Saturday, October 8, 2022

What can Cardiac Myocytes teach us about Teamwork and Workflow?

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

Today's post is short, but one that I think most clinical friends will understand and appreciate. For conceptual teaching purposes only, I'm going to ask the question : 

"Q : What can Cardiac Myocytes teach us 
about Teamwork and Workflow Design?"

Here's my theory : Clinicians may actually have an advantage here. If you've ever studied the human heart - it's anatomy, it's functions, its biology, and its electrophysiology - You already know a lot about teamwork, workflow design, clinical operations, and essentially how to get things done

After all, cardiac myocytes and humans (clinical leaders and team members) both work towards a common goal. We both can function as individual units, but we function even better together as a well-organized, well-synchronized team

[ DRAFT ] TABLE - A tongue-in-cheek but honest comparison of Myocytes with Humans (Clinicians)

Let's face it, healthcare is a team sport. So when I'm working with other clinical leaders, especially new ones - For support, I often remind them of the importance of the infrastructure and tools that, especially as clinicians, we sometimes take for granted - Good : 

  • Regulations (both Federal and State)
  • Governance (e.g. Committee structures)
  • Leadership
  • Direction
  • Management
  • Communication
  • Bylaws
  • Policies/Procedures
  • Training / Onboarding
  • Continuing Education
  • Offboarding
  • Teamwork
After all, when growing a plant - it's not just the seeds you need to worry about, it's also the soil. So without enough of this 'supporting soil' (the tools above) in place, it becomes very easy to run into problems growing the seeds - And so for end-users, managers, directors, leaders, and executives alike, this can sometimes result in loss of efficiency, frustration, disorganized workflows, problems not getting solved in a timely basis, etc.

Typically, these tools don't get enough attention from new clinical leaders, because until they are in a leadership position - their focus has largely been on 'clinical things' like working with patients, diagnosing and treating diseases, performing operations and procedures, etc. While those are all the reasons we are in healthcare, it's still important to understand the many 'non-clinical' tools that make those things happen. (In truth, those tools are just as clinical as penicillin - But due to time constraints, they usually don't teach much about them in medical schools.)

What I find especially interesting is that, as a physician who during my career has treated cardiac tachyarrhythmias at the bedside (using beta-blockers, calcium-channel blockers, adenosine, cardioversion, etc.) - There are often similar analogous ways to treat these same 'human tachyarrhythmia' problems on project teams : 
So when I have the opportunity to teach a new clinical leader about how to solve problems and function in teams, I simply remind them that modern human biology has evolved over thousands of years to solve these same sorts of problems that we experience in healthcare today - And so sometimes, looking inward with a microscope is just as helpful as looking outward with a telescope

Finally, one of my clinical informatics colleagues and good friend Stefanie Shimko-Lin, BSN RN CD-L CD-PIC FHIMSS once shared this cardiac analogy with me : "Collateral circulation is a workaround, that happens when the desired workflow doesn't work. If you make it easy to do the right thing, people will do it."

These analogies may all seem a bit peculiar and tongue-and-cheek, but if you're a clinical leader - I hope this blog post helps to spark helpful discussion and learning with your own clinical leadership and project teams, so that you can better solve the workflow and operational issues you might encounter in your daily clinical routines.

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any other helpful analogies or advice for new clinical leaders? Feel free to share them in the comments section below!

Sunday, October 2, 2022

Advice from a Wise Business Leader

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

A brief pause from Applied Clinical Informatics, just for a moment. 

Today's post is related to some helpful business ethics advice I once received from a wise and successful businessman my mother used to work for. His name was James ('Jim') Everett Robison (11/22/1915 - 2/21/1998), and he was a very successful businessman and Harvard Business School graduate who, in addition to having a wonderful and loving family, also counted Roy Little and Thomas J. Watson, Jr. as some of his business associates and friends.

(L) James E. Robison as an Air Force pilot circa 1940s, and (R) as a successful business leader circa 1990s.

A retired and decorated WWII Air Force Major (who flew 63 completed missions, 402 combat hours, 26 squadron leads, 7 group leads, and 1 wing lead!), Jim Robison lived and breathed integrity.

