Medical Information Systems

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1 Medical Information Systems Introduction The introduction of information systems in hospitals and other medical facilities is not only driven by the wish to improve management of patient-related data for the patient s benefit, but also by the fiscal necessity to improve efficiency of medical services. Computer-based patient record (CPR) Patient records serve the following purposes: Caregivers Record of Information from the Patient Caregivers Findings and Treatments Communication to Later Caregivers Coordinating and Organizing Caregivers in the Care of the Patient Creating a Formal Record of Patient Care Information for Public Health and Clinical Research The appendix lists typical records for both outpatients and inpatients. The average medical record weighs 1.5 pounds, and every visit to the doctor adds an average of 13 pieces of paper. Apart from the inconvenience of handling these files, which naturally can be only at one location at a time, paper records mayor weaknesses are: Lack of standardization in content Lack of standardization in format Incompleteness Inaccuracies Risk of misplacement or loss The computer-based patient record (CPR) (or electronic patient record, EPR) offers health professionals Complete patient data displayed in an integrated fashion that facilitates medical decision making, Access from any workstation in the hospital Ability to enter orders, notes, data at same workstation No double entry of information

2 Immediate availability of results Simultaneous users can access same medical record Access from on site or remote locations No loss of patient information However, initial costs, the necessity to change workflow, and employees reluctance to accept the new technology are mayor problems when introducing CPR in a hospital. Hospital information systems (HIS) An information system, that combines a computer-based patient record with other modules that support clinical workflow is called a hospital information system (HIS). As early HIS date back to the 1970s, modern more comprehensive approaches are sometimes labeled differently (clinical information system, CIS, health-care informtion system, HCIS), but definitions are not precise. Some important modules of an HIS are the following: Medical devices: access to medical devices via standardized protocols (DICOM) and/or Picture Archiving and Communications System (PACS) Telemedicine: access to external data (e.g. receive patient data from physician, notify physician electronically, send and receive medical images), typically by means of internet access via firewall. Scheduling: Staff can electronically make appointments with physicians, X-ray, laboratories, etc.. Billing: import, view, approve charges posted by therapists, file electronic claims and/or print claims, create reports (by patient, therapist, ward, clinic, diagnosis, etc.) to analyze individual and group productivity and financial performance. Hospital Information System med. devices & PACS telemedicine CPR scheduling add / connect systems billing CMPT 340 / part 09 /

3 Important aspects of an HIS are Reliability Response time Accessibility Flexibility Security/Privacy When designing an HIS, it is not only necessary to compromise between these performance aspects (e.g. between security/privacy, accessability, and response time), but also with the systems costs (initial costs as well as maintenance). Telemedicine Telemedicine is the transfer of electronic medical data (i.e. high resolution images, sounds, live video, and patient records) from one location to another. Telemedicine deals with two mayor problems: 1. Traditionally the healthcare environment consists of organizationally indepentent units with little coordination and sharing of data between them. The patients data is scattered between many facilities. 2. People living in remote areas have little access to specialty medical care. Technology is either "store and forward" (e.g. transfer stored medical images) or "two-way interactive" (e.g. videoconferencing) and can be based on regular telephone lines, ISDN, cable wiring or other kinds of high bandwidth telecommunications, or satellite, with the internet becoming more and more prevalent ("E-Health"). Some telemedicine applications that are in use or that are currently being developed are the following: videoconferencing of expert physicians or physician and patient, administartive functions physicians' education Teleradiology, the sending of x-rays, CT scans, or MRIs (store-and-forward) is the most common application of telemedicine in use today. Programs that have recently been suggested include: ECG recorded on board of an airplane is sent to experts on the ground for evaluation, "Personal Diagnosis Centre" as part of a home entertainment centre - this system would monitor the patient's daily health status and automatically notify a health professional if he or she becomes ill, One "Universal Patient Record" instead of many separate paper records with web enabled viewing access.

4 Telemedicine offers a great range of benefits: reduce time and cost for patient transportation, transportation of files etc., gives patients in remote areas access to specialist physicians, gives healthcare facilities access to existing patient record, X-rays, lab results etc., supports worldwide research cooperation. However, most telemedicine applications are still "projects" and only few applications are commonly used in hospitals' daily routine today. Technical aspects & standards Modern medical information systems are distributed systems. Various independent machines and local-area networks are connected by one or more networks, thus allowing local information procesing as well as sharing data. Ward 1 Radiology Ward 2 Laboratory Ward n Finance Pharmacy Peripherals CMPT 340 / part 09 / The key to running various hard- and software modules from different manufacturers together successfully is the application of standards. In addition to general technical standards an increasing number of specific standards for medical computing is been developed. Standards are created by groups of interested people and organizations, e.g. manufacturers and users of a certain technology. National (ANSI, DIN) and international (ISO, IEC) standards organizations or government agencies may approve/accredit, coordinate, or even establish groups and/or their standards.

