Tuesday, June 8, 2021

Welcome to Healthcare!

Hi fellow CMIOs, CNIOs, Clinical Leaders, and any healthcare newcomers,

Today's post came after I recently had someone actually thank me (!) for quickly explaining the fundamentals of healthcare to them. 

After this conversation, it dawned on me that I've never really found a good welcome introduction to healthcare, this industry that I've worked in for years. It's been open for business, 24/7, for roughly 250+ years, but has never had a good opportunity to pause and ask itself : What we are doing, and how we are doing it? 

If you're a newcomer to healthcare, the welcome can sometimes seem a little cold and informal, something like this graphic :


While there are some reasons why seasoned healthcare professionals might greet newcomers this way, it doesn't actually help newcomers to understand healthcare. Sure, it's an industry that saves lives and treats diseases - but it can also make technology companies throw in the towel, and can frustrate politicians, providers, and patients alike. We could probably all benefit from newcomers having a good understanding of it's inner workings, before they get started.

So as a Clinical Informaticist, clinical translator, and general 'tour guide', I thought I'd write a friendlier, more explanatory piece, to help newcomers succeed by better understanding the fundamentals of this industry.

First, let's start with a sample diagram showing the overall structure of a typical healthcare organization :

*Note : This is a sample general-purpose structure - Many healthcare organizations will differ
 from this structure, based on their mission and other local legal, financial, operational, or regulatory needs.
*Also note : To help keep the chart simple, the Board of Directors is not depicted in the slide above. 

If I actually did a walking tour of this 'House of Healthcare' (not an org chart!), it might actually sound like this :

1. THE ADMINISTRATIVE ROOM

Walking into the administrative room, you can look around to see a lot of departments here, collectively tasked with running the organization and providing services to the areas below them. From here, some of the departments you can see include : Finance, Human Resources, Legal/Regulatory/Compliance, Privacy and Information Security, Contracting/Procurement, Employee Health, Facilities Management / Physical Plant, Public Safety/Security, Staff Education, the Switchboard/Operator, the Staff Directory, Public and Internal Communications, Enterprise IT/Informatics, Enterprise Project Management, Enterprise Analytics and Data Governance, and even the Library!

These departments are all busy providing the day-to-day support necessary for the Academic/Education, Research, and Clinical domains below them - And that means understanding both the common and unique needs of these three areas. (This is no small task!)

1.a. THE ACADEMIC / EDUCATIONAL ROOM

Walking down the path from the Administrative area, the Academic/Educational room often has a lot of schools/departments here, including Medical, Nursing, Dental, Pharmacy, and other Ancillary types of schooling. While these students and staff may also do research, and may provide clinical support (work) to the clinical enterprise, the main focus of this area is academics and education. So, for example, a Medical school might have several divisions : 

  • Undergraduate Medical Education (UME)
  • Graduate Medical Education (GME)
  • Continuing Medical Education (CME) 

Before you think that these academic areas have it easy, keep in mind that clinical care and technology are constantly changing at an increasingly rapid pace. What was once considered desirable in the past - Memorizing textbooks full of science and clinical information - Is now considered passé, since a student who rotely memorizes facts is only memorizing clinical information that is rapidly outdated. Modern clinical educational thinking depends on not only learning a great deal of foundational knowledge, but also incorporating electronic databases and real-time decision-support tools into daily practices, with the goal of producing clinicians (doctors, nurses, and pharmacists) who continuously improve their knowledge while making decisions. 

Finally - Since the Research and Clinical Enterprises often depend on the students and staff from these Academic areas - They are a cornerstone of many healthcare institutions. (Except non-academic institutions, which do not have an academic/educational mission.)

1.b. THE RESEARCH ROOM

Walking up from the Academic/Educational room, you can walk down the hallway to the Research room, where you'll find a lot of very important departments, including : The Independent Review Board (IRB), Grant Management, Research Centers, Research Laboratories, Research Compliance, Research IT, Research Analytics and Translational science, and of course - a lot of highly-educated Researchers and Research Assistants!

This research is very important to us as a society, since it drives the foundations of medicine by creating the therapies and understanding that we all depend on. 

