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Khalid C
Asst. Manager
InformationTechnology
Hospital Information Systems (HIS) and
Electronic Medical Records (EMR)
What is health information system?
HIS and Electronic Medical Records2
It is a system for the
collection/processing of data from various sources,
and using the information for policy making and
management of health services.
It could be paper-based or electronic.
It is a discipline at the intersection of information science,
computer science, and health care.
Systematic Storage and Retrieval of Medical Records
What Is A Medical Record?
HIS and Electronic Medical Records3
A record or documentation of a patient’s
medical history,
examination,
and treatments.
What Is A Medical Record?
HIS and Electronic Medical Records4
Systematic documentation of a single patient's medical
history and care across time within one particular health care
provider.
The medical record includes
variety of types of "notes" entered by Physicians,
recording observations and administration of drugs and
therapies,
Laboratory test results, reports
demographics, medical history, medication and allergies,
 immunization status, radiology images,
vital signs, intake, output, observations
Why do we need a Medical record?
HIS and Electronic Medical Records5
In other words, why do we
need a documentation of a
patient’s medical care?
Potential Uses of Medical Records
HIS and Electronic Medical Records6
Continuity of providing care
Note important information for later use
Especially important in chronic diseases (e.g. hypertension,
diabetes) or in follow-up (e.g. after surgery)
Patient safety
Preventing something bad because of lack of information
Such as drug allergies, list of current medications, “problem
list”
Hospital Functions
HIS and Electronic Medical Records7
Potential Uses of Medical Records
HIS and Electronic Medical Records8
Communications between
providers
Referral to specialists or
other physicians
Consulting among
physicians
Communications between
physicians and nurses,
pharmacists, physical
therapists, etc.
Transfer from a hospital to
another
Potential Uses of Medical Records
HIS and Electronic Medical Records9
Medico-legal purposes
e.g. Court evidence
against malpractice
What was done or
provided to the patient?
Why? By whom? When?
Was the care provided up
to the professional
standard?
Potential Uses of Medical Records
HIS and Electronic Medical Records10
Clinical research
Find ways to improve
health care through new
knowledge
Potential Uses of Medical Records
HIS and Electronic Medical Records11
Claims and reimbursements
What services were provided to the patient
How (and how much) will the hospitals/doctors be paid?
Audit of medical records by “payers”
Patient’s uses
Health insurance claims
 Self-education & self-care
What is an Electronic Medical Record
(EMR)?
HIS and Electronic Medical Records12
Electronic medical records contain the same information as
your paper record but in an electronic form. This
information is accessible to your health care providers
through computers located throughout the Hospital.
Electronic documentation of patient care and to improve the
process of patient care through better documentation
Advantages of EMR
HIS and Electronic Medical Records13
Physicians and nurses have more time to spend with patients.
Improved legibility, accuracy and completeness.
With an EMR there is less potential for medical errors as well as
improved quality and safety in patient care.
Allergies and adverse drug reactions are prominently displayed
Reminders are activated when certain health maintenance tests
and/or procedures are due
Your prescriptions are electronically ordered directly to your
pharmacy
EMR permits more than one user to access your record at the
same time.
Why We Need IT tools in Healthcare ?
HIS and Electronic Medical Records14
Why We Need IT tools in Healthcare ?
HIS and Electronic Medical Records15
Simplification of administrative processes such as Physician
Order Entry, eMAR
Creation and maintenance of electronic health records
(EHR)
Reduction in data gathering and processing costs
Standardization of health data, coding, reporting and
transmission of data
Communication among key stakeholders – patients,
physicians, nurses, administrators.
Health care is information-rich
HIS and Electronic Medical Records16
Why We Need Health IT
HIS and Electronic Medical Records17
Health care is very
complex
Quality of care depends on
timely availability & quality
of information
Clinical knowledge body is
too large
Short time during a visit
Benefits of Going Electronic (EMR)
HIS and Electronic Medical Records18
Ubiquitous availability
(anytime, anywhere,
everyone who is authorized)
Multiple concurrent uses
Ability to control & enforce
access security
Structured data entry possible
Data presentation that is
easier to understand (e.g.
graphs)
No handwriting!!!!!
