Ebook: Health Informatics: Building a Healthcare Future Through Trusted Information

A record of twenty years of productive scientific output is a substantial achievement in any field of ICT, and especially in the youthful domain of health informatics. The Health Informatics Society of Australia, with the active support and involvement of the Australasian College of Health Informatics, is justifiably proud to have sustained the annual Australian National Health Informatics Conference (HIC) series of meetings through to this stage of maturity. As the largest national event of this type in Australia and New Zealand, with a dedicated scientific stream on health informatics, HIC provides a valued platform for academic and research contributions and interchange. It also consolidates the Australasian profile of strong and current research contributions in health informatics, marking our place on the world stage.

The HIC 2012 theme of “Health Informatics: Building a Healthcare Future Through Trusted Information” emphasises the importance of assuring the integrity and security of health data and communications. At a time when large scale health information flows are being initiated, through both the inauguration of the personally controlled electronic health record (PCEHR) and the National Broadband Network rollout, these issues need to remain prominent in the minds of designers and developers as well as the priorities of administrators and executives. They are naturally a major concern for consumers, and an immutable responsibility for vendors. A more trusted environment for managing and using health information will help to consolidate and accelerate the use of health informatics solutions as change mechanisms to drive the establishment and adoption of new models of care and new technology-oriented healthcare processes.

Papers in this volume will be found to both align with this theme, and to add colour to the landscape within which it resides by addressing peripheral but related topics. As always, it is a strength of HIC that a wide diversity of work is presented, and that a set of papers has been collected here that ranges from deeply theoretical to intensely practical. The careful reader will be rewarded with exposure to much diversity, and many elements of contemporary health informatics research endeavours.

The double blind peer review process established for HIC 2011 in a previous volume has been continued and augmented. All papers were reviewed by either 3 or 4 experts in the field of health informatics, selected as prominent academic and industry specialists. The assistance of the Australasian College of Health Informatics in supporting this processes through the voluntary efforts of a number of their Fellows is gratefully acknowledged, as is the similar contribution made by many senior members of the Health Informatics Society of Australia. This phase of reviewing resulted in the provisional acceptance of 38 papers from a much expanded submission field of 61 (compared with 39 for HIC 2011). The Scientific Program Committee, composed of several previous Scientific Program Chairs of past HIC conferences, then undertook a validation process for all such papers that were resubmitted in amended form, to ensure that reviewers' recommendations were appropriately addressed or rebutted. This resulted in 35 papers finally being included for publication in this book.

Anthony J. Maeder

Fernando J. Martin-Sanchez

Resistance to adoption has been identified as one of the major barriers to successful implementation of technological systems in hospitals. Acceptance of an electronic prescribing (e-prescribing) system is expected to occur if prescribers perceive a need for e-prescribing systems to reduce prescribing errors. We set out to examine doctors' perceptions of their prescribing competency and to identify perceived advantages and disadvantages of using an e-prescribing system, with the objective of determining the value doctors ascribed to the e-prescribing system. This study was conducted at a teaching hospital in Sydney, Australia. Sixteen prescribers participated in a 20-minute semi-structured interview where they were asked to comment on prescribing errors (their own errors and errors they believed to be common) and advantages and disadvantages of the e-prescribing system. Prescribers held the view that they rarely made prescribing errors. Although users recognised advantages and disadvantages of using the e-prescribing system, most preferred paper to electronic prescribing. Prescribers most likely overestimated their prescribing competency and so failed to see the value of an e-prescribing system to reduce prescribing errors. E-prescribing system implementation is a challenging task for any hospital. These results suggest that keeping prescribers informed about their prescribing errors and the quality improvement benefits of e-prescribing may lead to greater acceptance of and satisfaction with an e-prescribing system.

