MH0054-Finance, Economics&material management in health care services

7/30/2019 MH0054-Finance, Economics&material management in health care services

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Master of business administration- semester -3

MH0053 Hospital and healthcare information management

BOOK ID (B 1214) SET

1. EXPLAIN E-HEALTH

E-health is abbreviated from Electronic-health. E-health basically means use of electronic communication and

information technology in the health sector wherein digital form of data is stored and retrieved electronically-

for various purposes like clinical, educational and administrative, both in local areas as well as at a distance.


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The word E-health comprises of tele health, telemedicine, m-health and other health IT components, which are

covered in detail in the subsequent sections. In cases where speed is vital in delivering healthcare services E-

health can be used. Suppose a natural disaster has struck some location, E-health can be used to save many

lives. Internet and video conferencing is a familiar concept to most of us. E-health provides healthcare using

these concepts. Therefore, healthcare services can be provided electronically to areas where natural calamities

have struck. E-health has been adopted worldwide. It has made considerable amount of progress in India as

well.

Define E-health.

Elucidate concepts such as Telemedicine, E-health, m-Health and FPA.

Explain Consumer Health Informatics.

Explain the objectives and processes involved in Health Information Management.

Evaluate the healthcare scenario in India

Definition of E-health

E-health is defined as the use of communication and information technology in the field of medicine. Transfer

of medical records or other related data takes place through electronic processes. It also enables two

professionals at different geographical locations to interact with each other.

E-health is a relatively new term introduced in medical science. The concept of E-health is supported by

electronic and communication technology. The term covers a wide range of medical and healthcare services

like telemedicine and m-health. Some say that E-health is interchangeable with healthcare informatics and is a

sub set of health informatics. Few others use it in the narrow sense as using Internet in healthcare practice. E-

health covers more than just Internet and medicine.

Introduction to E-health

E-health is the utilization of emerging interactive technologies to facilitate health improvement and health care

services. The technologies include Compact Disc Read Only Memory (CD-ROM), Digital Video Disc ReadOnly Memory (DVD-ROM), Personal Digital Assistant (PDA), Internet, interactive television, kiosks and so

on.

E-health uses the growing technology to upgrade the quality, safety and efficiency of healthcare. While

adopting E-health a consumer must keep three things in mind: personal health record, electronic health record

and ensure safe sharing of these records between the doctors and patients.


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E-health provides many advantages in the field of healthcare services. They are:

Significant information from your health history is readily available to your doctor, without having to spend

time looking through a paper chart and possibly missing something important.

Your doctor can receive important awareness based on your specific history, such as whether a new medicationwill have side effects, or if you require other medications.

The health record will be transferred on time if you choose a different clinic site other than the clinic which

you normally visit.

The healthcare solutions provided by e-health are low cost.

Patients who are bedridden or disabled can have access to healthcare services through e-health.

Patients are comfortable talking about the healthcare issues to their friends and relatives. This is not the case

with mental health issues. Patients are comfortable discussing the mental health concerns through E-health.

Clinics are able to electronically and securely send your relevant health information to another doctor you have

to consult. This saves you

Challenges in E-health

E-health is a rapidly growing technology. However, it faces certain challenges as the population is widespread.

Most of the population in India is spread across villages and hilly terrains. Delivering E-health services to

these areas could prove a challenge. Let us look into some of the challenges faced by E-health in India.

India is highly populated country spread over a wide area. There are 600,000 villages in India and about

27,000 villages have no road or rail facilities, 51,000 villages are deprived of power connections. Few villages

are yet to get a simple analogue telephone. Telecom facilities do not exist. At this rate, providing E-health

would definitely prove a challenging task.

Nowadays, highly advanced communication systems are available. To utilize these resources, a minimum level

of education is expected. India has a large population of over one billion out of which approximately 400

million are illiterates. In rural areas the literacy rate is very less. Providing access to E-health to illiterates is a

challenging task.

The number of healthcare centers across our country is not satisfactory. As per census done in the year 2001 [1],

we require another 21,983 Sub-centers, 4436 PHCs and 3332 CHCs approximately to provide better healthcare

facilities across villages and other states. Only about a quarter of the population in villages have access to

healthcare services. Approximately 40% of the rural population sells their assets to meet their medical

expenses.
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There are about 15 official languages in India. The culture differs from state-to-state in our country. It is a

challenge to impart knowledge to the people in such cases. The developer of E-health modules must keep in

mind the difference in culture while developing the modules.

The other challenges are:

Coping with the rapid advancement in technology.

Determining the quality and effects of E-health applications.

Investigating the research approaches for E-health programs.

Developing the credible information sources on research tools and findings.

Protecting the records of patients is vital. Health information should not be revealed to un authorized

person. By doing so, the information could be tampered with or put to wrong use which could risk the

life of the patient.

2. DISCUSS THE PROCESS OF MEDICAL AUDIT WITH DIAGRAM

The content, completion, timeliness and accuracy of medical record documentation are extremely

important in a health care facility. Documentation has far reaching effect on most aspects of the

organizations operation. The quality and type of care and services delivered to the patient are determined,

in part, through documentation. Ongoing planning and assessment rely heavily on the quality and accuracy

of the documentation in the chart. The medical record is also used to determine survey compliance,

reimbursement, and serve as a source document for legal proceedings. Proactive (concurrent) monitoring


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of the completion, timeliness and accuracy of the medical record documentation is critical. Both the need

for good documentation and risk factors hindering quality support the importance of ongoing, scheduled

audits and monitoring for every residents medical record.

Qualitative vs. Quantitative Audits and Monitoring.

There are two broad types of audits qualitative and quantitative.

Qualitative audits look at the quality of documentation, assessing adherence to clinical practice

guidelines, evaluating consistency in charting and adherence to regulations standards, and interpretations.

This type of audit is usually completed by a staff member or consultant who has professional training,

education or experience. Qualitative audits are more subjective than quantitative. The auditor tries to

determine if proper care was delivered based on the documentation.

