HIS chapter 5 ( Tin Y học trong bệnh viện)

Reinhold Haux Alfred Winter Elske Ammenwerth Birgit Brigl Strategic Information Management in Hospitals An Introduction to Hospital Information Systems With 106 Illustrations Status: May 2002 (Version 0.22) Contents 1INTRODUCTION 1 1.1 SIGNIFICANCE OF INFORMATION PROCESSING IN HOSPITALS 1 1.2 PROGRESS IN INFORMATION AND COMMUNICATION TECHNOLOGY 4 1.3 IMPORTANCE OF SYSTEMATIC INFORMATION MANAGEMENT 8 1.4 EXAMPLES 12 1.5 EXERCISES 16 1.6 SUMMARY 17 2BASIC CONCEPTS 18 2.1 INTRODUCTION 18 2.2 DATA, INFORMATION AND KNOWLEDGE 18 2.3 INFORMATION SYSTEMS AND THEIR COMPONENTS 19 2.4 HOSPITAL INFORMATION SYSTEMS 22 2.5 HEALTH INFORMATION SYSTEMS 24 2.6 INFORMATION MANAGEMENT IN HOSPITALS 25 2.7 EXAMPLES 26 2.8 EXERCISES 28 2.9 SUMMARY 30 3WHAT DO HOSPITAL INFORMATION SYSTEMS LOOK LIKE? 33 3.1 INTRODUCTION 33 3.2 HOSPITAL FUNCTIONS 33 3.3 MODELING HOSPITAL INFORMATION SYSTEMS 43 3.4 A METAMODEL FOR MODELING HIS: 3LGM 58 3.5 INFORMATION PROCESSING TOOLS IN HOSPITALS 67 3.6 ARCHITECTURES OF HOSPITAL INFORMATION SYSTEMS 83 3.7 EXAMPLES 93 3.8 EXERCISES 100 3.9 SUMMARY 101 4HOW TO STRATEGICALLY MANAGE HOSPITAL INFORMATION SYSTEMS 103 4.1 INTRODUCTION 103 4.2 STRATEGIC, TACTICAL AND OPERATIONAL INFORMATION MANAGEMENT103 4.3 ORGANIZATIONAL STRUCTURES FOR INFORMATION MANAGEMENT 110 4.4 STRATEGIC PLANNING OF HOSPITAL INFORMATION SYSTEMS 116 4.5 STRATEGIC MONITORING OF HOSPITAL INFORMATION SYSTEMS 127 4.6 STRATEGIC DIRECTING OF HOSPITAL INFORMATION SYSTEMS 137 4.7 EXAMPLES 139 4.8 EXERCISES 139 4.9 SUMMARY 141 5WHAT ARE GOOD HOSPITAL INFORMATION SYSTEMS? 143 5.1 INTRODUCTION 143 5.2 QUALITY OF STRUCTURES 144 5.3 QUALITY OF PROCESSES 152 5.4 OUTCOME QUALITY 155 5.5 EXAMPLES 158 5.6 EXERCISES 158 5.7 SUMMARY 158 6FINAL REMARKS 159 7APPENDIX A: THESAURUS 161 8APPENDIX B: BIBLIOGRAPHY 162 8.1 BOOKS 162 8.2 PROCEEDINGS 163 8.3 JOURNALS 163 8.4 ASSOCIATIONS 163 8.5 INTERNET RESOURCES 164 8.6 RECOMMENDATIONS 165 9APPENDIX C: LIST OF EXAMPLES AND EXERCISES 166 10 APPENDIX D: LIST OF FIGURES AND TABLES 169 11 ABOUT THE AUTHORS 172 5 5 What Are Good Hospital Information Systems? 5.1 Introduction Quality in general is the ability to meet all the expectations of the purchaser of goods or services: “The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs 52 According to Donabedian, there are three major approaches to quality assessment: quality of structures, quality of processes, and outcome quality. 53 In the context of health care, the concept of quality of structures includes the human, physical, and financial resources that are needed to provide medical care (e.g. educational level of staff, availability of medical equipment). Quality of processes describes the quality of activities going on within and between providers and patients (e.g., adherence to professional standards, appropriateness of care). Finally, outcome quality describes the effects of patient care, i.e. the changes in the health status of the patient (e.g. mortality, morbidity, costs). While structure quality influences process quality, this in turn influences outcome quality. Those concepts can be transferred to hospital information systems: In this context, quality of structures refers to the availability of technical or human resources needed for information processing (e.g. number and availability of computer systems, computer knowledge of staff). Quality of processes deals with the quality of the information processes themselves which are necessary to meet the user’s needs. Outcome quality describes whether the goals of information management have been reached, or, in a broader sense, to what extent the hospital information system contributes to the goals of the hospital. Quality characteristics for hospital information systems help to describe the ‘fitness’ of a HIS, and finding diagnosis and therapy of ‘HIS diseases’. It may not be so difficult to describe what a really ‘bad’ hospital information system looks like. But what are characteristics and features of a ‘good’ hospital information system? In this chapter, we will introduce the most essential ones. After this chapter, you should be able to answer the following questions: 52 ISO. International Standard ISO 9000:2000. Quality management systems Fundamentals and vocabulary. International Organization for Standardization, International Electrotechnical Commission, Geneva; 2000. 53 Donabedian A. Explorations in quality assessing and monitoring Vol 2: The criteria and standards of quality. Ann Arbor: Health Administration Press; 1982. 144 Strategic Information Management in Hospitals • Which facets of quality have to be considered? • What are characteristics for structure quality (i.e. the quality of information processing tools, of HIS architectures, and of information management), and how can they be assessed? • What are characteristics for the quality of information processes, and how can they be assessed? • What are characteristics for the quality of outcomes, and how can they be assessed? 5.2 Quality of structures In the context of health care, the concept of quality of structures includes the human, physical, and financial resources that are needed to proved medical care (e.g. educational level of staff, availability of medical equipment). In the context of hospital information systems, the quality of structures refers to the availability of technical or human resources needed for information processing (e.g. number and availability of computer systems, computer knowledge of staff). It comprises quality characteristics for information processing tools, for HIS architectures, and for information management in hospitals. Quality of information processing tools Different characteristics of the computerbased or conventional information processing tools used influence structure quality which can be separated into software quality and hardware quality. In general, only a missing or erroneous information processing tool should attract attention. Software quality The main characteristics of software quality have been defined by ISO 9126 54 . The objective of this standard is to provide a framework for the evaluation of software quality. ISO 9126 sets out six quality characteristics with corresponding subcharacteristics: • Functionality: Are the required functions available in the software? • Reliability: How reliable is the software? • Usability: Is the software easy to use? • Efficiency: How efficient is the software? 54 ISO. International Standard ISOIEC 91261. Information technology Software product evaluation Quality characteristics and guidelines for their use. International Organization for Standardization, International Electrotechnical Commission, Geneva; 2001. 5. What are good Hospital Information Systems 145 • Maintainability: How easy is it to modify the software? • Portability: How easy is it to transfer the software to another environment? ISO 9241 55 specifically deals with software ergonomy. It contains 17 parts. Part 10 of this standard deals with dialogue principles for user interface design. The dialogue principles of ISO 9241 comprise: • Suitability for the task: Does the user interface support the user to fulfil his tasks effectively and efficiently? • Suitability for learning: Is the user being supported to learn and use the user interface? • Suitability for individualization: Can the user interface be adapted to the tasks and to the individual skills and wishes of the user? • Conformity with user expectations: Is the user interface consistent and adapted to the characteristics of the user (i.e. his knowledge, skill and expectations)? • Self descriptiveness: Is each step of the user interface understandabe for the user by providing direct feedback or explanation? • Controllability: Can the user, after having initiated the first step, control the flow and speed of tasks, until the aim is reached? • Error tolerance: Can the aim of the task even be reached following obviously wrong input by the user, either with no or little effort for correction? Hardware quality Their are no explicit norms to define the quality of hardware or of physical information processing tools in general. However, many aspects of software quality can be transferred to both computerbased and conventional physical tools. The quality of physical information processing tools can thus be described by the following characteristics: 55 ISO. International Standard ISO 9241. Ergonomics requirements for office work with visual display terminals (VDTs). Genf: International Organization for Standardization, International Electrotechnical Commission; 1993. Figure 100: An easetouse, stable, mobile information processing tool: Paperbased documentation at the patients bedside. 