Transcript Introduction to Health Information Systems (HIS)

INTRODUCTION TO HEALTH
INFORMATION SYSTEMS
(HIS)
What is an Information System?
• An information system (IS) is an arrangement of
information (data), processes, people, and information
technology that interact to collect, process, store, and provide as output the information needed to support the
organization (Whitten & Bentley, 2005).
What is a Health Information System?
A health care information system (HCIS) is an arrangement of
information (data), processes, people, and information technology that
interact to collect, process, store, and provide as output the information
needed to support the health care organization.
The discipline of health information systems (HIS) involves a synergy of
three other disciplines (Tan, 2005):
• Health is the end-purpose of HIS applications. The ultimate goal in
applying HIS solutions is to improve the health status of people.
• Organization management provides the managerial perspective on
developing and using HIS applications for health service
organizations.
• Information management is how the information is used. To achieve
their goals, health managers must rely on health information.
Difference between MIS and HIS
History of Health Information Systems and
their Evolution
• Post 1960s
 Guaranteed health care insurance benefits to the elderly and the poor.
(age>65)
 Provide health care coverage to individuals with long-term disabilities.
 Cost-based reimbursement: the more a hospital built, the more
patients it served, and the longer the patients stayed, the more
revenue the hospital generated.
 The primary focus was to collect and process patient demographic
data and insurance information and merge it with charge data to
produce patient bills.
 The mainframe was associated with centralized rather than distributed
computing.
Post 1960s
• The administrative applications that existed in the 1960s were generally found in
large hospitals, such as those affiliated with academic medical centers.
• Those facilities often developed their own administrative or financial information
systems in-house, in what were then known as data processing departments.
• The data processing department was generally under the direction of the finance
department or chief financial officer. The primary function is processing billing
data.
• These early administrative and financial applications ran on large mainframe
computers which had to be housed in large rooms, with sufficient environmental
controls and staff to support them.
• Because the IS focus at the time was on automating manual administrative
processes and computers were so expensive, only the largest, most complex
tasks were candidates for mainframe computing.
1960s
• Shared Systems: they allowed hospitals to share the use of a
mainframe with other hospitals. It captured billing data
manually or electronically and send them in batch form to a
company that processes the claims for the hospital.
• Most shared systems processed data in a central or regional
data center.
• Shared Medical Systems (now known as Siemens) was one of
the first vendors to offer data processing services to hospitals.
• Vendors charged participating hospitals for computer time and
storage, for the number of terminals connected, and for reports.
1970s
• Rapid inflation in the economy, expansion of hospital expenses and
profits, and changes in medical care contributed to the increase
health care costs.
• Departmental systems began to emerge as a way to improve
productivity and capture charges and thereby maximize revenues.
• The development of departmental systems coincided with the
availability of minicomputers.
• Minicomputers were smaller and more powerful than some mainframe
computers and available at a cost that could be afforded by a clinical
department such as laboratory or pharmacy.
• Showed a direct impact on the quality of patient care because of
faster turnaround of tests, more accurate results, and a reduction in
the number of repeat procedures (Kennedy & Davis, 1992).
1970s
• New companies wanted to develop applications for clinical
departments, particularly turnkey systems.
• These software systems, which were developed by a vendor
and installed on a hospital’s computers, were known as turnkey
systems because all a health care organization had to do was
turn the system on and it was fully operational.
• What you saw was what you got.
• Most systems were still stand-alone and did not interface well
with other administrative or clinical information systems in the
organization.
1980s
• Medicare shifted from a cost-based reimbursement system to a prospective
payment system based on diagnosis related groups (DRGs).
• This new payment system had a profound effect on hospital billing practices.
Reimbursement amounts were now dependent on the patient’s diagnosis.
• Hospitals received a predetermined amount based on the patient’s DRG,
regardless of the cost to treat that patient.
• The incentives were now directed at ordering fewer diagnostic tests, performing
fewer therapeutic procedures, and planning for the patient’s discharge at the time
of admission.
• Health care executives knew they needed to reduce expenses and maximize
reimbursement.
• Services that had once been available only in hospitals now became more
widespread in less resource-intensive outpatient settings and ambulatory surgery
centers.
1980s
• Overall health care costs in rose by double the rate of inflation.
• Health insurance companies argued that the traditional fee-for-
service method of payment to physicians failed to promote cost
containment.
• Managed care plans began to emerge in parts of the nation,
and they reimbursed physicians based on capitated or fixed
rates.
• Overall there was a shift toward privatization and
corporatization of health care. The integrated delivery system
began to emerge, whereby health care organizations offered a
spectrum of health care services, from ambulatory care to
acute hospital care to long-term care and rehabilitation.
