Hospital information system

From Wikipedia, the free encyclopedia

Jump to: navigation, search There are various titles and acronyms which all declare similar approaches to managing the information flow and storage in hospital routine services, as
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Hospital Information System (HIS), or Healthcare Information System, or Clinical Information System (CIS), or Patient Data Management System (PDMS)

are comprehensive, integrated information systems designed to manage the medical, administrative, financial and legal aspects of a hospital and its service processing. Traditional approaches encompass paper-based information processing as well as resident work position and mobile data acquisition and presentation.

Contents
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1 Architecture 2 Standardization 3 Aim 4 Benefits of HIS 5 See also 6 Further reading 7 References

[edit] Architecture
Generally all breeds are supported in client-server architectures for networking and processing. Most work positions for HIS currently are resident types. Mobile computing started with wheeled PC stands and now comes to age with tablet-PC and smartphone applications. Up to date a cloud computing alternative is not recommended, as data security of individual patient records services are not well accepted by the public[1][2][3][4]. HIS can be composed of one or a few software components with specialty-specific extensions as well as of a large variety of sub-systems in medical specialties, as e.g. Laboratory Information System (LIS), Radiology Information System (RIS) or Picture archiving and communication system (PACS).

CISs are sometimes separated from HISs in that one focuses the flow management and clinicalstate-related data and the other focuses the patient-related data with the doctor's letters and the electronic patient record. However, the naming varies from vendor to vendor and from hospital to hosptal.

[edit] Standardization
There is no standardization but for data formats and for data interchange, as with the HL7 initiative supported by ISO.

[edit] Aim
As an area of medical informatics the aim of an HIS is to achieve the best possible support of patient care and outcome and administration by presenting data where needed and acquiring data when generated with networked electronic data processing.

[edit] Benefits of HIS

Easy Access to Patient Data to generate varied records, including classification based on demographic, gender, age, and so on. It is especially beneficial at ambulatory (out-patient) point, hence enhancing continuity of care. As well as, Internet-based access improves the ability to remotely access such data. [5] It helps as a decision support system for the hospital authorities for developing comprehensive health care policies.[6] Efficient and accurate administration of finance, diet of patient, engineering, and distribution of medical aid. Improved monitoring of drug usage, and study of effectiveness. This leads to the reduction of adverse drug interactions while promoting more appropriate pharmaceutical utilization. Enhances information integrity, reduces transcription errors, and reduces duplication of information entries.[7]

[edit] See also

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Medical record Online office suite Electronic health record (EHR) Electronic medical record (EMR) Laboratory information system (LIS) ICU quality and management tools Radiology information system (RIS)

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PACS (medical imaging) Medical technologist

A medical record, health record, or medical chart in general is a systematic documentation of a single patient's long-term individual medical history and care[1]. The term 'Medical record' is used both for the physical folder for each individual patient and for the body of information which comprises the total of each patient's health history. Medical records are intensely personal documents and there are many ethical and legal issues surrounding them such as the degree of third-party access and appropriate storage and disposal[2]. Although medical records are traditionally compiled and stored by health care providers, personal health records (PHR) maintained by individual patients have become technically available and popular in recent years[3]. This concept is supported by US national health administration entities[4] and by AHIMA, the American Health Information Management Association.[5]

A medical record folder being pulled from the records

Despite the ownership of any special data container and for any tool providing access to the health record, the proprietor of the information is just the patient himself[6]. No clause in the service contract with the patient may countermand this proprietary ownership.

Contents
[hide]
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1 Purpose o 1.1 Auxiliary purpose 2 Contents 3 Media applied o 3.1 Medical history o 3.2 Medical encounters o 3.3 Orders and Prescriptions o 3.4 Progress notes o 3.5 Test results o 3.6 Other information 4 Administrative issues o 4.1 Demographics o 4.2 Production 5 Informational self-determination o 5.1 Ownership for patient's record o 5.2 US law and customs o 5.3 UK law and customs

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5.4 German law and customs 5.5 Accessibility 5.6 Destruction 5.7 Abuses 6 Standardization 7 See also 8 References 9 External links o 9.1 Organizations dealing with medical records
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[edit] Purpose
The information contained in the medical record allows health care providers to provide continuity of care to individual patients. The medical record also serves as a basis for planning patient care, documenting communication between patient, the health care provider and any other health professional contributing to the patient's care. The medical record shall mutually assist in protecting the medical needs and the legal interest of the patient and the health care providers responsible for the patient's care, and documenting the care and services provided to the patient. Personal health records combine many of the above features with portability, thus allowing a patient to share medical records across providers and health care systems.[5]. Hence the medical record has a scope afore and beyond the single actual case, however each case shall be identifiable as a separate data set.
[edit] Auxiliary purpose

In addition, the individual medical record anonymised may serve as a document to educate medical students/resident physicians, to provide data for internal hospital auditing and quality assurance, and to provide data for medical research.

[edit] Contents
A patient's individual medical record identifies the patient and contains information regarding the patient's entire case history. The health record as well as any electronically stored variant of the traditional paper files contain proper identification of the patient[7]. Further information varies with the individual medical history of the patient. The contents are written by medical providers, and the patient has no power regarding what is written or not written there, and whether a reported item is correct or not. This carries many consequences if medical providers' behavior is questioned, as the patient has no document to prove the facts or absence of facts in the record, while the medical staff would be able to assert that the entire factual content of a patient's medical history is what is recorded in the medical record.

