Nursing Diagnosis

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Hospital Information System
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Hospital Information SystemDefinition

• Hospital Information System is an integrated,
• computer-assisted system designed to store,
• manipulate, and retrieve information concerned
  with
• the administrative and clinical aspects of
  providing
• services within the hospital

CEN/TC 251 /PT001 Medical Informatics-Vocabulary F
irst Draft Working Document
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Hospital Information SystemAnother definition
A Hospital Information System (HIS) can be
defined as an open system which attempts to
integrate and communicate the outside and inside
flow of information within a hospitaland provide
the functions common for all applications.
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GOVERNMENT
rules regulations
rules
consolidated global patient data and hospital
data
rules regulations
Pat-info Pat-request
patient
INSURANCE COMPANIES
PRIMARY CARE health care
H.I.S. Institutions
H.I.S. Institutions
Pat-results
official documents bills
private
patient document
info patient
patient of
member of
PATIENT
Representation of a HIS and its external links
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Desciption of a hospital information system in
terms of the main functions
Management oriented
Patient oriented
Financial-economical 1. Financial general
ledger accounts receivable accounts
payable budget control 2. Material and
technical Management stock control
inventory maintenance planning
energy control purchase/order management 3.
Personnel system personnel management
loans and salaries 4. Patient billing
insurability medical act administration 5.
Strategic planning and study executive IS
cost accounting retrospective utilization
analysis
Patient-management
Medical
6. Outpatient Inpatient patient
registration ER registration patient
scheduling 7. Inpatient inpatient
(pre-)admission admission registration
bed census 8. Result reporting and order
entry order entry communication result
reporting
9. Nursing care-planning charting
nurse staffing food supply 10. Diagnostic
radiology function laboratory -
cardiology - pneumology laboratory
- chemistry - haematology -
microbiology 11. Therapeutic
operatingroom radiotherapy
pharmacy intensive care
OB-gynaecology
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Description of a Hospital Information System in
terms of the main Information Entities
Clinical subsystem patient central
Patient-Record
Medical information
Medical-administrative information

• Admission data
• Patient demographic data
• Orders
• Planning and appointment data
• Patient diets
• Material deliveries

• Diagnostic
• laboratory
• radiology
• nuclear medecine
• EEG, ECG, EMG, respiratory.Therapeutical
• operation history
• radiotherapy
• intensive care
• physiotherapy
• nursing
• medication

Hospital Communication system - Repository
system

• General accounting
• Accounts receivable
• Accounts payable
• Personnel data
• Loans and salaries
• Budget control
• Inventories

• Case mix
• Resource allocation data
• Simulations/Models
• Retrospective utilization data
• Cost/Quality information

Financial information
Strategic information
Management subsystem hospital central
Hospital Record
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Objectives of A Hospital Information System

• The most important goals of HIS are
• To have a common registration of total patient
  information at the point of each transaction
• To have the possibility to access information
  from any location at any time
• To recognise the health care provider as major
  user and thus ease of use
• To recognise integration as a conditio sine qua
  non
• To recognise that a HIS must be cost efficient.
• To provide tools for evaluating health care costs
  and quality
• To recognise the clinical communications hub of a
  HIS
• To recognise that technology must meet the users
  and applications needs
• To establish the basis for hospiatl controlled
  and developed applications
• To guarantee backward compatibility of new
  software releases
• To guarantee high availability of the system

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A modern HIS includes the following modules

• Patient record
• Admissions/discharge/transfer
• Order entry/results reporting
• Drug profile
• Care planning
• Personnel/staff planning
• Financial

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1. Patient Record

• The critical elements of a patient
  record-handling system are
• Access control functions
• Input and presentation functions
• Document-handling functions
• Information-handling functions
• Electronic mail functions
• Help functions
• Communications functions
• Functions for follow-up of the activities

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2. Admissions/Discharge/Transfer (ADT)

• Outpatient Care Modules
• Scheduling of appointments with physicians and
  nurses
• Registration of the visit
• Financial functions
• Statistics
• Data transfer to the hospital financial system

• Inpatient Care Modules
• Waiting list
• Preadmission data
• Admission and discharge
• Diagnosis
• Hospital statistics
• Data transfer to the hospital financial system

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3. Order Entry/Results Reporting
There are two subsets to the order system a.
Order Entry System includes all orders for a
patient and links that system
to the hospital financial
routines b. Referral Reply System- the order
for a procedure or an examination connected
with an
appointment scheduling module
- checks that all
referrals are handled and the results
signed and
included in the patient record
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4. Drug Profile

• Drug Information Systems
• is relevant to both inpatient and out patient
  care
• may include modules for retrieving information
  about drugs as well as for indicating what
  drugs a patient is using at a given moment
• provide formulations for specific prescriptions
• allow data manipulation
• link to the hospital financial system

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5. Care Planning

• Care Information System for
• giving every patient an individual care plan and
  following it up also contain functions that
  assist in selecting the appropriate care plan
• evaluating follow-up
• manipulating data for further analysis and study

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6. Personnel/Staff Planning

• These systems
• handle individual unit requirements in assigning
  staff
• provide follow-up reports
• assist in daily planning for staff allocation
• link to the hospital financial routines

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7. Financial

• Each individual local unit needs routines for
  planning financial transactions and for
  evaluating their effectiveness
• Linkages with the main financial system
  eliminate the need to duplicate data input and
  to refer to separate systems

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Implementation of HIS

• Implementation issues that must be addressed
  when satisfactory installing a hospital
  information system
• Access Control System
• Patient Identification System
• Patient Admission, Discharge, and Transfer System
• Data Communications Standards