AVERAGE HEALTH LITERACY SCORES OF ADULTS WHO GOT INFORMATION ABOUT HEALTH ISSUES FROM NEWSPAPERS MAGAZINES AND BOOKS OR BROCHURES BY GENDER 2003

Tìm thấy 10,000 tài liệu liên quan tới từ khóa "AVERAGE HEALTH LITERACY SCORES OF ADULTS WHO GOT INFORMATION ABOUT HEALTH ISSUES FROM NEWSPAPERS MAGAZINES AND BOOKS OR BROCHURES BY GENDER 2003":

TOPIC 2

TOPIC 2

TOPIC 2Recently, the number of children had injuries and neglect in Vietnam remainshigh. Injury is responsible for nearly 75 percent of deaths among children older than oneyear of age, according to the Viet Nam Multi-center Injury Survey. The leading causesinclude drowning, traffic accidents, and inadequate supervion of parents or caregivers. Asa public health worker in the future, I have some recommendations to reduce injuries andneglect in children in Vietnam.First, in many cases, children had injuries due to the inadequate supervison ofparents and caregivers. In addition, parents and caregivers do not have a properperception about the responsibility of ensuring children’s safety for example they are toobusy of working or they do not have time to take care of their children so they let theirchildren alone. In this case, the children are easy to get injured such as drowning, falls,electric shock... In order to solve this situation, I recommend to increase theresponsibility of parents and caregivers by making policies about the parentingresponsibility, emphasizing about the children care responsibility and children’s rights.Second, the parents and caregivers do not have proper knowledge of how toprotect their children from being injured. Therefore, I have a recommend to have acommunication campaign to firstly provide parents and caregivers with the knowledge ofinjury’s risk factors and secondly have consulting services about parenting such as how tomake your home environment safety for children or how to treat and protect yourchildren properly. In addition, the communication campaign will provide parents andcaregivers with supervision guildlines and some children care meterials or even trainningprograms.In conclusion,
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Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, UNITED STATES, 2017

Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger, UNITED STATES, 2017

This schedule includes recommendations in effect as of January 1, 2017. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP) statement for detailed recommendations, available online at www.cdc.govvaccineshcpaciprecsindex.html. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (www.vaers.hhs.gov) or by telephone (8008227967). Suspected cases of vaccinepreventable diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC online (www.cdc.govvaccineshcpadmin contraindications.html) or by telephone (800CDCINFO 8002324636).
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FRANCHISE PRESENTATION

FRANCHISE PRESENTATION

Passionately Caring INTRODUCING THE BUSINESS FRANCHISE OF NA SPA Passionately Caring CONTENT NA SPA PROFILE PROCESS TO SECLECT FRANCHISEES SUPPORTING FROM FRANCHISOR ALL FEES RELATING TO BUY A FRANCHISE BRAND HISTORY • 1996 The first outlet was opened as a haircare massage salon by Madam Ngoc Anh in Ho Chi Minh city, Vietnam. • 1997 The salon was converted to a traditional therapy practice in response to local regulations on massage therapy. • 1998 Tama Company Limited was established to develop Ngoc Anh as a brand in the spa massage industry in Vietnam, and the first official Ngoc Anh Spa was launched at 348 Cach Mang Thang 8 Street, District 3, Ho Chi Minh city, Vietnam. Passionately Caring BRAND HISTORY • 2000 The Second outlet was established at 311 Nguyen Binh Khiem Street, Dakao Ward, District 1, Ho Chi Minh city, Vietnam. The outlet is still in operation until today. • 2003 The third outlet was launched at 93 Nguyen Binh Khiem St., District 1, Ho Chi Minh city, Vietnam in response to the increasing needs of Ngoc Anh’s guests. • 2009The third outlet was relocated to 85 Mai Thi Luu Street, District 1, Ho Chi Minh city, Vietnam Passionately Caring BRAND HISTORY • 2011 VinaSpa School was established focusing on professional training for massage therapists in Vietnam • 2014 NA International Spa Development JSC was established to own the global rights of Ngoc Anh spa and to develop the brand globally through franchise model. Passionately Caring VISSION To become a respected global oriental brand in the health wellness industry Passionately Caring MISSION Passionately Caring We are committed to building a global community who consistently care for the health and wellness of our guests by providing professional, quality, natural products services with a heart to serve. VALUES • We will always strive for excellence and innovation in everything we do. • Our partnerships are built upon integrity trust. • We foster a culture of joy and passion. • We care for people with our heart and pledge to build better lives for our community. Passionately Caring ACCESSIBL E AUTHENTIC GENEROUS SPIRITED WHOLESOME BRAND CORE DRIVERS Passionately Caring MAIN LOGO Passionately Caring Passionately Caring DESIGN CONCEPT STEP 1 • Getting information from franchisees • Providing information about the brand and franchise model • Sending and receiving Franchise application form STEP 2 • Meeting between Franchisor and potential franchisees STEP 3 • Sening Letter of Intent (LOI) • Receiving the signed LOI STEP 4 • Sending Subfranchise agreement template • Meeting and discussing the contract to go through • Signing Subfranchise agreement STEP 5 • Deploying and implementing the project PROCESS TO SELECT FRANCHISEES Passionately Caring 1. TRAINING: Support training of executives and staff Support recruitment, training and providing Therapists SUPPORTING FROM FRANCHISOR Passionately Caring 2. OPERATION: Support managing the project from locating outlet till opening. Support providing an experienced manager in operating for the first month open. Providing operating manual in accordance with the standard of NA Spa. Inspecting, evaluating and recommending all actions to help develop outlet monthly. SUPPORTING FROM FRANCHISOR Passionately Caring SUPPORTING FROM FRANCHISOR 3. SUPPIER: Provide a list and referral all suppliers who provide equipments and smallwares using at spa base on the standard of NA  Provide design concept and referral design partner. Passionately Caring 4. MARKETING: NA company directly implements the programs to promote the Brand. Guiding and supporting to franchisees planning Local Store Marketing to promote outlet at surrounding area. Supporting and providing all POSM need to use for LSM program at the branch area. SUPPORTING FROM FRANCHISOR Passionately Caring Passionately Caring 5. FINANCE: Support evaluating the potential of outlet. Support forecasting the investment budget, revenue, profit, cash flow, ability, and investment payback period for franchisee partner. SUPPORTING FROM FRANCHISOR Passionately Caring ALL FEES RELATING TO BUY A FRANCHISE 1. License fee for 5 years (pay right after signing contract) 2. Royalty fee (8% over monthly revenue) 3. Marketing fee (2% over monthly revenue) Passionately Caring MAI HUONG NGUYEN General Manager NA Spa International Development Corporation Mob: (+84) 907 920 612 Email: huongmainnaspa.com CONTACT Passionately Caring
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COUNTABLE AND UNCOUNTABLE NOUNS

COUNTABLE AND UNCOUNTABLE NOUNS

Countable and uncountable nounsCountable nouns are the words for things that we can count. Countable nouns have singular and plural forms.Examples are: boy, boys, girl, girls, flower, flowers, book, books, chair, chairs, student, students etc.A singular countable noun requires an article or another determiner (e.g. the, my, this etc.) with it.I ate an orange. (NOT I ate orange.)She put the book on the table. (NOT She put book on table.)Would you like a piece of cake?Where shall I put my coat?Uncountable nouns are the words for things that cannot be counted. Uncountable nouns cannot be usedwith a/an. Also, they do not have plural forms.I would like some advice. (NOT I would like some advices.)Have you got any information? (NOT Have you got any informations?)Mix the water with the flour.Here are some examples of common uncountable nouns: advice, air, anger, beauty, behavior, damage, furniture,happiness, homework, information, meat, luggage, progress, safety, money, knowledge, water and work.You have to be careful with uncountable nouns because they can be countable in your language. Remember thatuncountable nouns are considered as singular and hence they should be followed by singular verbs.The meat has to be cooked properly.The information that we received from him was not correct.Your rude behavior upsets everyone.Stay on top of your writing! Download our grammar guide from www.englishgrammar.org to stay up-to-date.Powered by TCPDF (www.tcpdf.org)
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Computer EMAIL CHỨNG CHỈ B

COMPUTER EMAIL CHỨNG CHỈ B

From: vn7070tr7474gmail.com To: tien1234gmail.com Cc: Subject: computer. Hi, Tien How are you? Since I received your email, I have been happy that you have just bought a new computer. You said me: “Do you like playing games on the computer? I love it very much. It’s League legends game. Do you know it? Also, I use the computer to find information, buy something online from shop, share news and photos with my friends and you. When you have free time, you can contact me by Facebook, Skype and Gmail. Moreover, computer is being used for watching a movie or listening to songs. It’s simple for you. Besides advantages of computer, it can be so bad for you. Firstly, it can affect your health. For example: your eyes can be short sighted that eyes problems resulting from staring at the screen such a close distance from your face. Other health problems can arise from too much body inactivity when sitting in front of the computer for too long such as your neck may be hurt. You can be addicted to games then you will neglect your learning. Spending too much time on your computer can be bad for your life. You would use computer reasonable. This is all my answer to your email. Do you agree with me? I look forward to hearing from you. Love
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GIẢI BÀI TẬP SGK TIẾNG ANH LỚP 12 CHƯƠNG TRÌNH MỚI: REVIEW 2 (UNIT 4 - 5)

GIẢI BÀI TẬP SGK TIẾNG ANH LỚP 12 CHƯƠNG TRÌNH MỚI: REVIEW 2 (UNIT 4 - 5)

2. e3.g4. a5. d6. b7 .cSkills (Kỹ năng) - trang 72 Review 2 (Units 4 - 5) SGK tiếng anh 12 mớiTổng hợp các bài tập trong phần Skills (Kỹ năng) - trang 72 Review 2 (Units 4 - 5) SGK tiếng anh 12mớiSKILLSREADING1Read the text about advertising and the media.Đọc bài viết về quảng cáo và truyền thông.VnDoc - Tải tài liệu, văn bản pháp luật, biểu mẫu miễn phíAdvertising and the mass mediaHaving the power to deliver information to large audiences at the same time, the mass media havenaturally become ideal tools for advertising. This huge industry has reached and dominated almost alltypes of the mass media. Advertisements are everywhere, from broadcast media (the radio, television
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GIÁO ÁN TIẾNG ANH LỚP 7 Unit 4 tiết 25

GIÁO ÁN TIẾNG ANH LỚP 7 Unit 4 tiết 25

A. Objectives: By the end of the lesson Ss will be able to revise these words about the library. Reading about one of the world’s largest libraries SS practise listening and reading skills. B. Preparation: Text book, cassette player C.Procedure: I. Organization Date ...............................Class 7A .......... Absentee ......................................... Date ...............................Class 7B .......... Absentee .......................................... Date ...............................Class 7C........... Absentee ......................................... Teacher''s activities Ss'' activities II.Warm up and check: T ask ss to repeat the prepositions of place III. New lesson: 1. Listening: a- Pre listening * Open prediction - Ask Ss to look at the picture P48 and guess what books are on the racks and shelves(2,3,4+5,6+7) - Give feedback b- While listening - Read and open the tape2 times and ask Ss to listen to the tape and check their predictions - Get feedback and correct c- Post listening * Write it up - Ask Ss to work individually to write sentences about the position of books in the library, using the grid 2. Reading: a- Pre reading * pre teach (to) receive (example) (to) contain (example) an employee (translation) * Checking : rub out and remember * T/F Prediction - Give the poster with 5 statements and ask Ss to predict information about the text which they are going to read 1. The Library of Congress is in New York. 2. It receives copies of all English books. 3. There are over 100 million books in this library. 4. The shelves are about 300 km long. 5. 5,000 people work in the library - Get feedback b. While reading - Ask Ss to read the text in B4 to check their predictions - Correct mistakes * Questions : lucky numbers - Ask Ss to work in 2 teams to play the games and answer the questions 1d 2* 3e 4b 5* 6a 7c - Monitor the game and praise the winner c. Post reading - Draw the table and ask Ss to compare their school library with the library of congress Call one student complete the table on the board IV. Production: -Ask ss to learn by heart B4 ( class 7A) V . Homework: - Write it up: Ask Ss to write a paragraph to compare the school library with the library of Congress . - Work individually Work in groups - Answer key: No Guess Listen 1 Study center 2 Science and math 3 Geography, history 4 +5 newspapers and magazines 6+7 English 8 Librarian’s desk - Work individually - Choral repetition - Individual repetition Record - Work individually to predict information 1. 2. 3. 4. 5. - Whole class Read the text then correct the prediction * Answer key: 1 F 2. F 3.T 4.F 5. T - Teamwork * Answer key a. It''s in Washington DC, the capital of the USA b. It has over 100 million books c. It has about 1,000 km of selves d. Over 5,000 people work there e. Because It receives copies of all American books - Work individually * Answer key: Your school library The library of Congress Smaller v more modern v Has more books v has shorter bookshelves v more employees v largest v
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10 1111J 1744 6171 1995 TB00519 X

10 1111J 1744 6171 1995 TB00519 X

1985),several gaps exist in the research literature. Forexample, few studies have actually examined the relationship between obesity and children’s self- esteem.Further, the conclusions drawn from investigations int h area have been contradictory.Some studies have found that obese children reportlower levels of Self-esteem than do their nonobese peers(Sallade, 1973; Strauss, Smith, Frame, & Forehand, 1985).Other studies have either failed to find sigxuficant differences (Bell, Kirkpatrick, & Rim, 1986; Wadden, Foster,Brownell, & Finley, 1984)or have found equivocal results(Mendelson & Wkute, 1982; Worsley, 1981).A similar pattern of conflicting results has been found in studies ofobesity and other indicators of children’s and adolescents’ self-perceptions, such as body esteem and totalesteem (Hendry & Gillies, 1978; Mendelson & White,1982; 1985; 19911, and distortion of body- image (Bell etal.; Leon, Bemis, Melland, & Nussbaum, 1978).-have not addressed these issues. For example, the measurement tools used in most studies have been criticizedfor being &dimensional, or for measuring global selfesteem by summing the scores on different areas of performance (Harter, 1986; Rosenberg, 1979), and for notaddressing developmental differences among variousage groups (Harter, 1985). Unidimensional measures,and those that sum over different areas of self-concept,tend to mask both the complexity of self-perceptionsandddferences in patterns of self- perceptions between obeseand average-weight children. Virtually no research hasexamined whether obese children who exhibit low selfesteem differ from high self-esteem obese children, oraverage-weight cluldren, in their patterns of self-perceptions or in the cognitive defenses they use to maintainself-esteem.The author’s purpose was to address these issues byexploring not only whether differences in self-esteemexist between average-weight and obese children, but
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Báo cáo về Bảo hiểm nhân thọ ở Indonesia, Thái Lan, Vietnam

Báo cáo về Bảo hiểm nhân thọ ở Indonesia, Thái Lan, Vietnam

There are significant differences across the three countries, with people in Vietnam much more likely to have “Insurance product” compared with people in Indonesia and Thailand. For example, while 47.5% of Thai respondents and 44.0% of Indonesian respondents possess insurance product, this compares with 72.8% of those in Vietnam.  The highest proportion of life insurance ownership seen in Thailand where 90.9% of Thai individuals who own Insurance product purchased “Life Insurance”.  However, less people have a life insurance in Indonesia and Vietnam, with the lowest number of life insurance holder occurring in Indonesia (38.3%).  “Support Risk Accidents” becomes the top product of life insurance which selected by 62.2% of Thailand’s respondents. Meanwhile, “Health insurance option” is more common in Indonesia, where 82.2% of people say they purchased health coverage.  On the other hand, the most common products of Life Insurance in Vietnam are “Support Risk Accidents” and “Health Insurance”, with 55.0% and 55.5% respectively. “AIA Thailand” has the strongest impression registered in the mind of the surveyed respondents in Thailand. Among Indonesia’s respondents, “Prudential” leaves the most impression on consumers’ mind, while in Vietnam, the result shows the dominance of “Prudential”, “Bao Viet” and “AIA”.  People in Indonesia and Vietnam are most likely to have contract with “Prudential”: 62.4% and 71.1% of respondents in those countries respectively have a contract with “Prudential”. On the other side, 50.6% respondents in Thailand mostly choose “AIA Thailand” insurance company.  Thailand and Indonesian people relied more on “Insurance Agency” to find out information about the life insurance product with 54.8% and 66.3%. On the other side, respondents in Vietnam prefer to find out about the life insurance product by visiting “official site of insurance company” (48.6%).  Both Thailand and Indonesia respondents decided to purchase a life insurance policy through an “Agent insurance” with 61.8% and 69.3%, as opposed to only 27.5% of people in Vietnam. Vietnamese are more likely to have a contract with “Staff insurance” with 67.4%.  In terms of insurance companies considered to get contract previously, “Thai Life Insurance” takes the first place in Thailand (37.8%), while “Prudential” ranks the first in both Indonesia and Vietnam (56.4% vs. 82.1%, respectively)
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Mẫu CV tiếng anh 2 danh cho người mới đi làm

Mẫu CV tiếng anh 2 danh cho người mới đi làm

Personal information: Full name: Sex: female (or male) Date and place of birth: Marital status: single (or married) Health: Excellent. Interest: Music, reading, sports, travel, helping others... Personal features: eagerness to learn, hardworking, work endurance, creativeness, willing to work overtime and far from home even for a long time if necessary.

