INTRODUCTION TO HEALTH INFORMATION SYSTEMS (HIS)

What is an Information System?• An information system (IS) is an arrangement of

information (data), processes, people, and information technology that interact to collect, process, store, and pro- vide as output the information needed to support the organization (Whitten & Bentley, 2005).

What is a Health Information System?

A health care information system (HCIS) is an arrangement of information (data), processes, people, and information technology that interact to collect, process, store, and provide as output the information needed to support the health care organization.

The discipline of health information systems (HIS) involves a synergy of three other disciplines (Tan, 2005):

• Health is the end-purpose of HIS applications. The ultimate goal in applying HIS solutions is to improve the health status of people.

• Organization management provides the managerial perspective on developing and using HIS applications for health service organizations.

• Information management is how the information is used. To achieve their goals, health managers must rely on health information.

Difference between MIS and HIS

History of Health Information Systems and their Evolution• Post 1960s

Guaranteed health care insurance benefits to the elderly and the poor. (age>65)

Provide health care coverage to individuals with long-term disabilities.

Cost-based reimbursement: the more a hospital built, the more patients it served, and the longer the patients stayed, the more revenue the hospital generated.

The primary focus was to collect and process patient demographic data and insurance information and merge it with charge data to produce patient bills.

The mainframe was associated with centralized rather than distributed computing.

Post 1960s• The administrative applications that existed in the 1960s were generally found

in large hospitals, such as those affiliated with academic medical centers.

• Those facilities often developed their own administrative or financial information systems in-house, in what were then known as data processing departments.

• The data processing department was generally under the direction of the finance department or chief financial officer. The primary function is processing billing data.

• These early administrative and financial applications ran on large mainframe computers which had to be housed in large rooms, with sufficient environmental controls and staff to support them.

• Because the IS focus at the time was on automating manual administrative processes and computers were so expensive, only the largest, most complex tasks were candidates for mainframe computing.

1960s• Shared Systems: they allowed hospitals to share the use of a

mainframe with other hospitals. It captured billing data manually or electronically and send them in batch form to a company that processes the claims for the hospital.

• Most shared systems processed data in a central or regional data center.

• Shared Medical Systems (now known as Siemens) was one of the first vendors to offer data processing services to hospitals.

• Vendors charged participating hospitals for computer time and storage, for the number of terminals connected, and for reports.

1970s• Rapid inflation in the economy, expansion of hospital expenses and profits,

and changes in medical care contributed to the increase health care costs.

• Departmental systems began to emerge as a way to improve productivity and capture charges and thereby maximize revenues.

• The development of departmental systems coincided with the availability of minicomputers.

• Minicomputers were smaller and more powerful than some mainframe computers and available at a cost that could be afforded by a clinical department such as laboratory or pharmacy.

• Showed a direct impact on the quality of patient care because of faster turnaround of tests, more accurate results, and a reduction in the number of repeat procedures (Kennedy & Davis, 1992).

1970s• New companies wanted to develop applications for clinical

departments, particularly turnkey systems.

• These software systems, which were developed by a vendor and installed on a hospital’s computers, were known as turnkey systems because all a health care organization had to do was turn the system on and it was fully operational.

• What you saw was what you got.

• Most systems were still stand-alone and did not interface well with other administrative or clinical information systems in the organization.

1980s• Medicare shifted from a cost-based reimbursement system to a prospective payment

system based on diagnosis related groups (DRGs).

• This new payment system had a profound effect on hospital billing practices.

Reimbursement amounts were now dependent on the patient’s diagnosis.

• Hospitals received a predetermined amount based on the patient’s DRG, regardless of the cost to treat that patient.

• The incentives were now directed at ordering fewer diagnostic tests, performing fewer therapeutic procedures, and planning for the patient’s discharge at the time of admission.

• Health care executives knew they needed to reduce expenses and maximize reimbursement.

• Services that had once been available only in hospitals now became more widespread in less resource-intensive outpatient settings and ambulatory surgery centers.

1980s• Overall health care costs in rose by double the rate of inflation.

• Health insurance companies argued that the traditional fee-for-service method of payment to physicians failed to promote cost containment.

• Managed care plans began to emerge in parts of the nation, and they reimbursed physicians based on capitated or fixed rates.

• Overall there was a shift toward privatization and corporatization of health care. The integrated delivery system began to emerge, whereby health care organizations offered a spectrum of health care services, from ambulatory care to acute hospital care to long-term care and rehabilitation.

1980s• The microcomputer, or personal computer (PC), was

smaller, powerful, and affordable than a mainframe computer.

