Hospital Public Informtion Officer Policy

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					Medical Information Systems
The introduction of information systems in hospitals and other medical facilities is
not only driven by the wish to improve management of patient-related data for the
patient’s benefit, but also by the fiscal necessity to improve efficiency of medical

Computer-based patient record (CPR)
Patient records serve the following purposes:
   •   Caregivers’ Record of Information from the Patient
   •   Caregivers’ Findings and Treatments
   •   Communication to Later Caregivers
   •   Coordinating and Organizing Caregivers in the Care of the Patient
   •   Creating a Formal Record of Patient Care
   •   Information for Public Health and Clinical Research
The appendix lists typical records for both outpatients and inpatients. The
average medical record weighs 1.5 pounds, and every visit to the doctor adds an
average of 13 pieces of paper.
Apart from the inconvenience of handling these files, which naturally can be only
at one location at a time, paper records mayor weaknesses are:
   •   Lack of standardization in content
   •   Lack of standardization in format
   •   Incompleteness
   •   Inaccuracies
   •   Risk of misplacement or loss
The computer-based patient record (CPR) (or electronic patient record, EPR)
offers health professionals
   •   Complete patient data displayed in an integrated fashion that facilitates
       medical decision making,
   •   Access from any workstation in the hospital
   •   Ability to enter orders, notes, data at same workstation
   •   No double entry of information

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   •   Immediate availability of results
   •   Simultaneous users can access same medical record
   •   Access from on site or remote locations
   •   No loss of patient information
However, initial costs, the necessity to change workflow, and employees
reluctance to accept the new technology are mayor problems when introducing
CPR in a hospital.

Hospital information systems (HIS)
An information system, that combines a computer-based patient record with
other modules that support clinical workflow is called a hospital information
system (HIS). As early HIS date back to the 1970s, modern more comprehensive
approaches are sometimes labeled differently (clinical information system, CIS,
health-care informtion system, HCIS), but definitions are not precise.
Some important modules of an HIS are the following:
   •   Medical devices: access to medical devices via standardized protocols
       (DICOM) and/or Picture Archiving and Communications System (PACS)
   •   Telemedicine: access to external data (e.g. receive patient data from
       physician, notify physician electronically, send and receive medical
       images), typically by means of internet access via firewall.
   •   Scheduling: Staff can electronically make appointments with physicians,
       X-ray, laboratories, etc..
   •   Billing: import, view, approve charges posted by therapists, file electronic
       claims and/or print claims, create reports (by patient, therapist, ward,
       clinic, diagnosis, etc.) to analyze individual and group productivity and
       financial performance.

                           Hospital Information System

                        med. devices
                          & PACS


                         scheduling                                            billing
                                         add / connect
                                          CMPT 340 / part 09 / 2003-11-07

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Important aspects of an HIS are
   •   Reliability
   •   Response time
   •   Accessibility
   •   Flexibility
   •   Security/Privacy
When designing an HIS, it is not only necessary to compromise between these
performance aspects (e.g. between security/privacy, accessability, and response
time), but also with the systems costs (initial costs as well as maintenance).

Telemedicine is the transfer of electronic medical data (i.e. high resolution
images, sounds, live video, and patient records) from one location to another.
Telemedicine deals with two mayor problems:
1. Traditionally the healthcare environment consists of organizationally
   indepentent units with little coordination and sharing of data between them.
   The patients data is scattered between many facilities.
2. People living in remote areas have little access to specialty medical care.
Technology is either "store and forward" (e.g. transfer stored medical images) or
"two-way interactive" (e.g. videoconferencing) and can be based on regular
telephone lines, ISDN, cable wiring or other kinds of high bandwidth tele-
communications, or satellite, with the internet becoming more and more
prevalent ("E-Health").
Some telemedicine applications that are in use or that are currently being
developed are the following:
   •   videoconferencing of expert physicians or physician and patient,
   •   administartive functions
   •   physicians' education
Teleradiology, the sending of x-rays, CT scans, or MRIs (store-and-forward) is
the most common application of telemedicine in use today.
Programs that have recently been suggested include:
   •   ECG recorded on board of an airplane is sent to experts on the ground for
   •   "Personal Diagnosis Centre" as part of a home entertainment centre - this
       system would monitor the patient's daily health status and automatically
       notify a health professional if he or she becomes ill,
   •   One "Universal Patient Record" instead of many separate paper records
       with web enabled viewing access.

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Telemedicine offers a great range of benefits:
   •   reduce time and cost for patient transportation, transportation of files etc.,
   •   gives patients in remote areas access to specialist physicians,
   •   gives healthcare facilities access to existing patient record, X-rays, lab
       results etc.,
   •   supports worldwide research cooperation.
However, most telemedicine applications are still "projects" and only few
applications are commonly used in hospitals' daily routine today.

Technical aspects & standards
Modern medical information systems are distributed systems. Various indepen-
dent machines and local-area networks are connected by one or more networks,
thus allowing local information procesing as well as sharing data.

                            Ward 1                                      Radiology

                            Ward 2                                      Laboratory

                            Ward n                                       Finance


                                      CMPT 340 / part 09 / 2003-11-07

The key to running various hard- and software modules from different manufac-
turers together successfully is the application of standards. In addition to general
technical standards an increasing number of specific standards for medical
computing is been developed.
Standards are created by groups of interested people and organizations, e.g.
manufacturers and users of a certain technology. National (ANSI, DIN) and
international (ISO, IEC) standards organizations or government agencies may
approve/accredit, coordinate, or even establish groups and/or their standards.

