HCA521 Utica Unit 8 Healthcare Technologies And Information Assignment

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HCA521

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M08_GART2674_01_SE_C08.QXD 8 8/10/09 11:05 AM Page 182 Additional Health Information Systems LEARNING OUTCOMES H I should be able to: After completing this chapter, you 䊏 Describe departmental health G record systems 䊏 Explain how departmental health record systems contribute to the EHR G 䊏 Discuss the factors that cause facilities to use multiple information systems S and master patient indexes 䊏 Describe patient registration 䊏 Describe the workflow of ,electronic lab orders and results 䊏 䊏 䊏 䊏 䊏 䊏 Describe radiology information systems Describe workflow dictation and transcription S Explain how speech recognition works H department, and surgical information systems Describe pharmacy, emergency A Compare implant and transplant registries Explain the concept of clinical trials N I C Q Acronyms are used extensively in both medicine and computers. The following U acronyms are used in this chapter. ADT Admission, Discharge, Transfer EHR Electronic Health Record A ACRONYMS USED IN CHAPTER 8 CAP System EMT Emergency Medical Technician College of American Pathologists ER Emergency Room or Department FDA Food and Drug Administration HIS Health Information System HL7 Health Level 7 ICU Intensive Care Unit IOM Institute of Medicine of the National Academies IV Intravenous LIS Laboratory Information System LOS Length of Stay MPI Master Patient Index MRI Magnetic Resonance Imaging NMDP National Marrow Donor Program OR Operating Room CAT 1 Computerized Axial Tomography CD Compact Disk CDR CIO CPOE CR 1 Clinical Data Repository0 Chief Information Officer 5 Computerized Physician Order T Entry; Computerized Provider Order Entry S Computed Radiography CT SCAN Computed Tomography Scan DICOM Digital Imaging and Communications in Medicine DNR Do Not Resuscitate DR Digital Radiography DUR Drug Utilization Review ECG Electrocardiogram 182 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 183 ADDITIONAL HEALTH INFORMATION SYSTEMS PACS OR PAC SYSTEM Picture Archiving and Communication System PET Positron Emission Tomography RFID Radio-Frequency Identification RIS Radiology Information System UNOS United Network for Organ Sharing VBC Visible Black Character 183 Departmental Information Systems After reading the previous chapters, you might imagine that a hospital or doctor’s office has one large health record computer system. The reality, however, is Hthat health records originate from many separate systems. Some of these records are imported into the EHR or into a central cliniI from the EHR but actually remain cal data repository (CDR). Others are retrieved and displayed stored on their respective systems. G The overall health information system (HIS) includes both clinical and administrative sysG by the various specialized departtems. This chapter will focus primarily on systems that are used ments as they perform their daily tasks and that act as the source S of data for certain aspects of the EHR. Administrative, billing, and management systems will be discussed in Chapters 9 through 12. , software package, but rather a The HIS and even the EHR system are typically not a single complex arrangement of multiple individual systems contributing data to the whole patient record. It is not uncommon for an inpatient facility HIS to be comprised of 60 to 400 different software applications. Ambulatory facilities with an EHR S may have 2 to 6 different systems. Hospitals have these disparate systems in place for many reasons. H First, what is the overall philosophy of the IT selection committee? A Integrated Systems Approach: An integrated systems approach biases decisions toward N software compatibility. Insofar as possible, the approach calls for using one vendor’s sysI been interfaced with the ventems and where that isn’t possible selecting systems that have dor’s systems at other hospitals. C An integrated systems approach has the advantage that everything works together and there are fewer vendors to deal with. The disadvantage is Q that the preferred vendor’s solution for certain departments may lack functionality offered byU the competition, or the vendor may not offer software for those departments, forcing the hospital to select nonintegrated softA ware anyway. Best-of-Breed Approach: The best-of-breed approach is to select systems that best meet a department’s needs, regardless of the vendor. This ensures maximum software functionality 1 for the individual departments. The disadvantage of this approach is that department soft1custom interfaces. This approach ware products may not work with the EHR or may require also requires IT to deal with more vendors and makes it more 0 difficult to resolve software and interface issues. 5 Another reason hospitals sometimes have different software systems is because certain T and have the power to select departments wield more influence with the hospital management their own software, even if it is incompatible with other systems. Another reason is that CAT S scan, MRI, and PET equipment and even ICU monitors or other biomedical devices may come with their own software, which is required to operate the device. These systems must then be interfaced with the hospital registration, CPOE, and EHR systems. Outpatient facilities that are not affiliated with hospitals, such as a doctor’s office, tend to have fewer systems. Usually the doctors are the decision makers and typically a practice management system is already well established. If the practice management vendor offers an acceptable EHR system, that will be the system of choice. However, if the office has its own laboratory, a separate laboratory information system (LIS) will be used. Similarly, if the office has ECG or other diagnostic equipment, software supplied with the device may need to be interfaced. Specialists may have additional software important to their specialty. Radiologists may have a Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 184 8/10/09 11:05 AM Page 184 CHAPTER 8 radiology information system (RIS) and a small PAC system. Cardiologists have many different diagnostic devices and, therefore, may have different software for each of them. In summary, inpatient facilities generally consider the HIS to be the principal system and the various department systems to be ancillary systems that are integrated or interfaced with the HIS. Ambulatory facilities generally consider the practice management system to be the principal system and the EHR is often a component of it, from the same vendor. Other software in the doctor’s office usually consists of programs for specific equipment that may or may not be interfaced to the EHR. Patient Registration Though most of this chapter will discuss clinical departmental systems that contribute to the patient health record, one administrative H system is key to both paper and electronic charts: the patient registration system and master patient index (MPI). In some facilities this is called the admission, discharge, transfer (ADT)I system. The patient registration system G contains demographic information about the patient such as name, address, sex, date of birth, and next of kin. It also contains guarantor and insurance inforG shows a patient registration screen from the Paragon mation used for billing. Figure 8-1 Community Hospital information system. S ADT systems may also store some clinical data, such as the admitting and discharge diagno, sis, LOS, and organ donor, DNR, consent, and other forms that have been signed by the patient. These will be discussed in Chapter 9. Most important to the HIM department, the patient registration record contains the patient’s S medical record number. In an HIM department that files paper charts numerically, the patient H to find the chart. In a computerized facility, the patient registration or MPI system is necessary registration record is used by the EHR A and every departmental system to connect the electronic health records to the correct patient. N was manually kept on file cards. Today however, even At one time the master patient index paper-based facilities have computerized I their patient registration and MPI processes. The master patient index (MPI) may be a separate system or merely an index of the patient C Large healthcare organizations comprised of multiple database, depending on the facility. FIGURE 8-1 Patient registration screen. (Courtesy of McKesson Corporation.) Q U A 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 185 ADDITIONAL HEALTH INFORMATION SYSTEMS 185 FIGURE 8-2 Master patient index. (Courtesy of McKesson Corporation.) H I G G S , facilities maintain the MPI as a separate database, combining the patient information from mul- tiple registration systems. Facilities that are not affiliated with other entities may use the patient registration database as the MPI; this is especially true of group medical practices. If the MPI is S a separate database, it will contain fewer fields than the registration system, typically first name, H ID field. middle name, surname, suffix, date of birth, sex, and a unique The main purposes of the MPI are to provide patient lookup A and prevent duplicate registrations of the same patient. Figure 8-2 shows the master patient index for the Paragon Community N Hospital information system. 