INFORMATION SYSTEMS IN HEALTH CARE

OVERVIEW
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.:
A. The core business of providing healthcare to its clients
B. 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.
I. Patient Care Information System
II. Managerial Information System
Main Divisions of HIS

Healthcare Information System

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.
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.
SYSTEM INTEGRATION
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:
A. The Systems for the Patient Care Function
B. 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

Patient Care Information System

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:
a. Productivity
b. Effectiveness
c. Appropriateness
d. Efficiency
e. Quality
f. Safety
g. Privacy and confidentiality of information
To achieve the above objectives, the computerized information system is required to provide the following
functions:
i. Guide and enable the performance of Patient Care Processes
ii. Facilitate communication between care providers through sharing of information
iii. 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
iv. Provide clinical decision support at point of care
v. Gather, store and make available vital clinical information (individual and aggregated) for
primary and secondary use
vi. 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:
a. Patient/Client Management (Administration) Information System
b. Clinical Information System (CIS)
 CIS for various specialties
 Clinical Documentation
  Clinical Decision Support
 Centralized Continuous Monitoring System
 Electronic Medical Record
c. Clinical Support Systems
 Laboratory Information System
 Blood Banking Information System
 Radiology Information System
 Pharmacy Information System
 Food and Beverage Supply System
 Operation Theatre / Suite Information System
 Sterilization and Sterile Inventory & Supplies System
 Other support systems
d. Bridging or intermediary systems
 Order Entry – Result Reporting System (CPOE)
 Patient Information Database Management System
e. 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
f. Means of supplying data to external organizations
The relationships of the systems are as depicted the chart below:
Healthcare Information System

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:
1. Planning of care (use of Care Plans)
2. Provision of Clinical Decision Support
3. Clinical Data Documentation (Data entry)
4. Quality Control
5. Data Storage
6. Data Retrieval and Display
Components of the Clinical Information System

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
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.
A. Patient Administration/Management System (Registration, Scheduling, Resource
allocation)
B. Order-Entry Result Reporting Application (CPOE)
C. Database Management System (DBMS)
D. Electronic Medical Record
E. 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.
Chart Showing Bridging Role of Five Key Applications/Functionality of the Patient Care Information
System
Bridging 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

Patient 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

Order Entry, Task Performance and Result Reporting Functions

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
Sharing 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

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:
1. General Administration Information System & Office Automation
2. Charging, Billing and Receipt of Payment (Accounting) System
3. Human Resources Management System
4. Finance and Budgetary Systems
5. Consumables Purchasing and Inventory System
Systems for facilitating the hospitality services of a hospital include:
A. Bed management
B. Food-Beverage Order-Supply System
Systems for management of the hospital as a physical facility include:
A. Facility Engineering Systems
B. Equipment and Machinery Maintenance and Inventory System
 C. Environmental Safety, Housekeeping, Cleansing and Waste Management
Managerial Decision Support Systems (DSS) can be very helpful and include:
I. Business Management Decision Support
II. 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.
Chart Showing Components of Managerial Information System