Quyết định 5573/QD-BYT

DECISION

ON ADOPTION OF SOFTWARE CRITERIA AND DESCRIPTION OF SOME MODULES OF HOSPITAL MANAGEMENT SOFTWARE

MINISTER OF HEALTH

Pursuant to the Law on Information technology dated June 22, 2006;

Pursuant to the Government's Decree No. 49/2003/ND-CP dated May 15, 2003 defining the functions, tasks, entitlements and organizational structure of the Ministry of Health;

At the request of the Director of the Department and the Director of Science and Training Department,

DECIDES:

Article 1. “Software criteria and description of some modules of hospital management software” is promulgated together with this Decision.

Article 2. “Software criteria and description of some modules of hospital management software” is promulgated together with this Decision” are applied by hospitals, the institutes that have hospital beds, public and non-public medical facilities.

Article 3. This Decision takes effect from the day on which it is signed.

Article 4. The Chief of the Ministry Office, the Director of Treatment Department, the Director of Science and Training Department, chief inspectors, Directors of other Departments affiliated to the Ministry of Health, Directors of hospitals and the institutes that have hospital beds affiliated to the Ministry of Health, Directors of Services of Health, and heads of other health authorities are responsible for the implementation of this Decision./.

SOFTWARE CRITERIA AND DESCRIPTION OF SOME TYPES OF HOSPITAL MANAGEMENT SOFTWARE

I. CRITERION HOSPITAL MANAGEMENT SOFTWARE

1. Managerial criteria

a) The development and application of hospital management software must be invested in accordance with law and current regulations of the Government.

b) The management process of the hospital management software must satisfy the requirements of the Hospital regulations promulgated by the Ministry of Health.

c) The information and forms in the software must be consistent with the system of report forms and medical records promulgated by the Ministry of Health in terms of data structure.

d) Match the lists, the medical services, diagnostic tests, operations, procedures, etc. must be conformable with those complied by the Ministry of Health in order to ensure the consistency between expertise, statistics, and payment of hospital charges. Avoid entering one piece of information multiple times in the hospital.

dd) Prices of medical services, diagnostic tests, operations, procedures, medicines, consumed materials, etc. must be managed in accordance with current regulations of the Ministry of Health and Social Insurance Office The prices of services provided by the hospital must be reasonable and transparent.

e) Statistics and medical records shall be managed in accordance with regulations of the Ministry of Health.

2. Technical criteria

a) The software is able to connect with Medisoft 2003, or able to print reports and export data according to the standards for hospital statistics of Medisoft 2003 introduced by the Ministry of Health.

b) The software is able to connect with health insurance payment software or able to print and export data at the request of Social Insurance Office.

c) The software ensures the safety and confidentiality of information; the software is able to classify and verify users, able to supervise every user’s work and prevent unauthorized access. The security system consists of at least 03 layers: system, database, and application.

d) Font: UTF-8 Unicode fonts only.

dd) Regarding operating systems, database, and programming languages:

dd) The software should be compatible with free operating systems and free database management systems.

Able to backup and restore data.

Able to solve database problems.

Able to prove the copyright of the programming language.

Able to ensure the truthfulness and consistency between the database and statistics.

e) The hospital management software must be designed towards openness that is convenient for maintenance and future upgrade.

f) It is recommended to apply advanced technologies to the development of hospital management software;

g) Some lists applied to hospital management software:

List of administrative codes promulgated by General Statistics Office.

List of hospital codes promulgated by the Ministry of Health.

List of initial medical facilities of patients having health insurance promulgated by Social Insurance Office.

Patients codes: decided by each hospital.

Medical costs, medical record costs: decided by each hospital.

Drug substance codes according to Anatomical Therapeutic Chemical Classification System by WHO.

Antibiogram according WHONET.

International Statistical Classification of Diseases and Related Health Problems (ICD10).

h) Some database standards applied to hospital management software:

International standards for medical data exchange (HL7).

If the software does not support HL7 standards, the provide must make a written commitment to provide technical documents or assist the hospital in connecting with other software systems of the hospital, the Service of Health, and the Ministry of Health.

Standards for image exchange: Digital Imaging and Communications in Medicine (DICOM).