In an emergency there are many stages of Medical response. This paper focuses on the first response stage of an emergency medical incident, for example, a sporting accident. Today's Information Technology together with mobile devices now permits vital medical information regarding an individual to be available at the scene. Those first in attendance are often not medically trained. The literature shows the importance of appropriate first response in minimising harm and the significant investments being made to educate the public in this regard. It also highlights the privacy concerns that arise from the provision of sensitive health information in electronic form. The method utilised is a Privacy Impact Assessment to ascertain the suitability and compliance of the proposed technology. This approach follows the privacy guidelines specified by the Australian government to include information flow mapping, evaluation, compliance analysis, risk analysis and recommendations to management. The resultant output is a list of specific questions and a set of commendations and recommendations that are matched against the National Privacy Principles. The paper concludes that: the approach is both technical and pragmatically viable; it can meet all the reasonableness tests for privacy concerns; it can adopt standard security measures, and; it discusses its potential to be integrated into Personally Controlled Electronic Health Records.

In 2010 the Federal Government announced funding over two years to create a Personally Controlled Electronic Health Record (PCEHR) for Australians. One of the wave 2 implementation sites is the Cradle Coast in Tasmania. A PCEHR Program Benefits and Evaluation Partner (BEP) has been appointed to undertake evaluation activities with the e-health lead implementation sites. In addition to this implementation a comprehensive research plan has been developed and commenced through the Rural Clinical School at the University of Tasmania. The overarching aim of the research agenda is to evaluate the outcomes of various elements of the 4C project as it evolves and is implemented, from multiple perspectives. The research agenda is important as it expands upon the NEHTA mandated evaluation and provides an holistic overview of the PCEHR implementation process and outcomes for clinicians, patients and family members. This paper will detail the planned evaluation and its progress to date.

The Bridging Research in Ageing and ICT Development (BRAID) project has developed a comprehensive Research and Technological Development (RTD) roadmap for active ageing in European Union countries. This paper provides an overview of the BRAID project, including its methodological approach and outcomes, and suggests that a similar approach could be undertaken to consolidate research and development in relation to ICT and ageing in Australia.

Introduction: Information systems with clinical decision support (CDS) offer great potential to assist the co-ordination of patients with chronic diseases and to improve patient care. Despite this, few have entered routine clinical use.

Background: Tuberculosis (TB) is an infection of public health importance. It has complex interactions with many comorbid conditions, requires close supervised care and prolonged treatment for effective cure. These features make it suitable for use with an information management system with CDS features. In close consultation with key stakeholders, a clinical application was developed for the management of TB patients in Victoria.

Methods: A formal usability assessment using semi-structured case-scenario based exercises was performed. Subjects were 12 individuals closely involved in the care of TB patients, including Infectious Diseases and Respiratory Physicians, and Public Health Nurses. Two researchers conducted the sessions, independently analysed responses and discrepancies compared to the voice record for validity.

Results: Despite varied computer experience, responses were positive regarding user interface and content. Data location was not always intuitive, however this improved with familiarity of the program. Decision support was considered valuable, with useful suggestions for expansion of these features. Automated reporting for correspondence and notification to the Health Department were felt worth the initial investment in data entry. An important workflow-based issue regarding dismissal of alerts and several errors were detected.

Conclusion: Usability assessment validated many design elements of the system, provided a unique insight into workflow issues faced by users and hopefully will impact on its ultimate clinical utility.

This paper reports on a national study of the present approaches in Australian tertiary education, to preparing future clinical health professionals to work competently in an increasingly e-health enabled healthcare sector. The argument for increasing clinical health professionals' knowledge about e-health and health informatics has been advanced repeatedly over past decades in Australia and elsewhere. However, peer-reviewed accounts of good practice in implementing and evaluating e-health education in health profession degrees anywhere are scarce. Our study reports on surveying approximately 100 degree coordinators in 40 clinical health professions in 30 universities across Australia. It finds that currently, teaching and assessment of future clinical health professionals does not ensure that Australia will have a clinical workforce that is adequately professionally empowered to work with e-health. This paper provides important baseline data for planning improvements to e-health education for Australia's future clinical health professionals.