146 Strategic Information Management in Hospitals • usefulness (e.g. offering useful functionality for the user) • appropriateness (e.g. not dominating the physicianpatient relation) • easy to use • available (e.g. mobile tool, see Figure 100) • multipurpose (e.g. personal digital assistant) • efficient (low cost for purchase and support) • flexibility (e.g. can be modified easily, see Figure 101) • stable • secure (e.g. supporting basic data security and data safety) • harmless (e.g. not putting harm on the user of the patient) • usable (e.g. user friendly) • standardized (e.g. standardized form for order entry) Quality of HIS architecture HIS architecture should be organized in such a way that the different computerbased and conventional information processing tools can work smoothly and efficiently together, in order to provide a maximum quality of information processing by the information system as a whole. Quality of HIS architecture can display various characteristics: adaptability and maintenance, homogeneity vs. heterogeneity, integration aspects, object identity, data integrity, and functional mapping characteristics. Adaptability and maintenance In general, the architecture should be sufficiently flexible to be able to adapt to the changing needs of the hospital. For example, new computerbased application components should easily be added to the information systems, application components should be easily replaceable by other (better) application components, or the available bandwidth of the network infrastructure should easily be extended in order to match rising quantity of communicated data. Figure 101: A bed as flexible tool, also supporting information processing tasks. 5. What are good Hospital Information Systems 147 Homogeneity vs. Heterogeneity Information processing tools (both on the logical and on the physical tool layer) should be as homogeneous as possible and as heterogeneous as necessary. On the logical tool layer we often have to balance between the homogeneity of the hospital information system and the functional requirements of specific departments. On the physical tool layer, the heterogeneity is often the consequence of the constant development of the HIS, e.g. comprising different generations of computer systems. This could only be prevented when all physical data process components are regularly exchanged together, which is normally not feasible. In general, homogeneous information processing tools make training and support of users easier and thus leads to reduced costs for the HIS. Aspects of Integration In a heterogeneous HIS architecture with various communicating application systems and physical data processing components, all components must smoothly work together. This is called integration, being defined as combining or adding parts to make a unified whole. In general, integration needs standards (e.g. for communication, user interface design, installation routines etc.), as well as a strict organization (e.g. a systematically built up network structure). The quality of integration can be described by various integration characteristics: Hardware integrationmeans that the different physical data processing tools should be interconnected in order to avoid technical standalonesystems. Hardware integration can be realized, for example, by networking stationary computers, and by mobile computers connected via infrared or wireless networks. Access integration describes that all user relevant clinical functionality should be accessible from the health care professional workstation. All relevant application components should be available on one physical data processing component (see Figure 102). Presentation integration means that data from different applications are presented in an adequate and consistent way. There should thus be e.g. a uniform Figure 102: Insufficient access integration at the health care professional workstation. 148 Strategic Information Management in Hospitals graphical user interface and an overall uniform behavior for all userrelated functions on the health care professional workstation. Data integration comprises that data should only be recorded once and then be reused multiple times, in order to avoid duplication of data (single recording – multiple use). Data which is registered in one application component should thus be made available to other application components. For example, administrative patient data should be documented once in the patient management system and then be reused in other application components such as dedicated documentation systems. To achieve data integration, the HIS should have a global data model with clearly defined semantics of its concepts which should be revealed for the integration of new application components. Communication integration describes that application components should be able to exchange information by using standardized messages. This is the precondition for data and function integration in a DB n HIS architecture. Function integration means that a specific functionality (such as patient admission) which is offered by one application component, can also be used by other application components. New application components should therefore be designed so that functionality existing in prevailing application components are used. To achieve function integration, a HIS should include a repository of services offered globally. Visual integration comprises that the application context is maintained when the user changes the application component (e.g. because the functionality he wants to use is only offered by another application component).56 A task which has already been completed should not be repeated again. For example, on a ward, there may be two application components, one for report writing, the other for presentation of radiology results. When a physician is just writing a report, he may want to look up the recent radiology results. When he shifts the application component, the radiology results of his patient should immediately be displayed, without forcing him to enter a name, birthday of patient or identification number again. Thus, in this example, the selection of the patient is a task which must not be repeated if performed once, even when changing the application component. Object identity Each object in the hospital (such as patient, case, user, department) should be identified by a unique identifier. Data integrity Data integrity means that at each point in time, redundant data is identical in each database where it is stored. Changes of data in one application component’s 56 The Clinical Context Object Workgroup (CCOW) published standards for visual integration of independent application components, see Standard CCOW: http:www.hl7.orgSpecialcommitteesvisualvisual.cfm. 5. What are good Hospital Information Systems 149 database must therefore be communicated and reconstructed in the other application component’s databases where this data is also stored. Data integrity is especially important when data is stored redundantly in different locations in a DB n architecture. For example, when the patient administration system changes the name of the patient (e.g. correction of the name of the patient), this change has to be communicated to other application components such as the medical documentation systems or the ward management system which also have databases containing the patient’s name. Functional