PHYS THER
Vol. 86, No. 3, March 2006, pp. 446-447
Invited Commentary
Nancy J Zimny
Department of Physical Therapy
College of Nursing and Health Sciences
University of Vermont
Burlington, VT 05405
nancy.zimny{at}uvm.edu
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Introduction
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As Vreeman and colleagues point out, health care professions in general and physical therapy in particular have lagged well behind other information-based professions in embracing the computer as a tool for information management. At the bank, we would likely be astounded if the teller had to find or write paper copies of our transactions; hand calculate the necessary sums for our accounts, mortgages, and investments; or rely exclusively on memory to find solutions or options related to our financial issues. In fact, with the advent of ATMs and online banking, even the use of a human teller seems antiquated! And yet, when we visit our physician or physical therapist, we would likely still be surprised if he or she turned immediately to a computer for assistance to collect, organize, or interpret the myriad of details involved in making a clinical decision about our health problem.
The authors correctly point out, however, that there is a growing awareness of the need and outright pressure for better methods of information management in health care using information technology (IT). The president of the United States expects that most Americans will have electronic health records (EHRs) within the next 10 years.1 In October 2005, the Commission on Systemic Interoperability released a final report that recommended actions to be taken to achieve this goal.2 Among the imperatives are: to help clinicians and consumers embrace IT, to promote the interchange and ease of information sharing among different electronic systems, to ensure access and confidentiality to consumers, and to provide suitability for data aggregation that allows tracking of public health issues for population-based management and research.
Some of these initiatives may be more easily accomplished than others. Indeed, IT seems exceptionally well suited to many of the "administrative-like" tasks. Systems that improve the ease, accuracy, and efficiency of scheduling, billing, health check reminders, and even record keeping of specific clinical data over time no longer seem particularly novel and are therefore likely to be progressively instituted as they become commercially available. Perhaps this is, at least in part, because these uses are most akin to what we already experience daily as manipulation and transmission of information in business and educational environments. Similarity to existing systems and behaviors has been noted as one mechanism that makes acceptance of a novel idea more likely, at least in the short term.3
The stated focus of this article, however, is on the EHR and, according to the authors, its ability to provide "the right information at the right time and in the right format" so that clinical decisions in physical therapy can be more "effective and efficient." It is interesting that the authors do not, therefore, include improved clinical decision making in the potential benefits of the EHR. Furthermore, I would suggest that certain problems in the current state of clinical decision making in physical therapy may actually serve to delay acceptance of EHRs and as such could be added to the authors’ list of barriers.
As the authors note, use of an EHR requires some standardization of the data that are to be put into the system. Visit dates, codes for billing, charges, and even discrete clinical data are inherently compatible with this requirement. However, adequate decision making requires more than discrete clinical data even if the individual data points are both standardized and accurate. Patient data must be joined together into a coherent whole that suggests a diagnosis or a management plan. This process is typically done by putting individual findings into the context of some type of classification scheme of diagnosis or management. The lack of such generally accepted schemes may be a significant problem that could interfere with physical therapy being incorporated easily into a nationwide health information infrastructure.
Vreeman et al note that physical therapists make diverse types of clinical decisions, and they acknowledge the potential need for electronic systems that are customized to meet our clinical information demands. I agree that this scenario is highly likely and believe we should not underestimate the difficulty of this task. If we are going to incorporate the "unique body of knowledge" that constitutes physical therapy into the existing nationwide health information infrastructure, we must be clear about what that unique body of knowledge is. Furthermore, in order to benefit from what EHRs can do to "keep accurate and hurry up" the process, we need to establish consistent methods of manipulating that knowledge and the validity of whichever methods we choose. In other words, we need to avoid the dangers inherent in the cliché "garbage in, garbage out."
At present, the clarity, methodology, and validity of diagnosis and classification schemas unique to physical therapy are still under development and discussion. Indeed, as I and others have previously pointed out, the process of diagnosis and classification is inherently fraught with challenges, and the wide scope of domains on which many physical therapy clinical decisions depend (ie, psychological and sociological as well as physiological) further complicates the issue.4 Behavioral changes on the part of professional users should not lag behind those of consumers who are becoming quite accustomed to IT in many phases of daily life and may expect it as part of their health care.5 We might even be so radical as to listen more closely to those who suggest that we use the enormous advantages of IT to move out of our established patterns of decision-making behavior that are so highly algorithmic, probabilistic, and memory-dependent, and consider less familiar, more combinatorial and individualized approaches.6
The extent of the challenges should not deter us from moving forward with the effort to incorporate into health care and physical therapy the many advantages gained in other environments. This article is important because it raises our awareness of the imperative to move forward by highlighting the limited amount of work done so far and making some preliminary suggestions to guide future work in physical therapy. Finally, the authors rightly point out that any method used should be subjected to rigorous analysis of its effectiveness. They suggest that we use the "gold standard" of the randomized controlled trial. Given the complexity of clinical decision making and the number of differing environmental considerations involved in IT adoption, it might be helpful to consider newer research frameworks that use a systematic phased approach specifically designed to cope with complex health interventions such as computerized decision support.7
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References
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- The White House. A New Generation of American Innovation. April 2004. Available at: http://endingthedocumentgame.gov/PDFs/President_Bush.pdf. Accessed November 1, 2005.
- Commission on Systemic Interoperability. Ending the Document Game: Connecting and Transforming Your HealthCare Through Information Technology. Available at: http://endingthedocumentgame.gov/report.html. Accessed November 1, 2005.
- Weaver RR.
Computers and Medical Knowledge: The Diffusion of Decision Support Technology Boulder, Colo: Westview Press Inc; 1991:38–41.
- Zimny NJ. Diagnostic classification and orthopaedic physical therapy practice: what we can learn from medicine.
J Orthop Sports Phys Ther 2004;34:105–109; discussion 110–115.[ISI][Medline]
- Calabretta N. Consumer-driven, patient-centered healthcare in the age of electronic information.
J Med Libr Assoc 2002;90(1):32–37.
- Weed LL, Weed L. Reengineering medicine.
Federation Bulletin–The Journal of Medical Licensure and Discipline 1994;81:149–183.
- Campbell M, Fitzpatrick R, Haines A, et al. Framework for design and evaluation of complex interventions to improve health.
BMJ 2000;321:694–696.[Free Full Text]
Copyright © 2006 by the American Physical Therapy Association.
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