Medicine, Nursing and Health Sciences, Monash University, Monash, Victoria, Australia.
Int J Med Inform. 2009 Dec;78(12):815-26. doi: 10.1016/j.ijmedinf.2009.08.006. Epub 2009 Sep 26.
This manuscript describes the health information system security threat lifecycle (HISSTL) theory. The theory is grounded in case study data analyzing clinicians' health information system (HIS) privacy and security (P&S) experiences in the practice context.
The 'questerview' technique was applied to this study of 26 clinicians situated in 3 large Australian (across Victoria) teaching hospitals. Questerviews rely on data collection that apply standardized questions and questionnaires during recorded interviews. Analysis (using Nvivo) involved the iterative scrutiny of interview transcripts to identify emergent themes.
Issues including poor training, ambiguous legal frameworks containing punitive threats, productivity challenges, usability errors and the limitations of the natural hospital environment emerged from empirical data about the clinicians' HIS P&S practices. The natural hospital environment is defined by the permanence of electronic HISs (e-HISs), shared workspaces, outdated HIT infrastructure, constant interruption, a P&S regulatory environment that is not conducive to optimal training outcomes and budgetary constraints. The evidence also indicated the obtrusiveness, timeliness, and reliability of P&S implementations for clinical work affected participant attitudes to, and use of, e-HISs.
The HISSTL emerged from the analysis of study evidence. The theory embodies elements such as the fiscal, regulatory and natural hospital environments which impede P&S implementations in practice settings. These elements conflict with improved patient care outcomes. Efforts by clinicians to avoid conflict and emphasize patient care above P&S tended to manifest as security breaches. These breaches entrench factors beyond clinician control and perpetuate those within clinician control. Security breaches of health information can progress through the HISSTL. Some preliminary suggestions for addressing these issues are proposed.
Legislative frameworks that are not related to direct patient care were excluded from this study. Other limitations included an exclusive focus on patient care tasks post-admission and pre-discharge from public hospital wards. Finally, the number of cases was limited by the number of participants who volunteered to participate in the study. It is reasonable to assume these participants were more interested in the P&S of patient care work than their counterparts, though the study was not intended to provide quantitative or statistical data. Nonetheless, additional case studies would strengthen the HISSTL theory if confirmatory, practice-based evidence were found.
本文描述了健康信息系统安全威胁生命周期（HISSTL）理论。该理论基于案例研究数据，分析了临床医生在实践环境中使用健康信息系统（HIS）的隐私和安全（P&S）经验。
本研究采用“questerview”技术，对 26 名临床医生进行了研究，这些临床医生分布在澳大利亚（维多利亚州）的 3 家大型教学医院。questerview 技术依赖于数据收集，即在记录的访谈中应用标准化问题和问卷。分析（使用 Nvivo）涉及对访谈记录的迭代审查，以确定出现的主题。
从关于临床医生 HIS P&S 实践的经验数据中出现了一些问题，包括培训不足、法律框架含混不清包含惩罚性威胁、生产力挑战、可用性错误以及自然医院环境的限制。自然医院环境的定义是电子 HIS（e-HIS）的永久性、共享工作空间、过时的 HIT 基础设施、不断的中断、不利于最佳培训结果的 P&S 监管环境以及预算限制。证据还表明，P&S 实施对临床工作的侵扰性、及时性和可靠性影响了参与者对 e-HIS 的态度和使用。
HISSTL 是从研究证据的分析中产生的。该理论包含了财政、监管和自然医院环境等元素，这些元素阻碍了实践环境中的 P&S 实施。这些因素与改善患者护理结果相冲突。临床医生为避免冲突并强调患者护理高于 P&S 而做出的努力往往表现为安全漏洞。这些漏洞使临床医生无法控制的因素根深蒂固，并使临床医生可以控制的因素永久化。健康信息的安全漏洞可以通过 HISSTL 进展。提出了一些初步的解决这些问题的建议。
本研究排除了与直接患者护理无关的立法框架。其他限制包括仅关注入院后和出院前公共病房患者护理任务。最后，由于自愿参加研究的参与者人数有限，案例的数量也受到限制。可以合理地假设，与他们的同行相比，这些参与者对患者护理工作的 P&S 更感兴趣，尽管该研究并非旨在提供定量或统计数据。尽管如此，如果发现确认性的、基于实践的证据，更多的案例研究将加强 HISSTL 理论。
