- Email: [email protected]
Informatics Primer for Physiatric Practice
Practice Management
Informatics Primer for Physiatric Practice Louis E. Penrod, MD, Todd Rowland, MD INTRODUCTION This article is intended to be an introduction to the field of medical informatics for physiatrists in a variety of settings. Informatics is often divided into a number of subclassifications (eg, clinical informatics, bioinformatics, imaging informatics, telemedicine); however, for the purposes of this paper, the term will be used in a generic manner. Although a relatively new field of academic and practical focus, it is likely that informatics will touch on the clinical practice of most physicians within the near future. There have been many attempts to define the emerging field of informatics. A commonly acknowledged definition can be found in the textbook by Shortliffe et al [1]: “[T]he scientific field that deals with biomedical information, data, and knowledge—their storage, retrieval, and optimal use for problem solving and decision making.” From this definition, it can be seen that this field potentially touches all aspects of providing medical care. A brief review of the history and development of informatics will provide a framework for more detailed discussion. The initial successful application of automated data processing was Herman Hollerith’s use of a punch-card system for the 1890 U.S. census. This approach was further explored for epidemiology and public health purposes over the next several decades. With the development of totally electronic systems shortly after World War II, the potential for other applications started to be explored. A few large, academically based medical centers developed hospital information systems that provided practical benefits. Most notable of these were the systems at the Massachusetts General Hospital in Boston, Latter-Day Saints Hospital in Salt Lake City, and the Regenstrief Medical Record System in Indianapolis. Each of these efforts has been gradually refined over several decades, and each is notable for its ongoing use as well as the academic foundation provided to the field within the United States. Development of increasingly more powerful and more affordable computers, culminating with the development of the personal computer by the 1980s, set the stage for a radical transformation of information systems. Today, networked arrangements of a variety of computing devices (servers, client computers, medical monitors, and wireless devices including smart phones and personal digital assistants) provide the infrastructure to capture and share data at all points throughout the process of providing clinical care. The National Library of Medicine has assumed a central role in informatics, with support for basic research in the field over the last few decades [1]. There are now a number of electronic medical record (EMR) systems commercially available. The Office of the National Coordinator for Health Information Technology was established in 2004 to promote the goal of all Americans having access to interoperable (“portable”) EMRs, with a target date of 2014 [2]. The Certification Commission for Health Information Technology also was established in 2004 as a nonprofit organization that reviews and certifies commercial health information technology (HIT) products [3]. Certification Commission for Health Information Technology certification is intended to reassure providers and healthcare organizations that a product meets certain basic functional requirements. Most recently, the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) included funding to promote HIT adoption [4-6]. The following sections of this paper provide an overview of how the emerging discipline of informatics may affect physiatric practice, whether in an inpatient or outpatient setting. This will be divided into Business and Clinical Impact, and Career and Educational Options. A glossary at the end of the paper contains terms and acronyms frequently encountered in the field of informatics. PM&R
1030
1934-1482/09/$36.00 Printed in U.S.A.
L.E.P. Department of PM&R, University of Pittsburgh School of Medicine, Pittsburgh, PA Disclosure: nothing to disclose T.R. HealthLINC HIE, Bloomington, IN Disclosure: 1B, Executive Director of Health LINC HIE; 2A, President E-Health Consulting; 3A, Axolotl Corp.; 8B, HHS Office of National Coordinator, HRSA, Physicians Foundation Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org Submitted for publication August 21, 2008; accepted December 9.
© 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 1030-1034, November 2009 DOI: 10.1016/j.pmrj.2009.09.020
PM&R
BUSINESS AND CLINICAL IMPACT There are many forces advancing adoption of HIT. In the private sector, the Leapfrog Group is an association of major employers that promotes health care facilities’ adoption of medical practices that they judge instrumental in improving the quality of care [7]. Computerized provider order entry (CPOE) with integrated clinical decision support system (CDSS) is among the first of the practices they are promoting. Adherence to this process includes a test of CPOE that assesses a base level of decision support including allergy checking, drug-drug interaction, and some basic drug-disease interaction. Results of a facility’s test are posted on the Leapfrog Group’s website for public viewing. For private practices, provisions in the ARRA provide significant motivation for HIT adoption by rewarding “meaningful use” of EMR technology [4-6]. However, the exact interpretation of “meaningful use” has yet to be clarified. It is expected that this will include electronic prescription and reporting of quality measures. The Center for Medicare and Medicaid Services also is pushing HIT adoption indirectly through the Physician Quality Reporting Initiative. In the initial phases, practices reporting compliance with at least 3 standards will receive a small increment in reimbursement beyond usual levels for all patients covered by Medicare. The intent is to gradually expand the number of quality measures that must be reported as well as to impose a reimbursement penalty for practices that do not comply. It is difficult to conceive how this will ultimately be possible without an electronic system to track and report the data. Despite the relatively recent development of informatics, there are indications that further development is warranted