Tuesday, December 14, 2010

Find any document in your hospital in five clicks?

It's December. The squirrels have gathered their nuts. The leaves have fallen. People are having their holiday parties. It's a time for reflection, as we anticipate the new year 2011 that lies ahead. Healthcare is changing faster than ever before, and those who want to survive, need to keep up.

I've spoken in previous blog posts about the tools we commonly use to deliver care in modern healthcare. So as I've been thinking about how to streamline organizational efficiency in healthcare, one of the major challenges most hospitals face is : How do we manage all of this information?

Some people will immediately look to IT for solutions, since we think of information as living inside a computer, but IT can only build a system as organized as you ask them to build. The problem is : If you had chaos before, making things electronic will only perpetutate the confusion.

(I've spoken to plenty of healthcare informatics types who complain about not being able to navigate their web sites, shared electronic folders that never get updated, and not having "intuitive" organization of their information.)

I find the comment, "We don't have intuitive organization of our information" particularly interesting. Everyone seems to have a different idea of what is intuitive.

All of this speaks to the need for standardization in healthcare, and education to support those standards. (Nobody teaches this stuff in medical school, nursing school, or pharmacy school.)

So I hope I've attracted your attention with the title of this blog. My proposal : We develop a standard "document tree" that can be used to organize virtually all of your hospital's information. (Except emails, of course, which generally are private and not shared.)

The Healthcare Informational Tree

So I thought about all of the common tools we use in healthcare (the CMIO's Checklist and the Informatics Toolbelt), and sorted them first by function and then by division (Clinical versus Administrative) - And this is what I got as a final list :

  1. Telephone Numbers - Tools to contact a person
  2. Emails, Screen Savers, and Posters - Tools to help send a short message
  3. Schedules - Tools to show who is responsible at what date/time
  4. Policies and Procedures - Tools to learn organizational standards and how to achieve them
  5. Guidelines - Tools to help educate and guide staff towards a desirable outcome
  6. Documentation - Tools to record and transmit information
  7. Orders - Tools to document and transmit instructions to deliver care
  8. Order sets - Tools to standardize and expedite the ordering process for a common clinical scenario
  9. Clinical Protocols - Tools to standardize and automate a clinical process
  10. Clinical Pathways - Tools to standardize care for a diagnosis throughout a hospitalization
  11. Education Modules - Tools to help educate patients/staff
  12. Templates - Tools to help make a document
  13. Wikis - Tools to organize information / links for a department
  14. Committee Charters - Tools to assign committee duties and responsibilities
  15. Committee Minutes - Tools to record committee activities
  16. Glossary of Terms - Tool used to learn definitions for common organizational terms

I believe that by using the above directory/tree hierarchy, you could arrange your tools on your intranet in a way that you can essentially find any document in your hospital in five clicks - Each link, from this main page, then divides up into clinical and administrative divisions, e.g. :

  • Clinical Templates = e.g. Admission H&P template, Procedure Note template, Transfer Summary template, etc.
  • Administrative Templates = e.g. Policy and Procedure template, employee evaluation template, etc. 


  • Clinical Documentation = e.g. Admission H&P, Procedure Note, Transfer Summary, Vitals Flowsheet
  • Administrative Documentation = e.g. Employee Evaluation Form, Room Change Form, Maintenance Request Form


  • Clinical Policies = e.g. Pharmacy Policies, Infection Control Policies, Nursing Care Policies, etc.
  • Administrative Policies = e.g. Human Resources Policies, Safety Policies, etc.

The interesting thing about making such a tree is it shows you, pretty quickly, how much work you are actually doing in your hospital, how much it actually takes to run a hospital, and why you need people to worry about all of these tools.

It also can help you find your work products much quicker, and it interfaces nicely with the tools that you need to make a change in the clinical setting.

Adopting such a tree is not a small project, but it sure can tidy up your intranet homepage. It also helps reinforce informatics education by making almost everyone in your organization review the basic tools you use, and what they do, every time they look for something. By having centralized publishing, this also helps keep your intranet a "high-value" site that people will use to find things.

As someone who wants to see American healthcare be the best that it can be, I think it's an admirable goal. Those of us working to organize Health2.0 should be keeping this tree in mind as we develop our healthcare informatics policies.

Remember, my advice is free, and you get what you pay for. Your mileage may vary. :)

Would love to hear comments about potential additions/changes you would make to the tree at your organization! :)

Saturday, December 4, 2010

What is Medicine Reconciliation, anyway?

So recently I've been hearing and reading a lot about medicine reconciliation.

Medicine reconciliation is the safety practice that, it seems, The Joint Commission has recently announced they will set new expectations for.

