Transcript Document 710526

ULTIMA*DCF
ULTIMA*DCF CHOTS (component health-care off-theshelf) solution is dedicated to children and
adolescent psychiatric care institutions of the
Departments of Children and Families.
Copyright © 2004-2011 ITC Software All rights reserved
ULTIMA*DCF CHOTS (component health-care off-the-shelf) solution is dedicated to children and
adolescent psychiatric care institutions of the Departments of Children and Families.
ULTIMA*DCF CHOTS SOLUTION
ULTIMA*DCF offers ten (10) components for all interested institutions. Five (5) are dedicated to the patient
administration and five (5) to patient care, including comprehensive electronic patient/medical recording
of patient’s treatment progress.
Available Components
Patient Administration
Patient Care
Only certified physicians, psychologists, nurses and other authorized hospital/institution staff have
access to the ULTIMA*DCF application. This is enabled by activating the horizontal tabs according to each
user’s access privileges.
USER’S SIGN ON
Only certified physicians, psychiatrists or psychologists have access to the ULTIMA*DCF applications
enabled by activating the horizontal tabs according to each user’s access privileges.
Physicians
Nurses and other authorized hospital/institution nursing staff have access to the ULTIMA*DCF
application, enabled by activating the horizontal tabs according to each user’s access privileges.
Nurses
Authorized hospital/institution staff have access to the ULTIMA*DCF application, enabled by activating the
horizontal tabs according to each user’s access privileges and HIPAA guidelines.
Technologists/Administration
The HIPAA certified security officer, usually a DBA (database administrator), is authorized to assign user’s
roles, access to specific applications and user’s password.
HIPAA COMPLIANT ACCESS
The ULTIMA*DCF scheduler is a unique application seamlessly integrated with other system
components.
SCHEDULING
This form is used by the clinic front desk to capture data from new patients, who’s referring physician
usually contacts the clinic by phone.
SCHEDULING
The Physician and Staff listing allows the booking staff the selection of the requested or least busy
physician, psychologist or other mental caregiver.
SCHEDULING
The appointment calendar of the selected surgeon gives the staff a number of choices: open the data
entry by a click on the ‘zoom’ square to the right of the appointment time (see next form to enter
appointments). The daily, weekly or monthly schedules can be viewed by a single click of the mouse at
the left.
SCHEDULING
This is the appointment entry form that allows the entry of a new appointment or the cancellation of an
appointment and assigning the priority of the appointment by the established color codes.
SCHEDULING
The ULTIMA*DCF Scheduler features both the weekly and monthly appointment reviews.
SCHEDULING
This form is an online report for the medical records staff.
SCHEDULING
ULTIMA*DCF includes a number of reports and statistical analyses for the clinic management.
SCHEDULING
A click on the Registration button displays the child’s registration and admission component menu.
CHILD REGISTRATION
The hospital admission menu consists of six vertical tabs for easy access to registration components and
to the room/bed allocation.
CHILD’S ADMISSION
Patient demographics, mailing address, phone information and patient’s referring physician data are
entered into this form. Some of the data are selected by a simple click at the so-called LOV icon.
FAST AND EASY CAPTURE OF DATA
The Patient Family Contacts form captures the important family or child’s guardian data.
FAMILY CONTACTS
The information about the insurance coverage is entered in two forms, primary and secondary insurance,
if any.
CHILD’S PRIMARY INSURANCE
The information about the insurance coverage is entered into two forms, primary and secondary
insurance, if any.
SECONDARY INSURANCE
The assignment of the patient to a ward, room and bed is supported by a fully computerized bed
inventory.
ROOM & BED ALLOCATION
The Electronic Records component consists of two groups of applications: 1) EPR and 2) Patient Intake
Form.
ELECTRONIC RECORDS MENU
The wards/nursing stations applications are a hub of all patient care information.
WARDS/NURSING UNITS
The Ward Organization form is a convenient overview of the ward’s structure, by listing all rooms and
beds of each ward, selected from the hospital ward listing.
WARDS/NURSING UNITS
The top block of the Ward Staff Scheduling form displays the managers of each ward, i.e., the chief
physician and head nurse. Changes in the management staff are made by the hospital chief-of-staff who
has been authorized to update this list.
The second block is a list of the staff of each ward, their main responsibilities (‘Note’), and the current
shift. The head nurse usually maintains the ward’s schedule.
