project data model
DESCRIPTION
Project Data ModelTRANSCRIPT
Data Model
for Ophthalmology
Documentation
Published by the Project Management Division at ifa systems AG/
Cologne, Germany
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
Table of Contents
1. Concepts on structured medical documentation.................................................................................. 4
1.1 Computer Science in Ophthalmology ............................................................................................ 4
1.2 Individualizing and Standardizing .................................................................................................. 4
1.3 The 3 levels of medical Service procedures .................................................................................. 6
2 Data Entry Structure .............................................................................................................................. 6
2.1 Patient Context .............................................................................................................................. 7
2.2 Risk Factors .................................................................................................................................... 7
2.3 Ophthalmic Numerical Findings .................................................................................................... 7
2.4 Refraction data .............................................................................................................................. 7
2.5 Observation Classes....................................................................................................................... 8
2.6.1 Ophthalmic Surgery ................................................................................................................... 9
2.6.2 Orthoptics ................................................................................................................................ 10
2.7 Diagnoses for Refractions ............................................................................................................ 10
2.8 Ophthalmic and Global diagnoses ............................................................................................... 10
2.9 Treatment Plan ............................................................................................................................ 10
2.10 Service Codes............................................................................................................................... 11
2.11 Medications ................................................................................................................................. 11
2.12 Medical Surgery ........................................................................................................................... 11
2.13 Glasses/CL Prescriptions .............................................................................................................. 11
2.14 SNOMED Mapping Observation Classes ..................................................................................... 12
2.15 SNOMED Diagnosis Mapping ...................................................................................................... 12
2.16 SNOMED Medications (Database) ............................................................................................... 12
2.17 Free Text Documentation ............................................................................................................ 12
3. Data OUTPUT Structures ..................................................................................................................... 13
3.1 Complete Patient Record ............................................................................................................ 13
3.2 Filtered Patient Data ................................................................................................................... 13
3.3 Chart with Numerical Findings .................................................................................................... 14
3.4 Graphic Findings .......................................................................................................................... 14
3.5 Structured Reports ...................................................................................................................... 14
3.6 Administration reports, forms and Billing ................................................................................... 15
3.6.1 Administration reports ............................................................................................................ 15
3.6.3 Billing ....................................................................................................................................... 15
3.7 Statistics and Analysis.................................................................................................................. 16
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
3.8 Export Interfaces ......................................................................................................................... 16
3.9 SNOMED (Structured Reports) .................................................................................................... 16
4. Organization of Introducing Ophthalmic Documentation .............................................................. 18
4.1 Data Input and Output Areas ...................................................................................................... 18
4.1.1 Data Input Areas ...................................................................................................................... 18
4.1.2 Data Output Areas ................................................................................................................... 20
4.2 Checklist for generating and presetting the system ................................................................... 22
4.3 System Analysis for Data Interfaces ............................................................................................ 24
5. Summary ............................................................................................................................................. 26
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
Data Model for Ophthalmology
Documentation (ifa systems AG)
1. Concepts on structured medical documentation
By the use of computers, a milestone in history has been reached - to have the ability to document with
standardized terminology and structured data. Scientific development and quality can be increased
rapidly if valid and digitally processed data is available. The era of text reports in the medical field is over
and instead observations are being systemized and made communicable.
1.1 Computer Science in Ophthalmology
Ophthalmology was predestined for a complex data model for documenting medical and demographic
patient data for the computerized patient record. Within 20 years (from 1987 to 2006) a multi-
dimensional data model for documentation in eye clinics and practices was developed by the ifa systems
Group. The system was supported by the official EU project (OPHTEL – Telematics in Ophthalmology) and
the international IEE-Project (Integrated Eyecare Environments).
With the data model it is possible to systematically document more than 98% of all patient cases in
ophthalmology as well as in global medical observations. For this, there are approximately 40
terminology databases that are linked to one another for individualized as well as standardized
terminology. Doctors can link their own individualized vocabulary (coded) with a standardized
terminology dictionary (e.g. diagnosis codes (custom) with ICD terms).
Additionally, the data model offers very flexible and variable documentation because descriptive terms
as well as classifying terms are available in different databases. This makes the data model compatible
with the ICD classifying system and the descriptive SNOMED nomenclature.
1.2 Individualizing and Standardizing
A data model is only acceptable when a doctor can keep using the methods he/she has learned for
documentation. The digital data structure has to be flexible in a way that it can be adapted to the
doctor’s methods and not the other way around.
In ophthalmology, there are different models for examination and treatment procedures as it is the case
with medical documentation. Some ophthalmologists work systematically based on the area of the eye
(organ oriented e.g. cornea, retina, lens etc.). Others work based on the examination steps and
document accordingly (diagnosis, slit lamp, refraction, etc.).
