Post on 24-Dec-2015
HIMA 4160Fall 2009
HIS: Health Information SystemsEHR: Electronic Health RecordsEMR: Electronic Medical Records
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Level of conception. Data – factual Information – meaning of data Knowledge – model for information
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Data – Body temperature 103 Information – The patient is having a fever Knowledge -- The knowledge used to
generate the information: if a patient temperature is > 100 F, he might a fever (or hyperthermia).
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Concrete Abstract
Factual Conceptual
Volatile Stable
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General term cover all three levels Database – data level Information storage and retrieval system –
information level Knowledge system – knowledge level
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Information System
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In-house – developed and managed in the health care organization
Shared – developed and managed at the vendor site
Turnkey system – developed by vendor, installed and managed by health care organization
Stand-alone – lack of information sharing. Legacy system.
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Integration Continuality Standards Consumer oriented
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Clinical information systems – serving clinical activities◦ Hospital information system◦ Patient monitoring system◦ Nursing information system◦ Laboratory information system◦ Pharmacy information system◦ Computer based patient record ◦ Others
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Provide communication among health facility workers and support organizational information needs for operations, planning, patient care, and documentation.
Communication, coordination Various across different hosptials
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HIS should have following functions Central application Business and financial function Communications and Networking Department management Medical documentation Medical decision support
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Patient management◦ Scheduling◦ RADT (registration, admission, discharge, and
transfer)◦ RADT provides basic patient information to other
clinical systems.
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Payroll General ledger Accounts receivable Insurance
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Connect different systems. Need data standards to communicate. This is a disadvantage of paper based
system.
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Needs of individual department Pharm, lab, radiology, dietary, pathology,
etc The trend is to integrate these systems
while maintaining their functional independence.
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Medical record Will be paperless Provide support to managerial and
administrative decision making In order to do so, the medical record has to
be digitalized and codified.
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Help clinicians make decision Not replace clinicians data from various sources – hard to
managed by human Often integrated into physician order entry
system focal role in decreasing medical errors
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Physiological data Emergency room, operating room, intensive
are, critical care Can give real time alert
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Support nurse care process Clinical and managerial
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Associated with lab test Usually already available in the instrument Various types of lab tests have different
demands
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Data related to drug usage for patient Also can help decreasing medication errors
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IOM 1991 report first proposed the concept Other names include electronic health
record (EHR), electronic medical record (EMR).
It is not a single computer product or program
Based an changed model of managing patient data
Computer and information technology is necessary but not sufficient factor.
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Focus on integration Government support
◦ http://www.cnn.com/2004/ALLPOLITICS/04/27/bush.healthcare.ap/
◦ National Health Information Infrastructure◦ ARRA
Standardization◦ HL7
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Financial information system Accounting information systems Human recourse management information
systems Material management information system Facilities management information system Management planning and decisin support
system
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Computer based patient record◦ National health information infrastructure◦ Medical errors
E-Health and e-HIM◦ Web based technology
Standards Privacy and Security Technology
◦ Wireless◦ Voice recognition◦ Data warehouse and data mining
Enterprise information management Virtual information system – results of
integration, standardization, and personalization.
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Before we answer that, what is a patient record? • commonly referred to as the patient's chart or
medical record • amalgam of all the data acquired and created
during a patient's course through the heath care system
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"to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions"
Reiser, S. (1991). The Clinical Record in Medicine. Part 1: Learning from Cases. Annals of Internal Medicine, 114(10): 902-907
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• create the basis for the historical data
• support communication among providers
• anticipate future health problems
• record standard preventive measures
• identify deviation from expected trends
• provide a legal record
• support clinical research and public health
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• Pragmatic and Logistical issues.• Can I find the data I need when I need them?• Can I find the medical record in which they are recorded?• Can I find the data within the record• Can I find what I need quickly?• Can I read and interpret the data once I find them?• Can I update the data reliably with new observations in a
form consistent with the requirements for future access by me or other people?