mapping characteristics With regard to HIS architecture, functional mapping characteristics describe the quality of mapping between hospital functions and application components. Functional leannessdescribes a situation where one hospital function is supported by one and only one application component. The contrast is functional redundancy or functional overlap which means that a hospital function is supported by more than one application component. For example, patient admission may be available in different application components. In order to get a functional lean HIS architecture, only one application component should be used for patient admission. Functional leanness is greatly facilitated by functional integration and visual integration. Functional completenessmeans that each hospital function is supported by at least one application component. There is no hospital function which is not supported by the hospital information system. When both characteristics are fulfilled, then we can say that a (sub)information systems has functional correspondence. An application system is superfluous when it does not support a hospital function. Quality of information management Several characteristics can be defined for the quality of information management. Clear decision structures, roles and responsibilities Clear decision structures, roles and responsibilities should be defined for information management’s organization. The responsibility for strategic, tactical and operational management must clearly been established and known to each staff member. The role of a CIO as well as of other important groups (such as committees, support centers, or key users) should be explicitly defined and made known. In general, it is useful to define the most important roles and responsibilities in the hospital’s information management plan. 150 Strategic Information Management in Hospitals Systematic strategic information management A strategic information management plan should be defined and adapted by the hospital management. A strategic plan should encompass the hospital business strategy or strategic goals, the resulting information management strategies, the current state of the hospital information system, and an analysis of how well the current information system fits to the strategies. The planned architecture should be derived as a conclusion of this analysis. Systematic tactical information management Information processing projects should be planned, management and controlled in a systematic and transparent way. Project management standards should be developed and used. Project groups and project committees should comprise all relevant health professional groups. Systematic project controlling should be established. Information systems components should only be selected and introduced after a thorough analysis of needs and costs and a transparent selection process. When new computerbased application components are introduced, migration strategies for the transformation of data are to be established and used. Employee training New users should be trained in basic information processing tools as well as in the taskspecific application components on a regular basis. The installation of a training center and a training group is useful in order to offer efficient training. Renewed training sessions should be offered when new functionality or new application components are being introduced, or when deficiencies in users skills have been found. The effects of users training should be regularly monitored. Support strategy An appropriate support strategy should be defined which helps to guarantee the continuous and faultless operation of the information processing tools. This support strategy should define different support levels for user and information processing tools, as well as the problem management strategy. The users should know about their contact in case of hardware or software problems. Motivation and competence of IT staff The IT staff represent a service provider for the user. Their motivation and competence is essential for the efficient functioning of the information systems and for a high acceptance by the users. The IT staff should therefore be sufficiently and regularly trained, they should know the clinical workflow and typical user problems, and they should be sufficiently motivated. 5. What are good Hospital Information Systems 151 Examples Exercises Summary 152 Strategic Information Management in Hospitals 5.3 Quality of processes In general, quality of processes describes the quality of activities going on within and between providers and patients (e.g., adherence to professional standards, or appropriateness of care). In the context of hospital information systems, process quality deals with the quality of the information processes themselves which are necessary to meet the user’s needs. Multiple usability of data Application components often need the same data. For example, patient administrative data or basic medical data is needed by many different application components. In order to avoid duplicate data entry, which is inefficient and prone to error, data should only be recorded once, even when it is used by different application components and stored in different databases. This multiple usability of data requires communication interfaces in the computersupported part of HIS, and ways to print out data (e.g. labels, order entry forms) or scan data in order to provide communication between the computersupported and the not computersupported part of HIS. No transcription of data Transcription of data should be avoided. Transcription means to transfer data from one storage device to another storage device, e.g. to transfer patient diagnoses from the patient record to an order entry form, or to enter data from a printout into a computerbased application component (see Figure 103 and 104). Transcription usually leads to the duplication of data. This has to be avoided as it is timeconsuming and possibly erroneous. Transcription is usually combined with a change of the media (media crack), but can also include the transfer e.g. from paper to paper. Figure 103: Example of a transcription (1). Figure 104: Example of a transcription (2). 5. What are good Hospital Information Systems 153 Leanness of information processing tools The user wants to use as few application components and information processing tools as possible for a given tasks. For example, during nursing documentation, how often does a nurse have to change between application components and information processing tools? The less application components that have to be used for one tasks, the easier it is to avoid transcription. Workflow integration In general, new computerbased systems should be smoothly integrated into the daily clinical workflow. Thus, their functionality and usability should match the needs of the users and their typical tasks. The new computerbased system must therefore smoothly work together with the other computerbased and conventional information processing tools. Achieving such workflow integration is the most important task from the users point of view. Efficiency and effectiveness of information logistics Information processes should be as lean as possible: They should not contain unnecessary steps (e.g. documentation of data which is never used again), they should be as parallel as possible, allow the multiple usability of data (see above), and avoid redundant activities (e.g. transcription of data, see above). In general, information logistics should be organized as efficiently and effectively as possible: • The right information: is the information accessible, correct and complete? For example, does the received lab result really belong to the displayed patient? • At the right time: Is the information available when the clinician needs it, just in time? For example, are the recent results available during the physician’s round? • At the right place: Is the information available wherever the clinical needs it? For example, is nursing documentation available at the patient’s bedside as well as in the ward room? • To the right people: Is the information only available to the clinicians needing it? For example, are the Figure 105: In a senior physician’s office: Insufficient organization of work using paperbased tools. 