Background This paper reports on a small study in which we investigated factors influencing the adoption of Personal Health Records (PHRs), with specific reference to those linked to Electronic Health Records. Long term conditions are a growing concern in healthcare delivery, especially as the need for services outstrips resources. PHRs could be useful in supporting self-care of people with long term conditions, e.g. diabetes.

Method We used a Grounded Theory approach to gather initial data to inform future research. This meant that we were guided and informed by data collected.[1] The aim was to find a baseline for PHR research using the Technology Acceptance Model [2], after which emerging topics will be pursued with constant comparison to this first study and subsequent studies. We interviewed ten patients from a Wellington primary care practice who had been using a PHR linked to their doctor's Practice Management System, and observed them using and navigating the software at home.

Results: Three groups of factors appeared to influence the participants' use of the PHR. (1) Their perception that convenience, time saving (for them, their GP's practice personnel and their GP), efficiency and effectiveness of care is a result of using the PHR. (2) Computer and health literacy contribute to being able to effectively use the PHR. PHR usage impacts positively on the relationship with their doctor and vice versa, and improves their ability to navigate the health system. (3) It is not clear how PHR-related services are paid for, who pays and under what circumstances.

Discussion: These findings are in keeping with those of Santana et al[3] who indicate that patients are interested in viewing and using laboratory results, medicines and diagnosis lists, and ordering repeat prescriptions and corresponding with their clinicians. Literacy does matter, especially in terms of PHRs providing a transparent ‘source of truth’ and memory aid about medications, laboratory results and diagnoses. The combination of computer and health literacy requires further research. The cost of incorporating PHRs into healthcare services needs to be articulated so that it makes sense in the current capitation funding model.

Limitations of this research include the small sample size, bias based on small context and self-selection into the interview cohort.

In conclusion, three groups of influencing factors have been elicited from the interviews and observations to indicate potential acceptance and adoption of PHRs in self-care of long term conditions. The next step is to examine the social situatedness of long term conditions and how PHRs support self-care.

Accurate prediction of discharge time and identification of patients at risk of extended length of stay (LOS) can facilitate discharge planning and positively impact both the patient and the hospital in a variety of ways. To date, however, most studies only focus on the prediction of the overall LOS, which is generally estimated at admission time to hospital, emergency department or intensive care unit. This paper explores whether individual laboratory results can improve predictions of time of discharge as the tests become available. This study suggests that there is a statistically significant relationship between individual test results and remaining days in hospital and that there is a trend towards better estimates as more consecutive tests are taken into consideration. Their effect on the estimate of discharge time is generally weak. Further work integrating groups of test results into a more sophisticated dynamical model is required.

Falls are the leading cause of disability, injuries or even death among older adults. Exercise programmes that include a balance component reduce the risk of falling by 40%. However, such interventions are often perceived as boring and drop-out rates are high. The characteristics of videogames may overcome this weakness and increase exercise adherence. The use of modern input devices, such as the Microsoft Kinect, enables quantification of player performance in terms of motor function while engaging with games. This capability has just started to be explored. The work presented in this paper focuses on the development of a Kinect-based system to deliver step training while simultaneously measuring parameters of stepping performance that have shown to predict falls in older people.

One reason that it is so difficult to build electronic systems for collecting and sharing health information is that their design and implementation requires clear goals and a great deal of collaboration among people from diverse social and occupational worlds. This paper uses empirical examples from two Australian health informatics projects to illustrate the importance of boundary objects and boundary spanning activities in facilitating the high degree of collaboration required for the design and implementation of workable systems.

