Health Information Management (Australia)

BACKGROUND: Health information management (HIM) is at the core of health organisations, providing essential information. In Malawi, there is a substantial deficit of qualified personnel, specifically health information managers, who can properly manage health information in electronic and paper-based formats. The nation has no higher education institution offering an academic programme in HIM. OBJECTIVE: To investigate the need for HIM professionals in Malawi government health facilities, to determine the kinds of data managed by data users; competencies of HIM workers and challenges associated with the current HIM system...

BACKGROUND: The health and well-being of children in the first 2000 days has a lasting effect on educational achievement and long-term chronic disease in later life. However, the lack of integration between high-quality data, analytic capacity and timely health improvement initiatives means practitioners, service leaders and policymakers cannot use data effectively to plan and evaluate early intervention services and monitor high-level health outcomes. OBJECTIVE: Our exploratory study aimed to develop an in-depth understanding of the system and clinical requirements of a state-wide paediatric learning health system (LHS) that uses routinely collected data to not only identify where the inequities and variation in care are, but also to also inform service development and delivery where it is needed most...

BACKGROUND: Accurate coded diagnostic data are important for epidemiological research of stroke. OBJECTIVE: To develop, implement and evaluate an online education program for improving clinical coding of stroke. METHOD: The Australia and New Zealand Stroke Coding Working Group co-developed an education program comprising eight modules: rationale for coding of stroke; understanding stroke; management of stroke; national coding standards; coding trees; good clinical documentation; coding practices; and scenarios...

BACKGROUND: Electronic health records (EHR) are seen as a promising endeavour, in spite of policies, designs, user rights and types of health data varying across countries. In many European countries, including Austria, EHR usage has fallen short when compared to the deployment plans. OBJECTIVE: By adopting a qualitative approach, this research aimed to explore facilitators and barriers experienced by patients and physicians across the entire EHR usage process in Austria...

Background: Services data are an important source of information for policymakers and planners. In Australia, significant work has been undertaken to develop and implement collections of mental health services data. Given this level of investment, it is important that collected data are fit for purpose. Objective: This study aimed to: (1) identify existing national mandated and best endeavours collections of mental health services activity (e.g. occasions of service) and capacity (e.g. full-time equivalent staff) data in Australia; and (2) review the content of identified data collections to determine opportunities for data development...

BACKGROUND: Clinician notes are structured in a variety of ways. This research pilot tested an innovative study design and explored the impact of note formats on diagnostic accuracy and documentation review time. OBJECTIVE: To compare two formats for clinical documentation (narrative format vs. list of findings) on clinician diagnostic accuracy and documentation review time. METHOD: Participants diagnosed written clinical cases, half in narrative format, and half in list format...

BACKGROUND: Electronic medical records (EMRs) have been widely implemented in Australian hospitals. Their usability and design to support clinicians to effectively deliver and document care is essential, as is their impact on clinical workflow, safety and quality, communication, and collaboration across health systems. Perceptions of, and data about, usability of EMRs implemented in Australian hospitals are key to successful adoption. OBJECTIVE: To explore perspectives of medical and nursing clinicians on EMR usability utilising free-text data collected in a survey...

BACKGROUND: The implementation of emerging technologies has resulted in an increase of data breaches in healthcare organisations, especially during the COVID-19 pandemic. Health information and cybersecurity managers need to understand if, and to what extent, breach types and locations are associated with their organisation's business type. OBJECTIVE: To investigate if breach type and breach location are associated with business type, and if so, investigate how these factors affect information systems and protected health information in for-profit versus non-profit organisations...

BACKGROUND: Quantifying and dealing with lack of consistency in administrative databases (namely, under-coding) requires tracking patients longitudinally without compromising anonymity, which is often a challenging task. OBJECTIVE: This study aimed to (i) assess and compare different hierarchical clustering methods on the identification of individual patients in an administrative database that does not easily allow tracking of episodes from the same patient; (ii) quantify the frequency of potential under-coding; and (iii) identify factors associated with such phenomena...

OBJECTIVE: This article describes the first digital clinical information system tailored to support the operational needs of a forensic unit in Greece and to maintain its archives. METHOD: The development of our system was initiated towards the end of 2018, as a close collaboration between the Medical School of the University of Crete and the Forensic Medicine Unit of the University Hospital of Heraklion, Crete, where forensic pathologists assumed active roles during the specification and testing of the system...

