Thursday, November 7, 2019

Very funny IT video

Hi fellow HealthIT and Clinical Informatics friends,

I'm taking a break from my usual educational pieces, just had to share this hilarious video someone sent me from YouTube. If you've ever worked in HealthIT, you'll appreciate it:

Adapted from Jesus Quintero's show in Spain, adding the IT subtitles gives it a whole new life!

Hope you enjoyed it!

- Dirk :)

Wednesday, October 30, 2019

Intro to CPOE and Order Sets

Hi to my fellow CMIOs, CNIOs, Clinical Informaticists and other HealthIT and clinical friends,

Order sets can be a real gift to modern medicine, but only when they are designed by experienced, capable Clinical Informaticists and Analysts, in conjunction with the clinical end-users. Usually, this requires more work and planning than most people are aware of - until they dive into the waters themselves.

So for anyone who's ever had to explain the work it takes to produce good, evidence-based order sets that support smooth workflows with minimal clicks - I thought I'd share this cute little video I produced recently. Think of it as an easy way of teaching some of the basics to newcomers

This is the strategy I've used professionally to create great, evidence-based, easy-to-use order sets that give my fellow physicians the right guidance and confidence they need to navigate even the most complicated workflows. Feel free to share with anyone who's new, or looking to learn more about how good workflows and decision support strategies are designed. 

Have any secrets of your own? Feel free to share them in the comments field below!

Remember, this blog is for educational purposes only - Your mileage may vary. Have any other comments or feedback? Please leave them in the comments section below!

Wednesday, August 28, 2019

Improving EMR Satisfaction by Better Anticipating Clinical Needs

Hi fellow CMIOs, CNIOs, Clinical #Informatics professionals, and other #Healthcare leaders,

I'm writing today to share my thoughts about how to improve EMR user satisfaction through a better understanding of the user's clinical roles and responsibilities, and h
ow they impact EMR configuration and training. 

Allow me to explain. Imagine you see a group of people with white coats and stethoscopes, eating lunch together. What are their needs? Are they all one kind of provider, or different providers? How could you tell them apart? And even if you could somehow tell them apart, how would you know exactly what their EMR configuration and training needs are?

Most clinical people think of these as small details. To them, clinical roles seem fairly intuitive, and credentialing seems like little more than a time-intensive requirement to 'do paperwork' before you can begin working clinically. Both of these are common misunderstandings. 

The truth is that clinical roles in modern healthcare are very nuanced, each with their own clinical functions and supervisions needs, and so your exact clinical role and responsibilities have an enormous impact on your EMR configuration and training needs. Without a clear understanding of your clinical role and responsibilities, it's very  challenging to provide the right EMR configuration and training, which can lead to frustrated end users.

So to help improve EMR configuration, training, and user satisfaction - I thought I'd offer this little blog post to help you understand how clinical role terminology, supervision requirements, and onboarding/credentialing questions can help improve EMR configuration and training, as well as end-user satisfaction. 

So in short, we'll discuss some basics about four topics : 
  • A - What is a Doctor (Physician)? What are the different types of Doctors (Physicians), and when/how are they supervised?
  • B - What is an Advanced Practice Provider (APP)? What are the different types, and when/how are they supervised?
  • C - What is a Provider (Prescriber)?
  • D - What kind of questions can you ask during on-boarding/credentialing to help make sure you fully understand the provider's role and responsibilities, so you can better anticipate their needs and provide great configuration and EMR training?
Let's get started!

For those of us who have been through medical training, this all seems fairly intuitive. You finish medical school, get through internship, complete your residency, and many docs continue through a fellowship (subspecialty) training, before becoming an Attending Physician. And along the way, you will work with lots of great Advanced Practice Providers (APPs) including Advanced Practice Registered Nurses (APRNs), Physician Assistants (PAs), and others. 

But imagine if you weren't clinical. Looking at a group of people with white coats and stethoscopes, how could an administrative or IT person tell them apart? It helps to have some good definitions to work with!

