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My Top 5 articles from 2015-16 about Informatics and Digital Health in Physiotherapy and Stroke

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My Top 5 articles from 2015-16 about Informatics and Digital Health in Physiotherapy and Stroke

  1. 1. My Top 5 articles from 2015-16 about Informatics and Digital Health in Physiotherapy and Stroke Samantha Plumb Health Informatics and Digital Health 2016 1 The focus of my review is how informatics and digital health has and may influence the management of and clinical outcomes for stroke patients, in particular applying evidence based physiotherapy. I chose this topic because: • this is my clinical area of expertise • the number of people annually affected by stroke, living with stroke and dying from stroke is increasing worldwide • timely access to information and intervention, and co-ordinated care is critical to the outcome for stroke patients • application of evidence based practice (EBP) to reduce variation in care can be enhanced through digital health such as electronic medical records (EMR)
  2. 2. Search Strategy applied across 2015- 2016 Search terms: #1:“physiotherapy or “physical therapy” and #2:“stroke” and #3:“digital health” or “informatics” or “electronic medical record” or “electronic health record” Type of Database Search fields Search terms Total No. of articles Shortlisted for review Reason for exclusion Cinahl Title and abstract #1 and #2 and #3 0 0 Cochrane Title and abstract #1 and #2 and #3 0 0 Pedro Title and abstract #1 and #2 and #3 0 0 Medline Title and abstract #1 and #2 and #3 5 2 3 articles less relevant Embase Title and abstract #1 and #2 and #3 5 0 3 conference papers 2 not in English Scopus Title and abstract #1 and #2 and #3 6 3 2 articles less relevant 1 article duplicated from Medline search 2
  3. 3. Rationale for top 5 papers • All 5 papers link digital health with improving clinical outcomes for stroke patients • All 5 papers identify physiotherapy as an important component of treatment in stroke care. This includes important to patients (i.e.. physical outcomes) and demonstrated through EBP. • Papers identify areas of success and future considerations for digital health and stroke • Papers will all be useful in the development and build of an EMR • Only those papers that were in English were considered • The lack of literature to choose from in this area should be noted 3
  4. 4. Article 1: Poder U, Dahm MF, Karlsson N, Wadensten B. (2015) Standardised care plans for in hospital stroke care improve documentation of health care assessments. Journal of Clinical Nursing. 24, 2788-2796 Key messages from the article • It is imperative that patients are treated in accordance with evidence based practice to achieve best outcomes • A rapid reliable clinical diagnosis should occur as soon as possible to form the basis for continued management • Use of multidisciplinary standardised care plans (SCP) or clinical pathways within an EMR can assist in implementing EBP, reducing variation in care, providing high quality patient care, and improving patient outcomes • This study found that in comparison to working on paper pre EMR implementation, the SCP within the EMR led to improved documentation, more patients receiving the same high quality care and improved patient safety • The was also a significant improvement in the proportion of patients assessed by physiotherapists in accordance with the guidelines which led to improved opportunity for early rehabilitation • Critical success factors include ensuring the layout of the SCP in the EMR is of practical use, user-friendly, clarity on who is responsible for each section and that the SCP allows for flexibility while still upholding standardisation Link with the rationale • SCP or clinical pathways within an EMR are a proven tool to implement EBP and reduce variation in care • Clinical pathways for stroke should include • referrals to physiotherapy • evidence based physiotherapy assessment, intervention and discharge • Duke University Hospital in the USA is leading the way with demonstrating benefits from embedding clinical pathways into the EMR 4
  5. 5. Article 2: Amin K (2015). Replacing paper with digital recording. Journal of stroke and cerebrovascular diseases. 24(1), 144-147 Key messages from the article • This study implemented an electronic version from paper for documenting multi-disciplinary team meetings (eMDT) including therapy goals to be able to monitor patient progress. • Implementation resulted in patients being more likely to receive appropriate care as recommended by the stroke guidelines, enabled easy retrieval of information, enhanced documentation and communication and allowed monitoring of individual patient progress • Data points and objective measures were identified and agreed amongst the team as an essential item for objective and concise information to monitor progress • Widely used and recognised assessment scales were used to allow for data sharing and comparison with national and international projects • Training on the new system and change management through staff engagement were identified as reasons for project success • eMDT was interfaced with other ehealth systems e.g.: PAS • Functionality of the system included analytics such as trending data Link with the rationale • It is well known that co-ordinated care within a stroke unit significantly improves outcomes for stroke inpatients • This communication tool enables co-ordinated care • Improved communication amongst staff will ultimately lead to better care for patients. It also helps to reduce unnecessary investigations, duplication of tasks and time wasted searching for paper based forms • Training and change management are key to introducing any new IT system. • Implementing IT related to clinical areas should be led as a clinical project 5
  6. 6. Article 3: Rand M and Darbinian J. (2015). Effect of an evidence-based intervention on the level of function in acute intracerebral and subarachnoid hemorrhagic stroke patients on a neurointensive care unit. Archives of Physical Medicine and Rehabilitation. 96, 1191-1199. Key messages from the article • Evidence based practice is that an early mobilisation strategy, in the acute phase of stroke is associated with reduced physical impairments, enhanced functional recovery and decreased hospital length of stay • An evaluation of physiotherapy literature indicates that a mobility intervention lasting between 30 to 60 minutes, 5 to 7d/wk. provides significant benefit in functional recovery after stroke • Patients were identified for this study through the EMR identifying those within the inclusion criteria • The EMR was used for standardised patient level data and narrative notes • The study demonstrated that adoption of an evidence based early mobilisation strategy lead to enhanced mobility achievements for stroke patients • It is important to minimise adverse impacts on data quality such as incomplete information, inconsistency resulting in data source mismatch and inaccurate nonstandard-based information Link with the rationale • The EMR provides enhanced capability for conducting research • The EMR provides opportunity for implementing an EBP early mobilisation strategy • This can be supported with clinical decision support and close patient monitoring • Atomised data as compared to free text notes provide greater opportunity for research • Consideration should be given to mandatory fields within an EMR to minimise adverse impacts on data quality 6
