LESSON 11: Other Hospital Information Systems

Cardiology Information System

Definition

The cardiology information system (CIS) is mainly focused on the storage and
retrieval of cardiology centric images. This system usually receives an order with patient
demographics from other information management systems. Once the images are acquired
from imaging modalities. They are profiled based on the order and stored for further distribution,
viewing, and long-term archiving (Katipula & Ireland, 2013).

The information used by cardiologists for the diagnosis and treatment of illnesses caries
from personal notes (history, physical examination), to signals (electrocardiograms), images
(echocardiograms, angiograms, CT MRI), and reports from investigations and procedures. All
these types of information can currently be provided in digital format, and the system serves as
repository of these forms of images. Unfortunately, most systems are limited by their storage
capabilities and do not include post-processing functions.

Evolution of CIS

Decades ago, the requirements for an electronic medical information system were
restricted by the availability of equipment. A good database schema combined with a functional
user interface war deemed adequate. In the 1970s, available cardiology information systems
originated form manufacturer environment, whose technical specifies would be considered
ridiculous in today‟s context.

In the 19080s, modular systems that emphasized the use of real-time applications and
mini computers became the trend (Turney & Kohls, 1997). Over the years, the trend for smaller
computers remained, but the introduction of the internet became a turning point that shifted the
focus of most systems towards creating networks and facilitating integration. Cardiology
information systems nowadays have unique features that enable remote access and easy
retrieval. Some systems have also attempted to integrate radiology information systems (RIS) to
involve more administrative processes and go beyond storage purposes.

Benefits of CIS

Different CIS, coming from different sellers, vary in their available features. However, the
following in the most common benefits:

1. Ease of Access while Maintaining Data Security

CIS consolidates multiple types of patient cardiology information, thus eliminating
the need for doctors to request different imaging results from different departments.
2. Flexibility in the Workflow
Availability of mobile technology allows cardiologists to assess a wide array of
information without having to leave the patient‟s bedside. Having cardiological data in a
 single platform offers mobility to physicians and nurses, thereby improving the efficiency
of providing service.
3. Enhanced Comparability
CIS is an essential repository of cardiology imagery results, thereby, retrieval of
past data is convenient. This comparability enables health care professionals to make
more informed decisions on their patient‟s treatment.

Functionalities of CIS

1. Editing, Viewing, and Storing Multi-Modal Cardiology Data – With the help of CIS,
different types of data, including those of computed tomography (CT), cardiac ultrasound
(echocardiography), magnetic resonance imaging (MRI), nuclear imaging (PET and
SPECT), and angiography may be managed on a single platform.
2. Remote Access – The use of networks and integrated information systems, coupled
with the availability of the internet and tablets and smart phones, offers flexibility to CIS.
3. Visualization and Reporting Capabilities – Two of the main benefits of CIS are the
ease and the consistency of reporting. As a result, virtual real-time information retrieval
is possible anytime and anywhere with just a couple of clicks.
4. EHR Integration – CIS may be integrated with existing electronic health record systems;
this results in the enhancement of the quality of services of the health professionals by
offering a more comprehensive view of the patient care spectrum.

Radiology Information System

A radiology information system refers to a network system used in managing imagery

and associated data in the radiology department. The system tracks the orders and billing
information of the requesting department. It used picture archiving and communication systems
(PACS) for the storage and management of medical images and vendor neutral archivals (VNA)
to manage image archives and for record-keeping and billing within a hospital information
system (HIS) (Rouse, 2017).

The use of RIS in health care institutions has many advantages in the context of
improving overall operations of the institution. The system enables easier access to patient
information because it can be integrated in referring to the doctor‟s electronic health record
(HER) system, resulting in better patient experience. It also allows faster processing of
payments because the insurance plans of patients may be verified prior to their visit and
electronic payment is an available option. It also permits reports to be easily generated and sent
to the requesting department which dramatically improves the efficiency of the workflow of the
institution.
Functions RIS

Rouse (2017) describes the following function of a RIS:

 Patient Management – The system tracks the patient‟s entire workflow within the
radiology department. It can add images and generate reports to EHRs for easy retrieval
and viewing by the authorized radiology staff.
 Scheduling – The system allows staff to schedule appointments for in-patients and out-
patients.
 Patient Tracking – Patient tracking means tracing the patient‟s radiology history starting
from admission to discharge and coordinating it with his or her past, present, and future
appointments.
 Results reporting – Results reporting is possible through the statistical reports
generated by RIS. The reports may be done for a single patient or a group of patients,
as well as for specific procedures depending on the needs.
 Image tracking – RIS was traditionally used to track individual films and associated
data. Nowadays, RIS-PACS systems managed by radiology departments cover the
entire clinical workflow of the medical enterprise.
 Billing – Billing is made convenient through the system‟s financial record keeping and
processing of electronic payments and automated claims.

Key Points to Remember

 Cardiology information system (CIS) is mainly focused on the storage and retrieval of
cardiology centric images.
 The benefits and features of CIS include ease of access while maintaining data security,
flexibility in the workflow, and enhanced comparability.
 The functionalities of CIS are editing, viewing, and storing multi-modal cardiology data;
remote access; visualization and reporting capabilities; and EHR integration.
 A radiology information system (RIS) is a network software system designed to manage
medical imagery and associated data. An RIS is especially useful for tracking radiology
imaging orders and billing information, and is often used in conjunction with picture
archiving and communication systems (PACS) and vendor neutral archivals (VNA) to
manage image archives and for record-keeping and billing within a hospital information
system (HIS).
LESSON 12: Materials Management Systems

Materials Management System

The management function of hospital materials – that is, to ensure that services are
rendered successfully from one source to an end user – covers several areas of the hospital
and could dramatically affect the expenses of the medical institution. Executing this function in a
manner that lessens expenses and ensures adequate cash flow requires effective management
of a large amount of information from several sources.

To successfully manage such information, many hospitals implement a form of

materials management information system (MMIS). The aforementioned system can be
used to manage function like purchasing, accounting, inventory management, and patient
supply charges (“Materials management information systems,” 1996).

Purchasing

Figure 12.1 Purchasing Process

In HIS by BisBox, a purchase request marks the beginning of the procurement process.
Using this form, the user notifies the purchasing department regarding the needed items and
services. It contains the quantity, as well as a timeframe for the items requested. It has the
authorization information needed to proceed with the purchase. The requested items are then
confirmed using the purchase order and a supplier is nominated. Once completed, the order is
sent to the supplier for processing.

Finally, the items are checked during receipt of the delivery. The receiver, which is
usually the Central Supplies department, uses the purchase order as basis for accepting the
delivered items that should be checked for indents and damages. Afterwards, the said items are
then releases to the requesting department.
Inventory Control

Inventory is one of the biggest expenses for most medical institutions (Johnston, 2014).
Inventory control plays an important part in refining the quality of health care services since lives
of people are on the line and medical costs are increasing.

Strategies to improving inventory control in the health care facility:

1. Ensuring Shipment Accuracy

Checking shipments for accuracy means ensuring that the received items are the one
ordered and the supplies are free from possible damages during transit.
2. Aligning with Sales Projections
Coming up with an inventory tracking report in comparison with actual sales proves to be
a challenge in the field of medicine. However, it is necessary to prevent wastage, identify
trends, and ensure that there is no excess inventory.
3. Complying with Regulations
The health institution should be responsive to the current trends and needs of the highly
regulated health care industry. The regulators monitor health institutions and determine
the success of failure of companies to serve the best interest of the patients.
4. Establishing Buying Cycles
Buying cycles should be determined and understood by inventory personnel based on
the previous cycles, so that inventory ordering becomes manageable through the
elimination of shortages and overages. The said cycles determine the trends and
adjustments that can be made accordingly.