1.c. THE CLINICAL ENTERPRISE ROOM

Now walking from the Research Enterprise to the Clinical Enterprise, you'll notice some sudden, palpable cultural changes

  • The Clinical Enterprise is largely open-for-business 24/7, so many of the staff are used to working in shifts and on holidays
  • Patient safety is a constant focus of the workers here.
  • A lot of people in these areas are wearing scrubs or white coats, and the air often smells faintly of antiseptic cleaning fluids.
  • The fault tolerance is suddenly a lot less - requiring higher standards for hiring, budgeting, training, and implementing new tools. 
  • Because it never gets to shut down for maintenance, and the low fault-tolerance - both the change management and project management are higher-caliber and noticeably different.
  • The staff are often highly-educated, many with large amounts of student debt, so the salaries are suddenly higher
  • The language and culture change, and may sometimes overlap or be different than the culture and language of the Academic/Educational or Research enterprises.. 
  • Navigating the 'quasi-military' style clinical roles and responsibilities can sometimes be very complicated.
In this first top 1.c Clinical Enterprise box, we can see the many Clinical Enterprise Departments that support the patient care activities of all of the areas below them, including : Credentialing, Medical Staff Office, Nursing Department, Pharmacy & Therapeutics Department, Laboratory & Pathology Department, Diagnostic Radiology, Interventional Radiology, Non-Invasive Cardiology, Interventional Cardiology, Dietary/Nutrition, Physical Therapy, Occupational Therapy, Speech Therapy, Case Management / Social Work, Health Information Management, Registration, Access Management, Revenue (Billing/Coding), Housekeeping, Call Center, Scheduling, Clinical IT/Informatics, and Biomedical Engineering.

While many of these Departments above might be physically located inside the Hospital, it's important to note that the majority of these departments serve the needs of :
  • the Hospital-based care areas, and...
  • the Clinic-based care areas, and even ...
  • the Nursing Home / Patient Home care areas.  
Let's now take a walk through the first of our patient care areas, the Hospital-based patient care locations...

1.c.i. THE HOSPITAL-BASED PATIENT CARE LOCATIONS

Walking through here, we can see a number of hospital-based departments / patient care areas in this room : 

  • Emergency Department (technically an outpatient area!)
  • Inpatient Unit - Med/Surg
  • Inpatient Unit - Intermediate Unit (often Cardiac Telemetry)
  • Inpatient Unit - Intensive Care Unit (ICU)
  • Inpatient Unit - Labor and Delivery
  • Inpatient Unit - Nursery
  • Inpatient Unit - Pediatrics
  • Inpatient Unit - Psychiatry 
  • Perioperative Services (Pre-Op, OR, PACU) (technically all outpatient areas!)
  • Ambulatory Procedural Suites (e.g. Endoscopy, Bronchoscopy, Interventional Cardiology, Interventional Radiology, sleep labs, EKG/Echos, etc.) (technically all outpatient areas!)
  • Chemotherapy and Infusion Suites (note : in some organizations these are not hospital-based areas)

A lot of care is delivered in these hospital-based patient care areas! And keep in mind, it's a common mistake to either under- or over-estimate the acuity, complexity, or importance of these hospital-based areas - 

  • The clinic-based areas can be every bit as acute, complex, and important!
  • Many workflows start in the ambulatory clinic-based areas, and end in the Inpatient/ED (hospital)-based areas - And vice-versa! 
So understanding these many hospital-based patient care areas is only a part of the story.

1.c.ii. THE AMBULATORY (CLINIC) BASED LOCATIONS

In the Ambulatory (Clinic) based locations, you can find a lot of ambulatory clinics, along with sometimes some remote radiology services, blood draw services, and even some procedural and infusion services. For example, you'll commonly see Primary Care and clinics including : 

  • Neonatology / Maternal Fetal Medicine
  • General Pediatrics
  • Family Medicine
  • Medicine - General Internal Medicine
  • Medicine - Geriatrics
  • Medicine - Cardiology (General non-invasive and invasive/interventioal)
  • Medicine - Endocrinology
  • Medicine - Gastroenterology
  • Medicine - Pulmonary / Sleep Medicine
  • Medicine - Rheumatology
  • Neurology - General
  • Neurology - Movement Disorders
  • Surgery - General
  • Surgery - Neurosurgery
  • Surgery - Ophthalmology
  • Surgery - Plastics
  • Surgery - Otolaryngology (Ear, Nose, & Throat, or ENT)
  • Surgery - Orthopedics (Bone & Joint)
  • OBGYN
  • Maternal Fetal Medicine
  • Psychiatry - General Adult
  • Psychiatry - Pediatric and Adolescent
  • Dermatology - General Dermatology
  • Dermatology - Mohs Surgery
  • Hematology and Oncology (often divides up into several specialty subdivisions of care)
  • Radiation Oncology
  • Genetics Counseling
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Diet/Nutrition
  • Anesthesiology / Perioperative Medicine
  • Urgent Care

... and more!

While they are generally only open during business hours, these ambulatory clinics provide a tremendous amount of care to a tremendous number of patients, and often have acuity, complexity, and safety issues on par with the hospital-based areas.

