CHIA A1-5

Question 1

WHO definitiion of health

Answer 1

A state of complete physical mental and social wellbeing and not merely the absence of disease or infirmity

Question 2

Social view of health

Answer 2

health and illness are generated in a societal context – i.e., that the health we experience is directly related to the way our society operates. Health has a historical, cultural, and social context within this model.

Question 3

biomedical view of health

Answer 3

focuses on the presence or absence of disease. It assumes that disease occurs because of physical abnormalities in the body and treats people largely in isolation from their environment. This model works on the basis that understanding causal processes of a disease (its aetiology) leads to appropriate treatments - remove the symptoms, and the patient ceases to suffer; remove the cause, and the patient recovers their health.

Question 4

ecological model of health

Answer 4

reciprocal relationship between health-related behaviours and the environments where people live, work and play (behaviour does not occur in a vacuum).

Question 5

Participatory Health/Medicine

Answer 5

a movement in which patients and health professionals actively collaborate and encourage one another as full partners in healthcare

Question 6

Define Illness & Disease

Answer 6

Illness is a response to a condition (including a disease). It is a feeling of not being healthy. Illness may be due to a psychological imbalance. Perceptions of illness can have a strong cultural dimension, while disease usually does not.

Disease refers to a physical or mental disturbance involving symptoms (such as pain or feeling unwell), dysfunction or tissue damage that may lead to ill health (Australian Institute of Health and Welfare (AIHW), 2017).

Question 7

6 levels of biological organisation for the human body

Answer 7

Chemical, Cellular, Tissue, Organ, Organ system, Organismal

Question 8

Notable dimensions of homeostasis include

Answer 8

Thermoregulation, Acid-base, Iron levels, Blood glucose, thyroid

Question 9

Gross anatomy vs microscopic anatomy

Answer 9

1. Gross anatomy studies the large body parts visible to the naked eye (e.g., the heart, lungs, and kidneys).
2. Microscopic anatomy studies human structures too small to be seen with the naked eye (e.g., cells).

Question 10

what is CRISPR

Answer 10

Clustered Regularly Interspaced Short Palindromic Repeats.
Gene editing

Question 11

The Personalised Medicine Coalition describes personalised (or precision) medicine as:

Answer 11

“an evolving field in which physicians use diagnostic tests to determine which medical treatments will work best for each patient. By combining the data from those tests with an individual’s medical history, circumstances and values, health care providers can develop targeted treatment and prevention plans.”

Question 12

Implication of ppersonalised healthcare on health informatics

Answer 12

Genetic data is precise, complex, and extremely voluminous. Matching it with people, considering their personal circumstances (genetics is still only one factor contributing to health) and mapping their treatment experiences against responses and results over time is exceptionally intensive from data, information, and knowledge perspectives. The associated analytics are equally challenging.

Question 13

Health Informatics education in Australia

Answer 13

Despite their increasing importance to health service delivery, none of the undergraduate education above includes health informatics or digital health content. Instead, most health professionals learn about these disciplines during postgraduate studies (including data analytics subjects within population health studies) or on the job.

Question 14

Describe the determinants of health

Answer 14

AIHW “broad features of society, socioeconomic characteristics, health behaviours and biomedical factors, which interact with each other and with individual physical and psychological makeup. These include the different roles that women and men play in the community and sex-specific biological predispositions” (Australian Government, 2009).

Question 15

What is social gradient in health determninants

Answer 15

The social gradient in health is a term used to describe the phenomenon whereby people who are less advantaged in terms of socioeconomic position have worse health (and shorter lives) than those who are more advantaged

Question 16

What is soceioconomic status

Answer 16

In lay terms, socioeconomic status (SES) refers to a measure of overall social and economic position based on a combination of indicators. SES is generally not measured directly (e.g., by asking people to indicate the socioeconomic profile with which they identify), and single indicators (e.g., annual income) should be expressed as just that, even though they may be used as proxies for socioeconomic status.