[edit] Media applied

Traditionally, medical records have been written on paper and kept in folders. These folders are typically divided into useful sections, with new information added to each section chronologically as the patient experiences new medical issues. Active records are usually housed at the clinical site, but older records (e.g., those of the deceased) are often kept in separate facilities. The advent of electronic medical records has not only changed the format of medical records but has increased accessibility of files. The use of an individual dossier style medical record, where records are kept on each patient by name and illness type originated at the Mayo Clinic out of a desire to simplify patient tracking and to allow for medical research. Any transfer of medical records in hands of the patient requires security measures to prevent from unauthorized change of contents.
[edit] Medical history

The medical history is a longitudinal record of what has happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. It gives the clinician a feel for what has happened before to the patient. As a result, it may often give clues to current disease states. It includes several subsets detailed below.
Surgical history The surgical history is a chronicle of surgery performed for the patient. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did. Obstetric history The obstetric history lists prior pregnancies and their outcomes. It also includes any complications of these pregnancies. Medications and medical allergies The medical record may contain a summary of the patient's current and previous medications as well as any medical allergies. Family history The family history lists the health status of immediate family members as well as their causes of death (if known)[8]. It may also list diseases common in the family or found only in one sex or the other. It may also include a pedigree chart. It is a valuable asset in predicting some outcomes for the patient. Social history

The social history is a chronicle of human interactions. It tells of the relationships of the patient, his/her careers and trainings, schooling and religious training. It is helpful for the physician to know what sorts of community support the patient might expect during a major illness. It may explain the behavior of the patient in relation to illness or loss. It may also give clues as to the cause of an illness (e.g. occupational exposure to asbestos). Habits Various habits which impact health, such as tobacco use, alcohol intake, exercise, and diet are chronicled, often as part of the social history. This section may also include more intimate details such as sexual habits and sexual orientation. Immunization history The history of vaccination is included. Any blood tests proving immunity will also be included in this section. Growth chart and developmental history For children and teenagers, charts documenting growth as it compares to other children of the same age is included, so that health-care providers can follow the child's growth over time. Many diseases and social stresses can affect growth and longitudinal charting and can thus provide a clue to underlying illness. Additionally, a child's behavior (such as timing of talking, walking, etc.) as it compares to other children of the same age is documented within the medical record for much the same reasons as growth. [edit] Medical encounters

Within the medical record, individual medical encounters are marked by discrete summations of a patient's medical history by a physician, nurse practitioner, or physician assistant and can take several forms. Hospital admission documentation (i.e., when a patient requires hospitalization) or consultation by a specialist often take an exhaustive form, detailing the entirety of prior health and health care. Routine visits by a provider familiar to the patient, however, may take a shorter form such as the problem-oriented medical record (POMR), which includes a problem list of diagnoses or a "SOAP" method of documentation for each visit. Each encounter will generally contain the aspects below:
Chief complaint This is the problem that has brought the patient to see the doctor. Information on the nature and duration of the problem will be explored.

History of the present illness A detailed exploration of the symptoms the patient is experiencing that have caused the patient to seek medical attention. Physical examination The physical examination is the recording of observations of the patient. This includes the vital signs , muscle power and examination of the different organ systems, especially ones that might directly be responsible for the symptoms the patient is experiencing. Assessment and plan The assessment is a written summation of what are the most likely causes of the patient's current set of symptoms. The plan documents the expected course of action to address the symptoms (diagnosis, treatment, etc.). [edit] Orders and Prescriptions

Written orders by medical providers are included in the medical record. These detail the instructions given to other members of the health care team by the primary providers.
[edit] Progress notes

When a patient is hospitalized, daily updates are entered into the medical record documenting clinical changes, new information, etc. These often take the form of a SOAP note and are entered by all members of the health-care team (doctors, nurses, physical therapists, dietitians, clinical pharmacists, respiratory therapists, etc.). They are kept in chronological order and document the sequence of events leading to the current state of health.
[edit] Test results

The results of testing, such as blood tests (e.g., complete blood count) radiology examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing (e.g., pulmonary function testing) are included. Often, as in the case of Xrays, a written report of the findings is included in lieu of the actual film.

[edit] Other information

Many other items are variably kept within the medical record. Digital images of the patient, flowsheets from operations/intensive care units, informed consent forms, EKG tracings, outputs from medical devices (such as pacemakers), chemotherapy protocols, and numerous other important pieces of information form part of the record depending on the patient and his or her set of illnesses/treatments. There are several types of information needed to be recorded while tracing the state of a patient's daily health: 1. Vital Signs: Body Temperature, Pulse Rate(Heart Rate), Blood Pressure and Respiratory Rate. 2. Intake: Medication, Fluid, Nutrition, Water and Blood, etc. 3. Output: Blood, Urine, Excrement, Vomitus and Sweat, etc. 4. Observation of Pupil size. 5. Capability of four limbs of body

[edit] Administrative issues

Medical records are legal documents, and are subject to the laws of the country/state in which they are produced. As such, there is great variability in rules governing production, ownership, accessibility, and destruction. There is some controversy regarding proof verifying the facts, or absence of facts in the record, apart from the medical record itself.
[edit] Demographics

Demographics include patient information that is not medical in nature. It is often information to locate the patient, including identifying numbers, addresses, and contact numbers. It may contain information about race and religion as well as workplace and type of occupation. It may also contain information regarding the patient's health insurance. It is common to also find emergency

contacts located in this section of the medical chart.

[edit] Production

In the United States, written records must be marked with the date and time and scribed with indelible pens without use of corrective paper. Errors in the record should be struck out with a single line and initialed by the author. Orders and notes must be signed by the author. Electronic versions require an electronic signature.

[edit] Informational selfdetermination

The informational self-determination is a basic human right. Hence the should patient's record belongs to the patient, but it seldom happens so.
[edit] Ownership for patient's record

Ownership and keeping of patient's records varies from country to country.

