Clinical reviewABC of health informaticsImproving services with informatics toolsFrank Sullivan, Jeremy C WyattThis articl...
Clinical reviewAnalysis of approaches to changing clinical practice: internal processesApproach                      Theor...
Clinical reviewprotection. It aims to ensure that the processing (obtaining,                                              ...
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Improving services with informatics tools

  1. 1. Clinical reviewABC of health informaticsImproving services with informatics toolsFrank Sullivan, Jeremy C WyattThis article describes how many sources of data can be linked, This is the 10th in a series of 12 articlesinterpreted, and analysed before being presented to decision A glossary of terms is available at http://makers to improve care. It also discusses the legal issues data protection and freedom of information. DC1 A huge volume of data flows across the desk of a director ofpublic health (see box opposite). One of the director’s problemsis to know which signals to act upon and what “noise” to ignore.If the numbers being considered are small, as they probably willbe in the case described here, a critical incident analysis may be You are a director of public health. The local paediatricall that is needed. An individual prescriber, or group, may have intensive care unit sends you a paper describing fivean erroneous belief or inadequate training. Critical incidents or potentially avoidable admissions in the past two years—forother signals often indicate that more data (such as data on example, patients with severe asthma who were not beingprescribing steroids for paediatric asthma in primary care and prescribed prophylactic drugsoutpatients) are needed.Sources of dataHealth services are awash with data. Earlier articles in the seriesdescribed the large and increasing numbers of sources of dataavailable to consumers, patients, clinicians, and administrators.Clinicians, teams, divisions, and other groups collect the datathey need to carry out their work, and they may do so usingcoding and terms that others can understand and share. Theintensive care unit in this example integrated the data the teamneeds to manage patients during their stay with patients’pre-admission prescribing data. This local epidemiology mayhave been done as part of clinical governance activities, or as anad hoc exercise when a patient’s problem was investigated. One difficulty with secondary uses of clinical data is that,having obtained the data indicating a problem exists, the issuemust be dealt with effectively. It may be that the individual orgroup who identify the problem have the knowledge, skills, andresources to resolve it. In other cases, such as these potentiallyavoidable asthma admissions, those responsible are not thosewho have uncovered the issue, and those potentially responsiblemay be unaware of the problem. UK clinical governance definition* A framework through which NHS organisations are accountable forPresentation of data continually improving the quality of their services and safeguarding high standards of care by creating an environment in whichIdeally, the choice of measures, analysis, and presentation of excellence in clinical care will flourishdata should be determined by the purpose of measurement andthe use to which data are to be put. This poses another difficulty *From Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61-5with the secondary use of clinical data. Studies have shown thatinterpretation of data is influenced by the method used tosummarise the results. Health policy makers, like doctors, tendto prefer measurements that report relative risks (or benefits) tomeasurements providing estimates of absolute risks (or Categories of improvement for health services*benefits). Once the decision has been taken to act on data, how x Safetybest to present the information should be considered. x Effectiveness x Patient centredness x TimelinessFeedback of performance data x Efficiency x EquityDifferent approaches (using internal or external influences on *From Institute of Medicine Committee on Quality of Health Care indecision makers) can be taken when using data to improve care. America.Crossing the quality chasm: a new health system for the 21st century.The interventions chosen should be tailored to the underlying Washington, DC: National Academy Press, 2001problem. At least two, and preferably three, of the moreeffective approaches (see boxes on next page) should be taken.1190 BMJ VOLUME 331 19 NOVEMBER 2005
  2. 2. Clinical reviewAnalysis of approaches to changing clinical practice: internal processesApproach Theories Focus Interventions, strategyEducational Adult learning theories Intrinsic motivation of Bottom up, local consensus development professionals Small group interactive learning Problem based learningEpidemiological Cognitive theories Rational information seeking Evidence based guideline development and decision making Disseminating research findings through courses, mailing, journalsMarketing Health promotion, innovation Attractive product adapted to Needs assessment, adapting change and social marketing theories needs of target audience proposals to local needs Stepwise approach Various channels for dissemination (mass media and personal)Analysis of approaches to changing clinical practice: external processesApproach Theories Focus Interventions, strategyBehavioural Learning theory Controlling performance by Audit and feedback external stimuli Reminder systems, monitoring Economic incentives, sanctionsSocial interaction Social learning and innovation Social influence of important Peer review in local networks theories, social influence and peers or role models Outreach visits, individual instruction power theories Opinion leaders Influencing key people in social networks Patient mediated interventionsOrganisational Management theories, system Creating structural and Re-engineering care process theories organisational conditions to Total quality management and continuous improve care quality improvement approaches Team building Enhancing leadership Changing structures, tasksCoercive Economic, power, and learning Control and pressure, external Regulations, laws theories motivation Budgeting, contracting Licensing, accreditation Complaints and legal procedures Today, it is less necessary to rely on individual clinicians orteams to produce routine reports because computerised dataentry enables the routine extraction of data for many purposes. 