154 Strategic Information Management in Hospitals diagnoses of a patient only available to the treating clinicians? • In the right form: is the information available in a format usable to the clinician? For example, can information personally be filtered, not overwhelming the clinician with too much information (information overload)? Examples Exercises Summary 5. What are good Hospital Information Systems 155 5.4 Outcome quality In general, outcome quality describes the effects of patient care, i.e. the changes in the health status of the patient (e.g. mortality, morbidity, costs). In the context of hospital information systems, outcome quality describes whether the goals of information management have been reached, or, in a broader sense, to what extent the hospital information system contributed to the goals of the hospital. Quality of outcomes thus means whether the hospital information system finally fulfills the needs of its different user groups and thus supports efficient and effective patient care. Outcome quality describes the measurable value of the HIS for the hospital and its various stakeholders. Despite good quality of structures and processes, it is not sure, that the hospital information system contributes to the aims of the hospital or the expectations of the stakeholders. Quality of structure and quality of processes is just a prerequisite for the quality of outcomes. Goals of the hospital For the hospital as an enterprise, it may be interesting if the hospital information systems contributes to • Quality improvement • Patient satisfaction • Cost reduction as general aims of all hospitals. Additionally, there are further hospital aims, like • fulfillment of legal requirements • support of clinical research • being a specialized medical competence center Furthermore, each individual hospital wants to attain further specific goals, where the HIS should participate. For example: • Efficient communication with other health providers (e.g. quick communication of discharge reports to the next health provider) • During patients stay, all patientrelated information is available. Goals of information management Usually, in each country, different laws influencing information processing can be found, dealing for example with organization of health care, financing of health care, health statistics, or data protection. Those laws must be taken into account by information management. 156 Strategic Information Management in Hospitals Expectations of different stakeholders As well, distinct stakeholders have specific expectations. User needs typically to be addressed comprise: • Patient: availability of uptodate medical knowledge, staff which has time for the patient, not wasting time on unnecessary documentation tasks or inflexible information processing tools. • Relatives: the patient can easily be found in the hospital, information for home care is made available. • Physician: new findings are available at the physician’s round, not losing time with insufficiently designed information processing tools, multiple usability of data, availability of the whole patient record, simple and standardized forms for data entry, easy access to new medical knowledge. • Nurses: easy procedure for scheduling and order entry, availability of bedside documentation tools, support of ward organization, easy access to nursing guidelines and to nursing knowledge. • Administration staff: availability of uptodate administrative information, efficient tools to support billing and financial budgeting. • Hospital management: easy access to complete and uptodate information on the quality of patient care and on its costs. Examples Legal issues: German laws influencing hospital information systems The organization of health care in Germany is described in the Sozialgesetzbuch V (SGBV). In contains among others laws about quality management, administrative health cards, and data exchange of diagnoses and services for inpatients and outpatients between hospital and insurance companies. The hospital financing system is regulated in the Krankenhausfinanzierungsgesetz (KHG), together with the Bundespflegesatzverordnung (BPflV). The amount of reimbursement for outpatient care is described in different catalogues such as GOÄ, EBM and DKGNT. There are several laws concerning data protection: The national data protection law (Bundesdatenschutzgesetz) and the regional data protection laws (Landesdatenschutzgesetze) describe, among others, technical and organizational means to protect sensitive data. In addition, the regional hospital laws (Landeskrankenhausgesetze) regulate among others if the data collection, storage and use of patient centered data in hospitals is permitted. The hospital statistics law (KrankenhausstatistikVerordnung) contains guidelines for federalwide statistics about diagnoses and other health data and about cost data. 5. What are good Hospital Information Systems 157 The regional archive laws (Landesarchivgesetze) deal with archiving of documents such as patient records. The information and communication service law (Informations und KommunikationsdiensteGesetz, IuKDG) introduces the digital signature and contains guidelines for the use of telecommunication services. Further information is given in the Signaturverordnung (SigV). For university medical centers, the HBFG (Hochschulbauförderungsgesetz) deals with building and modernizing medical centers and describes the financing of medical devices such as computer systems. The MedGV (Medizinische Geräteveordnung) describes documentation and maintenance of the medical devices. Overall, there is a vast amount of different and often changing laws which provide a framework for information processing in inpatient and outpatient care. Exercises Summary 158 Strategic Information Management in Hospitals 5.5 Examples 5.6 Exercises 5.7 Summary

Reinhold Haux Alfred Winter Elske Ammenwerth Birgit Brigl Strategic Information Management in Hospitals An Introduction to Hospital Information Systems With 106 Illustrations Status: May 2002 (Version 0.22) Contents 1INTRODUCTION 1.1 1.2 1.3 1.4 1.5 1.6 SIGNIFICANCE OF INFORMATION PROCESSING IN HOSPITALS PROGRESS IN INFORMATION AND COMMUNICATION TECHNOLOGY IMPORTANCE OF SYSTEMATIC INFORMATION MANAGEMENT EXAMPLES EXERCISES SUMMARY 2BASIC CONCEPTS 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 INTRODUCTION DATA, INFORMATION AND KNOWLEDGE INFORMATION SYSTEMS AND THEIR COMPONENTS HOSPITAL INFORMATION SYSTEMS HEALTH INFORMATION SYSTEMS INFORMATION MANAGEMENT IN HOSPITALS EXAMPLES EXERCISES SUMMARY 3WHAT DO HOSPITAL INFORMATION SYSTEMS LOOK LIKE? 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 INTRODUCTION HOSPITAL FUNCTIONS MODELING HOSPITAL INFORMATION SYSTEMS A METAMODEL FOR MODELING HIS: 3LGM INFORMATION PROCESSING TOOLS IN HOSPITALS ARCHITECTURES OF HOSPITAL INFORMATION SYSTEMS EXAMPLES EXERCISES SUMMARY 1 12 16 17 18 18 18 19 22 24 25 26 28 30 33 33 33 43 58 67 83 93 100 101 4HOW TO STRATEGICALLY MANAGE HOSPITAL INFORMATION SYSTEMS 103 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 INTRODUCTION 103 STRATEGIC, TACTICAL AND OPERATIONAL INFORMATION MANAGEMENT 103 ORGANIZATIONAL STRUCTURES FOR INFORMATION MANAGEMENT 110 STRATEGIC PLANNING OF HOSPITAL INFORMATION SYSTEMS 116 STRATEGIC MONITORING OF HOSPITAL INFORMATION SYSTEMS 127 STRATEGIC DIRECTING OF HOSPITAL INFORMATION SYSTEMS 137 EXAMPLES 139 EXERCISES 139 SUMMARY 141 5WHAT ARE GOOD HOSPITAL INFORMATION SYSTEMS? 