Medical Information Systems

Medical Information Systems

Introduction

The introduction of information systems in hospitals and other medical facilities is not only driven by the wish to improve management of patient-related data for the patient’s benefit, but also by the fiscal necessity to improve efficiency of medical services.

Computer-based patient record (CPR) Patient records serve the following purposes:

• Caregivers’ Record of Information from the Patient

• Caregivers’ Findings and Treatments

• Communication to Later Caregivers

• Coordinating and Organizing Caregivers in the Care of the Patient

• Creating a Formal Record of Patient Care

• Information for Public Health and Clinical Research

The appendix lists typical records for both outpatients and inpatients. The

average medical record weighs 1.5 pounds, and every visit to the doctor adds an average of 13 pieces of paper.

Apart from the inconvenience of handling these files, which naturally can be only at one location at a time, paper records mayor weaknesses are:

• Lack of standardization in content

• Lack of standardization in format

• Incompleteness

• Inaccuracies

• Risk of misplacement or loss

The computer-based patient record (CPR) (or electronic patient record, EPR) offers health professionals

• Complete patient data displayed in an integrated fashion that facilitates medical decision making,

• Access from any workstation in the hospital

• Ability to enter orders, notes, data at same workstation

• No double entry of information

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• Immediate availability of results

• Simultaneous users can access same medical record

• Access from on site or remote locations

• No loss of patient information

However, initial costs, the necessity to change workflow, and employees

reluctance to accept the new technology are mayor problems when introducing CPR in a hospital.

Hospital information systems (HIS)

An information system, that combines a computer-based patient record with other modules that support clinical workflow is called a hospital information

system (HIS). As early HIS date back to the 1970s, modern more comprehensive approaches are sometimes labeled differently (clinical information system, CIS, health-care informtion system, HCIS), but definitions are not precise.

Some important modules of an HIS are the following:

• Medical devices: access to medical devices via standardized protocols (DICOM) and/or Picture Archiving and Communications System (PACS)

• Telemedicine: access to external data (e.g. receive patient data from physician, notify physician electronically, send and receive medical images), typically by means of internet access via firewall.

• Scheduling: Staff can electronically make appointments with physicians, X-ray, laboratories, etc..

• Billing: import, view, approve charges posted by therapists, file electronic claims and/or print claims, create reports (by patient, therapist, ward, clinic, diagnosis, etc.) to analyze individual and group productivity and financial performance.

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Hospital Information System

CPR med. devices

& PACS telemedicine

billing scheduling

add / connect systems

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Important aspects of an HIS are

• Reliability

• Response time

• Accessibility

• Flexibility

• Security/Privacy

When designing an HIS, it is not only necessary to compromise between these performance aspects (e.g. between security/privacy, accessability, and response time), but also with the systems costs (initial costs as well as maintenance).

Telemedicine

Telemedicine is the transfer of electronic medical data (i.e. high resolution images, sounds, live video, and patient records) from one location to another.

Telemedicine deals with two mayor problems:

1. Traditionally the healthcare environment consists of organizationally

indepentent units with little coordination and sharing of data between them.

The patients data is scattered between many facilities.

2. People living in remote areas have little access to specialty medical care.

Technology is either "store and forward" (e.g. transfer stored medical images) or

"two-way interactive" (e.g. videoconferencing) and can be based on regular telephone lines, ISDN, cable wiring or other kinds of high bandwidth tele- communications, or satellite, with the internet becoming more and more prevalent ("E-Health").

Some telemedicine applications that are in use or that are currently being developed are the following:

• videoconferencing of expert physicians or physician and patient,

• administartive functions

• physicians' education

Teleradiology, the sending of x-rays, CT scans, or MRIs (store-and-forward) is the most common application of telemedicine in use today.

Programs that have recently been suggested include:

• ECG recorded on board of an airplane is sent to experts on the ground for evaluation,

• "Personal Diagnosis Centre" as part of a home entertainment centre - this system would monitor the patient's daily health status and automatically notify a health professional if he or she becomes ill,

• One "Universal Patient Record" instead of many separate paper records with web enabled viewing access.

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Telemedicine offers a great range of benefits:

• reduce time and cost for patient transportation, transportation of files etc.,

• gives patients in remote areas access to specialist physicians,

• gives healthcare facilities access to existing patient record, X-rays, lab results etc.,

• supports worldwide research cooperation.

However, most telemedicine applications are still "projects" and only few applications are commonly used in hospitals' daily routine today.

Technical aspects & standards

Modern medical information systems are distributed systems. Various indepen- dent machines and local-area networks are connected by one or more networks, thus allowing local information procesing as well as sharing data.

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Ward 1

Ward 2

Ward n

Pharmacy

Radiology

Laboratory

Finance Peripherals

The key to running various hard- and software modules from different manufac- turers together successfully is the application of standards. In addition to general technical standards an increasing number of specific standards for medical computing is been developed.

Standards are created by groups of interested people and organizations, e.g.

manufacturers and users of a certain technology. National (ANSI, DIN) and international (ISO, IEC) standards organizations or government agencies may approve/accredit, coordinate, or even establish groups and/or their standards.

