hospital information systems & electronic health records

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”


• 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?


• 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


• Economist.com subscription $59• Print & web subscription $125

Class Exercise 3

• Cognitive Errors - Example: Decoy Pricing


• Economist.com subscription $59• Print subscription $125• Print & web subscription $125

(Ariely, 2008)

16084


• 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


External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN

From a teaching slide by Don Connelly, 2006


External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIANAbnormal lab

highlights


External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIANDrug-Allergy

Checks


External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN Drug-Drug Interaction

Checks


External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN

Diagnostic/Treatment Expert Systems


Issues• Alert sensitivity & alert fatigue


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?

hospital information systems & electronic health records

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