Information management

Information management (IM) is a broad concept connecting the processes, resources, and technologies (Choo 2002), but it is also a way to manage the life cycle of informa-tion, including processing of the data (Detlor 2010). Various meanings and interpre-tations of information management have been used in different contexts. Sometimes, the term is used interchangeably with the management of information resources, the management of information technology (IT), or the management of information policies or standards (Choo 2002, Detlor 2010). Although information technology and information standards are important parts of IM, the latter concept is much wider and more complex. It can be defined as “management of the processes and systems that create, acquire, organize, store, distribute, and use information” (Detlor 2010, p.103). Further, health information management represents a process, including the acquisition, organization, retrieval, and dissemination of health information (Medical Subject Headings, 2016), to be used in clinical or administrative decision-making in health care. The content of the concepts, however, might differ in terms of the contexts where they are used. When concerning clinical patient data, IM involves all health professionals at all phases of care.

In hospitals, health professionals process information using organizational and personal approaches (Choo 2002). The personal information management perspec-tive differs from the organizational perspecperspec-tive of IM in that personal information management concerns items of interest to the individual, not the organization (Choo 2002, Detlor 2010). From an organizational perspective, the goal of IM is to achieve the strategic objectives focusing on the items of interest to the organization (Detlor 2010).

When clinical data is managed for professional purposes, it is assumed to be organi-zational information management. This assumption is adopted in this study. Choo (2002) has defined information management process in an organization as a continuous cycle of six closely related activities (Figure 2): (1) identification of information needs, (2) information acquisition, (3) information organization and storage, (4) development of information products and services, (5) information distribution, and (6) information use. These phases are repeated during the care process multiple times (Choo 2002).

This definition of information management process is adopted in this study.

Figure 2. A process model for information management in clinical practice modified from Choo (2002).

Information needs arise when a person tries to make a sense of situation in order to solve problems. The information can be subject-matter requirements or situation-de-termined contingencies (Choo 2002). The need may be information at an individual level when making clinical decisions and at the organizational level when using ag-gregated clinical data for administrative decision-making (Goossen 1996). The di-mensions of problems define the types of information needed; for example, in simple problems, the needed information focuses on the path for solutions, and in complex issues, more information is needed about how to reduce problems than in simple tasks (Choo 2002). In clinical situations, information needs arise from patient status and problems in which the health professional recognizes information deficits when caring for the patient. Information needed in order to make proper decisions includes not only clinical patient data, but also research evidence, the knowledge arising from clinical expertise, and patient preferences (Thompson et al. 2004, DiCenso et al. 2005).

Thus, information from different sources is needed, and multiple methods are used to acquire information that is needed.

Not only health care professionals but also designers of information systems need to specify user´s information requirements in the organization in order to develop technological tools to help health care practice (Graves & Corcoran 1989). One type of safety concern relating to electronic patient record (EPR) system is a mismatch between information needs and displayed information (Meeks et al. 2014). However, deficits in information needs of individuals are not necessarily easy to recognize; for that reason, health professionals may not see some problems, and may have uniden-tified information needs (e.g., a need for evidence-based updates of the most effec-tive treatment options) (MacIntosh-Murray & Choo 2005). Misidentified information needs of different personnel groups challenge an organization’s information man-agement, and a systematic way to identify information needs is needed (Choo 2002, Kivinen & Lammintakanen 2013). In clinical situations, a patient’s status is a trigger for identifying needed data, but the information needs also rely on the ability of health care professionals to identify relevant needs for information (MacIntosh-Murray &

Choo 2005).

Identified information needs to lead to information acquisition in order to assess the patient’s situation by, for example, looking for medical history in the EPRs or the results of clinical examinations and clinical practice guidelines. Motivation and inter-ests of information-seekers, as well as quality and accessibility of sources, affect infor-mation-seeking (Faibisoff & Ely 1976, Choo 2006). Fragmented information has also challenged information-seeking in hospitals (Bowman 2013, ECRI Institute, Health Technology Assessment Information Service 2015), although EPRs have made infor-mation searches easier (Häyrinen et al. 2008). Once acquired, the inforinfor-mation must be organized and stored systematically—for example, in the EPRs or other records—in order to facilitate information distribution and use (Choo 2002). In other words, the stored data should be reused and available to health professionals when they need it (Choo 2002, Rudin & Bates 2014). Electronic documentation of patient data ensures effective data storage in hospitals. Health professionals are required to document all necessary patient data using uniform documentation practices (Decree of the Minis-try of Social Affairs and Health on the Patient Records 298/2009) in accordance with hospital guidance. In addition, part of the information is preserved in the memories of individuals as tacit knowledge gained through experience or transmitted via training (Kothari et al. 2012).

As a result of acquisition, information should be transformed into a usable form as information products and services, which formulate part of the knowledge base of the organization and assist health professionals to make better decisions in patient care (Choo 2002). Information products are written work products published for distribution via various channels; they can be prints, software, audiovisual material, or online materials, and may include content from procedures, research syntheses, and other relevant sources (Sullivan et al. 2007). One example: evidence-based guidelines that synthesize current research evidence and are adapted to the local context. Information services are organizational efforts made in order to serve users of information, and may include searchable databases and online libraries (Sullivan et al. 2007).