1 The MPI or registration system may also include a Soundex I field. Soundex is used to codify the phonetic sounds of surnames. The Soundex code consists of the first letter of the surname followed by a three-digit numeric code, for example, P630. TheC code is determined according to the table shown in Figure 8-3. Soundex is used for driver’s licenses,Qcollege student registration, genealogy searches, the U.S. Census Bureau, and healthcare organizations. The purpose of the Soundex Soundex Letters Code B, F, P, V 1 C, G, J, K, Q, S, X, Z 2 D, T 3 L 4 M, N 5 R 6 A, E, H, I, O, U, W, Y Skipped Zeroes are added if the code is less than 3 digits long 0 U A 1 1 0 5 T S FIGURE 8-3 Table for determining Soundex codes If code is longer than 3 digits extra digits are dropped 1 Soundex was created and patented by Robert C. Russell in 1918. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 186 8/10/09 11:05 AM Page 186 CHAPTER 8 lookup is to find surnames that sound phonetically alike when the user is unsure of the spelling. For example, the Soundex for Pardee is P630; Partie, Prat, and Parad are also P630. Soundex lookup provides the user with a list of similar sounding names from which they might locate the correct patient. Laboratory Services A laboratory information system (LIS) receives orders and sends results of medical tests performed by the lab. Laboratory services consist of many sciences: 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 䊏 Hematology Chemistry Immunology H Blood bank (donor and transfusion) Pathology I Surgical pathology G Cytology G Microbiology S Flow cytometry , Automated laboratory instruments, which are used to analyze blood and other samples, typically have an electronic interface connected to the LIS. This enables the test equipment to transfer test results directly to the LIS database. S The LIS can also send information about the equipment. For example, some instruments are capable of running several different types of tests. The LIS sysH instructions that it then sends to the test equipment. tem can translate ordered test codes into The HL7 interface standard (discussed in Chapter 4) is used to connect the LIS with HIS, A CPOE, EHR, and other healthcare systems. Figure 8-4 shows a laboratoryNinformation system screen displaying a batch of instrument results for patients and qualityI control material. Color-coded alerts are used to draw the FIGURE 8-4 LIS display of results received from an automated instrument. (Courtesy of Sunquest Information Systems.) C Q U A 1 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 187 ADDITIONAL HEALTH INFORMATION SYSTEMS 187 technologist’s attention to those results that might need extra review or need to be repeated to verify high or low results or a significant change from the last time the patient had the same test run. Not all lab work is performed by automated equipment. For example, some tests are performed by growing cultures and examining them, or by examining tissue or other samples through a microscope. The doctor who performs this work is a specialist called a pathologist. There are several areas of pathology: 䊏 䊏 Clinical pathology uses chemistry, microbiology, hematology, and molecular pathology to analyze blood, urine, and other body fluids. Anatomic pathology performs gross, microscopic, and molecular examination of organs and tissues and autopsies of whole bodies. Surgical pathology performs gross and microscopic examination of tissue removed from a patient by surgery or biopsy. Test results are first stored in the LIS and then transferred to the EHR. Test results that are H The pathology report is usually not electronically transferred into the LIS are manually entered. a text report, but it is also stored in the LIS. I Figure 8-5 shows the workflow of a laboratory test. Review the figure as you read the followG ing steps: Gorder is recorded in the patient 1. The clinician orders one or more tests for the patient. The records and sent to the LIS system. The order is assigned Sa unique ID called a requisition or accession number. , 2. A nurse, phlebotomist, or medical technician receives the order and obtains the required specimen from the patient. The specimen containers are labeled with the patient ID and requisition number. In many facilities the labels have barcodes. When several tests are S 1 EHR 7 6 FIGURE 8-5 LIS H A N I C Q U A 1 1 0 5 T S 2 3 5 4 Workflow of electronic lab orders and results. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 188 8/10/09 11:05 AM Page 188 CHAPTER 8 3. 4. 5. 6. 7. ordered, multiple tubes of blood may be drawn, one for each type of test. In other instances the blood may be divided into separate samples at the lab. The collected specimen is sent to the lab where its receipt is recorded in the LIS. Manual or automated testing begins with preparation of the specimen sample. The specimen labels and test orders are verified to ensure the right test is performed on the right patient. If the testing will be performed by an automated analyzer, the order is downloaded to the instrument and the sample is placed in the analyzer. The equipment reads the barcode on the label, locates the downloaded information, and performs the ordered test(s). When an automated test is complete, the analyzer sends the results to the LIS. Results are autoverified, verified by repeat analysis, and/or checked by the lab technician and pathologist. When a manual test is complete, the lab technician or pathologist enters the result manually in the LIS. Pathology reports may also be dictated; the transcribed report is then stored in the LISH and also sent to the EHR. The lab report is generated by the LIS and then faxed, printed, or sent electronically to the EHR—or in some facilities, all Iof the above. The ordering physician, nurses,G pharmacists, and other care providers read the results report and respond appropriately. G Not all tests are performed in the S laboratory. Certain tests may be performed by handheld instruments at the patient’s bedside or even the patient’s home. This is called point-of-care testing. One example of such an instrument is,a glucose monitor. The glucose monitor measures the amount of a type of sugar in a patient’s blood. The results of this test can be electronically transferred from the glucose monitor device to the EHR. In a hospital, this is usually transferred through the LIS. S by the College of American Pathologists (CAP). CAP Medical laboratories are accredited accreditation is so thorough that it isH accepted by the Joint Commission. In addition to the laboratory itself, CAP accreditation requires that nurses and other inpatient personnel who perform A point-of-care tests at bedside be trained and certified to do so. N the LIS can be used to perform and keep track of nonIn addition to test orders and results, patient-related duties. For example, it is necessary for the lab to calibrate the equipment periodiI cally and to keep maintenance logs; the LIS system can do this. C for maintaining records of the test equipment, certificaThe LIS provides management tools tion of lab technicians who perform Qthe tests, and nurses who perform point-of-care testing. Control tests are performed as required; serial or lot numbers of materials used for the tests are U for CAP audits and are, therefore, one of the most also tracked. These records are necessary important benefits of the LIS. A Stat Tests Stat, from the term statim, means “without delay.” It is used in the hospital to convey urgency in 1 many instances of patient care. In the laboratory, stat orders are given the highest priority. 1 Surgical pathology orders are sometimes ordered stat because the surgeon needs the results while the surgery is still going on. Nearly0all orders from an emergency department are ordered stat, because the results are usually needed for the diagnosis or emergency care of patients. THE FIVE RIGHTS OF 1. 2. 3. 4. 5. 5 T LABORATORY S TESTING 2 Right patient Right test Right time Right results Right diagnosis 2 Adapted from Effective Diagnostic Decisions: The Five Rights of Laboratory Testing (Tucson, AZ: Sunquest Information Systems, 2009), www.sunquestinfo.com. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 189 ADDITIONAL HEALTH INFORMATION SYSTEMS 189 FIGURE 8-6 A pathologist examines a specimen using digital pathology. (Courtesy of Aperio, Inc.) H I G G S , Digital Pathology S H A N I C Q U A Digital pathology imaging systems work like a microscope, except that the image of the specimen slide is captured digitally. A computer monitor is used 1 to display the image and allows the pathologist to digitally stain, zoom, or otherwise enhance the1image. Computer software can also be used to recognize unusual patterns or cells in the image. A digital pathology system, the 0 Aperio ScanScope XT™, is shown in Figure 8-6. Recent developments can also use ranges of light beyond 5 the visible spectrum, allowing pathologists to see what the human eye cannot. Another new breakthrough produces 3-D images of cells and proteins using a technology that works similar toTa miniature MRI. Digital pathology images can be stored in a PAC system.S The advent of digital pathology has the potential to make the pathologist’s workflow more like that of a radiologist. Radiology Department Radiologists are physicians who specialize in interpreting diagnostic images of the patient, such as x-rays and CT scans. The information systems they use are specific to the needs of their department, not a standard function of a generalized EHR or HIS system. Radiology departments typically have a radiology information system (RIS), a picture archiving and communication system (PACS) for storing diagnostic images, and a dictation/transcription or voice recognition system. