Improving services with informatics tools
0 likes1,019 views
This document summarizes key concepts around using clinical data and informatics tools to improve healthcare services. It discusses how data from multiple sources can be linked and analyzed to provide intelligence to decision-makers. However, issues around data protection, privacy and ensuring data is used appropriately must be addressed. Effective presentation of data is important so clinicians view it as valid and are motivated to change practices. Feedback of performance data can improve quality when done constructively and by considering the local context.
Improving services with informatics tools
- 1. Clinical review ABC of health informatics Improving services with informatics tools Frank Sullivan, Jeremy C Wyatt This article describes how many sources of data can be linked, This is the 10th in a series of 12 articles interpreted, 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 bmj.bmjjournals.com/cgi/content/full/331/7516/566/ surrounding data protection and freedom of information. DC1 A huge volume of data flows across the desk of a director of public health (see box opposite). One of the director’s problems is to know which signals to act upon and what “noise” to ignore. If the numbers being considered are small, as they probably will be in the case described here, a critical incident analysis may be You are a director of public health. The local paediatric all that is needed. An individual prescriber, or group, may have intensive care unit sends you a paper describing five an erroneous belief or inadequate training. Critical incidents or potentially avoidable admissions in the past two years—for other signals often indicate that more data (such as data on example, patients with severe asthma who were not being prescribing steroids for paediatric asthma in primary care and prescribed prophylactic drugs outpatients) are needed. Sources of data Health services are awash with data. Earlier articles in the series described the large and increasing numbers of sources of data available to consumers, patients, clinicians, and administrators. Clinicians, teams, divisions, and other groups collect the data they need to carry out their work, and they may do so using coding and terms that others can understand and share. The intensive care unit in this example integrated the data the team needs to manage patients during their stay with patients’ pre-admission prescribing data. This local epidemiology may have been done as part of clinical governance activities, or as an ad 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 issue must be dealt with effectively. It may be that the individual or group who identify the problem have the knowledge, skills, and resources to resolve it. In other cases, such as these potentially avoidable asthma admissions, those responsible are not those who have uncovered the issue, and those potentially responsible may be unaware of the problem. UK clinical governance definition* A framework through which NHS organisations are accountable for Presentation of data continually improving the quality of their services and safeguarding high standards of care by creating an environment in which Ideally, the choice of measures, analysis, and presentation of excellence in clinical care will flourish data should be determined by the purpose of measurement and the 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;317:61-5 with the secondary use of clinical data. Studies have shown that interpretation of data is influenced by the method used to summarise the results. Health policy makers, like doctors, tend to prefer measurements that report relative risks (or benefits) to measurements 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 Safety best to present the information should be considered. x Effectiveness x Patient centredness x Timeliness Feedback of performance data x Efficiency x Equity Different approaches (using internal or external influences on *From Institute of Medicine Committee on Quality of Health Care in decision 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, 2001 problem. At least two, and preferably three, of the more effective approaches (see boxes on next page) should be taken. 1190 BMJ VOLUME 331 19 NOVEMBER 2005 bmj.com
- 2. Clinical review Analysis of approaches to changing clinical practice: internal processes Approach Theories Focus Interventions, strategy Educational Adult learning theories Intrinsic motivation of Bottom up, local consensus development professionals Small group interactive learning Problem based learning Epidemiological Cognitive theories Rational information seeking Evidence based guideline development and decision making Disseminating research findings through courses, mailing, journals Marketing 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 processes Approach Theories Focus Interventions, strategy Behavioural Learning theory Controlling performance by Audit and feedback external stimuli Reminder systems, monitoring Economic incentives, sanctions Social 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 interventions Organisational 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, tasks Coercive 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 or teams to produce routine reports because computerised data entry enables the routine extraction of data for many purposes. 