Item Master Maintenance

Since the importance of inventory control has been recognized, the usage of a materials
management systems brings an advantage. In this system, the inventory item maintenance
screen has many sections. The upper portion contains master information. Additional options
appear after the selection of an existing items. “Item Lab” is used for maintenance of the
attributes of an inventory item, such as product type, item class, item type, and others. If the
balance and order activity is zero, items can be deleted using this option. Users may set the
product type to group similar items for sales analysis and inventory reporting. Most the inventory
reports are based on a certain product type. The “Item Availability” forms specific inventory level
across all warehouses.

Item Indents and Issues

There are some instances when items are damaged either upon receipt from the
supplier or during the move from the source to another location. Some suppliers allow return of
goods that have indents or the like, with a guarantee of replacement without any additional
payments. This applies to distribution and retail industries where the goods for sale are fast
moving. Normally, damaged items are moved to another warehouse for them to be monitored.
Reorder Level and Minimum and Maximum Inventory Ordering

In a typical materials management system, reorder level is the minimum quantity of an

item that a company has in stock, so when the stock reaches the stated minimum quantity, the
items must then be re-ordered (Purchase order/production order).

A basic reordering method implemented in many ERP‟s and other inventory

management software is the Min/Max Inventory ordering method. The “Min” value is
representative of a stock level that prompts a reorder, and the “Max” value is representative of a
new targeted stock level that follows the reorder. The main difference of these two – Max and
Min – is often interpreted as the economic order quantity (EOQ). Although the Min/Max method
is an unpolished method for inventory ordering, its setting could be adjusted to provide better
inventory performance (Vermorel, 2014).

Enquiries and Quotations for Drugs, Consumables, Assets, and General Items

According to Webrino (2018), the following documents are required in the materials
management process:

1. Enquiries – The enquiries mark the beginning of the purchasing process. These
establish the relationship between the entity and the right supplier. The supplier provides
information on the availability and price of the required items.
2. Quotations – Quotations contain vital information regarding the requirements which
include price, delivery details, payment terms, and etc. Companies usually review two to
three quotations before selecting the supplier.
3. Orders – The buyer shows the intention to purchase the required item by issuing a
purchase order. A purchase order is placed to signify intention to engage in commercial
operations for a specific product or service. Upon agreement, the order becomes a
contract between the health care institution and the supplier.
4. Invoices – An invoice is also called a bill. It is a commercial document that indicates the
product, the ordered quantity, and the agreed price. The supplier issues this to the buyer
to show the products and services that were sold or provided to the buyer.
5. Documents – Documents are statutory requirements used during purchase and sale
transactions. These ensure smooth transition and completion of the process.

Comparison of Quotations and Preferred Vendors

Purchase Quotations

A purchase quotations is a document for requesting prices and delivery information

form a vendor before the purchase order. It can be created then sent to a vendor. When a
response from a vendor is received, with a list of prices and delivery dates, the information can
be entered in the purchase quotation. In this way the complete history of the sourcing process
can already be stored in the system. From the quotations, the rigid vendor for the purchase can
be chosen based on the tracked information. It helps in lessening expenses, improving the
quality of the product or service, and increasing on time delivery. A purchasing quotation report
allows the comparison of offer in order to pick the appropriate vendor for the purchase scenario.
Afterwards, the purchase order can already be created from the selected quotation.

Preferred Vendors

Companies typically maintain a list of preferred vendors from whom inventory items are
usually purchased. They look for a vendor who has on time performance, offers reasonable
costs, provide high quality products and services, offers fully licensed, bonded, and insured
products and services, and has good business practices.

Purchase Requests, Orders, and Approval

Purchase Request

A purchase request or purchase requisition is a document that notifies the

purchasing department that certain items or services need to be replenished. The document
stipulates a timeframe and required quantities for the requested items. In certain instances, it
also contains authorization to acquire assets. For enhanced accountability and for
documentation purposes, some companies require a purchase requisition for all purchases, but
others only require them for specific kinds of purchases, such as those that would require
greater capital outlay (SAP, 2012).

Purchase Orders

A purchase order is a legally binding contract which shows that the seller has already
accepted the order issued by the buyer (SAP, 2012). It should contain: information about the
buyer and seller (name, address, contact details, and etc.): order number and order date; items
description (quantity, unit, and total price), shipping information (shipping date and address);
billing address; and the authorized signature.

Approval Process

The person who creates the document, either a purchase or order in the originator.
When the said originator adds documents to materials management system, the systems
checks for any approval requirements. If the document fails to meet the approval requisites, the
originator is notified that the document needs approval. The document is temporarily saved as a
draft.

When the approval process is launched, an internal request is immediately sent to the
first approval stage. This request is received in the messages/alerts overview window, and the
approver can access the document. Approval can be done through a mobile phone if the
devices are integrated. An internal notification goes back to the originator with a link to the
rejected document when the approver rejects the document. The originator can amend the
documents and the approval procedure will continue until the conditions are adequately satisfied
(SAP, 2012).

Receiving and Tracking Items

The following policies should be followed for the proper receipt and inspection of goods
(the York College, 2017):

1. Signing for Deliveries – The person who receives the delivery should inspect the
delivered items before signing the receiving document and the packing list. Then the
document should be submitted to the appropriate department for reconciliation.
2. Refusing Delivery – The receiving department should refuse to accept any shipment if
the packaging appears to be damaged or if there is any item that does not have a
corresponding purchase order.
3. Record Retention – The packaging list should be provided to the receiving department
during delivery to ensure that there is a proper documentation since it is are taking
possession and legal ownership of the delivered items. If no list was provided, the
department should request the copy from suppler. All files should be kept according to
the guidelines of the entity. This helps track partial and staggered deliveries.
4. Inspecting a Shipment – The personnel receiving the items should inspect the goods to
ensure that the following minimum conditions are met:
a. The received items match the requirements stated in the purchase order (type,
description, color, and etc.)
b. The quantity is correct.
c. The item has no damage, discoloration, and issues.
d. The quantity per unit of measurement is accurate (e.g. one dozen = 12 pieces).
e. Packaging list, certification, and other delivery documentation are completely
provided.
f. Perishable items should be in good condition and have not reached the
expiration dates.
g. The items are functioning properly.
5. Partial Deliveries – When items are delivered partially without proper notification from
the supplier, the receiving personnel should advise the purchasing department for
approval and further instructions, this should also be typically noted in the packaging list
or the receiving document.
6. Tracking of Goods – Goods can be easily tracked/traced when they are managed by
serial number or batch. Through that, aging of products can also be monitored based on
how long they have been in the warehouse.
Purchase Returns along with Returnable/Non-Returnable Gate Pass

Defective of substandard quality goods, incorrect order delivery, and deteriorated

purchased and old items are usually common in business. These lead to purchase or sales
returns. When purchased goods are returned, the materials management system updates
inventory levels to reflect the decrease in quantity.

Movement of inventory is not limited to purchase returns. Supplies and equipment are
also sometimes required to be taken out of the department for repairs or consignment. For
temporary movement, a returnable gate pass is issued whereas for permanent movement, a
non-returnable gate pass is given. The system can be configured to track returnable and non-
returnable items or equipment. It can also be set to monitor due dates for returnable items and
to provide detailed reports about the status of different inventory items.

Consignment Stock Receipt, Consumption, and Regularization

In the process of consignment, the vendor or consignor issues materials to the receiver
or consignee and these materials are stored in the consignee‟s premises. The vendor maintains
legal ownership until such materials are removed from consignment stores. The invoice is due
at predetermined intervals. In addition, customers can also arrange take over ownership of the
remaining consignment material after a certain period (SAP 2011).

Expired Stocks and Quarantine

Expired Stock/Inventory

Upon reaching their expiration dates, some goods, such as food and medicine, can no
longer be utilized. In rare instances, they may be sold to other parties at lower costs. Expiration
dates a decrease in values of items must be reflected in the financial records so discrepancies
in financial statements will be prevented. The amount that reduces inventory in the records is
recognized as a loss which equates to a reduction in profit (Keythman, 2017).

