1 1 Health Information Management Systems Technology and Analysis Domain 3: Assessment, System Selection and Implementation Module 3A: Purpose, Adoption and Use of Health Information Systems Lecture #2: Clinical Information Systems Developer: Suzanne A. Boren, PhD, MHA Slide 1: This is Module 3.A: Purpose, Adoption, and Use of Healthcare Information Systems. In this lecture, we will present and describe the major clinical information systems that are in use. Slide 2: The module developer is Dr. Suzanne Austin Boren, Associate Professor and Director of Graduate Studies in the Department of Health Management and Informatics, in the School of Medicine at the University of Missouri.
2 Slide 3: 2 A Clinical Information System (C-I-S) is a computer based system that is designed for collecting, storing, manipulating and making available clinical information important to the healthcare delivery process. Clinical Information Systems provide a clinical data repository that stores clinical data such as the patient s history of illness, and the interactions with care providers. The repository encodes information capable of helping clinicians decide about the patient s condition, treatment options, and wellness activities, as well as the status of decisions, actions undertaken and other relevant information that could help in performing those actions. Clinical information systems may be limited in extent to a single area, for example, laboratory information systems (L-I-S), or they may be more widespread and include virtually all aspects of clinical information systems, for example, electronic health records.
3 3 Slide 4: The following clinical information systems will be defined and discussed in this lecture: Electronic Health Records Computerized Provider Order Entry Clinical Decision Support Pharmacy Information Systems Electronic Prescribing Bar Coded Medication Administration Laboratory Information Systems Radiology Information Systems Telemedicine and Telehealth
4 Slide 5: 4 Before going any farther in talking about clinical information systems, it is important that we talk about the information exchange that occurs among the various clinical information systems and some of the administrative information systems. When we talk about an E-H-R, we are referring to a system that records, tracks, maintains and shares information about patients and their health. We often think about an E-H-R as a single thing. While it is certainly possible to implement a single software solution that might meet all of the electronic recordkeeping needs of a healthcare organization, in most healthcare organizations there are numerous systems that interact and exchange data. In such cases, the interoperability of these systems is critical to patient safety, usability, and workflow efficiency in a health care organization. The example pictured here is that of a hospital that has a separate information system in place, each serving separate functional units within the hospital. A patient admitted to the hospital for hip replacement surgery might have their data captured and shared through each of these information systems as the patient moves through his or her hospital stay. Hospital admissions use the scheduling and registration system to register and admit patients to the hospital. Details of the patient s medical history and problem lists are stored in the electronic health record. Ideally, computerized provider order entry (C-P-O-E) with clinical decision support (C-D-S) is available for placing orders with radiology, the lab, and the pharmacy. Radiology uses a radiology information system tied to a picture archiving and communication system, or PACS (pr: packs), to manage
5 5 imaging workflow and electronic storage of radiology results. Orders for lab tests and the results of those tests are tracked in a laboratory information system. Registration of prescriptions and the dispensing of prescriptions are tracked in the pharmacy information system. The bar-coded medication administration system is valuable to ensure that the right medication gets to the right patient, at the right time and in the right form. The supply chain or material management system tracks supply requirements and the management of inventory (for example, when a new hip joint is taken out of supplies, it is recorded so that orders for additional hip joints can take place to ensure constant supply at the levels needed). This is just a small sampling of the various information systems that may be in use by various departments within the hospital.
6 Slide 6: 6 Now we move on to the purpose and specific functions and features of the various clinical information system components. The E-H-R is a longitudinal, real-time patient health record of information generated by one or more encounters in any care delivery setting with access to evidence-based decision support tools that can be used to aid clinicians in decision-making. Key functions and features included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The E-H-R can automate and streamline a clinician's workflow, ensuring that all clinical information is communicated. It can also prevent delays in response that result in gaps in care. The E-H-R has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface, including evidence-based decision support. The E-H-R can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting.
7 Slide 7: 7 A conference at the N-I-H in the late 1980's led to an IOM report dealing with electronic health records. Three key aspects were explored: users, technology, policy and implementation. A re-thinking of the medical record was needed at this time to meet the emerging needs of health care. The term computer-based patient record was used, and 12 functions for computer-based patient records were described. This list of 12 functions remains timely and comprehensive. The record should provide a number of necessary functions with the patient, not medicine, at the center of the action. Relevant communication should be improved and recorded, and technology should be used to facilitate the work process redesign of health care. Slide 8: A 2008 survey of acute care hospitals that are members of the American Hospital Association about the presence of specific electronic health record functionalities used this list of comprehensive E-H-R system features. The features were grouped into the areas of clinical documentation, test and imaging results, computerized provider order entry, and decision support. According to Jha (pr: yah) et al in a study published in 2009, among the 63.1% of hospitals that responded to the survey, only 1.5% indicated that they had a comprehensive EHR system with all of these features present.