143 5.1 5.2 5.3 5.4 5.5 5.6 5.7 INTRODUCTION QUALITY OF STRUCTURES QUALITY OF PROCESSES OUTCOME QUALITY EXAMPLES EXERCISES SUMMARY 143 144 152 155 158 158 158 6FINAL REMARKS 159 7APPENDIX A: THESAURUS 161 8APPENDIX B: BIBLIOGRAPHY 162 8.1 8.2 8.3 8.4 8.5 8.6 BOOKS PROCEEDINGS JOURNALS ASSOCIATIONS INTERNET RESOURCES RECOMMENDATIONS 162 163 163 163 164 165 9APPENDIX C: LIST OF EXAMPLES AND EXERCISES 166 10 APPENDIX D: LIST OF FIGURES AND TABLES 169 11 ABOUT THE AUTHORS 172 5 5.1 What Are Good Hospital Information Systems? Introduction Quality in general is the ability to meet all the expectations of the purchaser of goods or services: “The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs"52 According to Donabedian, there are three major approaches to quality assessment: quality of structures, quality of processes, and outcome quality.53 In the context of health care, the concept of quality of structures includes the human, physical, and financial resources that are needed to provide medical care (e.g educational level of staff, availability of medical equipment) Quality of processes describes the quality of activities going on within and between providers and patients (e.g., adherence to professional standards, appropriateness of care) Finally, outcome quality describes the effects of patient care, i.e the changes in the health status of the patient (e.g mortality, morbidity, costs) While structure quality influences process quality, this in turn influences outcome quality Those concepts can be transferred to hospital information systems: In this context, quality of structures refers to the availability of technical or human resources needed for information processing (e.g number and availability of computer systems, computer knowledge of staff) Quality of processes deals with the quality of the information processes themselves which are necessary to meet the user’s needs Outcome quality describes whether the goals of information management have been reached, or, in a broader sense, to what extent the hospital information system contributes to the goals of the hospital Quality characteristics for hospital information systems help to describe the ‘fitness’ of a HIS, and finding diagnosis and therapy of ‘HIS diseases’ It may not be so difficult to describe what a really ‘bad’ hospital information system looks like But what are characteristics and features of a ‘good’ hospital information system? In this chapter, we will introduce the most essential ones After this chapter, you should be able to answer the following questions: 52 ISO International Standard ISO 9000:2000 Quality management systems Fundamentals and vocabulary International Organization for Standardization, International Electrotechnical Commission, Geneva; 2000 53 Donabedian A Explorations in quality assessing and monitoring - Vol 2: The criteria and standards of quality Ann Arbor: Health Administration Press; 1982 144 Strategic Information Management in Hospitals • Which facets of quality have to be considered? • What are characteristics for structure quality (i.e the quality of information processing tools, of HIS architectures, and of information management), and how can they be assessed? • What are characteristics for the quality of information processes, and how can they be assessed? • What are characteristics for the quality of outcomes, and how can they be assessed? 5.2 Quality of structures In the context of health care, the concept of quality of structures includes the human, physical, and financial resources that are needed to proved medical care (e.g educational level of staff, availability of medical equipment) In the context of hospital information systems, the quality of structures refers to the availability of technical or human resources needed for information processing (e.g number and availability of computer systems, computer knowledge of staff) It comprises quality characteristics for information processing tools, for HIS architectures, and for information management in hospitals Quality of information processing tools Different characteristics of the computer-based or conventional information processing tools used influence structure quality which can be separated into software quality and hardware quality In general, only a missing or erroneous information processing tool should attract attention Software quality The main characteristics of software quality have been defined by ISO 912654 The objective of this standard is to provide a framework for the evaluation of software quality ISO 9126 sets out six quality characteristics with corresponding sub-characteristics: • Functionality: Are the required functions available in the software? • Reliability: How reliable is the software? • Usability: Is the software easy to use? • Efficiency: How efficient is the software? 54 ISO International Standard ISO/IEC 9126-1 Information technology Software product evaluation Quality characteristics and guidelines for their use International Organization for Standardization, International Electrotechnical Commission, Geneva; 2001 5 What are good Hospital Information Systems • Maintainability: How easy is it to modify the software? • Portability: How easy is it to transfer the software to another environment? ISO 924155 specifically deals with software ergonomy It contains 17 parts Part 10 of this standard deals with dialogue principles for user interface design The dialogue principles of ISO 9241 comprise: • Suitability for the task: Does the user interface support the user to fulfil his tasks effectively and efficiently? • Suitability for learning: Is the user being supported to learn and use the user interface? • Suitability for individualization: Can the user interface be adapted to the tasks and to the individual skills and wishes of the user? • Conformity with user expectations: Is the user interface consistent and adapted to the characteristics of the user (i.e his knowledge, skill and expectations)? • Self descriptiveness: Is each step of the user interface understandabe for the user by providing direct feedback or explanation? • Controllability: Can the user, after having initiated the first step, control the flow and speed of tasks, until the aim is reached? • Error tolerance: Can the aim of the task even be reached following obviously wrong input by the user, either with no or little effort for correction? Hardware quality Their are no explicit Figure 100: An ease-to-use, stable, mobile information norms to define the quality processing tool: Paper-based documentation at the of hardware or of physical patients bedside information processing tools in general However, many aspects of software quality can be transferred to both computer-based and conventional physical tools The quality of physical information processing tools can thus be described by the following characteristics: 55 ISO International Standard ISO 9241 Ergonomics requirements for office work with visual display terminals (VDTs) Genf: International Organization for Standardization, International Electrotechnical Commission; 1993 145 146 Strategic Information Management in Hospitals • • • • • • • • • • • • usefulness (e.g offering useful functionality for the user) appropriateness (e.g not dominating the physician-patient relation) easy to use available (e.g mobile tool, see Figure 100) multi-purpose (e.g personal digital assistant) efficient (low cost for purchase and support) flexibility (e.g can be modified easily, see Figure 101) stable secure (e.g supporting basic data security and data safety) Figure 101: A bed as flexible tool, also harmless (e.g not supporting information processing tasks putting harm on the user of the patient) usable (e.g user friendly) standardized (e.g standardized form for order entry) Quality of HIS architecture HIS architecture should be organized in such a way that the different computer-based and conventional information processing tools can work smoothly and efficiently together, in order to provide a maximum quality of information processing by the information system as a whole Quality of HIS architecture can display various characteristics: adaptability and maintenance, homogeneity vs heterogeneity, integration aspects, object identity, data integrity, and functional mapping characteristics Adaptability and maintenance In general, the architecture should be sufficiently flexible to be able to adapt to the changing needs of the hospital