Question 17

Index of Relative Socio-economic Disadvantage (IRSD)

Answer 17

Socioeconomic indexes for areas (SEIFA)

IRSD is one of the indexes compiled by the ABS based on Census data. It represents the socioeconomic conditions of Australian geographic areas by measuring aspects of disadvantage associated with residents of those areas such as low income, low educational attainment, high unemployment, and employment in relatively unskilled occupations. Areas are then ranked groups, often quintiles, based on their rank.

Question 18

Examples of socioeconomnic status (10 total)

Answer 18

Consumption
Demographics
Education
Employment
Family structure
Health
Household Structure
Income
Location
Wealth

Question 19

2 methods for measuring remotenss

Answer 19

ARIA + & Modified Monash Model

Question 20

ARIA+ levels of remoteness (5)

Answer 20

Major city, Inner regonial, outer regional, remote & very remote

Question 21

Modified Monash levels of remoteness (7)

Answer 21

Metropitan, Regional centre, large rural town, medium rural town, small rural town, remote community, very remote community

Question 22

Define biomedical factors in health determinants

Answer 22

Biomedical risk factors are bodily states that are often influenced by behavioural risk factors. E.g. sHTN, high choelsterol, obesity, age/sex, family history, HIV status, BRCA gene

Question 23

Existing sources of biomedical risk factor data in Australia include

Answer 23

National Health Survey

Question 24

Define wellbeing

Answer 24

“well-being is multidimensional, covering aspects of life ranging from civic engagement to housing, from household income to work-life balance, and from skills to health status” (OECD, 2015, p. 17).

Wellbeing (e.g. house quality and status, employment, edication, safety and security, health, Contexual fdactions (e.g economic or environmental conditions), determenants of welbeing (e.g. family function, social engagement, material resources, housing security, personal behaviours), welfare services and supports (house services, child protection servies, disability and employment services, informal support from friends/family)

Question 25

Why is measurement of wellbeing difficult

Answer 25

The dimensions of well-being illustrated are just that – dimensions, components, or facets. They describe well-being characteristics, not well-being itself, and even developing composite indexes is problematic, as weightings between such factors likely differ significantly between individuals. The characteristics are also dimensions that are currently measured – i.e., they reflect the availability of data rather than its relevance. For example, ‘happiness’ is not shown as one of the components yet is arguably as least as significant a contributor to well-being as, say, educational attainment.

In Australia and internationally, measurement of well-being is work-in-progress and an area for health informaticians to watch closely as health and social care converge.

Question 26

How are social support services withing scope for health informatics

Answer 26

The outcomes (health and well-being) are functions of a set of determinants moderated by interactions with the service delivery system and influenced by contextual factors. Social care services come within the scope of health informatics if we are concerned with the achievement of well-being as well as health

Question 27

Why is communication impaired during healthcare

Answer 27

Healthcare interventions are typically not the best of times. They can involve high stress for both patients and providers, and impediments to the receipt and comprehension of information, whether due to the inability to comprehend due to illness or the presence of medical equipment that hinders communication.
There is also a range of cultures and languages within the microcosm of health itself.

Question 28

Factors which increase the the potential for miscommunication (9)

Answer 28

• Variations between health service providers and organisations, even concerning the same specialties.
• There are variations in training between institutions, particularly where training originates in multiple countries and cultures.
• Mobility of the health workforce.
• Disparities in health literacy and the use of language between patients and providers – e.g., when was the last time you heard a non-clinician talk about dental caries?
• The roots of many medical terms are ancient Greek or Latin, with supplementation from prefixes and suffixes. However, these are not necessarily the language constructs of everyday life.
• The rapid evolution of clinical knowledge and, therefore, of clinical terms and their usage.
• Changes in the context of healthcare. For example, many procedures previously undertaken in a hospital are now conducted in GP clinics, so the locus of language changes too.
• Generational change and its accompanying changes in the use of language, especially allied with SMS, Twitter and other technologies encouraging the use of ‘shortcut’ terms.
• The widespread use of clinical abbreviations, acronyms, and icons.

Question 29

Why is miscommunication an issue in healthcare

Answer 29

Miscommunication is both common and serious. It “can result in errors, misdiagnosis, inappropriate treatment and poor care outcomes … [is] a major contributing factor in sentinel events in health service organisations, … and [is] one of the most common underlying factors in complaints about the Australian healthcare system (Australian Commission on Safety and Quality in Health Care, n.d.).

