Hospital Information System

winny setyonugroho, M.T.

goal
Provide timely, complete, accurate, legible, and relevant information access

Evolution
It was electronic medical records (EMRs) in that they dealt with the record of disease and interventions transformed into a fluid electronic portal that describes local care and the interactions between health providers and their patients.

hospital

Advantage e-Record
Accessbility Ligibilty
Reduce health error from hand writing

Use of Discrete Data

In the elements of history, medical problems, medications, and even social history

Standardize
universal messaging protocols to allow for interchange of these data among different computer systems

HL7
health level 7 standards for the exchange, management and integration of electronic healthcare information

HL7
Each HL7 message consists of one or more segments. A carriage return character (\r, which is 0D in hexadecimal) separates one segment from another. Each segment is displayed on a different line of text. (as seen in the sample HL7 message below) Each HL7 segment consists of one or more composites (also known as fields). A pipe (|) character is used to separate one composite from another. If a composite contains other composites, these subcomposites (or sub-fields) are normally separated by ^ characters.

HL7: example
MSH|^~\&|EPIC|EPICADT|SMS|SMSADT|199912271408| CHARRIS|ADT^A04|1817457|D|2.5| PID||0493575^^^2^ID 1|454721||DOE^JOHN^^^^| DOE^JOHN^^^^|19480203|M||B|254 MYSTREET AVE^^MYTOWN^OH^44123^USA||(216)123-4567|||M|NON| 400003403~1129086| NK1||ROE^MARIE^^^^|SPO||(216)123-4567|| EC||||||||||||||||||||||||||| PV1||O|168 ~219~C~PMA^^^^^^^^^||||277^ALLEN MYLASTNAME^BONNIE^^^^|||||||||| || 2688684|||||||||||||||||||||||||199912271408||||||002376853

HL7: example

ICD 10 CM
International Classification of Diseases and its Clinical Modifications Diagnosis-related groups(DRGs)

ICD 10: example

Circulatory System (390-459)
401.0-405.99 Hypertensive disease (requires 4th and/or 5th digits) 410.00414.9 Ischemic heart disease (requires 4th and/or 5th digits) 430-438 Cerebrovascular Disease (requires 4th and/or 5th digits) 438.0 Cognitive Deficits 438.20 Hemiplegia affecting unspecified side 438.21 Hemiplegia affecting dominant side 438.22 Hemiplegia affecting nondominant side 438.30 Monoplegia of upper limb affecting unspecified side 438.31 Monoplegia of upper limb affecting dominant side

CPT
Current Prosedural Terminology
Describes medical services and procedures Uniform information among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes

CPT: example

LOINC
Logical Observation Identifiers Names and Codes Standard for identifying medical laboratory observations

DICOM
Digital Imaging and Communications in Medicine Standard for handling, storing, printing, and transmitting information in medical imaging
Includes a file format definition and a network communications protocol

NANDA
North American Nursing Diagnosis Association standardized nursing diagnoses
note that there is no correlation between ICD and NANDA, consequently, most inpatient records have two problem lists at any time

NDCs
National Drug Codes
Unique product identifier used in the United States for drugs intended for human use

Order Management
Phycisian order entry: now and then, comparation Computerized provider order entry (CPOE)
provide structure to physician orders and to allow for the rendering of decision support tools at the moment of ordering

CPOE

CPOE - medication
Inpatient Drug Orders
physician initiates the order, entering a series of discrete elements such as dose, frequency, route, priority (e.g., stat), start and stop times, etc pharmacist, may see additional alerts, modify the order according to local policy or on drug availability Than passed to another view for the physician provider

CPOE - medication
Outpatient Drug Orders
ambulatory physician must consider the medication dosage information, also insurance covered transmitted directly to a pharmacy to be produced.

CPOE - medication

Decission Support
support safe drug prescribing
a therapeutic drug level Drug dosage Drug interaction Drug allergies

Decission Support
associated with medication ordering
alerts and reminders is intended to prompt the physician to take action (to order) in a manner consistent with established, evidence-based guidelines
A common scenario: a provider seeing a patient with identified coronary artery disease on the problem list. The EHR show most recent lipid levels, as well as whether the patient is taking a medication to lower lipid levels. If the patient is not currently on an antilipemic agent or does not have a serum lipid level consistent with national guidelines, an alert will display Another screen will prompt the prescriber to order appropriate lipid-lowering therapy

The End