What is health information
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1) The article discusses health informatics and how it helps doctors make better decisions by improving how patient data and medical knowledge is captured, processed, communicated and applied. 2) It focuses on how information is handled during routine clinical tasks like consultations and covers broader issues related to things like medical record keeping, communicating with colleagues and patients, and keeping clinical knowledge up to date. 3) It explains the differences between actual information, representations of that information, and how individuals may interpret it, noting that information is best captured and represented in a way that helps both human and computer users find and interpret it.
What is health information
- 1. Clinical review ABC of health informatics What is health information? This is the first in a series of 12 articles A glossary of terms is available on bmj.com Jeremy C Wyatt, Frank Sullivan Information is an ethereal commodity. One definition describes it as the data and knowledge that intelligent systems (human and artificial) use to support their decisions. Health informatics helps doctors with their decisions and actions, and improves patient outcomes by making better use of information—making more efficient the way patient data and medical knowledge is captured, processed, communicated, and applied. These challenges have become more important since the internet made access to medical information easier for patients. This ABC series focuses on information handling during routine clinical tasks, using scenarios based on Pendleton’s seven-stage consultation model (see box opposite). The articles JOHN GREIM/SPL cover wider issues arising from, and extending beyond, the immediate consultation (see box below). Questions on clinical information that often arise in clinical and reflective practice are dealt with, but discussion of specific computer systems is avoided (a glossary of terms appears on bmj.com, and other glossaries are listed in the box at the end of this article). Some questions on clinical information Pendleton’s consultation model, adapted for ABC series Medical record keeping x Discover the reason for the patient’s attendance x What records to keep? x Consider other problems x In what format? x Achieve a shared understanding of the problems with the patient x What data to enter, and how? x With the patient, choose an appropriate action for each problem x How to store records, and for how long? x Involve the patient in planning their management x With whom to share the record? x Make effective use of the consultation How to use the information records contain x Establish or maintain a relationship with the patient x To manage my patients? x To audit and improve my service? x To support my research? x To feed another information system? How to communicate with my colleagues and patients x Face to face? Ms Smith is a 58 year old florist with a 15 year history of x On paper? renal impairment caused by childhood pyelonephritis x Using the internet? who is experiencing tiredness and muscle cramps. She Clinical knowledge sources has sought medical attention for similar problems in the x What knowledge sources are out there, and how to select them? past, and is considering doing so again x How to use these sources to answer my own, and my team’s, clinical questions? x How to keep knowledge and skills up to date? x How to use knowledge to improve my own, and my team’s, clinical practice? Clinical encounter Directory of staff, services... Capturing and using information Refers to Dr Jones Ms Smith Consider the different forms that information can take, where (consultant) Takes (patient) each form comes from, its cost, and how to assess the quality of action Communicates the information. These issues arise during a general with Captures Accesses data from practitioner’s (Dr McKay) encounter with Ms Smith. knowledge in Dr McKay Dr McKay applies her own clinical knowledge and skill, (general practitioner) perhaps augmented by a textbook or other knowledge source, Records data in, to capture relevant data from Ms Smith. Dr McKay browses Ms uses data from Smith’s record to check her medical history. She updates the record and either takes action herself, or telephones a Knowledge resource Patient record consultant nephrologist (Dr Jones), who suggests 1 -hydroxy cholecalciferol 0.5 g daily for Ms Smith. Dr McKay then Information flows in a clinical environment follows up the telephone conversation with the consultant by issuing an electronic prescription. The prescription transfers through a secure local network to Ms Smith’s usual pharmacist 566 BMJ VOLUME 331 10 SEPTEMBER 2005 bmj.com
