HEALTH INFORMATION SYSTEM IN MEDICAL LABORATORY SCIENCE
HMIS Data Quality
Data
 Representation of facts, concepts, or instructions in a
formalized manner, suitable for communication,
interpretation, or processing by manual or electronic
means. (Abdelhak, et.al, 1996)
 In healthcare, these describe specific characteristics
of individual patients. Either collected on paper or in a
computer, the data should be organized in such a way
that we can understand and retrieve then when
needed. (Lacour, 2002)
Types of Data
1. Primary Data
o Obtained from the original data source.
o Documentation in the patient's medical
record collected by staff at either a hospital,
clinic or aid post.
2. Secondary Data
o Data sets derived from primary data.
o Individual or aggregate healthcare data
found in reports that are summarized from
the source.
o Example:
 Health statistics and disease
registries
Data and Information
 Health data
o Items of knowledge about an individual
patient or group of patients.
o Captured in paper or electronic format during
his/her attendance at the health facility.
o Regardless if data collection is done
manually or computerized, it is important that
the encoding is correct at the point of entry.
 Health information
o Health data that have been organized into a
meaningful format.
o Refers to organized data collected about an
individual patient.
o May also refer to aggregated data about all
patients that have been attended.
Health Information should be
capable of:
1. Promoting excellent clinical care.
2. Describing the types of individuals using services and
the types of services they receive.
3. Measuring efficiency of the contact, treatment, referral
and interaction by healthcare professionals.
4. Helping in the coordination of care between services
provided.
5. Providing meaningful statistics for determining the
health status of the community.
6. Measuring quality from a patient and provider
perspective.
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7. Meeting accountability requirements.
Accurate and reliable health
data are needed for:
1. Determining the continuing and future care of the
patient at all levels of the healthcare.
2. Medico-legal purposes for the patient, physician, and
healthcare service.
3. Maintaining accurate, reliable, complete information
about disease, procedures, and programs, as well as
the number and types of participants.
4. Clinical and health service research and outcomes of
5.
healthcare interventions.
Teaching healthcare professionals.
6. Working out staffing requirements and planning
healthcare services.
Users of Health Data
1. Doctors, Nurses, and Other Healthcare Professionals
o Treating a patient admitted to a healthcare
facility.
o Use the medical/health record as a means of
communication during an episode of care
and treatment of a patient, and as an aide
memoire for continuing care of that particular
patient.
o Also used as health care data to evaluate the
services provided.
2. Nursing staff
o To evaluate data and develop critical
pathways and patient care plans for admitted
patients.
3. Health Insurers
o Require information to reimburse the patient
and/or health care facility for services
rendered whether for an inpatient or
ambulatory patient.
4. Legal Representatives and Courts
o As documentary evidence of a patient's care
and treatment by a health care worker in a
healthcare facility.
o Also used to protect the legal interests of the
patient, doctor and other health
professionals, the healthcare facility, and the
public.
5. National Ministry/Department of Health
o To review vital statistics and the incidence
and prevalence of disease in an area. The
provision of accurate and reliable aggregate
data is important for public policy
development and funding of health care
services.
6. Hospital Quality Assurance Committees
o Basis for analysis, study, and evaluation of
the quality of healthcare services rendered to
the patients.
7. Researchers
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o To analyze and interpret the data to  Administrators and managers