to improve the health care system. Several studies have shown a consistent and significant improvement in quality of care by adoption of CPOE with an integrated CDSS. In particular, medical errors associated with medication orders have been reduced by 50%-86% in select settings [8-10]. Typically these improvements result from legibility of orders and drug interaction checking (drug-allergy, drug-drug, and drug-disease state considerations are all important). Transitions in care (admission, discharge, changing care teams) are also high-risk events for preventable medical errors [11]. One potential cause of these errors is that test results often are not available at the time of discharge from acute care facilities. Roy et al [12] showed this occurred in 41% of cases discharged from 2 teaching hospitals. Of these, the results were judged to be “actionable” in 9.4%. Physiatrists frequently are involved in transitions of care and invest considerable time developing practice conventions with the goal of reducing the risk for these types of errors. Typical examples include following up on pending test results (an error of omission); medication reconciliation to minimize the risk of adverse drug events; and efforts to enhance communication with the acute care team, consultants still involved in the care of the patient, and with physicians who will assume care after the completion of inpatient rehabilitation. Patients with cognitive deficits are at higher risk for such
Vol. 1, Iss. 11, 2009
1031
errors because they are less able to understand and track details of the care plan. Providing an additional challenge, these patients often have complex medical conditions resulting in complex care plans. Informatics addresses many of these issues by developing and implementing solutions to enhance coordination of care—typically as a regional health information organization or health information exchange. However, obtaining sustainable funding for such endeavors has been challenging. One example that has demonstrated success is the HealthLINC Health Information Exchange in Bloomington, Indiana, a not-for-profit organization that provides a delivery and management system for test results enabled by a secure communication network operating across disparate HIT systems. In this community, neurologists, neurosurgeons, and physiatrists use the system to enhance patient transfers of care by electronic routing of results, pending results, consultations, and discharge summaries [13]. A few telemedicine demonstrations have shown promise in improving quality of care once an individual has been discharged from inpatient rehabilitation following spinal cord injury (SCI). A study based out of the Shepherd Center in Atlanta recruited newly injured patients during the initial rehabilitation phase. Through a telehealth intervention, health-related quality of life measures were improved significantly at 1 year post-discharge. There also appeared to be reduced hospitalization by improved education and early identification of problems. The impact on skin care practices was a major contributor to this trend [14]. A telerehabilitation program at the James J. Peters VAMC in the Bronx focused specifically on common comorbidities of SCI, including type 2 diabetes, hypertension, obesity, bladder infections, depression, and skin care. Interventions were tailored to the individual’s particular needs. This program was well received by both patients and their caregivers. Office visits increased, but hospitalizations and length of stay decreased [15]. Both of these reports emphasized the value of this technology for individuals who are commonly discharged to remote locations following the completion of their inpatient SCI rehabilitation. A survey of persons with chronic SCI showed internet use at least as frequent as the general population. E-mail and searching for disability and health information were the most frequent activities. For regular internet users, health-related quality of life indicators were significantly better [16]. There are potentially huge benefits to the adoption of HIT in building the scientific base of physical medicine and rehabilitation. Capturing large amounts of clinical data in electronic format allows analyses in ways never before practical in paper-based systems. Databases that capture detailed information on patient characteristics, interventions, and outcomes can be leveraged to discover what aspects of physiatric practice are most effective and where there is room for innovation. The work done by Stineman et al [17] in analyzing functional independence measure data for diagnosisspecific patterns of function is an example of the potential for
1032
Penrod and Rowland
collecting raw data in formats that can be then analyzed and reapplied in new clinical methods. One major consideration in adoption of HIT is the fundamental change in practice patterns that will undoubtedly occur on many levels. When considering automation of existing workflows, careful consideration should first be given to what has been working well and what could be improved irrespective of any technological solutions. Next, an understanding of how current practice should be changed for both efficiency and technological reasons, as well as how the technology must be modified to meet critical practice needs should be carefully assessed. Although a considerable investment in time and effort, in the long run this will be an investment that pays substantial rewards. Because HIT has a profound impact on the nature of both institutional and outpatient practice, a comprehensive analysis of return on investment is difficult to demonstrate. Specific markers of individual’s performance can be tracked that are then extrapolated to a generalized overall outcome of care. However, this type of measurement does not always offer a complete picture of what specifically happened or was the result of a specific transformation. Some tasks require more time and effort when HIT is employed (such as CPOE), others require much less time (results review), and still others require a complete change in activities (such as checking or adding quality measures). However, it can be noted that in the outpatient setting, survey data have shown that after the transformation to HIT has been completed, the overwhelming majority of practitioners respond that they would not return to paper systems if given the choice [18,19].
