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Position Paper

Clinical Informatics: Supporting the Use of Evidence in Practice and Relevance to Physical Therapy Education

Lobach, David F, MD, PhD

Author Information
Journal of Physical Therapy Education: December 2004 - Volume 18 - Issue 3 - p 24-34

Abstract

INTRODUCTION

What is Biomedical Informatics?

The volume of clinical research literature is exploding. More than 4,500 journals publish biomedical research generating more than 40,000 new articles each month.1 The days when clinicians could stay abreast of the latest advances in health care simply by “keeping up” with their journal reading have passed. In addition, as more laboratory tests and imaging techniques are developed, the amount of clinical and biological data that is collected about individual patients is continuing to increase.

Biomedical informatics is the discipline that has arisen to study and address the generation and handling of information related to human health and disease. As a formal definition, Greenes and Shortliffe2 describe biomedical informatics as “the rapidly developing scientific field that deals with resources, devices and formalized methods for optimizing the storage, retrieval and management of biomedical information for problem solving and decision making.” At the root of this discipline is a desire to use health information more effectively to improve the quality, lower the costs, and expand the accessibility of care. As a consequence, the potential benefits of health information technology for health care are being acknowledged from the highest levels of government.3 Additionally, groups such as the Institute of Medicine and the Leapfrog Group, a consortium of over 150 organizations that provide health care benefits, including several Fortune 500 companies, are looking to health information technology as a significant remedy for the “crisis of quality” facing health care in the United States.4,5 Recent reports have suggested that as many as 98,000 patients may die annually from preventable medical errors in the United States, implicating medical errors as one of the top 10 causes of death.4 A study of 439 indicators of care quality recently reported that adults in the United States only receive approximately half of the preventive, acute, and chronic care that has been recommended for optimal patient management.6 The explosion of biomedical research literature, the plethora of clinical data, and the crisis of health care quality all beckon better approaches and tools for handling health-related information. Creating, applying, and evaluating such approaches and tools for biomedical research, clinical research, health care delivery, and education are the business of biomedical informatics.

Biomedical informatics draws from several other more traditional and more established disciplines for principles and practices to define the field. These contributing disciplines include computer science, information science, cognitive science, decision science, management/organizational science, and statistics.7 Like many other disciplines, biomedical informatics can be subdivided into basic and applied areas. The basic research areas address the theories, techniques, and methods that transcend specific applications, such as the techniques for representing knowledge. In contrast, the applied research areas use the techniques and methods in a specific domain.

The general discipline of biomedical informatics can be partitioned into several subdisciplines that focus on the application of basic principles for a given area (Figure 1). The primary subdivision is into bioinformatics, which addresses biological research applications, and medical informatics, which focuses on clinical applications. Thus, bioinformatics constitutes information and computer science in the context of biological research at a molecular and cellular level.7 Medical informatics in turn represents the application of the contributing disciplines to health care.

Figure 1
Figure 1:
Relationship of various content areas within biomedical informatics. The tree “roots” illustrate the core basic science disciplines upon which biomedical informatics is based. The tree “branches” illustrate the many diverse subfields of biomedical informatics with a primary division into health care-related (medical informatics) and bioinformatics-related applications.

Further subdivisions of medical informatics that are particularly germane to evidence-based practice and physical therapy are the subfields of knowledge management and clinical informatics. Knowledge management addresses the storage, representation, and retrieval of health care information, such as research evidence and clinical practice guidelines. Clinical informatics is the application of specific approaches and tools to the delivery of health care, such as electronic health records (EHRs) and computerized physician/practitioner order entry (CPOE).

While the first practical application of automated computing in health care is attributed to Herman Hollerith, who developed a punch card data-processing system to analyze the 1890 US Census data, the origins of the field of biomedical informatics can be more directly traced to the late 1950s and early 1960s, when the newly developed digital computers began being used in health care.8 Early applications applied computer technology to modeling cardiac physiology, assisting clinicians with the diagnostic process, and creating hospital information systems.9 Many of these early applications were limited by the cost and technical restrictions of the available computers. The introduction of minicomputers in the 1970s facilitated some expansion of computer use in health care; however, the explosion of technology in medicine began with the personal computer era in the early 1980s.9 The availability of personal microcomputers ushered in an era in which computers began to touch all facets of health care. As a result, health care-oriented applications that had traditionally resided primarily in academic research centers became commercial products that were available on a broad scale. These applications included practice management systems, hospital information systems, diagnostic aids, laboratory systems, and rudimentary electronic health records.

