Clinical Information Systems


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Clinical Information Systems

  1. 1. Clinical Information Systems Nawanan Theera-Ampornpunt, M.D., Ph.D. Faculty of Medicine Ramathibodi Hospital June 14, 2014
  2. 2. 2003 M.D. (First-Class Honors) (Ramathibodi) 2009 M.S. in Health Informatics (U of MN) 2011 Ph.D. in Health Informatics (U of MN) - Instructor, Department of Community Medicine - Deputy Executive Director for Informatics Chakri Naruebodindra Medical Institute Faculty of Medicine Ramathibodi Hospital Research interests: • EHRs & health IT applications in clinical settings • Health IT adoption • Health informatics education & workforce development • Standards and interoperability A Bit About Myself
  3. 3. Class Outline • Health Care & Health IT • Clinical Information Systems • Electronic Health Records
  4. 4. Health Care & Health IT
  5. 5. Manufacturing Image Source:
  6. 6. Banking Image Source:
  7. 7. Health care ER - Image Source:
  8. 8. • Life-or-Death • Many & varied stakeholders • Strong professional values • Evolving standards of care • Fragmented, poorly-coordinated systems • Large, ever-growing & changing body of knowledge • High volume, low resources, little time Why Health care Isn’t Like Any Others?
  9. 9. • Large variations & contextual dependence Why Health care Isn’t Like Any Others? Input Process Output Patient Presentation Decision- Making Biological Responses
  10. 10. But...Are We That Different? Input Process Output Transfer Banking Value-Add - Security - Convenience - Customer Service Location A Location B
  11. 11. Input Process Output Assembling Manufacturing Raw Materials Finished Goods Value-Add - Innovation - Design - QC But...Are We That Different?
  12. 12. But...Are We That Different? Input Process Output Patient Care Health care Sick Patient Well Patient Value-Add - Technology & medications - Clinical knowledge & skills - Quality of care; process improvement - Information
  13. 13. “Information” in Medicine Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.
  14. 14. Information is Everywhere in Health Care
  15. 15. Various Forms of Health IT Hospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records (EHRs) Picture Archiving and Communication System (PACS)
  16. 16. Still Many Other Forms of Health IT m-Health Health Information Exchange (HIE) Biosurveillance Information Retrieval Telemedicine & Telehealth Images from Apple Inc.,, Google,, and American Telecare, I Personal Health Records (PHRs)
  17. 17. Why Adopting Health IT? “To Computerize”“To Go paperless” “Digital Hospital” “To Modernize” “To Get a HIS” “To Have EMRs” “To Share data”
  18. 18. • “Don’t implement technology just for technology’s sake.” • “Don’t make use of excellent technology. Make excellent use of technology.” (Tangwongsan, Supachai. Personal communication, 2005.) • “Health care IT is not a panacea for all that ails medicine.” (Hersh, 2004) Some Quotes
  19. 19. Health IT: What’s In A Word? Health Information Technology Goal Value-Add Tools
  20. 20. • Safety • Timeliness • Effectiveness • Efficiency • Equity • Patient-centeredness Dimensions of Quality Healthcare (IOM, 2001)
  21. 21. • Guideline adherence • Better documentation • Practitioner decision making or process of care • Medication safety • Patient surveillance & monitoring • Patient education/reminder Value of Health IT
  22. 22. Landmark IOM Reports (IOM, 2001)(IOM, 2000) (IOM, 2011)
  23. 23. • Humans are not perfect and are bound to make errors • Highlight problems in U.S. health care system that systematically contributes to medical errors and poor quality • Recommends reform • Health IT plays a role in improving patient safety Landmark IOM Reports: Summary
  24. 24. • Health care is very complex (and inefficient) • Health care is information-rich • Quality of care depends on timely availability & quality of information • Clinical knowledge body is too large • Short time during a visit • Practice guidelines are put “on-the-shelf” • “To err is human” Why We Need Health IT
  25. 25. Image Source: (Left) (Right) To Err is Human 1: Attention
  26. 26. Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital, Mahidol University To Err is Human 2: Memory
  27. 27. To Err is Human 3: Cognition • Cognitive Errors - Example: Decoy Pricing The Economist Purchase Options • subscription $59 • Print subscription $125 • Print & web subscription $125 Ariely (2008) 16 0 84 The Economist Purchase Options • subscription $59 • Print & web subscription $125 68 32 # of People # of People
  28. 28. • It already happens.... (Mamede et al., 2010; Croskerry, 2003; Klein, 2005; Croskerry, 2013) What If This Happens in Healthcare?
  29. 29. Cognitive Biases in Healthcare Mamede S, van Gog T, van den Berge K, Rikers RM, van Saase JL, van Guldener C, Schmidt HG. Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA. 2010 Sep 15;304(11):1198-203.
