My Top 5 articles in 2015-16 on Physiotherapy in Stroke and
Electronic Medical Records
My Top 5 articles from 2015-16 about Informatics and Digital
Health in Physiotherapy and Stroke
Samantha Plumb Health Informatics and Digital Health 20161The
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
expertisethe number of people annually affected by stroke, living
with stroke and dying from stroke is increasing worldwidetimely
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)
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 DatabaseSearch fieldsSearch termsTotal No. of
articlesShortlisted for reviewReason for exclusionCinahlTitle and
abstract#1 and #2 and #300CochraneTitle and abstract#1 and #2 and
#300PedroTitle and abstract#1 and #2 and #300MedlineTitle and
abstract#1 and #2 and #3523 articles less relevantEmbaseTitle and
abstract#1 and #2 and #350 3 conference papers2 not in
EnglishScopusTitle and abstract#1 and #2 and #3632 articles less
relevant1 article duplicated from Medline search
2
Rationale for top 5 papersAll 5 papers link digital health with
improving clinical outcomes for stroke patientsAll 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 consideredThe lack of
literature to choose from in this area should be noted
3
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, 2788-2796Key messages from the articleIt is imperative
that patients are treated in accordance with evidence based
practice to achieve best outcomesA rapid reliable clinical
diagnosis should occur as soon as possible to form the basis for
continued managementUse 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 outcomesThis 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 safetyThe 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 rehabilitationCritical 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 rationaleSCP or clinical pathways within an EMR
are a proven tool to implement EBP and reduce variation in
careClinical pathways for stroke should include referrals to
physiotherapyevidence 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 EMR4
Article 2:Amin K (2015). Replacing paper with digital recording.
Journal of stroke and cerebrovascular diseases. 24(1), 144-147Key
messages from the articleThis 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 progressWidely used and recognised
assessment scales were used to allow for data sharing and
comparison with national and international projectsTraining on the
new system and change management through staff engagement were
identified as reasons for project successeMDT was interfaced with
other ehealth systems e.g.: PASFunctionality of the system included
analytics such as trending dataLink with the rationaleIt is well
known that co-ordinated care within a stroke unit significantly
improves outcomes for stroke inpatientsThis communication tool
enables co-ordinated careImproved 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 formsTraining and change
management are key to introducing any new IT system.Implementing IT
related to clinical areas should be led as a clinical project5
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 articleEvidence
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
stayAn 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
strokePatients 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 notesThe study
demonstrated that adoption of an evidence based early mobilisation
strategy lead to enhanced mobility achievements for stroke
patientsIt 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 rationaleThe EMR provides enhanced capability for
conducting researchThe EMR provides opportunity for implementing an
EBP early mobilisation strategyThis can be supported with clinical
decision support and close patient monitoringAtomised data as
compared to free text notes provide greater opportunity for
researchConsideration should be given to mandatory fields within an
EMR to minimise adverse impacts on data quality6
Article 4:Yan L, Li C, Chen J, Miranda J, Luo R, Betteger J, Zhu
Y, Feigin V, ODonnell 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
articleMany causes of stroke are modifiable as identified by the
INTERSTROKE study, such as physical inactivityHighly active
individuals have a 27% lower risk of stroke incidence or mortality
than less-active individuals, and moderately active individuals
compared with inactive personsAppropriate physical activity is also
a secondary prevention for stroke interventionDigital 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 cliniciansMobile
technology such as the Stroke Riskometer App allows users to
identify their relative risk of stroke developmentDigital health
makes it possible to individualise interventions for physical
activitySelf management interventions have been demonstrated to
reduce the risk of stroke recurrenceInsufficient evidence to
support the effectiveness of tele-rehabilitation on mobility and
health related quality of lifeLink with the rationaleAn 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 environmentTelehealth 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
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 articleEMRs ensure timely and accessible information is
available across the hospital continuum of careStructured forms and
documents within the EMR provide groups of data and ensures a
common language to facilitate communication amongst health
professionalsStructured admission and discharge summaries are
valuable if they are similar across hospital EMR systemsUse of
stroke specific measurement tool data within an individuals EMR
(e.g.. Bergs balance scale) allows for atomised dataThis 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 EMRLink with the rationaleStructured physiotherapy forms
and documents will improve consistency of documentation and save
clinical timeAgreed measurement tools allow for greater research
capability and monitoring of patient progress over timeThe DHHS
will be focusing on patient reported outcomes measures in 2017 and
these should be included within the build of an EMR8
RecommendationsApplying digital health and informatics to the
care of stroke patients is critical to the ongoing improvements in
outcomes and quality of care provided to patientsThe 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.
PredictionsUse 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 EMRMany applications will be developed for
stroke . It will be important that these are appropriately tested
and validated and interoperable with other systemsDevice
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 wayPredictive 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 researchResearch is required into the
impact and implementation of digital health on the prevention of
stroke, and improving outcomes for those who experience a
strokeResearch is required into EMR enhanced predictive models for
physical outcomes after stroke to successfully guide physiotherapy
intervention and discharge planningResearch 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
Summary and ConclusionsAs 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 flowsOrder 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
EMRImplementing easy to use structured forms for physiotherapy
assessment and dischargeIncorporating an EBP early mobilisation
strategy into the EMR with best practice alertsEnsuring subject
matter experts inform these processesEnsuring reporting and
analytical functionality is available10
