HOSPITAL INFORMATION SYSTEM (HIS)

Dr Abdollah Salleh,
MBBS (Malaya), Diploma of Fellowship RCS Edinburgh, RCPS Glasgow,
Health Information Management Consultant,
Life Member Malaysian Society for Quality in Health, Malaysia,
Honorary Academician, Medical Faculty, UITM, Malaysia,
Former Consultant General Surgeon, Ministry of Health Malaysia,
Former Clinical-IT Coordinator Hospital Selayang, Malaysia.
e-mail: [email protected]
website: drdollah.wordpress.com

1 INFORMATION SYSTEMS IN HEALTH CARE

Information systems facilitate the activities of planning, management and delivery of health care
services at many levels. The main area discussed in this website is Hospital Information System
(HIS) and perhaps a bit regarding Telehealth plus some aspects of links of the HIS to Community
health systems.

2 HOSPITAL INFORMATION SYSTEM (HIS)

An information system that facilitates the activities of a hospital takes into consideration:
01. the functions of a health care facility
02. the capability of information technology

The information management system complements the other components of the very complex
organizational structure and operations of a hospital. Its scope, content and structure serve a
myriad of functions. It contains a set of sub-systems and applications that utilizes information
technology and computerization optimally to facilitate the delivery of services of the hospital.

In general, the various functions and services that can be facilitated by information systems can
be divided into two main group of activities:

01. The core business of care of patients

02. Managing the hospital as a business entity, a provider of hospitality services and a
physical facility

The set of fully integrated hospital-wide information systems that support the activities is called
the Hospital Information System (HIS). It is focused primarily on the Operations Management of
the hospital. However, data available from the system may be collated, analyzed and used for
strategic or project management and research. The HIS is envisaged as consisting of two broad
systems i.e.

01. Patient Care Information System

02. Managerial Information System

Hospital Information System (HIS)

Information System for Patient Care Functions Managerial Information System

 The division into these two broad categories is conceptual. The information system that supports
administrative, human resource, facility and hospitality management activities are placed
arbitrarily under the Managerial Information System. Articles in this website deals mainly with the
Information Systems for Patient Care Function, i.e. the core business activity of a hospital..

2.1 CONTRIBUTIONS TO OTHER HEALTH INFORMATION SYSTEMS

The Hospital Information System should be capable of sharing patient data with other health care
institutions so as to enable continuity of care via the Telemedicine approach or other means. It is
expected to contribute to the national health database (in Malaysia: the National Health-
Management Information System) by supplying information for health promotion, disease
prevention and early detection efforts as well as for planning, resource allocation, epidemiology,
case-mix calculations etc. at district, state and national level. It should also provide information to
systems belonging to third party institutions e.g. external agencies like the Drug Safety Council,
Registration Department, Road Safety Council, the Police, Insurance companies and many others.

2.2 HOSPITAL INFORMATION SYSTEM : CHARACTERISTICS

A Hospital Information System can be designed and built in-house from the outset or purchased.
Either way, the suite of applications software and databases need to be assessed or appraised to
determine suitability for use before being made available to intended users. Systems purchased
off the shelf, need to be customized to suit the hospital’s services, policies, procedures and
equipment. On the other hand, some compromises in the existing processes may be required.
The data structure needs to be elucidated by defining entities, relationships and naming of data
elements and possible values attributed to each data element. This is achieved through the
activity of Business Process Re-engineering, Customization and Database Design. User
Acceptance Testing should be thorough; initially on a TEST version of the system in a simulated
Operations environment, and subsequently on the actual Operations Version. After
implementation the system has to be appraised continuously and improved upon if necessary.
Where legacy systems are retained they should be aligned with the structure and arrangement of
the new HIS. A difficult issue is data migration. Success depends on ensuring technical
compatibility as well as semantic consistency between the new database with the old data such
that the data can be migrated into the new database and is accessible through the new
applications. Data migration is discussed in a separate section.
Some devices and instruments may need to be replaced or new ones added to enable interfacing.
There will be definite changes in the way data is collected because this needs to match with the
data structure, collection and presentation used by the system.
An important aspect of the design of the system is the use of standard naming conventions of
services, locations, care provider categories, visits, encounters and events. These static data
elements are made available in reference tables.
The data structure needs to be designed by defining entities, relationships and naming of data
elements and possible values attributed to each data element. This is achieved through the
activity of Business Process Re-engineering, Customization and Database design.