As a consequence of this expansion in functionality and availability of computers, the field of biomedical informatics also began to grow and diversify to the extent that biomedical informatics now touches almost every facet of health care and biomedical research. The general discipline of medical informatics has evolved into multiple subdisciplines that focus on specific areas of application. Clinical informatics is the subdiscipline that subsumes the study of the use of information technology in the clinical setting. This subdiscipline includes EHRs, CPOE, and clinical decision support systems (CDSS). Other subdisciplines include the areas of public health informatics, imaging informatics, knowledge management, knowledge representation, and information retrieval, to name a few.

Clinical Informatics in Practice

Some aspects of clinical informatics have been particularly noteworthy because of increased media attention. Specifically, the Leapfrog Group identified computerized physician/practitioner order entry as one of its initial three “leaps” to foster increased patient safety.5 CPOE systems require clinicians to enter orders directly into a computer to eliminate errors from misreading or misinterpreting handwritten instructions, to intercept orders that could result in adverse drug reactions, and to foster compliance with standard care protocols. The use of CPOE has been shown to reduce medication errors,10,11 decrease redundant ordering of laboratory studies,12-14 decrease hospital length of stay,14 and increase compliance with health care protocols.15,16 However, not all CPOE implementations have been successful. Most require increased effort on behalf of the clinician,17 and some have been perceived as so disruptive that clinicians demand that entire systems be shut down.18 While many advantages can be gleaned from CPOE, this relatively new technology still requires refinement in terms of both the design of the clinical application and the integration of these systems into the clinical environment.

The role of technology in health care has also received attention from the highest levels of government in the United States with the inclusion of a reference to electronic health records in the President's 2004 State of the Union address.19 Subsequent announcements have specified plans to create a nationwide, interoperable National Health Information Infrastructure, including a proposal to have electronic medical records for most US residents by 2014 for the purpose of improving the safety, quality, coordination, and efficiency of health care delivery.20 Specifically, on April 27, 2004, President George W Bush issued an Executive Order calling for widespread deployment of health information technology within 10 years. An important aspect of the President's initiative is the development of a nationwide interoperable health information technology infrastructure that can facilitate improvements in safety, quality, efficiency, and health care coordination. EHRs are touted as one tool for decreasing medical errors, increasing coordination of health care, and lowering costs. Studies have shown that EHRs facilitate the collection of clinical information,21,22 improve the completeness of health care documentation,22 enable more detailed tracking of the health care delivery process,21 improve compliance with recommendations for preventive health,23,24 increase compliance with disease-management protocols,23,25-27 and lower health care costs.28 The use of EHRs is steadily increasing but the prevalence of these systems is still on the order of 10%.29 As with CPOE, the adoption of EHRs has been slow to catch on in part because of high start-up costs, but also because this technology also needs refinement with regard to how it can most effectively fit into the clinical workflow with minimal disruption and maximal benefit.

A third group of applications that are particularly germane to evidence-based practice are known as clinical decision support systems. These systems are often integrated with CPOE or EHRs as a mechanism to promote evidence-based practice and improve patient safety. CDSS are defined as systems designed to aid in clinical decision making by using patient data to generate patient-specific assessments or recommendations that are then presented to a clinician for consideration.30 CDSS have been shown to reduce serious medication errors10,31; increase the delivery of preventive health care services32,33; improve adherence to care standards30,34,35; and optimize medication prescribing.36-38 An example of an operational CDSS is a printed sheet generated for a patient with diabetes at the time of registration at a clinic that summarizes the patient's data for specific health care guidelines, and makes recommendations for this patient to foster compliance with the established care standards.35

Resources for Clinical Informatics

As the field of biomedical informatics has grown, an increasing assortment of resources has become available to support academic pursuits in this discipline (Table 1). Several journals have emerged that focus exclusively on reporting scientific discoveries related to biomedical informatics.39 In addition, papers related to biomedical informatics are increasingly appearing in mainline clinical journals, such as the Journal of the American Medical Association.2

