A Systematic Approach to Using Case Studies in Health Informatics Education

Abstract

The complexity of health informatics (HI) projects necessitates a solid base of skills and knowledge in a variety of different fields. Case studies are an excellent way to introduce this complexity without overwhelming students. This paper makes a contribution to HI education by presenting a systematic approach to introducing HI concepts to future health informatics professionals (HIPs) and to health care professionals and administrators who need a solid grounding to participate in HI projects.

Introduction

The complexity of HI projects necessitates a solid base of skills and knowledge in a variety of different fields: clinical, financial, administrative, technical, communications, organizational culture, project management, and others [1–5]. At the beginning of HI education we need a tool that would gently introduce such complexity without overwhelming the students and which would point them to the importance of learning about all these different fields. As the students progress in their education, it would also be helpful to use such a tool in order to ensure that the students can integrate what they learn in their courses into a “large picture” of HI and, ultimately, successfully resolve HI challenges in the workplace.

One of the best ways to introduce the different concepts associated with the complexity of HI projects is by using case studies. Anderson [6, 7] argues that a case based approach helps to teach practitioners to identify, analyze, and make decisions regarding ethical issues in HI projects. This approach is equally useful in teaching other aspects of HI. Our experience indicates that the careful use of case studies meets the educational needs of diverse groups of students in terms of age, educational backgrounds, learning styles, career goals, etc.

Although numerous case studies reflecting different aspects of HI have been published [6, 8], clear guidelines for using such studies in HI education are lacking. For example, choosing from the many case studies currently available, making decisions on how to present a case study, deciding how to evaluate students’ progress, and accounting for varying levels of knowledge can be overwhelming for an educator. Although case studies can be extremely useful in HI education, without a systematic approach to teaching and learning from case studies, the results are haphazard at best. This paper offers educators guidelines for introducing the richness of HI both to future HIPs and to health care professionals and administrators who need a solid grounding to participate in HI projects.

This paper begins by describing the three HI programs at Conestoga College Institute of Technology and Advanced Learning (ITAL), in which this case based approach has been refined, and our integrated approach to HI curriculum (http://hi.conestogac.on.ca). The three programs are Bachelor of Applied Health Sciences – Health Informatics degree program, and two post-graduate certificates, Information Management for Health Care and Applied Health Informatics. It then provides a check-list for choosing case studies, and describes how case studies are used in the program. It then, it offers guidelines for analyzing case studies and different evaluation approaches for ensuring that students have achieved the learning objectives. Finally, the authors suggest future steps for using case studies in HI education.

HI Programs at Conestoga College ITAL

The Bachelor of Applied Health Sciences in Health Informatics at Conestoga College ITAL in Ontario, Canada, is a full-time, four-year undergraduate program with 3 four-month mandatory co-op workterms. The first student intake was in September 2005, and the first cohort will graduate in Fall 2009. The main focus of the program is to prepare the students for the role of business analysts in the HI industry, as well as for education at the graduate level. Starting September 2008, we began offering two post-graduate certificates. One of them, Information Management for Health Care (two semesters and one co-op), is aimed at individuals with backgrounds in information technology and computer sciences. The other, Applied Health Informatics (three semesters and one co-op), is aimed at individuals with backgrounds in health care and health sciences. By Summer 2009 our students have had successful co-op placements both domestically (e.g., hospitals, Community Care Access Centres, University Health Network, Canadian Institute for Health Information, 3M Canada, and private HI software companies, such as Agfa Healthcare and Medicalis) and internationally (Germany, Qatar and Australia). Mandatory evaluations of student performance during co-op workterms indicate a high level of satisfaction with students’ ability to successfully contribute to HI projects.

An Integrated Approach to HI Curriculum

The program curriculum was created with a focus on developing a set of competencies (skills, knowledge and attitudes) for Applied Health Informaticians based on the report “Pointing the Way” [1]. The goal was to help prepare individuals to fill the existing gap in the HI workforce. The courses are grouped in the following subject domains: health information science, information technology, health care, health sciences, management sciences, liberal studies and essential skills. Recognizing the need for students, from the beginning of their education, to understand and utilize the interconnectedness of various subject domains, we explored the possibility of using an integrated approach to developing HI competencies. Our challenge was that, on the one hand, we needed to teach a set of specific competencies (skills, knowledge and attitudes), and, on the another hand, to help students to develop a holistic view of HI.