Hospital Information System
HIS and Electronic Medical Records19
Master Patient Index (MPI)
Admit-Discharge-Transfer (ADT)
Electronic Health Records (EHRs)
Computerized Physician Order Entry(CPOE)
Clinical Decision Support Systems (CDSSs)
Picture Archiving and Communication System (PACS)
Nursing applications
Enterprise Resource Planning (ERP))
Departmental Applications
HIS and Electronic Medical Records20
Pharmacy applications
LIS – Laboratory Information System
PACS - Picture Archiving and Communication System
RIS – Radiology Information System
Specialized applications
Emergency Room
Operation Theatre
Labor Room
Anesthesia, Critical Care, Blood Bank
E-Learning
Master Patient Index (MPI)
HIS and Electronic Medical Records21
A hospital’s list of all
patients
Registration of patients
Captures/updates patient
demographics
Bar-coded Registration
Cards
Admission-Discharge-Transfer
(ADT)
HIS and Electronic Medical Records22
Supports Admission, Discharge & Transfer of patients
(“patient management”)
Provides status/location of admitted patients
Used in assessing bed occupancy
Linked to billing, claims & reimbursements
Appointment Scheduling
• Records appointments
of patients
• Pre-specified number of
open slots
• Ability to
postpone/cancel
appointments
• Displays list of patients
with appointments in a
specific date
HIS and Electronic Medical Records 23
Computerized Physician Order Entry
(CPOE)
• Physician directly orders
online
– medication
– Lab
– diagnostic
– imaging
• Nurse & pharmacy
process orders
accordingly
HIS and Electronic Medical Records 24
Clinical Decision Support Systems
(CDSSs)
HIS and Electronic Medical Records25
The real place where most of the values of health IT can be achieved
Is an application that analyzes data to help healthcare providers make
clinical decisions.
Expert systems
Based on artificial intelligence, machine learning, rules, or statistics
 differential diagnoses
 treatment options
Alerts & reminders
Based on specified conditions
 drug-allergy checks,
 drug-drug interaction checks,
 drug-lab interaction checks,
 drug-formulary checks,
 reminders for preventive services or certain actions (e.g. smoking cessation)
Evidence-based knowledge sources e.g. drug database, literature
Clinical Decision Support Systems
(CDSSs)
HIS and Electronic Medical Records26
Four key functions of electronic clinical decision support systems are
outlined
Administrative: Supporting clinical coding and documentation,
authorization of procedures, and referrals.
Managing clinical complexity and details: Keeping patients on
research and chemotherapy protocols; tracking orders, referrals
follow-up, and preventive care.
Cost control: Monitoring medication orders; avoiding duplicate
or unnecessary tests.
Decision support: Supporting clinical diagnosis and treatment plan
processes; and promoting use of best practices, condition-specific
guidelines, and population-based management.
Nursing Documentation & Charting
• Intake Output Chart
• Diabetic Chart
• NeuroAssessment
• Daily NursingAssessment
• Vital Signs Record
• IV Fluid Charting
HIS and Electronic Medical Records 27
Nursing Applications
• Document nursing assessments,
interventions & outcomes
• Facilitate charting & vital sign
recording
• Utilize standards in nursing
informatics
• Populate and documents care-
planning
• Support communication within
teams & between shifts
• Reduce paperwork / paper loss
HIS and Electronic Medical Records 28
Pharmacy Applications
• Streamlines workflow from
medication orders to
dispensing and billing
• Reduces medication
errors, improves
medication safety
• Improves inventory
management
HIS and Electronic Medical Records 29
Laboratory Information System
(LIS)
HIS and Electronic Medical Records30
Receives and processes lab
orders
Matches tube & specimen
Internal workflow within labs
Order processing
Specimen registration &
processing
Lab results validation &
reporting
Specimen inventory
Lab results viewing
Billing System
HIS and Electronic Medical Records31
Calculates service charges for services provided
Calculations based on patient’s insurance coverage and
eligibility
Records amount of money paid by the patient and remaining
amount
Sends information to accounting or Back Office ERP to send
reimbursement claims to insurance agencies
Imaging Applications
HIS and Electronic Medical Records32
Picture Archiving and
Communication System
(PACS)
Captures, archives, and
displays electronic images
captured from imaging
modalities
cardiology, endoscopy,
pathology, ophthalmology
PACS – (Picture Archiving and
Communication System )
HIS and Electronic Medical Records33
PACS enables x-ray and
scan images to be stored
electronically and viewed
on screens, helping to
improve diagnosis
methods.
