Supplements

Information management

Copyright © 2006 Society of Hospital Medicine

Information management refers to the acquisition and utilization of patient data for key hospital activities that include but are not limited to direct patient care. Optimal care of hospitalized patients and optimal work flow require basic clinical information systems. Advanced clinical information systems also provide decision support, which may include computer based provider order entry, event monitoring, electronic charting and bar coding. Hospitalists use local systems to acquire data and information that support optimal medical decision making at the point of care. Hospitalists can lead or coordinate efforts within their institution to develop, utilize and update clinical information systems to improve patient outcomes, reduce costs, and increase satisfaction among providers.

KNOWLEDGE

Hospitalists should be able to:

  • Describe how hospital information systems are utilized by different departments to manage patient registration and financial data, process clinical results, and schedule appointments and tests.

  • Identify and describe how to access available sources of reference information, which may include literature search engines, online textbooks, electronic calculators and practice guidelines to support optimal patient care.

  • Explain how information systems can facilitate the practice of evidence based medical decision making.

  • Explain how computer physician order entry (CPOE) with decision support favorably impacts on patient safety in the hospital setting.

  • Explain potential pitfalls of the use of CPOE.

  • Describe potential advantages and disadvantages of written and electronic patient records.

  • Explain the limitations of different forms of data and data systems available to clinicians and how information systems can facilitate timely and accurate clinician submissions of bills.

  • Explain Health Insurance Portability and Accountability Act (HIPAA) regulations and their impact on management of patient information.

SKILLS

Hospitalists should be able to:

  • Efficiently retrieve and interpret data, images, and other information from available clinical information systems.

  • Interpret data from digital devices, which may include EKG monitors, glucometers, or oxygen saturation monitors.

  • Access and interpret information from internet‐based clinical information systems when available.

  • Interpret results incorporating statistical principles of probability and uncertainty.

ATTITUDES

Hospitalists should be able to:

  • Recognize the limitations of acquisition devices or equipment, and use clinical judgment to interpret results that fall either within or outside the expected ranges.

  • Recognize the influence of individual patient factors in the interpretation of available information.

  • Adhere to principles of data integrity, security and confidentiality.

  • Lead, coordinate or participate in multidisciplinary initiatives to adopt hospital information systems that improve efficiency and optimize patient care.

  • Lead, coordinate or participate in multidisciplinary initiatives to continuously improve hospital information systems and physician practice patterns by providing constructive feedback and advice in system development.

  • Advocate for order entry systems that promote patient safety and ease of use.

  • Advocate for information decision support to facilitate efficient and optimal medical management.

  • Identify issues, provide feedback, and resolve conflicts within an information systems framework.

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