Growing up, I would run into Mr. Robison occasionally, while my mother was working for him in Armonk, NY back in the 1980s and 1990s. During one of my visits to my mother's workplace, he shared a message with me - one that he apparently also shared with many other people - about the importance of honesty, integrity, and ethics in business.

His message was once captured beautifully by his good friend Charles Osgood, who shared it in his November 24th, 1992 Osgood File message. 

The message is still so important and relevant, that I think it bears repeating today. Transcribed from an old cassette tape I found in my attic, here it is : 

TRANSCRIPT :

Charles Osgood
CBS 880 AM Radio 11-24-1992
[ Start of Transcript ]
The Osgood File, sponsored in part by ______ Heating and Cooling. I'm Charles Osgood.
Last night at the University Club in New York, I attended a reunion dinner of sixty (60) people who used to work for the same company my late father did. There were books of pictures, and in some of them I could hardly recognize dad because he was so much younger then, than I am now. It made me feel like Michael J. Fox in "Back to the Future".
And amongst the memorabilia I found something that impressed me so much, I wanted to share it with you, which I will do, in a moment. Stand by.
My father was in the textile business. His boss, at a company called Indianhead Mills, was a dynamic young man by the name of Jim Robison. Dad thought the world of Jim, not only because he was so smart and so successful, but also because he was such a straight shooter. Robison never wanted to outdo or get the better of anybody in a business deal. If both parties didn't benefit from the deal, he didn't want to do it.
My dad died several years ago, but last night I was invited to a reunion of Indianhead people, some of them I hadn't seen since I was a kid. Jim Robison was there, retired now and no longer a young man, but still sharp as ever. And looking through some materials they had there, I came on a company policy statement that he had issued 40 years ago. And I took a copy of it because I wanted to share it with you this morning. Here's what it said :
"There is one basic policy, to which there will never be an exception made by anyone, anywhere, in any activity owned and operated by Indianhead. That policy is as follows," Jim Robinson wrote. "Play it straight, whether in contact with the public, stockholders, customers, suppliers, employees, or any other individuals or groups. The only right way to deal with people is forthrightly and honestly. If any mistakes are made, admit them and correct them. Our commitments will be honored, and we have a right to expect the same performance from those people with whom we do business.
This is fundamental. We will not welch, weasel, chisel, or cheat. We will not be a party to any untruths, half-truths, or unfair distortions. Life is too short.
It is perfectly possible to make a decent living without any compromise with integrity."
I think I'm going to frame that and put it on the wall.
The Osgood File, Charles Osgood on the CBS Radio Network.
[ End of Transcript ]

I agree with Charles Osgood - I think I'm going to frame that and put it on the wall.
I hope this timeless message inspires you too!

Remember, this blog is for informational and educational purposes only - Your mileage may vary! Have any experience with studying business ethics? Please feel free to share in the comments below!

Saturday, June 11, 2022

How I Became a 'Document Whisperer'

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

I'm writing today to share some stories from my career path in Applied Clinical Informatics, and how I became a 'document whisperer' with regard to clinical workflow design. This post stems from a common question I get asked: 

'If you care so much about clinical workflows - Then why do you seem to care so much about bylaws, policies, procedures, guidelines, protocols, bylaws, charters, order sets, and other documents? Why don't you just worry about the things inside the EMR?

The reason is because all of these documents (whether they are inside or outside an EMR) work together to shape clinical workflow

To explain, I need to first offer some context

Back in 2007 when I first started my formal clinical informatics career, like most newcomers, I didn't yet have enough experience to fully understand my role. I figured my job was to 'help with the electronic medical record', so naturally, I focused mainly on the things that doctors interacted with inside the EMR

After a while, however, I started to see challenges we had with some of our projects. There were order sets that, after we built them, didn't get used. There were order sets that created turbulence with other workflows when we rolled them out. I received complaints from doctors who felt the computer was 'too clunky' and that 'it takes too long to get things done'. 

Initially, I wondered if this was simply a matter of an EMR just being more difficult to use. There were some people who told me, 'Oh, some doctors are just resistant to change' (which is partly true), and others who told me, 'Computers are just complicated and finicky' (which can also sometimes be true).