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These examination and treatment procedures are represented by so-called observation classes
(observation classes in SNOMED) which can be defined by users within the ifa program. The user can use
pre-existing terminology databases and –for a specialized field – can expand upon these and
differentiate.
The elements in observation classes are made up of 5 digit codes (abbreviations) each with a long text
description. Additionally, the codes can be modified, localized and ranked (SNOMED modifiers). For
example, a code for an embedded corneal foreign body might be COFBE. With the additional fields the
entry can be further qualified with e.g. OD for right eye, 3O for 3 o’clock localization and FR for rusty
iron. Another clinic (or practice) may use different abbreviations for the same observations.
Standardization comes through at a later point of time with the so-called mapping database.
The mapping functions can be understood clearly in an example with diagnosis. Ophthalmologist can
map (link) their own abbreviations with corresponding ICD Codes. A further advantage of this data model
is the fact that customized abbreviations can be linked to more than one diagnosis standardized term.
For example DR01 can be used for Diabetic Retinopathy, Retinopathy is the basic disease and diabetes is
the modifier. In a SNOMED report it is also possible for colleagues from different fields of medicine to
interpret the standardized report.
By linking customized terminology with standardized terminology a worldwide communication system is
created. This makes it possible for doctors in Italy to document in their own language, the system
summarizes the codes into a report and a colleague in the USA receives the report in English.
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1.3 The 3 levels of medical Service procedures
The procedures for patient examinations and treatments can be organized into 3 levels. At the beginning
level there are assorted observations, tests and patient interviews (findings survey). In the second level,
medical evaluation or classification takes place (diagnosis). From here the third level is derived e.g.
doctors orders, prescriptions, surgery or other therapy.
Level 1 Observation and Examination Results
- Reason for visit
- History
- Findings
- Test results, etc.
Level 2 Medical Classification
- Diagnosis
- Suspect diagnosis
- Rule out diagnosis
Level 3 Doctor’s Treatment Doctor’s Treatment
- Prescriptions (glasses , medicine, etc.)
- Surgery
- Treatment plan
- General therapy
The data model for ophthalmic documentation (ifa program) makes it possible to link 3 levels. Repeat
processes can be transferred to the data model where findings are linked with the diagnosis and these
are then linked to suggested doctor’s orders.
In all 30 observation classes up to 5 suggested diagnoses can be linked to one findings code. Diagnoses
can then be mapped with service codes (e.g. billing codes) and suggested medications.
Linking different levels of typical service procedures in the clinic can simplify data input on the one hand
and can function as a sort of a guideline on the other hand.
Presettings for the data model are made in the ”User“ and ”Abbrev.“ area of the program.
2 Data Entry Structure Ophthalmic documentation in the ifa program offers approx. 200 different types of data (with different field structures) for the fields of conservative ophthalmology as well as ophthalmic surgery and orthoptics/strabismus. Within the OP documentation it is possible to generate additional customized types of data.
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2.1 Patient Context
In order to optimize data input, age and sex are automatically generated from the demographic data
(date of birth and salutation). Since race can be relevant to certain eye diseases an additional data field
within the demographic part of the system is available for that use.
Other social patient factors are stored within the 30 findings classes and not in the demographic area of
the program so that these factors are available if needed for reports.
2.2 Risk Factors
In order to emphasize the importance of medical risk factors this data can be entered into a separate
area. Medical risk factors are defined as allergies, blood pressure, handicaps, etc. This area of the
program was designed so that assistants (non-physicians) can enter this data in the pretesting phase of
the examination. The 30 findings classes are generally used for differential and more discreet types of
risks since this data is entered by doctors.
The medical risk factors in this data category are constantly displayed at the top of the screen of the
patient’s medical record. This data can also be exchanged with monitoring programs in order to establish
an ”Early Warning System“ (watch dog) in the clinic.
2.3 Ophthalmic Numerical Findings
In ophthalmology important findings and results from tests made with instruments can be produced
which makes data interfaces available. These data records are compatible with standard output from
examining instruments. The following areas are available:
Intraocular Pressure (IOP) -> Connection to NCT
Visual acuity -> Connection to phoropter
Keratometer data -> AR/keratometer systems
Other numerical test results e.g. perimetry and biometer data are entered and stored in separate
software applications. More and more software modules are becoming available from the instruments
manufacturers. These applications are linked to the patient history via interfaces.
2.4 Refraction data
Two different types of data records are offered for refraction data:
objective refraction -> Connection to autorefractor
subjective refraction -> Connection to autophoropter
Results from refraction data are used to generate suggested prescriptions for glasses and contact lenses.
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2.5 Observation Classes
The observation classes are extremely important for structured ophthalmic documentation. 30 different
observation classes can be custom defined by the user. An unlimited number of codes (abbreviations) is
available for each observation class.
For example, observation classes can be defined for the following areas:
General history
Family history
Medical risks
Corneal findings
Fundus findings
etc.
