Information Systems in Health Care

1. Information Systems in Health Care Yung-Fu Chen, Ph.D. Department of Health Services Management, China Medical University

2. Learning Objectives • Distinguish between the concepts of data, information, and knowledge and give examples of each • Describe the evolution of IS in health-care delivery • Discuss how the management of IS in health-care facilities has changed over time and how this has affected the development of IT in health-care delivery • Distinguish between in-house developed, shared, turnkey, and stand-alone IS • Provide examples of clinical and administrative IS • Discuss the elements of a HIS • Discuss current trends in health-care IS

3. Administrative and managerial information systems Computer-based patient record (CPR) Data Hospital information system (HIS) Information In-house systems Knowledge Laboratory information systems (LIS) Nursing information systems (NIS) Patient monitoring systems Pharmacy information systems Shared systems Stand-alone systems Turnkey systems Key Terms

4. Outline • Information Systems in Health Care • History of IS in Health Care • Current Applications and Trends in Health Care • Current Trends in Health Information Systems

5. History of IS in Health Care • Studied from different standpoints • Technology • System design approaches • Management approaches • Data-information-knowledge model • Focus on data-information-knowledge model and contrast it to other three standpoints

6. Data are facts, images, or sounds that may or may not be useful to a particular task Non-interpreted items A data system only produces facts, images, or sounds without any contextual basis Information consists of data or sets of data whose content or form is useful to a particulat task Information systems maintain a long-term database use applications built on storage, retrieval, and communication concepts Data need to be formatted. Filtered, and/or manipulated in order to be converted to information Data can be converted to information in a number of ways: summarized, highlighted, and formatted or presented Knowledge is a combination of rules, relationships, ideas, and experience Knowledge systems are usually composed of an expert knowledge base, algorithms, or some type of rule-based or decision analysis adjunct. Diagnostic decision support systems (DDSS), which provide collegial assistance in making decisions to the user, are good examples of knowledge systems History of IS in Health CareDistinctions between data, information, and knowledge

7. History of IS in Health CareDistinctions between data, information, and knowledge Figure 3-1 Hierarchical view of data-information-knowledge • Knowledge • Rules • Relationships • Ideas • Information • Formatted • Filtered • Manipulated • Data • Facts • Images • Sound

8. History of IS in Health CareEvolution of IS in Health Care • 1960s-70s • Financial Focus • Few Clinical Systems • In-house Development • Shared Systems • Turnkey Systems • Transaction Processing Figure 3-2 Timelining Health Information Systems Evolution • 1980s • Continuing Financial Focus • More Clinical Development • Stand-alone Systems • Distributed Systems • Management Information Systems • 1990s • Focus on Clinical Systems • Integration of Systems • Executive Information Systems • Decision Support Systems • Enterprise-wide Systems • Office Automation • Virtual Systems • 2000s • Standards • E-health • Intranets and Extranets • Internet • Clinical Repositories • Data Warehouses • Data Mining

9. History of IS in Health CareEvolution of IS in Health Care • Financial and Clinical Systems • Although automation has been occurring since 1960s, IS in health care still remain primarily paper based • The initial use of computers in health care occurred during the 1960s and early 1970, but mostly focused on financial applications • Transferred from other industries to health care was an lateral movement • The nature, scope, and development of computer technology then supported data systems better than IS • Several exemplary applications in the clinical area

10. In-House Developed, Shared, Turnkey, and Stand-alone System 1960s-1970s In-house systems included on-site systems that were designed, programmed, supported, and modified by hospital data processing staff The advantage is more flexible in meeting hospital needs than vendor-developed products Shared systems included those designed, programmed, and maintained by a system vendor and run on computer equipment at the vendor site Shared by multiple hospitals and communicated through telephone lines or paper forms The advantages were low start-up costs, low technical staffing requirement in the hospital, and the availability of fully tested and proven system The drawback is lack of system flexibility to meet specific institution needs History of IS in Health CareEvolution of IS in Health Care

11. In-House Developed, Shared, Turnkey, and Stand-alone System Turnkey systems Developed by an information vendor, usually in only software side of the system Installed on a hospital computer and operated by the hospital staff The hospital could literally just turn the system on and be ready for business Attractive to smaller hospitals Stand-alone system Developed to support functional tasks for separate departmental areas that each claims ownership of its data Usually no attempt to share information among systems Lack of system integration Data that could be used on an enterprise-wide basis for decision making were difficult to provide through this decentralized approach History of IS in Health CareEvolution of IS in Health Care