The Intensive Care Unit (ICU) is an information intense environment where Clinical Information Systems (CISs) can greatly impact patient care and the workload of clinicians. With the introduction of an ICU CIS imminent across New South Wales hospitals, we aimed to understand how ICU clinicians perceived a new system would impact on work practices in Australian ICUs, as much of the current evidence is generated from overseas. We conducted interviews with 66 doctors and nurses in 3 ICUs without a CIS. Many had positive perceptions regarding the impact of its introduction, though others were more guarded and unsure. Clinicians believed information access to patient would improve, communication processes could potentially change and there was potential for work processes to be more efficient. It was expected that ward rounds and handover would be less disrupted with all information available at the bedside or at the handover setting. There were mixed responses about whether a CIS would save time and how it would influence patient care, though the majority believed a CIS would improve safety by providing a means for increasing accountability and reducing medication errors. Concerns were raised about the transition from paper to a CIS and the training required. This information provides valuable evidence in the Australian setting regarding clinicians' expectations of a new ICU CIS to assist with future implementations. It also provides baseline data as a foundation for future research once the CIS is implemented. It is clear that robust quantitative studies are required to gain a detailed understanding of how a new CIS will impact clinicians' work processes and that appropriate training is crucial for full benefits to be achieved.

Medication monitoring of ambulatory rheumatology patients on Disease Modifying Anti-Rheumatic Drugs (DMARDS) is time consuming and complex, with possibilities for error. Electronic systems have the potential to improve the process. The aim of this study was to evaluate the impact of an electronic Drug Monitoring System (eDMS) on the time nurses' spent on clinical documentation associated with monitoring. The study was conducted with all nurses (n=4) in the Rheumatology Department of a large metropolitan Australian teaching hospital. The eDMS was designed as a module of the Hospital Clinical Information System (HCIS) to assist clinicians in monitoring rheumatology patients on DMARDS. Timing data were collected using a modified time and motion work measurement technique using software on a handheld computer. Data included the time nurses spent on documentation regarding medication monitoring before and after the implementation of the eDMS. Results showed that following implementation of the eDMS nurses spent significantly less time documenting medication monitoring information (13.6% to 7.2%, P<.0001). The cumbersome paper-based Drug Monitoring Patient List was replaced entirely by the eDMS. Consequently, there was a significant decrease in the time nurses spent using the HCIS (13.01% to 2.8%, p<.0001) for monitoring and the use of loose-leaf paper also decreased (7.6% to 5.0%, p = 0.002). The eDMS made the process of drug monitoring quicker and simpler for nurses and thus permitted them to increase their time spent in direct patient care.

We describe the development of a method to distil routinely collected clinical data into patient flow information to aid hospital bed management. Using data from state-wide emergency department and inpatient clinical information systems, a user-friendly interface was developed to visualise patient flow conditions for a particular hospital. The historical snapshots employ a variable time scale, allowing flow to be visualised across a day, week, month or year. Flow information includes occupancy, arrival and departure rates, length-of-stay and access block observations, which can be filtered by age, departure status, diagnosis, elective status, triage category, and admission unit. The tool may be helpful in supporting hospital bed managers in their daily decision making.

Electronic systems that support clinicians in the task of medication management are now being developed and implemented in the hospital setting. Electronic Medications Management Systems provide support to all the stakeholders within the process of medications and support for the patient centric care model. In this paper we discuss the key elements an electronic medications management systems should possess and what type of these key elements it should possess from a clinical/health information manager perspective. Moreover, the paper considers how it could integrate Electronic Medications Management Systems within the current health information architecture with an acute care hospital.

Effecting early discharge is a widely recommended strategy for improving patient flow in acute hospitals. This paper analyses the impact of inpatient discharge timing on Emergency Department (ED) flow parameters such as access block and length of stay, while comparing this to the effect on hospital occupancy, to arrive at an understanding of a ‘whole of hospital’ response to discharge timing. The impact of hospital size is also investigated. The analysis reveals that, on days when the discharge peak lags the peak in inpatient admissions, hospitals of all sizes exhibit increased levels of occupancy, inpatient and ED length of stay, and access block. The findings corroborate the efficacy of early discharge initiatives and ‘whole of hospital’ flow improvement initiatives for addressing overcrowding and efficiency issues in hospitals.