Quarantine Stock/Inventory

When undecided about how to handle defective goods, whether to be sold as scraps,
reworked returned, or used as it is, a quarantine location or warehouse can be used to
temporarily house them until a final decision is reached.

Inventory is put into quarantine if it is initially rejected during (Infor LN Warehousing, 2018):

 Production, upon completion of an operation, when specified as “Move rejected end item
to quarantine.”
 Inbound inspection upon receipt of:
 Manufactured end items
  Purchased items
 Sold items on sales return orders
 Enterprise planning distribution orders
 Outbound inspection upon issue of materials to production

Drugs and Consumable Issues and Returns to Patients

Nagarajan (2017) affirms that 30 to 50 percent of hospital charges are actually

attributable to diagnostics, drugs, and consumables; and doctors get only between 10-20
percent. For both hospitals and patients, drugs and consumables take up the bulk of
expenditure. This is why materials management is critical for hospitals to optimize the
investment in these kinds of consumable assets.

While some hospitals have functional inventory databases, the lack of integration does
not give them holistic information, and this affects decision making, both on a managerial level
and during day to day operations. For instance, some drugs are misplaced or misappropriated,
or shortages and surpluses may occur as a result of improper inventory controls in a traditional
system (Infor LN warehousing, 2018). This is where materials management system becomes
advantageous. It provides an overview of the entire institution‟s purchasing and inventory
control processes. As a result, decision makers can have more reliable information and can
monitor the bigger picture.

Issue Methods

Inventory management is a crucial function for any product oriented business. Common
inventory handling methods includes:

a. First In, First Out (FIFO) – Inventory items are sold based on the order they are
purchases. This is the most common technique.
b. Last In, First Out (LIFO) – Last items to enter the system are sold first. This is common
among non-perishable items like petroleum, minerals, and metals.
c. First Expired, First Out (FEFO) – Materials are sold based on the dates they should be
consumed, regardless of when they were purchased.

Generic Tax Formula Configurations

Materials management systems usually allow tax rates to be defined internally via tax
codes or imported from an external source. Tax configurations are usually accounted on a per
country basis. The following taxes that can usually be processed while posting documents are:

 tax on sales and purchases,

 additional taxes like VAT;
 sales and use tax in USA, and
  withholding tax like income tax in India.

The automatic calculation of the tax dues during the purchasing process makes the
process less susceptible to clerical errors.

Periodic Physical Stock Taking and Adjustments with Tracking

An inventory count is a process where a business physically counts its entire inventory.
A physical inventory may be mandated by financial accounting rules or tax regulations to place
an accurate value on the inventory, or the business may need to count inventory so component
parts or raw materials can be restocked. Businesses may use the following tactics to minimize
the disruption caused by physical inventory (CTI Reviews, 2016).

 Inventory services provide labor and automation to quickly count inventory and minimize
shutdown time.
 Inventory control system software can speed up the physical inventory process.
 A perpetual inventory system tracks the receipt and use of inventory, and calculates the
quantity on hand.
 Cycle counting, an alternative to physical inventory, may be less disruptive.

The materials management systems offer all of these in addition to the barcode and
RFID capability which are supplementary technologies placed to give the institutions more
accurate and less burdensome inventory counts.

Key Points to Remember

 The successfully manage information, many hospital implement a form of materials

management information system (MMIS). The aforementioned system can be used to
manage functions like purchasing, accounting, inventory management, and patient
supply charges.
 Purchasing request could be used as a first step in the process of purchasing. This
should be followed by a quotation before proceeding to the purchase order depending
on the process by the management.
 Inventory control plays an important role in referring the quality of health care services
and different strategies can be employed to execute efficiency. These strategies include
ensuring shipment accuracy, aligning with sales projection, complying with regulations,
and establishing buying cycles.
 The MMS can handle issues such as item indents and recorder level.
 There are three issue methods that are currently need in the health care industry: First
In, First Out (FIFO), Last In, First Out (LIFO), and First Expired, First Out (FIFO).
 Periodic physical stock taking or inventory count may be mandated by financial
accounting. MMS have barcode and RIFD that can be used as tools to ensure accurate
and convenient counting.
LESSON 13: Clinical Data Repositories

Clinical Data Repositories

Nowadays, most institutions have existing clinical data repositories (CDR), in electronic
or written format, to represent an aggregated database of clinical information. The repositories
usually houses multitude of laboratory results, diagnostic reports, and various clinical
documentation. These data are readily researchable and exportable, often because the
information is gathered from standard clinical care procedures (Robertson and Williams, 2016).
The repositories integrate physician-entered data with data from different existing information
systems including laboratory, radiology, admission, and pharmacy. They are placed where both
clinical data and other data of interest, such as external data sources and financial data are
assimilated (Carter, 2001).

A clinical data repository can successfully depict the same sample across different
points in time, from varying sources both within and outside the health institutions. Common
kinds of available information in CDR are listed below:

 Patient demographics
 Patient‟s primary care provider
 Medication list
 Allergies
 Hospital in-patient visits
 Emergency department encounters
 Outpatient practice visits
 Immunizations
 Diagnoses
 Procedures
 Laboratory results
 Social history
 Vitals

Maintaining them poses a lot of advantages since longitudinal view of patient‟s medical
record can assist in improving patient experience, and having information about the prior test
results and procedures leads to more informed patient care decisions and helps avoid
redundant treatment.

CDR Integration with HIS

Bergeron (2013) describes a clinical data repository as a systematically structured and

gathered “storehouse” of patient-specific data, which is usually mirrored from a clinical
application or supplemented with data from other clinical systems. Since it is maintained as a
separate database particularly created in aiding decision analysis, the main application avoids
computational loading, and response time to a query is improved. Moreover because almost all
simple, customized, or complex patient records are mirrored in it, queries are possible without
sacrificing the performance of source applications. Furthermore, since the data typically
originated from one source with little to no manipulations, near real-time retrieval of clinical data
is possible.

These are different levels of integration in the said repository. These levels depend on
locations, indices, catalogues, semantic translations or equivalences, syntactic structures, and
links to external information. They influence functionality by setting constraints on how easily
someone can make queries for any of the contents. The integration structure from the CDR to
the laboratory information system, for example, may be different for radiology or pharmacy.
These differences might mean that a user may only access certain types of information and use
particular types of queries from a given information system depending on the restrictions which
were set during the integration process. The aforementioned restrictions vary on terms of the
user‟s access. While some CDRs are fairly open other are either employees of an institution or
to members of some research network. Access control to the CDR functions as a safeguard to
uphold data security and integrity.

Wade (2014) emphasized the longitudinal nature of the CDR required a way of linking
various observations of the same identified subject. Most repositories usually contain personally
identified data however, due to privacy issues, they only release de-identified data which can
lead to the emission of some data in dataset. The lack of identifiers could also prevent the
linking of data for some patients. Presented below (Table 13.1) are the different types of clinical
data repositories that Wade classified according to factors described above.

Table 13.1 Types of clinical data repositories

Repository Type Definition

A database that collects observations for a
Study
specific clinical research study.
A database of observations made as a result
Electronic Health Record
of direct health care.
Observations collected and organized for the
purpose of studying or guiding particular
Registry outcomes on a defined population; associated
studies are either multiple or long-term and
evolving over time.
A repository that adds levels of integration and
quality to the primary (research of clinical) data
Warehouse of a single institution to support flexible queries
for multiple users; is broader in application
than a registry.
A library of heterogeneous datasets from more
organizations than a registry; organized to
Collection
help users find a particular data set, but not to
query for data combined across datasets.
 A repository distributed across multiple
locations, where each location retains control
Federation over access to its own data, and is responsible
for making the data comparable with the data
of other locations.
These repositories are beneficial in consolidating patient information, a disadvantage is
that most CDRs are only integrated with clinical data. Laboratory results, diagnoses, and
demographics might be available in one platform, but overall patient satisfaction, the amount of
time a patient had to wait before being treated, and other information not directly related to
patient care might be unavailable.