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LECTURE HEALTH ECONOMICS - CHAPTER 1: INDUSTRY OVERVIEW

LECTURE HEALTH ECONOMICS - CHAPTER 1: INDUSTRY OVERVIEW

a medium-rare hamburgerNote: These slides draw from material in Viscusi WP and Aldy JE, “The Value of a StatisticalLife: A Critical Review of Market Estimates Throughout the World,” The Journal of Risk andUncertainty 2003; 27(1): 5-76.Valuing Human LifeMany of these decisions involve observablemarket choices Purchase Workingof a safety device.on a risky job.These decisions involve implicit tradeoffsbetween risk and money.Economists can use data on these decisionsto construct the value of a statistical life(VSL).Valuing Human LifeExample: How much additional money must a firmoffer a worker to take on a risky job, versus one withno risk?To answer this question, one could compare theaverage wages of risky jobs vs. non-risky jobs.
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HIS chapter 2 ( Tin y học trong bệnh viện)

HIS chapter 2 ( Tin y học trong bệnh viện)

Reinhold Haux Alfred Winter Elske Ammenwerth Birgit Brigl Strategic Information Management in Hospitals An Introduction to Hospital Information Systems 2 2 Basic Concepts 2.1 Introduction Each domain usually has its own terminology which often differentiates from the ordinary understanding of concepts and terms. This chapter presents terminology for hospital information systems and its information management, as used in this book. It is, therefore, essential to read this chapter carefully. All relevant concepts can also be found in the thesaurus at the end of the book. After this chapter, you should be able to answer the following questions: • Which basic concepts are needed in order to work on hospital information systems? • What terms do we use? 2.2 Data, information and knowledge Data constitute a reinterpretable representation of information, or knowledge, in a formalized manner suitable for communication, interpretation, or processing by humans or machines. Formalization may take the form of discrete characters or of continuous signals (e.g., sound signals). In order to be ‘reinterpretable’, there has to be agreement on how data represent information. For example, Peter Smith or 001001110 are data. A set of data which is collected for the purpose of transmission and which is considered to be an entity is called a message. There is no unique definition of information. Depending on the point of view, the definition may deal with the syntactic aspect (the structure), the semantic aspect (the meaning) or the pragmatic aspect (the intention or goal of information). We will simply define information as specific knowledge about objects such as facts, events, things, persons, processes, or ideas. For example, when a physician knows the diagnosis (facts) of a patient (person), then he or she has information. Information as specific knowledge contrasts with general knowledgeabout concepts (for example diseases, therapeutic methods). The knowledge of a nurse, for example, comprises how to typically deal with patients suffering from decubitus. For the sake of simplicity, we will often use the term information processing, when we mean processing of data, information and knowledge. 2. Basic Concepts 19 2.3 Information systems and their components Systems and subsystems Before talking about information systems, let us first define the concept system. As defined here, a systemis a set of persons, things andor events which form an entity, together with their relationships. We distinguish between natural systems and manmade systems. For example, the nervous system is a typical natural system, consisting of neurons and their relationships. A manmade system is, for example, a hospital, consisting of staff, patients and relatives, and their interactions. If a (manmade) system consists of both human and technical objects, it can be called a sociotechnical system. A system can, in principle, be divided into subsystemswhich comprise a subset of all objects and the relationships between them. For example, a possible subsystem of the nervous system is the sympathetic nervous system. A subsystem of a hospital is, for example, a ward with its staff and patients. Subsystems themselves are again systems. Models of systems When dealing with systems, we usually work with modelsof systems. A model is a description of what the modeler thinks to be relevant of a system. In the sciences, models commonly represent simplified depictions of reality or excerpts of it (see Figure 17). Models are adapted to answer certain questions or to solve certain tasks. Models should be appropriate for the respective questions or tasks. This means that a model is only ‘good’ when it is able to answer such a question or solve such a task. For example, a model which only comprises the patients of a ward cannot be used for nurse staffing and shift planning. Information Systems An information systemis that part of an enterprise which processes and stores data, information, and knowledge. It can be defined as the sociotechnical subsystem of an enterprise which comprises all information processing as well as the associated human or technical actors in their respective information processing role. ‘Socio’ refers to the people involved in information processing (e.g., health care professionals, administrative staff, computer scientists), whereas ‘technical’ refers to information processing tools (e.g., computers, telephones, patient Figure 17: A model of a computer is not the real computer. 20 Strategic Information Management in Hospitals records). The people and machines in an enterprise are only considered in their role as information processors, carrying out specific actions following established rules. An information system which comprises computerbased information processing and communication tools is called a computersupported information system. The subsystem of the information system where computerbased tools are used is called the computersupported part, the rest is called the conventional part of the information system. Components of information systems When describing an information system, it can help to look at the following typical components of information systems: Enterprise functions, business processes, application components and physical data processing components. An enterprise functiondescribes what acting human or machines have to do in a certain enterprise to contribute to its mission and goals. For example, patient admission, clinical data management or financial controlling describe typical enterprise functions. Enterprise functions are ongoing and continuous. They describe what is to be done, not how it is done. Enterprise functions can be put together in a hierarchy of functions, where a function can be described in more detail by refined functions. Enterprise functions are usually denoted by nouns or gerunds (i.e. words ending with ing). An activity is an instantiation of an enterprise function working on an individual object. For example, Dr. Doe admits patient Jane Smith is an activity of the enterprise function patient admission. Just as enterprise functions, they can be put together in a hierarchy of activities. In contrast to enterprise functions, activities have a definite beginning and end. To describe the chronological and logical sequence of a set of activities, business processesare useful. They describe the sequence of activities together with the conditions under which they are invoked, in order to achieve a certain enterprise goal. Business processes are usually denoted by verbs (for example, dismiss a patient, document a diagnosis or write a discharge letter). As they are composed of individual activities, they also have a definite beginning and end. We will only refer to enterprise functions and business processes in respect to information processing. Whereas enterprise functions and business processes describe what is done, we now want to have a look at tools for processing data, in particular at socalled application components and at physical data processing components. Both are usually referred to as information processing tools. They describe the means used for information processing. Application components support enterprise functions. We distinguish computerbased from conventional application components. Computerbased application components are installations of software products on computers. A software product is an acquired or selfdeveloped 2. Basic Concepts 21 piece of software which is complete in itself and which can be installed on a computer system. For example, the application component patient management system stands for the installation of a software product to support the enterprise functions of patient admission, management, and discharge. Conventional application components are realized by conventional means such as organizational plans which describe how to use conventional data processing components. For example, the application component nursing documentation organization contains rules how and in which context to use the given forms for nursing documentation. The communication respectively the cooperation among application components must be organized in such a way that the business processes can be executed. Physical data processing components, finally, describe the information processing tools which are used to realize the computerbased and the conventional application components (see Figure 18). Physical data processing components can be human actors (such as the person delivering mail), conventional physical tools (such as printed forms, telephones, books, patient record), or computer systems (such as terminals, servers, personal computers). Computer systems can be physically connected via data wires, leading to physical networks. Architecture and infrastructure of information systems The architecture of an information system describes its fundamental organization, represented by its components, their relationships to each other and to the environment, and by the principles guiding its design and evolution. 13 The architecture of an information systems can be described by the enterprise functions, the business processes, and the information processing tools, together with their relationships. There may be several architectural views of an information system, e.g. a functional view looking primarily at the enterprise functions, a process view looking primarily at the business processes, etc. Architectures which are equivalent with regard to certain characteristics, can be summarized to a certain architectural style. 13 Institute of Electrical and Electronics Engineers (IEEE). Std 14712000: Recommended Practice for Architectural Description of SoftwareIntensive Systems. September 2000. http:standards.ieee.org. Figure 18: Typical physical data processing components on a ward. 22 Strategic Information Management in Hospitals When the focus is put onto the types, number and availability of information processing tools used in a given hospital, this is also called infrastructureof its hospital information system. 2.4 Hospital information systems With the definition of information systems in mind, a hospital information system can easily be defined. A hospital information systemis the sociotechnical subsystem of a hospital, which comprises all information processing as well as the associated human or technical actors in their respective information processing roles. Typical components of hospital information systems are its enterprise functions, business processes, application components and physical data processing components. For the sake of simplicity, we will denote ‘enterprise functions of a hospital’ as ‘hospital functions’. As a consequence of this definition, a hospital has a hospital information system from the beginning of its existence. Therefore the question is not whether a hospital should be equipped with a hospital information system, but rather, whether its performance should be enhanced, for example, by using state of the art information processing tools, or by systematically managing it. All groups of people and all areas of a hospital must be considered when looking at information processing. A sensible integration of each hospital function and of different information processing tools in a hospital information system is important. Hospital staff can be seen in two roles: In one, they are part of the hospital information system. For example, when working in the department for patient records, or as operator in an ICT department, they directly contribute to information processing. In the other role, they use information processing tools (e.g. a nurse may use a telephone or a computer), in other words, they are users of the hospital information system. Each employee may continuously switch between these two roles. The goalof a hospital information system is to sufficiently enable the adequate execution of hospital functions for patient care, including patient administration, taking into account economic hospital management as well as legal and other requirements. Legal requirements concern e.g. data protection or reimbursement aspects, other requirement can be, e.g., the decision of a hospital executive board on how to store patient records. In order to support patient care and the associated administration, the tasksof hospital information systems are: • to make information, primarily about patients, available: current information should be provided on time, at the right location, to authorized staff, in an appropriate and usable form. For this purpose, data must be correctly collected, stored, processed, and systematically documented in order to 2. Basic Concepts 23 ensure that correct, pertinent and uptodate patient information can be supplied, for instance, to the physician or a nurse (see Figure 19); • to make knowledge, for example about diseases and side effects and interactions of medications, available to support diagnostics and therapy; • to make information about the quality of patient care and the performance and cost situation within the hospital available. In addition to patient care, university medical centers undertake research and education to gain medical knowledge and to teach students. When hospital information systems make available • the right information and knowledge • at the right time • at the right place • to the right people • in the right form • so that these people can make the right decisions, this is also described as the information and knowledge logistics of a hospital. Hospital information systems have to consider various areasof a hospital, such as • wards, • outpatient units, • service units: diagnostic (e.g. clinical laboratory, radiological department), therapeutic (e.g. operation room) and others (e.g. pharmacy, patient records archive, library, blood bank), • hospital administration areas (e.g. general administration, patient administration and accounting, technology, economy and supply, human resources), • offices and writing services for (clinical) report writing. In addition, there are the management areas, such as: hospital management, management of clinical departments and institutes, administration management and nursing management. These areas are related to patient care. They could be broken down further. For university medical centers, additional areas, needed for research and education, Figure 20: Different people working in a hospital (here: an emergency department). Figure 19: A health care professional accessing patient information. 24 Strategic Information Management in Hospitals must be added to the above list. Obviously, the most important peoplein a hospital are the patients and, in certain respect, their visitors. The groups of people working in a hospital (see Figure 20) are • physicians, • nurses, • administrative staff, • technical staff, • health informaticians, health information management staff, etc. Obviously, within each group of people, different needs and demands on the hospital information systems may exist, depending on the tasks and responsibilities. Ward physicians, for example, will require different information than physicians working in service units or than senior physicians. 2.5 Health information systems In many countries, the driving force for health care and for ICT in health care during the last years has been the trend towards a better coordination of care, combined with rising cost pressure. One consequence is the shift towards better integrated and shared care. This means that the focus changes from isolated procedures in one health care institution (e.g. one hospital or one general practice) to the patientoriented care process, encompassing diagnosis and therapy, spreading over institutional boundaries (see Figure 21). In the US, e.g. health care organizations are merging into large integrated health care delivery systems. These are health care institutions that join together to consolidate their roles, resources and operations in order to deliver a coordinated continuum of services and to enhance effectiveness and efficiency of patient care. The situation in Europe is also changing from hospitals as centers of care delivery to decentralized networks of health care delivery institutions which are called regional networks or health care networks. Enterprise boundaries are blurring. Hospital information systems will increasingly be linked with information systems of other health care organizations. The future architecture of hospital information systems must take these developments into account. They must be open to provide access or to exchange patientrelated and general data (e.g., about the services offered in the hospital) across its institutional boundaries. Figure 21: A general practitioner, contacting a hospital. 2. Basic Concepts 25 A lot of technical and legal issues have to be solved before the vision of transinstitutional computersupported health information systems will adequately support transinstitutional patient care. For example, general willingness to cooperate with other health care providers must exist; optimal care processes must be defined, and recent business processes be redesigned; accounting and financing issues must be regulated; questions of data security and data confidentiality must be solved, together with questions on data ownership (patient or institution) and on responsibilities for distributed patient care; issues on longterm patient records (centralized or decentralized) must be discussed; and technical means for integrated, transinstitutional information processing must be offered (‘telemedicine’, ehealth), including general communication standards. When dealing with hospital information systems, we will keep these aspects of health information systems in mind. 2.6 Information management in hospitals In general, management comprises all leadership activities that determine the enterprises’ goals, structures, and behaviors. Accordingly, information management in hospitals are those management activities in a hospital which deal with the management of information processing in a hospital and therefore of its hospital information system. The goal of information management is systematic information processing which contributes to the hospitals strategic goals (such as efficient patient care and high satisfaction of patients and staff). Information management therefore directly contributes to the hospital’s success and capability to compete. Information management encompasses the management of all components of a hospital information system: the management of information, of application components, and of physical data processing components. The general tasks of information management are planning, directing, and monitoring. In other words, this means • planning the hospital information system respectively its architecture; • directing its establishment and its operation; • monitoring its development and operation with respect to the planned objectives. Information management can be differentiated into strategic, tactical, and operational management. Strategic information management deals with information processing as a whole, and lays down strategies and principles for the evolution of the whole information system. Tactical information management deals with the execution of certain projects concerning just part of the information system, e.g. the introduction of an application component for a certain hospital function such as patient administration or documentation of operations. Operational information management, finally, must secure the 26 Strategic Information Management in Hospitals smooth operation of the information system, e.g. planning of necessary personal resources, failure management, or network monitoring. 2.7 Examples Example 2.7.1 Architecture of a hospital information system In the following, an extract of the description of the architecture of the hospital information system of the Plötzberg Medical Center and Medical School (PMC) is presented. As mentioned, PMC is a fictitious institution, which will be used in examples and exercises in this book. The hospital information system of Plötzberg Medical Center and Medical School (PMC) supports the hospital functions of patient treatment with patient admission and discharge, decision support, order entry, clinical documentation and service documentation; handling of patient records; work organization and resource planning; and hospital management. Those hospital functions are supported by some bigger and over a hundred smaller application components (partly computerbased, partly conventional). The biggest application component is the patient management system (PMS), the computerbased application component which supports patient admission and discharge, management of patient treatment, part of administrative and clinical data management, and handling of patient records. In addition, several computerbased departmental application components are used for work organization and resource planning (e.g. in the radiological department, in the laboratory department and in outpatient units). Nearly all computerbased application components are interconnected, using a communication server. Some computerbased application components are isolated systems without interfaces ... Conventional application components are used for special documentation purposes (e.g. documentation in operation rooms), and for order entry and communication of findings. … The application components are realized by physical data processing components. As computerbased physical data processing component, approx. 40 application and database servers are operated, and over 4,000 personal computers are used. Over 1,000 printers of different types are installed. Most computerbased physical data processing components are interconnected to a highspeed communication network. … As conventional physical data processing components, over 2,000 telephones and 800 pagers are used. Over 2,000 different paperbased forms are used to support different tasks. More than 400,000 patients records are created and used each year, a dozen archives are responsible for patient record archiving. A conventional mailing system allows for conventional communication between departments. …” 2. Basic Concepts 27 Example 2.7.2 Comments on the future of health information systems For the physicians of the 1990s and beyond, computer workstations will be their windows on the world. Much of the necessary technology already exists. Desktop or bedside, in the office or at the hospital, computers can respond to a simple click of a mouse pointing device. … In the future, the physician will be able to access the patient record largely by using the mouse and doing very little typing. Moreover, the record will include graphics and images as well as extensive text. Outpatient records will be integrated with inpatient data by using the capabilities of communications networks that link hospitals with the clinics and private offices of their medical staff members. … 14 “Through the further development of information systems at the university hospitals, the following goals are of special importance: • Patient based (facilitywide) recording of and access to clinical data for teambased care. • Workflow integrated decision support made available for all care takers through uptodate, valid medical knowledge. • Comprehensive use of patient data for clinical and epidemiological research, as well as for health reports. ... The following tasks shall have priority and will be worked on in the next years: • The introduction of a patient based, structured, electronic health record. • The stepwise introduction of information system architectures which support cooperative, patient centered and facilitywide care. Workflow support in the area of patient care. • The establishment of a suitable network and computer infrastructure in order to be able to, via the Internet, inform about the care offered at a particular hospital. • The introduction of efficient, usable mobile information and communication tools for patient care. ...” 15 From the experience gained so far ..., a number of direct benefits from health telematics can be identified: ... 14 Ball M, Douglas J, ODesky R, Albrigh J. Health care Information Management Systems A Practical Guide. New York: Springer; 1991. p. 3. 15 Deutsche Forschungsgemeinschaft (DFG): Informationsverarbeitung und Rechner an Hochschulen Netze, Rechner und Organisation. Empfehlungen der Kommission für Rechenanlagen für 20012005 (information processing and computer systems for universities; in German), Kommission für Rechenanlagen der Deutschen Forschungsgemeinschaft. Bonn: DFG; 2001. http:www.dfg.de. 28 Strategic Information Management in Hospitals • More people can be diagnosed and treated at their local clinics or hospitals, though without the facilities of urban referral hospitals. For the first time, it is technically feasible to contemplate the provision of universal health care. ... • Health telematics allows the global sharing of skills and knowledge. Access to international centers of excellence for various specialties becomes possible from many locations. Medical expertise can be available to anyone on request. ... • Cost savings can be achieve by reducing the transport of patients and travel of health care professionals, as well as by allowing home care of patients who would otherwise require hospitalization. ... 16 The future tasks of health care include: greater cooperation, more quality and economics and greater adjustment to the needs of patients. The information age offers great possibilities to solve these tasks, maybe even possibilities that we can’t begin to imagine today. The neuralgic point though in the discussion of telematics in health care is the uniting of data. Especially with regard to personal patient data, we are forthright dealing with the most personal of all data, and special caution is to be exercised when dealing with these data. Afterall, questions of power are raised through the uniting of data: greater transparency also means greater control. 17 2.8 Exercises Exercise 2.8.1 HIS as a system As introduced, a system can be defined as a set of people, things andor events, which form an entity, together with their relationships. Which people, things or events can you find when looking at a hospital information system? In what relationship do they stand to one another? To solve this exercise, take into account the components of hospital information systems as defined in section 2.8. Exercise 2.8.2 Goals of models Find two models which represent a city. What are the goals of these models? What are their components? 16 World Health Organization (WHO). A Health Telematics Policy, Report of the WHO Group Consultation on Health Telematics 1116 December 1997, Geneva. World Health Organization: Geneva; 1998. 17 Speech of German Minister for Health, Andrea Fischer, at the occasion of the first meeting of the symposium ‘telematics in health care’, August 19th 1999, Bonn. 2. Basic Concepts 29 Exercise 2.8.3 Information processing tools in a hospital Look at the following Figures 22 25, taken from a University Medical Center. Which information and communication tools are used? Which hospital functions may be supported by those tools? Exercise 2.8.4 Information processing of different health care professional groups Please have a look at the different groups in a hospital (e.g. : physician, nurse, administrative staff, hospital manager, patient, visitor), and describe some of their typical information processing needs. Exercise 2.8.5 Information and knowledge logistics Select one typical business process in a hospital (such as admitting a patient, requesting an examination, planning of therapeutical procedures, documenting diagnoses etc.) and find three examples how information and knowledge Figure 25: In a laboratoryunit. Figure 22: In the office of a senior physician. Figure 23: Admission at a general practitioner. Figure 24: In an intensive care unit. 30 Strategic Information Management in Hospitals logistics can fail. Which consequences may arise for the quality and for the costs of patient care from this failure? Exercise 2.8.6 Buying a HIS Is it possible to buy a hospital information system? Please explain your answer. What do ‘vendors of hospital information systems’ really sell? Exercise 2.8.7 Health information systems Please have a look at the statement on the comments for the future of health information systems (example 2.2). Which chances are discussed, and which problems? 2.9 Summary When working on hospital information systems, we must distinguish between data, information and knowledge: • Data can be defined as a representation of information, or knowledge, suitable for communicating, interpreting or processing. • Information can be defined in connection with objects which have a particular meaning in a specific context (specific knowledge). • Knowledge can be defined in connection with a certain discipline using specific terminology (general knowledge). Systems can be defined as a set of people, things andor events which can be regarded as an entity. Systems can be divided into subsystems and represented using models. Models commonly represent simplified depictions of reality or excerpts of it. Remember that models • usually form a simplified representation of reality, • should be adapted to a specific question or task, and • should be appropriate to provide answers for these question or tasks. A hospital information system can be defined as the sociotechnical subsystem of a hospital which comprises all information processing functions and the human or technical actors in their information processing role. Thus, when looking at a hospital information system, try to identify the following components or objects: • The enterprise, where it is located. • The hospital functions supported. • The business processes which take place. • The information processing tools used. • The human actors involved (both as part of the information system and as users). The goal of a HIS is to 2. Basic Concepts 31 • adequately enable the execution of hospital functions for patient care, • taking financial, legal and other requirements into account. Information and knowledge logistics means to make available • the right information (about patients, ...) and the right knowledge (about diseases, ...) • at the right time • in the right place • for the right people • in the right form • so that these people can make the right decisions. When working on a hospital information system, you must consider • all areas of a hospital, such as wards, outpatient units, service units, administration departments, writing services, management units, .... • all groups of people in a hospital, such as patients, visitors, physicians, nurses, administrative staff, technical staff, health informaticians, .. Information management in hospitals are those management activities in a hospital which deal with the management of information processing and therefore the management of the hospital information system. The architecture of an information system describes its fundamental organization, represented by its components, their relationships to each other and to the environment, and by the principles guiding its design and evolution.
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MELAB SAMPLEESSAYS COMMENTARY 2013