Let's start by looking at what exactly is a "Doctor" (Physician).
Note that the supervision model above requires a number of workflow configurations in an EMR - Most commonly, with orders and clinical documentation (notes) - 
  • Which order(s) WILL require an attending countersignature?
  • Which order(s) will NOT require an attending countersignature?
  • Which note(s) WILL require an attending countersignature?
  • Which note(s) will NOT require an attending countersignature?
  • Knowing the EMR will function differently for Residents, Fellows, and Attendings - How will the EMR be configured for Fellows who sometimes moonlight as Attending providers?
In addition to a clear understanding of these roles, responsibilities, and configuration differences - It's also important that an organization have an easy way of knowing when doctors change their roles. (July 1st is not a guarantee that a doctor's clinical role will change!)

With the expansion of medical technology and clinical specialties in the 1970s and 1980s, came a new set of providers who could help 'extend' the reach of the attending physician, including Advanced Practice Providers (APPs) such as : 
These roles also have unique EMR configuration and training needs, which are highly dependent on the supervision needs, which often depend on state regulations. Like Doctors/Physicians, having a clear understanding of these clinical roles and their supervision needs is key in providing the proper configuration, security, and training. 

So to put this all together, we can now represent the Doctors (Resident, Fellow, and Attending Physicians) and Advanced Practice Providers (APPs) as a common set of Providers (Prescribers), each with a DEA number and prescriptive authority, but with different supervision needs and expectations
Again, this catch-all term can be helpful, especially for pharmacies that want to provide services to all of these roles. It's not as helpful in legal/billing scenarios, where usually the Supervising Attending Provider (1c) (and sometimes the independent APRN!) are more commonly the focus of discussion.

So we've discussed how these clinical roles impact EMR security, configuration, and training. What other questions can you ask, to better anticipate a user's clinical needs, configuration needs, and training needs? While it may not be comprehensive, I recently drafted this list of questions you might ask a provider during on-boarding and credentialing, to better understand and anticipate their clinical, academic, research, and administrative needs:  
Again, this list of questions may not be comprehensive, but it helps show how good credentialing and provider on-boarding can help HealthIT people to better understand a user's clinical, administrative, research, and academic roles, and anticipate the specific needs for each role. 

I hope this was helpful in shedding some light on these important topics! Remember : It's the little details that matter. If you have any feedback or comments, please leave them in the comments section below.

Remember this blog post is for academic and educational discussion only - Your mileage may vary, and always check with your local Legal, Compliance, and Clinical Informatics experts for guidance in your own organization. Have any feedback or thoughts? Feel free to share below!

Friday, August 9, 2019

What exactly does "Inpatient" mean?

Hi fellow CMIOs, CNIOs, Clinical Operations, HIM, and other Clinical Informatics leaders,

I'm constantly amazed by the complexity of medical terminology. A lot of unnecessary heartache comes from the unappreciated differences in understanding between different parts of the clinical care team and other billing/administrative stakeholders.

In modern healthcare, there are a few words which can trigger a special level of confusion, and surprisingly one of them is the word "inpatient". It is one of the most context-sensitive, role-dependent words that I can think of, commonly used across the table in healthcare operational and workflow discussions. 

What exactly does it mean, how does it work, and how can it be misunderstood?

1. THE HISTORY      

While I'm not an expert medical historian, the history of the word "inpatient" likely derives from the 200-or-so-year history of healthcare. Most hospitals were not really hospitals like we think of them today - They were charity and alms houses, often with beds, with nuns, nurses, and practitioners/physicians tending to sick and dying patients in them.

In a local nearby community hospital, where I once worked, I once interviewed some older nurses who volunteered in our coffee shop - Just to ask them what they remember about the history of the hospital. (For those of you who are lucky enough, ask some older nurses about the history of healthcare - The stories they tell are unbelievable!)

What I found out is that our hospital was once, back in the late 1800s, a simple house, on a hill, donated by a local farmer to help tend to the sick in our area. "It was a place where old and sick farmers came to die," they explained to me. "And then, one day, penicillin arrived - And suddenly, the farmers didn't die, but actually felt better and wanted to go home." And voila - The discharge process was born. 