Quantitative audits can be completed by trained facility staff and it focuses on whether a document is

complete (all sections of a form), authenticated or timely rather than what the documentation states. A

training process is necessary to help staff understand what they are to look for and why. This type of audit

is more objective than a qualitative audit.

On an ongoing basis, healthcare facilities should have quantitative monitoring in place to assure complete

and timely records. Admission, concurrent and discharge record monitoring assures that analysis is

completed throughout the patients stay. The goal to continuous monitoring throughout a patients stay is

to identify problems or omissions when correction is possible. Analyzing the record on discharge makes it

virtually impossible to legally and ethically address or correct most documentation problems or omissions.

For example, if an assessment is not completed on admission nothing can be done on discharge, but if it is

found during an admission audit the assessment can still be completed in order for the healthcare facility to

provide appropriate care and services for the patient.

Assessing the Quality of Documentation.

When completing a qualitative audit, the reviewer should have the ability to assess the following

issues, identify strengths and weaknesses, and provide suggestions to correct future documentation

discrepancies.

Consistency in documentation between progress notes, assessments , care plans etc


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Duplication or redundancy in documentation

Contradiction in documentation without a clear reason for the differences. This may occur between

two disciplines or within one discipline such as nursing, where multiple staff members chart on a

similar issue.

Documentation that is missing key elements for the proper assessment or planning of a problem.

Documentation reflects application of appropriate practice guidelines, standards, regulations,

reimbursement rules, and clinical protocols across all disciplines.

Understanding of the reason for all types of documentation in a health care record and the

underlying guidelines, standards, regulations or clinical practice protocols.

A health information consultant should have the ability to provide a qualitative analysis of the

documentation and content of the medical record and provide feedback and suggestions for problem.

An ongoing quality improvement process should be used to monitor the types of deficiencies

in discharge records and the reasons for records to become delinquent, identify the causes for the

deficiencies and delinquencies, and then implement corrective measures. The number of delinquent

records, delinquent record rate and reasons for delinquency can be reported at the Quality Assurance

Committee meetings. Completing a run chart with the number of delinquent records and delinquent

record rate each month can show a pattern over time.

Maintaining a Control log for Discharge Records.

It is important to maintain a monitoring system or control log for managing the completion of

discharge records. The following table can be used to track records through the process

Discharg

e date

IP no Assembled Analyzed coded completed comments

Filing and Retrieval.

The healthcare organizations and health information management departments filing system,

policies and procedures comply with federal and state regulations and accepted standards of practice to ensure


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that all health records and resident identifiable data are well organized and readily available for resident care,

research , education and other authorized uses.

Policies and procedures exist to facilitate the prompt, consistent, uniform and efficient filing of all

health records and patient identifiable data.

The filing system is designed and implemented to ensure the safety, security and accuracy of health

records and patient identifiable data.

Policies and procedures exist to facilitate the prompt, consistent, uniform and efficient retrieval of all

health records and patient identifiable data, and the policies and procedures to ensure that

confidentiality is maintained and the retrieval is performed only by authorized persons.

The retrieval system is designed and implemented to ensure safety, security and accuracy of health

records and patient identifiable data; to keep track of the locations and holders of health records and

patient identifiable data removed from file; to follow up at appropriate intervals on the return of healthrecords and data; and to identify health records and data to be converted to alternative medium moved

to inactive storage, or destroyed.

Every healthcare provider should have established a system for filing and retrieving of their

medical records. The sophistication of the filing system is dependent on the volume of filing, admissions,

discharges, and requests for records. Only trained staff should have access to the records and perform the

filing and retrieval functions.

Handling a request for medical records.

Every request for healthcare information includes a valid authorization to disclose confidential

patient identifiable data and healthcare information. All requests for information should be handled by the

health information department to assure uniform application of the hospital policy and adherence to

applicable laws and practice standards. When a request for information is made the following issues should

be considered before releasing information.

Is an authorization to release information required to be signed by the patient or their legal

representative?

What is the nature of the information requested?

Is the information considered confidential or non confidential?

What is the purpose of the request?

What is the authority of the person or agency requesting the information?

Are there any revocations or notices to withhold information file?


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Consent for use and Disclosure of Protected Health Information.

In US, under the HIPPA privacy rule, the hospital must obtain the patients consent prior to

using or disclosing protected health information to carry out treatment,

payment or health care operations (reviews the privacy rule for specifics on exceptions and

requirements). Once the consent is signed, the facility may disclose information without additional

authorizations for treatment purposes, to obtain payment for services and for activities related to

The signed authorization form should be retained as a part of the patients medical record. On the

form, make a notation stating the information disclosed, the staff member disclosing /copying the

information and the date the information was sent to the requesting party

3. DESCRIBE THE VARIOUS BENEFITS OF PACS

A picture archiving and communication system (PACS) is a medical imaging technology which provides

economical storage of, and convenient access to, images from multiple modalities (source machine types).

PACS work with x-ray and scanning technology such as computerized tomography (CT), magnetic resonance

imaging (MRI) and ultrasound to make x-rays and scanned images available to view on screens within

radiology, and to share with other hospital departments like accident and emergency, neurology and

orthopaedics.

With PACS, clinical images are instantly and simultaneously available for study at multiple locations within a

Date

received

Requested

by/sent to

Resident

name

Informatio

n

copied/sent

&purpose

Copied

/released

by

Copy

charge

Date sent
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trust. PACS supports more effective team working between clinicians and therefore aids swifter and more

accurate diagnoses and treatment for patients.

In radiology, PACS is combined with a radiology information system, or RIS. Radiologists report on the x-

rays and scanned images they can view on PACS, and the subsequent reports they produce are then accessible

from the images with which they are associated.

Electronic images and reports are transmitted digitally via PACS; this eliminates the need to manually file,

retrieve, or transport film jackets. The universal format for PACS image storage and transfer is DICOM

(Digital Imaging and Communications in Medicine).

