Sunday, November 21, 2010

Converting paper order sets to electronic

If you're reading this, I hope you're the person in your institution trying to "convert the paper order sets to electronic ones".

Don't worry - you're perfectly normal. The job is usually a lot harder than it looks. And no, you're not the only one who hears, "Why can't you just take the paper order sets and put them on the screen?"

(Most people think it's simple, until they actually start to dissect the order sets.)

First, let's start with some of the challenges of paper order sets :
  1. Paper order sets generally keep multiplying - Let's say you decide to fix the paper order sets, and so you need to take the old versions "off the shelves". Beware - People tend to make copies of paper order sets. So the old ones can turn up weeks and months later.
  2. Paper order sets are often engineered differently - In the electronic (CPOE) world, orders are very concrete. You may have specific safety features put into your electronic PCA (Patient-Controlled Anesthesia) order. How will you put those safety features into your paper order set? You may also have hidden "protocols" in your paper order sets. What will you do with those protocol (conditional) orders? 
  3. Paper order sets are sometimes ignored, after a hospital "goes electronic" - If you ignore your paper order sets, what will your hospital use during electronic downtimes? Can you afford not to have paper backup order sets, if your OR/ED are busy?
Believe it or not, how you address these paper-order-set problems will be vitally important in your long-term electronic success. Ignore the paper order sets, and you will miss an opportunity to really set up a robust electronic platform.

Let's look at each of these issues in a little more detail :

1. The "Multiplying paper order sets" -
This is a phenomenon many organizations struggle with. The solution : Centralize all of your order sets on one common electronic web site, and publish them as non-editable .PDF files. Create a clinical policy where "If it's not on this site, it's not an acceptable order set".  It will take you a while to get the site together, and organize all of your paper order sets there, but in the end, you will have a way of controlling the paper order sets in use. 

2. The "Engineering differences" between paper and electronic order sets
Some organizations, on going electronic, focus on developing electronic order sets, while the paper order sets continue to be produced in the way they "always have been built". If you have two separate processes (an electronic and a paper process), the problem is that you will start to have significant engineering differences between the two. 
If you have different paper and electronic order sets, you will then encounter :
  • Paper order sets that don't meet the engineering standards needed for order entry in your EMR, so they will be very hard to "send-to-pharmacy-so-someone-else-can-do-the-order-entry"...
  • Paper order sets that don't match the electronic order sets
  • Two cultures : Docs who use electronic order sets, and docs who use paper order sets. (If your organization does a "flip-the-switch" approach to EMR/CPOE, then this won't apply to you. If you do a "gradual conversion", then this will apply to you.)
The way you fix this, of course, is to develop simultaneous paper and electronic order sets. Set up your informatics platform, update your policy on order set development (to include paper and electronic order sets), and ask your informaticists to develop the paper and electronic order sets simultaneously. Have them tested by the same people, and approved by the same committee. This will ensure that they match, and even if you are a "100% CPOE" organization, you will still appreciate having matching paper order sets during electronic downtimes.
Remember, the solution isn't to make electronic orders that mirror your bad paper processes. Make good, solid, and safe electronic orders, and then use those in your updated paper order sets.
A final tip : Embedded "protocol" (conditional) orders generally need to get pulled out of the paper order sets, before you can "make them electronic" - and you will need to decide what to do with those : A. publish them as new protocols, or B. throw them out. This will take work and can be politically challenging. 

3. The "Ignored Paper Order Sets"
Some organizations, on going electronic, ignore the paper order sets, thinking, "We don't need them anymore, right?". My advice : Don't ignore them. Not only will you need to figure out what your pharmacy will do if they end up getting faxed paper orders, but you will still need them for computer downtimes.

If all of this sounds complicated, and it sounds like a lot of work, you're right - It is. This is why order sets are the political and organizational challenge that they are. A good informaticist can help sort out the issues and put a plan and process into place for your organization, where it doesn't have to be too painful. Unfortunately, because healthcare doesn't have standards in clinical processes, every organization handles this conversion differently, and as a result, order sets are notoriously hard to standardize. (Think of them as a "custom-fitted suit".)

One last tip : Beware the "quick fix" - There are consultants who will "easily and quickly convert your paper order sets to electronic ones". The way they usually do this is by taking the paper orders, no matter how they are engineered, and simply build new electronic orders that match them. In the short term, this may appear to work, but in the long term, it may leave the nurses with orders which are unclear (and may create extra pages to doctors to clarify), since some paper orders are not as well-defined as their electronic counterparts. You may also miss out on the opportunity to streamline your clinical processes, and miss out on the time and cost savings that an EMR can really bring. My recommendation : Build the new paper order sets to match the engineering standards of your electronic order sets - Not the other way around. 

As always, my advice with order sets : There are no quick fixes. Hire a good informaticist to help you with this. :)

Hey, by the way, I'm open for questions - If anyone has any EMR conversion or informatics questions that you'd like to chat about, feel free to leave a comment here or email me. I'll try to devote my next posts to reader questions! So send me stories, questions, or whatever else you'd like to discuss in upcoming posts - I look forward to hearing from folks! :)

Saturday, November 6, 2010

What's in the Informatics Toolbelt?

