Health Information Technology & Management Chapter 2 HEALTH INFORMATION SYSTEMS

Health Information Technology & Management Chapter 2 HEALTH INFORMATION SYSTEMS

INFORMATION SYSTEM *Use of computer hardware and software to process data into information. *Healthcare information system (and hospital information system) a group of systems used to support and enhance healthcare

TYPES OF INFORMATION SYSTEMS There are two different types of information systems: 1-Clinical Information systems (CISs). 2-Administrative System.

DEFINITION OF CLINICAL INFORMATION SYSTEMS (CISS). CIS is a computerized system that organizes, stores and double checks all Patients medical information. The patient health history, prescriptions, doctor's notes and dictation and all other information are kept together, electronically. This replaces the paper charts of the past.

ADVANTAGE OF USING CIS *In an emergency, patient doctor has immediate access to his/her complete medical history. *During patient office visit, doctors can schedule and order the tests that the patient needs directly through the system. *Doctors can access test results immediately. *Doctors can send patient prescriptions directly to the pharmacy, where the patient can pick them up as he/she leaves the clinic.

AREA TO USE CIS *Nursing *Multidisciplinary *Monitoring *Laboratory *Pharmacy *Radiology *Emergency department *Physician practice management systems *Long term *Home care

ADMINISTRATIVE SYSTEM Contain information to used to manage personnel, finances, materials, supplies or equipments. It also might be a system for human resources management, materials management, patient accounting or billing, or stuff scheduling.

ADVANTAGE OF USING ADMINISTRATIVE SYSTEM *To organizing staff monthly salaries. *To control recruitment processes and cost. *Determine number of new employees that the hospital will need in the future. *Analyzing employees productivity. *Ordering medical & non medical materials. *Scheduling patients appointments. And many other things.

AREA TO USE ADMINISTRATIVE SYSTEM * Client management (registration) * Financial * Payroll * Human resources * Quality assurance * Contract management * Risk management systems * Materials management

COMPARING BETWEEN CIS & ADMINISTRATIVE SYSTEM Clinical information systems (CISs) Directly support patient care Individual systems may be stand alone Goal: data exchange among systems Administrative systems Indirectly support patient care Individual systems may be stand alone Goal: data exchange among systems

HIM DEPARTMENT PROFESSIONALS 1- Health information manager: *Manages HIM department *Implements and monitors HIM systems, policies, procedures *Educates employees *Enforces confidentiality, information security,information storage and retrieval *Requires bachelor s or master s degree.

HIM DEPARTMENT PROFESSIONALS 2- Health information technician: *Enters medical records data into computer systems *Validates accuracy and completeness of records *Performs other tasks as determined by needs and training *Requires associate degree.

HIM DEPARTMENT PROFESSIONALS 3- Coding specialists: *Clinical data specialists *Clinical coding and reimbursement specialists 4- Other HIM professionals: *Medical transcriptionists

HIM AND IT COMPARISON HIM: concerned with security, accuracy, and completeness of health records and the information reported in them IT: concerned with operation of HIS computers as well as phone systems and other computers # Both: managed by Chief Information Officer (CIO)

DEPARTMENTAL INFORMATION SYSTEMS * HIS is core system for hospital: - Includes both clinical and administrative systems - Consists of complex arrangement of multiple individual systems * Practice management system is principal system for medical office

(EHR) ELECTRONIC HEALTH RECORD An electronic health record (EHR) is an official health record for an individual that is shared among multiple facilities and agencies.

TYPES OF DATA THAT (EHR ) INCLUDE: Contact information. Information about visits to health care professionals. Allergies. Insurance information. Family history. Immunization status. Information about any conditions or diseases. A list of medications. Records of hospitalization. Information about any surgeries or procedures performed.

THE BENEFITS OF EHRS INCLUDE: The ability to automatically share and update information among different offices and organizations. The ability to share multimedia information, such as medical imaging results, among locations. The ability to link records to sources of relevant and current research. Easier standardization of services and patient care. Provision of decision support systems (DSS) for healthcare professionals. Lower cost to the medical system once implementation is complete.