Multiple Views for Patient Medical Record

Information on patients is typically scattered across multiple subsystems. A clinical data

repositories standardized data from disparate sources into cohesive format. It comprises
numerous tables which offer partial view of patient information (Gensinger, 2014). Its structure
allows data to be extracted along dimensions such as time (by year, month, week, or day),
location, or diagnoses. These data can often be accessed in smaller united within the same
dimension. For instance, use can view the number of patients with certain type of diagnosis,
laboratory result, or prescription within a year, then a month in that year, and further into a day
in that month.

Ball and Douglas (2013) elaborate that a well0deployed clinical repository has multiple
advantages. First advantage is the CDR function to provide longitudinal views of patient
information. It is often organized primarily around patients and secondly around visits or
encounters, a method that easily accommodates views that span multiple visits. This allows
clinicians to trend and chart results independent of the visits and test panel organization.

Another advantage is its capability to provide access to information when needed. Since
it receives information from a multitude of feeder systems, it can create a non-stop shopping
environment. This is done by allowing the clinical staff to access variety of patient-focused
information through consistent and easy-to-use graphical interface (GUI). The GUI access can
be deployed through hand-held devices, bedside computing devices computers in physician‟s
office.

Finally, CDR provides cross-continuum view of information since it allows information to

be gathered and viewed from sources other than an acute setting. This type of ambulatory-
focused information combines with the acute information to give clinicians a new level of insight
into the wellness of their patients.

Data Visualization of Laboratory Results and Vitals

Data collected through an electronic health record system may be retrieved at the
request of an authorized user, whether a physician, medical technologist, nurse, or radiologist.
The electronic health record may present patient care information as text, tables, graphs,
sounds, images, full-motion video, or signals on an electronic screen, phone, pager, or paper
(Bronzino and Peterson, 2014).

Unfortunately, analyzing trends and patterns from large data sets can be challenging
process. This is where data visualization, the art of representing data in a pictorial or graphical
format becomes useful. It helps in simplifying a wide array of information, and it allows decision-
makers to derive analytical results from the information presented visually. Through this,
correlations, patterns, and trends which might be undetected from text-based clinical data can
be revealed and recognized with more ease.

For example, the physician can easily review the results of multiple chest x-rays
obtained over the course of months or years when deciding if a nodule has grown. This
information would have not been accessible basing on textual clinical data alone. Moreover,
patients suffering from specific diseases that require careful carting or monitoring of laboratory
values, including anticoagulation or blood sugar values, can understand what is expected in
their care because of better means of data presentation.

Visualization of clinical data is increasingly becoming an important tool in decision-

making. The graphical representation feature most clinical data repositories enable scenario
analysis, which helps users use different kinds of filters in order to change the level of
information that may be seen. Common filters include age and gender, in order to assess
outcomes of certain interventions based on isolating certain factors. This kind of analysis is a
good opportunity in empowering the frontline staff by giving them straightforward data which will
efficiently and effectively facilitate the performance of their tasks (Rains and McCuistion, 2018).

Key Points to Remember

 Clinical data repositories (CDR) integrate physician-entered data with data from different
existing information systems including laboratory, radiology, admission, and pharmacy.
 A CDR is a systematically structured and gathered “storehouse” of patient-specific data,
which is usually mirrored from a clinical application, or supplemented with data from
other clinical systems.
 Repository types include study, electronic health record, registry, warehouse, collection,
and federation.
 CDRs offer a cross-continuum view of information since they allow information to be
gathered and viewed from sources other than an acute setting.
 Data visualization helps in simplifying a wide array of information, and it allows decision-
makers to derive analytical results from information presented visually.
LESSON 14: Ethics, Privacy, and Security

Ethics in Health Informatics

Technology helped in the modernization of the health care industry; however, this made
practitioners to be dependent on the use of mechanical aids providing patient treatment.
Conversely, human values should continue to govern research and the actual practice in health
care.

Health care informatics covers issues on honourable actions and proper and improper
behaviors in the field of health care. However, most health practitioners are not familiar with
ethical issues even if some issues have been controversial.

Nowadays, privacy and confidentiality are among the popular sources of debate.
However, more important issues such as the use of appropriate informatics tools in clinical
settings, determination of users, system evaluation, system development, and many others
need attention. These and other questions on the various legal and regulatory requirements
need to be addressed (Goodman, 2016).

Listed below is a set of ethical principles for appropriate use of decision-support

systems, particularly in informatics, as described by Shortlife and Cimino (2013).

1. A program should undergo appropriate evaluation prior to use of clinical practice. It

should perform efficiently at an acceptable financial and timeframe cost.
2. Adequate training and instruction should be completed before proceeding to the
implementation.
3. A qualified health professional should be assigned to handle concerns regarding
uses, licenses, and other concerns. The software systems‟ applications should not
replace functions such as decision-making.

Information systems store patient‟s records that can be retrieved when needed. These
records assist in the dispensation of health care or other supplementary services which are part
of health informatics. Health informatics is guided by health information ethics defined as the
application of the principles of ethics in the domain of health informatics. The three main
aspects of information ethics are general, informatics, and software ethics (Samuel & Xaiane,
2014).

General Ethics

In public health, general ethics guide the reasoning and decision-making of all people
and organization involved in health care. Two of the ethical principles a health professional must
uphold are autonomy and beneficence and non –maleficence.

1. Autonomy
Autonomy is defined as the idea of either allowing individuals to make their own
decisions in response to a particular societal context, or being free from external
influence or control. Electronic health records (EHR) must maintain respect for
 patient autonomy, and this entails certain restrictions about the access, content, and
ownership of records. A compromise must be reached between levels of patient
autonomy and quality of patient records. When patients are given too much control
over their EHRs, this could defeat the purpose of the use of such document because
critical information might be modified or deleted without the knowledge of the health
professionals. Limiting patient access and control over patient records improves
document quality because patients can also verify their own records (Mercuri, 2010).
2. Beneficence and Non-maleficence
These two principles are respectively defined as do good and do no harm. In
health informatics, beneficence relates most significantly with the usage of stored
data in the EHR system, and non-maleficence with how the stored data is protected.
Deeply integrated EHR systems will contain substantial amounts of raw data, and
great potential exists for the conduct of groundbreaking biomedical and public health
researches. These kinds of research will be beneficial to both the individual patient
and the society. With this in mind, new EHRs systems should be developed with the
capacity to allow patients to release information from their EHRs which can be
valuable to researchers and scientists. Similarly, the available consolidated data from
clinical data repositories will allow health care professionals to provide the best
possible treatment for their patients, further upholding the principle of beneficence.
However, the integrated data storage in health informatics is also a breeding
ground for varying threats. Temporary outages, at a minimum, might prevent health
care professionals from performing necessary procedures. At worst, it could even
result in significant patient mortality. Total system failures, however, may cause even
greater damage. In order to avoid these instances, all data must have multiple back-
ups for fast and easy recovery. Since medical records contain very sensitive
information about an individual, the highest level of data security possible should
also be upheld. Vulnerabilities in security put patients at a risky position, and might
ultimately lead to the violation of the principle of non-maleficence (Mercuri, 2010).

