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INTRODUCTION TO BAHMNI Bahmni is a highly configurable and modular system, it can be implemented in phases and in different ways to support hospital operations. Bahmni can be setup with all or only some of the sub-products. It is meant to be implemented considering the hospital’s setup and the end user capabilities and use cases. For example, in a hospital which has outsourced Laboratory can choose to not install and setup OpenELIS. It is possible for a hospital or clinic to start with a basic implementation and then keep increasing the adoption in the facility. For example, one may start with Non-clinicals first and then introduce basic clinical entry in some departments. And as the comfort level of clinicians and other staff goes up, move to capturing more details directly in the system. Here are some example scenarios in which Bahmni is being used currently.

1.1 Non-Clinical Implementation In this setup Bahmni is used primarily for managing hospital’s operations and not for any clinical purposes. The setup involves using Bahmni for Registration, Laboratory, Billing and Administrative Reporting. Key business processes: • Patient Registration is done using the Non-Clinical Implementation system. • orders given on paper - Enter samples and Lab results in the system-Laboratory. • paper based prescription - Enter drug orders in the system, dispense drugs, generates bill and manage inventory- Pharmacy. • paper orders - Enter services availed, products consumed (OPD & IPD) and generate bills from paper based records- Billing.

1.2 Basic Clinical Implementation Key Business Processes: • Patient Registration is done using the basic clinical implementation system. • Basic Clinical entry is done in Diagnosis, clinical history or specific observation system. • Laboratory - Based on orders given on paper - Enter sample and Lab results in the system. • Paper based prescription - Enter drug orders in the system, dispense drugs, generates bill and manage inventory-Pharmacy. • paper orders - Enter services availed, products consumed (OPD & IPD) and generate bills from paper based records-Billing. • Doctors get to see clinical history on patient dashboard based on data entered by other departments

1.3 Basic Clinical Implementation - Data Entry In this setup Bahmni is used for managing hospital operations and for clinical data entry at the end of the visit. The setup involves using Bahmni for Registration, Laboratory, Pharmacy and / or Billing and Reporting. Clinical information is captured in post facto Data Entry mode Key Business Processes: • Patient Registration is done using the basic clinical implementation-data entry system. • Clinicians enter all clinical details on paper including diagnosis, prescriptions order etc. • Based on orders given on paper - Enter samples and Lab results in the system-Laboratory. • paper based prescription - Enter drug orders in the system, dispense drugs, generates bill and manage inventory- Pharmacy. • paper orders - Enter services availed, products consumed (OPD & IPD) and generate bills from paper based records- Billing. • All Clinical entry is done by a data entry operator at the end of the visit (same day or next day) - e.g. Diagnosis, clinical history, observations, prescriptions, clinical notes etc. Some of the non-structured clinical details continue to be present on paper.

1.4 Complete Implementation In this setup Bahmni is used for Clinical activities as well as for managing hospital operations. The setup involves using Bahmni for Registration, Clinical (OPD & IPD), Laboratory, Pharmacy and / or Billing and Reporting. Key Business Processes: • Patient Registration is done using the Complete Implementation system. • Clinicians enter all clinical details in the system including Vitals, clinical history, diagnosis, prescriptions, Lab & radiology orders etc. • orders given by doctors in the system - accept samples and enter Lab results in the system- Laboratory. • prescription given by doctors in the system - drug orders are pre-populated in the system, dispense drugs, generates bill and manage inventory- Pharmacy. • Based on clinical orders and some paper based consumption entries - Some of the services and items consumed are pre-populated - for others, enter services availed, products consumed (OPD & IPD) and generate bills from paper based records- Billing. • Some of the non-structured clinical details including Nursing and Doctor’s notes in IPD continue to be present on paper

1.5 Program Specific Implementation In this setup Bahmni is used for capturing disease specific program data. The setup involves using Bahmni for Registration and capturing program specific Clinical data and Reporting. This typically involves installing Bahmni with only OpenMRS. This could be done during a patient visit or as a post facto data capture Key Business Processes: • Patient Registration is done using the Program Specific Implementation system. • Program enrollment, Managing program progress and End programs. • Capturing program specific observation forms