- 2. Clinical review along with a formal online outpatient referral request. Dr Jones Common sense meets semiotic theory checks a hospital phone directory on the web before referring Ms Smith to the dietician for a low calcium diet. Ms Smith is In her shop, Ms Smith sells a kind of flower that grows on shrubs with prickly stems and serrated leaves. Humans use consistent symbols to kept informed of these developments by telephone before her represent these things (for example, “rose; roos”). However, each appointment the next week. person privately adds their own connotations to these symbols Some definitions of rose from Chambers 21st Century Dictionary x An erect or climbing thorny shrub that produces large, often Representing, interpreting and fragrant, flowers that may be red, pink, yellow, orange, or white, or displaying information combinations of these colours, followed by bright-coloured fleshy fruits When Dr McKay reads Ms Smith’s patient record what she sees x The national emblem of England on the page is not actually information, but a representation of x A light pink, glowing complexion (put the roses back in one’s it. A “real” item of information, such as the fact that Ms Smith cheeks) x A perforated nozzle, usually attached to the end of a hose, watering has hypercalcaemia, is distinct from how that item is can, or shower head that makes the water come out in a spray represented in an information system (for example, by selecting Ms Smith’s record and writing “Hypercalcaemia,” or choosing a Read code that updates Ms Smith’s computer-based record). The real information is also distinct from a person’s interpretation of it, which might resemble a fragment in a stream of consciousness, “Remember to check on Ms Smith—calcium problem back again.” These distinctions reflect common sense and semiotic theory: real things only exist in the physical world, and each person interprets them in private and associates their own images with them. Back in the clinical world, the lesson is that we should capture and represent each item of information in a form that helps each user—whether human or computer—to find and interpret it. The next time Dr McKay logs into Ms Smith’s computer record, although Ms Smith’s serum calcium may be represented internally in the computer as the real number 2.8, on the computer screen it can be shown as a figure, a red warning icon, a point on a graph showing all her calcium results, or as the words “Severe hypercalcaemia” in an alert. These display formats can all be achieved with a paper record, but it would take more time and effort to annotate abnormal Possible formats to display information include informal or structured text, tables, graphs, sketches, and images. The best format for each item of laboratory results with a highlighter pen, graph the values on a information depends on who will use it, how they will use it, for what task, paper chart, or write an alert on a Post-it note and place this on and on the formats readily available. With permission from Klaus the front of Ms Smith’s record. Gulbrandsen/SPL Selecting a format is important because it determines how to represent each item of information in a system, and in turn how each item is captured. When information is captured and represented on paper or film, it is hard to change the order in Clinical environment Directory of staff, which each item appears or to display it in other formats. When services... information is captured and stored on a computer, however, it Refers to can be shown in a different order or grouped in different ways. Dr Jones Ms Smith When data is coded and structured, or broken down into simple (consultant) Takes (patient) elements, it can be processed automatically—for example, the action Communicates computer can add the icon, graph the data, or generate the alert with Captures Accesses data from about Ms Smith. knowledge in Dr McKay (general practitioner) Sources of clinical information Records data in, uses data from Clinicians use three types of information to support patient Quality Knowledge resource Patient record care: patient data, medical knowledge, and “directory” improvement information. This description ignores two questions, however: actions where does the knowledge in a textbook come from, and how Content Data extraction, assembly checking do we improve on the methods used to manage patients? Patient data are the source in both cases (see box opposite). Generic clinical Registry etc Local problem Local problems—such as an adverse event or failure to solution (evidence) or opportunity Clinical Clinical implement a guideline that everyone agrees to apply to their research audit, patients—can be picked up by quality improvement activities quality activity such as clinical governance. In well organised clinical environments and specialties, a registry is used to capture Information flows in clinical and non-clinical environments patient experiences and monitor for adverse outcomes. Sometimes, however, patient data are used to suggest, or even answer, more general questions—for example, about drug BMJ VOLUME 331 10 SEPTEMBER 2005 bmj.com 567