But I kept looking for a better answer - There must be some sort of symmetry here that I was missing

And then, over the next 2-3 years, I experienced two important things : 

  1. I once worked on a complex titration protocol, which required an extensive analysis to fully build out the protocol, and...
  2. One day, a Registered Nurse complained to me about a policy that would need to be updated, in conjunction with a project we were actively working on.
So it was while confronting the question of 'How exactly do you write a protocol?' that I started to really confront the question : "What exactly is a protocol?" This led to even more questions, like : 


Trying to find more concrete answers, I looked to various potential sources, including various regulations, the International Standards Organization (ISO), the National Institute of Standards and Technology (NIST), the CMS web site, various HealthIT/Informatics societies, ITIL, and even Black's Law Dictionary, without much help

So around 2010, I decided to look at this from a more analytical, design-thinking standpoint : 
"If we gathered every document in healthcare, both those sitting on desks and on hard-drives - what would they be, and what would they look like?"
This led me to scribbling down some commonly-used words people use in healthcare, putting them into a spreadsheet, and in 2010 I came up with my first CMIO's Checklist

[ FIRST DRAFT ] Note : My workflow definitions have evolved since this 2010 version.
FIRST DRAFT ] Note : My workflow definitions have evolved since this 2010 version.

... which turned out to be my first real foray into clearly-defined terms, tools, and functions. Yes, a sample size of one - based only on my own clinical and administrative experiences - but a fairly comprehensive function-based analysis, nonetheless, that helps to clarify concepts and increase shared understanding.

(What good, functional, policy-grade definitions do to clarify concepts
and increase shared understandingHit PLAY to see animation)

Now with this new function-based analysis in hand, I stumbled into two interesting [DRAFTfunctional definitions
Template (n.) - A tool used to standardize and expedite the creation of a document
... and ...
Document (n.) - A tool used to record and transmit information.
... both of which shed light on an important concept - For many of you, this may be common-sense or trivial, but for me it was a 'eureka' moment
  • Definitions can be used to create templates.
  • Templates can be used to create documents.
  • Documents can be used to store and transmit the information needed to support workflows.
So around 2015, this led me to the realization that these concepts all depend on each otherAnd so, realizing that workflow inconsistencies sometimes arise from misalignment of these concepts, I wrote this blog post about workflow management and the Clinical Informatics domain

 

This also led me to the realization that all of the documents and tools contained in drawer #4 above :
  • needed to be aligned with the workflows, goals, and mission above it, and... 
  • were shaped by the concepts contained in #5, #6, #7, and #8 below it
It also revealed to me that some of the documents and tools that support workflows are typically contained inside the EMR, and others were contained outside the EMR : 


So now being able to mentally visualize this conceptual structure (above), I also realized that : 
  • Workflow depends on all of these tools (above) for support. 
  • Changing workflow means changing all of the tools (both inside and outside the EMR) that are used to support the workflow.
... and so effective workflow change management means : 
  1. Clearly understanding each deliverable (tool) above.
  2. Identifying the deliverables (both inside and outside the EMR) that are needed (or need to change) to support the desired workflow
  3. Quickly drafting those deliverables, to demonstrate to users and HealthIT professionals how the deliverables need to fit together,
  4. Reviewing those draft deliverables with clinical stakeholders, to confirm their needs/expectations before committing them to a formal build, and to help get their input and align expectations.
So to help quickly draft the deliverables in step #3 above, I had to quickly make templates for these roughly 24 documents that we commonly use in healthcare. And this brought me back to my pursuit for high-quality, high-grade definitions so that my workflow templates were quick, easy-to-use, and maybe most important - functionally sound

And this is essentially how I became a document whisperer for good clinical workflow design and EMR support. Using this deeper understanding of how these common concepts are related has helped me to quickly draft the 'workflow blueprints' that help to outline workflows, identify deliverables, identify stakeholders, create clarity, develop understanding, and align expectations before beginning a project. (This understanding has proven especially useful when scoping/analyzing clinical project requests prior to approval.)
 
I hope sharing this journey helps give you a roadmap for your own journey, and helps you develop your own definitions, templates, and tools for rapid workflow analysis and scoping before undertaking any significant projects. 