[edit] US law and customs

In the United States, the data contained within the medical record belongs to the patient[citation needed] , whereas the physical form the data takes belongs to the entity responsible for maintaining the record per the Health Insurance Portability and Accountability Act[9]. Therefore, patients have the right to ensure that the information contained in their record is accurate[citation needed]. Patients can petition their health care provider to remedy factually incorrect information in their records.[citation needed]
[edit] UK law and customs

In the United Kingdom, ownership of the NHS's medical records belong to the Department of

Health,[10] and this is taken by some to mean copyright also belongs to the authorities.[11]
[edit] German law and customs

In Germany ownership of patient's records is not explicitly codified. Hence traditional keeping of patient's records is with the hospitals and the practitioners. There is no comprehensive data set containing all information on one patient in one file defined yet. Since 1995, patients are identified via a health insurance card that includes name and address information as well as an ID assigned by the insurance provider. An upgrade to advanced health insurance cards (Elektronische Gesundheitskarte) that can store additional medical information was planned for 2006. Discussion on the benefit, the associated cost, and on data privacy issues is still ongoing as of 2011.
[edit] Accessibility

In the United States, the most basic rules governing access to a medical record dictate that only the patient and the health-care providers directly involved in delivering care have the right to view the record. The patient, however, may grant consent for any person or entity to evaluate the record. The full rules regarding access and security for medical records are set forth under the guidelines of the Health Insurance Portability and Accountability Act (HIPAA). The rules become more complicated in special situations.
Capacity When a patient does not have capacity (is not legally able) to make decisions regarding his or her own care, a legal guardian is designated (either through next of kin or by action of a court of law if no kin exists). Legal guardians have the ability to access the medical record in order to make medical decisions on the patient s behalf. Those without capacity include the comatose, minors (unless emancipated), and patients with incapacitating psychiatric illness or intoxication. Medical emergency

In the event of a medical emergency involving a non-communicative patient, consent to access medical records is assumed unless written documentation has been previously drafted (such as an advance directive) Research, auditing, and evaluation Individuals involved in medical research, financial or management audits, or program evaluation have access to the medical record. They are not allowed access to any identifying information, however. Risk of death or harm Information within the record can be shared with authorities without permission when failure to do so would result in death or harm, either to the patient or to others. Information cannot be used, however, to initiate or substantiate a charge unless the previous criteria are met (i.e., information from illicit drug testing cannot be used to bring charges of possession against a patient). This rule was established in the United States Supreme Court case Jaffe v. Redmond[6].

In the United Kingdom, the Data Protection Acts and later the Freedom of Information Act 2000 gave patients or their representatives the right to a copy of their record, except where information breaches confidentiality (e.g., information from another family member or where a patient has asked for information not to be disclosed to third parties) or would be harmful to the patient's wellbeing (e.g., some psychiatric assessments). Also, the legislation gives patients the right to check for any errors in their record and insist that amendments be made if required.
[edit] Destruction

In general, entities in possession of medical records are required to maintain those records for a given period. In the United Kingdom, medical records are required for the lifetime of a

patient and legally for as long as that complaint action can be brought. Generally in the UK, any recorded information should be kept legally for 7 years, but for medical records additional time must be allowed for any child to reach the age of responsibility (20 years). Medical records are required many years after a patients death to investigate illnesses within a community (e.g., industrial or environmental disease or even deaths at the hands of doctors committing murders, as in the Harold Shipman case).[12]
[edit] Abuses
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The outsourcing of medical record transcription and storage has the potential to violate patient-physician confidentiality by possibly allowing unaccountable persons access to patient data. Falsification of a medical record by a medical professional is a felony in most United States jurisdictions. Governments have often refused to disclose medical records of military personnel who have been used as experimental subjects.

[edit] Standardization

Online office suite

From Wikipedia, the free encyclopedia

Jump to: navigation, search This article may require cleanup to meet Wikipedia's quality standards. (Consider using more specific clean up instructions.) Please improve this article if you can. The talk page may contain suggestions. (March 2008)

An online office suite or online productivity suite is a type of office suite offered by websites in the form of software as a service. They can be accessed online from any Internet-enabled device running any operating system.[1] This allows people to work together worldwide and at any time, thereby leading to international web-based collaboration and virtual teamwork. Usually, the basic versions are offered for free and for more advanced versions one is required to pay a nominal subscription fee. Applications are often developed on the Web 2.0 paradigms with leverage on the existing developer community. Players come from both the commercial software market and from the open source, free software communities.

Contents
[hide]
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1 Office 2.0 2 Examples 3 Advantages 4 Disadvantages 5 Criticism 6 Components o 6.1 Document creation and editing applications o 6.2 Publishing Applications o 6.3 Collaborative Applications o 6.4 Management Applications 7 See also 8 References 9 External links

[edit] Office 2.0

The term Office 2.0, which is sometimes used to refer to online office suites, originated with Ismael Ghalimi in an experimental effort to test whether he could perform all of his computer based work in online applications. It is a marketing neologism representing the concepts of office productivity applications as published applications rather than stand-alone programs, leveraging the Web 2.0 concept to conjure imagery of collaborative, community based and centralised effort

rather than the more traditional application running on a platform locally. It is also the focus of the annual Office 2.0 Conference.

[edit] Examples
Examples of where the term may apply include:
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The centralized administration of office productivity software, installation, licensing and version control; Collaborative applications which improve personal and organizational productivity; Centralized storage of data, rather than traditional personal data responsibility; Applications which focus on collaborative data sharing, document review and document resource management; Office applications which are able to be run from multiple independent platforms with a suitable back-end framework to present the application in a uniform manner.

