and control the process of developing an information system - this includes
the pre-definition of specific deliverables and artifacts that are created and completed by a
project team to develop or maintain an application.
Each software development project has to go through the following stages:
1. Requirement gathering
2. Writing functional specifications
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3. Creating architecture and design documents
4. Implementation and coding
5. Testing and quality assurance
6. Software release
7. Documentation
8. Support and new features
There may be many additional steps and stages depending upon the nature of the software
product. My project covered the initial part or stages of the software development life cycle.
Software Development Model used at Fresco Informatics
The Software Development Method which is being used at Fresco Informatics is
scrum which is an iterative and incremental agile software development method for
managing software projects and product or application development.
Figure 1: Scrum Model of Software Development
Scrum contains sets of methods and predefined roles. The main roles in Scrum are:
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1. The "Scrum Master", who ensures the process is followed, removes impediments, and
protects the Development Team from disruption
2. The "Product Owner", who represents the stakeholders and the business
3. The "Development Team", a cross-functional, self-organizing team who do the actual
analysis, design, implementation, testing, etc.
Sprint
A sprint is the basic unit of development in Scrum. Sprints last between one week and one
month, and are a "time boxed" (i.e. restricted to a specific duration) effort of a constant
length.
Each sprint is preceded by a planning meeting, where the tasks for the sprint are identified
and an estimated commitment for the sprint goal is made, and followed by a review or
retrospective meeting, where the progress is reviewed and lessons for the next sprint are
identified.
During each sprint, the team creates finished portions of a product. The set of features that go
into a sprint come from the product backlog, which is a prioritized list of requirements.
Which backlog items go into the sprint is determined during the sprint planning meeting.
During this meeting, the Product Owner informs the team of the items in the product backlog
that he or she wants completed (the ones with the highest priority). The team then determines
how much of this they can commit to complete during the next sprint, and records this in the
sprint backlog. During a sprint, no one is allowed to change the sprint backlog, which means
that the requirements are frozen for that sprint. Development is time boxed such that the
sprint must end on time; if requirements are not completed for any reason they are left out
and returned to the product backlog. After a sprint is completed, the team demonstrates how
to use the software.
Scrum enables the creation of self-organizing teams by encouraging co-location of all team
members, and verbal communication between all team members and disciplines in the
project.
A key principle of Scrum is its recognition that during a project the customers can change
their minds about what they want and need (often called requirements churn), and that
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unpredicted challenges cannot be easily addressed in a traditional predictive or planned
manner. As such, Scrum adopts an empirical approach—accepting that the problem cannot
be fully understood or defined, focusing instead on maximizing the team’s ability to deliver
quickly and respond to emerging requirements.
Like other agile development methodologies, Scrum can be implemented through a wide
range of tools. Many companies use universal tools, such as spreadsheets to build and
maintain artifacts such as the sprint backlog. There are also open-source and proprietary
packages dedicated to management of products under the Scrum process. Other organizations
implement Scrum without the use of any tools, and maintain their artifacts in hard-copy
forms such as paper, whiteboards, and sticky notes.
Programming Language used at Fresco Informatics
The programming language used at Fresco Informatics is JAVA. Java is a programming
language originally developed by James Gosling at Sun Microsystems (which has
since merged into Oracle Corporation) and released in 1995 as a core component of Sun
Microsystems' Java platform. Java applications are typically compiled to byte code (class
file) that can run on any Java Virtual Machine (JVM) regardless of computer architecture.
Java is a general-purpose, concurrent, class-based, object-oriented language that is
specifically designed to have as few implementation dependencies as possible. It is intended
to let application developers "write once, run anywhere" (WORA), meaning that code that
runs on one platform does not need to be recompiled to run on another. Java is currently one
of the most popular programming languages in use, particularly for client-server web
applications, with a reported 10 million users.
One characteristic of Java is portability, which means that computer programs written in the
Java language must run similarly on any hardware/operating-system platform. This is
achieved by compiling the Java language code to an intermediate representation called Java
byte code, instead of directly to platform-specific machine code. Java byte code instructions
are analogous to machine code, but are intended to be interpreted by a virtual machine (VM)
written specifically for the host hardware. End-users commonly use a Java Runtime
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Environment (JRE) installed on their own machine for standalone Java applications, or in a
Web browser for Java applets.