PATIENT REGISTRATION SYSTEM Demographic information about patient Guarantor and insurance information used for billing Some clinical data (admitting and discharge diagnosis, LOS, and organ donor, DNR, consent, other forms) Patient s medical record number

PATIENT REGISTRATION SYSTEM

MASTER PATIENT INDEX (MPI) Includes all previously registered patients Contained in special database (large healthcare organization) or patient registration database (smaller facility) Prevents duplicate entry of same patient Provides quick universal lookup of patients for all systems interfaced to the HIS

MASTER PATIENT INDEX (MPI) (CONTINUED) Helps locate patient chart (paper-based system) Often includes Soundex field to facilitate finding surnames when name s spelling unclear.

NURSING INFORMATION SYSTEM (NIS) * Information system that supports the use and documentation of nursing processes and provides tools for managing the delivery of nursing care.

ADVANTAGES OF USING NURSING INFORMATION SYSTEM * Improved access to information * Better documentation * Improved quality of care * Improved productivity and communications * Tracking capability

ADVANTAGES OF USING NURSING INFORMATION SYSTEM * Provide a common language for all nurses in all locations. * Important to the development of the electronic health record. * Measure nursing s contributions. * Contribute to the body of nursing knowledge.

CLINICAL INFORMATION SYSTEMS IS USEFUL IN MONITORING * These devices monitor temperature, pulse, respirations, blood pressures, oxygen saturation, or other measures automatically feeding the input into a clinical information system. *Alarms notify caregivers of readings that are outside the range of normal.

LABORATORY INFORMATION SYSTEMS * A laboratory information system (LIS) is a series of computer programs that process, store and manage data from all stages of medical processes and tests.

LABORATORY INFORMATION SYSTEMS * Issues that LIS address منعطف الوقت - Turnaround time - Duplicate testing - Errors

LABORATORY INFORMATION SYSTEMS CAPABILITIES Can do the following: * Alert providers when new or stat tests results are back or values are critical * Send results to clinical system for view * Generate labels for specimen collection *Use rules to order additional tests when indicated

LABORATORY INFORMATION SYSTEMS CAPABILITIES * Receives orders and sends results of medical tests performed by lab * Receives information directly from automated lab instruments via electronic interface * Sends information about equipment * Uses HL7 interface standard to connect with HIS, EHR, other healthcare systems

WORKFLOW OF ELECTRONIC LAB ORDERS * Some clinical pathology tests performed with automated instruments receive orders from LIS; send results back to LIS * Anatomic pathology findings and nonautomated clinical pathology tests entered manually * LIS generates printed or faxed lab report; also sends to EHR if interfaced

WORKFLOW OF ELECTRONIC LAB ORDERS * Digital pathology captures specimen images digitally, displays on computer monitor; images stored on (PAC) Picture Archiving and Communication system

WORKFLOW OF ELECTRONIC LAB ORDERS

RADIOLOGY INFORMATION SYSTEM (RIS) * A radiology information system (RIS) is a computerized database used by radiology departments to store, manipulate, and distribute patient radiological data and imagery.

RADIOLOGY INFORMATION SYSTEM (RIS) CAPABILITIES RIS can do the following: * Allows direct order entry or accepts orders from other systems * Provides scheduling of diagnostic tests * Generates client instructions * Permits transcription of results * Provides picture archiving and transmission of images and tracking of film * Generates charges once procedures are done

PHARMACY INFORMATION SYSTEMS * Pharmacy information system is a complex computer system that has been designed to meet the needs of a pharmacy department. It will allow pharmacists to supervise and have inputs on how medication is used in a hospital.

PHARMACY INFORMATION SYSTEMS CAPABILITIES *Comprised of one or more computer systems for tracking, ordering, dispensing medications *Interfaced with registration, billing, EHR systems * Include decision support, patient medication administration reports, controlled substance tracking, intervention documentation, inventory control, pricing, purchasing, repackaging, distribution

EMERGENCY DEPARTMENT INFORMATION SYSTEM * An Emergency Department Information System (EDIS) is an extended EHR system used to manage data in support of Emergency Department patient care and operations.

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