Smart use of data, information and communication: the INFORM-ed Best Local Practice Project--Grafton Base Hospital.
Abstract: This paper describes current progress for an information management project in a medium-sized rural hospital after the first four months of the one-year project. In particular, the article examines some of the project outcomes to date as these relate to the National Hospitals and Health Reform recommendations for the smart use of data, information and communication. The paper identifies a number of important challenges and issues that have been addressed by the project and proposes that the project findings may be used to inform similar projects in other settings. These findings relate to clinician requirements for reports, investment in human resources, development, and time for information management activities. An understanding of data collected, information systems, and presentation of clinician data are also important. The benefits of information sharing in assisting quality improvement activities are particularly relevant but, more importantly, they can engage and involve clinicians in the use of information. The importance of local data, information, and knowledge is described. Finally, issues for the health information management profession, such as working collegially and sharing knowledge and expertise, are outlined.

Keywords (MeSH): Data Collection; Data Sharing; Hospital Information Systems; Informatics or Public Health Informatics; Medical Records; Australia

Supplementary keyword: Health Information Management
Subject: Medical informatics (Analysis)
Medical personnel (Practice)
Medical personnel (Management)
Medicine (Practice)
Medicine (Usage)
Authors: Lloyd, Sheree
Collie, Jean
McInnes, Alastair
King, Kevin
Lollback, Alison
Garland, Angie
Pub Date: 10/01/2011
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Oct, 2011 Source Volume: 40 Source Issue: 3
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8010000 Medical Personnel NAICS Code: 62 Health Care and Social Assistance
Geographic: Geographic Scope: Australia Geographic Code: 8AUST Australia
Accession Number: 271051799
Full Text: Background

In September 2010, a small project at the Grafton Base Hospital was funded by the University Centre for Rural Health, North Coast. This project, INFORM-ed Best Local Practice, had a key objective to provide information from routine administrative information systems to clinicians to support their programs and activities. The project was funded for one year and will have completed its objectives in September 2011. This paper reports on preliminary findings after the first four months of the project.

In 2009, a major report was published by the Commonwealth of Australia's National Health and Hospitals Reform Commission. The 'Healthier Future for All Australians' Report urges a range of actions to strengthen and improve our health system. Importantly, a specific reform agenda is to 'create an agile, responsive and self-improving health system for future generations' (National Health and Hospitals Reform Commission 2009: 3). One of the levers for achieving this is 'smart use of data, information and communication' (National Health and Hospitals Reform Commission 2009: 8). The Report explains that health system data should:

enhance decision making, drive improvements in clinical practice, guide how resources are marshalled and deployed and provide the basis for feedback loops to promote improvement in access to, and quality and efficiency of, care. A data rich environment should be the expectation across all health settings. (National Health and Hospitals Reform Commission 2009:127)

The Commission made a range of recommendations and one of particular interest to the INFORM-ed Project is having in place systems to 'provide comparative clinical performance data back to health services and hospitals, clinical units and clinicians' (National Health and Hospitals Reform Commission 2009: 8).

Aims of the current research

The purpose of this paper is to report key findings to date of a hospital information management project in a medium-sized rural hospital with a specific focus on the National Health and Hospitals Reform Commission's recommendation for the 'smart use of data, information and communication'. The paper presents findings to date from this project, and aims to identify barriers and highlight key issues that need to be addressed in order to embrace the 'smart use of data and information' recommendation. These observations from the hospital's INFORM-ed--Best Local Practice Project are necessarily preliminary. However, current findings have demonstrated a number of important challenges and issues to be addressed by this hospital, which may also inform other settings and projects working toward this recommendation.

The case study hospital

Grafton Base Hospital is a medium-sized rural hospital with affiliations with the University of New South Wales and the University Centre for Rural Health, North Coast. The hospital has a busy Emergency Department and visiting specialists provide services to surgical, obstetrics and gynaecology, paediatrics and medical wards. Key activity indicators are shown in Table 1: Specialty areas offered at the hospital are: emergency medicine; general medicine; general surgery; anaesthetics; obstetrics and gynaecology; orthopaedics; and paediatrics.