- 3. Clinical review effectiveness, disease aetiology, or the accuracy of tests. The results should be high quality, generic evidence that can be Diseases safely applied outside the specific clinical environment that is being studied. Often, this evidence is published as if it were the Renal diseases final word. Clinical epidemiology shows us, however, that the Chronic diseases results of a single study often differ substantially from the “truth.” Well conducted systematic reviews of all rigorous, Chronic pyelonephritis relevant studies are a better approximation, and are an example of the content assembly methods used to develop good quality Chronic renal impairment knowledge resources. Secondary hyperparathyroidism The costs of information Partial hierarchy of diseases To a businessman, information must seem the ultimate product: once it is captured, it can be sold any number of times without Quality criteria for patient data using up the original supply. Unfortunately for clinicians, each item of information that is captured, processed, and displayed Criterion How to test it Comment has an associated cost or risk. By choosing to code the current Accurate Comparison with a gold Technically, validity—does problem as chronic pyelonephritis only (see figure above), Dr standard source of the data item measure what data—for example, the it is meant to? Reliability is McKay fails to record the endocrine dimension with potential patient a related concept—do two loss of explanatory power for others looking at Ms Smith’s observers agree on the data records. Entering more than one code takes extra time and may item? cause difficulties in interpretation for secondary use of the data. Complete Per cent missing data at Often difficult to estimate Information costs are especially high for data captured by a given point without access to multiple health professionals in the structured, coded representation often sources of information required by computerised record systems. If the information is Timely Delay from the event Unless data are available at only ever going to be read by humans, it should not be captured the data describes to its the point they are needed availability for use on to inform decisions, as structured data because this will discourage doctors from the information system fulfilling the other criteria recording useful free text that computers do not need to is almost worthless “understand”—for example, “Ms Smith is going to Spain for a Relevant Amount that data alter Unless data are relevant to holiday, her cat died last week.” All patient record systems should decisions or actions of information users, they allow easy entry of such unstructured text (perhaps by voice the user; the impact of contribute to information recognition) to support the human side of medicine, and to help leaving an item out of overload maintain the therapeutic relationship with patients. the dataset Appropriately Degree of structuring Depends on the user of represented and coding of items the item and their needs Assessing the quality of information Relevant detail If data are detailed Highly dependent on the included enough to support purpose and Imagine that Dr Jones is auditing outcomes in his decisions confidentiality of the hypercalcaemic patients and wishes to include Ms Smith’s data. information Is her data of adequate quality for this task? Relevant Is there enough context A key issue, only partially Information only exists to support decisions and actions: if context (for example, date solved in current it fails to do this, it is irrelevant noise. The aims of clinical audit included patient seen, by whom) electronic patient records are to understand current practice and suggest appropriate to support appropriate actions for the future. If the data are full of errors or interpretation of data? incomplete, refer to patients seen years ago, or cannot be interpreted by the user, they are unlikely to help. More subtly, if Further reading useful data items are present—for example, serum calcium—but vital context is omitted, such as serum albumin or current x Hersh W. What is Medical Informatics? www.ohsu.edu/dmice/ whatis/index.shtml (accessed 26 August 2005) treatment, it is still hard to use the data. Without this context, x Pendleton D, Schofield T, Tate P, Havelock P. The consultation: an information is often useless; with it, data collected for one approach to learning and teaching. Oxford: Oxford University Press, purpose can often, but not always, be used for another. 1987 x Nygren E, Wyatt JC, Wright P. Medical records 2: helping clinicians find information and avoid delays. Lancet 1998;352:1462-6 Glossaries for informatics terms x Morris AD, Boyle DI, MacAlpine R, Emslie-Smith A, Jung RT, x Coiera E. Guide to health informatics. 2nd ed. London: Hodder Newton RW, et al. The diabetes audit and research in Tayside Arnold, 2003. www.coiera.com/glossary.htm (accessed 26 August Scotland (DARTS) study: electronic record linkage to create a 2005) diabetes register. DARTS/MEMO Collaboration. BMJ x Wyatt JC, Liu J. Basic concepts in medical informatics. 1997;315:524-8 http://jech.bmjjournals.com/cgi/content/full/56/11/808 x Naylor CD. Grey zones of clinical practice: some limits to evidence (accessed 26 August 2005) based medicine. Lancet 1995;345:840-2 x Brody H. Stories of sickness. Yale: Yale University Press, 1987 Jeremy C Wyatt is professor of health informatics, and Frank Sullivan x Tanenbaum SJ. What physicians know. N Engl J Med is NHS Tayside professor of research and development in general 1996.329:1268-71 practice and primary care, University of Dundee. x van Bemmel JH, Musen MA, eds. Handbook of medical informatics. London: Springer, 1997 www.mihandbook.stanford.edu/ The series will be published as a book by Blackwell Publishing in spring 2006. handbook/home.htm (accessed 26 August 2005) Competing interests: none declared BMJ 2005;331:566–8 568 BMJ VOLUME 331 10 SEPTEMBER 2005 bmj.com