HIMA 4160
Fall 2009
HIS: Health Information Systems
EHR: Electronic Health Records
EMR: Electronic Medical Records
HIMA 4160 Fall 2009
4/13/2015
2




Level of conception.
Data – factual
Information – meaning of data
Knowledge – model for information
HIMA 4160 Fall 2009
4/13/2015
3



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).
HIMA 4160 Fall 2009
4/13/2015
4
Concrete
Abstract
Factual
Conceptual
Volatile
Stable
HIMA 4160 Fall 2009
4/13/2015
5




General term cover all three levels
Database – data level
Information storage and retrieval system –
information level
Knowledge system – knowledge level
HIMA 4160 Fall 2009
4/13/2015
6
Information System
HIMA 4160 Fall 2009
4/13/2015
7

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.
HIMA 4160 Fall 2009
4/13/2015
9




Integration
Continuality
Standards
Consumer oriented
HIMA 4160 Fall 2009
4/13/2015
10
HIMA 4160 Fall 2009
4/13/2015
11

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
HIMA 4160 Fall 2009
4/13/2015
12



Provide communication among health facility
workers and support organizational
information needs for operations, planning,
patient care, and documentation.
Communication, coordination
Various across different hosptials
HIMA 4160 Fall 2009
4/13/2015
13
HIS should have following functions
 Central application
 Business and financial function
 Communications and Networking
 Department management
 Medical documentation
 Medical decision support
HIMA 4160 Fall 2009
4/13/2015
14

Patient management
◦ Scheduling
◦ RADT (registration, admission, discharge, and
transfer)
◦ RADT provides basic patient information to other
clinical systems.
HIMA 4160 Fall 2009
4/13/2015
15




Payroll
General ledger
Accounts receivable
Insurance
HIMA 4160 Fall 2009
4/13/2015
16



Connect different systems.
Need data standards to communicate.
This is a disadvantage of paper based system.
HIMA 4160 Fall 2009
4/13/2015
17



Needs of individual department
Pharm, lab, radiology, dietary, pathology, etc
The trend is to integrate these systems while
maintaining their functional independence.
HIMA 4160 Fall 2009
4/13/2015
18




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.
HIMA 4160 Fall 2009
4/13/2015
19





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
HIMA 4160 Fall 2009
4/13/2015
20



Physiological data
Emergency room, operating room, intensive
are, critical care
Can give real time alert
HIMA 4160 Fall 2009
4/13/2015
21


Support nurse care process
Clinical and managerial
HIMA 4160 Fall 2009
4/13/2015
22



Associated with lab test
Usually already available in the instrument
Various types of lab tests have different
demands
HIMA 4160 Fall 2009
4/13/2015
23


Data related to drug usage for patient
Also can help decreasing medication errors
HIMA 4160 Fall 2009
4/13/2015
24





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.
HIMA 4160 Fall 2009
4/13/2015
25


Focus on integration
Government support
◦ http://www.cnn.com/2004/ALLPOLITICS/04/27/b
ush.healthcare.ap/
◦ National Health Information Infrastructure
◦ ARRA

Standardization
◦ HL7
HIMA 4160 Fall 2009
4/13/2015
26






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
HIMA 4160 Fall 2009
4/13/2015
27







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.
HIMA 4160 Fall 2009
4/13/2015
28
HIMA 4160 Fall 2009
4/13/2015
29
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
HIMA 4160 Fall 2009
4/13/2015
30
"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
HIMA 4160 Fall 2009
4/13/2015
32
• 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
HIMA 4160 Fall 2009
4/13/2015
33
•
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
HIMA 4160 Fall 2009
4/13/2015
35






Accessibility
Legibility
Adaptive
Structure
Reusability
Flexibility
HIMA 4160 Fall 2009
4/13/2015
36




Comprehensiveness of information
Duration of use and retention of data
Degree of structure of data
Ubiquity of access
HIMA 4160 Fall 2009
4/13/2015
37