2. MODULES 2.1 Patient Registration Patient Registration provides the ability to start and edit a patient file at a hospital. Most hospitals have a front desk where patients have to register before starting medical interactions such as consultation, lab tests, admission, procedures etc. The Registration Module in Bahmni is designed to be used at the front desk to capture patient information that can be collected by non-clinical staff. Using the Bahmni Registration Module, users can search for existing patients and add new patients to the system. For every patient record being created, information such as patient name, photograph, address and specific attributes that the hospital may be interested in can be captured. This information can be printed out as an identification card for the patient, which can be configured. There is a provision in the Registration module for the user to specify which department or doctor the patient is being directed to. This can later be used to configure custom queues for that specific department / doctor. The Registration module can also be configured to capture clinical information for the patient such as height and weight, which can later be shown to clinicians, if the current hospital workflow demands it. Where is it Used? At the front desk of the hospital, this is the first touch-point for the patient in the hospital, where the patient record is created or updated. Benefits • Configurable patent search based on the name, identifier, address or custom attributes. • Capture of patient details (multiple identifiers, name, age, gender, photograph, custom attributes). • Patient's address details (optionally a pre-defined location hierarchy can be used) • Capture relationships between patients and other patients/doctors • Print out custom configurable patient identification cards • Drive patient workflow in other departments of the hospital based on information collected • Ease facility management by tracking the number of times a patient visits a hospital and the kind of encounters he/she goes through during a particular visit.

2.2 Treatment Programs A Program is a feature that is typically used when a patient is identified as belonging to a group which needs regular consultations or interventions. For example, programs might be used for diseases such as HIV, tuberculosis or even conditions such as pregnancy or interventions such as childhood immunization. These are situations that demand periodic monitoring to ensure that the patient is progressing on the right path. Other important reasons for using a program are for situations where entry and exit dates of a patient in a program are required for reporting purposes and to trigger specific workflows. Using Bahmni, a program can be defined with a specific workflow and patients can be enrolled into this program. The patient's state changes over a timeline can be easily visualized. Separate reports can be generated for encounters within a program and for encounters that are not part of the program. With the program module, it is possible to : • Enroll a patient to a program • Track patient progress • Remove a patient from the program Where is it Used? Hospitals which run programs involving frequent/periodic followups for specific diseases or conditions (eg. TB care or Pre/Post Natal Care). Benefits The program module is useful in monitoring patients with diseases that require prolonged/extended treatment. It helps in monitoring when the patient enrolled in the program and keeps track of their progress over time. This is also useful in generating reports to check efficacy of a particular treatment regimen for a patient.

2.3 Clinical Services The Clinical Services feature is used to view the treatment history of existing patients, as well as to start a registered patient's treatment process in the medical facility. Where is it Used? It is used in the hospital to start a registered (new or repeat) patient's clinical observation and consultation process during the course of the patient's treatment. It is also used to search for, view and edit a patient's observation notes.

Benefits • Enter Patient data retrospectively or on behalf of another provider. • View Patient Dashboard including Patient Details, Active and Past Programs, etc. • View the summary of a Patient's visit along with graphs and trend mapping. • Capture specific clinical observations for the patient such as Obstetrics, Gynecology, etc. • Autocompletes most data fields for easier data entry. • Capture various diagnoses for the patient. • Capture Dispositions for the patient with Disposition notes. • Capture Consultation notes for the patient. • Prescribe treatment orders for medications. • Place orders for radiology tests via PACS (Picture Archiving and Communication System) integration. • Place orders for Laboratory tests. • View the consultation history of the patient. • View scanned documents and results of tests. • Capture Bacteriology test results for the patient (different from laboratory tests). Bacteriology includes smear test results, culture test results and drug-sensitivity test results. • View Patient Lists with support for sorting by filters.

2.4 Patient Lists This feature provides a list of patients registered at the facility with filtering capabilities. Using this list, the staff at the hospital can navigate to the Patient Dashboard to view and add clinical information for the patient. Where is it Used? Patient lists are mainly used as springboards for viewing and capturing clinical information of the patient. Patient lists are supported in all modules in Bahmni, including Clinical, Program Management, In-Patient, Orders etc. These lists can be configured to be displayed either as tiles or as a list with configurable information per patient. Benefits Patient Lists bring multiple benefits to the hospital staff - • A quick snapshot of patients in various categories, either as a tile or list view. • The tile view displays the patient picture, if the patient image has been captured in the registration module. If the patient is admitted, the tile view also displays an icon indicating the patient is admitted. • In the list view, a configurable of set of information for each patient can be displayed. • Additionally, the queues themselves are configurable, and can be setup based on different parameters. For example a list of all patients who have an active visit or all patients who have been sent to a particular department.