Question 30

What is the general stance on abbreviations and accromyns in healthcare

Answer 30

The use of documentary shortcuts such as abbreviations, initialisms, icons, and acronyms appears to be frequently associated with miscommunication.

the National Safety and Quality Health Service (NSQHS) Standards direct that “acronyms and abbreviations are avoided (in both design and completion) if there is any potential for ambiguity”, though “the use of approved abbreviations” is permitted

The Joint Commission International (JCI) now “prohibits the use of abbreviations in informed consent forms, patient rights documents, discharge instructions, and other documents patients and families receive” from hospitals it accredits.

Question 31

Documentary shortcuts are typically justified as a time saver for clinicians. However, this is potentially spurious to the extent that

Answer 31

• It may simply transfer time from one clinician (the documenter) to others (the readers) and magnify the time lost since every reader may have the same problem.
• Miscommunication errors arising may have significant downstream consequences. For example, the cost of dealing with adverse events or even near misses can include substantial clinical time, effort, and other resource usage.
• Even if other clinicians understand, patients may view their health records and find them incomprehensible.
• Clinical documents have long lifespans, and conventions change over time. The risk of perpetuating abbreviations in clinical records can only grow over time.

Question 32

Good practices concerning document shortcuts include (4)

Answer 32

•Ensuring that approved and non-approved shortcuts are articulated, communicated, and periodically reviewed.
• Monitoring the use of abbreviations – e.g., via record audits and in incident monitoring systems.
• Using technologies to convert shortcuts into approved long forms and seeking clinician validation and querying non-approved ones at the entry point.
• Orienting all new clinical staff and periodically reminding existing staff about the use of shortcuts.

Question 33

defiune clinical decision making and the 4 steps

Answer 33

Clinical decision making is the application of clinical reasoning and judgement to develop definitive action (or non-action) steps in a specific clinical scenario requiring choice. It is concrete, not abstract
1. Gather and analyse patient data
2.. Make judgemenbts in what could be happening, look for patterns, assess further information needs, look for evidence, use intuition or personal knowledge base
3. Make a decision (what to do and how to do it)
4. Evaluate the outcome (and repeat as necessary)

Question 34

Underlying princples of clnical decision making

Answer 34

• Patient-centricity – ensuring that clinical decisions are founded first and foremost on the patient’s needs, desires (e.g., not to receive certain treatments), capabilities and support networks. There is a focus on autonomy, encouraging capable patients to make their own decisions as far as possible.
• Accountability – taking ongoing responsibility for clinical decisions made and their implications.
• Transparency – ensuring full disclosure to maximise the patient’s ability to participate.
• Collaboration and communication – ensuring that clinical decision making is based upon a respectful patient-clinician relationship in which each party ensures that information is passed on and understood, and the patient and clinician are both able to add value to the decision-making process.
• Evidence-based practice.

Question 35

Common constraints to clnical decision making

Answer 35

• Regulation – the use of some therapies and/or the means of their application may be restricted by law (e.g., use of some drugs).
• Standards of professional practice – some approaches to therapy may be inconsistent with accepted standards of clinical practice, for example, as espoused by professional colleges or articulated through case law.
• Organisational policies and standards – for example, guidelines on informed consent, the scope of practice or the use of specific prosthetics within a public hospital.
• Cost – some potentially

Question 36

Common approaches to clinical decision making including summary (3)

Answer 36

Pattern recognition (immediate hypothesis formation based on a pattern of highly significant features/cues recognised in a case that are matched with similar instances from prior experience.)
Heuristics (“rules of thumb”, educated guesses or mental shortcuts. They usually involve pattern recognition and rely on a conscious or subconscious integration of patient cues with prior experience)
Hypothetico-deductive reasoniung (generation of hypotheses, followed by data search/investigation to evaluate the hypothesis or generate additional or alternate ones until a final hypothesis is accepted)

Question 37

Name the errors which pervade clinical decision-making processes

Answer 37

incorrect information (e.g., through faulty patient identification and thereby incorrect attribution of clinical data),
cognitive errors
“no-fault” errors, which occur when the disease is silent, appears in an atypical fashion, or mimics another more common condition.

