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FUNCTIONAL REQUIREMENTS
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In defining the functional requirements for our EHR system, it is essential to adhere to the guidelines and stipulations set forth in the EHR Due Diligence & Data Requirement Document published by the Ministry of Health Suriname in February 2023. This document provides a comprehensive overview of all functional requirements. While the EHR Due Diligence & Data Requirement Document provides a holistic framework for our system, the following sections delineate specific functional requirements for certain modules of our EHR system.These requirements are designed to cater to the unique needs of different user classes and to support various workflows within our healthcare settings.
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Please note that although specific modules and parameters are outlined below, the EHR Due Diligence & Data Requirement Document's guidelines should be considered as all-encompassing and integral to every aspect of the EHR system, even
beyond the modules explicitly mentioned.
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Patient Registration
The Patient Registration module in the EHR system should have the following functional requirements




DemoableAvailableCustomizationDevelopmentComment
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1. Patient Identification: The system shall have the capability to uniquely identify each patient using a unique patient identifier (National ID Number). The system should also be able to prevent duplication of patient records.XXAdvanced search features prevent duplications, but this can be pushed so that possible duplication matches are verified directly upon registration.
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2. Patient Demographic Information: The system shall capture and store demographic information including, but not limited to, patient's name, date of birth, gender, contact information, address information and ethnicity.X
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3. Emergency Contact Details: The system shall capture and store the patient's emergency contact details including name, relationship to the patient, contact number, and address.X
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4. Insurance Information: The system shall allow for the entry, update, and storage of patient's insurance details, such as provider name, policy number, effective date, and policy holder information.X
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5. Record Creation and Modification Tracking: The system shall track and record the creation and last modification date of a patient's registration information, including the user who performed the operation.X
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6. Data Validation: The system shall validate entered data where appropriate to minimize errors. For instance, it should be able to verify that a entered phone number or email address follows the correct format.X
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7. Consent Management: The system should facilitate the recording and management of patient no consent for treatment, no data sharing, and other important healthcare considerations.X
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8. Search Functionality: The system should offer robust search functionality to retrieve patient records using different identifiers such as name, date of birth, or patient identifier.X
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9. Security and Privacy: The system must adhere to privacy regulations, ensuring that patient data is secure and access is controlled and logged. Demographic data should be encrypted in a separate table from health-related items.XX
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Medical Records
The Medical Records module in the EHR system shall have the following functional requirements:		AvailableCustomizationDevelopmentComment
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1. Health History: The system shall allow for the entry, modification, and viewing of comprehensive health histories including past and current medical conditions, surgeries and hospitalizations, allergies, and familial medical history.XX
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2. SOEP Structure Support: The system shall support the documentation of medical records following the SOEP (Subjective, Objective, Evaluation, and Plan) structure.
1. Subjective (S): The system shall provide fields for capturing the patient's reported symptoms, medical history, and any other subjective information. This includes but is not limited to the patient's chief complaint, history of present illness, review of systems, and personal and family history. Also including the possibility to register the ICPC-S code
2. Objective (O): The system shall enable the recording of objective data gathered during the clinical encounter, such as vital signs, physical examination findings, and results of diagnostic tests.