A Java virtual machine is software that is implemented on virtual and non-virtual hardware
and on standard operating systems. A JVM provides an environment in which Java byte code
can be executed, enabling such features as automated exception handling, which
provides root-cause debugging information for every software error (exception), independent
of the source code. A JVM is distributed along with a set of standard class libraries that
implement the Java application programming interface (API). Appropriate APIs bundled
together with JVM form the Java Runtime Environment (JRE).
JVMs are available for many hardware and software platforms. The use of the same byte
code for all JVMs on all platforms allows Java to be described as a write once, run
anywhere programming language, versus write once, compile anywhere, which describes
cross-platform compiled languages. Thus, the JVM is a crucial component of the Java
platform.
The syntax of Java is largely derived from C++. Unlike C++, which combines the syntax for
structured, generic, and object-oriented programming, Java was built almost exclusively as
an object-oriented language. All code is written inside a class, and everything is an object,
with the exception of the primitive data types (integers, floating-point numbers, Boolean
values, and characters), which are not classes for performance reasons.
Unlike C++, Java does not support operator overloading or multiple inheritance for classes.
This simplifies the language and aids in preventing potential errors and anti-pattern design.
Java uses similar commenting methods to C++. There are three different styles of comments:
a single line style marked with two slashes (//), a multiple line style opened with /* and
closed with*/, and the Javadoc commenting style opened with /** and closed with */. The
Javadoc style of commenting allows the user to run the Javadoc executable to compile
documentation for the program.
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Here is an example of JAVA program code for a sentence such as “Development of Doc
Engage”:
public class DocApp{
public static void main(String args[]){
System.out.println("Development of Doc Engage");
}
}
The Graphic User Interface (GUI) being used at Fresco Informatics is HTML5. HTML5 is
a markup language for structuring and presenting content for the World Wide Web, and is a
core technology of the Internet originally proposed by Opera Software. Its core aims have
been to improve the language with support for the latest multimedia while keeping it easily
readable by humans and consistently understood by computers and devices (web
browsers, parsers, etc.). HTML5 is intended to subsume not only HTML 4, but XHTML 1
and DOM Level 2 HTML as well.
Following its immediate predecessors HTML 4.01 and XHTML 1.1, HTML5 is a response to
the observation that the HTML and XHTML in common use on the World Wide Web are a
mixture of features introduced by various specifications, along with those introduced by
software products such as web browsers, those established by common practice, and the
many syntax errors in existing web documents. It is also an attempt to define a single markup
language that can be written in either HTML or XHTML syntax. It includes detailed
processing models to encourage more interoperable implementations; it extends, improves
and rationalizes the markup available for documents, and introduces markup and application
programming interfaces (APIs) for complex web applications.
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METHODOLOGY AND TOOLS USED
Study Type- Questionnaire based Study
Sample size- 50 Respondents
Sample included- Working Physiotherapists
Method Used- Survey and Interviewing individuals
Data Type- Primary
Tools Used for Functional specifications- MS Word, and Microsoft Visio
Tool Used for Evaluation of Responses- SPSS 16.0
Requirement gathering for the Physiotherapy Specific EHR involved conducting a survey
and visit to a renowned Physiotherapy centre in Bangalore, Karnataka. The survey conducted
was an online survey which was a semi structured one to get an idea of the features to be
included in the EHR for physiotherapists. The visit to the physiotherapy centre involved
understanding the current workflow and features of assessment of patients done by
physiotherapists over there along with interview of the physiotherapists working over there.
The studied involved a sample of 50 respondents which included currently practicing
physiotherapists out of which 45 were from the online survey and 5 were from the visit to the
physiotherapy centre.
The requirement gathering tools which I used were survey and interviews.
After carrying out the above procedures I did a gap analysis of existing features of the
assessment procedure being followed by physiotherapists and found out the features which
should be included in the EHR. According to the gap founds I recommended the features
required in the EHR for Physiotherapists.
These features were listed down in some specific formats called the Functional Documents
that can be understood by the technical team (Software Engineers) while developing the
EHR. The tools used to prepare the Functional documents were Microsoft word and
Microsoft Visio.
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Steps followed at Fresco Informatics
It begins by leading a meeting session to capture high-level business goals and project vision.
IT staff and business users/analyst participate. Business goals and project vision are the
guideposts of the requirements process. One cannot expect to deliver the right solution at the
right time if they do not know the vision and goals of the solution.