CAREER AND EDUCATIONAL OPTIONS It is fairly easy to recognize how integration of informatics is a natural extension of physiatric practice. Compiling data from a variety of sources (eg, therapy progress notes and test results) and from various environments (eg, inpatient or outpatient) produces a comprehensive picture of a given patient’s functional status that is integral to physiatric care. As these data sources individually transition to electronic format, it will likely be the role of the physician (in this case, physiatrist) to facilitate synthesis of this aggregated information for enhancement of clinical care. Indeed, a number of physiatrists already have entered the field of informatics on a part- to full-time basis. As mentioned previously, the ARRA funding for “meaningful use” of HIT will certainly drive adoption across many practice settings [4-6]. The availability of this funding also is likely to increase the availability of physician “informaticist” positions. Individual physiatrists will have a range of opportunities, depending on their practice setting. In a solo or small group setting, informatics is likely to be only an area of interest. For individuals working in an institutional setting, it would be more feasible for informatics to become a substantial portion of their work effort. Particularly for larger inpatient facilities, it would be important to have local resources to lead the institution’s informatics initiatives. It is reasonable
INFORMATICS PRIMER FOR PHYSIATRIC PRACTICE
to expect this activity to be compensated fairly as it will take away from the physiatrist’s potential to generate billings from direct patient care. For the physiatrist who wishes to become more proficient in informatics, there are a number of routes to gain expertise. Local chapters of the Healthcare Information and Management Systems Society usually have programs that provide both background and networking opportunities. Both Healthcare Information and Management Systems Society and the American Medical Informatics Association (AMIA) have educational sessions as part of their yearly meetings [20,21]. AMIA also has a short-term, focused training program called “AMIA 10⫻10” that has been well received as an introduction to didactic training in the field [20]. For those seeking additional training, there are several “executive master’s degree” type programs that involve limited on-campus sessions integrated with distance learning. Another source that may be valuable as it develops is the Physicians’ Electronic Health Record Coalition [22]. This organization is dedicated to meeting the needs of small- to medium-sized practices in evaluating and implementing technology. The Physicians’ Electronic Health Record Coalition is particularly focused in addressing the particular aspects care provision needed by the 20 medical specialty societies that contribute to the coalition. The American Academy of Physical Medicine and Rehabilitation is one of the specialty societies engaged in this effort. AMIA is pursuing subspecialty certification recognition for medical informatics by the American Board of Medical Specialties. For those already in practice, there is likely to be a typical grandfathering process for certification, but the exact details have not yet been determined. For physicians in training, after the subspecialty certification is established, there will be fellowship programs similar to other subspecialty training.
SUMMARY As with medical technology in general, informatics and HIT are rapidly evolving. The conforming pressures that federal regulation will place on individual practices and institutions regarding integration of these technologies with medical care is uncertain. It is clear, however, that the health care field is on the cusp of a fundamental change in the methods of accumulating and processing medical information. There is little question that physiatrists will be working with electronic rather than paper-based data systems in the future. For this reason, physiatrists must be aware of the nature and extent of how these changes will affect them on a long-term basis in order to continue to have successful practices.
GLOSSARY The following is not intended to be an exhaustive glossary of terms one might encounter in approaching the subject of informatics. Rather, it is a collection that will provide an initial familiarity for practitioners so they can engage in
PM&R
meaningful discussion with other clinicians and vendors of electronic information systems. ADE—Adverse drug event. AMIA—The American Medical Informatics Association is a multidisciplinary, academically focused organization promoting the development of informatics through conferences, its Journal of the American Medical Informatics Association, and advocacy activities on the national level [20]. ASP—Application service provider. A model in which an application (such as an electronic medical recordEMR) is provided through a web-enabled connection. Both the application and patient data are stored on servers provided by the ASP. Typically, this solution allows small practices to install an EMR at considerably less cost than other solutions. The provider needs to be careful with regard to terms of the contract that detail ownership of the data if the relationship with the ASP is terminated. Over time, the value in electronic systems resides with the data, not with the hardware or software that supports use of the data. Asynchronous—Communication that does not occur simultaneously between two parties, such as occurs with e-mail. CCHIT—Certification Commission for Health Information Technology. CCD—Continuity of care document. An electronic summary of specific patient information intended to provide the basis for an accepting provider to initiate care. CDSS—Clinical decision support system. A system that assists the clinician in the provision of care. Although typically thought of as assisting in diagnosis, most successful CDSS have involved assistance with medication ordering, adherence to quality guidelines, and other routine tasks. The Institute of Medicine’s publication “Crossing the Quality Chasm” highlights integration of decision support with computerized provider (or physician) order entry as one of the key factors in improving care and reducing medical errors [23]. Client—A computing device that is accessed directly by an end-user that receives and transmits information over a computer network. Examples include personal computers, smart phones, and personal digital assistants. CPOE—Computerized provider (or physician) order entry. The process of direct entry of orders into an EMR by the provider. EMR—Electronic medical record. Term is sometimes used interchangeably with electronic health record, although in a technically correct use an EMR is a stand-alone system used by a single practice or institution intended to manage records of individual patients, whereas an electronic health record is a longitudinal
Vol. 1, Iss. 11, 2009
1033
record that is interoperable across institutions and can aggregate data for populations as well as individuals. HIE—Health information exchange is a system that allows the exchange of electronic patient data among organizations within a defined geographic area. Typically this is done through establishment of a “minimal data set” that provides enough information for care of a patient (eg, problem list, allergies, medications, immunizations, and encounters) without requiring an exhaustive exchange of all data that exists at each organization within the HIE. HIMSS—The Healthcare Information and Management Systems Society is “the healthcare industry’s membership organization exclusively focused on providing global leadership for the optimal use of healthcare information technology (IT).” In addition to conferences and materials available through its website, there are local organizations that can be a valuable resource to exploring the field of informatics [21]. HIS—Hospital information systems. HIS features can range from basic electronic display of results through full EMR functionality including CPOE with integrated CDSS. HIT—Health information technology is a generic term that includes the software and hardware used to automate medical practice. HL7—Health Level 7, the standard format used for transmission of medical information across a network. HL7 specifies the overall structure of the message, but not necessarily the details of the content; therefore, there remains a considerable gap to achieving full interoperability of medical information. Interoperability—The ability of data to be exchanged among computer systems. Interoperability can exist on many levels, with the ultimate goal being “full semantic interoperability” that allows the exchange of not only raw data, but the meaning associated with the context of a particular data element. Knowledge—The product of the aggregation and interpretation of individual data elements to provide a level of meaning beyond that provided by the data elements in isolation. NHII—National Health Information Infrastructure. An idealized model in which all providers of care are able to share patient information with other providers in an interoperable fashion. ONCHIT—Office of the National Coordinator for Health Information Technology, housed within the Department of Health and Human Services of the federal government. PACS—Picture archiving and communication system. A digital system that captures, stores, and transmits image-based information such as radiology examinations.