Table 1
Table 1:
Resources for Clinical Informatics and Biomedical Informatics Training/Education
Table 1
Table 1:
continued from page 38
Table 1
Table 1:
continued from page 39
Table 1
Table 1:
continued from page 40

Training in biomedical informatics has also become increasingly available (Table 1). The National Library of Medicine (NLM) supports 18 university-based biomedical informatics research training programs situated in 15 different states.40 The nature of these programs varies from a concentration on bioinformatics, such as the program at Rice University, to a dominant clinical focus, such as that of the University of Utah. Some of these programs grant formal degrees in biomedical informatics (master's or doctoral level), while others provide a certificate or fellowship experience. A few of these programs have begun to offer distance education via the World Wide Web, eg, Oregon Health Sciences University.41 In addition to these institutionally based training programs, the NLM also funds training grants for individuals.42 Aside from NLM-sponsored institutions, several universities offer degrees in biomedical informatics.43 Less intensive training is also possible through 1-week overview “short courses” offered by the NLM44 or universities such as Stanford University.45

An increasing number of organizations, most of which also sponsor conferences, are also emerging to facilitate the sharing of biomedical informatics knowledge and experience (Table 1). The American Medical Informatics Association (AMIA) is the premier organization in the United States that focuses on the academic interests related to medical information. AMIA sponsors two annual conferences and publishes a leading academic informatics journal known as JAMIA, the Journal of the American Medical Informatics Association. The Healthcare Information and Management Systems Society (HIMSS) is the leading organization representing individuals involved in the industry side of medical informatics. This group sponsors an annual conference that is the primary trade show for medical informatics companies. Other organizations, such as the College of Healthcare Information Management Executives (CHIME), for chief information officers, and the American Health Information Management Association (AHIMA), for medical records professionals, focus on the needs of specific groups. Still, others concentrate on specific topic areas; this includes the Medical Records Institute (MRI), which is for the promulgation of electronic health records, and Health Level Seven (HL7), which promotes the development of industry standards for medical informatics. At an international level, IMIA, the International Medical Informatics Association, promotes professional interaction related to biomedical informatics among various nations and sponsors a triennial conference called “MedInfo.”

The Role of Clinical Informatics in Evidence-Based Practice

Clinical informatics promotes evidence-based practice through the infrastructure that enables information retrieval for accessing the primary literature and through clinical decision support systems that apply evidence in practice.46 Through a complex indexing scheme based on MeSH (medical subject heading) terms, the NLM systematically categorizes over 4,600 of the world's leading biomedical journals to create the MEDLINE/PubMed database so that the content of the articles can be accessed through natural language queries.1 The NLM indexing scheme allows for either expansion or limitation of search results through a hierarchical indexing of the MeSH terms.

Well-designed CDSS promote having the right information in the right form and quantity at the right time.47 These systems can take many forms ranging from structured order sets derived from an evidence-based clinical practice guidelines to alert notice sent via a pager regarding a published potentially harmful drug-drug interaction. While clinicians have often out-performed computers in collecting data and in the deductive reasoning required to arrive at a diagnosis,48,49 CDSS have a valuable role in consistently reminding clinicians who are often afflicted with information overload to perform routine evidence-based practices, such as preventative services (eg, mammography) or disease/medication surveillance testing (eg, glycated hemoglobin testing for patients with diabetes).50 Several reviews have shown the efficacy of CDSS in practice.30,51 In randomized controlled trials these systems have shown improved compliance with evidence-based standards for preventive services, lab test ordering, and disease surveillance. They have also contributed to supporting the use of evidence in practice by improving blood pressure control, decreasing length of hospital stay, reducing redundant laboratory testing, and lowering costs of care.

Clinical Informatics Education

In recognition of the growing role of information technology in health care, the Association of American Medical Colleges (AAMC) established an expert panel to develop specific learning objectives for training in biomedical informatics for inclusion in medical school curricula as a continuation of the AAMC Medical School Objectives Project. The report of this panel was published in 1998 and represented landmark high-level support for including biomedical informatics as part of routine medical education.52 The report content focused on equipping physicians in five professional roles: life-long learner, clinician, educator/communicator, researcher, and manager. It provided general objectives to achieve competency in a variety of areas, including accessing medical literature, obtaining information from clinical systems, using technology in decision making, presenting clinical information, managing data, and using data for administrative decisions (Table 2). At this juncture, these AAMC recommendations are due for revision to reflect advances in technology since 1998, such as the growth of the Internet and the use of personal digital assistants.

