Health Care Information Systems

1. Health Care Information Systems

2. Information System • Information system: Use of computer hardware and software to process data into information to solve problems • Healthcare information system (and hospital information system)—a group of systems used to support and enhance healthcare

3. HIS • HIS comprises of two major types of information system: • Clinical Information system • Administrative information system

4. Types of Information Systems • Clinical information systems (CISs) • Directly support care • Plan, implement, evaluate patient care • Physician orders • Results retrieval • Documentation • Administrative systems • Indirectly support patient care by managing financial and demographic info

5. Clinical Information Systems (CISs) • Nursing • Multidisciplinary • Monitoring • Laboratory • Pharmacy • Radiology

6. Administrative Systems • Client management (registration) • Financial • Payroll • Human resources • Quality assurance • Contract management

7. Nursing Information System (NIS) • Supports the use and documentation of nursing process, activities and provides tools for managing the delivery of nursing care • Support the nurses functions • Access to PMH, allergies, test results, progress notes • Support nursing practice • Access to online databases such as MEDLINE

8. Nursing Information SystemAdvantages • Improved access to information • Better documentation • Improved quality of care • Improved productivity and communications • Tracking capability • Enhanced regulatory compliance

9. NIS Status • Despite advantages, information systems that are used by all clinicians are seen more commonly.

10. Two approaches for nursing documentation 1. Nursing process: automated documentation based on traditional documents with nursing diagnosis as organizing framework, may use standardized nursing languages • Allow documentation using structured format • Admission assessment • Problem list • Care plan

11. Nursing process approach • Documentation of nursing admission assessment and discharge • Documentation of discrete data such as VS • Standard care plans • Nursing notes in a progress note format • Documentation of med administration

12. Standardized Nursing Languages • Provide a common language across all nursing disciplines to describe nursing problems, Rx, and outcomes. • North American Nursing Diagnosis Ass. (NANDA) • Nursing Interventions Classifications (NIC) • Nursing Outcomes Classification (NOC) • Measure nursing’s contributions • Contribute to the body of nursing knowledge

13. Two approaches for nursing documentation • 2. Critical pathway—often used for multidisciplinary documentation, may incorporate physician orders • Used by everyone • Nurses, dietitians, social workers, physicians …

14. Clinician Information Systems CIS • Can be used by any clinician • User may be able to edit the data while others’ access may be limited to viewing the data • Support provider order entry, results retrieval, documentation • Wireless networks more convenience

15. Monitoring • These devices monitor temperature, pulse, respirations, blood pressures, oxygen saturation, or other measures automatically feeding the input into a clinical information system. • No need to enter BP manually • Alarms notify caregivers of readings that are outside the range of “normal.”

16. Order Entry Systems • Orders entered into the computer are transmitted to the appropriate areas such as the pharmacy, laboratory, radiology, and social services. • Eliminate issues related to illegible hand writing • Faster • Enhance staff productivity • Save money

17. CPOE • Computerized provider order entry • Initiative by the Institute of Medicine and Leapfrog Group to improve the quality of care and reduce medication errors • Eliminates transcription error • Expedites treatment • Encourages more accurate, complete orders • Order entry system alerts all departments to carry out orders • List order status: Pending, complete, cancelled

18. Laboratory Information Systems • Issues that LIS address • Identification of abnormal results • Duplicate testing • Errors

19. Laboratory Information Systems • 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 • Accept input from bedside devices • Generate labels for specimen collection • Use rules to order additional tests when indicated • Send critical values to PCP • Culture and sensitivity testing suggest treatment to PCP

20. Questions?