Remember this blog is for educational purposes only - Your mileage may vary. Have any anecdotes or stories to share about workflow analysis or development? Feel free to leave them in the comments section below!

Tuesday, May 31, 2022

A Tale of Applied Clinical #Informatics, in Four Parts

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

Today I'm writing today to share a tale of Applied Clinical #Informatics, in four parts(Or, "Why workflow analysis, naming conventions, indexing, and usability all really do matter.")

Feel free to leave comments at the end - Hope you enjoy it!

1. PART ONE - 

"I'm sorry, I don't have time to talk about workflow analysis, naming conventions, indexing, or usability - just give me everything I need in one place, and quick!!"


2. PART TWO - 

"Wait, that's not right, I can't use that. I still don't have time to talk about any of that workflow or usability stuff, but can you just put everything I need in one place so I can see it all and easily access everything I need with just one click?"


3. PART THREE - 

"Wait, that still doesn't look right, and I'm afraid I'm going to be scrolling forever. I still don't have the time to meet, but I heard there's some tool they use at another organization - Can you just find out what tool they use to do this, and then just put my stuff into whatever tool they use?"


4. PART FOUR - 

"OK, wait... I think I see the problem. Let's make some time to talk about workflow, including exactly what these tools do - Both what I use them for, and when I use them. Then let's talk about the naming conventions and indexing for each tool, so they all have a standard look and feel. Then let's talk about usability, so that I keep the most commonly-needed tools in one place, and the less common tools in a separate but nearby place. And then finally after you build it - I'll help test it to make sure it's both functional (what-we-need) and also easy-to-use."


"Eureka - That's it!" 

[ THE END

Remember, this blog is for educational/discussion purposes only - Your mileage may vary. Have a good teaching example you'd like to share? Feel free to leave in the comments section below!

Sunday, May 1, 2022

Applied Clinical Informatics Progress Bar Video

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

I recently put together a quick animation, help tell the story of Applied Clinical Informatics in a short (2 minute 38 second) YouTube video.

There's not much to say, other than it frames one potential journey - from beginning to end - and the progress that eventually leads to improved engagement, improved usability, improved return-on-investment, and most importantly - improved patient care.  


At the end, the bar suddenly returns to the very beginning - Letting the viewer consider their own journey. 

Feel free to share with anyone who's looking to better understand the Applied Clinical Informatics journey, and the many benefits it (and #BlueprintsBeforeBuild) can bring. 

Remember - This blog is for academic and discussion purposes only - Your mileage may vary!
Have any experience from your own journey that you would like to share? Feel free to leave in the comments section below!

Sunday, March 27, 2022

Difference between Specialty, Service, Level-of-Care, and Location?

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

In today's post, I thought I'd help answer a common clinical terminology question I sometimes get asked, about information management during inpatient hospitalizations : 


I thought I'd write this post, largely because these very important terms

  1. Specialty / Subspecialty
  2. Service
  3. (Nursing) Level-of-Care
  4. Geographic Location
... can often look alike and sound alike, and so they are sometimes easily confused (or used interchangeably) by both clinical and administrative staff.

Unfortunately, getting this terminology right is essential to good communication, good patient flow, good bed management, and good data reporting - So for clinical educational purposes, I figured I'd write this helpful primer on these terms, what they do, and how to use them. 

A. WHAT IS SPECIALTY (and SUBSPECIALTY)

Specialty (and subspecialty) is what a Provider is trained to do. While the Association of American Medical Colleges (AAMC) recognized the need to stratify medical training back in 1876, this specialty (and subspecialty) training has since continued to evolve

Today, we recognize a number of :