8 Slide 9: 8 Computerized Provider Order Entry, or C-P-O-E, is a computer application that allows a physician's orders for diagnostic and treatment services (pharmacy, radiology, laboratory, consultations, nursing) to be entered electronically instead of being recorded on order sheets or prescription pads. For example, the computer compares the order against standards for dosing, checks for allergies or interactions with other medications, and warns the physician about potential problems. A classic study of inpatient medication errors, as reported by Dr. David Bates and his colleagues, found that, when medications were ordered with paper and pencil, approximately 90% of the errors occurred at either the ordering or transcribing stage. These errors can be due to a variety of causes, including poor handwriting, ambiguous abbreviations, or simple lack of knowledge on the part of the ordering clinician.
9 Slide 10: 9 CPOE has four dimensions: The first dimension is entering information by the practitioner into a healthcare computing device. The second dimension is functionality, for example, the system s ability to enter all types of orders such as those for medications, lab tests, radiology exams and so on. The third dimension is decision support directly linked with the function. For instance, duplicate therapy checking, drug-drug interaction, drug-allergy interaction, formulary interaction, alerts, etc. And finally, the fourth dimension is the integration of the function into the information system. A C-P-O-E system, at a minimum, ensures standardized, legible, and complete orders and has the potential to greatly reduce errors at the ordering and transcribing stages. When operated with a decision support system such as a drug database, C-P-O-E decision support could provide notifications of drug-to-drug interaction, and conflicts relative to drug allergy, drug dose errors, duplication of order, information of substitute medication and test recommendations. Additionally, C-P-O-E should be equipped with decision support capability that can monitor patient treatment ensuring, for example,
10 10 that the right drug is administered to the right patient at the right time. C-P-O-E can issue an alert or reminders and suggest a different course of treatment if, for example, a patient s condition changes, if test results are abnormal, and it can provide health professionals with immediate electronic access to their orders and comprehensive views of patient clinical data and lab results. Slide 11: Clinical decision support is comprised of computer tools and applications to assist physicians in clinical decisions by providing evidence-based knowledge in the context of patient specific data. Examples of key functions include drug interaction alerts at the time medication is prescribed and reminders for specific guideline-based interventions during the care of patients with chronic disease. Information should be presented in a patient-centric view of individual care and also in a population or aggregate view to support population management and quality improvement.
11 Slide 12: 11 Pharmacy information systems (or P-I-S) are complex computer systems that have been designed to meet the needs of a pharmacy department for efficiency and reduction of medication errors. Through the use of such systems, pharmacists can supervise and have input on how medication is used in a hospital. Some of the key functions and features of Pharmacy Information Systems include: Clinical Screening: The Pharmacy Information System can assist in patient care by the monitoring of drug interactions, drug allergies and other possible medication-related complications. When a prescription order is entered, the system can check to see if there are any interactions between two or more drugs taken by the patient simultaneously or with any typical food, any known allergies to the drug, and if the appropriate dosage has been given based on the patient s age, weight and other physiologic factors. Alerts and flags come up when the system picks up any of these. Prescription Management: The Pharmacy Information System can also be used to manage prescriptions. When prescription orders are received, the orders are matched to available pharmaceutical products and then dispensed. It is possible to track all prescriptions passed through the system from who prescribed the drug, when it was prescribed, to when it was dispensed. It is also possible to print out prescription labels and instructions on how a medication should be taken based on the prescription.
12 12 Inventory Management: Pharmacies require continuous inventory in order to ensure that drugs do not go out of stock. Pharmacy Information Systems aid inventory management by maintaining an internal inventory of all pharmaceutical products, providing alerts when the quantity of an item is below a set quantity and providing an electronic ordering system that recommends the ordering of the affected item, at the appropriate quantity, from approved suppliers. Patient Drug Profiles: These are patient profiles managed by the Pharmacy Information System and contain details of their current and past medications, known allergies and physiological parameters. These profiles are used for clinical screening anytime a prescription is ordered for the patient. Report Generation: Most Pharmacy Information Systems can generate reports that range from determining medication usage patterns in the hospital to the cost of drugs purchased and/or dispensed. It is important that Pharmacy Information Systems should be able to interact with other available systems such as the clinical information systems to receive prescription orders and financial information system for billing and charging.
