The document below is being submitted by the Information Group of the
Academy of Royal Colleges (ACIG) to the Academy early in September. I
would very much appreciate comments.
Dr Jonathan Kay
Chairman, Informatics Committee, Royal College of Pathologists
...................
Clinicians and information: support for training & life long learning
14/06//2000
The problem
The importance of readily available, reliable and timely information to
a practising clinician is self-evident. The 1995 Audit Commission Report
found that a quarter of clinical time was spent handling information and
that some 15% of hospital running costs were consumed by information.
Most doctors and dentists realise that information about patients,
information for patients, and knowledge to help the clinician can be
accessed much more easily in electronic form. They may also realise that
skills in information management will lie at the core of quality
assurance, governance, audit, risk management, service development, and
lifelong learning. These skills go far beyond simple computer skills.
Information for Health properly called for greater clinical involvement
and leadership in NHS Information planning and development. This poses
two problems:
1. Lack of expertise and knowledge in the clinical community. Wheels are
re-invented and mistakes repeated. Lack of exposure to good clinical
systems means lack of knowledge of what is possible, and of the
discipline required to produce the best outcome.
2. Lack of time. The serious involvement of clinicians in projects
relevant to Information Management takes much time. Inadequate training,
curtailed because of clinical pressures, can damage the successful
implementation of even the best system.
The solution
We believe that there is an urgent need to accept and implement the
national education infrastructure outlined in 'Learning to Manage Health
Information' available at www.etd.nhs.ia.nhs.uk .The document outlines
the core elements of a generic framework for the health informatics
component of clinical education, including discussion of the needs of
both established and new healthcare professionals. Topics include:
* The importance of the medical record, and the need to be aware of its
use to provide data for audit and other secondary purposes
* Confidentiality and security
* The multi-professional record and team-working
* How information systems can support patient care
* Critical appraisal of telemedicine and telecare
* Basic computing skills
The opportunity exists for College regional advisors to liaise with
NHSIA regional offices to ensure that these training standards have
become part of each Information for Health Local Implementation
Strategy.
Junior trainees
The trainee must be exposed to best practice in relevant information and
communication areas. For most, this is at present informal and self
taught ? for example E-mail ability - while other skills may date back
to university, for example use of on-line information. Both of these
facilities may be available in hospital, but often not in the clinical
areas, and certainly with little formal training. A suggested entry
standard demonstrating basic computing skills is the so-called European
Computer Driving Licence. Appropriate courses are available in many
centres (see details at www.bcs.org.uk and www.etd.nhsia.nhs.uk). A
pilot of the qualification in 9 NHS sites in England has concluded that
this should be adopted as the basic IT skills standard for all NHS
professionals.
In hospital there is currently little scope to undertake essential R & D
on how to improve clinical information and communications, which in any
event would probably be considered non-clinical. The trainee who moves
to general practice is much more likely to be exposed to computerisation
as part of routine clinical activity. The SpR curriculum can be altered
to include information management, and a proposal is attached (Appendix
1). These measures will support and facilitate the required transition
from traditional medical practice into the new information-rich
environment. For this transition to be smooth and effective several
activities are required, from system redesign to end-user training. The
support of the Academy of Medical Royal Colleges is sought to agree and
formalise these information management training needs and build them
into training requirements.
There are now many informatics departments capable of offering training,
ranging from 'day release' level activities to MSc courses (Appendix 2).
If the Royal Colleges could write into the curriculum for trainees an
obligation or opportunity to include information management in their
'portfolio' we could ensure a stream of junior trainees equipped to deal
with the changing environment in which they will be working. They would
have the skills to help commission, tailor and evaluate systems, and the
knowledge to insist on and disseminate standards in data collection and
use. Support is sought from the Academy to promote information
management as part of a core curriculum for all trainees, and for some
to include a period of research in an information related field in their
portfolios.
Record Structure
It must be recognised that information handling problems now are usually
not technical but clinical, such as an agreed structure for clinical
communication. One example of such a standard is the use of headings
(http://www.sci.port.ac.uk~headings/), with which the Academy is
involved . This will give form and content to communications, which
would allow more rational development of analysable data sets,
guidelines and care pathways. This in turn would allow trainees simpler
access to on-line audit and governance. Continuing support is sought
from the Academy for the promotion of an agreed structure for the
medical record and communications to improve not only clinical
information handling but also teamwork and patient care.
Senior trainees and doctors and dentists in established posts
The senior trainee meets a different problem. It would still be
considered eccentric to have a clinical base with informatics as a major
interest. Ideally posts should be created to combine a strong clinical
base with a major interest in information management. When a senior
trainee looks at the future it is evident that there are no substantive
posts offered as a consultant in a mainline speciality with a special
interest in Information Management. Both acute and primary care trusts,
however, need one or two individuals with such a background as data
guardians and clinical directors of Information Departments. Clinicians
with such a background and links to specialists in computing,
epidemiology, librarianship, psychology and education would finally make
it possible to bring Information Departments out of the Finance
Directorates, where clinical benefit was never an issue, hence the
clinically disappointing outcome of many IM&T projects. The support of
the Academy is sought to encourage Joint Committees for Higher Training
and relevant SACs to recognise in the assessment of a consultant/career
grade post the validity of a substantial information management
interest.
The established doctor or dentist needs time and resource to allow
participation in these training activities. An essential part of the
re-accreditation process should be evidence of such training. The
maintenance of good records and audit information should be a
requirement. There would need to be a corresponding obligation on Trusts
and employers to provide the tools which allow this process.