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 190 8/10/09 11:05 AM Page 190 CHAPTER 8 H I G G S , FIGURE 8-7 system. Radiologist dictates report; monitors display RIS and PAC S H A The radiology department will also N have a large number of interfaces. Because the RIS is not typically a module of the HIS, interfaces to registration and billing will be necessary. Also, most of the imaging devices used in the Idepartment will transfer images directly to the PACS; the devices may also be capable of receiving C order and patient data electronically from the RIS system. Patient data is then incorporated in the image when it is captured. Interfaces will be used to Q receive orders and send the transcribed radiology report to the EHR. In Figure 8-7, a radiologist dictates Uthe radiology report concerning the images displayed on the center and right monitors in the photo. The monitor on the left displays information from the RIS. A (Photo provided courtesy of Carestream Health, Inc.) Digital X-Ray Images Traditional x-rays used to be taken on 1 photographic film. To be stored in a PAC system, the film then had to be digitized using a scanner. Today, x-ray systems can record the image on a special 1 eliminating the steps of developing the film and then scanplate that captures the image digitally, ning it. Terminology from the days0of film is still used though. For example, a set of related images interpreted by the radiologist is called a study; a hanging protocol refers to the number of images that simultaneously display 5 on the radiologist’s monitor. The term comes from the days when x-ray films were viewed by hanging T them on light boxes. S FLASH CARD Some x-rays are still taken with photographic film. When images are captured on film, a flash card is used. A flash card is a small card with the patient’s name or ID on it that is photographed on the negative at the time the x-ray is exposed. This ensures that the x-ray is matched to the proper patient when the films are developed. Digital systems do not need a flash card; the patient information is stored in the DICOM file containing the image. DICOM stands for Digital Imaging and Communications in Medicine. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.qxd 8/22/09 5:12 PM Page 191 ADDITIONAL HEALTH INFORMATION SYSTEMS 191 CAT/CT, MRI, and PET Images In addition to x-rays, other equipment used in the radiology department can capture images digitally and transfer them to a PAC system. These include: 䊏 䊏 䊏 Computerized axial tomography (CAT) systems use x-rays to see into the patient’s body and capture thousands of digital images. Using computer software, it then constructs a view of cross sections of the body from the digital images. In some facilities this is also referred to as CT or computed tomography. Magnetic resonance imaging (MRI) uses magnetic fields and pulses of energy to create images H of organs and structures inside the body that canI not be seen by x-ray or CAT scan. Figure 8-8 shows an MRI device. G Positron emission tomography (PET) combines CT and G nuclear scanning using a radioactive substance called a tracer, which is injected into a patient’s vein. A computer records S data into 3-D images of the the tracer as it collects in certain organs, then converts the organ. PET can be used to detect or evaluate cancer. , High-Resolution Monitors FIGURE 8-8 Magnetic resonance imaging. (Used with permission of GE Healthcare.) S The radiologist must be able to see the smallest detail to ensure an accurate interpretation. To H facilitate this, the computer monitor (screen) used by the radiologist has a higher resolution than a typical computer screen. Resolution refers to the size and number of pixels the screen can disA play. Radiology monitors have much smaller pixels, so they are capable of displaying a much N view of the image. The software larger quantity of them. This gives the radiologist a much better radiologists use to view the image also has many features that I allow the radiologist to enhance the digital image. Features include the ability to zoom in or out, change the contrast, and comC pare several images side by side. Dictation/Transcription Systems Q U A Dictation systems are prevalent in healthcare. The clinician dictates his or her notes into a recording device. The dictation is subsequently transcribed (typed) by a professional called a medical transcriptionist. When completed, the transcribed document 1 is returned to the clinician to review and approve. 1 transcribed has been around for The concept of dictating medical notes and having them many years. Transcribed documents provided a great improvement over illegible handwritten 0 notes and reports. However, the process causes a significant delay between the time when 5 patients are treated and when their charts are updated. It also does not produce a codified medical record and adds numerous steps to the workflow: T 1. 2. 3. 4. 5. 6. 7. 8. S The doctor examines the patient. The doctor dictates the note (usually from memory after leaving the exam room). The recording of the dictation is sent to the transcriptionist. The transcriptionist types the document as he or she listens to the recording. The transcriptionist or a supervisor checks the document for accuracy. The document is sent to the doctor for approval. The doctor reads the document (usually without benefit of the original recording). If there are errors, the doctor notes the necessary corrections and waits for the transcriptionist to make the changes. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 192 8/10/09 11:05 AM Page 192 CHAPTER 8 FIGURE 8-9 A doctor (on left) dictates notes which are then transcribed (on right). (Photos Courtesy Nuance, Inc.) H I G G S , S 9. The doctor signs the completed H document. 10. A file clerk pulls the patient chart from the filing system, inserts the document, and refiles A the chart. N One of the benefits of an EHR is to eliminate the time delay and extra work inherent in using I specialties. The EHR improves the workflow because dictation/transcription for most medical the note is finished when the exam is finished and does not require additional steps of transcribC ing, reviewing, and filing. There are, however, some specialties where dictation/transcription is Q mentioned in this chapter, pathology and radiology, are likely to continue. Two of the specialties examples. U Pathologists performing autopsies must dictate their findings because they cannot use a keyA use the computer to display and manipulate images, board at that time. Similarly, radiologists which keeps their hands busy, so they cannot easily type at the same time. Therefore, most radiologists dictate their observations as they are viewing them. 1 there may also be some established physicians who are In both group practices and hospitals, unwilling to stop dictating their exam 1 notes or discharge summaries. In these cases, wordprocessed files of the transcribed documents can be imported into the EHR. This is preferable to 0 scanning the typed document. There are also costs associated 5 with transcription. Transcription charges are based on number of lines or words that are transcribed. Line calculations are based on a 65-character line. A T newer method proposed for calculating transcription charges is based on visible black characters (VBCs); in other words, characters you S can see (not spaces or tabs).3 Dictation may be recorded on microcassette tapes, digital voice files, or even via telephone. Transcriptionists use special equipment that allows their hands to remain on the keyboard (Figure 8-9). A foot pedal controls the playback of the recording as the transcriptionist word processes the report. 3 A Standard Unit of Measure for Transcribed Reports, AHIMA/MTIA Joint Task Force on Standards Development White Paper (Chicago: AHIMA, February 14, 2007), http://library.ahima.org/xpedio/groups/public/documents/ahima/ bok1_034023.html. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.qxd 8/24/09 6:12 PM Page 193 ADDITIONAL HEALTH INFORMATION SYSTEMS 193 Speech Recognition Software Speech recognition software translates the sounds of the human voice into text. In some places it is used to eliminate the dictation/transcription steps; elsewhere it is used to complement the process, by providing the transcriptionist with a text file to be reviewed and edited. Because radiologists rely heavily on dictation/transcription, they are leading the way in using voice recognition systems. Having clinical dictation instantly and automatically transcribed by a computer reduces turnaround time and reduces or eliminates the cost of a transcription service. For some doctors, speech recognition systems can accurately recognize up to 99% of their words, but with most people, it seems to average about 95%. This means a full-length dictation will have one or more errors that must be corrected. The time spent backing up and making corrections slows down the overall rate of efficiency. This is one reason some practices using speech recognition software continue to use transcriptionists to edit and correct their documents. H improve as they are used. Each Even though speech recognition systems make errors, they time the speaker makes a correction, the system learns a littleImore about the speaker’s voice patterns. Recognition is also improved by using special medical versions of the software that recogG nize medical terms that might not be used in a layperson’s vocabulary. Most often speech recognition is used to produce a textG document, but it is possible to use speech recognition to produce a codified medical record. Ray Kurzweil, a scientist and inventor, S systems to medicine in 1985. By brought the first commercial large vocabulary speech recognition 1990, his system was able to create structured medical records , by voice recognition alone. Today