Health Care Information Systems Information System Information system

Health Care Information Systems

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

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

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

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

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

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

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

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

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

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

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

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 …

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

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. ”

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

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

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

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

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