A friend of mine, who went to an IHI conference last year, told me that on a wall full of posters of "problem subjects", the "Med Reconciliation poster" seemed to have the most hospitals reporting challenges.

So what is this Med Reconciliation thing, anyway?
  • Is it a mythical creature that people see, but nobody ever really gets a picture of?
  • Is it something that inspires poets and artists, because it's so intangible?
  • Is it something that we can even achieve?
Most practicing physicians learned in medical school that it's "good practice to rip up and re-write all the orders when a patient comes out of the OR". Most practicing physicians are also used to documenting the patient's home medication list in an admission H&P. The interesting thing : These are both different facets of the same med reconciliation picture.

So then, I think one of the biggest challenges in implementing "Med Reconciliation" is that it's so hard to nail down. What is it, exactly? Who does it? And how? 

So I thought I'd share some answers.


 First, the premise is simple : It's all about safety.

Med reconciliation is built on the basic premise that a physician and a patient work best together, when they're with eachother. For the purposes of this discussion, I've lovingly decided to call the "place where they work with eachother" the "Patient Care Cubicle" (instead of the industry term, "Level of Care" which is a little confusing.).

The process is then pretty simple. To perform med reconciliation, a physician needs two separate documents :
  1. The 'home medication list', to know what the patient is 'usually on'.
  2. The 'active medication list', to know what the patient is 'currently on' while sitting in this "patient care cubicle".

And the steps for doing med reconciliation? A doctor should basically follow these four steps :
  1. Look at the Patient
  2. Look at the HomeMedList
  3. Look at the CurrentMedList
  4. Make a new CurrentMedList!

This allows a physician can make the decision : What meds does the patient need to be on right now.

So remember, the recipe for med reconciliation needs these four ingredients :

   MED RECONCILIATION = [ Patient ] + [ Physician ] + [ HomeMedList ] + [ CurrentMedList ]

(While they are connected, remember - Med reconciliation is NOT the process of collecting the home med list - But you will need to collect the home med list before a doc can do med reconciliation.)

So... when does a physician actually do these four steps of "med reconciliation"? Optimally, it happens at two times :
  1. When the patient appears in your cubicle (in hospital terms this is known as a "change in level of care")
  2. When the patient has had some significant event (like delivering a baby, a code blue, a surgery, etc.)

So far, so good. Now comes the implementation challenges.


The first thing you might do to map out the implementation of med reconciliation, is to make a general map of all of the "patient care cubicles" your patient might pass through, when he/she goes through your hospital. Typically, this map will start with the outpatient cubicle, and end with the outpatient cubicle. (On discharge, then, you need to do med reconciliation one last time to define the "new home med list", aka the "discharge medication list").

So if each "cubicle" has the patient and a physician :
  1. The physician covering the "outpatient cubicle" is the primary care physician.
  2. The physicians covering the other cubicles are the ones you assign.
And so if you need two lists - The home med list, and the current med list - To perform med reconciliation, you can see by the above slide that the first challenge will be getting the home med list available in your ED.

This brings us to some challenges with med reconciliation...


The first challenge is just getting the home med list in your ED. How long does it take to actually assemble the list of home medications? (Remember : THIS IS NOT MED RECONCILIATION YET - Collecting this list is probably the thing most commonly confused with the term "med reconciliation".)

I did an informal study of this, while working clinically last year, and found that my median time for most adult medical inpatients was about 20 minutes. About 2/3 of my population was less than this, but about 1/3 of my patients were more than this, and there were some significant outliers - some patients took up to 45 minutes or more. (While slightly tongue-in-cheek, I called the standard I used the "mother standard", figuring I would work to achieve the same accuracy I would expect for my own mother.)

The reason it can take some time to assemble is this : There are up to seven data sources a person can use to assemble the home medication list. They include :

  1. The patient - Who usually knows their home med list... but not always.
  2. The family - Who is often helpful at establishing an accurate med list, but not always
  3. The PCP - Who is usually accurate, as long as the office is open and they know what the specialist might be prescribing, so...
  4. The specialist - Who sometimes needs to be contacted for clarification about new specialty medications
  5. The outpatient pharmacist - Can be helpful to get a broad view, assuming the pharmacy is open and the patient doesn't use a mail-order pharmacy
  6. The previous chart - Can also be helpful, assuming the last visit wasn't too long ago
  7. The "insurance-based electronic prescription database", available at some hospitals - Which also still sometimes takes time to sort through, and you have to make certain assumptions...
So if the first step is to assemble this list in the ED, then the first challenge is to figure out who will assemble this list, and how?

