SAP is-H Functions in Detail - R3 System - Hospital Information System
Functions in Detail - IS-H ®
R/3 System Hospital Information System
Current Challenges Facing Hospitals
Current Challenges Facing Hospitals The hospital of today faces dramatic structural changes in the healthcare field. As a result, there are numerous requirements as well as new opportunities for successfully managing the hospital of the future, such as:
Structural Changes in Healthcare
❑ Competition between hospitals and the burden of financial risk shift from insurance companies to healthcare provider leading to the need for better internal controlling of hospital processes.
Competition between Hospitals and Risk Shift
❑ Constant change of legislative requirements regarding charges leading to short possible reaction times for their fulfillment.
New Types of Charge
❑ Larger hospital organizations with the need for better information structure. ❑ Increased integration of inpatient and outpatient treatment (such as pre-admission and post-discharge treatment, outpatient surgery) and clinical and administrative tasks in hospitals.
Integration of Inpatient and Outpatient Treatment
❑ Outdated technology infrastructure leading to high maintenance effort, reduced scalability and slow changes in the information infrastructure.
A critical component for meeting these requirements is the use of a hospital-wide information and communications system which consistently reflects and offers integrated support for the processes involved in providing support for all administrative business processes in hospitals, whether they are performed in the administrative department or by nurses and doctors. A tight integration component with departmental systems is also provided.
Integration of Medical Care, Nursing Care and Administration
In partnership with hospitals and competent system houses, SAP AG has developed such a leading-edge hospital information system which meets these modern requirements and which has demonstrated its capabilities and reliability in numerous customer installations. This system will be presented in the following chapters.
SAP Hospital Information System
SAP Hospital Information System
SAP Hospital Information System SAP Hospital Information System Components This brochure describes the architecture and performance features of the Industry Specific solution for Hospitals (IS-H). It provides a leading-edge, patient-oriented Hospital Information System when used together with the standard SAP business applications for: ❑ Financial Accounting ❑ Assets Management ❑ Controlling ❑ Material and Inventory Management ❑ Maintenance Management ❑ Human Resources Management
Fig. 2-1: The SAP Industry Solution for Hospitals
SAP Hospital Information System
Overview of the Standard SAP Business Systems The standard SAP business systems included in the healthcare industry solution offer the following functions (for more detailed information see the brochures describing the functions of the individual modules). If you want direct information on the patient management and accounting part, please proceed to Chapter 3.
Financial Accounting Uniform Database
The financial accounting applications use a uniform database for general ledger and sub-ledger accounting which is also an important prerequisite for integrating financial accounting and controlling.
Common Chart of Accounts
At the core of this database is the shared chart of accounts which is flexible and can easily be adapted to the needs of individual hospitals. Single documents are used to enter and store all posting transactions in financial accounting. These documents contain both the data for general ledger and sub-ledger accounting and account assignment information for controlling and allow integrated and interactive processing by simultaneously updating all financial accounting and controlling data. You can display the latest financial accounting data such as account balances, profitability analyses, or key figures. In addition, you can retroactively display any document with all document lines and additional account assignments or key data for interactive review of business transactions. In addition to general ledger accounting, financial accounting offers the following functions:
Document Principle Integrated Interactive Processing Real-Time Processing
❑ The Accounts Receivable module handles the traditional tasks of accounts receivable management (open items, incoming payments, dunning, etc.). An accounts receivable master record is created from Patient Management for each patient with payment transactions and for each insurance provider (e. g. health insurance companies). This master record tracks open items and integrates down payments and copayments.
❑ The Accounts payable module maintains and manages the accounting data for all vendors and integrates them with the purchasing functions of the Materials Management System.
❑ Financial Controlling is a tool for short-, medium- and long-term liquidity planning with electronic banking support.
Financial Assets/ -Inputs Funds Management Consolidation
❑ Management of financial assets and inputs. ❑ Funds Management for planning and controlling budgeting and funds utilization with active availability control. ❑ Consolidation to generate consolidated financial statements.
Financial Accounting is a real-time system independent of charts of accounts which is set up based on the documentation principle. It offers fully integrated sub-ledger accounting and extensive functions.
SAP Hospital Information System
Asset Management A look at balance sheets and capital spending lists confirms the importance of fixed assets for today’s hospitals: medical equipment and devices, physical plant and technical equipment represent a steadily increasing percentage of a hospital’s physical and liquid assets. The SAP Asset Management System covers the complete life cycle of fixed asset items and contains all functions necessary to comply with government regulations:
Compliance with Legal Requirements
❑ The Investment Management module integrates planning and control of capital with asset accounting. It allows alternative profitability calculations, budgeting of capital investment projects and monitoring adherence to budgetary limits.
❑ The Asset Accounting function records, calculates and processes acquisitions and retirement of assets, repostings, depreciation and write-ups. You can apply the legally mandated valuation methods as well as define and apply multiple depreciation and valuation methods for internal cost accounting. These include preliminary invoicing and interactive simulation to analyze the effects of parameter changes in such areas as depreciation methods. The Reporting module allows controlling-oriented evaluation of key figures and rankings of relevant objects in addition to government mandated reporting.
Preliminary Invoicing Asset Information System
In the overall model, Asset Accounting is the sub-ledger accounting part of the Financial Accounting System and is also fully interactive. The Asset Accounting System is integrated not only with Financial Accounting, but also with the Cost Accounting and Materials Management Systems.
Integrated Interactive Processing
The options available in the system provide appropriate support for handling hospital-specific financing problems.
Support of Hospital Specifications
❑ Technical Assets Management is used to administer and manage maintenance orders. The features of this module include planning, entering actual data, cost evaluation and settlement for common maintenance orders. For complex, one-time maintenance orders a project system can be used, which is part of Asset Accounting and provides advanced resource planning functions.
Technical Assets Management
Integrated assets management allows you to meet legal requirements. In addition, it can be used for planning and control of capital investment projects, detailed analysis of all assets and for technical assets management.
SAP Hospital Information System
Controlling Centralized Controlling Tool
Controlling is generally understood to mean the hospital-wide control of all measures for optimizing profitability. This requirement can only be met by using a comprehensive cost and income controlling system. The SAP Controlling System offers the following tools:
Cost Element and Cost Center Accounting
❑ Cost element and cost center accounting for short-term planning and control related to specific areas.
Order and Project Cost Accounting Cost Object Controlling
❑ Order and project cost accounting for the ongoing control and analysis of resource utilization.
❑ Profitability analysis analyzes hospital services provided based on sales, costs, and contribution margins with multiple summaries to show the results for individual service groups.
Profit Center Accounting
❑ Profit center accounting generates periodic results analyses for individual service areas of the hospital.
Executive Information System (EIS)
❑ The Executive Information System (EIS) is a flexible and easy-to-use system to enter and process hospital-wide information from all functional areas.
Integration with Financial Accounting, Logistics and Human Resources
The efficient implementation of meaningful cost and profitability controlling requires both the complete integration of the individual Controlling modules and the integration between Controlling and Financial Management, Assets Accounting, the Logistics Systems of Materials Management and Maintenance, Human Resources Management and in particular the hospital-specific patient accounting systems, service communication and medical documentation. Cost object controlling without complete, process-oriented integration between Controlling and Patient Management is simply not possible, since the Patient Management module maps all patient-related processes involved in providing hospital services.
Integration with Patient Management Interactive, Various Cost Accounting Systems Flexible Information System
❑ Cost object controlling is used to plan and control costs and revenues from hospital services, such as procedures surcharges, flat rates per case, or departmental per diems.
The SAP Controlling System is interactive and supports the simultaneous operation of various cost accounting systems, from actual cost accounting to flexible planned cost accounting. It offers a comprehensive, flexible reporting and information system with which the displayed values can be traced back to the single document. The government mandated cost accounting reports can be generated very easily.
The SAP Controlling System makes it possible to implement a meaningful cost and service analysis including detailed cost object controlling.
SAP Hospital Information System
Materials and Inventory Management The Materials Management System facilitates fully integrated processing of all logistic transactions in the central warehouse and pharmacy utilizing the following functions:
Central Warehouse and Pharmacy
❑ Consumption-based materials planning according to the reorder point procedure or based on forecasts.
Material Requirement Planning Purchasing
❑ Purchase processing from requests for bids to vendor selection and monitoring of order placement. ❑ Stock and warehouse management with online display of the processes affecting stock (goods received, stock removal, stock transfers, stock corrections, etc.) with the option of managing various warehousing structures as well as inventory management.
Stock and Inventory Management
❑ Largely automated invoice verification.
Invoice Verification Inventory Controlling
❑ Inventory Controlling with variable evaluation options. The components of Materials Management are fully integrated into Financial Accounting and Controlling. This means that value-based stock is updated at the same time as quantity-based stock. In addition, material consumption data and the corresponding account assignment (e.g. to a cost center or to an order which is related to a cost object) are transferred directly to Cost Accounting. Based on this data, you can perform detailed analyses of medication utilization, either for each nursing station (ward) or cost center and, if the controlling system is configured accordingly, also for each cost object.
Integration of Financial Accounting and Controlling Analyses of Medication Utilization
The Materials Management System integrated into Financial Accounting permits efficient purchasing and inventory control as well as detailed consumption analyses.
Maintenance Management Maintenance has gained in importance with the increasingly high-tech nature of hospitals. The (Plant) Maintenance System (PM) provides extensive tools which enable you to meet all requirements in this area, from management of non-patient technical and medical equipment to maintenance planning and processing and closing of maintenance work orders. The system also includes extensive analysis capabilities that provide up-to-date overviews of the status and history of technical objects. This module is an integral part of the SAP system, which means that data regarding the cost of maintenance work orders flows directly to Controlling and Asset Management.
Maintenance Planning Maintenance Orders Comprehensive Analysis Options
The Maintenance System is suitable for general maintenance and processing for the entire technical structure of the hospital.
SAP Hospital Information System
Human Resources Common Functions High Degree of Flexibility Integration into Financial Accounting and Cost Accounting Personnel Planning
Recruitment Personnel Data Management Shift Planning Time Recording
The SAP Human Resources System covers all aspects of human resources management, from the selection of applications to master data administration, shift planning, time management and payroll procedures and further education and training planning. The system is flexible and can easily be adapted to legal and pay scale requirements and to specific situations such as internal company agreements. Like all SAP systems, it is completely interactive: all functions are available online and fully integrated with other SAP modules. Payroll as well as travel expense data is transferred automatically to Financial Accounting and Cost Accounting. Specifically, the Human Resources System covers the following areas: ❑ Personnel planning (organization and position descriptions, qualifications and requirements, planning and management of further education and training measures, etc.) ❑ Applicant management and selection ❑ Personnel data management (flexible definition of subject matter and functional processes) ❑ Work schedule and shift planning ❑ Time recording and evaluation
❑ Flexible payroll accounting
Trip Costs Accounting
❑ Travel expense accounting
Statements Suitable for the Public Sector
❑ Statements and numerous evaluations and statistics The system is suitable both for private enterprises and the public sector.
The Human Resources System supports all personnel aspects including payroll and reporting for private enterprises and the public sector.
The IS-H Architecture
The IS-H Architecture Structure and Components of the Hospital-Specific IS-H System The hospital-specific IS-H system supports all aspects of patient management. As the central component of the SAP Hospital Information System it manages the (relational) patient database which contains integrated data for administrative, medical and nursing purposes.
Integrated Patient Database
The IS-H system currently includes the following application components:
IS-H Application Components
❑ Patient Management (inpatient, outpatient)
❑ Patient Accounting (inpatient, outpatient)
❑ Hospital Controlling
All IS-H application components are based on a universal data model which is part of the central R/3 data model and ensures full integration with the other SAP standard systems.
Universal Data Model
Data Model The SAP Hospital Information System utilizes a hospital-wide data model. The system formally maps all relevant data structures within the hospital, such as patients, cases, diagnoses, services, invoices, etc. and the relationships between them. For data modeling, an advanced version of the classical entity relationship model (ERM) which increases the transparency of large data models as they are required for comprehensive, integrated information systems is used.
Hospital-Wide Data Model
Modeling of the data structures within a hospital is an important step in the development of a hospital information system, because it forms the basis for a logically designed, flexible, fully integrated, and fully functional system. In addition, the availability of a data model with open data structures facilitates the subsequent implementation of the system and any necessary enhancements.
Essential Development Basis Open Data Model as Implementation and Enhancement Tool
Excluding the partial-data business models of the complete SAP Hospital Information System, the IS-H data model consists of approximately 150 entities which ensures a sufficiently realistic system (see the IS-H data model excerpt in the appendix of this brochure).
Realistic Data Structure
Entity Relationship Model
The IS-H data model is: ❑ Patient-oriented In contrast to a strictly case-oriented approach, multiple cases (inpatient, outpatient, observation patient) can be assigned to a patient, and corresponding movements (admission, transfer, discharge, leave of absence, outpatient visits) can be assigned to these cases, which provides a comprehensive picture of the patient including all relevant data.
Patient as Central Object
The IS-H Architecture
The IS-H data model takes account of the integration requirements of a hospital information system with regard to:
Integration between Administration/Medical Care
❍ Integration between outpatient and inpatient areas to ensure transparency between these treatment types.
Integration between Nursing Station/Outpatient Clinic
❍ Integration of administrative, medical and nursing requirements by providing a patient-oriented data model with all relevant data to avoid duplicate data entries and redundancies.
Integration between Patient Care/Business Administration
❍ Integration of patient-related and business-related aspects to utilize patient-related information as a basis for charge determination and hospital controlling. ❑ Realistically structured
Flexible, Linked Hospital Structures
The hospital structures are depicted in a flexible and realistic manner; the building structure and cost center structures are represented and linked together as different views of a hospital rather than combined in an unstructured representation. ❑ Implemented in a relational database
Open Relational Structures
All data model objects and their attributes are stored in open tables of a relational database which is described in a central repository and is included in each R/3 system delivered to the customer.