2.3 SYSTEM INTEGRATION

The information systems and applications are usually considered to consist of modules for ease of
description. Each module may have its own subsystem or the various modules may be shared in a
virtual server. It is expected that the Hospital Information System is fully integrated so as to
function seamlessly across modules. Integration refers to the interaction between applications
software with each other and with the hardware that supports it, enabling one to work with
another for a desired purpose. Poor integration often make it necessary for the user to go
through extra steps to complete a task and also slows down the system response time. A
substantial part of integration is the interfacing of information system computers with computers
of hardware (machines, measuring apparatus and etc.) enabling them to engage in transfer and
retrieval of data or instructions. Integration can be achieved at the stage of:
 A. HIS design
B. Implementation

It would be desirable to design or procure a HIS that have been fully integrated from the start and
where the modules and sub-systems are proven to interact smoothly with acceptable response
time and ease of use. Trying to integrate disparate applications software with different data
structure and using different operation systems at the time of implementation would be an
unenviable task. Integration usually involves two or more parties. Sharing out of responsibilities,
agreeing on a schedule and assigning costs are issues that can pose a stumbling block to speedy
and successful implementation.

Another important consideration is the coordination between services and units within the
hospital so that the each module takes into consideration differences in their policies and
procedures. It would be desirable for these policies and procedures to be made complementary,
uniform and standardized. Minor variations can be allowed.

2.4 ENABLING AND ENHANCING COMMUNICATIONS

Communications between users of the system especially care providers is of paramount
importance. Various approaches and means can be used to facilitate and enhance
communications. The main method is through the sharing of information. This is achieved if data
generated by each user is placed in a common database and then made available to others
through tailored views and displays. Instructions, orders and reminders can be placed in the
individuals users in-box. Messages can be relayed from the information system to users via both
internal and external communications systems and devices such as computers (in-boxes, e-mails
via intranet and internet), electronic white boards and mobile phones. Communications with
patients can be through the same means, interactive kiosks and through web portals

3 INFORMATION SYSTEM FOR PATIENT CARE

The Hospital information System (HIS) can be broadly divided into two halves:

01. The Systems for the Patient Care Function

02. The Managerial Information Systems

The clinical and other functions relating to the care of a patient is facilitated by a set of systems
which can be given a generic name of Information Systems for the patient care function. The
term Patient Care Information System is attractive and acceptable but, unfortunately, is used
only by small number of advocates. This term will be used in all subsequent discussions here
because this extra category level clarifies the nomenclature of systems. The entire system is made
up of sub-systems each of which can be discrete and seldom integrated when built. The term
Clinical Information System (CIS) should not be used to mean the whole Information Systems for
patient care. The name CIS should be confined to the system that facilitates or supports direct
patient care functions. Another commonly used term is 'EMR/EHR Systems'. This should not be
used at all because information systems are useful only if they facilitate work rather than "the
creation, storage, and organization of electronic medical records" as understood by some.

3.1 OBJECTIVES & FUNCTIONS OF PATIENT CARE INFORMATION SYSTEM

Being a system for facilitating operations, these set of sub-systems and applications are expected
to utilize information technology and computerization optimally to realize the following
objectives:
a. Productivity
b. Effectiveness
c. Appropriateness
d. Efficiency
e. Quality
f. Safety
To achieve the above objectives, the computerized information system provides the following
functions:

01. Guide and enable the performance of Patient Care Processes

02. Facilitate communication between care providers through sharing of information
03. Enable automation of work processes through links within it, integration with other
components of the hospital information system and interfacing with other computers,
machines, printers and scanners.
04. Provide clinical decision support at point of care
05. Gather, store and make available vital clinical information (individual and aggregated)
for primary and secondary use
06. Maintain a permanent record of events and all activities of patient care (as the Electronic
Medical Record and other documents based on medico-legal requirements)

Any system being designed, proposed or implemented must possess characteristics that would
fulfil all the above objectives and functions; both in its content and the methods used.