determine causes, prevention and treatment o Leaders in the move to improve the quality of
for diseases, injuries, and disabilities. data collected in the healthcare facility.
8. Accrediting/Licensing Agencies of Healthcare  Senior physicians
Facilities o Take the lead in ensuring quality data by
o To review medical/health records to provide taking time to ensure junior physicians
public assurance that quality health care is record clinical data accurately and in a timely
provided. manner.
9. National Government  Senior allied health professionals
o Uses the information to develop healthcare o Responsible for the provision of accurate
policy and provide and regulate funds. and timely reporting and better checks on the
quality of the report content.
Data Quality  Senior medical records staff
o Ensure that medical records are complete,
 Quality consists of the ability to achieve desirable available, and accessible when needed.
objectives using legitimate means.
(Donabedian,1988)
 Quality data represent what was intended or defined
by their official source, are objective, unbiased, and Routine Data Quality
comply with known standards. (Abdelhak, et al., 1996)
 It includes: (1) accuracy and validity; (2) reliability; (3) Monitoring
completeness; (4) legibility; (5) timeliness; (6) 1. Quantitative Analysis of Medical Records
accessibility; (7) meaning or usefulness; (8) o Medical records should be reviewed to check
confidentiality and security. that all documentation has been included
and complete. (Huffman,1963)
Components of Data Quality o All relevant documentation must be present
and authenticated.
1. Accuracy and Validity o The medical records department can verify
o The original data must be accurate to be the completeness of medical records by
useful. formal medical record review using a simple
o Recording data is subject to human error and random sampling on a regular basis.
steps must be taken to ensure that errors do o The information pertaining care is reviewed
not occur or are picked up immediately if for accuracy, validity, and timeliness
they do occur. (Huffman,1963).
2. Reliability 1. Data Entry Checks
o Data should yield the same results on  Patient demographics are
repeated collection, processing, storing, and checked in the admission
display of information. office, emergency
3. Completeness department, or outpatient
o All data should be present, and the medical reception, health center or
record should contain all pertinent clinic reception (crucial for
documents with complete and appropriate proper ID) prior to
documentation. provision for health
4. Legibility services.
o All data, whether written, transcribed, and/or  Healthcare professionals
printed should be readable. at all levels of healthcare
5. Timeliness should check the accuracy
o Health information should be documented as of the data for which
an event occurs, treatment is performed, or he/she is responsible.
results noted.  When medical records is
o Delaying documentation could cause returned to the records
information to be omitted and errors department after
recorded. discharge, death, or OPD
6. Accessibility attendance, records staff
o All necessary data are available when check for data completion
needed for patient care and for all other before filing.
official purposes. 2. Checks on the Quality of Abstracted
o The value of accurately recorded data is lost Data
if it is not accessible.
2. Qualitative Analysis of Medical Records
Leadership in Data Quality
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o The information pertaining to patient care is o Data quality control programs or measures
reviewed for accuracy, validity, and should be in place.
timeliness (Huffman,1990).  No Single Record
 Reviewing medical records to o A problem of quality arises if more than one
ensure that all clinically pertinent medical record is kept on each patient (some
data have been accurately departments insist on keeping their own
recorded. records).
 Checking the front sheet to ensure  Data Discrepancies
that the patient's diagnosis and o Arising when errors occur at the point of
treatment have been recorded and collection and plans are not in place to check
are supported by documentation in the entry and verify the data.
the body of the medical record.
3. Audit of Accessibility of Medical Records
o To help the accessibility and the quality of To Maintain Data Quality,
the medical/health record services, study
programmes should be instituted. For Health Data must be:
example, the medical record retrieval should 1. Appropriate
be studied using predetermined criteria and o For the overall needs of the patient and
data collection form. healthcare services.
4. Audit of Medical Records 2. Organized
o A retrospective review of selected o To enable it to be understood and used
medical/health records or data documents to when required.
evaluate the quality of care or services 3. Timely and Available
provided compared with predetermined o To users when required.
standards. 4. Accurate and Complete
o To validly assess the completeness, o Otherwise, it would be difficult to make
accuracy, consistency, and legality of the appropriate decisions.
medical record, an evaluation of the 5. Cost-effective
adequacy of medical record content can be o If the cost of collecting and disseminating
conducted. information exceeds its value, the usefulness
of the data collected must be addressed.
Issues in Data Quality
Improvement
 Lack of Uniformity of Data
o Without predetermined standards and
uniform data sets, problems relating to the
quality of health data are difficult to solve.
 Poorly Designed Data Collection Forms
o If forms are not well designed, the collection
of data could be affected, resulting to poor
quality data.
 Limitations to Physician's Capacity to Communicate
o Some MDs find it difficult to record data in a
clear and concise manner, resulting in poor
information; often use non-standardized
abbreviations and are "too busy" to complete
medical records once the patient has been
discharged from the facility.
 Limitations to Information Transfer from Different
Parts of the Facility
o Transfer of information from one department
to another or from a hospital to a clinic is
often slow or information is lost in
transmission.
 Limited Education of Processing Staff
o Production of quality data is compromised if
staff handling the records are not properly
trained.
 Lack of Planning