1980s
• The microcomputer, or personal computer (PC), was
smaller, powerful, and affordable than a mainframe
computer.
• Health care information system vendors were developing
administrative and clinical applications.
• Health care executives viewed this as an enormous
opportunity to acquire and implement needed clinical
information systems.
• the major focus was on revenue-generating departments.
1980s
• Organizations that adopted the best-of-breed approach then
faced a challenge when they tried to build interfaces or
integrate data so that the different systems could interoperate,
or communicate with each other.
• Even today, system integration remains a challenge for many
health care organizations despite progress in the use of
interoperability standards.
• The advent of the microcomputer brought computing
capabilities to a host of these smaller organizations. It also led
to users’ being more demanding of information systems, asking
the information system function to be more responsive.
• Sharing information among microcomputers also became
possible with the development of local area networks.
1990s
• It marked the evolution and widespread use of the
Internet along with a new focus on electronic medical
records.
• After the success of the DRG-based reimbursement
system for hospitals, Medicare introduced a new method
for reimbursing physicians.
• Formerly paid under a customary, prevailing, and
reasonable rate methodology, physicians treating
Medicare patients were now reimbursed for services
under the resource-based relative value scale (RBRVS).
1990s
• The RBRVS payment method factored provider time, effort, and degree
of clinical decision making into relative value units.
• The system would reward financially the physicians who spent time
educating patients but would discourage or limit reimbursement to highly
skilled specialists who tended to perform invasive procedures and order
an extensive number of diagnostic and therapeutic tests.
• Health care organizations and communities promoted preventive
medicine with the goal of promoting health and well-being and preventing
disease.
• If we educate and help keep patients well, the overall cost of providing
health care services will be lower in the long run.
• The primary care provider was viewed as the gatekeeper and assumed a
pivotal role in the management of the patient’s care. Under this managed
care model, physicians were reimbursed on a capitated or fixed rat.
1990s
• Several vendors developed electronic disease
management programs that facilitated the management of
chronic diseases and were incorporated into clinical
applications.
• Patients could assume a more active role in monitoring
their own care.
• For example, clinicians at a Partners Community Hospital
introduced a disease management program called Matrix
that enables providers to plan, deliver, monitor, and
improve the quality and outcomes of the treatment and
care delivered to patients with diabetes.
1990s
• In 1991, the Institute of Medicine (IOM) published its landmark report
The Computer-Based Patient Record: An Essential Technology for
Health Care.
• This report brought international attention to the numerous problems
inherent in paper-based medical records and called for the adoption
of the computer-based patient record (CPR).
• The IOM defined the CPR as “an electronic patient record that resides
in a system specifically designed to support users by providing
accessibility to complete and accurate data, alerts, reminders, clinical
decision support systems, links to medical knowledge, and other aids”
(IOM, 1991, p. 11).
• IOM report viewed the CPR as a tool to assist the clinician in caring
for the patient by providing him or her with reminders, alerts, clinical
decision-support capabilities, and access to the latest research
findings on a particular diagnosis or treatment modality.
1990s
• During the 1990s, a number of vendors developed CPR
systems. Yet only 10 percent of hospitals and less than 15
percent of physician practices had implemented them by the
end of the decade (Goldsmith, 2003).
• CPR systems had reached the stage of reliability and technical
maturity needed for widespread adoption in health care.
• Health Insurance Portability and Account- ability Act (HIPAA)
• HIPAA was designed to make health insurance more affordable
and accessible, but it also included important provisions to
simplify administrative processes and to protect the
confidentiality of personal health information.
1990s
• The adoption of electronic transaction and code set standards and the greater
use of standardized electronic transactions is expected to produce significant
savings to the health care sector.
• In addition, the administrative simplification provisions led to the establishment of
health privacy and security standards .
• Health care organizations and vendors used the Internet to market their services,
provide health information resources to consumers, and give clinicians access to
the latest research and treatment findings.
• The Internet has provided affordable and nearly universal connectivity, enabling
health care organizations, providers, and patients to connect to each other and
the rest of the health care system.
• Along with the microcomputer, the Internet is perhaps the single greatest
technological advancement in this era. It revolutionized the way that consumers,
providers, and health care organizations access health information, communicate
with each other, and conduct business.
1990s
• Consumers began to use e-mail to communicate with
colleagues, businesses, family, and friends.
• It substantially reduced or eliminated needs for telephone
calls and regular mail. E-mail is fast, easy to use, and
fairly widespread.
• Telemedicine is the use of telecommunications for the
clinical care of patients and may involve various types of
electronic delivery mechanisms. It is a tool that enables
providers to deliver health care services to patients at
distant locations.
2000s
• Health care quality and patient safety emerge as top priorities at the
start of the millennium.