at least one system, CliniTalk, enables a clinician to use speech recognition to record findings hands-free in the same EHR shown in Chapter 7, Figure 7-11. S The words we speak are really made up of Hin the dictionary, you will find its multiple sounds called phonemes. When you look up a word pronunciation represented with symbols for its phonemes (for Aexample, phoneme: fo´nĕm). In English, there are about 16 vowel sounds and 24 consonants making about 50 phonemes. N found that phonemes were repComputer scientists measuring electrical patterns of sound waves resented by differing levels of energy across various frequency I bands over a period of time. The first step in speech recognition is to transform the sound of your voice into a digital file. A noise-canceling microphone discards background noise C and sends your word sounds to the computer, which converts it into digital data. Q Using mathematical calculations, the speech recognition software identifies the phonemes in U the digital data. The phonemes are then compared to the “language model,” which contains the rules of the speech recognition software. A Because certain sounds would be impossible to articulate, phonemes cannot appear in just any order. Therefore, the language model knows that only certain sequences of phonemes actu1 ally correspond to words or word syllables. An average word has about six phonemes. Most people speak 1 about three words per second. This means the computer must process about 18 phonemes per second. The software must not 0 into words. For example, the only identify the phonemes, it must also group them correctly phonemes b ⫹ el instantly match “bell” while t ⫹ el match5“tell.” Though English has 10,000 possible syllables, these also will normally appear only in certain combinations and sequences. Tsound alike. To identify the correct One problem is that words such as they’re, their, and there word, the language model compares groups of three to fourSwords called trigrams to common speech patterns to help it identify the correct word. For example, if you dictated: “There appears to be a blockage . . . ,” the software would recognize that you didn’t mean their or they’re by the placement of the word there in the sentence. Once the correct words are identified, they are displayed on the screen as though you had keyed them in. Usually there is a lag of a few seconds between the words you just spoke and the appearance of the text on your screen. If the software misidentifies a word, you can back up and correct it. Each time the software misrecognizes a word and you correct it using the speech recognition software, the computer stores your pronunciation for the corrected word. The next time you dictate that word, it will then identify it correctly. HOW SPEECH RECOGNITION SOFTWARE WORKS Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 194 8/10/09 11:05 AM Page 194 CHAPTER 8 A REAL-LIFE STORY Radiology in the Digital Age By Wesley McCann Wesley McCann, BA, MA, RT-R, a Registered Technologist in Radiography and PACS clinical assistant at a large hospital in Michigan. O ur radiologists work in a darkened room using multiple monitors, three to four in most cases. One monitor displays our RIS (radiology information system), while images associated with these charges are retrieved from the PACS (picture archiving and communication system) and displayed on two high-resolution monitors, normally 2 to 5 megapixels. A dual-monitor review station can cost $49,000, compared to a few hundred dollars for the normal CRT monitors used by the radiological technologists and most other personnel in the hospital. Our RIS is where we enter, store, and review all patient radiology charges. Before PACS, every patient study was handled by numerous people before the radiologist. This goes back to the days when staff would have to hang films in a certain order on a large image viewing box, like that seen on the show Scrubs. Staff would have to find old relevant exams for that patient and hang them in a certain order according to the radiologist’s preference. For example, if a person came in for a chest x-ray, the staff would find an old chest x-ray and hang it alongside the new exam in a certain order. This is called hanging protocol. The radiologist’s hanging protocol and prior relevancy rules will determine how many studies are displayed and how the images are arranged on the screen. Each radiologist is very particular about how they want to review studies. With PACS, we can automate this entire process. In general radiology we have what we call a study tree under which the exams are organized. Different parts of the anatomy are separated into different groups. If the technologist selects chest x-ray, everything that could be captured during a chest x-ray would be available for them. They can then choose ribs or chest within that subset. PACS puts the entire exam realm at their fingertips. With film, the radiologist never had the capability to change the image contrast level, making it brighter or darker. You just had an image. If it wasn’t perfect, you had to take it again. With a digital x-ray, radiologists can adjust the image any way they wish, which is good for the patient because it will reduce the radiation exposure caused by repeated studies due to inferior images. We use both computed radiography (CR) and digital radiography (DR) systems for general radiology. The advantage of CR is that it uses the same x-ray equipment used for film-based x-rays, except that a phosphor plate captures the image instead of film. However, the CR image plate must then be scanned and digitized using a CR reader, which converts the analog image to digital. With digital radiography, no digital conversion is required. Images are captured digitally and displayed instantly, thereby decreasing the time technologists have to wait to review their study. If there is a disadvantage to DR, it is that it requires replacing existing equipment, and DR systems can cost up to four times as much as CR systems. All of our radiology images are stored on our PACS archive in DICOM files. DICOM is a national standard that most vendors are now adhering to. DICOM files include data fields about the patient and the study. We no longer have to use flash cards to burn that information on the image; PACS takes care of that. Most everything is DICOM based, but we have to map it specifically for each machine. For example, our CR machine populates a field called “series description.” But when we purchased a new DR from a different vendor, we had to program PACS so that it would populate the field, otherwise there was no data there and we would have had to manually type it in. We also can import studies the patients bring with them on CD, or that we receive electronically over a high-speed network connection we have with the University of Michigan. However, our PACS is very strict; the patient, the medical record number, and the accession number have to match or else the system will not allow us to import the images correctly. To accomplish this, we create an order number and assign the imported images to it. When the doctor pulls the images up, it will clearly indicate that it is from an outside source, and is only for comparison, not interpretation. We can also burn a CD for patients to take with them. We do this a lot for ER patients, so they can take copies of their x-rays back to their physician. Normally we can fit an entire study on a CD, but longer studies like angiograms may require two disks. PACS has increased the availability of data to be exchanged from facility to facility, reduced patient exposure, and improved patient care. PACS has also allowed the healthcare community to make a patient health record portable in one form or another. No longer does a patient have to carry film jackets. With PACS, their entire record can be recorded on a few CDs. H I G G S , S H A N I C Q U A 1 1 0 5 T S Speech recognition software must also deal with the diversity of regional accents and the variety of ways that we pronounce words. Most programs start with a simple training session in which you read into the software a document that it already recognizes. It then compares your pronunciation of the words to its existing language model and adjusts accordingly. It continues to build a personal profile of your speech by learning from its mistakes. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 195 ADDITIONAL HEALTH INFORMATION SYSTEMS 195 Modern speech recognition software typically comes with a vocabulary of about 150,000 words, most of which you do not have to train the system to recognize. Medical versions of the software have language models with additional medical terminology. Healthcare facilities using speech recognition should purchase a medical version. Pharmacy Systems All acute care hospitals have inpatient pharmacies. These pharmacies have one or more computer systems for tracking, ordering, and dispensing medications. These systems are interfaced with the registration, billing, CPOE, and EHR systems. The hospital pharmacy receives and fills medication orders and delivers the drugs to the nursing units and other departments. Most hospitals will also store some drugs in the patient care areas where nurses can access them immediately, without H waiting on the pharmacy. These drugs are usually locked in cabinets that dispense a prepackaged amount of the drug when an I system computer. The pharmacy authorized person enters a medication order in the dispensing stocks these cabinets and reconciles the records of medications G that have been given to patients from them. G Most of the drugs dispensed by hospital pharmacies today are manufactured by pharmaS other standard forms. However, ceutical companies and come in vials, tablets, capsules, or inpatient pharmacies also create medications by combining ingredients according to the doc, tor’s order. In particular, the pharmacy prepares solutions for intravenous (IV) administration to patients. Ever since the IOM report (discussed in Chapter 7) revealed S that high numbers of deaths have occurred due to preventable medical errors, hospitals have increased their focus on patient safety. These efforts have included CPOE, computerizing theHpharmacy, and using positive identification systems to correctly match the medication with A the patient, thus ensuring the right patient receives the right medication. MEDICATION ADMINISTRATION—THE 1. 