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Laboratory
 Mobile
o Gartner’s (2016) reports that mobile LIMS
offerings are limited. But with the accepted

Information
use of smartphones in the laboratory, it is
better for LIMS to be mobile-friendly.
 Enterprise Resource Planning

Management
o A LIMS that can handle inventory functions is
recommended. The enterprise resource
planning (ERP) solution is especially useful in
viewing current supplies, calculating storage

System capacity, and managing location.

 Designed to help process information in medical Core Components of LIMS

research to improve the efficiency of the department's
services and laboratory operations by reducing manual 1. Electronic Laboratory Notes
tasks and procedures. 2. Sample Management Programs
3. Process Execution Software
Functional Requirements and 4. Records Management Software
5. Applications to Interface with
Features of LIMS Analytical Instruments or Data
Systems
 Sample Management 6. Workflow Tools
o Accurate and detailed records are necessary 7. Client Tracking Applications
to make sure that samples are not lost or 8. Best Practice and Compliance
mixed up.
o A record should show whether the sample
Databases
meets the acceptable values. 9. Enterprise Resource Planning (ERP)
o LIMS automates sample management by Software
using radiofrequency identification (RFID) or
barcodes in recording and updating logs and
track the chain of custody of the sample. Applications of LIMS
 Workflow Management  Patient Registration
o LIMS can be used to automate records and
workflows which saves time.
 Billing
o Existing coding methods and procedures  Contract Management
enable the system to take part in the decision
process.
o Using preset rules, it can suggest instruments Worklist and Workflow
needed for the procedure and assign the  LIMS assists laboratories in setting priorities of current
medical laboratory technician or specialist to workloads based on analyst and instrument availability.
complete the test.  Queuing can also be done by sample or by workflow
 Reporting which is a block of repetitive procedures in a certain
o Using LIMS, reports can be run and exported process.
to make them standard and customized.  This function allows the user to track a sample, a batch
o Reports on the most frequently used of samples, or numerous batches through their
instrument, the average handling time of lifecycle.
sample, and list of backlogs are useful in data  The queuing and work list feature provides insights
analysis and formulation of recommendation about when an event occurred, how long it was, and
for future policy making. who was involved.
 Electronic Medical Records
o Some LIMS have a built-in electronic medical
records (EHR) functionality which is capable
Quality Control
of handling patient records and billing  Diagnostic tests executed inside the clinical laboratory
information. may yield two kinds of results, a patient result or a
o A health institution should consider this during quality control (QC) result.
acquisition because this feature will greatly  QC results are used to verify whether the instrument is
help in managing clinical laboratory working within prescribed parameters.
procedures.
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 LIMS functions enable users to set standards about the

relevant range of patient test results or to extract test
result information for the purpose of quality assurance.
 Outliers and deviations can be flagged, and
appropriate warning signals can notify users about
issues which might involve the quality of the samples
or the equipment currently in use.

Barcode Generation, Printing,

and Reading
 LIMS modules are commonly linked to a barcoding
label generator which enables a fast and easy method
to identify tubes, samples, documents.
 The code can simply be printed on a label sticker to be
placed on any item which need identification.
 With this kind of technology, information about a tube,
a specimen, or equipment within the laboratory can be
found and retrieved effortlessly using a barcode
scanner.

Key Points to Remember:

 A laboratory information system
(LIMS) is a software designed to make
laboratories more efficient and
effective.
 The ultimate aim of LIMS is to enhance
efficiency in laboratory operations by
reducing manual process.
 LIMS assists laboratories in setting
priorities of current workloads based
on availability of analysis and
instruments.
 LIMS functions enable users to set
standards for the relevant range of
patient test results or to extract test
information for the purpose of quality
assurance.
 LIMS modules are commonly linked to
a bar-coding label generator, enabling
a fast and easy method of identifying
tubes, samples, documents, and
many others.