Taking care of these patients, 24/7, inside the 'house' took a lot of work and attention. Unfortunately, the local community physicians weren't available 24/7 (many had families!), so how exactly did they care for patients 24/7 when there were no physicians available?

In most academic hospitals, there were younger student doctors, who as part of their training agreed to basically live "in" the house - Hence, the name "Residents", since during training they were basically committed to living inside the house, while the Attending providers went home at night to their families.  

Meanwhile, in many community hospitals, this was probably a complex situation for the nurses, who fought heroic battles to keep their patients alive and comfortable until the morning, when the community providers would return and do morning rounds in the hospital. Remember, it was the 1990s when Hospitalist medicine was born, so before that - I can only imagine it must have been a difficult situation for nurses who fought for their sickest patients. (If you know any nurses from this era, make sure you appreciate them.)

In any case, from this era of healthcare, came two important concepts : 

  • "Inpatient" - Patients INSIDE the 'house'/hospital
  • "Outpatient" - Patients OUTSIDE  the 'house'/hospital

During this era, this terminology was probably somewhat helpful in judging patient acuity, e.g.:
  • If you were sick enough to need to be in a hospital --> INPATIENT
  • If you weren't, and could walk around --> OUTPATIENT
And so, healthcare appears to have made it through the 1960s-1970s with those terms mostly intact. 

In the 1960s and 1970s, with increased technology, specialization, and standards, the price of healthcare increased. Eventually payment reform became necessary to help control the costs of this care. 

So to help better understand patient acuity and care needs, two terms became important - Taken from is this : 
  • "LEVEL OF CARE" - The intensity of effort required to diagnose, treat, preserve, or maintain an individual's physical or emotional status
  • "LEVEL OF SERVICE" - Based on the patient's condition and the needed level of care, used to identify and verify that the patient is receiving care at the appropriate level.
So these terms were stratified to help better organize our healthcare system. In general : 
Looking at the above list, one might ask, "Why is the Emergency Department considered an outpatient level-of-care/acuity? Don't they have really sick patients?" The answer is yes, they often do have sick patients - But :
  • because the modern-day Emergency Department grew (circa 1960s-1970s) out of what was once a combination of primary care, urgent care, and the historical "Accident Room" in most hospitals, AND
  • because many of the patients seen in an Emergency room are treated, fixed, and sent home
  • because patients in the ED are usually waiting to be admitted to inpatient levels-of-care/locations
... the Emergency Department is kind of an unusual hybrid patient care location, staffed with critical care-trained doctors and nurses, but is still considered an outpatient patient care location (even when they have patients with inpatient acuity needing an inpatient level-of-care).

And with regard to nurse training and staffing? Generally, nurses train and staff uniquely in each of these levels-of-care. (Interesting note : Staffing usually depends on the routine vitals!)

And finally, with regard to "bed" management? 
  • INPATIENT BEDS = A bed with a patient assigned to one of the inpatient levels-of-care, usually (but not always!) geographically located in an inpatient area*
  • OUTPATIENT BEDS = A bed with a patient assigned to one of the outpatient levels-of-care, usually (but not always!) geographically located in an outpatient area*
* NOTE - In "bed overflow" situations, it's entirely possible to "make" an "Inpatient" bed in a geographically "outpatient" location - E.g. A patient waiting for an inpatient intermediate/cardiac bed might be physically lying in a bed in an outpatient/ED location, but if they are admitted to the inpatient intermediate/cardiac level-of-care, they are still considered to be an inpatient, in an inpatient bed, "boarding" in the ED/outpatient location.
So this level-of-care index was at least a little more helpful in roughly estimating a patient's acuity, and for planning the kind of care that would need to be delivered in these locations.

With these newer, better-defined levels-of-care, some providers started to distinguish themselves and their clinical practices : 
  • "I do inpatient medicine."
  • "I do outpatient medicine."
  • "I do inpatient neurology."
  • "I do outpatient neurology."
  • "I do inpatient hospitalist work."
  • "I do inpatient pulmonary and critical care."
  • Etc...
And so physicians started to define and stratify themselves - again with the curious hybrid of the Emergency Department, where modern ED providers have critical care training but are still considered to be working in an outpatient location, hence, are technically outpatient providers.

