Introduction to Healthcare Information Technology - PowerPoint Presentation

Slide1

Introduction to Healthcare Information Technology

Chapter FiveMedical Business OperationsSlide2

Objectives

Define frequently used healthcare termsIdentify and describe the functions of certain healthcare departmentsDescribe the uses for clinical softwareList and describe the steps in the clinical process or environmentIdentify

and describe the functions of various medical devices

2Slide3

Healthcare IT: Challenges and Opportunities

Health care is one of the largest industries in the US14.2 million workersBureau of Labor Statistics forecast:Over 3 million new jobs in healthcare between 2008 and 2018Home healthcare servicesOne of the fastest growing areas until 2018

3Slide4

Medical Terminology

HealthcareSpecialized terminologyNumerous acronymsImagingOften called radiologyUse of technologies to provide visual representation of internal body structures

Can eliminate the need for biopsies or surgery in some cases

4Slide5

Medical Terminology (cont’d.)

Major types of imaging technologiesX-rayCT scanFluoroscopyMagnetic resonance imaging (MRI)Ultrasound

Nuclear medicine

Newer techniques

Capsule endoscopy

5Slide6

6

Figure 5-1 Modern x-ray machine

© Tyler Olson/www.Shutterstock.comSlide7

Primary Care Physician

Over 20 physician specialties in medicinePrimary care physician specialtiesFamily or general practiceBroad range of ailments and chronic disordersInternal medicineAdult diseases and chronic disorders

Pediatrics

Diagnosis and treatment of children

7Slide8

Stat

Term meaning “immediately”Derived from Latin word statim8Slide9

Acuity

Measure of the degree of patient disease or injuryCan refer to:SeverityTime sensitivityPhysical effectsPsychological sufferingHigh-acuity patient less healthy than low-acuity patient, in general

9Slide10

Code Blue

Emergency codeIndicates patient needs immediate helpCan be announced over the public address systemExpedites correct staff moving to location where patient needs help

10Slide11

Trauma Levels

TraumaPhysical wound or injury to the bodyMay be caused by accident or violenceCommonly treated at hospital ERsTrauma centerCenters classified according to their ability to handle different types of trauma

11Slide12

12

Table 5-1 Trauma center levels and resources

© Cengage Learning 2013Slide13

Controlled Substances

Controlled Substances Act of 1970Established government control of certain drugs and chemicals known as controlled substancesClassification scheme with five levelsSchedule 1 substancesHigh abuse potential

No currently accepted medical use

Schedule 2 substances

Can cause dependence

High abuse potential

13Slide14

Controlled Substances (cont’d.)

Schedule 3 substancesLower abuse potential than schedule 1 and 2Example: drugs containing less than 15mg hydrocodone per dosageSchedule 4 substancesLower abuse potential than schedule 3Examples: diazepam, alprazolam, propoxyphene

Schedule 5 substances

Cough and cold preparations with limited quantities of certain narcotics

14Slide15

Controlled Substances (cont’d.)

Healthcare providers that use controlled substances:Have well-defined policies and procedures for useExample controlled substance policy componentsLocked storageStaff authorization to accessSubstance abuse protocol

Substance audits

15Slide16

Electronic Medical Record

Medical record (chart)Location where provider records aspects of diagnosis and treatmentElectronic medical recordCan be viewed by authorized individuals anywhere in the worldCan be interfaced to other electronic systems

Lab or radiology results can be instantly updated

Controlling access can be more difficult than with paper record

16Slide17

Electronic Health Record

Broader than an EMRIncludes demographics, billing, and all historical medical informationGives providers the widest possible perspective on a patientPotential for abuse of information exists

17Slide18

Medical Departments

Ambulatory/day surgeryProvides surgery on an outpatient basisBehavioral healthProvides care for mental disordersCardiac care unitsTreat patients requiring specialized cardiac monitoring

18Slide19

Medical Departments (cont’d.)

CardiovascularIncludes advanced cardiac specialtiesElectrophysiologyHeart failureHeart transplantationDermatology

Treats skin diseases:

Usually on an outpatient basis

19Slide20

Medical Departments (cont’d.)

Ear, nose, and throatAlso called otolaryngologyFacial plastic surgeryLaryngology (voice)Neuro-otology (middle/inner ear, base of skull)Otology (ear)

Rhinology (sinuses)

20Slide21

Medical Departments (cont’d.)

