2. What is health information system?
HIS and Electronic Medical Records2
It is a system for the
collection/processing of data from various sources,
and using the information for policy making and
management of health services.
It could be paper-based or electronic.
It is a discipline at the intersection of information science,
computer science, and health care.
Systematic Storage and Retrieval of Medical Records
3. What Is A Medical Record?
HIS and Electronic Medical Records3
A record or documentation of a patient’s
medical history,
examination,
and treatments.
4. What Is A Medical Record?
HIS and Electronic Medical Records4
Systematic documentation of a single patient's medical
history and care across time within one particular health care
provider.
The medical record includes
variety of types of "notes" entered by Physicians,
recording observations and administration of drugs and
therapies,
Laboratory test results, reports
demographics, medical history, medication and allergies,
immunization status, radiology images,
vital signs, intake, output, observations
5. Why do we need a Medical record?
HIS and Electronic Medical Records5
In other words, why do we
need a documentation of a
patient’s medical care?
6. Potential Uses of Medical Records
HIS and Electronic Medical Records6
Continuity of providing care
Note important information for later use
Especially important in chronic diseases (e.g. hypertension,
diabetes) or in follow-up (e.g. after surgery)
Patient safety
Preventing something bad because of lack of information
Such as drug allergies, list of current medications, “problem
list”
8. Potential Uses of Medical Records
HIS and Electronic Medical Records8
Communications between
providers
Referral to specialists or
other physicians
Consulting among
physicians
Communications between
physicians and nurses,
pharmacists, physical
therapists, etc.
Transfer from a hospital to
another
9. Potential Uses of Medical Records
HIS and Electronic Medical Records9
Medico-legal purposes
e.g. Court evidence
against malpractice
What was done or
provided to the patient?
Why? By whom? When?
Was the care provided up
to the professional
standard?
10. Potential Uses of Medical Records
HIS and Electronic Medical Records10
Clinical research
Find ways to improve
health care through new
knowledge
11. Potential Uses of Medical Records
HIS and Electronic Medical Records11
Claims and reimbursements
What services were provided to the patient
How (and how much) will the hospitals/doctors be paid?
Audit of medical records by “payers”
Patient’s uses
Health insurance claims
Self-education & self-care
12. What is an Electronic Medical Record
(EMR)?
HIS and Electronic Medical Records12
Electronic medical records contain the same information as
your paper record but in an electronic form. This
information is accessible to your health care providers
through computers located throughout the Hospital.
Electronic documentation of patient care and to improve the
process of patient care through better documentation
13. Advantages of EMR
HIS and Electronic Medical Records13
Physicians and nurses have more time to spend with patients.
Improved legibility, accuracy and completeness.
With an EMR there is less potential for medical errors as well as
improved quality and safety in patient care.
Allergies and adverse drug reactions are prominently displayed
Reminders are activated when certain health maintenance tests
and/or procedures are due
Your prescriptions are electronically ordered directly to your
pharmacy
EMR permits more than one user to access your record at the
same time.
14. Why We Need IT tools in Healthcare ?
HIS and Electronic Medical Records14
15. Why We Need IT tools in Healthcare ?
HIS and Electronic Medical Records15
Simplification of administrative processes such as Physician
Order Entry, eMAR
Creation and maintenance of electronic health records
(EHR)
Reduction in data gathering and processing costs
Standardization of health data, coding, reporting and
transmission of data
Communication among key stakeholders – patients,
physicians, nurses, administrators.
16. Health care is information-rich
HIS and Electronic Medical Records16
17. Why We Need Health IT
HIS and Electronic Medical Records17
Health care is very
complex
Quality of care depends on
timely availability & quality
of information
Clinical knowledge body is
too large
Short time during a visit
18. Benefits of Going Electronic (EMR)
HIS and Electronic Medical Records18
Ubiquitous availability
(anytime, anywhere,
everyone who is authorized)
Multiple concurrent uses
Ability to control & enforce
access security
Structured data entry possible
Data presentation that is
easier to understand (e.g.
graphs)
No handwriting!!!!!
19. Hospital Information System
HIS and Electronic Medical Records19
Master Patient Index (MPI)
Admit-Discharge-Transfer (ADT)
Electronic Health Records (EHRs)
Computerized Physician Order Entry(CPOE)
Clinical Decision Support Systems (CDSSs)
Picture Archiving and Communication System (PACS)
Nursing applications
Enterprise Resource Planning (ERP))
20. Departmental Applications
HIS and Electronic Medical Records20
Pharmacy applications
LIS – Laboratory Information System
PACS - Picture Archiving and Communication System
RIS – Radiology Information System
Specialized applications
Emergency Room
Operation Theatre
Labor Room
Anesthesia, Critical Care, Blood Bank
E-Learning
21. Master Patient Index (MPI)
HIS and Electronic Medical Records21
A hospital’s list of all
patients
Registration of patients
Captures/updates patient
demographics
Bar-coded Registration
Cards
22. Admission-Discharge-Transfer
(ADT)
HIS and Electronic Medical Records22
Supports Admission, Discharge & Transfer of patients
(“patient management”)
Provides status/location of admitted patients
Used in assessing bed occupancy
Linked to billing, claims & reimbursements
23. Appointment Scheduling
• Records appointments
of patients
• Pre-specified number of
open slots
• Ability to
postpone/cancel
appointments
• Displays list of patients
with appointments in a
specific date
HIS and Electronic Medical Records 23
24. Computerized Physician Order Entry
(CPOE)
• Physician directly orders
online
– medication
– Lab
– diagnostic
– imaging
• Nurse & pharmacy
process orders
accordingly
HIS and Electronic Medical Records 24
25. Clinical Decision Support Systems
(CDSSs)
HIS and Electronic Medical Records25
The real place where most of the values of health IT can be achieved
Is an application that analyzes data to help healthcare providers make
clinical decisions.
