Understanding the Hospital Environment:
A hospital is a complex environment where expert teams collaborate to provide holistic care to a patient. Due to this complexity, it becomes vital to clearly understand the work flow and different processes in a hospital. Only then would it be possible to understand the requirement of ICT at a hospital and the need and type of interoperability required. On completion of this group of sessions, the student would:
· Understand the layout of a hospital
· Understand the working of different departments and their interdependence
· Understand the patient and work flow
· Get and over view of IT support required in various departments
· Get and over view of the type of IT applications used in these departments
· Deep dive into details of important IT applications used in clinical environments, as detailed below
Medical terminologies, nomenclatures, coding and classification systems
Clinical vocabularies, terminologies or coding systems, are structured list of terms which together with their definitions are designed to describe unambiguously the care and treatment of patients. Terms cover diseases, diagnoses, findings, operations, treatments, drugs, administrative items etc., and can be used to support recording and reporting a patient's care at varying levels of detail, whether on paper or, increasingly, via an electronic medical record.
A nomenclature is a relatively simple system of names; a vocabulary is a system of names with explanations of their meanings; a classification is a systematic organisation of things into classes, and a thesaurus (such as MeSH) is designed to index medical literature and support search over bibliogaphic databases. But many of the terms used in this field can prove difficult to define accurately, and their use in practice can be inconsistent.
Medical coding and classification systems work towards implementing a standardised "language for health": a common (computerized) medical language for global use.
The following will be discussed in detail:
LONIC, SNOMED-CT, ICD, CPT
HL7
HL7, which is an abbreviation for Health Level Seven, is a standard for exchanging information between medical applications. This standard defines a format for the transmission of health-related information.
Information sent using the HL7 standard is sent as a collection of one or more messages, each of which transmits one record or item of health-related information. Examples ofHL7 messages include patient records, laboratory records and billing information.
DICOM
DICOM (Digital Imaging and Communications in Medicine) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format.
DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). DICOM has been widely adopted by hospitals , dentists' and doctors' offices.
ICD 9 – ICD 10 Migration
The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. Under this system, every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases. The International Classification of Diseases is published by the World Health Organization (WHO) and used worldwide for morbidity and mortality statistics, reimbursement systems, and automated decision support in medicine. This system is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics. The ICD is revised periodically and is currently in its tenth edition. The ICD is part of a "family" of guides that can be used to complement each other, including also the International Classification of Functioning, Disability and Health which focuses on the domains of functioning (disability) associated with health conditions, from both medical and social perspectives.
Clinical Information Systems
CISs can be component of a HIS in that the former concentrate on patient-related and clinical-state-related data (electronic patient record) whereas the latter keeps track of administrative issues.
Decision Support Systems
A decision support system (DSS) is a computer-based information system that supports business or organizational decision-making activities. DSSs serve the management, operations, and planning levels of an organization and help to make decisions, which may be rapidly changing and not easily specified in advance.
Clinical decision support system (CDSS or CDS) is an interactive decision support system (DSS) Computer Software, which is designed to assist physicians and other health professionals with decision making tasks, as determining diagnosis of patient data. A working definition : "Clinical Decision Support systems link health observations with health knowledge to influence health choices by clinicians for improved health care".
MIRTH
MIRTH is the leading Open source (freeware) interface engine for HL7. It makes interoperability between healthcare applications a snap, reducing effort from months to days.
EMR
An electronic medical record is dedicated to collecting, storing, manipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient record systems). Such records are restricted to a single hospital or domain.
EHR
An EHR is a longitudinal Electronic Medical record of a single patient and spans his complete health records (both during health and illness) from birth to death. It contains episodes and encounters from different healthcare establishments which could span continents.
PHR
Personal Health Records (PHRs) are "electronic application[s] through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment"
HIS (HIMS)
A hospital information system (HIS) is a comprehensive, integrated information system designed to manage the administrative, financial and clinical aspects of a hospital. This encompasses paper-based information processing as well as data processing machines.
It can be composed of one or a few software components with specialty-specific extensions as well as of a large variety of sub-systems in medical specialties (e.g. Laboratory Information System, Radiology Information System).
LIS
A lab information system is a class of software that receives, processes, and stores information generated by medical laboratory processes. These systems may or may not interface with instruments and other information systems such as hospital information systems (HIS). A LIS is a highly configurable application which is customized to facilitate a wide variety of laboratory workflow models. There are as many variations of LISs as there are types of lab work. Some vendors offer a full-service solution capable of handling a large hospital lab's needs; others specialize in specific modules. Disciplines of laboratory science supported by LISs include hematology, chemistry, immunology, blood bank (Donor and Transfusion Management), surgical pathology, anatomical pathology, flow cytometry and microbiology.
Radiology Information Systems
A radiology information system (RIS) is an application used by radiology departments to store, manipulate and distribute patient radiological data and imagery. The system carries out patient tracking and scheduling, result reporting and image tracking. The RIS complements HIS (Hospital Information Systems) and is critical for efficient workflow in radiology practices.
PACS
A picture archiving and communication system is a combination of hardware and software dedicated to the short and long term storage, retrieval, management, distribution and presentation of images. The biggest consumers of PACS are hospitals. PACS main purpose is to replace hard film copies with digital images that can be used and seen by several different medical professionals and different medical automation systems simultaneously.
Nursing Information System
Nursing information systems (NIS) are computer systems that manage clinical data from a variety of healthcare environments, and made available in a timely and orderly fashion to aid nurses in improving patient care.
To achieve this, most Nursing Information Systems are designed using a database and at least one nursing classification language such as North American Nursing Diagnosis (NANDA), Nursing Intervention Classification (NIC) and Nursing Diagnosis Extension and Classification (NDEC).
Evidence-Based Medicine
Evidence-based medicine (EBM) or evidence-based practice (EBP) aims to apply the best available evidence gained from the scientific method to clinical decision making.[1] It seeks to assess the strength of evidence of the risks and benefits of treatments (including lack of treatment) and diagnostic tests.[2] Evidence quality can range from meta-analyses and systematic reviews of double-blind, placebo-controlled clinical trials at the top end, down to conventional wisdom at the bottom.
EBM/EBP recognizes that many aspects of health care depend on individual factors such as quality- and value-of-life judgments, which are only partially subject to scientific methods. EBP, however, seeks to clarify those parts of medical practice that are in principle subject to scientific methods and to apply these methods to ensure the best prediction of outcomes in medical treatment, even as debate continues about which outcomes are desirable.
GxP and 21 CFR Part 11 training
GxP is a general term for Good Practice quality guidelines and regulations. These guidelines are used in many fields, including the pharmaceutical and food industries.
In 1997 the United States Food and Drug Administration (FDA) issued Rule 21 CFR Part 11 that provides criteria for acceptance of electronic records, electronic signatures and handwritten signatures. Based on this rule, electronic records can now be legally considered the equivalent of paper records and handwritten signatures.
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