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Clinical Information Systems Overview
1. Clinical Information Systems
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Faculty of Medicine Ramathibodi Hospital
June 14, 2014
http://www.slideshare.net/nawanan
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
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
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
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
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. 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)
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. • “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. Health IT: What’s In A Word?
Health
Information
Technology
Goal
Value-Add
Tools
21. • Guideline adherence
• Better documentation
• Practitioner decision making
or process of care
• Medication safety
• Patient surveillance &
monitoring
• Patient education/reminder
Value of Health IT
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. • 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. Image Source: (Left) http://docwhisperer.wordpress.com/2007/05/31/sleepy-heads/
(Right) http://graphics8.nytimes.com/images/2008/12/05/health/chen_600.jpg
To Err is Human 1: Attention
26. Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital, Mahidol University
To Err is Human 2: Memory
27. To Err is Human 3: Cognition
• Cognitive Errors - Example: Decoy Pricing
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Ariely (2008)
16
0
84
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68
32
# of
People
# of
People
28. • It already happens....
(Mamede et al., 2010; Croskerry, 2003; Klein, 2005; Croskerry,
2013)
What If This Happens in Healthcare?
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. 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. 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”
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
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. 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. 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. 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. 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. 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. Pharmacy Applications
Functions
• Streamlines workflow from medication orders to dispensing and
billing
• Reduces medication errors, improves medication safety
• Improves inventory management
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. 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. 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. 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. 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. The Bigger Picture:
Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
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. 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. 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. 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. 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. 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. 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. 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. “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. Longitudinal Records
• Records documented over time (multiple encounters)
• Ideally, “life-long” is a complete record of the patient’s health
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. • Are they just electronic documentation?
• Or do they have some other values?
Diag-
nosis
History
& PE
Treat-
ments
...
Electronic Health Record (EHR) Systems
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. • 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. 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
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. • 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
