1-4 An Introduction to Clinical Informatics: Clinical Information Systems

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Section One: An Introduction to Clinical Informatics

Module 1-4 Clinical Information Systems

What They Are Types of Each

EHR Integration



What is a Clinical Information System?

Clinical Information Systems (or Healthcare Information Systems) are systems that

capture, store, manage, transmit, and/or recall organizational or personal health

information



Uses of Clinical Information Systems

•  Clinical Functions •  Patient Management •  Practice Management •  Health System Management •  Public Health Management •  Research Management •  Payer Management



Where Clinical Information Systems are Used

Inpatient Outpatient

Medical Specialties Research Trials

Laboratory Pharmacy

Non-Clinical Settings



Electronic Health Record (EHR)

•  A systematic collection of electronic health information about an individual patient or population of patients – Allows practitioners to record and share data



EHRs

•  Benefits: Eliminates paper records, decrease handwriting errors, allows for implementation of error-reducing technology, lays foundation for a longitudinal health record, allows those eligible to receive meaningful use incentives

•  Drawbacks: Additional privacy, security, cost, software,

and quality of care concerns. Possibility for unintended consequences and changes to workflows, communication, and data entry demands.



Clinical Decision Support & Clinical Decision Support Systems

(CDS/CDSS) •  Clinical Decision Support [Systems] provide

clinicians, staff, patients, and other individual with knowledge and person-specific information, intelligently filtered or presented at appropriate times to enhance health and health care – Provides alerts, pop-ups, reminders, condition-

specific order sets, diagnostics, patient reports and summaries, and other relevant information



CDS/CDSS

•  Benefits: Reduced clinical errors, increased quality of care, improved efficiency, increased patient and provider satisfaction

•  Drawbacks: Alert Fatigue, Ethics and Malpractice



Computerized Patient Order Entry (CPOE)

•  A system that allows physicians and medical practitioners to electronically enter patient treatment instructions –  Information may be sent directly to the

pharmacy, lab, or radiology departments. CPOE can incorporate patient decision support, patient safety features, billing codes, and more



CPOE

•  Benefits: Decreases time to order completion, reduces prescription errors, improves dosage timing for patients, reduces transcription errors

•  Drawbacks: Time-consuming and problematic usability, enforcement of predefined relationships between clinical tasks and between providers



Imaging / Picture Archiving and Communication System (PACS)

•  A system that provides add to and storage of medical image documents in electronic form – Allows X-rays, CT, MRIs, and other images to be

reviewed and interpreted by physicians in a timely matter

– Uses Digital Imaging and Communications in Medicine (DICOM) standard



PACS

•  Benefits: Replaces traditional film retrieval/ distribution/display, allows for remote access, improves image workflow, integrates with EHRs and other CIS

•  Drawbacks: Once “filmless”, difficult to revert to a film environment, utilizes large amounts of bandwidth, requires high-resolution monitors for reading “films”, expensive



Laboratory Information System (LIS)

•  Provides workflow management, data tracking, data exchange, and other features to support laboratory operations – Varying levels of LIS complexity can do

everything from simply track samples to provide lab analytics, audit trails, compliance, calibration, maintenance, QA, and reporting



LIS

•  Benefits: Sample management, quality control, sample data storage, instrumentation and application integration, limit checking

•  Drawbacks: May need custom workflow interfaces, must use adequate validation



Inventory Management System

•  Manages supply levels and usage throughout a health care system



LIS

•  Benefits: Real-time inventory levels, increase charge capture for supplies, allows for lower inventory levels

•  Drawbacks: Must be fully integrated into providers workflow to be useful – un-captured usage of inventory results in inaccurate results



Personal Health Record

•  A health record where the data is managed by the patient, not the healthcare provider – Allows patients to share their information with

providers



Personal Health Record

•  Benefits: Improves communication between provider and patient, covers medical history that may otherwise be spread out between EHRs

•  Drawbacks: Privacy concerns, patient failure to disclose some health activities/events/histories, not clinically detailed



EHR as the Foundation



Review Questions

1.  The CIS which helps pharmacies electronically receive prescriptions from physicians is a:

1.  LIS 2.  EHR 3.  CPOE 4.  PHR



Review Questions

1.  The CIS which helps pharmacies electronically receive prescriptions from physicians is a:

1.  LIS 2.  EHR 3.   CPOE 4.  PHR

Computerized patient order entry lets physicians send their orders electronically to the pharmacy. CPOE combined with CDSS & EHR can check for drug-allergy and drug-drug reactions and alert users to possible errors.



Review Questions

1.  A system that provides alert, pop-ups, and reminders based on clinical guidelines and rules is known as a(n):

1.  EHR 2.  CDSS 3.  CPOE 4.  PACS



Review Questions 1.  A system that provides alert, pop-ups, and

reminders based on clinical guidelines and rules is known as a(n):

1.  EHR 2.   CDSS 3.  CPOE 4.  PACS

CDSS provide alerts, pop-ups, and reminders, as well as guidelines, order sets, diagnostics, reports, summaries, and other relevant information for physicians to make informed decisions regarding their patient’s health.

1-4 An Introduction to Clinical Informatics: Clinical Information Systems

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