1.c.iii. THE OFF-SITE (NURSING HOME) or HOME CARE LOCATIONS

For our final stop in our tour of the 'House of Healthcare', we'll be stopping at the nursing-home and patient-home-based care. Yes, house visits still exist! These are growing areas for many healthcare institutions, and especially since COVID, this segment is only expected to grow in the near future. It often requires providers with unique documentation/billing practices, but this is an important source of care for hospice, homebound, and nursing home patients. 

SOME FINAL WORDS

Before we wrap up our walking tour, it's important to note that Population Health is a growing trend, which ties reimbursement strategies to improved health and improved patient outcomes. While much of the focus is on outpatient/ambulatory clinics, it can also impact a number of hospital-based workflows, and so it's important for everyone to understand the role that Population Health plays.

And for the particular segment that I work in (IT/Informatics), it's important to note that there are essentially four IT/Informatics domains that cover the spectrum of a typical healthcare organization : 

  • Administrative (Enterprise) IT/Informatics (often includes Analytics/Data Governance, and infrastructure like servers, network architecture, security, interface management, hardware/software procurement, life cycle management, desktop/application management, etc.)
  • Academic/Educational IT/Informatics
  • Research IT/Informatics
  • Clinical IT/Informatics
... each with their own unique language, culture, regulations, needs, and stakeholders.

I hope this has been a quick, helpful virtual tour of a typical healthcare organization - Remember, many organizations will vary slightly, based on mission and local financial, legal, or regulatory needs. If you have any questions or comments, please feel free to leave them in the comments section below!

Remember, this blog is for educational discussion only - Your mileage may vary. Have any insights into healthcare structures, or emerging trends that are shaping healthcare? Feel free to leave them in the comments section below!

Tuesday, April 13, 2021

Getting from A to B : Project Management for Clinical Leaders

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

Change is important. As a clinical leader, you'll want to know how to make workflow changes, either to help fix a workflow that's not ideal, update a workflow that needs updating, or build a new workflow. (As long as there are new journal articles and conferences, there will be necessary updates to clinical practice to stay current.)

So this week, I thought I'd write about a topic that can help a clinical leader to feel comfortable with making changes in their area: 

"How to get from Point A to Point B"

I once alluded to a problem with making changes back in 2016, when I blogged about the Red Sneaker Problem - And How To Fix It. To help avoid frustration for you and your team, it's helpful to understand 'How does anything change?'. Without understanding the change process, it can be hard to make change


Although clinical leaders often need to focus primarily on clinical services, functions, and expertise - it's still helpful to know the basics about two important things, related to 'how things get done' : 

  1. Project Intake / Scoping - Helps you secure necessary people, time, and resources before you start a change project.
  2. Project Management - Helps you effectively use those people, time, and resources to get things done (accomplish the change)

Without understanding these two steps, it can be very hard to accomplish much change. And without regular, smooth, and predictable changes, clinical leadership can seem more daunting than it needs to be. 

So as a brief introduction for new clinical leaders, let's review these two items in a little more detail. Borrowing some slides from a recent presentation I did for a group of clinical leaders, I present some high-level overview below. 

1. PROJECT INTAKE / SCOPING - 

Making change is work. It takes people, time, and resources, to move your CURRENT state (Point A) to your desired FUTURE state (Point B). 

Ideally, to make sure you have the 'gas' needed to drive your 'car' to where you want it to go, you'll first need to understand the scope ('size'of your project. Conceptually, think of this as collectively driving your car (with your team inside it!) from :
  • Your CURRENT state (Point A)
  • Your desired FUTURE state (Point B)
This is why I always advise people to formally map the current and future states. The distance between these two points is what will determine the scope (size) of your project,  and the work effort (and resources) needed to accomplish your goal.
  • If you have the time, people, and resources necessary to get from Point A to Point B - Great
  • If you don't... Then you may feel frustrated.
So to make sure you have a thorough, well-documented analysis that you can share with your project team - it's very helpful to formally document, in a folder, your CURRENT state, and also formally design your ideal FUTURE state, one that is formally signed off by the clinical leaders who oversee the clinical staff who will live in this new future-state workflow

People sometimes ask me : "Do I need to do this much for every change I want to make?" My advice : You only need to apply as much rigor as you need to get the change accomplished. E.g. : 
  • For small changes (e.g. making some small changes to a documentation template) --> Usually, less rigor is required
  • For large changes (e.g. implementing electronic med reconciliation at all transitions of care) --> Much more rigor is required
This exercise will not only help you scope your project, and identify the people, time, and resources you will need to secure - It will also help you formally plan a project, estimate the return on investment (ROI), and secure the necessary approvals before beginning your project. 