Standards for image management: Picture Archiving and Communications Systems (PACS).

II. SOME MODULES OF HOSPITAL MANAGEMENT SOFTWARE

1. Diagnostic ward management modules

The diagnostic ward management module is meant for managing administrative information and diagnosis information of patients that are used for the whole hospital management software system and for the next examinations

a) Patient admission management:

Generating patient codes must be so generated in a way that avoids repetition and every patient has only one code that can be used for the next examinations.

Managing administrative information according to the medical record forms provided by the Ministry of Finance, including:

Information about the patient’s identity: full name, date of birth (or age), address/block/neighborhood - ward/commune/street/ - district - province.

Information about the patient: whether the patient is exempt from charges, covered by health insurance, from a poor household, under 6, etc.

Information about the patient’s insurance (at the request of Social Insurance Office): insurance number, initial hospital, expiration date, initial issuer, reason for examination

Information about the transferor facility: code, name, etc.

b) Sickroom management

Managing patients’ diagnoses according to ICD10 (4 digits): medical histories, previous diagnoses, diagnosis of primary diseases, comorbidity diagnoses.

Managing information about medical examination: time of examination, names of physicians, names of the clerks.

Managing the orders for diagnostic tests and treatments.

Managing prescriptions at the clinic; printing and retaining prescription

Managing information about physicians’ decisions: giving prescriptions, ordering outpatient treatments and hospitalization, transferring patients, etc.

Print examination notes for inpatients using the forms provided by the Ministry of Health.

c) Outpatient management.

Managing medical records of outpatients.

Managing the orders for outpatients.

Counting the number of days of outpatient treatment.

d) Management of inpatients at the diagnostic ward.

Managing professional activities

Managing the treatment services at the diagnostic ward.

dd) Management of diagnostic tests for outpatients (see diagnostic test management)

e) Pharmacy management at the diagnostic ward (see Pharmacy management)

2. Clinical/inpatient management module

a) Management of patients’ information

Managing administrative information according to notes of hospitalization and the forms of medical records provided by the Ministry of Finance.

b) Management of medical information

Encoding diseases according to ICD10 (4 digits).

Managing sufficient information about diagnoses: previous diagnoses; clinical diagnoses, diagnoses of causes, comorbidity diagnoses, medical histories; diagnosis of primary diseases upon hospitalizations, intrahospital transfers, and discharges; diagnoses of death; post-mortem diagnoses.

c) Management of information about the wards and hospital beds

Managing hospital beds: number of beds, types of beds, prices, and transfers of patients.

Intrahospital transfers of patients.

Discharges and hospital-to-hospital transfers of patients

d) Management of information about operations and procedures

Scheduling the operations and procedures: name, time of operation, primary surgeon, anesthetist and other participants; types of operations or procedures and their prices.

Managing information in the operation record, operation and procedure results.

dd) Statistics management

Exporting statistics on treatment according to 11 statistical forms of the hospital.

Exporting the reports at the request of social insurance office and other entities (if any).

Exporting statistics at the request of the hospital.

3. Diagnostic test management module

The application of diagnostic test management module is subject to the capacity and intelligence infrastructure of the hospital. Manage the orders for diagnostic tests (calculate hospital charges), diagnostic test results (serving professional activities and electronic medical records), connect with testing machines to export results directly. This is a complicated module that requires connection with other modules such as diagnostic ward management, inpatient treatment management, storage management, and revenue management.

a) Management of diagnostic tests

Using the names in the list of diagnostic tests of the Ministry of Health in the “Medical record forms” to harmonize medical management and financial management, synchronize the health insurance price list and service price list, including:

- List of biochemical, hematological tests, cytological, microbiological, pathological tests, etc.

- List of function tests: ECG, EEG, cerebral blood flow; immunology, etc.

- List of medical imaging tests: x-ray, endoscopy, ultrasound, CT-Scanner, MRI, etc.

b) Management of diagnostic tests for outpatients

Managing the orders for testing from the diagnostic ward: patients’ codes, names, indicating departments; names, dates of tests; names of ordering physicians, etc.

c) Management of diagnostic tests for inpatients

Managing the orders for diagnostic tests of every patient.