[edit] Advantages
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The cost is low. In most cases, there is no specific charge for using the service for users who already have access to a computer with a web browser and a connection to the Internet. There is no need to download or install software outside of the office suite's web page, including the ongoing upgrade chores of adding new features to or eliminating bugs from the office suite. Online office suites can run on thin clients with minimal hardware requirements. Online office suites provide the ability for a group of people to share a document without the need to run their own server. There is no need to purchase or upgrade a software license. Instead, the online office suite is available as software as a service. Online office suites are portable. Users can access their documents from almost any computer with a connection to the Internet, regardless of which operating system they use. If the user's computer fails, the documents are still safely stored on the remote server. Online service providers' backup processes and overall stability will generally be superior to that of most home systems.

[edit] Disadvantages
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Access requires connectivity--if the remote server or network is unavailable, the content will also be unavailable. However, in many cases, the online suite will allow the user to regularly backup data or even provide synchronization of documents between the server and the local computer.[2] There are speed and accessibility issues. Most of the available online office suites require a high speed (broadband) Internet connection. That can be a problem for users who are limited by a slower connection to the Internet. The number of features available is an issue. Online office suites lack the more advanced features available on their offline counterparts. There may be a subscription charge to use the service. In that case, in the long run, the ongoing subscription cost may be more expensive than purchasing offline software upfront.

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The user has no control over the version of the software used. If the software is changed the user is forced to use the changed version, even if the changed version is less suited to the user. The user is reliant on the service provider for security and privacy of their documents.[3] [4] [5]

[edit] Criticism
As with most marketing neologisms which later become accepted public trends, technologists contend that these technologies have existed for some time, particularly in the form of Microsoft Terminal Services based applications and Citrix XenApp published application frameworks. The term itself is likely to only be used as a reference to a group of selling points. There are also questions as to how businesses will be affected by storing all of their documents in online environments. For example, the search and seizures provisions offered by the Fourth Amendment do not apply to online service providers storing third-party data.[6]

[edit] Components
An online office suite normally includes a broad set of applications, such as the following:
[edit] Document creation and editing applications
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Word processor Spreadsheet Presentation program Flowchart Raster image processor

[edit] Publishing Applications

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CMS Web portal Wiki Blog Forums

[edit] Collaborative Applications

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E-mail Instant messaging (VoIP) Calendar

[edit] Management Applications

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Data management Project management

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CRM ERP Accounting

[edit] See also

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Cloud computing Comparison of office suites Comparison of personal information managers List of online spreadsheets Office Online accounting Paperless office Telecommuting Web 2.0 Web desktop Web operating system

[edit] References
1. 2. 3. 4. 5. 6. ^ Online Office Suites: The Winner Is Clear ^ Google docs documentation for offline use. Accessed 18 January 2009. ^ Google software bug shared private online documents, AFP, March 10, 2009 ^ Google denies ownership of users' words, CNet.com, September 12, 2007 ^ Concerns About Google Docs, HowStuffWorks.com ^ NSA warrantless surveillance controversy

[edit] External links

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A project manager's practical study of project management and team collaboration tools. The study is centered around utilizing Google apps in combination with other SAAS tools as a project workspace / collaboration environment. Online Office Suites: The Winner Is Clear Will Web-based office suites beat Microsoft at its own game? How Will Microsoft Respond To Online Office Threat ICT Hub Knowledgebase The Web-based Office will have its day An article on Digital trends for 2008 highlights the coming of office applications on the mobile-based internet

Retrieved from "http://en.wikipedia.org/wiki/Online_office_suite"

A lab information system ("LIS") is a class of software that receives, processes, and stores information generated by medical laboratory processes. These systems often must interface with instruments and other information systems such as hospital information systems (HIS). A LIS is a highly configurable application which is customized to facilitate a wide variety of laboratory

workflow models. Deciding on an LIS vendor is a major undertaking for all labs. Vendor selection typically takes months of research and planning. Installation takes from a few months to a few years depending on the complexity of the organization. There are as many variations of LISs as there are types of lab work. Some vendors offer a full-service solution capable of handling a large hospital lab's needs; others specialize in specific modules. Disciplines of laboratory science supported by LISs include hematology, chemistry, immunology, blood bank (Donor and Transfusion Management), surgical pathology, anatomical pathology, flow cytometry and microbiology. This article covers clinical lab which encompasses hematology, chemistry and immunology.

Contents
[hide]
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1 Basic operation o 1.1 Order entry and check in o 1.2 Specimen receiving o 1.3 Send test orders to analyzers o 1.4 Results entry o 1.5 Lab reporting 2 Basic features 3 Additional features 4 Types 5 See also 6 External links

[edit] Basic operation

Laboratory Information Systems are often part of an integrated informatics solution which involves many disparate applications. Use of an LIS is a critical piece of the clinical IT spectrum of systems and contributes significantly to the overall care given to patients. The LIS is used in inpatient and outpatient settings and in many cases is designed to support both. From an outpatient/ambulatory perspective, LIS interaction frequently begins after a physician has arrived at an initial diagnosis. For example, a patient enters the hospital looking pale and complaining of fatigue. The physician, suspecting anemia, might decide to order a complete blood count (CBC). In an inpatient setting when that patient is admitted into the hospital, the system is used to order tests, provide specimen processing assistance, receive the results from analyzers and deliver lab reports to the attending physician.
[edit] Order entry and check in