12. In-House Developed, Shared, Turnkey, and Stand-alone System Information system types TPS, MIS, DSS, EIS, ES, and OAS Early systems were mainly TPS that automated operational functions such as accounting, payroll, inventory, and admission/discharge systems; order entry system was later added The introduction of national prospective payment system for Medicare patients influenced the growth of MIS Weakness in linking and integrating data for stand-alone system became magnified In the 1990s, a need for developing EIS and DSS were manifested by increase of health maintenance organization, development of alliances, and focus on managed care Optical fiber provided faster communication for both data and images In the 2000s, progress in system integration has been promoted Commitment to the development of standards such as HL-7, DICOM, and ASTM Advancement of computer technologies Client/server networks, DBMS, DDBMS, GUI, voice recognition, etc. Improvements in IS development tools, such as CASE and RAD History of IS in Health CareEvolution of IS in Health Care

13. Various system types Patient monitoring systems Nursing information systems Laboratory information systems Pharmacy information systems Other clinically oriented information systems There are frequently overlaps in function and purpose among system types Broadly defined as hospital information system (HIS) Provide communication among health facility workers and support organization need for operating, planning, patient care, and documentation Help to handle this complexity by coordinating work tasks, integrating information, organizing and storing information, and providing information decision support through communication architectures, databases, and application programs, HIS should provide the following functions Core applications Business and financial functions Communications and networking Departmental management Medical documentation Medical support Current Applications and Trends in Health CareClinical Applications and Systems

14. Core applications Patient scheduling, admission, and discharge embodied in a registration-admission-discharge-transfer (RADT) system Business and financial functions Provide traditional functions such as payroll, general ledger, and accounts receivable Communications and networking HIS is a hub for communication to systems such as pharmacy, radiology, laboratory, dietary, OR, housekeeping, and other services Order entry-results reporting system providing communication between physician orders and ancillary unit is another important function of HIS Departmental management Supports the internal needs of individual hospital departments Integration of individual departmental systems with core HIS application is a trend Medical documentation Performs the functions of the standard medical record in collecting, storing, and presenting clinical information Supports managerial and administrative decision making Medical support Assists health-care provider in interpretation of data and in making clinically related decisios Data generated, stored, and integrated by various systems can be used to monitor patients, issue alerts, and provide limited advice for diagnosis or therapy Alert of drug allergies Current Applications and Trends in Health CareClinical Applications and Systems

15. Current Applications and Trends in Health CareClinical Applications and Systems • Patient monitoring systems • Collect, store, interpret, and display physiological patient data • Critical in helping to detect life-threatening events • Found in various areas, such as emergency departments, operating rooms, general acute-care units, and intensive-care units • Nursing information systems • Support the nursing-care process both from clinical and managerial perspectives • Helping nurses in determining diagnosis, preparing and implementing of nursing-care plans, and evaluating care that was provided • Supporting nursing management functions including scheduling of personnel having appropriate level of education, training, or skill

16. Laboratory information systems Support processing of data associated with laboratory tests and management functions associated with daily operations Store, analyze, and distribute data of tests and examination including clinical chemistry, hematology, clinical microbiology, cytology, surgical pathology, and blood bank Perform test ordering and results reporting, patient and specimen identification, data processing and record keeping, data acquisition, report generation, quality control, and managerial reporting Pharmacy information systems Collect, store, and manage information related to drugs and use of drugs in patient care. Provide medications for patient care in response to a physician’s order is the primary activity Provide information regarding identification of drug-drug interactions, contraindications with patient allergies, and drug sensitivities Supported functions include online order entry, pharmacist review, medication profile update, label printing, drug-dispensing reports, medication administration reports, inventory maintenance and automatic drug reorder, drug-use reports, and controlled-drug reports Other clinically oriented information systems Radiological information systems Dietary information systems Emergency department systems Support system for central supply, operating room systems, anesthesia systems, etc. Current Applications and Trends in Health CareClinical Applications and Systems

17. Current Applications and Trends in Health CareComputer-Based Patient Record (CPR) • A concept of maintaining health-related and patient-related data electronically in a system so that end users may access complete and accurate data, and be provided with alerts, reminders, clinical support systems, and links to medical knowledge • A system of technology, software, and data subsystems working together to provide accurate, complete, and timely information when and where it is needed • Make up of one technology but supported by many technologies • Web-enabling technologies, client/server networks, fast computing speed, voice recognition, and DDMS • Multiple data sources are required to support CPR concept