2. 3. 4. 5. Right patient Right time and frequency Right medication Right dose Right route of administration N I FIVE C Q U A RIGHTS 1 1 When an order for medication is received in the pharmacy system, it is reviewed by a 0 The pharmacist performs a drug pharmacist and compared with information from the EHR. utilization review (DUR), which you learned about in Chapter 5 7. DUR software in the pharmacy system may be used to automate this review. Tdoctor is notified. In some hospiIf the DUR reveals any potential problems, the ordering tals, the pharmacist has the authority to change the drug order. S The pharmacist also serves as a consultant for the hospital doctors and may know of or suggest other drugs that would be more effective that the one originally prescribed. The pharmacist may also notify the hospital’s dietary service if the effectiveness of the drug might be compromised by certain foods. Filling the medication order may be a manual or automated process. Medication labels are printed, which include the patient location and identification. The labels may include barcodes. A small pharmacy may fill the order by manually counting the appropriate number of pills from a larger container and packaging and labeling them with the patient ID. Larger facilities use a more automated process. Figure 8-10 shows a robotic Rx system in operation. The pharmacy has stored its drugs in individual packages labeled with barcodes that identify the drugs. A computerized dispensing Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 196 8/10/09 11:05 AM Page 196 CHAPTER 8 FIGURE 8-10 Electronic order system. Guided Rx robot fills medication orders. H I G G S , FIGURE 8-11 Rx robot restocks prepackaged drugs using barcode reader. S H A Ndata and directs the robotic arm to locate and retrieve the system receives the medication order drugs on the order. These are then deposited into a container or bag for delivery to the nursing I unit caring for the patient. The system is highly accurate. A barcode reader on the arm of the robot C confirms the drug before selecting the package. When it is not being Q used for filling orders, the robot can also be used to restock the storeroom, as shown in Figure 8-11. U Once the orders have been filled, they are transported to the nursing A unit, emergency department or other department. The pharmacy system also transfers charge information to the billing system. A1nurse, doctor, or other caregiver administers the medication and records 1 the fact in the patient’s chart. The patient wears a wristband that positively identifies the patient. The band may 0a barcode, and in some facilities, a radio-frequency identiinclude fication 5 (RFID) device. The patient identity is compared to the patient ID on the medication and the medication is compared to the T order. Only if everything matches is the drug administered doctor’s to the S patient. Pharmacy systems also include decision support, patient medication administration reports, controlled substance tracking, and extensive intervention documentation. Non-patient-related aspects of pharmacy systems include management functions for inventory control, pricing, purchasing, repackaging of large quantities into smaller units, and distribution from the central pharmacy to smaller units throughout the facility. These functions require additional interfaces to administrative systems such as accounts payable and to outside companies that supply the pharmacy. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 197 ADDITIONAL HEALTH INFORMATION SYSTEMS 197 Emergency Department Systems The emergency department (sometimes called ER for emergency room) is one of the busiest places in an acute care hospital. Patients arrive at the emergency department by ambulance or by presenting themselves for care. ER cases range from the most serious, life-threatening traumas to the common cold. When a patient presents at the emergency department, the first step is to register. A registration clerk will search the master patient index (MPI) to determine if the patient has been previously registered at the hospital or an affiliated facility. If the patient’s records are found, then the information is updated. If they are not found, the patient’s demographic and insurance information will be entered in the registration system computer. In either case, the patient may be asked to sign routine forms required by the facility. Except for cases of serious injury, the patient will likely be directed to a waiting area until he or she can be seen. H taken into the ER, bypassing the When patients arrive by ambulance, they are immediately waiting room. The emergency medical technician (EMT) accompanying the patient will convey I to the ER staff the presenting problem, vital signs, and patient information, which have been G gathered during the drive to the hospital. In some cities, this information can be communicated to the ER while the ambulance is en route. G In emergency rooms, specially trained triage nurses are the first responders to patients. Their job is to quickly prioritize patient needs. Their review is oftenSa simplified, organ-specific review of systems determined by the presenting complaint. Emergency , room triage nurses help to decide how long treatment can be delayed without deterioration of the condition. Emergency department physicians use this screening to begin determining the diagnosis. In doing so, the nurse aids the physician assessment by presenting critical information to the Sphysician for review. Some issues concerning emergency departments: 䊏 䊏 䊏 䊏 䊏 H The ER may use a different software system than the rest Aof the hospital. The ER may not have access to the patient’s records in the N HIM department; the ER is not likely to have access to the patient’s doctor’s office records. I ER patients who are victims of accidents or crimes may not be conscious and may have not yet been identified. C Patient allergy or medical history information may not be Qknown until a family member can be contacted. U Patients without a primary care physician may treat the ER as a walk-in clinic, using emerA gency resources for ordinary conditions. One of the principal challenges for the HIM department in terms of the emergency depart1 identified. Patient records cannot ment concerns the patient who is unconscious and has not been be accessed without knowing who the patient is. Orders, medications, tests, and procedures 1 require a medical record number. Typically, the patient is registered with minimal information as 0 John or Jane Doe, and records begin to be created with this temporary ID. Once the patient is conscious or identified, then the records must be modified. If the5 patient already has a medical record number, then the records that were created under the temporary ID must be merged into the T patient’s actual chart. Traditionally, emergency departments used white boards S (similar to those found in classrooms) to track the patients in their care. Today, emergency departments rely on computer software to provide real-time updated information. For example: 䊏 䊏 䊏 䊏 䊏 䊏 ER census and capacity Staffing assignments Patient wait times Patient location Patient chief complaint Patient acuity status Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 198 8/10/09 11:05 AM Page 198 CHAPTER 8 H I G G S , FIGURE 8-12 S H A N I C Q U A Emergency department software replaces the ER white board. (Courtesy of GE Healthcare.) 1 1 0 䊏 Order status 5 䊏 Pending consults. T the ER relies on other departments, such as radiology This information is important because and laboratory, to perform diagnosticStesting and on specialists to consult with ER physicians in specific cases. Waiting for results and consults from these other departments can force emergency departments to keep patients for a prolonged time. Staying current with the status of many patients can be a challenge. Emergency department software, such as that shown in Figure 8-12, improves emergency department workflow, patient care, and satisfaction. Once the patient has been examined and diagnosed by the ER physician, the patient is either treated and sent home or admitted to the hospital. If the patient is admitted, then the ER records need to become part of the inpatient record for the current stay. If the patient is treated and sent home, charge data must be transferred to the billing system. However, if the patient is sent home, but then admitted to the hospital within 72 hours of the ER visit, the billing for the emergency room visit will be canceled and changed to inpatient billing. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 199 ADDITIONAL HEALTH INFORMATION SYSTEMS 199 Biomedical Systems A hospital’s biomedical department is responsible for those devices that actually touch or attach to patients. Examples include instruments for measuring vital signs and cardiac and arterial blood gas monitors. Today, many of these devices have wired or wireless telemetry to transmit their information to nurses and into the EHR. Although biomedical devices contribute a significant quantity of data to the EHR, in many facilities the biomedical department is separate from the IT department and does not report to the CIO. The devices themselves may require special software or interfaces for the EHR to be able to receive the data. The best outcome for the patients requires cooperation and effective communication between the biomedical and other departments. H I Glifesaving procedures, but are also Hospital surgical departments not only provide restorative and a significant source of patients and revenue. As such, surgery Gdepartments wield great influence in the selection of perioperative software, even when their choice is different from the other hosS pital information systems. The term perioperative refers to the entire surgical event,from surgery scheduling, the arrival Surgical Department Systems of the patient in the presurgery holding area, the actual surgery in the OR suite, and the immediate recovery in the postanesthesia area. Perioperative software includes nonpatient functions, such as management and scheduling of the operating rooms, Ssurgical supplies, equipment, and personnel. It may also include software for the anesthesiologist. H A Operative Reports The surgeon and anesthesiologist create preoperative notesN prior to the surgery. Nurses’ notes document preoperative preparation of the patient. The surgical procedure itself is recorded in its I entirety. Records are kept of the anesthesia during the operation and postanesthesia recovery. The anesthesia report includes the preanesthesia evaluation.C The operative report includes: 䊏 Preoperative and postoperative diagnosis Q 䊏 Surgeons’ and their assistants’ names U 䊏 Date, time, and duration of surgery A 䊏 䊏 䊏 䊏 䊏 䊏 䊏 Descriptive name of the surgery Type of anesthesia used 1 Estimated blood loss 1 Detailed record of the procedures performed 0 Any unique or unusual events that occurred during the surgery Number of ligatures, sutures, packs, drains, and sponges5used Description of all organs explored and all normal and abnormal findings. T If tissue is removed and sent to pathology, the pathologist’s S report is also included with the operative reports. As mentioned in Chapter 5, informed consent documents for the operation signed by the patient are also filed with the operative reports. Prior to, during, and following the surgery, various biomedical devices are attached to patients for monitoring purposes. Following surgery, the patients are moved into a special area called the recovery room where they will continue to be monitored. The recovery room report documents patients’ postanesthesia recovery, nurses’ notes, vital signs, and administration of intravenous fluids and medications. Patients remain in the recovery area until the effects of the anesthesia have worn off and they are sufficiently stable to move to another location. Surgery requires a great deal of record keeping. Electronic surgical record systems can store data from the patient monitors and record the nurses’ and surgeons’ notes. Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 200 8/10/09 11:05 AM Page 200 CHAPTER 8 FIGURE 8-13 Anesthesiologist using a GE Centricity perioperative system. (Courtesy of GE Healthcare.) H I G G S , S H A Figure 8-13 shows a perioperative N anesthesia system for documenting and tracking standard care elements with device level data capture. Perioperative software is also used for scheduling and planning for the needs of Ithe surgery. For example, surgeon preference cards specify the equipment and supplies the surgeons C will need on hand for different types of surgeries. Instruments must be tracked through assembly, sterilization, storage, and use. Consumable supQ Surgical case scheduling software, which replaces the plies must be purchased and managed. traditional white board, can be accessed U via the Internet by surgeons to find times when an OR is available. A Implant Registry 1 result of surgery is the implant registry. An implant is a Another record system that is a direct device or substance intentionally put 1 into the body to serve a particular purpose. Common implants include heart valves, pacemakers, breast implants, and artificial joints. Implant registries allow patients to be identified0in the event of safety issues regarding a particular type of implant. For example, in the 1990s silicone breast implants received much negative publicity and 5 were removed and replaced with saline implants, which were considered safer. T the study of the performance and longevity of implants. Implant registry data also facilitates Adverse events involving medical devices S must be reported. To facilitate reporting, implant registry data includes: 䊏 䊏 䊏 䊏 䊏 䊏 䊏 Patient demographic data Facility Implant manufacturer (name and address) Generic name of the implant and the manufacturer’s brand name Model, serial, catalog, and lot numbers Description of the adverse event Who the adverse event was reported to (the FDA, implant distributor or the manufacturer). Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 201 ADDITIONAL HEALTH INFORMATION SYSTEMS 201 Transplant Registry Whereas implants are substances or devices, transplants are tissues or organs. Most but not all transplanted organs come from organ donors who have died as a result of an accident. However, some types of transplants, such as bone marrow, are transplanted from living donors. Like implants, all transplants are carefully tracked and monitored. To be successful, a transplant organ or tissue must come from a biologically compatible donor. Transplant registries are used to keep track of potential recipients and to communicate with international registries to locate the best match. The most prominent of these registries is the United Network for Organ Sharing (UNOS), and for bone marrow transplants, the National Marrow Donor Program (NMDP). Patients with the greatest need for a transplant are given the highest priority; therefore, the registry includes clinical data about patient status and condition. In addition to the recipient data, transplant registries maintain information on the donor as well. This includes the cause of death, organ donor medical history, medications the donor was taking, the procurement process, and consent of the donor orH family to donate the organs. Post-transplant records are kept on the recipient, and in I the case of living donors, on the donor as well. Post-transplant information on the recipient includes orders for immunosuppresG sive drugs, survival rate, functional status, graft status, and one-year and five-year follow-ups. Research and Clinical Trials G S , Both inpatient and ambulatory facilities participate in clinical trials of new drugs and devices. Clinical trials are authorized by the FDA to ensure the safety and efficacy of new drugs by testing them on small groups of patients in controlled studies, tracking S the results and any adverse side effects. H The FDA divides clinical trials into four phases; each phase is considered a separate clinical Aon animals, the first phase of testtrial. Though a drug may have been tested in the laboratory or ing on human subjects is usually to see if the drug is safe and tolerated by a healthy person. Very N small groups of subjects are tested in a controlled setting. I treatment is intended. Phase II Phase II testing is performed on patients for whom the focuses on finding the right dosage levels and proving the drug C works. Once the drug has been shown to be safe and promises to be effective, phase III testing begins. Phase III uses larger Qor device being tested, while othgroups of patients, and typically some are given the new drug ers are given a placebo. Phase III clinical trials may continue U while FDA approval is pending. Phase IV trials occur after the drug has been approved and is on the market. Phase IV trials are A used to survey its interaction once it is in general use. Clinical trials are conducted according to designed protocols. Clinical trials may require the use of special software or tracking of data not normally in the facility’s EHR. One problem clini1 entry of the same data in two difcal trials pose for HIM is that they sometimes require separate ferent systems: the normal EHR and a special system provided 1by the organization conducting the clinical trial. In cases where the normal EHR system can be used, care must be taken that data 0 given to the research company is confined to just the clinical trial patients, in order to comply with HIPAA’s “minimum necessary” rule. Clinical trial software is5discussed further in Chapter 11. T S Chapter 8 Summary Departmental Information Systems Data for health records flow into the EHR from many different systems. An acute care hospital may have 60 to 400 different software applications. Many of these are departmental systems, such as those used by the laboratory, radiology, or surgery departments. Others are software provided by a vendor to operate a particular instrument or device, but which are capable of exchanging data with the EHR or HIS systems. Doctor’s medical practices tend to have fewer systems. Patient Registration The core system for a hospital is called the health information system (HIS). The principal system for a medical office is the Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 202 8/10/09 11:05 AM Page 202 CHAPTER 8 practice management system. One important function of these systems is patient registration. In hospitals, the patient registration system is sometimes referred to as the ADT system. A