Despite enormous investment world-wide in computerized health information systems their overall benefits and costs have rarely been fully assessed. A major new initiative in South Africa provides the opportunity to evaluate the introduction of information technology from a global perspective and assess its impact on public health. The Northern Province is implementing a comprehensive integrated hospital information system (HIS) in all of its 42 hospitals. These include two mental health institutions, eight regional hospitals (two acting as a tertiary complex with teaching responsibilities) and 32 district hospitals. The overall goal of the HIS is to improve the efficiency and effectiveness of health (and welfare) services through the creation and use of information, for clinical, administrative and monitoring purposes. This multi-site implementation is being undertaken as a single project at a cost of R130 million (which represents 2.5 per cent of the health and welfare budget on an annual basis). The implementation process commenced on 1 September 1998 with the introduction of the system into Mankweng Hospital as the pilot site and is to be completed in the year 2001. An evaluation programme has been designed to maximize the likelihood of success of the implementation phase (formative evaluation) as well as providing an overall assessment of its benefits and costs (summative evaluation). The evaluation was designed as a form of health technology assessment; the system will have to prove its worth (in terms of cost-effectiveness) relative to other interventions. This is more extensive than the traditional form of technical assessment of hardware and software functionality, and moves into assessing the day-to-day utility of the system, the clinical and managerial environment in which it is situated (humanware), and ultimately its effects on the quality of patient care and public health. In keeping with new South African legislation the evaluation process sought to involve as many stakeholders as possible at the same time as creating a methodologically rigorous study that lived within realistic resource limits. The design chosen for the summative assessment was a randomized controlled trial (RCT) in which 24 district hospitals will receive the HIS either early or late. This is the first attempt to carry out an RCT evaluation of a multi-site implementation of an HIS in the world. Within this design the evaluation will utilize a range of qualitative and quantitative techniques over varying time scales, each addressing specific aims of the evaluation programme. In addition, it will attempt to provide an overview of the general impact on people and organizations of introducing high-technology solutions into a relatively unprepared environment. The study should help to stimulate an evaluation culture in the health and welfare services in the Northern Province as well as building the capacity to undertake such evaluations in the future.

Computers↗

PubMed1998

Opportunities for and challenges of computerisation.

Information technology offers many potential advantages over paper for the storage and retrieval of patients' data. Enthusiasts predict that soon all records will be stored and viewed on computer, but others are more sceptical. The failure of some computer-based records may be due to poor information design. This paper explores how computers broaden the range of design options but points out that more attention to design is required for computer-based than for paper-based records.

Attitude to Computers↗

PubMed1998

How to limit clinical errors in interpretation of data.

We all assume that we can understand and correctly interpret what we read. However, interpretation is a collection of subtle processes that are easily influenced by poor presentation or wording of information. This article examines how evidence-based principles of information design can be applied to medical records to enhance clinical understanding and accuracy in interpretation of the detailed data that they contain.

Attention↗

PubMed1998

Helping clinicians to find data and avoid delays.

One major criticism of paper medical records is the time and effort required to find data items or to gain an overview. Computerisation does not necessarily help. To help clinicians find data faster and with less effort, everyone designing and writing in records needs to understand how and why we search records and the design features that make searching easier. This paper describes how clinicians search medical records and how to improve record design, whether on paper or computer, to help clinicians find all the data they need without delay.

Documentation↗

PubMed1998

Design should help use of patients' data.

Checklists and other tools help doctors to use published evidence in clinical practice. Two other important sources of evidence, however, are the patient and his or her medical record. This series aims to advance the practice of evidence-based medicine by helping in redesign of medical records, drawing on insights from psychology, information design, and medical informatics; and by promoting changes analogous to those occurring in the medical literature. The four papers look at: the uses of medical records and importance of organising them so doctors can use the data they contain; different methods doctors use to search for data and how design of records can help or hinder these approaches; how we interpret data once found, and how record formatting assists this process; and the issues raised by computerisation of records.

Evidence-Based Medicine↗

PubMed1998

The origin, content, and workload of e-mail consultations.

CONTEXT: Despite the common use of e-mail, little beyond anecdote or impressions has been published on patient-clinician e-mail consultation. OBJECTIVE: To report our experiences with free-of-charge e-mail consultations. DESIGN: Retrospective review of all e-mail consultation requests received between November 1, 1995, and June 31, 1998. SETTING AND PARTICIPANTS: Consecutive e-mail consultation requests sent to the Division of Pediatric Gastroenterology at the Children's Medical Center of the University of Virginia in Charlottesville. MAIN OUTCOME MEASURES: Number of consultation requests per month, time required to respond, who initiated the request and their geographic origin, and the kind of information requested in the consultation. RESULTS: During the 33-month period studied, we received 1239 requests, an average (SD) of 37.6 (15.9) each month. A total of 1001 consultation requests (81%) were initiated by parents, relatives, or guardians, 126 (10%) by physicians, and 112 (9%) by other health care professionals. Consultation requests were received from 39 states and 37 other countries. In 855 requests (69%), there was a specific question about the cause of a particular child's symptoms, diagnostic tests, and/or therapeutic interventions. In 112 (9%), the requester sought a second opinion about diagnosis or treatment for a particular child, and 272 consultations (22%) requested general information concerning a disorder, treatment, or medication without reference to a particular child. A total of 1078 requests (87%) were answered within 48 hours of the initial request. On average, reading and responding to each e-mail took slightly less than 4 minutes. CONCLUSION: E-mail provides a means for parents, guardians, and health care professionals to obtain patient and disease-specific information from selected medical consultants in a timely manner.

