clinical information systems

Clinical Information Systems

Nawanan Theera-Ampornpunt, M.D., Ph.D.Faculty of Medicine Ramathibodi Hospital

June 14, 2014

http://www.slideshare.net/nawanan

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 InformaticsChakri Naruebodindra Medical Institute

Faculty of Medicine Ramathibodi Hospital

nawanan.the@mahidol.ac.thhttp://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

Class Outline

• Health Care & Health IT• Clinical Information Systems• Electronic Health Records

Health Care & Health IT

Manufacturing

Image Source: Guardian.co.uk

Banking

Image Source: Cablephet.com

Health care

ER - Image Source: nj.com

• 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?

• Large variations & contextual dependence

Why Health care Isn’t Like Any Others?

Input Process Output

Patient Presentation

Decision-Making

Biological Responses

But...Are We That Different?

Input Process Output

Transfer

Banking

Value-Add- Security- Convenience- Customer Service

Location A Location B

Input Process Output

Assembling

Manufacturing

Raw Materials

Finished Goods

Value-Add- Innovation- Design- QC

But...Are We That Different?

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

“Information” in Medicine

Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11):1227-8.

Information is Everywhere in Health Care

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)

Why Adopting Health IT?

“To Computerize”“To Go paperless”

“Digital Hospital”

“To Modernize”

“To Get a HIS”

“To Have EMRs”

“To Share data”

• “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

Health IT: What’s In A Word?

HealthInformationTechnology

Goal

Value-Add

Tools

• Safety• Timeliness• Effectiveness• Efficiency• Equity• Patient-centeredness

Dimensions of Quality Healthcare

(IOM, 2001)

• Guideline adherence• Better documentation• Practitioner decision making

or process of care• Medication safety• Patient surveillance &

monitoring• Patient education/reminder

Value of Health IT

Landmark IOM Reports

(IOM, 2001)(IOM, 2000) (IOM, 2011)

• 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

• 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

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

Image Source: Suthan Srisangkaew, Department of Pathology, Facutly of Medicine Ramathibodi Hospital, Mahidol University

To Err is Human 2: Memory

To Err is Human 3: Cognition

• 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

• It already happens....(Mamede et al., 2010; Croskerry, 2003; Klein, 2005; Croskerry, 2013)

What If This Happens in Healthcare?

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.

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.

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”

Health IT Across Settings

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)

Health IT in Clinical Settings (“Clinical Information Systems”)

• 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

• 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

Workflow

Hospital Information System

Master Patient

Index (MPI)

ADT

Scheduling

Order

Pharmacy IS

Operation Theatre

Billing

Clinical Notes

LIS

RIS

PACS

CCIS

Medical Records

Portals

Modified 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)

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)

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

Strategic

Operational

ClinicalAdministrative

4 Quadrants of Hospital IT

CPOE

ADT

LIS

EHRs

CDSS

HIE

ERP

Business Intelligence

VMI

PHRs

MPIWord

Processor

Social Media

PACS

Electronic Health Records/Electronic Medical Records

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

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

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

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.

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

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

“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

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)

• 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

Literature Shows Benefits of Health IT

• 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

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

EHR/HIS Adoption in Thailand (2004)

Pongpirul et al., 2004

EHR/HIS Adoption in Thailand (2011)

HOSxP50%

Self-developed or outsourced16%

Hospital OS7%

SSB4%

Mit-Net2%

MRecord2%

H.I.M. Professional2%

MedTrak/TrakCare

2%

HoMC2%

None 2% THIADES2% HIMS

1%

Abstract ePHIS1%

Other7%

Theera-Ampornpunt, 2011 [Dissertation]

EHRs and the Bigger Picture

Health Information Exchange (HIE)

Hospital A Hospital B

Clinic C

Government

Lab Patient at Home

Google Flu Trends (Biosurveillance)

Source: Google.org/FluTrends

• 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

Next: Clinical Decision Support

Systems