Expert systems
Based on artificial intelligence, machine learning, rules, or statistics
differential diagnoses
treatment options
Alerts & reminders
Based on specified conditions
drug-allergy checks,
drug-drug interaction checks,
drug-lab interaction checks,
drug-formulary checks,
reminders for preventive services or certain actions (e.g. smoking cessation)
Evidence-based knowledge sources e.g. drug database, literature
26. Clinical Decision Support Systems
(CDSSs)
HIS and Electronic Medical Records26
Four key functions of electronic clinical decision support systems are
outlined
Administrative: Supporting clinical coding and documentation,
authorization of procedures, and referrals.
Managing clinical complexity and details: Keeping patients on
research and chemotherapy protocols; tracking orders, referrals
follow-up, and preventive care.
Cost control: Monitoring medication orders; avoiding duplicate
or unnecessary tests.
Decision support: Supporting clinical diagnosis and treatment plan
processes; and promoting use of best practices, condition-specific
guidelines, and population-based management.
27. Nursing Documentation & Charting
• Intake Output Chart
• Diabetic Chart
• NeuroAssessment
• Daily NursingAssessment
• Vital Signs Record
• IV Fluid Charting
HIS and Electronic Medical Records 27
28. Nursing Applications
• Document nursing assessments,
interventions & outcomes
• Facilitate charting & vital sign
recording
• Utilize standards in nursing
informatics
• Populate and documents care-
planning
• Support communication within
teams & between shifts
• Reduce paperwork / paper loss
HIS and Electronic Medical Records 28
29. Pharmacy Applications
• Streamlines workflow from
medication orders to
dispensing and billing
• Reduces medication
errors, improves
medication safety
• Improves inventory
management
HIS and Electronic Medical Records 29
30. Laboratory Information System
(LIS)
HIS and Electronic Medical Records30
Receives and processes lab
orders
Matches tube & specimen
Internal workflow within labs
Order processing
Specimen registration &
processing
Lab results validation &
reporting
Specimen inventory
Lab results viewing
31. Billing System
HIS and Electronic Medical Records31
Calculates service charges for services provided
Calculations based on patient’s insurance coverage and
eligibility
Records amount of money paid by the patient and remaining
amount
Sends information to accounting or Back Office ERP to send
reimbursement claims to insurance agencies
32. Imaging Applications
HIS and Electronic Medical Records32
Picture Archiving and
Communication System
(PACS)
Captures, archives, and
displays electronic images
captured from imaging
modalities
cardiology, endoscopy,
pathology, ophthalmology
33. PACS – (Picture Archiving and
Communication System )
HIS and Electronic Medical Records33
PACS enables x-ray and
scan images to be stored
electronically and viewed
on screens, helping to
improve diagnosis
methods.
34. Enterprise Resource Planning
HIS and Electronic Medical Records34
Finance
Accounting
Budgeting
Cost control and
management
Materials Management
Procurement
Inventory management
Human Resources
Recruitment, evaluation,
promotion & disciplinary
actions
Payroll
35. Our Mission
HIS and Electronic Medical Records35
Electronic documentation of patient care and then by
become paperless
Patient care processes such as ordering
medications,
lab tests
x-rays
Viewing lab results and x- ray reports (among others)
36. What we have done ?
HIS and Electronic Medical Records36
Already working in Siemens HIS
Not completely paperless
Doing Consultation, Lab Order, Billing, Pharmacy Sales,
Nursing Notes, LIS
Implementation Stage of International Standard Compliant
HIS
Will completely migrated to new innovative HIS within 2
Months
37. Upcoming HIS - Features
HIS and Electronic Medical Records37
HL7 Standard
HL7, which is an abbreviation of Health Level Seven, is a
standard for exchanging information between medical
applications. This standard defines a format for the transmission
of health-related information.
CCHIT (Certification Commission for Healthcare Information Technology) certified in
2011
US patent for HIS : the only player in the Indian marketplace
38. Upcoming HIS Clients
HIS and Electronic Medical Records38
BLK Super Speciality Hospital, New Delhi
Amrita Institute of Medical Sciences, Kochi
Sree Gokulam Medical College, Trivandrum
BARC (Babha Atomic Research Centre) Hospital in Mumbai.
J J hospital Mumbai
NIMHANS Bangalore
St. Gregorios Medical Mission Hospital, Parumala.
Punjab Institute of Medical Sciences (PIMS), Jalandhar
Sir Sundar Lal Hospital, Benaras Hindu University
39. HIS Demo
HIS and Electronic Medical Records39
Currently using HIS Consultation Module
Physician tasks
OP Consultation
Initial Examination Report
Followups
Lab Order / View
IP Progress Notes
Backlog MRD Viewer
OP / IP – Consultation Requests / Response
Drug Prescription
Discharge Summary
Referrals
