A lecture in March 2012 for third year undergraduate nursing students at Faculty of Medicine Ramathibodi Hospital, Mahidol University, in Thai.

1. Hospital Information
Systems (HIS) and
Electronic Health Records
(EHRs)
Nawanan Theera-Ampornpunt, MD, PhD
Health Informatics Division, Ramathibodi
Mar 15, 2012
http://www.slideshare.net/nawanan

2. A Bit About Myself
2003 M.D. (Ramathibodi)
2009 M.S. in Health Informatics (U of MN)
2011 Ph.D. in Health Informatics (U of MN)
Health Informatician/Systems Analyst
Health Informatics Division
Faculty of Medicine Ramathibodi Hospital
Mahidol University
ranta@mahidol.ac.th
Research interests:
• Health IT applications in clinical settings (including
EHRs)
• Health IT “adoption”
• Health informatics education

3. EHRs: Fundamentals

4. What Is A Medical Record?

5. What Is A Medical Record?
• A record or documentation of a patient’s
medical history, examination, and treatments.
• Medical Record vs. Health Record
– Essentially the same

6. Class Discussion 1
• Why do we need a health record?
• In other words, why do we need a
documentation of a patient’s medical care?

7. Potential Uses of Medical Records
• 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
• 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
• 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?

9. Potential Uses of Medical Records
• 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
• Clinical research
– Find ways to improve health care through new knowledge

10. “Electronic” Medical Records
• Electronic Medical Records (EMRs) vs.
Electronic Health Records (EHRs)
• Debate about similarities & differences
• Summary
– Definitions subjective, depending on how people think
– EMRs mostly refer to electronic documentation of
medical care at one visit
– EHRs mostly refer to electronic documentation that is
longitudinal in nature (may be several visits)
– EMRs commonly used in Thailand (but means the same
as EHRs)

11. Longitudinal Records
• Records documented over time (multiple encounters)
• Ideally, “life-long” is a complete record of the patient’s health

12. Various Forms of Health IT
Hospital Information System (HIS) Computerized Provider Order Entry (CPOE)
Electronic
Health
Records Picture Archiving and
(EHRs) Communication System
(PACS)

13. Still Many Other Forms of Health IT
Health Information
Exchange (HIE)
m-Health
Biosurveillance
Personal Health Records
(PHRs)
Telemedicine &
Information Retrieval Telehealth
Images from Apple Inc., Geekzone.co.nz, Google, PubMed.gov, and American Telecare, I

14. The Confusing Acronyms
Computer-Based
Patient Records
Electronic Medical
(CPRs)
Records (EMRs)
Electronic Patient
Electronic Health Records (EPRs)
Records (EHRs)
Personal Health
Records (PHRs)
Hospital
Information
Systems (HIS)

15. Benefits of EHRs

16. Class Exercise 3
• Why do we need to use an
electronic version of medical
records?

17. Common “Goals” for
EHRs/Health IT Adoption
“Computerize”
“Go paperless”
“Get an electronic
copy
“Digital Hospital”
“Have EMRs”
“Modernize”
“Share data”

18. Is There A Role for Health IT?
(IOM, 2000)

19. Why We Need Health IT
• Health care is very complex (and inefficient)
• Health care is information-rich
• Quality of care depends on timely availability &
quality of information
• Clinical knowledge body is too large
• Short time during a visit
• Practice guidelines are put “on-the-shelf”
• “To err is human”

20. To Err Is Human
• Perception errors
Image Source: interaction-dynamics.com

21. To Err Is Human
• Lack of Attention
Image Source: aafp.org

22. Class Exercise 3
The Economist Purchase Options
• Economist.com subscription $59
• Print subscription $125
• Print & web subscription $125

23. Class Exercise 3
The Economist Purchase Options
• Economist.com subscription $59
• Print & web subscription $125

24. To Err Is Human
• Cognitive Errors - Example: Decoy Pricing
# of
The Economist Purchase Options People
• Economist.com subscription $59 16
• Print subscription $125 0
• Print & web subscription $125 84
# of
The Economist Purchase Options People
• Economist.com subscription $59 68
• Print & web subscription $125 32
(Ariely, 2008)

25. What If This Happens in Healthcare?
• It already happens....
(Mamede et al., 2010; Croskerry, 2003; Klein, 2005)
• What if health IT can help?