3. Evaluation (E): The system should provide an area for healthcare providers to document their assessment of the patient's condition based on the subjective and objective information. This should include any diagnoses made. It should also give the possibility to register the ICPC-E code
4. Plan/Policy (P): The system must allow for the documentation of the healthcare provider's plan for the patient's care, which may include treatments, prescriptions, follow-up appointments, referrals, patient education, and other therapeutic interventions.		XX
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3. Medication Management: The system shall provide fields for recording current and past medications, including drug name, dosage, frequency, duration, and prescribing physician. It should also allow for the documentation of patient responses to medicationsX
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4. Diagnostic Test Results: The system shall enable the recording and viewing of diagnostic test results, such as laboratory, radiology, and pathology results. It should provide a means for visualizing trends over time.X
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5. Clinical Notes: The system shall allow healthcare providers to add, modify, and view clinical notes and observations.X
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6. Immunization Records: The system shall maintain a record of a patient's immunizations, including the type of vaccine, date of administration, and administering physicianX
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7. Problem List Management: The system shall enable healthcare providers to maintain an up-to-date problem list for each patient, including both acute and chronic health issuesX
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8. Referrals: The system shall have the ability to record referral information, including the reason for the referral, the specialist or institution to which the patient was referred, and any referral notes.X
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9. Health Maintenance: The system shall provide fields for the documentation of preventive care and screenings, such as mammograms, colonoscopies, cholesterol checks, etcX
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10. Security and Compliance: The system shall ensure that all medical record data is stored and transmitted securely. It should provide an audit trail of all access and modifications to the medical record.0X
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11. Interoperability: The system shall support HL7 interoperability standards to allow for the seamless exchange
of information with the Health Information Exchange Platform.		0X
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Clinical Documentation
The Clinical Documentation module in the EHR system shall have the following functional requirements:		AvailableCustomizationDevelopmentComment
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1. Clinical Note Creation: The system shall allow healthcare providers to create, edit, and view clinical notes during a patient visit. These may include medical history, physical examination findings, assessment, and plan.X
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2. Documentation Templates: The system shall provide customizable templates to facilitate standardized and efficient clinical documentation.
X
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3. Coded Data Entry: The system shall support coded data entry, using standard terminologies such as ICPC and LOINC, where appropriate to facilitate interoperability, data analysis, and reporting.
X
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4. Referrals and Prescriptions: The system shall facilitate the documentation of referrals and prescriptions, including medication prescriptions, lab referrals, imaging referrals, etc. It should also support electronic prescribing where possible.
XXX
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5. Integration with Other Modules: The clinical documentation module shall be fully integrated with other system modules, such as the medication management and lab results modules, allowing information entered in these modules to be accessible and referenced within the clinical documentation.X
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6. Clinical Decision Support: The system shall offer clinical decision support tools, such as alerting providers to potential drug allergies, or received lab results outside the reference indicators.XXX
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7. Accessibility and Sharing: The system should allow for the easy retrieval and sharing of clinical documentation with authorized personnel, respecting patient consent preferences and regulatory requirements for data privacy and security0X
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8. Audit Trails: The system shall maintain an audit trail of all entries, modifications, and deletions in the clinical
documentation, including the date, time, and identity of the user who made the change		0X
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Prescription Management
The Prescription Management module in the EHR system shall have the following functional requirements:		AvailableCustomizationDevelopmentComment
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1. Prescription Creation: The system shall allow healthcare providers to electronically generate prescriptions, including the drug name, dosage, route, frequency, and duration of treatment. It should also support free-text instructions for patients.1
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2. Medication Database: The system shall provide a comprehensive list of medications based on the provided catalogues, including drug name, dosages, routes of administration.1
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3. E-Prescribing: The system should support e-prescribing, enabling the direct transmission of prescriptions to the Health Information Exchange Platform.1
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4. Allergy Alerts: The system shall provide alerts for drug allergies based on the patient's medical records1-build1
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5. Medication History: The system shall maintain a medication history for each patient, including current and past medications, over-the-counter drugs, and patient-reported drug use.11
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6. Prescription Refills: The system should allow for easy processing of prescription refills.1X
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7. Prescription Tracking: The system shall track all prescriptions, including their status (e.g., transmitted, filled, picked up, etc.), providing visibility into the patient's medication adherence11
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8. Audit Trails: The system shall maintain an audit trail of all prescription activities, including the creation, modification, and deletion of prescriptions, with a timestamp and the user's identification0
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9. Security and Compliance: The system shall ensure that all prescription data is stored and transmitted securely, in compliance with all relevant regulations.0
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Referral Management
The Referral Management module in the EHR system shall have the following functional requirements:		AvailableCustomizationDevelopmentComment
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1. Referral Creation: The system shall allow healthcare providers to create and manage referrals, including details such as the reason for the referral, the specialist or institution to which the patient is being referred, and any relevant clinical notes1 - Config
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2. Integration with Patient Records: The system shall link referrals to the patient's medical record, ensuring that the referral is connected in the Health Information Exchange Platform and in the future the referred provider has access to relevant medical history, medications, allergies, lab results and other clinical information.1 - Config
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3. Status Tracking: The system has the possibility to track the status of each referral, from creation, through the patient's visit to the specialist, to the receipt of the specialist's report. As the digital transformation for secondary care is a future endeavor this functionality should be included in such a way that status updates are provided through the HIEP.1 - Caution
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4. Referral Communication: The system should support communication between referring and receiving providers through the Health Information Exchange Platform to facilitate coordinated care.1 - Caution
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5. Standardized Referral Templates: The system shall provide customizable referral templates, allowing for standardized and complete referral information, which can improve the efficiency of the referral process and the quality of care received by the patient1 - Config
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6. Audit Trails: The system shall maintain an audit trail of all referral activities, including the creation, modification, and deletion of referrals, with a timestamp and the user's identification.1 - Caution
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7. Security and Compliance: The system shall ensure that all referral data is stored and transmitted securely, in
compliance with all relevant regulations		0
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Decision Support
The Decision Support module in the EHR system shall have the following functional requirements:		AvailableCustomizationDevelopmentComment
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1. Alerts and Reminders: The system shall generate real-time alerts and reminders to inform healthcare providers of potential allergy issues, updated lab results, access of patients health information other than own general practitioner.