1034
Penrod and Rowland
Server—An information system component that provides services (typically data) to a client computer over a network. Synchronous—Communication that occurs simultaneously between 2 parties, such as occurs with a telephone conversation. Telemedicine—Transmission of medical information over an information network for the purpose of consultation or direct provision of medical care. Telerehabilitation—A subclassification of telemedicine related specifically to rehabilitation.
REFERENCES 1. Shortliffe EH, Cimino JJ. Biomedical Informatics: Computer Applications in Health Care and Biomedicine. 3rd ed. Springer; 2006. 2. Health IT Home. Available at: http://healthit.hhs.gov/portal/server.pt? open⫽512&objID⫽1204&parentname⫽CommunityPage&parentid⫽ 3&mode⫽2&in_hi_userid⫽10741&cached⫽true. Accessed September 12, 2009. 3. Certification Commission for Health Information Technology. Available at: http://www.cchit.org/. Accessed September 12, 2009. 4. Bauer JC. Double-edged sword: when it comes to ARRA, the devil is in the details. J Healthcare Inform Manage 2009;23:5-6. 5. Cassidy BS. A call for HIM action. ARRA holds opportunity, challenge for HIM professionals. J AHIMA 2009;80:32-33. 6. Rode D. Everything’s coming up ARRA. HIM-related provisions of stimulus bill blooming as spring turns to summer. J AHIMA 2009;80: 18-20. 7. The Leapfrog Group. Available at: http://www.leapfroggroup.org. Accessed August 18, 2009. 8. Bates DW, Cohen M, Leape LL, Overhage M, Shabot M, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 2001;8:299-308.
INFORMATICS PRIMER FOR PHYSIATRIC PRACTICE
9. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6:313-321. 10. Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000;160:2741-2747. 11. Tsilimingras D, Bates DW. Addressing postdischarge adverse events: a neglected area. Jt Comm J Qual Pt Safety 2008;34:85-97. 12. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005; 143:121-128. 13. HealthLINC HIE. Available at: http://healthlinc.org. Accessed August 18, 2009. 14. Phillips VL, Vesmarovich S, Hauber R, Wiggers E, Egner A. Telehealth: reaching out to newly injured spinal cord patients. Public Health Rep 2001;116(Suppl 1):94-102. 15. Galea M, Tumminia J, Garback LM. Telerehabilitation in spinal cord injury persons: a novel approach. Telemed J E Health 2006;12:160162. 16. Drainoni ML, Houlihan B, Williams S, et al. Patterns of Internet use by persons with spinal cord injuries and relationship to health-related quality of life. Arch Phys Med Rehabil 2004;85:1872-1879. 17. Stineman MG, Jette A, Fiedler R, Granger C. Impairment-specific dimensions within the Functional Independence Measure. Arch Phys Med Rehabil 1997;78:636-643. 18. Krall MA. Acceptance and performance by clinicians using an ambulatory electronic medical record in an HMO. Proc Annu Symp Comput Appl Med Care 1995;708-711. 19. Penrod LE, Gadd CS. Attitudes of academic-based and communitybased physicians regarding EMR use during outpatient encounters. Proc AMIA Annu Fall Symp 2001:528-532. 20. American Medical Informatics Association. Available at: http://www. amia.org. Accessed August 18, 2009. 21. Healthcare Information and Management Systems Society. Available at: http://www.himss.org/ASP/index.asp/. Accessed August 18, 2009. 22. Physicians’ Electronic Health Record Coalition. Available at: http:// www.pehrc.org/. Accessed September 23, 2009. 23. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.
