Improving services with informatics tools
Frank Sullivan and Jeremy C Wyatt 2005;331;1190-1192 Updated information and services can be found at: These include: This article cites 3 articles, 2 of which can be accessed free at: One rapid response has been posted to this article, which you can access forfree at: You can respond to this article at: Receive free email alerts when new articles cite this article - sign up in the box at the top left of the article A correction has been published for this article. The contents of the correctionhave been appended to the original article in this reprint. The correction is available online at: To order reprints follow the "Request Permissions" link in the navigation box

ABC of health informatics
Improving services with informatics tools
Frank Sullivan, Jeremy C Wyatt
This article describes how many sources of data can be linked, This is the 10th in a series of 12 articles
interpreted, and analysed before being presented to decision A glossary of terms is available at http://
makers to improve care. It also discusses the legal issues surrounding data protection and freedom of information.
A huge volume of data flows across the desk of a director of public health (see box opposite). One of the director's problemsis to know which signals to act upon and what "noise" to ignore.
If the numbers being considered are small, as they probably willbe in the case described here, a critical incident analysis may be You are a director of public health. The local paediatric
all that is needed. An individual prescriber, or group, may have intensive care unit sends you a paper describing five
an erroneous belief or inadequate training. Critical incidents or potentially avoidable admissions in the past two years—for
other signals often indicate that more data (such as data on example, patients with severe asthma who were not being
prescribing steroids for paediatric asthma in primary care and prescribed prophylactic drugs
outpatients) are needed.
Sources of data
Health services are awash with data. Earlier articles in the seriesdescribed the large and increasing numbers of sources of dataavailable to consumers, patients, clinicians, and administrators.
Clinicians, teams, divisions, and other groups collect the datathey need to carry out their work, and they may do so usingcoding and terms that others can understand and share. Theintensive care unit in this example integrated the data the teamneeds to manage patients during their stay with patients'pre-admission prescribing data. This local epidemiology mayhave been done as part of clinical governance activities, or as anad hoc exercise when a patient's problem was investigated.
One difficulty with secondary uses of clinical data is that, having obtained the data indicating a problem exists, the issuemust be dealt with effectively. It may be that the individual orgroup who identify the problem have the knowledge, skills, andresources to resolve it. In other cases, such as these potentiallyavoidable asthma admissions, those responsible are not thosewho have uncovered the issue, and those potentially responsiblemay be unaware of the problem.
UK clinical governance definition*
Presentation of data
A framework through which NHS organisations are accountable forcontinually improving the quality of their services and safeguardinghigh standards of care by creating an environment in which Ideally, the choice of measures, analysis, and presentation of excellence in clinical care will flourish data should be determined by the purpose of measurement andthe use to which data are to be put. This poses another difficulty *From Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 1998;317:61-5 with the secondary use of clinical data. Studies have shown thatinterpretation of data is influenced by the method used tosummarise the results. Health policy makers, like doctors, tendto prefer measurements that report relative risks (or benefits) tomeasurements providing estimates of absolute risks (or Categories of improvement for health services*
benefits). Once the decision has been taken to act on data, how best to present the information should be considered.
x Patient centredness Feedback of performance data
Different approaches (using internal or external influences on *From Institute of Medicine Committee on Quality of Health Care in decision makers) can be taken when using data to improve care.
America.Crossing the quality chasm: a new health system for the 21st century. The interventions chosen should be tailored to the underlying Washington, DC: National Academy Press, 2001 problem. At least two, and preferably three, of the moreeffective approaches (see boxes on next page) should be taken.