MELAB SAMPLEESSAYS COMMENTARY 2013

It is true that medical doctors are health professionals whose roles are ofgreat importance in the society. They are usually educated and people generallylook up to them to take good care of their health issues. In fact, whether peoplelive or die depends to a very great extend on the doctors in charge of their healthsituations, depending on how serious they are. Almost every one wants a doctorthat is vastly knowledgeable in the medical field, especially those with many years ofexperience.Although I agree that the level of education of a medical doctor is of muchimportance for a doctor to be regarded as a “good medical doctor”, I am also ofthe opinion that that is not the only criterion for a doctor to be regarded as a “goodmedical doctor”. Character and the integrity of the person contribute to a largeextend. I am also of the view that a medical doctor should be a very responsibleperson in the society because alot of people tend to emulate them. Young adultsusually look forward to becoming medical doctors in the future. That being the case,they tend to copy the behaviours of medical doctors they know.The country where I come from, Nigeria, where the health system has someissues, some medical doctors who lack good character and do not care about theirintegrity can, because a patient does not have enough money to pay their medicalbills, walk away from a dying patient. During oath taking, these doctors state thatthey will put patients first before any thing, but some of them do not keep up withthis. Although I agree that doctors in the third world countries usually face somechallenges, I am still of the opinion that when it comes to saving a patient’s life, a goodmedical doctor should always swing into action. In Canada, though I have stayed herefor just a year, I think many of their doctors can be regarded as “good doctors”from the little I have seen.In conclusion, I believe that a well educated doctor without a good characterand integrity and also without a passion to save lives is as good as a “bad doctor”since, with his education but with love for money rather than love for his patient’slives, can still lead to the loss of lives.
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STUDENT SELFASSESSMENT FORM – INFO

STUDENT SELFASSESSMENT FORM – INFO

English Banana.comSchoolsStudent Self-Assessment Form – Information PageThis form can be useful because it gives the teacher more background about a new student’sprevious and current experience of learning English – how they have interacted with thelanguage in the past, and how they are interacting with it now. It can be interesting tocompare a student’s own diagnosis of the level of their skills in reading, writing, speaking andlistening with the results of their initial assessment. For example, it can reveal a lack ofconfidence about learning English when a student rates themselves poorly on this form butachieves a good or above-average result on the initial assessment.Motivation & Learning Goals:It is always useful to find out basic information about a student’s previous experience oflearning English. For example, for how long did they study and what level did they achieve? Ifyou find out that they have only ever achieved a Basic Level certificate in English in the past,yet their initial assessment shows that the student is at Intermediate Level now, you can askthem what work they have been doing on their own in the meantime to improve their skills.Getting a student to complete this form can reveal interesting information about theirmotivation levels when they write about whether or not they read English-language books andmagazines outside of class time, or watch English-language TV at home. It also ties in withthe ILP (Individual Learning Plan) by asking students to talk about their learning goals – whythey want to learn English.Above all, by going through this form with a new student the teacher will get to know thembetter and will be able to ask them more individualised questions about their learning goalsand aspirations, which will better inform the lessons that they prepare and deliver during thecourse.English Banana Schools
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HAS THE MEDIA PAID TOO MUCH ATTENTION TO CELEBRITIES

HAS THE MEDIA PAID TOO MUCH ATTENTION TO CELEBRITIES

Has the media paid too much attention to celebrities?The personal lives of famous people known also as celebrities, havealways been the most alluring part for the media. Regular peopleare always eager to know some interesting information about theirfavorite celebrities, especially about their personal lives. The mediais a very efficient resource of gathering the juiciest facts aboutpersonal lives of our beloved celebrities.I totally agree that the media pays too much attention to thepersonal lives of famous people in order to get as muchinformation as possible. I think, all people, including celebrities,have a right to live a normal life.Unfortunately, celebrities are the victims of their own popularity.Once, they have been noticed by famous newspapers, magazines,and so on, celebrities would be in the center of the people`sattention. For example, gaining the popularity, a new TV-show,called “Celebrities Uncensored”, could show regular tv-watchers themost intriguing facts about personal lives of celebrities. Everyonecould see his favorite celebrity in the most private moments and thenrunning from numerous paparazzi. In my opinion, TV and radiomedias could provide for once unknown persons an immediate fame,but after a certain amount of time, being already celebrities, it wouldbecome very annoying for them. Their personal lives could bedestroyed by the constant appearance of paparazzi from nowhere.Everyone has his own right for life privacy. Celebrities should alsohave this right. Even though some very wealthy celebrities try to“defend” themselves from annoying visiting of media agents by livinga secret and very private life, the media would never leave them,because the more secret is the celebrities` life, the more eager arepeople to know about it. But on the other hand, if celebrities were outof the media`s sights for a long time, regular people would probablyforget about them.
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HIS chapter 3 (Tin y học trong bệnh viện)

HIS chapter 3 (Tin y học trong bệnh viện)