2.5 Patient Dashboard Overview The Patient Dashboard displays an overview of a patient's clinical personal information. This page, which has configurable sections, is used to display the most crucial information of the patient to enable quick and efficient care. Some of the information usually displayed on the Patient Dashboard may include patient diagnosis history, lab results, nutritional values, vitals, treatments, radiology documents etc. Bahmni provides the ability to configure multiple such dashboards per patient, which in turn gives users the option to view information which can be classified and organized based on their needs. Additional dashboards can be setup, for example to view graphical trends of numeric observations or a department specific view of patient clinical data. Bahmni supports various display control widgets that can be added and configured to display relevant patient information. A display control takes in configuration that specifies the context (patient, visit, etc.) and other parameters (display specific feature toggles), retrieves relevant data on its own and displays it based on where it is placed on the application. Where is it Used? Dashboards are used to display patient information as relevant to the context. These can be configured to view the clinical and other required information about the patient. Benefits The following are the main benefits of dashboard: • View patient information using display control widgets. • View a complete snapshot of patient clinical information either at the level of a patient or a visit. • Configure patient graphs and trends for convenient metrics and monitoring. 3.2.6 Patient Graphs and Trends When doctors use Bahmni to look at data for patients, it is very useful for them to look at certain observations as graphs or trends so that they can get an idea of how the patient in faring with the given treatment. This is clearly represented in the Trends tab in the clinical module. Where is it Used? The Trends dashboard is used by the doctors at the time of consultation to quickly refer to how the patient has been doing in the key areas over a period of time. Benefits • This information is conveyed quickly when the data is visualised as a graph instead of a table. • Clinicians can also view growth charts and reference charts in Bahmni • Examples of charts that are used at various hospitals are - for a diabetes patient the clinician can view the trend chart of their blood sugar levels over a period of time., for a TB patient the weight and BMI charts are used to see the trend over the period of the treatment. • For babies, growth charts can also be setup and the clinicians can easily make out which percentile the baby is in.

2.7 Patient Monitoring Flowsheet There are several treatments or programs that are run by medical organisations that require the patients to adhere to a particular order of visits, tests or other checks that are conducted as per a schedule. In such scenarios, the patient monitoring flowsheet gives a visual representation of the following: • The planned treatment schedule for the patient • The patient's position in the treatment schedule as of today • Missed or erroneously captured data This flowsheet is driven by a trigger that would define the beginning of the schedule. For instance, this could be a date like the date of enrolling the patient into a program or it could be an event, for instance birth of a child. The schedule of what needs to be recorded and when will be defined at a local level by the implementers in the configuration. Where is it Used? Some examples where this might be useful are diseases like HIV, TB etc, antenatal and postnatal programs or immunisation schedules. This display is meant for the end users who would want to look at the flowsheet and determine if the patient’s data is complete as per the schedule. These users might be clinicians, program mangers or data managers. Benefits This feature helps ensure data quality for a patient in terms of data entry. Further it provides a one shot view of the progress of a patient in a particular treatment schedule or program.

2.8 Capturing Consultation Data The Observations tab in the clinical module in Bahmni is a platform where clinicians can record and view clinical notes for general patients, emergency cases, surgery, vitals, intake-output, delivery, gynecology, and basically every disease or condition for which forms have been defined. Where is it Used? It is used in the hospital to start a registered (new or repeat) patient's clinical observation and consultation process during the course of the patient's treatment. It is also used to search, view and edit a patient's observation notes. Benefits • Enter Patient data retrospectively or on behalf of another provider. • View Patient Dashboard including Patient Details, Active and Past Programs, etc. • View the summary of a Patient's visit along with graphs and trend mapping. • Capture specific clinical observations for the patient such as Obstetrics, Gynecology, etc. • Autocompletes most data fields for easier data entry. • Capture various diagnoses for the patient. • Capture Dispositions for the patient with Disposition notes. • Capture Consultation notes for the patient. • Prescribe treatment orders for medications. • Place orders for radiology tests via PACS (Picture Archiving and Communication System) integration. • Place orders for Laboratory tests. • View the consultation history of the patient. • View scanned documents and results of tests. • Capture Bacteriology test results for the patient (different from laboratory tests). Bacteriology includes smear test results, culture test results and drug-sensitivity test results. • View Patient Lists with support for sorting by filters.

2.9 Capturing Observations The Observations tab in the clinical module in Bahmni is a tab in the clinical consultation where clinicians can capture clinical observations for patients. The different forms used in different departments and sections by different providers in a hospital can be setup here as individual forms. Examples of such may be surgery, vitals, intake-output, delivery, gynecology, ANC, diabetes etc. Bahmni provides the ability for the users to recall data previously filled in these forms, mark their favorite forms and compute drug orders automatically. Observations can be captured in various data formats including free text, numeric, boolean, drop-down with auto-complete ability, date, sigle select, multi select, grid etc. These forms can be created and edited by the implementer either manually using the OpenMRS administrator's interface or the custom CSV file import mechanism. Where is it Used? The Observations tab is mainly used by doctors and data entry personnel to record observations for a patient during a visit. These observations are captured across different forms that are configured for the hospital facility. Benefits This tab plays a key role in capturing patient's clinical information. The information is entered in forms that are exclusively set up for various diseases or conditions that a patient may have. For example, a facility can define a form for diabetes. This form would contain a list of all the questions that a doctor would need to ask a patient suffering from diabetes. Some questions can be populated with a pre-defined list of possible answers. This helps the doctors ensure that they have covered all the core questions that they need to ask the patient.

