For Mahidol University Faculty of ICT Class

1. Clinical Information Systems
(CIS), Hospital Information
Systems (HIS) & Electronic
Health Records (EHRs)
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Department of Community Medicine, Ramathibodi
Sep 20, 2014
http://www.slideshare.net/nawanan

2. What is an information system?

3. Information System
• Information System
–A system using information technology to
support certain human work processes
–Uses technology as a tool to deliver
information and support business
processes to users in a certain task
– Examples: Bank teller systems, online
course registration systems, e-learning
systems, flight reservation systems

4. ทำไมต้องมีระบบสารสนเทศ
• Connecting data from various places
• Fast processing
• Collaborative work
• Reducing errors or inconsistencies in the
process
Image Source: http://en.wikipedia.org/wiki/Logistics_automation

5. Components of Information Systems
Hardware Software
Peopleware Data
- Servers & Clients
- Network
- Operating System
- System Utilities
(such as antivirus)
- Applications (such as
Microsoft Word,
Hospital Information
System)
- Data stored in the
sytem
- Users
IT Infrastructure

6. ATM
Image Source: http://www.gsb.or.th/products/personal/services/atm.php

7. Flight Departure Display
Image Source: http://www.m7worldwide.com/checkaflight.html

8. EHRs: Fundamentals

9. What Is A Medical Record?

10. 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

11. 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?

12. 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”

13. 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?

14. 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

15. “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)

16. Longitudinal Records
• Records documented over time (multiple encounters)
• Ideally, “life-long” is a complete record of the patient’s health

17. Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic
Health
Records
(EHRs)
Picture Archiving and
Communication System
(PACS)

18. Still Many Other Forms of Health IT
m-Health
Health Information
Exchange (HIE)
Biosurveillance
Information Retrieval
Telemedicine &
Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I
Personal Health Records
(PHRs)

19. Electronic Medical
Records (EMRs)
The Confusing Acronyms
Computer-Based
Patient Records
(CPRs)
Electronic Patient
Electronic Health Records (EPRs)
Records (EHRs)
Personal Health
Records (PHRs)
Hospital
Information
Systems (HIS)

20. Benefits of EHRs

21. Class Exercise 3
• Why do we need to use an
electronic version of medical
records?

22. 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 prevent human errors

23. 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!!!!!

24. Electronic Health Record (EHR) Systems
• Are they just electronic documentation?
Diag-nosis
History
& PE
Treat-ments
• Or do they have some other values?
...

25. Literature Shows Benefits of Health IT
• 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”

26. Alerts & Reminders

27. Functions That Should be Part of
EHR Systems
• 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

28. Clinical Information Systems
& Hospital Information Systems

29. 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)

30. Examples of Hospital IT
Enterprise-wide
• MPI, ADT
• EHRs/EMRs/HIS/CIS
• CPOE & CDSSs
• Nursing applications
• Billing, Claims & Reimbursements
• MIS, ERP

31. Examples of Hospital IT
Departmental Applications
• Pharmacy applications
• LIS, PACS, RIS
• Specialized applications (ER, OR, LR, Anesthesia,
Critical Care, Blood Bank)
• E-Learning

32. Hospital Information System
ADT
Workflow
Master
Patient
Index (MPI)
Scheduling
Pharmacy IS
Order
Medical
Records
Operation
Theatre
Billing
Clinical
Notes
LIS
RIS
PACS
CCIS
Portals
Modified from Dr. Artit Ungkanont’s slide

33. Hospital Information System
From Dr. Artit Ungkanont’s slide

34. 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

35. 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

36. Bed Management (from ADT System)

37. 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

38. 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

39. 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

40. Computerized Physician Order Entry
(CPOE)

41. 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

42. Clinical Decision Support Systems
(CDSSs)
External Memory
Knowledge Data
Long Term Memory
Knowledge Data
PATIENT
Perception
Attention
Working
Memory
Inference
DECISION
CLINICIAN
From a teaching slide by Don Connelly, 2006

43. 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

44. Pharmacy Applications
Functions
• Streamlines workflow from medication orders to dispensing and
billing
• Reduces medication errors, improves medication safety
• Improves inventory management

45. Stages of Medication Process
Ordering Transcription Dispensing Administration
CPOE
Automatic
Medication
Dispensing
Electronic
Medication
Administration
Records
(e-MAR)
Barcoded
Medication
Administration
Barcoded
Medication
Dispensing

46. 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

47. 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.

48. 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

49. 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

50. The Bigger Picture:
Health Information Exchange (HIE)
Hospital A Hospital B
Clinic C
Government
Lab Patient at Home

51. • 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

52. 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

53. Questions?