HANDOUT ON HOSPITAL INFORMATION SYSTEM HOSPITAL INFORMATION SYSTEM (HIS) is the sum of all automated* and non-automated* information

n and communication systems in a hospital is a computer system that is designed to: manage all the medical and administrative information in the hospital enable health professional perform their jobs effectively and efficiently Functions of HIS: Sending patient orders to hospital departments Reporting results back to patient health records Requesting supplies and equipments for clinics or offices Manage the ADT (admission-discharge-transfer) process Almost always interface with financial systems Used to produce a number of administrative reports 2 Parts of the Hospital Information System A. CLINICAL INFORMATION SYSTEM MEDICAL INFORMATION SYSTEM - includes face sheet, patient history, physical assessment, working diagnosis, doctors order/notes, abstract, etc. NURSING INFORMATION SYSTEM - includes assessment, health condition data, NCP, managing orders, administering and recording medication and treatment, etc. DEPARTMENTAL INFORMATION SYSTEM - supports daily operation of the clinical department SETTING SPECIFIC INFORMATION SYSTEM - systems or functions are customized for the specific setting B. NON-CLINICAL INFORMATION SYSTEM FINANCIAL INFORMATION SYSTEM - used to manage and report hospitals money matters ADT (Admission, Discharge, Transfer) INFORMATION SYSTEM management or registration PERSONNEL INFORMATION SYSTEM - used to track characteristics of employees and/or the use of employees within the hospital ADMINISTRATIVE SYSTEM - automate data used in the daily operation of the hospital as well as strategic and long range planning ELECTRONIC MEDICAL RECORD (EMR) computerized representation of the health information of an individual patient. ELECTRONIC HEALTH RECORD SYSTEM (EHRS) collection of EHR from different patients creating a large repository or database of health-related records Advantages of EMR:
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Improved quality of care Improved standardization Increased access to health information Good return of investment

Automated HIS Technologies Electric Chart System (ECS) - records, retrieves, and views patient data Electronic Monitoring Systems - monitor and display vital signs, cardiac, respiratory, or other physiologic activity Automated Medication Administration System - uses a barcode-enabled PDA to identify the patient at point-of-care (POC) Automated Medication Dispensing System - keeps track of the exact number of medications that remains in the cabinet and eliminates chances of picking up the wrong drug Automatic Labeling Machine - produces labels (barcodes) for specimens or sample bottles and other items specific to the patient Automated Billing Machine - presents a display and full page printout of the patient's latest billing statement

Home Health Care System - a monitoring system wherein the patient is at a distance (home), hooked to an electronic monitoring system and the nurse or doctor views the patients physiologic functions from another monitor. Implementing Automated HIS Steps: (also called Implementation Cycle) 1. Planning - involves convening with other clinical and non-clinical departments to define and discuss problems 2. System analysis - starts with feasibility study followed by investigation of the environment 3. System Design - designing on how to solve the problem 4. Development - writing codes of the program by the computer programmer, translating system design into programming language 5. Testing (alpha and beta) a. Alpha Testing - done before the software is made available to the hospital or general public b. Beta Testing - program is installed in the actual user environment 6. Training - education/training on computers and on the program 7. Implementation - program is loaded and allowed to operate on the whole environment where it is implemented 8. Evaluation Problems encountered in automating HIS Budget / Lack of funds Time Poor compliance Level of data sharing* STAND ALONE SYSTEM - also called Dedicated system or Turnkey system; developed for a single application or a specific set of functions INTERFACED SYSTEM - connecting two or more information systems that use different platforms INTEGRATED SYSTEM - uses a single program to cater all data processing COMBINATION - composed of stand alone, interfaced, and integrated systems NURSING MINIMUM DATA SET The nursing community should standardize its data to utilize health care information system i-NMDS - minimum data elements are set by international medical, nursing, and standards organizations

Criteria for NMDS Data must be useful to most potential users Items in the set must be readily collectable with reasonable accuracy Items should not duplicate other available data or elements Confidentiality must not be violated

The 16 elements of NMDS Demographic elements 1. Personal identification 2. Date of birth 3. Gender 4. Race 5. Residence Services elements 6. Service agency number 7. Health record number 8. Unique number of principal registered nurse provider 9. Episode admission or encounter 10. Discharge or termination date 11. Disposition of client 12. Expected payee Nursing care elements* 13. Nursing diagnosis 14. Nursing intervention

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Nursing outcome Intensity of nursing care

