Information systems facilitate the delivery of services at many levels. They support the activities of planning, management and the performance of processes besides enabling the recording of information. Healthcare Information Systems refers to a set of systems for the entire healthcare services encompassing patient care as well as services for the early detection of disease, prevention of health problems and promotion of wellness, at any location. The main subject discussed in this article is the Hospital Information System (HIS) which deals with the care of persons suffering from an illness (i.e. a patient). The system, as described here, is also applicable to a free-standing general or specialty outpatient clinic.
HOSPITAL INFORMATION SYSTEM (HIS)
An information system that facilitates the activities of a hospital takes into consideration:
- the functions of a health care facility
- the capability of information technology
The information management system complements the other components of the very complex organizational structure and operations of a hospital. It acts as an integrator of all these components by enabling the collection, storage and sharing of information. The scope, content and structure of the Hospital Information System (HIS) serve many different functions. It contains a set of sub-systems and applications (often referred to as modules) that utilizes information-communications technology and computerization optimally to facilitate the delivery of services of the hospital.
In general, information systems of a healthcare facility facilitate two main group of activities, functions and services i.e.:
- The core business of providing healthcare to its clients
- Managing the hospital as a business entity, a provider of hospitality services and a physical facility
The Hospital Information System (HIS) is focused primarily on the Operations Management of the hospital. However, data available from the system may be collated, analyzed and used for strategic management including research. The HIS is envisaged as consisting of two broad systems i.e.
- Patient Care Information System
- Managerial Information System
Main Divisions of HIS
The division into these two broad categories is conceptual. The information system that supports administrative, human resource, facility and hospitality management activities are placed arbitrarily under the Managerial Information System. This article and others in this website deals mainly with the Information Systems for Patient Care Function, i.e. the core business activity of a hospital.
Contributions to Other Health Information Systems
The Hospital Information System should be capable of sharing patient data with other health care institutions so as to enable continuity of care via the Health Information Exchange or Data Warehouse or other means. It is expected to contribute to the national health database (in Malaysia: the National Health-Management Information System) by supplying information for health promotion, disease prevention and early detection efforts as well as for planning, resource allocation, epidemiology, case-mix calculations etc. at district, state and national level. It should also provide information to systems belonging to third party institutions e.g. external agencies like the Drug Safety Council, Registration Department, Road Safety Council, the Police, insurance companies and many others.
The Capability of Information Technology
A computerized information system opens many possibilities in data management . A major advantage is the storage of data in a database from which relevant data can be extracted and manipulated to create views and reports for specific purposes. These capabilities is depicted in the diagram below and will be explained further:
HOSPITAL INFORMATION SYSTEM : CHARACTERISTICS
A Hospital Information System can be designed and built in-house from the outset or purchased. Either way, the suite of applications software and databases need to be assessed or appraised to determine suitability for use before being made available to intended users. Systems purchased off the shelf, need to be customized to suit the hospital’s services, policies, procedures and equipment. On the other hand, some compromises in the existing processes may be required in order to align them with the requirements of computerization and use of information technology.
The data need to be stored in a properly designed database. The data structure is formulated by defining entities, relationships and naming of data elements and possible values attributed to each data element. This is achieved through the activity of Business Process Re-engineering, Customization and Database Design. An important aspect is the use of standard naming conventions peculiar to the hospital such as that for services, locations, care provider categories, visits, encounters and events. These static data elements are made available in reference tables. For variable data, universally accepted standard nomenclature such as Snomed CT, LOINC, ICD 10 Classification of Diagnosis would facilitate data sharing and data analysis.
At implementation, User Acceptance Testing should be thorough; initially on a Development/Build version of the system in a simulated Operations environment, and subsequently on the actual Operations/Production Version. After implementation the system has to be appraised continuously and improved upon if necessary.
Where legacy systems are retained they should be aligned with the structure and arrangement of the new HIS. A difficult issue is data migration. Success depends on ensuring technical compatibility as well as semantic consistency between the new database with the old data such that the data can be migrated into the new database and is accessible through the new applications. Data migration is discussed in a separate section.
