Ebook: International Perspectives in Health Informatics

Around the world developed and developing countries are using health information systems to improve the health of populations, the quality of healthcare, reduce medical error rates and improve access to health information and health services. Health information systems are becoming key to country delivery of healthcare and health services, and health informatics is now recognized as a separate and unique area of disciplinary study and professional practice in many countries throughout the world. Countries and governments are supporting the education of health informatics professionals and engaging researchers to promote the advancement and integration of health information systems into healthcare.

World wide governments and healthcare organizations are choosing to implement health information systems such as the following:

• Electronic Health Records

• Clinical Decision Support Systems

• Clinical Information Systems

• E-learning Systems

• Personal Health Records

• Systems that support Online communities

• Public Health Information Systems

• Telehealth and Tele Intensive Care Unit Systems

• Mobile Health Information Systems

Governments, regional health authorities and other healthcare organizations from around the world are also evaluating the clinical and cost effectiveness of these health information systems. The goals of this work have included improving the quality of healthcare while at the same time ensuring the effective use of scarce healthcare resources (i.e. human, monetary and technological) to ensure the long-term sustainability of healthcare systems. Researchers are designing and developing health information systems, conducting research, developing new methods for evaluating health information systems and moving the science of health informatics forward.

Globally, the situations of countries and regional health authorities are not unique. Many countries are addressing key issues at the intersection of technology and healthcare such as privacy, ethics, patient safety, efficiency and effectiveness. Researchers are studying these issues and developing solutions in conjunction with country, regional and local healthcare organizations. There are many lessons that have been learned and many more that will be learned in the coming years. Many health informatics issues are not unique to one country or one organization. Many of these issues are present throughout the world – in each country, involving differing healthcare delivery systems and differing types of health information systems. There is a need for researchers to exchange ideas within this global context and, learn from each other so that knowledge can be transferred and international solutions and best practices form the basis of health informatics work. The improvement of our healthcare systems using health information systems and technologies is dependent upon these international exchanges and solutions to address many of the real-world problems we encounter today and into in the future.

The Information Technology and Communications in Health (ITCH) conference was first held in 1987 to promote the global exchange of ideas in health informatics. The conference is hosted by the School of Health Information Science at the University of Victoria. The theme of the 2011 conference is Health Informatics: International Perspectives. The conference provided a unique opportunity to share lessons learned by both developed and developing countries. In addition this ITCH conference was special as it honoured Professor Denis Protti's leadership and contributions to the field of health informatics. Professor Denis Protti was the founding Director of the School of Health Information Science at the University of Victoria and has contributed his knowledge and expertise to guiding health informatics education, projects and initiatives in Canada and internationally.

It is hoped that the exchange of knowledge among the participants at ITCH 2011 will lead to increased dialogue and greater improvements to health information systems and technologies leading to more sustainable healthcare systems worldwide today and into the future.

Elizabeth Borycki

School of Health Information Science

University of Victoria

Victoria, British Columbia

Canada

Automation bias – or a tendency to over-rely on automation – is a subject which has been studied in a variety of academic fields. Clinical Decision Support Systems (CDSS) aim to benefit the clinical decision making process. Although most research shows overall improved performance with use, there is often a failure to recognize the new errors that CDSS can introduce, and as such the healthcare field has a gap in this research. This paper summarizes the methodology and preliminary results of a systematic review over a broad range of fields into the effects of over-reliance on automation. Results indicate that though automation bias is a significant phenomenon, it is not well defined, and there is a gap in the research which must be addressed to optimize the use of decision support.

One of the key tasks in integrating guideline-based decision support systems with the electronic patient record is the mapping of clinical terms contained in both guidelines and patient notes to a common, controlled terminology. However, a vocabulary of pre-coordinated terms cannot cover every possible variation – clinical terms are often highly compositional and complex. We present a rule-based approach for automated recognition and post-coordination of clinical terms using minimal, morpheme-based thesauri, neoclassical combining forms and part-of-speech analysis. The process integrates MetaMap with the open-source GATE framework.

Different Clinical Decision Support Systems (CDSS) are reported to have different effects on clinicians' performance and various factors have been shown to be responsible for that (e.g. system's advice correctness, case difficulty, users' expertise...). The aim of this study is to determine how “advice correctness” and “case difficulty” affect users accepting/rejecting the comments of the system and consequently making a right or wrong decision. It was shown that in difficult cases, users level of making mistakes in clinical decision making was significantly higher when the comments were wrong. But there was no statistically significant difference between easy and difficult cases in how users accepted/rejected correct advice.

Automation bias – the tendency to over-rely on automation – has been studied in a variety of academic fields. Clinical Decision Support Systems aim to benefit the clinical decision making process. Although most research shows overall improved performance with use, there is often a failure to recognize the new errors that CDSS can introduce, and the healthcare field has a gap in this research. This paper outlines some of the most compelling theoretical factors in the literature involved in automation bias, and builds a simple model to be tested empirically. Ultimately, this will uncover the mechanisms by which this bias operates and help CDSS producers and healthcare practitioners optimize the medical decision making process.