• IOM published the report To Err Is Human: Building a Safer Health
Care System, which brought national attention to research estimating
that 98,000 patients die each year due to medical errors.
• A report by the Institute of Medicine Committee on Data Standards for
Patient Safety, Patient Safety: Achieving a New Standard for Care
(2004), called for health care organizations to adopt information
technology capable of collecting and sharing essential health
information on patients and their care.
• This IOM committee examined the status of standards, including
standards for health data interchange, terminologies, and medical
knowledge representation.
2000s
• To Err Is Human authors point out that earlier research on
patient safety focused on errors of commission, such as
prescribing a medication that has a potentially fatal interaction
with another medication the patient is taking, and they argue
that errors of omission are equally important.
• An example of an error of omission is failing to prescribe a
medication from which the patient would likely have benefited
• A significant contributing factor to the unacceptably high rate of
medical errors reported in these two reports and many others is
poor information management practices.
• Illegible prescriptions, unconfirmed verbal orders, unanswered
telephone calls, and lost medical records can all place patients
at risk.
2000s
• The Leapfrog Group, an initiative of public and private
organizations that provide health care benefits to their
employees, works to improve patient safety by identifying
problems and proposing solutions for hospital systems.
• It has developed a list of criteria by which health care
organizations should be judged in the future.
• One of the Leapfrog Group’s many recommendations to
improve patient safety is the widespread adoption of
computerized provider order entry (CPOE) systems
among health care organizations.
2000s
• Pay for performance (P4P) or value-based purchasing,
reimburses providers based on meeting predefined quality
measures and thus is intended to promote and reward
quality.
• The Centers for Medicare and Medicaid Services (CMS)
have already notified hospitals and physicians that future
increases in payment will be linked to improvements in
clinical performance.
• Medicare has also announced it will not pay hospitals for
the costs of treating certain conditions that could
reasonably have been prevented.
2000s
• Significant technological advances have occurred in
information technology.
• Electronic devices have become smaller, more portable, less
expensive, and multipurpose.
• Broadband access to the Internet is widely available, even in
remote, rural communities; wireless technology and portable
devices (personal digital assistants, multipurpose cell phones,
and so forth) are ubiquitous; significant progress has been
made in the area of standards pod- casts, wikis, and Web 2.0
technologies have emerged; and radio-frequency identification
devices (RFIDs), used more widely in other industries, have
found their way into the health care marketplace.
IT
• The health care sector has been slow to adopt health care information
systems, particularly clinical information systems.
1.
Health care information is complex, unlike simple bank
transactions, for example, and it can be difficult to structure. Health
care information may include text, images, pictures, and other
graphics.
• There is no simple standard operating procedure the provider can turn to for
diagnosing, treating, and managing an individual patient’s care.
• The provider relies on prior knowledge and experience and may order a battery
of tests and consult with colleagues before arriving at a diagnosis or an
individualized treatment plan.
• Terminologies used to describe health information are also complex and are
not used consistently among clinicians.
1.
Health information is highly sensitive and personal. Every patient
must feel comfortable sharing such sensitive information with
health care providers and confident that the information will be kept
confidential and secure.
IT
3.
Health care IT is expensive, and currently it is the health care
provider or provider organization that bears the brunt of the
cost for acquiring, maintaining, and supporting these
systems.
4.
In the U.S. health care system is not a single system of care
but rather a conglomeration of systems, including
organizations in both the public and private sectors.
• Thus another major challenge facing health care is the
integration of heterogeneous systems. Some connectivity
problems stem from the fact that when microcomputers
became available and affordable in the last half of the 1980s,
many health care organizations acquired a variety of
departmental clinical systems, with little regard for how they fit
together in the larger context of the organization or enterprise.
IT
• Integration issues may be less of an issue when a health
care organization acquires an enterprise-wide system
from a single vendor or when the organization itself is a
self-contained system.
• However, rarely does a single vendor offer all the
applications and functionality needed by a health care
organization. Significant progress has been made in
terms of interoperability standards, yet much work
remains.
challenges
• Rising Costs
• Medical Errors
• Coordination
Rising Costs
• New diagnostic technologies, such as magnetic
resonance imaging devices, lead to increased costs of
healthcare.
• The rapid rise in healthcare costs sets off a series of
events. Briefly stated, the rise in costs forces the
insurance programs and employ- ers to contain costs.
These efforts of the payers to contain healthcare
expenditures have an impact on the hospitals and
physicians.
Medical Errors
• Some estimates show that about 100,000 people die each year
in the United States from medical errors that occur in hospitals.
• Existing information systems, designed primarily for billing
purposes, often fail to record important information about a
patient’s condition.
• A comparison of claims and patient records reveals that claims
do not accurately reflect over half of the clinically important
patient conditions.