The first block is a summary view of each room. The second block displays the name of each patient,
admission date, and expected length of stay (LOS). An LOV button selects the name and unique ID of the
patient’s attending physician. Then the severity rate, patient diet and differential diagnoses are entered,
marking the primary diagnosis.
The third block is used for a patient’s discharge; indicating the reason and discharge summary. The
command button ‘Discharge’ activates a number of important transactions, namely the transfer of all
patient electronic records into an ARCH_ database for billing, reporting and statistics, as well as updating
the electronic bed inventory.
The S-O-A-PE methodology and format are used as a common denominator for every ward’s electronic
recording. In this manner it is possible to enter all Patient Treatment Progress Notes generally, yet
specific to each ward.The ‘Open S-O-A-PE’ button enables the ward staff to have fast, online access to the
patient’s treatments, orders and results.
The powerful Oracle 9i/10g database technology acts as an integrator of the current ‘legacy’ systems
throughout your hospital.
Patient’s chart and name, selected from the ‘List of Resident Patients’ are displayed automatically. The
date and time are displayed by default. The purpose of the Subjective notes is to record a patient’s
subjective communication or complaints to the nursing staff (remember: ‘what is not recorded – does not
exist’).
The entry of these subjective data are supported by two options: 1) the use of an LOV (list of value) button
which displays a pull-down list of the most frequently used subjective patient complaints, and 2) the
display of an edit window (called modal) for the entry of additional, specific subjective information. The
date, time, and the nurse’s internal code are mandatory items for each entry. The name of the nurse
responsible for the entry is displayed when the nurse’s code is entered. The ‘Save’ button secures the
entry of the information into the database.
The entry of the objective data is similar to entry of the ‘S’ section data; the nurses are aided by two
buttons, Search (LOV pull-down list) and Edit, in order to make the recording of data acceptable and
simplistic. The purpose of the Objective notes is to record all ‘objective’ data (remember again: ‘what is
not recorded – does not exist’), mainly vital signs and measurements, and important patient’s behavioral
and abnormal test results. Each nurse has convenient access to a patients’ laboratory test results, thus
having a more comprehensive understanding of a patient’s medical situation, usually reserved for
physicians.
There are two options for the capture of laboratory test results: 1) transferred from the clinical
laboratories, and 2) entered by the ward staff (e.g., a ward clerk) from the paper printouts.
LABORATORY TESTS
The patient’s attending physician, after reviewing and assessing the subjective and objective data, both in his/her home
office or at the time of the visit, has a considerable amount of pertinent information at his/her ‘finger tips’ – just a click
away for the following: 1) patient health care history, 2) patient physical examination/review of systems, 3) medication
orders and administration, and 4) orders of laboratory tests, diagnostic examinations and treatments, as well as
physiotherapy and other therapies.
The entry of the attending physician’s comments and instructions to nursing teams are aided by easy to use, and ward
care specific, pull-down lists of free text (Search). The physician and the ward staff do not need to know the
numerical/alphanumerical codes that are used, therefore they are not displayed. These are listed only as unique identifiers
and primary keys in the Oracle database. An Edit button displays a special ‘zoom’ window for the entry of a specific
physician’s treatment notes.
The patient’s medical history form, displayed by a click on the Pt Health History button, consists of four blocks:
1)
Patient identification (the chart number and full patient name are displayed automatically), 2) Past diseases (the name and
ICD9 code are entered by the ward staff from the LOV – list of values – pull down listing of codes entered during the
installation of the system), 3) Medications are entered based on the patient’s own recollection, and 4) As well as Allergies mainly drug and food adverse reactions. All entered data and updates are stored in the patient’s electronic record by a
click of the Save button.
PATIENT’S ASSESSMENT
The structure and contents of the block ROS (review of systems) is adjustable for each specialty. A click
on the ‘Zoom’ square displays a window, called a ‘modal’, that enables the entry of longer text. The length
of the text is also flexible depending upon the needs of each medical specialty.
Entry and Review of PE
The physician selects the drug from the approved list of drugs – hospital drug formulary – from a pull down list. The
National Drug Code (NDC), generic name, strength and dosage are displayed automatically. The physician enters only the
quantity, frequency and route of drug administration.