• Health care information system vendors were developing administrative and clinical applications.

• Health care executives viewed this as an enormous opportunity to acquire and implement needed clinical information systems.

• the major focus was on revenue-generating departments.

1980s• Organizations that adopted the best-of-breed approach then faced a

challenge when they tried to build interfaces or integrate data so that the different systems could interoperate, or communicate with each other.

• Even today, system integration remains a challenge for many health care organizations despite progress in the use of interoperability standards.

• The advent of the microcomputer brought computing capabilities to a host of these smaller organizations. It also led to users’ being more demanding of information systems, asking the information system function to be more responsive.

• Sharing information among microcomputers also became possible with the development of local area networks.

1990s• It marked the evolution and widespread use of the

Internet along with a new focus on electronic medical records.

• After the success of the DRG-based reimbursement

system for hospitals, Medicare introduced a new method for reimbursing physicians.

• Formerly paid under a customary, prevailing, and reasonable rate methodology, physicians treating Medicare patients were now reimbursed for services under the resource-based relative value scale (RBRVS).

1990s• The RBRVS payment method factored provider time, effort, and degree of

clinical decision making into relative value units.

• The system would reward financially the physicians who spent time educating patients but would discourage or limit reimbursement to highly skilled specialists who tended to perform invasive procedures and order an extensive number of diagnostic and therapeutic tests.

• Health care organizations and communities promoted preventive medicine with the goal of promoting health and well-being and preventing disease.

• If we educate and help keep patients well, the overall cost of providing health care services will be lower in the long run.

• The primary care provider was viewed as the gatekeeper and assumed a pivotal role in the management of the patient’s care. Under this managed care model, physicians were reimbursed on a capitated or fixed rat.

1990s• Several vendors developed electronic disease

management programs that facilitated the management of chronic diseases and were incorporated into clinical applications.

• Patients could assume a more active role in monitoring their own care.

• For example, clinicians at a Partners Community Hospital introduced a disease management program called Matrix that enables providers to plan, deliver, monitor, and improve the quality and outcomes of the treatment and care delivered to patients with diabetes.

1990s• In 1991, the Institute of Medicine (IOM) published its landmark report The

Computer-Based Patient Record: An Essential Technology for Health Care.

• This report brought international attention to the numerous problems inherent in paper-based medical records and called for the adoption of the computer-based patient record (CPR).

• The IOM defined the CPR as “an electronic patient record that resides in a system specifically designed to support users by providing accessibility to complete and accurate data, alerts, reminders, clinical decision support systems, links to medical knowledge, and other aids” (IOM, 1991, p. 11).

• IOM report viewed the CPR as a tool to assist the clinician in caring for the patient by providing him or her with reminders, alerts, clinical decision-support capabilities, and access to the latest research findings on a particular diagnosis or treatment modality.

1990s• During the 1990s, a number of vendors developed CPR systems.

Yet only 10 percent of hospitals and less than 15 percent of physician practices had implemented them by the end of the decade (Goldsmith, 2003).

• CPR systems had reached the stage of reliability and technical maturity needed for widespread adoption in health care.

• Health Insurance Portability and Account- ability Act (HIPAA)

• HIPAA was designed to make health insurance more affordable and accessible, but it also included important provisions to simplify administrative processes and to protect the confidentiality of personal health information.

1990s• The adoption of electronic transaction and code set standards and the greater use of

standardized electronic transactions is expected to produce significant savings to the health care sector.

• In addition, the administrative simplification provisions led to the establishment of health privacy and security standards .

• Health care organizations and vendors used the Internet to market their services, provide health information resources to consumers, and give clinicians access to the latest research and treatment findings.

• The Internet has provided affordable and nearly universal connectivity, enabling health care organizations, providers, and patients to connect to each other and the rest of the health care system.

• Along with the microcomputer, the Internet is perhaps the single greatest technological advancement in this era. It revolutionized the way that consumers, providers, and health care organizations access health information, communicate with each other, and conduct business.

1990s• Consumers began to use e-mail to communicate with

colleagues, businesses, family, and friends.

• It substantially reduced or eliminated needs for telephone calls and regular mail. E-mail is fast, easy to use, and fairly widespread.

• Telemedicine is the use of telecommunications for the clinical care of patients and may involve various types of electronic delivery mechanisms. It is a tool that enables providers to deliver health care services to patients at distant locations.

2000s• Health care quality and patient safety emerge as top priorities at the start

of the millennium.

