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Hospital Information Systems & Electronic Health Records


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A lecture in March 2012 for third year undergraduate nursing students at Faculty of Medicine Ramathibodi Hospital, Mahidol University, in Thai.

Published in: Health & Medicine, Business

Hospital Information Systems & Electronic Health Records

  1. 1. Hospital Information Systems (HIS) and Electronic Health Records (EHRs) Nawanan Theera-Ampornpunt, MD, PhD Health Informatics Division, Ramathibodi Mar 15, 2012
  2. 2. A Bit About Myself2003 M.D. (Ramathibodi)2009 M.S. in Health Informatics (U of MN)2011 Ph.D. in Health Informatics (U of MN)Health Informatician/Systems AnalystHealth Informatics DivisionFaculty of Medicine Ramathibodi HospitalMahidol interests:• Health IT applications in clinical settings (including EHRs)• Health IT “adoption”• Health informatics education
  3. 3. EHRs: Fundamentals
  4. 4. What Is A Medical Record?
  5. 5. 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
  6. 6. Class Discussion 1• Why do we need a health record?• In other words, why do we need a documentation of a patient’s medical care?
  7. 7. 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”
  8. 8. 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?
  9. 9. 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
  10. 10. “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)
  11. 11. Longitudinal Records• Records documented over time (multiple encounters)• Ideally, “life-long” is a complete record of the patient’s health
  12. 12. Various Forms of Health ITHospital Information System (HIS) Computerized Provider Order Entry (CPOE) Electronic Health Records Picture Archiving and (EHRs) Communication System (PACS)
  13. 13. Still Many Other Forms of Health IT Health Information Exchange (HIE) m-Health BiosurveillancePersonal Health Records (PHRs) Telemedicine &Information Retrieval Telehealth Images from Apple Inc.,, Google,, and American Telecare, I
  14. 14. The Confusing Acronyms Computer-Based Patient RecordsElectronic Medical (CPRs) Records (EMRs) Electronic Patient Electronic Health Records (EPRs) Records (EHRs) Personal Health Records (PHRs) Hospital Information Systems (HIS)
  15. 15. Benefits of EHRs
  16. 16. Class Exercise 3• Why do we need to use an electronic version of medical records?
  17. 17. Common “Goals” for EHRs/Health IT Adoption “Computerize”“Go paperless” “Get an electronic copy “Digital Hospital” “Have EMRs” “Modernize” “Share data”
  18. 18. Is There A Role for Health IT? (IOM, 2000)
  19. 19. Why We Need Health IT• 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”
  20. 20. To Err Is Human• Perception errors Image Source:
  21. 21. To Err Is Human• Lack of Attention Image Source:
  22. 22. Class Exercise 3 The Economist Purchase Options• subscription $59• Print subscription $125• Print & web subscription $125
  23. 23. Class Exercise 3 The Economist Purchase Options• subscription $59• Print & web subscription $125
  24. 24. To Err Is Human• Cognitive Errors - Example: Decoy Pricing # of The Economist Purchase Options People• subscription $59 16• Print subscription $125 0• Print & web subscription $125 84 # of The Economist Purchase Options People• subscription $59 68• Print & web subscription $125 32 (Ariely, 2008)
  25. 25. What If This Happens in Healthcare?• It already happens.... (Mamede et al., 2010; Croskerry, 2003; Klein, 2005)• What if health IT can help?
  26. 26. Fundamental Theorem of Informatics (Friedman, 2009) (Friedman, 2009)
  27. 27. Benefits of Going Electronic (EHRs)• Ubiquitous availability (anytime, anywhere, everyone who is authorized)• Multiple concurrent uses• The end of “Where the heck is the patient’s record?!?”• Ability to control & enforce access security• Structured data entry possible• Data presentation that is easier to understand (e.g. graphs)• Efficiency in data entry? (but sometimes it slows users down!)• Process improvement (business process reengineering/redesign, quality improvement)• No doctor’s handwriting!!!!!
  28. 28. Electronic Health Record (EHR) Systems• Are they just electronic documentation? History Diag- Treat- ... & PE nosis ments• Or do they have some other values?
  29. 29. Literature Shows Benefits of Health IT• 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• “Alerts & Reminders”
  30. 30. Alerts & Reminders
  31. 31. Functions That Should be Part of EHR Systems• 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
  32. 32. Hospital Information Systems