Standard presettings in the 30 observation classes cover from 6,000 to 10,000 abbreviation codes. The
basis code consists of a 5 digit abbreviation (that can be digitally stored) and a description that can be 40
characters long. The descriptions are linked with the presetting table to the stored abbreviation.
Example: GLAOA Glaucoma open angle
Within data entries observation classes (findings abbreviations) can be qualified with further
abbreviations called modifiers. These specific modifiers contain data on: whether the observation was
made on the left, right or both eyes, the localization of the finding, the severity of the finding. For each
finding 3 additional fields exist for entering these modifiers.
When designing the observation codes, two different concepts can be used. The observation code can be
entered very generally and the specifications will be entered into the modifier fields. Theoretically it
would be sufficient to differentiate between only two different types of glaucoma and any further
specifications could be made in the 3 modifier fields. The other option consists of using the findings
codes to differentiate distinctively between diseases and then only use the modifier fields for special
localization modification (or special cases). The advantage of the last concept is that by differentiating
the findings codes distinctively the findings can then be used for specific statistical analysis. The
modifiers are included in all data output functions i.e. text reports, letters, etc. but in quantitative
statistics only the observation codes (findings) of each class can be evaluated. The suggestions for
presettings are usually so distinctive that they can be used by other specialized eye clinics.
Currently, standardized terminology for ophthalmology is being written on an international level. A
committee from the AAO (American Academy of Ophthalmology) is currently developing proposed
terminology, based on the so-called SNOMED standard (SNOMED = Systemized Nomenclature for
Medicine).
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SNOMED is a descriptive documentation language that differentiates between model levels and
observation classes. The data model in the ifa program is completely compatible with the SNOMED
concept. As soon as the reworked ophthalmic SNOMED nomenclature is finished it will be possible to link
custom finding abbreviations (observation codes) with SNOMED codes with the so-called mapping
program.
In the data model it is also possible to link certain findings with proposed diagnoses. For example, the
finding ”visual field loss“ could be linked with several glaucoma diagnoses. If these links have been set,
when entering this finding, the linked diagnosis will be recommended to select from. The user can simply
click on the appropriate diagnosis or enter a different or new diagnosis into the medical record. These
links on different levels help to simplify data input and more than that help to establish the use of certain
documentation guidelines.
The abbreviations and the corresponding descriptions of observation classes are displayed in the
computerized patient history, printed out in reports or displayed in interfaces.
2.6 Special-Documentation
Ophthalmic documentation can cover all areas of ophthalmology because of the flexibility in the
program’s design (see 30 observation classes). Additionally, the CPR software offers special data models
for 2 extra areas in ophthalmology:
Ophthalmic surgery
Orthoptics
Both of these documentation areas are integrated in a way that they are directly linked with one
another. In practice, this means that all general findings and diagnoses are also available for the OP
documentation and patient orthoptics records.
2.6.1 Ophthalmic Surgery
Additional data records are supplied for documenting surgical cases. Types of OP’s (e.g. phaco) can be
preset to include all of the standard steps for that OP. Complete documents i.e. OP reports are linked
with these OP types. Changes can be added with customized information to accommodate any
deviations in the procedures for that surgery (e.g. complications).
A data record generator (designer) exists in the OP program. This designer can be used to generate
customized special data records that are not already included in the program. Data records for lens
specifications already exist in the OP program.
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2.6.2 Orthoptics
A complete additional data model is available for the area of orthoptics. Included in this model are data
records for e.g. binocular vision, stereopsis, motility testing with 9 or 49 positions, etc. This numerical
data is supplemented by observation codes from the 30 observation classes. If a special department for
orthoptics/strabismus exists in the clinic then it is recommended to define and preset one of the
observation classes just for that area.
2.7 Diagnoses for Refractions
Based on refraction values that have been entered, refraction diagnoses e.g. myopia will be
automatically proposed by the program. The system evaluates the refraction data and can even propose
combined diagnoses e.g. myopia and astigmatism. A single refraction diagnosis code can include up to 4
different diagnoses.
Refraction diagnoses are part of general diagnoses. They are made up of a 5 digit abbreviations, a 40
character description and a general classification for normal, permanent and quarterly diagnoses (see
below).
2.8 Ophthalmic and Global diagnoses
A separate database is available for diagnoses, independent of observation classes. Just like the
refraction diagnoses, global diagnoses are also 5 digit abbreviations, 40 character descriptions and
classified by normal, permanent and quarterly diagnoses.
A permanent diagnosis is automatically reentered into the patient’s medical record at every visit.
Permanent diagnoses are always visible in the header at the top of the patient’s medical record.
The user classifies which diagnoses are considered normal, permanent, etc. Examples of permanent
diagnoses might be pseudophakia, glaucoma, etc. Normal diagnoses are any acute illnesses, injuries, etc.