  7. 7. Article 4: Yan L, Li C, Chen J, Miranda J, Luo R, Betteger J, Zhu Y, Feigin V, O’Donnell M, Zhao D, and Wu Y. (2016). Prevention, management and rehabilitation of stroke and low-and middle-income countries. eNeurologiaSci. 2, 21-30. Key messages from the article • Many causes of stroke are modifiable as identified by the INTERSTROKE study, such as physical inactivity • Highly active individuals have a 27% lower risk of stroke incidence or mortality than less-active individuals, and moderately active individuals compared with inactive persons • Appropriate physical activity is also a secondary prevention for stroke intervention • Digital health is associated with improved clinical decision making and increased efficiency for health care providers, such as tablet base risk assessment tools and mobile phone apps for clinicians • Mobile technology such as the Stroke Riskometer App allows users to identify their relative risk of stroke development • Digital health makes it possible to individualise interventions for physical activity • Self management interventions have been demonstrated to reduce the risk of stroke recurrence • Insufficient evidence to support the effectiveness of tele- rehabilitation on mobility and health related quality of life Link with the rationale • An EMR provides an opportunity for greater self-management through a patient portal. The Royal Children's Hospital have successfully linked their patient portal to the My Health Record. • The use of mobile solutions by patients and clinicians will significantly increase over the next 10 years. • It is important that these are tested and validated and considered appropriate for use by a governing body within the healthcare environment • Telehealth is also a growing area of digital health where physiotherapy may have an impact. This has not been the case to date for stroke patients. 7
  8. 8. Article 5: Lee H, Seo S and Song J (2016).Information on functioning found in the medical records of patients with stroke. Journal of Physical therapy Science.28, 2722-2726. Key messages from the article • EMRs ensure timely and accessible information is available across the hospital continuum of care • Structured forms and documents within the EMR provide groups of data and ensures a common language to facilitate communication amongst health professionals • Structured admission and discharge summaries are valuable if they are similar across hospital EMR systems • Use of stroke specific measurement tool data within an individuals EMR (e.g.. Bergs balance scale) allows for atomised data • This study linked EMR related information to concepts and ICF codes (health related functioning framework) and noted information related to physical functioning, walking, transferring was frequently found within an EMR Link with the rationale • Structured physiotherapy forms and documents will improve consistency of documentation and save clinical time • Agreed measurement tools allow for greater research capability and monitoring of patient progress over time • The DHHS will be focusing on patient reported outcomes measures in 2017 and these should be included within the build of an EMR 8
  9. 9. Recommendations • Applying digital health and informatics to the care of stroke patients is critical to the ongoing improvements in outcomes and quality of care provided to patients • “The global burden of stroke requires innovative, effective and widely available strategies for stroke prevention”. (Yan et al. 2016) • It is known that patients who receive organised inpatient care in a stroke unit are more likely to be alive, independent and living at home within one year after stroke and implementing an EMR will assist in co-ordinating and organising care for these patients whilst in hospital. Predictions • Use of smart watches, iphones and fitbits will be a significant part of health care in the future with links to the patient my health record / EMR. • “Portable sensor technology may offer a future alternative to floor markers in measuring distance walked for stroke patients through wireless transmission of data to a mobile phone, and EMR” (Yan et al 2016) • Patients will become more involved in their healthcare in the future through the use of patient portals to the EMR • Many applications will be developed for stroke . It will be important that these are appropriately tested and validated and interoperable with other systems • Device integration where vitals automatically flow into the EMR during the acute phase of stroke will assist in identifying deteriorating patients in a more timely and accurate way • Predictive models for mobility achievement (prognosis of clinical outcomes) built into the EMR will assist with discharge planning for clinicians, patients and families Questions for further research • Research is required into the impact and implementation of digital health on the prevention of stroke, and improving outcomes for those who experience a stroke • Research is required into EMR enhanced predictive models for physical outcomes after stroke to successfully guide physiotherapy intervention and discharge planning • Research is required into the use of risk stratification via the EMR for secondary strokes and readmissions. Risk stratification will help to individualise physiotherapy intervention and requirements for community links once the patient is discharged from hospital. 9
  10. 10. Summary and Conclusions As the health service where I work embarks on implementing an EMR, it is important that the EMR enables translation of knowledge into practice. Important considerations for stroke and physiotherapy include: • Clinical pathways and work flows • Order sets to ensure standardisation of care and reduced variation. Order sets should include referrals to Allied Health (physiotherapy) • Multidisciplinary approach to care with appropriate documentation in the EMR • Implementing easy to use structured forms for physiotherapy assessment and discharge • Incorporating an EBP early mobilisation strategy into the EMR with best practice alerts • Ensuring subject matter experts inform these processes • Ensuring reporting and analytical functionality is available 10

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