Medical Informatics in Neurology

Medical informatics is most simply defined as computer applications in health care. The definition can be more complicated. Biomedical informatics is an diverse and expanding discipline that has been defined as the study, invention, and implementation of structures and algorithms to improve communication, understanding, and management of medical information. The end objective of biomedical informatics is the integration of data, knowledge, and tools necessary to apply that data and knowledge in the decision-making process associated with patient care. The focus on the structures and algorithms necessary to manipulate the information separates biomedical informatics from other medical disciplines where information content is the focal point.

According to Van Bemmel, medical informatics comprises the theoretical and practical aspects of information processing and communication based on knowledge and experience derived from processes in medicine and health care. ^{[1, 2]}

The applications of computers in health care are very extensive, but the field of medical informatics can be structured or divided into the following domains:

• Signal processing: electro- and neurophysiological analysis by computer

• Image processing: neuroimaging and neuropathology analysis by computer

• Health informaton systems including electronic health records

• Clinical decision support systems and tools

• Telemedicine/telehealth platforms

• Web-based medical communications

For excellent patient education resources, see eMedicineHealth's patient education articles Family Medical Records, CT Scan, Magnetic Resonance Imaging (MRI), Understanding X-rays, Electrocardiogram (ECG), and Electromyography (EMG).

Signal processing (EEG, EMG, ECG)

Computers are useful devices for processing electrical signals from various sources, such as ECG for detection of heart dysrhythmias and EEG for analysis and detection of spike and sharp waves that can sometimes be missed by the neurologist. ^{[3, 4]}  Although automated signal processing for most routine EEGs is not the norm, continous records of hospitalized patients are more and more adopting algorithms of signal-to-noise detection both in real time and over the course of several hours/days of records.

In nerve conduction studies and EMG, signal processing with computers can aid in waveform analysis, compound muscle action potentials (CMAP) and sensory nerve action potentials (SNAP) measurements, and amplitude and area quantitative measurements. Combined with a comparison system for reference range values, a custom-made report can be produced for easy recognition of abnormal values and final diagnosis. In general, computerized EMG can help the less experienced neurologist or electromyographer with early diagnosis of subtle EMG changes. ^[5]

Image processing (radiography, US, CT scanning, MRI/MRA, SPECT/PET scanning, cerebral angiography)

Image processing and pattern recognition are important fields in medical informatics, specifically in neuroinformatics as an emerging domain for CT scanning, MRI of the brain, and other new techniques such as SPECT and PET scanning and functional MRI (fMRI). For example, processing of spatially distributed patterns of brain activation in fMRI data sets using computerized analysis helps determine pathophysiology of many neurologic disorders and define functional structures of the brain. ^{[6, 7, 8]}  The FDA is increasingly clearing AI-enabled algirithms that parse through neuroimaging and pathological samples to enhance signal-to-noise detection.

Good medical care requires accurate records of greater detail than in the past. Malpractice protection mandates more organized and complete records. Third party payers are requiring more justification for the expenses generated by physicians' actions. Today's economics require more efficient and cost-effective methods of keeping the patient's clinical records. ^[9] In 1991, the Institute of Medicine (IOM) released an influential report, The Computer-Based Patient Record: An Essential Technology for Health Care. The report advocated adoption of the computer-based patient record (CPR) and now more commonly known as Electronic Health Records (EHRs) as standard medical practice.

According to the report, EHRs "can respond to health care's need for a ‘central nervous system' to manage the complexities of modern medicine — from patient care to public health to health care policy." The report described the EHR as a continuous chronological history of a patient's medical care linked to various aids for their user, such as programmed reminders and alerts generated by decision-making systems. The IOM report led to the creation of the Computer-Based Patient Record Institute, an advocacy group that is supported by corporations in the health care, insurance, data-processing, and computer industries, as well as by some professional groups.

With government regulations, penalities, incentives, interoperability guidelines, and the COVID-19 pandemic, the use of EHRs in office-based neurology is near ubiquitous.