Reinhold Haux Alfred Winter Elske Ammenwerth Birgit Brigl Strategic Information Management in Hospitals An Introduction to Hospital Information Systems 3 3 What do Hospital Information Systems look like? 3.1 Introduction A hospital information system (HIS) was previously defined as the subsystem of a hospital, which comprises all information processing as well as the associated human or technical actors in their respective information processing roles. We will now take a closer look at what hospital information systems look like. We will then present typical functions and processes of hospitals. We will discuss how to describe hospital information systems using appropriate modeling methods. We will in detail describe the three layer graphbased metamodel to describe HIS. Finally, we will discuss typical architectures of hospital information systems. After this chapter, you should be able to answer the following questions: • Which typical hospital functions exist? • Which metamodels exist for modeling which aspects of HIS? • What is the three layer graphbased metamodel (3LGM)? • Which typical information processing tools exist in hospitals? • Which architectural styles of HIS exist? 3.2 Hospital functions In this chapter, typical hospital functions will be presented in greater detail. Patient admission Patient admission (see Figure 26) aims at recording and distributing those patient data which are relevant for patient care and administration. In addition, each patient must be correctly identified, and a unique patient and case identification must be assigned. Subfunctions are: • Appointment scheduling: The hospital must be able to schedule an appointment for a patients visit. In addition, unplanned admissions must be possible (e.g., in case of emergencies). Figure 26: A patient being admitted in a patient admission department. 34 Strategic Information Management in Hospitals Figure 27: Typical organizational media. • Patient identification: A unique patient identification number (PIN) must be assigned to each patient. This PIN should be valid and unchangeable lifelong (i.e. the PIN should not be based on changeable patient’s attributes such as name). The PIN is the main precondition for a patientoriented combination of all information arising during a patients stay. Before a PIN can be assigned, the patient must be correctly identified, usually based on available administrative patient data. If the patient has already been in the hospital, she or he must be identified as recurrent, and previously documented information must be made available (such as previous diagnoses and therapies). If the patient is in the hospital for the first time, a new PIN must be assigned. In addition, the hospital must be able to distinguish between different cases or hospital stays of a patient. Therefore, in addition to the PIN, a case identification is usually assigned. • Administrative admission: Administrative admission starts following patient identification. For example, insurance data, type of admission, details about special services, patients relatives, admitting physician, and referral diagnoses must be recorded. The patient is assigned to a ward and a bed. Some of the administrative data must be made available to other hospital functions through the help of certain organization media (such as labels and magnetic cards, see Figure 27). Administrative data form the backbone of information processing. In case of changes, patient data must be maintained and communicated. If the admitting physician has communicated relevant information (e.g. previous laboratory findings), this information must be communicated to the responsible physician in the hospital. Administrative admission is usually either done in a central patient admission, or directly on the ward (for example, during emergencies or on the weekend). • Clinical admission: The responsible physician and nurse will proceed with the medical and nursing admission. This typically comprises the anamnesis (both by physician and nurse), and the introduction of the patient to the ward. These basic data have to be available for Figure 28: Information of patient’s relatives at a ward. 3. What do Hospital Information Systems Look Like? 35 each of the following hospital functions. • Information: The hospital management must always have an overview of the recent bed occupation, i.e. about the patients staying at the hospital. This is, for example, important for the porters which must be able to inform relatives and visitors correctly (see Figure 28), and also for some general hospital management statistics. Planning and organization of patient treatment All clinical procedures of health care professionals must be discussed, agreed upon, initiated, and efficiently planned. In contrast to patient admission, the management of patient treatment is a continuous task which is initiated each time new information is available. Subfunctions are: • Presentation of information and knowledge: Staff members must be able to access all relevant patient data specific to a situation, in addition to general clinical knowledge (e.g., guidelines and standards) supporting patient care (see Figure 29). • Decision making and patient information: Responsible team members must decide upon the next steps such as certain diagnostic or therapeutic procedures (see Figure 30). Depending on the complexity of a diagnostic or therapeutic decision, they should be able to consult internal or external experts (e.g., in specialized hospitals) to get a second opinion (e.g., about the question if a patient can be transported by exchanging CT images). In this context, (tele)conferences may be useful. Decisions about clinical procedures must be documented. The patient should be included in the decision making process, and his informed consent must be documented as well. • Care planning: The next steps now have to be planned in detail. For each procedure (such as an operation or a chemotherapeutic treatment), the type, extent, duration and responsible person have to be fixed. In nursing, treatment planning is documented in nursing care plans, containing nursing problems, nursing goals, and planned nursing procedures. If necessary, other health care professionals are ordered to execute the planned clinical Figure 29: Infrastructure to access medical knowledge. Figure 30: Regular meeting of health care professionals to discuss care plans for patients. 36 Strategic Information Management in Hospitals procedures (e.g., medical bandaging orders which have to be executed by a nurse). Order entry and communication of findings Diagnostic and therapeutic procedures must often be ordered at specialized service units (e.g., laboratory, radiology, or pathology). These units execute the ordered procedures and communicate the findings or results back to the ordering department. Subfunctions are: • Preparation of an order: Depending on the available service spectrum offered by a service unit, which may be presented in the form of catalogs, the physician or nurse selects the adequate service on an order entry form (see Figure 31). Patient and case identification, together with relevant information such as recent diagnoses, the concrete questions, the service ordered (e.g. laboratory, radiology), and other comments (e.g. on special risks) are documented. An order should only be initiated by authorized persons. • Taking samples or scheduling appointments and procedures: Depending on the type of order, specimens which must be unambiguously assigned to a patient are submitted (e.g., blood samples), or patient’s appointments must be fixed (e.g., in radiological units). During scheduling, the demands of all parties must be fairly balanced (e.g. ordering physician, service unit, patient, transport unit). • Transmission of the order: The order must quickly and correctly be transmitted to the service unit. If a specimen is transferred, it must be guaranteed that the order and specimen can be linked to each other at the service unit. If necessary, modification to already transferred orders by the ordering physician or nurse should be possible. • Reporting of findings: Findings and reports must be transmitted (as quickly as necessary) back to the ordering unit on time and presented to the responsible health care professional. They must be unambiguously assigned to the correct patient. The responsible physician should be informed about new results, and critical findings should be highlighted. Figure 31: Example of an order entry form for laboratory testing. Figure 32: Clinical examination at a pediatrician. 3. What do Hospital Information Systems Look Like? 37 Execution of diagnostic or therapeutic procedures The planned diagnostic, therapeutic or nursing procedures (such as operations, radiotherapy, radiological examinations, medication) must be executed (see Figure 32). The hospital must offer adequate tools and resources (e.g. staff, room, equipment) for necessary procedures. It is important that changes in care planning which may be due to new findings are directly communicated to all involved units and persons, enabling them to execute them as quickly as possible. Clinical documentation The goal of clinical documentation is to record all clinically relevant patient data (such as vital signs, orders, results, decisions, dates) as completely, correctly and quickly as possible. This supports the coordination of patient treatment between all involved persons, and also the legal justification of the actions taken. Data should be recorded in as structured a form as possible. It is important that data can be linked by patient and case identification, even when data originate in different areas (such as ward, service unit, outpatient unit). Usually, the hospital has to fulfill a lot of different legal reporting (such as epidemiological registers) and documentation requirements. Often, data must be adequately coded (for example, using the International Classification of Diseases, ICD10 18 , for diagnoses codes). The content of clinical documentation depends on the documenting unit and the documenting health care professional group (such as documentation by nurses or physicians, documentation in outpatient units or in operation rooms). Clinical information should be available for other purposes such as accounting, controlling, quality management, or research and education. Subfunctions are: • Nursing documentation (see Figure 33) comprises the documentation or the nursing care process (nursing anamnesis, care planning, procedure documentation, evaluation and reports writing), together with documentation of vital signs, medication, and other details of patient care. 18 World health organization (WHO): Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD10). http:www.who.intwhosisicd10 Figure 33: Nursing documentation on a ward. 38 Strategic Information Management in Hospitals • Physician documentation comprises the documentation of medical anamnesis, diagnoses, therapies and findings, and also documentation for special areas (such as documentation in intensive care units) or special purposes (such as clinical trials). It also comprises order entry for service units and for other health care professional groups (such as nurses). Administrative documentation and billing The hospital must be able to document all services carried out in a correct, complete, quick and patientoriented way. Those data are then the basis for the hospitals billing. The administrative service can also be used for controlling, cost center accounting and internal budgeting, cost responsibility accounting (i.e. the presentation of costs with regard to the source, for example a patient), and for other economic analysis. In addition, some of the data must be documented and communicated due to legal requirements. During administrative documentation, diagnoses and procedures are recorded in a standardized way, and then processed. Administrative documentation should be at least partly derivable from clinical documentation. To support administrative documentation, adequate catalogs must be offered and maintained, containing lists of typical diagnoses and procedures relevant for a unit or a hospital. Patient discharge and referral to other institutions When patient treatment is terminated, the patient is discharged and referred to other institutions (e.g., a general practitioner, or a rehabilitation center). Administrative patient’s discharge contains the initiation of final billing and the fulfillment of legal reporting requirements (e.g. statistics on diagnoses and procedures). Clinical and nursing patient’s discharge comprises the completing of documentation and writing of a discharge report. The hospital must be able to transmit this and other information (e.g., radiological images) to the other institutions as quickly as possible. To speed up this process, a short report (i.e., physicians discharge letter) is often immediately communicated to the next institution, containing for example the diagnoses and therapeutical propositions, which is then later followed by a more detailed report. Handling of patient records Relevant data and documents must be created, gathered, presented and stored such that they are efficiently retrievable during the whole process of patient treatment. This storage is primarily done in patient records. Usually, a certain amount of legal requirements must be considered. Subfunctions are: • Creation and dispatch of documents: Medical documents, such as physician letters and surgical reports, should be easy to create, be available on time and be patientoriented. Already documented information should be reusable as much as possible (e.g. laboratory results and coded diagnoses should be 3. What do Hospital Information Systems Look Like? 39 reusable for the discharge report). All documents should be signed with author and date of generation. • Management of documentation for special areas or special purposes and clinical registers: They should by easy to create and maintain, for example, to support quality management, research, or individual departments. Already documented data (e.g. from clinical documentation) should be reusable as much as possible. Queries for a given subset of patients should be possible. • Coding of diagnoses and procedures: Basic medical data such as diagnoses and procedures should be easy to document in a structured way. Basic dataset documentation serves for the internal hospital reporting structure as well as for the fulfillment of legal requirements. • Analysis of patient records (see Figure 34): All data from patient records (whether computerbased or not) should be available on time and in an easy, comprehensive and structured way. Therefore, a uniform structure for the patient record is useful. Healthrelated data are very sensitive, the hospital must, thus, guarantee data protection and data security. • Archiving of patient records: After discharge of the patient, patient records must be archived for a long time (e.g. for 10 or 30 years, depending on the legal regulations). The archive must offer enough space to allow the longterm storage of the created patient records. Their authenticity and correctness can be proven more easily, e.g. in case of civil actions, when they are archived in accordance to legal regulations. • Administration of patient records: The hospital archive must be able to manage patient records and make them available upon request within a defined timeframe. The exact location of each record should be available (e.g. in which archive, on which shelf). Lending and return of records (e.g. for recurring patients) has to be organized (see Figure 35), while respecting different access rights which depend on the role of the health care professionals in the process of patient care. Figure 34: Analysis of the patient record. Figure 35: Documenting the lending of patient records which have been ordered by clinical departments. 40 Strategic Information Management in Hospitals Work organization and resource planning The hospital must offer sufficient and wellorganized resources for patient care. This is true for wards (ward management), outpatient units (outpatient management), and service units (department management). Subfunctions are: • Scheduling and resource allocation: Resources needed for patient care are, for example, staff, beds, rooms and devices. Resource management, therefore, comprises staff planning, bed planning, room planning and device planning. All resource planning activities must be harmonized with each other. When procedures are scheduled, the interests to decide on the appointment of both the service unit and the ordering unit must be harmonized. Request, reservation, confirmation, notification, postponement and cancellation must be supported. All involved staff members and the patients should be informed about the next relevant appointments. Postponement and cancellations should be communicated in time to all involved persons. • Materials and pharmaceuticals management (see Figure 36 and 37): Supply and disposal of materials, food, drugs and so on must be guaranteed. All departments of the hospitals should be able to order them, based on uptodate catalogs. The corresponding service units (stock, pharmacy, kitchen) must be able to deliver correctly and on time. • Management and maintenance of equipment: Various medical devices are used in hospitals. They must be documented and maintained according to legal legislation. • General organization of work: An efficient process organization is extremely important for hospitals, for example in outpatient units or service units. This can be supported, for example, by offering working lists, by reminding of next appointments, or by visualizing optimal processes. • Office communication support (see Figure 38): The hospital must be able to support communication between all persons involved in patient care. This comprises synchronous (e.g., telephone) and asynchronous (blackboards, brochures, email) communication. Staff members must be contactable within a definite time. Figure 36: The stock of drugs on a normal ward. Figure 37: In the central pharmacy of a hospital. Figure 36: The stock of drugs on a normal ward. 3. What do Hospital Information Systems Look Like? 41 • Basic information processing support: The hospital must support basic information processing tasks such as writing letters or calculating statistics. Hospital management Hospital management supports the organization of patient care and controls the financial issues of the hospital. One of the main tasks is recording and billing of all accountable services. Subfunctions are: • Quality management: Quality management supports a definitive quality of structure, process and outcome of the hospital. This covers, for example, internal reporting containing quality indices. Quality management requires information about patients and treatments as well as knowledge about diagnostic and therapeutic standards. • Controlling and budgeting: The hospital must be able to gather and aggregate data about the hospitals operation in order to control and optimize it. This covers, for example, staff controlling, process controlling, material controlling, and financial controlling. • Costperformance accounting: For controlling purposes, it is necessary to keep track of services, their costs and who has received them. This covers for example, accounting of cost centers, cost units and process cost. • Financial accounting: All hospitals operations which deal with companies values (for example, money, values, fortune, debt) have to be systematically recorded according to legal requirements. Financial accounting comprises, for example, debtor accounting, credit accounting, and facility accounting. • Human resources management: This contains all tasks for the development and improvement of the productivity of staff. It comprises, for example, staff and position planning, staff recording, staff scheduling and staff billing. • General statistical analysis: The hospital must support general statistical analysis, for example calculation and analysis of economic data. Examples {Example for an index of hospital functions?} Figure 38: A physician communicating by phone with a general practitioner. 42 Strategic Information Management in Hospitals Exercises Exercise 3.2.1 Differences in hospital functions Please have a look at the hospital functions presented in this chapter. Now imagine a small hospital (for example, 350 beds) and a big university medical center (for example, with 1,500 beds). What are the differences between both hospitals with regard to their functions? Please explain your answer. Exercise 3.2.2 Different health care professional groups and hospital functions Please have a look at the hospital functions listed in this chapter. Analyze the relationships between the hospital functions and the different health care professional groups (physicians, nurses, administrative staff, others) working in a hospital. Which hospital functions are performed by which health care professional group? Please create a table with health care professional groups as columns, hospital functions as rows, and the following symbols as content in the boxes: ’++’ = hospital function is primarily performed by this profession; ’+’ = function is also performed by this profession; ’‘ = function is not performed by this profession; ‘.’ = neither ‘++’, ‘+’ nor ‘‘. Summary Typical main hospital functions are • patient admission with appointment scheduling, patient identification, administrative admission, clinical admission, and information processing; • planning and organization of patient treatment with presentation of information and knowledge, decision making and patient information, and care planning; • order entry and communication of findings with preparation of an order, preparation of specimen or scheduling of appointments and procedures, transmission of the order, and reporting of findings; • execution of diagnostic or therapeutic procedures; • clinical documentation with documentation performed by physician’s and nurses; • administrative documentation and billing; • patient discharge and referral to other institutions. These hospital functions are typically supported by functions such as • handling of patient records with creation and dispatch of documents, management of documentation for special areas or special purposes and 3. What do Hospital Information Systems Look Like? 43 clinical registers, coding of diagnoses and procedures, and analysis, archiving and management of patient records; • work organization and resource planning with scheduling and resource allocation, materials and pharmaceuticals management, management and maintenance of equipment, support in the general organization of work, office communication support, and basic information processing support; • hospital management with quality management, controlling and budgeting, costperformance accounting, financial accounting, human resources management, and general statistical analysis. 3.3 Modeling hospital information systems Modeling HIS is an important precondition for their management: What we cannot describe, we usually cannot manage adequately. We will present some types of information system metamodels, describing different aspects of HIS, and present some smaller examples of HIS models. HIS models and metamodels A model was defined in chapter 2.3 as a description of what the modeler thinks to be relevant of a system. The significance of models is based on their ability to present a subset of the (usually complex) reality and to aggregate the given information in order to answer certain questions or to support certain tasks. That means that models should present a simplified, but appropriate view of a HIS in order to support its management, and operation. Models should be appropriate for respective questions or tasks. Examples of questions or tasks which are important with regard to hospital information systems could be: • Which hospital functions are supported by a HIS? • Which information processing tools are used? • What are the steps of the business process of patient admission? • What will happen if a specific server breaks down? • How can the quality of information processing be judged? A model is only good when it is able to answer given questions or can support a given task (such as detection of weaknesses, or planning the future state of HIS). The better you can see a HIS, and the better a model assists you in managing it (e.g. in identifying good or also critical parts of HIS), the better the model is. Thus, the model you select depends on the problems or questions you have. When looking at the amount of possible (and important) questions and tasks, it is clear that a large number of different classes of models exists. The class of a model is described by its metamodel We can distinguish some typical metamodelswhich each describe a class of similar models. Metamodels describe the modeling framework which consists of: 44 Strategic Information Management in Hospitals • modeling syntax and semantics (the available modeling objects together with their meaning), • the representation of the objects (how the objects are represented in a concrete model, e.g. often in a graphical way), • the modeling rules (e.g. the relationships between objects), • and (sometimes) the modeling steps. Just as different architectural views on HIS exist, there also exist various metamodels. Typical types of metamodels for HIS are: • functional metamodels, focusing on hospital functions which are supported by the information system, i.e. on the functionality of a HIS; • technical metamodels that are used to built models describing the information processing tools used; • organizational metamodels that are used to create models of the organizational structure of HIS; • data metamodels, used for building models of the structure of data processed and stored inside a HIS; • business process metamodels, focusing on the description of what is done in which chronological and logical order; • enterprise metamodels, that combine different submodels to an integrated, enterprisewide information system model. Business process metamodels are also referred to as dynamic metamodels in contrast to the other more static metamodels. The art of HIS modeling is based on the right selection of a metamodel. Thus, for HIS modeling, you should consider the following steps: 1. Define the questions or tasks to be supported by the HIS model. 2. Select an adequate metamodel. 3. Gather the information needed for modeling. 4. Model the information in a model (e.g., in a graphical way) 5. Analyze and interpret the model (answer your questions). 6. Evaluate if the right metamodel was chosen, i.e. if the model was adequate to answer the questions. If not: proceed with step 2. In the next paragraphs, we will focus on some typical metamodels. We will answer the following questions for each metamodel: • What elements does the metamodel offer? • Which relationships between the elements can be modeled? • Which questions can be answered by using this metamodel? • What could a typical model look like, when derived from this metamodel? Functional modeling Functional metamodels are used to build models which represent the functionality of a hospital (what is to be done). The elements they offer are the hospital functions which are supported by the hospital information system. The relationships of the hospital functions can, for example, represent the 3. What do Hospital Information Systems Look Like? 45 information exchange between them. In addition, functions are often described in a hierarchical way, comprising more global functions (such as patient management) and more specific (refined) functions (such as patient billing). Typical questions to be answered with models derived from functional metamodels are: • Which hospital functions are supported by which HIS components? • Which specific hospital functions are part of which global hospital function? • Which hospital functions share the same data? • Does the functional model correspond to a reference model? Typical representations of functional models are (hierarchical) lists of functions, as well as graphical presentations of the hospital functions. Table 2 presents an extract from a threelevelhierarchy of hospital functions for information processing in nursing: Documentation of patients resources Documentation of nursing goals Planning and documentation of nursing tasks Writing of nursing reports Nursing documentation ... Documentation of orders Documentation of findings Management of the patient record Physician’s documentation relevant for nursing ... Admission of a patient Discharge of a patient Patient management ... Patientrelated ward organization Generation of organizational tools .... ... ... ... Table 2: An extract from the functional HIS model, describing some nursing hospital functions at the Plötzberg Medical Center and Medical School (PMC). 19 Technical modeling Technical metamodels are used to build models which describe the information processing tools used. As elements, they typically use physical data processing components (e.g., computer systems, telephones, forms, pagers, records) and application components (application programs, working plans). As 19This example is an extract from: Ammenwerth E, Haux R. A compendium of information processing functions in nursing development and pilot study. Computers in Nursing 2000; 18(4): 18996. 46 Strategic Information Management in Hospitals relationships, they describe the data transmission between physical data processing components (e.g., network diagrams), or the communication between application components. Typical questions which can be answered with models derived from technical metamodels are: • Which information processing tools are used? • Which application components communicate with each other? • What are the data transmission connections between the physical data processing components? • What does the network technology look like? • What technical solutions are used to guarantee security and reliability of information processing components? • Technical models are typically presented as lists (e.g., lists of information processing tools used) or as graphs (e.g., graph of the network architecture of computer systems). Examples for graphical models are presented in Figures 39 and 40. Storage Area Network Switch inf001S 2x50 GB data inf002S 2x50 GB data inf003S 2x50 GB backup inf004S 2x50 GB backup Figure 39: An extract of a technical HIS model with some physical data processing components and their data transmission links of the hospital information system of the Plötzberg Medical Center and Medical School. 3. What do Hospital Information Systems Look Like? 47 Organizational modeling Organizational metamodels are used to build models which describe the organization of a unit or area. For example, they may be used to describe the organizational structure of a hospital (e.g., consisting of departments with in and outpatient units). In the context of HIS, they are often used to describe the organization of information management, i.e. how it is organized in order to support the goals of the hospital. The elements of those models are usually units or roles which stand in a certain organizational relationship to each other. Typical questions to be answered with models derived from organizational metamodels are: • Which organizational units exist in a hospital? • Which institutions are responsible for information management? • Who is responsible for information management of a given area or unit? Clinical documentation system (Clindoc) (≈3700 user) Electronic patient record (EPA) (≈2900 user) Communication server (KomServ) Radiologic information system (RadIS) (≈250 user) Laboratory information system (LIS) (≈400 user) Anaesthesia documentation system (AnIS) (≈10 user) Pathological information system (PATH) (≈50 user) others ... Tumo r documentation system (Tumorix) (≈15 user) Dental information system (Dental) (≈150 user) Rostering information system (Timy) (≈300 user) Mail system (Exchange) (≈2000 user) Medical Knowledge Server (≈2500 user) Web Server Business Management Systems (Personal management, Controling Financing management, material management ...) (≈450 user) Office Products (≈4000 user) Patient management system (PMS) (≈500 user) Figure 40: An extract of a technical HIS model with some application components and their communication links of the hospital information system of the Plötzberg Medical Center and Medical School. 48 Strategic Information Management in Hospitals Organizational models are typically represented as a list of organizational units (e.g., list of the departments and sections in a hospital), or as a graph (e.g., graphical description of the organizational relationships). An example is presented in Figure 41. Data modeling Data metamodels are used to create models which describe the data processed and stored in a hospital information system. The elements they offer are typically data objects and their relationships. Typical questions to be answered with models derived from data metamodels are: • What data are processed and stored in the information system? • Which relationship do the data elements have? E.g., the class diagrams in UML20 offer a typical metamodel for data modeling. An example is presented in Figure 42. 20 Object Management Group (OMG): Unified Modeling Language – UML. http:www.uml.org. Figure 41: Extract from the organizational model of Plötzberg Medical Center and Medical School. Hospitals Executive Commitee Dept. of Surgery Dept. of Internal Medicine Dept. of Pathology Hospitals administration General surgery Paediatr ic s surgery inpatient units outpatient units Human resources Financal accountancy Engineering Acquisition ... ... Dept. of Information Management ..... ... 3. What do Hospital Information Systems Look Like? 49 Business process modeling Business process metamodels are used to create models which focus on a dynamic view of information processing. The elements used are activities and their chronological and logical order. Often, other elements are added, such as the role or unit which performs an activity, or the information processing tools which are used. The following perspectives can usually be distinguished: • Functional perspective: What activities are being performed, and which data flows are needed to link these activities? • Behavioral perspective: When are activities being performed, and how are they performed, using mechanisms such as loops and triggers? • Organizational perspective: Where and by whom are activities being performed? • Informational perspective: Which entities (documents, data, products) are being produced or manipulated? Typical questions to be answered with models derived from business process metamodels are: • Which activities are executed with regard to a given hospital function? • Who is responsible, and which tools are used, in a given process? • Which activity is the pre or postcondition for a given activity? • What are the weak points of the given process and how can it be improved? identification number name birthday address Patient identification number insurance Case type date provider Procedure 1 1 admission date discharge date ward identification Inpatient treatment date clinic identification Outpatient Figure 42: A simplified data model (UML class diagram), describing the relationships between the objects patient, case, and procedure, as extract from the data model of the HIS of the Plötzberg Medical Center and Medical School. 50 Strategic Information Management in Hospitals Due to the amount of different perspectives, various business process metamodels exist. Example are simple process chains, eventdriven process chains, activity diagrams, and petri nets. Simple process chainsdescribe the (linear) sequence of process steps. They simply describe the specific activities which form a process, in addition to the responsible role (e.g., a physician). Eventdriven process chainsadd dynamic properties of process steps: events and logical operators (and, or, xor) are added to the functions, allowing the more complex modeling of branching and alternatives. In addition, some instances of eventdriven process chains allow the addition of data objects (e.g., a chart). 21 Activity diagrams(as part of the modeling technique of the Unified Modeling Language, UML) also describe the sequence of process steps, using activities, branching, conditions, and data objects (see Figure 43). In addition, the method allows the splitting and synchronization of parallel subprocesses. 22 Finally, petri netsalso describe the dynamic properties of processes, but in a more formal way than the other methods which are mentioned.23 21 Scheer AW. ARIS Business Process Frameworks. Berlin: Springer; 1999. 22 Object Management Group (OMG): Unified Modeling Language – UML. http:www.uml.org. 23 Mortensen KH, Christensen S, editors. Petri Nets World. http:www.daimi.au.dkPetriNets. 3. What do Hospital Information Systems Look Like? 51 Enterprise modeling Enterprise modeling intends to describe the architecture of the enterprise, and especially the enterprises information system. Enterprise models do not only contain several enterprise views, such as functional models, technical models, organizational models, data models, or process models, but also the interactions between them, and, therefore, offer a more holistic view. Metamodels for enterprise modeling are often presented as matrices where the rows reflect distinctive layers and the columns reflect several views on these layers. A model has to be created for each cell of the matrix (which, of course, is normally based on a more specific metamodel). Typical questions to be answered with models derived from enterprise metamodels are: • Which hospital functions are supported by which information processing tools? Figure 43: Example of a business process model, based on a UML activity diagram, describing a part of the admission process in the Department of Child and Juvenile Psychiatry at Plötzberg Medical Center and Medical School. patients relative is calling holding first conversation get patient record start new record necessary not necessary necessity unclear forward call to physician arrange date note made check admission check if its patients first admission make a note of date secretary not necessary necessary physician administrative staff check admission no finish call finish call record got record started yes 52 Strategic Information Management in Hospitals • Are the information processing tools sufficient to support the enterprise functions? • Is the communication between the application components sufficient to fulfil the information needs? One of the most well known metamodels for enterprise modeling is the Zachman24 framework for information systems architectures (see Figure 44). Data (What) Function (How) Network (Where) People (Who) Time (When) Motivation (Why) Scope (Contextual) Enterprise Model (Conceptual) System Model (Logical) Technology Model (Physical) Detailed Representations Individual modeling aspects as mentioned above can be found within this framework. Data models are placed in the dataenterprise model cell, if the more conceptual aspect is stressed, or in the datasystem model cell if the database aspect is stressed. Technological models may be found at the system model or the technology model level especially in the function and network rows. Organizational models are placed in the people row, and functional models in the function row. The difficulty in using such a comprehensive framework will lay in the task to present the dependencies between the separated cells. Reference models for hospital information systems Until now we talked about HIS metamodels, i.e. about models to describe hospital information systems from various views. To support HIS modeling, it may also be helpful to use reference models. Reference models present a kind of 24 Zachman JA. A framework for information systems architecture. IBM systems journal 1999; 38(23): 45470 (Reprint). Figure 44: The Zachman Enterprise Architecture Framework. 3. What do Hospital Information Systems Look Like? 53 model pattern for a certain class of aspects. On the one hand, these model patterns can help to derive more specific models through modifications, limitations or addons (generic reference models). On the other hand, these model patterns can be used to directly compare models, e.g. concerning their completeness (nongeneric reference models). As well as specific models, reference models are instances of metamodels. A specific model may be considered as a variant of a reference model developed through specialization. This variant is an instance of that metamodel which also underlies the corresponding reference model. A reference model is always directed towards a certain aspect. For example, we can define reference models for hospital information systems, for communication systems, or for the gastrointestinal system. A (general) model can be defined as a reference model for a certain class of aspects. A reference model should be followed by a description of its usage, e.g. how specific models can be derived from the reference model, or how it can be used for the purpose of comparison. Specific models can be compared with a reference model, and consequently models can also be compared with each other, judging their similarity or discrepancy when describing certain aspects. Reference models can be normative in the sense that they are broadly accepted and have practical relevance. Reference models are more likely to be accepted if they are either recommended by a recognized institution, or if they are reliable and welltested. Different types of reference models can be described. For example, business reference modelsdescribe models of processes, data and organization of a certain class of organizations (e.g., of a certain industrial branch). A subtype of these reference models are information system reference models. They focus on information processing of a class of organizations. These reference models will be based on the metamodels we have presented in the previous chapter. For example, data reference models can describe typical data structures for a hospital information system. Organizational reference models can describe typical organizational structures for information management. Enterprise reference models can describe typical functions and architectures of hospital information systems. A second type of reference models are software reference models. They serve to derive models for different variants of a software product. Such a derived model can, e.g., describe in which form a software product can be parameterized for a specific usage. These models normally integrate different views on the software product, such as a data, functional or process view. A third class of reference models are procedure reference models. They focus on how to do certain things, e.g. how to introduce an information system component. Examples of procedure reference models from other areas include clinical guidelines. Using such a reference model together with additional 54 Strategic Information Management in Hospitals information, a project plan can be derived for a specific project to introduce a component. Various reference models for hospital information systems exist. Already in the 1980s, the Dutch National Hospital Institute developed a catalogue of hospital functions, which comprised the description of hospital functions and information needs. 