Clinical information systems support diagnosis, treatment planning, and evaluation of medical outcomes. The number of installations of clinical systems has increased as healthcare managers recognize their importance for continuous quality improvement, cost control, and reducing medical errors. Key attributes of an effective comprehensive patient record include a problem list delineating clinical problems and status, supporting systematic measurement of health status, documenting clinical rationale for diagnoses, and linking records across settings over time.

1. HIMP 375Health Informatics Review Learning Outcome 5

2. Patient Care Applications Clinical information systems support 3 things. What are they?? Diagnosis Treatment planning Evaluation of medical outcomes 3/1/2010 Free Template from www.brainybetty.com 2

3. Patient Care Applications Why has the number of installations of clinical systems increased in healthcare facilities? Governing boards & healthcare managers recognize importance for Continuous quality improvement of patient care Cost control Reduction of medical errors 3/1/2010 Free Template from www.brainybetty.com 3

4. Patient Care Applications What are felt to be the key attributes of the CPR as defined by the IOM (Institute of Medicine) Comm. CPR includes a problem list that clearly delineates the Pt’s clinical problems & current status of each Encourages & supports systematic measurement & recording of Pt’s health status & functional levels Documents the clinical rationale for all diagnoses or conclusions Links to clinical records from various settings & time periods to provide “longitudinal record of events” 3/1/2010 Free Template from www.brainybetty.com 4

5. Patient Care Applications Examples of Patient Care Applications Order Entry & Results Reporting Entry of orders for diagnostic tests, Pt treatments & subsequent reporting of test results back to caregivers Dr’s orders are entered at nursing station & are transmitted to appropriate area (ie. Lab, pharmacy) Test results & treatment summaries are transmitted back for entry into the Pt’s chart Record of charges for tests & treatments transmitted to Business Office 3/1/2010 Free Template from www.brainybetty.com 5

6. Patient Care Applications Examples of Clinical (Patient Care) Applications Laboratory 2 phases Automation of test processes and Automation of processing lab data Done by electronically linking lab instruments to computer Benefits Immediate reporting Reduced duplication, therefore reduced costs Better scheduling 3/1/2010 Free Template from www.brainybetty.com 6

7. Patient Care Applications Examples of Clinical (Patient Care) Applications Pharmacy Information System Controls ordering, stocking & distribution of drugs to avoid medication errors Orders are entered at Nursing Station, communicated directly to Pharmacy Worksheets generated Patient labels generated Patient profile updated 3/1/2010 Free Template from www.brainybetty.com 7

8. Patient Care Applications Examples of Clinical (Patient Care) Applications Pharmacy . . . Major screenings include Drug-drug interactions Drug-food interactions Dose range checking Benefits of Pharmacy Information System Can eliminate the time gap between point of care and point of service Can reduce medication errors Can improve quality of care Can increase patient satisfaction 3/1/2010 Free Template from www.brainybetty.com 8

9. Patient Care Applications Examples of Clinical (Patient Care) Applications Radiology Information Systems Include Recording test requisitions Scheduling procedures Recording & reporting test results Reporting charges to Business Office Preparing management reports 3/1/2010 Free Template from www.brainybetty.com 9

10. Patient Care Applications Why is the involvement of physicians so important to successful implementation of clinical information systems? If Dr’s don’t understand how to use system or don’t know what the information system can do for them, they will resist it’s use Success directly dependent on the commitment of senior management. Physicians must be involved as trainers, problem-solvers as well as users of the system 3/1/2010 Free Template from www.brainybetty.com 10

11. Patient Care Applications What are “clinical decision-support systems” (CDSS)??? CDSS’s are computer-based information systems designed to assist physicians in diagnosis and treatment planning. 3/1/2010 Free Template from www.brainybetty.com 11

12. Patient Care Applications Two categories of CDSS – Passive system collects, organizes & communicates Pt data to physician Data on Pt’s history Physical exam Diagnostic tests Active system utilizes medical data stored in computer to suggest diagnoses & treatment protocols 3/1/2010 Free Template from www.brainybetty.com 12

13. Patient Care Applications Define “evidence-based medicine” Clinical practice guidelines developed by experts Software created which ‘suggests’ clinical pathway for caregivers to follow when treating patient Designed to assist healthcare organizations in providing quality care at the most reasonable cost possible Quality of information a concern…addressed by Accreditation standards 3/1/2010 Free Template from www.brainybetty.com 13

14. Patient Care Applications Examples of information systems being used in ambulatory care, longterm care and home health care. . . Ambulatory Care Pt scheduling Electronic medical records Billing Electronic communication with other providers 3/1/2010 Free Template from www.brainybetty.com 14

15. Patient Care Applications Long-term care applications Used to monitor health status indicators such as infections and skin problems Home Health On-site documentation of Pt’s health Reduces amount of administrative work needed Caregivers can view Pt’s record at their home via laptop Pt can communicate & view results, appointments, etc. from home 3/1/2010 Free Template from www.brainybetty.com 15