The heath information system in any health care organization setting would ensure proper billing, cost control, quality control especially when the information system provides demonstrable cost saving and patient retention. The introduction of health information system in any organization requires a thorough understanding of the basic principles of health informatics. Some of the salient features are discussed in this presentation.
Database Characteristics and Structure
A database consists of one or more large structured tables of persistent data. The data are usually associated with the software capable of updating and making queries about the data. A single table containing a number of records may form a simple database. It is necessary that the records in the table should contain the same fields. In a table, a row includes a record, a column contains a field and a cell contains a data item. The data item represents a particular value in a field for a particular record. Object modeling is the process that helps the structure of data in to be formatted into the relevant fields. It is important that a qualified database expert be consulted when devising databases having more number of tables (Beaumont).
Types of Medical Data and Information Records
The medical records are maintained and used by many people including doctors, nurses, office staff, administrator, lab personnel, radiologist and physical therapist among others. Data can be organized in several ways. Doctor’s journal is the traditional way of organizing the data. Time order of collection per patient (Mayo), and Problem Oriented Medical Record (POMR) are some of the other ways of organizing the medical information and records.
These models use the notes organized by the problems or a “subjective, objective, assessment, plans” (SOAP) method. Under Mayo, model paper records are mainly used with pneumatic tube delivery. This limits the size of the records. This system has developed formal procedures for reaping and organizing records at the time of discharge. Paper records have the advantage of low training time and they can be carried to the point of care. There will be no downtime required to retrieve the data and the system has the flexibility to record information instantly. However, they have the major disadvantage of information or records being missing, illegible or inaccurate.
There are other weaknesses associated with the paper records, like discontinuity of information across different institutions and unavailability of records at the time of the visits of the patients, which make the computerized health information system preferable. There are a number of individual and institutional users, who are in need of patient records for various purposes. The patient records are required by the users for both primary and secondary uses. The important elements of information records are uniform core information, standardized coding, common data dictionary and information on customers of care and functional status (Szolovits, 2003).
Importance of Uniform Terminology and Coding
Continuity of patient care is ensured by Computer-based Patient Record (CPR) systems. This system enables the sharing of patient information across various users interconnected in information network. The CPR system also facilitates the measurement of outcomes by the greater availability and specificity of healthcare information. In order to derive the fullest advantage of healthcare information system it is essential that standards be established in respect of healthcare information.
These standards may take the form of classifications, guides, practices and common terminology so that all the individuals, institutions and agencies receiving the information would be able to perceive the information with the same intent and meaning (Blair, 1999).
Thus, the healthcare information system ensures undeterred flow of communication among the users of patient-related information so that a high level of patient service can be ensured.
Beaumont, R. (n.d.). Databases and Database Management Systems. Web.
Blair, J. S. (1999). An Overview of Healthcare Information Standards. Web.
Szolovits, P. (2003). Nature of Medical Data. Web.