Functional Structure IS-H currently contains the following application components: ❑ Patient Management
❑ Patient Accounting
❑ Hospital Controlling
These components provide the following main functions:
Patient Management (IS-HPM) ❑ Patient Movement
Movement-Related Processing of Patient, Case, and Movement Data
Movement-related processing of patient, case and movement data for inpatient or outpatient admissions, outpatient visits, pre-admission and post-discharge treatment, transfer or discharge and for the admission of companions and newborns.
The IS-H Architecture
❑ Patient Master Data Processing the specific, system-wide patient master data for each patient. This patient master record is the basis for all further patient-related inpatient and outpatient information.
Managing the Patient Master Data
❑ Case Data Isolated data processing for a specific case such as case information, movements, insurance relationships, services or medical information.
Processing Case Data
❑ Nursing Station Management Planning of beds in an organizational unit which supports beds (such as a nursing station) with the purpose of allocating a bed to a patient, recording nursing categories as a basis for determining nursing acuities and performing additional nursing station-related functions.
Bed Planning Nursing Acuities
❑ Outpatient Department Management Scheduling appointments for outpatient visits based on the availability of required resources (e.g. physician, treatment room) and different types of visits, status management for visits.
Appointment Scheduling for Outpatient Visits
❑ Patient Inquiry Providing patient- or case-related information (such as master and movement data) for one or several specifically selected patients as work lists (e.g. patient list, admission list, nursing station overview). ❑ Forms and Work Organizers
Event-driven output of forms (such as admission forms) and work organizers (e.g. labels, magnetic cards) for a patient based on a preset number and on freely selectable media (e.g. printer, card embosser) depending on the assigned organizational unit. ❑ Medical Record Administration
Event-Driven Output of Forms and Work Organizers
Management and administration of (borrowed) medical records and library management.
Medical Record Administration
Mandatory Patient Medical Information Standardized patient-related documentation of treatment data, in particular diagnoses, risk factors and surgical procedures.
Internal and External Reports
❑ Information Retrieval and Reporting Statistical evaluation of patient and structural data for internal purposes (business policy) and external reporting.
Mandatory Patient Medical Information
IS-HPM covers all patient administration requirements for inpatient and outpatient purposes and supports nursing station and outpatient department management as well as mandatory patient medical information.
The IS-H Architecture
Patient Accounting (IS-HPA) ❑ Insurance Relationships
Patient- and Case-Related Insurance Relationships
Patient- and case-related entry of multiple insurance relationships of a patient with insurance providers, administration of self-pay patients and patients required to make copayment. ❑ Treatment Certificates
Different Types of Treatment Certificates
For outpatient case billing, different types of treatment certificates can be entered and the services performed can be assigned to them. ❑ Service Entry
Case-Dependent and Case-Independent Documentation of Services
Case-dependent and case-independent documentation of services for service billing, service planning, and service allocation in cost center accounting and cost object controlling. Use of a hospital-specific service catalog to represent the range of services for outpatient and inpatient cases. ❑ Insurance Verification
Comprehensive Management of the Insurance Verification Process
Highly automated determination of a customer’s payment obligation (insurance provider, self-pay patient) for case-related, billable services. Managing communication with insurance provider and insurance verification monitoring. ❑ Copayment
Managing copayments integrated into Financial Accounting based on receivable or collection procedures. ❑ Down Payment
Managing Case-Related Down Payments
Entering case-related down payment requests and down payments integrated with Financial Accounting. ❑ Billing
Outpatient and Inpatient Accounting
Billing for billable services related to outpatient and inpatient cases, individually or as a collective invoice for many cases which are determined by case selection (e.g. by case type, patient name, admission and discharge dates, billing status). The module fully supports new charge methods such as flat rates per case, procedures surcharges, basic nursing charges and departmental per diems, outpatient surgery, etc.
Integration with Accounting Accrual and Deferral
Copayments and down payments made by the patient are taken into account, posting records are generated and transferred to Financial Accounting and Cost Accounting. Reversal management and accruals and deferrals are supported. ❑ Information Retrieval and Reporting
Internal and External Reports
Numerous evaluations of the billing and service data for internal purposes (business policy) and external reporting.
IS-HPA provides comprehensive support for entering and billing services performed for outpatient and inpatient cases and their statistical analysis.
The IS-H Architecture
Hospital Controlling (IS-HCO) ❑ Controlling - Master Data Linking organizational units with cost centers, posting rules for assigning hospital services from the services catalog to activity types under Controlling and assignment of preliminary costing to hospital services.
Linking IS-H with Controlling Objects
❑ Cost Center Accounting Posting hospital services performed to the cost centers involved with the option of posting additional statistical orders. Posting profits to profit centers.
Integration of Cost Center Accounting
❑ Cost Object Controlling Posting the costs of case-related, documented hospital services to case-related orders. Extended services such as nursing charges are assigned to the respective time periods. Revenues from a case are also posted to the related order. Order summaries for analysis.
Integrated Cost Object Controlling
IS-HCO provides a link between IS-H and the SAP Controlling System to implement meaningful cost and profitability controlling.
IS-HCM Communication ❑ Asynchronous transmission of patient data to subsystems. Event-driven transmission of patient, case, and movement data to authorized subsystems. Examples of events are the admission, transfer, or discharge of a patient. Profile options determine which subsystems receive which data at what time and the structure of the messages to be transmitted. A protocol converter allows the use of SAP message formats and supports individual communication structures and the use of HL7.
Patient Data Transmission
❑ Asynchronous transfer of service and diagnostic data from subsystems.
Transfer of Service and Diagnostic Data from Subsystems
Automatic transfer of service data and diagnoses from non-SAP systems or a hospital-specific format is supported. ❑ Synchronous admission reporting to subsystems. Express dispatch of data on admitted patients to authorized subsystems. ❑ Synchronous access to IS-H data from subsystems. Synchronous access to IS-H Data such as patients, cases, or services via remote function calls. ❑ External communication with insurance providers
Synchronous Access to IS-H Data Insurance provider
Providing data for transmission or receipt.
IS-HCM supports communication between IS-H and subsystems and insurance providers.
Chapter 4 Basic Data
Basic Data IS-H Basic Data Structure To be able to use the operational functions in IS-H for patient management, billing, etc., you first need to enter the basic data for the hospital in the IS-H System. This data includes firstly information on the hospital structure.
To present the hospital structure in a flexible and realistic manner and to take into account the various informational requirements, IS-H provides the following views of the hospital structure:
Hospital Structure Views
❑ Organizational Structure ❑ Building Structure ❑ Cost Center Structure
Fig. 4-1: Hospital Structures
These structures and the relationships between them are represented in the IS-H System based on each hospital situation. Using different views has the important advantage that the various aspects of the hospital structure can be represented and changed without regard to the other views. When a structure is changed, you only need to adapt the affected links to other structures.
Flexible Representation of Structures
Business Partners Charge Masters Catalogs for Diagnoses, Surgical Procedures, etc.
The basic data further includes the business partners, i.e. the persons or institutions which have a business relationship with the hospital, such as insurance providers or external physicians. Moreover, the IS-H System enables you to store multiple charge masters for service entry and billing as well as many other catalogs. This makes data entry simple and safe (error-free). Examples are catalogs for diagnoses, surgical procedures, risk factors, postal codes, geographical areas, etc. The following figure shows an example of how basic data is used in operational functions.
Fig. 4-2: Basic Data and Operational Functions
As a simple check, a subset of the basic data entered can also be represented graphically (e.g. the organizational structure in an organizational chart).
Hospital Structures Organizational Structure The organizational structure considers an institution strictly under organizational aspects. It defines the various structural units (organizational units) and presents them in a hospital-specific hierarchy.
Each organizational unit can be above other organizational units in the hierarchy. With the exception of the top hierarchy level, each organizational unit can be assigned to exactly one higher-level organizational unit. For example, certain nursing stations are under a department which in turn belongs to a clinic. The number of hierarchy levels is freely definable and is usually based on factors such as hospital size.
User-Definable Hierarchy Levels
In case of multi-specialty bed assignment to an organizational unit such as a nursing station, both the higher-level department and the departments assigning beds are recorded. With this procedure, bed assignment to organizational units can be precisely controlled during admission and transfer.
Multi-Specialty Bed Assignment
The user-definable organizational category (OE category) which is part of each organizational unit specifies the particular tasks of each organizational unit. It determines the basic functions of organizational units of a specific category, such as outpatient treatment or nursing care of patients assigned to an organizational unit. This provides maximum flexibility for representing the organizational structure in IS-H.
User-Definable Organizational Unit Categories
Cost centers and building elements can be assigned to defined organizational structures. Cost centers are required for hospital controlling, building elements for the assignment of beds or rooms to the patients of an organizational unit (e.g. a nursing station). These links - and those of the organizational hierarchy - can be limited to specific time periods so that structural changes can be tracked. The time periods are checked for overlaps and periods when no assignments were made, to the extent this is necessary for data structure consistency.
Assignment of Cost Centers and Building Elements
The organizational structure is used to represent the hospitals organization with as much detail as necessary, independent of all other structures.
Building Structure User-definable building units such as bed locations or rooms, their equipment, availability, position in the hierarchy, and time-based relationships to the organizational structure constitute the building structure of the hospital operation. This is particularly important when planning the use of space (e.g. bed assignment, scheduling of treatment rooms in outpatient departments) based on the assignment of patients to specific rooms.
User-Definable Building Units Planning Basis
User-Definable Hierarchy Structure Concept Includes All Institutions User-Definable Building Unit Categories Equipment Features and Planning Data
The building structure is organized in a hierarchy similar to the organizational structure. The specific hierarchy of building units in a hospital is user-definable. A building unit can be at a higher level than other building units. With the exception of the top hierarchy level it can be assigned to exactly one higher-level organizational unit; a hospital room, for instance, is at a higher hierarchy level than a bed location. While the organizational structure is defined within a specific institution, the building structure includes all institutions so that building units can be shared by several institutions. Each building unit is assigned a category which in turn specifies its purpose. For example, building units must be assigned the types “hospital room” and “bed location” so that a room or bed can be assigned to a patient during his/her stay. Equipment features (room with bathroom, oxygen supply, telephone) as well as planning data (maximum room occupancy, non-availability due to disinfection or construction) can be stored on a time-dependent basis.
Building units, their features and hierarchy, and their assignment to organizational units, are all defined under building structure.
Cost Center Structure Assignment to Organizational Units and Cost Centers
The cost centers and their relationships are defined in the SAP Controlling System CO, which is integrated with IS-H. An assignment to organizational units and cost centers, as described above, is necessary so that the account assignment information (for instance, services of a sending to a receiving cost center) required for Controlling can be derived from the data available in IS-H regarding services provided for a case or an (ordering) organizational unit. (For more detailed information, see the description of the Hospital Controlling module IS-HCO).
One or Several Cost Centers For Each Organizational Unit
In the simplest case, one organizational unit is assigned to exactly one cost center. In case of multi-specialty organizational units (e.g. nursing stations), several cost centers, such as a separate cost center for each assigning department, can be assigned to one organizational unit. Cost accounting and organizational data or analysis views can be defined independently of one another, but are fully integrated provided that the contents of the respective structures match.
The cost center structure is linked with the organizational structure for controlling purposes.
Business Partners The business partner concept allows you to centrally manage the various functions of persons and institutions that have a business relationship with the hospital. The system distinguishes between various functions of business partners based on the type of business relationship. For example, a physician can be both the referring physician and (with respect to financial accounting) the customer. Another hospital may act both as a customer and an employer.
Central Business Partner
Information stored for a business partner is divided into general (function-independent) data (names, address, communication data) and function-specific data.
General and Function-Specific Data
The function-independent data for a business partner is stored centrally and only once. IS-H manages the following business partner functions: ❑ Hospital All hospitals having contact with your hospital, for example, referring hospitals.
Functions of a Business Partner Hospitals
❑ Employers Employers whose names frequently appear can be stored as business partners. The patient’s master record can refer to this employer.
❑ Insurance Providers All insurance providers with which patients have an insurance relationship and their respective data must be entered as business partners. Insurance providers of specific types can be grouped together (e.g. local health insurance fund, employer-specific insurance fund of a district, workers’ compensation associations, welfare agencies). In addition, a central provider can be maintained for billing purposes.
❑ Employees/External Physician Indicators are used to distinguish between employees and external persons, physicians, members of the nursing staff, and other areas. External physicians are marked with an additional indicator.
❑ Customer IS-H Customer provides a link to Financial Accounting where all customerspecific information is managed.
Charge Masters The charge masters which can be stored in the system are the basis of the complete service documentation in IS-H.
99 Different Charge Masters Internal Service Catalog for Service Entry Conversion
A maximum of 99 different charge masters can be stored simultaneously in the IS-H System. The most important charge masters are provided by SAP. The SAP user can change or expand existing charge masters or create completely new charge masters. One charge master should be defined as the internal service catalog to be used for service entry. Services in the service catalog may be converted to one or more services of other charge masters for billing or statistical purposes.
Flexible Basic Structure
Charge masters are basically structured as follows: ❑ Charge Master Columns
User-Definable Charge Master Columns Allows Structural Changes
Each charge master has one or more columns in which the data required for the services of this catalog can be entered. Examples of entries into these columns are charge factors, prices and different cost values. The type and number of columns is specified for each charge master and may be defined based on hospital-specific needs. You can also add columns to existing charge masters. This open system allows you to change the structure of charge masters or adapt them to hospital-specific needs.
Fig. 4-3: Charge Master Structure
❑ Services Multiple services can be stored in each defined charge master. Each service is described by general information and by the respective entries in the columns of this charge master. General data include:
❍ Service and DP number ❍ Name of service ❍ Valuation formula ❍ Charge type ❍ Value-added tax indicator ❍ Maximum length of stay (normal, intensive) ❍ Regular length of stay ❑ The column entries may be related to specific time periods so that charge master histories allow retroactive billing runs and convenient maintenance of charge maters. In addition, each service is only valid for a certain time period. The charge master can contain a great number of heterogeneous services, including: ❍ Nursing, medical or basic services in the outpatient and inpatient area.