An order is placed in the system usually by a physician or laboratory scientist. The order or lab request contains a list of tests to be performed on one or more patient specimens (e.g., blood or urine). In many cases, each order is tracked with a unique identifier. This identifier (which is

usually a number) is often referred to as Lab ID. In this hypothetical case, a CBC is ordered which is a panel of sub-tests including white blood cell count, red cell blood count and other blood-related tests. A phlebotomist will be called on to collect the specimen(s) from the patient. Often, different specimens will be collected, so as to provide different tubes (each with a specific cap color) for each analyzer that will process the samples. In this case, the appropriate specimen (using a vacutainer tube with a lavender top) is taken from the patient and labeled with a bar code specimen label produced by the LIS. The LIS will print barcode labels (with the unique lab ID) for the draw tubes. In some cases, more advanced LIS products will also provide a unique identifier for each specimen. The newest of these systems are using RFID to eliminate human errors and automate the data capture. Serialized data through barcode or RFID provides the ability to track the specimen's chain of custody from the point it is taken from the patient to the point that it gets discarded. The specimen-accession-patient hierarchy is linked in a tree like numeric structure. In other cases,the patient is identified by a Lab ID linked to the patient's demographic record through the Hospital number.
[edit] Specimen receiving

After the specimen is collected, it is sent/brought to the lab for processing typically in a batch. This event should be recorded in the LIS. On reception of the specimen in the testing lab, either manual or automated lab work can begin. Many tests, such as CBCs or Chemistry profiles, are performed by automated analyzers.
[edit] Send test orders to analyzers

Most LIS systems can be configured to download the specimen data to an analyzer either after the order is placed or when a specimen is received in a testing lab. When the specimen's barcode is read by the instrument, the unique ID from the specimen label is matched with the order previously downloaded to the instrument. This system is often called "Batch Download". A more efficient system is called "Host Query", where the instrument reads the barcode on the specimen and "queries" the LIS for the test orders. The LIS will be listening on a communication port for queries and will download the requests only when required. In cases where the LIS transmits data such as test orders or control messages to analyzers the communication is set up to be bidirectional.
[edit] Results entry

When results of lab tests are available, they are entered into the system manually or automatically downloaded from an instrument. Once these results are double-checked by the Medical Laboratory Scientist or autoverified, they are released. Released results are often automatically printed or written on lab reports which are delivered to the attending physician or clinic. Results must be verified and released to attending physicians as soon as possible.

[edit] Lab reporting

Lab Reports are the final output of all LIS systems and, in many cases, the primary LIS interaction with healthcare professionals outside the lab. The reports can either be printed or faxed in paper-based labs; they can be delivered via email or file in paperless labs. The degree to which an LIS supports customizable lab reports and flexibility in modes of delivery of results is one major factor in determining its success in the marketplace.

[edit] Basic features

Laboratory Information Systems commonly support the following features:
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Patient Check In Order Entry Specimen Processing Result(s) Entry Reporting Patient Demographics Physician Demographics

[edit] Additional features

In addition LISs commonly support the following:
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Web-based order entry Web-based results inquiry Faxing and emailing of lab reports Custom report creation HL7 interfaces with reference labs and EMRs Preliminary reporting Final reporting Med tech worksheets Workload balancing Medicare medical necessity checking Billing Public health reporting Rule engines report check by reputed pathologist and senior technologist

[edit] Types
There are many laboratory disciplines requiring the support of computerized informatics. These include:
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Hematology

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Chemistry Immunology Blood bank donor center Blood bank transfusion Surgical Pathology Pathology Cytology (Cytopathology) Microbiology Flow cytometry TB

[edit] See also

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Clinical Pathology Laboratory information management system Laboratory informatics Medical technologist Histopathology Anatomic Pathology Genetic Laboratories
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ICU quality and management tools

From Wikipedia, the free encyclopedia

Jump to: navigation, search This article is an orphan, as few or no other articles link to it. Please introduce links to this page from related articles; suggestions may be available. (September 2008) This article is written like a personal reflection or essay and may require cleanup. Please help improve it by rewriting it in an encyclopedic style. (September 2008)

The intensive care unit (ICU) is one of the major components of the current health care system. The advances in supportive care and monitoring resulted in significant improvements in the care of surgical and clinical patients. Nowadays aggressive surgical therapies as well as transplantation are made safer by the monitoring in a closed environment, the surgical ICU, in the post-operative period. Moreover, the care and full recovery of many severely ill clinical patients as those with life-threatening infections occurs as a result of intensive care. However, despite many significant advances in various fields as mechanical ventilation, renal replacement therapy, antimicrobial therapy and hemodynamic monitoring this increased knowledge and the wise use of such technology is not available for all patients. Shortage of ICU beds are an important issue, however even when ICU beds are available significant variability in treatment and in the adherence to evidence-based interventions do not occur.

[edit] Tools for ICU quality monitoring

Several measures of ICU performance have been proposed in the past 30 years. It is intuitive, and correct, to assume that ICU mortality may be a useful marker of quality. However, crude mortality rates does not take into consideration the singular aspects of each specific patient population that is treated in a certain geographic region, hospital or ICU. Therefore approaches looking for standardized mortality ratios that are adjusted for disease severity, comorbidities and other clinical aspects are often sought. Severity of illness is usually evaluated by scoring systems that integrates clinical, physiologic and demographic variables. Scoring systems are interesting tools to describe ICU populations and explain their different outcomes. The most frequently used are the APACHE II, SAPS II and MPM. However, newer scores as APACHE IV and SAPS III have been recently introduced in clinical practice. More than only using scoring systems, one should search for a high rate of adherence to clinically effective interventions. Adherence to interventions as deep venous thrombosis prophylaxis, reduction of ICU-acquired infections, adequate sedation regimens and decreasing and reporting serious adverse events are essential and have been accepted as benchmarking of quality. The complex task of collecting and analyzing data on performance measures are made easier when clinical information systems are available. Although several clinical information systems focus on important aspects as computerized physician order entry systems and individual patient tracking information, few have attempted to gather clinical information generating full reports that provide a panorama of the ICU performance and detailed data on several domains as mortality, length of stay, severity of illness, clinical scores, nosocomial infections, adverse events and adherence to good clinical practice. Through implementing quality initiatives, increasing the quality of care and patient safety are major and feasible goals. Such systems (for example: Epimed Monitor) are available for clinical use and may facilitate the process of care on a daily basis and provide data for an in-depth analysis of ICU performance.