Managing diagnostic test results of patients.

Monitoring the complications during diagnostic tests.

Transmitting data such as films, pictures, and sounds of patients, and acquisition of information from diagnostic equipment (if any).

d) Management of results of diagnostic tests at the testing ward and medical imaging ward.

Allowing the update, storage, and display of diagnostic test results produced by diagnostic wards together with patients’ records.

Providing personal and clinical information about patients.

Providing information about the wards and the physicians that order diagnostic tests.

Providing information about diagnostic test results: names of the tests, time of order, time of sampling, time of testing, names of diagnostic technicians, test results, time of result, typists, etc.

- Connecting to diagnostic equipment to receive results directly.

dd) Management of diagnostic test prices (see Revenue management)

e) Management of supplies and chemicals serving diagnostic tests (see Management of pharmaceuticals, supplies, and chemicals for diagnostic tests)

f) Statistics management and data export.

Exporting data using the in the forms of diagnostic test statistics (about medical imaging and testing).

Exporting statistics at the request of hospital managers

4. Pharmacy management module

a) Management of information about medicines and supplies

Establishing norms for consumption of medicine and supplies.

Managing information about expiration dates of medicines; make a table to monitor expiration dates and issue warnings of the medicines expire soon.

Satisfying the demand for medicine recall at the request of the Drug Administration of Vietnam.

Developing a medicine dictionary.

b) Management of medicine delivery at the medicine storage

Designing a system of list serving medicine delivery. Providing an interface to enter information about creation, adjustment, or removal of each of the aforesaid lists.

Providing an interface to enter information about the inflow of medicines: medicines from suppliers, medicines returned by the wards and departments, medicines prepared by the hospital, including the information required by the Ministry of Health.

Providing an interface to enter information about the outflow of medicines: medicines returned to suppliers, medicines dispatches to separate storage, etc., including the information required by the Ministry of Health.

Providing an interface to compile lists of medicines and supplies that are used for precautions against epidemic, liquidated, lost/damaged/broken, etc. The software shall be designed to examine each of these cases according to the lists and issue corresponding records.

c) Medicine dispensary management

Providing an interface enter information about dispensing prescription medicines to patients; separate covered patients and outpatients patients; copies of outpatient records must be made whenever necessary.

The software program must be able to estimate medicines online for inpatients according to their medical records. The software must be able to separate medicines for treatment and medicines for cabinet replenishment.

Developing a mechanism for returning medicines when patients die, change medicines, or leave the hospital without permission, etc. receiving returned medicines, and making notes of medicine returns from the wards and departments.

d) Criteria for inventory management and medicine dispensing

Medicines must be dispensed according to their expiration dates (first in - first out rule).

Medicines must be sorted by funding source such as internal budget, health insurance, aid, etc.

The software must be able to quickly and accurately aggregate and report information about the inventory.

A search engine by various criteria must be available.

The forms and books printed by the software must be conformable with the Pharmacy Regulation.

The software must be able to export the forms and statistics on about hospital pharmacy according to the statistics system, which is established by the Ministry of Health. Other forms of statistical reports must be available at the request of the Service of Health or the hospital.

5. Health insurance and revenue management module

The health insurance and revenue management module plays a decisive role in the efficiency of the hospital management software. This module is connected with all other modules such as diagnostic ward management; testing, inpatient management, pharmacy management, etc., installed at the finance department and billing posts around the hospital. It is recommended to use only one software program for health insurance billing management, avoid collecting information repetitively for the convenience of patients.

a) Uniform management of the list of medical services

Ensuring the uniformity of the names of medical services in order to harmonize medical management and financial management. Using the names, codes of procedures and operations in the lists compiled by the Ministry of Health; using the names and codes of diagnostic tests (including testing and medical imaging) in the lists compiled by the Ministry of Health.

Managing prices of medical services: clinical services, diagnostic tests, operations, procedures, drugs, supplies, etc. in accordance with regulations of the Ministry of Health and Social Insurance Office.

b) Disclosure of expenditure on patients

Allowing calculation of hospital charges incurred by any patient at any time, regardless of method of payment.

c) Managing patients’ receipts and expenses, including:

Patients that pay directly:

Patients that pay indirectly: patients having covered by health insurance in part or in full; children under 6.