1 - Config & Devel
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2. Predictive Analytics: The system shall support predictive analytics to identify patients at risk for specific conditions or adverse events, enabling early intervention and improved patient outcomes. This is primarily focused on the HEARTS protocol where indicators are places on lab results.1 - CautionNot demoable, but support for configurable flags. Eg, Vitals ranges, Lab results (highs/lows...)
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3. Referral Sets: The system shall provide standardized lab referral sets based on best practices for common conditions, which can improve efficiency and consistency in care delivery.1 - Config
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4. Audit Trails: The system shall maintain an audit trail of all decision support activities, including the use of alerts, guidelines, and other tools, with a timestamp and the user's identification.1 - CautionIn Progress
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5. Security and Compliance: The system shall ensure that all referral data is stored and transmitted securely, in
compliance with all relevant regulations		0
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Interoperability
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The Interoperability module in the EHR system shall have the following functional requirements:AvailableCustomizationDevelopmentComment
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1. HL7 Version 2 Support: The system shall initially support HL7 version 2 for the transmission of healthcare data. This includes patient registration, referrals, billing, results reporting, scheduling, and other necessary operations.





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2. Transition to FHIR: The system should be designed with the flexibility to transition to the HL7 Fast Healthcare Interoperability Resources (FHIR) standard in the future. This transition plan should minimize disruptions and ensure continued data accuracy and security during the switch.1
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3. Standards-Based Interoperability: The system shall utilize standard terminologies (ICPC, LOINC, ICD-10, Custom Catalogues, etc.) and data exchange formats to support interoperability with other systems.1
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4. Secure Data Transmission: The system shall ensure the secure transmission of data, including encryption and other security measures, to protect patient information during transit.0
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5. APIs: The system shall provide APIs to allow the Health Information Exchange Platform to interact with the EHR data securely, enabling the update of catalogues, exchanging messages and other functionalities.1
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6. Audit Trails: The system shall maintain an audit trail of all data transmissions, including the source, destination, date, time, and user, to support data integrity and accountability1
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7. Regulatory Compliance: The system shall ensure that all data exchange activities comply with relevant
regulations,		0
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This document has outlined the functional requirements for the proposed Electronic Health Record (EHR) system, in alignment with the EHR Due Diligence & Data Requirement Document published by the Ministry of Health Suriname in February 2023. These requirements span several key modules, including Patient Registration, Medical Records, Clinical Documentation, Prescription Management, Referral Management, Decision Support, and Interoperability.0
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The requirements laid out in this document are designed to ensure that the EHR system will effectively serve its users, which includes healthcare providers, patients, administrators, and support staff. By addressing their unique needs and workflows, the system can enhance the delivery of care, improve patient outcomes, streamline operations, and contribute to overall organizational performance.0
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While we have endeavored to provide comprehensive requirements for the system, we recognize that these requirements may evolve over time due to changes in healthcare practices, technology advancements, regulatory updates, and user feedback. Thus, the EHR system must be designed with flexibility and adaptability in mind to accommodate future changes.1
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The successful implementation of this EHR system, guided by these functional requirements, will be a significant milestone in the journey toward digital transformation of RGD and Medical Mission, ultimately leading to improved health for individuals and communities.0
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