The descriptions for diagnosis codes may include the corresponding ICD codes. It is also possible to link
the ICD’s to the diagnosis with the mapping database.
2.9 Treatment Plan
A specific patient treatment plan can be derived and generated from service codes. In the treatment
plan, all examinations and measures taken are displayed graphically on a time axis. Call up the treatment
plan and get a quick overview of all examinations already carried out and all measures planned for the
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future. These measures can then be linked to the departmental “Appointment Scheduler” in the
program.
2.10 Service Codes
A database is available for all medical services (e.g. procedures, examinations, tests, etc.). The service
code field has 5 digits (for alphanumerical codes). The codes can be linked to a service legend. It is also
possible to store descriptive tests for the service code descriptions. This database can be used for
insurance codes.
2.11 Medications
A separate database just for ophthalmic medications is also available. A code is available for all
medications and combinations of medications that are on the market (including different package sizes).
The database stores the name, the package sizes and all other relevant data.
It is also possible to link internal medication databases (typical prescribed meds for that clinic) to an
external industry database, often available on CD.
The distinct central pharmaceutical number is used as the identification code for mapping with
corresponding data records (in Germany).
2.12 Medical Surgery
Codes for OP’s can be placed in different databases depending on the specific statistical needs. OP codes
are included as part of the general documentation within the 30 observation classes. This way, a special
class for OP history with the corresponding OP codes is often dedicated within the history part of the
program (e.g. ICPM codes).
Furthermore, codes like ICPM can be used to supplement or replace the service codes. This is practical if
statistics for service codes are needed.
The third possibility for ICPM codes is in the specialized OP documentation. The ICPM codes are part of
the data exchange for AODT (outpatient operations data transfer from the German insurance
companies).
2.13 Glasses/CL Prescriptions
Based on data input for refractions the program automatically proposes prescriptions for glasses/contact
lenses. For the actual prescription additional data (e.g. type of glasses, etc.) needs to be added. The data
in the data record “Glasses Prescriptions” is the basis for printing out prescriptions for glasses or contact
lenses.
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2.14 SNOMED Mapping Observation Classes
The introduction of the SNOMED codes in international ophthalmology represents a new additional
database for terminology. The codes from the 30 observation classes can be combined with SNOMED
codes. These links already exist for the area of diagnosis.
2.15 SNOMED Diagnosis Mapping
Standardized terminology is often not flexible enough for daily documentation in the computerized
patient record. For this reason, the data model provides the ability to link custom terminology with
standardized terminology (mapped).
The individualized diagnosis codes can be combined with ICD codes, which are part of the SNOMED
nomenclature. ICD 9 and ICD 10 databases are also available. These are classified based on WHO (World
Health Organization), in a 5 digit system, and further classified with 6 digits. The 6 digit code is based on
the ICD catalog published by the American Academy of Ophthalmology (see also book on ICD coding in
ophthalmology, published by Biermann Publishing in cooperation with ifa).
Mapping local diagnosis with standardized codes makes it possible to combine custom abbreviations to
several diagnoses. Then, for example, the abbreviation DR for diabetic retinopathy is linked to the ICD
code for diabetes as the basic disease, and to the code for diabetic retinopathy for the ophthalmic
disease.
The ICD database makes it easy to link both codes. An intelligent search algorithm screens and compares
the long descriptions in both databases.
In Germany, a linked database combination of local terminology with the ICD terminology already exists.
2.16 SNOMED Medications (Database)
Medications can also be linked with external standards. In Germany links exist between medication
abbreviations and the so-called Central pharmaceutical numbers.
2.17 Free Text Documentation
In addition to the structured input that has been described up until now, the data model also offers the
ability to enter free text into all areas of the program. The free text entries should be kept to a minimum
though, in order to allow for a systematic analysis of the digitally stored patient data. The custom
terminology should be so distinct, especially in the 30 observation classes, that more than 98% of the
observations can be systematically stored. The individualized free text should only be used in special
cases.
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The individual free text can be entered into the remarks line to all observation classes where codes are
attached (F4 function).
Another free text function exists in the program for entering multiple lines of free text. These too, can be
combined with the data model.
A third possibility exists by entering information into the so-called “Infobox”. The “Infobox” should be
seen as sort of a reminder note that is only usually used on a temporary basis – e.g. special notes about
patients.
The fourth possibility is the creation of text reports. Two different text systems exist:
ifa Write
MS Word for ifa
Documents can be created with both systems that can be included as part of the patient record.
3. Data OUTPUT Structures
Complex output structures also exist to the differential input areas within the CPR software. The stored
patient data in the CPR can be evaluated and exported in all possible forms e.g. text reports, forms,
digital data reports as well as billing and statistics.
3.1 Complete Patient Record
The complete patient record is a compilation of all stored data for that patient. This is displayed in the
screen and contains all numerical results from all 30 observation classes, diagnoses, medications, free
text, etc. This complete patient record can also be printed out.
