Wednesday, March 28, 2012

Linguistic issues in Healthcare

I'll admit it - I was flattered when Mark Hagland of Healthcare Informatics recently gave me my second interview about CMIO life. During our discussion, he asked me a lot of questions about "What does it mean to be a CMIO?" and "What makes a good CMIO?". And as I was responding, I told him that I feel like a lot of my job is about offering translational services between the clinical side, the administrative side, and the IT side of healthcare.

As a multilingual person who grew up in a multicultural household, I learned a lot about interpreting :

  • How culture, context, and language all interplay and influence each other.
  • How hard it is to pin down which of the three is more influential in communicating a message.
  • How language is sometimes unable to convey a specific message. (* - IMHO, this is why art, poetry, and music exist - To help send those messages where language fails.)

So I feel like a lot of my the CMIO role is like being a United Nations Interpreter - I have to consider the culture, context, and language that each member of a team is using, and try to make sure that the "same message" is being received at the other end of the line.

I can only say that quietly, I see a lot of confusion happening in the national healthcare discussion because we don't appreciate the linguistic issues which contribute to that confusion. We don't see it because we're all speaking English... right?

To give an example of what I'm talking about, I sometimes act as an interpreter between the German and American members of my family. This is a fairly straightforward act, where :
  • At dinner, one of my German family members will say something in German.
  • I listen to what they said, and have to consider both the context of the message, and the German cultural perspective of what they said
  • I have to mentally prepare a translation with a similar theme in English with an American perspective.
  • I have to help verify the context and quality of my mental translation by comparing it with a similar American cultural context (if one exists). 
  • Sometimes, despite your best efforts, there is no way to do this 100% effectively - This is why there are words that 'cannot really be translated', like "Kindergarten" and "schadenfreude" which make their way into the English/American lexicon.
  • I deliver the best English translation I can that, hopefully, is as close to the content, context, and spirit of the original message.
This process of translation is fairly intuitive to most people when speaking different languages because, well, they are different languages - There is virtually no way my American family and German family can talk to each other without an interpreter.

The problem in many healthcare discussions is that we're all speaking English - So the context and cultural perspectives of different members of the healthcare workforce are not as apparent, and so it's not as immediately clear that you've crossed cultural boundaries. In short - It's very easy for messages to get mixed up because people aren't always aware when they have crossed a cultural boundary. People may have experienced this in any business, but healthcare is particularly susceptible to this due to the many cultures that interplay in healthcare - Clinical, administrative, technical, business, etc.

As a CMIO who grew up multilingual, however, I'm keenly watching for those cultural boundaries, and playing so many roles, I try to act as an interpreter and watch to make sure the right message was received on both sides of the fence.

Still, even with my experience, I was recently humbled when I inadvertently crossed a culture boundary  - I tried to let a family member know I moved their mother to the ICU just as a precaution :
Me : "I moved your mother from the floor to the ICU just as a precaution."
Family : "What was my mother doing on the floor? Did she trip and fall?" 
(Same word, different culture and context - Good thing this person asked for clarification! What if the family hadn't asked for clarification?)

An interesting parallel to this discussion - UN interpreters are generally expected to study both of their languages equally well and to live in both cultures, so they understand the cultural context, jargon, slang, and idiomatic expressions in both languages. In the same way, I think that's why it's helpful for me to work both clinically and administratively - It helps me understand the language, jargon, slang, and idiomatic expressions of both cultures.

So Mark, as a multicultural, multinational, and multilingual guy himself, totally understood this issue and wrote this really interesting blog post where he spoke about an experience he had while visiting South Korea, when he participated in a 'translational daisy chain' where a diverse group of visitors were trying to help a French-speaking Belgian woman buy tickets. Using a combination of people, all bilingual but speaking different languages, they established a French <> English <> German <> Korean translation chain, and by each person working on their part of the translation, this French-speaking woman was able to buy tickets from a Korean-speaking vendor.

It's one of the craziest stories I've ever heard, but it beautifully demonstrates both the value of bilingualism and the work it takes to get even a simple message across four languages and four cultures. Anyone who has played the game "Telephone" just using English knows how easy it is to fail to relay a message - Imagine doing it across four languages and cultures!

I suppose this might be one of the reasons I see a lot of CMIOs from diverse backgrounds, where something about their life experience taught them to be comfortable crossing cultural boundaries and 'seeing both sides of the coin'. This seems to be a fairly common trait among the other CMIOs I meet. For me, it's part of the reason why I so enjoy helping to further define and clarify the CMIO role - to help healthcare evolve and adapt.

Remember, this is just academic banter, and your mileage may vary. Always enjoy comments, questions, thoughts, and discussion!

Friday, March 23, 2012

Improving organizational Informatics by leveraging your Intranet

A common problem with EMR and EHR implementation in a hospital is usually : How do we get enough Informatics staff?

You need the Informatics talent to help with the initial implementation. You need them later to help with the maintenance and training. You need them to help with "special new clinical projects" which require engineering many tools to a higher standard than you did in the paper world. You need them to help achieve Meaningful Use. You need them to help ensure the steady flow of good clinical data to quality management. You need them for expert advice on workflow redesign and systems issues.