25 The Common Basic Specification of the British National Health Service (NHS) from the early 1990s is also a functional reference model 26 . It describes the functions of different institutions which have to be supported by a computerbased information system. All functions are described as activities, combining the tasks enable, plan, do and execute. This also represents a part of a process reference model. In addition, a data reference model is described which contains objects types which are usually processed in hospitals. The NHS reference models are partly compulsory for the NHS institutions. In the framework of the European RICHE (Réseau dInformation et de Communication Hospitalier Européen) project, a process reference model for the description of activities in hospitals was established. This is the socalled orderandactmodel. 27 Activities are seen as part of a process, where a client (for example, a physician) orders an activity (order). This order is communicated to the executing person (for example, a nurse), which carries out the order (act) and reports the results to the client. A more recent example of a reference model for hospital functions is the Heidelberg reference model from 2000, developed with the support of the German Research Association.28 It is presented in Figure 45. This reference model focuses on the process of patient care. It distinguishes between functions central to the patient care process and functions supporting the patient care process. The main hospital functions supporting the process of patient care are presented as a sequence on the left side. The hospital functions which support patient care are presented on the right side. 25 van Bemmel JH, editor. Handbook of Medical Informatics. Heidelberg: Springer; 1997. p. 322 ff. 26 Herbert I. The Common Basic Specification (version 4.4), Information Management Group (IMG), United Kingdom National Health Service (NHS), 1993. 27 Frandji B. Open architecture for health care systems: the European RICHE experience. In: Dudeck J, Blobel B, Lordieck W, Bürkle T, editors. New technologies in hospital information systems Amsterdam: IOS Press; 1997. p. 1123. 28 Haux R, Ammenwerth E, Buchauer A et al. Requirements Index for Information Processing in Hospitals. Heidelberg: Dept. of Medical Informatics, Report No. 12001. Available at: http:www.umit.atreqhis. 3. What do Hospital Information Systems Look Like? 55 Figure 45: The Heidelberg reference model for hospital functions. Until now, there are only few available reference models for typical functions, processes or data of hospital information systems. Nevertheless, consultants create specific reference models for their clients. For example, a health care provider wants to standardize the business process of some hospitals. In this case, a system analysis will usually be performed in each hospital, and a general model of the planned state will be derived as the basis for detailed change planning. This is a (providerspecific) reference model and can be used to derive specific models to compare the current state with the planned state. Examples Example 3.3.1 A reference model for hospital functions The following Table 3 of hospital functions was established in 1997 by the German Research Association.29 The following list presents that part of the reference model relevant for patient care. 29 Haux R, Michaelis J. Investitionsschema zur Informationsverarbeitung in Krankenhäusern (investment scheme for information processing in hospitals). Das Krankenhaus 1997; 7: 42526. 1.1 patient admission 1.2 planning and organization of patient treatment 2.5 archiving of patient records 2.6 administration of patient records 1.3 order entry and taking samples 1.4 order entry and scheduling 1.5 execution of diagnostic or therapeutic procedures 1.8 clinical documentation 1.6 administrative documentation 1.7 billing 3.5 office communication support 3.4 general organization of work 4.3 costperformance accounting 3.1 scheduling and resource allocation 3.3 management and maintenance of equipment 4.5 human resources management 4.4 financial accounting 4.2 controlling and budgeting 1 Central Process:Treatment of patients 2 Handling of Patient Records 3 Work Organization and Resource Planning 4 Hospital Management 4.1 quality management 2.3 coding of diagnoses and procedures 3.6 basic information processing support 1.9 discharge and referral to other institutions 3.2 materials and pharmaceuticals management 2.1 creation and dispatch of documents 2.2 management of special documentation and clinical registers legend: x.x name hospital function logical operators process sequence including data exchange 2.4 analysis of patient records 4.6 general statistical analysis 56 Strategic Information Management in Hospitals Part I: patient care 1. General patient care functions 1.1 Patient administration 1.2 Management of the patient record 1.3 Electronic archiving of patient records (for example digitaloptical) 1.4 Basic clinical documentation 1.x Other functions 2 Ward functions 2.1 Ward management for physicians (including clinical documentation, writing documents, order entry, accounting) 2.2 Ward management for nurses (including nursing documentation, order entry, accounting) 2.3 Intensive care unit documentation 2.x Other functions 3 Outpatient unit functions 3.1 Management of outpatient units (including scheduling, process management, clinical documentation, document writing, order entry, accounting) 3.x Other functions 4 Diagnostic unit functions 4.1 Clinical laboratory 4.2 Radiology (organization) 4.3 Radiology (PACs – picture archiving and communication) 4.4 Immunology, microbiology, virology 4.5 Pathology 4.x Other functions 5 Therapeutic unit functions 5.1 Anesthesia documentation 5.2 Management of operating rooms (incl. documentation, reports, planning) 5.3 Radiotherapy 5.x Other functions 6 Functions for other units 6.1 Pharmacy 6.2 Blood bank 6.x Other functions 7 Other patient care functions 7.1 Roster planning 7.2 Documentation, organization and billing for dentistry departments 7.3 Telemedicine (especially telediagnostics) 7.x Other functions Part II: Support of patient care 1 Administrative functions 1.1 Accounting (in and outpatients) 1.2 Financial accounting 1.3 Maintenance of buildings 1.4 Calculation of costs and services, controlling 1.5 Stock management 1.6 Staff management 1.x Other functions 2 Communication functions 2.1 Office communication 2.2 Communication management (communication server) 2.3 Network management 2.x Other functions 3 Other functions for the support of research, education, patient care 3.1 Access to medical knowledge (for example Medline, diagnostic or therapeutic guidelines) 3.x Other functions Table 3: An example of a reference model for hospital functions. 3. What do Hospital Information Systems Look Like? 57 Exercises Exercise 3.3.1 Typical realization of hospital functions Please look at the hospital functions presented in Figure 45 and describe how they are realized in a hospital which you know. Try to classify each function according to how it is typically realized: • primarily conventional, • mostly conventional, • mixed, • mostly computersupported, • primarily computersupported. For example, patient admission is typically primarily realized with computersupported information processing tools, whereas nursing documentation is mostly realized conventionally. Exercise 3.3.2 Comparison of reference models for hospital functions Different reference models exist for hospital functions. Please compare the reference model presented in Table 3 with the Heidelberg reference model of hospital functions (Figure 45). • Which functions can be matched, and which cannot? • What could the reason be for the differences? Exercise 3.3.3 Modeling business processes with activity diagrams Goal of this exercise: To become familiar with a typical business process modeling method and its fields of application. a) Modeling a given process Design a graphical process model of nursing documentation. Use activity diagrams with the typical symbols for activities, transitions, branching, conditions and synchronization, responsible roles, and data objects to model the following process: Every time a patient is admitted to the ward, a new nursing plan is created: the nursing anamnesis is written down, together with the problems of the patients, the corresponding goals of the nursing treatment and the tasks to be executed. The anamnesis is written on conventional forms and then inserted in the conventional patient record. The other parts are created with the aid of a computerbased application component known as NDS and then printed out and inserted in the conventional patient record. At the beginning of each shift, the nurse reads the printed nursing plan to see which measures are to be executed. She copies the tasks to be executed during her shift onto a little paper which she carries with her. On this paper, she marks the tasks which have been taken care of. At the end of each shift, the nurse 58 Strategic Information Management in Hospitals documents which tasks have been executed in the printed nursing plan (by signing each task). She writes a short report on a special form about special occurrences during her shift. Finally, she validates the nursing plan and adopts it to the new state of the patients problems and the nursing goals. During the patient’s stay in the hospital, the nursing plan can be changed several times. The new plan is then again printed out and inserted into the conventional record. b) Weak point analysis of a given process Analyze the process modeled in a) and try to find weaknesses in the process. Weak points can, for example, be double documentation, changes in tools used, or possible transcription errors. If you find weak points, discuss possible solutions and redesign the process based on your improvements. Summary HIS models represent HIS. They are used to support description, management and operation of HIS. A good model adequately supports information managers in these tasks. According to their different purposes, different metamodels (models of models) exist for HIS. We can, for example, find functional metamodels, technical metamodels, organizational metamodels, data metamodels, business process metamodels, and enterprise metamodels. Functional models describe the functionality of a HIS. Technical models focus on the information processing tools used to reach this functionality. Organizational models describe the organization of areas or units. Data models describe the data processed and stored in an information system. Process models stress the dynamic aspects of HIS. Enterprise models provide a survey of an enterprise. Reference models are specific models which serve as model patterns. They can be used to derive concrete models, or to compare models. A typical reference model for hospital functions is the presented requirement catalog schema which distinguishes functions central to the patient care process from functions supporting the patient care process. 3.4 A metamodel for modeling HIS: 3LGM Let us now introduce a metamodel used to statically describe information processing functionality and tools, the so called three layer graphbased metamodel (3LGM) for modeling hospital information systems. It aims to support the systematic management of HIS, especially of heterogeneous ones, as well as the quality assessment of information processing. 3LGM combines a functional metamodel with technical metamodels. It is 3. What do Hospital Information Systems Look Like? 59 represented in UML notation. 30 The 3LGM distinguishes three layers of information management: The domain layer(see Figure 46) describes a hospital independent of its implementation. In the static view, a hospital is an accumulation of its functions. For example, PATIENT ADMISSION, NURSING, or TREATMENT may be functions. To fulfill these functions, information about objects (e. g. patients, findings, etc.) is used, generated, or deleted. Objects, which share the same attributes are classified as object types. For example, PATIENT, CASE, or LABORATORY RESULT may be object types. A function accesses an object type to get the information needed for its execution. This access may just use information (type: reading) or change information (type: writing) of an object. Which object types and which functions are modeled depends on the hospital being modeled. Reference models may offer recommendations about important object types and functions for certain kinds of hospitals. 1.. access 1.. object type 0..1 0.. function is part of 0.. 0..1 is part of  access type: reading, writing Figure 46: 3LGM domain layer. Figure 47 shows an example of a domain layer. Rectangles represent object types and ovals represent functions. An arrow from an object type to a function marks read access, from a function to an object type, write access. Note that in the static view there are no direct relations between functions. This would be part of a dynamic view, i.e. of business process modeling. The domain layer is restricted to information about objects, and to functions to be performed. 30 Object Management Group (OMG): Unified Modeling Language – UML. http:www.uml.org. 60 Strategic Information Management in Hospitals patient admission insurance ordering diagnosing patient case order result diagnosis patient discharge laboratory services treatment Figure 47: 3LGM domain layer example. To perform functions, application components, which may be installed and adapted software products or conventional working plans, are used. These belong to the logical tool layer(see Figure 48). On this layer we describe how information about objects is logically stored, and how tools have to communicate to ensure the access to information as described in the domain layer. Application components may have a local database system to store data. They are controlled by application programs, which are adapted software products (this is what we can buy). A software product may be installed multiple times on one or more physical data processing components. As a result, we get several different application components. Communication interfaces ensure the communication among application components based on message types (like HL7 31 messages), but also between a component and a user (user interfaces). Application components may be refined. 31 HL7 is a communication standard in health care. See Health Level Seven. http:www.hl7.org. 3. What do Hospital Information Systems Look Like? 61 application component database system database management system application program communication interface is_controlled_by 1  disposes_of 0..1 is_controlled_by 0..1  owns 0.. software product  is_based_on working plan {xor} user interface application component interface {disjoint} communication standard  is_based_on 1 0..1 sending interface receiving interface 0.. 1 0.. 1 communicates_with is_part_of 0.. 1 message type 1.. object type function object type application component configuration function 1.. 0.. contains  can_be_supported_by 1.. 1.. 1.. 1..  stores_objects_of_object_type 1 1 1 1.. 1.. 1..  can_support 1.. 1.. 1.. 1 1.. 1..  transports_information_about contains  1.. 1.. 1  is_mastered_by  communicates type: {receives, sends} Figure 48: 3LGM logical tool layer. Dotted lines denote interlayer relationships (see page 570 ff.) Figure 49 shows an example of a logical tool layer. In this example we just look at the application components depicted as large rounded rectangles and the relationships between them via communication interfaces (small rectangles), depicted as arrows. Here, communication is based on HL7 or proprietary interfaces. The direction of the arrow represents the direction of the communication. For clarity, this example does not include database system aspects. 62 Strategic Information Management in Hospitals prop. HL7 PMS (patient ADT) ARCHIVES (archives administration) prop. LABSYS (laboratory system) HL7 HL7 MEDDB (medical database system) HL7 COMSERV (communication server) HL7 WARD (clinical documentation system) HL7 HL7 HL7 prop. prop. prop. prop. prop. HL7 HL7 Figure 49: 3LGM logical tool layer example. This example refers to the computer supported part of a hospital information system. It is simplified and fictive, but reflects a typical situation: indeed there is a HL7 based communication server, but obviously not all application components are able to use this communication service. As a consequence, a lot of proprietary interfaces are needed. Additionally, some application components communicate directly via HL7 interfaces. The physical tool layer(see Figure 50) is a set of physical data processing components (like personal computers, servers, switches, routers, etc), which are physically connected via socalled data transmission connections (e.g. data wires). The constellation of these connections leads to physical networks, which are based on network? protocols. Arbitrary subnets can be defined as projections of the entire network. Note that physical as well as logical networks can be represented on the physical tool layer. 3. What do Hospital Information Systems Look Like? 63 subnet net type net protocol physical data processing component 1.. 1..  belongs_to 0.. location component type 0.. is_part_of data transmission connection 1 is_based_on 1 data processing component configuration application component  contains  can_be_used_via 1.. 1.. 1.. 1.. 1.. 1.. 1.. 1..  is_based_on 1 1.. 0.. 0..  belongs_to Figure 50: 3LGM physical tool layer. Dotted lines denote interlayer relationships (see page 570 ff.) Figure 51 shows an example of a physical tool layer. In this example we distinguish between two component types: the rectangles represent servers and personal computers (PC) and the black dots represent connection points. Data transmission connections are depicted as lines. In this example, all physical data processing components belong to one network, i.e. there are no subnets. Information about network type, or network protocol is not represented. file server communication server laboratory server database server application server PC1 PC2 PC3 PC4 PC5 PC6 PC7 firewall server Figure 51: 3LGM physical tool layer example. A variety of dependencies, called interlayerrelationshipsexist among components of different layers. Relations exist between classes of the domain layer and the logical tool layer and 64 Strategic Information Management in Hospitals between classes of the logical tool layer and the physical tool layer. Considering the domain layer and the logical tool layer, the most important relationship is between functions and application components which is represented by a socalled application component configuration. It states, that a hospital function may be supported either by several application components together, by a single application component, or by combinations of the two. Two questions lead to the application component configurations for a specific function: Which application components are jointly necessary to support a function completely? An application component configuration contains all application components which are together directly necessary to support a function. If we remove an application component from this configuration, the function can no longer be supported by this configuration. Which possible alternatives are there to support a function? A function may be supported by more than one application component configuration. If we remove such a configuration the function is still supported by one of the remaining configurations, but may suffer from loss of quality. Application component configurations can not only, e.g. give hints about redundancies within hospital information systems, but also about weaknesses in the domain layer model. Figure 52 shows an example of an application component configuration. function: patient admission application component: PMS application component: MED DB application component: WARD necessarily necessarily alternatively application component configuration 1 application component configuration 2 Figure 52: Example of an application component configuration. Other relations between classes of the domain layer and the logical tool layer are: The first relation between object type and database system (stores_objects_of_object_types) describes in which databases the information about objects of a certain object type are stored. It can give hints about redundant data storage. The second relation between object type and database system (has_as_master) describes which database is responsible for the storage of objects of a certain 3. What do Hospital Information Systems Look Like? 65 object type, and, therefore, in case of redundant data storage, contains the current data. The relation between object type and message type expresses that information about objects of a certain object type is transported by a message of a certain message type. The relation between function and software product
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Đề thi thử vào lớp 10 môn tiếng anh đề số 43