The complete patient record (as well as all other displays of data) can be custom defined by the user and
thus modified (see “User”).
3.2 Filtered Patient Data
The program offers a variety of possibilities for filtering patient data for compromised analysis and
interpretation.
As an example for this, the so-called “patient record short” can be used. This record can be custom
defined by the user. It may be used to include all data only from the last visit.
A so-called “Layout Medical Record Screen” can be created for each working area within the program
(e.g. observation classes, diagnosis input, etc.). This “Layout Medical Record Screen” displays any "other"
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data that is relevant for that working area or area of documentation. The user can use the information
system for entering data from already existing patients.
For clinical documentation it is also sensible and essential to document the "normal" findings. Since this
substantially increases the amount of data entered for each patient, it can overload the “quick
overviews”. For this reason, a function has been developed to highlight only the “important” findings.
This makes it easier to quickly evaluate the extracted data. The program can be set up in a way that only
“important” findings will be displayed thus producing a quicker overview.
Another method of filtering data exists of course in generating reports. All codes are imported into the
reports that are necessary to create an overview.
3.3 Chart with Numerical Findings
The data model provides graphic charts for visualizing observations and findings for tonometry and visual
acuities.
The tonometry trend chart is especially important. Pressures for the left and right eye are displayed
separately on a time axis. Additionally, an average of past IOP values can be displayed as a graph.
Graphic displays can have a positive influence on patient education and are often used in clinics to
optimize patient compliance (e.g. glaucoma patients).
3.4 Graphic Findings
Regardless of the type of data model, the ifa program makes it possible to display findings as graphics.
Symbols can be inserted or drawn onto templates (e.g. fundus picture, picture of the eye). These
symbols are stored in a database together with their corresponding descriptions i.e. findings (e.g. horse
shoe tear, cotton wool spots, etc.).
Photo documentation for ophthalmic data is also available (see separate pamphlet on storing images and
image documentation).
3.5 Structured Reports
Several alternatives within the program are available for text output e.g.:
MS Word for ifa
Report Generator within OP Documentation
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Form letters can be generated to be used for all patients where patient data is replaced from each
patient. Graphic charts, findings graphics and patient images can also be inserted into the documents.
Reports generated in “Word for ifa” can be sent automatically as attachments to emails.
With Word a complex word processor such as MS Word was combined with the patient data from the ifa
system to "MS Word for ifa". Prerequisite is the corresponding Word license. All of the patient data
records can also be inserted into these documents. Form documents can be created for doctor's reports,
OP reports or extensive individualized expert's reports.
A report generator within OP documentation is also available for quick text output. It generates the
preset OP steps in a form document.
3.6 Administration reports, forms and Billing
The system contains extensive possibilities for administration functions (e.g. clinic administration) which
differentiates between patient relative and time relative reports.
3.6.1 Administration reports
In administration reports there are direct and indirect ways of generating statistics. For the direct way,
functions like the so-called Explanation Statistics for Coding (explanation of why codes were used, etc.)
are available. The results are overviews of patient data with the corresponding diagnoses. On the one
hand these documents the quantity of the services rendered, on the other hand the efficiency of the
services (seen from an economic point of view).
For an indirect way of generating statistics, data can be exported into a standard database (e.g. MS
Access) and evaluated in that program with the appropriate tools.
3.6.2 Forms
All stored patient data can be used to create standard forms with a special “forms generator” – i.e.
prescriptions, glasses prescriptions, patient release reports and internal patient oriented documentation.
Additional forms are available within the OP documentation.
Users can generate forms or alter existing forms on their own if they have been trained on the forms
generator. (See guide to Forms Generator)
3.6.3 Billing
Based on procedures and services codes the system can be used for writing and administering insurance
bills and private patient bills.
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
In Germany and Austria, the ifa system holds a license from the union of national insurance carriers for
writing quarterly insurance bills based on ADT standards (exchange data protocol).
The program can also be used for private billing functions. Single or consolidated bills can be written.
Extensive service statistics are available for the area of patient billing.
3.7 Statistics and Analysis
The system also offers direct and indirect evaluation methods for the area of statistics and analysis.
Direct statistics can be calculated straight from the system on documented diagnosis and medications
prescriptions. Diagnoses are classified based on patient groups and age and the desired time periods can
be selected (month, quarter, year, etc.).
Patient profiles can also be created. Statistics based on new and existing patients and single and
combination diagnoses can be made (see also Recall).
If the diagnosis codes are mapped with ICD classifications, a distinct ICD statistic can then be made.
The direct evaluations can be supplemented by indirect evaluations with an external database. An export
interface exists that can export patient data, based on time periods, into an external database e.g.
Access. The Access standard tools can be used to produce statistics in lists, charts, etc.
The indirect data evaluation makes it possible to filter data or to extract certain data for research which
is not possible with the real data for forensic reasons.