  30. 30. Cognitive Biases in Healthcare Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003 Aug;78(8):775-80.
  31. 31. Cognitive Biases in Healthcare Klein JG. Five pitfalls in decisions about diagnosis and prescribing. BMJ. 2005 Apr 2;330(7494):781-3. “Everyone makes mistakes. But our reliance on cognitive processes prone to bias makes treatment errors more likely than we think”
  32. 32. Health IT Across Settings
  33. 33. Various Forms of Health IT Hospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records (EHRs) Picture Archiving and Communication System (PACS)
  34. 34. Still Many Other Forms of Health IT m-Health Health Information Exchange (HIE) Biosurveillance Information Retrieval Telemedicine & Telehealth Images from Apple Inc.,, Google,, and American Telecare, I Personal Health Records (PHRs)
  35. 35. Health IT in Clinical Settings (“Clinical Information Systems”)
  36. 36. • 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) Enterprise-wide Hospital IT
  37. 37. • Pharmacy applications • Laboratory Information System (LIS) • Radiology Information System (RIS) • Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Dietary Services, Blood Bank) • Incident management & reporting system Departmental IT
  38. 38. Workflow Hospital Information System Master Patient Index (MPI) ADT Scheduling Order Pharmacy IS Operation Theatre Billing Clinical Notes LIS RIS PACS CCIS Medical Records Portals Modified from Dr. Artit Ungkanont’s slide
  39. 39. Master Patient Index (MPI) • A hospital’s list of all patients • Functions – Registration/identification of patients (HN) – Captures/updates patient demographics – Used in virtually all other hospital service applications
  40. 40. Admission-Discharge-Transfer (ADT) • Functions – Supports Admission, Discharge & Transfer of patients (“patient management”) – Provides status/location of admitted patients – Used in assessing bed occupancy – Linked to billing, claims & reimbursements
  41. 41. Bed Management (from ADT System)
  42. 42. Insurance Eligibility System • Functions – Determines if a patient is eligible or is covered by a particular insurance scheme – Determines the services covered by the patient’s insurance plan – May need to link with the eligibility verification system of the government agencies
  43. 43. Appointment Scheduling • Functions – 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 – Ability to adjust number of open slots
  44. 44. Computerized Physician Order Entry (CPOE)
  45. 45. Values • No handwriting!!! • Structured data entry: Completeness, clarity, fewer mistakes (?) • No transcription errors! • Entry point for CDSSs • Streamlines workflow, increases efficiency Computerized Physician Order Entry (CPOE)
  46. 46. Nursing Applications Functions • 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 – e-Kardex • Risk/incident management
  47. 47. Pharmacy Applications Functions • Streamlines workflow from medication orders to dispensing and billing • Reduces medication errors, improves medication safety • Improves inventory management
  48. 48. Stages of Medication Process Ordering Transcription Dispensing Administration CPOE Automatic Medication Dispensing Electronic Medication Administration Records (e-MAR) Barcoded Medication Administration Barcoded Medication Dispensing
  49. 49. Laboratory Information System (LIS) Functions • 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
  50. 50. Imaging Applications Picture Archiving and Communication System (PACS) • Captures, archives, and displays electronic images captured from imaging modalities • Often refers to radiologic images but sometimes used in other settings as well (e.g. cardiology, endoscopy, pathology, ophthalmology) • Values: reduces space, costs of films, loss of films, parallel viewing, remote access, image processing & manipulation, referrals Radiology Information System (RIS) or Workflow Management • Supports workflow of the radiology department, including patient registration, appointments & scheduling, consultations, imaging reports, etc.
  51. 51. Billing System • Functions – 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 government agencies
  52. 52. Enterprise Resource Planning • Some Functions – Finance • Accounting • Budgeting • Cost control and management – Materials Management • Procurement • Inventory management – Human Resources • Recruitment, evaluation, promotion & disciplinary actions • Payroll
  53. 53. The Bigger Picture: Health Information Exchange (HIE) Hospital A Hospital B Clinic C Government Lab Patient at Home
  54. 54. Strategic Operational ClinicalAdministrative 4 Quadrants of Hospital IT CPOE ADT LIS EHRs CDSS HIE ERP Business Intelligence VMI PHRs MPI Word Processor Social Media PACS
  55. 55. Electronic Health Records/ Electronic Medical Records
  56. 56. What Is A Medical Record?
  57. 57. What Is A Medical Record? • A record or documentation of a patient’s medical history, examination, and treatments. • Medical Record vs. Health Record – Essentially the same
  58. 58. Potential Uses of Medical Records • 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”
  59. 59. Potential Uses of Medical Records • 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 • 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?
