Expertise and Empowerment: the Essential Prerequisites to Effectiveness in Health Information

Michael Rigby

Introduction

In the drive to modernise information management and information handling in the health sector, focus is nearly always placed on the technologies and on the conceptual issues such as coding and language. However, without competent and thus confident users, this important investment in modern information systems is at best unlikely to achieve its full potential, and at worst may lead to deterioration of service. This paper outlines the issues and reports on initiatives to address the different end user competency requirements.

Background

It is a truism that healthcare is one of the most information-intensive industries, and this information dependence continues to increase exponentially. This can be attributed to a number of interlinking factors:

• Population involvement. Every citizen is a subject and has an increasing number of concurrent health records with increasing specialist referral and consultation.
• Patient individuality. Every citizen involved in receiving healthcare, whether preventive or therapeutic, has a different personal history, and therefore, delivery of appropriate care and treatment is heavily dependent upon effective accessing of the personal health history.
• Scientific underpinning. All healthcare is based on application of science. With research progressing at a steady pace and the momentum towards evidence-based medicine, proper care requires up-to-date awareness of the latest evidence and its formulation into treatment guidelines.
• Litigation awareness. Increasingly, consumers are motivated to seek compensation for alleged poor or negligent treatment, and this increasingly drives healthcare providers to maximise not only the use of past records but also the amount of investigations undertaken.
• Increasing digitisation. Traditionally, many forms of diagnostic investigation were kept in paper files as prints of specialist types of analysis, ranging from X-ray pictures to scans and traces. Increasingly, however, these are being digitised, and therefore can stored within the integrated electronic record, which assumes ever-increasing importance and also greater volume and complexity.
• Electronic communication and networking. Until recently, health records were unique to the autonomous health organisation, which organised and maintained standalone record systems. However, modern communications paradigms enable not only electronic messaging to permit transfer of data, but enable records to be read remotely and care to be delivered remotely through telemedicine.
• Internet health sites. With the rise of the Internet, health in its broadest sense is one of the biggest subjects. Internet health sites range from professional updating sites to patient self-help groups and sites advocating alternative procedures including changing lifestyles. While on the one hand, the increasing availability of evidence and of choices is commendable, the Internet is also host for ill-informed and malicious sites too--therefore, navigating intelligently by differentiating the alternative site offerings is increasingly important.

Health professionals already have a challenging task in delivering modern and effective care to all citizens and patients presenting to them, with the pressure for clinical updating alone being significant. The advent of widespread and commonplace computing and information technologies presents a further challenge. By definition, the most experienced health professionals have been in post 20 or more years, and thus were educated both in their schooling and in their basic professional education in the era of paper-based information sources and recording. The enforced move to electronic communications and records can be daunting. System training may be provided, but this is significantly less than the required installation of knowledge, understanding, and application skills in the new information paradigms. Without this high degree of skill development, end-users will not be competent in using the technologies. This not only means they will use them suboptimally, but the quality of care they deliver may deteriorate as they struggle to record or retrieve information using the new technologies. In this area, as with any other technologically area, competence and confidence go hand in hand.

Approach

This paper differentiates the three types of user of health information systems, differentiates their information skills and knowledge requirements, and reports initiatives to meet these requirements. From these examples may be identified approaches which may be used universally in generic form, and indeed there may be opportunity for international collaboration to share frameworks while customising to local situations.

Three Types of Health Informatics System Users

Figure 1 indicates three types of health system users. From this it will be seen that these can be summarised as health informaticians, healthcare end-users, and patients and citizens. Their needs are significantly different, and the effort put into structuring their education and training historically has been different.

Figure 1. Types of Health Informatics System Users

Health Informatics Staff

Staff working in health informatics, whether employed by healthcare providers or by system and service providers, need not only technical competence in their area of information and communication technologies, but also a sound awareness of the health sector and its issues, and of the needs and responsibilities of healthcare providers. They are the smallest group in numbers, but have significance to the whole of modern healthcare.

End-users

Health professionals, and other staff in healthcare including global support and reception staff, are the principal users of health information systems. However, unlike the end-users of most other systems, such as financial applications, use of the system is only part of their duties and therefore does not feature as focally as it ought in their professional education.