Objective: This study aimed to examine the effects of e-health education content on the attitude of undergraduate health science students towards the efficiency of health ICT in healthcare provision.

Methods: A cross-sectional survey design was used. Participants were Health Sciences students attending The University of Sydney. Students were divided into three groups: junior students enrolled in a subject with non e-health content; senior students enrolled in a subject with non e-health content; and students enrolled in a subject with e-health content. Students' attitude towards the efficiency of ICT in healthcare provision was measured by a modified version of the Information Technology Attitude Scales for Health (ITASH).

Results: Students enrolled in the subject with e-health content had a significantly higher average baseline attitude score than the other two groups (T198=-3.47, p=0.001; T93=-2.43, p=0.017). The repeat measures analysis yielded a result with significant interaction between survey time and student group (F2, 267=4.99, p=0.007) suggesting that changes of score was dependent on student group status.

Conclusion: Subjects rich in e-health content significantly enhanced student attitudes, even with a group of students with a rather positive initial attitude. To facilitate the uptake and utilisation of health ICT by the future health workforce, it is important for tertiary educational institutes to provide students with sufficient exposure to specific health–related ICT training, via specifically designed subjects delivering both generic and specific e-health content.

Background: A personally controlled electronic health record (PCEHR) system is being implemented in Australia. Every Australian that wants a PCEHR will be able to opt-in from July 2012.

Aim: To explore the opinions of Australian consumers and healthcare providers about the PCEHR.

Methods: In this qualitative study, consumers and healthcare providers were interviewed using a semi-structured interview guide.

Results: Perceived benefits identified by participants regarding the PCEHR included instant access to clinical information, and safer and more efficient healthcare delivery. The risk of unauthorised access and breaches of privacy were some of the perceived drawbacks. Although consumers seemed unwilling to opt-in to have a PCEHR, the vast majority of healthcare providers were positive towards this development and predicted better and safer healthcare as a result.

Conclusions: Consumers and healthcare providers appeared uniformed about the imminent PCEHR. The wide-spread unwillingness among participants to opt-in to have a PCEHR could potentially jeopardise successful implementation and uptake of this system. A well-designed system without security glitches and with individualised information from trusted healthcare providers regarding the benefits of having a PCEHR appears critical in engaging consumer opt-in.

Clinical trial data have historically been implemented using relational databases. While this has expedited the dissemination of data among partners, it has hindered on the ability to swiftly query the data by relying on monolithic tables. This paper outlines a project that investigates the semantic enrichment of a large-scale longitudinal clinical trial, the AIBL study, by reusing entities from existing ontologies. The implication of the semantic enrichment of the AIBL study is that it is possible to query the data more effectively and efficiently. We are now able to implement our model and focus on an end-to-end data capture and analysis pipeline to query and visualise clinical trial data. The main contribution of this paper is a discussion of the methodology to semantically enrich clinical trial data using entities from existing ontologies.

The implementation of clinical information systems and electronic medical records does not have a good track record. It is estimated that more than 50% of implementations fail. A review of electronic health information system (EHIS) models incorporating clinical information systems and electronic medical records was undertaken to determine the models developed and applied in health. Twenty one health and five non-health models were identified. The non-health models were included as a number of health models were derived form these. The findings and evaluation of the models has identified varying contents and results. The models identified were assessed to determine how these related to each other, whether models were tested and how, if benefits were identified and if costsavings were projected or realised. This review of EHIS implementation models has identified a need for clear definition of terms used, careful categorisation and for models to be comprehensive, extensive and rigorous if successful outcomes are to occur.