Time-Related Column Entries
Different Types of Services
❍ Immediate services such as laboratory or radiology services, or extended services such as nursing services. ❍ Billable or non-billable services. ❍ Controlling-relevant services or services only needed for other purposes. ❍ Objects of Cost Object Controlling such as procedures surcharges or flat rates per case, or services which are not objects of Cost Object Controlling. ❑ The service catalog can be designed to represent all services provided throughout the hospital so that the entered services can be used in all required areas, such as billing for inpatient and outpatient services, service communication, Cost Object Controlling , or documentation.
Service Catalog as HospitalWide Charge Master
❑ Service Groups Services can be combined in service groups (see Fig. 4-4). This helps define department-related service profiles, simplify the management of the insurance verification process, or define service exclusions or service combinations. This significantly increases user friendliness. Different groups can be defined for different purposes.
Fig. 4-4: Service Groups
❑ Price Information
Price Modifications as Conditions
In addition to charge factor values or cost information for a service, price modifications (e.g. surcharges and discounts) can be stored as conditions which need to be taken into account when billing this service. ❑ Conversion Rules
In addition to the actual charge masters, it is possible to store rules for converting the services of one charge master to those of another charge master. This is particularly important for billing purposes, if billing is based on a billing charge master which is different from the charge master used for entering the service.
Code Catalogs Possible Entries Facility
Checking the Input Value Automatic Data Entry
To allow the simple, fast, and error-free entry of information such as patient, case, or service data, IS-H offers many input facilities based on charge masters and code catalogs stored in the system. Rather than having to make manual entries into fields, you can call a dialog box containing possible entries for input from a predefined catalog, from which you can make your selection. When data is entered manually, the entered value is checked against the corresponding catalog to avoid incorrect entries. Examples of such catalogs are postal codes, forms of address, admission types, etc. Other data such as geographical areas can be determined automatically from catalogs and does not have to be entered manually. ISH can also manage national or international medical code catalogs such ICD-9, ICD-10, or ICPM. Major catalogs are already included in IS-H and will be supplied with the system.
Patient Management Patient Master Data The system contains one master data record for each patient. This record is the central element linking all administrative, medical, and nursing care data. As a result, both outpatient and inpatient procedures are made available via a single view.
Central Patient Master Record
Fig. 5-1: Patient Master Record and Related Information
A patient is identified in the IS-H System by a unique 10-digit patient identification number which is valid throughout the life cycle of the system. The system requires no specific semantics; the patient identification can be designed according to your requirements and can be established, for example, as an:
Unique Patient Number
❑ An internally assigned consecutive number with a check digit
Internal and External Number Assignment
❑ An externally (manually) assigned number to which you add a check digit ❑ An externally assigned alphanumeric patient number Together with the identifying patient number, another number can be assigned which can be defined, for instance, as an I-number. This allows you to switch from the I-number method to a nonmnemonic patient number when IS-H is implemented.
Every case for a patient is assigned to the corresponding master data record and receives a case number unique for the corresponding healthcare institution. The case number as well as the patient number can be assigned manually or automatically.
Patient Search Using Combined Attributes
In a patient-oriented system it is essential to maintain a consistent patient database. To do this, you need to determine the correct patient master record both when admitting previous patients whose master records are already in the system, and when processing other patient-related data. Usually, the patient master record is not selected by entering the patient number, but by using descriptive, patient-related information. There are two possible ways to search for a patient: either by entering combinations of patient-specific attributes (see Fig. 5-2):
❑ Last name ❑ First name ❑ Birth name ❑ Date of birth ❑ Gender
Search by Movements
Or using movement lists, such as patients admitted during a certain period to a selected organizational unit.
Fig. 5-2: Patient Index Search
This search using patient attributes allows you to search for a name by entering only part of the name (generic entry). Due to name standardization, the search function is not case sensitive. You may also search for compound names and former names. For last names, the phonetic search according to a freely selectable phonetic method is also supported.
Depending on the parameters set for your system, you perform a search using all patients or - if this is not desirable, or if you are restricted by data security considerations - a limited search for a specific institution is possible.
If the search attributes apply to several patients, the patients found are displayed in a list for subsequent selection. If it is not possible to identify a patient using the specifications in the list, additional data is available via a dialog box (see Fig. 5-3).
Change of Case Type
Fig. 5-3: Selection List of Patients found in the Database
As an alternative to entering the search criteria manually, you can import data from a healthcare smart card into the IS-H System and use it for the patient search.
Healthcare Smart Card
One common way to search for patient master records is to use movement lists. Using this approach, you search for patients by movement and case-related attributes. Examples are lists of all patients who were admitted, transferred, or discharged during a certain period or who made outpatient visits or were registered through quick or emergency admission during that period. These latter lists are particularly important for selecting quick and emergency admissions for further processing.
Patient Search Using Movement Lists
Unique Patient Master
As stated earlier, a consistent patient database requires that exactly one patient several features which can be activated by the user: ❑ Convenient patient search options ❑ Mandatory search for any existing patient master record when creating a new record ❑ Interactive verification to ensure that no duplicates are present before the new patient master record is saved.
Patient Record Merging
If a second patient master record was created for a particular patient, this new record can be merged with the existing record. Related information (such as cases, movements) will be retained.
Patient Movement Different Movement Categories Optimum Support of Work Processes
Patient movement refers to any change affecting the patient stay with respect to location or organization, such as admission, transfer, or outpatient department visits. These different movement categories may be processed in separate system functions. To provide optimum support of work processes, you can manage the actual movement data and also the patient and case data depending on the category of movement. IS-H documents different categories of patient movements for inpatient and outpatient cases. Companions and newborns are also taken into account and assigned movements accordingly.
Patient Admission Admission is the main function for entering patients in the IS-H System. You use the function to enter all data required for administrative, medical, and nursing purposes during the patient’s hospital stay.
Patient and Case Data
During patient admission, both patient- and case-related data are processed. The amount of data depends on the admission method selected (standard, quick, or emergency admission). Outpatient, observation patient, and inpatient admission
Outpatient and Inpatient Admission Method
are basically structured in the same way, but differ somewhat with regard to the type and amount of information to be entered.
Admission basically includes the following sub-functions: ❑ Patient index search ❑ Patient master data ❑ Admission/referral data ❑ Diagnostic data ❑ Accident data ❑ Insurance relationships/treatment certificates ❑ Services
All functions also allow you to display or suppress fields from the screen. You also control which sub-functions to carry out and in what order.
Flexible User Interface
Patient Admission offers functions which are suitable for the hospital work processes involved in the admission of inpatient and outpatient cases.
Standard Inpatient Admission The standard admission screen contains all functions and fields to be completed for patient admission. The interactive admitting process begins with the patient search; you have to determine whether the patient is new to the system and a record has to be created or whether he/she is a previous patient whose master data has only to be verified and updated, if necessary.
Patient Index Search
The patient master data contains all attributes applicable to the patient regardless of each individual case. Once the patient master data has been entered or verified, the actual case is processed. If the patient is a previous patient, his/her case list will be called up (see Fig. 5-4). At this point, you can decide whether to continue an existing case or create a new one. A case would be continued if, for example, a scheduled patient is admitted.
Fig. 5-4: Case List of a Patient
When admitting the case, all data relevant to the patient’s current hospital visit is entered (see Fig. 5-5).
Fig. 5-5: Case with Related Information
❑ Admission data such as date and time of admission, admission type, reason for the admission, planned length of stay, accident data, emergency indicator, admission status (waiting list/planned/actual), etc. ❑ Patient assignment: Each patient can be assigned to a:
Nursing Care and Specialty Assignment
Nursing organizational unit such as a nursing station.
Specialty organizational unit such as the department involved.
Room Assignment Multi-specialty Assignment
Room and/or a bed.
❑ All system functions including Controlling support the distinction between specialty and nursing responsibilities. This allows an easy and correct representation of multi-specialty assignments. The system also supports two-level admission procedures where the patient is first assigned to organizational units only, then later to a bed, for instance, on the nursing station.
❑ Admission data such as the referring physician, referring hospital or the referral diagnosis.
❑ Multiple insurance relationships between patient and insurance providers; when self-pay patients are admitted, open items can be displayed from Accounts Receivable.
❑ Services to be provided to the patient such as nursing charges, personal items, but also individual services such as laboratory tests or a flat rate per case. Requests for insurance verification directed to the respective insurance providers can be generated directly for the billable services entered.
Fig. 5-6: Admission Data for Inpatient Case
Various catalogs and overviews (e.g. postal data, physicians, hospitals, diagnosis code catalogs, etc.) are available in the admission procedure to simplify input. The system also contains a patient census indicating available rooms and beds as well as current bed assignments for specific patients. This allows optimum distribution of available bed resources as well as the most suitable room assignment. This nursing station overview may be displayed as a table or in a graphical format (see section ”Nursing Station Management”).
Patient Census Overview
Admission is further facilitated by automatic input functions such as geographical areas. Parameters can be set for automatically generating service and billing data by entering the treatment category (e.g. generating the basic nursing charge, semi-private room surcharge and chief physician choice for ”private patient, semiprivate room”).
Automatic Input Functions
During or after completing the admission procedure, definable work organizers can be created, such as patient master sheets, labels, or admitting release forms.
The entire admission process may be performed on the planning level or by waiting lists. In this case, you only need to check and/or supplement the planned data when the patient actually arrives. This reduces the workload during peak admission periods and greatly increases the quality of the admission process.
Standard admission enables you to enter all required patient and case data, including bed assignment if necessary.
Standard Outpatient Admission Outpatient Case
During standard outpatient admission, patient data is processed and an outpatient case with a first visit is created. The process is similar to inpatient admission with the exception of the data which pertains specifically to the outpatient area.
Data Required for Outpatient Admission
In addition to patient master data, outpatient admission requires the entry of data such as: ❑ Visits ❑ Patient assignment ❑ Referral data ❑ Treatment certificates ❑ Services
Outpatient Department Planning
As an alternative, outpatient department planning can be used for outpatient admission by simply scheduling an appointment for a free time slot. Both physicians and treatment rooms can be scheduled (for more information see the chapter ”Outpatient Department Management”).
Fig. 5-7: Outpatient Case
If treatment for an outpatient is to be continued in the hospital, the outpatient case can easily be converted to an inpatient case. This supports the required transparency between outpatient and inpatient treatment areas.
Outpatient emergency admission enables you to enter all patient and case information pertaining to outpatient cases.
Quick Admission (inpatient and outpatient) A complete patient admission requires you to enter extensive data on the patient and his/her case. The dialog for this procedure consists of several screens. In cases where there is a high workload, shortage of departmental staff, or missing data, the admission should still be performed as quickly as possible. IS-H provides an abbreviated admission function with only the minimum amount of data required for proper case processing at a later time. Patients admitted via quick admission are marked as such and their complete data can be entered at a later date. Followup lists can be called up to remind you of such patients. This follow-up procedure also applies to emergency admissions. If the admissions office is not staffed on the weekend, the patient can easily be admitted to the respective nursing station, and the missing data can be entered by the admissions office at a later time. Quick admission is available both for inpatient and outpatient cases.
Quick Admission with Minimum Data Follow-Up
Inpatient and Outpatient Quick Admissions
Quick admission allows you to quickly enter a case and add the missing data at a later time.
Emergency Admission (inpatient and outpatient) The emergency admission function is used to register patients who cannot be immediately identified or for whom a complete admission procedure is not performed. A prior patient index search is not mandatory for emergency admissions. This form of admission is even more limited in scope than quick admission. Emergency admissions are marked as such in the system and must be checked and subsequently completed using the standard admission function. Should you discover that the patient had already been entered in the system, functions are available enabling you to merge patient master records.
Incomplete Admission if Identification Impossible
Complete at a Later Date
Emergency admission enables you to quickly admit patients who cannot be identified.
Newborn Admission Newborns as Patients
Delivery Data/ Birth Data
With few exceptions, newborns are entered as patients after birth and are managed in the system as a patient master record with an outpatient or inpatient case. The newborn’s case is assigned to the mother’s case. When admitting a newborn, all statistically relevant delivery data is entered first, such as the delivery method and time as well as the birth data of the newborn(s). In case of a documented stillbirth, or if the newborn is not admitted after an outpatient delivery, the admission process can be terminated at this point - the delivery data is stored, but no case is created for the newborn. When you enter the master data and admission data for the newborn, certain information is transferred from the mother’s data record or the delivery data to make admission as simple as possible. In the case of multiple births, all the newborns may be admitted and assigned to the mother in one procedure.
Time-Dependent Status Information
The assignment between mother and newborn(s) does not depend on the admission method, so that outpatient and inpatient assignments are possible. Whether the newborn is healthy or sick, which is important information for patient billing, is stored as period-dependent status information together with the newborn case.
Newborns are normally entered into the system as patients with a related case, and assigned to the mothers case.
Admission of Companions Separate Cases for Companions
Persons who accompany a patient and benefit from services are admitted as a separate inpatient or outpatient case. The case is assigned to the related patient on a time-dependent basis. One person can be the companion for several patients and vice versa.
Assigning the Companion to the Patient
The companion’s case is assigned to the patient who is accompanied either when the companion is admitted or at a later date, if necessary.
Companions are also entered and their cases are assigned to the respective patient (s).
Outpatient Visit Visit in the Outpatient Department/Medical Service Facility Visits for Inpatient and Outpatient Cases
The planned or completed treatment of a patient in an outpatient department or a medical service facility is entered as an outpatient visit. Such visits are possible for outpatient cases, but also in the course of inpatient treatment or for an observation patient. Both visits before and after an inpatient hospital stay (pre-admission and post-discharge treatment) and during an inpatient stay (e.g. for a second opinion) can be represented.
To enter and process an outpatient visit requires correct patient identification. Using the patient index search described previously, you may determine whether the patient is returning or needs to be entered as a new patient. The respective visit is then logged indicating the place and time and assigned either a Waiting List, Planned, or Actual status. In addition, the outpatient department or medical service facility providing treatment is specified.
If a visit has already been documented via preregistration, it only needs to be confirmed upon the patient’s arrival. The visit status changes from Planned to Actual.