Information Ethics

Information ethics is about the ethical behavior expected from an individual assigned to
handle information as prescribed by the International Medical Informatics Association (2016). It
follows seven principles:

1. Principle of Information-Privacy and Disposition

Everyone has the fundamental right to privacy. Every individual should ensure
that he or she has control over the collection, access, use, communication,
manipulation, storage, linkage, and disposition of data about himself or herself.
2. Principles of Openness
The control measures of particular data should be disclosed to the concerned
individual in an appropriate and timely fashion.
 3. Principle of Security
Legitimately collected data should be protected through all appropriate measures
against access, use, modification or communication, manipulation, linkage, loss,
degradation, and unauthorized destruction.
4. Principle of Access
Authorized individuals should be given access to electronic health records and
the right to correct the data with respect to their completeness, accuracy, and
relevance,
5. Principle of Legitimate Infringement
The right to privacy and control over personal data should be conditioned by the
appropriate, legitimate, and relevant data-requirement of a democratic society and by
the equal rights of others.
6. Principle of the Least Intrusive Alternative
Any infringement of privacy rights should occur in the least intrusive manner and
with the least amount of interference with the rights of the affected parties.
7. Principle of Accountability
Any infringement must be justified to the concerned individuals in a timely and
appropriate fashion.

Software Ethics

Health informatics ethics relies on the use of the software and process information. It
follows that the activities carried out by the developers might affect the end-users. Therefore,
software ethics is the ethical duties and responsibilities of software developers to the
stakeholders (society, institution and employees, and the profession). They should execute all
system activities with the best interest of the society in mind. They should disclose any threats
or known defects in the software. They should ensure that completed activities serve the best
interests of the institutions and its employees. They should be straightforward about their
personal limitations and qualifications. Finally, they must build products that meet the
professional standards through testing and detailing unresolved issues. In support of the
mentioned responsibilities of software developers, the management should require ethical
approaches in software development (Samuel & Zaiane, 2014).

Privacy, Confidentiality, and Security

Privacy and confidentiality are often used interchangeably, but they are not synonymous.
Privacy generally applies to individuals and their aversion to eavesdropping, whereas
confidentiality is more closely related to unintended disclosure of information. For example,
someone who is spying on a certain person to find out about his or her visit to an acquired
immunodeficiency syndrome (AIDS) clinic is a violation of that person‟s privacy. On the other
hand, if someone breaks into the clinic to view an individual‟s patient record, that is in violation
of confidentiality.
 There are numerous significant reasons to protect privacy and confidentiality. First,
privacy and confidentiality are widely regarded as rights of all people which merit respect
without the need to be earned, argued, or defended. Second, protection of these rights is
ultimately advantageous for both individuals and society. Patients are more likely to be
comfortable to share sensitive health care data when they believe this information would not be
shared inappropriately. This kind of trust essentially establishes a successful physician-patient
or nurse-patient relationship, and enables the practitioners to perform their jobs better.
Furthermore, the protection of privacy and confidentiality benefits the public health. When
people are not afraid to disclose personal information, they are more inclined to seek out
professional assistance which helps in diminishing the risk of increasing untreated illness and
spreading infectious diseases (Goodman, 2016).
When patients trust medical professionals and health information technology enough to
disclose their health information, the latter will have more holistic view of patients' overall health
and both health care professional and patient can formulate more informed decisions. In
circumstances in which breaches of privacy and confidentiality occur, serious consequences for
the organization await, such as reputational and financial harm, or personal harm to patients.
Poor privacy and security practices heighten the vulnerability of patient information and increase
the risk of successful cyber-attacks (USA Department of Health and Human Services, 2015).
In summary, the idea that physicians should hold health care information in confidence
should be applicable no matter what the circumstance. The obligation to protect privacy and to
keep health information confidential fall on system designers, maintenance personnel,
administrators, and, ultimately to the physicians, nurses, and other frontline users of the
information. The protection of privacy and confidentiality is non-negotiable because it is a duty
that does not fluctuate (Goodman, 2016).

Levels of Security in Hospital Information System

Safeguards are the solutions and tools which may be utilized to implement security
policies at different levels of health organization. At the administrative level, they may be
implemented by the management as organization-wide policies and procedures. Mechanisms
can be put in place to protect equipment, systems, and locations at the physical levels, while
automated processes to protect the software and database access and control can be
implemented at the technical level. Examples are enumerated in Table 14.1 below, as
discussed by the USA Department of Health and Human Services.
It is important to note that the types of safeguards may be prescribed or restricted by
law. Another important consideration is the cost-benefit principle. If it is not cost effective for an
institution to avail of an expensive technology to mitigate a risk to electronic health information,
an alternative is to require the staff to follow a new administrative procedure that equally
reduces the risk. Conversely, if an institution cannot afford to place additional burden on the
staff due to possibilities of human error, it may choose to purchase a technology that automates
the procedure in order to minimize the risk.
Regardless of the type of safeguard (Table 14.1) choses to be implemented, it is
important to monitor effectiveness and regularly assess the health IT environment to determine
if new risks are present.
Table 14.1 Administrative, Physical, and Technical Safeguards for HIS
 Regular risk assessment of the health IT
environment
 Continuous assessment of the
effectiveness of safeguards for
electronic health information
 Detailed processes and procedures for
viewing and administering electronic
Administrative Safeguards health information
 Training for the users of health IT to
appropriately protect electronic health
information
 Reporting of security breaches (e.g., to
those entitles required by law or
contract) and continued health IT
operations
 Placing office alarm systems
 Locking offices and areas that contain
Physical Safeguards computing equipment that stores
electronic health information
 Having security guards that make
regular rounds in the vicinity
 Configuration of computing equipment
to ensure security (e.g., virus checking,
firewalls)
 Using certified applications and
technologies that store or exchange
electronic health information
 Setting up access controls to health IT
Technical Safeguards
and electronic health information
 Encryption of electronic health
information
 Regular audit of the health IT operations
 Having backup capabilities (e.g., regular
backups of electronic health information
to another computer file server)
Source: Reassessing your security practices in a Health IT environment: A guide to small health care
practices (Office of the National Coordinator for Health Information Technology, n.d.)

The National Research Council (1997) emphasizes that technological security tools are
essential components of modern distributed health care information systems, and that they
serve five key functions:

1. Availability – ensuring that accurate and up-to-date information is available when

needed at appropriate places
2. Accountability – helping to ensure that health care providers are responsible for
their access to and use of information, based on legitimate need and right to know
 3. Perimeter Identification – knowing and controlling the boundaries of trusted access
to the information system, both physically and logically
4. Controlling Access – enabling access for health care providers only to information
essential to the performance of their jobs and limiting the real or perceived
temptation to access information beyond legitimate need
5. Comprehensibility and Control – ensuring that record owners, data stewards, and
patients understand and have effective control over appropriate aspects of
information privacy and access

Levels of Security in the Laboratory Information System

McPherson and Pincus (2017) narrate the following flow of information, described in
Table 14.2, in a specific portion of the hospital information system, that is, the laboratory
information system.
Table 14.2 Key Steps in Laboratory Information Flow for a Hospital Patient

Step Description
The patient record (e.g., ID Number,
name, age, sex, location) must be
created in the LIS prior to the test(s). The
Register Patient LIS usually receives these data
automatically from the hospital
registration system when a patient is
admitted.
The attending physician orders the tests
for patient and the procedure is
requested as part of the laboratory‟s
Order Tests
morning blood collection rounds. These
orders are entered into the CIS and they
are sent to the LIS electronically.
The LIS prints a list of all patients who
have to be drawn which also includes the
appropriate number of sample barcode
labels for each patient order. Each
barcode contains the patient ID, sample
contained, and laboratory workstation
which is used to sort the tube once it
Collect Sample
reaches the laboratory. An increasingly
popular approach is for caregivers or
nurses to collect the blood sample.
Sample barcode labels can be printed (on
demand) at the nursing station on a LIS
printer or portable bedside printer prior to
collection.
 Once the sample arrives in the
laboratory, the status is updated in the
LIS from “collected” to “received.” This is
done by scanning each sample
Receive Sample container‟s barcode ID into the LIS. Once
the status becomes “received,” the LIS
then transmits the test order to the
analyzer that will perform the required
test.
The sample is loaded to the analyzer,
and the barcode is then read. No work list
is needed because the analyzer knows
what test to perform from order provided
by the LIS. However, when tests are
Run Sample performed manually, the technologist
prints a work list from the LIS. The work
list should contain the names of the
patients and the tests ordered on each
and next to each test is space to record
the result.
The analyzer then produces the results
and sends the same to the LIS. The
result is only viewable to the assigned
technologists until it is released for
general viewing. The LIS can also be
Review Results
programmed to flag certain results-for
example, critical values-so the
technologist can easily identify what
needs to be repeated or further
evaluated.
The technologist is responsible for the
release of the results. Unflagged results
are reviewed and released at the same
time. The LIS can be programmed to
automatically review and release normal
Release Results
results or results that fall within a certain
range. This approach reduces the
number of tests that a technologist has to
view. The results are automatically
transmitted to the CIS upon release.
The physician can now view the results
Report Results on the CIS screen. Reports can be
printed when needed.