master patient index is a list of all the patients who have previously been registered. In a large healthcare organization with multiple facilities, the MPI will be a special database that contains records of patients registered at all related facilities. In a healthcare organization with only a single facility, the MPI may be the same as the patient registration database. The purpose of the MPI is to prevent duplicate entry of the same patient and to provide a quick universal lookup of patients for all systems interfaced to the HIS. In paper-based systems, the MPI is necessary to locate the patient’s medical record number. A Soundex field may be included in the MPI system to allow surnames to be found based on how they sound phonetically when the user is unsure of the name’s spelling. The images can be stored on a PAC system. Digital pathology has the potential to allow the pathologist to see cells in a way that an ordinary microscope cannot. Medical laboratories are accredited by the College of American Pathologists (CAP). The laboratory, equipment, supplies used for testing, and all personnel must meet certain CAP criteria regarding polices, procedures, and training to remain certified. Radiology Department • Clinical pathology uses chemistry, microbiology, hematology and molecular pathology to analyze blood, urine, and other body fluids. • Anatomic pathology performs gross, microscopic, and molecular examination of organs and tissues and autopsies of whole bodies. Surgical pathology performs gross and microscopic examination of tissue removed from a patient by surgery or biopsy. A radiology information system (RIS) is used to manage the workflow in radiology departments, communicate with PAC systems, schedule and track radiologic studies and post H charges. RIS systems communicate with other systems such as I HIS, EHR, and billing. Radiologists are specialists who interpret x-rays and G CT, MRI, and PET scans and other diagnostic tests. A hanging protocol is used to automatically display a number G of images in the order the radiologist prefers. S Today most of the images the radiologist studies are ,digital. Traditionally, x-rays were taken with photographic film and then developed. Computed radiography (CR) replaces the film with a phosphor plate that can be processed S by a computer to yield a digital x-ray image. Digital radiography H (DR) captures the image directly and does not require processing. A Digital radiology images are stored in a Picture Archiving and Communication System (PACS) using a stanN dard file format called DICOM, which stands for Digital IImaging and Communications in Medicine. The DICOM file includes fielded data about the patient and the study, elimiC nating the need for flash cards. Flash cards were used to add Q patient ID information when film x-rays were exposed. U High-resolution monitors allow the radiologist to see the smallest detail. Resolution refers to the size and number A of pixels a screen can display. Radiology monitors have much smaller pixels, so they are capable of displaying a much larger quantity of them. Software used to view the 1 images allows the radiologist to change the contrast, inten1 sity, zoom in, zoom out, and otherwise enhance the image. The 0 radiologist’s interpretation of the study is produced in a radiology report. Many of the clinical pathology tests can be performed using automated instruments that receive orders from the LIS and send results back to the LIS. Results of anatomic pathology findings (and clinical pathology tests that are not performed on automated analyzers) are entered in to the LIS system manually. Pathology reports are sometimes dictated and transcribed. When the LIS has received the test results data or pathology reports, it generates a lab report. These maybe printed or faxed reports. If the LIS is interfaced with the EHR, the lab report data is sent to the EHR as well. Digital pathology captures specimen images digitally and displays them for the pathologist on a computer monitor. tate their reports and patient notes and either have the report transcribed or use speech recognition software. Though necessary in some situations, dictation/transcription does not produce a codified medical record, adds steps to the workflow, and takes longer to produce the final note or report. Speech recognition software interprets the sound of the human voice and converts it into text. The results are not perfect and require some editing or correction. However, over time the computer learns the speaker’s diction and recognizes more words, which reduces the error rate. Laboratory Systems A laboratory information system (LIS) receives orders and sends results of medical tests performed by the lab. The laboratory services include: • • • • • • • • • Hematology Chemistry Immunology Blood bank (donor and transfusion) Pathology Surgical pathology Cytology Microbiology Flow cytometry. The laboratory is supervised by a pathologist. There are two branches of pathology: 5 Dictation/Transcription Systems T Radiologists and many other medical specialists often dicS Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 203 ADDITIONAL HEALTH INFORMATION SYSTEMS Pharmacy Systems 203 • ER patients who are victims of accidents or crimes may not be conscious and may have not yet been identified. • Patient allergy or medical history information may not be known until a family member can be contacted. • Patients without a primary care physician may treat the ER as a walk-in clinic, using emergency resources for ordinary conditions. All acute care hospitals have inpatient pharmacies. A hospital pharmacy receives and fills medication orders and delivers the drugs to the nursing units and other departments. Most of the drugs are in pill, vial, or capsule form and are manufactured by pharmaceutical companies; but some hospital pharmacies also create medications by combining ingredients into solutions for intravenous (IV) administraBiomedical Systems tion to patients. Hospital pharmacies have one or more computer sys- Prior to, during, and following the surgery, various biomedtems for tracking, ordering, and dispensing medications. ical devices are attached to the patient for monitoring purThese systems are interfaced with the registration, billing, poses. The biomedical department is responsible for any CPOE, and EHR systems. Generally, medication orders are systems that are attached to or come in contact with the filled by the pharmacy and delivered to the nursing units onH patient. Modern biomedical monitoring devices transmit the floors. The nurses then administer the medications to theI data to the EHR. patient. Hospital pharmacists act as consultants to doctors, per-G Surgical Department Systems forming drug utilization reviews (DURs) on medicationG Surgical departments provide restorative and lifesaving proorders and suggesting therapeutic alternatives where appro- cedures, but are also a significant source of patients and priate. Hospital pharmacists are also responsible for pur-S revenue for the hospital. chasing and managing pharmacy inventory. , The entire surgical event from surgery scheduling, the arrival of the patient in the presurgery holding area, the actual surgery in the OR suite, and the immediate recovery The emergency department or emergency room (ER) is oneS in the postanesthesia area is encompassed by the term of the busiest places in an acute care hospital. Patients areH perioperative. seen in the ER for problems that range from the common Perioperative software records all aspects of presurgery, cold to the most life-threatening injuries. Patients whoA surgery, and postsurgical recovery. It also includes nonpacome to the ER on their own begin with patient registra-N tient functions, such as management and scheduling of the tion. Patients who arrive by ambulance are taken directly operating rooms, surgical supplies, equipment, and personI nel. It may also include software for the anesthesiologist. into the ER. A specially trained triage nurse sees the patient first.C The operative report is a combination of reports from The triage nurse’s job is to quickly decide which patients the surgeon, assistant surgeon, nurses, anesthesiologist, and Q need priority and to help decide how long treatment can be pathologist. The patients’ informed consent documents are delayed without deterioration of the patient’s condition. U filed with the other operative reports. The situation is especially complicated when an injured A During some operations, patients receive an implant or person arrives unconscious and without identification. transplant. An implant is a device or substance intentionally Because the emergency department physicians need a med- put into the body to serve a particular purpose. Common ical record number to order tests or medications, a temporary1 implants include heart valves, pacemakers, breast implants, chart is created. Once the patient is identified, these records and artificial joints. 