BACKGROUND: Healthcare data frequently lack the specificity level needed to achieve clinical and operational objectives such as optimising bed management. Pneumonia is a disease of importance as it accounts for more bed days than any other lung disease and has a varied aetiology. The condition has a range of SNOMED CT concepts with different levels of specificity. OBJECTIVE: This study aimed to quantify the importance of the specificity of an SNOMED CT concept, against well-established predictors, for forecasting length of stay for pneumonia patients...

BACKGROUND: Medical certification of cause of death (MCCD) provides valuable data regarding disease burden in a community and for formulating health policy. Inaccurate MCCDs can significantly impair the precision of national health information. OBJECTIVE: To evaluate the accuracy of cause of death certificates prepared at two tertiary cancer care hospitals in Northern India during the study period (May 2018 to December 2020). METHOD: A retrospective observational study at two tertiary cancer care hospitals in Varanasi, India, over a period of two and a half years...

BACKGROUND: Patient online access to medical records is assumed to foster patient empowerment and advance patient-centred healthcare. Since July 2020, patients in the Netherlands have been legally entitled to electronically access their medical record in general practice. Experience from pioneering countries has shown that despite high patient interest, user rates often remain low. How to best support implementation depends on individual needs and expectations of patient populations, which are as yet unknown in the Dutch context...

BACKGROUND: Administrative data are used extensively for research purposes, but there remains limited information on the quality of these data for identifying comorbidities related to stroke. OBJECTIVE: To compare the prevalence of comorbidities of stroke identified using International Classification Diseases, Australian Modification (ICD-10-AM) or Anatomical Therapeutic Chemical codes, with those from (i) self-reported data and (ii) published studies. METHOD: The cohort included patients with stroke or transient ischaemic attack admitted to hospitals (2012-2016; Victoria and Queensland) in the Australian Stroke Clinical Registry (N = 26,111)...

BACKGROUND: The percentage of total body surface area (%TBSA) burned and burn depth provide valuable information on burn injury severity. OBJECTIVE: This study investigated the concordance between The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) codes and expert burn clinicians in assessing burn injury severity. METHOD: We conducted a retrospective population-based review of all patients who sustained a burn injury between July 1, 2009, and June 30, 2019, requiring admission into a specialist burn service across Australia and New Zealand...

BACKGROUND: The Australian hospital-acquired complication (HAC) policy was introduced to facilitate negative funding adjustments in Australian hospitals using ICD-10-AM codes. OBJECTIVE: The aim of this study was to determine the positive predictive value (PPV) of the ICD-10-AM codes in the HAC framework to detect hospital-acquired pneumonia in patients with cancer and to describe any change in PPV before and after implementation of an electronic medical record (EMR) at our centre...

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BACKGROUND: Historically, national programs for collecting stroke data in Australia required the use of multiple online tools. Clinicians were required to enter overlapping variables for the same patient in the different databases. From 2013 to 2016, the Australian Stroke Data Tool (AuSDaT) was built as an integrated data management solution. OBJECTIVE: In this article, we have described the development, implementation, and evaluation phases of establishing the AuSDaT...

BACKGROUND: Standardised terminologies and classification systems play an increasingly important role in the continuous work towards high quality patient care. Currently, a standardised terminology for nutrition care, the Nutrition Care Process (NCP) Terminology (NCPT), is being implemented across the world, with terms for four steps: Nutrition Assessment (NA), Nutrition Diagnosis (ND), Nutrition Intervention (NI) and Nutrition Monitoring and Evaluation (NME). OBJECTIVE: To explore associations between individual and contextual factors and implementation of a standardised NCPT among Swedish dietitians...

BACKGROUND: The professional identity and motivation of qualified health information managers (HIMs) is largely unexplored. OBJECTIVES: A larger study has investigated the motivators of HIMs in the construction of their professional identity and associated relationships to job satisfaction and engagement with their profession. The aims of this component of the study were to: (i) identify and analyse the characteristics of members of the profession who have different motivation profiles; (ii) obtain HIMs' perspectives on their professional identity; and (iii) measure correlation between HIMs' professional identity and different motivating factors...