Steps involved in development of software
Preliminary investigation or analysis
Specification and requirement analysis
Design or architecture
Development or coding
Testing and documentation
Implementation or deployment
Maintenance
Steps covered by me-
1. Preliminary investigation or analysis - This is the task of extracting the
requirements from users and gauging the feasibility of the project. Project sponsors
usually know what they want but often have incomplete, ambiguous or contradictory
requirements. It is the job of software developers and project managers to steer them
in the right direction and to clarify the requirements. Upper management, both in it
and the sponsoring department, should determine if the project has business value to
the organization and if there are sufficient resources to complete the project as
requested.
2. Specification and requirement analysis - This step can vary a lot depending on the
formality, size, and scope of the project and the methodology used in an organization.
In general, it involves taking the requirements and describing them in a way
meaningful to programmers. In your average business application this usually is a
mapping between the user requirements and a description of the functionality to be
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coded into a program, such as a screen that displays current inventory or a report that
has this month's sales figures.
Tools Used
1. Microsoft Word
Microsoft Word is a commercial word processor designed by Microsoft. It was first released
in 1983 under the name Multi-Tool Word for Xenix systems. Subsequent versions were later
written for several other platforms including IBM PCs running DOS (1983), the Apple
Macintosh (1984), the AT&T UNIX PC (1985), Atari ST (1986), SCO UNIX, OS/2, and
Microsoft Windows (1989). It is a component of the Microsoft Office software system; it is
also sold as a standalone product and included in Microsoft Works Suite. The current
versions are Microsoft Word 2010 for Windows and 2011 for Mac.
Microsoft word was used to make a detailed Requirement Document describing the each
feature for what it‘ll be used, so that it can be well and clearly understood by the technical
team.
2. Microsoft Visio
Microsoft Visio (formerly known as Microsoft Office Visio), is a commercial diagramming
program for Microsoft Windows that uses vector graphics to create diagrams. Microsoft
Visio is a powerful drawing and diagramming application. It allows the user to create a
variety of diagrams and technical drawings either from scratch or with the aid of templates.
By using a visual format as opposed to relying on words and numbers, complex information
can be communicated effectively in a clear and concise fashion to the target audience. As a
result, understanding is enhanced and outcomes are improved.
Once an individual has learned how to use Microsoft Visio software, their skills can be put to
use in a variety of ways. For example, in a business environment, Microsoft Visio can be
used to display workflow diagrams and business processes. Organization charts can be used
by HR managers to illustrate the position of employees within a company or project
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managers can create timelines to visualize how a particular task is progressing. Financial
planners can analyze market trends using charts and graphs or IT professionals can use
network diagrams to assist in the creation of complex systems. Building plans can be
designed to illustrate the office floor plan, the layout of security systems and emergency exit
routes. Furthermore, Microsoft Visio can also have applications in the home environment.
3. SPSS 16.0
SPSS (Statistical Package for the Social Sciences) was released in its first version in 1968.
SPSS is among the most widely used programs for statistical analysis in social science. It is
used by market researchers, health researchers, survey companies, government, education
researchers, marketing organizations and others. In addition to statistical analysis, data
management (case selection, file reshaping, creating derived data) and data documentation
(a metadata dictionary is stored in the data file) are features of the base software.
In SPSS frequency count was used to analyze the responses received from the survey
conducted among working physiotherapists.
Stages covered at Fresco Informatics
The steps of software development which were covered by me at Fresco Informatics are:
1. Preliminary investigation or analysis
2. Specification and requirement analysis
At Fresco Informatics the above mentioned steps were covered in two major stages:
1. Requirement gathering & gap analysis (Both steps preliminary investigation and
requirement gathering was covered under this step)
This phase is actually a base for the whole development effort. If the base is not laid
correctly, the product will not find a place in the market. If you develop a very good software
product which is not required in the market, it does not matter how well you build it.
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Requirements gathering techniques provide project team members with a choice of methods
for eliciting needs or requirements from stakeholders and for validating requirements with
stakeholders. Certain techniques are appropriate in gathering stakeholder needs, while other
techniques are most helpful in defining high-level and detailed requirements, or validating
detailed requirements with the stakeholders.