History and evolution of PACS:

The principles of PACS were first discussed at meetings of radiologists in 1982. Various people are credited

with the coinage of the term PACS. Cardiovascular radiologist Dr Andre Duerinckx reported in 1983 that he

had first used the term in 1981.[4] Dr Samuel Dwyer, though, credits Dr Judith M. Prewitt for introducing the

term.[5]

Dr Harold Glass, a medical physicist working in London in the early 1990s secured UK Government funding

and managed the project over many years which transformed Hammersmith Hospital in London as the first

filmless hospital in the United Kingdom.[6] Dr Glass died a few months after the project came live but is

credited with being one of the pioneers of PACS.

The first large-scale PACS installation was in 1982 at the University of Kansas, Kansas City.[2] This first

installation became more of a teaching experience of what not to do rather than what to do in a PACS

installation.

Modalities involved in PACS:

Electronic images and reports are transmitted digitally via PACS; this eliminates the need to manually file,

retrieve, or transport film jackets. The universal format for PACS image storage and transfer is DICOM

(Digital Imaging and Communications in Medicine). Non-image data, such as scanned documents, may be

incorporated using consumer industry standard formats like PDF (Portable Document Format), onceencapsulated in DICOM. A PACS consists of four major components: The imaging modalities such as X-ray

computed tomography (CT) and magnetic resonance imaging (MRI), a secured networkfor the transmission of

patient information, workstations for interpreting and reviewing images, and archives for the storage and

retrieval of images and reports. Combined with available and emerging web technology, PACS has the ability
http://en.wikipedia.org/wiki/Digital_imagehttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-3http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-4http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-5http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-Oosterwijk.2C_Herman_2004-1http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-Oosterwijk.2C_Herman_2004-1http://en.wikipedia.org/wiki/Digital_imagehttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/Image_scannerhttp://en.wikipedia.org/wiki/Portable_Document_Formathttp://en.wikipedia.org/wiki/X-ray_computed_tomographyhttp://en.wikipedia.org/wiki/X-ray_computed_tomographyhttp://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Computer_networkhttp://en.wikipedia.org/wiki/Workstationhttp://en.wikipedia.org/wiki/Computer_data_storagehttp://en.wikipedia.org/wiki/World_Wide_Webhttp://en.wikipedia.org/wiki/Digital_imagehttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-3http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-4http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-5http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system#cite_note-Oosterwijk.2C_Herman_2004-1http://en.wikipedia.org/wiki/Digital_imagehttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/DICOMhttp://en.wikipedia.org/wiki/Image_scannerhttp://en.wikipedia.org/wiki/Portable_Document_Formathttp://en.wikipedia.org/wiki/X-ray_computed_tomographyhttp://en.wikipedia.org/wiki/X-ray_computed_tomographyhttp://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Computer_networkhttp://en.wikipedia.org/wiki/Workstationhttp://en.wikipedia.org/wiki/Computer_data_storagehttp://en.wikipedia.org/wiki/World_Wide_Web


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to deliver timely and efficient access to images, interpretations, and related data. PACS breaks down the

physical and time barriers associated with traditional film-based image retrieval, distribution, and display.

Most PACSs handle images from various medical imaging instruments, including ultrasound (US), magnetic

resonance (MR),positron emission tomography (PET), computed tomography (CT), endoscopy

(ES), mammograms (MG), Digital radiography (DR),computed radiography (CR) ophthalmology, etc.

Additional types of image formats are always being added. Clinical areas beyond radiology; cardiology,

oncology, gastroenterology and even the laboratory are creating medical images that can be incorporated into

PACS.

Typically a PACS consists of a multitude of devices. The first step in typical PACS systems is the modality.

Modalities are typically computed tomography (CT), ultrasound, nuclear medicine, positron emission

tomography (PET), and magnetic resonance imaging (MRI). Depending on the facility's workflow most

modalities send to a quality assurance (QA) workstation or sometimes called a PACS gateway. The QA

workstation is a checkpoint to make sure patient demographics are correct as well as other important attributes

of a study. If the study information is correct the images are passed to the archive for storage. The central

storage device (archive) stores images and in some cases reports, measurements and other information that

resides with the images. The next step in the PACS workflow is the reading workstations. The reading

workstation is where the radiologist reviews the patient's study and formulates their diagnosis. Normally tied to

the reading workstation is a reporting package that assists the radiologist with dictating the final report.

Reporting software is optional and there are various ways in which doctors prefer to dictate their report.

Ancillary to the workflow mentioned, there is normally CD/DVD authoring software used to burn patient

studies for distribution to patients or referring physicians.

Implementing PACS

For successful implementation of PACS in a clinical environment, two fundamental concepts must be

considered. They are as follows:

Nowadays the concept of PACS is not restricted to radiology department. The entire healthcare

organisation uses PACS. Therefore, careful consideration of decisions and strategies should include all the

departments of healthcare organisation. A champion or champions must be chosen for the PACS process.

A champion is usually the medical director of radiology but it can be an IT administrator or a physician.
http://en.wikipedia.org/wiki/Photographic_filmhttp://en.wikipedia.org/wiki/Ultrasonographyhttp://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Positron_emission_tomographyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Endoscopyhttp://en.wikipedia.org/wiki/Endoscopyhttp://en.wikipedia.org/wiki/Mammographyhttp://en.wikipedia.org/wiki/Digital_radiographyhttp://en.wikipedia.org/wiki/Computed_radiographyhttp://en.wikipedia.org/wiki/Photographic_filmhttp://en.wikipedia.org/wiki/Ultrasonographyhttp://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Positron_emission_tomographyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Endoscopyhttp://en.wikipedia.org/wiki/Endoscopyhttp://en.wikipedia.org/wiki/Mammographyhttp://en.wikipedia.org/wiki/Digital_radiographyhttp://en.wikipedia.org/wiki/Computed_radiography


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PACS is a system with multiple complex components interacting with each other. A general clinical

PACS includes the interface of archive, DICOM gateway, archive server, Web server and so on. All these

components must be assessed during implementation of PACS.