13 Slide 13: 13 Electronic Prescribing (e-r-x) is a type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage, and to transmit prescriptions to a printer or to a local pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physician access to patient specific information to screen for drug interactions and allergies. Slide 14: Bar-coded medication administration protects the patient from medication related harm. Before the administration of a medication in hospitals and other institutionalized care settings, the five rights must be verified: the right patient, drug, dose, route, and time. Traditionally, the nurse does this by visually checking the medicine and the patient. However, there is evidence to suggest that this traditional method does not adequately protect the patient from medication-related harm. According to Cummings work published in 2005, about 35% of all medication errors occur at the administration stage, and these errors are more likely to affect the patient than errors introduced at earlier stages. Case studies and anecdotal reports provided by Cummings et al, in 2005; Poon et al in 2006; and Paoletti et al, in 2007, suggest that bar-coded medication administration can produce significant reductions of at least 50% in the number and types of medication administration errors. Besides patient safety, secondary reasons for implementing bar-coded medication administration include improved workflow, documentation, billing, and public relations. (continues next page)
14 14 In bar-coded medication administration a nurse typically scans a bar code on the employee identification badge, the patient's wristband, and the medication to be administered. The portable computer at the bedside sends the information to a server, which checks the prescription. The system can generate warnings or approvals, provide administration instructions and information about the drug, or deliver reminders for further actions. After administration, the system documents the activity in the patient's medication record for future use. Slide 15: A laboratory information system (LIS) is a computer information system that manages laboratory information for all the laboratory disciplines such as clinical chemistry, hematology, and microbiology. Laboratory Information Systems provide modules for sending laboratory test orders to the instruments through its multiple instrument interfaces, track those orders, and then capture the results as soon as they become available. The result can then be analyzed, and a report can be generated from it. This report can be sent for printing at a specific point, sent off to other systems either to be added to patient s electronic medical record or for billing. Laboratory Information Systems communicate with other information systems using clinical information standard such as H-L-7. Laboratory systems might also make use of LOINC (Pr: Loink) which is the Laboratory Observation Identities, Names and Codes standard to exchange laboratory results with other systems.
15 15 Other features include patient management where patient details like the admission date, admitting physician, and admission number can be maintained by a Laboratory Information System. Other information concerning the patient s specimen including the ordering physician, department ordering the test, specimen type, date and time of collection and receipt, and the initials of the collecting technician, can also be managed in a Laboratory Information System. With decision support, lab orders can be cross-referenced against classification codes such as I-C-D-9 and LOINC, and also verified that that the correct test is being carried out. Quality Assurance processes ensure that the tests are carried out using the currently available standards.
16 Slide 16: 16 A radiology information system (R-I-S) is a computer system that assists radiology services in the storing, manipulation and retrieving of information. These systems were first used in the 1970s and their primary aim was to manage and store radiology information. Since the 1990s, PACS (pr: Packs) have been integrated with radiology information systems, providing the basic features and adaptations needed to manage the acquisition, processing and storage of radiological information. Through patient management, radiology information systems can be used to manage a patient s entire workflow within the radiology department, images and reports can be added to and retrieved from electronic medical records and viewed by the authorized radiology staff. Through scheduling, patient appointments for inpatients and outpatients can be scheduled when an order is received. Functions for scheduling the various available radiology staff with the allocated time slots can also be handled by the radiology information system. Through patient tracking features, the patient can be tracked from admission to discharge, with all the radiology procedures recorded. This would include the patient s past, present and future appointments. (continues next page)
17 17 The results reporting function supports the generation of reports concerning the results of an individual patient procedure and those of a group of patients, or a particular procedure, can be generated using a radiology information system. The Picture Archiving Communication System, or PACS, provides timely delivered and efficient access to images, interpretations and related data throughout the organization. This helps to ease consultations between physicians who can now simultaneously access the same images over networks, leading to a better diagnosis process. It is also beneficial to physicians in emergency situations, as they need not wait for long periods in order to view a patient s radiological images as these are instantly available on the network when ready. Another feature of PACS is the ability to digitally enhance the images, providing more detailed and sharper images. This improves diagnostic capabilities at radiological examinations.
18 Slide 17: 18 Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Telehealth is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. It may, for example, support monitoring of a patient. Key functions and features of telemedicine and telehealth include videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care.
19 Slide 18: 19 There are a variety of telemedicine services available. Specialist referral services involve a patient "seeing" a specialist over a live, remote consult or the transmission of diagnostic images and/or video along with patient data to a specialist for viewing later. Radiology continues to make the greatest use of telemedicine with thousands of images "read" by remote providers each year. Other major specialty areas include: dermatology, ophthalmology, mental health, cardiology and pathology. Patient consultations use telecommunications to provide medical data, which may include audio, still or live images, between a patient and a health professional for use in rendering a diagnosis and treatment plan. This might originate from a remote clinic to a physician's office using a direct transmission link or may include communicating over the Web. Remote patient monitoring uses devices to remotely collect and send data to a monitoring station for interpretation. This might include a specific vital sign, such as blood glucose, or heart E-C-G, or a variety of indicators. Medical education provides continuing medical education credits for health professionals and special medical education seminars for targeted groups in remote locations through videoconferencing and the Internet. (continues next page)
20 20 Consumer health information includes the use of the Internet for consumers to obtain specialized health information and on-line discussion groups to provide peer-to-peer support. Slide 19: In summary, in this lecture, we described the major clinical information systems and their functionalities. These include: Electronic Health Records Computerized Provider Order Entry Clinical Decision Support Pharmacy Information Systems Electronic Prescribing Bar-Coded Medication Administration Laboratory Information Systems Radiology Information Systems Telemedicine and Telehealth This concludes lecture 2 in this module. Thank you.