This phase was very important for the development of physiotherapy EHR. It included the
conducting survey among working physiotherapists, visit to a physiotherapy centre and using
the various techniques of requirement gathering process viz. surveys, interviewing and
prototyping for understanding the process of assessment and assessing the requirements and
features that could be included in the EHR.
Gap analysis
In business and economics, gap analysis is a tool that helps companies compares actual
performance with potential performance. At its core are two questions: "where are we?" and
"where do we want to be?. I studied the existing workflow of patient assessment by
physiotherapists and found the Gaps, listed them down that we can add the features as per the
requirement of the patient assessment recording that can be fulfilled by Physiotherapy EHR
that we are planning to develop. This reveals areas that can be improved and properly
utilized. Gap analysis involves determining, documenting, and approving the variance
between business requirements and current capabilities
This stage of requirement gathering and gap analysis included a one week study at the day
care centre which involved observational and analytical study with the help of questioners.
2. Documentation of functional requirements (This included the specification of the
requirements)
After understanding the requirements of the prospective client and the process of patient
assessment the functional requirements were interpreted and written so that it can be
conveyed to and understood by the technical team.
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Discussing the many ways in which requirements can be gathered can end up in a heated and
impractical debate. The short answer is that you should gather requirements using whichever
method works for you. Whether you prefer a written document, screen diagrams, prototyping
or use cases the most important outcome is that the people who need to understand the
requirements can do so. If the people that form the project team (client, stakeholders,
designers, developers) are happy with the format, that‘s half the battle won.
Functional specifications may consist of one or more documents. Functional specification
documents show the behavior or functionality of a software product on an abstract level.
Assuming the product is a black box, the functional specifications define its input/output
behavior. Functional specifications are based upon the product requirements documentation
put forward by people who have contact with the end-user of the product or the customers.
The art of writing requirements takes great skill and, like writing code, the end result is
usually cleaner and more consistent if you have understood and interpreted or conveyed the
requirements of the software in an eligible way to the technical team. It‘s a matter of
balancing the need for a thorough understanding of the project domain (i.e. the client‘s
business) against understanding the process of software development.
During this phase the requirements we got by visiting the day care center were documented
into certain formats that can be well understood by the technical team. The formats
included:-
A detailed functional document in word format mentioning the functional
specifications and technical complexity of a feature.
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OBSERVATIONS
After conducting the requirement gathering process, the following observations and findings
were made:
Workflow
It was found that the workflow at any physiotherapy setup involves a particular set of
procedures once the patient comes to the clinic for the treatment:
Patient arrives at the clinic and comes to the front office desk
The patient undergoes registration
Patient is attended by the physiotherapist
Patient undergoes the process of consultation where his assessment is done under the
SOAP note plan
The treatment protocol of the patient is decided
The patient undergoes treatment
Treatment protocol of the patient is recorded in the SOAP note
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Figure 2: Workflow of Consultation Process at a Physiotherapy Centre
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Consultation Process
The consultation process of a patient by a physiotherapist is done under the SOAP note
which is divided into 4 parts:
Subjective
Objective
Assessment/ Analysis
Plan
Subjective
The subjective part of the SOAP note is where you write what your patient has to say about
his or her current condition. Initially is the patient's Chief Complaint, or CC. This is a very
brief statement of the patient (quoted) as to the purpose of the office visit or hospitalization.
If this is the first time a physiotherapist is seeing a patient, he will take a History of Present
Illness, or HPI. This describes the patient's current condition in narrative form. The history or
states of experienced symptoms are recorded in the patient's own words. It will include all
pertinent and negative symptoms under review of body systems. Pertinent medical history,
family history, and social history, along with any treatment taken, is also recorded.
Subsequent visits for the same problem briefly summarize the History of Present Illness
(HPI), treatments, outcomes and follow-ups.
Objective
The "objective" part includes all the measurements that you've obtained from your client.
This includes features like vital signs, manual muscle testing measurements, joint range of
motion measurements, etc .
The specific physiotherapy treatments are also included in the objective part of your SOAP
note. The treatments provided should be specific enough so as another PT can provide
treatment if the treating physiotherapist is out for the day. The treatment should include the
specific weight, repetitions, intensity and duration whenever applicable.
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Assessment/ Analysis
This is where the physiotherapist impression regarding patient's current situation since his or
her last visit. This may also include the physiotherapist's perspective on whether a particular
treatment will be continued or modified according to client's needs.