Enterprise Resource Planning
HIS and Electronic Medical Records34
Finance
 Accounting
Budgeting
Cost control and
management
Materials Management
Procurement
Inventory management
Human Resources
Recruitment, evaluation,
promotion & disciplinary
actions
Payroll
Our Mission
HIS and Electronic Medical Records35
Electronic documentation of patient care and then by
become paperless
Patient care processes such as ordering
medications,
lab tests
x-rays
Viewing lab results and x- ray reports (among others)
What we have done ?
HIS and Electronic Medical Records36
Already working in Siemens HIS
Not completely paperless
Doing Consultation, Lab Order, Billing, Pharmacy Sales,
Nursing Notes, LIS
Implementation Stage of International Standard Compliant
HIS
Will completely migrated to new innovative HIS within 2
Months
Upcoming HIS - Features
HIS and Electronic Medical Records37
HL7 Standard
HL7, which is an abbreviation of Health Level Seven, is a
standard for exchanging information between medical
applications. This standard defines a format for the transmission
of health-related information.
CCHIT (Certification Commission for Healthcare Information Technology) certified in
2011
US patent for HIS : the only player in the Indian marketplace
Upcoming HIS Clients
HIS and Electronic Medical Records38
BLK Super Speciality Hospital, New Delhi
Amrita Institute of Medical Sciences, Kochi
Sree Gokulam Medical College, Trivandrum
BARC (Babha Atomic Research Centre) Hospital in Mumbai.
J J hospital Mumbai
NIMHANS Bangalore
St. Gregorios Medical Mission Hospital, Parumala.
Punjab Institute of Medical Sciences (PIMS), Jalandhar
Sir Sundar Lal Hospital, Benaras Hindu University
HIS Demo
HIS and Electronic Medical Records39
Currently using HIS Consultation Module
Physician tasks
OP Consultation
Initial Examination Report
Followups
Lab Order / View
IP Progress Notes
Backlog MRD Viewer
OP / IP – Consultation Requests / Response
Drug Prescription
Discharge Summary
Referrals
HIS Demo
HIS and Electronic Medical Records40

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Hospital information systems - HIS

  • 1. Khalid C Asst. Manager InformationTechnology Hospital Information Systems (HIS) and Electronic Medical Records (EMR)
  • 2. What is health information system? HIS and Electronic Medical Records2 It is a system for the collection/processing of data from various sources, and using the information for policy making and management of health services. It could be paper-based or electronic. It is a discipline at the intersection of information science, computer science, and health care. Systematic Storage and Retrieval of Medical Records
  • 3. What Is A Medical Record? HIS and Electronic Medical Records3 A record or documentation of a patient’s medical history, examination, and treatments.
  • 4. What Is A Medical Record? HIS and Electronic Medical Records4 Systematic documentation of a single patient's medical history and care across time within one particular health care provider. The medical record includes variety of types of "notes" entered by Physicians, recording observations and administration of drugs and therapies, Laboratory test results, reports demographics, medical history, medication and allergies,  immunization status, radiology images, vital signs, intake, output, observations
  • 5. Why do we need a Medical record? HIS and Electronic Medical Records5 In other words, why do we need a documentation of a patient’s medical care?
  • 6. Potential Uses of Medical Records HIS and Electronic Medical Records6 Continuity of providing care Note important information for later use Especially important in chronic diseases (e.g. hypertension, diabetes) or in follow-up (e.g. after surgery) Patient safety Preventing something bad because of lack of information Such as drug allergies, list of current medications, “problem list”
  • 7. Hospital Functions HIS and Electronic Medical Records7
  • 8. Potential Uses of Medical Records HIS and Electronic Medical Records8 Communications between providers Referral to specialists or other physicians Consulting among physicians Communications between physicians and nurses, pharmacists, physical therapists, etc. Transfer from a hospital to another
  • 9. Potential Uses of Medical Records HIS and Electronic Medical Records9 Medico-legal purposes e.g. Court evidence against malpractice What was done or provided to the patient? Why? By whom? When? Was the care provided up to the professional standard?