09 11 64 02 5 0 Data from multiple sources may be linked to records, and so Date of birth Sex Sequence Checksum provide additional intelligence beyond the purposes for which number digit they 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 so Record linkage that their encounters with the health service can be linked Deterministic or probabilistic methods can be used with similar success rates to link records. In the former case, a unique patient identifier, such as a 10 digit community health index Genera number, is applied to all personal health data—for example, Laboratory practiti l data oner Dental laboratory test requests and prescriptions. In the latter case, algorithms determine the likelihood that two items of data belong to the same person. The Soundex system converts a name to a code (for example, Michael becomes M240). The first letter is the first letter of the word, and the numbers represent phonetic parts of latter syllables. The algorithm determines that Hospital John Smyth and John Smythe is the same child with asthma if Pharmacy sufficient other characteristics (date of birth, street name) on the CHNo admission data and community prescriptions match. After linkage, each individual item of data may then be linked and anonymised for disease surveillance purposes. Social Investigations services Screening Data protection The main provisions of the 1998 Data Protection Act were implemented on 1 March 2000. This act builds on the earlier The community health index number (CHNo) allows the fragmented 1984 Data Protection Act. It is the means whereby the United episodes of care experienced by individuals to be integrated into the Kingdom enforces the 1995 European directive on data completed jigsaw of an electronic health record BMJ VOLUME 331 19 NOVEMBER 2005 bmj.com 1191
- 3. Clinical review protection. It aims to ensure that the processing (obtaining, Principles of good practice in the 1998 Data Protection Act recording, holding, doing calculations on) of information using data is done in accordance with the rights of individuals. The Data are: x Fairly and lawfully processed European directive also extends the legislation to manual, as x Processed for limited purposes well as computerised, records containing personal information. x Adequate, relevant, and not excessive Under the provisions of the act, data controllers (for example, x Accurate general practitioners) are responsible for ensuring that access to x Not kept longer than necessary patient data should be under strictly controlled conditions and, x Processed in accordance with the rights of the subject of the data if necessary, with patients’ consent. x Secure x Not transferred to countries without adequate protection Eight principles of good practice are in the act. Patients should be aware, at least in broad terms, of the purposes for which their personal data are used. However, it is the view of the data 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 purpose Caldicott guardians believe that the activities of the NHS are x Information transferred only when absolutely necessary often in the public interest, and in most cases the consent of the x Only the minimum required patient can be inferred. Other bodies, such as the General x Need to know access controls x All to understand their responsibilities Medical Council and the BMA, advise that explicit consent is x Comply with and understand the law still preferable in some cases, and examples include: x Release of details of patients to diabetic and cancer registers * http://pmj.bmjjournals.com/cgi/content/full/79/935/516 x 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 the January 2005. It is intended to “promote a culture of openness conflict between the the Freedom of Information Act and and accountability amongst public sector bodies by providing data protection legislation people with rights of access to the information held by them.” It will probably conflict with data protection legislation because x Use personal data with consent or other assent from the subjects of the data information about individuals is contextualised within families, x Anonymise the data, then use them communities, practices, and hospital units. It will be difficult to x Use personal data without explicit consent, under a public interest ensure that an individual’s data are protected while giving mandate freedom 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 change In many medical cultures it is difficult to provide feedback that x It takes time to develop the credibility of data will be taken in a constructive manner. Certain principles make x The source and timeliness of data are critical to perceived validity it more likely that the feedback will be considered constructive x Benchmarking improves the meaningfulness of data feedback by recipients, and changes that could improve care will x Opinion leaders can enhance the effectiveness of data feedback probably 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 performance Research governance *Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. Data feedback efforts in quality improvement: lessons learned from US Confidentiality and security of data is probably a greater hospitals. Qual Safety Health Care 2004;13:26-31 concern for researchers than clinicians, although clinical researchers need to live with concept of governance in both worlds. Data collected for patient care may only be used to Further reading produce 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;8:1-72 standards apply to use of personally identifiable data, where x NHS Health Technology Assessment Programme. Effectiveness and explicit signed, informed consent is often required. Some efficiency of guideline dissemination and implementation jurisdictions relax this standard if it is impossible, or extremely strategies: www.ncchta.org/execsumm/summ806.htm (accessed 4 difficult, 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 secondary Summary uses of data. London: The Nuffield Trust, 2002 x Berwick DM. Errors today and errors tomorrow. N Engl J Med A public health consultant faced with complex, difficult choices, 2003;348:2570-72 such as the data on asthma prescribing, will prefer to discuss the reasons for apparent prescribing failures rather than taking Frank Sullivan is NHS Tayside professor of research and development pre-emptive action, which may do harm to the service overall. in general practice and primary care, and Jeremy C Wyatt is professor The 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 in often means changing the system. The consequences of failing spring 2006. to act when there is a problem need to be counterbalanced Competing interests: None declared. against the damage caused by incorrect interpretation of data collected for one purpose but used for another. BMJ 2005;331:1190–2 1192 BMJ VOLUME 331 19 NOVEMBER 2005 bmj.com