Patients and Citizens

There are two drivers increasing the citizen use of health information systems. One is the increasing amount of record sharing with patients, not least the disclosure of records that is a legal requirement in many countries, through to patients entering or updating observations and readings in a dedicated part of their record. Secondly, with the use of the Internet as a source of health information including information on alternative treatment modalities, the citizen needs some guidance on navigating the multiplicity of sites available. They comprise the whole population, but are only involved indirectly in the majority of health informatics interactions.

These three requirements areas are distinct and different. Figure 1 shows one area of overlap, which exists where some health professionals express an interest or have a responsibility for aspects of informatics systems--for instance, the primary care physician supervising the local application or the senior nurse ensuring that the whole nursing team is competent in using a specialist application. Conversely, informatics support staff dedicated to working in a specific application area need to have an insight into the end-user's objectives and priorities. Second, patients may ask health professionals for advice in obtaining information from the Internet or may attend the physician armed with information they have already obtained. Clearly, it is important in these circumstances for health professionals to know how to navigate the Internet and appraise sites and their contents.

Apart from this one area of direct overlap, however, these three competence requirements are quite distinct, and to confuse them or treat them as homogenous is inappropriate. While overall awareness of the three dimensions is important for any health staff, competence in each needs to be much deeper and more dedicated in specific competencies according to role. The remainder of this paper will examine these three domains, the types of knowledge and skill needed, and examples of initiatives taken to address each.

Competencies of Health Informaticians

The NHS in England has recognised that health informaticians are key to a modern and effective health service, and they require their own career-orientated skills ladder with explicit levels of understanding and competence related to role and to seniority. It is also important for such staff, as well as for the reassurance and safety of patients, that these skills are recognised and individuals receive recognition of their proven competency. While academic programmes in health informatics are important, alone they do not provide a guarantee that workplace operational requirements are covered and achieved.

The National Health Service in England has moved to meet this need. It has developed the Professional Awards in Information Management and Technology (Health), based on a defined set of Learning Outcomes. 1   There are four levels for this, as shown in Figure 2.

Figure 2. The Four Levels of the Professional Awards in IM&T (Health)

Source: Rigby, Millen, Benjamin 1

The Professional Awards are based on the concept of Learning Outcomes, against which the candidate is required to demonstrate competency according to exemplar Assessment Criteria. The overview of the contents of the Awards at the four levels is shown in Figure 3.

Figure 3. Overview of the Contents of the Professional Awards in IM&T (Health)

Source: Rigby, Millen, Benjamin¹

The National Health Service Information Authority has established a dedicated Health Informatics Qualifications Management Board to promote and manage the Awards, including the registration of candidates and of successful persons who demonstrate competency and are thus submitted to the Register. At the same time, the HIQMB is successfully promoting partnerships with higher education institutions, whereby academic educational programmes whose curriculum and assessments map successfully to the Learning Outcome requirements of one or more Professional Awards have their programmes recognised as leading to proof of professional competence as well as of academic attainment. Currently, nine academic institutions in England are offering the Awards on this basis, with others in the submission and recognition process. Discussions are also commencing with a view to making the qualification one that is mutually recognised across member states within the European Union, as well as seeking mutual academic recognition.

The whole purpose of this programme is to ensure that the professionals who are essential to ensuring effective health informatics support to healthcare professionals and organisations themselves have a recognised and stable education and competency-based career pathway. Moreover, this is firmly within the objectives of good information governance, as it provides reassurance both to the health professionals and to the patients, who are equally totally dependent upon the electronic information systems, that these are being soundly managed.

Competencies of Health Professional and Other End Users

The education and training needs of those who use automated information systems in their daily practice--doctors, nurses, other health professionals, information staff, receptionists, and others--are totally different. They do not need to know how to implement or run modern electronic systems. However, they do need to know how to use them, and the skills required are significantly different from those required to operate paper systems. Information recording, information retrieval, and the more structured format of record entries and messages in electronic records can all be major challenges as well as having their beneficial side. It is far from unusual for staff who would have written updating notes in the paper record, when faced with a computerised record system not to update it regularly, but instead to make notes on informal sheets of paper kept in coat pockets because they feel uncomfortable with the electronic record. They then distil a personal summary for their successors when they change shifts or hand over care, updating the computer only then. Training in using a particular application, important though this is, is alone inadequate as it fails to address this changed paradigm in information handling.

