Information systems in healthcare

Introduction into Health Services and Information Systems

Incorporating information technology into healthcare systems can improve provider practices, increase the quality of patient care, and reduce medical errors. Clinical Information Systems can support patient care in a direct manner by providing healthcare providers with access to relevant clinical information that is both timely and complete. In these types of systems, healthcare practitioners are also capable to use clinical information to diagnose, treat, and manage patient care; However, Clinical Information Systems are commonly absent in most long term care facilities. Most long term care facilities are missing out on clinical data being stored in an information system that is able to assist the facility by bettering management of chronic conditions, increasing efficiencies, and improving access to information. Venetian Gardens is a skilled nursing facility located in Loveland, Ohio. Skilled nursing facilities are licensed healthcare facilities that are inspected and regulated annually by a state’s Department of Health Services. They accommodate the needs of patients who either need short-term rehab while recovering from surgery, or require long-term nursing and medical supervision. Venetian Gardens offers services such as skilled nursing, rehabilitation, and long–term care; they also participate in Medicaid and Medicare. Venetian Garden’s facility in Loveland is a for-profit corporation chain that can house up to 99 residents; they currently house 92 residents.

The facility serves mostly the elderly population, but they do also house mentally and/or physically handicapped residents of all ages that need assistance with activities of daily living. They are issued a license from the state licensing bureau. The state also conducts surveys in order to certify the facility and to provide services to eligible Medicare and Medicaid beneficiaries. The users of health information are any individuals who enter, verify, correct, analyze, or obtain information, either directly or indirectly. All the users of health information effect patient care in some way, but they use the information for numerous reasons and in diverse ways. For example, primary users such as physicians and nurses refer to the health information of specific patients as their daily work. Secondary users, such as accreditation organizations and licensing bodies, never have direct access to the health records of individual patients. Instead, they use the clinical and demographic information collected from health records. At Venetian Gardens, primary users of health information record their services directly in their patients’ health records. Registered Nurses, Licensed Practical Nurses, and Certified Nurse Assistant’s all are primary users of health information at the facility and they are responsible for providing and documenting patient care. Administrators and patient care managers supervise the services provided to patients within the facility.

The health information provides data needed to evaluate the performance of individual patient care providers and to determine the effectiveness of the services provided. According to Mark Abler, HIM Administrator of Venetian Gardens, “The health records of patients serve as critical tools for interconnecting important information, services provided, patient care, etc., throughout departments and the facility.” The state licensing bureau also analyzes health information to determine whether the facility is complying with licensing regulations in the area. Venetian Gardens has paper medical records and an electronic information system. The security of the paper health records is of a vital importance throughout the entire facility. The records are filed in locked storage unit that also serves as protection from fire. Access to the health records storage room is restricted to authorized staff only. As stated by Mark Abler, “The patient medical records consist of all information relating to the patient, such as dietary information and daily personnel care. If a record is needed, let’s say by a patient care provider, they submit a request for the record. It is then retrieved by an authorized employee and is directly forwarded to the patient care provider. The patient care provider then must sign the record out in the log book. Security is a top priority when it comes to medical records, any move made when it leaves the storage shelf is recorded and tracked.

This reduces any risk of inappropriate access, tampering, or loss of records.” The electronic information system at Venetian Gardens consists of billing and financing. This system is similar to the health records in terms of security. Only authorized users can access the software using a username and password. Mr. Abler also stated that every employees that uses electronic information must sign a user agreement that covers patient confidentiality and discretion. The facility uses paper health records along with the PracticeSuite Billing System. The software is Medicare certified and provides the ability to maintain, track, and recall patient accounting, billing, collection letters, and general accounting information. The facility’s reason for purchasing the software was to provide fast and efficient client/facility billing. The system also specializes in reports for patients, such as patient ledgers, balance summary, balance detail, referrals summary, and insurance authorization. The PracticeSuite Billing System supports electronic Medicare payment posting, Medicare Part A and B, and electronic Medicare claims. The software is very user-friendly for employees and is also very secure of behalf of their patients. When asked the greatest strength of the billing software, Mr. Abler stated, “There are several great benefits of using the software, such as reduced number of errors and reduced paper waste. However the greatest strength of the software is the overall ability to perform several efficient functions. Functions include claims generated and submitted electronically, productivity reports, and accounts receivable reports.” There are few disadvantages of the software in terms of functions performed. Mr. Abler said, “The system definitely has room for improvement in terms of functions performed, but I would have liked to see more interactive software that involves patient registration, transfers, and discharges.” The biggest weakness of the software was the initial high costs.

The facility had to purchase computers and printers, as well as the installation for the computers. They also had to purchase the billing software. When all the costs were totaled the facility took a little hit financially, but now with all the reduced errors and time efficiency gained, it seems as if the system has been well worth the cost. Venetian Gardens maintains an efficient staff and facility through policies regarding paper health records and their electronic billing system. The security of patient information is of upmost importance and the facility and employees work diligently every day to protect the rights of their patients. A Clinical Information System would greatly benefit Venetian Gardens due to its capability for increased accessibility to information. All patient information could be interconnected throughout the entire facility. All health records, dietary information, and daily personnel care could all be accessed together whenever and where ever as needed. There are an array of benefits from upgrading their software to a clinical information system, such as better management of chronic conditions, greater efficiencies, increasing the quality of patient care, and reducing medical errors through alerts and reminders.


(Center for Medicare/Medicaid Services, 2013)

(Council on Aging of Southwestern Ohio, 2013)

(Johns, M., 2010). Health Information Management Technology (3rd ed). AHIMA Press. Retrieved from

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