A check off box informs the pharmacy if there is a requirement to prepare a Medication Administration Record (MAR) for
this prescription. The physician is able to access the preferred Drug Consultant available on the Internet or hospital’s
intranet before approval is given to print the MAR or to send the prescription to the hospital pharmacy.
The physician’s electronic signature (full name) is mandatory data to be entered. Without it the Save button will not
function and the prescription(s) will not be saved in the patient’s electronic medication profile .
DRUG WEB CONSULTANT OPTION
www.rxlist.com is an example of a ‘free of charge’ Internet RxList. In
addition to the Rxlist Web site, there are a number of highly reliable
drug consultant sites, such as Medscape, Electronic Medicines
Compendium (eMC), Scholz Healthcare, Drug InfoNet, RxMed,
RxCentric, Drugs.com, Consumer-Oriented Databases, etc.
A simple click on the Treatment Orders button displays a menu with three vertical tabs of the most
frequently ordered tests and examinations, namely Laboratory Tests, X-ray/Diagnostic Imaging, and
Therapy Orders. Each of the order forms/requisitions has an identical layout of two blocks: 1) A list of
approved tests, examinations and therapies, 2) A list of all orders placed for the selected/designated
patient during his/her hospitalization. A check off box indicates if the results have arrived or are available.
A single click on the Treatment Orders button displays a menu with three vertical tabs of the most
frequently ordered tests and examinations, namely Laboratory Tests, X-ray/Diagnostic Imaging, and
Therapy Orders. Each of the order forms/requisitions has an identical layout of two blocks: 1) A list of
approved tests, examinations and therapies, 2) A list of all orders placed for the selected/designated
patient during his/her hospitalization. A check off box indicates if the results have arrived or are available.
A simple click on the Treatment Orders button displays a menu with three vertical tabs of the most
frequently ordered tests and examinations, namely Laboratory Tests, X-ray/Diagnostic Imaging, and
Therapy Orders. Each of the order forms/requisitions has an identical layout of two blocks: 1) A list of
approved tests, examinations and therapies, 2) A list of all orders placed for the selected/designated
patient during his/her hospitalization. A check off box indicates if the results have arrived or are available.
The last form of the S-O-A-PE electronic records is the Patient Plan and Education (PE) section. The entry
of the Nursing care plan based on NANDA nursing diagnosis is optional. For more information visit:
http://www.nanda.org/
PATIENT CARE PLANS & EDUCATION
In all ULTIMA*DCF forms the entry of data is simplified by the deployment of pull-down list of values
(LOV). A single click at the LOV icon attached to most fields, activates the underlying coding structure database schemas - to enable the operator the selection of data for the field. There are four groups of
codes included in the ULTIMA*DCF Code Menu.
ULTIMA*DCF - Codes
General codes used by the registration staff are simple to maintain. Here are examples of Citizenship and
Ethnic/Race codes.
ULTIMA*DCF – General Codes
General codes used by the registration staff are simple to maintain. Here are examples of Language and
School Grade codes
ULTIMA*DCF – General Codes
General codes used by the registration staff are simple to maintain. Here are examples of Religion and
State codes
ULTIMA*DCF – General Codes
Ward and room codes maintain the list of all hospital units and rooms including the charge/diem.
ULTIMA*DCF – Spec. Codes
List of physicians licensed (approved) by the hospital and their specialties are maintained by these two
forms.
ULTIMA*DCF - Spec. Codes
Nursing staff and their certified/official specializations are entered and maintained by these forms.
ULTIMA*DCF - Spec. Codes
Nursing position codes could be expanded for the HR and payroll applications.
ULTIMA*DCF - Spec. Codes
These are examples of subjective and objective typical statements or complaints used for entry into the
Subjective and Objective sections of S-O-A-PE electronic patient treatment progress notes.
ULTIMA*DCF - Spec. Codes
Medical assessments and nursing plans, as well as patient education statements, are used for entry into
the Assessment and PE sections of the S-O-A-PE electronic patient treatment progress notes.
ULTIMA*DCF - Spec. Codes
ICD-9 CM codes as well as CPT (‘Current Procedural Terminology’ by the American Medical Association)
are maintained for the US institutions. For installations outside the US the system coding schemes
include ICD-10 and other codes for reimbursement, e.g., fee codes.
