Information in healthcare

Before installing any technology in a hospital, the organisation should ensure a culture of documenting pertinent patient information and be able to retrieve and archive it effectively, writes Sheenu Jhawar

Information Technology has become an inseparable phrase of late. We often forget the word information while using this phrase and start concentrating on technology instead. It’s already too late with that attitude. Technology is a boon, with advances like telemedicine and smart cards. It is a wonderful thing, but to make use of technology, the first and foremost thing that we require is ‘information.’ Correctly placed as prefix within the phrase, it is of prime importance to put technology to its highest use.

However, strangely the problem is not of lack of information. It is lack of documentation of information and thereupon, of an inability to capture, analyse and disseminate the right information at the right time to the right people.

Before the upcoming technology can be employed in the hospital/healthcare delivery organisation, it is of utmost value to the organisation to ensure a system and more importantly ensure a culture of documenting pertinent patient information, whether electronic or manual, and be able to retrieve it and archive it in an effective and efficient way possible.

Every society differs in what they consider ‘pertinent information’, and as a thumb rule, this definition also changes with time, alongside changes in the legal framework, patient expectations, values and clinician choice. The concept has become more important than ever before, because of the current trends toward increasing litigation, and closer scrutiny for insurance, the system of third party payers.

Besides, with the dawn of management techniques including audit and effectiveness of both cost and treatment, the documentation of medical details from admission to discharge becomes very useful. Therefore, the first step towards better patient management through information technology is to document relevant patient data. Going the electronic way is a giant leap for the healthcare professionals.

In the current scenario, this leap is worthwhile and very rewarding, but the leaping pad should be the culture of recording patient information. A lot of hard work has to be put into this. Starting from the time a patient comes to triage/ out-patient/admission to when he is first seen, details of initial history, initial diagnosis, discussion with the patient regarding his condition and preliminary options, medicines prescribed, instructions given to the nursing staff, their actions, patient consent and others form some of the vast clinical information that needs to be documented right until the day the patient is discharged.

In other words, a written translation of the entire patient journey forms the backbone of ‘information’. The reason for this is not just protection against litigation, or a routine documentation because it should be done, but the realisation that as the need for healthcare expands, so does the need to collect, codify, analyse and manage health data. Whether used to determine trends, improve efficiency, measure healthcare quality or facilitate reimbursement, accurate and organised health data is crucial to effective health care systems.

As is obvious, electronic/computerised medical records can prove to be a priceless resource to the organisation for its seamlessness of care. Specifically, computerisation of processes can substantially improve both efficiency and quality, as well as dramatically facilitate quality measurement.

This kind of data helps resolve many problems of documentation, which may arise by keeping paper records.

Primitive problems

• A common /standard framework of record keeping
• Improvement in clinical communication and sharing of information for better clinical practice
• Avoiding the system of parallel record keeping, wherein each discipline involved in the care of a patient, keeps a separate record. This results in wastage of time plus resources, and use of different formats becomes difficult to follow.

Inherent problems

• Fragmented records - Information can be recorded in different places, which may be difficult to access and thus limit the wholesomeness of care. However, a modular approach to documentation with an integrated output would avoid this problem.
• Simple documentation- Reams of paper with intelligible words, but of little use if a clinician /management want to assess ‘information’ rather than data. There can be inherent mechanism for sorting data into meaningful information for the purpose of audits, cost structure, trends over past years and a general assessment of healthcare demand and supply.

There are many sophisticated electronic systems that provide state-of-the-art, cutting edge expertise. These are best discussed with the information-tech experts to suit the organisation, once the decision to embrace technology has been taken.

Electronic systems fall within the remit of

• Accountability
• Accuracy
• Communication
• Completeness and validity
• Exhaustive coverage
• Security and confidentiality
• Timeliness
• Training
• Validation and quality assurance

The healthcare system has been in the midst of a rapid transition in response to changing trends and patterns of care. The growing emphasis on evidence based medical practice, continuous quality improvement, clinical and cost-effectiveness, and risk management have led to a sea change in medical practice that has been stressful for clinicians, patients, and managers. As care becomes more tightly managed, it becomes a challenge to balance time, money, resources, and clinical outcomes.

A question often asked is: ‘Can emerging technologies help solve these complex problems?’ Yes. But, they can only help. The ultimate onus of bringing this about lies with the hospital management.

How the ‘information’ from and through ‘technology’ is put to use becomes a creative process. The end product is not just ‘record-management’, but ‘a record’ management of hospital services for improving quality and saving costs.

The author is clinical auditor, Mid Stafford General Hospital, UK. Email:sheenujhawar@yahoo.com