  • RESIDENCIES (SPECIALTY TRAINING)
  • FELLOWSHIPS (SUBSPECIALTY TRAINING)
...which together, gives us some of the physician specialties (and subspecialties) that most people will recognize today : 
  • Select ONE :
  • (  ) INTERNAL MEDICINE (General Internal Medicine)
  • (  ) INTERNAL MEDICINE > CARDIOLOGY
  • (  ) INTERNAL MEDICINE > ENDOCRINOLOGY
  • (  ) INTERNAL MEDICINE > GASTROENTEROLOGY
  • (  ) INTERNAL MEDICINE > RHEUMATOLOGY
  • (  ) INTERNAL MEDICINE > GERONTOLOGY (Geriatrics)
  • (  ) INTERNAL MEDICINE > PULMONARY/CRITICAL CARE
  • (  ) INTERNAL MEDICINE > HEMATOLOGY / ONCOLOGY
  • (  ) PEDIATRICS (General Pediatrics)
  • (  ) PEDIATRICS > EMERGENCY MEDICINE
  • (  ) PEDIATRICS > NEONATOLOGY
  • (  ) EMERGENCY MEDICINE (General emergency medicine)
  • (  ) EMERGENCY MEDICINE > TRAUMATOLOGY
  • (  ) EMERGENCY MEDICINE > TOXICOLOGY
  • (  ) RADIOLOGY (General Radiology)
  • (  ) RADIOLOGY > INTERVENTIONAL
  • (  ) SURGERY (General Surgery)
  • (  ) SURGERY > ORTHOPEDICS
  • (  ) SURGERY > PLASTIC SURGERY
  • (  ) SURGERY > NEUROSURGERY
  • (  ) SURGERY > TRANSPLANT
  • (  ) SURGERY > GYNECOLOGIC
  • (  ) SURGERY > VASCULAR
  • (  ) NEUROLOGY (General Neurology)
  • (  ) NEUROLOGY > MOVEMENT DISORDERS
  • (  ) NEUROLOGY > MULTIPLE SCLEROSIS
  • (  ) OBGYN (General OBGYN)
  • (  ) OBGYN > MATERNAL FETAL MEDICINE
  • (  ) OBGYN > FERTILITY MEDICINE
  • (  ) PSYCHIATRY (General Psychiatry)
  • (  ) PSYCHIATRY > CHILD AND ADOLESCENT
Note : While there may be some occasional variation about how one ended up in a particular subspecialty (e.g. Pediatrics>Emergency Medicine, or Emergency Medicine>Pediatrics), historically - this system of categorization has generally worked fairly well, and gives people a good sense of what training the provider has had
The key take-home point : Specialty/Subspecialty training is what the provider has been clinically trained and licensed to do.

B. WHAT IS A SERVICE?

Service is what the provider actually does. It'stypically one-or-more clinical function(s) that they have been assigned to deliver.

Services are commonly categorized as either INPATIENT, ED, or OUTPATIENT services, and again, a provider may function in one or more services

  • Select ALL THAT APPLY : 
  • [  ] OUTPATIENT Internal Medicine (Ambulatory Internal Medicine Clinic)
  • [  ] INPATIENT Hospitalist
  • [  ] INPATIENT Intensivist
  • [  ] INPATIENT Labor and Delivery
  • [  ] OUTPATIENT Psychiatry
  • [  ] INPATIENT Psychiatry
  • [  ] EMERGENCY MEDICINE (Emergency Services)
  • [  ] INPATIENT Neurology
  • [  ] OUTPATIENT Neurology (Ambulatory Neurology Clinic)
  • [  ] INPATIENT Surgery 
  • [  ] OUTPATIENT Surgery (Ambulatory Surgery Clinic)

... and many other clinical services (functions) that have been designed to provide patient care services in various settings

This is where confusion can sometimes arise, especially for scenarios where a provider might have one specialty but two services, e.g. : 

  • SPECIALTY/SUBSPECIALTY = INTERNAL MEDICINE (General Internal Medicine)
  • SERVICE1 (Primary Service= OUTPATIENT INTERNAL MEDICINE (General Internal Medicine)
  • SERVICE2 (Secondary Service= INPATIENT HOSPITALIST

Confusing specialty and service can lead to incorrect scheduling of meetings - E.g. Let's say you want to introduce a new outpatient televideo service to your OUTPATIENT INTERNAL MEDICINE docs, then : 

  • [ WRONG WAY ] Mail to SPECIALTY = Internal Medicine ('Please mail this to all Internal Medicine Docs!')
  • [ RIGHT WAY ] Mail to SERVICE = Outpatient Internal Medicine ('Please mail this to all docs who work in the Outpatient Internal Medicine Clinic/Service!')