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             international                  ISO
                                                                     & approve
               national                   ANSI

                group                      HL7                       standards

           interested people
           and organizations

                                   CMPT 340 / part 09 / 2003-11-07

Some of the most important groups for healthcare standards are:
   •   American College of Radiology / National Electrical Manufacturers
       Association (ACR/NEMA) that develops DICOM (see for more information),
   •   Health Level 7 (HL7) that develops standards for clinical-data interchange
   •   ISO technical committee for medical informatics (TC 215) that deals with
       compatibility and interoperability between independent systems.

DICOM (Digital Imaging and Communications in Medicine) is the industry
standard for transferal of radiologic images and other medical information
between computers:
HL7 is a standard for the electronic interchange of clinical, financial and
administrative information among independent health care oriented computer
systems, e.g. hospital information systems, clinical laboratory systems, and
pharmacy systems.
Current medical standards already cover a wide range of application areas:
communication, knowledge representation, medical images and data, patient
record, etc.. The main problem is the uncoordinated work of various standards
development groups and the overlap of their standards. As the market for both
medical hard- and software being international, international coordination of the
development of standards is required.

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Privacy and security aspects
All individually identifiable health information is confidential (protected health care
information, PHI). But with increasing electronic storage and exchange of patient
data privacy and security are growing concerns.
Recent legislation has furthermore put the focus on privacy and security aspects.
The American "Health Insurance Portability and Accountability Act" of 1996
(HIPAA) mandated the development of standards to protect the confidentiality
and security of patient medical records.
Pursuant to HIPAA, the "Department of Health and Human Services" (HHS)
developed “Standards for Privacy of Individually Identifiable Health Information”
(see for further information). Among the suggested safety
measures are the following:


       Restricted access to sensitive areas
              - Data center (e.g. servers)
              - Networks (e.g. routers, network closets)
              - Workstations (e.g. public areas vs. private offices)
       Backup systems
       Uninterruptible power supply


       User access privileges
       Authorization control (e.g. who has access)
       Access privileges (e.g. what can they see)
             - Role-based or individual-based access
             - Emergency access
       Authentication control (e.g. who they are)
       Password controls (e.g. expiration, nonrepeating, suspension)
       Audit controls
              - Retrospective
              - Warnings (e.g. break-the-glass)
       Automatic backup
       Virus protection

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      Security policy
      Security officer(s)
      Contact person and procedure for complaints
      Security incident procedures, penalties
      Internal audits
      Certification of compliance

As there is no unlimited security and as many security measures affect the
accessability of information the goal is to take "reasonable" measures and to
balance the goals of care with the protection of information.

Further reading
Health Care Technology Project; links to information on computerized patient
record, hospital information systems, telemedicine, standards, and privacy and
security aspects

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                  Appendix: Typical Patient Records

                        Outpatient Clinical Documents
            Document                                       Description
History and Physical               The patient's initial medical examination and evaluation
                                   data. This document includes the following: chief
                                   complaint (CC), history of present illness (HPI), past
                                   medical history (PMH), family history (FH), social history
                                   (SH) and marital history, review of systems (ROS),
                                   physical exam (PE), assessment, diagnosis (Dx),
                                   impression, rule out (R/O), plan, prognosis (Px).

Progress notes                     Documentation for a follow-up visit. The physician's
                                   objective findings concerning improvement or aggravation
                                   of the condition, any change in treatment or medication,
                                   and the patient's own report about the condition.
Physician's orders                 A record of a physician's medical orders.
X-rays, other diagnostic images,
EKGs, etc.
Diagnostic findings                Diagnostic and laboratory data--for example, hematology,
                                   pathology, radiology, and X-ray test results and
Correspondence / E-mail            Letters and E-mail conveying clinical information on the
Phone messages                     Phone messages conveying clinical information on the
Consent forms                      A patient's or patient's guardian's consent for treatment,
                                   special procedures or to release information.
Consultation reports               An opinion about the patient's condition by a practitioner
                                   other than the primary care physician.

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                         Inpatient Clinical Documents
             Document                                       Description
Face sheet                          Information identifying the patient, including name,
                                    admission date, address and birth date, emergency
                                    contact and closest relative, allergies, admitting diagnosis
                                    and attending physician.
Medical history and physical        The patient's initial medical examination and assessment
examination                         data completed by the physician.
Initial nursing assessment form     Initial assessment.
Physician's orders                  A record of a physician's medical orders.
Problem or nursing diagnosis list   List of nursing diagnoses.
Nursing plan of care                Plans for patient care.
Graphic sheet                       A type of flow sheet showing graphic recording of the
                                    patient's temperature, pulse rate, blood pressure, and
                                    possibly daily weight.
Other flow sheets                   Abbreviated progress notes, recording dates, times,
                                    changes in the patient's condition.
Medication administration record    A recording of each medication the patient receives,
(MAR)                               including name, dosage, route, site, and date and time of
Physician's progress notes          Physician's observations, notes on the patient's progress,
                                    and treatment data.
Nurses' progress notes              Patient care information, interventions, and patient's
Consultation sheets                 Reports of evaluations made by physicians and others
                                    called in for opinions and treatment recommendations.
Health care team records            Notes from other departments, including physical therapy
                                    and respiratory therapy.
X-rays, other diagnostic images,
EKGs, etc.
Diagnostic findings                 Diagnostic and laboratory data--for example, hematology,
                                    pathology, radiology, and X-ray test results and
Consent forms                       A patient's or patient's guardian's consent for treatment,
                                    special procedures or to release information.
Incident report                     Information about a reportable event.
Advance directives                  A legal, written document that specifies patient
                                    preferences regarding future health care or specifies
                                    another person to make medical decisions in the event
                                    that the patient is unable to do so.
Discharge plan and summary          A brief review of the patient's hospital stay and plans for
                                    care after discharge.

CMPT 340                              09_information_systems                             Nov. 12, 2003

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