Emergency roomTreats patients with life-threatening condition or immediate needCertified to a specific trauma levelIntensive care unitTreats patients needing high level of specialized careCan include intensive monitoring with electronic equipment

Patient may need ventilator, feeding tubes, etc.

21Slide22

Figure 5-3 Intensive care monitoring

© Edwin Verin/www.Shutterstock.comSlide23

Medical Departments (cont’d.)

LaboratoryProvides chemical, microbial, microscopic, and other studies to diagnose and treat injuryMedical/surgicalCare for adult patients before and after surgeryNuclear medicine

Uses radioactive decay of radiopharmaceuticals to diagnose and treat disease

23Slide24

Medical Departments (cont’d.)

Obstetrics/gynecologyProvides care for the female reproductive systemObstetrics provides care surrounding childbirthOB/GYN related departmentsFamily birth center

Labor and delivery

Neonatal intensive unit

24Slide25

Medical Departments (cont’d.)

Occupational therapyCare for patients recovering from injury to regain work-related skillsHelping people with disabilities accomplish self-care tasksOncologyCare for cancer patientsOperating room

Department where surgical operations are conducted

25Slide26

Medical Departments (cont’d.)

OphthalmologyDiagnose and treat various eye conditionsPediatricsSpecialized treatment for childrenPatients may be medium or high acuityPhysical therapy

Assists patients to regain lost range of motion

26Slide27

Medical Departments (cont’d.)

Plastic surgeryProvides reconstruction of the human bodyPost-anesthesia care unitProvides care during recovery from anesthesiaRadiologyProvides imaging equipment using x-ray, ultrasound, or nuclear isotopes to diagnose disease or injury

27Slide28

Medical Departments (cont’d.)

RespiratoryProvides breathing treatments for inpatients or outpatientsBronchodilatorsPulmonary rehabilitationMechanical ventilationTransitional/progressive care unit

Provides transitional care between CCU/ICU and standard care unit

28Slide29

Clinical Software

SoftwareSet of instructions that helps hardware process data into informationClinical softwareUsed to manage data and information in a clinical environment

29Slide30

Patient Tracking

Patient tracking software benefitsTracks services providedManages patient demographicsManages patient visit historyTracks time-specific illnesses like allergies

Many patient tracking systems can interface with scheduling, medical records, and lab software packages

30Slide31

Scheduling

Scheduling software manages patient scheduling processCapabilitiesQuickly scan for open appointmentsTrack patient cancellations, no-shows, and reschedulesTrack patient visits by time of check-in and departure

31Slide32

Order Entry

Computerized physician order entry (CPOE)Electronic systems transmit physician’s orders to other healthcare professionalsAdvantages of CPOEInstant availability of patient’s medical historyCurrent information helps prevent unwanted drug interactions

Statistical reports improve resource management

Linking diagnoses to the order improves billing management

32Slide33

Billing/Coding/Auditing

Billing software helps manage billing processSoftware decision engines can validate claimsSubmits claims to appropriate payerInternational Statistical Classification of Diseases and Related Health Problems Codes (ICD-9)

List of over 13,000 codes used in billing

ICD-10

Complete revision of the diagnosis code set

Includes about 68,000 codes

33Slide34

34

Table 5-2 ICD-9 and ICD-10 code examples

© Cengage Learning 2013Slide35

Billing/Coding/Auditing (cont’d.)

Audit softwareComputer algorithms determine whether correct CPT and ICD codes are usedCan use historical data for trending and analysis to predict and improve performance

35Slide36

Practice Management

Practice management software (PMS) functionsPatient trackingSchedulingComputerized physician order entryBillingCoding

Audit

PMS can be interfaced with EMR systems

36Slide37

The Clinical Environment

Clinical process (clinical environment)Sequence of operations that must occur for the patient to be examined, diagnosed, and treatedMay vary by environmentCommon features of the clinical environment

Registration, consultation, examination, CPOE, dictation/transcription, referrals

37Slide38

Registration

Patient must be registered or admitted:Prior to being seen by medical staffExamples of patient data collected during registrationContact informationBilling informationNext of kin

Current medications

Other pertinent information

38Slide39

Consultation

Also known as medical historyQuestions about pain levels, location, and intensityBrief history of activity:To determine if behavior or actions contributed to the illness

39Slide40

Examination

Checking the patient’s physical statusVital signsBody temperatureBlood pressurePulse rateRespiratory rateInitial examination normally performed by nurse or other medical professional