  • 10. Potential Uses of Medical Records HIS and Electronic Medical Records10 Clinical research Find ways to improve health care through new knowledge
  • 11. Potential Uses of Medical Records HIS and Electronic Medical Records11 Claims and reimbursements What services were provided to the patient How (and how much) will the hospitals/doctors be paid? Audit of medical records by “payers” Patient’s uses Health insurance claims  Self-education & self-care
  • 12. What is an Electronic Medical Record (EMR)? HIS and Electronic Medical Records12 Electronic medical records contain the same information as your paper record but in an electronic form. This information is accessible to your health care providers through computers located throughout the Hospital. Electronic documentation of patient care and to improve the process of patient care through better documentation
  • 13. Advantages of EMR HIS and Electronic Medical Records13 Physicians and nurses have more time to spend with patients. Improved legibility, accuracy and completeness. With an EMR there is less potential for medical errors as well as improved quality and safety in patient care. Allergies and adverse drug reactions are prominently displayed Reminders are activated when certain health maintenance tests and/or procedures are due Your prescriptions are electronically ordered directly to your pharmacy EMR permits more than one user to access your record at the same time.
  • 14. Why We Need IT tools in Healthcare ? HIS and Electronic Medical Records14
  • 15. Why We Need IT tools in Healthcare ? HIS and Electronic Medical Records15 Simplification of administrative processes such as Physician Order Entry, eMAR Creation and maintenance of electronic health records (EHR) Reduction in data gathering and processing costs Standardization of health data, coding, reporting and transmission of data Communication among key stakeholders – patients, physicians, nurses, administrators.
  • 16. Health care is information-rich HIS and Electronic Medical Records16
  • 17. Why We Need Health IT HIS and Electronic Medical Records17 Health care is very complex Quality of care depends on timely availability & quality of information Clinical knowledge body is too large Short time during a visit
  • 18. Benefits of Going Electronic (EMR) HIS and Electronic Medical Records18 Ubiquitous availability (anytime, anywhere, everyone who is authorized) Multiple concurrent uses Ability to control & enforce access security Structured data entry possible Data presentation that is easier to understand (e.g. graphs) No handwriting!!!!!
  • 19. Hospital Information System HIS and Electronic Medical Records19 Master Patient Index (MPI) Admit-Discharge-Transfer (ADT) Electronic Health Records (EHRs) Computerized Physician Order Entry(CPOE) Clinical Decision Support Systems (CDSSs) Picture Archiving and Communication System (PACS) Nursing applications Enterprise Resource Planning (ERP))
  • 20. Departmental Applications HIS and Electronic Medical Records20 Pharmacy applications LIS – Laboratory Information System PACS - Picture Archiving and Communication System RIS – Radiology Information System Specialized applications Emergency Room Operation Theatre Labor Room Anesthesia, Critical Care, Blood Bank E-Learning
  • 21. Master Patient Index (MPI) HIS and Electronic Medical Records21 A hospital’s list of all patients Registration of patients Captures/updates patient demographics Bar-coded Registration Cards
  • 22. Admission-Discharge-Transfer (ADT) HIS and Electronic Medical Records22 Supports Admission, Discharge & Transfer of patients (“patient management”) Provides status/location of admitted patients Used in assessing bed occupancy Linked to billing, claims & reimbursements
  • 23. Appointment Scheduling • Records appointments of patients • Pre-specified number of open slots • Ability to postpone/cancel appointments • Displays list of patients with appointments in a specific date HIS and Electronic Medical Records 23
  • 24. Computerized Physician Order Entry (CPOE) • Physician directly orders online – medication – Lab – diagnostic – imaging • Nurse & pharmacy process orders accordingly HIS and Electronic Medical Records 24
  • 25. Clinical Decision Support Systems (CDSSs) HIS and Electronic Medical Records25 The real place where most of the values of health IT can be achieved Is an application that analyzes data to help healthcare providers make clinical decisions. Expert systems Based on artificial intelligence, machine learning, rules, or statistics  differential diagnoses  treatment options Alerts & reminders Based on specified conditions  drug-allergy checks,  drug-drug interaction checks,  drug-lab interaction checks,  drug-formulary checks,  reminders for preventive services or certain actions (e.g. smoking cessation) Evidence-based knowledge sources e.g. drug database, literature
  • 26. Clinical Decision Support Systems (CDSSs) HIS and Electronic Medical Records26 Four key functions of electronic clinical decision support systems are outlined Administrative: Supporting clinical coding and documentation, authorization of procedures, and referrals. Managing clinical complexity and details: Keeping patients on research and chemotherapy protocols; tracking orders, referrals follow-up, and preventive care. Cost control: Monitoring medication orders; avoiding duplicate or unnecessary tests. Decision support: Supporting clinical diagnosis and treatment plan processes; and promoting use of best practices, condition-specific guidelines, and population-based management.