Information products and services are distributed to users using various means of communication including electronic, written and verbal tools (Sullivan et al. 2007).

Information technology has changed the way people communicate and dissemi-nate information to each other. However, the selection of the distribution channels should be based on work processes in order to enable effective information flow (Choo 2002). Information sharing increases organizational learning, creates new insights and knowledge about situations in organizations, and enables the use of information in patient care during transitions of care and in handovers during and between shifts, leading to the appropriate clinical decision-making (Choo 2002, Nagpal et al. 2010a).

Subjective information (e.g., patient’s experience) and objective facts and details (e.g., measurements) are used as the basis of clinical decision-making in hospitals. Com-munication of clinical data is not only needed for clinical purposes, but also required for collaboration with other professionals and for management and policy purposes on the regional and national levels (Goossen et al. 1997).

The target of an organization’s information management is to support the actions of the organization (e.g., hospital) to guarantee safe and effective care. Table 2 de-scribes the dimensions of IM in terms of patient safety using four operational levels:

macro, meso, micro, and nano. The latter refers to patient-provider interaction during clinical care that is guided by an organization at the micro-level. Thus, micro-level de-scribes collaboration and guidance at a certain organization. Meso-level information management includes regional initiatives, whereas macro-level concerns the whole na-tionwide health system. As in the DIKW framework, presented previously in section 2.1, the patient data is produced at the nano-level to be processed as information that is used in clinical decision-making. Aggregated patient data are generated as knowledge to be used in administrative decision-making at organizational and regional levels as well as in policy decisions at the national level (Goossen et al. 1997).

The dimensions of information management at different levels are described using the triangle of structure, process, and outcome in Table 2 (Donabedian 1988, EXPH 2014). Structure refers to the attributes of the environment where information manage-ment is arranged, whereas process describes interactions and the actions taken in the environment in order to achieve desired outcomes (Donabedian 1988). In the context of information management, outcomes are defined as effects of information manage-ment in certain environmanage-ments. These three elemanage-ments are interrelated, as a good struc-ture creates good processes that result in good outcomes (Donabedian 1988). These elements are consistent with the stages of development of organizational accidents (Figure 3) presented in the next chapter.

Table 2. Dimensions of information management. Modified from EXPH (2014).

• Availability of norms and standards

• Regulation of information manage-ment in health care

• Privacy protection

• Processing of aggregated patient data for policy decisions

Regional level • Information culture

• Regional and local information systems

• Information exchange and commu-nication between organizations

• Processing of aggregated patient data for administrative

• Information exchange and commu-nication inside one organization

• Information management practices

• Information management behaviors

• Information technology practices

• Processing of patient data for clini-cal decision-making

• Information retrieval, storage, distribution, and use of information in patient care at organizational perspective.

At the macro-level, national governance – including laws, regulations, and policies – guides information management in hospitals, and technology intended for national use. In Finland, processing of health information in hospitals is based on the Personal Data Act 523/1999 that defines the principles of the privacy protection in processing of personal information. In comparison, the Act on the Status and Rights of Patients 785/1992 regulates the processing of patient records and requires the concealment of confidential health information. Detailed requirements for the content of documen-tation and storing of patient records are given in the Decree of the Ministry of Social Affairs and Health on the Patient Records 298/2009.

In Finland, the nationwide patient data management system—The National Ar-chive of Health Information (KanTa)—has been implemented in accordance with the Act on the Electronic Processing of Client Data in Social and Health Care 159/2007.

The KanTa enables hospitals to enter patient records from their information systems in a secure way; additionally, the records are available regardless of the user’s location.

Further, citizens have the right to access and manage their own personal health data as regulated by law (Kanta 2016). The Act on Electronic Prescriptions 61/2007 regulates the processing of electronic prescriptions that are stored in the national electronic Prescription Centre, which created to improve medication safety. The basic premise of the Health Care Act 1326/2010 is that health care needs to be evidence-based, high quality and safe for patients. The overall purpose of the macro-level regulations is to guarantee trustworthy information management in hospitals and to improve privacy, patient safety, and effectiveness.

Information processing at the meso- and micro-level is strongly guided by that at the macro-level, but information culture and information systems also build the en-vironment in which the information management occurs (Marchand et al. 2002, Choo 2006). Information exchange and communication between primary and specialized care organizations at the regional level enables continuity of care when patient data is available as needed in patient transfers (Vermeir et al. 2015, Kattel et al. 2016). The regional and organizational levels are linked with each other, and similar information systems are used when managing patient information. Further, organizational guid-ance at the micro-level is based on macro-level regulations, but information culture and local conditions also formulate the ways information is exchanged and transferred at the organization (Choo et al. 2006). Information management practices, behaviors, and technology define the organization’s ability to manage information safely and effectively (Marchand et al. 2002, Choo 2013).

At the clinical level, the data is collected and further transferred to information to be used in clinical decision-making. The patient-provider interaction in the informa-tion management process includes verbal and written communicainforma-tion; the latter is the most common form of communication (Vermeir et al. 2015). Written communication includes both electronic and manual information processing. Health professionals’

competence, education, skills, and attitudes affect the compliance with organizations’

guidance. In addition, usability of information systems and user interfaces has an impact on the outcomes of information management (Meeks et al. 2014).