Health Information System Design

Chapter 6 of 11

Health Information System (HIS) has become an essential aspect of the healthcare sector. Over the years, the amount of information related to patient care has significantly increased, thanks to the advent of HIS. HIS commonly access, process, or maintain large volumes of sensitive data – security is a primary concern. Everyone associated with healthcare – patients, clinicians and public health officials can use HIS. The system enables data collection and compilation geared towards making meaningful healthcare decisions. HIS, however, cannot be effective without well thought out design, aimed at a refined implementation that meets user needs.

6.1. DEFINITION

HIS design is an organized structure of HIS management that aims to ensure the proper use of resources and enable information processes to produce high-quality information. HIS focuses on formulating the right mixture of inputs that can produce the correct type of outputs. HIS design can only generate relevant and adequate information if the essential components of the information process have been adequately designed.

6.2. PURPOSE

The primary purpose of a HIS design is to match HIS processes with the health services system. HIS should provide sufficient information support to the decision-making processes at all levels of health services. Designing a usable and efficient information process is necessary to make HIS a useful management tool that is compatible with the overall management structure of the health services system. Other reasons for having a HIS design include:

  • Improving the relevance of the health information gathered
  • Increasing the quality of recorded data
  • Avoid duplication and waste among parallel HISs
  • Improving the timeliness of reporting and feedback
  • Permitting the development of the necessary information for rational decision making at each level of the health services system

6.3. HISTORY

The inefficient and chaotic nature of most traditional HISs was due to the structural weaknesses and lack of integration at almost all levels of the information system. These inadequacies can be traced back to the unexpected use of HIS in the integrated management support of the health services. Before 1985, most management information systems were focused on the use of computer technology. These organizations only used information systems to address the need for recording admission and discharge, staff payroll, medical billing, medical insurance, and other related tasks.

Today, the role of HIS has evolved from a mere information handler to a crucial tool for information management. With this shift, the information system became an integral part of clinical decision-making support, information management, communication, and simulation for teaching and surgery.

However, the remarkable progress of HISs is still hindered by inadequacies in security and privacy, socio-economic differences, and access to and distribution of resources to achieve the highest good for the most considerable number of users. As a result, health information professionals are now pressured to design, develop, and implement new systems that can keep pace with the rapid development of the technology itself.

6.4. COMPONENTS

HIS design has two essential components:

6.4.1. HIS RESOURCES

HIS resources form a holistic overview of people, processes, and reports of health information most important for decision making in the health sector.

  • Persons: data collectors, planners, managers, epidemiologists, statisticians
  • Hardware: computers, registers, telephone
  • Software: data processing programs, report forms

6.4.2. ORGANIZATIONAL RULES

Organizational rules are used to ensure efficient utilization of HIS resources.

  • Diagnostic and treatment standards
  • Supply management procedures
  • Definition of staff responsibilities
  • Computer maintenance procedures

6.5. TOOLS AND TECHNIQUES
6.5.1. ORGANIZATIONAL MODEL OF HEALTH SERVICES

The organizational model of health services defines the different management functions at various concentration levels. Developers use organizational models to identify information of users from different concentration levels. The decisions these users make to define the information needs and design methods for data collection, transmission, processing procedures, and feedback reports are as follows:

6.5.2. DATA SOURCES

Information system developers use data sources to help pinpoint the exact information system design needed for a healthcare organization.  The data for an integrated information system has five different sources:

Enrollment Data: The enrollment data is the set of information generated by employers and individuals. This data identifies people who are eligible for coverage. By using the enrollment data, analysts can closely examine the performance of the current HIS. Additionally, health researchers can identify health needs and differences in treatment outcomes across population subgroups.

Administrative Data: Administrative data is the information extracted from a patient’s healthcare provider. It is used to monitor changes in the healthcare system, compare the effect of different cost-sharing arrangements on the use of medical care, monitor the use of various health services, and evaluate the relationship between hospital characteristics and hospital death rate.

Clinical Data: Medical records are the most important source of clinical data; they describe the patient’s health problems from the doctor’s perspective. Clinical data contain confidential information, which cannot be accessed without special permission. Clinical data can be used to assess the quality of care performed by healthcare providers and health plans.