Plan
In the SOAP plan part, the physiotherapist writes the plans for the client's next physiotherapy
visit. This may include the objectives, treatments, progression parameters, and precautions.
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FINDINGS AND RECOMENDATIONS
FINDINGS
An online survey was conducted to find out the requirements among working
physiotherapists regarding various aspects for developing an EMR for them along
with a visit to physiotherapy centre in Bangalore, Karnataka.
Responses of 50 working physiotherapists were recorded and analyzed using SPSS.
Number of patients coming to the clinic per day: 30
Number of physiotherapists at the clinic: 4
Number of attendants at the clinic: 3
Figure 3: Number of Patients, Physiotherapists and staff
Average time spent in initial assessment: 20 minutes
Average time spent in treatment of the patient: 40 min
30
4 3 0
5
10
15
20
25
30
35
Number of patients coming to the clinic
per day
Number of Physiotherapists at the
clinic
Number of attendants and other staff at the
clinic
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Figure 4: Time Spent for Assessment and Treatment
63% of the physiotherapists conduct their assessment of the patient before the start of
treatment while 33% of the physiotherapists conduct their assessment both before and
during the course of treatment.
Figure 5: Conducting Assessment
Most of the physiotherapists said that patient history taking and examinations
consumed their maximum amount of time in the assessment of the patient. While in
the treatment part of the patient manual therapy, exercises and modality application
consumed their maximum amount of time.
Most of the physiotherapists utilize their in between treatment time to:
20
40
0
10
20
30
40
50
Assessment Treatment
Time spent (in Minutes)
63%
4%
33%
Conducting Assessment
Before start of treatment
During course of treatment
Both
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Update and complete patient records
Treat other patients
Discus the case with the patients and other colleagues
80% of the physiotherapists found themselves easy working with the computer and
internet while only 6% of them found it difficult.
Figure 6: Working with Computer & Internet
95% of the physiotherapists expressed their willingness to adopt the computerized
system of maintaining the patient records.
Figure 7: Willing to adopt a Computerized System
80%
14% 6%
Working with Computer & Internet
Easy
Modearte
Difficult
95%
5%
Willing to adopt a computerized patient record system
YES
NO
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Out of the above 88% wanted to have features in their record system which should
include:
Patient demographic details
Patient history (present, past, medical)
Observations made by you (E.g.: posture, body type, facial expression, etc.)
Examinations done by you (E.g.: Range of motion, MMT, special tests done,
etc.)
Treatment given to the patient
Patient prognosis
Others wanted to have all the features mentioned above excluding the patient
prognosis part.
Figure 8: Features they want in the system
88%
12%
Features they want in the system
Patient Demographic details, History, Obseravations, Examinations, Treatment, Prognosis
All excpet the prognosis part
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RECOMMENDATIONS
Physiotherapist signup and login
The physiotherapist will sign up into the system filling all his details and hence will be
registered with the system where later he can sign up through his user name and password.
Advantages
Physiotherapist will have access to the full database
Time saving for accessing and viewing records
Can store all his data in a single place where his data can remain secure
Figure 9: Snapshot of Login Screen Specifications
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Patient Registration and Appointment Scheduling
Patients can be registered into the system as the book an appointment with the
physiotherapist and their appointment can be scheduled according to the time slot available.
Advantages
Time saving
Lowers regular expenditure of stationary
Lowers patient waiting time
Creates authenticity of patient records
It create fast backup
It has less error
It reduces space
Helps to maintain centralized data
Environmental friendliness
Figure 10: Snapshot of Appointment Screen Specification
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Physiotherapist Profile
In it the physiotherapist can have various features like:
List of his patients
List of consultants with whom he is connected
Is able to manage his staff access to the system
Advantages
Easier access and view of the database
Ability to monitor and control access of other staff to the system
Figure 11: Snapshot of Physiotherapist profile Specifications
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Patient consultation
The consultation of the patient should follow the SOAP note protocol where systematic
capturing of information can take place so that no details of the patient are missed out and
proper and effective treatment of the patient will take place.
Advantages
Increase efficiency of physiotherapist
Physiotherapist spends less time recording the details manually
Completeness of patient assessment
All the patient information can be accessed easily and much faster
Recording and storage of information can take place in a more systematic and easier
way
Figure 12: Snapshots of the Consultation Module Specifications
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CONCLUSION
Requirement gathering, functional documentation and designing architecture of any software
based on the priorities from the end user‘s perspective is an essential part of a software
development project as understanding what a project will deliver is critical to its success.