Table 2
Table 2:
AAMC Objectives for Medical Informatics Education*

Potential Clinical Informatics Content for Physical Therapy Education

In light of the growing role of information and information technology in health care, what facets of clinical informatics are relevant in the field of physical therapy? The health care literature has little to offer to this discussion to date. A set of search terms for physical therapy combined with various terms for medical informatics identified only 17 references in MEDLINE and 29 references in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Table 3). None of these references addressed informatics education in the context of physical therapy. In contrast, considerable material discussing the education of biomedical informatics specialists has been published.53-60 Components of these education programs can be extrapolated to the domain of clinical informatics training in physical therapy (Table 4).

Table 3
Table 3:
Literature Search on the Union of Physical Therapy and Biomedical Informatics
Table 4
Table 4:
Proposed Content for Clinical Informatics Education for Physical Therapy

Basic computer literacy is fundamental for all clinicians as increasingly more information is communicated electronically. Such core skills include mastering electronic mail, using personal productivity software applications (eg, word processing, spreadsheets), accessing the Internet, and searching the World Wide Web. In addition to the use of a personal computer, clinicians also need functional familiarity with personal digital assistant devices.

In order to pursue life-long learning, clinicians need to learn how to obtain information from electronic textbooks, from bibliographic reference databases such as MEDLINE, and from the Web. They should also know how to assess the quality of the information they retrieve.

A core component of medical informatics that is relevant to physical therapy is understanding how clinical data are represented through various coding systems, terminologies, and nomenclatures. Coding clinical information for billing is already common practice, and there is increasing emphasis on using coded data for the purpose of clinical documentation. Thus, an awareness of systematic terminologies (eg, SNOMED, the Systematized Nomenclature of Medicine) and approaches to associate terms across vocabularies (eg, UMLS, the Unified Medical Language System) are growing in importance.

An understanding of how clinical information flows through the clinical environment and is stored in databases will promote insight into the complexities of managing clinical data. Also included under data management is the use of data for quality assessment, for population health, and for knowledge discovery through data mining of data warehouses. Studying data management also highlights the challenges and limitations of using aggregated data as well as the security issues associated with electronically sending and storing clinical information.

A focus on the diversity of clinical information systems (eg, billing systems, laboratory systems, pharmacy systems, and image storage and retrieval systems for radiology) will promote awareness of the complexity of many health care information system networks along with the issues related to exchanging data between systems and the advantages and disadvantages of such networks. Similarly, electronic health records have a great amount of diversity that is associated with advantages and limitations with which clinicians should be familiar. Clinical decision support systems are playing an increasing role in efforts to improve patient safety, increase the quality of care delivery, and promote evidence-based practice. These systems range from complete decision-making programs to alert or reminder messaging tools.

A rudimentary understanding of the network architecture of the Internet and how information is conveyed using the Internet will underscore the potential power of this global information resource. Finally, an awareness of telehealth applications will broaden students' appreciation for how this growing field of health care may be useful for promoting physical therapy at remote sites.

CONCLUSION

Biomedical informatics is a relatively new, rapidly evolving academic discipline that studies the creation and use of information related to human health and disease. The subdivision of biomedical informatics that focuses specifically on the generation, management, and use of information in the clinical setting is known as clinical informatics. Through specific applications such as CPOE, EHRs, and CDSS, clinical informatics supports the use of evidence in practice and improves the quality and lowers the costs of health care. Many resources are now available to promote education in bioinformatics. Because of the growing role of technology in health care, exposure to fundamental aspects of biomedical informatics is critical for all clinicians, including physical therapists. Such exposure should include functional use of personal computers and personal digital assistants, training in retrieval of medical literature, understanding of coding systems for clinical data, appreciation of how data is stored and transferred, exposure to the diverse array of systems currently used in health care networks, appreciation for ways in which information systems improve the care process, and an awareness of the use of the Internet in health care through the World Wide Web and through Internet-based telemedicine applications.

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Keywords:

Physical therapy; Computers; Medical informatics; Education.

Copyright2004 (C) Academy of Physical Therapy Education, APTA