Đề thi thử vào lớp 10 môn tiếng anh đề số 43

  I. Choose the word or phrase(a, b, c or d) that best fits the blank space in each sentence.(3 pts) 1. Mr Nam ___________ is a well- known doctor in our city, has just moved to Hanoi. a. who                         b. which                     c. that                                     d. whose 2.___________ their being poor, they are very self- confident and generous. a. However                b. Although               c. Because.                d. Despite 3. I live _________ 53 Nguyen Trai Street. a. in                             b. on                           c. at                             d. for 4. Don't worry, We still have _________ money to buy a new house. a. many                      b. enough                   c. too                          d. few 5. I'll wait for you _________ you come back. a. as                            b. until                        c. while                      d. when 6. My brother enjoy ________ badminton with his friends after school. a. play                        b. playing                   c. played                    d. plays 7. I came home when my mother _________ dinner alone. a. was having            b. had                                     c. have                        d have            had. 8. If I _________ hard, I would have got good marks in the last term. a. study                      b studied                    c. have studied          d. had studied. 9. They wish they _________ have to work hard to earn money. a. couldn't                  b. can't                        c. don't                       d. didn't 10. I __________ play marbles with my friends after school when I was a schoolboy. a. use                          b. use to                     c. used to                   d. was used to. 11. Passer- by: Is there a post office near here?/ Mai: _________ a. Go straight and then turn left, It is on your right. b. No, there isn't c. Oh, there are some in our city. d. Why do you want there? 12. Ha: Why don't we go for a picnic this Sunday?/ Hoa: ­­­­__________ a. You're welcome                                        c. Great! That is a good idea! c. Lovely! Let's go.                                       d. Both B and C are correct. II. Choose the word whose underlined part is pronounced differently from that of the others. (1pt) 1 a. house                  b. hour                        c. hundred                 d. head 2.a. worked b. stopped c. forced d. wanted 3.a sugar                    b. sister                      c. sign                         d. singer 4.a. after                     b. advice                    c. agree                       d. alone III. Choose and correct the one error in each of the following sentences. (1pt) Of two boys, Long is the best at English. During his trip to Vietnam, John enjoyed seeing the boys to fly the kites. I am very interested in the poems writting by Xuan Dieu. She studies hard in order to having good marks III. Reading: Choose one word below to fill in each blank space in the follwing passage. (1pt)   Subjects                          difficult                    for                  in                adults Every year, students from many countries learn English. Some of these students are young children. Other are teenagers. Many are (1) ___________Some learn at school, others study by themselves. Why do all  these people want to learn English ? It is ­­­­­­­(2) ___________to answer that question. Many boys and girls learn English at school because it is one of their (3__________They study thier own language and mathematics...and English. Many adults learn English because it is useful (4)________their work. Teenagers often learn English for their higher studies because some of their books are (5)________English at college or university. Other people learn English for their hobby because they  want to read newspapers or magazines in English or listen to English songs. B. Read the above passage again and answer the following questions (1pt) 1. Who want to learn English? ........................................................................ 2. Why do many people learn English? ................................................................ 3. Do all people have to go to  school to learn English? Why or Why not? ....................................................................................................................... 4. Why is English necessary for higher education? ............................................................................. V. Use the correct form of the words in the parentheses in each sentence:(1pt) 1. His parents are very.............of him because he studies very well. (pride) 2. Our main ..........to export are rice,coffee and rubber.                  (produce) 3. Passover of the Jewish people is a festival which celebrates..........from slavery.(free) 4 .He got a terrible accident because he drove so..........                    (care) VI. Rewrite the sentences so that they are closest in meaning to the sentences printed before them.Use the given words(2pts) 1. Some one has just washed our car. " We............................................................................... 2.I didn't have enough money,so I didn't buy laptop. " If.................................................................................. 3. "I must study hard for my next examination." " She said........................................................................ 4. I didn't borrow her some money yesterday. " If only...........................................................................   ĐÁP ÁN  I. Choose the word or phrase(A, B, C or D) that best fits the blank space in each sentence.(3 pts) 1. a. who        2.d. Despite               3. d. for          4. b. enough               5. b. until 6. b. playin    7. a. was having        8. d. had studied.      9. d. didn't      10. c. used to 11. a. Go straight and then turn left, It is on your right. 12. d. Both B and C are correct. II. Choose the word whose underlined part is pronounced differently from that of the others. (1pt) 1 b. hour                    2.d. wanted 3.a sugar        4.a. after III. Choose and correct the one error in each of the following sentences. (1pt) best ->better  6.to fly ->flying 7. writting->written        8. having->have III. Reading: A.Choose one word below to fill in each blank space in the follwing passage. (1pt) (1) adults ­­­­­­­   (2) difficult               (3) subjects    (4)for                         (5)­­­­­­­­­­­­­­­­­­­­­­ in. B. Read the above passage again and answer the following questions (1pt) 1. Students, teenagers and adults (want to learn English) 2. Teenagers and students learn English for their study and adults lear English for their work, some orthers learn it for their hobby 3. No, they don't have because they can study English by themselvess. 4. Because some of books are in English at college or universily. V. Use the correct form of the words in the parentheses in each sentence:(1pt) 1. proud                     2. products                            3. freedom                             4 .carelessly VI. Rewrite the sentences so that they are closest in meaning to the sentences printed before them.Use the given words(2pts) 1. We have had our car washed 2. If I had had money, I would have bought that laptop. 3. She said said she had study hard for her next examination 4. If only I had borrowed her some money yesterday.
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Sex, Brains, and Video Games [Jennifer_Burek_Pierce]

Sex, Brains, and Video Games [Jennifer_Burek_Pierce]

"In this guide, Jennifer Burek Pierce provides a look at today''s teen through the lens of neurological, psychological, and educational research. Putting this research in the context of library services, she challenges librarians to question their assumptions about teen patrons and provides new answers based on research findings. Much as early literacy research informed library services to our youngest patrons, Sex, Brains, and Video Games outlines what others who work with adolescents have learned from their professional activities and how that knowledge can encourage new priorities and partnerships in youth services." "With further reading suggestions rounding out each chapter, this guide offers school, public, and academic librarians further ways of thinking about young adults and the services provided for them."--BOOK JACKET.
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TOPIC 51: THE IMPORTANCE OF READING NEWSPAPERS

TOPIC 51: THE IMPORTANCE OF READING NEWSPAPERS

The importance of reading newspapers As the name suggests newspapers are a source of news and information. In several respects they are also a medium of communication among the peoples of the world.    Today there are hundreds of newspapers all over the world. Everywhere there is a keen desire to learn more and more about the affairs of the world. This is partly the result of the spread of education which sharpens one's curiosity to learn about distant lands.    As a source of news: the newspaper is almost indispensable to those whose thirst for knowledge is insatiable. They contain news on events in distant corners of the earth. Information about such events arrives almost immediately. As a result. people everywhere are informed about the most important events in the world verỵ quickly and almost all the same time. For example, if a war breaks out in one part of the world today , the people in the other parts will certainly come to know about it tomorrow. As a result, all the countries of the world are able to do something quickly to help those who have suffered because of the war or to persuade the countries at war to cease fighting.    Newspapers also play an important part in keeping the peoples of the world informed about the troubles that might arise in the future, if nothing is done to prevent them from happening. For example, if a dispute arises between two countries for any reason: the newspapers can keep the peoples of the world informed about what might happen if nothing is done to persuade the two countries to resolve their differences peacefully. In this way many wars have been avoided because of the intervention of some countries in the disputes of many countries which were given prominences in newspapers.    When all this is considered, we feel that there is some silent communication among countries through the medium of newspapers for the common benefit of the countries of the world.    Further, constant reading of newspapers improves one’s outlook on life and makes one a more reasonable person. The importance of the newspaper is therefore obvious.    NEW WORDS: 1. respect (n): phương diện, khía cạnh 2. medium (n): phương tiện 3. keen (adj): mãnh liệt, thiết tha, nhiệt tình 4. insatiable (adj): không thể thoả mãn được 5. cease (v): dừng, ngừng, ngớt, tạnh 6. arise (v): xuất hiện, nảy sinh ra, xảy ra 7. intervention (n): sự can thiệp, sự xen vào 8. prominence(n): sự nổi bật, sự đáng chú ý
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HIS chapter 5 ( Tin Y học trong bệnh viện)

HIS chapter 5 ( Tin Y học trong bệnh viện)

