Information technology has brought major changes in how things are done. With many information elements to manage, information systems have brought easier ways for managing information and integrating with various departments in a business, institution or government. Among areas where information systems have been used successfully is health sector. Ensuring the health of people is one of the major objectives of any society. Because of the importance of health, many governments spend a big proportion of their budgets on health. Effective health information management is one of the areas which have attracted much attention. Health information systems try to improve health management by improving information management.
Application of information technology in health sector has a long history. There are two main areas in health that has attracted the use of information technology: developing health instruments and managing health information. Use of information technology in health instruments range from application in health monitoring instruments to diagnosis and scanners. The need to manage various data in medical sector such as registration, processing bills, and managing patients’ trend has attracted application of information technology (McGlynn 13). The various forms of use of information systems in health include electronic data processing, ancillary registration system and health information systems. With increased importance of health information systems, various governments and insurance companies have emphasized on the need these system in health institutions.
Initially health information systems worked separately. However, with increase in use of information technology in health sector new integrated systems are being developed. Integrated health information systems integrate various information requirement, operations and departments. An example of an integrated health information system is a laboratory Information Management System that integrates various operations such as registration and analysis.
Health sector has been slow to adopt information technology. Before 2000, use of Electronic Health Records, and other computer technology was low (Ambinder par 3). By 2000, less than ten percent of American hospitals used hospital information technology. Most of the hospitals used the conventional method of information record process and other operations. This trend, however, has changes as many hospitals are appreciating the need for information technology and information systems (McGlynn 13). By 2005, individual health physicians and some hospitals had started to use Electronic Health Record, though partially. As compared to other areas such as business, health sector lag behind in use of information technology. The major impediment to adopting information system in health sector has been cost. However, government incentive to physicians and hospitals to adopt health information system is likely to increase use of information technology in health management.
Electronic Health Records
The major area of use of information systems in health is in Electronic Health Records (EHR). An Electronic Health Records is a computerized system for providing systematic health information of patients (Gartee 7). Unlike the conventional health record systems, this system provides an easy way of collecting, processing and sharing information about a patient. Since health sector has a lot of information to be kept, this method provides an efficient way of keeping records.
Before the adoption of Electronic Health Records, hospitals and health practitioners used manual record. Use of manual records had various disadvantages including volumes of physical records to be kept, information loss, and difficulty in information retrieval (Wager, Lee, & Glaser 67). Electronic Health Records is used to manage various information including medical history, demographic information, medication, laboratory test results, billing information and radiology images. ERH is developed in the context of an institution such as a hospital.
Electronic Health Records is recommended for any institution that keeps health information. The size of the institution may vary but Electronic Health Records is customized to meet the needs of the institution. The system integrates information management in various departments. For example; in a hospital with various departments such as registry, laboratory, treatment rooms and wards, EHR provides a central unit for managing data. EHR is also used in institutions with more than one unit. For example, EHR can be used to integrate and manage information in a hospital with several affiliated hospitals, diagnostic centres and also medical research departments.
Importance of Electronic Health Records
Electronic Health Records is an example of an integrated clinical system. The major benefit of this integrated system is to enable capture and processing of clinical data in a centralized system. EHR enables important information to be availed to the administrators, physicians, nurses, and researchers (Wager, Lee, & Glaser 34). The administrators can access data on billing, registration and other relevant information. A physician can access patients’ medical history, access laboratory results among others. On the other hand, researchers can benefit from EHR by having easy access to important research data.
Components to EHR
Electronic Health Records is designed to integrate data from various supplementary services with clinical data. The data collected by the system create an important foundation for decision making. Data from auxiliary services such as laboratory and pharmacy is integrated with clinical data such as nurse plans, physician order and medical administration record (Gartee 29). There are various components to an Electronic Health Records. Although there are general features to an Electronic Health Records, EHR are customized to a particular institution.
Administrative components are some of the most important components of an Electronic Health Records system. These components are mainly designed for administrative roles. Some of the sources of data for these components include admission, registration, transfer and discharge data. These are essential to any institution but most of all to hospitals (Gartee 51). These data provide important information for indentifying and assessing patients. The information include name, demographic information, patient disposition, next of kin, chief complaint, employer information and any other necessary information.
The registration component of an Electronic Health Records system contains distinctive patient identifier that is customized to a particular institution. The identifier can contain sequence of numeric or alphanumeric that provides a unique identification to every patient. Registration, admission, discharge and transfer data collected in an Electronic Health Records system allows health information of an individual to be used for clinical analysis as well as research. The unique patient identifier provides a way to link clinical observation, procedures, tests, diagnosis, complains and evaluation to a patient (Ambinder par 7). This unique identifier is also referred as master patient index or medical record number. With many patients to serve and a lot of data to be kept, medical record number has helped to bring efficiency in data management.
