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The Medical Documentation and Coding ES bundle uses application-to-application (A2A) services to seamlessly integrate, from an administrative and billing point of view, SAP Patient Management with third-party applications like clinical systems or OR systems.

Medical documentation is normally created in clinical systems, but is also needed in SAP Patient Management for administrative, billing and reporting purposes. For example, the most important medical diagnoses typically have to be communicated to the insurance provider, along with the corresponding claim for reimbursement.

This ES Bundle offers asynchronous services for the reception of this medical documentation, which can be used instead of the existing interfaces of the Hospital Communication Module (IS-HCM).

Medical Documentation and Coding (click to enlarge)

Audience

Healthcare Providers will benefit from the services in the Medical Documentation and Coding ES bundle, particularly hospitals or hospital chains.

Business Objects and Service Operations

This Enterprise Services Bundle contains the following interfaces with related service operations:

InterfaceServiceDescription
Medical Diagnosis In Maintain Medical Diagnosis based on Medical Diagnosis Collection NotificationTo maintain multiple medical diagnoses based on notification from a third-party system.
Medical Record Folder Event Out Inform of Medical Record Folder CreationTo inform third-party systems about the creation of a medical record folder.
Medical Record Folder Event Out Inform of Medical Record Folder Change To inform third-party systems about a changed medical record folder.
Medical Record Folder Event Out Inform of Medical Record Folder Status Change To inform third-party systems about the changed status of a medical record folder.
Medical Record Folder Event Out Inform of Medical Record Folder Cancellation To inform third-party systems about a cancelled medical record folder.

How To Use This ES Bundle

In the past, the medical documentation required by administrative systems had either to be re-entered manually, or, in some cases, proprietary interfaces needed to be created to automatically transmit this information.

Now, with the introduction of the new Medical Documentation and Coding ES bundle, healthcare providers have at their disposal a method of integrating their myriad systems that offers connectivity and standardization.

Use Case 1: Diagnosis Documentation In Clinical System

During his examination of a patient, the physician Dr. Miller documents the diagnoses he stated. A subset of these diagnoses is relevant for billing and has to be communicated to the insurance provider. Therefore they should be sent over to SAP Patient Management.

Step

Enterprise Services Invoked

Step 1: Dr. Miller searches for the patient and the search returns two patient records that may be for the same patient.

Find Patient by Basic Data Optional Step

Step 2: Dr. Miller selects a record to copy the details of the patient demographics into his clinical system.

Read Patient Optional Step

Step 3: Dr. Miller documents the diagnoses for his patient.

(No Enterprise Service invoked during this step)

Step 4: The clinical systems sends an asynchronous message with the entered details.

Maintain Medical Diagnosis based on Medical Diagnosis Collection Notification

Use Case 2: Document Surgery

During a surgery, the surgery team documents an important set of medical parameters for this encounter like diagnoses, procedures, time of mechanical ventilation etc. Once the surgery is completed and documented, a subset of the data is transmitted from the OR system to SAP Patient Management.

Step

Enterprise Service Invoked

Step 1: Optional steps to search for patient (see above).

Find Patient by Basic Data Read Patient Optional Step

Step 2: The surgeon and his team document the surgery with the related medical activities, diagnoses and procedures.

(No Enterprise Service invoked during this step)

Step 3: The OR system sends an asynchronous message with all the documented data like the patient encounter itself, the performed procedures and the documented diagnoses can be transmitted.

Maintain Surgery based on Patient Encounter Record Surgery Notification

Use Case 3: Notifications On Medical Record Folder Events

Dr. Johnson participates in a clinical study to evaluate the effects of a new drug against stomach cancer. This status change of the corresponding medical record folders is documented in SAP Patient Management. As connected third party systems might also want to reflect this status change, SAP Patient Management sends out an asynchronous information.

Step

Enterprise Service Invoked

Step 1: Dr. Johnsons asks his assistant Mrs. Smart to fetch all medical records of patients with stomach cancer.

(No Enterprise Service invoked during this step)

Step 2: Mrs. Smart walks over to the oncology department and asks for the relevant medical records. The clerk in the medical archive hands over the requested folders and documents the borrowing in their system. The system immediately sends out an asynchronous information message.

Inform of Medical Record Folder Status Change

Connectivity

The Patient Administration ES bundle connects to SAP Patient Management and SAP ERP 6.0. Because of the standards-based communication offered by enterprise services, the ES bundle supports the Integrating the Healthcare Enterprise (IHE) initiative, which provides guidance for deploying standards such as HL7 and enabling the integration with those third-party systems typically deployed in the healthcare industry.

System Requirements

The Medical Documentation and Coding ES bundle requires the following systems:

Related ES Bundles

This bundle is related to the following ES Bundles for SAP Patient Management: Patient Administration and Hospital Communication Module (IS-HCM).

SOA Homepage on SDN

Links to SAP Healthcare Blogs

"How to find & test Enterprise Services for Healthcare" by Bettina Lieske

"Engineering a Business Process Platform for Healthcare Part 5 - How To Provide Value" by Claudius Metze

"Engineering a Business Process Platform for Healthcare Part 4 - Here's the beef" by Claudius Metze shows the wiki for Patient Administration.

Health Level 7
Integrating the Healthcare Enterprise (IHE)

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