3.8 Export Interfaces
Extensive export interfaces are available within the ifa system. Data can be exchanged with local
evaluation programs or with external administration systems. Although standard tools exist for export
interfaces, each interface has to be programmed individually. For this, the IT Dept. will supply a system
analysis with examples of data records. The data protocol can either be individualized or follow the HL7
standard. The ifa systems group is a member of the HL7 Organizational Committee.
The different possibilities for export interfaces are described in detail in the OPHTEL EU project (see
“Status Report and Interface description“ WP11/Integration).
3.9 SNOMED (Structured Reports)
Currently, efforts are being made to introduce the SNOMED structure (standardized terminology) on an
international level. ifa is currently working together with CAT, a workgroup from the American Academy
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
of Ophthalmology, on a special issue of the existing codes for ophthalmology. Standard reports, called
Structured Reports (SR) have been worked out within this cooperation.
3.10 DICOM Documents
The DICOM standards were initially developed in the field of radiology and are used as the standard for
all other areas of medicine. A DICOM document (DICOM = Digital Imaging and Documentation in
Medicine) is made up of 3 areas:
Technical header
Image information
Medical data document (SNOMED)
The technical header in a DICOM document depends on the instrument that is used (e.g. camera or
diagnostic laser). In addition to the image data stored in a specific format, the document will be linked
with information from the CPR software based on the SNOMED standards. The ifa systems Group is a
member of the international DICOM committee and responsible (with others) for ophthalmology.
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
4. Organization of Introducing Ophthalmic Documentation
The complexity of the data model requires consistency in preparation for the computer documentation.
The data flow within the eye clinic/eye department needs to be analyzed ahead of time. The existing
type of manual data input and output will then be changed with the corresponding presettings.
4.1 Data Input and Output Areas
4.1.1 Data Input Areas
The data to be entered in ophthalmology comes from very different areas and data sources. Data
categories can be classified as follows:
General patient data
Secondary history (not medical)
Pretests
General examinations
Diagnosis statements
OP area
Specialized areas (orthoptics, strabismus, etc.)
Administration and billing
Data input can generally be separated into the 4 following areas:
Data export from administration systems (demographic patient data)
Data collection from non-physician (secondary history, pretests, etc.)
Data collection from physicians (primary history, findings, etc.)
Data export from digital diagnostic and examination instruments (autorefractor, perimeter, etc.)
An overview of the areas for data collection, the sources and the corresponding areas of responsibility
helps to support professional use of the computerized data model (see next page).
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
Overview Data Input Eye Clinic/Eye Department
Collection of Data No. Area of
responsibility
Dept.
General patient data
- Basic data (address, etc.)
- Admin. Data (internal pat. no. etc.)
- Reason for visit
- Referring doctor
- Billing code
Secondary History
- Risk factors
- Chief complaints
-
-
Pretesting
- Objective Refraction
- Lensmeter
- Vision
- Subjective Refraction
- Perimetry
-
-
General Examination
- History
- Chief complaint
- General finding
- Ophthalmic findings
- Special examinations results
-
-
Diagnosis statements
OP area (separate entries)
Special area (orthoptics, CL etc.)
Administration and billing data
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
4.1.2 Data Output Areas
Similar to data input areas, data output areas can also be classified into different areas:
Monitor screens
Form printouts
Invoices
General reports and doctor’s reports
Statistics
Data interfaces to external systems
Furthermore it is important to differentiate between different data recipients and their communication
forms:
Administration department (billing and statistics)
Colleagues (referrals, other treating physicians, etc.)
Patients (private billing, patient education fliers, etc.)
Team (training, internal studies, etc.)
With data output it is important to note the goals of the project (see Compendium for Introducing the
Computerized Patient Record in an Eye Clinic). By using computerized data processing, information is
consolidated substantially when compared with traditional hand written records. It is important to
establish which additional areas for data output would be desired to attain even more efficiency when
introducing the CPR.
On the following pages you will find an overview of possible data output areas as checklists.
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
Overview of Data Output Areas in Eye Clinic/Eye Department
Data Output No. Area of
Responsibility
Dept.
Monitor Screens
- Patient history (complete)
- Patient overview
- Layout of Medical Screen
-
Forms
- Patient registration overview
- Exam form
- Prescription for meds
- Changes in glasses prescrip.
-
Billing
- Internal services documentation
- Insurance billing
- Private billing
- Billing statistics
-
Reports and Doctor’s Reports
- Release reports
- OP reports
- General doctor’s letters
- Standard examinations
- Special examination results
Statistics
- Diagnoses
- Services
- Patient profile
Data Interfaces
- Data import
- Data export
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
4.2 Checklist for generating and presetting the system
The CPR system enables the user to customize presettings and adapt the program to fit the existing
practice routines (data flow chart). Various working areas are available for this e.g. “User” and “System”.
