Hospital Italiano EHR System
The Hospital Italiano de Buenos Aires (HIBA) is a non-profit health care academic center in Argentina.
The Hospital Italiano is a private hospital sited in Buenos Aires city, in Argentina. The Health Information Department is working since 10 years in a Electronic Health Record system focused in the first step of development in the ambulatory care and then in the inpatient registry. The system is developed by open source tools like PHP language and JAVA, and works with Oracle databases in the backend. Up to now the system has the following modules: ADT, Outpatient management, Inpatient management, EMR, Pharmacy and Laboratory results on line. The EMR works with terminology server (matching with SNOMED), web based DRG's and their own medical thesaurus. .
Statistics about Hospital Italiano de Buenos Aires
The Hospital Italiano de Buenos Aires was founded in 1853. It has over 1,500 physicians and 3,500 employees. In the domain of healthcare delivery, HIBA has a network of 2 hospitals with 750 beds (200 for intensive care) 500 home care patients under care, and 23 clinics. It has an insurance plan that covers approximately 150,000 people and also coordinates insurance for another 1,500,000 people who are covered by affiliated insurers. Each year over 36,000 inpatients (pediatric and adult) are admitted to our hospitals that are located in the city of Buenos Aires and suburban area. More than 2,400,000 outpatient visits from patients from all over the country and Latin America.
Information added and edited by Jorge Rodriguez - Department of Databases - Ministery of Health. Government of Buenos Aires
Overview of Hospital Italiano CIS
In 1998, development began on the electronic medical record system of Hospital Information Department. The first step was to develop the ambulatory system. Professional involved in first design of the system were: Fernan Bernaldo de Quiroz, MD - Daniel Luna, MD - Paula Otero, MD between others.
The Hospital Information Department is working since more than 10 years in a Electronic Health Record system focused in the first step of development in the ambulatory care and then in the inpatient registry. The system is developed by open source tools like PHP language and JAVA, and works with Oracle databases in the backend. Up to now the system has the following modules: ADT, Outpatient management, Inpatient management, EMR, Pharmacy and Laboratory results on line. The EMR works with terminology server (matching with SNOMED), web based DRG's and their own medical thesaurus. For more information see History (in spanish)
Up to now the Hospital Italiano has an intranet with more than 1,700 workstations and a fully integrated EHR system.
The regional importance of this development is that it was the first integrated EMR in private hospitals in Argentina using terminology server and SNOMED, and one of the most rubust in Latin America.
Information added by Paula Otero - Department of Medical Informatics - Hospital Italiano de Buenos Aires
Building our Clinical Information System: Project ITALICA
Until the 90’s HIBA was primarily focused on delivering acute care and the hospital information system had been developed for the automation of administrative, billing and reimbursement tasks. With the emergence of our own insurance plan and the growing need of the ambulatory care we were directed to expand our information systems beyond the administrative arena.
In the year 1998 HIBA decided to gradually implement a Healthcare Information System (HIS) by incorporating the clinical layer to the administrative applications that were already in use. It is an in-house project that currently handles all the information related to healthcare both clinical and administrative from capture to analysis. As part of the project that was called ITALICA, the Department of Medical Informatics was created in 2001 involving over 110 people between clinicians, IT professionals and technicians. Our Department of Medical Informatics works on the development and maintenance of the hospital’s health information system. Before the decision of informatizing the clinical layer, all the administrative and financial areas were computerized in legacy systems that needed to be integrated in a HIS, and at the time the project started a patient could have up to 40 different ID´s depending on what area of the hospital they were being treated. There was an urgent need of the implementation of physical interoperability and the use of standards in order to achieve semantic interoperability.
In order to achieve physical interoperability HL7 version 2.x was implemented so as to create fluent communication between three components that had been found: the administrative component that included not only financial and administrative issues but also took care of ADT (admission, discharge and transport), the ancillary services component that included Laboratory and Radiology that already had informatics applications working on their Departments and finally the clinical component that would be developed as had to be integrated with the other components. The focus was made on achieving all the data for a medical encounter or test and the patient characteristics were stored in patient centered health information system so the “medical encounter” would be the main axis of the information model. Once the physical interoperability was solved, the creation of local Master Files mapped to standard terminologies and classifications were created in order to achieve semantic interoperability. The following Master Files were created:
- Master Patient Index (MPI)
that allows the unequivocal identification of patients. The quality of the data included is guaranteed by correct identification of data from different centers of registration within the institution and a constant audit of data, process, and registration operators. The CORBAMed conceptual model was used to create this master file.
