MOD 4

• Hospital Information System (HIS)


  Computer system structured to manage all the records of health care providers to make available information and reports useful to health care personnel in doing their job more efficiently

  
• HIS introduced and has evolved since then to cope with the changes and demands of modern times

  1960s
• HIS


  • Used mainly for billing and inventory back then
  • Should be affordable, scalable, centered on the needs of patients and medical personnel, adaptable to rapid technological changes
  • Enhances integrity of facts, minimizes transcription error and duplication of records, shorter turnaround times of reports
• HIS


  Integrated information system that improves patient care by increasing users' knowledge and reducing uncertainty, allowing rational decisions to be made from the information provided
• HIS


  • Integrated with other applications and technologies
  • Delivers the information necessary to the professional in a usable format, allowing him/her to make life-saving decisions accurately and promptly
  • Timely and accurate information must be delivered cost-effectively
  • Pride of ownership is one guarantee of a successful system
• HIS


  Integrated electronic system that collects, stores, retrieves, and displays overall patient data and information

  
• HIS

  • Could be accessed via a browser, touch screen, or pen tablet technology
  • Used to store patients' information quickly and easily
• HIS


  The entire information processing and information storage subsystem of a hospital, not just about computer systems and networks and the computer-based application systems that are installed on them, but about the information in a hospital as a whole

  
• HIS architecture development


  Process of development of methodical information technology specifications, models and guidelines, using a variety of information technology notations
• HIS core modules


  • Registration
  • Order communication system (OCS)
  • Medical record
  • Billing
  • Emergency, inpatient, and outpatient unit
• Healthcare Information Technology (HIT)


  Area that combines information system, computer science, and health care

  
• HIT systems for patient monitoring

  • Clinical setting (supported with clinical information systems [CIS])
  • Remotely (usually from home), such as telemedicine/telehealth or m-health
• Clinical information system (CIS)


  Computer-supported applications with a relatively large, long-term database containing clinical data that are used to assist in patient care management

  
• Components of an HIS


  • Electronic medical records (EMR)/electronic health records (EHR)
  • Computerized physician order entry (CPOE)
  • Telemedicine
  • Picture archiving and communication system (PACS)
  • Radiofrequency identification (RFID)
  • Financial information systems (FIS)
  • Laboratory information systems (LIS)
  • Nursing information systems (NIS)
  • Pharmacy information systems (PIS)
  • Radiology information systems (RIS)

  
• EMR/EHR and CPOE are considered prerequisites for the efficient delivery of high-quality care and are instrumental to the decrease in medical errors in healthcare delivery to enhance patient safety
• To communicate between health applications or technologies

  Hospitals should specify communication standards such as Health Level (HL) 7, Digital Imaging and Communications in Medicine (DICOM), and Clinical Context Object Workgroup (CCOW)

  
• Functionality of the system


  • Seamless integration with the hospital information system (HIS), picture archiving and communication system (PACS), laboratory information system (LIS) and electronic medical records (EMR)
  • Automatic collection and recording of data from bedside monitoring devices and respirators via a centralized transmitter
  • Extraction of physician order entries from the HIS
  • Bar-code verification of a patient's identity and the medication to be administered for preventing medication errors
  • Generation of line charts of patient vital signs
  • Automatic generation of a daily one-page, 24-h "Critical Care Chart"
  • Provision of an interface for nurses to enter patient intake and discharge records, body temperature, nursing records, and medication management records

  
• Aspects to consider in selecting a HIS

  • Total cost of the package
  • Web-based system
  • Implementation and Support
• Functions of the Hospital Information System


  • Help Desk
  • Scheduling
  • Patient Registration
  • Admission, Discharge, and Transfer Procedures
  • Billing, Contract Management, and Package Deal Designer
  • Laboratory, Radiology, and Cardiology Reporting

  
• Help Desk


  Manual information retrieval is no longer needed, clients are provided with information and guidelines associated with a company's or institution's products and services without hassle
• Scheduling


  Managers and employees can access work schedules from anywhere they are and effectively discuss their scheduling preferences
• Patient Registration


  The HIS patient registration form records the name, age, gender, marital status, and other relevant information regarding the patient, used for record-keeping and account management purposes
• Admission


  Before a patient is admitted, an admissions counselor will call him or her to gather preliminary information, offer vital information concerning the hospital stay, and answer questions if there are any
• Discharge


  The HIS provides instructions that accompany a patient's discharge or transfer more efficiently, including discharge planning
• Transfer


  The term 'transfer' means movement (along with the discharge) of an individual outside of the hospital premises at the instruction of any authorized hospital personnel
• Billing


  Billing statements show all records on the invoices, payments, and the current balance of a patient's account, HIS is very useful for patients who require frequent health care services
• Contract Management


  The process of managing contract creation execution and analysis to maximize the operational and financial performance of an organization while reducing financial risk
• Package Deal Designer


  Posting diagnostic medical packages for inpatients, outpatients, and emergencies, HIS help in accessing information regarding package deals without going through the hassle of paperwork
• Elements of a Laboratory Report

  • Patient name and identification number or a unique identifier and identification number
  • Name and address of the laboratory location where the test was performed
  • Date when the report was printed
  • Test report date
  • Name of doctor or legally authorized person ordering the test(s)
  • Specimen source (if applicable)
  • Date and time of specimen collection
  • Laboratory accession number
  • Name of the test performed
  • Test results
  • Abnormal test results
  • Critical results
  • Units of measurement (for quantitative results)
  • Reference intervals (or reference ranges)
  • Interpretation of results
  • Condition of specimen
  • Deviations from test preparation procedures
  • Medications, health supplement, etc. taken by the patient
• Radiology Report


  An official medical document that provides the details of the requested radiology examination and the procedure conducted by the radiologist
• Basic sections of a radiology report

  • Administrative information
  • Patient identification
  • Clinical history
  • Imaging technique
  • Comparison
  • Observations
  • Summary or impression
  • Signature of the radiologist
• Cardiology Report


  Contains essential medical information based on the test results of the patient, which are set against past medical records
• Vascular sonography reports are accurately created using the cardiology information systems with only a few clicks
• The basic sections of a radiology report enumerated in the American College of Radiology's practice guideline on communication must include administrative information, patient identification, clinical history, imaging technique, comparison, observations, summary or impression, and signature of the radiologist
• The length of the radiology report is dependent on the complexity and cost of the examination
• Cardiology reports


  Contain essential medical information based on the test results of the patient, which are set against past medical records
• Information on cardiology reports could include ultrasound and diagrams
• Physicians opt to provide automated reports through the use of information systems
• The medical staff can process laboratory reports for the approval of the physician, which means the results are generated more efficiently, translating to an improved patient experience
• Materials management


  Concerned with planning, identifying, purchasing, storing, receiving, and distributing materials