If you accidentally did mail your announcement to SPECIALTY = Internal Medicine, then half of the recipients might wonder why you contacted them about this new outpatient tool : 

  • SPECIALTY = INTERNAL MEDICINE - Includes both
  • [ INTENDED AUDIENCE ] SERVICE = Outpatient Internal Medicine
  • [ UNINTENDED AUDIENCE ] SERVICE = Inpatient Hospitalist

As you can see, it's very easy to get tripped up on this terminology, when it looks so similar

One final note about SERVICE - This is often used during inpatient admissions to describe the "Admitting/Covering Service", as in, who should Nursing call when they identify something that needs a Physician's attention?

C. WHAT IS A (Nursing) LEVEL-OF-CARE

The (Nursing) Level-of-Care is an important concept that basically answers the question, "What are the nursing standards that are required for a patient admitted in this hospital bed?" Typically, this is based on patient type and acuity, and is developed in conjunction with both Nursing Leadership and Physician Leadership. From a practical standpoint, this usually needs to include some agreements about : 

  • Patient Acuity - How active are the patient's medical problems, and how much care will they need? (Low/Medium/High?)
  • Standard Frequency of Vitals - How often does a Nurse need to monitor the patient?
  • Standard Nursing Skill Set - What are the Nurses trained/certified to do? Is it general care, or specialty care? On what patient population? Adults? Pediatric? Neonates?
  • Standard Nurse Staffing Ratios - How many patients are Nurses routinely expected to manage concurrently for this Level-of-Care?

Because these are all important to establish a level-of-care, they are commonly laid out in a table that might look something like this : 


So to help standardize care along the needs of the patient (and patient acuity), most admission order sets are aligned along these Nursing Levels-of-Care, with vitals that default to the institutional standards - E.g. :

  • ADMIT TO ADULT MED/SURG
  • [   ] Vital Signs every 8 hours
  • [   ] Vital Signs every 6 hours
... and ...
  • ADMIT TO ADULT ICU
  • [   ] Vital Signs every 1 hour
  • [   ] Vital Signs continuously
... and so on. 

D. WHAT IS A GEOGRAPHIC LOCATION?

Geographic location technically should be the easiest concept to manage - It's just the floor/room (and sometimes bed slot, E.g. Bed A or Bed B) that the patient's bed is geographically located in. Sometimes it also includes a temporary location, such as when a patient is being temporarily located in Radiology for an X-ray :

  • Geographic Location = Room 401 
  • Temporary Location = Radiology
  • Sometimes displayed as "Room 401 (Radiology)"

However, location can occasionally be confused with a (Nursing) Level of Care, especially when naming conventions sometimes combine these concepts, usually intended for convenience purposes. (E.g. "5th Floor Telemetry")

Note that there are two challenges that can sometimes occur when combining these concepts in the naming convention for your geographic locations/floors : 

1. FIRST CHALLENGE : The first of these challenges is boarding - which is when a patient bed needs to be created in a non-standard location, usually for patient flow and/or surge purposes. For example - 

  • If you usually have ten (10) beds on your FOURTH floor, where you commonly care for up to ten (10) Med/Surg patients...
  • One day, you have a patient surge, and need to be able to care for twelve (12) Med/Surg patients...
  • ... then you will need to create two (2) extra Med/Surg beds, maybe on the FIFTH floor

Assuming you are approved to 'surge' your bed capacity like this, and have the Med/Surg nurses available to support those two (2) extra Med/Surg beds on the FIFTH floor, then you can hypothetically create a bed with a defined (Nursing) level-of-care in any geographic location that can support the delivery of the necessary (Nursinglevel-of-care

For example, in an disaster scenario, you could hypothetically make a med/surg bed available in your cafeteria (assuming you had the available resources) : 

  • ADMIT TO = Med/Surg Level-of-care
  • GEOGRAPHIC LOCATION = CAFETERIA Bed 2
  • SERVICE = Inpatient Hospitalist

Or, if you are admitting a Med/Surg Patient from the Emergency Room to your FOURTH floor (where you commonly care for Med/Surg patients) - If there is no bed available on the FOURTH floor, you you could hypothetically admit and 'board' the Med/Surg patient (temporarily) in an Emergency Department location : 

  • ADMIT TO = Med/Surg Level-of-Care
  • GEOGRAPHIC LOCATION = ED Bed 2
  • SERVICE = Inpatient Hospitalist
... and then once the bed becomes available on the FOURTH floor, you could update the status: 

  • ADMIT TO = Med/Surg Level-of-Care
  • GEOGRAPHIC LOCATION = Fourth Floor Bed 401
  • SERVICE = Inpatient Hospitalist

As you can see, keeping this terminology clear and concise is important for the delivery of services. 