QUESTION : Dirk... How do I make change in a clinical setting?

A lot of modern healthcare asks for standardization. Common questions I get asked are focused on change and standardization, such as:
  1. "How can we make sure the doctors use the order sets?"
  2. "How can we make sure the doctors document ______ properly?"
  3. "How can we make sure the doctors enter orders for ventilator changes?"
  4. "How can we make sure the nurses document the vitals properly?"
  5. "How can we make sure the pharmacists document the medication substitutions properly?"
The first tool most people reach for, to standardize care, is the order set. As a result, order sets are notoriously political. In the paper world, they generated enough debate, but in the electronic world, it often gets worse, as the political power shifts from a physician-centered process to a more organization-wide process.

Question : Huh? Dirk? Electronic order sets have a different political structure than paper order sets?

The short answer is yes. Why?

In a paper order set, most hospitals let doctors type their commonly-used orders on a piece of paper, put little check boxes next to each order, and a committee reviewed them - if the group of orders looked safe and met the right formatting requirements, and didn't have any unapproved abbreviations, the order set was generally approved, and the doctors could use them. End of discussion, for the most part, until the order set had to be updated. The doctors wrote what they wanted, and the organization approved them as long as there wasn't any major safety or organizational problem.

In an electronic order set, every electronic order (in the order set) has to be built by a programmer. So quite often, those programmers design the orders with extensive safety in mind. To figure out how to make them safer and more effective, the programmers ask the entire team (not just the doctor) for advice on how the order should be built. So programmers may ask the pharmacists, "How can we make this order safer?". They may ask the respiratory therapists, "What should this order look like?". They might ask the nurses, "What should the doctors really be asking for in this order?". They might ask the dietitians, "What should a diet order look like?". They might even add evidence-based links to the orders, on the order sets, to help guide the physicians about when best to use which orders.

As a result of these discussions with all of these different parts of the hospital, it's not uncommon for the programmers to design the electronic orders to look and behave differently than the paper orders did.

For example, a common safety tool used by programmers, after these discussions, is to build mandatory fields into the orders, that the doctors have to complete for the order to be accepted. As a result, the doctors are suddenly forced to think differently about these electronic orders, than they used to think about the paper orders.

I know it's still still sort of complicated, but a good example of this phenomenon is the diet order.
  1. In the paper world, most paper order sets simply refer to an order, "REGULAR DIET".
  2. In the electronic world, however, after discussion with speech therapists and dietitians, many electronic diet orders are built with mandatory fields for texture and liquid modification, so a doctor HAS to think about texture and liquid modification just to be able to enter a diet order. As a result, many electronic diet orders, on an electronic order set, will refer to the diet order, "REGULAR DIET, NO TEXTURE MODIFICATION, NO LIQUID MODIFICATION".
So doctors moving from the paper world to the electronic world will generally sense this loss of control - Suddenly, dietitians and pharmacists and radiologists can have enormous impact on the way they order something. In the paper world, doctors could simply write whatever they felt was best.

As a natural result of this political shift, electronic order sets often generate even more political discussion and debate than the paper order sets did. And this is another reason you may want to hire a CMIO, to help guide your doctors past the political debates and focus on good patient care.

Question : Aha. Interesting... Never thought about that. So what about this "Informatics Toolbelt" you mentioned?

The reason I bring up the "Informatics toolbelt" is because, as a hospital tries to standardize care by crafting workflows, everyone seems to reflexively reach for one tool : The order sets. By fixing the order sets, we can standardize care, right?

While order sets are certainly a good tool to help standardize care, they are not the only tool. Just to remind you that there are other tools, I present the following list of tools which I think sit in the Informatics Toolbelt : (Remember, most of these tools can be published either on paper or electronically...)
  1. An order - A medicolegal instruction to provide a defined portion of patient care, via a defined route, at a defined rate, for a defined period of time. (Remember, in the paper world, you didn't have to "build" orders - In the electronic world, you have to "build" them, so you can actually engineer them to your advantage - The source of much political debate.)
  2. An order set - A grouping of orders, to help standardize and expedite the ordering process for a common clinical scenario. Physicians generally start, modify, and stop the orders on an order set.
  3. A protocol - A document that allows a nurse or pharmacist to start, modify, or stop orders based on a well-defined clinical condition.
  4. A guideline - (aka care plan, etc.) A document that educates care team members about desired outcomes and processes, but generally carry less medicolegal weight than a protocol or policy, more negotiable, so they are engineered differently.
  5. A policy (clinical or administrative) - A defined organizational goal or rule. 
  6. A procedure - The steps requires to achieve a goal (or policy).
  7. Documentation - (aka a forms, a flowsheet, etc.) - A permanent recording of patient status, activities, responses, and outcomes in time, authenticated by the signature of a licensed medical professional.
  8. A patient education module - A document with media (written, video, or other) that explains a defined set of educational objectives to patients.
  9. A staff education module - A document with material (written, video, or other) that explains a defined set of educational objectives to staff members.
  10. A committee charter - By creating a charter, you can create a committee that helps standardize your care and monitor your processes
  11. Committee minutes - By creating minutes, you can show effective supervision and committee activity to meet the organization's goals.
  12. A staff meeting - Can be helpful for education and organizational purposes.
  13. Email, paper mail - Can also be helpful for educational purposes.
There are probably other tools to put into the Informatics Toolbelt, but these are the most common ones. And a good informaticist can help you figure out the right mix of tools to craft the workflows you want to create to improve safety and standardize care.

