HM311

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Introduction to Information Systems
for Health Information Technology
Chapter 8: Clinical Information Systems
© 2020 American Health Information Management
Association

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Learning Objectives
Differentiate between the various clinical information systems
Define clinical information system
Determine what clinical information system is needed to meet the
needs of the healthcare facility
Make recommendations on the use and implementation of document
management systems

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Clinical Information System (C I S), 1
Collects and stores medical, nursing, clinical ancillary areas (such as
radiology and laboratory), and therapy department information
related to patient care
Data contained within various information systems are patient
identifiable and are therefore protected by Health Insurance
Portability and Accountability Act (HIPAA)

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Clinical Information System (C I S), 2
Document management system (DMS)
Radiology information system (R I S)
Laboratory information system (L I S)
Nursing information system (N I S)
Pharmacy information system (P I S)
Interdisciplinary charting system

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Clinical Information System (C I S), 3
Emergency department system
Anesthesia information system
Patient monitoring system
Telehealth
Smart cards

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Document Management System (DMS), 1
Electronic method of capturing and managing documents
DMS is used primarily by H I M departments and other departments
to handle documents regarding patient care
Documents can be scanned or obtained electronically from other
information systems

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Document Management System (DMS), 2
More than scanning paper images
Voice, video, electronic transactions, and other forms of technology
may be used to capture data
• One example is optical character recognition (O C R): a method of
encoding text from analog paper into bitmapped images and translating the
images into a form that is computer readable
• With O C R, a text can be scanned, and the content can be edited

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Document Management System (DMS), 3
With O C R, text can be scanned and content can be edited
Document indexing, barcoding, and character/form recognition are
ways to link documents to a particular patient
• Allows for retrieval
Index: An organized (usually alphabetical) list of specific data that
serves to guide, indicate, or otherwise facilitate reference to the data

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Document Management System
Indexing tools allow user to locate and retrieve specific patient’s
health record, specific encounter, and even specific document
through use of indexing by entering search criteria into one or more
of index fields
DMS is not the same as the electronic health record (E H R)
• E H R: Health-related information on an individual that conforms to nationally
recognized interoperability standards and that can be created, managed, and
consulted by authorized clinicians and staff across more than one healthcare
organization

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Document Management System (DMS)
Image can be retrieved by any authorized user from any location
Multiple users can view same image at same time, enhancing
communication between care providers
Image of scanned document cannot be searched, edited, or
changed unless O C R is used
Many HCOs that elect to implement a DMS use it as a component of
the E H R

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Components of a Document Management System, 1
Scanner: Hardware used to transform paper document into a digital
image
• Rated based on the number of pages per minute (PPM) the scanner can
process
Target sheets: Pages that contain only a barcode that tell the
scanner and computer the content of the pages that follow
Scanning workstation: Desktop computer that controls the scanner
• The workstation compresses the file created by the scanner in order to save
storage space

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Components of a Document Management System, 2
Abstracting and quality control workstation
• Used for indexing and quality control
• HCO determines data elements to be indexed based on needs
• Quality control process: Clerk views every image to check for quality of image
and verifies that indexing is accurate and patient demographics are correct
File server
• File server receives the request for the document images
• Retrieves the document images
• Sends the document images back to the requester

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Components of a Document Management System, 3
Retrieval workstation
• Workstation used by the physician, H I M staff, or other users to retrieve
patient information and view document images

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Components of a Document Management System, 4
Printers
• HCO needs to determine who has the rights to print reports from the DMS
• Electronic or computerized print tracking log
• Who requested or submitted the print order
• Where the printing occurred (which printer was used and in what area of the
healthcare facility)
• Date and time of printing
• What forms or reports were printed
• Any other pertinent information the healthcare facility deems appropriate

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Components of a Document Management System, 5
Annotation: The ability to add to the image in some way
• Note: Allows physician/other user to add a note to the image
• Highlighting: Emphasizes important sections of text
• Drawing: Used to draw circles, arrows, or other markings
• Zoom and reduction: Enlarges or reduces size of image to enhance viewing
• Rotate: Allows user to flip image