2. SECOND CHALLENGE : The second challenge that comes from naming conventions that combine concepts (e.g. "FOURTH Floor Med/Surg") is data-reporting. Suppose that when beds are needed - you 

  • sometimes have to board MED/SURG patients on your FIFTH floor, or 
  • sometimes you have to board TELEMETRY patients on your FOURTH floor.

And then one day, you need to know, "How many Med/Surg patients did we see last month?"

  • If you generate a report of 'How many patients were geographically admitted to the FOURTH floor', you may miss any Med/Surg patients who were boarded in other locations, or over-count other telemetry patients who might have been temporarily boarded on the FOURTH floor.
  • If, instead, you generate a report of 'How many patients were admitted with a Level-of-Care=Med/Surg", your report will be accurate and will account for any patients who were temporarily boarded in non-standard locations.
If this all seems confusing, you're not alone. Even seasoned professionals can sometimes confuse/interchange these terms. It's helpful to have an experienced Clinical LeaderBed Manager, HIM/Billing/Coding person, or Applied Clinical Informatics person to help translate/validate, help design your bed management and patient flow strategy, and then help turn that into build/configuration that meets the needs of your patients, Nurses, Physicians, Bed Managers, Billers/Coders, and Data Reporting teams

In conclusion - These terms are all very important, and are the reason most hospital admissions contain the following information : 
  • [ REQUIRED ] ADMIT TO = ________ (NursingLevel-of-care
  • [ REQUIRED ] SERVICE = ___________
  • [ OPTIONAL ] GEOGRAPHIC LOCATION=(Use only if a particular location is necessary, otherwise Nursing may not have any flexibility about where to geographically locate the patient in a surge/boarding scenario.)

... and why it's also helpful to track doctors by both their specialty/subspecialty and also their service(s)

  • SPECIALTY/SUBSPECIALTY = Internal Medicine (General Internal Medicine)
  • SERVICE1 (Primary Service) = Inpatient Hospitalist
  • SERVICE2 (Secondary Service) = Outpatient General Internal Medicine

While this may have been somewhat lengthy, I hope this helps you review and discuss this terminology with your own teams. 

Remember, this blog is for academic/discussion purposes only - Your mileage may vary! Have any patient flow or bed management tips you'd like to share? Have any experiences managing this terminology with your teams, or any other feedback you'd like to share? Leave it in the comments section below!

Saturday, March 19, 2022

What Multicultural, Bilingual Clinical Informaticists Know

Hi fellow CMIOs, CNIOs, Clinical Informaticists, and other HealthIT friends,

Can growing up in a multicultural, bilingual (or polylingual) household help to prepare you for a career in Applied Clinical Informatics? In today's post, I'll explain why I believe the answer to this is "Yes".

Almost all of my Applied Clinical Informatics colleagues that I've met over the years have amazing educational and experiential backgrounds. However, I've noticed that a surprising number of them also come from multicultural backgrounds, where they grew up speaking multiple languages. 

In full disclosure : I don't have great data to support this claim. And I might be biased (or more sensitive) to this issue because I grew up in a polylingual household myself, the son of a German immigrant mother and a polyglot American father, who counted German as one of this favorite and most fluent languages. 

Left : My father during his US military servjce.
Right : My American father and German immigrant mother, circa 1965. 

My father's passion for languages started as a high school student in Yonkers, NY, and would continue to develop until he became a Military Policeman (MP) for the US Army, in Germany, where he also served as a court interpreter. This would also eventually lead him to meet my mother (who had immigrated from Herford, Germany to Westchester County, NY), and to a future career as a high school language teacher at White Plains High School in White Plains, NY.