Also, we can conclude that development of physiotherapy specific EHR is very important to
facilitate paperless operations at a physiotherapy clinic which in turn will increase efficiency
and quality of the treatment being administered thus resulting in patient satisfaction. This will
overall result in improved profitability for the physiotherapists.
Recommendations for requirement Gathering
To be successful at requirement gathering and to give your project an increased likelihood of
success follows the given rules:-
Don‘t‘assume you know what the customer wants, ask.
Involve the user from the start
Ensure requirements are specific, realistic and measurable.
Create a clear specification document.
Avoid duplication of requirements in a functional document.
Create a prototype if necessary to confirm or refine the customers‘requirements.
Priorities the functionalities in specification document keeping in mind the technical
complexity and end user demand.
Mistake one should avoid-
Not prioritizing the User requirements, for example “must have”, “should have”,
“could have” and “would have”
Lacking a clear understanding and making assumptions rather than asking
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CASE STUDY
FEEDBACK AND EVALUATION OF A HMS
(HOSPITAL MANAGEMENT SYSTEM) IN A
PHYSIOTHERAPY HOSPITAL IN
BANGALORE
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INTRODUCTION
A hospital consists of various organizational units with differing tasks for various types of
healthcare professionals. Since integrated care should be the aim, a high degree of ability has
to be reached. This requires intensive internal communication among organizational units
and healthcare professionals as well as external communication (e.g. to insurance
organizations, general practitioners, etc.). The hospital is itself a system, in which human
beings and machines carry out specific actions following established rules. Accordingly we
can say that the hospital’s system for communicating and processing information, i.e. the
hospital management system (HMS), is that socio-technical subsystem of a hospital which
allows this ability by presenting information at the right time, in the right place to the right
people So, modern computer-based information processing tools, legacy systems, and still
paper-based records, forms etc. exist side by side as part of a HMS.
Hospital management systems are large, complex computer systems designed to help manage
the information needs of a hospital. They are tools for interdepartmental and
intradepartmental use (Linda Roussel, Russell C. Swansburg and Richard J. Swanburg,
2005). Hospital Management System (HMS) is vital to decision making and plays a crucial
role in the success of the organization. Computerization of the medical records and
documentation has resulted in efficient data management and information dissemination for
the users. Managers, Clinicians and other healthcare workers can now access the information
without delay or errors.
Hospital Visited
RECOUP, established in 2001, is located in India, and has a hospital and 6 clinics in
Bangalore and 1 each in New Delhi, Ghaziabad, Patna, Hyderabad and Thrissur (Kerala).
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RECOUP's mission is to maintain its position as one the world’s topmost
centres for Repetitive Strain Injury (RSI), other Musculoskeletal Disorders (MSD),
Ergonomics and Childhood Disabilities.
Dr. Deepak Sharan, Consultant in Orthopaedics, Rehabilitation and Ergonomics, heads
RECOUP. Dr. Sharan has supplemented 21 years of International clinical experience in
Musculoskeletal Rehabilitation with qualifications in Biomechanics, Ergonomics,
Orthopaedic Engineering, and Rehabilitation Technology. Dr. Sharan, described as a
"cult figure in the world of RSI" by the Wall Street Journal, is an advisor on RSI and
Cerebral Palsy to the Govt. of India.
RECOUP has a multi-disciplinary team of over 150 highly trained, qualified, experienced
and reputed Physicians and Rehabilitation Professionals.
HMS being Used
HealthObject ™ is a health care application of Idea Object which is a Chennai based
company. HealthObject ™ seamlessly combines the traditional healthcare clinical and
administrative functionality with the latest trends in community networking. It enables to
create local healthcare community involving patients, clinics, hospitals, labs, scan
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centres, pharmacies become partners or community members in the application and
provide efficient care for the patient.
HealthObject ™ is a rich internet application comprising of three main components
highlighted below, with all the three of them operating on the same data repository.
