Teaching at Rangsit University, Bangkok, Thailand

1. Clinical Information Systems
Nawanan Theera-Ampornpunt, MD, PhD
Faculty of Medicine Ramathibodi Hospital
Jun 29, 2013
http://www.slideshare.net/nawanan

2. 2003 M.D. (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics (U of MN)
Deputy Chief, Informatics Division
Faculty of Medicine Ramathibodi Hospital
nawanan.the@mahidol.ac.th
http://groups.google.com/group/ThaiHealthIT
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. Class Outline
• Health Care & Health IT
• Clinical Information Systems
• Electronic Health Records

4. Health Care & Health IT

5. Manufacturing
Image Source: Guardian.co.uk

6. Banking
Image Source: Cablephet.com

7. Health care
ER - Image Source: nj.com

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. • Large variations & contextual dependence
Why Health care Isn’t Like Any Others?
Input Process Output
Patient
Presentation
Decision-
Making
Biological
Responses

10. But...Are We That Different?
Input Process Output
Transfer
Banking
Value-Add
- Security
- Convenience
- Customer Service
Location A Location B

11. Input Process Output
Assembling
Manufacturing
Raw
Materials
Finished
Goods
Value-Add
- Innovation
- Design
- QC
But...Are We That Different?

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. Information is Everywhere
in Health Care

14. Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic
Health
Records
(EHRs)
Picture Archiving and
Communication System
(PACS)

15. Still Many Other Forms of Health IT
m-Health
Health Information
Exchange (HIE)
Biosurveillance
Information Retrieval
Telemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I
Personal Health Records
(PHRs)

16. Why Adopting Health IT?
“To Computerize”“To Go paperless”
“Digital Hospital”
“To Modernize”
“To Get a HIS”
“To Have EMRs”
“To Share data”

17. • “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

18. Health IT: What’s In A Word?
Health
Information
Technology
Goal
Value-Add
Tools

19. • Safety
• Timeliness
• Effectiveness
• Efficiency
• Equity
• Patient-centeredness
Dimensions of Quality Healthcare
(IOM, 2001)

20. • Guideline adherence
• Better documentation
• Practitioner decision making
or process of care
• Medication safety
• Patient surveillance &
monitoring
• Patient education/reminder
Value of Health IT

21. Fundamental Theorem of Informatics
(Friedman, 2009)(Friedman, 2009)

22. Is There A Role for Health IT?
(IOM, 2000)

23. Landmark IOM Reports
(IOM, 2001)(IOM, 2000)

24. • Humans are not perfect and are bound to make
errors
• Highlight problems in the U.S. health care system
that systematically contributes to medical errors
and poor quality
• Recommends reform that would change how
health care works and how technology
innovations can help improve quality/safety
Landmark IOM Reports: Summary

25. • 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

26. • Perception errors
To Err Is Human
Image Source: interaction-dynamics.com

27. Image Source: aafp.org
• Lack of Attention
To Err Is Human

28. • Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59
• Print subscription $125
• Print & web subscription $125
Ariely (2008)
16
0
84
The Economist Purchase Options
• Economist.com subscription $59
• Print & web subscription $125
68
32
# of
People
# of
People
To Err Is Human

29. • It already happens....
(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)
• What if health IT can help?
What If This Happens in Healthcare?

30. Health IT Across Settings

31. M/B/H Informatics As A Field
(Shortliffe, 2002)

32. M/B/H Informatics As A Field
(Hersh, 2009)

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. Still Many Other Forms of Health IT
m-Health
Health Information
Exchange (HIE)
Biosurveillance
Information Retrieval
Telemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I
Personal Health Records
(PHRs)

35. Health IT in Clinical Settings
(“Clinical Information Systems”)

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. • 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. 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. HIT Systems (Inpatient)
Clinical Decision Support:
“Any system designed to
improve clinical decision making
related to diagnostic or
therapeutic processes of care.”
From Dr. Artit Ungkanont’s slide

40. 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

41. 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

42. Bed Management (from ADT System)

43. 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

44. 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

45. Computerized Physician Order Entry
(CPOE)

46. 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)

47. • The real place where most of the
values of health IT can be achieved
– Expert systems
• Based on artificial intelligence,
machine learning, rules, or
statistics
• Examples: differential
diagnoses, treatment options
Clinical Decision Support Systems
(CDSSs)
(Shortliffe, 1976)

48. – Alerts & reminders
• Based on specified logical conditions
• Examples:
–Drug-allergy checks
–Drug-drug interaction checks
–Drug-disease checks
–Drug-lab checks
–Drug-formulary checks
–Reminders for preventive services or certain
actions (e.g. smoking cessation)
–Clinical practice guideline integration
Clinical Decision Support Systems
(CDSSs)

49. Example of “Alerts & Reminders”

50. – Evidence-based knowledge sources e.g. drug
database, literature
– Simple UI designed to help clinical decision
making
• E.g., Abnormal Lab Highlights
Clinical Decision Support Systems
(CDSSs)

51. Clinical Decision Support Systems
(CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
Working
Memory
CLINICIAN
From a teaching slide by Don Connelly, 2006

52. Clinical Decision Support Systems
(CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
Working
Memory
CLINICIAN
Abnormal lab
highlights

53. Clinical Decision Support Systems
(CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
Working
Memory
CLINICIAN
Drug-Allergy
Checks

54. Clinical Decision Support Systems
(CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
Working
Memory
CLINICIAN Drug-Drug
Interaction
Checks

55. Clinical Decision Support Systems
(CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
Working
Memory
CLINICIAN
Diagnostic/Treatment
Expert Systems

56. • CDSS as a replacement or supplement of
clinicians?
– The demise of the “Greek Oracle” model (Miller & Masarie, 1990)
Clinical Decision Support Systems
(CDSSs)
The “Greek Oracle” Model
The “Fundamental Theorem”
(Friedman, 2009)

57. Clinical Decision Support Systems
(CDSSs)
Issues
• Alert sensitivity & alert fatigue

58. Clinical Decision Support Systems
(CDSSs)
Issues
• Unintended Consequences (e.g. workarounds)

59. 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

60. Pharmacy Applications
Functions
• Streamlines workflow from medication orders to dispensing and
billing
• Reduces medication errors, improves medication safety
• Improves inventory management

61. Stages of Medication Process
Ordering Transcription Dispensing Administration
CPOE
Automatic
Medication
Dispensing
Electronic
Medication
Administration
Records
(e-MAR)
Barcoded
Medication
Administration
Barcoded
Medication
Dispensing

62. 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

63. 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.

64. 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

65. 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

66. The Bigger Picture:
Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

67. 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

68. Electronic Health Records/
Electronic Medical Records

69. What Is A Medical Record?

70. 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

71. 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”

72. 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?

73. 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

74. 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

75. 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.

76. 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

77. 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

78. “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)

79. Longitudinal Records
• Records documented over time (multiple encounters)
• Ideally, “life-long” is a complete record of the patient’s health

80. 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)

81. • Are they just electronic documentation?
• Or do they have some other values?
Diag-
nosis
History
& PE
Treat-
ments
...
Electronic Health Record (EHR) Systems

82. • 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

83. • 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

84. 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

85. EHR/HIS Adoption in Thailand (2004)
Pongpirul et al., 2004

86. 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]

87. EHRs and the Bigger Picture

88. Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

89. Google Flu Trends (Biosurveillance)
Source: Google.org/FluTrends

90. • 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

91. • 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

92. Questions?