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. :)

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