HealthObject ™ Core: The application that provides comprehensive administrative and
clinical functionality used by doctors, administrators and other care providers. It supports
management of uniform processes and practices in a multi location and multi-specialty
care setting. HealthObject ™ Core application is offered in the following services:
Clinics Service
Hospitals Service
Lab and Pharmacy Service
Optical Service
Patient Portal: An online web portal through which the patients can login in a secure
manner and view their medical records such as prescriptions, lab results, discharge summary,
etc. The patient can search of clinics and doctors and schedule appointments online.
DisplayObject: A digital information signage which can be set up in the reception / waiting
area / lobby though which the clinic / hospital can display slide shows comprising of
facilities offered, awards received, disease awareness, patient education, appointments,
doctors availability, etc. The display panel can pull-in real-time information asuch as next
appointment, doctors holidays, etc and display them.
The product is built using enterprise class architecture and frameworks using the latest
Microsoft .Net 3.5 technologies.
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METHODOLGY
Meetings with the users of this software at RECOUP Hospital were conducted to take
their feedback on HealthObject.
The users of HealthObject whose responses were recorded and analysed were:
Doctors
Physiotherapists
Front Office Staff
System Administrators
Separate discussions were conducted with all the users to record their feedback and
experience of using HealthObject. All of their views, opinions and responses were noted
down and evaluated.
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OBSERVATIONS
The software has been used by RECOUP for its hospital and 6 clinics in Bangalore only at
present. They have been using it for the past one year. The one thing which came out quite
evidently after reviewing the feedback of all the users was that they had an opinion that the
software is not user friendly at all.
Technical Details
Technology being used: Microsoft .Net 3.5
Database being used: SQL Server
Various issues and drawbacks were identified after discussion with all the users as they had
to face problem due to it as it was affecting the overall functioning of the hospital and
disturbing the workflow.
The various issues and drawbacks which were identified in the software are:
Integration issues
The most major issue and drawback which they face while using the software is the
integration issue of the software as it is not centralized. A patient coming and registered at
one of their centre cannot be viewed as a registered patient at other centre and hence the
patient has to undergo the process of registration all over again.
The doctors and physiotherapists are not able to see the patient records and details who are
visiting other centres as the system is not centralized.
Data Entry Issues
There is no specific template for recording patient assessment for the doctor and all the entry
has to be made by the doctor through typing only. The mode of all the data entry is in free
text form where a blank prescription note is displayed on the screen where he enters all the
details by typing only. This was found to be a major reason for the doctors being irritated by
the software and reporting it to be not at all user friendly.
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Backend Issues
These were many issues at the backend of the software due to which work had been
interrupted many times also which were being reported to the system administrator:
1. At times doctors and physiotherapists reported to them of the software not working
properly when they are entering details in it
2. Users of the software often report of problem in accessing and signing up in the
system and that need resetting the password again
3. The billing department also reports of discrepancies in the bill with wrong units being
billed or a particular treatment being billed multiple times.
4. At times it does not show the payments of the patient being made in advance on the
landing page and the billing desk has to go into billing details to check for it.
5. At times the doctors and physiotherapists see that the date of birth, gender and area
location of the patient has changed when they open the patient records to make
further addition to the patient assessment note.
6. Sometimes the system does not save the data which the doctor has entered into the
system and hence the doctor has to enter all the data again which was not saved.
7. Data entered into the system has been reported for errors and mismatch at multiple
occasions.
8. Another issue which they are facing is a problem with the email and SMS alert
service of theirs. The system does not send SMS and emails at the same time and
often they are long delays in receiving either of them (more commonly seen in case of
email delays).
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DISCUSSION
The evaluation of responses gave us an insight about the functioning of HealthObject and the
various issues which its users have to face while working on it. The major problem which is
associated with HealthObject is it not being centralized and hence it is not able to connect all
the centers within Bangalore. Along with this provision of no specific templates for recording
patient assessment and doctors having to do most of the recording by typing only has made
the users more resistant to adopting it. All the backend issues with HealthObject have only
invited more complains and problems only from the users.
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RECOMMENDATIONS
The following points are recommended for rectification in HealthObject to make it function
properly and suit RECOUP’s needs:
Centralization of the system is very essential as it is a multi-location establishment
and hence access to records of all places should be available to the users so that we
can save the patient time and improve delivery of services
Specific templates for recording of patient assessment need to be formulated as
doctors will only adopt the system when they will feel that their workload is being
reduced with the help of the system. At present as the doctors have to enter all the
data through typing only they are not comfortable using it.