Communication↗

PubMed1998

Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units.

OBJECTIVE: To evaluate the effectiveness of an educational visit to help obstetricians and midwives select and use evidence from a Cochrane database containing 600 systematic reviews. DESIGN: Randomised single blind controlled trial with obstetric units allocated to an educational visit or control group. SETTING: 25 of the 26 district general obstetric units in two former NHS regions. SUBJECTS: The senior obstetrician and midwife from each intervention unit participated in educational visits. Clinical practices of all staff were assessed in 4508 pregnancies. INTERVENTION: Single informal educational visit by a respected obstetrician including discussion of evidence based obstetrics, guidance on implementation, and donation of Cochrane database and other materials. MAIN OUTCOME MEASURES: Rates of perineal suturing with polyglycolic acid, ventouse delivery, prophylactic antibiotics in caesarean section, and steroids in preterm delivery, before and 9 months after visits, and concordance of guidelines with review evidence for same marker practices before and after visits. RESULTS: Rates varied greatly, but the overall baseline mean of 43% (986/2312) increased to 54% (1189/2196) 9 months later. Rates of ventouse delivery increased significantly in intervention units but not in control units; there was no difference between the two types of units in uptake of other practices. Pooling rates from all 25 units, use of antibiotics in caesarean section and use of polyglycolic acid sutures increased significantly over the period, but use of steroids in preterm delivery was unchanged. Labour ward guidelines seldom agreed with evidence at baseline; this hardly improved after visits. Educational visits cost pound860 each (at 1995 prices). CONCLUSIONS: There was considerable uptake of evidence into practice in both control and intervention units between 1994 and 1995. Our educational visits added little to this, despite the informal setting, targeting of senior staff from two disciplines, and donation of educational materials. Further work is needed to define cost effective methods to enhance the uptake of evidence from systematic reviews and to clarify leadership and roles of senior obstetric staff in implementing the evidence.

Costs and Cost Analysis↗

PubMed1998

The new NHS: commentaries on the white paper. Encouraging responsibility: different paths to accountability. Will improved clinical information help realise the new NHS?

Explore the source record for details and available documents.

Hospitals, Public↗

PubMed1998

Relation of impaired energy metabolism to apoptosis and necrosis following transient cerebral hypoxia-ischaemia.

This study investigated whether both mild and severe hypoxia-ischaemia (HI) caused significant numbers of cells to die by apoptosis in the developing brain in vivo. Newborn piglets were subjected to transient global HI and the fraction of all cells in the cingulate gyrus that were apoptotic or necrotic counted 48 h after resuscitation. The mean (S.D.) proportion of apoptotic cells was 11.9% (6.7%) (sham operated controls 4.1% (2.7%)), while 11.4% (8.4%) were necrotic (controls 0.7% (1.3%)) (P<0.05). Apoptotic and necrotic cell counts were both linearly related to the severity of impaired cerebral energy metabolism measured by magnetic resonance spectroscopy (P<0.05), as shown by: (1) the decline in the ratio of nucleotide triphosphates to the exchangeable phosphate pool during HI; (2) the fall in the ratio of phosphocreatine to inorganic phosphate 8 - 48 h after HI; and (3) an increased ratio of lactate to total creatine at both these times. Thus both apoptosis and necrosis occurred in the cingulate gyrus after both severe and mild HI in vivo in proportion to the severity of the insult.

Animals↗

PubMed1997

Commentary: measuring quality and impact of the World Wide Web.

Explore the source record for details and available documents.

Computer Communication Networks↗

PubMed1995

Hospital information management: the need for clinical leadership.

On 12 July the Audit Commission published For Your Information, a well researched report about information and its management in acute hospitals in Britain, how and why it is failing, and steps that clinicians, managers, and the NHS should take to correct this. This article discusses why information management matters to clinicians and considers the problems identified by the Audit Commission--most of which will strike chords with doctors--and possible remedies. Finally, it describes possible routes to administer these remedies and the proposal, recently supported by the BMA Council, for a national centre for health informatics with the goals of educating and enthusing clinicians about informatics, empowering them to participate in local and national information management decisions; exploring how information can be used to improve patient care and outcomes; and evaluating clinical information systems and helping to realise their benefits.

Communication↗