The aforementioned principles regarding administrative, technological, and physical

safeguards can be applied similarly to the laboratory information system in order to improve its
security. Examples are listed in Table 14.3.
Table 14.3 Administrative, Physical, and Technical Safeguards for LIS

 Continuous training for the users of

the LIS
 Periodic review of standards used to
identify results that should be flagged
 Review of the authorization and
supervision policies
 Strict implementation of the rules and
Administrative Safeguards regulations for the testing procedures
 Release and dissemination of
guidelines on the proper disposal of
laboratory specimen
 Enforcement of strict policies on the
proper use of laboratory workstations
 Requiring appropriate disciplinary
measures as needed
 Ensuring the periodic maintenance of
laboratory equipment
 Having biometrics or other security
measures for laboratory access
 Maintenance of controlled
Physical Safeguards temperature both for equipment and
specimen
 Presence of contingency operations
plan
 Use of appropriate personal
laboratory safety equipment
 Presence of automated identity
confirmation procedures for users
requesting access
 Regular updating of passwords
Technical Safeguards  Requiring different authorizations
based on user level
 Capacity of the unit to automatically
log-off after a specified period of
inactivity

Philippine Data Privacy Act of 2012

Business process management, particularly involving health information technology, is
an increasingly growing industry within the Philippine economy. With total IT expenditure
reaching $4.4 billion in 2016, the industry is forecasted to go beyond doubling itself by 2020. In
addition, Filipinos utilize social media heavily, with a whopping 3.5 million users on LinkedIn, 13
million on Twitter, and 42.1 million on Facebook (Wall, 2017).
Given the rapid evolution of the digital economy and heightened international data
trading, the Philippines has decided to strengthen its privacy and security protection by passing
the Data Privacy Act of 2012, with an aim “to protect the fundamental human right of privacy of
communication while ensuring free flow of information to promote innovation and growth”
(Republic Act No. 10173, Ch. 1, Sec 2).
The Act applies to individuals and legal entities that are in the business of processing
personal information. The law applies extraterritorially, applying both to companies with offices
in the Philippines and even those located outside that use equipment based in the Philippines. It
covers personal information of Filipino citizen regardless of the place of residence. The main
principles that govern the approach for this Act include transparency, legitimacy of purpose, and
proportionality.
Furthermore, in the Data Privacy Act of 2012, consent is one of the major elements
highly valued. The Act provides that consent must be documented and given prior to the
collection of all forms of personal data; and the collection must be declared, specified, and used
for a legitimate purpose. In addition, the subject must be notified about the purpose and extent
of data processing, with derails specifying the need for automated processing, profiling, direct
marketing, or sharing. These factors ensure that consent is freely given, specific, and informed.
However, an exception to the requirement of consent is allowed in cases of contractual
agreements where processing is essential to pursue the legitimate interests of the parties,
except when overridden by fundamental rights and freedom. Such is also the case in
responding to national emergencies.
Processing of sensitive and personal information is also forbidden, except in particular
circumstances enumerated below. The data policy act of 2012 describes sensitive personal
information as those being

 about an individual‟s race, ethnic origin, marital status, age, color, and religious,
philosophical, or political affiliations,
 about an individual‟s health, education, genetic or sexual life of a person, or to any
proceeding or any offense committed or allegedly committed,
 issued by government agencies “peculiar” (unique) to an individual such as social
security number, and
 marked as classified by an executive order or act of congress.

The exceptions are

 consent of the data subject,

 pursuant to law that does not require consent,
 necessity to protect life and health of a person,
 necessity for medical treatment, and
 necessity to protect the lawful rights of data subjects in court proceedings, legal
proceedings, or regulation.

The provisions of the law necessitate covered entities to create privacy and security
program to improve the collection of data, limit processing to legitimate purposes, manage
access, and implement data retention procedures.
The act provides for different penalties for varying violations, majority of which include
imprisonment. These violations include:

 unauthorized processing,
  processing for unauthorized purposes,
 negligent access,
 improper disposal,
 unauthorized access or intentional breach,
 concealment of breach involving sensitive personal information,
 unauthorized disclosure, and
 malicious disclosure .

Any combination or series of acts enumerate above shall make the person subject to
imprisonment ranging from three years to six (6) years, and fine of not less than one million
pesos (₱1,000,000.00) but not more than five million pesos (₱5,000,000.00) (Republic Act No.
10173, Ch. 8, Sec. 33).

Key Points to Remember

 Health informatics ethics is the application of the principles of ethics to the domain of
health informatics. There are three main aspects of health informatics ethics; general
ethics, information ethics, and software ethics.
 General ethics covers autonomy, beneficence, and non-maleficence.
 Informatics ethics refers to privacy, openness, security, access, infringement, least
intrusion and accountability.
 Software developers should consider the best interest of the society in general, the
institution and its employees, and the profession.
 Administrative, physical, and technical safeguards are placed to regularly monitor
effectiveness and assess the health IT environment.

LESSON 15: Change Management in Health Informatics

Change Management
Generally, there are four kinds of changes that all kinds of organizations might
encounter, with the likelihood of overlap among the conceivable outcomes.
a. Operational changes can influence the way dynamic business tasks are led, including
the computerization of particular business segment.
b. Strategic changes occur when the business direction, in relation to its vision, mission,
and philosophy is altered. For instance changing the business technique from growth to
increasing market share in the overall industry is a case of strategic change.
c. Cultural changes influence the internal organization culture, for example the way the
business is conducted such as actualizing a CQI (continuous quality improvement)
framework.
d. Political changes in human resources occur primarily due to political reasons of varying
types, commonly changes that happen on top patronage levels in the government
agencies.
 Different sorts of changes typically have dissimilar impacts on different organizational
levels. Operational changes tend to have highest impact on lower organization levels and
mostly affect frontline employees. Employees working at the upper levels might be indifferent to
the changes which may cause significant distress to those attempting the implementation of
change.
Conversely, the effect of political changes is more strongly felt on the higher levels of
organization. When changes occur relatively in bureaucratic organization, those working in the
bottom level often notice the change at the top (Lorenzi & Riley, 2000).
There is no denying that organization changes have varying degrees of impact on both
the organization and in effect, its clientele. This lesson discusses change management
contextualized in health informatics which is increasingly becoming course of action that health
institutions avail in order to improve their services.
Changes are inevitable especially in organization because they need to evolve to meet
the demands of the stakeholders which include global competition, changes in customer
demand, technological advances, and new legislation.
Organization may even change the way they operate in order to cope with the demands.
Redefining roles, eliminating ineffective processes, or initiating new ways of working are
considered minor adjustments. Conversely, there are times when pressures necessitate major
disruption which transform the culture, reorganize people, processes and systems and change
the organization‟s strategy radically.
For more than 100 years, change management has been evolving with its beginnings
rooted I health and job-related grief studies. Currently, most change management processes
which are designed to drive business transformations draw their inspiration from behavioral and
social sciences and IT, and business solutions.
A survey on change management conducted in 2007 involving over 400 senior HR
managers in the US revealed the following reasons behind the percentages of organization
implementing or planning change over the previous two years:

 New performance management process (58%)

 Relocation or facility closure (57%)
 Organizational culture changes (54%)
 New IT systems (51%)
 Change of strategy (45%)
 New financial/accounting systems (41%)
 Downsizing, layoffs (40%)
 Operational changes resulting from new legislation, economic conditions, or
national/international events (30%)
 Product rebranding (26%)
 Acquisition (25%)
 Off shoring or outsourcing (16%)
 Merger (10%)
 Corporate ownership change (8%).
 Meanwhile in the health care industry, the following are factors that contribute to the
changes:

1. Regulatory adjustments
2. Shifts in consumer behavior patterns
3. Accelerated pace of IT development

Health care consumers want a more customized experience and greater opportunity to
participate in their health care decisions. This means that heath care institutions need to adapt a
more innovative technology, implement an informed patient engagement strategy, and adjust
their organizational structures to drive better patient experiences which may result in numerous
and rapid changes (Quinn, 2017). However, technology alone is not enough. The truth of matter
is that no technology can be successfully implemented without the human factor which
intensities the work processes and gives the appropriate guidance. The need to find the right
balance between technology and human factor is necessary in the roadmap for organizational
changes.