If the Colleges were to indicate that Regional Advisors should include
consideration of the support offered to clinicians in data and knowledge
management and communication skills in the approval of consultant posts,
there would be greater willingness on the part of the NHS to improve
clinical information facilities and training. Access to information
tools for governance and life-long learning will be vital for all
clinicians, for their own protection. The support of the Academy is
sought to encourage an appraisal of information and communication
resources as a routine part of accreditation visits to hospitals.
The Academy of Colleges Information Group, with particular thanks to
Jeremy Wyatt for his help.
Appendix 1:New curriculum for Specialist Registrar training in health
Informatics
1. Background
Health informatics is " The science of information management in health
care and its application to support clinical practice, decision making
and research" (Wyatt J. Medical Informatics - Artefacts or Science? Meth
Inform Med 1996;35:197-200). Information management in health care
embraces communication; the use of medical and multi-professional
records; language and nomenclature; team-working; confidentiality and
security of records and information; data quality and management;
secondary uses of clinical information for activity analysis; monitoring
of quality, research and planning; management of knowledge; decision
support; clinical information systems and electronic health records;
telemedicine, and the use of computers (Learning to manage health
information: a theme for clinical education. NHSE Bristol, Feb 1999).
This syllabus is drawn from Learning to manage health information: a
theme for clinical education. It focuses primarily on the use and
management of health information as an essential aid to the delivery of
quality patient care. While the issues surrounding the enabling
technology for health information should be considered, training should
not be confined to a course in IT or computer skills. Neither should
such skills be a pre-requisite for attendance, although familiarity with
commonplace health computer systems would be an advantage to Specialist
Registrars undertaking this training. It is felt that a basic level of
familiarity would be widespread amongst most SpRs today and that those
requiring further instruction would have no problems finding basic
computing skills elsewhere.
2. Aim
The aim of this curriculum is to educate specialist registrars in the
scope and application of information management in clinical practice,
and to establish health informatics as an educational theme so that it
becomes an integral part of career long learning.
3. Objectives
3.1 To promote the standards for authoring and reading health records
that are laid down by the General Medical Council and Royal Colleges so
that uniform, high quality clinical records are maintained, in paper or
electronic form, as appropriate in the organisation.
3.2 To impart a clear understanding of the position of the health
records with regard to the law, the patient and National Health Service
policies and procedures, so that the purposes of the record are met
appropriately.
3.3 To enable the appreciation of the relevance, application and
limitations of multi-professional information processes, so that
communication is appropriate and effective.
3.4 To give an understanding of the actual and potential uses of
aggregate clinical data so that structured patient data are collected
appropriately for valid use at local and national levels.
3.5 To impart the skills necessary for retrieval and utilisation of data
recorded in clinical systems so that data extraction and use is
appropriate.
3.6 To instil awareness of the impact of human, organisational and
clinical system characteristics on clinical and administrative data
quality so that the validity of information derived from operational
processes is understood and improved.
3.7 To impart an understanding of the issues which surround
confidentiality and security of information held about patients, so that
patient data are protected.
3.8 To enable critical appraisal of new developments in telemedicine so
that the appropriate introduction of such technology in practice can be
considered, planned and implemented.
3.9 To impart an understanding of the principles and practice of
evidence based medicine so that best use is made of external knowledge
resources, and the benefits and limitations of external knowledge
sources are fully understood.
4. Subject Matter
The curriculum is set out in detail in 'Learning to manage health
information' and covers:
* authoring and reading health records
* clinical standards for health records
* clinical language and nomenclature
* team-working and communication
* data quality and management
* uses of clinical data and information
* working clinical systems
* confidentiality and security
* telemedicine and telecare
* accessing and using the knowledge base of health care
5. Teaching and learning methods
The curriculum should be delivered with a minimum of didactic teaching
and an emphasis on case studies, practical examples and interactive
learning. Students should be encouraged to explore information
processes in their own environment and share the positive and negative
findings with other members of the course.
6. Evaluation
Students should identify their learning needs at the beginning of the
course and revisit these at the end. They should review the impact of
the course on their own working practices and report changes that they
have or would wish to implement.
There should be objective assessment by the students of the quality of
teaching and the learning environment.
7. Assessment methods
These should be agreed with the educational provider.
(Draft courtesy of Prof John Williams FRCP)
Appendix 2: UK Health Informatics units with significant training
capacity
England and Wales (18 units)
* Birmingham University: Health Informatics Group, Primary Care
Department
* Cambridge University Medical School
* Exeter / Plymouth Universities: Health Informatics unit, postgraduate
medical school
* Guyís, Kingís and St Thomasís Medical School (in collaboration with
City University)
* Imperial College of Science, Technology & Medicine
* Leeds University: Centre for Medical Information Science
* Liverpool University Medical School: Medical Informatics unit, Dept.
of Medical Education
* Loughborough University: Health information Science Unit
* Manchester University: Medical Informatics Group
* Newcastle University: Centre for Primary Care Informatics
* Oxford University: Oxford Medical Informatics
* Portsmouth University: Health Informatics unit, Health Sciences School
* Royal London & St Bartholomewís Medical College: Primary care
informatics group
* Salford University: Medical Informatics Unit
* Sheffield University: Health informatics unit, School of Health &
Allied Sciences
* St Georges’ Hospital Medical School in collaboration with European
Inst. Of Health Informatics, Surrey University
* University College, London: Centre for Health Informatics &
Multi-professional education
* University of Wales Swansea: Post-graduate Medical School.
Scotland (4 units combined as one virtual centre)
* Scottish Centre for Health Informatics, with bases at Glasgow,
Aberdeen, Edinburgh, Dundee Universities
Northern Ireland (2 units)
* University of Ulster
* Queen's University of Belfast
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