At the time of hospital discharge, communication between inpatient and outpatient physicians is poor. Multiple studies demonstrate that discharge summaries, a means of improving information exchange between inpatient and outpatient providers, are frequently not available to the outpatient provider at the time of the post discharge visit. We have constructed a web-based solution for generating discharge summaries, SignOut Discharge Summary System (SDSS) which uses the workflow byproduct of SignOut data to pre-populate summaries, a post-discharge preparation module to ensure quality, a discharge edit module to designate accurate discharge summary assignment, and integration with HIM. SDSS had 1130 unique users in a recent period and captured signout information for 75% of hospitalized patients. The system has generated 78740 D/C summaries for 17 specialties since going live July 2005. Overall SDSS is responsible for 69% of all hospital discharge summaries and SDSS discharge summaries on average are available 1.91 days after discharge.

Psychosocial distress is common in cancer patients. Although common, psychosocial distress is frequently under-diagnosed and poorly managed in the U.S. health system. This paper describes 25 in-depth telephone interviews with health care professionals working within cancer care centers. Interview questions address perception of the psychosocial services offered within their cancer care organizations. Results indicate that access to psychosocial care is frequently dependent upon the subjective judgment of busy clinicians. Information technology could improve the delivery of psychosocial care by easing the administration of psychosocial assessments and increasing clinician contact with research evidence regarding distress management.

Electronic documentation methods may assist critical care providers with information management tasks in Intensive Care Units (ICUs). We conducted a quasi-experimental observational study to investigate patterns of information tool use by ICU physicians, nurses, and respiratory therapists during verbal communication tasks. Critical care providers used tools less at 3 months after the CCIS introduction. At 12 months, care providers referred to paper and permanent records, especially during shift changes. The results suggest potential areas of improvement for clinical information systems in assisting critical care providers in ensuring informational continuity around their patients.

Many have addressed the challenge of defining Health Informatics (HI) competencies, and eleven efforts have produced detailed lists of competencies. Although there are commonalities among these lists, several aspects of this work frustrate our using it to define a consensus view of HI competencies. This project has involved the documentation and comparison of the competencies produced by key authors and an effort to suggest competency terminology that derives from and harmonizes these efforts, but does not emphasize any one contribution. It is our hope that this will enable us to use what has gone before with a minimum of reinvention.

Our greatest hope for the future of eHealth and the enabling of our health system is today's students. However, we face a challenge: few students are aware of careers in Health Informatics and other aspects of eHealth. This paper describes an initiative to engage our future workforce in HI. The National Student Forum for Health Informatics was established, in collaboration between the National Institutes of Health Informatics and COACH, to provide much needed opportunities for students to become involved in HI educational programs, research and student-student interaction. A key activity of NSF is the instantiation of Health Informatics Clubs at Canadian colleges and universities. We describe the rationale for NSF, its goals and objectives, its leadership and organization, and the development of the first HI Club at the University of Waterloo. Initiatives such as NSF are essential if we are to resolve the human resources crisis in HI.

We are reporting on a recent experience with Health Informatics (HI) teaching at undergraduate degree level to an audience of HI and Pharmacy students. The important insight is that effective teaching of clinical informatics must involve highly interactive, applied components in addition to the traditional theoretical material. This is in agreement with general literature underlining the importance of simulations and role playing in teaching and is well supported by our student evaluation results. However, the viability and sustainability of such approaches to teaching hinges on significant course preparation efforts. These efforts consist of time-consuming investigations of informatics technologies, applications and systems followed by the implementation of workable solutions to a wide range of technical problems. In effect, this approach to course development is an involved process that relies on a special form of applied research whose technical complexity could explain the dearth of published reports on similar approaches in HI education. Despite its difficulties, we argue that this approach can be used to set a baseline for clinical informatics training at undergraduate level and that its implications for HI education in Canada are of importance.

The use of e-Learning in educational institutes has rapidly increased along with the development of information and communication technology (ICT). In healthcare, more medical educators are using e-Learning to support their curriculum design, delivery and evaluation. However, no systematic work exists on characterizing a collective set of Critical Success Factors (CSFs) for implementing e-Learning in the healthcare education institutions. The aim of this paper is to study the CSFs of implementing healthcare e-Learning

This paper provides an overview of a newly developed course in E-health and Emerging Technology for King Saud Bin Abdul Aziz University for Health Sciences (KSAU-HS) Masters of Health Informatics program. The paper provides an overview of the program, description on the course development process, instructional methods, and course evaluation. The paper also describes the faculty's experience in the development of the course. Future evaluation will focus on students' learning experience and content used in the course.

Background: Replication studies evaluate technologies in usual use settings. Methods: We conducted a clinical trial to determine whether reductions in clinical and economic results observed in a previous study could be replicated in a larger setting. Subjects were randomized to receive intervention (email notifications for sentinel health events sent to their care managers) or control. Main Outcome Measures: The primary outcome was the rate of emergency department visits for low severity conditions. Secondary outcomes included: medical costs and other clinical event rates. Results: We randomized 13,454 individuals (intervention, 6740; control, 6714). Subjects in both groups had similar rates of clinical events and medical costs. Conclusion: The use of email notifications to care managers was associated with no reductions in clinical events or medical costs.