INFORM-ed Best Local Practice Project

The INFORM-ed Best Local Practice Project was funded for one year (2 days a week), with the following aims:

* to integrate information and its use into the practice of students and clinicians so that they better understand how information can inform their practice, professional development and life-long learning

* to build on students' understanding of information as a tool for ensuring the safety and quality of clinical practice

* to evaluate the project and document its applicability to other rural health sites.

This project is part of a range of quality improvement activities overseen by the Hospital Quality and Risk Management Committee. A project Advisory Group has been formed with membership comprised of the hospital's Director, Medical Services; Health Information Manager; Chair, Medical Quality Committee; Quality Co-ordinator; Business Manager; and Research Officer, INFORM-ed--Best Local Practice Project. The Research Officer reports regularly to the Hospital Quality and Risk Management Committee on project progress and findings. The Advisory Committee works with the Research Officer to direct and to monitor the project and ensure that it is meeting its stated aims and objectives.

Project findings to date

The INFORM-ed-Best Local Practice project still has much work to be completed, although in the first four months much has been learnt. Key findings to date in relation to the smart use of data and information are described below. The issue of smart use of communication has not been discussed in this paper, as this aspect will present its own challenges.

Current reports and information disseminated to clinicians

Comparative performance information is provided to the hospital and is now routinely available in a number formats from the following sources: New South Wales (NSW) Health; Northern NSW Local Health District; Commonwealth Department of Health and Ageing (My Hospital website); NSW Bureau of Health Information; and the Australian Institute of Health and Welfare.

This information demonstrates how the hospital performs in relation to peer hospitals on a range of indicators including: Emergency Department performance; waiting list; admitted patients; and infection rates. For example, the hospital has been provided with regular reports of casemix, admission and other broad indicator data. This summative information is used by hospital management and distributed to key stakeholders. While this type of information can be used by clinicians, timeliness and difficulties in 'drilling down' to answer further questions have been barriers to fully exploring the usefulness of these reports for clinicians.

Clarke et al. (2010: S111) noted that 'it is not clear that using administrative data to measure performance in a summative way is valid or even appropriate'; and Duckett et al. (2007: 574-575) stated that hospital level control chart information, such as Variable Life-Adjusted Displays (VLADs), cannot provide definitive answers about the quality of care, and should be used 'to develop theories about why variations occur and suggest possible solutions: improving data quality, improving casemix adjustment, or implementing system changes to improve quality of care'.

The hospital's Quality Coordinator has reported routinely on a range of indicators including falls, readmissions within 28 days, infection control clinical indicators, and clinical and other incident information. These reports are examined by the hospital's quality committees and necessary discussion, remedial and preventive actions taken.

What has long been recognised by Hospital Management is that there are many other information systems used at the Grafton Base Hospital that have the potential to provide information at a more detailed level to clinicians. The patient administration system (PAS) collects a range of data at a patient level and has great potential to provide meaningful clinician-level information. This information system has not been used to routinely report to hospital clinical staff and this has provided the impetus for the Director of Medical Services to seek funding for the INFORM-ed--Best Local Practice project.

Other findings that relate to information dissemination to clinicians include:

* The Health Information Manager (HIM) and coders are providing a timely coding service that will enable routine reporting to occur once data extraction and report formats are negotiated with clinical staff at Grafton Base Hospital.

* Data quality is assessed frequently and any errors detected in coded or admissions, transfers and separations (ATS) data are corrected regularly. Medical staff at Grafton Base Hospital are readily available for review and discussion of the clinical content of their documentation, allowing for quality coding.

* A decision support tool, Business Objects, Web-Intelligence is available and can be used to extract information from the PAS at the Grafton Base Hospital.