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group

interested people and organizations

develop standards

international

ISO

HL7 ANSI

national

coordinate

& approve

Some of the most important groups for healthcare standards are:

• American College of Radiology / National Electrical Manufacturers Association (ACR/NEMA) that develops DICOM (see

http://medical.nema.org/ for more information),

• Health Level 7 (HL7) that develops standards for clinical-data interchange (see http://www.hl7.org/),

• ISO technical committee for medical informatics (TC 215) that deals with compatibility and interoperability between independent systems.

DICOM (Digital Imaging and Communications in Medicine) is the industry standard for transferal of radiologic images and other medical information between computers:

HL7 is a standard for the electronic interchange of clinical, financial and administrative information among independent health care oriented computer systems, e.g. hospital information systems, clinical laboratory systems, and pharmacy systems.

Current medical standards already cover a wide range of application areas:

communication, knowledge representation, medical images and data, patient record, etc.. The main problem is the uncoordinated work of various standards development groups and the overlap of their standards. As the market for both medical hard- and software being international, international coordination of the development of standards is required.

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Privacy and security aspects

All individually identifiable health information is confidential (protected health care information, PHI). But with increasing electronic storage and exchange of patient data privacy and security are growing concerns.

Recent legislation has furthermore put the focus on privacy and security aspects.

The American "Health Insurance Portability and Accountability Act" of 1996 (HIPAA) mandated the development of standards to protect the confidentiality and security of patient medical records.

Pursuant to HIPAA, the "Department of Health and Human Services" (HHS) developed “Standards for Privacy of Individually Identifiable Health Information”

(see www.hipaa.org for further information). Among the suggested safety measures are the following:

Hardware:

Restricted access to sensitive areas - Data center (e.g. servers)

- Networks (e.g. routers, network closets)

- Workstations (e.g. public areas vs. private offices) Backup systems

Uninterruptible power supply Software:

User access privileges

Authorization control (e.g. who has access) Access privileges (e.g. what can they see)

- Role-based or individual-based access - Emergency access

Authentication control (e.g. who they are)

Password controls (e.g. expiration, nonrepeating, suspension) Audit controls

- Retrospective

- Warnings (e.g. break-the-glass) Automatic backup

Virus protection Firewall

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Organizational:

Security policy Security officer(s)

Contact person and procedure for complaints Training

Security incident procedures, penalties Internal audits

Certification of compliance

As there is no unlimited security and as many security measures affect the accessability of information the goal is to take "reasonable" measures and to balance the goals of care with the protection of information.

Further reading

http://www.hctproject.com/solutions.asp

Health Care Technology Project; links to information on computerized patient record, hospital information systems, telemedicine, standards, and privacy and security aspects

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Appendix: Typical Patient Records

Outpatient Clinical Documents

Document Description

History and Physical The patient's initial medical examination and evaluation data. This document includes the following: chief complaint (CC), history of present illness (HPI), past medical history (PMH), family history (FH), social history (SH) and marital history, review of systems (ROS), physical exam (PE), assessment, diagnosis (Dx), impression, rule out (R/O), plan, prognosis (Px).

Progress notes Documentation for a follow-up visit. The physician's objective findings concerning improvement or aggravation of the condition, any change in treatment or medication, and the patient's own report about the condition.

Physician's orders A record of a physician's medical orders.

X-rays, other diagnostic images, EKGs, etc.

Diagnostic findings Diagnostic and laboratory data--for example, hematology, pathology, radiology, and X-ray test results and

transcriptions.

Correspondence / E-mail Letters and E-mail conveying clinical information on the patient.

Phone messages Phone messages conveying clinical information on the patient.

Consent forms A patient's or patient's guardian's consent for treatment, special procedures or to release information.

Consultation reports An opinion about the patient's condition by a practitioner other than the primary care physician.

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Inpatient Clinical Documents

Document Description

Face sheet Information identifying the patient, including name, admission date, address and birth date, emergency contact and closest relative, allergies, admitting diagnosis and attending physician.

Medical history and physical

examination The patient's initial medical examination and assessment data completed by the physician.

Initial nursing assessment form Initial assessment.

Physician's orders A record of a physician's medical orders.

Problem or nursing diagnosis list List of nursing diagnoses.

Nursing plan of care Plans for patient care.

Graphic sheet A type of flow sheet showing graphic recording of the patient's temperature, pulse rate, blood pressure, and possibly daily weight.

Other flow sheets Abbreviated progress notes, recording dates, times, changes in the patient's condition.

Medication administration record

(MAR) A recording of each medication the patient receives, including name, dosage, route, site, and date and time of administration.

Physician's progress notes Physician's observations, notes on the patient's progress, and treatment data.

Nurses' progress notes Patient care information, interventions, and patient's responses.

Consultation sheets Reports of evaluations made by physicians and others called in for opinions and treatment recommendations.

Health care team records Notes from other departments, including physical therapy and respiratory therapy.

X-rays, other diagnostic images, EKGs, etc.

Diagnostic findings Diagnostic and laboratory data--for example, hematology, pathology, radiology, and X-ray test results and

transcriptions.

Consent forms A patient's or patient's guardian's consent for treatment, special procedures or to release information.

Incident report Information about a reportable event.

Advance directives A legal, written document that specifies patient preferences regarding future health care or specifies another person to make medical decisions in the event that the patient is unable to do so.

Discharge plan and summary A brief review of the patient's hospital stay and plans for care after discharge.

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