An integrated approach to informatics education was advocated by the American College of Medical Informatics [9]. However, one of the big challenges with innovative curriculum design and delivery, including an integrated approach to curriculum, is ensuring that the faculty is fully collaborating and that key principles and best practices are established from the very first days of the program. A fully integrated curriculum would require a heavy commitment of faculty time and organizational resources. Therefore, we began by integrating three Year One courses, “Health Informatics I,” “Health Records,” and “Foundations of Communication for Health Informatics,” and by systematically using case studies as a holistic framework for these courses. The assumption was that this framework would allow the students to make better sense of the skills, knowledge, and attitudes learned in other courses.

Characteristics of Excellent Case Studies in HI

The careful choosing and systematic presentation of case studies can allow educational programs to ensure they meet the best practices advocated by the American College of Medical Informatics. These best practices include, among others, collaboration in a multi-disciplinary setting, integrating data of varied types and from varied sources, and promoting mutual respect and understanding among individuals who work in varying domains [9].

In order to meet these criteria, we developed the following check-list for choosing and adapting case studies. Case studies should (a) possess sufficient detail for analysis and manipulation of information; (b) encourage critical thinking as to the potential benefits and limitations of HI theory and practice; (c) have solution(s) that are not transparent and require a high level of skills and knowledge; (d) engender a high degree of discussion, debate and investigation in the search for solution(s); (e) encourage the use of HI resources (journals, magazines, web sites, books, etc.); (f) be intrinsically interesting and add to students’ knowledge of HI within the context of real or possible HI projects; (g) advance students’ knowledge of emerging issues in HI (bioinformatics, bio-surveillance, Open Source software, internationalization, etc.); (h) force students to consider human and social aspects of HI and how they interact with IT; (i) build life-long learning skills and other essential skills (interpersonal, team, and communication skills); (j) develop generalizable principles that can be transferred to other cases; (k) reinforce the fact that HI is a multidisciplinary professional environment; (l) help learners/teachers identify gaps in knowledge that need to be addressed; (m) encourage students to look at issues from a variety of perspectives (cultural, professional, generational, etc); (n) raise relevant, practical questions; (o) force students to analyze what different people would do differently and why; (p) identify problems that HIPs need to address, (r) introduce challenging issues such as ethics, politics, power, etc.

Case Studies Used in the Course

Fortunately, two resources were available for learners to be introduced to the HI concepts for the first time. The book “Ethics and Information Technology” [6] provided short cases that allowed the professor to demonstrate the systematic approach to analyzing case studies that would be used both for teaching and student group work and evaluation. The book “Transforming Health Care Through Information” [8] was the major resource for case studies. The students purchased this textbook and were given the course schedule with associated readings. They were expected to pre-read and evaluate a case before coming to each class. Both peer pressure and understanding of the small world of HI (today’s classmate can be tomorrow’s boss or colleague) plus the intrinsic usefulness of the activities helped to ensure that the students came prepared.

A Framework for Case Study Analysis

We developed a rubric for analyzing case studies. The steps of analysis correspond closely with the competencies that our students have to develop in order to be successful HI business analysts. The rubric serves as a guideline for analyzing HI situations, both in courses and in industry. The following are the steps in the framework of case study analysis:

Introduction to the Case Study

This grabs the attention of the learner and also serves the following three key purposes. First, it allows the learners to contextualize and situate the problems in the case study in space and time. For this, the professor can prepare news items, personal anecdotes, visuals, statistics, and applicable research findings. For example, if the case study relates to emergency room waiting times, historical and geographical data can be used to provide perspective prior to starting the case analysis. It must become obvious to the learners that HIPs must understand the specifics of an emergency room in Canada versus in China or Germany based on the social, political, economical, legal and cultural factors. Second, the introduction should activate students’ prior knowledge so that new knowledge can be easily “pegged.” Third, it should allow for the identification and compensation of knowledge gaps that could impede students’ learning from the case. For example, if the students do not understand the specifics of working in an intensive care unit (ICU), it would be very difficult for them to analyze a case study on implementing a decision support system in an ICU. If knowledge gaps are identified, the professor should compensate for them and might have to adjust the lesson plan accordingly. It is possible that some students with previous educational or work experience can serve as experts. Videos from nursing and medical education can serve as useful tools to illustrate the complexity and urgency of different health care situations.