There are four steps involved in the implementation of PACS. They are as follows:

Risk Assessment Analysis: It is important to assess the risk involved in implementing PACS. The problems

and challenges are mapped out and the timeline schedules are made to identify potential hurdles. Some areas to

be focused on are physical space for PACS equipment, resource availability, image storage space and so on.

Implementation Phase Development: There are various phases involved in the implementation of PACS.

These phases are based on the results of the risk assessment analysis. The first phase occurs when the archive,

archive server, network infrastructure and so on are implemented. The next phase involves implementing the

modality types for the off-site distribution of PACS examination. This approach gradually introduces PACS in

the clinical environment and it is ultimately transformed into a filmless hospital.

Development of Workgroups: PACS covers a large area within the healthcare organisation. It is important to

develop workgroups to handle some huge tasks and responsibilities. For example, the RIS-PACS interface and

testing workgroup is responsible for testing of RIS-PACS interfaces including the modality type. RIS stands

for radiology information systems. These teams must meet frequently as the date of actual implementation of

PACS approaches.

Implementation Management: To manage the implementation process, a schedule and implementation

checklist has to be developed. This includes specifying the tasks, the task description, the date on which the

task begins, the owner of the task and so on. While following the checklist, all tasks will be included and no

task will be overlooked.

Need or benefits of PACS:

For the past 100 years, film was the predominant medium for capturing, storing and displaying radiographic

images. However, film is a fixed medium with usually only one set of images available.

PACS allows for a near filmless process, with all of the flexibility of digital systems. It also removes the costs

associated with hard film processing and releases valuable space previously used for film storage. Mostimportantly, PACS is helping to transform patients' experience of the care they receive across the NHS. It does

this by enabling a speedier diagnosis and by removing the risk of images being lost or misplaced.

PACS supports clinicians in performing their roles and is contributing to a more efficient and advanced NHS.

PACS has four main uses:


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Hard copy replacement: PACS replaces hard-copy based means of managing medical images, such as

film archives. With the decreasing price of digital storage, PACSs provide a growing cost and space

advantage over film archives in addition to the instant access to prior images at the same institution.

Digital copies are referred to as Soft-copy.

Remote access: It expands on the possibilities of conventional systems by providing capabilities of off-

site viewing and reporting (distance education, telediagnosis). It enables practitioners in different physical

locations to access the same information simultaneously forteleradiology.

Electronic image integration platform: PACS provides the electronic platform for radiology images

interfacing with other medical automation systems such as Hospital Information System (HIS), Electronic

Medical Record (EMR), Practice Management Software, and Radiology Information System (RIS).

Radiology Workflow Management: PACS is used by radiology personnel to manage the workflow of

patient exams.

PACS is offered by virtually all the major medical imaging equipment manufacturers, medical IT companies

and many independent software companies.

With PACS clinicians can access the right image in the right place at the right time. The technology enables:

. Faster accessibility to medical images for the clinicians who evaluate and report on them. This can lead to

the speedier availability of results.

No lost or misplaced images, which means fewer patients having their consultations or operations postponed or

cancelled.

Fewer unnecessary re-investigations, which in turn reduces the amount of radiation to which patients are

exposed.

Flexible viewing,with the ability to manipulate images on screen, ensuring that patients can be diagnosed more

effectively.

Instant access to historic images,so that new and old images can be compared and the progress of patients'

treatment and condition(s) monitored.

Better teamwork and collaboration because, with PACS, images can be viewed from multiple terminals and

locations within a trust by a range of clinicians. And the vast majority of trusts now have the ability to share

images electronically with other trusts.
http://en.wikipedia.org/wiki/Hard_copyhttp://en.wikipedia.org/wiki/Distance_educationhttp://en.wikipedia.org/wiki/Telediagnosishttp://en.wikipedia.org/wiki/Teleradiologyhttp://en.wikipedia.org/wiki/Hospital_Information_Systemhttp://en.wikipedia.org/wiki/Electronic_Medical_Recordhttp://en.wikipedia.org/wiki/Electronic_Medical_Recordhttp://en.wikipedia.org/wiki/Practice_Management_Softwarehttp://en.wikipedia.org/wiki/Radiology_Information_Systemhttp://en.wikipedia.org/wiki/Hard_copyhttp://en.wikipedia.org/wiki/Distance_educationhttp://en.wikipedia.org/wiki/Telediagnosishttp://en.wikipedia.org/wiki/Teleradiologyhttp://en.wikipedia.org/wiki/Hospital_Information_Systemhttp://en.wikipedia.org/wiki/Electronic_Medical_Recordhttp://en.wikipedia.org/wiki/Electronic_Medical_Recordhttp://en.wikipedia.org/wiki/Practice_Management_Softwarehttp://en.wikipedia.org/wiki/Radiology_Information_System


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As a result of all of these improvements, PACS is enabling patients to move on quickly to the next stage in

their treatment.

4. WHAT ARE THE STEPS INVOLVED IN RISK MANAGEMENT PROCESS? EXPLAIN ALL THE

STEPS.

In any industry, risk management addresses liability, both proactively and reactively. Risk management

in health care considers patient safety, quality assurance and patients rights. The potential for risk permeatesall aspects of health care, including medical mistakes, electronic record keeping, provider organizations and

facility management.

According to the Insurance Bureau of Canada, Risk, in insurance terms, is the possibility of a loss or other

adverse event that has the potential to interfere with an organizations ability to fulfill its mandate.

Examples of adverse events in health care are unexpected death, failure to diagnose or treat disease, surgical

mistakes or accidents. All of those can interfere with a providers delivery of medical care. Some can result in

litigation. So the objectives of a good risk management can be concluded as

Minimize the potential for injuries occurring

Minimize the Potentially compensable events (PCEs)

Respond appropriately to the injured patient

Anticipate and plan for ensuring liability when injuries occur

Prevent or reduce financial loss.

