Patty Buttner
Understanding the need for effective health information systems
August 15, 2017
By Patty Buttner
Most people, patients and health professionals alike, have heard the term “informatics,” but they may not really know what it means.
Even a simple Google search of the term “health informatics” produces a variety of definitions. The American Health Information Management Association (AHIMA) Pocket Glossary of Health Information Management and Technology identifies the concept of informatics as the following:
“Scientific discipline that is concerned with the cognitive, information-processing and communication tasks of health care practice, education and research, including the information science and technology to support these tasks.”
Recently, I witnessed how effective informatics can better play a role in patient care in various health care settings. One of the settings included outpatient surgical departments in both a small and a large hospital. I found it very interesting that even in this electronic age, much of the paperwork associated with a same day surgical procedure was still housed in a binder in paper format, and this was the case in both hospitals. Staff had to check both the electronic health record (EHR) and the paper binder for all pertinent documents and information for each patient. I thought about how this likely impacted the workflow of the clinicians and staff. After surgery, the staff was seen either attending to the patient or standing in front of computers on wheels entering vital signs and charting progress.
During an inpatient stay on a separate visit, I observed some confusion over dietary orders and noted that it took six hours to obtain a serving of Jell-O. Would this have happened in the days of 100 percent paper records? I can’t answer that for sure, but the confusion seemed to stem from one order for “nothing by mouth” (NPO) status that had not been canceled by the provider. Although a new order for a regular diet had been written, the provider’s documentation was not clear whether this most recent order should be carried out or not.
Right outside the door of the hospital room I could overhear the nurses’ conversation and confusion related to the dietary order. Finally one nurse said, “Well since the order for the regular diet was written after the order for NPO, let’s go with the newest order.”
This led me to think: If it takes six hours to get a diet order figured out, is there also confusion about the medication orders and all the other care orders? And what kind of impact could this lack of clarity cause when carrying out patient care?
Here I could see how workflow and processes are essential to compiling an EHR. Several of the tasks listed in Domain 4 of AHIMA’s Certified Professional in Health Informatics (CPHI) outline deal with “workflow processes.” A workflow refers to the sequences of steps in a process. Process refers to the manner in which work is performed to achieve a particular result. (Amatayakul, 2017)
In both of these cases, the flow of diet order origination and execution seemed to have faced a number of obstacles. Would a carefully mapped out workflow and process map have prevented a six-hour delay in the delivery of gelatin or was this an outlier? Is the simultaneous use of both paper documents and the EHR adding steps in the workflow and process of the staff in the outpatient surgical areas? Was a workflow study completed after the implementation of the EHR to determine if time and resources were being utilized most efficiently and effectively?
This is where health informatics, in our evolving, technological world, can play a bigger role . It is the health informatics professional’s job to carefully evaluate the workflow processes and improve them with the use of health information technology. These two real world examples paint a picture beyond the paper definition of “health care informatics.” The health informatics professional’s job is to ensure all the pertinent health care information is collected and entered correctly, is comprehensive, accurate and available for healthcare decision-makers, creating the most seamless workflow and quality of care for everyone involved.
Health care information has been a fundamental component of AHIMA’s mission since 1928 when the Association of Record Librarians of North America (ARLNA) was first formed at the request of the American College of Surgeons to impart standards in clinical records. While the format of these records has changed, the job of the health information management professional is still to know where and when this information is collected, how it is being used and where it is shared and stored.
About the author: Patty Buttner, RHIA, CDIP, CHAS, CCS, is a director of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members. She authors and provides technical reviews for AHIMA publications and articles on ICD-9-CM, CPT and ICD-10-CM/PCS topics and clinical documentation improvement (CDI). Buttner serves as faculty for CDIP Exam Preps and Academies, CDI Academies, CHDA Exam Preps and ICD-10-CM/PCS Academies.
Most people, patients and health professionals alike, have heard the term “informatics,” but they may not really know what it means.
Even a simple Google search of the term “health informatics” produces a variety of definitions. The American Health Information Management Association (AHIMA) Pocket Glossary of Health Information Management and Technology identifies the concept of informatics as the following:
“Scientific discipline that is concerned with the cognitive, information-processing and communication tasks of health care practice, education and research, including the information science and technology to support these tasks.”
Recently, I witnessed how effective informatics can better play a role in patient care in various health care settings. One of the settings included outpatient surgical departments in both a small and a large hospital. I found it very interesting that even in this electronic age, much of the paperwork associated with a same day surgical procedure was still housed in a binder in paper format, and this was the case in both hospitals. Staff had to check both the electronic health record (EHR) and the paper binder for all pertinent documents and information for each patient. I thought about how this likely impacted the workflow of the clinicians and staff. After surgery, the staff was seen either attending to the patient or standing in front of computers on wheels entering vital signs and charting progress.
During an inpatient stay on a separate visit, I observed some confusion over dietary orders and noted that it took six hours to obtain a serving of Jell-O. Would this have happened in the days of 100 percent paper records? I can’t answer that for sure, but the confusion seemed to stem from one order for “nothing by mouth” (NPO) status that had not been canceled by the provider. Although a new order for a regular diet had been written, the provider’s documentation was not clear whether this most recent order should be carried out or not.
Right outside the door of the hospital room I could overhear the nurses’ conversation and confusion related to the dietary order. Finally one nurse said, “Well since the order for the regular diet was written after the order for NPO, let’s go with the newest order.”
This led me to think: If it takes six hours to get a diet order figured out, is there also confusion about the medication orders and all the other care orders? And what kind of impact could this lack of clarity cause when carrying out patient care?
Here I could see how workflow and processes are essential to compiling an EHR. Several of the tasks listed in Domain 4 of AHIMA’s Certified Professional in Health Informatics (CPHI) outline deal with “workflow processes.” A workflow refers to the sequences of steps in a process. Process refers to the manner in which work is performed to achieve a particular result. (Amatayakul, 2017)
In both of these cases, the flow of diet order origination and execution seemed to have faced a number of obstacles. Would a carefully mapped out workflow and process map have prevented a six-hour delay in the delivery of gelatin or was this an outlier? Is the simultaneous use of both paper documents and the EHR adding steps in the workflow and process of the staff in the outpatient surgical areas? Was a workflow study completed after the implementation of the EHR to determine if time and resources were being utilized most efficiently and effectively?
This is where health informatics, in our evolving, technological world, can play a bigger role . It is the health informatics professional’s job to carefully evaluate the workflow processes and improve them with the use of health information technology. These two real world examples paint a picture beyond the paper definition of “health care informatics.” The health informatics professional’s job is to ensure all the pertinent health care information is collected and entered correctly, is comprehensive, accurate and available for healthcare decision-makers, creating the most seamless workflow and quality of care for everyone involved.
Health care information has been a fundamental component of AHIMA’s mission since 1928 when the Association of Record Librarians of North America (ARLNA) was first formed at the request of the American College of Surgeons to impart standards in clinical records. While the format of these records has changed, the job of the health information management professional is still to know where and when this information is collected, how it is being used and where it is shared and stored.
About the author: Patty Buttner, RHIA, CDIP, CHAS, CCS, is a director of HIM Practice Excellence for AHIMA. She provides professional practice expertise to AHIMA members. She authors and provides technical reviews for AHIMA publications and articles on ICD-9-CM, CPT and ICD-10-CM/PCS topics and clinical documentation improvement (CDI). Buttner serves as faculty for CDIP Exam Preps and Academies, CDI Academies, CHDA Exam Preps and ICD-10-CM/PCS Academies.