Analysis of approaches to changing clinical practice: internal processes
Adult learning theories Intrinsic motivation of Bottom up, local consensus development Small group interactive learningProblem based learning Cognitive theories Rational information seeking Evidence based guideline development and decision making Disseminating research findings through courses, mailing, journals Health promotion, innovation Attractive product adapted to Needs assessment, adapting change and social marketing theories needs of target audience proposals to local needs Stepwise approachVarious channels for dissemination (mass media and personal) Analysis of approaches to changing clinical practice: external processes
Controlling performance by Audit and feedback Reminder systems, monitoringEconomic incentives, sanctions Social interaction Social learning and innovation Social influence of important Peer review in local networks theories, social influence and peers or role models Outreach visits, individual instruction Opinion leadersInfluencing key people in social networksPatient mediated interventions Management theories, system Creating structural and Re-engineering care process organisational conditions to Total quality management and continuous quality improvement approaches Team buildingEnhancing leadershipChanging structures, tasks Economic, power, and learning Control and pressure, external Regulations, laws Budgeting, contractingLicensing, accreditationComplaints and legal procedures Today, it is less necessary to rely on individual clinicians or teams to produce routine reports because computerised dataentry enables the routine extraction of data for many purposes.
09 11 64 02 5 0
Data from multiple sources may be linked to records, and so provide additional intelligence beyond the purposes for which they were originally collected.
The community health index number (CHNo) is a unique 10 digit number
that includes the date of birth of individuals born, or moving to, Scotland so
that their encounters with the health service can be linked

Deterministic or probabilistic methods can be used with similarsuccess rates to link records. In the former case, a uniquepatient identifier, such as a 10 digit community health index number, is applied to all personal health data—for example, laboratory test requests and prescriptions. In the latter case,algorithms determine the likelihood that two items of databelong to the same person. The Soundex system converts aname to a code (for example, Michael becomes M240). The firstletter is the first letter of the word, and the numbers representphonetic parts of latter syllables. The algorithm determines that John Smyth and John Smythe is the same child with asthma if sufficient other characteristics (date of birth, street name) on the admission data and community prescriptions match. Afterlinkage, each individual item of data may then be linked andanonymised for disease surveillance purposes.
The main provisions of the 1998 Data Protection Act wereimplemented on 1 March 2000. This act builds on the earlier The community health index number (CHNo) allows the fragmented
1984 Data Protection Act. It is the means whereby the United episodes of care experienced by individuals to be integrated into the
Kingdom enforces the 1995 European directive on data completed jigsaw of an electronic health record
protection. It aims to ensure that the processing (obtaining, Principles of good practice in the 1998 Data Protection Act
recording, holding, doing calculations on) of information usingdata is done in accordance with the rights of individuals. The Data are:
European directive also extends the legislation to manual, as x Fairly and lawfully processed x Processed for limited purposes well as computerised, records containing personal information.
x Adequate, relevant, and not excessive Under the provisions of the act, data controllers (for example, general practitioners) are responsible for ensuring that access to x Not kept longer than necessary patient data should be under strictly controlled conditions and, x Processed in accordance with the rights of the subject of the data if necessary, with patients' consent.
Eight principles of good practice are in the act. Patients x Not transferred to countries without adequate protection should be aware, at least in broad terms, of the purposes forwhich their personal data are used. However, it is the view of thedata protection registrar that consent should normally be Dame FIONA Caldicott's principles of data processing*
obtained when processing data about a patient's health. Many x Formal justification of purpose
Caldicott guardians believe that the activities of the NHS are x Information transferred only when absolutely necessary
often in the public interest, and in most cases the consent of the x Only the minimum required
patient can be inferred. Other bodies, such as the General x Need to know access controls
Medical Council and the BMA, advise that explicit consent is x All to understand their responsibilities
x Comply with and understand the law
still preferable in some cases, and examples include:x Release of details of patients to diabetic and cancer registers Release of summaries of patient date to out of hours services.
The 2000 Freedom of Information Act came into force in Approaches identified by the Nuffield Trust to deal with the
January 2005. It is intended to "promote a culture of openness conflict between the the Freedom of Information Act and
and accountability amongst public sector bodies by providing data protection legislation
people with rights of access to the information held by them." Itwill probably conflict with data protection legislation because x Use personal data with consent or other assent from the subjects of information about individuals is contextualised within families, x Anonymise the data, then use them communities, practices, and hospital units. It will be difficult to x Use personal data without explicit consent, under a public interest ensure that an individual's data are protected while giving freedom of information to others within that context.
