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What is health information


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What is health information

  1. 1. Clinical reviewABC of health informaticsWhat is health information? This is the first in a series of 12 articles A glossary of terms is available on bmj.comJeremy C Wyatt, Frank SullivanInformation is an ethereal commodity. One definition describesit as the data and knowledge that intelligent systems (humanand artificial) use to support their decisions. Health informaticshelps doctors with their decisions and actions, and improvespatient outcomes by making better use of information—makingmore efficient the way patient data and medical knowledge iscaptured, processed, communicated, and applied. Thesechallenges have become more important since the internetmade access to medical information easier for patients. This ABC series focuses on information handling duringroutine clinical tasks, using scenarios based on Pendleton’sseven-stage consultation model (see box opposite). The articles JOHN GREIM/SPLcover wider issues arising from, and extending beyond, theimmediate consultation (see box below). Questions on clinicalinformation that often arise in clinical and reflective practice aredealt with, but discussion of specific computer systems isavoided (a glossary of terms appears on, and otherglossaries are listed in the box at the end of this article).Some questions on clinical information Pendleton’s consultation model, adapted for ABC seriesMedical record keeping x Discover the reason for the patient’s attendancex What records to keep? x Consider other problemsx In what format? x Achieve a shared understanding of the problems with the patientx What data to enter, and how? x With the patient, choose an appropriate action for each problemx How to store records, and for how long? x Involve the patient in planning their managementx With whom to share the record? x Make effective use of the consultationHow to use the information records contain x Establish or maintain a relationship with the patientx 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 patientsx Face to face? Ms Smith is a 58 year old florist with a 15 year history ofx On paper? renal impairment caused by childhood pyelonephritisx Using the internet? who is experiencing tiredness and muscle cramps. SheClinical knowledge sources has sought medical attention for similar problems in thex What knowledge sources are out there, and how to select them? past, and is considering doing so againx 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 SmithConsider 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 Communicatesthe information. These issues arise during a general with Captures Accesses data frompractitioner’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 fromSmith’s record to check her medical history. She updates therecord and either takes action herself, or telephones a Knowledge resource Patient recordconsultant nephrologist (Dr Jones), who suggests 1 -hydroxycholecalciferol 0.5 g daily for Ms Smith. Dr McKay then Information flows in a clinical environmentfollows up the telephone conversation with the consultant byissuing an electronic prescription. The prescription transfersthrough a secure local network to Ms Smith’s usual pharmacist566 BMJ VOLUME 331 10 SEPTEMBER 2005
  2. 2. Clinical reviewalong with a formal online outpatient referral request. Dr Jones Common sense meets semiotic theorychecks a hospital phone directory on the web before referringMs 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 tokept informed of these developments by telephone before her represent these things (for example, “rose; roos”). However, eachappointment 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, oftenRepresenting, interpreting and fragrant, flowers that may be red, pink, yellow, orange, or white, ordisplaying information combinations of these colours, followed by bright-coloured fleshy fruitsWhen Dr McKay reads Ms Smith’s patient record what she sees x The national emblem of Englandon the page is not actually information, but a representation of x A light pink, glowing complexion (put the roses back in one’sit. 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, wateringhas hypercalcaemia, is distinct from how that item is can, or shower head that makes the water come out in a sprayrepresented in an information system (for example, by selectingMs Smith’s record and writing “Hypercalcaemia,” or choosing aRead code that updates Ms Smith’s computer-based record).The real information is also distinct from a person’sinterpretation of it, which might resemble a fragment in astream of consciousness, “Remember to check on MsSmith—calcium problem back again.” These distinctions reflectcommon sense and semiotic theory: real things only exist in thephysical world, and each person interprets them in private andassociates their own images with them. Back in the clinical world, the lesson is that we shouldcapture and represent each item of information in a form thathelps each user—whether human or computer—to find andinterpret it. The next time Dr McKay logs into Ms Smith’scomputer record, although Ms Smith’s serum calcium may berepresented internally in the computer as the real number 2.8,on the computer screen it can be shown as a figure, a redwarning icon, a point on a graph showing all her calciumresults, 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 oflaboratory 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 Klausthe front of Ms Smith’s record. Gulbrandsen/SPL Selecting a format is important because it determines howto represent each item of information in a system, and in turnhow each