• Even when information system software allows for the entry of
additional information, that information often is incorrectly
entered.
Medical Errors
• Important to patient safety is the ordering, transcribing, and
administering of medications.
• The most common error is in dosing, which occurs three times more
frequently than the next type. The top causes of failure include:
• Prescribing errors due to deficiency in drug knowledge related to incorrect
•
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•
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dose, form, frequency, and route.
Order transcription errors due to manual processes.
Allergy errors due to the systems poor notification to healthcare providers.
Poor medication order tracking due to a cumbersome, inefficient system, that
is, dose administration is recorded in more than one location.
Poor interpersonal communication, that is, illegible orders.
• Proper information systems could reduce the incidence of these
errors.
Avoidable Error
The health care industry is not perfect. The people administering health care are also not perfect. They tire
after 12-hour shifts. They at times must make quick decisions with very little support around them. Their
handwriting at times is less than ideal, and above all else, they are human. Whether we want to admit it or
not, humans make mistakes. Because we in the health care industry are aware of our human characteristics
that leave us exposed to the possibility of making mistakes, we do everything possible to prevent those
mistakes from occurring in the first place. Information technology can help. Medication errors in hospitals are
frequent and may harm patients. Medication errors include incorrect dosing, incorrect drug given, or incorrect
timing of drug administration. Medication administration is a primary responsibility of nurses, and error
prevention is taught during their training. Still, competent nurses may make mistakes. An example of a device
and information system that is in widespread use in hospitals today and that has dramatically decreased the
number of medication errors is called Pyxis. Pyxis is a medication-dispensing computer that is maintained by
the pharmacy, is located on each unit, and is stocked with medications for each patient on that unit. The
patient s medication administration profile is updated in the system by the pharmacy and when medications
are due to be given, a nurse, using password entry, signs into the system and obtains the medication.
Medications can be obtained only when due and only in the correct dose required. The Pyxis system can be
overridden, but the nurse must then take extra steps. This computer-supported dispensing helps to prevent
errors by nurses who are rushing and tired and who might otherwise be reading orders written in difficult to
read hand-writing. Medication errors can still occur but are less frequent due to the enforced double check
(pharmacy and nursing).
Coordination
• Because of its decentralized nature, the healthcare industry
has a very complex business model consisting of a fragmented
community of trading partners.
• Improvements in information systems also are needed to
support the coordination of care.
• To provide effective care, health professionals and providers
need access to a patient’s treatment history, test results, and
related information.
• Paper records are difficult to transfer between organizations.
Where computer records are kept, the use of incompatible
hardware and software configurations makes file sharing
difficult.
A Failure to Share.
My grandmother died because there was no medical history available so that the physician could be aware of
her condition and provide appropriate treatment to save her life. She always went to Adventist Hospital for
surgery and other procedures. All of her medical histories were at this hospital, and this is where her primary
care physician was affiliated. One tragic weekend my grandmother went to see my mom in Adamsville. That
morning my grandmother told my mom that she was having stomach pain, and about noon the pain was still
there and my grandmother felt tired and short of breath. My mom called the ambulance to take my
grandmother to the emergency room. When the ambulance personnel arrived, they took her to St. Mary s
Hospital. My mom said no, we want you to take us to Adventist Hospital . The ambulance personnel replied
we must take her to the nearest hospital . When my grandmother got to St. Mary s Hospital, the medical staff
didn’t know what to do. They asked us to give them my grandmother s medical history. Our family gave all the
information that we knew to the nurse. After a few hours, my grandmother cried and asked for medication.
The nurse responded that the ER physician was trying to contact her primary care provider for further
information so that the ER physician could determine the best treatment. Another hour passed, and nothing
was done to stop the pain. The ER physician decided to admit my grandmother to the hospital for further
evaluation. After they took my grandmother to her room, still nothing had been done for the pain. My
grandmother lay in bed and cried. Two hours later my grandmother went into cardiac arrest. Nurses gave her
CPR and were able to bring her back, but she was in a coma and connected to numerous machines. For 10
days my grandmother never awoke or responded to the family. Finally, our family had to make the painful
decision to remove the machine that was keeping her alive. The problem was that St. Mary s Hospital did not
have any medical records of my grandmother so the ER physician was not able to determine a treatment for
her. Her primary care physician wasn’t affiliated with the hospital; he didn’t have privileges to access the
facility. Think of the senseless deaths that are the result of an ER physician being unable to make an accurate
decision on which care to give a patient.
References
• “Health Care Information Systems: A Practical Approach
for Health Care Management”
By Karen A. Wager, Frances W. Lee, John P. Glaser
• “Information Systems and Healthcare Enterprises”
By Roy Rada