Patient examined in more detail by a physician

40Slide41

Physician Order Entry

Process of storing and transmitting orders to other healthcare providersTypes of order entryHandwritten or typed paper ordersVerbal ordersCPOE

Digital signatures

Encrypted messages similar to handwritten signatures

Allow for electronic transmission and storage

41Slide42

Dictation/Transcription

Used with verbal ordersCentralized voice-recording system shared among physiciansTranscriptionist transcribes orders to electronic, paper, or film format

42Slide43

Referrals/Consults

Physician may refer (send) patient to another professional for further diagnosisConsultCommunication between physicians or specialists regarding a patient’s diagnosis or treatment

43Slide44

Medical Devices

FDA regulates the manufacture and distribution of medical devices in the USDefinition of medical deviceRecognized in the official National Formulary or the United States Pharmacopoeia

I

ntended

for use in the diagnosis

or prevention of disease

Intended

to affect the structure or

function

of the body

without chemical action

44Slide45

Computerized Axial Tomography Scanner

TomographyImaging technique in which sections are created by a penetrating waveComputerized axial tomography (CAT or CT)X-ray system in which the tomography is created by computer processingAdvantages of CAT scans

High contrast resolution

Tissues that differ in density may be distinguished

45Slide46

Electrocardiogram Machine

Electrocardiogram (EKG or ECG)Two-dimensional representation of electrical heart activityRead by trained professionals to detect heart disease or abnormalityEKG machinesCommonly transported by hand or small cart

46Slide47

Electroencephalograph Machine

Measures ionic current flows within the brain’s neuronsUsually portable and transported by utility cartTrained professionals can read EEG:To determine disorders such as coma, epilepsy, and brain death

47Slide48

Glucose Monitor

Portable electronic device that directly reads level of glucose in the bloodResults available in secondsUsed in diagnosis of diabetes mellitus

48Slide49

Magnetic Resonance Imaging

Uses very strong magnetic fields to create image of internal body structuresCertain viewpoints more easily obtained than with other imaging techniquesGreater detail of internal body structures compared with traditional techniquesMRI machinesLarge (room-size)

C

omplex

49Slide50

Figure 5-6 Human brain scan from an MRI

© Donna Beeler/www.Shutterstock.comSlide51

Portable X-Ray Machine

X-ray machineUses x-rays to cast static shadows of internal body structures on film or image sensorLarge devices (typically room-size)Portable x-ray machine

Can be transported to the patient:

In cases where patient cannot be easily transported to a traditional x-ray machine

Machines are portable yet heavy

51Slide52

Positron Emission Tomography

Positronic emission tomography (PET) scansCertain radiopharmaceuticals behave in different ways in different body organsRadiopharmaceutical administered to a patient emits gamma raysPET scanner creates 3D image of tracer concentrationScanners are large and complex

52Slide53

Ultrasound

Uses high-frequency sound waves to image soft tissue structuresImage quality less detailed than x-ray or other technologiesUltrasound usesEvaluating fetal health during pregnancyEvaluating blood flow to the brainDiagnosis of heart abnormalities

53Slide54

Vascular/Nuclear Stress Test

Cardiac stress testUsed to determine the heart’s response to physical stress Vascular or nuclear stress testUses radiopharmaceuticals that emit gamma rays

Gamma camera captures detailed images of blood flow in the heart

54Slide55

Vitals Cuff

Standard baseline measurementsBody temperatureBlood pressurePulse rateRespiratory rateVitals cuff

Device that integrates the entire vital sign measurement process

55Slide56

Medical Interfaces

Standards for exchange of health informationHealth Level Sevene-prescribingContinuity of Care Document (CCD)Continuity of Care Record (CCR)International Statistical Classification of Diseases and Related Health Problems,

10

th

Revision

(ICD-10

)

Current Procedural Terminology (CPT)

56Slide57

Medical Interfaces (cont’d.)

Standards for exchange of health information (cont’d.)Systematized Nomenclature of Medicine (Snomed)National Drug Code ID (NDCID)Picture archiving and communication system (PACS)Evaluation and Management Coding (E/M codes)

57Slide58

Summary

Health care has specialized terminology and numerous acronymsHospitals have different medical departments that provide different types of patient careClinical software is used to manage and manipulate data and information in the clinical environmentThe healthcare environment workflow may include registration, consultation, examination, physician order entry, dictation/transcription, and referrals or consults

58Slide59

Summary (cont’d.)

Medical devices are used to diagnose and treat patients and are regulated by the FDAThere are many interfaces and standards that support information sharing between devices and systems

59