2011 Hospital Information System

7/30/2019 2011 Hospital Information System

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Hospital Information System

winny setyonugroho, M.T.


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goal

Provide timely, complete,accurate, legible, and relevant

information access


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Evolution

It was electronic medical records

(EMRs) in that they dealt with therecord of disease and interventions

transformed into a fluid electronic

portal that describes local care and theinteractions between health providersand their patients.


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hospital


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Advantage e-Record

Accessbility

LigibiltyReduce health error from hand writing

Use of Discrete DataIn the elements of history, medicalproblems, medications, and evensocial history


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Standardize

universal messaging protocols to allow

for interchange of these data amongdifferent computer systems


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HL7

health level 7

standards for the exchange,management and integration ofelectronic healthcare information


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HL7

Each HL7 message consists of one or more segments. Acarriage 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 sampleHL7 message below)

Each HL7 segment consists of one or more composites (alsoknown as fields). A pipe (|) character is used to separate onecomposite from another.

If a composite contains other composites, these sub-composites (or sub-fields) are normally separated by ^

characters.


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HL7 : example

MSH|^~\&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADTÂ04|1817457|D|2.5|

PID||0493575^^^2ÎD 1|454721||DOE^JOHN^^^^|

DOE^JOHN^^^^|19480203|M||B|254 MYSTREETAVE^^MYTOWNÔH^44123ÛSA||(216)123-4567|||M|NON|400003403~1129086|

NK1||ROE^MARIE^^^^|SPO||(216)123-4567||EC|||||||||||||||||||||||||||

PV1||O|168 ~219~C~PMA^^^^^^^^^||||277ÂLLENMYLASTNAME^BONNIE^^^^|||||||||| ||2688684|||||||||||||||||||||||||199912271408||||||002376853


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HL7 : example


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ICD 10 CM

International Classification of Diseasesand its Clinical Modifications

Diagnosis-related groups(DRGs)


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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


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CPT

Current Prosedural Terminology

Describes medical services and procedures

Uniform information among physicians, coders,

patients, accreditation organizations, and payers foradministrative, financial, and analytical purposes


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CPT : example


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LOINC

Logical Observation Identifiers Namesand Codes

Standard for identifying medicallaboratory observations


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DICOM

Digital Imaging and Communications inMedicine

Standard for handling, storing,printing, and transmitting informationin medical imaging

Includes a file format definition and a networkcommunications protocol


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NANDA

North American Nursing DiagnosisAssociation

standardized nursing diagnoses

note that there is no correlation between ICD

and NANDA, consequently, most inpatientrecords have two problem lists at any time


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NDCs

National Drug Codes

Unique product identifier used in the UnitedStates for drugs intended for human use


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Order Management

Phycisian order entry : now and then,comparation

Computerized provider order entry(CPOE)

provide structure to physician orders and toallow for the rendering of decision

support tools at the moment of ordering


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CPOE


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CPOE - medication

Inpatient Drug Orders

physician initiates the order, entering a series of discreteelements such as dose, frequency, route, priority (e.g., stat),start and stop times, etc

pharmacist, may see additional alerts, modify the orderaccording to local policy or on drug availability

Than passed to another view for the physician provider


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CPOE - medication

Outpatient Drug Orders

ambulatory physician must consider the medication dosageinformation, also insurance covered

transmitted directly to a pharmacy to be produced.


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CPOE - medication


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Decission Support

support safe drug prescribing

a therapeutic drug level Drug dosage

Drug interaction

Drug allergies


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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 identifiedcoronary artery disease on the problem list. The EHR show mostrecent lipid levels, as well as whether the patient is taking a

medication to lower lipid levels. If the patient is not currently onan antilipemic agent or does not have a serum lipid levelconsistent with national guidelines, an alert will display

Another screen will prompt the prescriber to order appropriatelipid-lowering therapy


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The End

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2011 Hospital Information System

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