• IOM published the report To Err Is Human: Building a Safer Health Care System, which brought national attention to research estimating that 98,000 patients die each year due to medical errors.

• A report by the Institute of Medicine Committee on Data Standards for Patient Safety, Patient Safety: Achieving a New Standard for Care (2004), called for health care organizations to adopt information technology capable of collecting and sharing essential health information on patients and their care.

• This IOM committee examined the status of standards, including standards for health data interchange, terminologies, and medical knowledge representation.

2000s• To Err Is Human authors point out that earlier research on patient

safety focused on errors of commission, such as prescribing a medication that has a potentially fatal interaction with another medication the patient is taking, and they argue that errors of omission are equally important.

• An example of an error of omission is failing to prescribe a medication from which the patient would likely have benefited

• A significant contributing factor to the unacceptably high rate of medical errors reported in these two reports and many others is poor information management practices.

• Illegible prescriptions, unconfirmed verbal orders, unanswered telephone calls, and lost medical records can all place patients at risk.

2000s• The Leapfrog Group, an initiative of public and private

organizations that provide health care benefits to their employees, works to improve patient safety by identifying problems and proposing solutions for hospital systems.

• It has developed a list of criteria by which health care organizations should be judged in the future.

• One of the Leapfrog Group’s many recommendations to improve patient safety is the widespread adoption of computerized provider order entry (CPOE) systems among health care organizations.

2000s• Pay for performance (P4P) or value-based purchasing,

reimburses providers based on meeting predefined quality measures and thus is intended to promote and reward quality.

• The Centers for Medicare and Medicaid Services (CMS) have already notified hospitals and physicians that future increases in payment will be linked to improvements in clinical performance.

• Medicare has also announced it will not pay hospitals for the costs of treating certain conditions that could reasonably have been prevented.

2000s• Significant technological advances have occurred in

information technology.

• Electronic devices have become smaller, more portable, less expensive, and multipurpose.

• Broadband access to the Internet is widely available, even in remote, rural communities; wireless technology and portable devices (personal digital assistants, multipurpose cell phones, and so forth) are ubiquitous; significant progress has been made in the area of standards pod- casts, wikis, and Web 2.0 technologies have emerged; and radio-frequency identification devices (RFIDs), used more widely in other industries, have found their way into the health care marketplace.

IT• The health care sector has been slow to adopt health care information

systems, particularly clinical information systems.

1. Health care information is complex, unlike simple bank transactions, for example, and it can be difficult to structure. Health care information may include text, images, pictures, and other graphics.

• There is no simple standard operating procedure the provider can turn to for diagnosing, treating, and managing an individual patient’s care.

• The provider relies on prior knowledge and experience and may order a battery of tests and consult with colleagues before arriving at a diagnosis or an individualized treatment plan.

• Terminologies used to describe health information are also complex and are not used consistently among clinicians.

2. Health information is highly sensitive and personal. Every patient must feel comfortable sharing such sensitive information with health care providers and confident that the information will be kept confidential and secure.

IT3. Health care IT is expensive, and currently it is the health care

provider or provider organization that bears the brunt of the cost for acquiring, maintaining, and supporting these systems.

4. In the U.S. health care system is not a single system of care but rather a conglomeration of systems, including organizations in both the public and private sectors.

• Thus another major challenge facing health care is the integration of heterogeneous systems. Some connectivity problems stem from the fact that when microcomputers became available and affordable in the last half of the 1980s, many health care organizations acquired a variety of departmental clinical systems, with little regard for how they fit together in the larger context of the organization or enterprise.

IT• Integration issues may be less of an issue when a health

care organization acquires an enterprise-wide system from a single vendor or when the organization itself is a self-contained system.

• However, rarely does a single vendor offer all the applications and functionality needed by a health care organization. Significant progress has been made in terms of interoperability standards, yet much work remains.

challenges• Rising Costs

• Medical Errors

• Coordination

Rising Costs• New diagnostic technologies, such as magnetic

resonance imaging devices, lead to increased costs of healthcare.

• The rapid rise in healthcare costs sets off a series of events. Briefly stated, the rise in costs forces the insurance programs and employ- ers to contain costs. These efforts of the payers to contain healthcare expenditures have an impact on the hospitals and physicians.

Medical Errors• Some estimates show that about 100,000 people die each year

in the United States from medical errors that occur in hospitals.

• Existing information systems, designed primarily for billing purposes, often fail to record important information about a patient’s condition.

• A comparison of claims and patient records reveals that claims do not accurately reflect over half of the clinically important patient conditions.