The following are some of the areas that will be preset:
Screen design
Database documentation (abbrevation system)
Mapping function (links internal and external)
OP Documentation and other specialized areas
Graphic surfaces (Smart Screen)
System generation and presettings are carried out in the preparation phase together with the systems
partner. Suggested presettings are given to the user to be used as a basis for modifying and customizing
their own.
Smart Screen (templates and buttons for quick data input) demands a separate special training session.
Customized templates can only be created after all areas of the system have been preset and the
routines for data input are concrete and on paper.
On the following page you will find an additional checklist for support on these topics.
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
Additional Checklist for Presetting the System in the Eye Clinic/Department
Generated Screen No. Area of
Responsibility
Dept.
- Menu per workstation
- Routine definition per workstation
- Medical Screen Layout per workstation
- Patient history
- Patient file short
- Positive findings/negative findings
Database Documentation
- Diagnosis codes
- Observation classes (30)
- Service codes
- Medications
- Other abbreviations
-
Mapping Functions (Links)
- Observations/ Findings – Diagnosis
- Diagnosis codes
- Diagnosis medications
- Diagnosis ICD codes
- Functions billing codes
-
OP Documentation
- OP classes and types
- OP standards steps
- OP services (ICPM)
- OP reports
-
User Surface SMART SCREEN
- Menu templates
- Entry templates
- Functions templates
(see separate description)
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
4.3 System Analysis for Data Interfaces
Establishing data exchange between the CPR system and other systems in the clinic is done in a separate
system analysis. Included are the requirements from the IT Dept. The system analysis contains the
following areas:
Description of target system (functions, operating system, etc.)
Technical protocol descriptions (transmission, protocols, etc.)
Data description (data form and type of transmission)
Mapping overview (if one category is to be transmitted into another category)
Examples of desired data transmission
Organizational information (Areas of responsibility, time schedule, etc.)
Different interface and data export programs exist (see OPHTEL deliverable Status of Integration). In any
case, it is necessary to program and adapt each system individually, since the systems are
heterogeneous. This is calculated based on time needed within the project. The system analysis should
be available approx. 4 weeks before the test installation. Further changes will be made on the basis of
supplements to the system analysis. On the following page, there is an outline for a proposal for a
system analysis.
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
System Analysis for Export and Import Interfaces for CPR System (ifa)
Table of Contents:
1. Description of target system - Admin. system
- General documentation system
- System platform
2. Technical description of
transmission
- Physical transmission (e.g. file, serial,
TCP/IP, FTP)
- Logical transmission
- Protocol (e.g. HL7, etc.)
3. Description of data for transmission - ID
- Diagnosis
- CPT codes, etc.
4. Mapping overview (if data from
observation class has been
transmitted)
5. Examples of desired data
transmissions
- Standard examples
- Record with all possible patient data to be
transferred
- Examples as printouts and on data medium
6. Organization information - Responsibility in the IT Dept.
- Time schedule
- Confirmation for changes and budget
Remarks to conditions: The system analysis is a part of the project contract. Any changes in requirements
after the system’s analysis are additions to the contract and will be invoiced accordingly. Missing
information or false information is carried by the project client.
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
5. Summary
The data model for ophthalmic documentation in the ifa system has been developed based on modern
requirements from medical information sciences. Specialized medical ophthalmic documentation has
already been realized for more than 30 million patients.
The system is completely compatible to existing international standards and standards that are currently
being developed (i.e. SNOMED and DICOM). Existing classification systems such as ICD and ICPM are
already included.
Data export from more than 200 examination and diagnosis instruments into the patient medical record
have already been developed for the field of ophthalmology. Approximately 20 new instruments and
data interfaces are programmed each year.
The success of introducing a computerized patient record depends on how well the custom adaptation
of the data model for that clinic’s or department’s specific requirements have been fulfilled. The systems
partner (ifa team) gives support by training and acting as a consultant in organizational queries.
Exchange of experience from existing users and information exchange on a regular basis is sensible and
necessary. This exchange is supported by the system partner with user meetings and information
exchange and communication via internet).