18. CPR requirements An integrated view of patient data Access to knowledge resources Physician and clinician order entry Integrated communications support Clinical decision support Barrier to CPR Development Lack of a clear definition of a CPR and costs and risks associated with development Barriers to diffusion including Fragmented organization of the health-care system Lack of leadership for establishing the necessary infrastructure for national CPR implementation Requirements for education and training of health-care personnel CPR adoption costs Legal and social issues Lack of a communications infrastructure and standards Current status of CPR Development of integration among a variety of independent systems, such as pharmacy, laboratory, radiology, and nursing information systems, is a trend Integration involves the application of client/server protocols, DDMS, and application of vocabulary and other types of standard Work on defining the basic architecture for data contained in the CPR needs to be accomplished if data are to be seamlessly transmitted among health-care providers, internal and external to the organization Computer-Based Patient Record Institute (CPRI) has established the Nicholas E. Davies Annual CPR Recognition Symposia Current Applications and Trends in Health CareComputer-Based Patient Record (CPR)

19. The applications, especially in the financial areas, were the first functions widely deployed Clinical and financial systems were rarely integrated, also poor integration among various managerial and administrative systems Lack of appropriate integration has adverse impact on decision making Examples Financial information system Accounting information system Human resource MIS Material management systems Facilities MIS Management planning and decision support systems Current Applications and Trends in Health CareAdministrative and Management Applications

20. Financial information system Initially automated accounting functions such as payroll preparation, accounts payable, patient accounting, general ledger, and budgeting; with the implementation of DRG the need for case-mix management systems and integration of clinical and financial systems were recognized Categorization Cash management Investment management Capital budgeting Financial forecasting and planning Accounting information system Essential business operations that record organizational business and economic transactions by recording and reporting how funds flow through the organization, producing financial statement A mix of different systems Order processing system captures and process order Inventory control system processes data related to inventory and inventory tracking Account receivable system records the amounts owed by health-care facility patients, clients, clients, and produce invoices, monthly statements, and credit management reports Account payable system records the purchases, the amount of purchases, and from whom purchases were made Payroll transaction system includes mechanisms for timekeeping for work performed, records employee compensation data, and produces paycheck and other payroll documents General ledger system glues all of the accounting systems together Current Trends in Health Information SystemsAdministrative and Management Applications

21. Human resource MIS Traditional functions include only maintaining and updating employee records, currently access to data for monitoring productivity, assessing personnel-related barriers to productivity, and determining appropriate levels of the human resources mix are implemented Be able to support three important functions Staff administration supports recording and tracking of human resources Training administration helps managers to plan and monitor employee training and to develop and analyze the success of training programs Development and compensation administration analyze the range and distribution of employee compensation including wages, salaries, incentives, and fringe benefits internal and external to the organization Material management systems Management of inventory and purchasing of materials and supplies Encompasses front-end and back-end processes Front-end processes involve handling requisitions for supplies and materials from departments Back-end process include managing inventory and ordering materials and supplies Benefits of this system Reductions in inventory Improvement in bid and contracting procedures Updating of daily patient charges Improvements in avoiding lost patient charges interface with accounts payable to obtain payment discounts Reduction in labor costs Current Trends in Health Information SystemsAdministrative and Management Applications

22. Facilities MIS Well-maintained physical facilities are essential for the provision of quality patient care as well as providing a pleasing atmosphere for workers and patients and their families Include capture, storage, and manipulation of data used to monitor preventive maintenance, energy management, and project (construction) scheduling Management planning and decision support systems Information from external and internal is necessary for good strategic decision making External prospective Understand the environmental context, know the strength and weakness of its competition, and understand opportunities upon which it can capitalize Internal prospective Recognize its own internal strengths and weakness and how these decision making must integrate data from internal and external database DSS provides information for strategic decision making by supplying tools for the manipulation of data and presenting answers to what-if scenarios DSS includes forecasting, marketing, cost accounting, and case-mix systems Quality improvement systems Current Trends in Health Information SystemsAdministrative and Management Applications

23. Elements of management information, decision support, and executive information systems IS designed to help in the support of strategic and managerial decision making are classified into three categories: MIS, DSS, and EID Management information systems Developed for managing daily business operations Exception report is generated when exceptional conditions occur Some allow managers to interactively request information through Web browser, query languages, and report generators Decision support systems Include more sophisticated features for analysis of data than MIS Consist of several characteristics such as a body of knowledge or a database, analytical models used to analyze data, and interactive modeling capability to support semi-structure and unstructured management decisions Software for managers to develop their own DSS: spreadsheet, management sciences packages (SPSS or SAS), query languages, and data mining packages Executive information systems Combine many features of MIS and DSS, but is developed for top executive decision making Current Trends in Health Information SystemsAdministrative and Management Applications

