Clinical informatics in rehabilitation practice

Author(s): David Haustein, MD, Richard Riggs, MD and Matthew McLaughlin, MD

Originally published:09/20/2013

Last updated:02/13/2017

Overview and Description:

Informatics is the scientific field that deals with acquisition, storage and use of information pertinent to a specific domain, facilitated by technology.1 The discipline of informatics is commonly divided into three areas:

  • Bioinformatics
  • Public Health Informatics
  • Clinical or Medical Informatics

Bioinformatics is concerned with molecular biology or genomics, whereas public health informatics is concerned with population health. Clinical informatics can be further subdivided into informatics associated with different healthcare disciplines (e.g., medical, nursing, dental, or specialty-specific) and consumer health informatics (information access and use from healthcare consumers’ or patients’ perspective).

https://www.amia.org/sites/amia.org/files/AMIA-Clinical-Informatics-Core-Content.pdf

See Figure 1: Domains of Clinical Informatics. J Am Med Inform Assoc. 2009;16(2):153-157. doi:10.1197/jamia.M3045

The increased role of informatics in medicine requires physicians to be skilled in the field. In 2011, the American Board of Medical Specialties approved a new subspecialty of clinical informatics, in which physicians of any primary specialty can subspecialize. Clinical informatics subspecialists will take leadership roles at the intersection of clinical care (information), healthcare organizations (people), and technology.

2. Relevance to Clinical Practice

A. Clinical Care (Information)

The scope of clinical informatics is broad.  Informatics impacts clinical care through:

  • Electronic health record (EHR) design
    • Relevant data display delivers the right information about the right patient at the right time
  • Providing information related to evidence-based medicine (EBM) to the clinical team at the right time and location within the clinical workflow
  • Clinical workflow analysis, including process redesign and quality improvement
  • Clinical decision support (CDS):
    • Understanding how to apply the evidence and research to create useful decision support that results in positive functional outcomes without disrupting clinical workflow is extremely important. CDS in the context of a typical patient-physician encounter may involve order entry with drug-drug interactions, dosing suggestions, informational alerts, links to EBM, applicable data summary presentation, and knowledge-based templates.2
    • Examples:
      • An alert can notify the provider it is time to complete the next NIHSS form
      • Risk factors for early seizures in a traumatic brain injury can be brought to the physician’s attention at the time of order entry to suggest prophylaxis for seven days
      • Physician order sets can assist in assuring standardization of care occurs based on guidelines

Informatics also allows researchers to store and access large amounts of information and to ‘mine’ clinical data to test research hypotheses. Precision medicine aims to provide personalized treatment that considers individual variability in genes, environment and risk factors.3 In the future, this emerging approach may provide valuable insights as to precise rehabilitation interventions across the spectrum of impairments. To accomplish this, the EHR or Personal Health Record (PHR) serves as the platform for documentation to guide personalized treatments and interventions.

B. Healthcare Organizations (People)

Today, most medical care is delivered by people working for healthcare organizations. Providers use the tools of technology to care for patients. In order to achieve adoption of technology by people, clinical informatics must also address the human factor. Studies suggest that it is this human factor that makes the difference as to whether technology is utilized, and not the choice of a technology. Decision support is only beneficial if the technological tools providing CDS are adopted; for example, providers must utilize the EHR and be willing to adopt it.  Providers practice in a world that is dependent upon healthcare organizations, referrals, and government regulations. Clinical informatics employs a physiatrist’s skill of uniting interdisciplinary clinical teams to provide leadership in the face of change management at an organizational level. Original studies depict varying degrees of EHR adoption in separate practices implementing the same EHR.4,5. Despite these challenges, informaticists may be able to unify medical record systems to improve data sharing across healthcare organizations.

C. Technology

Health information technology (HIT) encompasses computers and technology to deliver healthcare. It is often thought of as the EHR, PHR and health information exchange (HIE). In addition, information systems have an expected lifecycle that requires management through collaboration from both the HIT and informatics teams.

This core technology must account for data privacy and security, yet maintain standards for exchange of information.  Information is exchanged through the HIE. IRFs receive patients from other hospitals and discharge patients to the community or to SNFs. These disparate systems communicate via an HIE. For example, the CDS illustrated above using the NIHSS was started in an acute inpatient hospital. It can be electronically transmitted to the IRF and then to the ambulatory world, regardless of the vendor technology selection, thus further assisting patient care and outcomes. Private and state HIEs are beginning to connect the world of healthcare. Fortunately, exchanges utilizing radiographic images have initiated the ability to share medical records or tests across different health system platforms. This allows for improving access of information for providers currently treating patients acutely outside of their “medical home.”

3. Cutting Edge/Emerging Issues/Gaps in Knowledge

Many questions remain to be answered, including:

  • How to best approach decision support with minimal intrusion to workflow
  • What human factors are important to implementations
  • How data should be shared and by whom

Additionally, artificial intelligence (AI), which includes machine learning, deep learning and predictive analytics for patient outcomes, shows promise for its ability to both improve quality of care and immediately sense and respond to cybersecurity threats against healthcare organizations.

Other areas of interest include accountable care, population health, predictive medicine, and personalized medicine. Tools utilized for population management typically include a database or registry to collect information, data extraction techniques to define gaps in care and visualization applications or dashboards to facilitate understanding the population characteristics.  With these elements in place, concurrent analytics by data scientists can then facilitate prediction of potential risks or interventions at the patient level.  Personalized medicine will require platforms for genomic and proteomic disease related information to be stored at the patient level in order to be actionable.  As EHRs have been created for clinical care discrete elements, scaling for these large data sets will require agile integration to be clinically impactful for future potential treatment.

Spanning multiple domains, clinical informatics is the discipline that will bridge the intersection of clinical care, healthcare organizations and technology. Physician informaticists, with their expertise in the intersection of information, organizations and technology, will serve a critical role in the future of healthcare.

REFERENCES

1. Hersh W Stimulus to define informatics and health information technology. BMC Medical Informatics and Decision Making. 2009, 9:24. Accessed 4/28/2013.

2. Carter, Jero Electronic Health Records: A Guide for Clinicians and Administrators. 2nd ed. Philadelphia, PA: American College of Physicians; 2008:197-199.

3. National Institutes of Health, U.S. National Library of Medicine: Genetics Home Reference. https://ghr.nlm.nih.gov/primer/precisionmedicine/definition. Accessed 4/9/2017.

4. O’Connell RT, Cho C, Shah N, Brown K, Shiffman RN.Take note(s): differential EHR satisfactions with two implementations under one roo J Am Med Inform Assoc. 2004;11 (1).

5. Lanham HJ, Leykum LK, McDaniel RR. Same organization, same electronic health records (EHRs) system, different use: exploring the linkage between practice member communication patterns and EHR use patterns in an ambulatory care setting. J Am Med Inform Assoc. 2012;19:382-391.

Original Version of the Topic

Jodi Kodish-Wachs, MD, William Hersh, MD. Clinical informatics in rehabilitation practice. 09/20/2013.

Author Disclosure

David Haustein, MD
Nothing to Disclose

Richard Riggs, MD
Nothing to Disclose

Matthew McLaughlin, MD
Nothing to Disclose

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