An initiative has commenced to try to redress this deficit. There has been pioneered in Europe a generic computer user qualification, now known as the European Computer Driving Licence.²  This is entirely system- and domain-independent, and deals solely with how to use a computer, use word processing packages, spreadsheets, and the like and to understand the basic principles of good information management. It has been so successful that it is now used all over the world, in a version known as the International Computer Driving Licence (ICDL).

The National Health Service in England has seen the major value of a recognised qualification in competence as a computer user. It has therefore embarked on an ambitious programme to provide ready access to this Licence, with a dedicated portal for registering interest, and undertaking the assessment online.³  This has become one of the largest organisational education and training programmes using the ECDL, with a budget of £15 million ($27.5 million) over five years. The target is for this to achieve 450,000 completions (one third of the NHS staff). So far 11,500 staff have achieved this--two-thirds in the last year.

However, health data are significantly different for a number of reasons, as is the way they are handled in paper or electronic form. Moreover, health professional users of health informatics systems as tools in their daily practice are very different from staff employed to use modern information systems in other sectors. A proposal has therefore been developed to produce a health domain supplement to this, to give further understanding and confidence to those who are end users of electronic information systems in health,⁴ drawing on an initial airing at a European electronic health records conference.⁵ It has now been published in the health informatics literature.⁶

This has been based on an analysis of the special characteristics of health professional end users of systems, as reproduced in Figure 4. The idea was then reported to an international meeting of the Education Working Group of the International Medical Informatics Association in 2003, where considerable interest was stimulated. Subsequently, discussions have been held with opinion leaders in health informatics in nine European countries at an invitational workshop, as a result of which a proposal is now with the European Computer Driving Licence Foundation (the governing body of the qualification) at their invitation.

Figure 4. Characteristics of System End Users

Source: Rigby 4

Figure 5 highlights the type of topics that might possibly be included in this, though further work and consultation remains to be undertaken before final conclusion. A significant guideline was developed in the international consultations as being "if it is done differently electronically then it should be included; otherwise it has been previously covered as part of basic professional education."

Figure 5. Illustrative Contents of Proposed ECDL/ICDL Health Supplement

Source: Rigby 4

In summary, this is arguably an important development to ensure that health professionals are confident and thus competent in using the equipment supplied to them (probably not by their choice) to enable them to undertake their core professional duties. Whilst there have been expressions of interest from around the globe, through ECDL/ICDL channels as well as through health channels, translating this into an agreed qualification is a large challenge. Therefore nevertheless, it is hoped that the process has been commenced.

Competencies of Patients and Citizens

As health information systems grow, and in particular the Internet, so many citizens can and will want to avail themselves of the opportunities. On the one hand, this may come from patients asking for sight of their electronically stored health records. This may be taken a stage further with their being involved in entering information into a dedicated part of the record that collects observations and readings they obtain, or records their views and experiences. It is an exciting and constructive form of inclusion, as shown by innovative applications.⁷ While these opportunities are limited, the interaction of patients can be directed, but if this approach becomes more widespread, there will need to be ready consideration of educating the patient and citizen, including the very important issues of promoting the interests of those who are disadvantaged either economically or through compromised mental competence (young children, the mentally ill, the confused elderly) who run the significant risk of being excluded by default.

Second, there is the issue of the Internet and the confusion of health advice that can be found on it. On the positive side, the Internet can provide citizens with important health advice, ranging from treatment options, alternative patterns or styles of treatment, or access to opinions not available in their own immediate locality. Patient self-help groups and experiences of fellow users, often expressed through health condition interest groups, are particularly rich and important. However, on the negative side there are a number of ill-informed or even malicious sites. These have been described in the literature,⁸ and include sites that market unproven or indeed dangerous remedies, those which are provided by persons falsifying their alleged qualifications, and those that are scams seeking to obtain money or credit card details. Many citizens are using the Internet to obtain good health advice, frequently to good effect to reduce the knowledge imbalance between patient and clinician so that a more informed dialogue on treatment options or drug choices can be carried out. But without better guidance made available without inherent bias, patients and citizens are currently left wandering in a wilderness. The most informed will find the best answers, the least informed are the most vulnerable to being mislead.

