A proposed architecture for ambulatory systems development.

We have developed an architecture and application framework known as the Ambulatory Services Architecture (ASA) for computerized management of patient records for ambulatory care. Our primary design goals included the development of an architecture that will be readily adaptable to advances in technology needed to enhance computerized patient record systems (e.g., multimedia, human-computer interfaces such as voice-to-text, and a fully distributed objects, etc.) and a data model and database implementation capable of providing the flexibility and extensibility needed to support a broad spectrum of specialty medical practices. This report describes the data model, access control, and the client/server components of the Ambulatory Services Architecture.

Collaborative social and medical service application.

Baylor College of Medicine has five Teen Health Clinics (THC) dispersed throughout Harris county. The population served by the clinics includes inner-city adolescent boys and girls 19 years of age and under. Patients receive services such as family planning, sexually transmitted disease screening and treatment, perinatal care, counseling, and support services. Adolescents may receive services at any one of the clinics at no cost to the adolescent or their dependents. Given the geographical distribution of the clinics and the reliance on paper-based records, client services cannot be provided efficiently or expeditiously. According to the statistics developed by Clinic staff, ineffective coordination of service needs and client schedules undermine the follow-up needed for effective care. For example, a counselor will often need to balance a school schedule, clinic visits, well baby follow-up, and the Best Friends Program for a new mother. In addition, the lack of ready access to patient information impairs the ability of clinical and social service staff to provide continuity of care. In fact, some cases of client dropout are attributable to these difficulties. We have developed the Collaborative Social and Medical Service Application (CSMSA) to facilitate the provision of social and medical services to this population. The CSMSA is a domain-specific application based on a robust infrastructure known as the Ambulatory Services Architecture (ASA). This system is designed to support integrated social and ambulatory care. The ASA is a Baylor developed application framework and architecture for the computerization of the patient medical record in the ambulatory care setting. The working environment for the CSMSA user is an integrated desktop which provides an operating environment for both third-party applications and the CSMSA, as well as a fundamental set of services. The integrated desktop services include a mechanism for object organization or grouping, a facility for the management of desktop objects including disposal and storage, and an embedded search utility to assist in the location of desktop objects as well as other application objects. The access control mechanism will provide the security for the desktop environment by requiring the user to log into and out of the environment. This security mechanism will also enable/disable CSMSA tools based on the user's role at the clinic. The CSMSA is designed to provide work process, functionality and data access appropriate to the responsibilities of the user, e.g., a THC clerk may have permission to view a patient's orders but does not have the facility to create an order. Patient context is defined through a patient browser containing the master patient index or a user defined patient list. Patient encounters are managed using forms based on the process for each encounter type (e.g., initial visit). Forms are used for data entry and for queries. Data entry forms are only committed to the patient database (i.e., making the patient data available to other users who have permission to access the data) when the user approves the data. The CSMSA provides a means to suspend an entry into a chart by saving incomplete or non-committed data entry forms as part of the desktop state which is restored when the user logs into the system. CSMSA was designed to provide a robust, expandable application capable of accommodating the changes in health care and social services delivery while encompassing evolving software standards and new technology. This goal was achieved using object-oriented methodologies and technologies, combined with an object-oriented database management system as the foundation of our server to facilitate the evolution of our data model.

Analysis, requirements and development of a collaborative social and medical services data model.

In any medical and social service setting, patient data must be readily shared among multiple providers for delivery of expeditious, quality care. This paper describes the development and implementation of a generalized social and medical services data model for an ambulatory population. The model, part of the Collaborative Social and Medical Services System Project, is based on the data needs of the Baylor College of Medicine Teen Health Clinics and follows the guidelines of the ANSI HISPP/MSDS JWG for a Common Data Model. Design details were determined by informal staff interviews, operational observations, and examination of clinic guidelines and forms. The social and medical services data model is implemented using object-oriented data modeling techniques and will be implemented in C++ using an Object-Oriented Database Management System.

The development of a data security model for the Collaborative Social and Medical Services System.

This paper presents the development of the Collaborative Social and Medical Services System's (CSMSS) data security mechanism. This mechanism was synthesized from an analysis of the CSMSS problem domain, and from a study of the methods used by modern operating systems and database management systems. The resulting mechanism is more flexible and expressive than traditional access control methods and is generally applicable to the management of privacy and multi-provider access.

The development of a client application for the collaborative social and medical services system.

This paper describes the design and implementation of a client application for the Baylor College of Medicine Teen Health Clinics. The application is the front end to the Collaborative Social and Medical Services System (CSMSS) under development by Baylor's Medical Informatics and Computing Research Program [8]. The application provides distributed access to an underlying object oriented database system. A process driven and patient centered design will provide staff members with a complete set of services, including forms for data entry and viewing, query, and access management to facilitate efficient and effective delivery of services. Role-specific interfaces will be supplied for clerks, nurses, nurse practitioners, physicians, and social workers. The client application is being designed using object oriented methodologies and technologies with the C++ programming language, and will operate within a Microsoft Windows operating environment utilizing Object Linking and Embedding for application interoperability.

Collaborative Social and Medical Service System.

This paper describes the Collaborative Social and Medical Services System, a robust information infrastructure for integrated social and medical care. The Collaborative Social and Medical Services System design and architecture address the primary goals of creating a readily extensible social and ambulatory care system. Our initial step toward reaching this goal is the delivery of an application supporting the operations of the Baylor Teen Health Clinics. This paper discusses our prototype experiences, system architecture, components, and the standards we are addressing.