1. HIMA 4160 Fall 2009

2. HIS: Health Information Systems EHR: Electronic Health Records EMR: Electronic Medical Records 8/18/20152 HIMA 4160 Fall 2009

3.  Level of conception.  Data – factual  Information – meaning of data  Knowledge – model for information 38/18/2015 HIMA 4160 Fall 2009

4.  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). 48/18/2015 HIMA 4160 Fall 2009

5. 5 Concrete Abstract Factual Conceptual VolatileStable 8/18/2015 HIMA 4160 Fall 2009

6.  General term cover all three levels  Database – data level  Information storage and retrieval system – information level  Knowledge system – knowledge level 68/18/2015 HIMA 4160 Fall 2009

7. Information System 8/18/20157 HIMA 4160 Fall 2009

8.  Health care is a laggard when adopting information technology  Few clinical systems – Utah, Stanford, Harvard 88/18/2015 HIMA 4160 Fall 2009

9.  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. 98/18/2015 HIMA 4160 Fall 2009

10.  Integration  Continuality  Standards  Consumer oriented 108/18/2015 HIMA 4160 Fall 2009

11. 8/18/201511 HIMA 4160 Fall 2009

12.  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 128/18/2015 HIMA 4160 Fall 2009

13.  Provide communication among health facility workers and support organizational information needs for operations, planning, patient care, and documentation.  Communication, coordination  Various across different hosptials 138/18/2015 HIMA 4160 Fall 2009

14. HIS should have following functions  Central application  Business and financial function  Communications and Networking  Department management  Medical documentation  Medical decision support 148/18/2015 HIMA 4160 Fall 2009

15.  Patient management ◦ Scheduling ◦ RADT (registration, admission, discharge, and transfer) ◦ RADT provides basic patient information to other clinical systems. 158/18/2015 HIMA 4160 Fall 2009

16.  Payroll  General ledger  Accounts receivable  Insurance 168/18/2015 HIMA 4160 Fall 2009

17.  Connect different systems.  Need data standards to communicate.  This is a disadvantage of paper based system. 178/18/2015 HIMA 4160 Fall 2009

18.  Needs of individual department  Pharm, lab, radiology, dietary, pathology, etc  The trend is to integrate these systems while maintaining their functional independence. 188/18/2015 HIMA 4160 Fall 2009

19.  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. 198/18/2015 HIMA 4160 Fall 2009

20.  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 208/18/2015 HIMA 4160 Fall 2009

21.  Physiological data  Emergency room, operating room, intensive are, critical care  Can give real time alert 218/18/2015 HIMA 4160 Fall 2009

22.  Support nurse care process  Clinical and managerial 228/18/2015 HIMA 4160 Fall 2009

23.  Associated with lab test  Usually already available in the instrument  Various types of lab tests have different demands 238/18/2015 HIMA 4160 Fall 2009

24.  Data related to drug usage for patient  Also can help decreasing medication errors 248/18/2015 HIMA 4160 Fall 2009

25.  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. 258/18/2015 HIMA 4160 Fall 2009

26.  Focus on integration  Government support ◦ http://www.cnn.com/2004/ALLPOLITICS/04/27/b ush.healthcare.ap/ http://www.cnn.com/2004/ALLPOLITICS/04/27/b ush.healthcare.ap/ ◦ National Health Information Infrastructure National Health Information Infrastructure ◦ ARRA  Standardization ◦ HL7 HL7 268/18/2015 HIMA 4160 Fall 2009

27.  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 278/18/2015 HIMA 4160 Fall 2009

28.  Computer based patient record ◦ National health information infrastructure 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. 288/18/2015 HIMA 4160 Fall 2009

29. 8/18/201529 HIMA 4160 Fall 2009

30. 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 8/18/201530 HIMA 4160 Fall 2009

32. "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 8/18/201532 HIMA 4160 Fall 2009

33. 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 8/18/201533 HIMA 4160 Fall 2009

35. 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 8/18/201535 HIMA 4160 Fall 2009

36.  Accessibility  Legibility  Adaptive  Structure  Reusability  Flexibility 8/18/201536 HIMA 4160 Fall 2009

37.  Comprehensiveness of information  Duration of use and retention of data  Degree of structure of data  Ubiquity of access 8/18/201537 HIMA 4160 Fall 2009

38.  Disease Pattern Change  Health Care Delivery System Change  Specialization of Medicine  Advances of Computer and Information Technology 8/18/201538 HIMA 4160 Fall 2009

39.  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 8/18/201539 HIMA 4160 Fall 2009

40.  Health Information and Data  Results management  Order entry/management  Decision support  Electronic communication and connectivity  Patient support  Administrative processes  Reporting and population health management 8/18/201540 HIMA 4160 Fall 2009

41.  Key Data ◦ Problem list ◦ Procedures ◦ Diagnoses ◦ Medication list ◦ Allergies ◦ Demographics ◦ Diagnostic test results ◦ Radiology results ◦ Health maintenance ◦ Advance directives ◦ Dispositions ◦ Level of service 8/18/201541 HIMA 4160 Fall 2009

42.  Minimum Data Set (MDS) for nursing homes ◦ From CMS ◦ Support Long Term Care ◦ Current Version 3.0 8/18/201542 HIMA 4160 Fall 2009

43.  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 8/18/201543 HIMA 4160 Fall 2009

44.  Patient Acuity/Severity of Illness/ Risk Adjustment ◦ Nursing workload ◦ Severity adjustment  Capture of identifiers ◦ People and roles ◦ Products/devices ◦ Places (including directions) 8/18/201544 HIMA 4160 Fall 2009

45.  Results Reporting ◦ Laboratory ◦ Microbiology ◦ Pathology ◦ Radiology ◦ Consult  Results notification  Multiple views of data/presentations  Multimedia support 8/18/201545 HIMA 4160 Fall 2009

46.  Computerized provider order entry ◦ Electronic prescribing ◦ Laboratory ◦ Microbiology ◦ Pathology ◦ Radiology ◦ Ancillary ◦ Nursing ◦ Supplies ◦ Consults 8/18/201546 HIMA 4160 Fall 2009

47.  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 8/18/201547 HIMA 4160 Fall 2009

48.  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 8/18/201548 HIMA 4160 Fall 2009

49.  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 8/18/201549 HIMA 4160 Fall 2009

50.  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 8/18/201550 HIMA 4160 Fall 2009

51.  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 8/18/201551 HIMA 4160 Fall 2009

52.  Scheduling management ◦ Appointments ◦ Admissions ◦ Surgery/procedure schedule  Eligibility determination ◦ Insurance eligibility ◦ Clinical trial recruitment ◦ Drug recall ◦ Chronic disease management 8/18/201552 HIMA 4160 Fall 2009

53.  Patient safety and quality reporting ◦ Clinical dashboard ◦ External accountability reporting ◦ Ad hoc reporting  Public health reporting ◦ Reportable diseases ◦ Immunizations  De-identifying data  Disease registry 8/18/201553 HIMA 4160 Fall 2009

54.  Ambulatory (NEJM 2008) ◦ 4% fully functional EHR ◦ 13% basic system ◦ Small and solo practices struggle 8/18/201554 HIMA 4160 Fall 2009

55. 8/18/201555 HIMA 4160 Fall 2009

56.  Standardization of Clinical Information  Cost of implementation and maintenance  Physicians' readiness to adopt the EHR  Privacy issues and patients’ concerns with information sharing.  Legal liability 8/18/201556 HIMA 4160 Fall 2009