Clinical information systems support diagnosis, treatment planning, and evaluation of medical outcomes. The number of installations of clinical systems has increased as healthcare managers recognize their importance for continuous quality improvement, cost control, and reducing medical errors. Key attributes of an effective comprehensive patient record include a problem list delineating clinical problems and status, supporting systematic measurement of health status, documenting clinical rationale for diagnoses, and linking records across settings over time.

1. HIMP 375Health InformaticsReviewLearning Outcome 5

2. Patient Care ApplicationsClinical information systems support 3 things. What are they??DiagnosisTreatment planningEvaluation of medical outcomes3/1/2010Free Template from www.brainybetty.com2

3. Patient Care ApplicationsWhy has the number of installations of clinical systems increased in healthcare facilities?Governing boards & healthcare managers recognize importance forContinuous quality improvement of patient careCost controlReduction of medical errors3/1/2010Free Template from www.brainybetty.com3

4. Patient Care Applications What are felt to be the key attributes of the CPR as defined by the IOM (Institute of Medicine) Comm.CPR includes a problem list that clearly delineates the Pt’s clinical problems & current status of eachEncourages & supports systematic measurement & recording of Pt’s health status & functional levelsDocuments the clinical rationale for all diagnoses or conclusionsLinks to clinical records from various settings & time periods to provide “longitudinal record of events” 3/1/2010Free Template from www.brainybetty.com4

5. Patient Care ApplicationsExamples of Patient Care ApplicationsOrder Entry & Results ReportingEntry of orders for diagnostic tests, Pt treatments & subsequent reporting of test results back to caregiversDr’s orders are entered at nursing station & are transmitted to appropriate area (ie. Lab, pharmacy)Test results & treatment summaries are transmitted back for entry into the Pt’s chartRecord of charges for tests & treatments transmitted to Business Office3/1/2010Free Template from www.brainybetty.com5

6. Patient Care ApplicationsExamples of Clinical (Patient Care) ApplicationsLaboratory2 phasesAutomation of test processes andAutomation of processing lab dataDone by electronically linking lab instruments to computerBenefitsImmediate reportingReduced duplication, therefore reduced costsBetter scheduling3/1/2010Free Template from www.brainybetty.com6

7. Patient Care ApplicationsExamples of Clinical (Patient Care) ApplicationsPharmacy Information SystemControls ordering, stocking & distribution of drugs to avoid medication errors Orders are entered at Nursing Station, communicated directly to PharmacyWorksheets generatedPatient labels generatedPatient profile updated3/1/2010Free Template from www.brainybetty.com7

8. Patient Care ApplicationsExamples of Clinical (Patient Care) ApplicationsPharmacy . . .Major screenings includeDrug-drug interactionsDrug-food interactionsDose range checkingBenefits of Pharmacy Information SystemCan eliminate the time gap between point of care and point of serviceCan reduce medication errorsCan improve quality of careCan increase patient satisfaction3/1/2010Free Template from www.brainybetty.com8

9. Patient Care ApplicationsExamples of Clinical (Patient Care) ApplicationsRadiology Information SystemsIncludeRecording test requisitionsScheduling proceduresRecording & reporting test resultsReporting charges to Business OfficePreparing management reports3/1/2010Free Template from www.brainybetty.com9

10. Patient Care ApplicationsWhy is the involvement of physicians so important to successful implementation of clinical information systems?If Dr’s don’t understand how to use system or don’t know what the information system can do for them, they will resist it’s useSuccess directly dependent on the commitment of senior management. Physicians must be involved as trainers, problem-solvers as well as users of the system 3/1/2010Free Template from www.brainybetty.com10

11. Patient Care ApplicationsWhat are “clinical decision-support systems” (CDSS)???CDSS’s are computer-based information systems designed to assist physicians in diagnosis and treatment planning. 3/1/2010Free Template from www.brainybetty.com11

12. Patient Care ApplicationsTwo categories of CDSS –Passive system collects, organizes & communicates Pt data to physicianData on Pt’s historyPhysical examDiagnostic testsActive system utilizes medical data stored in computer to suggest diagnoses & treatment protocols3/1/2010Free Template from www.brainybetty.com12

13. Patient Care ApplicationsDefine “evidence-based medicine”Clinical practice guidelines developed by expertsSoftware created which ‘suggests’ clinical pathway for caregivers to follow when treating patientDesigned to assist healthcare organizations in providing quality care at the most reasonable cost possibleQuality of information a concern…addressed by Accreditation standards3/1/2010Free Template from www.brainybetty.com13

14. Patient Care ApplicationsExamples of information systems being used in ambulatory care, longterm care and home health care. . . Ambulatory CarePt schedulingElectronic medical recordsBillingElectronic communication with other providers3/1/2010Free Template from www.brainybetty.com14

15. Patient Care ApplicationsLong-term care applicationsUsed to monitor health status indicators such as infections and skin problemsHome HealthOn-site documentation of Pt’s healthReduces amount of administrative work neededCaregivers can view Pt’s record at their home via laptopPt can communicate & view results, appointments, etc. from home3/1/2010Free Template from www.brainybetty.com15