Informatics Primer for Physiatric Practice Louis E. Penrod, MD, Todd Rowland, MD INTRODUCTION This article is intended to be an introduction to the field of medical informatics for physiatrists in a variety of settings. Informatics is often divided into a number of subclassifications (eg, clinical informatics, bioinformatics, imaging informatics, telemedicine); however, for the purposes of this paper, the term will be used in a generic manner. Although a relatively new field of academic and practical focus, it is likely that informatics will touch on the clinical practice of most physicians within the near future. There have been many attempts to define the emerging field of informatics. A commonly acknowledged definition can be found in the textbook by Shortliffe et al [1]: “[T]he scientific field that deals with biomedical information, data, and knowledge—their storage, retrieval, and optimal use for problem solving and decision making.” From this definition, it can be seen that this field potentially touches all aspects of providing medical care. A brief review of the history and development of informatics will provide a framework for more detailed discussion. The initial successful application of automated data processing was Herman Hollerith’s use of a punch-card system for the 1890 U.S. census. This approach was further explored for epidemiology and public health purposes over the next several decades. With the development of totally electronic systems shortly after World War II, the potential for other applications started to be explored. A few large, academically based medical centers developed hospital information systems that provided practical benefits. Most notable of these were the systems at the Massachusetts General Hospital in Boston, Latter-Day Saints Hospital in Salt Lake City, and the Regenstrief Medical Record System in Indianapolis. Each of these efforts has been gradually refined over several decades, and each is notable for its ongoing use as well as the academic foundation provided to the field within the United States. Development of increasingly more powerful and more affordable computers, culminating with the development of the personal computer by the 1980s, set the stage for a radical transformation of information systems. Today, networked arrangements of a variety of computing devices (servers, client computers, medical monitors, and wireless devices including smart phones and personal digital assistants) provide the infrastructure to capture and share data at all points throughout the process of providing clinical care. The National Library of Medicine has assumed a central role in informatics, with support for basic research in the field over the last few decades [1]. There are now a number of electronic medical record (EMR) systems commercially available. The Office of the National Coordinator for Health Information Technology was established in 2004 to promote the goal of all Americans having access to interoperable (“portable”) EMRs, with a target date of 2014 [2]. The Certification Commission for Health Information Technology also was established in 2004 as a nonprofit organization that reviews and certifies commercial health information technology (HIT) products [3]. Certification Commission for Health Information Technology certification is intended to reassure providers and healthcare organizations that a product meets certain basic functional requirements. Most recently, the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA) included funding to promote HIT adoption [4-6]. The following sections of this paper provide an overview of how the emerging discipline of informatics may affect physiatric practice, whether in an inpatient or outpatient setting. This will be divided into Business and Clinical Impact, and Career and Educational Options. A glossary at the end of the paper contains terms and acronyms frequently encountered in the field of informatics. PM&R
1030
1934-1482/09/$36.00 Printed in U.S.A.
L.E.P. Department of PM&R, University of Pittsburgh School of Medicine, Pittsburgh, PA Disclosure: nothing to disclose T.R. HealthLINC HIE, Bloomington, IN Disclosure: 1B, Executive Director of Health LINC HIE; 2A, President E-Health Consulting; 3A, Axolotl Corp.; 8B, HHS Office of National Coordinator, HRSA, Physicians Foundation Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org Submitted for publication August 21, 2008; accepted December 9.
© 2009 by the American Academy of Physical Medicine and Rehabilitation Vol. 1, 1030-1034, November 2009 DOI: 10.1016/j.pmrj.2009.09.020
PM&R
BUSINESS AND CLINICAL IMPACT There are many forces advancing adoption of HIT. In the private sector, the Leapfrog Group is an association of major employers that promotes health care facilities’ adoption of medical practices that they judge instrumental in improving the quality of care [7]. Computerized provider order entry (CPOE) with integrated clinical decision support system (CDSS) is among the first of the practices they are promoting. Adherence to this process includes a test of CPOE that assesses a base level of decision support including allergy checking, drug-drug interaction, and some basic drug-disease interaction. Results of a facility’s test are posted on the Leapfrog Group’s website for public viewing. For private practices, provisions in the ARRA provide significant motivation for HIT adoption by rewarding “meaningful use” of EMR technology [4-6]. However, the exact interpretation of “meaningful use” has yet to be clarified. It is expected that this will include electronic prescription and reporting of quality measures. The Center for Medicare and Medicaid Services also is pushing HIT adoption indirectly through the Physician Quality Reporting Initiative. In the initial phases, practices reporting compliance with at least 3 standards will receive a small increment in reimbursement beyond usual levels for all patients covered by Medicare. The intent is to gradually expand the number of quality measures that must be reported as well as to impose a reimbursement penalty for practices that do not comply. It is difficult to conceive how this will ultimately be possible without an electronic system to track and report the data. Despite the relatively recent development of informatics, there are indications that further development is warranted to improve the health care