Survey Data: Survey data is used to study specific issues not routinely captured in routine data collection systems. Surveys can extract useful information about person-level information and issues, improve understanding in the clinical practice guidelines, evaluate the type of services provided, identify the types of patients encountered, and survey healthcare providers’ satisfaction.

Other sources of data:

  • Birth certificates
  • Birth defect registries
  • Disease registries
  • Death certificates
  • Facility characteristics
  • Provider characteristics

6.5.3. HIS DESIGN PRINCIPLES AND GUIDELINES

HIS design principles are the result of the integration of ethical and professional guidelines for both the medical and computing professions. On the other hand, the guidelines for HIS have three important dimensions:

  • General moral principles
  • Technical responsibilities for HIS design
  • Responsibilities for HIS designers

These principles serve as the cornerstone for the development of advanced directives decision support system (ADDSS). ADDSS, in turn, refines and tests these guidelines through an iterative and collaborative development process. The result of this process is the set of design principles that guides HIS developers in creating unique and complex information systems tailored to the needs of different healthcare organizations.

6.6. BEST PRACTICES

Start every HIS design development with the definition of indicators based on a health services system and the management function within each of these services.

The ideal outcome of HIS redesigning is to ensure better information support for the different levels of the health services system. To ensure adequate support, HIS designer should understand the structure of the health services system and the management function. By designing a support system based on a conceptually sound health system model, the designer can translate information support into appropriate indicators.

Therefore, to redesign a HIS, HIS designer must select the right indicators for the health services support, monitoring, and management. The designer must embark on a consensus-building process involving the health services managers from different levels, such as the program managers, senior executives, and district service staff.

Apply an evolutionary, problem-directed approach to uplift HIS.

HIS designer needs to assess and confirm the opportunities that can improve the collection, retrieval, and use of information. The system needs to communicate relevant health data and undertake assessments of all health information subsystems to learn the cause of different management and service issues. HIS designer can use these findings to find and prioritize information-related problems and formulate a short-term plan. The designer can extend the plan of action and include new issues, opportunities, and more components of the information system that need improvement.

Make policy a part of the full HIS assessment.

The designer must add rationality to HIS design while accommodating the diverse interests of different value systems and constituencies. The assessment of HIS should include identifying all the stakeholders in HIS reform and researching the administrative, socio-economic, and contextual political factors that are most likely to influence the outcome of such improvement.

Encourage broad participation in the process of HIS design.

HIS design team should encourage the key actors to participate in the reformation process to foster their understanding of and support for the system during its implementation. Choose the program managers and service staff needed for the selection of essential health indicators, assessment of HIS performance, and overseeing of specific functions, such as clinical diagnosis and recording.

Attempt to demonstrate useful information processes and products early in the development of HIS.

To gain support of a program managers, senior managers, and service staff, the designer must generate useful processes and products early during HIS development.

6.6.1. HIS AND USABILITY

Aside from HIS design, it is the implementation and satisfaction of users make the system whole. The first thing is to assess the usability of a system. You need to measure the effectiveness of the system. This can be achieved through:

Simple Interface

One major factor that determines the effectiveness of a HIS is its simplicity. It is important to have a system designed with a simple interface – as this reduces the chances of having physicians confused because of excessive amount of data displayed on the screen. A simple HIS is easy to understand and operate.

Natural Interface

Another factor that helps one measure how functional a HIS can be is naturalness. According to HIMSS, natural HIS interfaces should contain “screen metaphors that are familiar to everyday life, or commonly expected computer experiences for the clinician.” Such interfaces are easy to learn and operate, thus limiting the task of undergoing EHR training. Clinical workflows in a natural EHR interface are specific to the needs of clinicians.

Consistency

To reduce confusion and foster efficient workflow, there is a need for consistency in a HIS interface. All parts of the application are of the same look and feel. The data entries, as well as the terminologies are also positioned consistently. This helps providers to move effortlessly through diverse workflows.

Feedback and Forgiveness

Errors are inescapable during data entry and an efficient system should be designed with a forgiving application that can allow users to recover from errors. The system should have a feedback application that automatically notifies users about what is involved in an activity they are about performing or actions they have taken already; this helps to reduce the chances of a user taking an unplanned action. The system also tells users how long it will take to process a command, the outcome, and what to expect at any given time.

Effective Use of Language

The language used in a HIS also determines how effective clinicians can use words in practice. List and entries should be written in a simple, unambiguous language. HIS, with simple and clear language, is well-positioned to provide effective output.