2. CLINICAL PROJECT MANAGEMENT

Once you have secured the necessary people, time, and resources, and have the approvals of your leadership to move forward - It's helpful to identify a formal, trained, and experienced project manager to plan, orchestrate, and lead your project. For a high-level overview, you can see the Wikipedia piece : https://en.wikipedia.org/wiki/Project_management 

For planning purposes, many experienced project managers might develop a Gantt Chart ( see https://en.wikipedia.org/wiki/Gantt_chart ), a sort of ordered series of steps, with time estimates and dependencies, that will be needed to finish the project and achieve the desired outcome. Similar, but also helpful is a Responsibility Assignment Matrix, sometimes called a RACI Chart

Experienced clinical leaders, especially those who have worked with good project managers, can often help a project by anticipating steps and helping to answer questions before they arise. While there are different types of project management (from the more traditional waterfall model, to newer agile methodologies), I've stripped down some bare essentials that are helpful to think about before starting any clinical update or improvement project : 


These are the ten steps (above) that I commonly plan and follow for clinical projects, where the rigors of step two (2) above are often necessary to help adequately scope and plan clinical projects, and help ensure that there are no unanticipated surprises later in the project. Note: Clinical Informatics professionals often work in steps 2, 4, 5, 6, and 9 above, working closely with end-users, analysts, educators, and project managers.

As a clinical leader, you will want to help champion change and updated practices. While there is much more to be said about project intake, scoping, planning, and execution, I hope this little introduction will help my friends in clinical leadership see the value of good project managers, and good project planning, and the role they play in getting things done.

Remember, this blog is for educational purposes only - Your mileage may vary. Always ask your local Project Management and Clinical Informatics professionals for guidance, and work closely with your clinical leadership to review, prioritize, and approve your projects before initiating any changes.

Have any stories to share about clinical leadership in supporting clinical projects? Have any tips or tricks to share from your own clinical project management experiences? Feel free to leave them in the comments section below!

Sunday, March 21, 2021

Another Trick for Untangling Workflows - Improved Document Design

 Hi fellow CMIOs, CNIOs, and other Clinical #Informatics and #HealthIT friends,

In my last blog post, I shared some slides from a recent talk I gave to a group of newcomers to the world of Applied Clinical Informatics, and shared my first trick for untangling and controlling workflows - technical procedure writing ('the Cupcake Test')

For today's blog post, I'd like to share another helpful trick for untangling and controlling workflows - Designing documents, both inside and outside of your EMR, to help clarify and improve workflow.

There's a common saying in both Applied Clinical Informatics and technical document writing : "Control your documents, before they control you." This is basically how I learned to love documents - They actually do create standards, but only if you know how to use them properly

Documents are tools used to record and transmit information. To help better explain the power of documents, it's helpful to look back at patterns set into motion by our earliest human ancestors, when they first learned to document on the walls of caves. Their ideas could be turned into images and symbols, that would in turn put information into other heads. It was the first time that humans really learned the power of documentation

And so, an organization is simply four walls, into which a bunch of people and documents have been placed : 
  • If the documents are clear and easy-to-find, your staff will use them to understand your values and needs, and will create predictable patterns and outcomes
  • If the documents are vague or not easy-to-find, your staff will not use them to understand your values and needs, and will not create predictable patterns or outcomes
Interesting to note is that if you were to create a whole new hospital, from scratch - you would need about 24 document types to effectively run any hospital - About 12 are commonly found inside your EMR, and about 12 are commonly found outside your EMR

So if we assume that all of healthcare depends on these 24 document types to run, then this helps us simplify change management into three key steps : 
  1. STEP 1 : Define your current-state worfklow. ("Point A"
  2. STEP 2 : Design your desired future-state workflow. ("Point B")
  3. STEP 3 : Identify which of the 24 tool(s) (both inside the EMR and outside the EMR) you need to get FROM the workflow defined in step #1 above, TO the workflow defined in step #2 above. 
Another nice side-benefit to improving your document design is the opportunity to help get people better aligned in their understanding of commonly-used tools and concepts. 

For example, let's say you'd like to help get clinical staff better aligned in their understanding of the term "PROTOCOL". It's a term that is particularly difficult to nail down and define, so many people have slightly different interpretations of what-exactly-a-protocol-is-and-what-it-does : 

After first reviewing your State and Federal regulations, and then your own operational needs, you can then use these four steps to increase clarity and understanding : 
  1. STEP 1 : DEFINITION - Write a clear, simple, one-sentence, policy-grade definition to answer the question, "What is a protocol, and what does it do?"
  2. STEP 2 : TEMPLATE - After you have a good working definition, design a template for creating protocols. 
  3. STEP 3 : PROCEDURE - After you have a good working definition and template - design a good procedure for drafting, reviewing/vetting, approving, publishing, monitoring, and archiving protocols. 
  4. STEP 4 : EDUCATION - After you have the procedure in step #3 nailed down, you can start to educate your staff about your new definition, template, and process - And soon people's common understanding will increase, with this new foundation and support for this important document. 
This kind of foundational work is especially helpful when trying to get teams of people to work on complex clinical workflows. 