(Using these tools to craft a workflow, in the electronic world, is an art known as electronic decision support. This is why a clinical informaticist is a key role in managing your clinical processes in the electronic world.)

Hope this helped remind you that order sets are a good tool to help craft a workflow and standardize care, but not the only tool. If you forget about the other tools, you may be missing out on other opportunities. A good clinical informaticist will help you figure out which tools to use for which scenarios. :)

Friday, November 5, 2010

A Few Words About Education in Healthcare and Life

So I recently got a very nice email from a person at a healthcare informatics consulting company, asking me to participate in a webinar on healthcare informatics. Two pieces of the email that really made me smile :
"Your blog was sent to me by a colleague who found it extremely educational on the topic of medical informatics. I quickly agreed; you discuss what can be very complicated systems and the politics of implementing an EMR in terms a layperson such as myself can easily understand. It has become a great resource for our staff as we continue to learn and grow within the HIT community."
"We were very impressed by the information in your blogs along with your conversational style..."
So I'm thrilled that someone picked up on what I try to do - Educate in a painless, simple way that people actually enjoy. A great example of this style can be found in the NPR Radio Show This American Life, where every week Ira Glass and various other writers/readers tell stories that are actually very educational. On This American Life, they have recently tackled subjects as complicated as the economic meltdown, credit default swaps, and other hairy political, legal, and financial issues, all told through stories that people share about their lives.

A great example of painless education told through story is their show about the financial meltdown, called The Giant Pool of Money. This is a true educational masterpiece. Every sentence in the show show lures you in, grabs you, and explains world banking and finance in a way that is totally tangible and palpable by the masses. You leave the piece feeling full of amazement at what you just learned.

This is the style of education I try to emulate in healthcare informatics. There are a lot of discussions in healthcare that are full of drama and intrigue, worthy of a Shakespearean drama. I try to convey it that way. :) (Although admittedly, I don't have as much time, creativity, or talent to emulate the TAL writers.) :)

Anyway, this gets me to my subject of education in healthcare, and in life.

Education is not something that has to be painful. It just has to require work. The first step is approaching a subject with :

  1. An open mind
  2. Eagerness to learn
  3. The humility to admit you might not understand something
If you can achieve that, then you will be a great student and will learn a great deal, in school and in life. As social human beings, I think it's our nature to be BOTH a teacher and a student, as long as we live, and we have that responsibility to play both roles to keep our society intact.

I think part of the educational problem is that people don't appreciate how much work it takes to make education painless. Good teachers are worth their weight in gold and platinum. We also think of education as ending after high school, or after college. Yes, we pay attention to higher education too, but there are many, many ways we educate eachother, as humans :

  1. We go to grade school, high school, and college
  2. We talk to our friends and neighbors
  3. We watch eachother and watch our children play on a playground
  4. We tell stories at family reunions
  5. We ask questions (to learn and to teach!)
  6. We scribble ideas on cocktail napkins
  7. We create and watch movies and videos
  8. We write and read books and web pages
  9. We write and listen to songs.
  10. We write laws and policies.
Although the law, and most discussion centers around #1 as an educational medium, there are many other ways to achieve an educational goal.

One of my favorite stories I collected during medical school was when my parasitology professor, Dr. Calum Macpherson, told us about his time spent fighting parasitic diseases in Africa. In one story, he described a particular disease, echinococcus, which was causing disabling and life threatening liver and abdominal cysts in animals and people in a particular region.

The challenge to him and his team, he reported, was preventing the behavior where people would feed pieces of these large, salty, abdominal cysts from dead animals to the dogs in the neighborhood. (Gruesome, perhaps, but when you have dead animals, and hungry dogs, it only makes sense.) This behavior, unfortunately, perpetuates the life cycle for the parasite, and the disease continues to spread.

So how to prevent the behavior of feeding these cysts to neighborhood dogs? One way: To educate the village. So they developed a creative solution. Working with local people, they created a children's song that could be performed and sung at a playground, during playtime. They made the song catchy enough that kids liked to sing it.

Apparently, many years later he went back, and still found the kids on the playground singing the song they wrote about "not feeding cysts to dogs".

A creative approach, and effective. Perhaps the first example of a viral idea.

In conclusion : Don't let education intimidate you. It takes work, but it doesn't have to be painful. :)