With any endeavor in healthcare, there are definitions and acronyms that one has to be familiar with to effectively communicate. This is particularly true in the area of healthcare information management. The glossary at the end of this chapter lists many of these terms. With respect to information systems, Ledley and Lusted (52) in 1960 defined an information system as consisting of three essential components: a system for organizing or documenting the information in a file; a method or a routine for accessing the information in the file; and a method to ensure that the information was current. Lindberg (53) took the definition a step further and concluded that a medical information system (MIS) (or what we now would call an EHR) contained a set of formal arrangements by which healthrelated facts, those concerning the individual health of the patient as well as the care of that patient, were stored and processed in computers (27, 28, 29). Based on this conception, an MIS is a complex hierarchical integration of multiple systems that include an inpatient hospital information system (HIS); an outpatient information system; and clinical support systems, such as pharmacy, radiology, and laboratory information systems. In most current configurations, this can include an inpatient EHR, an outpatient EHR (sometimes integrated with inpatient), as well as ancillary departmental systems for laboratory and pharmacy. A true EHR would contain a longitudinal patient record that contains the complete health status and healthcare delivery of an individual patient from birth to death. Only a few, mostly closed, healthcare systems have even approached such an integrated information system (e.g., Kaiser Permanente), even so, patients often venture outside of such systems for some of their care over the course of their lives.

Both ambulatory and inpatient information systems usually include administrative and financial (or practice management) components and clinical components, all of which are usually separate systems. Administrative information systems (AISs) include data elements such as patient demographic, eligibility, and payer data; patient identification, registration, and appointment schedules; hospital admission, discharge, and transfer (ADT) data; bed census or occupancy data; cost accounting; resource utilization; employee records; and inventory. Generally, AISs are the first computer applications implemented in a hospital or outpatient setting.

Clinical information systems (CISs) are designed to manage information concerning the direct care of the patient and are the foundation of the EHR. The CIS contains both objective and subjective clinical data. Because the practice of medicine and the delivery of healthcare is a dynamic process, the functional requirements of a CIS are continually changing as new treatments, procedures, and diagnostics evolve. However, any CIS has some essential core functions. Some of these functions include an electronic medical record (EMR) that can communicate and manage patient data from multiple sources (e.g., pharmacy, radiology, surgery, laboratory) within the healthcare delivery system; provide healthcare workers with decision support tools; provide a clinical database for epidemiologic research; support medical education; maintain patient confidentiality; and satisfy the requirement for the integrity, reliability, and security of patient data.

In the United States, the hospital has been recognized since the 1960s as the natural laboratory for automation and computerization in healthcare. This realization was partly due to the complexity and scope of the information available within the bounds of a single organization, and the fact that the hospital represented the largest segment of the healthcare industry, commanding over 50% of all healthcare spending (54). Economies of scale dictate that a hospital would have access to much greater IT resources than, say, a small independent physician practice. Additionally, hospitals have regulatory requirements for collecting information and developing rates for defined outcomes such as mortality, length of stay, and costs for various diagnoses and surgical procedures (55, 56, 57). Indeed, the hospital setting is probably the most sophisticated segment of the healthcare market with respect to information management. However, to date, less than 10% of US hospitals can truly call themselves “paperless” across all disciplines, departments, and functions, and 85% of the outpatient record remains paper based. The US government’s 2009 HITECH stimulus program supporting “meaningful use” of EHRs (discussed below) hopes to rapidly stimulate much greater adoption.

The basic kinds of information that hospitals require and manage have changed little since the early 1960s. What has changed is the volume of that information and the recognition that numerous providers need simultaneous access to the information. Because of these factors and healthcare’s insatiable demand for information, the EHR has become a key emerging technology in US hospitals. What differentiates an EHR from a compilation
of departmental information systems within a hospital is the integrated database (18,58, 59, 60). Friedman and Dieterle (18) have called integration the “holy grail of hospital computing.” To effectively use patient care data to improve outcomes and manage care, hospitals need access to fully integrated information. The primary function of an EHR is to communicate data (58). To perform this function, an EHR must have software and hardware components that allow the computer to acquire, process, store, retrieve, and rearrange data, and then display that data throughout the institution. The premise that underlies this design strategy is that many providers, including the medical staff, nurses, pharmacists, radiology, laboratory, respiratory therapy, physical therapy, occupational therapy, dietary, and so on, create patient care data, and those providers need access at almost all times to a variety of patient care data. The key is that the provider-created data must be inclusive. Within an integrated EHR, the design should allow for patient data to be entered once and then be available for all users. Ideally, data should be entered at the point of care. For example, the temperature of a patient should be entered into the database at the bedside, once the healthcare provider has obtained the temperature. This allows for maximum use of patient data, since clinical data are now temporally related to the course of hospitalization. This temporal relationship allows providers to analyze the patient’s clinical progress and to relate outcomes to specific events during hospitalization. Point-of-care data entry goes beyond the human provider and is equally applicable to automated devices and analyzers, for example, ventilators or blood chemistries. The technology to accomplish this automated point of care data capture is readily available (61).

The inefficiencies of the paper medical record absorb large amounts of a hospital’s budget and are directly responsible for many of the failures in the quality of care delivered, including medication errors, misdiagnosis, and poor record keeping. Over the years, HISs and current EHRs have demonstrated many benefits, but perhaps the three that will have the greatest impact on healthcare delivery and cost are (a) improved logistics and organization of the medical record to speed care, prevent duplication of data and procedures, and improve the caregiver’s efficiency; (b) automatic computer review of the medical record to aid decision support, limit errors, identify exceptions in care, and identify those in need of care; and (c) systematic analysis of present and past clinical experiences and outcomes to guide future practice and policies (1,14,30).