system. Several studies have shown a consistent and significant improvement in quality of care by adoption of CPOE with an integrated CDSS. In particular, medical errors associated with medication orders have been reduced by 50%-86% in select settings [8-10]. Typically these improvements result from legibility of orders and drug interaction checking (drug-allergy, drug-drug, and drug-disease state considerations are all important). Transitions in care (admission, discharge, changing care teams) are also high-risk events for preventable medical errors [11]. One potential cause of these errors is that test results often are not available at the time of discharge from acute care facilities. Roy et al [12] showed this occurred in 41% of cases discharged from 2 teaching hospitals. Of these, the results were judged to be “actionable” in 9.4%. Physiatrists frequently are involved in transitions of care and invest considerable time developing practice conventions with the goal of reducing the risk for these types of errors. Typical examples include following up on pending test results (an error of omission); medication reconciliation to minimize the risk of adverse drug events; and efforts to enhance communication with the acute care team, consultants still involved in the care of the patient, and with physicians who will assume care after the completion of inpatient rehabilitation. Patients with cognitive deficits are at higher risk for such
Vol. 1, Iss. 11, 2009
1031
errors because they are less able to understand and track details of the care plan. Providing an additional challenge, these patients often have complex medical conditions resulting in complex care plans. Informatics addresses many of these issues by developing and implementing solutions to enhance coordination of care—typically as a regional health information organization or health information exchange. However, obtaining sustainable funding for such endeavors has been challenging. One example that has demonstrated success is the HealthLINC Health Information Exchange in Bloomington, Indiana, a not-for-profit organization that provides a delivery and management system for test results enabled by a secure communication network operating across disparate HIT systems. In this community, neurologists, neurosurgeons, and physiatrists use the system to enhance patient transfers of care by electronic routing of results, pending results, consultations, and discharge summaries [13]. A few telemedicine demonstrations have shown promise in improving quality of care once an individual has been discharged from inpatient rehabilitation following spinal cord injury (SCI). A study based out of the Shepherd Center in Atlanta recruited newly injured patients during the initial rehabilitation phase. Through a telehealth intervention, health-related quality of life measures were improved significantly at 1 year post-discharge. There also appeared to be reduced hospitalization by improved education and early identification of problems. The impact on skin care practices was a major contributor to this trend [14]. A telerehabilitation program at the James J. Peters VAMC in the Bronx focused specifically on common comorbidities of SCI, including type 2 diabetes, hypertension, obesity, bladder infections, depression, and skin care. Interventions were tailored to the individual’s particular needs. This program was well received by both patients and their caregivers. Office visits increased, but hospitalizations and length of stay decreased [15]. Both of these reports emphasized the value of this technology for individuals who are commonly discharged to remote locations following the completion of their inpatient SCI rehabilitation. A survey of persons with chronic SCI showed internet use at least as frequent as the general population. E-mail and searching for disability and health information were the most frequent activities. For regular internet users, health-related quality of life indicators were significantly better [16]. There are potentially huge benefits to the adoption of HIT in building the scientific base of physical medicine and rehabilitation. Capturing large amounts of clinical data in electronic format allows analyses in ways never before practical in paper-based systems. Databases that capture detailed information on patient characteristics, interventions, and outcomes can be leveraged to discover what aspects of physiatric practice are most effective and where there is room for innovation. The work done by Stineman et al [17] in analyzing functional independence measure data for diagnosisspecific patterns of function is an example of the potential for
1032
Penrod and Rowland
collecting raw data in formats that can be then analyzed and reapplied in new clinical methods. One major consideration in adoption of HIT is the fundamental change in practice patterns that will undoubtedly occur on many levels. When considering automation of existing workflows, careful consideration should first be given to what has been working well and what could be improved irrespective of any technological solutions. Next, an understanding of how current practice should be changed for both efficiency and technological reasons, as well as how the technology must be modified to meet critical practice needs should be carefully assessed. Although a considerable investment in time and effort, in the long run this will be an investment that pays substantial rewards. Because HIT has a profound impact on the nature of both institutional and outpatient practice, a comprehensive analysis of return on investment is difficult to demonstrate. Specific markers of individual’s performance can be tracked that are then extrapolated to a generalized overall outcome of care. However, this type of measurement does not always offer a complete picture of what specifically happened or was the result of a specific transformation. Some tasks require more time and effort when HIT is employed (such as CPOE), others require much less time (results review), and still others require a complete change in activities (such as checking or adding quality measures). However, it can be noted that in the outpatient setting, survey data have shown that after the transformation to HIT has been completed, the overwhelming majority of practitioners respond that they would not return to paper systems if given the choice [18,19].