Feedback of information
Key issues in data feedback to improve quality*
x Data must be perceived by clinicians as valid to motivate change In many medical cultures it is difficult to provide feedback that x It takes time to develop the credibility of data will be taken in a constructive manner. Certain principles make x The source and timeliness of data are critical to perceived validity it more likely that the feedback will be considered constructive x Benchmarking improves the meaningfulness of data feedback by recipients, and changes that could improve care will x Opinion leaders can enhance the effectiveness of data feedback probably be implemented.
x Data feedback that profiles an individual clinician's practices can be effective but may be perceived as punitive x Data feedback must persist to sustain improved performance *Bradley EH, Holmboe ES, Mattera JA, Roumanis SA, Radford MJ, Krumholz HM. Data feedback efforts in quality improvement: lessons learned from US Confidentiality and security of data is probably a greater hospitals. Qual Safety Health Care 2004;13:26-31 concern for researchers than clinicians, although clinicalresearchers need to live with concept of governance in bothworlds. Data collected for patient care may only be used to produce research evidence with adequate safeguards for the x Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, patients. Legislation varies between countries, but the highest Vale L, et al. Effectiveness and efficiency of guideline dissemination standards apply to use of personally identifiable data, where and implementation strategies. Health Technol Assess 2004;8:1-72 x NHS Health Technology Assessment Programme. Effectiveness and explicit signed, informed consent is often required. Some efficiency of guideline dissemination and implementation jurisdictions relax this standard if it is impossible, or extremely strategies: (accessed 4 difficult, to obtain the consent. In other countries acceptable anonymisation and adherence to rules of good epidemiological x Fahey T, Griffiths S, Peters TJ. Evidence based purchasing: practice allow the use of clinical data for research purposes.
understanding results of clinical trials and systematic reviews. BMJ1995;311:1056-9 x Lowrence WW. "Learning from experience." Privacy and the secondary uses of data. London: The Nuffield Trust, 2002 x Berwick DM. Errors today and errors tomorrow. N Engl J Med A public health consultant faced with complex, difficult choices, such as the data on asthma prescribing, will prefer to discuss thereasons for apparent prescribing failures rather than taking Frank Sullivan is NHS Tayside professor of research and development pre-emptive action, which may do harm to the service overall.
in general practice and primary care, and Jeremy C Wyatt is professor The factors that caused the presenting problem are often of health informatics, University of Dundee.
rooted in the culture of the health system, and so the solution The series will be published as a book by Blackwell Publishing in often means changing the system. The consequences of failing spring 2006.
to act when there is a problem need to be counterbalanced Competing interests: None declared.
against the damage caused by incorrect interpretation of datacollected for one purpose but used for another.
likely to be promoted may in part reflect this.
duced that have altered the career structures of hospi- Investigating this point would require complete data tal doctors. These include the Calman reforms, on employment history since graduation. The data will Modernising Medical Careers, further proposals for also include doctors in the training grades who may reform of the staff or associate specialist grades, and not want to become a consultant, and the results may new contracts for junior doctors and consultants. It is be partly reflecting the preferences of this group, who unclear what impact these changes will have on the are more likely to be female and work part time. How- issues discussed in this paper.
ever, this group is likely to be small.
Contributors: see Funding: The Health Economics Research Unit is funded by the The achievement of current government targets for Chief Scientist Office (CSO) of the Scottish Executive Health the numbers of consultants are influenced by the pro- Department. AS was funded through the Chief Scientist Office'score funding of the Health Economics Research Unit. KM was motion process and the quality control exercised by funded by the University of Aberdeen. The data were obtained for the royal colleges. As the proportion of female doctors research funded by the Scottish Executive Health Department on increases, it will be difficult to meet government NHS labour markets in Scotland. KM is guarantor.
targets unless the promotion process is re-examined.
Competing interests: None declared.
This should focus on the weight given to individuals'skills and ability and the flexibility of contracts and Wooldridge JM. Econometric analysis of cross section and panel data. London, working conditions. Safeguards will need to be in England: MIT Press, 2002:453-509 (chapter 15).