  • 27. Nursing Documentation & Charting • Intake Output Chart • Diabetic Chart • NeuroAssessment • Daily NursingAssessment • Vital Signs Record • IV Fluid Charting HIS and Electronic Medical Records 27
  • 28. Nursing Applications • Document nursing assessments, interventions & outcomes • Facilitate charting & vital sign recording • Utilize standards in nursing informatics • Populate and documents care- planning • Support communication within teams & between shifts • Reduce paperwork / paper loss HIS and Electronic Medical Records 28
  • 29. Pharmacy Applications • Streamlines workflow from medication orders to dispensing and billing • Reduces medication errors, improves medication safety • Improves inventory management HIS and Electronic Medical Records 29
  • 30. Laboratory Information System (LIS) HIS and Electronic Medical Records30 Receives and processes lab orders Matches tube & specimen Internal workflow within labs Order processing Specimen registration & processing Lab results validation & reporting Specimen inventory Lab results viewing
  • 31. Billing System HIS and Electronic Medical Records31 Calculates service charges for services provided Calculations based on patient’s insurance coverage and eligibility Records amount of money paid by the patient and remaining amount Sends information to accounting or Back Office ERP to send reimbursement claims to insurance agencies
  • 32. Imaging Applications HIS and Electronic Medical Records32 Picture Archiving and Communication System (PACS) Captures, archives, and displays electronic images captured from imaging modalities cardiology, endoscopy, pathology, ophthalmology
  • 33. PACS – (Picture Archiving and Communication System ) HIS and Electronic Medical Records33 PACS enables x-ray and scan images to be stored electronically and viewed on screens, helping to improve diagnosis methods.
  • 34. Enterprise Resource Planning HIS and Electronic Medical Records34 Finance  Accounting Budgeting Cost control and management Materials Management Procurement Inventory management Human Resources Recruitment, evaluation, promotion & disciplinary actions Payroll
  • 35. Our Mission HIS and Electronic Medical Records35 Electronic documentation of patient care and then by become paperless Patient care processes such as ordering medications, lab tests x-rays Viewing lab results and x- ray reports (among others)
  • 36. What we have done ? HIS and Electronic Medical Records36 Already working in Siemens HIS Not completely paperless Doing Consultation, Lab Order, Billing, Pharmacy Sales, Nursing Notes, LIS Implementation Stage of International Standard Compliant HIS Will completely migrated to new innovative HIS within 2 Months
  • 37. Upcoming HIS - Features HIS and Electronic Medical Records37 HL7 Standard HL7, which is an abbreviation of Health Level Seven, is a standard for exchanging information between medical applications. This standard defines a format for the transmission of health-related information. CCHIT (Certification Commission for Healthcare Information Technology) certified in 2011 US patent for HIS : the only player in the Indian marketplace
  • 38. Upcoming HIS Clients HIS and Electronic Medical Records38 BLK Super Speciality Hospital, New Delhi Amrita Institute of Medical Sciences, Kochi Sree Gokulam Medical College, Trivandrum BARC (Babha Atomic Research Centre) Hospital in Mumbai. J J hospital Mumbai NIMHANS Bangalore St. Gregorios Medical Mission Hospital, Parumala. Punjab Institute of Medical Sciences (PIMS), Jalandhar Sir Sundar Lal Hospital, Benaras Hindu University
  • 39. HIS Demo HIS and Electronic Medical Records39 Currently using HIS Consultation Module Physician tasks OP Consultation Initial Examination Report Followups Lab Order / View IP Progress Notes Backlog MRD Viewer OP / IP – Consultation Requests / Response Drug Prescription Discharge Summary Referrals
  • 40. HIS Demo HIS and Electronic Medical Records40