Need some guidance about how to go about writing clear, simple, one-sentence, policy-grade definitions (as in step #1 above)? - For this, I first recommend first working with your legal, regulatory, and compliance staff to review the applicable Federal, State, and local regulations. After reviewing the regulations, you can then use a spreadsheet to draft a "CMIO's Checklist", which is very helpful in creating definitions that meet or exceed these regulations : 


You can use this type of spreadsheet to work on elevating your definitions, for presentation back to your legal and compliance team, for their review and final approvals. With improved definitions comes improved understanding

In my next post, I'll share two more helpful tricks (from my recent presentations) that clinical leaders and informaticists can use to help untangle workflows. 

Remember - This blog is for education and discussion purposes only - Your mileage may vary. Always review with your Clinical Leadership, Legal/Compliance teams, and Informatics leadership before publishing or changing any definitions or document templates. 

Have any experience with redesigning document archetypes to enhance clarity or understanding? Feel free to leave in the comments section below!

Sunday, March 7, 2021

Untangling Workflows - The Cupcake Test

 Hi fellow CMIOs, CNIOs, and other Clinical Informatics friends,

As I mentioned in my last post, I recently had the opportunity to share some workflow design tips with an online group of new physicians who are getting into Applied Clinical Informatics and workflow building. During my talk, I shared some helpful workflow tricks that I use to untangle even the most complex clinical workflows. Even though I've written about this one before, it's so useful I figured I should re-review and elaborate with this new audience. 

One of my favorite tricks is this very simple one with pretty impressive impact. It's basically just writing a technical procedure, but with a little more detail. I affectionately call it, "The Cupcake Test", because it uses good procedure writing to help answer the metaphorical question - Does this 'cupcake recipe' (or 'cupcake workflow') actually bake a cupcake?

Writing a good technical procedure can be a helpful substitute for the common Visio swimlane diagram that seems to be more of a popular industry standard. From my recent presentation : 

To understand how good procedure writing can be used as a substitute for Visio swimlanes, I need to first explain two important concepts that are necessary to understand before writing a procedure that passes the 'Cupcake test' : 
  • What is a TASK?
  • What is a PROCEDURE? (Synonyms : Workflow, recipe, process)
And so from my presentation, my slide showing the definitions of both : 
Using these two definitions, and the procedure template outlined above, we can now write a simple and clear technical procedure, and even color code it to help quickly identify and align concepts. Here's a sample of what it looks like : 


While this approach is not exactly an industry standard, there are some pros and cons to using it : 
And in my experience, a good procedure can usually be quickly and easily converted to a good swimlane diagram - But sometimes swimlane diagrams can't be as easily converted into good technical procedures that pass this 'Cupcake Test'. That is, they are not written with the template : 
TASK = [WHO] will/may [WHAT] {how} {where} {when} {why}
... in each line of the procedure

Not only does this approach include the benefits listed in the slide above, but it's easy to teach, and it also helps you easily generate cost estimates of workflows/procedures before you build them.

Next time you have a complex workflow you're trying to figure out - just start by writing good technical procedures, and the workflow will start to immediately reveal itself right in front of you. If you have any experience with using this approach, please leave it in the comments section below.

Remember - This blog is for educational and discussion purposes only - Your mileage may vary. If you have any feedback or questions, or experiences writing workflows or technical procedures, feel free to share them in the comments section below. 

Saturday, March 6, 2021

Optimizing Lumbar Punctures, Part II

 Hi fellow Clinical Informatics, CMIO, CNIO, HealthIT, and other #workflow friends,

Sorry about the delay in following up my last post - As most people can probably understand, the COVD-19 pandemic has been a very busy time in healthcare.

Anyway, in my last blog post - I introduced the surprising complexity of a lumbar puncture - Not to complicate a fairly simple bread-and-butter clinical procedure that's performed in healthcare settings every day, but to help create clarity and understanding, set expectations, and help reduce clicks while delivering a great user experience that your providers can use to deliver great patient care

To help understand the complexity of this workflow, I thought I'd even share this academic poster which was developed by Deandra 'Uju' Momah, MS4, an outstandingly talented medical student from UConn Med who I've had the honor to work with. At a recent AMIA conference, Uju presented her academic poster which very nicely summarizes the workflow issues : 

(Academic poster by Deandra 'Uju' Momah, MS4 - Click to enlarge)

The take-home point : Diagnostic LPs are not one workflow - They are at least four. (That is, if you carve out intrathecal chemotherapy, epidurals, blood patches, and therapeutic LPs.)