Rationale for Choosing the Case

At this step of the case analysis we ask the students to identify at least five reasons why working on the case would contribute to the development of their HI competencies. We have the students choose the competencies from a check list based on the work by Covvey, Zitner, and Bernstein [1].

Short Summary of the Situation in the Case

This part gives the students practice in succinctly describing the cases. The students are taught this skill in our program’s Communication courses by writing summaries and abstracts.

Discussion of the Key Players and Power Dynamics

The students have to identify the main individuals, professions, departments, regulatory bodies or organizations that impact on or are impacted by the situation in the case. After such identification, the interests, mandates, influences, and agendas contributing to relationships between key players are discussed. It is very important at this point to identify the history of such relationships. For example, the learners have to appreciate the historical development of different health care professions, e.g., doctors, nurses, lab technicians, pharmacists, etc., their ways of practicing and the responsibilities. The students also need to become familiar with various jobs in health organizations, e.g., CEO, CIO, CFO, heads of departments, etc. Organizational charts from different health care organizations are usually available on the Web. Students can be asked to find job postings related to each position and to compare and comment on responsibilities. It is also imperative to emphasize the changing role of health care recipients as patients, consumers or customers.

Discussion of the Underlying Problems in the Health Care System that the Individuals in the Case Were Initially Trying to Address

This is one of the most critical and challenging aspects of case analysis for students to understand. It takes some time for them to truly appreciate that the primary objective of HI is to resolve health care problems. Instead, the tendency of the students is either to identify problems in the case study situation or to focus on technological aspects discussed in the case. However, students with previous health care backgrounds are able to immediately appreciate this point and help others to understand this dimension of case analysis. The professor needs to explain to students that such underlying problems are ubiquitous and are common to the majority of health care organizations internationally. For example, medical errors, information sharing, continuum of care, staffing, privacy, security and confidentiality, etc. would be some of the problems that can potentially be addressed by HI.

We begin the term by asking students to identify problems and group them into three simple categories: clinical, financial, and administrative. As the term progresses, and the students’ knowledge and insight into the complexity of HI and case studies grow, additional categories are organically added. By the end of the term, each class has co-created its own list of over 20 categories, including, for example, information flow, data/information requirements, diversity, privacy and security, regulatory and legislative, ownership, leadership, user training and professional development, technological, project management, and others.

Despite the usefulness of such a list, the focus is not on the actual terminology and categorization. The main goal is to lead the students beyond the “surface” expression of the cases towards a deep appreciation of the complexity of HI projects in health care organizations.

Discussion of Issues Specifically Related to the Health Care Problems in the Case

The health care system problems discussed above are “located” on a higher level, as they are quite general and can apply to any organization. For example, waiting times in an emergency room is a common administrative problem for many health care organizations. However, the students must know how to identify issues specific to the situation discussed in the case that are contributing to the problem. For example, in one of the cases some of the issues that contributed to the inefficient work of the emergency room included unclear job descriptions, a lack of concern for patient satisfaction, lack of staff, cumbersome paper-based processes, and others [10]. It is important for the professor to explain that sometimes an issue can contribute to different health care problems that the people in the case are trying to resolve. One simple issue such as ineffective communication between the emergency department and the lab can cause problems in any category mentioned above, for example, clinical (delay in diagnosis and treatment), administrative (inefficient utilization of ER resources such as beds), financial (cost of repeated tests), privacy and confidentiality (rushed transfer of papers from one location to another), and others.

Discussion of the Ways HI Can Contribute to Resolving the Issues Involved

In this part of the case analysis, the professor has to make clear the ways that managing data and information using appropriate information and communication technology can help to address the underlying problems in the health care system and contributing issues that the individuals in the case are trying to resolve. Even though, on the surface, the original plan of the people in the case is sound, it is important to push the students to come up with novel alternatives. In fact, it is our experience that some of students’ suggestions are both creative and plausible and could resolve the problems in the case.