Some devices and instruments may need to be replaced or new ones added to enable interfacing. There will be definite changes in the way data is collected because this needs to match with the data structure, collection and presentation used by the system.
The information systems and applications are usually considered to consist of modules for ease of description. It is crucial that the Hospital Information System is fully integrated so as to function seamlessly across modules. Integration refers to the interaction between applications software with each other and with the hardware, enabling one to work with another for a desired purpose. Poor integration often make it necessary for the user to go through extra steps to complete a task and also slows down the system response time. A substantial part of integration is the interfacing of information system computers with computers of peripheral hardware (machines, measuring apparatus etc.) enabling them to engage in transfer and retrieval of data or instructions. Integration need to be addressed at the stage of HIS design as well as implementation.
It would be desirable to design or procure a HIS that have been fully integrated from the start and where the modules and sub-systems are proven to interact smoothly with acceptable response time and ease of use. Trying to integrate disparate applications software with different data structure and using different operation systems at the time of implementation would be an unenviable task. Integration usually involves two or more parties. Issues that can pose a stumbling block to speedy and successful implementation are sharing out of responsibilities, agreeing on a schedule and apportioning costs.
Another important consideration is the coordination between services and units within the hospital so that the each module takes into consideration differences in their policies and procedures. It would be desirable for these policies and procedures to be made complementary, uniform and standardized. Minor variations can be allowed.
ENABLING AND ENHANCING COMMUNICATIONS
Communications between care providers is of paramount importance. Various approaches and means can be used to facilitate and enhance communications. The main method is through the sharing of information. This is achieved by is placing data generated by each care provider in a common database and then making them available to others through views and displays tailored to the needs of various categories of users. Instructions, orders and reminders can be placed in the individual user’s in-box within an in-built e-mailing system. Messages can be relayed from the information system to users via both internal and external communications systems and devices such as computers (in-boxes, e-mails via intranet and internet), electronic white boards and mobile phones. Communications with patients can be through the same means, interactive kiosks and through web portals
INFORMATION SYSTEM FOR PATIENT CARE
The Hospital information System (HIS) can be broadly divided into two halves:
- The Systems for the Patient Care Function
- The Managerial Information Systems
The clinical and other functions relating to the care of a patient is facilitated by a set of systems which can be given a generic name of Information Systems for the patient care function. The term Patient Care Information System is attractive and acceptable but, unfortunately, is used only by small number of advocates. This term will be used in all subsequent discussions here because having this extra category level as the parent, with the Clinical Information System (CIS) considered as a child, clarifies the nomenclature. The term Clinical Information System is not used to mean the whole information systems for patient care. Instead, the name CIS is confined to the system that facilitates or supports direct patient care functions. The other half of the system is the Information systems for Clinical support services which are made up of several modules.
Conceptual Division of Systems for Patient Care
The term is ‘EMR/EHR Systems‘ is commonly used. This term is a misnomer and should not be used at all because information systems are useful only if they facilitate work rather than just “the creation, storage, and organization of electronic medical records” as understood by some.
OBJECTIVES & FUNCTIONS OF PATIENT CARE INFORMATION SYSTEM
Being a system for facilitating operations, these set of sub-systems and applications are expected to utilize computerization and information technology optimally to realize desired objectives in the following areas:
- Privacy and confidentiality of information
To achieve the above objectives, the computerized information system is required to provide the following functions:
- Guide and enable the performance of Patient Care Processes
- Facilitate communication between care providers through sharing of information
- Enable automation of work processes through links within it, integration with other components of the hospital information system and interfacing with other computers, machines, printers and scanners
- Provide clinical decision support at point of care
- Gather, store and make available vital clinical information (individual and aggregated) for primary and secondary use
- Maintain a permanent record of events and all activities of patient care (as the Electronic Medical Record and other documents based on medico-legal requirements)
Any system being designed, proposed or implemented must possess characteristics that would fulfill all the above objectives and functions; both in its content and the methods used.
