Khalid C Asst. Manager Information Technology Hospital Information Systems (HIS) and Electronic Medical Records (EMR)
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Khalid CAsst. Manager
Information Technology
Hospital Information Systems (HIS) and Electronic Medical Records (EMR)
What is health information system?
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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
What Is A Medical Record?
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A record or documentation of a patient’s medical history, examination, and treatments.
What Is A Medical Record?
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Systematic documentation of a single patient's medical history and care across time within one particular health care provider.
The medical record includesvariety of types of "notes" entered by Physicians, recording observations and administration of drugs and
therapies, Laboratory test results, reportsdemographics, medical history, medication and allergies, immunization status, radiology images, vital signs, intake, output, observations
Why do we need a Medical record?
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In other words, why do we need a documentation of a patient’s medical care?
Potential Uses of Medical Records
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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”
Hospital Functions
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Potential Uses of Medical Records
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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
Potential Uses of Medical Records
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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?
Potential Uses of Medical Records
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Clinical research Find ways to improve
health care through new knowledge
Potential Uses of Medical Records
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Claims and reimbursements What services were provided to the patientHow (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
What is an Electronic Medical Record (EMR)?
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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
Advantages of EMR
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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 dueYour prescriptions are electronically ordered directly to your
pharmacyEMR permits more than one user to access your record at the
same time.
Why We Need IT tools in Healthcare ?
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Why We Need IT tools in Healthcare ?
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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.
Health care is information-rich
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Why We Need Health IT
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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
Benefits of Going Electronic (EMR)
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Ubiquitous availability (anytime, anywhere, everyone who is authorized)
Multiple concurrent usesAbility to control & enforce
access securityStructured data entry possibleData presentation that is
easier to understand (e.g. graphs)
No handwriting!!!!!
Hospital Information System
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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 applicationsEnterprise Resource Planning (ERP))
Departmental Applications
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Pharmacy applicationsLIS – Laboratory Information SystemPACS - Picture Archiving and Communication System RIS – Radiology Information SystemSpecialized applications
Emergency RoomOperation TheatreLabor RoomAnesthesia, Critical Care, Blood Bank
E-Learning
Master Patient Index (MPI)
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A hospital’s list of all patients
Registration of patients Captures/updates patient
demographicsBar-coded Registration
Cards
Admission-Discharge-Transfer (ADT)
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Supports Admission, Discharge & Transfer of patients (“patient management”)
Provides status/location of admitted patientsUsed in assessing bed occupancy Linked to billing, claims & reimbursements
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
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Computerized Physician Order Entry (CPOE)
• Physician directly orders online– medication – Lab– diagnostic– imaging
• Nurse & pharmacy process orders accordingly
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Clinical Decision Support Systems (CDSSs)
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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
Clinical Decision Support Systems (CDSSs)
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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.
Nursing Documentation & Charting
• Intake Output Chart• Diabetic Chart• Neuro Assessment• Daily Nursing Assessment• Vital Signs Record• IV Fluid Charting
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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
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Pharmacy Applications
• Streamlines workflow from medication orders to dispensing and billing
• Reduces medication errors, improves medication safety
• Improves inventory management
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Laboratory Information System (LIS)
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Receives and processes lab orders
Matches tube & specimenInternal workflow within labs
Order processing Specimen registration &
processing Lab results validation &
reportingSpecimen inventory
Lab results viewing
Billing System
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Calculates service charges for services providedCalculations 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
Imaging Applications
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Picture Archiving and Communication System (PACS)
Captures, archives, and displays electronic images captured from imaging modalities
cardiology, endoscopy, pathology, ophthalmology
PACS – (Picture Archiving and Communication System )
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PACS enables x-ray and scan images to be stored electronically and viewed on screens, helping to improve diagnosis methods.
Enterprise Resource Planning
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Finance Accounting Budgeting Cost control and
managementMaterials Management
Procurement Inventory management
Human Resources Recruitment, evaluation,
promotion & disciplinary actions
Payroll
Our Mission
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Electronic documentation of patient care and then by become paperless
Patient care processes such as ordering medications, lab testsx-raysViewing lab results and x- ray reports (among others)
What we have done ?
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Already working in Siemens HISNot completely paperlessDoing Consultation, Lab Order, Billing, Pharmacy Sales,
Nursing Notes, LISImplementation Stage of International Standard Compliant
HISWill completely migrated to new innovative HIS within 2
Months
Upcoming HIS - Features
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HL7 StandardHL7, 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
Upcoming HIS Clients
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BLK Super Speciality Hospital, New DelhiAmrita Institute of Medical Sciences, KochiSree Gokulam Medical College, TrivandrumBARC (Babha Atomic Research Centre) Hospital in Mumbai.J J hospital MumbaiNIMHANS BangaloreSt. Gregorios Medical Mission Hospital, Parumala.Punjab Institute of Medical Sciences (PIMS), JalandharSir Sundar Lal Hospital, Benaras Hindu University
HIS Demo
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Currently using HIS Consultation Module Physician tasks
OP ConsultationInitial Examination ReportFollowupsLab Order / ViewIP Progress NotesBacklog MRD ViewerOP / IP – Consultation Requests / ResponseDrug PrescriptionDischarge SummaryReferrals
HIS Demo
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