[edit] ReferencesRadiology
From Wikipedia, the free encyclopedia

information system

Jump to: navigation, search A radiology information system (RIS) is a computerized database used by radiology departments to store, manipulate and distribute patient radiological data and imagery. The system generally consists of patient tracking and scheduling, result reporting and image tracking capabilities. RIS complements HIS (Hospital Information Systems) and is critical to efficient workflow to radiology practices.

[edit] Basic Features

Radiology information systems commonly support the following features:
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Patient Registration and scheduling Patient List Management Interface with modality via Worklist.

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Radiology Department workflow management Request and document scanning Result(s) Entry Reporting and printout Result(s) Delivery including faxing and e-mailing of clinical reports Patient Tracking Interactive Documents Technical Files Creation Modality and Material management.

[edit] Additional Features

In addition a RIS often supports the following:
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Appointment booking PACS workflow Custom report creation HL7 interfaces with a PACS. HL7 also enables communication between HIS and RIS in addition to RIS and PACS. Billing Rule engines

Picture archiving and communication system

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An image as stored on a picture archiving and communication system (PACS)

The same image following contrast adjustment, sharpening and measurement tags added by the system A picture archiving and communication system (PACS) is a medical imaging technology which provides economical storage of, and convenient access to, images from multiple modalities (source machine types).[1] Electronic images and reports are transmitted digitally via PACS; this eliminates the need to manually file, retrieve, or transport film jackets. The universal format for PACS image storage and transfer is DICOM (Digital Imaging and Communications in Medicine). Non-image data, such as scanned documents, may be incorporated using consumer industry standard formats like PDF (Portable Document Format), once encapsulated in DICOM. A PACS consists of four major components: The imaging modalities such as X-ray computed tomography (CT) and magnetic resonance imaging (MRI), a secured network for the transmission of patient information, workstations for interpreting and reviewing images, and archives for the storage and retrieval of images and reports. Combined with available and emerging web technology, PACS has the ability to deliver timely and efficient access to images, interpretations, and related data. PACS breaks down the physical and time barriers associated with traditional film-based image retrieval, distribution, and display.

Contents
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1 Types of images 2 Uses 3 Architecture 4 Querying (C-FIND) and Image Retrieval (C-MOVE) 5 Image archival and backup 6 Integration 7 History 8 Regulatory concerns 9 See also 10 References 11 External links

[edit] Types of images

Most PACSs handle images from various medical imaging instruments, including ultrasound (US), magnetic resonance (MR), positron emission tomography (PET), computed tomography (CT), endoscopy (ENDO), mammograms (MG), Digital radiography (DR), computed radiography (CR) ophthalmology, etc. Additional types of image formats are always being added. Clinical areas beyond radiology; cardiology, oncology, gastroenterology and even the laboratory are creating medical images that can be incorporated into PACS. (see DICOM Application areas).

[edit] Uses
PACS has four main uses:
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Hard copy replacement: PACS replaces hard-copy based means of managing medical images, such as film archives. With the decreasing price of digital storage, PACSs provide a growing cost and space advantage over film archives in addition to the instant access to prior images at the same institution. Digital copies are referred to as Soft-copy. Remote access: It expands on the possibilities of conventional systems by providing capabilities of off-site viewing and reporting (distance education, telediagnosis). It enables practitioners in different physical locations to access the same information simultaneously for teleradiology. Electronic image integration platform: PACS provides the electronic platform for radiology images interfacing with other medical automation systems such as Hospital Information System (HIS), Electronic Medical Record (EMR), Practice Management Software, and Radiology Information System (RIS). Radiology Workflow Management: PACS is used by radiology personnel to manage the workflow of patient exams.

PACS is offered by virtually all the major medical imaging equipment manufacturers, medical IT companies and many independent software companies. Basic PACS software can be found free on the Internet.

[edit] Architecture

PACS workflow diagram

The architecture is the physical implementation of required functionality, or what one sees from the outside. There are different views, depending on the user. A radiologist typically sees a viewing station, a technologist a QA workstation, while a PACS administrator might spend most of their time in the climate-controlled computer room. The composite view is rather different for the various vendors.[2] Typically a PACS consists of a multitude of devices. The first step in typical PACS systems is the modality. Modalities are typically computed tomography (CT), ultrasound, nuclear medicine, positron emission tomography (PET), and magnetic resonance imaging (MRI). Depending on the facility's workflow most modalities send to a quality assurance (QA) workstation or sometimes called a PACS gateway. The QA workstation is a checkpoint to make sure patient demographics are correct as well as other important attributes of a study. If the study information is correct the images are passed to the archive for storage. The central storage device (archive) stores images and in some cases reports, measurements and other information that resides with the images. The next step in the PACS workflow is the reading workstations. The reading workstation is where the radiologist reviews the patient's study and formulates their diagnosis. Normally tied to the reading workstation is a reporting package that assists the radiologist with dictating the final report. Reporting software is optional and there are various ways in which doctors prefer to dictate their report. Ancillary to the workflow mentioned, there is normally CD/DVD authoring software used to burn patient studies for distribution to patients or referring physicians. The diagram above shows a typical workflow in most imaging centers and hospitals. Note that this section does not cover integration to a Radiology Information System, Hospital Information System and other such front-end system that relates to the PACS workflow. More and more PACS include web-based interfaces to utilize the internet or a Wide Area Network as their means of communication, usually via VPN (Virtual Private Network) or SSL (Secure Sockets Layer). The client side software may use ActiveX, JavaScript and/or a Java Applet. More robust PACS clients are full applications which can utilize the full resources of the computer they are executing on and are unaffected by the frequent unattended Web Browser and Java updates. As the need for distribution of images and reports become more widespread there is a push for PACS systems to support DICOM part 18 of the DICOM standard. Web Access to DICOM Objects (WADO) creates the necessary standard to expose images and reports over the web through truly portable medium. Without stepping outside the focus of the PACS architecture, WADO becomes the solution to cross platform capability and can increase the distribution of images and reports to referring physicians and patients. PACS image backup is a critical, but sometimes overlooked, part of the PACS Architecture (see below). HIPAA requires that backup copies of patient images be made in case of image loss from the PACS. There are several methods of backing up the images, but they typically involve automatically sending copies of the images to a separate computer for storage, preferably offsite.