2.10 Recording Diagnosis Diagnosis is the most important clinical information of a patient. Bahmni provides the ability to capture, edit and delete diagnoses for patients on a diagnosis tab inside clinical consultation. Clinicians can use this feature to capture diagnosis of patients and manage their old diagnoses. In the database these diagnoses can be mapped to ICD-10 codes for reporting purposes. Bahmniallows users to configure your own attributes for each diagnosis, such as inactive, ruled out, etc. Where is it Used? The Diagnosis tab is used mainly by the clinicians to record the diagnosis of the patient. If the diagnosis being entered has not been saved as part of the coded set of diagnoses in the database, the clinician can save the diagnosis as a "non coded" diagnosis by Accepting it as a new diagnosis being entered. Along with the diagnosis, the clinicians can also indicate whether a diagnosis is primary or secondary and if it is presumed or confirmed. In addition to this, they can also rule out or mark a diagnosis as inactive if applicable. Additional notes can also be entered against each diagnosis. Clinicians can also delete or edit past diagnoses on this tab. Benefits The Diagnosis tab provides the history of diagnoses of a patient at one place. This is important for clinicians to understand a patient's clinical history. It is particularly helpful for the clinicians as it provides a quick snapshot of previous diagnoses.

2.11 Ordering Laboratory and Radiology Tests Using this feature, a doctor can place place lab orders and procedure orders from clinical module. The procedure orders placed can then be viewed, relevant information can be added and it can be marked as completed. For lab orders, integration is built between the clinical (OpenMRS) and lab (OpenELIS/Odoo) systems to enable the lab dashboard to be auto-populated based on the order from the Clinical module. Where is it Used? The need for an Order arises when the doctor or any other medical provider wants some action to be taken by some other medical provider in the Hospital for a particular patient. The work flow would be as follows: • The Medical practitioner who wants to place an order goes to the tab "Orders" under Clinical Consultation. • The Orders tab lists all the possible types of orders (this can be configured). • Once an Order type is selected, all the concepts that are needed to specify that particular type of order are listed in a hierarchical manner from where they can be selected for specifying the order • This Order then resides in a queue which contains all the orders. The orders will be fulfilled through different views of this queue. • The Orders fulfillment is set up as a separate module in the application. Clicking on the icon for this module will take the user to a page where all the pending orders are listed in different queues based on their order types. Benefits This allows the clinician to place an order from the system. The lab technician can immediately see the order in their queue and hence they do not have to wait until the patient comes to know what samples need to be collected or tests need to be done.

2.12 Prescribing Medications The Medications tab in the Clinical module in Bahmni is a platform where clinicians can prescribe drug/medication orders to the patients. They can also manage old prescriptions for the patient here. A drug order can be added, edited, stopped or refilled on the Treatments tab. For each drug order, the system allows the clinicians to choose route, frequency, dosage and instructions. This feature has been designed to make the users highly time efficient, by providing them sensible defaults wherever possible. Where is it Used? The Medications tab is used by the clinicians to capture what medicines they have prescribed to the patient. In some cases, it is also used to indicate the medicines that the patient was on. Benefits • The Medications tab provides an easy way to order drugs for a patient. • It has key features like edit, stop and refill a drug order, all of which simplify management of drug orders. • The tab provides a clear visual distinction of the current active, scheduled and past drugs. The drug orders with a green tag are scheduled, the ones with an orange tag are those that are currently active and the ones without any tag are the past drug orders of that patient. • It can also be configured to group drug orders into sub-sections if desired by the hospital/clinicians.

2.13 Dispensing Drugs This feature provides the ability to mark the drugs as dispensed against a drug order. In most scenarios this is done by the person dispensing the drugs - pharmacist(s) or doctor(s). This feature additionally helps to provide clear segregation of stocks, so that the inventory can be managed well in OpenERP. This is achieved by mapping login location to shops. The quotation gets created in the pharmacy that is mapped to the location from where the drug is dispensed. Where is it used? This feature is used either by the clinician or the pharmacist to mark the drugs as dispensed after providing the drugs to the patients. There are scenarios where apart from the pharmacy, the drugs can be stocked at different locations within the hospital. In such cases, this feature provides a finer mechanism to mark only those drugs which have been dispensed from the current location of the clinician or pharmacist. A typical use-case would be if the physician dispenses the "physician's free sample" so that the cost of treatment can be lowered for the given patient. The physician can click on the "D" button which is mapped to a "discount shop" in OpenERP. The pharmacist then can dispense only those drugs which the physician has not given to the patient. Benefits The major benefits of this feature are: • Ability to mark the drugs as dispensed. • Manage drug stocks at different locations within the hospital - e.g.: pharmacy (one or more), OPD (one or more), other locations, etc. • Provide a clear separation of quotations in OpenERP for different OpenMRS locations.