Patients that are exempt from fees: beneficiaries of incentive policies, the poor. The total exempted fees must be calculated.

Other fee payers (if any).

d) Management of charges for outpatient services

Managing the collection of hospital charges from outpatients at the diagnostic ward: charges for examination, diagnostic tests, operations, procedures, and other treatment services at the clinics.

dd) Management of charges for inpatient services

Managing advance payments (made by the patients that pay directly).

Managing treatment costs: medicines, blood, fluids, bed, operations, procedures, diagnostic tests (testing, medical imaging).

Disclosing patients' finance everyday; allowing calculation of treatment costs of patients at any time.

Printing receipts and invoices according to set forms.

Managing the costs of high-tech services covered and not covered by health insurance.

e) Management of hospital charges incurred by holders of health insurance cards.

Managing the costs of high-tech services covered and not covered by health insurance (paid by patients).

Printing reports and exporting detailed information about medical costs incurred by holders of health insurance cards in the formats required by Social Insurance Office. Information about the policyholders of the medical examination and treatment facilities shall be verified by social insurance officials and transferred to the provincial Social Insurance Offices.

f) Printing invoices and financial statements

Printing designed receipts (subject to the hospital).

Printing reports on collected hospital charges, including reports on hospital charges at clinics; reports on advance payments, temporary charges, and payments upon discharge.

Exporting data and printing statistics on hospital charges and health insurance using the set forms.

6. Payroll and HR management module

a) HR management

Managing employees’ profiles

Managing employee training process.

Managing contract information.

Accessing the biography of every employee and manager (work experience, education, family, overseas activities).

Managing statistical reports: printing and exporting HR reports using the form provided by the Ministry of Health and reports on other issues (e.g. average age of hospital or ward personnel, average wage of the hospital or ward, etc.).

b) Social insurance and payroll management

Managing the wages and benefits of every employee.

Social insurance management: List of employees and social insurance fund; social insurance payment table for comparison; list of adjustments to social insurance rates.

Monitoring time and attendance, including monthly attendance, overtime work, operations - procedures, nightshifts, etc.

c) Statistics management

Managing information and print the statistics at the request of finance authorities e.g. payroll table, timekeeping table, etc.

Some common forms of reports in payroll and HR management software: employees’ profiles, list of employees, employees’ work experience, list of employees that have quit, personnel statistics, employment registration, list of employers that wish to sign labor contracts, list of employees that wish to keep the social insurance books, list of employees that ask for a raise, personnel and payroll statistics, reports on personnel quality of every department, reports on number of employees holding managerial positions, reports on the list, payroll, and quality of officials and civil servants, reports on salary scales, report on contraction or extension of the payroll and salary fund, the list and result of salary scale increase (according to the Ministry of Health) reports requested by the hospital, and summary report to the Ministry of Health (Medisoft 2003)

7. In-line service management module

Ma provision of training for inferior facilities.

Managing initial health care and periodic check-ups at inferior facilities (if any).

Managing medical programs (if any).

Managing reports of the above tasks.

8. Medical equipment management module

Compiling a list of medical equipment of the hospital. Designing a system of lists of medical equipment serving the purchase, sale, and allocation of equipment. Providing an interface to enter information about creation, adjustment, and removal of each of the aforesaid lists.

Managing information about the condition of medical equipment; export reports on current condition of medical equipment.

Providing an interface to enter information about new equipment and equipment returned by the wards and departments.

Providing an interface to control the allocation and circulation of medical equipment among the wards and departments, and beyond the hospital. Providing an interface to enter information about equipment maintenance and repairs. Identifying the cases of repairs or upgrades in which equipment value is increase as the basis for depreciation.

Providing an interface to compile a list of equipment that needs liquidating and to liquidate equipment.

Updating every information about the management procedure established by the Ministry of Health or the Service of Health.

Automating the calculation; enabling users to search by various criteria.

The statistical reports exported must be conformable with the forms provided by the Ministry of Health.

Statistics must be produced at the request of the Service of Health or the hospital.