Pre-admission or post-discharge treatments are entered as visits and are assigned to the inpatient case as movements. These visits are identified as special visit types with specific plausibility checks (e.g. maximum number of pre-admission treatments, maximum time interval between pre-admission treatments and inpatient admission, etc.). The services billable for pre-admission and post-discharge treatments can also be assigned to the case and invoiced as such.
Pre-Admission and Post-Discharge Treatments
Outpatient visits are used to enter treatments in outpatient departments and medical service facilities and can be assigned to outpatient and inpatient cases.
Transfer When a patient is transferred, the patient’s location is changed at organizational and/or building unit level (departmental, nursing station, room, or bed location transfers). Like all movements, transfers can also be performed in planning. When a patient is transferred, other related information such as nursing category, diagnoses, case classification (e.g. chief physician choice), attending physician, companion have also be maintained if necessary.
Changes of Organizational/ Building Units Planned Transfers
Fig. 5-8: Transfer
Since services performed for a case (for example, personal items, departmental per diems) are always linked to specific organizational units , the extended services entered for the previous movement are automatically delimited (service split). Services can also be processed manually to document added or deleted services.
Transfers are changes in the patients location at organizational and/or building unit level; service data, diagnoses, etc., must also be processed.
Leave of Absence Documenting Leave of Absence
The periods of time during which a patient has temporarily left the hospital have often to be tracked. This enables you to monitor the patient’s location and organizational assignment, calculate the care and operational services rendered, and react to changes (such as reduced nursing charges) within the accounting system.
Planned Leave of Absence
Leave of absence may also be entered in planning for a future time period by specifying the leave of absence start and end dates in advance. In this case, the data must be confirmed and modified (if necessary) when the actual absence occurs. In addition to the time frame, you also maintain the reason for the absence, the approval, and the approving physicians, if necessary.
Periods of absence can be entered as planned or actual data, and are taken into account for staffing, accounting, etc.
Discharge Related Activities Entering Discharge Data
When you discharge a patient, discharge data such as discharge type, date and status, post-discharge physician or hospital have be entered. In addition, certain activities related to the discharge are included in the processing flow, similar to transfer processing. These activities include entering the discharge diagnosis, determining the hospital main diagnosis, or checking the nursing categories of the case for completeness. IS-H provides these processing functions when the patient is being discharged. Planned transfers, absence periods, and other planned movements may be canceled or changed.
Final Check of Services and Insurance Verifications
Extended services such as nursing care charges and personal items are ended automatically. You can double-check whether benefits coverage has been confirmed by an insurance provider for every service performed. If necessary, the case can be billed at discharge so that private patients receive the invoice upon discharge.
Assignments to other related cases are also checked. A companion has to be discharged together with the respective patient, unless the person is a companion for other patients as well. The assigned cases may be discharged immediately after the patient.
Assignment to Other Cases
IS-H also supports planned discharges.
Fig. 5-9: Discharge
Discharges can be processed together with the corresponding sub-activities.
Pre-Registration Every patient movement, from admission to discharge, may be entered in planning. For example, an admission can be entered for a future date. In this case, the patient’s master data and admission data such as assignment to a specific department or applicable insurance relationships can be entered in advance.
Entering planned movements, including the services involved, becomes particularly important when performing resource or capacity planning.
For planned admissions in particular, it is sometimes not possible to specify the exact date of the actual admission. In this case, the patient master data and known case and admission data such as assignment to the departmental organizational unit or planned services are entered. These time-independent entries are given a priority status. Based on this status, such a waiting list entry can be changed to a planned or actual admission.
Prioritized Entries in Waiting Lists
Easing the Workload of Admission Personnel
This option of entering movements in planning enables the admission personnel to enter data outside periods of maximum work load. When the movement actually occurs, the amount of data to be entered and work load peaks are reduced.
In addition to scheduling all movements, you can create a prioritized waiting list.
Variable Case Information Hospital-Specific Additional Information
In addition to mandatory data which describes a case and is maintained in the IS-H operational functions, each hospital can define and document additional attributes as additional information. This information covers the following areas: ❑ Case-to-person assignment Persons may be assigned to a case with user-definable functions. Examples: Attending nurse, attending physical therapist ❑ Case-to-case-assignment Cases can be assigned to each other with freely definable functions. Examples: Organ donor/organ recipient, parents/child ❑ Case classification You have the option to define and maintain user-definable case attributes including authorized characteristics. Examples: Treatment type: somatic/psychiatric, diet: Regular/body building/ bland/diet.
Hospital-specific additional information can be maintained in addition to mandatory case data.
Nursing Station Management Nursing Station-Specific User Interface
All IS-H Functions Available
Nursing Station Management offers an approach to processing patient-related data which is different from the patient management functions described so far. It looks at the nursing station and the patients assigned to this station. Nursing Station Management provides the IS-H functions required on the nursing stations in a user-friendly environment which takes into consideration the workplace requirements on the nursing stations. The general IS-H menus with all IS-H functions are also available on the nursing stations.
An important administrative function of Nursing Station Management is bed assignment planning, i.e. the planning and administration of bed assignments within organizational units supporting beds. The room and bed listing serves as a starting point for bed assignment planning. It offers a summary of bed assignments for each organizational unit at any level of the hierarchy at a user-defined time. This summary shows the accumulated bed assignment numbers for this organizational unit. The display includes information such as the number of free bed locations, assignable bed locations, planned beds, etc. In addition, the arrivals and departures planned for a definable period may be displayed. Starting with the selected organizational unit, this information can be called up in detail for all lower-level organizational units down to the lowest level, the units supporting beds (see Fig. 5-10).
Bed Assignment Planning Room and Bed Listing
Fig. 5-10: Summarized Room and Bed Listing
The nursing station overview illustrates the beds assigned to patients at a selectable time for an organizational unit supporting beds. The screen shows the assignment of patients to rooms and bed locations and can be displayed as a list or in graphic form. From the nursing station overview, further functions may be performed such as: ❑ Processing patient, case, or movement data for a patient ❑ Maintaining diagnoses or nursing categories ❑ Requesting medical records ❑ Entering services ❑ Entering surgical procedures ❑ Generating work organizers
Fig. 5-11: Graphical Nursing Station Overview
Planning in the Nursing Station Overview
Replacing the Patient Traffic List Access to Central Patient Database Additional Nursing Station Functions
Actual planning is another important function of the nursing station overview. The screen displays the assignment of each bed location during a selectable planning period and a list of all patients assigned to the nursing station, but not to a specific bed (arrival list), and all patients transferred or discharged during this period (departure list). Special planning functions such as assigning a patient to a bed location within the nursing station, the swapping of beds among patients or the transfer or discharge of a patient may be performed so that the nursing staff can enter patient movements into the system very easily. A patient traffic list for the nursing station linked to IS-H is not necessary. In addition to the functions described in the nursing station overview, Nursing Station Management provides all additional important functions required on the nursing station. Since the nursing station has direct access to the central IS-H database, the latest data is always available. Additional Nursing Station Management functions include: ❑ Information functions, such as listings of standard, quick, or emergency admissions, outpatient visits, waiting lists, etc. ❑ Patient admission ❑ Admission of newborns and companions ❑ Managing diagnoses and nursing categories for the patients on the nursing station ❑ Requesting medication and material from the central warehouse
Outpatient Department Management Outpatient Department Management provides a user interface similar to that of Nursing Station Management. It allows you to plan outpatient department visits and offers those IS-H functions which are required in outpatient departments. ❑ Visit Planning Resources considered relevant for outpatient visits are the attending physicians and the available treatment rooms. Available time slots are stored on a daily and weekly basis for these resources and for the outpatient departments themselves. The planning types are user-definable, such as initial visits, follow-up examination, etc. For instance, it is possible to specify that follow-up visits by a specific physician may only be scheduled at pre-defined times on selected weekdays. Based on these available time slots, on-screen appointment schedules are generated for the resources which need to be planned. The patient visits are entered into these appointment schedules and are assigned to the respective physician or treatment room. New cases and/or patients can be scheduled and admitted at the same time. A detailed visit status management function allows you to easily control patient treatment including visit planning, making the appointment, and actual treatment. You may also schedule an appointment without having to create a patient master record or case.
Outpatient Dept Mgmt as User Interface Visit Planning Phys./Rooms as Resources Available Time Slots for Different Planning Type On-Screen Appointment Schedules Visit Status Management Provisional Appointments
Fig. 5-12 Appointment Schedule
All IS-H Functions are Available
❑ Additional outpatient department functions: Outpatient Department Management provides all IS-H functions required in an outpatient department, such as: ❍ Patient Master Data ❍ Service entry ❍ Medical documentation (diagnoses, etc.) ❍ Administration of certificates ❍ Administration of medical records ❍ Printing of forms
Forms Management and Work Organizers Standard Forms Forms Editor Bar Codes
The standard system includes a number of forms such as patient status reports, patient labels, admitting release forms for patient and insurance provider, etc. You can customize these forms using a forms editor or define additional forms. It is also possible to define any type of bar code for labels. Bar codes and labels are generated automatically after certain functions have been performed (e.g. during patient admission) or upon request. Tables can be set up which specify where the item will be printed, how many copies will be printed, etc.
Medical/Nursing Documentation Nursing acuities Nursing Acuities
To determine the professional staff needed for adult and pediatric patient care in relation to nursing acuities the system supports the following processes:
Nursing Effort per Nursing Acuity
❑ Definition of nursing acuity for determining the nursing effort as well as the assignment of nursing care minutes per day. Storing minimum requirements for patient care and case weights to determine the staff required for adult and pediatric patient care.
Assignment to Nursing Acuity
❑ Assignment of inpatient cases to nursing acuity. Case-related nursing acuity management by selecting a case (case view) or managing the nursing acuity for all patients of a nursing station (nursing organizational unit) at a certain key date (nursing station view of Nursing Station Management).
❑ A comprehensive reporting system is offered to ensure a complete database for determining staff requirements and analyzing data for internal purposes.
The system supports the assignment of patients to nursing acuities and the determination of staff requirements based on this assignment.
Diagnoses IS-H manages diagnoses for each case and departmental stay and makes them available both for medical documentation and for statistical purposes.
Diagnoses for Each Case and Department Stay
The system distinguishes between two types of diagnoses:
❑ Admission or transfer diagnoses ❑ Treatment diagnoses made while the patient was treated in the medical facility. Treatment diagnoses are definable as:
Classification of Diagnoses
❑ Admission diagnosis ❑ Surgery diagnosis ❑ Discharge diagnosis ❑ Departmental main diagnosis ❑ Hospital main diagnosis Multiple diagnoses can be maintained for each case or departmental stay. Each diagnosis is entered as free text or as a code using a combination of two diagnosis code catalogs (e.g. ICD-9, ICD-10). The diagnosis code catalogs are user-definable. Available input facilities take the form of the text search in diagnosis code catalogs, hit lists, hierarchy search in hierarchic catalogs, and automatic conversion using connectable special systems.
Multiple Diagnoses Parallel Coding Possible Entry Facilities
Fig. 5-13: Diagnoses
The diagnosis is entered as part of the work process so that you may edit the information when processing admissions, transfers and discharges. As an alternative, diagnoses are processed separately from movements, for instance, as postdischarge documentation. The diagnoses can be maintained on a case-related basis for a specific case or collectively, for instance for all cases of an organizational unit.
Reports as Work Tools
Various reports (for example, a list of all cases without a discharge diagnosis) support you in maintaining a complete database.
IS-H allows you to enter multiple case- and department-related diagnoses which can be coded based on different catalogs and assigned to several classifications.
Surgery Legally Mandated Surgery Documentation ICPM Coding Surgery Diagnosis
IS-H offers a surgery documentation function which complies with legal requirements. For each surgery performed, you can enter administrative data such as time of surgery, organizational unit in charge, operating surgeon, operating room, etc. and the services performed (in the service catalog), surgery codes according to the ICPM catalog, and a surgery diagnosis for each ICPM code.
IS-H supports surgery documentation which is legally mandated for determining charges.
Risk Factors Risk Factors at Patient Level
While the medical/nursing information described above is maintained on a case level, risk factors are maintained on a patient level and apply to all cases.
Hospital-Specific Catalog Maintenance
The possible risk factors are stored in a catalog which is maintained based on specific hospital needs. Possible factors are: ❑ Allergies to antibiotics ❑ Hypertension ❑ Diabetes
Risk factors are documented at patient level.
Medical Record Administration Because of the many organizational models in the hospital with respect to filing, the file system, and archive management, individual medical records for each patient are created with varying frequency and in varying numbers. The system therefore supports the following record creation strategies:
Different Record Creation Strategies
❑ Creation of a new medical record upon initial admission to the hospital; no record created upon re-admission ❑ Creation of a new medical record upon every admission to the hospital ❑ Creation of a medical record per department ❑ Creation of a medical record per case and department ❑ Creation of a medical record per patient movement (e.g. transfer) The system manages data regarding the existence, location, and movements of a medical record. It also contains information on who borrowed a record, when it was borrowed, and why.
Medical Record List
Medical Record Administration provides the following functions:
❑ Display, input, and change of medical records ❑ Information on: ❍ newly created medical records ❍ lists of patients admitted after the date you specify, nursing station location, whether medical records exist for the patient, and the location of said records ❑ Create reminders for borrowed medical records ❑ Administration of borrowed medical records (request, lend, transfer, return medical records) ❑ Evaluations ❍ current medical records (for example, to obtain an overview of archive occupancy and reorganize the archives where necessary) ❍ borrowed medical records; selection criteria include: - medical records for which a reminder was created - borrowed records by borrower - borrowed records by date, etc. ❍ externally-stored old medical records A detailed data security concept ensures that only authorized users have access to medical records.
Patient Accounting Insurance Relationship To bill for services you must enter the patient’s insurance data in the system. This is performed by processing the insurance relationships on a patient- and caserelated basis. Multiple insurance relationships can be defined for each patient, each of which is assigned to either an insurance provider (usually an insurance company) or is processed as an insurance relationship for self-pay patients if the patient pays him-/herself or is required to make copayments.
