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HIS and EHR

HIS and EHR. HIMA 4160 Fall 2009. Acronyms. HIS: Health Information Systems EHR: Electronic Health Records EMR : Electronic Medical Records. Data, Information, and Knowledge. Level of conception. Data – factual Information – meaning of data Knowledge – model for information. Example.

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HIS and EHR

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  1. HIS and EHR HIMA 4160 Fall 2009

  2. Acronyms HIS: Health Information Systems EHR: Electronic Health Records EMR: Electronic Medical Records HIMA 4160 Fall 2009

  3. Data, Information, and Knowledge • Level of conception. • Data – factual • Information – meaning of data • Knowledge – model for information HIMA 4160 Fall 2009

  4. Example • Data – Body temperature 103 • Information – The patient is having a fever • Knowledge -- The knowledge used to generate the information: if a patient temperature is > 100 F, he might a fever (or hyperthermia). HIMA 4160 Fall 2009

  5. Data Information Knowledge Concrete Abstract Factual Conceptual Volatile Stable HIMA 4160 Fall 2009

  6. Information System • General term cover all three levels • Database – data level • Information storage and retrieval system – information level • Knowledge system – knowledge level HIMA 4160 Fall 2009

  7. Components Information System HIMA 4160 Fall 2009

  8. Where is the information system located? • In-house – developed and managed in the health care organization • Shared – developed and managed at the vendor site • Turnkey system – developed by vendor, installed and managed by health care organization • Stand-alone – lack of information sharing. Legacy system. HIMA 4160 Fall 2009

  9. Trends of Health care Information Systems • Integration • Continuality • Standards • Consumer oriented HIMA 4160 Fall 2009

  10. HIMA 4160 Fall 2009

  11. Current applications of information systems in health care • Clinical information systems – serving clinical activities • Hospital information system • Patient monitoring system • Nursing information system • Laboratory information system • Pharmacy information system • Computer based patient record • Others HIMA 4160 Fall 2009

  12. Hospital Information Systems • Provide communication among health facility workers and support organizational information needs for operations, planning, patient care, and documentation. • Communication, coordination • Various across different hosptials HIMA 4160 Fall 2009

  13. Freidman and Martin Model HIS should have following functions • Central application • Business and financial function • Communications and Networking • Department management • Medical documentation • Medical decision support HIMA 4160 Fall 2009

  14. Core hospital function • Patient management • Scheduling • RADT (registration, admission, discharge, and transfer) • RADT provides basic patient information to other clinical systems. HIMA 4160 Fall 2009

  15. Business and financial functions • Payroll • General ledger • Accounts receivable • Insurance HIMA 4160 Fall 2009

  16. Communications and Network • Connect different systems. • Need data standards to communicate. • This is a disadvantage of paper based system. HIMA 4160 Fall 2009

  17. Departmental management system • Needs of individual department • Pharm, lab, radiology, dietary, pathology, etc • The trend is to integrate these systems while maintaining their functional independence. HIMA 4160 Fall 2009

  18. Medical documentations system • Medical record • Will be paperless • Provide support to managerial and administrative decision making • In order to do so, the medical record has to be digitalized and codified. HIMA 4160 Fall 2009

  19. Decision support system • Help clinicians make decision • Not replace clinicians • data from various sources – hard to managed by human • Often integrated into physician order entry system • focal role in decreasing medical errors HIMA 4160 Fall 2009

  20. Patient monitoring system • Physiological data • Emergency room, operating room, intensive are, critical care • Can give real time alert HIMA 4160 Fall 2009

  21. Nursing information system • Support nurse care process • Clinical and managerial HIMA 4160 Fall 2009

  22. Laboratory Information System • Associated with lab test • Usually already available in the instrument • Various types of lab tests have different demands HIMA 4160 Fall 2009

  23. Pharmacy Information System • Data related to drug usage for patient • Also can help decreasing medication errors HIMA 4160 Fall 2009

  24. Computer based patient record • IOM 1991 report first proposed the concept • Other names include electronic health record (EHR), electronic medical record (EMR). • It is not a single computer product or program • Based an changed model of managing patient data • Computer and information technology is necessary but not sufficient factor. HIMA 4160 Fall 2009

  25. Current status • Focus on integration • Government support • http://www.cnn.com/2004/ALLPOLITICS/04/27/bush.healthcare.ap/ • National Health Information Infrastructure • ARRA • Standardization • HL7 HIMA 4160 Fall 2009

  26. Administrative and Management Applications in Health care • Financial information system • Accounting information systems • Human recourse management information systems • Material management information system • Facilities management information system • Management planning and decisin support system HIMA 4160 Fall 2009

  27. Trends in Health Information System • Computer based patient record • National health information infrastructure • Medical errors • E-Health and e-HIM • Web based technology • Standards • Privacy and Security • Technology • Wireless • Voice recognition • Data warehouse and data mining • Enterprise information management • Virtual information system – results of integration, standardization, and personalization. HIMA 4160 Fall 2009