I recently had the opportunity to discuss LPs to an online audience of new Informaticists - below are some of the slides from my presentation, which I'll borrow and annotate here for clarity and educational purposes. 

First - A review of some of the complexities of designing a Lumbar Puncture order set : 
Again, it's very important to remember that Lumbar Punctures are not just one workflow - Diagnostically, there are at least four. So for now, we will focus on the third of four below, the outpatient ID/Specialist LP, where in many institutions this is commonly collected by Interventional Radiology
Now before we can examine this in more detail, I thought I'd share the large (complex) set of stakeholders who all have an interest in how LPs are ordered, performed, and resulted in your organization : 

In my current role, I'm very fortunate to be able to work with the great Karen Gurba, RN MS, an experienced and outstanding Clinical (Nurse) Informaticist who I partner with to help investigate and design workflows. (Remember, Applied Clinical Informatics is a team sport!) Karen and I have done a number of interviews with the stakeholders in the list above, and through repeated iterations of blueprints, reviews, discussions, and updated blueprints - The picture starts to become more clear. 

In each of these cases, there are a six main features that almost all clinical staff seem to generally agree on : 
  1. There are some PRE-LP labs, that are typically collected 24 hours before the procedure, to help establish that it's safe to proceed with the lumbar puncture lab. (They often include a simple BMP, CBC, and PT/INR.)
  2. There are other PRE-LP serology labs, that are typically collected 1 hour before the procedure, for diagnostic purposes. (They often include a serum glucose, serum protein, and in some cases, oligoclonal banding.)
  3. There is the LP procedure order itself, used to schedule the procedure and plan charges for doing the procedure. 
  4. There are four BASIC LP labs, that most docs use for general purposes, including a CSF cell count and differential, a CSF gram stain and culture, a CSF glucose, and a CSF protein
  5. There are some additional speciality-specific CSF labs, which can be very complex and specialty-specific. (Some of these can be very expensive, and so care should be taken so that they are not ordered unnecessarily or by accident.)
  6. Finally, there are a limited number of nursing orders, mostly importantly a nursing communication order that allows the ordering provider to give the Interventional Radiology nurses a 'heads up' on any unique patient needs. 
 The problem is - When you have so many specialties needing access to specific labs in #5 above, how exactly do you build this out?


And so, now I'd like to present a mockup of an Outpatient LP via Interventional Radiology (IR) order set, that helps address all of these needs in one coherent order set, that relies on cascading logic to help guide the ordering provider to the best-practices for their unique clinical needs. (Pardon my amateur cartooning, which I used to customize my presentation.)
And the order set starts with the first clinical decision - Is the ordering provider ordering a DIAGNOSTIC LP, or a THERAPEUTIC LP?

Let's say in this case, the provider is ordering a DIAGNOSTIC LP

This then brings up four choices, seen above : 
  • FOR ATTENDINGS, FELLOWS, AND RESIDENTS - Routine diagnostic LPs - Mon-Fri 8am-5pm
  • FOR ATTENDINGS AND FELLOWS ONLY - ROUTINE Malignancy Evaluations - Mon-Thurs 8am-12pm
  • FOR ATTENDINGS AND FELLOWS ONLY - URGENT Malignancy Evaluations - Friday-Sunday 8am-12pm
  • FOR ATTENDINGS AND FELLOWS ONLY - PRION Disease Evaluations - Mon-Fri 8am-5pm
 This gives us the opportunity not only to confirm the role of the ordering provider, but also to stratify the routine diagnostic workflow from the more complex workflows that require additional notifications or supervision before ordering. This helps us to make sure that unnecessary orders are not added to the workup. 
In this case, clicking the first option (ROUTINE DIAGNOSTIC LUMBAR PUNCTURES) would then produce the list of specialties that commonly use this order set : 

And here, if an Infectious Disease provider were to click their section, the order set can now produce the tailored, specialty-specific orders that the provider needs : 
Using this naming convention and design, we now know : 
  • Scenario = Specialty, outpatient LP for collection in IR
  • LP type = Diagnostic
  • User = Attending, Fellow, or Resident
  • Specialty = Infectious Disease
... and so now the order set can allow a tailored, specialty-specific palette of orders that are most commonly used for the user's needs. 
And with that, a significant reduction in clicks and improvement in utilization, diagnostic accuracy, and diagnostic yield. 