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Advantages and Disadvantages to DMS, 1
Space savings
Retrieval of large number of records
Productivity gains
Online availability of information
System security and control

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Advantages and Disadvantages to DMS, 2
Database retrieval
Lack of manipulation or reporting
Fear of change

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Implementation of DMS, 1
Backscanning: Process of scanning past health records into DMS
so there is an existing database of patient information
HCO should choose how far back to go with the scanning
Scanning performed by H I M or other staff or outsourced to a
vendor

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Implementation of DMS, 2
Justification of cost
Forms
• Barcode makes indexing more efficient because the barcode can enter
metadata automatically
Staffing changes
Process redesign

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Implementation of DMS, 3
When to scan the health record
• Immediately after discharge
• Upon completion
Retrieval of images
Future of document management system

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Radiology Information System, 1
R I S: Collect, store, and provide information on radiological tests
• X-rays
• Ultrasound
• Magnetic resonance imaging (M R I)
• Computed tomography (CT)
• Positron emission tomography (P E T)

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Radiology Information System, 2
Other radiological procedures performed in radiology
• Ultrasound-guided biopsies and tests
• Upper and lower gastrointestinal series

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Radiology Information System, 3
Perform many administrative tasks:
• Schedule patient examinations and procedures
• Report charges to the financial information system
• Generate management reports
• Generate radiology reports
• Track nuclear materials
• Transcribe documents

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Radiology Information System, 4
• Retrieve test results
• Fax radiology reports to the ordering physician
• Monitor supply inventory
Picture Archival Communication system (P A C S): Integrated
information system that obtains, stores, retrieves, and displays
digital images
X-ray films, M R Is, mammograms, cardiac catheterization films, and
ultrasounds are stored digitally, thus eliminating the need to store
and manage the physical film

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Radiology Information System, 5
Teleradiology: Ability to view radiology images from any location by
radiologist and other users
Images can be viewed at multiple locations at the same time
Radiologist can read images from home, from another city, or from
other countries
Teleradiology is also used frequently for consultations between
radiologists who are in distant locations

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Laboratory Information System (L I S), 1
Collects, stores, and manages laboratory tests and respective
results
Can speed up access to test results through improved efficiency
from various locations, including anywhere in the hospital, the
physician’s office, or even the clinician’s home

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Laboratory Information System (L I S), 2
Physician order for a laboratory test is generally received from a
computerized physician order entry (C P O E) or other order entry
system
C P O E
• Identifies what tests need to be run
• Schedules them
• Creates a list that indicates where the patient is located
• Notes whether the test is routine or urgent

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Laboratory Information System (L I S), 3
Other functions
• Printing out specimen labels
• Notifying laboratory staff and physicians of panic (very high or low) values
• Identifying normal ranges for each laboratory test
• Marking laboratory values as high, low, or panic (very high or very low)
• Printing barcodes to track specimens
• Recording quality control activities
• Generating management reports
• Generating laboratory reports
• Submitting charges to the financial information system

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Nursing Information System (N I S), 1
Clinical documentation: Any manual or electronic notation or recording
made by a physician or other healthcare clinician related to patient’s medical
condition or treatment
May be different N I Ss available for emergency department,
intensive care areas, and other nursing areas because of the
differing needs of each specialization

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Nursing Information System (N I S), 2
Advantages to N I S:
• Reduction in costs of providing nursing care
• Improved patient care
• Immediate access to information on services rendered by nursing staff
• Immediate notification of results from laboratory, radiology, or other ancillary
departments
• Reduction in lost charges
• Reduced average length of stay
• Submitting charges to the financial information system

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Nursing Information System (N I S), 3
Nursing documentation traditionally includes:
• Admission assessment
• Nursing activities
• Intake and output
• Graphic information
• Activities of daily living
• Nursing care plans
• Nurses’ notes
• Medication administration record

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Nursing Information System (N I S), 4
N I S can also assist in the administrative management and daily
operations of the nursing department by
• Monitoring staffing allocation
• Scheduling nursing staff
• Generating performance improvement reports