Multiple Insurance Relationships
The insurance provider relationship establishes a link with the insurance provider who is entered into the system as a business partner. For self-pay patients, the patient is assigned a customer in Financial Accounting to process his/her open items, payments, dunning letters, etc. In addition, a different invoice recipient may be entered for self-pay patients. It is important that all insurance relationships are assigned to the patient and that those insurance relationships applicable to a specific case are selected and assigned to it (see Fig. 6-1). An insurance relationship that has been entered for a patient will be available for all future cases and need not be re-entered for future inpatient or outpatient cases. The data will only be verified and updated as required.
Insurance Provider Self-Pay Patients Patient- and Case-Related Insurance Relationships
Fig. 6-1: Insurance Relationships
Insurance relationships are managed on a time-dependent basis so that the insurance situation of a patient is represented accurately and a history can be generated. Each insurance relationship is assigned a start and an end date, and there may
be several insurance relationships with the same insurance provider over time. Incorrectly entered insurance relationships are canceled, so that the history is retraced in such cases as well.
Patient-Related Insurance Relationship Customer-Defined Types of Coverage
In addition to assigning the patient to an insurance provider, the patient-related insurance relationship specifies the type of insurance coverage. In the case of dependent coverage for family members, for example, data for the insured family member and optionally for their employer can be entered. You may also define your own types of coverage.
Healthcare Smart Card
Healthcare smart card data can be included in the related insurance relationship.
Ranking of Case-Related Insurance Relationships
Ranking and copayment information are important data for case-related insurance relationships. When requests for insurance verification are generated automatically, the ranking of the insurance relationship determines the order in which the insurance relationships are used to request insurance verification for the caserelated services. For insurance providers requiring copayments, copayment information specifies either the copayment obligation with the respective copayment amount or provides a reason why the copayment obligation is waived.
Fig. 6-2: Overview of the Insurance Data of a Case
Service Entry Central Function Services for Inpatient and Outpatient Cases Import From Subsystems
Service entry is a key function of all hospital information systems. It is used to document planned and performed services for inpatient and outpatient cases. The documented services are used for managing the insurance verification process, billing, hospital-specific controlling (cost center accounting, cost object controlling), medical documentation and statistical evaluations (legally mandated and internal). In addition, services are frequently entered into subsystems, and this data can be imported into IS-H using the communications module IS-HCM or special data transfer programs.
The service catalog (internal charge master) is usually the basis for service entry. Services entered using this catalog are medical, nursing, and operational services, or services of functional areas such as the laboratory or radiology department.
Internal Charge Master as a Basis for Service Entry
Services are usually entered on a case basis and may also be assigned to the movements, treatment certificates, or insurance verification requests of the case. Both billable and non-billable services are definable. Non-billable services can be documented for a specific organizational unit as service recipient and transferred to Controlling. They may also be documented on a case basis which is necessary to set up cost object controlling. You can enter many different types of information for each entered service. This information is necessary for subsequent functions and includes:
Billable and Non-Billable Services Service Information
❑ Time or time interval when the service was performed (planning or actual) ❑ Service quantity ❑ Departmental and nursing organizational unit ordering the service ❑ Organizational unit performing the service ❑ Billing information such as assessment rate or different price including reasons ❑ Service number in the billing charge master, etc.
Fig. 6-3: Case-Related Service Entry
Service entry is facilitated by the hierarchy structure of the service catalog; in addition, default values are stored for many entry fields so that most of the time no manual entry is necessary. Filter functions are available for processing services
Service Catalog Hierarchy Structure Filter Functions
Automatic Service Splits
which have already been entered. These filters select certain services to avoid confusion, particularly for cases with many services. For extended services involving transfers and discharges, the system automatically splits the services. In case of a transfer, the services are ended, and corresponding services are generated for the newly assigned organizational unit.
Services can be entered manually or transferred from subsystems; they can be generated automatically, such as departmental per diems by the attending departments or other services by treatment categories.
Automatically Generated Requests for Insurance Verification Plausibility Checks Billable Services and Specific Forms of Charging Rule-Based Charge Determination Case Monitor
Service entries may be used for automatically generating most of the requests for insurance verification. For services already billed, the billing information is displayed for each service directly from service processing. Plausibility checks for service exclusions, combinations, and limits may be performed during service entry or at a later date. Another important group of service entry functions ensures the complete entry of billable services as specific forms of charging. For instance, services may be billed as flat rates per case, procedures surcharges, departmental per diems and base nursing charges. To determine billable services, a special function proposes potentially billable flat rates per case and/or procedures surcharges for the combination of diagnoses and surgical procedures entered (based on user-expandable rules). You may select the appropriate form of charging from this list. The case monitor is another tool for determining charges. It allows you to display billing-related case information in compressed form, such as insurance relationships, insurance verification requests, treatment certificates, services performed, diagnoses and movements. (see Fig. 6-4).
Fig. 6-4: Case Monitor
In addition, a verification program can be used to compare days spent in the hospital and days billed based on flat rates per case (and their maximum allowable stay) and procedures surcharges.
Comparing Days in Hospital and Billed Days
Services are entered locally or centrally. For central service entry, a quick entry function is available. To enter services, you can use the function specifically designed for service entry, or you enter services from one of the many other functions.
Integrated Service Entry
The appropriate charge master for the insurance verification process and billing is assigned based on assignment tables when insurance verification is requested or during billing. Service input is therefore independent of such charge masters. As a result, the patient’s insurance situation can be ignored when entering services. This also applies to any services in the patient’s insurance data during inpatient treatment (e.g. workers’ compensation instead of legal health insurance). These changes do not affect services already entered.
Service Entry independent of Billing Charge Master
Insurance Verification Process The insurance verification process is essential for billing for inpatient case services in the IS-H System. The insurance verification process is used to assign billable services to the case-related insurance relationships and to insurance providers, which will be billed for some or all of the services involved.
Assigning Billable Services to Insurance Providers
IS-H provides comprehensive support for the insurance verification process and automatic functions to facilitate this process.
Fig. 6-5: Insurance Verification Process
A billable service in an insurance verification item may be assigned to one insurance provider or split among several providers directly from the service entry function. You can split the price of a service among multiple insurance providers with which the hospital has a case-related insurance relationship either as a percentage or as an absolute value.The price can also be assigned to self-pay patients. It is possible also to assign groups of services to an insurance provider.
Insurance Verification Integrated with Service Entry Apportioning Among Several Insurance Providers
The system automatically generates billing proposals based on stored pre-approved insurance rates and default values. Pre-approved insurance rates may be stored for each insurance provider separately or for all insurance providers of an insurance provider type. This pre-approved insurance is usually covered by the insurance provider. In addition, you can specify whether a charge will be covered in full, in part or up to a specified limit. For such pre-approved insurance no insurance verification request has to be issued; the status of the related insurance verification is changed immediately to “confirmed” and billing can subsequently take place.
Default values are stored in the same system structure as pre-approved insurance, however the generated insurance verification proposals receive the “requested” status, rather than the “confirmed” status, and benefits coverage usually has to be requested from and approved by the insurance provider before an invoice can be issued. With the default values, you can also store information regarding the services usually not approved by an insurance provider, such as personal items not covered by legal insurance providers. This prevents the system from generating such insurance verification defaults.
Insurance Verification Proposals
Based on pre-approved insurance and default values which are defined by each hospital, IS-H generates insurance verification proposals. In this process, insurance providers are selected for insurance verification in the order of the case-related insurance relationships. In addition, insurance verification items are generated automatically for selected cases, e.g. for all patients admitted during a specific time period. As a result, with fully maintained insurance verification items and default values, insurance verification requests and benefits approvals are largely automated.
You can, of course store insurance verification information in the system without first having entered services.
Insurance verification requests can be printed individually or in a batch mode. Different forms are used based on the insurance provider or the insurance provider type and the respective organizational unit.
Depending on the response received from the insurance provider, insurance verification requests or their items can be marked as “confirmed” or “rejected”. An integrated reminder procedure enables you to send reminders for outstanding insurance verification requests to the insurance provider after the predefined waiting period has elapsed.
Integrated Reminder Procedure Monitoring the Insurance Verification Situation Automatic Extension
To monitor insurance verification, a function is available which monitors the insurance verification situation for inpatient cases. You can check, for instance, whether a requested or confirmed insurance verification is available for all billable services, whether the insurance verification for extended services covers the whole period up to the evaluation key date, or whether the diagnoses required by the insurance provider are available. A checklist is generated so that the activities required for insurance verification can be performed directly. Any necessary extensions for insurance verification requests with a time limit are generated automatically.
Copayments Copayments can be managed in two different ways: ❑ Receivable Procedure The insurance provider assigns the copayment receivable to the hospital. As a result, the receivable amount billed to the insurance provider is reduced by the amount of copayment, regardless of whether the patient actually made the copayment or not. ❑ Collection Procedure The invoice sent to the insurance provider takes into account only copayments actually made. Copayments received later are sent to the insurance provider collectively for several cases. Both procedures rely heavily on Financial Accounting for administering copayment requests and open items, reminders, machine payments, etc. IS-H and FI are fully integrated. As a result, the relevant copayment postings in FI can be made conveniently from IS-H.
Down Payments If the patient pays him-/herself, a down payment is required (down payment request). Outstanding down payment amounts are dunned.
Down Payment Request
Down payments which have been made are displayed by the system and taken into account when billing. The SAP standard Financial Accounting module processes down payments.
Down Payment Accounting
Billing Billing Methods Every hospital performs a variety of services, which in turn must be billed in various ways in accordance with government regulations, contractual obligations, organizational rules, etc.
Different Billing Methods
IS-H supports you in billing inpatient, observation patient, and outpatient services.
Inpatient and Outpatient Billing
Together with the SAP Financial Accounting module and SAP Controlling, IS-H ensures safe control of receivables and cash flow and detailed controlling including cost object controlling and profitability accounting which supports hospital liquidity and profitability.
Particular features of IS-H Patient Accounting are:
❑ Using services as the only basis for accounting
Modular Accounting Approach Great Flexibility with Numerous Profile Options
❑ A highly modular accounting approach using combinable modules to support different organizational processes ❑ A highly flexible system with numerous profile options which can be specified individually by each institution and which ensure that IS-H will remain a state-of-the-art system in particular in view of the impending structural changes in the healthcare system.
Fig . 6-6: Supported Billing Methods
Support for Inpatient Charge Types Case Monitor Flexible Rules for Determining Charge Completeness Check Direct Patient Billing/Billing for Observation Patient Services Outpatient Billing
In the inpatient area, the system supports all types of charge, such as flat rates per case, procedure surcharges, departmental per diems, and base nursing charges, pre-admission and post-discharge treatments, as well as general nursing charges, personal items, etc. Charge determination is facilitated by a case monitor which displays an overview of all billing data, by flexible rules to determine potentially billable flat rates per case and procedure surcharges from entered diagnoses and ICPM codes as default values as well as by functions which check for completeness of billable services for a case. Other automatic functions to ensure complete and accurate billing such as automatic generation of billable services from available information are being developed. Direct patient billing for inpatient cases and billing for observation patient services such as dialysis treatments is performed very easily. The following billing methods are supported for outpatient cases: ❑ Billing for outpatient surgery ❑ Self-pay patient billing
❑ Direct patient billing (including calculation and evaluation of physician reimbursement, also for direct inpatient billing) ❑ Workers compensation billing
IS-H billing provides for inpatient, observation patient, and outpatient billing, and offers maximum flexibility to make for a safe investment.
Billing Procedure As a first billing step, you have to select the cases to be billed. For individual billing this is exactly one case, for collective billing it is a large number of cases which are determined by a selection function and are saved collectively under a specific name. Selection criteria are general attributes such as the type of case, last name of the patient, discharged/not discharged, the presence of a discharge diagnosis, the insurance verification status, or other visit-related criteria such as any outpatient visits during a certain time period or certain types of visits. The latter item is particularly useful for outpatient cases.
Individual Billing Collective Billing
To prevent billing, a billing block can be set for certain cases.
Fig. 6-7: Billing
Billing Parameters Final or Interim Billing
Subsequent billing is determined by user-definable parameters. The most important are: ❑ Final or interim billing? Interim billings allow billing by period.
Test or Production Billing
❑ Test or production billing. Test billing allows you to perform plausibility checks only without actually generating an invoice or a financial accounting document. This function is particularly important for collective billing, since any errors are logged and corrected interactively from the error log prior to production billing.
❑ Billing date as the date up to which the services of a case are included in the invoice. The billing date serves as the posting date for financial accounting.
❑ Optional posting block imposed on Financial Accounting to prevent direct posting of the invoice document in Financial Accounting. The invoice is posted later after an explicit invoice release. ❑ Determining the billing scope by selecting the billable services(s) and insurance provider(s).
Billing Scope Plausibility Checks
After the billing parameters have been specified, you start billing. First, a number of plausibility checks are performed. They check, for instance, whether the required insurance verification documents have the “confirmed” status, if this is required by the insurance provider, whether the patient was actually discharged, when you want to do final billing, whether a discharge diagnosis is available, etc.
Highly Flexible With Definable Rules
If the plausibility checks have been successful, a number of rules are applied and processed which will finally result in an invoice. Since each hospital can adjust these rules according to its specific needs, IS-H provides for extremely flexible billing simply by adjusting the parameters and without having to modify the program. The billing process is basically as follows (see Fig. 6-8)
Fig. 6-8: Billing Process
❑ The system determines the billing type (such as direct inpatient billing) based on the case type, insurance provider and billing organizational unit. The billing type affects the billing charge master and pricing.
Billing Type Determination
❑ The charge mater used for billing is selected based on the insurance provider, billing type, service master and, if necessary, the billable service.
Billing Charge Master Determination
❑ The billable services entered from the service catalog may be converted to billing master services based on grouping categories stored in the system. As a result, a service catalog service is converted to different billing charge master services based on the various billing conditions.
Fig. 6-9: Service Conversion
❑ The system generates a pricing procedure based on the case type and billing type. You use this procedure to enter types of conditions which determine which price elements (e.g. basic price, surcharges/discounts) are to be used in pricing.
