Health Informatics in Clinical Practice

Clinical Information Management Tools

Types of clinical information management tools

Clinical Information Management tools can be used to order, prioritise and relate the new information from research into actual clinical practises.They can be divided into:

  1. Searchable databases such as "MEDLINE" which contains primary source of clinical information.

  2. Web based peer-review journals and guidelines such as the ACP Journal Club, NEJM, BMJ, Cochrane Database of Systematic Reviews, the SIGN network and the NICE website. These would represent the secondary sources of information.

  3. "Push" web technologies such as the "POEMs (patient orientated evidence that matters)" alert service and e-mail notification services that are provided by most web-based journals.

  4. Annual subscription based services such as "UpToDate" and "Essential Evidence Plus", which provide peer reviewed tertiary sources of clinical information.

  5. "Map of Medicine" is a web-based tertiary source, which presents the information in the form of care pathways. However, access is limited to licensed countries only.

  6. Supporting hardware, software and networking technologies.

As we have already dealt with the software aspects in the other sections, this section will primarily deal with the networking, hardware and databases issues.

Hardware tools

The important hardware tools are wireless enabled portable devices such as tablet personal computers, personal digital assistant devices and smartphones with in-built networking capabilities.

In view of concerns with patient privacy and networking security, these devices must support the latest wireless networking protocols such as WPA and WPA2 encryption.

It is now widely recognise that WEP encryption standard is not sufficient to secure wireless connections.

PDAs have been displaced and replaced by smartphones in terms of technology, functions and the practicality of carrying one mobile device instead of two at work.

They are no longer supported for all intent and purposes.

Hardware usability issues

Other considerations for the successful use of these devices are screen size, weight, durability and touch screen input capabilities.

Screen size should not be smaller than 3.5 inches. Otherwise, legibility becomes an issue especially if used for long periods of time. The 4 inch screens may be a good compromise between mobility and legibility for young users.

However, for best visibilty, particularly in the setting of Presbyopia where focusing at near object can be challenging, the 5.7" screen on the Samsung Note 3 or Note 4 is a pleasure to use. This screen size have continued on the Note 5.

All three models have 32GB of in-built memory which would be useful for the downloading of the entire database of UpToDate onto the smartphone. This then enables extremely fast access to data and search results, regards less of the quality and availability of WiFI or mobile 3G/4G telecommunication networks and data-plan subcriptions. We look forward to external storage capabilities in the up-coming Note 8 with expected microSD support of additional 256 GB capacity.

Technological Developments on the Horizon

Some of these issues may be addressed in the near future in the ongoing development of the next generation of mobile devices and smartphones. For example, Nokia and the University of Cambridge join forces in 2007 to investigate the use of nanotechnology in the development of a device which would be self cleaning, power by solar energy, flexible and modular in form and have in-built bio-sensors amongst all the other communications modules that already exist in current smartphones.

The screen size would be physically adjustable for best viewing and the device can be moulded into a wearable form when not in use. See this article for more - Beyond Morph

This tantalising glimpse of the future is demonstrated using animation in the short video clip below (please enable speakers):

Nokia Nanotechnology Morph Concept Video (9.35MB)

Video download:

It is unfortunate that after the fatal embrace with Microsoft via Stephen Elop in 2011, Nokia as the original iconic Finnish mobile company is no more, and along with the massive lay off of 9,650 staff, the above promise and project.

Smartphone-compatible tertiary level clinical databases

Smartphone-compatible databases such as UpToDate and Essential Evidence Plus provide mobile devices versions of their tertiary database for subscribers. Essential Evidence Plus also includes daily POEMs ("Patient-Oriented Evidence that Matters").

They can be installed on Secure Digital memory cards or on the internal built-in memory, and can be accessed quickly and locally on the device without the need for local WiFi or wireless mobile telecommunication networks. The importance of how easy it is to obtain information to make that information useful cannot be over-emphasised over and over again.

This is the most pragmatic way to pratice evidence-based medicine in a clinical environment, where access to desktop, tough-books, mobile computing units and tablets may be scarce at peak hours.

Access is also preserved during network outages or downtime, which may be critical at times. There is some qualitative literature (free full text) on the patterns of use, the perceived benefits and barriers, and proposed strategies on how to overcome these by McAlearney et al (2004).

We recognise that in the ideal world, each medical team would have access to their own mobile wireless unit on a wheeled-cart, with radiology-grade display units, dedicated bandwidth which does not suffer from bottlenecks during peak hours of use, and accessible 24/7 technical support with on the ground support staff whom are immediately available on request.

In the last 10 years, we have made progress exactly as described, with the above scenario everyday practice in many developed countries.

Trial versions of the above knowlege support tools can be downloaded and used for 30 days. This is highly recommended as each of the service takes a different approach in the structuring and delivery of the clinical information. You will find that one will suit your style of reasoning better than the other.

Effectiveness of Clinical Databases and Decision Support Systems

The effectiveness of these tools is derived from their in-built search engines, which are extremely fast and can recognise "natural language" search terms as well as acronyms and partial or even misspelled terms.

A database, no matter how comprehensive or up-to-date, is not useful if you cannot find the information that you are looking for, and find it fast when you need it.

This will have a major impact on whether the information is "usable" or not at the point of care, and hence the success or failure to practise evidence based medicine at the patient's bedside consistently and reliably.

Clinical expert systems, which are also known as Clinical Decision Support Systems (CDSS), are the other alternative source of information.

Despite their sophistication and many years of development, they have not been widely used or accepted. The reasons being that the usefulness of the system depends on the user’s ability to identify and use the relevant information produced; and ignore the irrelevant information that can also be produced.

It may also lead to over-investigation or over-treatment in inexperienced clinicians who cannot differentiate between the two (Berner et al, NEJM 1994, free full text).

Hence, paradoxically, they are less useful or may even be harmful, in the hands of junior clinicians whom might have been thought to benefit most, if these systems are used as a substitute for clinical judgement and pre-existing clinical knowledge instead of as a tool to support clinical decisions.


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Page Updated: 17 May, 2017

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