Discussion of Things That Went Wrong in the Case

Although this is a pretty obvious section, it is important to have the students articulate precisely what went wrong. As they go through more cases, it becomes clear that there are common themes underlying the project failures in HI. Such themes include leadership issues, executive level support, training, system interoperability, lack of clinician buy-in, ineffective project management, etc.

Discussion of Possible Solutions to the Things That Went Wrong in the Case

Here students get to be creative and come up with a plan that reflects best practices in HI to prevent or resolve the drawbacks of the case.

Analysis of Key Learning Points From the Case to Facilitate Other Health Care Informatics Projects in the Future

Here students are asked to list at least five things that they have learned from the case. After identifying these key learning points, the students have to explain why each identified point is important and how it can be implemented.

Identification and Explanation of Skills and Knowledge That Can Help HIPs to be Successful in Resolving Similar Cases

This part is related to HI competencies (knowledge, skills, and attitudes) and helps the students to appreciate the need for the diverse course work they are undertaking during the program. The students are encouraged to master these competencies via their course work, co-op placements, and use of our in-house Agfa Clinical Systems lab. They can also add such competencies to their resumes and explain them during job interviews.

Conclusion to the Case Study Analysis

It is important to precisely state the importance of the case for the students’ education. When students work on the conclusion, they need to summarize what they have learned from the case linking the important points from each part of the case analysis. It is very useful for students to work on creating a written version of such conclusions in order to practice their written communication skills.

By the end of the first term (15 weeks, 4 hours per week) the students in “Health Informatics I” usually have analyzed 8 to 10 case studies in depth. When the students go to their first co-op after 8 months in the program, one of the things that has most impressed our students’ co-op supervisors is their ability to step into the organization and do a deep analysis of a situation thus providing insights that surprise even seasoned HIPs.

Course Evaluation

We have experimented with four different types of evaluation for the “Health Informatics I” course. First, the students worked in groups on an assigned case study and presented and facilitated a two-hour case study analysis to the class. This required frequent meetings with the professor to prepare each group. The students had to create agendas and minutes for each meeting. A variety of evaluation rubrics were used. The next alternative involved the students working either individually or in small groups (2–3 students) to create a formal report (10–15 pages) on their case analysis. The third evaluation involved the students writing explanations of case analysis methodology using examples from the case studies discussions in class. The fourth option used was midterm and final exams featuring short answer questions using information from case studies.

Future Steps For the Use of Case Studies in HI Education

Although the current case study resources are extremely useful, there is a need to develop additional resources. Ideally, we would suggest the following four resources: (1) the development of a large number of realistic case studies that meet the criteria of our check-list; (2) the creation of multiple expert solutions for each case study that have been commented on by a team of HIPs so that the professor and students have a point of comparison and can also discuss the opposing views presented; (3) the collection of additional information that is applicable to analyzing case studies; (4) the development of a yearly competition held by an international education committee for the best response to a critical incidence scenario with a prize attached.

Conclusion

This paper offers a contribution towards establishing a pedagogy of HI by illustrating how a pedagogical tool, such as case studies, can be used in a systematic way to illustrate HI subject matter knowledge. The results of our approach can be used for planning HI workshops, classes, and courses.

The way the subject is delivered to students has a significant bearing on the development of future professionals. Using case studies provides a vehicle for a professor to illustrate to students at the very beginning of their HI education how separate subjects covered in different courses are crucial for HIPs. Introducing the interrelationships between subjects helps the students to better grasp the fundamentals and recall facts later.

One of the most frequently complimented aspects of our students’ co-op evaluations was their ability to understand the complexity of health care problems, rather than focusing primarily on technological aspects of HI projects. Thus, the systematic approach to teaching and learning from case studies, repeated multiple times during the course of learning, can lead to the rapid development of HI competencies. This increased ability to quickly develop HI competencies would support IMIA’s and AMIA’s initiatives to develop an HI workforce.