❑ To access the basic price of a service, a mandatory formula is assigned to the respective condition type which is used to determine the price for a service from the appropriate column of the billing charge master. For other condition types (surcharges or discounts), the system uses a search strategy (access sequence) to determine in which order condition records pertaining to a condition type are to be read (for instance, do you want to search for a specific discount for a combination of insurance provider and service, and, if this cannot be found, do you want to search for a value which only depends on the service, etc.).
Basic Service Price
❑ Conditions allow you to take into account different criteria when determining regular and graduated prices.
These steps produce the invoice which is created based on the billing parameters. If necessary, it can be processed with the many functions which are available centrally (Fig. 6-10).
Fig. 6-10: Invoice Processing Functions
As an example, you may display all invoices for the selected case as well as related documents in financial accounting, if the invoice was released for posting; invoice documents which have not been posted in financial accounting can be processed to a limited extent, invoices blocked for financial accounting can be released, open items for self-pay patients displayed, etc. In addition, the case monitor provides an overview of all data pertaining to billing such as insurance relationships, insurance verification requests and approvals, certificates, services, diagnoses, surgical procedures, movements.
Service Entry After Final Billing
You can still enter and bill for services, even after final billing has been completed for a case.
Printing the Invoice
As a last billing step the invoice is printed, either immediately during billing or at a later time. The necessary forms can be designed according to hospital-specific requirements using a forms editor which is integrated in the system. You can call up various forms depending on factors such as billing type or insurance provider type.
A collective invoice (invoice list) with invoices selected for an insurance provider can be generated in addition to the individual invoice.
The system allows individual or collective billing with different parameters. Billing is determined by adjustable rules offering maximum flexibility.
Reversal IS-H allows you to reverse all invoices or one invoice of a case completely or partially by referring to the original invoice. The system always tracks the processing via a reference to the source document (invoice). Reversals are also posted automatically to Financial Accounting.
Complete/Partial Reversal Integration with Financial Accounting
Complete and partial reversals are processed as special billing types in addition to the actual invoice.
Reduction of Balance via Down Payment and Copayment Down payments made can be deducted from self-pay invoices. Down payments are managed as special transactions in customer accounts. A special down payment account is maintained in the main Financial Accounting module.
Reduction of Balance via Down Payment
You may specify whether the balance of the payer invoice should be reduced only when a copayment is made by the patient (collection procedure), or generally (receivable procedure). Comments may be entered on the invoice in cases where a patient does not make a copayment. You can list the paid and settled copayment amounts either from the SAP Financial Accounting module or from Patient Management.
Reduction of Balance via Copayment
Copayments and down payments are taken into account during invoicing.
Accruals and Deferrals Using special evaluations, accrued services which have been performed but not yet billed are displayed; that is, the services are valued for internal purposes only. Accruals and deferrals are updated in special accounts using the Financial Accounting module. As a result, all sales revenues from hospital services are shown in the year-end closing. Accruals and deferrals are reversed when the accrual services are billed.
Complete Year-End Closing
For accurate accounting, services performed but not yet billed can be valued and posted.
Accounting Integration Posting Records for Financial Accounting and Controlling
During billing in IS-H, posting records for the Financial Accounting and Controlling modules are generated automatically. The Financial Accounting module monitors payment receipt and issues dunning letters for unpaid items.
Instead of transferring invoices directly, first use the invoice posting block. By lifting the block you release the invoice for posting in Financial Accounting. Blocked invoices are listed and processed separately.
Flexible Cost Determination
The accounts used for posting revenues and sales reductions are generated automatically based on rules set by the hospital. This allows you to post the charge for each service and all surcharges and discounts to a separate G/L account. The various flat rates per case, procedures surcharges, departmental per diems (with a further breakdown by reduced and full departmental per diems, if desired), departmental per diem discounts, etc. may be posted to multiple revenue accounts. Additional differentiating attributes are used for account assignment, such as institution, insurance provider, insurance provider type, or case type.
Cost Center Accounting
For controlling purposes, revenues and revenue reductions are assigned to cost centers or profit centers or case-based orders. The latter is required if you want to implement cost object controlling. The exact relationship and the processes between IS-H and Controlling are described in the chapter “IS-HCO Hospital Controlling”.
Revenues and revenue reduction flow from IS-H Accounting directly to Financial Accounting and Controlling.
Information Retrieval and Reporting Statistical Evaluations
Government regulations and hospital information needs are making statistical evaluations necessary on a regular basis. Evaluations derived from service and patient census data under Patient Management are offered as standard reports such as diagnostic statistics, service statistics, occupancy data, and departmental key figures. The system supports the legally required breakdown of data by inpatient, observation patient, and outpatient cases. Other statistical data such as cost and service listings (e.g. personnel, revenues) are generated in the respective SAP standard systems.
Diagnoses Geographical Areas Midnight Patient Census
Diagnostic statistics according to hospital statistics regulations and geographic data can also be provided. The standard system also compiles inpatient census statistics based on the midnight patient census.
Detailed Patient Overview
Overviews of the current patient count including scheduled or performed treatments for a defined period are accessible in list format or via online display. Patient inquiry restrictions and display authorizations are also taken into account.
Various evaluations are available to monitor insurance verification; for example, insurance verification requests needing reminders and missing referral certificates. A large number of evaluations is also available for service entry and billing, for example, to compare days spent in the hospital and days billed, to analyze the hospital stay for flat rates per case, to analyze billed services by insurance provider type or regulator, to determine the billing status of discharged cases, etc. The healthcare institution is able to easily generate individual evaluations using the tools provided.
Insurance Verification Service Entry and Billing Individual Evaluations
Hospital Controlling Integrating IS-H with CO Efficient Controlling functions are an increasingly important tool for controlling the service processes. The ultimate goal is to implement a cost object controlling system which makes it possible to determine the planned and actual costs and revenues for each cost object and compare them via variance analyses. These analyses can be case- or period-related, and implemented as multi-level contribution margin accounting. Cost objects include any hospital services which are provided to the patient, such as flat rates per case, procedures surcharges, departmental per diems, or outpatient surgical procedures.
Controlling Services Processes Cost Object Controlling Multi-Level Coverage Contribution Margin Accounting Multiple Cost Objects
Fig. 7-1: Cost Object Controlling
To implement cost object controlling you need to set up a meaningful cost center accounting system as a tool for allocating (cost object) overhead to the various cost objects based on the cost origin.
Cost Center Accounting
Fig. 7-2: Data Flow in the Cost Center System
Profit Center Accounting
As a first step, profit center accounting is used to make the revenue structures of the hospital transparent.
The SAP Standard Controlling System CO provides all the tools required for cost element, cost center, and cost object accounting. For effective controlling, the Controlling System has to be provided with the controlling-relevant data such as costs and services from the (quantity-based) operational systems in an appropriate form. This affects Financial and Assets Accounting, Human Resources and Material Management, and in particular IS-H, since this module centrally plans, documents and bills for patient-related service processes. In doing so, it provides the data essential for Controlling regarding the services performed by the hospital organizational units and the revenue derived from them.
Patient-Related Service Processes
Integration Between IS-H and CO
The components of IS-HCO provide the necessary integration between IS-H and CO. In particular, IS-HCO comprises the following functional areas:
Linking CO with IS-H Objects Service Transfer
q Linking CO with corresponding IS-H objects (e.g. cost centers with organizational units, activity types with service catalog services) q Transferring and posting the services performed from IS-H to CO for internal activity allocation
q Determining and transferring statistical key figures from IS-H to CO
Statistical Key Figures
q Transferring and posting revenues from IS-H to CO
Transfer of Revenues
Fig. 7-3: Data Flow in the Hospital
In Customizing, you determine whether to implement only cost center accounting or cost object controlling in CO. Depending on this decision, internal activity allocation is used to post the case-related services performed from the cost center which performed the service either to the receiving cost center (or to a statistical order) or to case-based orders. Similarly, revenues are posted to cost centers or profit centers, but also to case-based orders.
Cost Center Accounting or Cost Object Controlling
Master Data To be able to use the operational functions of IS-HCO, you have to manage master data which is primarily used to assign CO objects to the corresponding IS-H objects.
Assigning CO to IS-H Objects
q Assigning organizational units (IS-H) to cost centers (CO)
Organizational Units/ Cost Centers
One or several cost centers from CO are assigned to each organizational unit in IS-H. The latter is possible, so that a separate nursing station cost center can be defined for each assigning department when multi-specialty nursing stations are used. This assignment is necessary to determine the cost centers to which services are to be posted, based on the organizational units ordering and performing the services. The organizational units are specified together with the services performed.
Multi-Specialty Nursing Stations
Fig. 7-4: Cost Centers and Activity Types
IS-H Services/ CO Activity Types
❑ Assignment of IS-H services to CO activity types: When services were performed with regard to a case or an organizational unit, the case-based order or the receiving cost center should be debited with the costs of the performing cost center in CO. Therefore, you have to specify how the CO-relevant IS-H services of the service catalog will be assigned to CO activity types. The following options are available:
Single Account Assignment
m Single account assignment: Exactly one CO activity type is assigned to a service in IS-H and vice versa (1:1 assignment).
m Summarization: One CO activity type is assigned to several IS-H services (1:n assignment, for instance, to summarize all radiology services in one CO activity type “Charge factors”).
Multiple Account Assignment
m Multiple account assignment: Several CO activity types are assigned to one IS-H service (n:1 assignment, for instance, account assignment of “Nursing care minutes” and “Physician minutes” from the IS-H service “Nursing charge“). For each assignment you must also store information on how to determine the quantity of the CO activity type from the IS-H service. To determine the “Nursing care minutes” quantity, for instance, you can use the patient classification in nursing care categories; to determine “Charge factor,” you may use the charge factor from the appropriate column of a charge master.
q Assigning preliminary costing to a cost object: A preliminary costing from CO can be assigned to IS-H services which are designated as cost objects. If such a service is performed for a patient, an order is created for the respective case, and the costs from preliminary costing are entered on the order as planned costs. This allows a comparison between these planned costs and the actual costs for cost analysis purposes.
Preliminary Costing/ Cost Objects
Fig. 7-5: Preliminary Costing
q Assigning IS-H key figures to statistical key figures under CO: IS-H allows you to determine the nursing days, billing days, and the number of outpatient visits for a certain period as key figures for each organizational unit. For posting to the cost center assigned to the organizational unit, the corresponding statistical key figures in CO must be assigned to the IS-H key figures.
IS-H Key Figures/ Statistical Key Figures
Cost Center Accounting Based on the assignments defined in the IS-HCO master data you determine the activity relationships between sending and receiving cost centers from the services which were performed for a case or an organizational unit and entered in IS-H and then make the appropriate postings in CO. Revenues are treated similarly.
Services are transferred to the CO module periodically, or when the patient is discharged. It is also planned to support transfer immediately the performed service is entered into IS-H. To avoid duplicate postings in CO, the IS-H module logs which and how many services have been transferred. As a result, CO postings are automatically corrected when the IS-H service is changed or canceled.
Transfer Log Automatic Correction of CO Postings
Extended services are posted in the CO module by period. The service quantity provided is divided among the posting periods according to the service period. As a result, the extended service quantities and costs are available on the cost centers for analysis purposes.
Period-Based Service Posting
Services From Subsystems
Services from subsystems which enter IS-H via IS-HCM or by other means are transferred to CO the same way as services directly entered into IS-H.
Statistical Key Figures
As mentioned above, statistical key figures are also transferred to the CO module
Cost Object Controlling Costs and Revenues Profitability Analyses
To implement hospital-specific cost object controlling, you have to be able to determine and analyze the planned and actual costs and revenues from market-oriented hospital services (“products”) and perform period-based profitability analyses.
Case-Related Cost and Revenue Determination
At present, IS-H supports case-related cost and revenue determination: as a next step their will also be support when several cost objects are involved in a case.
Cost Object Accounting Procedure Preliminary Costing
Case-related cost-object controlling requires the following procedure: q Create a CO order for each inpatient case (automatically during patient admission or periodically). q If a service is entered for the case in IS-H which was designated a cost object and if a preliminary costing is assigned to it, this preliminary costing is included in the order to establish the planned costs. q Post actual costs from case-related IS-H services performed. This is similar to the cost center accounting procedure. q Post case-related revenues from IS-H accounting.
q Classify case-related orders: To classify and describe a case-based order in CO, IS-H provides the following characteristics: m Patient age m Patient age group m Patient gender m Admission diagnosis m Discharge diagnosis m Hospital main diagnosis m Length of stay m Procedures surcharge m Flat rate per case m Number of surgeries m Number of surgical procedures
Hierarchical Order Analyses
Each case-based order can then be described by the values of the selected characteristics. These characteristics and their values can be used to search for orders and for reporting. This allows you to perform order analyses, as illustrated in the figure below.
Fig. 7-6: Cost Objects in Profitability Analysis
Communication The Hospital Communications module IS-HCM supports the following internal and external communication possibilities: q Event-controlled, asynchronous transmission and receipt of information to and from subsystems
Internal and External Communication Possibilities
q Synchronous admission notification of subsystems q Synchronous access to IS-H data from subsystems (queries) q Data exchange between hospital and health insurance companies
Asynchronous Communication with Subsystems IS-H provides integrated support for linking medical subsystems (such as laboratory, radiology, etc.). This linkage is essential for implementing a uniform, integrated information system for hospitals.
Currently, the most popular communication mode is asynchronous, message-oriented communication which is supported by most subsystems. IS-HCM offers this communication possibility. At present, IS-HCM sends messages regarding defined events to subsystems, such as for inpatient admission, outpatient admission, outpatient visit, discharge, merging of patient master records or orders.
Asynchronous, Message-Oriented Communication
For movement-related events, a distinction is made between creating, changing, and canceling a movement.
Services, surgical procedures, and diagnoses performed are supported as incoming messages. The range of message types supported by IS-HCM is constantly being expanded (e.g. transfer of findings is planned).
Messages Received from Subsystems
The interface between IS-HCM and the non-SAP application is provided by several files in a mandatory directory of the non-SAP computer. The message standards supported are the HCM format and HL7 in the ADT area. In addition, HCM message types are adaptable to create hospital-specific message types.