We are now working with our department Chiefs to help confirm the final orders (to appear in the fifth section of each specialty-specific area), and maybe once they are completed, I can help publish the final result here. 

Until then, I hope this helps you develop your own strategy for ordering Lumbar Punctures! If you have any secrets or feedback you can share, please leave them in the comments below!

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any recommendations or tricks to share about designing lumbar puncture workflows? Feel free to share in the comments box below!


Sunday, October 25, 2020

Optimizing Lumbar Punctures, Part I

Hi fellow Clinical Informaticists, CMIOs, CNIOs, #workflow gurus, and other #HealthIT friends,

How do you say 'Lumbar Puncture' in CPOE? Today, I'm writing to share the translation of one of the oldest, most common medical procedures that's routinely done in modern healthcare : The lumbar puncture, sometimes referred to as an 'LP'.

Lumbar punctures (LPs) are routinely performed to help look for infections, look for malignancy, and look for antibodies and other markers of neurologic disease. While they are a common mainstay of modern healthcare, building them electronically can be quite a challenge. 

Want to reduce clicks when ordering your LPs? It helps to first have a solid understanding of the most common LP workflows in healthcare, so you can build your order sets with the most common studies, priorities, indications, and order statuses all properly built and correctly defaulted.

So in this post, I figured I'd share some secrets about the four most common lumbar puncture workflows, and how to build them into an EMR, in a really gourmet fashion - for the best diagnostic yield, fewest clicks, and maximal success. 

1. THE WORKFLOWS

Lumbar punctures are commonly done for diagnostic purposes, but can also sometimes be done for therapeutic purposes. But as it turns out, the LP is not just one workflow - It's actually four different workflows


In each of these scenarios, there are different clinical specialties using the LP, commonly for different purposes : 


In addition to these workflow descriptions, some helpful notes : 
  • In workflows #2 and #3 above, there is a often a communication challenge between the ordering provider and the Interventional Radiologist, who has to collect, label, and transport the samples to the lab, and also report back some findings to the ordering provider (e.g. opening pressures, turbidity, etc.)
  • In workflow #3 above, there is also sometimes a patient education challenge, whereby the patient needs to come before the scheduled IR LP to have 'pre-procedure' labs drawn (e.g. CBC, BMP, PT/INR) to help ensure that the LP can proceed without problems. 

2. THE STAKEHOLDERS

Given the above workflows, the physician specialties most commonly involved with lumbar punctures then include :

  1. Emergency Medicine
  2. Inpatient Physicians - Pulmonary/Critical Care (Intensivists)
  3. Inpatient Physicians - General Inpatient Medicine (Hospitalists)
  4. Interventional Radiologists (IR)
  5. Ambulatory/Inpatient Specialists - Infectious Disease Physicians
  6. Ambulatory/Inpatient Specialists - Neurologists - General
  7. Ambulatory/Inpatient Specialists - Neurologists - Movement Disorders
  8. Ambulatory/Inpatient Specialists - Neurologists - Multiple Sclerosis
  9. Ambulatory/Inpatient Specialists - Neuro-ophthalmologists
  10. Ambulatory/Inpatient Specialists - Hematology/Oncologists

If we include :

  • the Registered Nurses (who have to help care for the patient before/after lumbar punctures), 
  • the pharmacists (who help provide the medications the provider has ordered for sedation/anesthesia)
  • the laboratory workers (who receive the fluid, provide the on-site analysis of certain labs, and send out other labs to external labs) 
  • the IT/Informatics workers (who connect with stakeholders, map the current state, and work with the clinical stakeholders to design, build, and test the future state)
... then this gives us a fairly long list of stakeholders in the most common lumbar puncture workflow discussions : 
  1. Emergency Medicine Providers
  2. Inpatient Physicians - Pulmonary/Critical Care (Intensivists)
  3. Inpatient Physicians - General Inpatient Medicine (Hospitalists)
  4. Interventional Radiologists (IR)
  5. Ambulatory/Inpatient Specialists - Infectious Disease Physicians
  6. Ambulatory/Inpatient Specialists - Neurologists - General
  7. Ambulatory/Inpatient Specialists - Neurologists - Movement Disorders
  8. Ambulatory/Inpatient Specialists - Neurologists - Multiple Sclerosis
  9. Ambulatory/Inpatient Specialists - Neuro-ophthalmologists
  10. Ambulatory/Inpatient Specialists - Hematology/Oncologists
  11. Nursing - Interventional Radiology
  12. Nursing - Floor/Bedside
  13. Nursing - Clinics
  14. Laboratory
  15. Pharmacy
  16. Clinical IT/Informatics
... and you'll quickly see why you it's helpful to have a good clinical informatics and project management team available, to help coordinate all of the meetings, discussion, architecture, building, testing, and approvals before you can go-live. In shortOptimizing LP order sets is usually a significant project effort, requiring many meetings.

