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Using Health Informatics to Develop and Sustain Quality Clinical Practice

By Obi Igbokwe
A look at how health informatics can be used to improve clinical practice.

Doctors use some two million pieces of information to manage patients. However textbooks, journals, and other existing information are not adequate for answering the questions that arise; textbooks are out of date, and the “signal to noise” ratio of journals is too low for them to be useful in daily practice.

Often doctors are not asking simply for information but for support, guidance, affirmation and feedback, and need information sources that are relevant, valid material that can be accessed quickly and with minimal effort. Thus, during a consultation, a clinician should be able to access two kinds of information – the patient’s medical record and medical knowledge relevant to the present problem.

This information can be made electronic, portable, fast, easy to use, connected to both a large valid database of medical knowledge and patient records, and be a servant of patients as well as doctors.

This is in keeping with the objectives outlined by the Information Technology strategy for the National Health Service (NHS) in the United Kingdom. Some of which include:
? Ensuring that patients can be confident that healthcare professionals caring for them have reliable and rapid access, 24 hours a day, to the relevant personal information to support their care.
? Providing access for patients to accredited, independent, multimedia background information and advice about their condition.
? Provide healthcare professionals with an online access to the best local guidance and national evidence in treatment, and the information they need to evaluate the effectiveness of their work and support their professional development.

Health informatics’ direction has been towards the management, transfer and representation of information in electronic medical records (EMRs). Electronic medical records would not only store the patients’ names and contact details but also record every contact that the patient has with the organisation, including test results and investigations. The use of EMRs have already been associated with an improved quality of care in healthcare organisations that have implemented them.

St. Jude’s Children’s Hospital in Memphis, Tennessee, a hospital dedicated to the treatment of children with catastrophic illnesses and the research studies to improve the clinical outcomes of such diseases, implemented an electronic medical record system as a way to facilitate a centralized patient information repository. The projected outcome of this was to provide a paperless patient medical record that linked research and clinical data.

The system installed is now the centre for providing the best possible care as it maintains and organizes all the information necessary to support clinical and research efforts, as well as guide healthcare providers in their daily treatment of patients. The system successfully links clinical treatments with research protocol information, providing valuable information to users assessing the effectiveness of particular treatment plans.

Electronic medical record systems can also incorporate electronic prescription systems to address the ills in paper-based system of getting drug orders from physicians to pharmacies. Electronic prescribing, with prompts, reminders and warnings about the drugs prescribed from a clinical decision support application, allow physicians to write appropriate, legible and safe prescriptions quickly and easily.

Aurora Healthcare, a Milwaukee-based organisation began an e-prescribing pilot in November 2001, with an official rollout in July 2003 and noticed a dramatic decrease in the number of queries concerning misunderstood prescriptions.

Clinical decision support systems (CDSS) are useful tools for reducing errors that are made that are made by providers. They are based on best practice guidelines drawn by experts on individual specialties and are usually built around an alerting system based on the rules of logic. The alerts are generally generated over time after relating date from various sources or when clinical data entry is made to electronic medical records.

An Orthopedic surgery department in a hospital based in Paris , France , noticed that there was an increased compliance with clinical guidelines for venous thromboembolism prophylaxis through a CDSS.
It is important that electronic records should be made accessible on a 24-hour basis with accessibility at different levels based on a need to know basis.

Clinicians should also be able to access a much wider range of material (not only journal articles but also passages from textbooks, drug monographs, protocols for patient care, medicological information and reference images. Information sources would include the Internet, Intranet and clinical databases.

Patient confidentiality is a priority especially with the regard to clinical databases and the Internet. Those systems that do have Internet connections should use s a firewall, a software program or piece of hardware, to screen all connections to the Internet and prevent inappropriate transfer of data. Measures should also be put in place to look at attacks from within. This could include different level access passwords and audit trails.

The supply of information would rely on four technologies, information sources in digital form, data communication networks, computer devices at the point of care, and information retrieval systems.
Communications networks should be based on wired and wireless broadband networks which are capable of transferring a full size, high resolution radiograph in less than a second.

Laptops and palmtops should be able to access information from the wireless network adequately and appropriately, store and encrypt that information, display text and pictures, recognise handwriting and be activated by speech.

Evidence based patient information retrieved from such networks should be made available in a manner that patients could become active participants in decisions about their care and this should be in accordance with available evidence and be prepared in a form that is both acceptable and useful.

Issues such as accessibility, acceptability, readability and comprehensibility, style and attractiveness of presentation, accuracy and reliability of content, coverage, currency and arrangements for review and updating; reference to sources of information, credibility of authors, publishers and sponsors, relevance and utility should be carefully addressed. This is to ensure that patient information is approached in a manner that makes the information meet the needs of any patient despite their different educational, cultural, demographic and not least clinical background.

It is equally important to put in place measures to evaluate and implement new technologies that would help in the management and dissemination of information.
To achieve all these, the acquisition of the appropriate technology is important. Some of the criteria for choosing potential vendors include the clinical requirements, the financial needs of the organisation, the geographic setting and an analysis of the existing and predicted flow of information and work within the clinical systems.

