The research conducted for this thesis has raised several issues. The issues are centred on information use, and evaluation for information quality, in clinical context. The issues were revealed not only through the original research conducted for the thesis, but also due to extensive investigation of the many, and varied, research domains investigated for this project. The interviews with the general practitioners (GPs) revealed these issues were common across those GPs interviewed
6.3.1 Access Alone Is Insufficient
Being professionals, the general practitioners (GPs) must first and foremost exercise a duty of care toward their patients. This is encapsulated in the New Zealand Medical Associations Code of Ethics. Just having the information is not sufficient. With the
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duty of care, the GPs do not trust, or distrust, information at face vale, but constantly assess the information for its fitness for purpose.
From the group of GPs interviewed it is clear that they approach information, for clinical decision making, in a specific, practical way. It is an approach reflected by other professionals, charged with a duty of care e.g. engineers, and reflects the privileged status of the professions as a group in society (Pitman, 2012). The application of
phronesis, or practical wisdom, has been studied since Aristotle distinguished it as an intellectual virtue in Book VI of the Nicomachean Ethics. It has been applied to the study of the professions, including healthcare.Phronesis is about not ignoring practical wisdom, and being caught in routine, that does not take account of the current situation, but is followed anyway. As an example, at times in healthcare, protocols may be followed regardless of context, or what is best for the patient, as routines such as protocols provide a defence, should treatment go badly. Practical wisdom is the opposite; it is about basing decisions on expertise, using reflection to break routine, thus increasing personal responsibility (Frank, 2012).
The concept of practical wisdom is related here, as it applies to how the GPs interviewed judge information. They do not just accept information in a routine manner, but apply expertise, based on the current context, with the well-being of the patient uppermost. There is routine in the assessment of information, but it is in the process, the ticking, or not, of boxes, but not routine on how similar information would be applied to different patients, in different contexts.
When providing information to the GPs, this philosophy should be noted. It is unrea- sonable to expect that the information should just be taken on faith, that simply having the information is of utility. This is especially true as the amount of information likely increases, and as the GP becomes more remote from the source of the information i.e. as information is aggregated from multiple sources. It would be well to take this in to account for systems intended to deliver information. Increased information volume, without the desired accompanying information used for assessment, may just cause less information use, as users feel unable to rely on it, and it would take too long to find what they want.
6.3.2 Form Is Important
Using health information is beyond a semantic interoperability, or format, issue. These issues are systems issues, with the focus appearing to be on how to easily get information into a system, storage and retrieval, security of access, and transmission. These are not end user issues, as identified in this research. The group of GPs in this research (the
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end users), look for criteria within what they are presented with to assess information fitness for purpose. This is a form issue. Focus, for the end user, should be on supplying the health information in a form that allows for ease of assessment. It should provide the criteria used in assessment “up front” so the GP does not need to take extra steps to find these criteria, to make the assessment. To match the information form, to the GPs internal framework, used for assessment. The Quality Criteria Model (QCM) may be a step in this direction, by modelling criteria for assessment.
It may sometimes appear that assessment is not taking place, as the particular informa- tion strikes the GP as being of quality. However something has always keyed them in to this conclusion. Through tacit knowledge, experience and community knowledge, it has happened very quickly, but the assessment has still taken place. This is the application of the GPs practical wisdom. Instead of the focus being on systems just getting the information to the GP, though this is important, it should also take into account the way the information is assessed. The GPs are looking for information on the content, should something within the information trigger a need to look further. From the GPs interviewed this occurs frequently.
The Electronic Health Record (EHR) entry should be the logical, self-contained, discrete unit, for communicating health information. Communicate, rather than transmit, is the correct term, as communication requires a mutually understood channel. A logical unit is required, as proposed strategies for communicating health information are focusing on aggregation of data from disparate sources, where documents containing information will be fragmented (based on required context), and assembled “on the fly” e.g. New Zealand’s National Health IT Plan (2010). The entry should carry with it all data (meta-data) that is required for the end user to be able to use the information. One aspect of this use, is to ensure it can be used safely, with a judgement of the information fitness for purpose.
6.3.3 Subjective Criteria Are Problematic
Those Quality Criteria (QC) that are unequivocally subjective i.e. reputation, past experience, or expertise based, will be non-trivial to implement in a system. Not just how to evaluate them, but also their representation. Also, their very nature, being subjectively determined, makes a “one size fits all” approach, not only difficult, but probably undesirable.
Proposed strategies for the NZHS may provide some help. For example, the proposed introduction of league tables for New Zealand health organisations could be leveraged
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where organisational expertise (C2), or organisational reputation (C3), criteria are in- volved. It is likely that the best approach for subjective criteria is some form of peer, or community, rating from GPs. This approach is likely to encounter heavy resistance, even if confidentiality, or anonymity could be preserved. It may sound counter-intuitive to talk of anonymity for something like reputation of sources. However, a potential solution could be a confidential rating for sources of information, where peers confi- dentially rate one another, and the rating is anonymously applied to information. This would rely heavily on an ethical use of ratings by peers.
6.3.4 Difficulties with Multiple Entry Criteria
Entries will not appear in health information in isolation. They occur as collections i.e. in a document structure of some type. This is true for current health information. Two Quality Criteria (QC) relate specifically to a collection of entries (C1, and C5), not single entries, or the source for an entry. These are the three dimensions entry, source and document, described in Chapter 4, Section 4.4.2 . If information sources are to become more connected, as is proposed, potentially aggregated from disparate sources, for delivery of information to the end user, the issues with these two criteria become even more important.
Even if the aggregation of data is limited to that required for the current context of need, there is the potential for a lot of information. Having the ability to have quickly highlighted, where contradictions occur (C1: Contradictory Entries), was rated highly by the GPs interviewed. Leaving it to the GP to decipher this criterion may result in the criterion being missed, or too much time taken, especially for information they are not familiar with, or when information volume is high.
C5: Consistency/cohesion is a quality criterion that evaluates the collection of entries as a whole i.e. Does the collection/record “hang together” as a whole, or “make sense” as a whole? C5 is categorised in Chapter 3, Figure 3.9, as being an objective criterion. This was based on finding contradictory entries, implying inconsistency, as per processing example in Chapter 4, Figure 4.7. However it could be argued that the nature of the question, just posed, means it could be interpreted as a subjective criterion. Either way, assessing if a collection of entries is consistent/cohesive, especially for information from disparate sources, and not seen before, would be challenging, for both human or system. Having said that, it is deemed by the GPs interviewed to be a highly rated criterion, and therefore important to know when judging information.
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