The backend of the software needs to be rectified for all the bugs and errors which are
affecting and interrupting the workflow at present. A proper backend of the system
will only ensure proper functioning of the software.
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CONCLUSION
A properly functioning HMS is very essential to make it user friendly which will ultimately
help in increasing the adoption rate of EMR achieve our goal of integrating healthcare and
information technology. Therefore proper steps need to be carried out to ensure that we
present to the users a system which is user friendly and suited to their needs and
requirements.
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REFERENCES
http://en.wikipedia.org/wiki/Electronic_health_record (Accessed on Date: 10/5/2012)
www.frescoinformatics.com (Accessed on Date: 10/5/2012)
www.physiotherapyindia.org (Accessed on Date: 10/5/2012)
http://en.wikipedia.org/wiki/Physical_therapy#Specialty_areas (Accessed on Date:
10/5/2012)
http://en.wikipedia.org/wiki/Agile_Modeling (Accessed on Date: 10/5/2012)
http://en.wikipedia.org/wiki/Scrum_(development) (Accessed on Date: 11/5/2012)
http://en.wikipedia.org/wiki/SOAP_note (Accessed on Date: 12/5/2012)
http://www.physiotherapynotes.com/2011/03/parts-physiotherapy-soap-notes.html
(Accessed on Date: 12/5/2012)
www.scribd.com/doc/5195326/PPT-on-SDLC-Models (Accessed on Date:
15/5/2012)
http://www.outsource2india.com/software/RequirementAnalysis.asp (Accessed on
Date: 16/5/2012)
Douglas Havelka and Sooun Lee (2002), Critical success factors for information
requirements gathering, Information Strategy: The Executive's Journal, Summer
Issue, Page- 98-105
www.himss.org/content/files/Amb_EHR_Implemention081507.pdf (Accessed on
Date: 13/5/2012)
itsupportcorona.weebly.com/.../emr-implementation-convert-paper-charts Accessed
on Date: 13/5/2012)
Into-electronic-format.html (Accessed on Date: 13/5/2012)
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www.informationmanagementcompare.com/.../1121-Electronic-Medical- Records-
EMR-Implementation (Accessed on Date: 13/5/2012)
Winter, B. Brigl, T. Wendt (2003), Modeling Hospital Information Systems (Part 1): The
Revised Three-layer Graph-based Meta Model 3LGM2
http://www.recoup.in/jcms/index.php (Accessed on Date: 30/5/2012)
http://www.ideaobject.com/products.html (Accessed on Date: 30/5/2012)
Gunter, T.D. and Terry, N.P. 2005 The Emergence of National Electronic Health
Record Architectures in the United States and Australia: Models, Costs, and
Questions in J Med Internet Res 7(1)
Habib JL. EHRs, meaningful use, and a model EMR.Drug Benefit Trends. May
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Patrick Kierkegaard (2011) Electronic health record: Wiring Europe’s healthcare,
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515
Schwaber, Ken (1 February 2004). Agile Project Management with
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2009-03-30
Sutherland, Jeff (2004-10). "Agile Development: Lessons learned from the first
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ANNEXURE
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QUESTIONNAIRE FOR REQUIREMENT GATHERING
Physiotherapist’s Name:
Name of the Clinic:
Clinic’s Address:
No. of Physiotherapists at the clinic:
No. of Attendants and other staff at the clinic:
1. How many patients come to your clinic per day?
2. What is average time you spend per patient in initial assessment?
3. What is average time you spend per patient in treatment?
4. When do you conduct the full assessment of the patient?
• Before starting the treatment
• During the course of treatment
• Both
5. Which areas of assessment consume your maximum amount of time?
6. Which areas of treatment consume your maximum amount of time?
7. How do you utilize the time when you do not have to be continuously present with
the patient? (E.g.: when you have put the patient on a modality for 10-15 min)
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8. How do you find yourself working with computer & internet?
• Easy
• Moderate
• Difficult
9. Do you wish to have a computerized patient record system to be installed at your
clinic enabling you in faster workflow?
Yes
No
10. If yes, then what all features of the assessment and treatment do you wish to have in
this system?
Patient demographic details
Patient history (present, past, medical)
Observations made by you (E.g.: posture, body type, facial expression, etc.)
Examinations done by you (E.g.: Range of motion, MMT, special tests done,
etc.)
Treatment given to the patient
Patient prognosis
All of the above