Abstract
Managing routinely collected data in health care and public health is important for evaluation of interventions and answering research questions using “real life” and ”big data”. In addition to the technical requirements of information systems, both standardized terminology and standardized processes are needed. The aim of this project was to analyse and assess the integration of standardized terminology and document templates for a dietetic care process (DCP) into the health information system (HIS) in a hospital in Austria. Using an action research approach, the DCP was analysed through four expert interviews and the integration into the HIS through two expert interviews with observations. Key strengths and weaknesses for the main criteria (“integration of the ICF catalogue”, “adaption of the document templates”, “adaption of the DCP”, and the “adaption of the user authorizations”) were presented and proposals for improvement given. The system and process integration of the DCP is possible, and the document templates can be adapted with the software currently in use. Although an increase in resources and finances required is to be expected initially, the integration of a standardized dietetic terminology in combination with a standardized process is likely to improve the quality of care and support outcomes management and research.
Highlights
Managing routine outcome data is essential for auditing and benchmarking, evaluating current interventions and conducting pragmatic research on big data in health care and public health [1,2]
The use of a standardized care process and standardized terminology for the documentation of individual therapy and population-level interventions provides clear, unambiguous terms to support the comparability and management of routinely collected data [3,4]. This is supported by the World Health Organization (WHO) in their recommendation to use the International Classification of Functioning, Disability, and Health (ICF), a multipurpose classification for various disciplines describing the functional state of health and its contextual factors [5,6]
This study reports on a system and process technology analysis and assessment focussing on integrating a dietetic care process (DCP) into an existing health information system (HIS)
Summary
Managing routine outcome data is essential for auditing and benchmarking, evaluating current interventions and conducting pragmatic research on big data in health care and public health [1,2]. The use of a standardized care process and standardized terminology for the documentation of individual therapy and population-level interventions provides clear, unambiguous terms to support the comparability and management of routinely collected data [3,4]. Use of the ICF is recommended in combination with the International Classification of Diseases (ICD) [7] and the International Classification of Health Interventions (ICHI) [8,9] Together, these capture the situation of patients at a given point in time and cover the most important parts of the health system [5,10].
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