Interactions

Efficient interaction in a HIS helps reduce the number of steps required to complete a task. Efficient interaction in a system is one parameter that justifies its usability. Efficient interaction includes navigation options such as shortcuts to experienced users. This includes scrolling and switching between typing and clicking the mouse.

Effective Information Presentation

A HIS interface requires clear fonts and visually appealing elements to help users capture information easily. Fonts must be simple, clear, and visually appealing to meet users’ needs. High-value data or irregular values for clinical data are highlighted in certain ways that express meaning. A system may use green text or image to highlight high-value data and a red text to indicate that an element in the data is abnormal and requires urgent attention. All visuals should be clear enough to display information effectively.

Minimized Cognitive Load

Minimizing cognitive load in a HIS requires the data to be organized cohesively according to the task needing users to access several screens concurrently. HIS alert should be informative and accurate and should be used only in cases of high impact. This helps lessen HIS alert exhaustion, which poses a threat to patents safety.

To reduce cognitive load and prevent human error, a user-friendly system also does calculations for providers automatically. It can be challenging to find out if a HIS is packed with all these features. Healthcare organizations can set up industry research when finding ways to carry out all-inclusive HIS usability assessments.

Carrying out HIS Usability Assessments

Carrying out HIS usability assessment requires some key concepts to make the process successful. According to a 2018 report, Pew Charitable Trusts, AMA, and MedStar Health’s National Center for Human Factors in Healthcare pointed out several ways in which healthcare organizations can carry out HIS usability assessment correctly. They recommended that healthcare leadership considers all major tasks when planning to carry out a usability assessment.

In a bid to ensure that HIS usability assessments are representative of a healthcare organization’s end-users, Pew Charitable Trusts suggests that healthcare establishments consider the needs for its clinical workflows, environment, and any HIS integrated third-party technologies. According to Pew Charitable Trusts and its partners, to measure HIS functionality, there is a need to assess HIS usability regularly. They also recommended that healthcare organizations take note of the socio-technical environment.

These concepts will help healthcare organizations to effectively identify tangible goals and procedures for a significant HIS usability assessment. The recommended healthcare organization leadership should ensure that the test cases are re-producible and clear.

6.6.2. HIS USABILITY TESTING METHODS FOR HEALTHCARE ORGANIZATIONS

According to HIMSS, HIS usability testing can be categorized into formative and summative methods. The formative testing method consists of activities that help the developer to gain a better understanding of the user and clinical workflows, improve on the product as well as design HIS in-line with users’ needs. Summative testing is to be performed by healthcare organizations. Summative HIS usability testing activities consist of expert review, assessment of risk, and individual usability testing.

The following are operational ways in which healthcare organizations can test HIS usability (as recommended by HIMSS):

Efficiency

HIMSS recommends an expert review and individual usability testing as effective ways of measuring efficiency. Individual usability testing can be done together with an expert, intermediate, or novice end-user. End-users are prompted to finish basic tasks within HIS interface and collect data of performance in each task.

Close monitoring is needed to ensure that performance data is recorded accurately. Users can take inventory of main indicators such as time taken to complete a particular task and the number of screens that have visited to complete a task. Users should record a setting within clinical workflows, how many times the back button was used, as well as the time used to complete given instructions within HIS. Healthcare organizations can easily identify labor-intensive aspects of clinical documentation to guide workflow optimization through taking inventories of time.

Effectiveness

To test HIS usability, it is essential to measure the effectiveness of the system. One way to do this is through risk analysis exercise. This helps determine the system’s capability in avoiding errors during clinical tasks. The Failure Modes and Effects Analysis (FMEA) is a risk management tool that detects and measures the effect of potential failures in a process can be used in analyzing possible failure in three ways:

  • Occurrence: determining the cause of failure and frequency which they can occur
  • Severity: measures the impact failure on the patent or end-user
  • Detection: measures the possibility of the system to detect the failure

With topological risk analysis, users can identify risk components, single-point failures, and common mode failures. A wrong prescription of a drug to an allergic patient, since drug allergy data did not display on the ordering screen, would be a single-point failure. On the other hand, a safety incident where several actions by the clinician come from a single cause is considered a common-mode failure.