5 international national ISO ANSI coordinate & approve group HL7 develop standards interested people and organizations CMPT 340 / part 09 / Some of the most important groups for healthcare standards are: American College of Radiology / National Electrical Manufacturers Association (ACR/NEMA) that develops DICOM (see for more information), Health Level 7 (HL7) that develops standards for clinical-data interchange (see ISO technical committee for medical informatics (TC 215) that deals with compatibility and interoperability between independent systems. DICOM (Digital Imaging and Communications in Medicine) is the industry standard for transferal of radiologic images and other medical information between computers: HL7 is a standard for the electronic interchange of clinical, financial and administrative information among independent health care oriented computer systems, e.g. hospital information systems, clinical laboratory systems, and pharmacy systems. Current medical standards already cover a wide range of application areas: communication, knowledge representation, medical images and data, patient record, etc.. The main problem is the uncoordinated work of various standards development groups and the overlap of their standards. As the market for both medical hard- and software being international, international coordination of the development of standards is required.

6 Privacy and security aspects All individually identifiable health information is confidential (protected health care information, PHI). But with increasing electronic storage and exchange of patient data privacy and security are growing concerns. Recent legislation has furthermore put the focus on privacy and security aspects. The American "Health Insurance Portability and Accountability Act" of 1996 (HIPAA) mandated the development of standards to protect the confidentiality and security of patient medical records. Pursuant to HIPAA, the "Department of Health and Human Services" (HHS) developed Standards for Privacy of Individually Identifiable Health Information (see for further information). Among the suggested safety measures are the following: Hardware: Restricted access to sensitive areas - Data center (e.g. servers) - Networks (e.g. routers, network closets) - Workstations (e.g. public areas vs. private offices) Backup systems Uninterruptible power supply Software: User access privileges Authorization control (e.g. who has access) Access privileges (e.g. what can they see) - Role-based or individual-based access - Emergency access Authentication control (e.g. who they are) Password controls (e.g. expiration, nonrepeating, suspension) Audit controls - Retrospective - Warnings (e.g. break-the-glass) Automatic backup Virus protection Firewall

7 Organizational: Security policy Security officer(s) Contact person and procedure for complaints Training Security incident procedures, penalties Internal audits Certification of compliance As there is no unlimited security and as many security measures affect the accessability of information the goal is to take "reasonable" measures and to balance the goals of care with the protection of information. Further reading Health Care Technology Project; links to information on computerized patient record, hospital information systems, telemedicine, standards, and privacy and security aspects

8 Appendix: Typical Patient Records Document History and Physical Outpatient Clinical Documents Description The patient's initial medical examination and evaluation data. This document includes the following: chief complaint (CC), history of present illness (HPI), past medical history (PMH), family history (FH), social history (SH) and marital history, review of systems (ROS), physical exam (PE), assessment, diagnosis (Dx), impression, rule out (R/O), plan, prognosis (Px). Progress notes Physician's orders X-rays, other diagnostic images, EKGs, etc. Diagnostic findings Correspondence / Phone messages Consent forms Consultation reports Documentation for a follow-up visit. The physician's objective findings concerning improvement or aggravation of the condition, any change in treatment or medication, and the patient's own report about the condition. A record of a physician's medical orders. Diagnostic and laboratory data--for example, hematology, pathology, radiology, and X-ray test results and transcriptions. Letters and conveying clinical information on the patient. Phone messages conveying clinical information on the patient. A patient's or patient's guardian's consent for treatment, special procedures or to release information. An opinion about the patient's condition by a practitioner other than the primary care physician.

9 Face sheet Document Medical history and physical examination Initial nursing assessment form Physician's orders Problem or nursing diagnosis list Nursing plan of care Graphic sheet Other flow sheets Medication administration record (MAR) Physician's progress notes Nurses' progress notes Consultation sheets Health care team records X-rays, other diagnostic images, EKGs, etc. Diagnostic findings Consent forms Incident report Advance directives Discharge plan and summary Inpatient Clinical Documents Description Information identifying the patient, including name, admission date, address and birth date, emergency contact and closest relative, allergies, admitting diagnosis and attending physician. The patient's initial medical examination and assessment data completed by the physician. Initial assessment. A record of a physician's medical orders. List of nursing diagnoses. Plans for patient care. A type of flow sheet showing graphic recording of the patient's temperature, pulse rate, blood pressure, and possibly daily weight. Abbreviated progress notes, recording dates, times, changes in the patient's condition. A recording of each medication the patient receives, including name, dosage, route, site, and date and time of administration. Physician's observations, notes on the patient's progress, and treatment data. Patient care information, interventions, and patient's responses. Reports of evaluations made by physicians and others called in for opinions and treatment recommendations. Notes from other departments, including physical therapy and respiratory therapy. Diagnostic and laboratory data--for example, hematology, pathology, radiology, and X-ray test results and transcriptions. A patient's or patient's guardian's consent for treatment, special procedures or to release information. Information about a reportable event. A legal, written document that specifies patient preferences regarding future health care or specifies another person to make medical decisions in the event that the patient is unable to do so. A brief review of the patient's hospital stay and plans for care after discharge.

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