Chapter 9. Automating the Hospital Information System

The sum of all automated and non-automated information system is known as hospital information system or HIS. His were originally developed for hospitals, today, however, they may be found in nursing homes, rehab centers, health centers and other healthcare institutions. Clinical information system processes data related to patient care. It includes documentation in 4 specific areas. Medical Information Systems, where the physician shares information with the nurse in the clinical information system. Nursing Information System, where documentation system includes patient assessment and health condition data, developing care plans, managing order entry, administering and recording medication and treatment which are Assessment, Nursing Diagnosis, Planning, Implementation and Evaluation. Departmental Systems, supports the daily operation of a clinical department. It includes the services done by the lab, pharmacy, radiology, cardiology, and other ancillary departments. Setting Specific Information System, includes any of the functions already discussed; however the functions are customized for the specific area like emergency rooms, intensive care unit, outpatients or ambulatory care clinics. Non Clinical Information Systems include the Financial System for managing and report money matters. Admission, Discharge, Transfer for management of registration and assigning of beds and rooms to patients, transfer to other rooms or facilities and discharging of patients. Personnel Systems, used to track characteristics of employees and/or the use of employees within the institution, it consists of Human Resource Management Systems which keep details about the employee and Scheduling Systems, used to arrange dates and times that an employee will be working or not working. Administrative Systems for automating data used in the daily operation in the healthcare institution as well as data used for strategic and long range planning. An electronic medical record or EMR is a computerized medical record created in an organization that delivers care, such as a hospital or physician's office. Electronic medical records tend to be a part of a local stand-alone health information system that allows storage, retrieval and modification of records. An electronic health record or EHR is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is theoretically capable of being shared across different health care settings. In some cases this sharing can occur by way of network-connected enterprise-wide information systems and other information networks or exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.