Clinician requirements for reports

The project commenced work on the presentation and content of information reports to inform best local practices. It has used information collected by the PAS and other information systems and will be presented in formats that are digestible and agreed to by hospital clinicians. From initial consultations and discussion, clinicians would welcome even the most basic reporting reflecting their own and peer performances. Clinicians have also asked for the inclusion of comparative data showing peer comparisons and demonstrating changes over time.

Clarke et al. (2010) showed that it is clinician involvement and response to the information reported to them that is important. Therefore, facilitating their examination of data through reporting in an easy-to-understand way should facilitate their participation in quality initiatives.

Information is a strategic resource but investment in human resources, development and time is important

Grafton Base Hospital collects a vast amount of data in the information systems that are implemented. Investment in time and resources for data extraction, data presentation, reporting and for analysis is an important commitment at a medium-sized rural hospital. In larger settings, there may be access to a range of technical, health information management and systems professionals. This means there will be greater potential resources available to extract, present and analyse data for clinicians. However, in the smaller rural setting HIMs are often sole practitioners with no excess capacity or access to technical and other resources to assist them in these important roles.

As mentioned, decision support tools to extract information from the PAS do exist at Grafton Base Hospital. Business Objects Web Intelligence, an extremely powerful reporting tool to retrieve information, is available. However, provision of ongoing training in Business Objects for staff and the time and opportunity to put skills into practice has been an historical limitation.

Understanding the data collected, information systems and presenting the information

An understanding of the flow and sources of health information, how it is collected and data definitions is an extremely important aspect of the smart use of data and information. Lack of understanding of the context of underlying data can lead to the provision of erroneous information or conclusions. HIMs have particular skills and expertise in this area. A simple reconciliation of a report produced using Business Objects Web Intelligence requires an understanding of data items and should be reconciled to originating data systems, such as the PAS. However, sometimes these simple checks may not be performed by the report generators, who do not understand in detail the daily business activities of the medium-sized rural hospital.

Credibility of data reported is important to hospital clinical staff, who do know intuitively about their local activity. Reports must be consistent and they must be validated; for example, the number of overnight admissions in a Business Object report compared back to the PAS before distribution to clinicians. The INFORM-ed--Best Local Practice has worked with staff of the Maternity Unit at Grafton Base Hospital to examine their obstetric information system and has identified extremely powerful performance information, which can now be routinely distributed to midwifery and medical staff to initiate quality improvement discussion. The project plans to utilise the Classification of Hospital Acquired Disorders (CHADx) in order to identify potential cases for clinicians to study and has included the condition onset code in Business Objects reports that have been designed by the Research Officer to enable this analysis.

Information sharing for clinical improvement activities

Sharing the information we collect is important. A huge investment is made in collecting, inputting and providing the information infrastructure in our healthcare organisations. As well as investing in time and resources, we need to share the information. HIMs and others need to involve clinicians to determine their requirements for presenting this information in a timely and digestible format. This will be a major activity in the INFORM-ed Best Local Practice Project in the coming months.

The 'bolt and key approach' to information management, where information is captured, stored away and not accessible to clinicians, is not consistent with an environment of 'smart use of data and information' and will not enable our health settings to work towards improvements to data quality. Therefore, we must determine ways to share the current information that is collected and disseminate it now.

Board and Watson (2010: S93) stated that we should be 'using what we gather (and) harnessing information for improved care'. Information sharing of currently collected administrative and other data is a vital strategic resource that can be used to inform decision making and enable us to respond to safety and quality issues.

Data use for clinical improvement is well supported by the literature and, as Ben-Tovim et al. (2010: S100-S103) conveyed, hospital mortality information can be used to alert institutions to the need for further investigation. Studies in the United Kingdom have demonstrated that the second highest barrier to involvement of clinicians in improvement activities has been 'lack of widely shared knowledge [for example] access to performance data' (The Health Foundation 2010:152). This data barrier was rated ahead of 'lack of leadership', 'poor handover from other staff' and 'lack of financial rewards'.