Disease Pattern Change
Health Care Delivery System Change
Specialization of Medicine
Advances of Computer and Information
Technology
HIMA 4160 Fall 2009
4/13/2015
38

Primary Uses

Second Uses
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Patient Care Delivery
Patient Care Management
Patient Care Support Processes
Financial and Other Administrative Processes
Patient Self-Management
Education
Regulation
Research
Public Health and Homeland Security
Policy Support
HIMA 4160 Fall 2009
4/13/2015
39








Health Information and Data
Results management
Order entry/management
Decision support
Electronic communication and connectivity
Patient support
Administrative processes
Reporting and population health
management
HIMA 4160 Fall 2009
4/13/2015
40

Key Data
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Problem list
Procedures
Diagnoses
Medication list
Allergies
Demographics
Diagnostic test results
Radiology results
Health maintenance
Advance directives
Dispositions
Level of service
HIMA 4160 Fall 2009
4/13/2015
41

Minimum Data Set (MDS) for nursing homes
◦ From CMS
◦ Support Long Term Care
◦ Current Version 3.0
HIMA 4160 Fall 2009
4/13/2015
42

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
HIMA 4160 Fall 2009
4/13/2015
43

Patient Acuity/Severity of Illness/ Risk
Adjustment
◦ Nursing workload
◦ Severity adjustment

Capture of identifiers
◦ People and roles
◦ Products/devices
◦ Places (including directions)
HIMA 4160 Fall 2009
4/13/2015
44

Results Reporting

Results notification

Multiple views of data/presentations

Multimedia support
◦
◦
◦
◦
◦
Laboratory
Microbiology
Pathology
Radiology
Consult
HIMA 4160 Fall 2009
4/13/2015
45

Computerized provider order entry
◦
◦
◦
◦
◦
◦
◦
◦
◦
Electronic prescribing
Laboratory
Microbiology
Pathology
Radiology
Ancillary
Nursing
Supplies
Consults
HIMA 4160 Fall 2009
4/13/2015
46

Access to knowledge sources

Drug alert
◦ Domain knowledge
◦ Patient education
◦
◦
◦
◦
◦
◦
◦
Drug dose defaults
Drug dose checking
Allergy checking
Drug interaction checking
Drug-lab checking
Drug-condition checking
Drug-diet checking
HIMA 4160 Fall 2009
4/13/2015
47


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
HIMA 4160 Fall 2009
4/13/2015
48





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
HIMA 4160 Fall 2009
4/13/2015
49





Provider to provider
Team coordination
Patient-provider
◦ Email
◦ Secure web messaging
Medical Devices
Trading partners
(external)
◦
◦
◦
◦

Integrated medical
record
◦ Within setting
◦ Cross-setting
 Inpatient-outpatient
 Other cross-setting
◦ Cross-organizational
Outside pharmacy
Insurer
Laboratory
Radiology
HIMA 4160 Fall 2009
4/13/2015
50

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
HIMA 4160 Fall 2009
4/13/2015
51

Scheduling management
◦ Appointments
◦ Admissions
◦ Surgery/procedure schedule

Eligibility determination
◦
◦
◦
◦
Insurance eligibility
Clinical trial recruitment
Drug recall
Chronic disease management
HIMA 4160 Fall 2009
4/13/2015
52

Patient safety and quality reporting
◦ Clinical dashboard
◦ External accountability reporting
◦ Ad hoc reporting

Public health reporting
◦ Reportable diseases
◦ Immunizations


De-identifying data
Disease registry
HIMA 4160 Fall 2009
4/13/2015
53

Ambulatory (NEJM 2008)
◦ 4% fully functional EHR
◦ 13% basic system
◦ Small and solo practices struggle
HIMA 4160 Fall 2009
4/13/2015
54
HIMA 4160 Fall 2009
4/13/2015
55





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
HIMA 4160 Fall 2009
4/13/2015
56