09 11 64 02 5 0Data from multiple sources may be linked to records, and so Date of birth Sex Sequence Checksumprovide additional intelligence beyond the purposes for which number digitthey were originally collected. The community health index number (CHNo) is a unique 10 digit number that includes the date of birth of individuals born, or moving to, Scotland soRecord linkage that their encounters with the health service can be linkedDeterministic or probabilistic methods can be used with similarsuccess rates to link records. In the former case, a uniquepatient identifier, such as a 10 digit community health index Generanumber, is applied to all personal health data—for example, Laboratory practiti l data oner Dentallaboratory test requests and prescriptions. In the latter case,algorithms determine the likelihood that two items of databelong to the same person. The Soundex system converts aname to a code (for example, Michael becomes M240). The firstletter is the first letter of the word, and the numbers representphonetic parts of latter syllables. The algorithm determines that HospitalJohn Smyth and John Smythe is the same child with asthma if Pharmacysufficient other characteristics (date of birth, street name) on the CHNoadmission data and community prescriptions match. Afterlinkage, each individual item of data may then be linked andanonymised for disease surveillance purposes. Social Investigations services ScreeningData protectionThe main provisions of the 1998 Data Protection Act wereimplemented on 1 March 2000. This act builds on the earlier The community health index number (CHNo) allows the fragmented1984 Data Protection Act. It is the means whereby the United episodes of care experienced by individuals to be integrated into theKingdom enforces the 1995 European directive on data completed jigsaw of an electronic health recordBMJ VOLUME 331 19 NOVEMBER 2005 1191
  3. 3. Clinical reviewprotection. It aims to ensure that the processing (obtaining, Principles of good practice in the 1998 Data Protection Actrecording, holding, doing calculations on) of information usingdata is done in accordance with the rights of individuals. The Data are: x Fairly and lawfully processedEuropean directive also extends the legislation to manual, as x Processed for limited purposeswell as computerised, records containing personal information. x Adequate, relevant, and not excessiveUnder the provisions of the act, data controllers (for example, x Accurategeneral practitioners) are responsible for ensuring that access to x Not kept longer than necessarypatient data should be under strictly controlled conditions and, x Processed in accordance with the rights of the subject of the dataif necessary, with patients’ consent. x Secure x Not transferred to countries without adequate protection Eight principles of good practice are in the act. Patientsshould be aware, at least in broad terms, of the purposes forwhich their personal data are used. However, it is the view of thedata protection registrar that consent should normally be Dame FIONA Caldicott’s principles of data processing*obtained when processing data about a patient’s health. Many x Formal justification of purposeCaldicott guardians believe that the activities of the NHS are x Information transferred only when absolutely necessaryoften in the public interest, and in most cases the consent of the x Only the minimum requiredpatient can be inferred. Other bodies, such as the General x Need to know access controls x All to understand their responsibilitiesMedical Council and the BMA, advise that explicit consent is x Comply with and understand the lawstill preferable in some cases, and examples include:x Release of details of patients to diabetic and cancer registers * Release of summaries of patient date to out of hours services. The 2000 Freedom of Information Act came into force in Approaches identified by the Nuffield Trust to deal with theJanuary 2005. It is intended to “promote a culture of openness conflict between the the Freedom of Information Act andand accountability amongst public sector bodies by providing data protection legislationpeople with rights of access to the information held by them.” Itwill probably conflict with data protection legislation because x Use personal data with consent or other assent from the subjects of the datainformation about individuals is contextualised within families, x Anonymise the data, then use themcommunities, practices, and hospital units. It will be difficult to x Use personal data without explicit consent, under a public interestensure that an individual’s data are protected while giving mandatefreedom of information to others within that context. Key issues in data feedback to improve quality*Feedback of information x Data must be perceived by clinicians as valid to motivate changeIn many medical cultures it is difficult to provide feedback that x It takes time to develop the credibility of datawill be taken in a constructive manner. Certain principles make x The source and timeliness of data are critical to perceived validityit more likely that the feedback will be considered constructive x Benchmarking improves the meaningfulness of data feedbackby recipients, and changes that could improve care will x Opinion leaders can enhance the effectiveness of data feedbackprobably be implemented. x Data feedback that profiles an individual clinician’s practices can be effective but may be perceived as punitive x Data feedback must persist to sustain improved performanceResearch governance *Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. Data feedback efforts in quality improvement: lessons learned from USConfidentiality and security of data is probably a greater hospitals. Qual Safety Health Care 2004;13:26-31concern for researchers than clinicians, although clinicalresearchers need to live with concept of governance in bothworlds. Data collected for patient care may only be used to Further readingproduce research evidence with adequate safeguards for the x Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR,patients. Legislation varies between countries, but the highest Vale L, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004;8:1-72standards apply to use of personally identifiable data, where x NHS Health Technology Assessment Programme. Effectiveness andexplicit signed, informed consent is often required. Some efficiency of guideline dissemination and implementationjurisdictions relax this standard if it is impossible, or extremely strategies: (accessed 4difficult, to obtain the consent. In other countries acceptable October)anonymisation and adherence to rules of good epidemiological x Fahey T, Griffiths S, Peters TJ. Evidence based purchasing:practice allow the use of clinical data for research purposes. understanding results of clinical trials and systematic reviews. BMJ 1995;311:1056-9 x Lowrence WW. “Learning from experience.” Privacy and the secondarySummary uses of data. London: The Nuffield Trust, 2002 x Berwick DM. Errors today and errors tomorrow. N Engl J MedA public health consultant faced with complex, difficult choices, 2003;348:2570-72such as the data on asthma prescribing, will prefer to discuss thereasons for apparent prescribing failures rather than taking Frank Sullivan is NHS Tayside professor of research and developmentpre-emptive action, which may do harm to the service overall. in general practice and primary care, and Jeremy C Wyatt is professorThe factors that caused the presenting problem are often of health informatics, University of Dundee.rooted in the culture of the health system, and so the solution The series will be published as a book by Blackwell Publishing inoften means changing the system. The consequences of failing spring act when there is a problem need to be counterbalanced Competing interests: None declared.against the damage caused by incorrect interpretation of datacollected for one purpose but used for another. BMJ 2005;331:1190–21192 BMJ VOLUME 331 19 NOVEMBER 2005