• Even when information system software allows for the entry of additional information, that information often is incorrectly entered.

Medical Errors• Important to patient safety is the ordering, transcribing, and

administering of medications.

• The most common error is in dosing, which occurs three times more frequently than the next type. The top causes of failure include:• Prescribing errors due to deficiency in drug knowledge related to incorrect

dose, form, frequency, and route.• Order transcription errors due to manual processes.• Allergy errors due to the systems poor notification to healthcare providers.• Poor medication order tracking due to a cumbersome, inefficient system, that

is, dose administration is recorded in more than one location.• Poor interpersonal communication, that is, illegible orders.

• Proper information systems could reduce the incidence of these errors.

Avoidable Error

The health care industry is not perfect. The people administering health care are also not perfect. They tire

after 12-hour shifts. They at times must make quick decisions with very little support around them. Their

handwriting at times is less than ideal, and above all else, they are human. Whether we want to admit it or

not, humans make mistakes. Because we in the health care industry are aware of our human characteristics

that leave us exposed to the possibility of making mistakes, we do everything possible to prevent those

mistakes from occurring in the first place. Information technology can help. Medication errors in hospitals are

frequent and may harm patients. Medication errors include incorrect dosing, incorrect drug given, or incorrect

timing of drug administration. Medication administration is a primary responsibility of nurses, and error

prevention is taught during their training. Still, competent nurses may make mistakes. An example of a device

and information system that is in widespread use in hospitals today and that has dramatically decreased the

number of medication errors is called Pyxis. Pyxis is a medication-dispensing computer that is maintained by

the pharmacy, is located on each unit, and is stocked with medications for each patient on that unit. The

patient s medication administration profile is updated in the system by the pharmacy and when medications

are due to be given, a nurse, using password entry, signs into the system and obtains the medication.

Medications can be obtained only when due and only in the correct dose required. The Pyxis system can be

overridden, but the nurse must then take extra steps. This computer-supported dispensing helps to prevent

errors by nurses who are rushing and tired and who might otherwise be reading orders written in difficult to

read hand-writing. Medication errors can still occur but are less frequent due to the enforced double check

(pharmacy and nursing).

Coordination• Because of its decentralized nature, the healthcare industry has a

very complex business model consisting of a fragmented community of trading partners.

• Improvements in information systems also are needed to support the coordination of care.

• To provide effective care, health professionals and providers need access to a patient’s treatment history, test results, and related information.

• Paper records are difficult to transfer between organizations. Where computer records are kept, the use of incompatible hardware and software configurations makes file sharing difficult.

A Failure to Share.My grandmother died because there was no medical history available so that the physician could be aware of her condition and provide appropriate treatment to save her life. She always went to Adventist Hospital for surgery and other procedures. All of her medical histories were at this hospital, and this is where her primary care physician was affiliated. One tragic weekend my grandmother went to see my mom in Adamsville. That morning my grandmother told my mom that she was having stomach pain, and about noon the pain was still there and my grandmother felt tired and short of breath. My mom called the ambulance to take my grandmother to the emergency room. When the ambulance personnel arrived, they took her to St. Mary s Hospital. My mom said no, we want you to take us to Adventist Hospital . The ambulance personnel replied we must take her to the nearest hospital . When my grandmother got to St. Mary s Hospital, the medical staff didn’t know what to do. They asked us to give them my grandmother s medical history. Our family gave all the information that we knew to the nurse. After a few hours, my grandmother cried and asked for medication. The nurse responded that the ER physician was trying to contact her primary care provider for further information so that the ER physician could determine the best treatment. Another hour passed, and nothing was done to stop the pain. The ER physician decided to admit my grandmother to the hospital for further evaluation. After they took my grandmother to her room, still nothing had been done for the pain. My grandmother lay in bed and cried. Two hours later my grandmother went into cardiac arrest. Nurses gave her CPR and were able to bring her back, but she was in a coma and connected to numerous machines. For 10 days my grandmother never awoke or responded to the family. Finally, our family had to make the painful decision to remove the machine that was keeping her alive. The problem was that St. Mary s Hospital did not have any medical records of my grandmother so the ER physician was not able to determine a treatment for her. Her primary care physician wasn’t affiliated with the hospital; he didn’t have privileges to access the facility. Think of the senseless deaths that are the result of an ER physician being unable to make an accurate decision on which care to give a patient.

References• “Health Care Information Systems: A Practical Approach

for Health Care Management”By Karen A. Wager, Frances W. Lee, John P. Glaser

• “Information Systems and Healthcare Enterprises”By Roy Rada