An effective risk management has to be formalized for this with scientific approaches and steps and aim and

vision.

Indian Health Service (IHS) risk management (RM) program activities are addressed at both the service unit

and Agency level. For the service unit, a RM or quality assurance committee often serves as the focal point for

the overall program, and receives and acts upon information provided through personal contacts and reports.
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From a national perspective, the IHS RM Program has primarily evolved from the analysis and review of

malpractice tort claims that have been filed against the Federal Government involving medical care provided at

IHS or tribally operated facilities.1In this regard, the Agencys RM Program is by nature predominantly

reactive in scope.

The attitudes, knowledge, and skills important to the understanding of risk management and medical liability

are outlined in this Manual. Details regarding the Federal Tort Claims Act and the processing of federal

medical malpractice tort claims are provided, with particular focus on the Agencys role and the practitioners

responsibilities with respect to those processes. Finally, suggestions are provided in various sections indicating

ways to possibly reduce the incidence of malpractice claims.2 A good starting point is to examine situations

that adversely influence the frequency of malpractice claims

Risk management program

Risk management refers to strategies that reduce the possibility of a specific loss. The systematic gathering and

utilization of data are essential to this concept and practice. Risk management programs consist of both

proactive and reactive components. Proactive components include activities to prevent adverse occurrences

(i.e., losses), and reactive components include actions in response to adverse occurrences. In both cases, the

risk management process comprises:

Diagnosis (Risk identification) Identification of risk or potential risk.

Assessment (Risk analysis)Calculation of the probability of adverse effect from the risk situation.

Prognosis (Risk evaluation)Estimation of the impact of the adverse effect.

Management (Risk reduction or elimination)Control of the risk.

A detailed plan of each step can be said as:

Risk identification

Risk identification is the first process in a risk management program. Risks need to be identified for prevention

and reduction of risks. Risk identification starts with identifying problem prone and high risk areas andcollection of data on past events which led to PCEs. The primary tool used in identification of risks is the

incident report. It is a written description of any event not consistent with routine operational procedures or

patient care activities. Incident reporting provides early detection of problems or PECs and helps in early

investigation of serious incidents. Most healthcare organizations have some type of incident reporting, and
http://www.ihs.gov/riskmanagement/index.cfm?module=part01#_edn1http://www.ihs.gov/riskmanagement/index.cfm?module=part01#_edn1http://www.ihs.gov/riskmanagement/index.cfm?module=part01#_edn2http://www.ihs.gov/riskmanagement/index.cfm?module=part01#_edn1http://www.ihs.gov/riskmanagement/index.cfm?module=part01#_edn2


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incident reporting systems concurrently identify the incident that occurs. The following are common examples

of reportable occurrence:

Needle sticks

Patient or employee fall

Medication error

A patients refusal to accept treatment.

The other method of risk identification is occurrence screening. Occurrence screening is very useful

mechanism to identify risks, specifically liabilities resulting from physician-related occurrence. Occurrence

screening allows concurrent or retrospective identification of physician and hospital related adverse patient

occurrences. In short we can say occurrence screening is a procedure for reviewing health records to identify

documentation of any adverse clinical events for which health care facility could be held accountable if the

patient seeks to take legal recourse. Occurrence screening is sometimes termed as generic screening because

the process is applicable to all patients, regardless of the patients diagnosis or procedure.

Examples of occurrence screening are:

1. Admission for adverse results of outpatient management.

2. Admission for a complication resulting from incomplete management of a pervious hospital admission

3. Adverse reaction to medications, transfusions, and anesthetics.

4. Unplanned transfer to another acute care facility.

5. Unscheduled return to operating room.

6. Perforation, laceration, tear, or injury of an organ during an invasive procedure.

7. Unplanned organ removal or repair subsequent to or during surgery.

Risk Analysis and evaluation:

In incident reporting mechanism the risks are analyzed and evaluated during the patients stay in the hospital

and potential liability is assessed. Occurrence screening data are used in a similar way as in incident reporting.If the mechanism is on concurrent basis, an event is analyzed and evaluated while the patient is admitted. In

retrospective occurrence, screening system cases are reviewed by medical staff committees or departments and

inappropriate physician practices are handled within the medical staff peer review structure.

Risk reduction or elimination:


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Once various risks are analyzed and evaluated, the next step is to eliminate or reduction of such risks in future.

In many instances the events led to PCEs being discussed with those involved, and serve as an educational

device to prevent future problems. The incident report is a tool to eliminate or reduce future adverse

occurrences. The data from incident reports are also collected and analysed to identify high risk areas which

require more care or restructuring to eliminate future risk. The hazard surveillance functions as a part of risk

identification and is a helpful mechanism in reduction or elimination of risk through prior identification of

areas of potential environmental risk prior to an adverse occurrence. The adverse patient occurrences identified

through generic screening are usually physician related, and it is co-ordinate with the medical staff peer review

and credentialing function.

Risk analysis is best done in a group with each member of the group having a good understanding of the tasks

and objectives of the area being analysed. Monitor and Review: the monitoring of all risks and regular review

of the unit's risk profile is an essential element for a successful risk management program.

5. KIRLOSKAR HOSPITAL IN NASIK, MAHARASTRA IS A200 BEDDED HOSPITAL AND ITS

GETTING DIFFICULT FOR THEM TO KEEP ALL THE MEDICAL RECORDS MANUALLY ON

HARD COPIES, SO ADMINISTRATOR IS SUGGESTING IMPLEMENTING EMR IN THE

HOSPITAL. THE MANGEMENT IS NOT SURE ABOUT HOW TO CHOOSE THE EMR. WRITE

SHORT NOTES ON HOW TO CHOOSE AND INSTALL EMR.

The terms EHR, EPR (electronic patient record) and EMR (electronic medical record) are often used

interchangeably, although differences between them can be defined. The EMR can, for example, be defined as

the patient record created in hospitals and ambulatory environments, and which can serve as a data source for
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the EHR. It is important to note that an EHR is generated and maintained within an institution, such as a

hospital, integrated delivery network, clinic, or physician office, to give patients, physicians and other health

care providers, employers, and payers or insurers access to a patient's medical records across facilities.