Another vital element in change management initiatives is communication. Information

should be shared so the stakeholders would be advised about the timing, nature, and
importance of changes in the business. Participation from management is crucial to the
successful implementation of the planned changes. Any change can only be successful when
the employees are motivated towards the change and are willing accept the vision presented by
the organization‟s leadership (Aljohani, 2016).
Those organizations which are able to manage change well will definitely service and
thrive. This is basically the concept of change management. The managers need to direct
control, and monitor the changes to ensure that the objectives are met. They must ensure that
the employees adapt the change without disrupting the regular operations (Downy, 2008).
Change management process has a wide range of models with each model having its
own strategic approaches. The more common change practice examples include:
1. Kurt Lewin’s Unfreeze-Change-Refreeze model
This three-step model was proposed by Kurt Lewin, founder of social psychology
in the 1950‟s. This is still widely used as the basis for many change management
strategies.
2. Proski’s ADKAR model
This acronym means “Awareness of the business reasons for change; Desire to
engage and participate in the change; Knowledge about how to change; Ability to
implement change; and Reinforcement to ensure change sticks” (ADKAR).
3. Kotter’s Change model
This eight-step was developed by John Kotter of Harvard business school.
Building a strong collaborative team by using a solid strategy, creating effective
communication channels, supporting staff empowerment, using a phased and steady
approach, and securing the change within an organization‟s culture are the core
concepts of this method (Quickbase, 2017).
Application of Change Management
Change management is defined as a series of tools, techniques, and processes aimed
at successfully effecting change. These tools support the application of other initiatives such as
Six Sigma, Customer Relationship Management (CRM), Total Quality Management (TQM), or
Enterprise Resource Planning (ERP), but can be implemented in variety of contexts.
Downey (2008) enumerates the common tools and techniques that can be used during a
change initiative:

 Gathering information about the „as is‟ and „to be‟ status of the current process
 Mapping of the process for both „as is‟ and „to be‟ status
 Gap analysis
 Business care development
 Project management
 Problem solving
 Requirements elicitation techniques
 Negotiation skills

In addition, the progress of the change imitative can be measured against the objectives
set by the organization (Downey, 2008). The said objectives will be measures by the key
performance indicators (KPIs) which include reducing rework by x%, improving in stakeholder
satisfaction, for example, customer/employee surveys, reducing time to marker, enhanced
speed of delivery, and having good return on investment (ROI) which is total cost to implement
the initiative versus total savings gained from initiative per period.
In the world of health care, some hospitals are reluctant and indignant towards the idea
of change, and they find it difficult to adjust. Thus, health informatics hopes to change the way
health care institutions conduct their business on a daily basis. Health care providers need to
welcome change and approach information technology with an open mind. Aziz (2007)
emphasizes that mechanism for the transformation of business and clinical processes should be
in place. By encouraging the adoption of innovation in health care information technology by
clinicians, therapists, nurses, and physicians, health care providers can achieve key success
factors (Table 15.1).
Table 15.1 Key Success Factors

Key success factors at the leadership level

Key success factors at the program level
in health care programs
1. Setting the vision and strategy 1. Clear and timely dissemination of
roadmap for the organization. information.
2. Forming a governing body to set 2. Building a strong project leadership
direction and priorities, and to allocate team and other functional teams.
resources. 3. Providing proper training on the new
3. Designating of the organization‟s changes especially on the workflow
executive sponsor, departmental and technology.
champions, and program manager. 4. Forming integrated teams to address
4. Defining reporting requirements for the and resolve critical and complex
project. issues.
 5. Setting and managing the user‟s 5. Empowering staff and end-users to
expectations. improve the process by removing
barriers and obstacles.
6. Maintaining changes through by
positive reinforcement.
7. Frequent celebration of success by
acknowledging contributors thus
keeping the motivation and
momentum.
8. Monitoring and constant measurement
of key indicators (ex. using a
dashboard to report progress and
benchmarks)
9. Involving those who are affected by the
change in decision-making (ex, choice
of computer carts, COW)
10. Other creative actions and incentives
ex. monthly prizes for high performing
teams, providing snacks, and drinks

Working with Physicians

Most physicians have patients in multiple hospitals since they are non-hospital
employees. Systems of health institutions may differ from each other which complicates the
situation. Thus, they should have clear cut adoption methods to avoid any issues. Azis (2007)
lists some ideas for the success of the transformation.
1. Communicate patiently the benefits of the changes in terms of patient care and safety.
2. Nominate physician leaders at the start of the program.
3. Use web, CBT, and other multi-channel learning and training opportunities.
4. Be ready and available to answer questions and clarifications.
5. Make sure that there is a process in place in handling enhancement requests and
developments.

Training and Education in Health Informatics

Below is list of practices that emphasize life-long learning in support of the change
management that must be initiated by the leaders of the organization (Aziz, 2007).

1. Provide instructor-led training classes to cover different shifts.

2. Present contemporary models of training.
3. Make computer laboratories available for practice 24/7.
4. Roll out accompanied by on-the-job/real-time training.
5. Summarize the steps and make cheat sheets handy.
6. Print easy to carry colorful booklets in a pocket.
7. Provide a short manual with key facts and how to tips.
 8. Have well equipped training rooms.
9. Schedule train the trainer program to give enough time to practice.
10. Assign a super-user to keep people involved.
11. Provide the business process maps and process workflows.
12. Prepare a day in the life scenario for the stimulation.
13. Walk them through the flow several times until they are able to adapt.
14. Entertain and answer questions clearly and provide details.
15. Prepare the users by discussing some of the challenges and frustrations they might
encounter in the early stages of the rollout.

Enumerated are the fundamental practices that management needs to embrace as its
well-rounded strategy (Aziz, 2007).

1. Align business leaders with clinical leaders by creating a governance structure.

2. Focus on the process design and map the workflow clearly.
3. Have due diligence to ensure a thorough organizational and business impact analysis.
4. Encourage the involvement of clinicians at various levels at the start of the project.
5. Show commitment by staying on the course and communicating the objectives clearly.
6. Have a strong program customized to address different needs.
7. Get feedback into the loop and work on it.
8. Have 24 x 7 help desk to ensure that the program is well structures and has ample
support.
9. Select a couple of measurement criteria for benchmarking and system evaluation.