ULTIMA*DCF – Diag. Codes
The patient’s intake form is a unique component of ULTIMA*DCF. It’s main goal is to enable a thorough
assessment of the child’s or adolescent’s status and admission to the treatment facility. It also creates a
powerful database for statistics and research as well as flexible adjustment of the questionnaire for each
psychiatric facility.
ONLINE CHILD’S INTAKE FORM
The Patient Intake Form’s first tab opens the section of the patient’s demographic data, usually already
entered during the child’s registration. If the registration has not been done, the data from the data
captured here will be available at the time of registration/admission.
ONLINE CHILD’S INTAKE FORM
The information about the insurance coverage is entered in two forms, primary and secondary insurance,
if any.
ONLINE CHILD’S INTAKE FORM
The information about the insurance coverage is entered in two forms, primary and secondary insurance,
if any. Note that the date, chart number and child’s name are displayed by default.
ONLINE CHILD’S INTAKE FORM
The fourth data entry tab opens the section of patient’s information about parents, mother and father in
two separate blocks.
ONLINE CHILD’S INTAKE FORM
The Siblings data entry tab opens the section of the patient’s information about any siblings, as well as
about other members of the household.
ONLINE CHILD’S INTAKE FORM
The birthmother pregnancy problems required answers are aided by lists of optional statements (e.g.,
YES, NO) that are displayed by a click on the ‘down’ arrow icon. Note that the date, chart number and
child’s name are displayed by default.
ONLINE CHILD’S INTAKE FORM
The child’s delivery required answers are aided by lists of optional statements (e.g., YES, NO, NATURAL,
HOSPITAL, etc.) that are displayed by a click on the ‘down’ arrow icon.
ONLINE CHILD’S INTAKE FORM
The infant’s data entry is also aided by lists of optional statements (e.g., YES, NO) that are displayed by a
click on the ‘down’ arrow icon.
ONLINE CHILD’S INTAKE FORM
The infant’s development data entry is also aided by lists of optional statements (e.g., YES, NO) that are
displayed by a click on the ‘down’ arrow icon.
ONLINE CHILD’S INTAKE FORM
The child’s behavior data entry is also aided by lists of optional statements (e.g., YES, NO) that are
displayed by a click on the ‘down’ arrow icon.
ONLINE CHILD’S INTAKE FORM
A child’s medical history covers mainly allergies and adverse drug reactions. A child’s physician as well
as the diagnosis are included in this section of the intake questionnaire.
ONLINE CHILD’S INTAKE FORM
This section of the Patient Intake Form covers the child’s family tree and the health status of each family
member.
ONLINE CHILD’S INTAKE FORM
The Pharmacy component is an option for larger hospitals. This menu – Introduction - consists of nine
applications accessed by a click on the vertical tabs.
ULTIMA*DCF PHARMACY
The Patient Data Entry form is a duplicate copy of the patient registration form. This is an option for a
stand-alone pharmacy.
ULTIMA*DCF PHARMACY
The Incoming Drug Orders form lists all prescriptions sent from the hospital wards.
ULTIMA*DCF PHARMACY
All orders/prescriptions of drugs are listed for the dispensing approval (OK box) by the pharmacist.
Details of each approved item are displayed in the second block.
ULTIMA*DCF PHARMACY
The Patient Medication Profile, consists of four blocks of important information: 1) Patient’s ID code and
full name, 2) Patient’s allergies and adverse drug reactions, 3) Listing of all current drugs and medications
with three check off boxes: A = approved, D = dispensed, X = not approved,
4) Item details.
ULTIMA*DCF PHARMACY
The medication administration record (MAR) is prepared by the hospital pharmacy at the request of the
physician who prescribed the medication. The form consists of four blocks: 1) Patient’s ID,
2) A list of
current patient’s drugs/medications, 3) MAR plan prepared by the pharmacy 4) Actual administration.
‘Note’ fields could be displayed in full by a click on the ‘Zoom’ icon.
ULTIMA*DCF PHARMACY
The Inventory Stock Control offers the hospital pharmacy a powerful online review of all items including
the quantity on hand (QOH) and quantity on order (QOO) as well as the total inventory value based on the
hospital internal costing guidelines. Details of each stock item are displayed in the second section of the
form.
