Clinical information and its management in hospitals

Although the Audit Commission states that “information is one of the most important resources that a hospital holds,”1 information is also its least tangible resource. Information can be defined only by its function—“organised data or knowledge that provides a basis for decision-making”2—and consists of knowledge about how to achieve a goal and data about the starting point and the intervening terrain. When a clinician takes a patient management decision, these data consist of patient findings (history, observations, and test results), hypotheses (including assessments, such as the referral diagnosis, and plans), and previous actions taken.3 However, when a decision is taken about a group of patients, a clinical service, a purchaser-provider contract, or a health care organisation, data about individual patients must be grouped and abstracted before being combined with data about staffing, facilities, and other resources. Thus, high quality patient data is the foundation for decisions at all levels in a health care system (figure).