26. Fundamental Theorem of Informatics
(Friedman, 2009)
(Friedman, 2009)

27. Benefits of Going Electronic (EHRs)
• Ubiquitous availability (anytime, anywhere, everyone who is
authorized)
• Multiple concurrent uses
• The end of “Where the heck is the patient’s record?!?”
• Ability to control & enforce access security
• Structured data entry possible
• Data presentation that is easier to understand (e.g. graphs)
• Efficiency in data entry? (but sometimes it slows users
down!)
• Process improvement (business process
reengineering/redesign, quality improvement)
• No doctor’s handwriting!!!!!

28. Electronic Health Record (EHR) Systems
• Are they just electronic documentation?
History Diag- Treat-
...
& PE nosis ments
• Or do they have some other values?

29. Literature Shows Benefits of Health IT
• Literature suggests improvement in health care
through
– Guideline adherence
– Better documentation
– Practitioner decision making or process of care
– Medication safety
– Patient surveillance & monitoring
– Patient education/reminder
– Cost savings and better financial performance
• “Alerts & Reminders”

30. Alerts & Reminders

31. Functions That Should be Part of
EHR Systems
• Patient Demographics
• Physician Notes
• Computerized Medication Order Entry
• Computerized Laboratory Order Entry
• Computerized Laboratory Results
• Problem Lists
• Medication Lists
• Discharge Summaries
• Diagnostic Test Results
• Radiologic Reports

32. Hospital Information Systems

33. Different Kinds of IT in Hospitals
IT Infrastructure
- Hardware
- Network
Hardware
People &
- Operating
System
ware Network (Windows, etc.)
- Antivirus
- Other system
software
Software Software
Applications
- Microsoft Office
- Business
software (HIS,
EHRs, MIS)

34. Software Applications in Hospitals
• Front Office
– Electronic Health Records (EHRs)
– Hospital Information Systems (or Clinical Information Systems)
• Back Office
– Management Information Systems (MIS)
– Enterprise Resource Planning (ERP) systems
– Research and Education
– Office Automation Tools (such as Microsoft Office)

35. Examples of Hospital IT
Enterprise-wide
• MPI, ADT
• EHRs/EMRs/HIS/CIS
• CPOE & CDSSs
• Nursing applications
• Billing, Claims & Reimbursements
• MIS, ERP

36. Examples of Hospital IT
Departmental Applications
• Pharmacy applications
• LIS, PACS, RIS
• Specialized applications (ER, OR, LR, Anesthesia,
Critical Care, Blood Bank)
• E-Learning

37. Hospital Information System
Clinical
Medical ADT Notes
Records
Workflow
Pharmacy IS
Operation Master
Patient LIS
Theatre
Index (MPI)
Order
CCIS
RIS
Scheduling
Portals Billing
PACS
Modified from Dr. Artit Ungkanont’s slide

38. Hospital Information System
From Dr. Artit Ungkanont’s slide

39. Master Patient Index (MPI)
• A hospital’s list of all patients
• Functions
– Registration/identification of patients (HN)
– Captures/updates patient demographics
– Used in virtually all other hospital service applications

40. Admission-Discharge-Transfer (ADT)
• Functions
– Supports Admission, Discharge & Transfer of patients
(“patient management”)
– Provides status/location of admitted patients
– Used in assessing bed occupancy
– Linked to billing, claims & reimbursements

41. Bed Management (from ADT System)

42. Insurance Eligibility System
• Functions
– Determines if a patient is eligible or is covered by a particular
insurance scheme
– Determines the services covered by the patient’s insurance
plan
– May need to link with the eligibility verification system of the
government agencies

43. Appointment Scheduling
• Functions
– 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
– Ability to adjust number of open slots

44. Computerized Physician Order Entry
(CPOE)
Functions
• Physician directly enters medication/lab/diagnostic/imaging
orders online
• Nurse & pharmacy process orders accordingly
• Maybe considered part of an EHR/HIS system
Values
• No handwriting!!!
• Structured data entry (completeness, clarity, fewer mistakes)
• No transcription!
• Entry point for CDSSs
• Streamlines workflow, increases efficiency