The problem is that many hospitals don't have as much Informatics support as they'd like. Why?
  • Informatics is commonly confused with IT, making for difficult budgeting decisions when trying to build an Informatics platform.
  • The term "Informatics" is used so loosely, many people just don't really know what they're looking for.
  • Even if you know what you need, and have the budget - There are not a lot of well-trained, experienced Informaticists around!
So if you're a lonely Informaticist in a large organization, you might be facing the challenge of : How do I help everyone in our organization to achieve their dreams and accomplish their goals, when it's just me?

Often the stretch on Informatics resources makes it almost impossible to help everyone achieve the workflow clarity they need.

So it's not uncommon that Informaticists start to fantasize, "What if I could teach people in every department some basic Informatics so they could manage their own projects that will work with our EMR?" You're never going to get them all to take the AMIA 10x10 class, but what if you could get them to start thinking differently about their tools so they could engineer them better BEFORE they approach your Informaticists and Clinical IT Analysts?

There's a little tool most hospitals have, that can help you bring clarity to virtually everyone in your hospital - It's your Intranet. Yep, that page that comes up every time you open a web browser - Is it helping your organization as much as it can? Are you using it to publish your important documents internally?

Some signs that your Intranet needs some updating include :
  • You don't really look at it much.
  • You only use it to get to Up-to-Date, or to the phone paging system.
  • You have trouble finding what you're looking for.
  • It's very lengthy.
  • You set your home page to Google rather than your Intranet.
Remember - This is the one place virtually every person in your organization starts off with - Why isn't it helping them more? 

The challenge, of course, is to make it as chock-full of deliciousness as you can. Cut out the waste, and only include the good stuff. And not just for the docs, or the nurses, but for *everyone* - Administrators, pharmacists, respiratory therapists, etc...

So after developing the CMIO's checklist, it dawned upon me that one could leverage their Intranet home page in a way that would :
  • Bring clarity about the documents your organization manages.
  • Bring all of the documents "close" to that home page in an organized, methodical way.
  • Give a little "drop" of Informatics education at every click.
  • Create real ownership of all of your important documents.
  • Creates real organizational transparency for those documents you want to be transparent.
  • Create linguistic harmony in your organization (to help meetings run more efficiently)
  • Facilitate supervision of your employees and committees
So by putting apples-with-apples and oranges-with-oranges, you can use the definitions from your organization's CMIO's checklist in a way that puts virtually every piece of paper within (I estimate) five clicks of that Intranet home page. Here's what it hypothetically could look like :


  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 scenario
  9. Clinical Protocols - Tools to standardize and automate a clinical process
  10. Clinical Pathways - Tools to standardize daily care for a diagnosis
  11. Education Modules - Tools to help educate patients/staff
  12. Dashboards and Reports - Tools to help you monitor something
  13. Templates - Tools to help make a document
  14. Wikis - Tools to help organize information/links for  a department
  15. Committee Charters - Tools to assign committee duties and responsibilities
  16. Committee Minutes - Tools to record committee activities
  17. Glossary of Terms - Tools to learn organizational definitions for common terms
    Need to add something to this page? Call Dirk Stanley at 555-1212 or email him at

    First, you'll notice at the end I have a link about "add something to this page" - That's your cue to bring a user to the documentation they need to understand when making/drafting one of the tools. It's not too hard to write a page or two on "how to write a protocol" or "how to write a policy" - This puts that documentation in their hands, easily-found, in the same-place-everytime, and empowers them to help organize their projects before they approach the Informaticist.

    Next, you'll notice there is less clutter. It keeps your Intranet home page tidy and makes every link meaningful. Aesthetically it's pleasing, even as text. Could look even better with some good graphics design.

    It also fits nicely into a Drupal-style framework - Flexible, easy-for-departments-to-maintain, and your organization's history is well-documented.

    Finally - if you keep this same sort of format throughout your entire Intranet, then I predict :
    • Users will learn about the tools and their definitions every time they look for a document
    • Users will learn that "it's more than just order sets" that are involved in clinical changes
    • You will make it very easy to link these electronic documents to your EMR for various purposes (e.g. reports, protocols, etc.)
    • Virtually every important document will end up about 5 clicks from the home page
    • Users will find the Intranet a high-value site
    • It won't just be the clinical side that "goes electronic"
    • Your Intranet Home Page will become a tool and a resource for everyone in your organization.
    I haven't fully implemented this framework myself, yet - Make no mistake, achieving this level of efficiency on your Intranet is no small task, and will likely require an entire team and a lot of buy-in from your organization. But it's the conceptual framework I am working on - Tight, efficient, smooth information flows that bring employees together in one place, rather than allowing technology to separate them.

    Remember, your mileage (and definitions) may vary! Would love to know if any readers have achieved this level of informational efficiency. How did it go? What were the setbacks and successes you had along the way? We're all both teachers and students, so I always welcome comments!