- Master File of Healthcare Professionals is a part of the MPI where all the healthcare professionals that work at the Hospital are assigned a role according to the specialty and type of work done. This master files also interacts with the Master Files of Professional Areas that identifies on what type of area a professional works.
- Master File of Payors and Insurers all the payors that have a contract for healthcare delivery with the Hospital are included in this application.
- Master File of Medical Tests==: includes all the tests that are carried out at the Hospital (lab, radiology, pathology, etc.) each test has its description, attributes for ordering and information for patients regarding preparation and additional information for the ordering of the test for healthcare professionals.
- Master File of Drugs and Medical Devices==: in this master file all the information for each drug that is needed to interact with the CPOE is included (8).
- Master File of Diagnosis==: includes all the information harvested from the EHR as a medical problem or healthcare encounter at different levels of care, this information is stored in a clinical data repository so it can be used for Clinical Decision Support Systems.
The Master Files that include clinical terminology: diagnosis, medical tests, drugs and medical devices are stored in clinical terminology server that handles a local interface terminology and uses SNOMED CT as reference terminology.
The Terminology Server is a software composed of a local interface vocabulary (thesaurus) mapped to a reference vocabulary, SNOMED CT. The Terminology Server also has capabilities to reject invalid terms already flagged as not appropriate for the intended use The key objective of our Terminology Server project was to build a local Interface Terminology that allowed users to record clinical data choosing options from a list of familiar terms but storing information SNOMED CT compatible.
The Interface Terminology provides adequate coverage for our reality. Users have the ability to refine terms, choosing a more specific option of a given term, and propose new terms to improve coverage. The system also provides the equivalence of a given local term in standard classifications. A “Terminology Team” is in charge of the maintenance of the Interface Terminology. The Terminology Server maps from our local Interface Terminology to standard classifications like ICD-9CM, ICD-10 or ICPC2 through the SNOMED CT standard cross-maps mechanism and concepts included in the local Interface Terminology that are not present in the original SNOMED CT distribution, are mapped through its super-types, the more general, standard concepts used for represent their meaning. The local Interface Terminology was implemented in our health information system on June 2006 using a set of Terminology Services.
The first area was the inpatient structured discharge summary input. Subsets for Diagnosis and Procedures are used in a user interface that allows text input and search of related terms. The user interface uses the rules for dealing with invalid, ambiguous and refinement rules. We are also using a model for dynamic subset definitions, that are a set of rules that allow the definition of a subset in terms of their relationships with SNOMED CT concepts. In this way we can define in the local Interface Terminology a “Diabetes Subset” with all the terms related to the concept “Diabetes Mellitus” in SNOMED CT or any of its subtypes.
The Electronic Health Record
Our electronic health record is patient centered and problem oriented and currently is working in the outpatient, inpatient and emergency care settings with different modalities of implementation. We have recently implemented a Picture Archive and Communication Systems (PACS) and a Signal Archive and Communication System (SACS) so as to have a multimedia EHR, meaning that there is full interoperability between images and the EHR, and the images and signals can be seen directly from the EHR application. A Chronic Disease Management Systems (CDMS) that uses clinical information from the EHR has been also implemented. This CDMS enable health care providers to surveillance and manage patient within our HMO that have diabetes and hypertension among other chronic conditions. This program was awarded with the “Best International Disease Management Program” prize, during the 5th Annual DMAA (Disease Management Association of America) Conference in 2003, Chicago, USA. A Personal Health Record was created that will help patients participate more actively and interact with different areas of our HIS. We are currently involved in a project with Duke University for the implementation of a clinical decision support system called “Sebastian” that works between institutions in two languages (English and Spanish).
For a list of publications of this professional team refer to Published work section.