To provide a seamless network, it is important that the hardware systems are compatible with each other. Other aspects that should be considered during hardware acquisition are:
? Cost – The cost of operation, maintenance and cost of upgrade should be as low as possible so as not to eat into much needed finds that might be needed elsewhere.
? Performance – A low speed, low capacity network is frustrating to any user, who might eventually turn his or her back on it.
? Reliability – The risk of malfunction should be low and there should be readily available support to overcome reliability problems when needed.
? Connectivity – Connection to LAN/WAN by peripherals should be secure and appropriate.
? Ergonomics – The hardware equipment design should human-engineered and user-friendly, with consideration for comfort and safety.
Software that would run on the systems should also be evaluated and the appropriate ones purchased. Criteria for selecting software should include:
? Contract – terms and conditions, ownership of modified work, indemnity and insurance against loss or damage should be carefully scrutinised.
? Costs – purchase, leasing, cost of operation, and cost of maintenance kept as low as possible with affecting the quality of the product.
? Efficiency – Low CPU requirements, disk requirements and peripheral requirements are hallmarks of a properly designed software product.
? Robustness and Security – Errors arising from malfunctions and/or improper use, and known bugs should be properly documented.
? Programming Language – The language used to write the software should be standard, portable and likely to remain popular
? Flexibility – Any modification carried out should be easy and skills required to use it should be beyond the reach of most users.
Along with the appropriate acquisition of technology, careful planning to the information delivery process to physicians is required to improve knowledge transfer.
One of ways of doing this is treating both information and knowledge as clinical objects with the same modelling requirements. An organisation should draw upon the contribution of many individuals in the management of its knowledge base.
Some of the issues that would have to be addressed when the information is being acquired are:
? What are the processes within the organisation that would have the biggest impact on improving healthcare delivery?
? What knowledge, and if the organisation possesses it, would make these processes work more effectively?
? Does the organisation posses the appropriate knowledge but not at right places at the right time? Or would the knowledge have to be acquired from outside?
? Would use the knowledge?
? How would the knowledge brought across to people?

The necessary information can then be acquired by going through these five questions and made available to the appropriate individuals would who read relevant knowledge and by recognition that knowledge is converted into subjective knowledge. Now through re-interpretation, the knowledge would be converted into a form that is easily communicated and this knowledge is hereby known as public knowledge.

The public knowledge can then be reviewed for validation, referencing and listing before it is made widely available within the organisation. Once released, individuals within the organisation can use it as a resource from which to retrieve relevant knowledge. Relevant knowledge once retrieved must be read, and then recorded in the document of various form, including training programs, policies and procedures, and converted for the cycle to recommence.

This ensures that people encounter information regularly and not only when they go looking for it.
Appropriate staff such as information managers and IT personnel would be needed to make the information accessible as envisioned by the organisation.

The personnel should be divided into manageable teams and the following guidelines expected of each team:
? It should be agreed with the teams precisely what is expected of them to achieve.
? The team leader and other the team members are confident that they have the skills and resources to achieve their objectives.
? Teams are given feedback in a regular basis in achieving the objectives.
Also steps should be taken to assess training needs of staff and patients alike and to implement programmes that would adequately take care of such needs.
Some of the likely pitfalls to avoid that would hinder the success of effectively distributing knowledge throughout the organisation are:
? Staring too big: Sharing of knowledge is not a natural process found in most organisations, so it is advisable to start with small projects which can then be geared up at regular intervals.
? Relying on technological shortcuts: Dumping of information into databases with no organisation or analysis is a recipe to ensure that the information never gets used. Information should be should properly organised and distributed not only within the databases but in other places where it is readily accessible to people even if they do not go looking fir it.
? Poor behaviour modelling: Measures should be in place to ensure that acquisition of skills needed for accessing and retrieving information is an ongoing process. If this is not done, the whole process is likely to fail.

Opportunities available to organisations
• Improvement in the quality of clinical care that is offered to patients, as clinicians are able to access complete medical records at any time of the day and almost any where in the hospital (from wireless access points). Providers would also have access to evidence-based material during patient consultations, access laboratory and test results almost immediately.
• Improvement in the quality of care through the delivery of easily accessible and accurate information would present other opportunities such as attracting and holding on to top quality staff.
• Through training and better access to information, organisations can improve the quality of their own staff.
• Proper management and delivery of information would be an advantage in improving clinical research and audit.

Risk and constraints
• There is a possibility that the technology acquired might quickly become obsolete and inappropriate for routine use in clinical care.
• If the members of the organisation are not involved in the design process there is a possibility that the information services provided would not be used.
• There is the risk of acquiring incompatible systems that would lead to stand alone systems or systems that are not being used at all.
• Technology that is inappropriate for routine use in clinical practice is a possibility that has guarded against.
• If the process is not properly managed, it can lead to an increase in the cost and time used for its implementation and possibly a decrease in the outcomes expected.
• One constrain to the project would be that of the culture in many healthcare organisations. Many doctors feel that frequent searches are not compatible with an average consultation time of seven minutes. Many also feel that real data entry during consultations are inappropriate.
• Many doctors have expressed concerns about patients’ attitude to information searching during clinical consultation or that they themselves might feel uncomfortable about it.
• Many practitioners might try to resist changing over to the new style of doing things as they might be happy with the old ways.
• Such a project is capital intensive and many physicians might believe that the money might be better spent on other things that have a direct effect on patient care rather the acquisition of technology, especially in these days of finite resources.

Resources Required
? Staff – the right number and quality, including support staff, would be essential to make the whole process a success. This varies from project to project so it is essential to have leaders on the project who understand and know what needs to be done and by whom.
? Skills – the right people with the required skills such as information mangers and IT personnel would be essential.
? Funding – the whole process would require funds for the employment of staff and the acquisition of technology.
? Knowledge – knowledge present within the organisation would have to be tapped and converted into a form tat is easily understood, accessible and spread across the whole organisation.
Carefully managed information that is accessible, acceptable and reliable would not only help in improving the quality oh care given by a healthcare organisation but also enhance its reputation as a care provider.

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