The need for some form of certification of sites to validate their integrity, and indeed a proposal to undertake a detailed feasibility study has been provisionally agreed by the Health and Consumer Protection Directorate General of the European Commission, if the balance of funding can be found. Second, there are some important initiatives to develop support for the citizen, of which one strong example is the "Informed Patient" project.⁹ Being more open and inclusive in advising patients and citizens on how to use the Internet, share records, and in other ways to benefit directly from e-Health, is much overdue. The World Health Organisation's Declaration of Alma Ata emphasised the importance of primary care, and of personal and societal responsibility for health--it is important to ensure that the electronic revolution in health does not further disempower the citizen.

Conclusion

In the inexorable move towards e-health applications, the issue of efficient and effective use is often overlooked by the enthusiasts (and sometimes idealists) who propose them. Implementation training is usually limited and restricted to operational functions. When educational preparation is considered, it is usually naively assumed that there is one homogenous issue in the health domain, and that this is not significantly different from the situation in other domains. All these premises are false. As shown in this paper, health informatics staff, professional end users, and citizen users have quite different requirements, and the first two will benefit from structured formal qualifications appropriate to their role. Moves have been outlined to develop such programmes, and stronger international recognition of the importance of these, bedded into the local culture and health economies, is essential to ensuring efficiency, effectiveness, and safety of health informatics applications. Health records staff, moving on from their historic role of librarians for paper records systems, should apply their expertise and their trusted intermediary role and become active leaders promoting and applying these developments.

Endnotes

1. Rigby M, Millen D, Benjamin D. Creating a Structured Progressive Qualifications Path in Applied Health Informatics; in Proceedings of Teach Globally, Learn Locally: Innovations in Health and Biomedical Informatics Education in the 21st Century - International Medical Informatics Association Working Group on Education Conference, Portland, Oregon USA, April 23-25, 2003; CD ROM, Oregon Health and Science University, Portland, Oregon, 2003.
2. www.ecdl.com/main/index.php
3. www.ecdl.nhs.uk
4. Rigby M. Protecting the Patient by Ensuring End-User Competence in Health Informatics Systems - Moves Towards A Generic Health Computer User "Driving Licence"; in Proceedings of Teach Globally, Learn Locally: Innovations in Health and Biomedical Informatics Education in the 21st Century - International Medical Informatics Association Working Group on Education Conference, Portland, Oregon USA, April 23-25, 2003; CD ROM, Oregon Health and Science University, Portland, Oregon, 2003.
5. Rigby M, Draper R, Sheridan A. Confidentiality, Competence, and Confidence - Ensuring Ethics whilst Recognising Reality; in Proceedings, EuroRec '99 Third European Conference on Electronic Health Care Records, 6-7 de Mayo 1999, Sevilla, España; Sadiel, Sevilla, 1999, 122-126.
6. Rigby M. Protecting the Patient by Promoting End-user Competence in Health Informatics Systems - Moves towards a Generic Health Computer User "Driving License"; International Journal of Medical Informatics, 73, 151-156, 2004.
7. van der Linden H, Boers G, Tange H, Talmon J. Hasman A, PropeR: a multi disciplinary EPR System ; International Journal of Medical Informatics, Jul 2003.
8. Rigby M, Forsström J, Roberts R, Wyatt J. Verifying Quality and Safety in Health Informatics Services; British Medical Journal, 323, 7312, 552-556, 2001.
9. Detmer DE, Singleton PE, MacLeod A, Wait S, Taylor M, and Ridgwell J. The Informed Patient: Study Report; Cambridge, Judge Institute of Management, 2003.

About the Author

Michael Rigby's first career was in the English National Health Service, progressing over 20 years from a Policy Researcher for Cheshire County Council Health Department through various planning and information posts to become Regional Service Planning Officer for the then Mersey Regional Health Authority, serving 2.5 million population. His subsequent academic career at the Centre for Health Planning and Management has progressed from Lecturer through Senior Lecturer to Reader. In this time he has undertaken a number of national and international projects focused on health information and its related issues in healthcare delivery.