SCOPE, CONTENT & RELATIONSHIPS OF PATIENT CARE INFORMATION SYSTEM
The Patient Care Information System consists of:
- Patient/Client Management (Administration) Information System
- Clinical Information System (CIS)
- Clinical Support Systems
- Bridging or intermediary systems
- Order Entry – Result Reporting System (CPOE)
- Patient Information Database Management System
- Applications that support Clinical Governance
- Clinical Managerial Decision Support Application
- Quality and Productivity Management Application
- Infection Prevention and Control Application
- Clinical Data Extraction and Reporting Application
- Means of supplying data to external organizations
The relationships of the systems are as depicted the chart below:
Healthcare Information System
All the above systems are used by health care personnel to care for patients. Care is here defined as all work activities to deliver services to patients in response to their needs.
Clinical Information System
The Clinical Information System (CIS) facilitates direct patient care i.e. activities where care providers i.e. mainly doctors and nurses but also includes Dietitians, Therapists, Clinical psychologists, Clinical pharmacists, Clinical Microbiologists, Interventional Radiologists, Endoscopists, Optometrists, Audiologists and many others. A good CIS provides assistance and guidance for clinicians to perform their work besides capturing pertinent data that is generated.
The CIS contains application modules (however named) that enable the following:
- Planning of care (use of Care Plans)
- Provision of Clinical Decision Support
- Clinical Data Documentation (Data entry)
- Quality Control
- Data Storage
- Data Retrieval and Display
Components of the Clinical Information System
Clinical Support Systems
Clinical support refers to services that
- perform tests
- provide supplies
Direct care providers request for these services through the Order Entry functionality. Test results are submitted to the database from where they are made available. Supplies like drugs, blood products, sterile supplies and food are delivered to persons/units requesting them. Their delivery and receipt are recorded in the database.
System for Clinical Support Services
INTEGRATION OF THE COMPONENTS PATIENT CARE INFORMATION SYSTEM
Integration within the Patient Care Information System is essential. The smooth running of this system are dependent on proper linkages between sub-systems/modules within it. It is desirable that they are already fully integrated at the time of procurement.
KEY BRIDGING APPLICATIONS
The main patient care applications software i.e. the Clinical Information System and the various Clinical Support Systems are built around key bridging (intermediary) components i.e.
- Patient Administration/Management System (Registration, Scheduling, Resource allocation)
- Order-Entry Result Reporting Application (CPOE)
- Database Management System (DBMS)
- Electronic Medical Record
- A common user-system interface (front end screen, GUI)
These applications are thought of and designed first and then amended as each clinical and clinical-support application is designed. Additional applications software are designed to be compatible with these key bridging (intermediary) applications.
Role of Patient Administration/Management System (PMS)
The Patient Administration/Management System (PMS) supplies identification, demographic and other static data such as payment class to the Patient Information Database. Other systems derive these data from the database thus ensuring that they are standardized and making it unnecessary for them to be obtained repeatedly.
Components of Patient/Client Management/Administration System
Role of Order Entry application
The Order Entry application acts as a means of communications between care providers and the tool for planning, initiation and execution of processes or tasks. It enables transactions started in one module to go across to another module and be executed. Labels printed with identification data can be attached to samples so that the patient identity is known and results can be placed in his/her record in the database.
The Order Entry -Result Reporting Function
Role of Patient Information Database
The ability to share data is essential for the success of an integrated HIS. The Patient Information Database enables data generated and submitted by each user to be stored and then shared with others through displays on the computer screen, or printed material (documents and labels). Accumulated data can be analyzed using various tools to create reports for clinical and managerial use.
Sharing of Information Through a Common Database
Data can also be exported to other systems such as:
- Shared operations database(s) where patient data is made available to other institutions for purposes of patient care
- Data warehouse(s) where anonymized patient data is pooled and used for epidemiology, strategic management and research.
Shared Operations Database and Data Warehouse
Secondary Use of Patient Data
The capability to analyse, interpret and make them available as reports to managers and external agencies (e.g. the Ministry of Health) should be in-built in any HIS. Otherwise a third party analysis and reporting system need to be procured. Its function would be to and keep them in a repository before distributing them to agencies involved in planning, budgeting, resource allocation and performance monitoring.