  33. 33. Different Kinds of IT in Hospitals IT Infrastructure - Hardware - Network Hardware People & - Operating System ware Network (Windows, etc.) - Antivirus - Other system softwareSoftware SoftwareApplications- Microsoft Office- Business software (HIS, EHRs, MIS)
  34. 34. Software Applications in Hospitals• Front Office – Electronic Health Records (EHRs) – Hospital Information Systems (or Clinical Information Systems)• Back Office – Management Information Systems (MIS) – Enterprise Resource Planning (ERP) systems – Research and Education – Office Automation Tools (such as Microsoft Office)
  35. 35. Examples of Hospital ITEnterprise-wide• MPI, ADT• EHRs/EMRs/HIS/CIS• CPOE & CDSSs• Nursing applications• Billing, Claims & Reimbursements• MIS, ERP
  36. 36. Examples of Hospital ITDepartmental Applications• Pharmacy applications• LIS, PACS, RIS• Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Blood Bank)• E-Learning
  37. 37. Hospital Information System Clinical Medical ADT Notes Records Workflow Pharmacy IS Operation Master Patient LIS Theatre Index (MPI) Order CCIS RIS Scheduling Portals Billing PACSModified from Dr. Artit Ungkanont’s slide
  38. 38. Hospital Information SystemFrom 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)Functions• Physician directly enters medication/lab/diagnostic/imaging orders online• Nurse & pharmacy process orders accordingly• Maybe considered part of an EHR/HIS systemValues• No handwriting!!!• Structured data entry (completeness, clarity, fewer mistakes)• No transcription!• Entry point for CDSSs• Streamlines workflow, increases efficiency
  45. 45. Computerized Physician Order Entry (CPOE)
  46. 46. Clinical Decision Support Systems (CDSSs)• The real place where most of the values of health IT can be achieved• A variety of forms and nature of CDSSs – Expert systems • Based on artificial intelligence, machine learning, rules, or statistics • Examples: differential diagnoses, treatment options – Alerts & reminders • Based on specified conditions • Examples: 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), clinical practice guideline integration – Evidence-based knowledge sources e.g. drug database, literature – Simple UI designed to help clinical decision making
  47. 47. Clinical Decision Support Systems (CDSSs) PATIENT Perception CLINICIAN Attention Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data InferenceFrom a teaching slide by Don Connelly, 2006 DECISION
  48. 48. Clinical Decision Support Systems (CDSSs) PATIENT PerceptionCLINICIAN Abnormal lab Attention highlightsLong Term Memory External Memory Working MemoryKnowledge Data Knowledge Data Inference DECISION
  49. 49. Clinical Decision Support Systems (CDSSs) PATIENT PerceptionCLINICIAN Drug-Allergy Attention ChecksLong Term Memory External Memory Working MemoryKnowledge Data Knowledge Data Inference DECISION
  50. 50. Clinical Decision Support Systems (CDSSs) PATIENT PerceptionCLINICIAN Drug-Drug Interaction Attention ChecksLong Term Memory External Memory Working MemoryKnowledge Data Knowledge Data Inference DECISION
  51. 51. Clinical Decision Support Systems (CDSSs) PATIENT PerceptionCLINICIAN AttentionLong Term Memory External Memory Working MemoryKnowledge Data Knowledge Data Inference Diagnostic/Treatment Expert Systems DECISION
  52. 52. Clinical Decision Support Systems (CDSSs)Issues• Alert sensitivity & alert fatigue
  53. 53. Clinical Decision Support Systems (CDSSs)Issues• Unintended Consequences (e.g. workarounds)
  54. 54. Nursing ApplicationsFunctions• 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
  55. 55. Pharmacy ApplicationsFunctions• Streamlines workflow from medication orders to dispensing and billing• Reduces medication errors, improves medication safety• Improves inventory management
  56. 56. Stages of Medication ProcessOrdering Transcription Dispensing Administration Automatic ElectronicCPOE Medication Medication Dispensing Administration Records (e-MAR) Barcoded Medication Barcoded Dispensing Medication Administration
  57. 57. 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
  58. 58. Imaging ApplicationsPicture 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, referralsRadiology Information System (RIS) or Workflow Management• Supports workflow of the radiology department, including patient registration, appointments & scheduling, consultations, imaging reports, etc.
  59. 59. 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
  60. 60. 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
  61. 61. The Bigger Picture: Health Information Exchange (HIE) GovernmentHospital A Hospital B Clinic C Lab Patient at Home
  62. 62. Summary• 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)
  63. 63. Summary• 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
  64. 64. Questions?