Decision support systems are real-time computerized algorithms that help physicians in their clinical practice. For example, when clinicians perform a task (eg, order entry) using the EHR, they are warned if the task appears to be inappropriate on the basis of patient data. The system presents this warning automatically using consensus-based clinical decision support "rules" that are derived from medical knowledge (or financial data) and patient-specific information.

Telemedicine is distance consultation among health professionals or between health professionals and patients by use of telecommunications technology such as real-time audio or visual systems, most notably video conferencing. ^[10] The potential advantages are obvious in dispersed communities, where expertise is thinly spread, and when traveling is difficult or inconvenient for doctor or patient. The COVID-19 pandemic forced many neurology practices to covert to telemedicine sessions. Uses are wide and varied and include direct interview and history taking, observation of physical signs, and distance reporting of imaging procedures. The location of consultation varies from hospital inpatient and outpatient settings to broader residential and home settings and even outer space. ^{[11, 12]}

Remember that communicating with patients through email is prudent only if the following guidelines are employed: ^[13]

• Establish turnaround time for messages and do not use email for urgent matters.

• Inform patients about privacy issues.

• Establish types of transactions (eg, prescription refill, appointment scheduling) and sensitivity of subject matter (eg, HIV status, mental health care) permitted over email.

• Instruct patients to put the category of transaction (eg, prescription, appointment, medical advice, billing question) in the subject line of the email message for filtering.

• Request that patients put their name and patient identification number in the body of the message.

• Configure automatic reply to acknowledge receipt of messages.

• Print all messages, with replies and confirmation of receipt, and place in patient's paper chart.

• Send a new message to inform patient of completion of request.

• Request that patients use autoreply feature to acknowledge reading provider's message.

• Maintain a mailing list of patients but do not send group mailings where recipients are visible to each other. Use the blind courtesy copy feature in email software.

• Avoid anger, sarcasm, harsh criticism, and libelous references to third parties in messages.

• Consider obtaining patient's informed consent for use of email.

• Never forward patient-identifiable information to a third party without the patient's express permission.

• Use encryption for all messages when encryption technology becomes widely available, user-friendly, and practical.

• Do not use unencrypted wireless communications with patient-identifiable information.

• Commit policy decisions to writing and electronic form.

The Internet has had a profound effect on medicine as a source of health information include convenient access to a massive volume of information, ease of updating information, and the potential for interactive formats that promote understanding and retention of information. Health information on the Internet may make patients better informed, leading to better health outcomes, more appropriate use of health service resources, and a stronger physician-patient relationship.

However, health information on the Internet may be misleading or misinterpreted, compromising health behaviors and health outcomes or resulting in inappropriate requests for clinical interventions. Physicians may accede to inappropriate requests, either because refusal is time consuming or because they fear refusal would weaken the physician-patient relationship. Responding to inappropriate patient requests may be particularly difficult in managed care, where patients may believe that physician refusals may be motivated by the need to control costs.

Physicians can access professional Internet sites for the following purposes:

• Access/maintain patient records

• Blogging

• Complete CME credits

• Information on clinical trials, message going to consumers/patients

• Information on medical equipment/devices

• Information on medication/procedures

• Interactive learning

• Medical discussion groups (eg, Sermo, peer-to-peer social networking)

• Meeting/conference information

• Patient information/educational materials

• Medical news, journal

• Research specific clinical situations and read medical books

• Webcast/podcasts

In conclusion, Web-based communications has had important impact in the practice of medicine. Physicians need to know the importance of this media and how to use it in a pragmatic and efficient way. Many physicians believe that they save personal time by using the Internet and that they can use the Internet for better practice of medicine. They can have easy access to clinical guidelines, journal contents, and reference textbooks and even provide patients with educational materials. Physicians will be able to obtain information on state-of-the-art conferences and have direct communication with other physicians and specialists or practice telemedicine, thereby expanding the depth and extent of medical knowledge and providing better diagnosis and patient care.