• Redundancy and Inefficiency
• Influence on Clinical Research
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Accessibility Legibility Adaptive Structure Reusability Flexibility
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Comprehensiveness of information Duration of use and retention of data Degree of structure of data Ubiquity of access
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Disease Pattern Change Health Care Delivery System Change Specialization of Medicine Advances of Computer and Information
Technology
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Primary Uses◦Patient Care Delivery◦Patient Care Management◦Patient Care Support Processes◦Financial and Other Administrative Processes◦Patient Self-Management
Second Uses◦Education◦Regulation◦Research ◦Public Health and Homeland Security◦Policy Support
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Health Information and Data Results management Order entry/management Decision support Electronic communication and connectivity Patient support Administrative processes Reporting and population health
management
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Key Data◦ Problem list◦ Procedures◦ Diagnoses◦ Medication list◦ Allergies ◦ Demographics◦ Diagnostic test results◦ Radiology results◦ Health maintenance◦ Advance directives◦ Dispositions◦ Level of service
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Minimum Data Set (MDS) for nursing homes◦ From CMS◦ Support Long Term Care◦ Current Version 3.0
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Narrative (clinical and patient narrative)◦Free text◦Template based◦Deriving structures from unstructured text
NLP◦Structured and coded
Signs and symptoms Diagnoses Procedures Level of service
◦Treatment plan Single discipline interdiscipline
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Patient Acuity/Severity of Illness/ Risk Adjustment◦ Nursing workload◦ Severity adjustment
Capture of identifiers◦ People and roles◦ Products/devices◦ Places (including directions)
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Results Reporting◦ Laboratory◦ Microbiology◦ Pathology◦ Radiology ◦ Consult
Results notification
Multiple views of data/presentations
Multimedia support
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Computerized provider order entry◦Electronic prescribing◦Laboratory◦Microbiology◦Pathology◦Radiology◦Ancillary◦Nursing◦Supplies◦Consults
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Access to knowledge sources◦Domain knowledge◦Patient education
Drug alert◦Drug dose defaults◦Drug dose checking◦Allergy checking◦Drug interaction checking◦Drug-lab checking◦Drug-condition checking◦Drug-diet checking
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Other rule-based alert (e.g., significant lab trends, lab test)
Reminders◦ Preventive services
Clinical guidelines and pathways◦ Passive ◦ Context-sensitive passive◦ Integrated
Chronic Disease Management
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Clinician work list Incorporation of patient and/or family
preference Diagnostic decision support Use of epidemiologic data Automated real-time surveillance
◦Detect adverse vents and near misses◦Detect disease outbreaks◦Detect bioterrorism
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Provider to provider Team coordination Patient-provider
◦ Email◦ Secure web
messaging Medical Devices Trading partners
(external)◦ Outside pharmacy◦ Insurer◦ Laboratory◦ Radiology
Integrated medical record◦ Within setting◦ Cross-setting
Inpatient-outpatient Other cross-setting
◦ Cross-organizational
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Patient education◦Access to patient
education materials◦Custom patient
education◦Tracking
Family and informal caregiver education
Data entered by patient, family, and/or informal caregiver◦Home monitoring◦Questionnaires
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Scheduling management◦ Appointments◦ Admissions◦ Surgery/procedure schedule
Eligibility determination◦ Insurance eligibility◦ Clinical trial recruitment◦ Drug recall◦ Chronic disease management
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Patient safety and quality reporting◦ Clinical dashboard◦ External accountability reporting◦ Ad hoc reporting
Public health reporting◦ Reportable diseases◦ Immunizations
De-identifying data Disease registry
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Ambulatory (NEJM 2008)◦ 4% fully functional EHR◦ 13% basic system◦ Small and solo practices struggle
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Standardization of Clinical Information Cost of implementation and maintenance Physicians' readiness to adopt the EHR Privacy issues and patients’ concerns with
information sharing. Legal liability
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