Once upon a time, the terminology was pretty simple : 
  • ADMITTED = Admitted to an inpatient level-of-care / location
  • NOT ADMITTED = Not admitted to an inpatient level-of-care / location
But as the price of healthcare continued to rise in the 1980s, this was too granular a concept, and some payors started to question whether everyone in the hospital really needed to be admitted to the hospital - Did they all need to be inpatients? (Were they all really that sick?)

So again, new terminology was developed, to help distinguish : 
  • "INPATIENT" - Patients who are admitted to an inpatient level-of-care/location, and sick enough to need to stay in the hospital for at least two midnights (E.g. The "sick" sepsis patient with multiple organ failure)
  • "OBSERVATION/OUTPATIENT" - Patients who are admitted to an inpatient level-of-care/location, but not sick enough to require a stay in the hospital for more than two midnights. (E.g. the long-distance runner who got dehydrated and dizzy, and just needed a night of IV fluids and observation before being sent home)
Unfortunately, the use of the billing status "INPATIENT" can be easily confused with the level-of-care/location "INPATIENT".

5. THE SUMMARY       
So it's entirely possible to have : 
  • An admitted inpatient with 
  • a CMS billing status = OBSERVATION/OUTPATIENT
  • being cared for in BED/LEVEL-OF-CARE = INPATIENT(MED/SURG),
  • temporarily boarded in a LOCATION = OUTPATIENT(ED),
  • until they arrive in their final LOCATION = INPATIENT(MED/SURG UNIT),
  • being routinely cared for by their INPATIENT HOSPITALIST or
  • being emergently cared for their OUTPATIENT ED PROVIDER (e.g. during a code?)
And during that emergency code, the OUTPATIENT ED PROVIDER may come to work on the INPATIENT (currently in OBSERVATION status) in an INPATIENT LEVEL-OF-CARE/ACUITY and in an INPATIENT LOCATION, along with nurses trained to deliver inpatient care

And after the code, if the patient is sick and is estimated to require more than 2 midnights of care in the hospital - the INPATIENT HOSPITALIST may ask the Case Manager to change their CMS Billing Status from OBSERVATION/OUTPATIENT to INPATIENT

Makes perfect sense, right? It can be complicated! Unfortunately, our healthcare system is somewhat limited by the lack of terminology development, so I thought I'd summarize it here : 

Hope this helps! Need help interpreting or translating during discussions? Ask your own Clinical Informatics, Health Information Management, or other Clinical Operational leadership for help!

Remember, this blog is for educational purposes only - Your mileage may vary. Have any stories to share about translating this terminology? Have ideas of how to simplify? Feel free to leave in the comments below!

Tuesday, July 9, 2019

Why You Should Always Map the Current State

Hi fellow CMIOs, CNIOs, #Informatics, and other #HealthIT leaders,

Today I'm writing to discuss a fairly common question in clinical change management, related to the practice of 'mapping the current state': Is it really necessary?

When planning a clinical improvement project, it may be one of the most common newbie mistakes: Thinking you can't, or don't need to analyze the current state : 

It has been said that Clinical #Informatics and #workflow engineering is a bit like 'rebuilding the plane while it is still in the air' - Healthcare is in business 24x7, and can't really shut down, even for a few minutes, without a potential impact on patient care. (This is one of the things that separates #HealthIT from #BusinessIT, #AcademicIT, and #ResearchIT.)

So in today's fast-paced healthcare environment, it's more important than ever to make sure that projects are executed well, on-time, on-budget, and according to plan. And this is where our discussion starts : How to make sure you're really planning well

First - Without mapping the current state, it looks something like this : 

... and then it becomes impossible to tell if your project is going to look like this : 

... or this...

... and so without a current-state assessment, it's easier to either under- or over-estimate the work it will require to get to Point B. 