Background: New data management models are emerging in multi-center clinical studies. We evaluated the incremental costs associated with decentralized vs. centralized models. Methods: We developed clinical research network economic models to evaluate three data management models: centralized, decentralized with local software, and decentralized with shared database. Descriptive information from three clinical research studies served as inputs for these models. Main Outcome Measures: The primary outcome was total data management costs. Secondary outcomes included: data management costs for sites, local data centers, and central coordinating centers. Results: Both decentralized models were more costly than the centralized model for each clinical research study: the decentralized with local software model was the most expensive. Decreasing the number of local data centers and case book pages reduced cost differentials between models. Conclusion: Decentralized vs. centralized data management in multi-center clinical research studies is associated with increases in data management costs.

The radiation therapy (RT) department at the British Columbia Cancer Agency - Vancouver Island Centre (VIC) is responsible for delivering radiation treatments to cancer patients from Vancouver Island, which has a population base of approximately 750,000. The purpose of this analysis is to examine a process transformation project undertaken by a VIC clinical champion using a sociotechnical approach and identify factors that influenced the project outcome. Beginning in January 2009, a radiation oncologist at VIC initiated a project to transform the clinical process of generating prescriptions for radiation therapy. The project objective was to replace the paper-based process for radiation therapy (RT) prescriptions with an electronic process to achieve benefits such as increased legibility, accuracy, and accessibility of prescriptions. The electronic prescription (e-Rx) process was designed and developed by health informatics students from the University of Victoria, and the new process was trialed and implemented for approximately half of the new patients seen by the VIC RT department. This pilot implementation was brought to a halt two weeks later, due to concerns raised by the RT department. Using a sociotechnical approach, the authors identify several factors that negatively impacted the project's successful implementation: lack of leadership endorsement and organizational strategy, insufficient formal and informal organizational power of the clinical champion, underestimation of complexity, and inadequate management of the implementation process. Although these factors have been well documented in the literature for large-scale system implementation projects, understanding the way by which they influence smaller-scale process transformation projects in highly specialized clinical settings may help future project managers and coordinators to set such projects up for success.

Governments and providers are investing in health information technologies with little evidence as to their ultimate value. We present a conceptual framework that can be used by hospitals, clinics, and health care systems to evaluate their health information technologies. The framework contains three dimensions that collectively define generic evaluation types. When these types are combined with contextual considerations, they define specific evaluation problems. The first dimension, domain, determines whether the evaluation will address the information intervention or its outcomes. The second dimension, mechanism, identifies the specific components of the new information technology and/or its health care system that will be the subject of the evaluation study. And, the third dimension, timing, determines whether the evaluation occurs before or after the health information technology is implemented. Answers to these questions define a set of evaluation types each with generic sets of evaluation questions, study designs, data collection requirements, and analytic methods. When these types are combined with details of the evaluation context, they define specific evaluation problems.

Ontologies can assist with translating information from an electronic health record to a clinical practice guideline and reformatting it into a compliance report. A 2009 literature search reviews publications on the use of ontologies to support automated reporting of compliance with clinical practice guidelines via electronic health records. Research stage, data-pulling capabilities, ontologies used, and issues raised are some of the comparative data pulled from 13 articles from the literature review results. Suggestions for further research are given.

The emergence of the Personal Health Record (PHR) has made individual health information more readily accessible to a wide range of users including patients, consumers, practitioners, and healthcare providers. However, increased accessibility of PHR threatens the confidentiality, privacy, and security of personalized health information. Therefore, a need for robust and reliable forms of authentication is of prime concern. The concept of biometric authentication is now highly visible to healthcare providers as a technology to prevent unauthorized access to individual health information. Implementing biometric authentication mechanisms to protect PHR facilitates access control and secure exchange of health information. In this paper, a literature review is used to explore the key benefits, technical barriers, challenges, and ethical implications for using biometric authentication in PHR.

Document management systems (DMS) have widespread in major hospitals in Japan as a platform to digitize the paper-based records being out of coverage by EPR. This study aimed to examine longitudinal trends of actual use of DMS in a hospital in which EPR had been in operation, which would be conducive to planning the further information management system in the hospital. Degrees of utilization of electronic documents and templates with DMS were analyzed based on data extracted from a university-affiliated hospital with EPR. As a result, it was found that the number of electronic documents as well as scanned documents circulating at the hospital tended to increase. The result indicated that replacement of paper-based documents with electronic documents did not occur. Therefore it was anticipated that the need for DMS would continue to increase in the hospital. The methods used this study to analyze the trend of DMS utilization would be applicable to other hospitals with with a variety of DMS implementation, such as electronic storage by scanning documents or paper preservation that is compatible with EPR.