24. Systems can be examined and views in relations to management of the resources, architecture, applications, communications, and technology Vision must be toward fully integrated systems supported by flexible data models, communication technologies, and tools that enhance decision making, improve quality and productivity, and reduce administrative costs Current trends in Clinical information systems E-commerce and E-health Standard development Privacy and security Technology developments Management of information resources and standards development The virtual health-care system Current Trends in Health Information Systems

25. Current Trends in Health Information SystemsClinical Information System • Continued design, development, and implementation of CPR • CPR will require continued development and application of a number of technologies • Clinical data repositories • Communication technologies to link various repositories, information resources, and users • Enterprise-wide and inter-enterprise data models • Voice entry to improve user input • AI and DSS • Communications and other standards • Integration of voice, text, data, and image processing systems • Policies, procedures, and methods that will ensure security of patient-related data and communications

26. Current Trends in Health Information SystemsE-Commerce and E-Health • E-commerce can be defined as the marketing, buying, selling, and support of products and services over the Internet, Intranet, and Extranet • E-commerce involves electronic data interchange (EDI) and secure electronic funds transfer (EFT) • Health-care organization will continue to use the Internet to create a dialog with customers and others through online discussion groups, electronic bulletin boards, electronic surveys, newsletters, blogs, and e-mail exchanges • Continuing growth in e-health companies which provide a range of services including storing personal health data, providing reference information on a variety of health issues, running health-care superstores • Telehealth applications, such as telehome health care, teleradiology, telecardiology, teledentistry, teledermatology, and others, will continue to grow

27. Standards are essential for the collection, storage, and exchange of data, which are fundamentals of developing CPR and e-commerce applications, therefore the development of standards will continue Vocabulary standards establish common definitions for medical terms Structure and content standards identify essential data elements and provide for standardization of element characteristics such as length, data type, and content Message standards establish the format and sequence of data during transmission Security standards identify practices required to maintain the confidentiality, integrity, and availability of health-care information Organizations International Standard Organization (ISO) American National Standards Institute (ANSI) does not develop standards but serves as a clearinghouse for nationally coordinated voluntary standards Health Level 7 (HL7) Accredited Standards Committee (ASC) Digital Imaging and Communications in Medicine (DIACOM) National Council on Prescription Drug Programs (NCPDP) American Society for Testing and Materials 9ASTM) Mandatory standards Health Insurance Portability and Accountability Act of 1996 (HIPAA) Current Trends in Health Information SystemsStandard Development

28. Current Trends in Health Information SystemsPrivacy and Security • HIPAA promulgated mandatory rules with regard to both data privacy and security for health-care organizations • Health-care organizations must be concerned with confidentiality, integrity, and availability of the information resource • Management of data security will force organizational change in structure, behavior, training and education, and management of technology • Chief security officer (CSO) will be a new role • Encrypted keybased authentification and biometric authentification for guarding data access • Web server guards and server-side session management through a secure socket layer will be a regular feature for engaging in any type of e-commerce

29. Current Trends in Health Information SystemsTechnology Development • Wireless technology accompanied with handheld computers and personal digital assistants will be applied widely in health-care institutions • Interactive technologies such as continuous speech recognition, touch screen, and multimedia technology will be applied more widely, especially in CPR • Continuing growth and applications of database, data repository, and data warehousing technologies in the health-care arena

30. Current Trends in Health Information SystemsManagement of information resources and standards development • A distinction between information technology and systems and IM will emerge • An expended role for information resources manager, CIO, reporting directly to CEO by providing him/her with vision and leadership in the strategic planning, implementation, and operation of enterprise-wide IS • CIO will play a vital role on the leadership team in helping to define the strategic objectives of the organization as a whole

31. Current Trends in Health Information SystemsThe virtual health-care system • In a virtual IS, health-care enterprises view their information resource from the perspective of VR • View of information goes beyond an IS confined in an organization • Critical data reside anywhere, either internal or external to an organization • Virtual IS will be embraced by developing and implementing the following facility communication links • Physician-healthcare • Third-party-healthcare • Government-healthcare • Alliance and partner-healthcare • Customer/client-healthcare