CAREER AND EDUCATIONAL OPTIONS It is fairly easy to recognize how integration of informatics is a natural extension of physiatric practice. Compiling data from a variety of sources (eg, therapy progress notes and test results) and from various environments (eg, inpatient or outpatient) produces a comprehensive picture of a given patient’s functional status that is integral to physiatric care. As these data sources individually transition to electronic format, it will likely be the role of the physician (in this case, physiatrist) to facilitate synthesis of this aggregated information for enhancement of clinical care. Indeed, a number of physiatrists already have entered the field of informatics on a part- to full-time basis. As mentioned previously, the ARRA funding for “meaningful use” of HIT will certainly drive adoption across many practice settings [4-6]. The availability of this funding also is likely to increase the availability of physician “informaticist” positions. Individual physiatrists will have a range of opportunities, depending on their practice setting. In a solo or small group setting, informatics is likely to be only an area of interest. For individuals working in an institutional setting, it would be more feasible for informatics to become a substantial portion of their work effort. Particularly for larger inpatient facilities, it would be important to have local resources to lead the institution’s informatics initiatives. It is reasonable
INFORMATICS PRIMER FOR PHYSIATRIC PRACTICE
to expect this activity to be compensated fairly as it will take away from the physiatrist’s potential to generate billings from direct patient care. For the physiatrist who wishes to become more proficient in informatics, there are a number of routes to gain expertise. Local chapters of the Healthcare Information and Management Systems Society usually have programs that provide both background and networking opportunities. Both Healthcare Information and Management Systems Society and the American Medical Informatics Association (AMIA) have educational sessions as part of their yearly meetings [20,21]. AMIA also has a short-term, focused training program called “AMIA 10⫻10” that has been well received as an introduction to didactic training in the field [20]. For those seeking additional training, there are several “executive master’s degree” type programs that involve limited on-campus sessions integrated with distance learning. Another source that may be valuable as it develops is the Physicians’ Electronic Health Record Coalition [22]. This organization is dedicated to meeting the needs of small- to medium-sized practices in evaluating and implementing technology. The Physicians’ Electronic Health Record Coalition is particularly focused in addressing the particular aspects care provision needed by the 20 medical specialty societies that contribute to the coalition. The American Academy of Physical Medicine and Rehabilitation is one of the specialty societies engaged in this effort. AMIA is pursuing subspecialty certification recognition for medical informatics by the American Board of Medical Specialties. For those already in practice, there is likely to be a typical grandfathering process for certification, but the exact details have not yet been determined. For physicians in training, after the subspecialty certification is established, there will be fellowship programs similar to other subspecialty training.
SUMMARY As with medical technology in general, informatics and HIT are rapidly evolving. The conforming pressures that federal regulation will place on individual practices and institutions regarding integration of these technologies with medical care is uncertain. It is clear, however, that the health care field is on the cusp of a fundamental change in the methods of accumulating and processing medical information. There is little question that physiatrists will be working with electronic rather than paper-based data systems in the future. For this reason, physiatrists must be aware of the nature and extent of how these changes will affect them on a long-term basis in order to continue to have successful practices.
GLOSSARY The following is not intended to be an exhaustive glossary of terms one might encounter in approaching the subject of informatics. Rather, it is a collection that will provide an initial familiarity for practitioners so they can engage in
PM&R
meaningful discussion with other clinicians and vendors of electronic information systems. ADE—Adverse drug event. AMIA—The American Medical Informatics Association is a multidisciplinary, academically focused organization promoting the development of informatics through conferences, its Journal of the American Medical Informatics Association, and advocacy activities on the national level [20]. ASP—Application service provider. A model in which an application (such as an electronic medical recordEMR) is provided through a web-enabled connection. Both the application and patient data are stored on servers provided by the ASP. Typically, this solution allows small practices to install an EMR at considerably less cost than other solutions. The provider needs to be careful with regard to terms of the contract that detail ownership of the data if the relationship with the ASP is terminated. Over time, the value in electronic systems resides with the data, not with the hardware or software that supports use of the data. Asynchronous—Communication that does not occur simultaneously between two parties, such as occurs with e-mail. CCHIT—Certification Commission for Health Information Technology. CCD—Continuity of care document. An electronic summary of specific patient information intended to provide the basis for an accepting provider to initiate care. CDSS—Clinical decision support system. A system that assists the clinician in the provision of care. Although typically thought of as assisting in diagnosis, most successful CDSS have involved assistance with medication ordering, adherence to quality guidelines, and other routine tasks. The Institute of Medicine’s publication “Crossing the Quality Chasm” highlights integration of decision support with computerized provider (or physician) order entry as one of the key factors in improving care and reducing medical errors [23]. Client—A computing device that is accessed directly by an end-user that receives and transmits information over a computer network. Examples include personal computers, smart phones, and personal digital assistants. CPOE—Computerized provider (or physician) order entry. The process of direct entry of orders into an EMR by the provider. EMR—Electronic medical record. Term is sometimes used interchangeably with electronic health record, although in a technically correct use an EMR is a stand-alone system used by a single practice or institution intended to manage records of individual patients, whereas an electronic health record is a longitudinal
Vol. 1, Iss. 11, 2009
1033
record that is interoperable across institutions and can aggregate data for populations as well as individuals. HIE—Health information exchange is a system that allows the exchange of electronic patient data among organizations within a defined geographic area. Typically this is done through establishment of a “minimal data set” that provides enough information for care of a patient (eg, problem list, allergies, medications, immunizations, and encounters) without requiring an exhaustive exchange of all data that exists at each organization within the HIE. HIMSS—The Healthcare Information and Management Systems Society is “the healthcare industry’s membership organization exclusively focused on providing global leadership for the optimal use of healthcare information technology (IT).” In addition to conferences and materials available through its website, there are local organizations that can be a valuable resource to exploring the field of informatics [21]. HIS—Hospital information systems. HIS features can range from basic electronic display of results through full EMR functionality including CPOE with integrated CDSS. HIT—Health information technology is a generic term that includes the software and hardware used to automate medical practice. HL7—Health Level 7, the standard format used for transmission of medical information across a network. HL7 specifies the overall structure of the message, but not necessarily the details of the content; therefore, there remains a considerable gap to achieving full interoperability of medical information. Interoperability—The ability of data to be exchanged among computer systems. Interoperability can exist on many levels, with the ultimate goal being “full semantic interoperability” that allows the exchange of not only raw data, but the meaning associated with the context of a particular data element. Knowledge—The product of the aggregation and interpretation of individual data elements to provide a level of meaning beyond that provided by the data elements in isolation. NHII—National Health Information Infrastructure. An idealized model in which all providers of care are able to share patient information with other providers in an interoperable fashion. ONCHIT—Office of the National Coordinator for Health Information Technology, housed within the Department of Health and Human Services of the federal government. PACS—Picture archiving and communication system. A digital system that captures, stores, and transmits image-based information such as radiology examinations.