ULTIMA*DCF PHARMACY
A complete log of all transactions (opening balance, issued, received, returned, physical inventory count
+ -) enables the pharmacy management an online review of the stock movement.
ULTIMA*DCF PHARMACY
The Review of Drug Orders is a listing of all items on order from suppliers. The entry of new orders and
the electronic order, electronic data interface (EDI), deployment is done by a check off of the Act (activate)
box. Details of each purchase order are displayed in the lower section of this form.
ULTIMA*DCF PHARMACY
The hospital pharmacy is responsible for the entry and maintenance of coding schemes of all
applications.
ULTIMA*DCF PHARMACY - Codes
The Drug Formulary, i.e., a list of approved drugs and medications, is the foundation of the hospital
pharmacy management, as well as drug orders/prescription from physicians. It contains all information
for drug orders from suppliers, plus the maintenance of stock.
ULTIMA*DCF PHARMACY - Codes
The pharmacy has an option of using traditional abbreviations derived from Latin or their own codes, e.g.,
instead of ACL – BL = Before lunch, etc.
ULTIMA*DCF PHARMACY - Codes
The Drug Administration Route codes are based on the pharmacy internal coding, e.g., RTE01, etc.
It is important to note that these alpha-numerical codes are only for the database unique item’s
identification.
ULTIMA*DCF PHARMACY - Codes
This is an example of drug manufacturers codes, usually well established within the pharmaceutical
professional community.
ULTIMA*DCF PHARMACY - Codes
The details of drug suppliers (primary, secondary, etc.) are captured and maintained by this form.
ULTIMA*DCF PHARMACY - Codes
One of the most important issues of any electronic hospital system is the reliability and confidentiality of
the sensitive patient information. Oracle9i/10g database systems are one of the, if not the best in the
world and fully compliant with HIPAA requirements.
POWERFUL ORACLE9i/10g DATABASE
U_DCF_SECOND_INSREG
PT_ID: INTEGER NOT NULL (FK)
SECOND_INS_ENTRY_DATE: DATE NULL
SECOND_INS_NUMBER: VARCHAR2(20) NULL
SECOND_INS_PLAN_NUMBER: VARCHAR2(20) NULL
SECOND_INS_HOLDERNAME: VARCHAR2(50) NULL
SECOND_INS_DOB: DATE NULL
SECOND_INS_SEX: VARCHAR2(10) NULL
SECOND_INS_EMPLOYER: VARCHAR2(30) NULL
SECOND_INS_NAME: VARCHAR2(50) NULL
SECOND_INS_ADDRESS: VARCHAR2(50) NULL
SECOND_INS_PHONE: VARCHAR2(15) NULL
SECOND_INS_CONTACT: VARCHAR2(30) NULL
U_DCF_PRIM_INSREG
PT_ID: INTEGER NOT NULL (FK)
INS_SEQ_NO: NUMBER NULL
INS_ENTRY_DATE: DATE NULL
INS_SIN: NUMBER NULL
INS_HOLDER_NAME: VARCHAR2(50) NULL
INS_RELATIONSHIP: VARCHAR2(1) NULL
INS_HOLD_ADDRESS1: VARCHAR2(30) NULL
INS_HOLD_ADDRESS2: VARCHAR2(20) NULL
INS_HOLD_ADDRESS3: VARCHAR2(20) NULL
INS_HOLD_ADDRESS4: VARCHAR2(20) NULL
INS_HOLD_PHONE: VARCHAR2(15) NULL
PRIM_INS_GRP_ID: VARCHAR2(20) NULL
PRIM_INS_PLAN_NUMBER: VARCHAR2(20) NULL
PRIM_INS_GRP_HOLDER_DOB: DATE NULL
PRIM_INS_GRP_HOLDER_SEX: VARCHAR2(10) NULL