Apersonal health record (PHR) is, in modern parlance, generally defined as an EHR that the individual patient

controls.

EMR is a software database application, which is designed to automate the medical office workflow. Each

phase of the patient encounter is duplicated by the EMR through which efficiency and productivity is gained. It

provides electronic information sharing system over the Internet for both doctors and patients. This enables

doctors to update their data, research, or prescriptions into this web-based system as well as access them from

anywhere in the world.

This software product is designed mainly for the healthcare industry. It works as a standalone health

information system that allows storage, retrieval and maintenance of records.

While there are many advantages to have electronic medical records, there are also disadvantages which

should be kept in mind before moving to this type of system.

An EMR enables you to view and update a complete, secure, electronic record, at the point of patient care. The

EMR system captures data at the time of patients examination using a database. The data is then transmitted

into the system via computer workstation or voice recognition system.

The digital form of EMR offers an opportunity to operate a clean and paperless clinic. There are two options

available in its digital form, they are:

Standalone Software

Online Software

Standalone Software

You can ask a computer programmer to develop and install standalone software in your office computer. Once

the EMR software is properly installed, your patients data is then stored on the computer in its electronic

form. With proper backing of the data, you can protect it from virus problem and data lose.

Online Software
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You can use online EMR software, which stores the patients data on the Internet. The IT Company which is

providing their online software maintains this stored data in their computer, at a monthly fee. The computer

experts of this IT Company deal with your problems you come across while using this software.

Advantages of EMR

There are both advantages and disadvantages to electronic medical records. Many argue that positive aspects

of employing a medical records system outweigh disadvantages. Even though the investment in

electronic medical records systems is at first costly, most argue that over time this outset cost will result in

greater savings for both clinicians and health insurance companies.

As well as cost saving, many cite one advantage of medical records is that they save space. Instead of keeping

huge paper files on patients, all records are kept on computer files. Though someone must store these records

in computers, this still represents a small percentage of the space required to store physical records.

Along with saved space is reduction of paper needed by medical offices, hospitals or insurance companies.

Computer medical records do not render paper obsolete, but they certainly do reduce needed paper

significantly.

Another advantage of electronic medical records is the ability for all in a health care team to coordinate care.

This helps avoid duplication of testing, prescribing medicines that in combination might be dangerous, and the

ability for anyone on the medical team to understand the approaches taken to a condition. A person with

complex health issues may see several specialists, and can easily become confused by overlapping or contraryadvice. When specialists and primary care doctors use the same system for electronic medical records, then

everyone on the team should be aware of all the other team members actions and recommendations.

Some of the advantages of implementing EMR software are:

Repository of vital clinical information: An integrated electronic medical record system helps you to access

medical records at the speed of modern computer. It can also manage, share, collect and protect all the vital

medical information without lose.

Manage risk at lower cost: The EMR systems provide 24-hour information, which help to make better

decision, reduce errors, improve results, and lower the risk of negligence. Information such as admission,

service delivery, coding/billing accuracy, treatment, lab, and all other information of the clinical operations are

well maintained at the lower operating costs. Example: The Medical Group Management Association recently

calculated that staffing per physician can be reduced after implementing an EMR system.
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Quality of care: Quality patient care is obtained by integrating and retaining your patients information.

EMR maintains privacy requirements by providing the business professional an appropriate access to its

patient data. It offers clinical treatments on time and good tools to manage the entire process.

Information Integration Capability: Integrated solutions create a clinical healthcare system that combinesthe critical patient information with the varied departments. The EMR system interacts with external system

such as Laboratories, Pharmacies, Imaging Centers and Hospitals via HL7 interfaces. With this information

integration capability, you can facilitate better quality care and manage risks.

There are many administrative and management benefits offered by EMR. It:

Reduces the labour-intensive chart pulls and files.

Provides complete information at rapid rate.

Provides better and accurate information.

Reduces risk of misplaced or duplicate charts.

Saves transcription costs.

Increases Return on Investment (ROI).

Improves and track overall processes.

Though there are many advantages of EMR, there are some disadvantages of EMR too.

Disadvantage of EMR;

Financial difficulties faced during up gradation of EMR.

Staff training to utilize and understand the capabilities of this new system is difficult.

Technology factors, which you require to make sure that it is integrated with widely, used systems and

computer software is very difficult.

High security is needed to keep the information safe.

Legal issues may be of concern regarding privacy and confidentiality of records.


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How to Choose an EMR

EMR vendors are not all the same and it is important for healthcare professionals considering implementation

of an EMR system to select the best vendor for their needs. Whether your organization has one practitioner or

one hundred, choosing an EMR vendor whose product meets your specific practice requirements, will ensurethat the transition to an electronic system is more likely to succeed.

Each EMR vendor offers a range of features and differing functionality. Even when all of the systems you are

considering are HIPAA-certified and meet the standards for Meaningful Use, their structures are not

guaranteed to meet your practice's unique needs.

EMR solutions often include optional features related to billing, charts, record-keeping and reporting. Some

offer mobile capability that your office may or may not need. Comparing the offerings from a variety of

vendors will help your office make a sound investment and better adapt to EMR.

1.Define your practice's needs by making a list of the top 20 functions that you need your EMR to be able to

perform. Think carefully about how you'd like to improve your office and list all the features you think you'll

want. The software you choose should best support your specific practice workflow. Most of the top EMR

vendors combine EMR software with Practice Management software. Because they come from the same

vendor, they are well integrated with each other.

2. Rank your required features by importance. Turn the list into a scorecard with a number-based

scoring system (like 1-5) to rate how necessary the feature is to your office. Leave extra columns on your

scorecard to make notes about the different vendors and products you encounter, which will help you keep

track of which vendors offer a better product for that feature.

