[Gnumed-devel] re: vista cprs

[catmat]

finally took a look at vista, can see why it might be "free". Googling 
found
a guy called Bashkar who 1 year ago was trying to get vista running on linux
and the free M replacement GT. M
on the openhealth list, and said he had difficulty knowing which of the 100s
of modules in vista need to be configured.
Recently, he released on sourceforge a dvd iso for vista , gt.m on knoppix.
Not sure if it runnable though.

So I suppose Vista is "free" because it's so hard to configure, vista people
make money by support.  Don't know if Vista Office will be any different,
in terms of need for massive amounts of support.


I must be the last person on the list to have read the CPRS,
but here's a rundown. Having browsed through the user manual,
now I seem to get why oscar has these wierd text paste "templates" into
the progress notes, and where gnumed gets its ideas for templates , 
medications
etc 
(look if we are going to re-invent the wheel, why not be explicit about it.
At least we've got a certain level of functionality to aim at, that has 
preceded us).
Comparing cprs to our venerable most- popular -GP- emr- in- Oz, you notice
it is written for a team approach, vs.  the Phantom (works alone),   
with its
emphasis on signing orders, Postings , Patient (Red) Flags :  the senior
gp at our clinic uses the Warnings little box under allergies for PRFs.
The Reminder system in CPRS is like Richard's TODOs and MDs Recalls,
except it's easier to understand how it works: a blue clock means not due,
a red clock means due, and a question mark with describing text means 
lapsed.
There seems to be no personal TODO in CPRS, which is Richard's clinician
attached functionality. The CPRS problems tab seems the easiest to 
implement:
problems are conceptually central, but there's not much detail to deal with
(active/inactive,  service type, search coded term, special 
classifications - basically subselect views). MD deals with this with a 
pretty simple dialog,
and the CPRS dialog is only slightly more complex.
Vitals entry is pretty simple too, ( BP, PR, RR, T, Ht, Wt ,  CPRS adds 
Pain;
debatable would be colour , conscious state)  .
  The Medications entry dialog , for simple dosing, I think, we should just
outright copy the dialog on the cprs manual p 107.  It is not much different
from MD, except that a textual form is in a display box at the bottom as 
each component of medication ordering is selected/entered.
Complex medications is just a editable grid of each row being a dose , route
and a linking "then / and"  e.g.   migraine - diclofenac 50mg o stat and 
metoclopramide 10mg o stat,  then diclofenac 50mg in 2 hours if 
required  ,then  50 mg diclofenac  3 times a day if required .

The templating system for notes insertion is a way of  putting standard
forms for progress notes - mainly numeric text entry boxes,  checkboxes
for present/absent  examination findings, and possibly dropdown lists 
for standard  descriptions   e.g. diabetic checkup, minimental exam, 
physicals exams e.g. for employment.  With a web client like Oscar , 
that doesn't do DOM tree
re-writing javascript,  a template insertion is just a paste in of
line separated text items into a textarea box, whereas a gui client can 
bring up a form with widget fields to constrain entry.

The orders section groups ordering tests, radiology, specialist requests,
asking the nurse to do obs, and perhaps investigative procedures like
colonoscopy, gastroscopy, respiratory function tests , exercise stress 
tests.

If we can't get our act together to design a gui, why don't we just
do the Asian thing and assimilate some features of the cprs into gnumed.
  Vista is advantaged in that it has a proven track record, and it's known
to be scalable,  and integrating a Vista based GP system with a hospital
based vista system might be an easier task (see the Remote view feature
of CPRS);  however MUMPs really is  a difficult language to read.
On the other hand, if  gnumed goes
down the track of not reusing available python libraries and wrapping
every little library protrusion in "home-grown" code,  or duplicating 
library available functionality ( app configuration , logging, dbapi) it 
might decrease
the value of being open source
(PS don't think open source assembly language
is much different from disassembled machine code, which GTM seems 
largely to be ).   Or maybe that is whats  wanted.


I downloaded cprs, and there is no installable module, just a client exe 
program
apparently written in delphi. There seems to be no configuration file, and
it seems to try to find a fixed internet address (localhost:someport?),
and returns a windows socket error. 

The cprs user manual is a good read, it describes with screenshots how 
it is supposed
to work.  The focus appears to be on individualized tracking .
There is a 340+page technical manual and a 240 page user manual.

I suppose the problems that prevented CPRS from becoming
the most widely used "free" gui EMR are:-
   - Vista is hard to configure
   - Cache is not free, although GT.M seems to be,
   - Vista needs to be configured to run on GT.M ( recently
done)
   - CPRS  was designed with veterans affairs in mind :
it appears to be both an inpatient/outpatient EMR,
billing/ classification needs to be have a "war-related" linking
and is in built into it.





The functionality sections are:
- Signing in to CPRS
- Selecting a Patient
   - Notifications
- Keeping Diagnostic / Procedural Coding current
- Features Available from Any Tab
      Clinical Context Mnaagement
      Patient Inquiry
      Encounter Information
      Primary Car Info
      Patient Record Flags (PRF) -
      Remote Data - Viewing patient data on other sites.
      Reminders Button - Scheduling Tasks
      Postings  -  Patient Directives, Warnings, Allergies
- Electronic and Digital Signatures
     -Digital Signatures
         -Smart cards
               -PIN numbers
     - Review and Signing Dialogs
         -Signing Selected Orders
         - Viewing unsigned Notes and Discharge Summaries
-Printing
      - single items
      - selected items ( notes, consults, discharge items)
-Tools menu
      - Lab Test Descriptions
      - Options

Cover Sheet
      - Navigating a Patient Chart
      - Encounter Information Entry
      - Viewing Reminders
      - Viewing and Entering Vitals
      - Reviewing Postings
      - Notifications and Alerts

Problems Tab
      - relating to a Service Condition
      - Adding, Annotating, Changing, Deactivating, Removing , Verifying

Meds
      - Details
      - Administration History
      - Other Actions
      - Inpatient / Outpatient Ordering
      - Simple / Complex dosing
      - Medication order actions - hold, renew, discontinue, change, 
place, view, transfer inpatient/outpatient

Orders
      - Viewing Orders
            - Viewing Results
      - Writing
            - Allergies
            - Diet
            - Medications
            - IV Fluids
            - Lab tests
            - Radiologing Imaging
            - Consults
            - Procedures
            - Vitals
 Text only Order
      Event-delayed Orders (after a release event - 
admission/discharge/transfer)

Notes
   Viewing - select by signed/unsigned, author, date range
    entering,  using a template
   Encounter form data

Reminders
   - Reminder Drawer ( tree) - Due , Applicable , lapsed; attached dialogs
  
Templates
 - Viewing
 - Adding to notes
 - Importing
 - Creating
      -Template Field Editors - (includes associated widget selection, 
placement)
 - Using Templates  ( Template Drawer is a long button just above
the Reminders button, in the progress notes tab), open drawer, select 
template, drag-n-drop into progress notes area

Consults
   - ordering, viewing, creating and signing via notes entry

Discharge Summaries
   - viewing
   - creating via notes entry

Reports
   - viewing
   - navigating to Postings , Reminders