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HEALTH INFORMATION SYSTEM IN MEDICAL LABORATORY SCIENCE
Hospital
Information
System
Hospital Information System
 A computer system structured to manage all the
records of health care providers to make available
information and reports useful to health care personnel
in doing their job more efficiently.
 Introduced in the 1960s and has evolved since then to
cope with the changes and demands of the modern
times.
 The modern HIS has applications built to address the
needs of the various departments of health facilities
such as nursing, pharmacy, finance, radiology, and
pathology.
 Delivers high quality patient care and better
management of financial records; it needs to be
affordable, scalable, and centered on the needs of
patient and medical personnel.
 Links computers that are capable of quickly optimizing
operations and delivering quality service. The systems
gather, process, retrieve patient information, and
provide hospital stakeholders with relevant information
through reports for better decision making.
Application in Different
Departments
Nursing Information Systems
 Developed to enhance patient care by providing nurses
with accurate information to assist them in performing
their duties more efficiently.
 NIS carries out numerous functions including the
handling of personnel schedules, accurate patient
charting, and better clinical data integration.
Physician Information Systems
 Physician information systems are designed to
improve the practice of physicians.
 Electronic medical records (EMRs) and electronic
health records (EHRs) are some programs where PIS
is deployed and extensively used.
 Most systems offer support 24/7 to facilitate easier
usage of the system by health care professionals.
Pharmacy Information Systems
 Pharmacy information systems help monitor the
utilization of medicines in health institutions.
 The system also handles information on medication-
related complications and drug allergies of patients.
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 It provides information to identify drug interactions
which help in administering the appropriate drugs by
considering the physiological conditions of the patient.
Selecting a Hospital Information System
Provider
 Total Cost of Package
 Web-based System
 Implementation and Support
Providers of Hospital Information Systems
in the Philippines
 BizBox, Inc.
 Kaiser-Dela Cruz Consulting, Inc.
 Comlogik Business Systems, Inc.
Functions
 Helpdesk
 Scheduling
 Patient Registration
Laboratory Reports
 Despite the differences in presentation and form, all
laboratory reports must process common elements as
required by institutional and company policies.
 They may also contain supplementary items not
specifically required, but which the laboratory chooses
to report to aid in the interpretation of results of medical
testing.
 For identification and filing purposes, some laboratory
reports display elements with administrative or clerical
information such as the following:
1. Patient name and identification number or a
unique identifier and identification number.
2. Name and address of the laboratory location
where the test was performed.
3. Date Report Printed
4. Test Report Date
5. Name of Doctor or Legally Authorized Person
Ordering the Test(s)
 Information about the specimen and the test itself, such
as those included below, are other elements that make
a laboratory report more meaningful:
 Specimen source
 Date and Time of Specimen Collection
 Laboratory Accession Number
 Name of the Test Performed
 Test Results
 Abnormal Test Results
 Critical Results
 Units of Measurements
 Reference Ranges
 Interpretation of Results
 Condition of Specimen
 Deviation from Test Preparation Procedures
 Medications, Health Supplements etc. Taken
by the Patient
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Radiology Reports  The following should be considered

 Radiology report is an official medical document that during the selection of the hospital
provides the details of the requested radiology
examination and the procedure conducted by the
information system: total cost of the
radiologist. package; web-based system; and
 A qualified physician authorized by the health care implementation and support.
institution interprets the report.
 The top 3 provider in the Philippines
 The main objective of the report is to address the
queries in the request. are BizBox, Inc., KCCI, and
 The findings in the report should consider both positive COMLOGIK.
and negative findings important findings should be  The functions of hospital information
stated followed by incidental findings.
 The basic sections of a radiology report enumerated in system address the following
the American College of Radiology's practice guideline concerns: help desk, patient
on communication must include: registration, admissions, discharge
1. Administrative Information
2. Patient Identification and transfer procedures, billing,
3. Clinical History contract management, and package
4. Imaging Technique details.
5. Comparison
6. Observations
7. Summary of Impression
8. Signature of Radiologist
 The length of the report is dependent on the complexity
and cost of the examination.