[edit] Querying (C-FIND) and Image Retrieval (C-MOVE)

The communication with the PACS server is done through dicom objects that are similar to dicom images, but with different tags. A query typically looks as follows:

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The client establishes the network connection to the PACS server. The client prepares a query object which is an empty dicom dataset object. The client fills in the query object with the keys that should be matched. E.g. to query for a patient ID, the patient ID tag is filled with the patient's ID. The client creates empty tags (tags with zero length string values) for all the tags it wishes to receive from the server. E.g. if the client wishes to receive an ID that it can use to receive images (see image retrieval) it should create the tag SOPInstanceID (0008,0018) in the query object. The query object is sent to the server. The server sends back to the client a list of response dicom objects. The client extracts the tags that are of interest from the response dicom objects.

Images are retrieved from a PACS server through a C-MOVE request, as defined by the DICOM network protocol. This request specifies where an image instance should be sent through an identifier known as the destination Application Entity Title (AE Title). The server must be configured with mapping of the AE Title to a TCP/IP address and port, and as a consequence the server must know in advance all the AE Titles that it will ever be requested to send images to. Typically a radiologist is looking for prior studies on a patient to compare the progression of some pathology. In some cases prior studie(s) may be on an off-site archive or a long term storage device. In the example being used, the radiologist or radiology technical must query the off-site or long term archive for the prior exam(s). The archive receives the C-FIND and if the CFIND is successful the archive invokes a C-MOVE on the study to the called AE Title, in-turn sending the study from the archive to the device requesting the study.

[edit] Image archival and backup

Digital medical images are typically stored locally on a PACS for retrieval. It is important (and required in the USA by the Security Rule's Administrative Safeguards section of HIPAA) that facilities have a means of recovering images in the event of an error or disaster. While each facility is different, the goal in image back-up is to make it automatic and as easy to administer as possible. The hope is that the copies won't ever be needed, but, as with other disaster recovery and business continuity planning, they need to be available if needed. Ideally, copies of images should be streamed off-site as they are created. (If using the Internet, the Security Rule's Technical Safeguards section of HIPAA requires that the images be encrypted during transmission.) Depending on upload bandwidth and image volume, this may not be practical if the back-up system cannot be configured to tune bandwidth usage and frequency of back-ups. Other options include removable media (hard drives, DVDs or other media that can hold many patients' images) that is physically transferred off-site. The content of these copies must be protected via encryption from exposure to unauthorized personnel or stiff penalties can be assessed.[3] Images may be stored both locally and remotely on off-line media such as tape or optical media, or partially or exclusively on hard disks ("spinning") media. The latter is becoming more common. The hard drives may be configured and attached to the PACS server in various ways,

either as Direct-Attached Storage (DAS), Network-attached storage (NAS), or via a Storage Area Network (SAN). However the storage is attached, the drives themselves are usually configured as a Redundant Array of Inexpensive (or Independent) Discs RAID, which may be configured to provide appropriate combination of faster disk access or protection against the failure of one (or even two) discs in the physical RAID array. Typically, failed drives may be physically replaced (hot swapping) without interruption of service. Since costs of computers has fallen, some sites opt for fully redundant Archives, rather than just protecting the drives through RAID. Further, RAIDs are fragile and can be rendered useless by one erroneous hit on the controller. Data stored on disk may also be backed up to tape or optical media or copied, in real time, to a slower, inexpensive disc in another machine at another location. Some sites make two such backups and remove them from the site on a rotating basis. In the event that it is necessary to reconstruct a PACS partially or completely from the back-up images, some means of rapidly transferring all of its images back to the PACS is required, preferably whilst the PACS continues to receive and provide current images. The back-up infrastructure may also be capable of supporting the migration of images to a new PACS.

[edit] Integration

A chest image displayed via a PACS A full PACS should provide a single point of access for images and their associated data. That is, it should support all digital modalities, in all departments, throughout the enterprise. However, until PACS penetration is complete, individual islands of digital imaging not yet connected to a central PACS may exist. These may take the form of a localized, modalityspecific network of modalities, workstations and storage (a so-called "mini-PACS"), or may consist of a small cluster of modalities directly connected to reading workstations without long term storage or management. Such systems are also often not connected to the departmental information system. Historically, Ultrasound, Nuclear Medicine and Cardiology Cath Labs are often departments that adopt such an approach.