Laboratory system components
These components of an Electronic Health Records are designed for managing laboratory information. In most cases these components are designed as standalone components that are interfaced to Electronic Health Records. Some of laboratory information systems are used to integrate schedules, laboratory results, billing, orders and other administrative information (McGlynn 13). Although laboratory systems are components of an Electronic Health Records, data in these components is not entirely integrated to the EHR. Laboratory systems mainly aim at integrating information from various machines used in laboratory diagnosis and analysis. For example, Cerner Laboratory Information System provides interface to more than four hundred laboratory instruments. Although most of Laboratory Information Systems are standalone, there are EHR that provide interfaces to allow integration.
These components are used in radiology departments of health institutions. Radiology information systems are used to integrate patients’ information with radiology information such as images. The systems mainly include scheduling, patient tracking, image tracking and result reporting. In most cases Radiology Information Systems are used together with Picture Archiving Communication Systems. Like Laboratory components, Radiology components are mostly standalone but some of them are integrated to Electronic Health Records.
Pharmacy system components
These components are used to automate operations in pharmacy department. The system keeps track of drugs, patient information, prescription, order and billing information (Gartee 47). Most hospitals have automated their pharmacy with technology such as pharmacy robots and payer formulation. Some of the automations such as pharmacy robots work as standalones but most of operations are integrated to EHR.
Computerized Physician Order Entry
Computerized Physician Orders Entry components are designed for ordering clinical services. By using this system, clinical providers can order pharmacy, laboratory, and radiology services electronically. The components make it easy for physicians to execute their duties. Some of these systems provide more services such as alerting, ancillary service ordering and result reporting (Ambinder par 8).
Clinical Documentation components
These components of Electronic Health Records are used for providing electronic clinical documentation. It provides electronic capture of medical documents, clinical reports and patient assessment. The components are used to transform physical clinical data to electronic form that can be easily managed. When integrated with Electronic Health Records, the components provide important information for health management.
Special Requirement for Health information systems
Health information includes information on medical history of individuals. This information is critical to health service provision (Gartee 15). For this reason, accuracy of information in an Electronic Health Records is very important. Accuracy is one of the most important considerations made in an Electronic Health Records. The designers have to ensure that data entry, processing and output is free from error (Wager, Lee, & Glaser 113). Electronic health Records is designed to keep individuals’ health information for a long period of time. Information kept in an Electronic Health Records provides a foundation for future medical services. Inaccurate medical records kept in Electronic Health Record may hinder health service provision.
Many individuals regard information concerning their health as very sensitive. For this reason, access to individuals’ medical information has to be controlled. Health Insurance Portability and Accountability Act (HIPAA) provides standards for ensuring privacy in medical records. Various states have also created laws on medical records. In designing Electronic Health Records, provisions of HIPAA and individual state’s laws have to be considered. Privacy of medical records is ensured by ensuring controlled data access and manipulation. Privacy criteria ensure patients that their health information is protected from a third party.
Electronic Health Records provides integration of health information in an institution. This system provides various departments and individuals in a health institution with and central information management system. As a system that integrates many departments and individuals, access control is very important (Wager, Lee, & Glaser 92). There are various considerations to access control in an Electronic Health Records: department, health workers, doctors, emergent and privacy. Access control should provide criteria on the individuals that can input, access or manipulate medical records. In most cases health workers are required to sign a confidential agreement before they are allowed access to medical records. Deletion or manipulation of medical records is usually reserved to senior officers in a health institution. There is also control on how doctors access medical information of patients. For example, visiting doctor can be allowed access their patients only. In addition, access control should provide access criteria in case of emergency.
Health information system is viewed as a revolution in health services. Although health sector lag behind other sectors in adopting information technology, there is great improvement in the recent past. One area where information systems are use in health sector is in Electronic Health Records. Electronic Health Records is used to keep medical records electronically. There are various benefits to use of information systems in health sector. One of the major benefits is efficiency in keeping medical records. Electronic Health Records brought efficiency in recording, access and processing medical information. Integrated information provided by EHR has also improved doctors’ efficiency by providing them with all necessary patients’ health history. The systems have also played a major role in improving medical research.
Ambinder, Edward. Electronic Health Records. Journal of Oncology Practice. 2005. Web.
Gartee, Richard. Electronic health records: understanding and using computerized medical records. New York: Pearson Prentice Hall, 2006.
McGlynn, Elizabeth. Health information systems: design issues and analytic applications. New York: Rand Corporation, 1998.
Wager, Karen. Lee, Frances. & Glaser, John. Managing health care information systems: a practical approach for health care executives. New York: John Wiley and Sons, 2005.