PRIM_INS_GRP_HOLDER_EMPLOYER: VARCHAR2(30) NULL
PRIM_INS_NAME: VARCHAR2(50) NULL
PRIM_INS_ADDRESS: VARCHAR2(50) NULL
PRIM_INS_PHONE: VARCHAR2(15) NULL
PRIM_INS_CONTACT: VARCHAR2(30) NULL
SECOND_INS_FLAG: VARCHAR2(5) NULL
U_DCF_USER_REG
USER_ID: INTEGER NOT NULL
ACCOUNT_CODE: VARCHAR2(15) NOT NULL
USER_NAME: VARCHAR2(30) NOT NULL
PASSWORD: VARCHAR2(15) NOT NULL
OLD_PASSWORD: VARCHAR2(15) NULL
ROLE_CODE: VARCHAR2(5) NULL
FUNCTION_CODE1: VARCHAR2(5) NULL
FUNCTION_CODE2: VARCHAR2(5) NULL
FUNCTION_CODE3: VARCHAR2(5) NULL
FUNCTION_CODE4: VARCHAR2(5) NULL
ENTRY_DATE: DATE NULL
U_DCF_MPIREG
PT_ID: INTEGER NOT NULL
PT_CODE: VARCHAR2(15) NOT NULL
PT_NAME1: VARCHAR2(30) NOT NULL
PT_NAME2: VARCHAR2(20) NULL
PT_NAME3: VARCHAR2(20) NULL
PT_NAME4: VARCHAR2(20) NULL
PT_REGNO: NUMBER NULL
PT_REGDATE: DATE NOT NULL
PT_DOB: DATE NULL
PT_SEX: VARCHAR2(10) NULL
RELIG_ID: INTEGER NULL (FK)
CITIZEN_ID: INTEGER NULL (FK)
LANG_ID: INTEGER NULL (FK)
ETHNIC_ID: INTEGER NULL (FK)
GRADE_ID: INTEGER NULL (FK)
PT_ADDRESS_LINE1: VARCHAR2(30) NULL
PT_ADDRESS_LINE2: VARCHAR2(20) NULL
PT_ADDRESS_LINE3: VARCHAR2(20) NULL
STATE_ID: INTEGER NULL (FK)
PT_HPHONE: VARCHAR2(15) NULL
PT_OPHONE: VARCHAR2(15) NULL
PT_EMAIL: VARCHAR2(15) NULL
PT_MDREFER: VARCHAR2(30) NULL
CONT_TXT: VARCHAR2(100) NULL
CONT_ENTRY_DATE: DATE NOT NULL
U_DCF_CONTACTS
PT_ID: INTEGER NOT NULL (FK)
CONT_HPHONE: VARCHAR2(15) NULL
CONT_OPHONE: VARCHAR2(15) NULL
CONT_NAME: VARCHAR2(50) NULL
Model: DCF physical database
model
Version: 1.0
Author: Ruslan Vagizov
U_CD_DCF_CITIZENSHIPLIST
CITIZEN_ID: INTEGER NOT NULL
CITIZEN_CODE: VARCHAR2(10) NOT NULL
CITIZEN_DESCRIPTION: VARCHAR2(30) NOT NULL
U_CD_DCF_STATELIST
STATE_ID: INTEGER NOT NULL
STATE_CODE: VARCHAR2(10) NOT NULL
STATE_DESCRIPTION: VARCHAR2(30) NULL
U_CD_DCF_LANGUAGELIST
LANG_ID: INTEGER NOT NULL
LANG_CODE: VARCHAR2(10) NOT NULL
LANG_DESCRIPTION: VARCHAR2(30) NULL
U_CD_DCF_RELIGIONLIST
RELIG_ID: INTEGER NOT NULL
RELIG_CODE: VARCHAR2(10) NOT NULL
RELIG_DESCRIPTION: VARCHAR2(30) NULL
U_CD_DCF_SCHOOLGRADELIST
GRADE_ID: INTEGER NOT NULL
GRADE_CODE: VARCHAR2(10) NOT NULL
GRADE_DESCRIPTION: VARCHAR2(30) NULL
U_CD_DCF_ETHNICGRPLIST
ETHNIC_ID: INTEGER NOT NULL
ETHNIC_CODE: VARCHAR2(10) NOT NULL
ETHNIC_DESCRIPTION: VARCHAR2(30) NULL
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We hope you enjoyed our presentation !
Please call or email us, if you have any questions, need more information, would like to
embark on a research project, or require software development services
Tel. +1 978 287 4855
[email protected]
Become a high performance enterprise with Strategic Outsourcing, visit www.itcsoftware.com
Thank you!
We hope you enjoyed our presentation !
Please call or email us, if you have any questions, need
more information, would like to embark on a research
project, or require software development services.
Thank you!
ITC Software
Tel. +1 978 287 4855
[email protected]
www.itcsoftware.com