Remember, smooth workflow change is not just about the configuration you need to do inside the EMR - It's the work you need to do outside of the EMR too, including development of staff education needed to get your clinical teams from Point A to Point B - See #7 in the grey box on the left-handed side below : 
Taken from my 11-18-2015 blog post, 

Again, in today's healthcare environment, having smooth, well-executed workflows and projects is more important than ever. As an example, Dr. Danielle Ofri recently wrote this very relevant opinion piece in the New York Times which really introduces the importance of well-designed, well-planned workflows :

(June 8th, 2019)

... in which she writes, "With mergers and streamlining, [corporate medicine] has pushed the productivity numbers about as far as they can go." After she describes some real problems with the efficiency of some EMR documentation, she shares this insight, "But in health care there is a wondrous elasticity - you can keep adding work and magically it all somehow gets done."

While Dr. Ofri is quite right that this is a commonly-held belief, there's still a basic problem: Math is math. Healthcare should not plan to do 25 minutes of work in a 15 minute timeframe. So in the national discussion about physician burnout (#physicianburnout, or as ZDoggMD describes it, 'moral injury'), it's more important than ever to make sure workflows serve the needs of the patients, providers, nurses, pharmacists, and other clinical and administrative people working in #healthcare. To make sure we're not overloading our clinical teams, every data element needs to be well-analyzed, well-studied, well-planned, and serve a legitimate patient care or business function.

And this is why the current state is important. Without studying the current state, it becomes very challenging to answer questions like: 
  • Which stakeholders need to be involved in this project?
  • How much time will this project take?
  • What training and support will we need to go-live with the planned future state?
Still, some people express concern about the work it takes to map the current state, or question the real benefits. Allow me to share some common arguments, along with my counter-arguments
ARGUMENT : "We don't have time or resources to map the current state." 
COUNTER-ARGUMENT : "Will we have time or resources to fix things that we didn't account for? How will we know the scope of the effort, who to invite to meetings, or how much educational effort we will need to plan for?" 
ARGUMENT : "It's not worth mapping the current state, last time it took us hours and we still couldn't figure it out." 
COUNTER-ARGUMENT : "Not being able to map the current state, despite best efforts, is still a really important factor to consider when scoping and planning a project." 
ARGUMENT : "We don't want to map the current state because we don't want to bring old habits into our new workflow." 
COUNTER-ARGUMENT : "Even though there may be parts of your current-state workflow worth keeping, it's not to bring old habits into your new workflow - It's to make sure we're covering all of our bases, and doing the best job planning, designing, and executing that we can."
ARGUMENT : "It takes too much work to map the current state." 
COUNTER-ARGUMENT : "It doesn't need to take a lot of work, and you don't always need Visio swimlane diagrams. For many workflows, a simple well-written procedure with each line written as [WHO] will/may [WHAT] will do the trick. Even if it's not documented - it's still important that whoever plans the project has ample access to someone with a good understanding of the current-state workflow(s)."
Fortunately, most experienced Clinical #Informatics and #HealthIT professionals know the importance of mapping the current state in planning clinical improvement projects, and how to map it quickly. So if you ever need help mapping the current state, ask your local Clinical #Informatics or #HealthIT experts for assistance!

Remember, this blog is for academic discussions only - Your mileage may vary. Seek expert advice from your leadership, legal counsel, clinical informatics, or project management teams before changing strategies. Do you have any questions, comments, or feedback? Leave them in the comments section below!

Thursday, June 6, 2019

Working in Healthcare, are you "Clinical"?

Hi fellow #Informatics friends and other #healthcare leaders,

So for this post, I thought I'd tackle an interesting question - What does the word "clinical" mean, exactly?

This is an interesting challenge - When people hear the word "clinical", they usually think someone taking care of a patient, usually in scrubs, often with a stethoscope around their neck - E.g. : 
While that may be true, it's also an incomplete definition. There is more to the story. What about people who don't wear scrubs, like social workers and case managers and registration, who all have a great deal to do with clinical care and patient safety? Or people without stethoscopes, like pharmacists

If we ask Google for a definition of "clinical", on 06-01-2019 it gives us this result : 
... which, interestingly, includes the description of "efficient and unemotional; coldly detached". (How exactly did that happen?)

Anyway, what I find more interesting is the part of the definition above, "...relating to the observation and treatment of actual patients..." - To me, this is more relevant, because it brings into focus the connection with "actual patients", who are what clinical care is all about.

