Emerald Group Publishing Limited
Copyright © 2011, Emerald Group Publishing Limited
Health informatics and clinical governance
Article Type: Editorial From: Clinical Governance: An International Journal, Volume 16, Issue 4
This issue of Clinical Governance International Journal is dedicated to health informatics: the application of knowledge, skills, information and information systems to technical and social activities, ultimately directed at making life better for patients.
Clinical governance places major emphasis, both on the efficient utilisation of major capital assets and on patients’ experience and satisfaction with their treatment. When, for example, inefficient theatre scheduling frustrates the access of patients to the surgeons who have the capacity to transform their lives, it is well worthwhile to consider how computer modelling can contribute to improved governance and changes in clinical, as well as administrative, practices.
Ferreira, Gomes and Yasin present the operating theatre complex as a “closed operational system”. This can be modelled and the model populated with observed or hypothetical data in order to propose and evaluate prospectively, future change. So much for the technical side: we have a model but who will use it and to what effect?
The issue for managers is twofold. First, they need to generate the social climate where the evidence of the need for change, the quality of the computer model and the data it contains, the barriers to change and the ways they can be overcome, can be debated intelligently and constructively. Second, in order to make modelling feasible, the system to gather authentic, real data to populate the model needs to be compatible with the patterns of clinical work where the data is collected, if those data are to be credible.
On a systems view, Ferreira, Gomes and Yasin’ paper refers to the control element of a duality, whose other component is the practical activity that clinical governance oversees. Once the need for clinical practice to change has been accepted, can information systems facilitate the change?
One such circumstance has been the world wide anticipation, in 2009 and 2010 of an influenza pandemic. The public health question was, how to minimise the impact of a pandemic, through activity planning in hospitals and immunisation programmes in primary care.
Patwardhan, Kelleher, Cunningham, Menke and Spencer describe the incorporation of a best practice reminder within an electronic health record and suggests this had a causal impact on the observed threefold increase in immunisation rates against influenza in a paediatric rheumatology clinic.
What does the world need to be like for such an impact to be replicated in other places or at different times ?
First of all, clinicians using the system were able to feed their experience and critique back, through a Delphi process, into the continuous refinement of the intervention. The intervention’s sponsors were able effectively to acknowledge variation between individual clinicians in the way the relevance of the intervention to the core mission of their clinic.
Second, provider commitment to the immunisation effort needed also to be matched by the commitment of patients and their parents. This may have varied between subgroups of patients, even at a time when world-wide anxiety over a ’flu pandemic was waxing.
Finally, many patients were members of a parallel health promotion network which also subscribed to the same health record system.
Electronic Health Record systems span the boundary between clinical and planning functions by virtue of the opportunity they afford, to capture the times key process events and resource consumptions occur whilst assembling the clinical record. They represent a complex interrelationship between technical, organisational and social aspects of any organisation. Cresswell, Worth and Sheikh provide practical guidance to assist the translation of these aspects into the implementation and evaluation of Electronic Health Records and other information systems in healthcare.
The basis of their approach is actor network theory. An excursion into social theory may surprise and even alarm some readers but contemporary social theory justifiably claims its place in a journal dedicated to clinical governance, exactly because the rational and objective aspects of governance take place within a social milieu, whose understanding is critical to the success of governance activities in general.
The basic understanding of contemporary social theory that Cresswell and colleagues offer is not just interesting: it is a key competence that equips those responsible for clinical governance to understand the social and political dimensions that complicate otherwise simple governance programmes. Ellis and Howard argue that health informatics and good information management are keys to good clinical governance. Clinical governance is less a matter of regulation and compliance monitoring and more a matter of negotiated situation appreciation and problem solving by mutually sensitive parties who all bring different interests and concerns to the table.
Where Ferreira, Gomes and Yasin focus on a “closed operational system”, accepting the problem as a pre-defined “given”, Ellis and Howard see the activity of organisational problems solving as a “complex adaptive system”, in which the nature of the problem, the goals of problem solving and the methods to be adopted, are all identified by negotiation rather than definition.
Planners and managers, responsible for clinical governance, rely heavily on professionals at the front line of healthcare delivery to diagnose and overcome barriers to better quality healthcare. Ellis and Howard set an agenda for the educational programmes these three groups need, to equip them to generate, analyse critically and apply informatics competences, foster the capability to generate and utilise information and extend the ownership of clinical governance activities beyond the senior team.
Too often, the introduction of new information resources is presented as an exercise in managing a pre-ordained change, on the assumption that the change will be beneficial.
Shaw, Aceti, Campbell-Scherer, Leyland, Mozgala, Patterson, Sunley, Manca and Grunfeld provide the North American perspective for this issues by exploring the uncertain zone that lies between the provision of Electronic Medical Records (EMR) and the realisation of benefits, taking their use and contribution towards chronic disease management as a concrete example.
These authors advance socio-technical theory to highlight the gap between the “practice in theory” embedded (actor network theorists would say “inscribed”) in the design of EMR and the “theory as practiced” when the EMR is deployed in the real world. If EMR and other information systems for healthcare are not designed for usefulness to front-line practitioners, and usability in the environment of front-line practice, the expected benefits of their introduction will not be realised. The quality of patients’ interaction with, and experience of, the healthcare system depends on the willingness of planners and managers to recognise that a defective “fit”, between an EMR and the surrounding clinical tasks, carries human, organisational and financial costs. The statement of anticipated benefits in the business case for EMR needs to be matched by a clear understanding: of the risks that will hinder benefits realisation, and their mitigation through effective user-focused design and a responsive plan of post-implementation software improvement.
In this issue, we have set out to mix the description of some informatics interventions relevant to clinical governance with insight into the kinds of knowledge and understanding that will help the planners, managers and senior professionals responsible for clinical governance ensure the success of their informatics interventions. We hope that readers will find this issue interesting and thought provoking.
Nick Harrop, Alan GilliesUK