Question 38

Give exmaples of cognitive errors in clinical decision making (12)

Answer 38

• Faulty initial assessment - overestimating or underestimating the likelihood of disease.
• Lack of comprehensiveness - failure to seriously consider all relevant possibilities.
• Representation error occurs when a clinician judges the probability of disease based on how closely the patient’s findings fit the manifestations of a disease without taking into account disease prevalence. An example would be the dismissal of the possibility of myocardial infarction (MI) in a well-exercised, non-smoking, healthy 60-year-old male who has reported unspecific chest discomfort because the patient does not fit a stereotypical profile (even though MI is highly prevalent among men of this age).
• Premature closure – where a clinician makes a quick conclusion and does not collect other data. This can occur when a clinician accepts the conclusions reached by another clinician without independent validation or when a patient presents with symptoms approximating those of a condition that the patient has had previously, but which may now be attributable to a different cause.
• Anchoring errors occur when clinicians adhere to their initial impression even though further data conflict with this impression.
• Confirmation bias occurs when clinicians selectively accept clinical data that support a desired hypothesis and ignore data that do not (cherry-picking).
• Attribution errors involve the clinician being influenced by stereotypes, thereby prematurely narrowing their considerations. An example would be assuming that an incoherent drunk is suffering from the effects of alcohol, whereas they may have had a stroke.
• Affective error involves avoiding unpleasant but necessary tests or examinations because of “consideration” for the patient. An example would be avoiding a pelvic examination on a modest patient.
• Cognitive Overload occurs when too much information is available at a point in time (e.g., in a busy emergency department) or when too much irrelevant data is presented.
• Fatigue - optimal perception, attention, vigilance, memory and reasoning all depend on being well-rested and having an adequate amount of sleep. Yet, long work hours, sleep deprivation and accumulated sleep debt are common in the medical workplace. Generally, the longer people stay awake, the sleepier they become, resulting in impairment of their cognitive and psychomotor performance.
• Psychomotor events – these include improper techniques and distraction.
• Rule-based errors occur when a ‘rule’ used to assist in deriving a conclusion is erroneous or misleading (e.g., in a clinical decision support system).

Question 39

When is variation in healthcare undesirable

Answer 39

Variation in healthcare is desirable where it reflects differences in people’s healthcare needs or the informed choices they make about their treatment options. “But when variation in the use of health services is due to other factors – such as the provision of patient care that is not supported by evidence, uncertainty about the intervention’s place in therapy, or differences in access to care or appropriateness of care – it is unwarranted variation and represents an opportunity for the health system to improve”

Question 40

Define evidence based practice and 5 steps

Answer 40

“integrating the best available research evidence with clinical expertise and the patient’s unique values and circumstances”

1. Frame the question
2. Find the evidence
3. Assess the evidence
4. Apply the evidence
5. Evaluate the outcome

Question 41

Explain PICO

Answer 41

Frames the question for EBP

Popuation, Intervention, Comparison, Outcome (Time)

Question 42

NHMRC levels of evidence

Answer 42

1 - Systematic Review
2 - RCT
3-1 - Well designed pseudo RCT
3-2 - Comparitive studies with concurrent control (but not randomised), cohort, case control, interrupted time series
3-3 - Comparitive studies with historical control, single arm studies or interriputed time without control
4 - Case series

Question 43

Describe the interplay between statistical significance and clinical significance

Answer 43

Clinical significance largely depends on the effect being studied and requires clinical judgement. It refers to whether the difference between alternate approaches (intervention versus comparison) is significant enough to warrant a change in clinical practice. Studies can be statistically significant yet clinically insignificant.
On the other hand, a clinically significant but not statistically significant result should not necessarily be “discarded”. Instead, it may highlight the need for a follow-up study.
Applicability is also an important dimension. A clinically and statistically significant result still may not be applicable in a practice setting. It may require highly specialised resources, a controlled environment that isn’t practical or be too costly.