Reinhold Haux Alfred Winter Elske Ammenwerth Birgit Brigl Strategic Information Management in Hospitals An Introduction to Hospital Information Systems With 106 Illustrations Status: May 2002 (Version 0.22) Contents 1INTRODUCTION 1 1.1 SIGNIFICANCE OF INFORMATION PROCESSING IN HOSPITALS 1 1.2 PROGRESS IN INFORMATION AND COMMUNICATION TECHNOLOGY 4 1.3 IMPORTANCE OF SYSTEMATIC INFORMATION MANAGEMENT 8 1.4 EXAMPLES 12 1.5 EXERCISES 16 1.6 SUMMARY 17 2BASIC CONCEPTS 18 2.1 INTRODUCTION 18 2.2 DATA, INFORMATION AND KNOWLEDGE 18 2.3 INFORMATION SYSTEMS AND THEIR COMPONENTS 19 2.4 HOSPITAL INFORMATION SYSTEMS 22 2.5 HEALTH INFORMATION SYSTEMS 24 2.6 INFORMATION MANAGEMENT IN HOSPITALS 25 2.7 EXAMPLES 26 2.8 EXERCISES 28 2.9 SUMMARY 30 3WHAT DO HOSPITAL INFORMATION SYSTEMS LOOK LIKE? 33 3.1 INTRODUCTION 33 3.2 HOSPITAL FUNCTIONS 33 3.3 MODELING HOSPITAL INFORMATION SYSTEMS 43 3.4 A METAMODEL FOR MODELING HIS: 3LGM 58 3.5 INFORMATION PROCESSING TOOLS IN HOSPITALS 67 3.6 ARCHITECTURES OF HOSPITAL INFORMATION SYSTEMS 83 3.7 EXAMPLES 93 3.8 EXERCISES 100 3.9 SUMMARY 101 4HOW TO STRATEGICALLY MANAGE HOSPITAL INFORMATION SYSTEMS 103 4.1 INTRODUCTION 103 4.2 STRATEGIC, TACTICAL AND OPERATIONAL INFORMATION MANAGEMENT103 4.3 ORGANIZATIONAL STRUCTURES FOR INFORMATION MANAGEMENT 110 4.4 STRATEGIC PLANNING OF HOSPITAL INFORMATION SYSTEMS 116 4.5 STRATEGIC MONITORING OF HOSPITAL INFORMATION SYSTEMS 127 4.6 STRATEGIC DIRECTING OF HOSPITAL INFORMATION SYSTEMS 137 4.7 EXAMPLES 139 4.8 EXERCISES 139 4.9 SUMMARY 141 5WHAT ARE GOOD HOSPITAL INFORMATION SYSTEMS? 143 5.1 INTRODUCTION 143 5.2 QUALITY OF STRUCTURES 144 5.3 QUALITY OF PROCESSES 152 5.4 OUTCOME QUALITY 155 5.5 EXAMPLES 158 5.6 EXERCISES 158 5.7 SUMMARY 158 6FINAL REMARKS 159 7APPENDIX A: THESAURUS 161 8APPENDIX B: BIBLIOGRAPHY 162 8.1 BOOKS 162 8.2 PROCEEDINGS 163 8.3 JOURNALS 163 8.4 ASSOCIATIONS 163 8.5 INTERNET RESOURCES 164 8.6 RECOMMENDATIONS 165 9APPENDIX C: LIST OF EXAMPLES AND EXERCISES 166 10 APPENDIX D: LIST OF FIGURES AND TABLES 169 11 ABOUT THE AUTHORS 172 5 5 What Are Good Hospital Information Systems? 5.1 Introduction Quality in general is the ability to meet all the expectations of the purchaser of goods or services: “The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs 52 According to Donabedian, there are three major approaches to quality assessment: quality of structures, quality of processes, and outcome quality. 53 In the context of health care, the concept of quality of structures includes the human, physical, and financial resources that are needed to provide medical care (e.g. educational level of staff, availability of medical equipment). Quality of processes describes the quality of activities going on within and between providers and patients (e.g., adherence to professional standards, appropriateness of care). Finally, outcome quality describes the effects of patient care, i.e. the changes in the health status of the patient (e.g. mortality, morbidity, costs). While structure quality influences process quality, this in turn influences outcome quality. Those concepts can be transferred to hospital information systems: In this context, quality of structures refers to the availability of technical or human resources needed for information processing (e.g. number and availability of computer systems, computer knowledge of staff). Quality of processes deals with the quality of the information processes themselves which are necessary to meet the user’s needs. Outcome quality describes whether the goals of information management have been reached, or, in a broader sense, to what extent the hospital information system contributes to the goals of the hospital. Quality characteristics for hospital information systems help to describe the ‘fitness’ of a HIS, and finding diagnosis and therapy of ‘HIS diseases’. It may not be so difficult to describe what a really ‘bad’ hospital information system looks like. But what are characteristics and features of a ‘good’ hospital information system? In this chapter, we will introduce the most essential ones. After this chapter, you should be able to answer the following questions: 52 ISO. International Standard ISO 9000:2000. Quality management systems Fundamentals and vocabulary. International Organization for Standardization, International Electrotechnical Commission, Geneva; 2000. 53 Donabedian A. Explorations in quality assessing and monitoring Vol 2: The criteria and standards of quality. Ann Arbor: Health Administration Press; 1982. 144 Strategic Information Management in Hospitals • Which facets of quality have to be considered? • What are characteristics for structure quality (i.e. the quality of information processing tools, of HIS architectures, and of information management), and how can they be assessed? • What are characteristics for the quality of information processes, and how can they be assessed? • What are characteristics for the quality of outcomes, and how can they be assessed? 5.2 Quality of structures In the context of health care, the concept of quality of structures includes the human, physical, and financial resources that are needed to proved medical care (e.g. educational level of staff, availability of medical equipment). In the context of hospital information systems, the quality of structures refers to the availability of technical or human resources needed for information processing (e.g. number and availability of computer systems, computer knowledge of staff). It comprises quality characteristics for information processing tools, for HIS architectures, and for information management in hospitals. Quality of information processing tools Different characteristics of the computerbased or conventional information processing tools used influence structure quality which can be separated into software quality and hardware quality. In general, only a missing or erroneous information processing tool should attract attention. Software quality The main characteristics of software quality have been defined by ISO 9126 54 . The objective of this standard is to provide a framework for the evaluation of software quality. ISO 9126 sets out six quality characteristics with corresponding subcharacteristics: • Functionality: Are the required functions available in the software? • Reliability: How reliable is the software? • Usability: Is the software easy to use? • Efficiency: How efficient is the software? 54 ISO. International Standard ISOIEC 91261. Information technology Software product evaluation Quality characteristics and guidelines for their use. International Organization for Standardization, International Electrotechnical Commission, Geneva; 2001. 5. What are good Hospital Information Systems 145 • Maintainability: How easy is it to modify the software? • Portability: How easy is it to transfer the software to another environment? ISO 9241 55 specifically deals with software ergonomy. It contains 17 parts. Part 10 of this standard deals with dialogue principles for user interface design. The dialogue principles of ISO 9241 comprise: • Suitability for the task: Does the user interface support the user to fulfil his tasks effectively and efficiently? • Suitability for learning: Is the user being supported to learn and use the user interface? • Suitability for individualization: Can the user interface be adapted to the tasks and to the individual skills and wishes of the user? • Conformity with user expectations: Is the user interface consistent and adapted to the characteristics of the user (i.e. his knowledge, skill and expectations)? • Self descriptiveness: Is each step of the user interface understandabe for the user by providing direct feedback or explanation? • Controllability: Can the user, after having initiated the first step, control the flow and speed of tasks, until the aim is reached? • Error tolerance: Can the aim of the task even be reached following obviously wrong input by the user, either with no or little effort for correction? Hardware quality Their are no explicit norms to define the quality of hardware or of physical information processing tools in general. However, many aspects of software quality can be transferred to both computerbased and conventional physical tools. The quality of physical information processing tools can thus be described by the following characteristics: 55 ISO. International Standard ISO 9241. Ergonomics requirements for office work with visual display terminals (VDTs). Genf: International Organization for Standardization, International Electrotechnical Commission; 1993. Figure 100: An easetouse, stable, mobile information processing tool: Paperbased documentation at the patients bedside. 146 Strategic Information Management in Hospitals • usefulness (e.g. offering useful functionality for the user) • appropriateness (e.g. not dominating the physicianpatient relation) • easy to use • available (e.g. mobile tool, see Figure 100) • multipurpose (e.g. personal digital assistant) • efficient (low cost for purchase and support) • flexibility (e.g. can be modified easily, see Figure 101) • stable • secure (e.g. supporting basic data security and data safety) • harmless (e.g. not putting harm on the user of the patient) • usable (e.g. user friendly) • standardized (e.g. standardized form for order entry) Quality of HIS architecture HIS architecture should be organized in such a way that the different computerbased and conventional information processing tools can work smoothly and efficiently together, in order to provide a maximum quality of information processing by the information system as a whole. Quality of HIS architecture can display various characteristics: adaptability and maintenance, homogeneity vs. heterogeneity, integration aspects, object identity, data integrity, and functional mapping characteristics. Adaptability and maintenance In general, the architecture should be sufficiently flexible to be able to adapt to the changing needs of the hospital. For example, new computerbased application components should easily be added to the information systems, application components should be easily replaceable by other (better) application components, or the available bandwidth of the network infrastructure should easily be extended in order to match rising quantity of communicated data. Figure 101: A bed as flexible tool, also supporting information processing tasks. 5. What are good Hospital Information Systems 147 Homogeneity vs. Heterogeneity Information processing tools (both on the logical and on the physical tool layer) should be as homogeneous as possible and as heterogeneous as necessary. On the logical tool layer we often have to balance between the homogeneity of the hospital information system and the functional requirements of specific departments. On the physical tool layer, the heterogeneity is often the consequence of the constant development of the HIS, e.g. comprising different generations of computer systems. This could only be prevented when all physical data process components are regularly exchanged together, which is normally not feasible. In general, homogeneous information processing tools make training and support of users easier and thus leads to reduced costs for the HIS. Aspects of Integration In a heterogeneous HIS architecture with various communicating application systems and physical data processing components, all components must smoothly work together. This is called integration, being defined as combining or adding parts to make a unified whole. In general, integration needs standards (e.g. for communication, user interface design, installation routines etc.), as well as a strict organization (e.g. a systematically built up network structure). The quality of integration can be described by various integration characteristics: Hardware integrationmeans that the different physical data processing tools should be interconnected in order to avoid technical standalonesystems. Hardware integration can be realized, for example, by networking stationary computers, and by mobile computers connected via infrared or wireless networks. Access integration describes that all user relevant clinical functionality should be accessible from the health care professional workstation. All relevant application components should be available on one physical data processing component (see Figure 102). Presentation integration means that data from different applications are presented in an adequate and consistent way. There should thus be e.g. a uniform Figure 102: Insufficient access integration at the health care professional workstation. 148 Strategic Information Management in Hospitals graphical user interface and an overall uniform behavior for all userrelated functions on the health care professional workstation. Data integration comprises that data should only be recorded once and then be reused multiple times, in order to avoid duplication of data (single recording – multiple use). Data which is registered in one application component should thus be made available to other application components. For example, administrative patient data should be documented once in the patient management system and then be reused in other application components such as dedicated documentation systems. To achieve data integration, the HIS should have a global data model with clearly defined semantics of its concepts which should be revealed for the integration of new application components. Communication integration describes that application components should be able to exchange information by using standardized messages. This is the precondition for data and function integration in a DB n HIS architecture. Function integration means that a specific functionality (such as patient admission) which is offered by one application component, can also be used by other application components. New application components should therefore be designed so that functionality existing in prevailing application components are used. To achieve function integration, a HIS should include a repository of services offered globally. Visual integration comprises that the application context is maintained when the user changes the application component (e.g. because the functionality he wants to use is only offered by another application component).56 A task which has already been completed should not be repeated again. For example, on a ward, there may be two application components, one for report writing, the other for presentation of radiology results. When a physician is just writing a report, he may want to look up the recent radiology results. When he shifts the application component, the radiology results of his patient should immediately be displayed, without forcing him to enter a name, birthday of patient or identification number again. Thus, in this example, the selection of the patient is a task which must not be repeated if performed once, even when changing the application component. Object identity Each object in the hospital (such as patient, case, user, department) should be identified by a unique identifier. Data integrity Data integrity means that at each point in time, redundant data is identical in each database where it is stored. Changes of data in one application component’s 56 The Clinical Context Object Workgroup (CCOW) published standards for visual integration of independent application components, see Standard CCOW: http:www.hl7.orgSpecialcommitteesvisualvisual.cfm. 5. What are good Hospital Information Systems 149 database must therefore be communicated and reconstructed in the other application component’s databases where this data is also stored. Data integrity is especially important when data is stored redundantly in different locations in a DB n architecture. For example, when the patient administration system changes the name of the patient (e.g. correction of the name of the patient), this change has to be communicated to other application components such as the medical documentation systems or the ward management system which also have databases containing the patient’s name. Functional mapping characteristics With regard to HIS architecture, functional mapping characteristics describe the quality of mapping between hospital functions and application components. Functional leannessdescribes a situation where one hospital function is supported by one and only one application component. The contrast is functional redundancy or functional overlap which means that a hospital function is supported by more than one application component. For example, patient admission may be available in different application components. In order to get a functional lean HIS architecture, only one application component should be used for patient admission. Functional leanness is greatly facilitated by functional integration and visual integration. Functional completenessmeans that each hospital function is supported by at least one application component. There is no hospital function which is not supported by the hospital information system. When both characteristics are fulfilled, then we can say that a (sub)information systems has functional correspondence. An application system is superfluous when it does not support a hospital function. Quality of information management Several characteristics can be defined for the quality of information management. Clear decision structures, roles and responsibilities Clear decision structures, roles and responsibilities should be defined for information management’s organization. The responsibility for strategic, tactical and operational management must clearly been established and known to each staff member. The role of a CIO as well as of other important groups (such as committees, support centers, or key users) should be explicitly defined and made known. In general, it is useful to define the most important roles and responsibilities in the hospital’s information management plan. 150 Strategic Information Management in Hospitals Systematic strategic information management A strategic information management plan should be defined and adapted by the hospital management. A strategic plan should encompass the hospital business strategy or strategic goals, the resulting information management strategies, the current state of the hospital information system, and an analysis of how well the current information system fits to the strategies. The planned architecture should be derived as a conclusion of this analysis. Systematic tactical information management Information processing projects should be planned, management and controlled in a systematic and transparent way. Project management standards should be developed and used. Project groups and project committees should comprise all relevant health professional groups. Systematic project controlling should be established. Information systems components should only be selected and introduced after a thorough analysis of needs and costs and a transparent selection process. When new computerbased application components are introduced, migration strategies for the transformation of data are to be established and used. Employee training New users should be trained in basic information processing tools as well as in the taskspecific application components on a regular basis. The installation of a training center and a training group is useful in order to offer efficient training. Renewed training sessions should be offered when new functionality or new application components are being introduced, or when deficiencies in users skills have been found. The effects of users training should be regularly monitored. Support strategy An appropriate support strategy should be defined which helps to guarantee the continuous and faultless operation of the information processing tools. This support strategy should define different support levels for user and information processing tools, as well as the problem management strategy. The users should know about their contact in case of hardware or software problems. Motivation and competence of IT staff The IT staff represent a service provider for the user. Their motivation and competence is essential for the efficient functioning of the information systems and for a high acceptance by the users. The IT staff should therefore be sufficiently and regularly trained, they should know the clinical workflow and typical user problems, and they should be sufficiently motivated. 5. What are good Hospital Information Systems 151 Examples Exercises Summary 152 Strategic Information Management in Hospitals 5.3 Quality of processes In general, quality of processes describes the quality of activities going on within and between providers and patients (e.g., adherence to professional standards, or appropriateness of care). In the context of hospital information systems, process quality deals with the quality of the information processes themselves which are necessary to meet the user’s needs. Multiple usability of data Application components often need the same data. For example, patient administrative data or basic medical data is needed by many different application components. In order to avoid duplicate data entry, which is inefficient and prone to error, data should only be recorded once, even when it is used by different application components and stored in different databases. This multiple usability of data requires communication interfaces in the computersupported part of HIS, and ways to print out data (e.g. labels, order entry forms) or scan data in order to provide communication between the computersupported and the not computersupported part of HIS. No transcription of data Transcription of data should be avoided. Transcription means to transfer data from one storage device to another storage device, e.g. to transfer patient diagnoses from the patient record to an order entry form, or to enter data from a printout into a computerbased application component (see Figure 103 and 104). Transcription usually leads to the duplication of data. This has to be avoided as it is timeconsuming and possibly erroneous. Transcription is usually combined with a change of the media (media crack), but can also include the transfer e.g. from paper to paper. Figure 103: Example of a transcription (1). Figure 104: Example of a transcription (2). 5. What are good Hospital Information Systems 153 Leanness of information processing tools The user wants to use as few application components and information processing tools as possible for a given tasks. For example, during nursing documentation, how often does a nurse have to change between application components and information processing tools? The less application components that have to be used for one tasks, the easier it is to avoid transcription. Workflow integration In general, new computerbased systems should be smoothly integrated into the daily clinical workflow. Thus, their functionality and usability should match the needs of the users and their typical tasks. The new computerbased system must therefore smoothly work together with the other computerbased and conventional information processing tools. Achieving such workflow integration is the most important task from the users point of view. Efficiency and effectiveness of information logistics Information processes should be as lean as possible: They should not contain unnecessary steps (e.g. documentation of data which is never used again), they should be as parallel as possible, allow the multiple usability of data (see above), and avoid redundant activities (e.g. transcription of data, see above). In general, information logistics should be organized as efficiently and effectively as possible: • The right information: is the information accessible, correct and complete? For example, does the received lab result really belong to the displayed patient? • At the right time: Is the information available when the clinician needs it, just in time? For example, are the recent results available during the physician’s round? • At the right place: Is the information available wherever the clinical needs it? For example, is nursing documentation available at the patient’s bedside as well as in the ward room? • To the right people: Is the information only available to the clinicians needing it? For example, are the Figure 105: In a senior physician’s office: Insufficient organization of work using paperbased tools. 154 Strategic Information Management in Hospitals diagnoses of a patient only available to the treating clinicians? • In the right form: is the information available in a format usable to the clinician? For example, can information personally be filtered, not overwhelming the clinician with too much information (information overload)? Examples Exercises Summary 5. What are good Hospital Information Systems 155 5.4 Outcome quality In general, outcome quality describes the effects of patient care, i.e. the changes in the health status of the patient (e.g. mortality, morbidity, costs). In the context of hospital information systems, outcome quality describes whether the goals of information management have been reached, or, in a broader sense, to what extent the hospital information system contributed to the goals of the hospital. Quality of outcomes thus means whether the hospital information system finally fulfills the needs of its different user groups and thus supports efficient and effective patient care. Outcome quality describes the measurable value of the HIS for the hospital and its various stakeholders. Despite good quality of structures and processes, it is not sure, that the hospital information system contributes to the aims of the hospital or the expectations of the stakeholders. Quality of structure and quality of processes is just a prerequisite for the quality of outcomes. Goals of the hospital For the hospital as an enterprise, it may be interesting if the hospital information systems contributes to • Quality improvement • Patient satisfaction • Cost reduction as general aims of all hospitals. Additionally, there are further hospital aims, like • fulfillment of legal requirements • support of clinical research • being a specialized medical competence center Furthermore, each individual hospital wants to attain further specific goals, where the HIS should participate. For example: • Efficient communication with other health providers (e.g. quick communication of discharge reports to the next health provider) • During patients stay, all patientrelated information is available. Goals of information management Usually, in each country, different laws influencing information processing can be found, dealing for example with organization of health care, financing of health care, health statistics, or data protection. Those laws must be taken into account by information management. 156 Strategic Information Management in Hospitals Expectations of different stakeholders As well, distinct stakeholders have specific expectations. User needs typically to be addressed comprise: • Patient: availability of uptodate medical knowledge, staff which has time for the patient, not wasting time on unnecessary documentation tasks or inflexible information processing tools. • Relatives: the patient can easily be found in the hospital, information for home care is made available. • Physician: new findings are available at the physician’s round, not losing time with insufficiently designed information processing tools, multiple usability of data, availability of the whole patient record, simple and standardized forms for data entry, easy access to new medical knowledge. • Nurses: easy procedure for scheduling and order entry, availability of bedside documentation tools, support of ward organization, easy access to nursing guidelines and to nursing knowledge. • Administration staff: availability of uptodate administrative information, efficient tools to support billing and financial budgeting. • Hospital management: easy access to complete and uptodate information on the quality of patient care and on its costs. Examples Legal issues: German laws influencing hospital information systems The organization of health care in Germany is described in the Sozialgesetzbuch V (SGBV). In contains among others laws about quality management, administrative health cards, and data exchange of diagnoses and services for inpatients and outpatients between hospital and insurance companies. The hospital financing system is regulated in the Krankenhausfinanzierungsgesetz (KHG), together with the Bundespflegesatzverordnung (BPflV). The amount of reimbursement for outpatient care is described in different catalogues such as GOÄ, EBM and DKGNT. There are several laws concerning data protection: The national data protection law (Bundesdatenschutzgesetz) and the regional data protection laws (Landesdatenschutzgesetze) describe, among others, technical and organizational means to protect sensitive data. In addition, the regional hospital laws (Landeskrankenhausgesetze) regulate among others if the data collection, storage and use of patient centered data in hospitals is permitted. The hospital statistics law (KrankenhausstatistikVerordnung) contains guidelines for federalwide statistics about diagnoses and other health data and about cost data. 5. What are good Hospital Information Systems 157 The regional archive laws (Landesarchivgesetze) deal with archiving of documents such as patient records. The information and communication service law (Informations und KommunikationsdiensteGesetz, IuKDG) introduces the digital signature and contains guidelines for the use of telecommunication services. Further information is given in the Signaturverordnung (SigV). For university medical centers, the HBFG (Hochschulbauförderungsgesetz) deals with building and modernizing medical centers and describes the financing of medical devices such as computer systems. The MedGV (Medizinische Geräteveordnung) describes documentation and maintenance of the medical devices. Overall, there is a vast amount of different and often changing laws which provide a framework for information processing in inpatient and outpatient care. Exercises Summary 158 Strategic Information Management in Hospitals 5.5 Examples 5.6 Exercises 5.7 Summary
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