Various parameters are used to control the transfer of data from IS-H to authorized subsystems. When a communication-relevant activity is performed, the defined message is sent asynchronously to the corresponding system. This requires several steps which can be automated:
q A communication-relevant event generates a transmit order for the corresponding message type.
Steps in Sending a Message
q Transmittable messages are generated from the transmit orders in a format which the subsystem expects for this message type. q The messages are transmitted periodically to the subsystem. A trace of the transmission is created for documentation purposes.
Fig. 8-1: Patient Data Transmission
On the receiver side, the IS-HCM Transceiver receives the message and stores it in the interface file “messages received from IS-H”. The application running in this system has to read this file at regular intervals to enter new IS-H data into its own database as soon as possible. When processing has been successfully completed, the corresponding record can be deleted from the interface file.
If a communication-relevant event occurs in IS-H, the corresponding message is transmitted asynchronously to the authorized subsystems.
Communication Flow: Transferring Data Steps in Receiving Messages
When data is transferred to IS-H from the non-SAP system, the non-SAP application places the messages in the interface file “messages to be transmitted to IS-H” using the specified format. Then, the sequence of steps is as follows: q IS-HCM retrieves the messages at regular intervals, or the subsystem sends the messages. q IS-H immediately writes the message to its database or generates batch input folders, and logs the received message. q IS-HCM acknowledges receipt of the message file to the subsystem or reports an error if reception was faulty with appropriate error handling.
Fig. 8-2: Buffered Data Transfer
Non-SAP Systems transmit Messages to IS-H via IS-HCM .
Synchronous Admission Notification of Subsystems In addition to the asynchronous, message-oriented communication described above, Patient Admission also provides for the synchronous notification of the subsystems. This method is based on RFC technology (RFC = Remote Function Call) and enables you to transmit patient and case data to subsystems immediately after patient admission.
Synchronous Notification of Subsystems
This interface has to be activated for individual subsystems. During the admission procedure, IS-H calls up a customer- or system-specific function outside IS-H. This call is specified in IS-H Customizing. The most important patient and case data is transmitted in a special format. With this data, the patient is simultaneously admitted in the subsystem. Patient and case data is immediately available in the subsystem, and data is not entered in duplicate. The waiting periods of asynchronous data transmission are avoided. In addition to the communication options between IS-H and subsystems described above, subsystems may also access IS-H data synchronously by Remote Function Call. IS-HCM provides object-oriented function modules with which data such as patient master data or case data can be read. This allows the object-oriented integration between IS-H and subsystems, provided the subsystem satisfies the necessary technical prerequisites.
Synchronous Access to IS-H Data (Queries) Object-Oriented Integration
General IS-H Concepts
General IS-H Concepts The features of the IS-H system described in the following section cover all IS-H application components.
Hospital Operators and Institutions A number of clients can be set up in the system, each with specific parameters and data, thereby allowing you to manage the institutions of different hospital operators within IS-H. If a hospital operator runs multiple institutions, this can be represented in the system by assigning the institutions to the same accounting unit (company code). If required, the variable system parameters for controlling processes can be set specifically for each institution, enabling you to structure processes on an individual basis.
Multiple Hospital Operators Multiple Institutions Individual Processes
Process-Oriented IS-H functions are basically designed to meet the work process requirements of users. It is our goal to provide maximum support for user tasks. Since the various institutions have different organizational rules for work processes, IS-H offers maximum flexibility. An object, such as services or case diagnoses, can be processed in different functions or contexts. In this way, the services for a case can be entered during the admission procedure, when the patient is transferred or has an outpatient visit, or during the discharge procedure. Furthermore, services can be generated automatically, via a case-related service entry transaction, quick service entry or can be transferred automatically from subsystems. Object-oriented design features allow you to use functions for different purposes and in different areas.
Tailored to User Work Processes Processing an Object in Different Contexts
Object-Oriented Function Design
Many functions are available to support shared work processes, to determine the workload of a user and display it on screen as a work “list”. Examples are the listing of all quick or emergency admissions which have to be completed by the admission staff. The integration of workflow functions is planned for a future release.
Planned Integration with Workflow Functions Support for Shared Work Processes
In some functions, you can adapt the selection and sequence of screens to hospital-specific requirements.
Customizable Screen Sequence
Data Security and Authorization Concept An extensive authorization concept has been implemented in IS-H to support organizational and technical data security measures such as user, access, input, and storage control.
Detailed Authorization Concept
Use of the IS-H system is restricted to persons who have a user master data file and password in the respective client (hospital operator) After a specific number of unsuccessful logon attempts, the user is locked out for the day. All logon attempts are recorded by the system.
Access to the IS-H System
General IS-H Concepts
Access to Functions and Data
You can only carry out functions and access objects for which you received authorization in your user master file. The authorizations allow you to process general objects such as patient master records or cases, or objects which are assigned to specific organizational units (e.g. departments) such as movements or services. Authorizations relating to functions allow you to protect transactions such as calling up patient admission or evaluation reports.
To minimize the maintenance required for individual users and structure authorizations based on user operations and locations, authorizations are assigned to groups of users in the form of profiles. These profiles contain all required authorizations for a group of users. The group is usually established by organizational characteristics; for instance, the nursing staff of a specific nursing station can be combined in a group. This authorization profile is then assigned to all users of the group, and additional authorizations can be added as required. This means that you need to maintain only one authorization profile per group, and profile changes automatically affect all assigned users.
Fig-9-1: Authorization Concept
Separate Maintenance Activation Entry Date Change Documentation Time-Dependent Objects
To increase data security, user master files, authorizations, and profiles are maintained separately and are assigned to different persons. Authorizations and profiles must be explicitly activated before they become effective. To comply with input control measures, the system records your user ID and the date when you enter data. When you change data assigned master data status, a change document is created containing your user ID, the changed fields, and the old and new field content to document the changes. In addition, IS-H manages numerous time-dependent objects with different contents for different time periods. As a result, this data is managed quite comfortably (you can specify new prices for services starting at a future date), and older data sets can be maintained for histories. A cancellation concept is used in many places to increase data security even further. This concept allows you to cancel incorrect entries, without deleting them, thereby ensuring that user actions are always tracked.
General IS-H Concepts
Number Assignment Objects assigned key values usually receive them from predefined number range intervals. The ranges are maintained in a special table. The objects in question include patients, cases, organizational units, and insurance providers.
Predefined Number Range Intervals
The number ranges for objects are established or defined for each institution. Numbers can be assigned manually by you (external) or automatically by the system (internal). In addition, it is possible to permit (manual) assignment of alphanumeric key values. You may also differentiate the number ranges within an object using certain criteria. For example, inpatient and outpatient cases can be assigned to different number ranges within the institution.
Internal/External Number Assignment Alphanumeric Key Values Differentiated Number Ranges
Number ranges are also differentiated based on mode of operation. You indicate whether the application runs in normal operation with the central database, or whether the application runs independent of the central database. The numbers assigned for the standalone system are outside the number range for the central database. As a result, objects entered in the standalone system can be imported into the central database because the numbers do not overlap. However, during transfer the content of the objects created centrally and in the standalone system must be compared.
Mode of Operation Intervals
Matchcodes You have to enter the identifying key value for an object to begin a display or change transaction for that object. Since you frequently do not know the key value, the system must provide alternatives for finding the search object.
Online Search Tool
In addition to mandatory entry tools such as patient index search using patient attributes, matchcodes are another basis for finding key values using descriptive attributes of the object in question. An example is using a name or address data to find a business partner. In fields where you enter a specific object such as business partner, the search by matchcodes can be activated in two different ways: either by entering the matchcode search term into the field or by calling the possible values for input.
Mandatory Entry Tools Matchcode Search
The matchcode search returns a hit list from which you choose the desired object. The key value of the selected object is then copied into the input field. The rest of the procedure is identical to manual input of the corresponding value.
Multiple matchcodes may be assigned to an object in the IS-H system, e.g. a business partner, so that you can search by name in one case and by location in the other.
Multiple Matchcodes per Object
The sequence of fields within a matchcode determines the sequence of fields for the matchcode search term. You can make generic entries for the various fields of the search term.
In addition to working as an online search function as described above, matchcodes are also used as the basis for evaluations or as an index in programs. You may add your own matchcodes based on the search preferences in your environment.
General IS-H Concepts
Extended Screen Modification Modifying Screen Fields
Extended screen modification is used for institution- and user group-specific modification of screen fields. The field attributes can be changed based on the following parameters: ❑ Institution ❑ Screen ❑ User groups from the SAP user master record ❑ Function code ❑ Processing mode (display, change, add, delete) The following attributes can be set for each field:
❑ Required entry ❑ Optional entry ❑ Suppress from screen ❑ Display only
Customized IS-H Screen Layout
Since the modification function is available for all screens, each IS-H screen layout can be customized for a user group. For example, screens can be configured so that more data is displayed for a physician than for a nurse.
Free-Form Text Processing
Free-Form Texts of Any Length
Where required, IS-H allows you to save free-form texts of any length in conjunction with an object. In this case, you will only see the first few lines on-screen. You can edit the complete text in SAPscript by simply clicking the text. If the field length on the original screen is sufficient for the text, only the short text field is displayed. If the system contains free-form text for the object in question, the system will inform you of this.
Several Texts per Object
Frequently, you store several texts for a single object simultaneously. For a patient movement, for instance, you may enter a general comment on the movement and a comment regarding the accident.
Implementing IS-H When implementing IS-H, we pursue the following goals:
❑ Short project run time ❑ Low implementation cost ❑ Implementing departmental requirements ❑ Optimizing work processes. To reach these goals we offer various types of support:
❑ The R/3 Procedure Model describes the activities required for implementing an R/3 system and summarizes them in several phases.
R/3 Procedure Model
❑ The reference model represents data, process and organizational models.
❑ An implementation guide and extensive configuration options support the adaptation of IS-H to the actual hospital operation.
❑ IS-H can be used with heterogeneous systems. Various tools are available for linking IS-H with non-SAP systems.
Linking with Non-SAP Systems
Fig. 10-1: R/3 - Implementation Strategy
Procedure Model The success of an IS-H implementation depends to a large extent on general hospital conditions. How the project implementation is organized and how the departmental requirements are translated into IS-H are particularly important aspects. General data affecting the implementation project includes type and extent of the IS-H modules to be implemented, existing system landscape to which IS-H
Organizing the Implementation Project General Data
Project Team R/3 Process Model Main Project Phases
will be added, type and number of areas and employees affected by the implementation and anticipated implementation deadlines. In addition to the project leader, you need to assign specialists and data processing personnel who will help implement the project. The R/3 Procedure Model provides general basic information regarding the steps and activities required for implementing a R/3 system. The main phases are ❑ Organization and conceptual design ❑ Detailed design and system set-up ❑ Preparations for going live ❑ Productive operation
Fig. 10-2: R/3 Procedure Model
The implementation of IS-H will be of maximum benefit to the hospital if the capabilities offered by the system are utilized to the fullest extent. To achieve this goal, you may have to take organizational measures to complement system implementation.
IS-H Reference Model Data, Process, and Organization Models
Models are designed to translate real-life conditions into a representative information system. Primary examples are data, process, and organizational models. All required elements, relationships, and designations are stored in the R/3 repository. They provide an integrated and consistent description of the data, processes, and the organizational structure which serves as a complete, system-wide basis for implementing the R/3 system.
Fig. 10-3: SAP Reference Model
Chapter 3 contains an overview of the content of the IS-H data model. A sample IS-H data model excerpt is provided in the appendix.
IS-H Data Model
The business processes in the Business Navigator are supported by R/3. These process models are available for all standard R/3 systems and will be available for IS-H in the near future. Event-driven process chains which link the individual functions of a business process via events are the basic representation tool. Events trigger processes, and are in turn triggered by processes, thereby triggering additional processes. In addition to a simple representation of business processes you can display the data which is used in individual processes as input and generated as output, data flows, or function hierarchies.
The process models provided by SAP in the Reference Model facilitate implementation of the R/3 system and are used to determine the planned processes so that business processes can be optimized, or to compare R/3 with other software systems during the selection process.
Optimizing Business Processes
Event-Driven Process Chains
Customizing IS-H was designed as a standardized software system for hospitals, with the result that every hospital using this system works with the same programs. To tailor the system to the individual requirements of your institution without modifying the programs, several options have been made available.
Simple Adaptation to Hospital-Specific Needs
System Parameter Settings
❑ Management of system parameters in tables which you can modify easily. With these parameters you may define organizational unit types (e.g. department, nursing station, nursing care group), specify admission and discharge types and decide which billing method should be used for a case. SAP provides defaults for all parameters.
Integrated Implementation Guide
Control Parameters Can be Set Directly Basic Data
All system parameters are described in the IMG (Implementation Guide) provided. This guide is an important tool for implementing the R/3 system. A detailed representation of all functions allows you to decide which subfunctions are currently relevant for your requirements. The hospital-specific implementation guide will include only these functions. The functions for adjusting the various control parameters can be called up directly from the online documentation. The IMG serves as an interactive guide which provides the required system functions as well as explanations and detailed documentation material. ❑ Comprehensive basic data administration Information regarding your organizational structure, building structure, business partners (insurance providers, external physicians, etc.), charge masters, diagnosis code catalogs, ICPM, etc. maybe maintained and structured to your requirements in the basic data (see Chapter 4). The standard system includes a large set of basic data. ❑ Variable process control
Variable Sequence of Processing Steps
You can change the sequence of processing steps for all comprehensive processes such as admissions, transfers, and discharges. ❑ Dynamic screen modification
Screen Contents Modification
Screen contents can be modified dymanically based on the user group to which the user belongs, the actual task being performed, and the processing mode (create/display/ change). In this way, you can set the system to display more data for a physician than for a nurse, for example. You may delimit the data which can be entered in the same manner. ❑ Individual enhancements to the standard system
R/3 Development Environment
Using the R/3 development tools available, additional reports, ad hoc queries, or enhanced system components are created as integrated modules of the standard system without affecting releases.