1034
Penrod and Rowland
Server—An information system component that provides services (typically data) to a client computer over a network. Synchronous—Communication that occurs simultaneously between 2 parties, such as occurs with a telephone conversation. Telemedicine—Transmission of medical information over an information network for the purpose of consultation or direct provision of medical care. Telerehabilitation—A subclassification of telemedicine related specifically to rehabilitation.
REFERENCES 1. Shortliffe EH, Cimino JJ. Biomedical Informatics: Computer Applications in Health Care and Biomedicine. 3rd ed. Springer; 2006. 2. Health IT Home. Available at: http://healthit.hhs.gov/portal/server.pt? open⫽512&objID⫽1204&parentname⫽CommunityPage&parentid⫽ 3&mode⫽2&in_hi_userid⫽10741&cached⫽true. Accessed September 12, 2009. 3. Certification Commission for Health Information Technology. Available at: http://www.cchit.org/. Accessed September 12, 2009. 4. Bauer JC. Double-edged sword: when it comes to ARRA, the devil is in the details. J Healthcare Inform Manage 2009;23:5-6. 5. Cassidy BS. A call for HIM action. ARRA holds opportunity, challenge for HIM professionals. J AHIMA 2009;80:32-33. 6. Rode D. Everything’s coming up ARRA. HIM-related provisions of stimulus bill blooming as spring turns to summer. J AHIMA 2009;80: 18-20. 7. The Leapfrog Group. Available at: http://www.leapfroggroup.org. Accessed August 18, 2009. 8. Bates DW, Cohen M, Leape LL, Overhage M, Shabot M, Sheridan T. Reducing the frequency of errors in medicine using information technology. J Am Med Inform Assoc 2001;8:299-308.
INFORMATICS PRIMER FOR PHYSIATRIC PRACTICE
9. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6:313-321. 10. Teich JM, Merchia PR, Schmiz JL, Kuperman GJ, Spurr CD, Bates DW. Effects of computerized physician order entry on prescribing practices. Arch Intern Med 2000;160:2741-2747. 11. Tsilimingras D, Bates DW. Addressing postdischarge adverse events: a neglected area. Jt Comm J Qual Pt Safety 2008;34:85-97. 12. Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med 2005; 143:121-128. 13. HealthLINC HIE. Available at: http://healthlinc.org. Accessed August 18, 2009. 14. Phillips VL, Vesmarovich S, Hauber R, Wiggers E, Egner A. Telehealth: reaching out to newly injured spinal cord patients. Public Health Rep 2001;116(Suppl 1):94-102. 15. Galea M, Tumminia J, Garback LM. Telerehabilitation in spinal cord injury persons: a novel approach. Telemed J E Health 2006;12:160162. 16. Drainoni ML, Houlihan B, Williams S, et al. Patterns of Internet use by persons with spinal cord injuries and relationship to health-related quality of life. Arch Phys Med Rehabil 2004;85:1872-1879. 17. Stineman MG, Jette A, Fiedler R, Granger C. Impairment-specific dimensions within the Functional Independence Measure. Arch Phys Med Rehabil 1997;78:636-643. 18. Krall MA. Acceptance and performance by clinicians using an ambulatory electronic medical record in an HMO. Proc Annu Symp Comput Appl Med Care 1995;708-711. 19. Penrod LE, Gadd CS. Attitudes of academic-based and communitybased physicians regarding EMR use during outpatient encounters. Proc AMIA Annu Fall Symp 2001:528-532. 20. American Medical Informatics Association. Available at: http://www. amia.org. Accessed August 18, 2009. 21. Healthcare Information and Management Systems Society. Available at: http://www.himss.org/ASP/index.asp/. Accessed August 18, 2009. 22. Physicians’ Electronic Health Record Coalition. Available at: http:// www.pehrc.org/. Accessed September 23, 2009. 23. Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001.