More recently, Full Field digital mammography (FFDM) has taken a similar approach, largely because of the large image size, highly specialized reading workflow and display requirements, and intervention by regulators. The rapid deployment of FFDM in the US following the DMIST study has led to the integration of Digital Mammography and PACS becoming more commonplace. All PACS, whether they span the entire enterprise or are localized within a department, should also interface with existing hospital information systems: Hospital information system (HIS) and Radiology Information System (RIS). There are several data flowing into PACS as inputs for next procedures and back to HIS as results corresponding inputs: In: Patient Identification and Orders for examination. These data are sent from HIS to RIS via integration interface, in most of hospital, via HL7 protocol. Patient ID and Orders will be sent to Modality (CT,MR,etc) via DICOM protocol (Worklist). Images will be created after images scanning and then forwarded to PACS Server. Diagnosis Report is created based on the images retrieved for presenting from PACS Server by physician/radiologist and then saved to RIS System. Out: Diagnosis Report and Images created accordingly. Diagnosis Report is sent back to HIS via HL7 usually and Images are sent back to HIS via DICOM usually if there is a DICOM Viewer integrated with HIS in hospitals (In most of cases, Clinical Physician gets reminder of Diagnosis Report coming and then queries images from PACS Server). Interfacing between multiple systems provides a more consistent and more reliable dataset:
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Less risk of entering an incorrect patient ID for a study modalities that support DICOM worklists can retrieve identifying patient information (patient name, patient number, accession number) for upcoming cases and present that to the technologist, preventing data entry errors during acquisition. Once the acquisition is complete, the PACS can compare the embedded image data with a list of scheduled studies from RIS, and can flag a warning if the image data does not match a scheduled study. Data saved in the PACS can be tagged with unique patient identifiers (such as a social security number or NHS number) obtained from HIS. Providing a robust method of merging datasets from multiple hospitals, even where the different centers use different ID systems internally.

An interface can also improve workflow patterns:

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When a study has been reported by a radiologist the PACS can mark it as read. This avoids needless double-reading. The report can be attached to the images and be viewable via a single interface. Improved use of online storage and nearline storage in the image archive. The PACS can obtain lists of appointments and admissions in advance, allowing images to be pre-fetched from off-line storage or near-line storage onto online disk storage.

Recognition of the importance of integration has led a number of suppliers to develop fully integrated RIS/PACS. These may offer a number of advanced features:

Dictation of reports can be integrated into a single system. The recording is automatically sent to a transcript writer's workstation for typing, but it can also be made available for access by physicians, avoiding typing delays for urgent results, or retained in case of typing error. Provides a single tool for quality control and audit purposes. Rejected images can be tagged, allowing later analysis (as may be required under radiation protection legislation). Workloads and turn-around time can be reported automatically for management purposes.

[edit] History
The principles of PACS were first discussed at meetings of radiologists in 1982. Various people are credited with the coinage of the term PACS. Cardiovascular radiologist Dr Andre Duerinckx reported in 1983 that he had first used the term in 1981.[4] Dr Samuel Dwyer, though, credits Dr Judith M. Prewitt for introducing the term.[5] Dr Harold Glass, a medical physicist working in London in the early 1990s secured UK Government funding and managed the project over many years which transformed Hammersmith Hospital in London as the first filmless hospital in the United Kingdom.[6] Dr Glass died a few months after the project came live but is credited with being one of the pioneers of PACS. The first large-scale PACS installation was in 1982 at the University of Kansas, Kansas City.[2] This first installation became more of a teaching experience of what not to do rather than what to do in a PACS installation.

[edit] Regulatory concerns

In the US PACS are classified as Medical Devices, and hence if for sale are regulated by the USFDA. In general they are subject to Class 2 controls and hence require a 510(k), though individual PACS components may be subject to less stringent general controls.[7] Some specific applications, such as the use for primary mammography interpretation, are additionally regulated[8] within the scope of the Mammography Quality Standards Act.

[edit] See also

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X-ray DICOM eMix Medical device Medical imaging Medical software Computed axial tomography Telemedicine Electronic health record (EHR) Radiology

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Radiology Information System Electronic Medical Record (EMR)

[edit] References
1. ^ Choplin, R., (1992). Picture archiving and communication systems: an overview. Radiographics January 1992 12:127-129 2. ^ a b Oosterwijk, Herman. PACS Fundamentals. Aubrey: OTech Inc, 2004. ISBN 9780971886735 3. ^ HealthcareITnews: HHS cracks down: provider to pay $100,000 in HIPAA penalties over lost laptops. July 17, 2008, Diana Manos, Senior Editor 4. ^ Duerinckx AJ, Pisa EJ. Filmless Picture Archiving and Communication System (PACS) in Diagnostic Radiology. Proc SPIE 1982;318;9-18. Reprinted in IEEE Computer Society Proceedings of PACS'82, order No 388. 5. ^ Samuel J. Dwyer III. A personalized view of the history of PACS in the USA. In: Proceedings of the SPIE, "Medical Imaging 2000: PACS Design and Evaluation: Engineering and Clinical Issues", edited by G. James Blaine and Eliot L. Siegel. 2000;3980:2-9. 6. ^ Bryan S, Weatherburn GC, Watkins JR, Buxton MJ (1999). "The benefits of hospital-wide picture archiving and communication systems: a survey of clinical users of radiology services". Br J Radiol 72 (857): 46978. PMID 10505012. 7. ^ USFDA (27 July 2000). "Guidance for the Submission Of Premarket Notifications for Medical Image Management Devices". http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm07 3720.htm. Retrieved 11 February 2010. 8. ^ USFDA (30 May 2008). "Guidance for Industry and FDA Staff: Display Accessories for FullField Digital Mammography Systems-Premarket Notification (510(k)) Submissions". http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm10 7549.htm. Retrieved 11 February 2010.

[edit] External links

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Teleradiology, PACS and DICOM Software List of free PACS and DICOM software available on the web History of PACS PACS History Web Site USC IPILab Research Article on Backup

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