For example, new computer-based application components should easily be added to the information systems, application components should be easily replaceable by other (better) application components, or the available bandwidth of the network infrastructure should easily be extended in order to match rising quantity of communicated data 5 What are good Hospital Information Systems Homogeneity vs Heterogeneity Information processing tools (both on the logical and on the physical tool layer) should be as homogeneous as possible and as heterogeneous as necessary On the logical tool layer we often have to balance between the homogeneity of the hospital information system and the functional requirements of specific departments On the physical tool layer, the heterogeneity is often the consequence of the constant development of the HIS, e.g comprising different generations of computer systems This could only be prevented when all physical data process components are regularly exchanged together, which is normally not feasible In general, homogeneous information processing tools make training and support of users easier and thus leads to reduced costs for the HIS Aspects of Integration In a heterogeneous HIS architecture with various communicating application systems and physical data processing components, all components must smoothly work together This is called integration, being defined as combining or adding parts to make a unified whole In general, integration needs standards (e.g for communication, user interface design, installation routines etc.), as well as a strict organization (e.g a systematically built up network structure) The quality of integration can be described by various integration characteristics: Hardware integration means that the different physical data processing tools should be interconnected in order to avoid technical stand-alone-systems Hardware integration can be realized, for example, by networking stationary computers, and by mobile computers connected via infrared or wireless networks Access integration describes that all user relevant clinical functionality Figure 102: Insufficient access should be accessible from the health integration at the health care care professional workstation All professional workstation relevant application components should be available on one physical data processing component (see Figure 102) Presentation integration means that data from different applications are presented in an adequate and consistent way There should thus be e.g a uniform 147 148 Strategic Information Management in Hospitals graphical user interface and an overall uniform behavior for all user-related functions on the health care professional workstation Data integration comprises that data should only be recorded once and then be reused multiple times, in order to avoid duplication of data (single recording – multiple use) Data which is registered in one application component should thus be made available to other application components For example, administrative patient data should be documented once in the patient management system and then be reused in other application components such as dedicated documentation systems To achieve data integration, the HIS should have a global data model with clearly defined semantics of its concepts which should be revealed for the integration of new application components Communication integration describes that application components should be able to exchange information by using standardized messages This is the precondition for data and function integration in a DBn HIS architecture Function integration means that a specific functionality (such as patient admission) which is offered by one application component, can also be used by other application components New application components should therefore be designed so that functionality existing in prevailing application components are used To achieve function integration, a HIS should include a repository of services offered globally Visual integration comprises that the application context is maintained when the user changes the application component (e.g because the functionality he wants to use is only offered by another application component).56 A task which has already been completed should not be repeated again For example, on a ward, there may be two application components, one for report writing, the other for presentation of radiology results When a physician is just writing a report, he may want to look up the recent radiology results When he shifts the application component, the radiology results of his patient should immediately be displayed, without forcing him to enter a name, birthday of patient or identification number again Thus, in this example, the selection of the patient is a task which must not be repeated if performed once, even when changing the application component Object identity Each object in the hospital (such as patient, case, user, department) should be identified by a unique identifier Data integrity Data integrity means that at each point in time, redundant data is identical in each database where it is stored Changes of data in one application component’s 56 The Clinical Context Object Workgroup (CCOW) published standards for visual integration of independent application components, see Standard CCOW: http://www.hl7.org/Special/committees/visual/visual.cfm 5 What are good Hospital Information Systems database must therefore be communicated and reconstructed in the other application component’s databases where this data is also stored Data integrity is especially important when data is stored redundantly in different locations in a DBn architecture For example, when the patient administration system changes the name of the patient (e.g correction of the name of the patient), this change has to be communicated to other application components such as the medical documentation systems or the ward management system which also have databases containing the patient’s name Functional mapping characteristics With regard to HIS architecture, functional mapping characteristics describe the quality of mapping between hospital functions and application components Functional leanness describes a situation where one hospital function is supported by one and only one application component The contrast is functional redundancy or functional overlap which means that a hospital function is supported by more than one application component For example, patient admission may be available in different application components In order to get a functional lean HIS architecture, only one application component should be used for patient admission Functional leanness is greatly facilitated by functional integration and visual integration Functional completeness means that each hospital function is supported by at least one application component There is no hospital function which is not supported by the hospital information system When both characteristics are fulfilled, then we can say that a (sub)information systems has functional correspondence An application system is superfluous when it does not support a hospital function Quality of information management Several characteristics can be defined for the quality of information management Clear decision structures, roles and responsibilities Clear decision structures, roles and responsibilities should be defined for information management’s organization The responsibility for strategic, tactical and operational management must clearly been established and known to each staff member The role of a CIO as well as of other important groups (such as committees, support centers, or key users) should be explicitly defined and made known In general, it is useful to define the most important roles and responsibilities in the hospital’s information management plan 149 150 Strategic Information Management in Hospitals Systematic strategic information management A strategic information management plan should be defined and adapted by the hospital management A strategic plan should encompass