Reports are used by various users and managers of the institution or at higher management levels to:
- facilitate the business managerial functions and clinical governance within the hospital/health care facility
- provide data to external agencies (e.g. those within the Ministry of Health) for use at the community and national levels
Hospitals would require reports that are standard (routine, used on a regular basis) plus as and when required (ad hoc). Data from a group of patients can be extracted and manipulated, for purposes of managerial oversight, audit and research. At a higher level essentials reports that can be generated include those for determining current performance such as Key Performance Indicators (KPIs), the Health Management Information System Reports (HMIS), Information Documentation System Reports (IDS), Disease or Procedure Registry Reports and Quality Assurance reports.
Role of Medical Record
The traditional function of the paper-based Medical Record is to retain and make available historical data to current and future clinical users for continuity of care and to non-clinical users for various valid purposes. In a computerized environment, most of the functions of the paper record (i.e. the capture, storage, distribution and communication of data) is taken over by the Patient Information Database. During care, providers (clinical and non-clinical) submit, record and retrieve data to and from this database rather than the Electronic Medical Record. However, it is still necessary to create and maintain a Medical Record for each patient, for medico-legal and professional reasons. Therefore, the content and arrangement of data in the clinical applications and database need to take into account of the legal and professional requirements of the Medical Record. The Electronic Medical Record is generated through a specially designed data extraction application using a query tool that defines its content and structure. It can then be printed if necessary or made available in various format. The EMR is discussed further in another article.
Role of Common User-System Interface (GUI)
It is important for the user-system interface i.e. the front end screen viewed by users to access applications and input/retrieve data to be the same for all instances of use of the system. The interface are made to be intuitive and familiar by fixing positions, shapes and colour scheme of the navigation menu and by standardizing the way they operate. It is best that the set of applications or views required by a user is made available to him/her, on logging-in, by matching them with his/her role. The need to log-in and out of various applications should be minimized.
INTEGRATION WITH THE REST OF HIS
It is crucial that the Information System that the Patient Care Function is able to integrate with other systems of HIS. For the sake of choosing the best of the breed, it may be necessary to procure separate systems or modules from different vendors. Due consideration must be given to areas where Management Information Systems interact with the Information System for the Patient Care Function. Examples of such areas are Charging and Billing, Human Resource deployment, Bed allocation and Food-Beverage services.It is imperative that these are demonstrated to be capable of full integration with the rest of HIS.
Use of a common Patient Information Database and good data extraction-analysis tools will support the activities of incident reporting, clinical epidemiology, disease surveillance, quality management, utilization review, risk management and similar functions.
MANAGERIAL INFORMATION SYSTEM
FUNCTIONS OF MANAGERIAL INFORMATION SYSTEM
The Managerial Information System refer to the set of sub-systems and applications that assist managers in running the hospital as a:
- business entity
- provider of hospitality services
- physical facility
The term ‘managerial’ is generic and refers to a set of sub-systems useful for managers. It is used here because other terms such as Management / Operations / Business / Enterprise Resource Planning systems have their own usage.
COMPONENTS OF MANAGERIAL INFORMATION SYSTEM
Systems that support the business operations include:
- General Administration Information System & Office Automation
- Charging, Billing and Receipt of Payment (Accounting) System
- Human Resources Management System
- Finance and Budgetary Systems
- Consumables Purchasing and Inventory System
Systems for facilitating the hospitality services of a hospital include:
- Bed management
- Food-Beverage Order-Supply System
Systems for management of the hospital as a physical facility include:
- Facility Engineering Systems
- Equipment and Machinery Maintenance and Inventory System
- Environmental Safety, Housekeeping, Cleansing and Waste Management
Managerial Decision Support Systems (DSS) can be very helpful and include:
- Business Management Decision Support
- Clinical Governance Decision Support
The DSS can be of variable capability. It can range from simple statistical tools to business intelligence software. Large organizations may also want to create a Data Warehouse and use Enterprise Resource Planning software.
The components making up the Managerial Information System is wide-ranging and complex. They are not within the scope of this discussion (at this point) but mentioned here for completion. However certain components that integrate or interface with the Information System for Patient Care Function will be discussed.