Board and Watson (2010) found that currently available data can be used to focus quality improvement and to support accountability and transparency through the creation and use of timely and accurate information on clinical quality. The benefit of examining data is provided in an example given by Clarke et al. (2010: S112), where a routine report identified patients who were developing thrombophlebitis. The clinicians pursued this information and discovered that intravenous (IV) appliances were being left in situ for longer than necessary. They subsequently reviewed the guidelines for the removal of IV appliances and as a result the rate of thrombophlebitis as a complication of IV appliances decreased. Clarke et al. (2010) recognised that the key was not the data itself but the involvement of clinicians and their response to the data. Sharing of information with clinicians and integration with their quality practices is a key aim of the INFORM-ed project.

Data quality issues are often presented by clinicians and others as an argument to resist data acceptance. The role of the HIM is to present and explain the data, acknowledge its weaknesses, and work with clinicians to further improve documentation, coding and data capture. Clinicians cannot contribute to improvements in data quality if they are not able to see and use the information on a regular basis.

The INFORM-ed Best Local Practice aims to disseminate and use routinely available information to clinicians to support their quality activities and it is an example of the 'smart use of data and information', which is recommended as part of the Health Reforms being pursued by the Commonwealth government.

Local data, information and knowledge

The National Health and Hospitals Reform Commission (2009) stated that a self-improving health system is one that learns, creates, and uses new information wisely, and is driven by innovation and continuous quality improvement (National Health and Hospitals Reform Commission 2009: 121). The Report mentions that during many consultations multiple data requirements disappeared into bureaucratic 'black holes', with no useful data provided back to health services (National Health and Hospitals Reform Commission 2009:133). Continual improvements in accessibility and the breadth of information available to health services are occurring through the NSW Health Information Bureau and Northern NSW Local District's reporting systems. However, what is needed are local data and information at an individual clinician level.

Berwick (2005: 316) argued that as part of a 'pragmatic scientific' approach, one of the elements is to use local knowledge--'the knowledge of local workers--in measurement (rather than relegating measurement to people least familiar with the subject matter and work)'. The study by Clarke et al. (2010: S111) also demonstrated that 'the measurement of indicators by means of administrative data offers a formative way of driving improvement at local levels'. Clarke et al. (2010: S112-113) discovered that 'care at the bedside will only improve if clinicians have confidence in the information they receive, and have the resources required to generate improvement in care processes'. This will only occur through data use and the consequent improvements to data quality that can occur through its examination by clinicians and informed by their local knowledge and experience. The work of the INFORM-ed project to date has identified that this information is available and now needs to be provided to hospital clinicians routinely in meaningful formats.

Health information professional issues

While coding is an important aspect of our professional knowledgebase, our most strategic contribution to the health reform agenda will be in assisting health services to leverage data and information for decision making and self-improvement. As professional colleagues, it is important that we share our knowledge, skills and expertise. Barriers to information sharing must be removed, and time and resources allocated to data extraction, analysis and presentation. Our contributions in enabling the 'smart use of data and information' can be published in our professional Journal. In the workplace, close collaboration and support of one another is important.

Future project work

At the stage of writing this report, the INFORM-ed Best Local Practice project still has much work to complete. In the remaining months the project will focus on:

* use of the CHADx as a tool to identify cases from the PAS for quality improvement review activities by clinicians; alternatives to CHADx will also be explored

* putting in place a process to routinely report relevant information to clinicians from the PAS and other systems such as FirstNet and SurgiNet

* working with clinicians in designing report formats and integrating peer information into these reports

* involving clinicians in responding to report information and improving the information collected

* working with clinicians to understand, interpret and value add to data

* liaising with HIMs to develop local reports using Business Objects

* putting in place processes to ensure the sustainability of the project efforts over the long term.

Conclusion

Smart use of data and information is an important component of creating an agile and self-improving health system and HIMs can make a valued contribution.

