PHYS THER
Vol. 86, No. 3, March 2006, pp. 448-449
Author Response
Daniel J Vreeman,
Samuel L Taggard,
Michael D Rhine and
Teddy W Worrell
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Introduction
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We would like to thank Zimny for her insightful comments on our article, and we appreciate the opportunity to respond. In the time since our manuscript was accepted for publication, we have continued to see growing support for adopting information technology in health care, as Zimny notes. We are particularly encouraged that the American Physical Therapy Association Board of Directors identified electronic medical records/information technology as a Priority Level 2 issue for 2006.1 By synthesizing the current evidence and making practical recommendations on where to start, we hope that our work can inform the continued dialogue about the implications of adopting information technology in physical therapy.
Literature reviews such as ours are limited by the quality and content of the included studies. In this review, we synthesized the findings of a heterogeneous set of studies. Although all of the studies reported benefits to implementing electronic health record (EHR) systems, these reported benefits varied considerably. Using individual studies as our unit of analysis, we presented the general themes (most commonly reported benefits) that emerged across these studies, and thus we did not report every benefit identified in every study. Furthermore, there are many other benefits and barriers to implementing EHRs reported in broader medical informatics literature, but not in the studies we reviewed. Zimny notes that we did not include "improved clinical decision making" in our summary of EHR benefits, which reflects the fact that this was not one of the commonly reported benefits. This is not to say that is an unimportant potential benefit. Indeed, the computer's ability to suggest and remind clinicians of preferred care options is one of the most effective and well-studied benefits of EHRs in other disciplines.2–4
Likewise, we concur with Zimny's assertion that the present state of decision making in physical therapy presents unique challenges for adopting EHRs and participating in the emerging nationwide health information network. In our review, only one study5 specifically noted physical therapists' clinical decision making as a barrier to implementing EHRs. We aggregated this specific barrier into the broader theme of behavior and workflow modification to reflect the important psychosocial and other nontechnical barriers that emerged in these EHR implementations. In our discussion, we described challenges to implementing EHRs primarily at the institutional level because this was the focus of the studies we reviewed. However, as Zimny suggests, addressing the challenges in our current state of clinical decision making requires the attention of the physical therapy profession. Similarly, institutions can create data standards that meet their internal purposes, but unless they are linked to nationally recognized vocabulary standards, this will likely proliferate the idiosyncrasies in local naming conventions and impede information exchange. Linking local terms to standardized terms allows the standardized vocabulary to serve as the lingua franca among separate systems and enables results to be pooled for clinical practice and research. As a profession, we must work to develop the existing nationally recognized clinical vocabularies, such as the Systematized Nomenclature of Medicine and Logical Observations Identifiers Names and Codes, to represent the concepts of interest to physical therapists.
We find it intriguing that Zimny recommends evaluating EHRs using a research framework for complex health interventions, such as the framework developed by the Medical Research Council.6 This framework involves an iterative approach and includes both qualitative and quantitative evaluations. In the third phase of the framework, a definitive randomized controlled trial is conducted, informed by previous exploratory trials. The final phase in this framework consists of evaluating the implemented intervention over the long term. In a previous version of our manuscript, we, too, suggested that the framework developed by the Medical Research Council may be valuable for evaluating EHRs. Our advocacy for conducting controlled trials of EHRs, however, was met with criticism from reviewers who suggested that it was unrealistic and of little utility. We remain convinced that an important finding of our review is that the studies lacked rigorous methods for showing that EHRs measurably affected important outcomes. Moreover, we feel that controlled trials can and should be designed to demonstrate whether or not the touted features of EHRs can improve outcomes in the settings where physical therapists practice.
Investigators in the broader field of medical informatics have evaluated many features of EHRs with controlled trials. This does not necessarily imply that they randomized the actual implementation of EHRs. Most commonly, specific EHR features of interest are differentially applied and evaluated between comparison groups, such as teams or clinics. The increasing number of high-quality studies on EHRs in medicine is one reason why the national initiatives to adopt information technology are growing with such fervor. Without conducting such studies in the settings where physical therapists practice, we have little evidence for the relative costs and benefits of implementing electronic systems for physical therapists. Although there are growing national pressures to adopt information technology in health care, the sociotechnical complexities of implementing EHRs make it unlikely that blind investment will produce the intended benefits. Designing, implementing, and evaluating information technology in live clinical environments creates a unique set of challenges that requires investigators who are trained in both informatics and the conduct of controlled trials.7 At present, there are too few investigators who possess these skills,8 particularly in the profession of physical therapy. We need clinical informaticians in physical therapy, because they understand these unique challenges and can develop the rigorous studies that will help us invest our limited resources wisely.
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References
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- American Physical Therapy Association. 2006 Critical Issues in Federal Government Affairs. Available at: http://www.apta.org/AM/Template.cfm?Section=APTA_Policies_and_Priorities&Template=/MembersOnly.cfm&ContentID=26949. Accessed December 2, 2005.
- McDonald CJ. Protocol-based computer reminders: the quality of care and the non-perfectability of man.
N Engl J Med 1976;295:1351–1355.[Abstract]
- McDonald CJ. Use of a computer to detect and respond to clinical events: its effect on clinician behavior.
Ann Intern Med 1976;84:162–167.[ISI][Medline]
- Dexter PR, Perkins S, Overhage JM, et al. A computerized reminder system to increase the use of preventive care for hospitalized patients.
N Engl J Med 2001;345:965–970.[Abstract/Free Full Text]
- Zimny NJ, Tandy CJ. Development of a computer-assisted method for the collection, organization, and use of patient health history information in physical therapy.
J Orthop Sports Phys Ther 1993;17:84–89.[ISI][Medline]
- 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]
- Vreeman DJ. Why life is hard: challenges in conducting research on information technology.
HPA Resource 2004;4(4):11–13.
- Baker ML. Health Industry Searches for Next Informaticians. eWeek. October 1, 2004. Available at: http://www.eweek.com/article2/0,1759,1665052,00.asp. Accessed December 2, 2005.
Copyright © 2006 by the American Physical Therapy Association.
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