Unfortunately, in some healthcare settings, the word "clinical" is sometimes used to distinguish, incorrectly, between two 'types' of workers in healthcare :
  • Those people who directly or indirectly take care of patients. (?"clinical"?)
  • Those people who don't directly (or indirectly?) take care of patients. (?"administrative"?)
When compared to the term "administrative", the word "clinical" becomes meaningless and confusing. This confusion is sometimes perpetuated by policy manuals which generally describe two sets of policy standards commonly found in healthcare operations : 

It may not be that big a deal, but in my opinion, this older terminology division sets up an unnecessary and incorrect misunderstanding in healthcare, leading some to wrongly believe that a healthcare organization is essentially made of two tribes : 
  • The "Administrative" Tribe - Finance, HR, IT, and legal/compliance workers who are necessary to help the organization run but don't really understand or get involved in patient care.
  • The "Clinical" Tribe - Doctors, nurses, pharmacists, and others who are taking care of the patient, but don't need to understand administrative functions.
  • And maybe a few people who fall somewhere in between these two tribes, to help each tribe understand the other (e.g. Clinical leaders)??
Conceptually, this old-fashioned thinking might be thought of as a Venn diagram, with a few key "clinical leaders" who might fall in the middle :

In this context, the word "clinical" only helps reinforce an outdated notion that creates unnecessary antagonism. It incorrectly implies :
  • That there are "clinical staff" who know intimately well what patient care needs are, but no need to understand administrative functions.
  • That there are "administrative staff" who know intimately well what the organization needs, but don't need to understand patient care, or have any responsibility for patient safety. 
Both of these are misleading and incorrect. We in healthcare can do better

For this reason, I'd propose a new way of thinking about healthcare operations, using a different way of categorizing operational standards :

In this way, we avoid the unnecessary "Clinical" versus "Administrative" distinctions, and encourage teamwork, collaboration, and understanding. Organizationally, I believe this would help both sides to better understand each other : 
  • As the Google definition of "Clinical" implies,  almost everyone in a healthcare organization has a relationship (direct or indirect) with patient care.
  • The traditionally "Clinical" workers (those with a direct relationship with patient care) can benefit by learning more about the needs of the traditionally "Administrative" workers (those with an indirect relationship with patient care).
  • The traditionally "Administrative" workers (those with an indirect relationship with patient care) can benefit by learning more about direct patient care, and their own indirect but real relationship with good, safe, efficient patient care.
So perhaps a newer way of thinking about this could be presented in a new Venn diagram:

While changing this thinking may not be a high-priority issue, I do hope it stimulates discussion and helps encourage understanding, collaboration, and teamwork. Whether you are direct or indirect - In Healthcare, we are all clinical. :)

Remember, this blog is for discussion and education purposes only - Your mileage may vary. Have any feedback or thoughts? Leave them in the comments section below.

Sunday, April 28, 2019

The Tribes of Healthcare

Hi fellow Informatics friends,

#whyinformatics... This weekend I worked on a video little video, for a team building meeting, to try to explain the different 'Tribes of Healthcare', the clinical and administrative teams that work together to make patient care happen. 

As we've explored in prior posts, healthcare has a uniquely complex set of stakeholders, each with its own skill set, culture, and terminology. Together, they can make amazing things happen - Real advances in patient care and treatment of disease. Separately, they can struggle. 

It's intended to be a little tongue-in-cheek, but clinical informaticists may find this especially amusing, since informatics sits at the intersection of all of these stakeholders - working to translate their needs and concerns into actionable items, projects, and EMR configurations. If you're struggling to assemble these teams for an operational discussion, make sure to ask your local clinical informatics professional for help. :)

The video has a little introduction from one of my educational side projects, with the sound of a cardiac monitor during a code, so make sure your volume is low if you're using headphones. (Believe it or not, it was all created with some very common phone and laptop tools.)

The result is only about three minutes long, so enjoy!

(Click to open)

Remember - This blog is for educational discussions only - Your mileage may vary. Have any anecdotes you'd care to share? Feel free to leave them in the comments below!