Cardiology Reports
 Cardiology reports, like other laboratory reports,
contain important medical information based on the
test results of the patient which are set against past
medical records.
 Using the cardiology information systems (CIS),
vascular sonography reports are accurately created
with only a few clicks.
 This means that results are generated more efficiently
which translates to improved patient experience.

Pharmacy Main Stores and Purchase

 Materials management is primarily concerned with
planning, identifying, purchasing, storing, receiving,
and distributing materials.
 Its purpose is to guarantee that the right and sufficient
materials are in the right location when needed.

Key Points to Remember:

 A hospital information system is a
fundamental computer system that
could manage all the information to
permit health care providers to do
their jobs efficiently.
 Hospital information systems are
useful in different hospital
departments such as physician
clinics, nursing services, radiology
laboratory, pharmacy, etc.

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 HEALTH INFORMATION SYSTEM IN MEDICAL LABORATORY SCIENCE
Other Hospital
Key Points to Remember:
Information
System
Cardiology Information System
 CIS is mainly focused on the storage and retrieval of
cardiology-centric images.
 In 1970s CIS uses mainframe environments. The trend
moved to modular systems in the 1980s. With the
introduction of the internet, CIS nowadays have unique
features that enable remote access and easy retrieval.
Benefits and Functionalities
Benefits
 Ease of Access While Maintaining Data Security
 Flexibility in the Workflow
 Enhanced Comparability
Functionalities
 Editing, Viewing, and Storing Multi-Modal Cardiology
Data
 Remote Access
 Visualization and Reporting Capabilities
 HER Integration
Radiology Information System
 RIS refers to a network system used for managing
imagery and associated data in the radiology
department. It tracks the orders and billing information
of the requesting department.
 It uses picture archiving and communication systems
(PACS) for the storage and management of medical
images and vendor neutral archival (VNA) to manage
image archives and for record-keeping and billing
within a hospital information system (Rouse, 2017).
Functions of Radiology Information System
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 Cardiology Information System (CIS)
is mainly focused on the storage and
retrieval of cardiology-centric images.
 The benefits and features of CIS
include ease of access while
maintaining data security, flexibility in
the workflow, and enhanced
comparability.
 The functionalities of CIS are (a)
editing, viewing, and storing multi-
modal cardiology data; remote
access; visualization and reporting
capabilities; and HER Integration.
 A radiology information system (RIS)
is a network software system
designed to manage medical imagery
and associated data. An RIS is
especially useful for tracking
radiology imaging orders and billing
information, and is often used in
conjunction with picture archiving
and communication systems (PACS)
and vendor neutral archivals (VNA) to
manage image archives and for
record-keeping and billing within a
hospital information system (HIS).
 The functions of a RIS are patient
management, scheduling, patient
tracking, results reporting, image
tracking, and billing.
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Material
 Min/Max Inventory Ordering Method
o The basic reordering method implemented in
many ERPs and other inventory management

Management
software.
 Minimum value
 represents the stock level
that prompts the reorder.

System  Maximum value

 sets the new targeted level
that follows the reorder.
 Economic Order Quantity (EOQ)
Materials Management System  Often interpreted as the
main difference between
the Min and Max value.

Enquiries and Quotations for

 The Materials Management System can be used to
Drugs, Consumables, Assets,
manage functions like purchasing, accounting,
inventory management, and patient supply charges
and General Items
(Materials Management Systems, 1996).  Documents required in materials management
process:
o Enquiries
Inventory Control o Quotations
 Strategies in improving inventory control in the health o Orders
care facility. o Invoices
1. Ensuring Shipment Accuracy o Documents
2. Aligning with Sales Projections
3. Complying with Regulations
4. Establishing Buying Cycles Comparisons of Quotation and
Item Master Maintenance Preferred Vendors
 Item Master Maintenance
o Has many sections. The upper portion contain
master information. The "item" tab is used for  Purchase Quotation
maintenance of the attributes of the item. o A document requesting prices and delivery
 Item Availability Form information from a vendor before the
o Specifies inventory levels across all purchase order.
warehouses.  Preferred Vendor
o
Item Indents and Issues
Part of the list that a company keeps from
whom they purchase their supplies. They look
 Goods that are damaged or have indents while being for vendors who has on-time performance,
transported from the source to the warehouse may be offers reasonable costs, provides high quality
returned when the supplier allows it. products and services, fully licensed, bonded,
 Damaged items are moved to another warehouse for and insured product and services, and has
them to be monitored. good business practices.