3. List out your potential vendors. After you've eliminated companies whose product isn't certified or who

don't fit your practice's basic needs, go over your scorecard and make a list of all potential vendors you might

be interested in. You can find potential vendors in online directories or through EMR consulting resources.

4. Do your research and seek reviews online. Another helpful consideration when selecting a vendor is to

seek out reviews online from EMR software users in similar practices and organizational structures. These

reviews are helpful in determining the level of success other healthcare providers have experienced using the

system and can also expose any major flaws or glitches within the software. Also whenever possible, reach out

directly to similar specialty practices with EMR in place - to ask if their experience to date has been positive.

The number of live implementations reported by the vendor can also be important. The software should be


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modifiable to adapt to specific healthcare focuses. s how often the EMR software is updated and patched for

potential errors.

5. Consider an independent HIT consultant. Independent HIT Consultants (without specific reseller

relationship to any one vendor) can evaluate and consider the best options with you. The benefit of this

relationship is that the same consultant can often manage the entire project for you - including the acquisition

of correct hardware, analysis of workflow, review of systems and provide implementation oversight.

Another way to choose an EMR can be

Realistic Goals:

Take a good look at your office to decide the needs. Consider the categories such as transcription, digitalimaging, and billing. The right EMR software enables you to reduce your office operating cost, medical errors,

documentation cost/time and number of staff. To meet all these benefits, you need to compare all the different

software packages available. You need to set milestones and implement the right plan.

Cost-Benefit Analysis:

As the cost of EMR software ranges between $1000 and $45,000, there should be clear idea of the amount of

money available for making a purchase of an EMR. You should have realistic expectations of type of Return

on Investment (ROI)[2] you need. Evaluate the cost against the current expenses in the office which might

reduce upon the implementation of an EMR. You should also consider the costs that are mostly overlooked

such as office supplies, chart management, and storage.

Sources of Information:

Marketing material supplied by the EMR vendors provide partial information on EMR software. You need to

consult the expertise of IT Company to help you in selecting the right vendor. Some vendors provide on-site

demonstration while others offer working demonstration disc and have Internet-based information with

example screens.

On-site visits:

Site visits to clinics which are using EMR software brings you clearer picture to take a final decision. This

helps you to see the actual function of the software and meet users to know their views about this program.
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Certified EMR Industry:

In 2006, Certification Commission for Healthcare Information Technology (CCHIT) organisation took

initiative to certify EMR products. This helped to eradicate many bad EMR products in the market.

Organizations such as CCHIT, TEPR, AC Group, KLAS and MS-Hug have started ranking EMR vendors.You can use this CCHIT certified vendors list as an added advantage to select the right vendor for the

implementation of EMR software.

Return on Investment (ROI):

The concept of Return on Investment (ROI) is similar to that of Cost Benefit Analysis. This is considered as

final steps in the selection process. You must be overlook the publicity of some vendors claims and must

concentrate on some practices that have experienced their ROI related claims.

At the same time, you must look after the general costs in EMR implementation such as billing, networking

and other computer systems. Implementation of EMR software will also incur some additional costs such as

hardware and software maintenance and up gradation.

6. Explain the significance of clinical information system?

A clinical information system is a collection of various information technology applications that provides a

centralized repository of information related to patient care across distributed locations. This repositoryrepresents the patient's history of illnesses and interactions with providers by encoding knowledge capable of

helping clinicians decide about the patient's condition, treatment options, and wellness activities. The

repository also encodes the status of decisions, actions underway for those decisions, and relevant information

that can help in performing those actions. The database could also hold other information about the patient,

including genetic, environmental, and social contexts.


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We will define such a CIS as a computer-based system that is dedicated to the collection, storage,

manipulation, and presentation of all the clinical information important to delivery of patient care. We must

examine the organizational and social issues surrounding these systems to truly understand their potential use,

benefit, and impact on health care delivery overall.

Some of the areas addressed by CIS are the following:

Clinical Decision Support: It provides users with the means to collect, manipulate, apply and present

appropriate information to help make correct, timely and evidence-based clinical decisions. Clinical

Decision Support Systems search for unusual patterns or possible adverse effects of drugs, recommend

optional actions to remedy situations, predict and alert for drug-drug interactions. It also provides a

complete plan to provide better patient care based on the patients health history and clinical

assessment. It helps save lives, reduce healthcare costs, increase clinician and patient satisfaction,

improve communication, and enhance the overall process of care. Electronic Medical Records: It contains information about the patient including patient details like name

and age along with every aspect of care given by the hospital, for example, from routine checkups to major

operations.

Training and Research: Patient information is made available to physicians for training and for

conducting research. Data mining the information stored in the repositories can provide insights into the

state of the illness and how to manage it.

Results of Using a CIS: Identifying Progress

In the last 50 years, numerous research efforts have been designed to help investigators learn more about CIS

and their effect on the health care delivery process. The following sections highlight several of the most

important dependent variables that have been examined. Within each study area, research can span all

functional aspects of a CIS. For example, researchers might be evaluating a new CIS feature to detect adverse

drug events and thus improve quality of care in an intensive care unit, but they may illustrate in the process the

need for a system to help clinicians order the appropriate antibiotic.

Clinical information systems are often touted for their potential ability to improve quality of health care. One

way they improve care is by supporting clinicians in the decision-making process. The most widely used CIS

function for this support is presenting patient-specific information in a legible, organized, and timely

manner. Other CIS interventions that have been examined include allowing clinicians to:

access the medical literature,

ask clinical or administrative questions of aggregates of patient data,


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receive automatic warnings or suggestions when the patient's data satisfy certain logical rules,

receive critiques when proposing therapies or ordering diagnostic tests,

access guidelines for standards of care,

analyze tradeoffs and the likelihood of alternative outcomes (decision analysis), and

receive lists of differential diagnoses.