item is captured. When information is captured andrepresented 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 tocan be shown in a different order or grouped in different ways. Dr Jones Ms SmithWhen data is coded and structured, or broken down into simple (consultant) Takes (patient)elements, it can be processed automatically—for example, the action Communicatescomputer can add the icon, graph the data, or generate the alert with Captures Accesses data fromabout Ms Smith. knowledge in Dr McKay (general practitioner)Sources of clinical information Records data in, uses data fromClinicians use three types of information to support patient Quality Knowledge resource Patient recordcare: patient data, medical knowledge, and “directory” improvementinformation. This description ignores two questions, however: actionswhere does the knowledge in a textbook come from, and how Content Data extraction, assembly checkingdo 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 problemLocal problems—such as an adverse event or failure to solution (evidence) or opportunity Clinical Clinicalimplement a guideline that everyone agrees to apply to their research audit,patients—can be picked up by quality improvement activities quality activitysuch as clinical governance. In well organised clinicalenvironments and specialties, a registry is used to capture Information flows in clinical and non-clinical environmentspatient experiences and monitor for adverse outcomes. Sometimes, however, patient data are used to suggest, oreven answer, more general questions—for example, about drugBMJ VOLUME 331 10 SEPTEMBER 2005 567
  3. 3. Clinical revieweffectiveness, disease aetiology, or the accuracy of tests. Theresults should be high quality, generic evidence that can be Diseasessafely applied outside the specific clinical environment that isbeing studied. Often, this evidence is published as if it were the Renal diseasesfinal word. Clinical epidemiology shows us, however, that the Chronic diseasesresults of a single study often differ substantially from the“truth.” Well conducted systematic reviews of all rigorous, Chronic pyelonephritisrelevant studies are a better approximation, and are an exampleof the content assembly methods used to develop good quality Chronic renal impairmentknowledge resources. Secondary hyperparathyroidismThe costs of information Partial hierarchy of diseasesTo 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 datausing up the original supply. Unfortunately for clinicians, eachitem of information that is captured, processed, and displayed Criterion How to test it Commenthas an associated cost or risk. By choosing to code the current Accurate Comparison with a gold Technically, validity—doesproblem 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 isMcKay fails to record the endocrine dimension with potential patient a related concept—do twoloss of explanatory power for others looking at Ms Smith’s observers agree on the datarecords. 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 multiplehealth professionals in the structured, coded representation often sources of informationrequired by computerised record systems. If the information is Timely Delay from the event Unless data are available atonly 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 criteriarecording 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 toholiday, her cat died last week.” All patient record systems should decisions or actions of information users, theyallow easy entry of such unstructured text (perhaps by voice the user; the impact of contribute to informationrecognition) to support the human side of medicine, and to help leaving an item out of overloadmaintain 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 needsAssessing the quality of information Relevant detail If data are detailed Highly dependent on the included enough to support purpose andImagine that Dr Jones is auditing outcomes in his decisions confidentiality of thehypercalcaemic patients and wishes to include Ms Smith’s data. informationIs 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 currentit fails to do this, it is irrelevant noise. The aims of clinical audit included patient seen, by whom) electronic patient recordsare to understand current practice and suggest appropriate to support appropriateactions for the future. If the data are full of errors or interpretation of data?incomplete, refer to patients seen years ago, or cannot beinterpreted by the user, they are unlikely to help. More subtly, if Further readinguseful data items are present—for example, serum calcium—butvital context is omitted, such as serum albumin or current x Hersh W. What is Medical Informatics? 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: aninformation 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;352:1462-6Glossaries 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. (accessed 26 August Scotland (DARTS) study: electronic record linkage to create a 2005) diabetes register. DARTS/MEMO Collaboration. BMJx Wyatt JC, Liu J. Basic concepts in medical informatics. 1997;315:524-8 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, 1987Jeremy C Wyatt is professor of health informatics, and Frank Sullivan x Tanenbaum SJ. What physicians know. N Engl J Medis NHS Tayside professor of research and development in general 1996.329:1268-71practice and primary care, University of Dundee. x van Bemmel JH, Musen MA, eds. Handbook of medical informatics. London: Springer, 1997 series will be published as a book by Blackwell Publishing inspring 2006. handbook/home.htm (accessed 26 August 2005)Competing interests: none declared BMJ 2005;331:566–8568 BMJ VOLUME 331 10 SEPTEMBER 2005