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
Definition of Observation Classes
Version: Example 1
No. Code
2-digit
Class Description
(up to) 20 digits
Responsibility Area
01 A1 History– Allergies
02 A2 History – Family
03 A3 Risks– Allergies
04 A4 Risks– Medications
05 A5 Risks– Ophthalmology
06 RF Risks
07 RV Reason for visit
08 GL Glasses
09 OR Objective Refraction
10 VI Vision
11 CC Chief Complaint
12 OM Orthoptic/Muscle
13 PU Pupil
14 LL Lids/Lacrimal
15 CJ Conjunctiva
16 CO Cornea
17 AC Anterior Chamber
18 IC Iris/Ciliary Body
19 LE Lens
20 GK Vitreous
21 AH Choroid
22 NH Retina
23 OP Optic Nerve.
24 PE Perimetry
25 FA Fluo-Angiography
26 OP Surgery
27 US Ultrasound
28 TP Treatment Plan
29 N.N.
30 N.N.
Definition of Observation Classes
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
Version: Example 2
No. Code
2-digit
Class Description
(up to) 20 digits
Internal:
Responsible area
01 RS Review of Systems
02 PH Past Medical Hx
03 PS Past Surgical Hx
04 PO Past Ocular Hx
05 EM Eye Medications
06 MD General Medications
07 AL Allergy Hx
08 FH Family General Hx
09 FO Family Ocular Hx
10 SH Social Hx
11 CC Chief Complaint
12 HP Hx of Present Illness
13 PU Pupils
14 EE External Exam
15 MO Motility
16 LI Lids
17 CJ Conjunctiva
18 CO Cornea
19 IR Iris
20 AC Anterior Chamber
21 GO Gonioscopy
22 LE Lens
23 VI Vitreous
24 RE Retina
25 ON Optic Nerve
26 VE Vessels
27 MA Macula
28 AT Additional Tests
29
30
Definition of Observation Classes
Version: Example 3
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
No. Code
2-digit
Class Description
(up to) 20 digits
Internal:
Responsible area
01 Y1 Symptom 1
02 Q1 Quality 1
03 L1 Location 1
04 S1 Severity 1
05 D1 Duration 1
06 T1 Timing 1
07 C1 Context 1
08 A1 Associated 1
09 Y2 Other Symptoms
10 Q2 Quality 2
11 L2 Location 2
12 S2 Severity 2
13 D2 Duration 2
14 T2 Timing 2
15 PA Pachometer
16 EC Endothelium Count
17 Y3 Symptom 3
18 Q3 Quality 3
19 L3 Location 3
20 S3 Severity 3
21 D3 Duration 3
22 T3 Timing 3
23 C3 Context 3
24 A3 Associated 3
25 SE Specialty Exams
26 PO Past Ocular Hx
27 CH Contact Lens Hx
28 EM Eye Medications
29 PR Ocular Procedures
No. Code
2-digit
Class Description
(up to) 20 digits
Internal:
Responsible area
30 AL Allergies
31 PH Past Medical Hx
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
32 MD Systemic Medications
33 FH Family Medical Hx
34 SH Social Hx
35 GE Gen.\ Mental Status
36 CN Constitutional
37 PS Psychological
38 EN Ear, Nose and Throat
39 HB Cardiovascular
40 LR Lungs & Respiratory
41 GA Gastrointestinal
42 MU Muskuloskeletal
43 GN Genitourinary
44 SB Skin and Breast
45 NE Neurological
46 ED Endocrine
47 IS Immunological
48 BL Hem./Lymphatic
49 LV Low Vision
50 PU Pupils
51 DL Pupils Dilation
52 VF Visual Fields
53 MO Motility
54 AD Adnexae
55 EL AD/Eyelids
56 LG AD/Lacrimal Glands
57 LD AD/Lacrimal Drainage
58 PN AD/Preauricular Node
59 FA Facial
60 CB Conjunctiva
61 CP Conj./Palpebral
No. Code
2-digit
Class Description
(up to) 20 digits
Internal:
Responsible area
62 CO Cornea
63 EP Cornea/Epithelium
64 EO Cornea/Endothelium
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
65 ST Cornea/Stroma
66 CS CL Soft
67 CR CL RGP
68 IR Iris
69 AC Anterior Chamber
70 FC Fulfilment Center
71 L Letters
72 GO Gonioscopy
73 LY Lens
74 LA Lens/Ant. Capsule
75 LC Lens/Cortex
76 LN Lens/Nucleus
77 LP Lens/Post. Capsule
78 VI Vitreous
79 OA Optic Nerve
80 CD ON CD Ratio
81 ON ON Nerve Fiber Layer
82 RT Retina
83 MA Macula
84 VE Vessels
85 PP Periphery
86 TP Treatment Plan
87 TM Treatment Meds
88 TS Treatment Procedures
89 TC Treatment CL
90 TL Treatment LV
91 SO Soft CL Order
92 RO RGP Order
93 TT Test/Labs Ordered
94 AT Additional Tests
95 TI Test Interpretation
96 TF FU/To Do/RTC
97 OP CPT Codes
98 RM Relationship Mgmt
99 SG Sign Off
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es
ifa systems AG ifa united i-tech Inc. ifa systems iberia S.L. Augustinusstr. 11 b 1850 SE 17th St. Ste. 107 Cami de Can Manuel 24 50226 Frechen, Germany Ft. Lauderdale, FL 33316, USA 07120 Son Espanyol - Espana phone: +800-43222557 phone: +1-888-4432367 phone: +34-971-438555 www.ifasystems.de www.ifa4emr.com www.ifasystems.es