3. THE LABS

With regard to the actual laboratories, it's helpful to keep in mind that workflows #1 and #2 are general-purpose LPs, usually for the emergent ruling out of CNS infection. It typically doesn't get much more complicated than that. So for Inpatient/ED purposes, the most common studies include : 

  • CSF Cell Count and Differential
  • CSF Gram Stain and Culture
  • CSF Protein
  • CSF Glucose
  • (Occasionally CSF HSV PCR, if clinically indicated)
But for workflows #3 and #4, they are more specialty-oriented, so their labs may include the general labs above, but also include a number of complex, high-cost specialty panels, antibodies, proteins, and pathology / flow cytometry. 

Commonly, the occasional ordering of these specialty studies (commonly from workflows #3 and #4 above) in the Inpatient/ED settings (commonly workflows #1 and #2 above) can generate a lot of discussion. For reimbursement reasons, it's helpful to stratify these workflows, but keep in mind - In complex cases, there may still be reasons to order the more complex outpatient labs on an inpatient, but generally they should only happen with specialist review and approval.

4. THE ORDER SETS

So now you're faced with the question - One order set, or four order sets?

If you do one order set, you'll probably end up needing to stratify them (with radio buttons!) into the four different workflows, e.g. : 


Or, more likely for operational, culture, and other EMR configuration reasons, you may end up with four different order sets - In which case you will want to choose your naming convention very carefully, e.g. : 

  1. LUMBAR PUNCTURE (LP) - INPATIENT/ED - AT BEDSIDE
  2. LUMBAR PUNCTURE (LP) - INPATIENT/ED - IN IR
  3. LUMBAR PUNCTURE (LP) - AMBULATORY/OUTPATIENT - IN IR
  4. LUMBAR PUNCTURE (LP) - AMBULATORY/OUTPATIENT - IN CLINIC
Even though #1 and #2 above are typically used by generalists, and #3 and #4 above are typically used by specialists - You'll still want to have specialty input into #1 and #2, to help make sure that the common specialty scenarios can still be addressed (when they arise) in the inpatient settings. (E.g. Having Infectious Disease provide input into #1 and #2 can help make sure your ED providers/Hospitalists/Intensivists are ordering the right ID labs for the right scenarios.)


In my next post, we will look at these four LP workflows in more detail, and discuss some of the common educational, operational, and ordering challenges that organizations may come across when building out and optimizing these order sets. 

Have any thoughts, comments, feedback, or stories to share about building highly-optimized (gourmet!) lumbar puncture workflows? Feel free to leave in the comments section below!

Remember, this blog is for educational / discussion purposes only, and does not constitute medical advice - Your mileage may vary. Always consult your clinical leadership, your clinical informatics team, and your medical specialists before building out any order sets in your own organization.

Monday, October 12, 2020

Top 15 Signs You May Work in Clinical Informatics

Hi fellow CMIOs, CNIOs, Clinical Informaticists, Clinical Informaticians, and other #workflow and #HealthIT friends,

Over the last 10 years, I've blogged a lot about different topics in applied Clinical Informatics, from change management to glossary development and workflow terminology management, to order set development. And yet, across the industry, it can sometimes be a challenge to find the other people who do this type of work, partly because: 

  • There are some people who 'do Clinical Informatics work', but are not labeled Clinical Informaticists / Clinical Informaticians in their job title. (Some are labeled CMIOs, CNIOs, Directors of Clinical Informatics, Clinical IT Analysts, Business Analysts, etc.)
  • There are some people who do have a job title like 'Clinical Informaticist/Clinical Informatician', but focus their efforts mostly on a particular branch of Informatics, without clear support for the other branches (often due to resource limitations).
  • Some 'Clinical Informatics' people focus their work for only their clinical specialty (e.g. 'Physician Informaticist', 'Nurse Informaticist', etc.)
So since in some regions, applied Clinical Informatics in 2020 still seems to be an emerging field, one that is fortunately becoming more formal and structured with the advance of more formal training and certification programs - I decided to spontaneously write a humorous piece on Twitter that could appeal to the 'Clinical Informaticist' (or 'Clinical Informatician') in all of us : 



Feel free to share with any Clinical Informaticists (
or Clinical Informaticians) you know with a sense of humor! :)

Remember, this blog is for education and discussion purposes only - Your mileage may vary. Have any helpful humor or insights about Clinical Informatics, job titles, and professional development? Feel free to leave them in the comments box below!