1 must be merged into the patient’s actual health records. A transplant operation replaces some part of the Emergency room treatment is often dependent on labo-0 patient’s body with an organ or tissue from a human donor. ratory, radiology, and consultation reports. With a high vol- Some examples of transplanted organs include the kidney, ume of patients and many urgent activities occurring simul-5 heart, or liver. Bone marrow replacement is also considered taneously, emergency room software is used to monitor andT a transplant. track the status of each patient. Implant registries and transplant registries are separate. After being treated by the emergency department,S They are used to track what was put in the patient (recipient) patients are either sent home or admitted to the hospital as and where it came from, how well it worked, and what the inpatients. patient’s functional status was as a result. Transplant regImportant issues concerning emergency departments istries also track donors. include these: Emergency Department Systems • The ER may use a different software system than the rest of the hospital. • The ER may not have access to the patient’s records in the HIM department; the ER is not likely to have access to the patient’s doctor’s office records. Research and Clinical Trials Clinical trials are authorized by the FDA to ensure the safety and efficacy of new drugs and medical devices by testing them on small groups of patients in controlled studies, tracking the results and any adverse side effects. Large Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 204 8/10/09 11:05 AM Page 204 CHAPTER 8 and small healthcare organizations alike participate in clinical trials. There are four phases of clinical trials on humans: Phase I Phase II Phase III Very small groups of subjects are tested in a controlled setting to see if the drug is safe and tolerated by a healthy person. Testing is performed on patients for whom the treatment is intended and focuses on finding the right dosage levels and proving the drug works. In this phase, larger groups of patients undergo controlled studies, in which Phase IV. some patients are given the new drug or device being tested and others are given a placebo. This phase surveys the drug’s interaction in general use once the drug has been approved and is on the market. Clinical trials follow designed protocols and sometimes require duplicate entry of patient exam data in special software used by the researcher. In cases where the normal EHR system can be used, care must be that data given to the research company is confined to the clinical trial project to comply with the HIPAA “minimum necessary” rule. H I Critical Thinking Exercises G 1. Using Figure 8-3 determine the GSoundex code for your surname. 2. Many medical errors occur when patients are given medications. How do the “five S does a CPOE system contribute to patient safety? rights” prevent these errors? How , S Testing Your Knowledge of ChapterH8 A 1. What does the acronym PACS stand for? 10. What is the difference between an implant and a N transplant? 2. What does the acronym MRI stand for? 3. What does the acronym DUR stand for? I11. Which devices are the biomedical department responsible for? 4. Name at least four things checked for in a DUR. C 12. What does it mean when an order is “stat”? 5. What is an MPI? What is its purpose? Q 13. What is the standard file format for diagnostic 6. Which branch of pathology is concerned with blood: U radiology images? anatomical or clinical? 14. Name three problem areas related to health records for A 7. What is a hanging protocol? emergency departments. 8. What organization audits and certifies medical laboratories? 9. Where is a patient taken after surgery? 15. True or false?: Clinical trials violate the HIPAA 1 privacy rule. 1 0 5 T S Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 8/10/09 11:05 AM Page 205 Comprehensive Evaluation of Chapters 5–8 This comprehensive evaluation will enable you and your instructor to determine your understanding of the material covered so far. 1. Health records are classed as primary or secondary records. Which of the following is a primary record? a. insurance claim b. quality improvement report c. aggregate admissions data d. patient history and physical H I G 2. Health records are classed as primary or secondary G records. Which of the following is a secondary record? S a. admission report b. operative report , c. insurance claim d. discharge summary 8. Using terminal digit filing, which section of the file room would chart 46-78-01 be found? a. section 01 b. section 04 c. section 46 d. section 78 9. When paper charts are filed alphabetically the file system must be reorganized periodically. Why is this necessary? a. Paper charts wear out. b. Charts get misfiled. c. Some charts are thicker than others. d. More surnames start with certain letters. 10. A group medical practice adds 100 patients per month. The average thickness of a new patient’s chart is 1Ⲑ4 inch. If each file room shelving unit can hold 368 inches of files, how many new shelving units must be added per year just to accommodate new patient charts? a. 1 b. 5 c. 10 d. more than 10 S H A N I C A patient health record is comprised of administrative and demographic data and clinical data. For each of the follow-Q ing indicate whether the data is administrative or clinical: U 11. What is a nomenclature? A a. an EHR coding system 4. HIPAA Consent to Use and Disclose PHI form 3. What is an E-visit? a. emergency room visit b. emergency department visit c. electronic visit d. extended visit a. administrative data b. clinical data 5. Doctor’s orders a. administrative data b. clinical data 6. Consult referral a. administrative data b. clinical data 7. How many pages are in the average inpatient paper chart? a. 10 b. 20 c. 50 d. 100 1 1 0 5 T S b. a PHI encryption system c. a network protocol d. a medical protocol 12. Which of the following is a nomenclature? a. DICOM b. PACMED c. SNOMED d. HL7 The tabs on an EHR screen are used to logically group findings. The tabs have medical abbreviations. Write the meaning of each of the following acronyms: 13. Sx __________________________________________ 14. Hx __________________________________________ 15. Px __________________________________________ 205 Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. M08_GART2674_01_SE_C08.QXD 206 8/10/09 11:05 AM Page 206 COMPREHENSIVE EVALUATION OF CHAPTERS 5–8 16. What does stat mean on a test order? a. statistical analysis timed b. send to administration c. double-blind test d. without delay 17. Which branch of pathology analyzes body fluids? a. anatomical b. surgical c. clinical d. hydraulic 18. A biomedical device is a. a lab instrument b. a medical chemistry analyzer c. a device attached to a patient d. none of the above 19. Where is the patient taken after surgery during postanesthesia? a. operating room b. recovery room c. patient’s room d. admission, transfer and discharge 20. What is the standard file format for diagnostic radiology images? a. ACORN b. RIS c. DICOM d. RADCOM 21. Which of the following emergency department problems affects the HIM department? a. Patients without physicians who use the ER as a walk-in clinic b. Patients who arrive by ambulance c. Patients who arrive without their insurance cards d. Patients who are unconscious and do not have identification 22. Which of the following is not checked during a DUR? a. dosage b. diagnosis c. expiration d. interaction with other medications 24. Patient health records serve as the primary communication document between various providers who might care for the patient at different times in different departments. T. true F. false 25. Filing by reverse chronological order puts the newest documents at the front. T. true F. false 26. Having patients entering their own symptoms and H history poses a security risk for the EHR. I T. true G F. false 27. The minimum record retention period for adult health G records is age 65 or five years after the last encounter. S T. true , F. false 28. Terminal digit filing is not used where medical record S numbers exceed six digits. H T. true A F. false 29. A deficiency report indicates items that are incomplete N or missing from a chart. I T. true C F. false Q 30. HIM policies and procedures help ensure quality U patient records. A T. true F. false 131. Doctors and nurses do not have to follow HIM policies and procedures because they do not report to the health 1 information manager. 0 T. true 5 F. false T32. The patient record provides the basis for all billing and S reimbursement. T. true F. false 23. Clinical trials are permitted by the HIPAA privacy rule. T. true F. false Health Information Technology and Management, First Edition, by Richard Gartee. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc. Instructions: This assignment must be done in APA format. A minimum word count for the overall assignment is 1600 words (not including reference portion). A minimum requirement of 4-6 references (with in-text citations) is required. Although this assignment is APA format, it must keep the answer and question format. See details below. Format for Assignment: Question: XYZ Answer: XYZ Reference: XYZ Instructor Notes: In professional writing avoid using first person "I" and third person "we", as they detract from the quality and turn professional researched statements into opinions. Instead of "I" use, for example, use "the writer, the author or the researcher". Instructors General Note: 1. Beyond 4 things checked for please explain why/how/when. 2. Give examples of application of MPI and how it is used specifically. Give an example 3. Name three problems then identify, from the research, a best practice, applied solution for each. e.g. Johns Hopkins solved this problem by................... 4. Who would use this Soundex code? Why? What benefit measured benefit would it be for you? Please answer these as separate, numbered questions. Questions 1. Name at least four things checked for in a DUR. 2. What is an MPI? What is its purpose? 3. Name three problem areas related to health records for emergency departments. 4. Using Figure 8-3 determine the Soundex code for your surname. Reference Book: Gartee, R. (2011). Health information technology and management. Upper Saddle River, NJ: Pearson.
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