Guidance for Writing a Clinical Informatics Case Report

Introduction

Variation in human biology means that two seemingly similar patients may have different clinical presentations or therapeutic responses. Patient-centered case reports highlight these novel cases and help to broaden clinicians' knowledge of clinical manifestation of disease, diagnostic approach, or therapeutic alternatives. Similarly, in applied clinical informatics (CI), informatics professionals must grapple with the heterogeneity of health system structures and digital health tool configurations. Exposure to a breadth of different informatics program designs and implementations is crucial to this learning process. Sometimes known as organizational case reports, these nonclinical case reports provide educational exposure to multiple perspectives, different health system settings, and a variety of electronic health record (EHR) products. In the informatics literature, we call these CI case reports, and they offer insights into CI in a specific real-word context while illustrating fundamental CI principles. Examples of CI case reports are published in NEJM Catalyst, the Journal of the American Medical Informatics Association (JAMIA), and JAMIA Open, Applied Clinical Informatics (ACI) and ACI Open, Journal of Medical Internet Research (JMIR), and others.

CI case reports should be viewed as inspiration and education and not necessarily limited by a requirement for evidence generation. Organizational case reports are the springboard for ideas and future novel discovery from those on the frontlines. In this editorial, we want to facilitate a process where innovation and implementation at the local or regional level can have a wide impact on the broader community. We provide a brief outline of expectations for CI case reports, and our goal is to explain how authors can demonstrate CI significance, relevance, and impact ([Table 1]) in their case reports. Additionally, we provide guidance to trainees and early career faculty on how to structure the planning phases of a local pilot project to facilitate dissemination of their findings in a manuscript or other scholarly presentation.

Table 1 Checklist for completion of elements of a clinical informatics case report

	Complete?
Problem statement and study design
Statement of problem and importance?
Explanation of why an informatics solution is needed?
Study type delineated (proof of concept, implementation, or case series)?
Context
Contextual factors (patient population, software used, type of health system) sufficiently described to assess generalizability?
Methods
Core informatics concept(s) utilized?
Uses an established design methodology or evaluation framework?
Sufficient methodological detail to evaluate the validity and feasibility of the product or process described?
Data collection and data evaluation
Data type(s) feasible and consistent with the study type?
Research question is aligned with the appropriate framework, data collection plan, and method of analysis?
Results
Results address the problem statement?
Discussion/conclusion
Findings are of broad interest?
Includes limitations and lessons learned?

Publication History

Received: 29 December 2021

Accepted: 10 March 2022

Article published online:
27 May 2022

• References

• 1 The EQUATOR Network | Enhancing the quality and transparency of health research.. Accessed November 7, 2021 at: https://www.equator-network.org/
• 2 Rodgers M, Thomas S, Harden M, Parker G, Street A, Eastwood A. Developing a methodological framework for organisational case studies: a rapid review and consensus development process. Health Serv Deliv Res 2016; 4 (01) 1-142
• 3 Silverman HD, Steen EB, Carpenito JN, Ondrula CJ, Williamson JJ, Fridsma DB. Domains, tasks, and knowledge for clinical informatics subspecialty practice: results of a practice analysis. J Am Med Inform Assoc 2019; 26 (07) 586-593
• 4 Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach. BMC Med Res Methodol 2011; 11 (01) 100
• 5 Adler-Milstein J, Adelman JS, Tai-Seale M, Patel VL, Dymek C. EHR audit logs: a new goldmine for health services research?. J Biomed Inform 2020; 101: 103343
• 6 Glasgow RE, Harden SM, Gaglio B. et al. RE-AIM planning and evaluation framework: adapting to new science and practice with a 20-year review. Front Public Health 2019; 7: 64
• 7 Sittig DF, Shiffman RN, Leonard K. et al. A draft framework for measuring progress towards the development of a National Health Information Infrastructure. BMC Med Inform Decis Mak 2005; 5 (01) 14
• 8 Bakken S, Ruland CM. Translating clinical informatics interventions into routine clinical care: how can the RE-AIM framework help?. J Am Med Inform Assoc 2009; 16 (06) 889-897
• 9 Carayon P, Schoofs Hundt A, Karsh BT. et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006; 15 (Suppl. 01) i50-i58
• 10 Carayon P, Wooldridge A, Hoonakker P, Hundt AS, Kelly MM. SEIPS 3.0: Human-centered design of the patient journey for patient safety. Appl Ergon 2020; 84: 103033
• 11 Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf 2021; 30 (11) 901-910
• 12 Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci 2016; 11 (01) 72
• 13 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4 (01) 50
• 14 Sittig DF, Singh H. A new sociotechnical model for studying health information technology in complex adaptive healthcare systems. Qual Saf Health Care 2010; 19 (Suppl. 03) i68-i74
• 15 Talmon J, Ammenwerth E, Brender J, de Keizer N, Nykänen P, Rigby M. STARE-HI–Statement on reporting of evaluation studies in health informatics. Int J Med Inform 2009; 78 (01) 1-9
• 16 Larsen K, Eargle D. Theories Used in IS Research Wiki. Accessed December 19, 2021 at: https://is.theorizeit.org/wiki/Main_Page