Cardiovascular disease (CVD) is the leading cause of mortality in Australia, and places large burdens on the healthcare system. To assist patients with CVDs in recovering from cardiac events and mediating cardiac risk factors, a home based cardiac rehabilitation program, known as the Care Assessment Platform (CAP), was developed. In the CAP program, patients are required to manually enter health information into their mobile phones on a daily basis. The manual operation is often subject to human errors and is inconvenient for some elderly patients. To improve this, an automated wireless solution has been desired. The objectives of this paper are to investigate the feasibility of implementing the newly released Bluetooth 4.0 (BT4.0) for the CAP program, and practically evaluate BT4.0 communications between a developed mobile application and some emulated healthcare devices. The study demonstrated that BT4.0 addresses usability, interoperability and security for healthcare applications, reduces the power consumption in wireless communication, and improves the flexibility of interface for software development. This evaluation study provides an essential mobile BT4.0 framework to incorporate a large range of healthcare devices for clinical assessment and intervention in the CAP program, and hence it is useful for similar development and research work of other mobile healthcare solutions.

A case study in the development of online educational material for a patient with type 2 diabetes (T2DM) is presented in this paper. Analysis of an interview of a patient with T2DM was conducted and analysed using Interpretive Phenomenological Analysis. Emerging themes were identified and used as the basis for the development of online educational material and the online platform for hosting this material is discussed. The method presented in this paper for the development of online learning environments for one patient with T2DM is considered to be one way of developing authentic and patient-centred educational resources.

Clinical information systems have become important tools in contemporary clinical patient care. However, there is a question of whether the current clinical information systems are able to effectively support clinicians in decision making processes. We conducted a survey to identify some of the decision making issues related to the use of existing clinical information systems. The survey was conducted among the end users of the cardiac surgery unit, quality and safety unit, intensive care unit and clinical costing unit at The Prince Charles Hospital (TPCH). Based on the survey results and reviewed literature, it was identified that support from the current information systems for decision-making is limited. Also, survey results showed that the majority of respondents considered lack in data integration to be one of the major issues followed by other issues such as limited access to various databases, lack of time and lack in efficient reporting and analysis tools. Furthermore, respondents pointed out that data quality is an issue and the three major data quality issues being faced are lack of data completeness, lack in consistency and lack in data accuracy.

Conclusion: Current clinical information systems support for the decision-making processes in Cardiac Surgery in this institution is limited and this could be addressed by integrating isolated clinical information systems.

A large scale, long term clinical study faced significant quality issues with its medications use data which had been collected from participants using paper forms and manually entered into a data capture system. A method was developed that automatically mapped 72.2% of the unique medication names collected for the study to the AMT and SNOMED CT-AU using Ontoserver, a terminology server for clinical ontologies. These initial results are promising and, with further improvements to the algorithms and evaluation, are expected to greatly improve the analysis of medication data gathered from the study.

Objective: To develop a system for the automatic classification of pathology reports for Cancer Registry notifications.

Method: A two pass approach is proposed to classify whether pathology reports are cancer notifiable or not. The first pass queries pathology HL7 messages for known report types that are received by the Queensland Cancer Registry (QCR), while the second pass aims to analyse the free text reports and identify those that are cancer notifiable. Cancer Registry business rules, natural language processing and symbolic reasoning using the SNOMED CT ontology were adopted in the system.

Results: The system was developed on a corpus of 500 histology and cytology reports (with 47% notifiable reports) and evaluated on an independent set of 479 reports (with 52% notifiable reports). Results show that the system can reliably classify cancer notifiable reports with a sensitivity, specificity, and positive predicted value (PPV) of 0.99, 0.95, and 0.95, respectively for the development set, and 0.98, 0.96, and 0.96 for the evaluation set. High sensitivity can be achieved at a slight expense in specificity and PPV.

Conclusion: The system demonstrates how medical free-text processing enables the classification of cancer notifiable pathology reports with high reliability for potential use by Cancer Registries and pathology laboratories.