Reorder Level and Minimum Purchase Request, Orders,

and Maximum Inventory and Approval
 Purchase Request or Purchase
Ordering Requisition
o A document that notifies the purchasing
department that certain items or services
 Reorder Level need to be replenished.
o The minimum quantity of an item that a  Purchase Order
company has in stock, so when the stock o Legally binding contract which shows that the
reaches the stated minimum quantity, the seller has already accepted the order issued
item must then be reordered. by the buyer (SAP, 2012).

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 Approval Process information regarding the drugs and consumables

o The request for approval is sent to the first
approver when the document fails to meet the
approval requisites. Once the document has
been approved an internal notice is sent to the
originator. He can the process the document.
Receiving and Tracking Items
which is critical to decision making.
Issue Methods
 First In, First Out (FIFO)
 Last In, First Out (LIFO)
 First Expired, First Out (FEFO)

 Proper Receipt and Inspection of Goods General Tax Formula Configurations

 Materials Management System usually allow tax rates
to be defined internally via tax codes or imported from
an external source. The automatic calculation of tax
dues during the purchasing process makes the process
Purchase Returns along with less susceptible to clerical errors.

Returnable/ Non-Returnable Periodic Physical Stock Taking and

Adjustments with Tracking
Gate Pass  Inventory Count
 When purchased goods are returned, the materials o A process where a business physically counts
management system updates inventory levels to reflect its entire inventory. Barcode and RFID can be
the decrease in quantity. used to ensure accurate and less
 For temporary movement, a returnable gate pass is burdensome counts. The following tactics can
issued, whereas for permanent movement, a non- be used to minimize disruption during the
returnable gate pass is given. physical inventory:
 Inventory Services
Consignment Stock Receipt,  Inventory
Software
Control System

Consumption, and  Perpetual Inventory System

 Cycle Counting
Regularization
Key Points to Remember:
 In the process of consignment, the vendor or consignor
issues materials to the receiver or consignee, and  To successfully manage such
these materials are stored in the consignee's premises. information, many hospitals implement a
The vendor maintains legal ownership until such form of materials management
materials are removed from consignment stores. information system (The aforementioned
systems can be used to manage
Expired Stock and Quarantine functions like purchasing, accounting,
 Expired Stock/inventory inventory management, and patient
o Expiration dates and decrease in values of supply charges (“Materials management
items must be reflected in the financial information systems,” 1996).
records so discrepancies in financial
statements will be prevented.  Purchasing request could be used as a
 Quarantine Stock/Inventory first step in the process of purchasing
o When undecided about how to handle This could be followed by a quotation
defective goods, whether to be sold as scrap, before proceeding to the Purchase Order
reworked, returned, or used as it is, a depending on the process preferred by
quarantine location or warehouse can be
used to temporarily house them until a final the management.
decision is reached.  Inventory control plays an important role
in refining the quality of healthcare
Drugs and Consumable Issue services and different strategies could be
employed to ensure efficiency These
and Returns to Patients strategies include ensuring shipment
 Materials Management System provides an overview accuracy, aligning with sales projections,
of the entire institution's purchasing and inventory complying with regulations, and
control processes, so they have more reliable establishing buying cycles.

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 The MMS handles issues such as item

indents and reorder level.
 There are three issue methods that are
currently used in the healthcare industry
First In, First Out (FIFO), Last In, First Out
(LIFO), and First Expired, First Out
(FEFO).
 Periodic physical stock taking, or
inventory count may be mandated by
financial accounting MMS have Barcode
and RFID that can be used as tool to
ensure accurate and less burdensome
counts.

HEALTH INFORMATION SYSTEM IN MEDICAL LABORATORY SCIENCE MARIA ANTONETTE I T. RABAGO