Advantages of NMDS: Helps nurses better understand, communicate, and quantify care provided to clients/community Enhances interdisciplinary communication Enhances ability to conduct cost-benefit analysis of nursing care, research, and policy ANA-approved nursing care elements standards for NMDS NANDA (North American Nursing Diagnosis Association) NIC (Nursing Interventions Classification) NOC (Nursing Outcomes Classification) Omaha system CCC (Critical Care Classification) PNDS (Peri-operative Nursing Data Set) Patient Care Data Set SNOMED CT COMMUNITY HEALTH INFORMATION TRACKING SYSTEM (CHITS) an open source electronic medical record designed to run in public health centers and rural health units. created by Dr. Herman Tolentino through a grant from the International Development Research Centre of Canada. Basic word processing (i.e. typing), internet browsing and computer hardware operations (i.e. use of keyboard and mouse, turning on and shutting down computers) How does it enable RHUs to produce significant quality data? CHITS-EMR works by capturing health information at the actual point of encounter (i.e. right after health worker provides service to patient). As the data comes in and saved on a local server, data collection and recording is already done. Data entry forms are patterned after the actual paper forms but with built-in input filters Advantages of CHITS Streamlining the workflow. It has features that can help in needs projection and planning. Access to the data is not just convenient but secured as well. Launch CHITS by: Going to http://emnp.chits.ph/info/index.ph Or http://demo2010.chits.ph Once you have entered the correct address, you should be presented with the login screen. Your log-in username and password is: admin; for nurses, it will be provided by the MHO/PHN. Activities for CHITS 1. Register new patient There are two ways to register patient. Main Menu>>Patients>>Menu>>Records Main Menu>>Consults>>Menu>>Todays patient *On the screen you should be presented with an Old and New Patient. To register a new patient, fill out the info pertaining to the New Patient such as First/Middle/Last Name, Birthday (MM/DD/YYYY), Gender, Mothers Name, Mobile Number. If you are looking for an old patient, type First/Last name and then select search. The screen will present all names r/t the one you are searching. To make sure that you are not making any duplication of the patients record, you can also search first the name on the old patient and if there is no records found, proceed adding the name as new patient. You will receive a notification if the registration is successful and the Patients name will appear on Todays Patient. Select load patient record icon beside the newly registered pt.s name to view the full record of the patient. 2 and 3: Create a family folder and assign members and household head to the family folder

Main Menu>>Patients>>Menu>>Family Folder>>No member>>Type the name of your patient>>Check the box>>Add to family>>Click on the name once it appears on the family box>>Select either Family head or Family Member>>Assign role 4. Create a new consult: Creating a new consultation for Pediatric Patient(from the case study/FCA) Click TODAYS PATIENTS at the top portion of the screen to know the patients that are for consultation today. If your patient (from the case study) is a pediatric patient and has records already at CHITS, select the name of the patient from the list. Updating Vaccinations The patients record will appear. Click MODULE-VACCINE under CONSULT MODULE list located at the right lower corner of the record. A vaccination list will appear. Check the necessary vaccines to be given and then click UPDATE VACCINATION. A vaccination record will appear at the right corner of the patients record bearing the vaccines given to the patient. Updating Vital Signs Update the patients record by clicking the VITAL SIGNS link beside the APPTS command. Blank boxes will appear and will require you to fill in the necessary data. Fill in the vital signs and weight using the data from your case study/FCA. After filling it up, click SAVE VITAL SIGNS box under the boxes. A VITAL SIGNS record will appear at the right portion of the record. Click VIEW to see the previous vital signs from the last visit. Updating Patients notes Click the NOTES link beside the LABS link at the patients record. A NOTES ARCHIVE link will then appear. Click this link. After clicking, a CONSULT NOTES ARCHIVE form will appear. Click the CONSULT DATE link to view notes, and click EDIT NOTES. Use data from your previous case study (MATERNAL) to supply the needed data. Click SAVE NOTES box. Creating a new consultation for Maternal Patient(from the case study/FCA) Click TODAYS PATIENTS at the top portion of the screen to know the patients that are for consultation today. If your patient (from the case study) is a maternal patient and has records already at CHITS, select the name of the patient from the list. Updating Family Planning Status The patients record will appear. Under the VISIT DETAILS link the PATIENT GROUP list will appear. Check the box for FAMILY PLANNING and then click the SAVE DETAILS box. A FAMILY PLANNING module will then appear at the right corner of the record under PATIENT GROUP. Click the FAMILY PLANNING link. A FAMILY PLANNING form will appear containing boxes for PLAN MORE CHILDREN, NO. OF LIVING CHILDREN, TYPE OF ACCEPTOR, PREVIOUS METHOD USED, HIGHEST EDUCATIONAL ATTAINMENT, OCCUPATION, NAME OF SPOUSE, SPOUSE HIGHEST EDUCATIONAL ATTAINMENT, SPOUSE OCCUPATION, AVERAGE FAMILY INCOME. Fill in the data from the case study/FCA or your corresponding instructor will identify the data to be inputted. Click SAVE VISIT under the boxes filled up. Updating Vital Signs Update the patients record by clicking the VITAL SIGNS link beside the APPTS command. Blank boxes will appear and will require you to fill in the necessary data. Fill in the vital signs and weight using the data from your case study/FCA. After filling it up, click SAVE VITAL SIGNS box under the boxes. A VITAL SIGNS record will appear at the right portion of the record. Click VIEW to see the previous vital signs from the last visit. Updating Patients Appoinment Click APPOINTMENT link beside the VITAL SIGNS link at the patients record.

An appointment scheduler will appear, asking for the APPOINTMENT DATE and APPOINTMENT CODE. Type in the appointment date APRIL 26,2011, and check the boxes for FAMILY PLANNING, POSTPARTUM, VACCINATIONS. Click SEND REMINDERS box under the options. Updating Labs Click the LABS link beside the VITAL SIGNS link at the patients record. A MAKE LAB REQUESTS form will appear containing a list of boxes for lab exams, data for pending labs and lab requests completed. Check CERVICAL CANCER SCREENING, CBC, U/A, F/A, HGB/HCT. Click SEND REQUEST box under the list. Updating Patients Notes Click the NOTES link beside the LABS link at the patients record. A NOTES ARCHIVE link will then appear. Click this link. After clicking, a CONSULT NOTES ARCHIVE form will appear. Click the CONSULT DATE link to view notes, and click EDIT NOTES. Use data from your previous case study (MATERNAL) to supply the needed data. Click SAVE NOTES box. 5. Retrieve and save patient information