So with parents like these, I grew up in a multicultural, multilingual household, where we commonly spoke German at home, and then spoke English when other people came to visit our house. Vacations were often spent visiting relatives in Germany, immersed in German language and culture, before returning to America and resuming daily activities in English.

Given my father's interpreter experiences, he always took languages and translation very seriously. Growing up outside of NYC in the 1970s and 1980s, he would occasionally take me into the city to the United Nations, to learn about and watch the famous UN Interpreter pool at work. Over our dinner table, we would often discuss the inseparable bond between culture and language, the real responsibilities of professional interpreters, and the occasional fallibility of both written and spoken words. 

This sort of cross-cultural upbringing led me to some frequent challenges, that most multicultural people can probably relate to

  • Having to explain "American things" to my German family.
  • Having to explain "German things" to my American friends.
  • Occasionally having to do real-time interpretation of English-to-German, and German-to-English, to facilitate discussions between my German family and American friends.

I didn't fully appreciate this sort of multicultural upbringing until I was older, and learned that not everyone struggled with (or learned to manage) these types of issues. 

One of the things you learn from this sort of cross-cultural upbringing is that communication is actually much more frail and fragile than you might imagine. Success often depends on a number of factors helping you achieve a desired comprehension rate

For most routine, practical, day-to-day communications, about 75%-80% comprehension is just fine. Typically, your brain fills in the gaps (without your awareness), and you usually don't even notice the small details you might have missed. It still gets you to work, gets you to dinner on time, lets you order food at restaurants, and lets you manage your typical day-to-day activities. Informally, I personally refer to this as "Kitchen Language", since it's what you'd typically hear in a kitchen when people are making dinner and talking about their day. Failures sometimes happen, but when they do - they usually only result in some brief confusion, a wrong or forgotten birthday gift, or an impromptu discussion about 'ineffective communication' from a loved one. After a little more discussion - The error or conflict usually gets resolved. Failure is usually pretty well-tolerated.

And then there is another standard, which I informally call "High Risk Language". This is where failure is NOT well-tolerated, and so additional work and terminology are commonly required to help ensure a higher accuracy rate, typically >90-95%. Political, industrial, and clinical discussions all fall into this range. Successfully navigating High-Risk Language often requires additional analysis/planning, work, and often even new terminology that both sides (separately) agree to and understand, to help align concepts for effective cross-cultural communication.

*Interesting historical side-note : 
Ever wonder about the June 1961 Cuban Missile summit between Kennedy and Kruschev? Viktor Sukhodrev was the interpreter in between them - Talk about responsibility for ensuring both accurate translation and comprehension!

Don't believe me that age is an important factor in effective communication, even in the same language? Check out this Saturday Night Live skit, "Gen Z Hospital" - Your appreciation of this skit will largely depend on the year you were born. Similarly, different upbringings, experiences, education, and culture can also quietly degrade comprehension rates, sometimes to the point of failure. (Applied Clinical Informaticists often see this cultural boundary when translating across clinical and administrative realms, which both have their own culture and terminology.)

So to overcome these differences across different languages - for both Kitchen Language and High-Risk Language scenarios - good interpreters need to know how different people speak and write. They need to know different cultures and subcultures, and the specific context and nuances of the language they use in each culture

I think this may be why I notice a lot of multicultural, polylingual people in Applied Clinical Informatics. Even in English, this sort of cross-cultural interpretation requires an understanding of two different cultures - Both Clinical, and Information Technology (IT) : 

And then once you have mastered the art of interpreting the culture and language of both sides - you can then become even more helpful when you add clinical architecture to your repertoire, developing new terminology and documented 'blueprints' that meet the needs of both sides

So in closing - I'd say a bilingual (or polylingual), multicultural upbringing can serve as an excellent model for the same interpretation functions that Applied Clinical Informaticists provide in their daily work. It would be interesting to do some formal research into these concepts, to help confirm the value of this sort of early training.

Remember, this blog is for education and discussion only - Your mileage may vary!

Have any thoughts or feedback about this post? Did you grow up in a multicultural household, and do you speak multiple languages? Do you find these experiences helped you in your career in Applied Clinical Informatics? If so, please feel free to leave a comment in the comments box below!