the hospital business strategy or strategic goals, the resulting information management strategies, the current state of the hospital information system, and an analysis of how well the current information system fits to the strategies The planned architecture should be derived as a conclusion of this analysis Systematic tactical information management Information processing projects should be planned, management and controlled in a systematic and transparent way Project management standards should be developed and used Project groups and project committees should comprise all relevant health professional groups Systematic project controlling should be established Information systems components should only be selected and introduced after a thorough analysis of needs and costs and a transparent selection process When new computer-based application components are introduced, migration strategies for the transformation of data are to be established and used Employee training New users should be trained in basic information processing tools as well as in the task-specific application components on a regular basis The installation of a training center and a training group is useful in order to offer efficient training Renewed training sessions should be offered when new functionality or new application components are being introduced, or when deficiencies in users skills have been found The effects of users training should be regularly monitored Support strategy An appropriate support strategy should be defined which helps to guarantee the continuous and faultless operation of the information processing tools This support strategy should define different support levels for user and information processing tools, as well as the problem management strategy The users should know about their contact in case of hardware or software problems Motivation and competence of IT staff The IT staff represent a service provider for the user Their motivation and competence is essential for the efficient functioning of the information systems and for a high acceptance by the users The IT staff should therefore be sufficiently and regularly trained, they should know the clinical workflow and typical user problems, and they should be sufficiently motivated 5 What are good Hospital Information Systems Examples Exercises Summary 151 152 5.3 Strategic Information Management in Hospitals Quality of processes In general, quality of processes describes the quality of activities going on within and between providers and patients (e.g., adherence to professional standards, or appropriateness of care) In the context of hospital information systems, process quality deals with the quality of the information processes themselves which are necessary to meet the user’s needs Multiple usability of data Application components often need the same data For example, patient administrative data or basic medical data is needed by many different application components In order to avoid duplicate data entry, which is inefficient and prone to error, data should only be recorded once, even when it is used by different application components and stored in different databases This multiple usability of data requires communication interfaces in the computer-supported part of HIS, and ways to print out data (e.g labels, order entry forms) or scan data in order to provide communication between the computer-supported and the not computer-supported part of HIS No transcription of data Transcription of data should be avoided Transcription means to transfer data from one storage device to another storage device, e.g to transfer patient diagnoses from the patient record to an order entry form, or to enter data from a print-out into a computer-based application component (see Figure 103 and 104) Transcription usually leads to the duplication of data This has to be avoided as it is time-consuming and possibly erroneous Transcription is usually combined with a change of the media (media crack), but can also include the transfer e.g from paper to paper Figure 103: Example of a transcription (1) Figure 104: Example of a transcription (2) 5 What are good Hospital Information Systems Leanness of information processing tools The user wants to use as few application components and information processing tools as possible for a given tasks For example, during nursing documentation, how often does a nurse have to change between application components and information processing tools? The less application components that have to be used for one tasks, the easier it is to avoid transcription Workflow integration In general, new computer-based systems should be smoothly integrated into the daily clinical workflow Thus, their functionality and usability should match the needs of the users and their typical tasks The new computer-based system must therefore smoothly work together with the other computer-based and conventional information processing tools Achieving such workflow integration is the most important task from the user's point of view Efficiency and effectiveness of information logistics Information processes should be as lean as possible: They should not contain unnecessary steps (e.g documentation of data which is never used again), they should be as parallel as possible, allow the multiple usability of data (see above), and avoid redundant activities (e.g transcription of data, see above) In general, information logistics should be organized as efficiently and effectively as possible: • The right information: is the information accessible, correct and complete? For example, does the received lab result really belong to the displayed patient? • At the right time: Is the information available when the clinician needs it, just in time? For example, are the recent results available during the physician’s round? • At the right place: Is the information available wherever the clinical needs it? For example, is nursing documentation available at the patient’s bedside as well as in the ward room? Figure 105: In a senior physician’s office: • To the right people: Is the Insufficient organization of work using paper-based information only available tools to the clinicians needing it? For example, are the 153 154 • Strategic Information Management in Hospitals diagnoses of a patient only available to the treating clinicians? In the right form: is the information available in a format usable to the clinician? For example, can information personally be filtered, not overwhelming the clinician with too much information (information overload)? Examples Exercises Summary What are good Hospital Information Systems 5.4 Outcome quality In general, outcome quality describes the effects of patient care, i.e the changes in the health status of the patient (e.g mortality, morbidity, costs) In the context of hospital information systems, outcome quality describes whether the goals of information management have been reached, or, in a broader sense, to what extent the hospital information system contributed to the goals of the hospital Quality of outcomes thus means whether the hospital information system finally fulfills the needs of its different user groups and thus supports efficient and effective patient care Outcome quality describes the measurable value of the HIS for the hospital and its various stakeholders Despite good quality of structures and processes, it is not sure, that the hospital information system contributes to the aims of the hospital or the expectations of the stakeholders Quality of structure and quality of processes is just a prerequisite for the quality of outcomes Goals of the hospital For the hospital as an enterprise, it may be interesting if the hospital information systems contributes to • Quality improvement • Patient satisfaction • Cost reduction as general aims of all hospitals Additionally, there are further hospital aims, like • fulfillment of legal requirements • support of clinical research • being a specialized medical competence center Furthermore, each individual hospital wants to attain further specific