Individual usability testing is another good way of measuring effectiveness. This requires experts or users to record the number of errors, the path that is taken to complete a task, the gravity of the mistakes, as well as the number of requests for help to measure effectiveness during usability testing.

Naturalness and Consistency

Testing the usability of a HIS also requires measuring the consistency of the system. Healthcare organizations can ask users to carry out individual usability testing via several key metrics to measure consistency. Then, a healthcare organization can measure how long it took users to attain expert performance, the number of icons users can remember, as well as the time spent carrying out manual processes. Comparing the differences in completion time among novice and experienced users can be used by healthcare organizations to measure how acquaintance with a system contributes to successful use.

Cognitive Load

Measuring cognitive load is also a good way of testing HIS usability. Though this could be a challenging process, healthcare organizations can rely on cognitive psychologists to help in administering assessments of cognitive load.

ONC (Office of the National Coordinator for Health Information Technology) suggests that the NASA Task Load Index can be utilized to assess cognitive load. As reported by ONC officials, “The NASA Task Load Index (TLX) is a workload assessment tool that allows users to assess task load or burden based on the mental demand, physical demand, temporal demand, performance effort, and frustration of the human,”

User satisfaction

A system cannot be efficient when users are not satisfied. To test users’ satisfaction, healthcare organizations can ask users to complete tasks within HIS and rate the ease and quality of their experience based on a point scale after the exercise. HIS usability is essential to evaluate clinical productivity, provider satisfaction, and patient safety. Herewith, healthcare organizations can understand how the system is working and to determine if the system fits within their specific clinical environment.

6.7. OUTCOMES

HIS plays an increasingly important role in the improvement of coverage and quality of health services in the United States. National healthcare has shifted from curative to preventive, inpatient to outpatient, and community to the public. This created a need to redesign the fragmented HISs into an integrated and comprehensive health and management of the HIS. Restructuring a HIS is now an important trend in the entire healthcare sector and is strengthening the information system to a learning process.

HIS professionals and healthcare providers are continuously working to help better our understanding of the role and design of HIS in improving the quality of healthcare services. With the growing needs of the continuously evolving global environment, the present condition of the traditional institution based HIS design needs to catch up to deal with global “trans-institutional” demand for a stable and highly reliable HIS.

HIS redesigning approach can help designers and developers address the weaknesses found in the existing HISs. It will also address different information needs of health services at different operational and strategic planning levels, including healthcare providers.

By reinventing the wheel of the traditional HIS, designers can develop an information system that supports the health services system in its entirety, rather than fragmented systems with different disease-oriented vertical programs.  By using HIS development as a strategy to improve the healthcare organization’s management environment, HIS designers and developers can match the information system with the planned or existing health service system more imperative.  By improving the quality and specification of HIS design, a globally integrated and interoperable “trans-institutional” HIS can be achieved.

6.8. CITATIONS

  1. Lippeveld, T., Sauerborn, R., & Bodart, C. (2000).  Design and implementation of health information systems.  Boston:  John Snow.
  2. Ibid.
  3. Ibid.
  4. Chaulagai, C.N., Moyo, C.M., Koot, J., Moyo, H.B., Sambakunsi, T.C., Khunga, F.M., & Naphini, P.D. (2005, November).  Design and implementation of a health management information system in Malawi:  issues, innovations and results.  Health Policy and Planning.
  5. Ibid.
  6. Op. Cit.  Lippeveld, Sauerborn, & Bodart
  7. Ibid.
  8. McGlynn, E.A., Damberg, C.L., Kerr, E.A., & Brook, R.H. (1998).  Health information systems: design issues and analytic applications.  Santa Monica, CA:  RAND Corporation, 1998.  https://www.rand.org/pubs/monograph_reports/MR967.html
  9. Richardson, S. M. (2006). Healthcare Information Systems: Design, Theory, Principles, and Applications (Doctoral dissertation, University of Central Florida).  Retrieved from https://stars.library.ucf.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1885&context=etd
  10. Op. Cit.  Lippeveld, Sauerborn, & Bodart
  11. Op. Cit.  Chaulagai, et al.
  12. Haux, R. (2006). Health information systems — past, present, future.  International Journal of Medical Informatics, 268-281.
  13. Ibid.
  14. Op. Cit.  Lippeveld, Sauerborn, & Bodart