45. Computerized Physician Order Entry
(CPOE)

46. Clinical Decision Support Systems
(CDSSs)
• The real place where most of the values of health IT can be
achieved
• A variety of forms and nature of CDSSs
– Expert systems
• Based on artificial intelligence, machine learning, rules, or statistics
• Examples: differential diagnoses, treatment options
– Alerts & reminders
• Based on specified conditions
• Examples: 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), clinical practice
guideline integration
– Evidence-based knowledge sources e.g. drug database, literature
– Simple UI designed to help clinical decision making

47. Clinical Decision Support Systems
(CDSSs)
PATIENT
Perception
CLINICIAN
Attention
Long Term Memory External Memory
Working
Memory
Knowledge Data Knowledge Data
Inference
From a teaching slide by Don Connelly, 2006 DECISION

48. Clinical Decision Support Systems
(CDSSs)
PATIENT
Perception
CLINICIAN
Abnormal lab
Attention highlights
Long Term Memory External Memory
Working
Memory
Knowledge Data Knowledge Data
Inference
DECISION

49. Clinical Decision Support Systems
(CDSSs)
PATIENT
Perception
CLINICIAN
Drug-Allergy
Attention Checks
Long Term Memory External Memory
Working
Memory
Knowledge Data Knowledge Data
Inference
DECISION

50. Clinical Decision Support Systems
(CDSSs)
PATIENT
Perception
CLINICIAN Drug-Drug
Interaction
Attention Checks
Long Term Memory External Memory
Working
Memory
Knowledge Data Knowledge Data
Inference
DECISION

51. Clinical Decision Support Systems
(CDSSs)
PATIENT
Perception
CLINICIAN
Attention
Long Term Memory External Memory
Working
Memory
Knowledge Data Knowledge Data
Inference Diagnostic/Treatment
Expert Systems
DECISION

52. Clinical Decision Support Systems
(CDSSs)
Issues
• Alert sensitivity & alert fatigue

53. Clinical Decision Support Systems
(CDSSs)
Issues
• Unintended Consequences (e.g. workarounds)

54. Nursing Applications
Functions
• 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
– e-Kardex
• Risk/incident management

55. Pharmacy Applications
Functions
• Streamlines workflow from medication orders to dispensing and
billing
• Reduces medication errors, improves medication safety
• Improves inventory management

56. Stages of Medication Process
Ordering Transcription Dispensing Administration
Automatic Electronic
CPOE
Medication Medication
Dispensing Administration
Records
(e-MAR)
Barcoded
Medication Barcoded
Dispensing Medication
Administration

57. Laboratory Information System (LIS)
Functions
• 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

58. Imaging Applications
Picture Archiving and Communication System (PACS)
• Captures, archives, and displays electronic images captured from
imaging modalities
• Often refers to radiologic images but sometimes used in other
settings as well (e.g. cardiology, endoscopy, pathology,
ophthalmology)
• Values: reduces space, costs of films, loss of films, parallel
viewing, remote access, image processing & manipulation,
referrals
Radiology Information System (RIS) or Workflow Management
• Supports workflow of the radiology department, including patient
registration, appointments & scheduling, consultations, imaging
reports, etc.

59. Billing System
• Functions
– 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 government agencies

60. Enterprise Resource Planning
• Some Functions
– Finance
• Accounting
• Budgeting
• Cost control and management
– Materials Management
• Procurement
• Inventory management
– Human Resources
• Recruitment, evaluation, promotion & disciplinary actions
• Payroll

61. The Bigger Picture:
Health Information Exchange (HIE)
Government
Hospital A Hospital B
Clinic C
Lab Patient at Home

62. Summary
• EHRs (or EMRs) are both
– Electronic documentation of patient care and
– a broad term for an information system used to
improve the process of patient care through
better documentation and other care
processes such as ordering medications, lab
tests, or x-rays and viewing lab results and x-
ray reports (among others)

63. Summary
• There are various kinds of applications in
hospitals
• HIS often refers to the “Front Office” part of
hospital IT
• Sometimes HIS refers to the entire hospital IT
• HIS and EHRs are used to support clinical
workflows, improve decision-making and care
quality, and reduce costs
• EHRs and HIS are just one piece of the big
puzzle for the whole healthcare system

64. Questions?