Integration With Non-SAP Systems The system supports integration of the IS-H system with non-SAP systems as follows: Use of the IS-HCM module as described in Chapter 8.
❑ Transfer of data from non-SAP systems into IS-H .
Using an SAP standard interface, you can supply IS-H transactions with input data from non-SAP systems and subsequently perform the transaction. Manual execution of the transactions is simulated. All checks and database updates are performed as with interactive transactions, thus ensuring the logical integrity of the database. Incorrect data is rejected by the system but stored separately so that it may be processed once corrected. The procedure is performed interactively or in batch mode.
Transfer of Data from Non-SAP Systems Ensuring Data Integrity
❑ Transfer of data from IS-H to non-SAP systems without IS-HCM Besides using IS-HCM, you can read, edit and transfer data from the IS-H database to other systems via reports and functional modules generated with the R/3 development tools. This can be done interactively by RFC (Remote Function Call) or by CPI-C (program to program communication), via extract files, etc. Since the R/3 tables are stored transparently in the relational database system which is used, you are also able to access the data of the R/3 system directly via ODBC or SQL. To ensure data consistency, this should be restricted to read functions only.
Data to Non-SAP Systems Interactive Communication Data Extracts Direct Access to R/3 Tables
Fundamentals of the R/3 System
Fundamentals of the R/3 System R/3 System Concept Client/Server Architecture The R/3 System is based on a software-oriented three-tier client/server architecture.
Owing to this type of architecture, the central functions of an application system comprising data management, the application logic itself and communication with the user are implemented in separate modules which can be distributed among dedicated servers. This results in the following R/3 System implementation levels:
❑ Central database server for managing both system- and application-related data in a relational database system. Data can be distributed among R/3 Systems with ALE (Application Link Enabling).
Central Database Server
❑ Unlimited number of application servers on which the application programs run. All the applications available in the R/3 System can be used on each application server.
Unlimited Number of Application Servers
❑ A presentation server for each user which ensures communication between the application and the user through the standard R/3 graphical user interface.
With distribution over all three system levels, communication between the various components is provided by the TCP/IP protocol. The use of this standard network protocol also makes it possible to connect a presentation server to an application server across a wide area network.
The client/server architecture provides R/3 customers with the freedom to upgrade their hardware installation in line with technological innovation and individual requirements. For instance, new PCs can simply be added if the number of users increases. This kind of scalability allows you to install the optimum computer capacity on each of the three levels and provide for optimum load distribution even in client/server configurations with several thousand users.
Scalability Suitable for Configurations with Several Thousand Users
This is a major requirement for achieving shorter system response times in hospitals where physicians, nursing and administrative staff work with the system and a considerably high number of users is therefore to be expected.
Fundamentals of the R/3 System
Fig. 11-1: Three-Tier Client/Server R/3 Architecture
The Client/Server Architecture enables the R/3 System to adapt to hardware installations of virtually any size.
Integrated Development System
SAP’s R/3 standard application software enables you to meet the demands of your hospital’s business environment by selecting the modules and setting the parameters you require (Customizing). This requires no modification of the standard software and is upward compatible.
ABAP/4 Development Workbench
To incorporate even greater detail on specific hospital characteristics, R/3 software includes a fully integrated development system complete with the following technological components:
❑ The centralized Repository contains all development objects in the ABAP/4 Development Workbench. These objects include data model objects, ABAP/4 programs, screens and table logic, documentation.
❑ Integrated tools for presenting and modeling data structures and business processes.
Fundamentals of the R/3 System
❑ An interpretative, platform-independent 4th generation language tailored to the development of business applications.
❑ Library of ready-made function modules which are reusable units of code.
❑ Screen Painter and Menu Painter for the platform-independent development of the graphical user interface.
Graphical User Interface
❑ Integrated tools for creating application documentation, including contextsensitive online user documentation.
Fig. 11-2: Integrated R/3 - Development System
All applications developed within the R/3 development environment can, analog to the R/3 System itself, be used in a client/server architecture, without the developers having to take care of the distribution aspect. These applications can be seamlessly integrated in the R/3 standard System.
Seamless Component Integration
In addition to hospital-specific customer developments, the customer exists available within the standard R/3 applications allow you to extend the functionality of your R/3 System without changing the source code of standard SAP programs or affecting software upgrades.
Customer-specific functionality can be simply and seamlessly added to the R/3 standard applications using the SAP development system.
System Management To ensure the reliable operation of a distributed application system, tools are required for monitoring, tuning and analyzing the R/3 System. These are contained in the Computing Center Management System (CCMS) toolset which is highly
Computing Center Management System
Fundamentals of the R/3 System
integrated with the operating, database and network management systems used and which relies on their services.
Graphical User Interface
The CCMS provides the system administrator with a user-friendly graphical interface to facilitate the execution of all system tasks:
❑ System monitoring is provided by the performance monitor, alert monitor and the performance figures history.
❑ System control supports all system administration functions (e.g. configuration, starting and stopping systems and processes), load distribution, background processing, data backup and restore.
❑ Open interfaces with management systems in the network, database and operating system areas.
Integrated system management components guarantee the reliable operation of the R/3 System.
User Interface Design Ergonomic Interface Design Graphical User Interface
Interaction between the user and the R/3 business applications is ensured by a graphical user interface resulting from the latest findings of ergonomic research.
SAP Style Guide
The design standards of the R/3 operator interfaces are documented in the SAP Style Guide which takes account of the Windows Style Guide and the recommendations of CUA, OSF/Motif and Apple Macintosh. All SAP applications are designed according to this guideline. This has the advantage that you are presented with a consistent work environment. As a result, adjustments to a new application and using all the options in an existing application are made considerably easier. The uniformity achieved by the SAP style guide affects all sub-areas of interface design:
Uniformly Structured Menus
Session Manager Standard Tool Bars
❑ Menus: All R/3 application functions can be accessed through menus. Menus are uniformly structured throughout the system. To simplify operation, you can also define customized menus that are adapted to your field of activity. The Session Manager takes simplification further. It allows you to access individual transactions directly from a user-specific menu. ❑ Tool bars A standard tool bar contains symbols, known as icons, for frequently-used navigation commands and for calling up Online Help.
Fundamentals of the R/3 System
❑ Push button bars
The essential functions used to control an application are accessed through function keys. ❑ Control elements
Graphical Control Elements
Along with input/output fields, there are check boxes, list boxes, push buttons and radio buttons. Scroll bars are used wherever more information needs to be displayed than fits on the screen. ❑ Input values
Wherever it is practical to limit the number of possible input values for a field, you can display this limit number and use the mouse to select an entry. ❑ Online Help
Offers documentation on using R/3 applications. Help functions, which are always accessible, offer various ways to access Online Help. Examples are through the glossary or directly from an application. Examples of the R/3 System user interface are given in chapter 5 of this booklet. The interface is designed in such a way that you can work predominantly with the mouse. The keyboard is only required for entering text or figures, but can nevertheless serve as the R/3 System input medium in its own right.
Mouse or Keyboard Operation
Wherever additional display options are required, SAP presentation uses special graphics tools. Interactive SAP Business Graphics is integrated in many R/3 applications for displaying and processing data.
Interactive SAP Business Graphics
The uniformity of the R/3 System graphical user interface makes use and adjustment to new applications considerably easier.
Multi-Level User Documentation Although the graphical user interface is largely self-explanatory, it is backed up by consistent and clearly written documentation to assist you in implementing and using the R/3 System.
The R/3 System provides both “online” and paper documentation. The documentation is divided into implementation guides and end-user manuals, depending on the tasks being performed. The objective of the R/3 System is to combine online and paper documentation to offer maximum support to the user. You can, for instance, search for a particular documentation element online and print out all related texts and notes which could be of interest.
Implementation and End-User- Related Documentation Online Display / Paper Documentation
Fundamentals of the R/3 System
There are various types of documentation which differ in content as outlined below:
❑ Context-sensitive field documentation on data elements, error and system messages
❑ User manual with extensive conceptual discussions, examples and system application functions. You can also call these manuals online from the application screen.
❑ Online implementation guides, data and process models to assist you in implementing the R/3 System (see chapter 10).
Integrated Documentation Elements
Online documentation combines all the various documentation types interactively on the screen (from field descriptions, via extended conceptual notes to glossary definitions). In addition, you can access particular documentation elements via hierarchical structures.
Online, context-sensitive and user-friendly documentation simplifies working with the R/3 System.
Additional Features Worldwide Support Since its foundation in 1972, SAP has developed into one of the largest independent software houses in the world. With branch offices all over Europe, North and South America, in South Africa, South-east Asia, and Australia, the company can guarantee uniform customer support around the globe. In addition to the sophisticated data processing technology used, the comprehensive SAP software systems provide complete business application solutions. The market for the R/3 System covers a wide spectrum of users:
q Group headquarters q Group subsidiaries q Medium-sized companies. Common to all these different types of user is the demand for a wide-ranging business functionality, as well as an expansion of the integrated, business data processing technology and enhancement of international and multinational functions.
Development and Maintenance SAP offers the wide range of business functionality in the R/3 System in the form of modern data processing solutions. Customer requirements, national and international regulations, and new concepts in business management, mean that the functionality of the system must be continuously enhanced. This means recognizing new trends early, and realizing them as standard software solutions, often at very short notice. Before new developments or enhancements are released for sale, they are thoroughly tested in pilot installations at carefully selected sites.
SAP provides a comprehensive and reliable maintenance service which guarantees the stability of the individual software modules.
Price The installation and use of R/3 modules must also be within the bounds of economic feasibility. The uniform price structure, modular organization of the system, and prices related to the size of the installation and customer concerned ensure that every potential R/3 customer can see the costs likely to be incurred for the software. This allows you to plan the costs both for the initial installation and for any subsequent enhancements fairly exactly, based on the business requirements of your company.
Uniform Price Structure
Support Services Services
SAP also offers a wide range of support services to help you decide how R/3 can best be used to meet your particular data processing needs. These services include: q Advice when deciding on the modules required q Comprehensive training in all system components q Consulting services during implementation and application q Miscellaneous services, such as telephone hotline, written problem, and so on These services strengthen still further the economic viability of installing and using SAP software.
Fig. 12-1: Integrated Customer Solution
You can use the various services on offer individually. The SAP support services guarantee that price, deadlines, and content are all tailored to suit the requirements and budgets of your particular company.
Glossary G Glossary
Process designating the beginning of a case (treatment and/or stay) in a healthcare facility. During the admission procedure, a new case is opened and a new case number is assigned. For outpatient cases, admission is equivalent to the first outpatient visit.
Organizational unit which is allowed to admit patients. This department must be included in the organizational structure and a corresponding category must be assigned to it.
Specially marked diagnosis made during the admission examination. It is used primarily to verify the referral diagnosis and as an indication for all procedures performed on the patient. The admission diagnosis is forwarded to the insurance provider as part of the insurance verification process.
Benefits Coverage Rate
The portion of the charge billed by the hospital for services performed which must be covered by the insurance provider.
Business Partner (Hospital)
All persons or institutions having a relationship with the hospital. The general business partner section contains primarily address data. Business partners have various functions: ❑ Health insurance funds ❑ Insurance providers ❑ Employees ❑ Physicians ❑ Hospitals ❑ Employers
Charge Factor (Hospital)
Factor specified for the relative value of a medical service.
Chief Physician Contract
Contract between the hospital and physician regarding additional services provided by the physician and the resulting rights and obligations of both parties.
Process describing the termination of a case (treatment and/or stay) in an institution. The only exception is the outpatient case where a case is not terminated by a discharge. The discharge “releases” the case for follow-up processing. Example: Final billing
Healthcare facility which is legally independent and functions as an independent organization. Enterprises where physicians and the nursing staff diagnose, heal and alleviate illnesses and bodily injuries and provide obstetric services and where the persons to be cared for can be accommodated. Legally mandated evaluations are made at institution level. Several institutions can be set up for one client so that patient management can cover several hospitals simultaneously. An institution is part of a company code. When preparing an internal balance sheet and a profit and loss statement, an institution can be assigned to a business area.
Insurance Provider Group (Hospital)
Insurance provider groups are used as a selection criterion or as a control parameter. One or several insurance providers (e.g. health insurance funds) can be assigned to an insurance provider group. The insurance provider hierarchy can have as many levels as the user needs.
Through insurance verification, the insurance provider confirms to the hospital that the charge to be billed by the hospital will be covered by the insurance provider subject to the insurance conditions.
Charge Factor Value (Hospital)
Monetary value of a charge factor.
Leave of Absence
Period during which treatment is suspended. It is defined by the two movement types “leave of absence start date” and “leave of absence end date”. During this period, a different nursing charge can be billed. Leave of absence can be documented for the case types Inpatient, Observation Patient, and Nursing Home Patient. Especially for inpatient cases, leave of absence must be expressly approved by an attending physician.
Process describing a case-related change of building unit, organizational, and planning criteria. The general term “movement” comprises the following movement categories: ❑ Admission ❑ Transfer ❑ Discharge ❑ Outpatient visit ❑ Leave of absence start date and leave of absence end date Movements can also be planned
Characterizes a movement. Movement categories are: ❑ Admission ❑ Transfer ❑ Discharge ❑ Outpatient visit ❑ Leave of absence start date and leave of absence end date These movement categories are mandatory in the system since they are firmly linked with existing functions.
Planned admission of a patient for a future date. Pre-registration helps planning (beds, staff, rooms, etc.) and shortens and optimizes the actual admission process during peak workload periods. A preregistered patient takes up resources and is therefore included in planning.
In addition to nursing charges, the hospital can bill for procedures surcharges. Procedures surcharges are not time-based. Special forms of charging are available in the hospital for defined services.
Request for Insurance Verification
The hospital generates the request for insurance verification to ask the insurance provider if and to what extent a patient is entitled to benefits coverage.
Self-Pay Patient (Hospital)
Patient, who is a payer or invoice recipient.
Hospital-specific charge master used for entering services.
Type of Coverage
Frequently used break-down of insured persons into billing groups for purposes of cost object controlling.