  28. Electronic Health Records (EHR) HIMA 4160 Fall 2009

  29. What is an Electronic Health Record? Before we answer that, what is a patient record? • commonly referred to as the patient's chart or medical record • amalgam of all the data acquired and created during a patient's course through the heath care system HIMA 4160 Fall 2009

  30. Purpose of a Patient Record "to recall observations, to inform others, to instruct students, to gain knowledge, to monitor performance, and to justify interventions" Reiser, S. (1991). The Clinical Record in Medicine. Part 1: Learning from Cases. Annals of Internal Medicine, 114(10): 902-907 HIMA 4160 Fall 2009

  31. Purpose of Patient Records • create the basis for the historical data • support communication among providers • anticipate future health problems • record standard preventive measures • identify deviation from expected trends • provide a legal record • support clinical research and public health HIMA 4160 Fall 2009

  32. Weakness of the Paper Record System • Pragmatic and Logistical issues. • Can I find the data I need when I need them? • Can I find the medical record in which they are recorded? • Can I find the data within the record • Can I find what I need quickly? • Can I read and interpret the data once I find them? • Can I update the data reliably with new observations in a form consistent with the requirements for future access by me or other people? • Redundancy and Inefficiency • Influence on Clinical Research HIMA 4160 Fall 2009

  33. Difference between Paper and Electronic Health Records • Accessibility • Legibility • Adaptive • Structure • Reusability • Flexibility HIMA 4160 Fall 2009

  34. Value of an EHR is determined by • Comprehensiveness of information • Duration of use and retention of data • Degree of structure of data • Ubiquity of access HIMA 4160 Fall 2009

  35. Influences on EHR • Disease Pattern Change • Health Care Delivery System Change • Specialization of Medicine • Advances of Computer and Information Technology HIMA 4160 Fall 2009

  36. Primary and Secondary Uses of an EHR • Primary Uses • Patient Care Delivery • Patient Care Management • Patient Care Support Processes • Financial and Other Administrative Processes • Patient Self-Management • Second Uses • Education • Regulation • Research • Public Health and Homeland Security • Policy Support HIMA 4160 Fall 2009

  37. Core Functionalities • Health Information and Data • Results management • Order entry/management • Decision support • Electronic communication and connectivity • Patient support • Administrative processes • Reporting and population health management HIMA 4160 Fall 2009

  38. Health Information and Data • Key Data • Problem list • Procedures • Diagnoses • Medication list • Allergies • Demographics • Diagnostic test results • Radiology results • Health maintenance • Advance directives • Dispositions • Level of service HIMA 4160 Fall 2009

  39. Health Information and data • Minimum Data Set (MDS) for nursing homes • From CMS • Support Long Term Care • Current Version 3.0 HIMA 4160 Fall 2009

  40. Health Information and Data • Narrative (clinical and patient narrative) • Free text • Template based • Deriving structures from unstructured text • NLP • Structured and coded • Signs and symptoms • Diagnoses • Procedures • Level of service • Treatment plan • Single discipline • interdiscipline HIMA 4160 Fall 2009

  41. Health Information and Data • Patient Acuity/Severity of Illness/ Risk Adjustment • Nursing workload • Severity adjustment • Capture of identifiers • People and roles • Products/devices • Places (including directions) HIMA 4160 Fall 2009

  42. Results Management • Results Reporting • Laboratory • Microbiology • Pathology • Radiology • Consult • Results notification • Multiple views of data/presentations • Multimedia support HIMA 4160 Fall 2009

  43. Order Entry/Management • Computerized provider order entry • Electronic prescribing • Laboratory • Microbiology • Pathology • Radiology • Ancillary • Nursing • Supplies • Consults HIMA 4160 Fall 2009

  44. Decision Support • Access to knowledge sources • Domain knowledge • Patient education • Drug alert • Drug dose defaults • Drug dose checking • Allergy checking • Drug interaction checking • Drug-lab checking • Drug-condition checking • Drug-diet checking HIMA 4160 Fall 2009

  45. Decision Support • Other rule-based alert (e.g., significant lab trends, lab test) • Reminders • Preventive services • Clinical guidelines and pathways • Passive • Context-sensitive passive • Integrated • Chronic Disease Management HIMA 4160 Fall 2009

  46. Decision Support • Clinician work list • Incorporation of patient and/or family preference • Diagnostic decision support • Use of epidemiologic data • Automated real-time surveillance • Detect adverse vents and near misses • Detect disease outbreaks • Detect bioterrorism HIMA 4160 Fall 2009

  47. Electronic Communication and Connectivity • Provider to provider • Team coordination • Patient-provider • Email • Secure web messaging • Medical Devices • Trading partners (external) • Outside pharmacy • Insurer • Laboratory • Radiology • Integrated medical record • Within setting • Cross-setting • Inpatient-outpatient • Other cross-setting • Cross-organizational HIMA 4160 Fall 2009

  48. Patient Support • Patient education • Access to patient education materials • Custom patient education • Tracking • Family and informal caregiver education • Data entered by patient, family, and/or informal caregiver • Home monitoring • Questionnaires HIMA 4160 Fall 2009

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