3.2 SCOPE, CONTENT & RELATIONSHIPS OF PATIENT CARE INFORMATION

SYSTEM

The Patient Care Information System consists of:

1. Patient/Client Management (Administration) Information System

2. Clinical Information System (CIS)
o CIS for various specialties
o Clinical Documentation
o Clinical Decision Support
o Centralized Continuous Monitoring System
o Electronic Medical Record
3. Clinical Support Systems
o Laboratory Information System
o Blood Banking Information System
o Radiology Information System
o Pharmacy Information System
o Food and Beverage Supply System
o Operation Theatre / Suite Information System
o Sterilization and Sterile Inventory & Supplies System
o Other support systems
4. Bridging or intermediary systems
o Order Entry - Result Reporting System (CPOE)
o Patient Information Database Management System
5. Clinical Governance Systems
o Clinical Managerial Decision Support Application
o Quality and Productivity Management Application
o Infection Prevention and Control Application
o Clinical Data Extraction and Reporting Application
6. Supply of Data for External Organizations

The relationships of the systems are as depicted the chart below:

Relationships of HIS

For the sake of choosing the best of the breed it may be necessary to procure separate systems
or from different vendors e.g. for Systems for Clinical Support functions, the Charging-Billing-
Receipt of Payment Application and various clinical support systems. It is imperative that these
are demonstrated to be capable of full integration with the rest of HIS.

All the above systems are used by health care personnel to care for patients. Care is here defined
as all work activities to deliver services to patients in response to their needs.

3.3 INTEGRATION OF THE PATIENT CARE INFORMATION SYSTEM WITH THE

REST OF HIS

It is crucial that the Information System for the Patient Care Function is able to integrate with
other systems of HIS. It must support the activities of incident reporting, clinical epidemiology,
disease surveillance, quality management, utilization review, risk management and similar
functions. Due consideration must be given to areas where Management Information Systems
interact with the Information System for the Patient Care Function. Examples of such areas are
Charging and Billing, Human Resource deployment, Bed allocation and Food-Beverage services.

3.4 KEY BRIDGING APPLICATIONS

Integration within the Patient Care Information System is essential. The main patient care
applications software i.e. the Clinical Information System and the various Clinical Support Systems
are built around key bridging (intermediary) applications i.e.

1. Patient Administration/Management System (Registration, Scheduling, Resource

allocation)
2. Order-Entry Result Reporting Application (CPOE)
3. Database Management System (DBMS)
4. Electronic Medical Record

These applications are thought of and designed first and then amended as each clinical and
clinical-support application is designed. Any additional applications software is designed to be
compatible with these key bridging (intermediary) applications.
Chart Showing Bridging Role of Four Key Applications of the Patient Care Information System

The Patient Administration/Management System (PMS) supplies data to the Patient Information
Database from which the Electronic Medical Record (EMR) is derived, thus obviating the necessity
for identification and demographic data to be obtained repeatedly.

The Order Entry (CPOE) application acts as a means of communications between care providers
and the tool for planning, initiation, execution of processes and enabling charging-billing.

The Patient Information Database enables data generated by each user to be shared with others
through displays on the computer screen, printed material (documents & labels) or exported to
other communication systems.

The traditional function of the paper-based Medical Record is to make available historical data to
future clinical users for continuity of care and to non-clinical users for various valid purposes. In a
computerized environment, most of the functions of the paper record (i.e. the capture, storage,
distribution and communication of data) is taken over by the Patient Information Database. The
content and arrangement of data in the clinical applications and database need to take into
account of the legal and professional requirements of the Medical Record. A data extraction
application is then designed to generate the Electronic Medical Record.

4 MANAGERIAL INFORMATION SYSTEM

4.1 FUNCTIONS OF MANAGERIAL INFORMATION SYSTEM

The Managerial Information System refer to the set of sub-systems and applications that assist
managers in running the hospital as a:

 business entity
 provider of hospitality services
 physical facility
The term 'managerial' is generic and refers to a set of sub-systems useful for managers. It is used
here because other terms such as Management / Operations / Business / Enterprise Resource
Planning systems have their own usage.

4.2 COMPONENTS OF MANAGERIAL INFORMATION SYSTEM

Systems that support the business operations include:
1. General Administration Information System & Office Automation
2. Charging, Billing and Receipt of Payment (Accounting) System
3. Human Resources Management System
4. Finance and Budgetary Systems
5. Consumables Purchasing and Inventory System

Systems for facilitating the hospitality services of a hospital include:

1. Bed management
2. Food-Beverage Order-Supply System
Systems for management of the hospital as a physical facility include:
1. Facility Engineering Systems
2. Equipment and Machinery Maintenance and Inventory System
3. Environmental Safety, Housekeeping, Cleansing and Waste Management
Managerial Decision Support Systems can be very helpful and include:
1. Business Intelligence Systems
2. Enterprise Resource Planning System

The components making up the Managerial Information System is wide-ranging and complex.
They are not within the scope of this discussion (at this point) but mentioned here for
completion. However certain components that integrate or interface with the Information
System for Patient Care Function will be discussed.

Chart Showing Components of Managerial Information System