Curiously, if you examine med reconciliation needs in the ED department, it usually falls along these steps :
  1. Triage desk Officer : Generally drug classes are most important, not actual drug names. (E.g. a triage officer may consider bringing someone in if they are on blood thinners, or antibiotics.)
  2. ED physicians : Generally drug names are most important, sometimes doses. Most ED visits are short, so there has not traditionally been much focus on doing med reconciliation in the ED. Of course, if we expect ED physicians to perform med reconciliation, they will need more information. (Some patients do miss medication doses while waiting for care in the ED.)
  3. Inpatient Physicians : Here is where the drug, dose, route, frequency, indication, and last dose are most important, because the patient staying in-house will need to continue the right medications at the right times.
Because of these varying needs, at these different levels, it's sometimes hard to figure out who's responsible for how much of the puzzle.

The second challenge, assuming you can get the home med list assembled in the ED, is figuring out : Which physicians will be responsible for actually doing med reconciliation in each cubicle?

While it's tempting to answer :
  1. ED - Would be performed by ED physicians, 24/7
  2. Floor - Would be performed by hospitalist physicians, 24/7
  3. ICU - Would be performed by intensive care physicians, 24/7
  4. Etc...
...the PreOP setting/OR/PACU usually presents some unique challenges (challenge #3)

The challenge for many ORs/PACUs is this : Operating room schedules are tight. Hospitals count on maximum efficiency in an operating room. Even small delays can be magnified into cancelled procedures if everything doesn't run like clockwork. Also : Surgeons and anesthesiologists spend a good part of their day in procedures that simply can't be interrupted. Briefly pulling a hospitalist out of a family meeting to "do med reconciliation" will have a very different cost than briefly pulling a surgeon / anesthesiologist out of a surgery.

To accommodate with these demands, many anesthesiologists focus mainly on anesthesia meds, and many surgeons write post-operative orders in the PACU. If the patient goes up to the floor, after the PACU, then the nurses depend on the post-op orders written by the surgeons in the PACU. Unless you create a cubicle where the PACU has the same level of care as the floor, you might have to do med reconciliation again after the patient reaches the floor.

Figuring out this workflow can be very challenging. It's why my friend, going to the IHI conference last year, saw Med Reconciliation as one of the 'top challenges' hospitals face.

The fourth, and final challenge, is deciding on the "triggers" you will use for med reconciliation. As described above, there are typically two things that should trigger a physician to actually perform med reconciliation :
  1. Patient arrives in your patient care cubicle (aka "Change in level of care") - This is usually pretty easy to enforce electronically.
  2. Patient has a significant change in status (e.g. delivery, surgery, code blue) - This can only be enforced by a policy/clinical practice.

So you will need to decide on these two triggers, knowing that
  1. For your EMR to trigger med reconciliation electronically, you will need to organize your levels of care and their relationship to your patient locations.
  2. For your staff to trigger med reconciliation during a significant patient event, you will need good policy design and education.


Fear not, my reader! This may seem daunting, but the problem can be solved! Many hospitals have started down this pathway already, and many more will continue as The Joint Commission and other regulatory bodies reinforce med reconciliation practices.

To help you, I've offered the following recommendations and steps you can take to advance the discussion in your own hospital.

  1. Define who is responsible for collecting the home med list in the ED
  2. Define what home medication information they will collect, and how? (It's challenging to figure out how many of the seven potential data sources to use, but until our whole country is wired together electronically, your organization will need to decide this.)
  3. Define where this home med list will be kept, once assembled, so that every doctor in the "chain of cubicles" will be able to access it and use it to perform and document "med reconciliation".
  4. Define your "patient care cubicles", where your EMR can help trigger the med reconciliation process.
  5. Define your policy that will help educate physicians about clinical scenarios in which you expect med reconciliation to be performed (e.g. delivery, code blue, surgery, etc.)
  6. Define which physician's will be responsible for the med reconciliation process in each cubicle, 24/7.
Regarding the unique challenges that most Operating Rooms/PACUs present, this is a very common challenge, but I'll present the following possible scenarios I came up with :
  1. Your hospital might consider asking the surgeons to perform med reconciliation after the patient arrives back up on the floor. (This may cost your hospital in OR time/efficiency.)
  2. Your hospital might consider transferring all post-op patients to your hospitalist group, to allow the hospitalists to perform med reconciliation on the floor. (This may cost your hospital by needing more hospitalists to care for these patients.)
  3. Your hospital might consider hiring a Physician's Assistant (PA) or Nurse Practitioner (NP) to assist the surgeons with the med reconciliation process. (This may also cost money, but I believe in most settings this would be more affordable than option #1 or  #2 above.)
Enjoy - I hope this discussion has been helpful. A good sample policy to support med reconciliation is available here from the University of Wisconsin Hospital and Clinics.  Again, I'm eager for any feedback folks have. Feel free to leave your own stories about tackling med reconciliation! :)