  60. 60. Potential Uses of Medical Records • 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 • Clinical research – Find ways to improve health care through new knowledge
  61. 61. Data Elements in Medical Records • Patient demographics • General information about each visit (visit = encounter) – Type (outpatient, inpatient, emergency) – Date/Time – Location (clinic or ward) “Clinical Notes” • Patient’s problems (“Patient history”) – Chief complaint – Present illness – Past history – Family and social history
  62. 62. Data Elements in Medical Records • Clinical findings by physicians (“Physical examination”) – Any important positive (usually abnormal) findings – Also important negative (usually normal) findings • “Investigations” – Laboratory tests (blood tests, urine, etc.) – Radiological examinations (X-rays, CT, MRI, ultrasound) – Other diagnostic procedures • Electrocardiography (EKG/ECG) -- heart’s function • Electroencephalography (EEG) -- brain wave scans • Etc.
  63. 63. Data Elements in Medical Records • “Problems” or “Diagnoses” – Summary of problems relevant to this visit • Treatments – Medications – Surgical procedures – Advice to patients – Admission (hospitalization) • Plans – Surgeries – More investigations to be done later – Follow-up appointments
  64. 64. Data Elements in Medical Records • Inpatient clinical notes – Admission notes – Orders (medications, procedures, investigations, nursing care, etc.) – Medication administration records – Vital signs and other measurements – Results of lab tests and radiological examinations – Progress notes – Discharge summary
  65. 65. “Electronic” Medical Records • Electronic Medical Records (EMRs) vs. Electronic Health Records (EHRs) • Debate about similarities & differences • Summary – Definitions subjective, depending on how people think – EMRs mostly refer to electronic documentation of medical care at one visit – EHRs mostly refer to electronic documentation that is longitudinal in nature (may be several visits) – EMRs commonly used in Thailand (but means the same as EHRs)
  66. 66. Longitudinal Records • Records documented over time (multiple encounters) • Ideally, “life-long” is a complete record of the patient’s health
  67. 67. Electronic Medical Records (EMRs) Computer-Based Patient Records (CPRs) Electronic Patient Records (EPRs)Electronic Health Records (EHRs) Personal Health Records (PHRs) The Confusing Acronyms Hospital Information Systems (HIS)
  68. 68. • Are they just electronic documentation? • Or do they have some other values? Diag- nosis History & PE Treat- ments ... Electronic Health Record (EHR) Systems
  69. 69. • Literature suggests improvement in health care through – Guideline adherence – Better documentation – Practitioner decision making or process of care – Medication safety – Patient surveillance & monitoring – Patient education/reminder – Cost savings and better financial performance Literature Shows Benefits of Health IT
  70. 70. • Patient Demographics • Physician Notes • Computerized Medication Order Entry • Computerized Laboratory Order Entry • Computerized Laboratory Results • Problem Lists • Medication Lists • Discharge Summaries • Diagnostic Test Results • Radiologic Reports Functions That Should be Part of EHR Systems
  71. 71. EHR Adoption: Thailand (2011) Estimate (Partial or Complete Adoption) Nationwide Basic EHR, combined inpatient & outpatient settings 49.8% Comprehensive EHR, combined 5.3% order entry of medications, combined 90.2% order entry of all orders, combined 79.4% Basic EHR: a score > 1 in a 5-point scale for IT support for demographics, MD notes, nursing assessments (inpatient only), discharge summaries (inpatient only), test results, order entry for medications Comprehensive EHR: a score > 3 in a 5-point scale for Basic EHR functions + electronic image viewing, order entry for lab tests and radiologic tests, drug-allergy alerts, drug-drug alerts
  72. 72. EHR/HIS Adoption in Thailand (2004) Pongpirul et al., 2004
  73. 73. EHR/HIS Adoption in Thailand (2011) HOSxP 50% Self-developed or outsourced 16% Hospital OS 7% SSB 4% Mit-Net 2% MRecord 2% H.I.M. Professional 2% MedTrak/ TrakCare 2% HoMC 2% None 2% THIADES 2% HIMS 1% Abstract ePHIS 1% Other 7% Theera-Ampornpunt, 2011 [Dissertation]
  74. 74. EHRs and the Bigger Picture
  75. 75. Health Information Exchange (HIE) Hospital A Hospital B Clinic C Government Lab Patient at Home
  76. 76. Google Flu Trends (Biosurveillance) Source:
  77. 77. • EHRs (or EMRs) are both – Electronic documentation of patient care and – a broad term for an information system used to improve the process of patient care through better documentation and other care processes such as ordering medications, lab tests, or x-rays and viewing lab results and x- ray reports (among others) Summary
  78. 78. • There are various kinds of applications in hospitals • HIS often refers to the “Front Office” part of hospital IT • Sometimes HIS refers to the entire hospital IT • HIS and EHRs are used to support clinical workflows, improve decision-making and care quality, and reduce costs • EHRs and HIS are just one piece of the big puzzle for the whole healthcare system Summary
  79. 79. Next: Clinical Decision Support Systems