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Pharmacy Information System (P I S), 1
Assists providers:
• In ordering
• Allocating
• Administering medication
With a focus on patient safety issues, especially medication errors,
the P I S is a key tool in providing optimal patient care

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Pharmacy Information System (P I S), 2
P I S assist in reducing medication errors
• Using combined hospital information system, the E H R, and P I S
• Would use any knowledge (from medical databases, drug formularies, etc.) and
documentation of patient’s condition and treatment to assist in reducing errors
• Check for drug interactions, food and drug interactions, and other
contraindications

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Pharmacy Information System (P I S), 3
Manage the inventory of drugs in the pharmacy
• Ordering drugs
• Inventory control
• Managing the formulary
• Tracking the costs of drugs
• Reporting on the usage of controlled medications

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Pharmacy Information System (P I S), 4
P I Ss can assist in dispensing of medications in the pharmacy,
which can help the nursing units in a number of ways:
• Creating individual dosages
• Use of secure storage systems
• Robotics
• Secure access to medications
• Documentation of medications administered, including when and by whom
• Barcodes

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Interdisciplinary Charting System
Used by any healthcare professional to collect and store patient
assessments, progress notes, and care plans
• Examples: physicians, nurses, physical and occupational therapists,
respiratory therapists, pharmacists, dietitians, etc.

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Emergency Department System (E D S), 1
Designed to meet the unique needs of the emergency department
Tracking patients from triage to discharge
Record test results and other clinical information
Demographic information is obtained from the hospital information
system

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Emergency Department System (E D S), 2
Notify state health authorities regarding diagnoses of newly
emerging diseases
• Zika virus infection or multidrug-resistant tuberculosis
Injuries due to mass casualty events
• Terrorist bombings
• Train derailments

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Emergency Department System (E D S), 3
Injuries due to natural disasters
• Tornadoes
• Hurricanes

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Anesthesia Information System
Collects information on preoperative, operative, and postoperative
anesthesia-related clinical information
Follows the patient through the surgical process
Collects information on risk factors, vital signs, type of anesthesia,
anesthetic agents used, dosage of anesthetic agents

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Patient Monitoring System
Data collected include fetal monitoring, vital signs, and oxygen
saturation rates
Patient monitoring systems are typically utilized in the intensive care
units and other specialty areas such as the operating and recovery
rooms

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Telehealth, 1
Also known as telemedicine, has two aspects:
• Professional services given to a patient through an interactive
telecommunications system by a practitioner at a distant site
• A telecommunications system that links healthcare facilities and patients from
diverse geographic locations and transmits text and images for (medical)
consultation and treatment

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Benefits of Telehealth, 1
Improved access to healthcare, such as specialty consultations,
biomedical monitoring, and second opinions
Improved continuity of care, patient education, and timely treatment:
follow-up visits for chronically ill patients, reduced travel time,
increased care to underserved areas
Cost efficiency: managing chronically ill patients more efficiently
decreases admissions and shortens length of stay

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Benefits of Telehealth, 2
Improved access to health records and patient information with
online health information available for learning, peer support groups,
research information
Improved training and education for medical/clinical personnel as
well as patients, clinical trial research, improved interactions with
medical personnel for disease management

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Telehealth, 2
Telesurgery: Use of robotics to perform surgery
Technology used includes virtual reality and robotics, which may be
used to assist with the examination or treatment
This allows surgery to be performed on a patient in a different
location

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Telehealth Issues, 1
Privacy, confidentiality, and security must be ensured during the
telemedicine event
Liability is usually shared between referring provider and consulting
provider, but for telemedicine vendors and technical staff there is no
legal precedent yet
Licensure and accreditation rules differ by states for both licensure
and accreditation; there is no federal legislation for telemedicine at
this time

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Telehealth Issues, 2
Fraud: Vendor services, billing for healthcare services provided, and
contracts need clear legal analysis
Policies and procedures must be developed and agreed to by all
parties
Documentation requirement for patient information and services is
provided

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Smart Card
A plastic card, similar in appearance to a credit card, with a
computer chip embedded in it
Three uses of smart cards in healthcare are:
• Emergency treatment,
• Reducing fraud and abuse,
• Reducing administrative costs