Points to ponder

Related to quality of health care, safety of the systems and their underlying software has recently become an

important topic. Studies have examined patient safety, especially as it relates to errors of omission and

commission made by clinicians or the entire health care system. In a seminal study, McDonald found that

physicians prompted by computer were more likely to respond to various clinical events for common

conditions routinely managed or caused by medications. He concluded that these oversights were due more to

"man's limitations as a data processor rather than to correctable human deficiencies.

In cost-related evaluations, many investigators have examined whether a CIS can affect health care resource

utilization. For example, Tierney et al looked at how a physician's direct entering of patient orders affects the

charges assessed the patient during an inpatient stay. Evans et al showed that a complex clinical decision

support system integrated with a comprehensive electronic patient record could both improve quality of care

and reduce its costs. Time efficiency of clinical computers has been investigated from the standpoint of the

effect of a CIS on the time required to perform certain clinical tasks. Investigators have also examined whether

a CIS can improve various patient-focused, time-related measures, including: outpatient clinic waiting time,

time to receive appropriate treatment, and hospital length of stay.

Research has also examined various issues surrounding clinicians and providers. Satisfaction of patients with

their clinicians and the care they receive as well as satisfaction of clinicians with their work environment is a

major concern. Adoption of CIS as a routine component of the process of delivering patient care has received

considerable attention. The historical patterns of technology implemented in health care have been investigated

to try to understand the technologic and sociologic factors that create barriers or facilitate the process. By

providing direct access to relevant clinical information at the time and place it is needed, a CIS can have apositive effect on both patient and provider education. Various electronic-information-technology-based

communication systems have been examined for their ability to improve continuity of care for patients by

improving access and coordinating the activities of clinicians.


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The article most often credited with starting the entire field of computer applications in medicine focused on a

statistical method of reasoning about medical conditions. Investigators then began experimenting with different

ways to implement algorithmic reasoning techniques that exploit the variety of relationships that exist in

different medical domains. These include associations, probabilities, causality, functional relationships,

temporal relations, locality, similarity, and routine clinical practice. The process of representing, maintaining,

querying, and reasoning about time-oriented clinical data is another major theoretical and practical research

area in CIS.

Challenges and research in cis:

Given this CIS research background, a CIS clearly is much more than simple installation of a computer system

within a health care institution. CIS represents a major change in the way health care is delivered. Although the

list of potential research questions related to CIS design, development, and implementation is lengthy,

reviewing a small group of examples is useful. The next 13 generic research questions are followed by a

specific sample question that could be asked and answered with appropriate CIS functionality by a group of

experienced CIS researchers.

1. Does the system work as designed?

Are the alerts and reminders generated for a specific patient correct and "of use" to the clinician?

2. What is the impact of various system enhancements or modifications?

Does the new patient summary display screen help clinicians quickly understand the patient's past medical

conditions and treatment and allow more meaningful discussion of the current reason for the visit?

3. Is the system used as anticipated?

After implementation of a physician order entry (POE) system, the percentage of orders entered by physicians

could be examined.

4. Does the system produce the desired results?

Does the new POE system actually reduce occurrence of adverse drug events?

5. Does the system work better than the procedures it replaced?


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Does the new clinical laboratory alerting system reduce the time patients spend in a critically abnormal

physiologic state compared with the previous telephone notification system?

6. Is the system cost-effective?

Does the increased time clinicians spend entering data during the patient visit lead to efficiency or

improvement in quality within the overall health care system and thus justify its continued use of this practice?

7. How well have individuals been trained to use the system?

What percentage of clinicians can successfully perform a series of tasks required to manage a simulated patient

encounter?

8. What is the anticipated long-term impact on how departments interact?

When routine drug/drug-interaction checking is moved out of the pharmacy and onto the clinician's desktop

machine, what is the impact on the pharmacy department's morale and productivity?

9. What are the long-term effects on the delivery of medical care?

Does provision of regular health maintenance reminders to clinicians at the point of care improve the long-

term health outcomes of chronically ill patients?

10. Will the system have an impact on management of the organization?

Does incorporation of real-time reminders about the current drug formulary decrease variability in prescribing

behavior and thus reduce costs of managing the organization?

11. To what extent does impact depend on the practice setting?

Can the same data entry and review screens be used by both primary care and specialty care clinicians?

12. Can we establish a performance baseline against which future CIS enhancement can be compared? Can

such regularly collected clinical or administrative data be used to measure impact of future CIS enhancement?

And are there additional data items that, if recorded, would present a different picture?

13. Does the increasing complexity of modern medicine and the CIS required to implement it help or hinder

clinicians and their patients? And how does use of the CIS affect the patient-provider relationship?


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A CIS potentially touches and affects all aspects of the health care delivery system. Therefore, a research

agenda should address the key components of any potential system and the way that these components interact

in the course of care delivery. We thus began by considering an abstract model of health care delivery that

made explicit these key components and the interaction among them.

Key Participants in the Health Care Delivery System

The most important participants in the health care delivery system are the patients and their families who

receive the care and the clinicians (physicians, nurses, and members of the allied health professions) who

provide the care. In addition, we identified the interaction between these two sets of participants, which we

termed the "processes" of delivering the care. These processes describe or control the way care is delivered.

We also recognized that the organizations (hospitals, integrated delivery networks, health maintenance

organizations, insurance companies, and government agencies) supporting the providers are key participants in

the overall system. Considering entire populations of patients as a single participant is also often valuable.

Finally, we identified the data, information, and knowledge that the CIS must record, store, and display for all

of the other participants.

The scientific fields associated with design, development, implementation, and evaluation of CIS have made

tremendous progress to date. Although various aspects of these systems have been successfully incorporated

into the routine health care delivery processes, much remains to be discovered, implemented, and tested. The

CIS research landscape we have described should help researchers and research funders alike focus their time,

effort, and money on important research questions. The answers to these questions should, in turn, significantly

improve the overall health care delivery process. In the succeeding article, we will describe how we used this

research landscape in conjunction with the known operational, financial, technical, governmental, and social

constraints present within KP to develop a specific CIS research agenda.

Documents

MH0054-Finance, Economics&material management in health care services