Analysis of the quality of hospital information systems audit trails

BMC Medical Informatics and Decision Making

Research Article

Isabel Boldt¹  Cátia Santos-Pereira¹  Ana Margarida Ferreira²  Alberto Freitas²  Ricardo Cruz-Correia²  Pedro Pereira Rodrigues²  Luís Lapão³ 

[1] CINTESIS – Centre for Research in Health Technologies and Information Systems, Faculdade de Medicina da Universidade do Porto, Porto, Portugal;CINTESIS – Centre for Research in Health Technologies and Information Systems, Faculdade de Medicina da Universidade do Porto, Porto, Portugal;Department of Health Information and Decision Sciences, Faculdade de Medicina da Universidade do Porto, Porto, Portugal;CINTESIS – Centre for Research in Health Technologies and Information Systems, Faculdade de Medicina da Universidade do Porto, Porto, Portugal;International Public Health and Biostatistics and WHO Collaborating Center for Health Workforce Policy and Planning, Instituto de Higiene e Medicina Tropical – Universidade Nova de Lisboa, Lisbon, Portugal;

关键词: Electronic Health Record;    Electronic Patient Record;    Hospital Information System;    Health Information System;    Radiology Information System;   

DOI  :  10.1186/1472-6947-13-84

 received in 2013-01-14, accepted in 2013-07-29,  发布年份 2013

来源: Springer

【 摘 要 】

BackgroundAudit Trails (AT) are fundamental to information security in order to guarantee access traceability but can also be used to improve Health information System’s (HIS) quality namely to assess how they are used or misused. This paper aims at analysing the existence and quality of AT, describing scenarios in hospitals and making some recommendations to improve the quality of information.MethodsThe responsibles of HIS for eight Portuguese hospitals were contacted in order to arrange an interview about the importance of AT and to collect audit trail data from their HIS. Five institutions agreed to participate in this study; four of them accepted to be interviewed, and four sent AT data. The interviews were performed in 2011 and audit trail data sent in 2011 and 2012. Each AT was evaluated and compared in relation to data quality standards, namely for completeness, comprehensibility, traceability among others. Only one of the AT had enough information for us to apply a consistency evaluation by modelling user behaviour.ResultsThe interviewees in these hospitals only knew a few AT (average of 1 AT per hospital in an estimate of 21 existing HIS), although they all recognize some advantages of analysing AT. Four hospitals sent a total of 7 AT – 2 from Radiology Information System (RIS), 2 from Picture Archiving and Communication System (PACS), 3 from Patient Records. Three of the AT were understandable and three of the AT were complete. The AT from the patient records are better structured and more complete than the RIS/PACS.ConclusionsExisting AT do not have enough quality to guarantee traceability or be used in HIS improvement. Its quality reflects the importance given to them by the CIO of healthcare institutions. Existing standards (e.g. ASTM:E2147, ISO/TS 18308:2004, ISO/IEC 27001:2006) are still not broadly used in Portugal.

【 授权许可】

CC BY   
© Cruz-Correia et al.; licensee BioMed Central Ltd. 2013