hospital information systems & electronic health records
DESCRIPTION
A lecture in March 2012 for third year undergraduate nursing students at Faculty of Medicine Ramathibodi Hospital, Mahidol University, in Thai.TRANSCRIPT
Hospital Information Systems (HIS) and
Electronic Health Records (EHRs)
Nawanan Theera-Ampornpunt, MD, PhDHealth Informatics Division, Ramathibodi
Mar 15, 2012
http://www.slideshare.net/nawanan
A Bit About Myself
2003 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 [email protected]
Research interests:• Health IT applications in clinical settings (including
EHRs)• Health IT “adoption”• Health informatics education
EHRs: Fundamentals
What Is A Medical Record?
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
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?
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”
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?
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
“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)
Longitudinal Records
• Records documented over time (multiple encounters)• Ideally, “life-long” is a complete record of the patient’s health
Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic Health
Records (EHRs)
Picture Archiving and Communication System
(PACS)
Still Many Other Forms of Health IT
m-Health
Health Information Exchange (HIE)
Biosurveillance
Information RetrievalTelemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I
Personal Health Records (PHRs)
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)
Benefits of EHRs
Class Exercise 3
• Why do we need to use an electronic version of medical records?
“Computerize”“Go paperless”
“Digital Hospital”
“Modernize”
“Get an electronic copy
“Have EMRs”
“Share data”
Common “Goals” for EHRs/Health IT Adoption
Is There A Role for Health IT?
(IOM, 2000)
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”
To Err Is Human
• Perception errors
Image Source: interaction-dynamics.com
Image Source: aafp.org
To Err Is Human
• Lack of Attention
The Economist Purchase Options
• Economist.com subscription $59• Print subscription $125• Print & web subscription $125
Class Exercise 3
The Economist Purchase Options
• Economist.com subscription $59• Print & web subscription $125
Class Exercise 3
• Cognitive Errors - Example: Decoy Pricing
The Economist Purchase Options
• Economist.com subscription $59• Print subscription $125• Print & web subscription $125
(Ariely, 2008)
16084
The Economist Purchase Options
• Economist.com subscription $59• Print & web subscription $125
6832
# of People
# of People
To Err Is Human
What If This Happens in Healthcare?
• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)
• What if health IT can help?
Fundamental Theorem of Informatics
(Friedman, 2009)(Friedman, 2009)
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!!!!!
• Are they just electronic documentation?
• Or do they have some other values?
Diag-nosis
History & PE
Treat-ments ...
Electronic Health Record (EHR) Systems
• 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”
Literature Shows Benefits of Health IT
Alerts & Reminders
• 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
Hospital Information Systems
Different Kinds of IT in Hospitals
Hardware &
Network
Software
Peopleware
IT Infrastructure- Hardware- Network- Operating
System (Windows, etc.)
- Antivirus- Other system
software
Software Applications- Microsoft Office- Business
software (HIS, EHRs, MIS)
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)
Examples of Hospital IT
Enterprise-wide• MPI, ADT• EHRs/EMRs/HIS/CIS• CPOE & CDSSs• Nursing applications• Billing, Claims & Reimbursements• MIS, ERP
Examples of Hospital IT
Departmental Applications• Pharmacy applications
• LIS, PACS, RIS
• Specialized applications (ER, OR, LR, Anesthesia, Critical Care, Blood Bank)
• E-Learning
Workflow
Hospital Information System
Master Patient
Index (MPI)
ADT
SchedulingScheduling
OrderOrder
Pharmacy IS
Operation Theatre
BillingBilling
Clinical Notes
LIS
RIS
PACS
CCIS
Medical Records
Portals
Modified from Dr. Artit Ungkanont’s slide
Hospital Information System
From Dr. Artit Ungkanont’s slide
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
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
Bed Management (from ADT System)
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
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
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 system
Values• No handwriting!!!• Structured data entry (completeness, clarity, fewer mistakes)• No transcription!• Entry point for CDSSs• Streamlines workflow, increases efficiency
Computerized Physician Order Entry (CPOE)
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
Clinical Decision Support Systems (CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
From a teaching slide by Don Connelly, 2006
Clinical Decision Support Systems (CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIANAbnormal lab
highlights
Clinical Decision Support Systems (CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIANDrug-Allergy
Checks
Clinical Decision Support Systems (CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN Drug-Drug Interaction
Checks
Clinical Decision Support Systems (CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
Inference
DECISION
PATIENT
Perception
Attention
WorkingMemory
CLINICIAN
Diagnostic/Treatment Expert Systems
Clinical Decision Support Systems (CDSSs)
Issues• Alert sensitivity & alert fatigue
Clinical Decision Support Systems (CDSSs)
Issues• Unintended Consequences (e.g. workarounds)
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
Pharmacy Applications
Functions• Streamlines workflow from medication orders to dispensing and
billing• Reduces medication errors, improves medication safety• Improves inventory management
Stages of Medication Process
Ordering Transcription Dispensing Administration
CPOEAutomatic Medication Dispensing
Electronic Medication
Administration Records (e-MAR)
BarcodedMedication
Administration
BarcodedMedication Dispensing
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
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.
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
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
The Bigger Picture:Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home
• 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
• 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
Questions?