Baltagi B. Econometric analysis of panel data. 2nd ed. Chichester: John place to ensure that factors less likely to be related to Wiley, 2001:11-27 (chapter 2).
ability or performance (such as sex, place of Lambert TW, Goldacre MJ, Vallance E, Mallick N. Characteristics ofconsultants who hold distinction awards in England and Wales: database graduation, or part time working) will not influence analysis with particular reference to sex and ethnicity. BMJ 2004;328:1347.
promotion chances. Since 2000, when the data used in (Accepted 16 September 2005) this paper finish, several changes have been intro- Corrections and clarifications
Achieving the millennium development goals for health: Cost alter the conclusions of the paper. Also, in the effectiveness analysis of strategies to combat malaria in abstract,the figures in parentheses after the median cotinine values are interquartile ranges not confidence A mix-up during submission led to the wrong version of table 3 being included in the full version of this Primary care in the United States: problems and possibilities paper (see by Chantal M Morel andcolleagues (BMJ 2005;331:1299-302, 3 Dec). The R Electronic difficulties while handling the proofs led to value for case management with chloroquine should an error and an omission in this article by Robert L be 0.35 (rather than 0.3). The adherence for Phillips (BMJ 2005;331:1400-2,10 Dec). The author's artemisinin based combination treatment should be job title was wrong; he is in fact director of the Robert 35% (not 40%), and neither that nor the adherence for Graham Center. In addition, the article should have non-artemisinin based treatment needs a footnote.
contained the following disclaimer: "The information Values for probability of success when patients were and opinions contained in research from the Graham not fully compliant should be 35% for non-artemisinin Center do not necessarily reflect the views or policy of based treatment and 0% for intermittent presumptive the American Academy of Family Physicians." treatment during pregnancy (rather than 35% and Extra scrutiny for industry funded trials 10% respectively, as given). These revised values alsoapply to table B on
The title of this editorial by Kenneth J Rothman andStephen Evans (BMJ 2005;331:1350-1, 10 Dec) should ABC of health informatics: Improving services with have referred to "studies," not "trials." The authors informatics tools discussed all reports containing original data, so The authors of this ABC article, Frank Sullivan and "studies" would have been more accurate. The use of Jeremy C Wyatt (BMJ 2005;331:1190-2, 19 Nov), the word "trials" was the result of a late editorial inadvertently omitted an acknowledgment from the two tables at the top of p 1191 containing information Treatment of bites by adders and exotic venomous snakes on the analysis of approaches to changing clinicalpractice: internal and external processes. They were In this Clinical Review by David A Warrell, the author's first published by Grol R. BMJ 1997;315:418-21.
email address was wrong (BMJ 2005;331:1244-7, 26Nov). The correct address is Legislation for smoke-free workplaces and health of bar workers in Ireland: before and after study Two errors occurred in this paper by Shane Allwright Randomised placebo controlled multicentre trial to assess and colleagues (BMJ 2005;331:1117-20, 12 Nov). The short term clarithromycin for patients with stable coronary model coefficients for cotinine concentrations in table heart disease: CLARICOR trial 5 in the full version of this paper (see were The main text and the summary box in this paper by wrong because they had not been corrected to take Christian M Jespersen and colleagues (BMJ account of the conversion to SI units in table 6. The 2006;332:22-4, 7 Jan) refer to the patients in the trial corrected table is at (http:// being followed for up to three years. The authors have clarified that the mean follow-up was 960 (range 1117/DC1). The authors state that the revisions do not 900-1070) days.



SULLA TESTA.UN MONDO DA SCOPRIRE di Sujan Singh Non mi ero mai chiesto cosa spingesse diversi insegnanti, e non solo, ad indossare un turbante. Prima di avvicinarmi alla pratica dello Yoga pensavo si trattasse di un vezzo o di un segno distintivo, e non avevo mai sentito l'interesse ad osservare, oltre i limiti della mia superficialità, questo aspetto così particolare.fino a che non è stata la pratica stessa, spontaneamente, a suscitare in me un interesse sincero e quindi più profondo.

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