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Patty Buttner

Understanding the need for effective health information systems

From the August 2017 issue of DOTmed HealthCare Business News magazine

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:

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“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?
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