Question 44

5 steps for applying evidence

Answer 44

1. What are the beneficial and harmful effects of the intervention?
2. Are there variations in the relative treatment effect (can the same [or average] treatment effect be applied to all subjects, or does the impact vary according to varying characteristics of the patient, intervention or disease?)
3. How does the treatment effect vary with baseline risk level?
4. What are the predicted absolute risk reductions for individuals?
5. Do the benefits outweigh the harms?

Question 45

What stakeholders sholuld be consulted for EBP changes

Answer 45

Considering the following groups of stakeholders and noting that they will require different types of information, presented in targeted ways: patients/consumers of health services, clinical decision-makers, individual practitioners caring for patients and groups developing clinical guidelines and other directives, administrative/governance decision-makers and potentially legislative decision-makers and industrial/academic decision-makers (e.g. scientists, health software personnel etc.).

Question 46

Explain PDSA cycle

Answer 46

The “Plan Do Check Act” (PDCA) cycle, depicted below, is widely used to introduce improvements in healthcare in Australia. It is also referred to as the Deming Cycle or the Shewhart Cycle.

Question 47

Outcome evaluation time objectives

Answer 47

Outcome evaluation takes an extended view to measure the realisation of immediate, intermediate and ultimate objectives, an approach advocated by Avedis Donabedian, an early advocate for the study of quality in healthcare and medical outcomes research. Immediate outcomes are first-order changes, including to participant behaviours and observable practice results. Intermediate changes are generally concerned with the effects of these first-order changes. They include benefits and costs. Ultimate outcomes address the longer-term goals of the change.

Question 48

Steps to evaluation a EBP change

Answer 48

1. Engaging stakeholders, including those involved in implementing the change, those served or affected by the change and primary users of the evaluation results.
2. Describing the program, including the need, expected effects, activities, resources, stage, context and logic model.
3. Focusing the evaluation design on assessing the issues of greatest concern to stakeholders while using time and resources as efficiently as possible.
4. Gathering credible evidence to strengthen evaluation judgments and the recommendations that follow. These aspects of evidence gathering typically affect perceptions of credibility: indicators, sources, quality, quantity and logistics.
5. Justifying conclusions by linking them to the evidence gathered and judging them against agreed-upon values or standards set by the stakeholders. Conclusions are justified based on evidence using these five elements: standards, analysis/synthesis, interpretation, judgment and recommendations.
6. Ensuring use and sharing lessons learned with these steps: design, preparation, feedback, follow-up and dissemination.

Question 49

Criticisms of evidence-based practice

Answer 49

• The number of, and potential conflict between, sources of guidelines and evidence.
• The applicability of generalised evidence to specific cases and/or the relevance of evidence generated in specific cohorts to other sub-populations.
• The expense involved in generating and disseminating evidence, and in particular of maintaining their currency and relevance.
• Published studies may not represent all studies, and those reporting negative results may be under-represented even though they convey important lessons.
• Guidelines impinge upon clinicians’ professional autonomy and/or they are a covert means of rationalising resources.
• Evidence contributes to information overload.

Question 50

Barriers to widespread and timely implementation of EBP

Answer 50

Relevant information is difficult to access.
• Online knowledge management resources (e.g. CIAP in NSW Health) enabling workplace-based access.
• Decision support systems enabling workflow embedded access.
Skill and resource deficiencies in finding and applying evidence.
• Separation of tasks between skilled clinical informaticians/health knowledge managers and practising clinicians, enabled by collaboration tools.
Lack of appropriately skilled clinicians in some places (distribution of the health workforce).
• Delivery of care remotely or with online assistance (e.g. telehealth, robotics).
Lack of systemic incentives and disincentives.
• Closer alignment of clinical governance and performance management systems, data-enabled (e.g. big data).
Lack of influential and credible leadership across many varied practice settings.
• ICT enabled virtual presences and flexible learning/informational approaches.
Long lead times in assimilating and analysing evidence.
• The promise of electronic (including personal) health records delivering clinical data for secondary purposes such as research.
• Data analytics.
Relevant information is highly dispersed.
• Aggregation and clinical portals.