Health Information Profession

Roles of Health Information Management Professionals
Health information management (HIM) professionals have special skill set that
qualifies them to assume the role of privacy and security officers who take care of the storage,
protection, and maintenance of the information in the health care institutions. This is coupled
with their academic preparations experiences in the health sector and commitment to advocacy
of patient care and professional code of ethics (May, 2014).
HIM professionals should be committed to the timely and accurate collection and
management of data which cover the aggregation, analysis, and dissemination of patient health
information. They manage the said information and medical records, administer the computer
information systems, and standardize the coding systems for the diagnoses and procedures of
the services provided to patients. Such information is kept secure and private in accordance
with the state laws.
A career in health information management and health information technology is not
limited to data capture, documentation, and maintenance of clinical information but also includes
data analytics and interpretation, and management of the health information technology
systems.
 HIM professionals may fall into various job categories with carried titles including:

1. Health information management department director

2. Health information management system manager
3. Information security officer
4. Chief privacy officer
5. Health data analyst
6. Health record technician specialist
7. Clinical coding specialist
8. Patient information coordinator
9. Physician practice manager
10. Health information administrator
11. Revenue cycle specialist
12. Director of quality management
13. Health information manager
14. Health information technologist/technician

These professionals also ensure that a patient is billed accurately and assure that the
accumulated health care information is compiled and analyzed to assist in making
recommendations that can improve the health care services. They are also expected to devise
policies that address concerns on the delivery of high quality health care and the availability of
quality information for decision making (May, 2014).

Philippine Health Information Profession

Advancements in ICT (Information and communication technology) are upsetting not
only for traditional businesses, but even those not immediately though of probable beneficiaries
such as the health care sector. From electronic patient records to wireless transmittal of patient
files for remote diagnosis, improvements in communication and technology will lead to better
delivery of health care services. Telemedicine, or the use of electronic communications to
transmit and exchange medical information and data to provide patient treatment is quickly
gaining information within the country and the rest of the ASEAN region.
With the increasing popularity of smart phones, wireless tools, and other comparable
technology primary care and specialist referral services, as well as remote patient monitoring
and patient medical health information are undeniably improved with the help of telemedicine.
Thailand, Singapore, and Malaysia have started adopting health care IT solutions to bring the
sector to the next level. In 2009, Singapore developed its National Electronic Health Record
initiative, which permitted health care practitioners in the country to access patient‟s records
across the health care continuum. Malaysia initiated a Hospital Implementation System in 1993,
with its first telemedicine project in 1996, and Thailand created its national health information
committee in 2010.
Likewise, the Philippines has developed an e-Health strategic framework and plan for
2014 to 2020 whose objective is to utilize information and communication technologies inn
health sector. This will assist in the delivery of health services and manage health systems for
greater efficacy, with the ultimate goal of providing universal health care for the Filipinos. One of
the strategic goals of this framework is to establish unified and coherent health and
management information systems, to take advantage of ICT to reach and provide better health
services, and support the attainment of the UN‟s sustainable development goals. In line with
this, the department of health in region IV-B has launched the first interactive telemedicine
system in Marinduque, and seemingly the entire country at the Dr. Damian J. Reyes Provincial
Hospital. The system currently provides medical consultations and diagnostics through video
calls (De Dios, 2016).

Telemedicine in the Philippines

For an archipelago such as Philippines, the delivery of health care services might be
proven to be challenging. Fortunately, the rise of the telemedicine within the region has been a
beneficial turns of events for the Philippine health care sector.
Multiple players in telemedicine scene currently exist, ranging from mobile apps to call
center services. Some providers of over the phone telemedicine services are Medgate and
Lifeline. Common features include 24/7 call centers, diagnosis using images sent via email,
medical certificates, and treatment plan summaries. Telemedicine centers usually have
corresponding mobile app to facilitate easier access. Unique to lifeline, however, is video
consultation with doctors, patient education, free doctor or nurse home visits, and delivery of
medication and prescriptions in exchange for fixed monthly subscription fee.
Mobile app based telemedicine centers, include MyPocketDoctor and MyDocNow. These
providers are usually in partnership with other international telemedicine centers. Medway
Healthcare Inc. offers the most comprehensive telemedicine services by using telefollow up
and teleconsultation procedures. These applications are accessible online. It is first medical
clinic in the Philippines which mobilized the pre-employment medical examination (PEME).
Telefollow-up is a specialized application which notifies patients of the medical
evaluations results via text messages. Patients will know the status if they are fit to work or still
have pending workups within 24 hours of PEME. On the other hand, follow-up teleconsultation
takes care of online communication between the patient and other physician regarding the
follow up of medical results when the patient is unavailable to get the results personally. The
physician gives the necessary advice and schedules.
The specialist teleconsultation is also available which gives way to consultation despite
distance barrier. This application enables real-time consultation with physician with the
assistance of nurse and utilization of the appropriate telemedicine equipment. If the specialist
needs to listen to patient‟s breathing, nurse would place the telephonic stethoscope on the
appropriate areas of patient‟s body and the sound would then be transmitted back to specialist.
The equipment uses high-definition cameras to focus on lesions or specific body parts. As for
the test results, they are transmitted by using store and forward technology if real time option is
not available.
The government pioneered nationwide telemedicine efforts through research and
service work of the National Telehealth Center (UP-NTHC) of the University of the Philippines-
Manila and funding from the Commission on Information and Communication Technology
(CICT). It implemented the Buddyworks Telehealth project from 2004 to 2007. This uses a web-
based and SMS-based telehealth platform. Subsequently, the Department of Health, funding
from 2011 to 2014 and Department of Science and Technology (DOST 2007 to present)
supported the UP-NTHC‟s continuing telehealth program expanding its geographic scope and
telehealth innovations. From initial 10 isolated and disadvantaged sites, it grew to link over
thousand young doctors with clinical specialists based in the UP-Philippine General Hospital
and regional hospitals of the Cordillera Administrative Region and Eastern Visayas to support
them in their clinical decision making. Other DOH regional hospitals are being prepared by the
UP-NTHC to become telehealth hubs in the locale.
The RxBox diagnostic telemedicine device was incorporated in the government
telehealth program through DOST‟s support. The first version was developed in 2007 by Dr.
Alvin Marcelo and Dr. Luis Sison of UP-NTHC and UP Engineering in Diliman, respectively. The
RxBox device included sensors that can measure blood pressure, pulse-rate, temperature, and
even an electrocardiogram. Dr. Marcelo, a trauma surgeon, envisioned that RxBox would be
used in ambulances transmitting a patient‟s clinical parameters via telehealth to prepare better
the emergency room clinicians to receive these critical patients. Dr. Sison continue to develop
the second version beginning 2012, this time Dr. Portia Fernandez-Marcelo. They added
sensors that will detect fetal heart beats and the pregnant woman‟s uterine contractions and
envisioned its use in rural health units. The objective was to equip these rural centers with
lifesaving diagnostic tools and better manage health information. Clinical data gathered by the
RxBox is exchanged with the community health information tracking system (CHITS) electronic
medical records system, in the event of clinical dilemma, data can be pulled from CHITS and
transmitted to specialists for teleconsultation. In the latter part of 2018, the seamlessly linked
systems of RxBox, CHITs and telehealth will be implemented in 1,000 rural municipalities and
with medical specialists in all regions nationwide.

Key Points to Remember

 Change is inevitable and pervasive. Organizations are driven to change in order to

respond to the many pressures they encounter from their environment. These pressures
include global competition, changes in customer demand, technological advances, and
new legislation.
 Change management is a series of tools, techniques, and processes aimed at
successfully effecting change.
 Health information management (HIM) professionals, credentialed with their academic
preparations, work experience, and commitment to patient advocacy and professional
code of ethics, have a specialized skillset that uniquely qualifies them to assume the role
of both privacy of officials and/or security officials who store, protect, and transmit
information in all media and formats.
 One of the strategic goals of the e-Health Strategic Framework and Plan for 2014-2020
is to establish unified and coherent health and management information systems to take
advantage of ICT to reach and provide better health services, and support the
attainment of the UN‟s Sustainable Development Goals.
 Telemedicine efforts from the government and other non-profit organization have also
ensued. The National Telehealth Center is the leading research unit in the University of
the Philippines responsible for developing cost effective tools and innovations in the
realm of information and communications technology (ICT) for improving health care.