goals, where the HIS should participate For example: • Efficient communication with other health providers (e.g quick communication of discharge reports to the next health provider) • During patients stay, all patient-related information is available Goals of information management Usually, in each country, different laws influencing information processing can be found, dealing for example with organization of health care, financing of health care, health statistics, or data protection Those laws must be taken into account by information management 155 156 Strategic Information Management in Hospitals Expectations of different stakeholders As well, distinct stakeholders have specific expectations User needs typically to be addressed comprise: • Patient: availability of up-to-date medical knowledge, staff which has time for the patient, not wasting time on unnecessary documentation tasks or inflexible information processing tools • Relatives: the patient can easily be found in the hospital, information for home care is made available • Physician: new findings are available at the physician’s round, not losing time with insufficiently designed information processing tools, multiple usability of data, availability of the whole patient record, simple and standardized forms for data entry, easy access to new medical knowledge • Nurses: easy procedure for scheduling and order entry, availability of bedside documentation tools, support of ward organization, easy access to nursing guidelines and to nursing knowledge • Administration staff: availability of up-to-date administrative information, efficient tools to support billing and financial budgeting • Hospital management: easy access to complete and up-to-date information on the quality of patient care and on its costs Examples Legal issues: German laws influencing hospital information systems The organization of health care in Germany is described in the "Sozialgesetzbuch V" (SGBV) In contains among others laws about quality management, administrative health cards, and data exchange of diagnoses and services for inpatients and outpatients between hospital and insurance companies The hospital financing system is regulated in the "Krankenhausfinanzierungsgesetz" (KHG), together with the Bundespflegesatzverordnung (BPflV) The amount of reimbursement for outpatient care is described in different catalogues such as GOÄ, EBM and DKG-NT There are several laws concerning data protection: The national data protection law (Bundesdatenschutzgesetz) and the regional data protection laws (Landesdatenschutzgesetze) describe, among others, technical and organizational means to protect sensitive data In addition, the regional hospital laws (Landeskrankenhausgesetze) regulate among others if the data collection, storage and use of patient centered data in hospitals is permitted The hospital statistics law (Krankenhausstatistik-Verordnung) contains guidelines for federal-wide statistics about diagnoses and other health data and about cost data 5 What are good Hospital Information Systems The regional archive laws (Landesarchivgesetze) deal with archiving of documents such as patient records The information and communication service law (Informations- und Kommunikationsdienste-Gesetz, IuKDG) introduces the digital signature and contains guidelines for the use of telecommunication services Further information is given in the Signaturverordnung (SigV) For university medical centers, the HBFG (Hochschulbauförderungsgesetz) deals with building and modernizing medical centers and describes the financing of medical devices such as computer systems The MedGV (Medizinische Geräteveordnung) describes documentation and maintenance of the medical devices Overall, there is a vast amount of different and often changing laws which provide a framework for information processing in inpatient and outpatient care Exercises Summary 157 158 Strategic Information Management in Hospitals 5.5 Examples 5.6 Exercises 5.7 Summary [...]... know the clinical workflow and typical user problems, and they should be sufficiently motivated 5 What are good Hospital Information Systems Examples Exercises Summary 151 152 5. 3 Strategic Information Management in Hospitals Quality of processes In general, quality of processes describes the quality of activities going on within and between providers and patients (e.g., adherence to professional... information personally be filtered, not overwhelming the clinician with too much information (information overload)? Examples Exercises Summary 5 What are good Hospital Information Systems 5. 4 Outcome quality In general, outcome quality describes the effects of patient care, i.e the changes in the health status of the patient (e.g mortality, morbidity, costs) In the context of hospital information systems, outcome... must be taken into account by information management 155 156 Strategic Information Management in Hospitals Expectations of different stakeholders As well, distinct stakeholders have specific expectations User needs typically to be addressed comprise: • Patient: availability of up-to-date medical knowledge, staff which has time for the patient, not wasting time on unnecessary documentation tasks or inflexible... as computer systems The MedGV (Medizinische Geräteveordnung) describes documentation and maintenance of the medical devices Overall, there is a vast amount of different and often changing laws which provide a framework for information processing in inpatient and outpatient care Exercises Summary 157 158 Strategic Information Management in Hospitals 5. 5 Examples 5. 6 Exercises 5. 7 Summary ... patient can easily be found in the hospital, information for home care is made available • Physician: new findings are available at the physician’s round, not losing time with insufficiently designed information processing tools, multiple usability of data, availability of the whole patient record, simple and standardized forms for data entry, easy access to new medical knowledge • Nurses: easy procedure... should only be recorded once, even when it is used by different application components and stored in different databases This multiple usability of data requires communication interfaces in the computer-supported part of HIS, and ways to print out data (e.g labels, order entry forms) or scan data in order to provide communication between the computer-supported and the not computer-supported part of HIS No... easier it is to avoid transcription Workflow integration In general, new computer-based systems should be smoothly integrated into the daily clinical workflow Thus, their functionality and usability should match the needs of the users and their typical tasks The new computer-based system must therefore smoothly work together with the other computer-based and conventional information processing tools... task from the user's point of view Efficiency and effectiveness of information logistics Information processes should be as lean as possible: They should not contain unnecessary steps (e.g documentation of data which is never used again), they should be as parallel as possible, allow the multiple usability of data (see above), and avoid redundant activities (e.g transcription of data, see above) In general,... hospital information systems, process quality deals with the quality of the information processes themselves which are necessary to meet the user’s needs Multiple usability of data Application components often need the same data For example, patient administrative data or basic medical data is needed by many different application components In order to avoid duplicate data entry, which is inefficient... patient diagnoses from the patient record to an order entry form, or to enter data from a print-out into a computer-based application component (see Figure 103 and 104) Transcription usually leads to the duplication of data This has to be avoided as it is time-consuming and possibly erroneous Transcription is usually combined with a change of the media (media crack), but can also include the transfer e.g