Healthcare organisations are extremely adept at reporting data to health departments and other government agencies but the clinician at the bedside may not be provided with routine, meaningful information to inform their practice. Information is a strategic resource and, like human resources, this asset needs to be used to its full capacity. Even in the rural setting, a huge investment is made in terms of data collection, technology and systems. Perhaps an even bigger challenge in a medium-sized rural setting is to allocate resources for training, data extraction, data manipulation, and to develop the necessary skills to present information in its most optimal format. It is evident from the project findings to date that in the smaller rural hospital health setting there is huge potential to better utilise existing information and provide this to clinicians on a routine basis.

Issues of investment, information presentation, and knowledge sharing are relevant to all HIMs, who will be involved in helping staff in their health settings to implement the recommendations of the National Hospitals and Health Reform Commission. Working with clinicians so they are better able to understand, interpret and 'value add' to data is crucial. If clinicians understand the limitations of the data in systems such as the PAS and how they can utilise tools such as the CHADx as part of their routine quality activities then they will be more able to drive and recommend improvements.

Acknowledgements

The authors wish to acknowledge The University Centre for Rural Health (North Coast) for the funding to support this project.

References

Ben-Tovim, D. I., Pointer, S. C., Woodman, R., Hakendorf, P H. and Harrison, J. E. (2010). Routine use of administrative data for safety and quality purposes--hospital mortality. Medical Journal of Australia. 193(8): S 100-102.

Berwick, D. M. (2005). Broadening the view of evidence-based medicine quality and safety in health care. Quality and Safety in Health Care 14: 315-316.

Board, N. and Watson, D. (2010). Using what we gather--harnessing information for improved care. Medical Journal of Australia 193(8): S93-S94.

Clarke, A. L. L., Shearer, W., McMillan, A. J. and Ireland, P. D. (2010). Investigating apparent variation in quality of care: the critical role of clinician engagement. Medical Journal of Australia. 193(8): S111-113.

Duckett, S. J., Coory, M. and Sketcher-Baker, K. (2007). Identifying variations in quality of care in Queensland hospitals. Medical Journal of Australia 187(10): 19

National Health and Hospitals Reform Commission (2009). A healthier future for all Australians--final report June 2009. National Health and Hospitals Reform Commission. Available at: http://www.health.gov.au/internet/nhhrc/publishing.nsf/ Content/nhhrc-report

The Health Foundation (2010). How do you get clinicians involved in quality improvement? Evaluation report. Available at: http://www.health.org.uk/publications/how-do-you-get-clinicians-involved-in- quality-improvement/ (Accessed 21 July 2011).

Corresponding author

Sheree Lloyd DipMRA, BBus(Comp) MTM, AFCHSM, CHIM

Research Officer

INFORM-ed--Best Local Practice Project

Grafton Base Hospital

University Centre for Rural Health, North Coast

61 Uralba Street

Lismore NSW 2480 AUSTRALIA

email: sheree.lloyd@ncahs.health.nsw.gov.au

Jean Collie MBBS, MHP, FRACMA, FAFPHM

Director of Medical Services

Grafton Base Hospital

Lismore NSW 2480 AUSTRALIA

Clinical Sub-dean, University Centre for Rural Health, North Coast

Alastair McInnes MBBS

Chair Medical Quality Committee

Grafton Base Hospital

Lismore 2480

Senior Lecturer, University of Wollongong

Kevin King RN

Quality Co-ordinator

Grafton Base Hospital

Lismore NSW 2480 AUSTRALIA

Alison Lollback BAppSc(MRA)

Health Information Manager

Grafton Base Hospital

Lismore NSW 2480 AUSTRALIA

Angie Garland RN, RM, WHN

Nurse Unit Manager, Maternity & Women's Care Unit

Grafton Base Hospital

Lismore NSW 2480 AUSTRALIA
Table 1: Grafton Base Hospital Activity 2009-2010

INDICATOR                   NUMBER

Overnight admissions        5,517
Same day admissions         7,462

Source: http://www.health.nsw.gov.au/hospitals/detail.asp
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