Wednesday, June 13, 2012

Med Reconciliation and Midlevels

Sorry folks - I know it's been a few weeks since my last post. Blogging is fun, but it's hard work. New CMS regulations on Order Sets, Meaningful Use, HIE, EMR/EHR... It keeps a CMIO busy!

Anyway, so now onto this post. Working in front-line applied medical informatics, I see some general healthcare trends evolving. Some are predictable, other's aren't. Here's one of the things I've noticed recently, that might be encouraging to the midlevels (PAs, NPs, CRNAs, and Midwives) in the audience.

What I'm seeing : As three trends merge -
... it's becoming very clear to me that the demand for accurate electronic med reconciliation practices will go up inside hospitals.

The problem is that this is not the always the easiest thing to do. Just assembling medications and allergies at the point-of-entry can be complicated, having to potentially reconcile up to seven data sources (patient, family, PCP, specialist, pharmacy, chart, and med database). Many hospitals hire a position (pharm tech, or other equivalent position), just to compile the list of home medications.

But then, once you have the list, entering them into an EMR can be a challenge.

Once you have them in the EMR, then, you can perform electronic med reconciliation. It's one thing to do it at the point of admission and discharge to your hospital - It's another to do it at every transition of care.

But knowing that the goal is for med reconciliation at every transition of care, I sometimes wonder : Who will do this, and how? Especially in some areas where there are frequent transitions of care (e.g. your perioperative areas), how will you manage those medications?

Some feel surgeons should be responsible for med reconciliation of their patients in the perioperative period. The challenge, however, is that surgeons are often under intense pressure to get back to the OR, or else there are OR delays which cause a whole different set of issues.

It's also common for anesthesiologists to care for patients in the post-operative setting - But again they face pressure to go back to the OR, to avoid delays, so they mainly only focus on the immediate medication needs of the patient.

So it's not unusual for the conversation to then lead to hospitalists managing the medications for the surgical patients, especially in the post-operative period. (After all, who better to manage medications than someone trained in a medical specialty, right? :) )  The challenge here is often that hospitalist services may not be able to handle the additional workload, without expanding their workforce, and hiring an extra hospitalist can be pricy.

And so, I suspect many organizations will start to look at midlevels as a more cost-effective way of  helping to fill this need. And so, my impression : The demand for midlevels (PAs, NPs, RNAs, Nurse Midwives) will continue to increase in the near future.

How much will it increase? I suspect as long as midlevels are more cost-effective than hospitalists, the demand for them will go up. So if I wanted to play futurist, I would guess the increased demand would drive midlevel salaries up until they reach that of an average hospitalist - and at that point I think the demand would level off :

Of course, this trend will depend on many factors, including regulatory issues, licensing/credentialing issues, physician supply issues, and other state and federal controls on physician and midlevel training. And my prediction could be totally wrong! I'm going to keep scanning the horizon, but I suspect the healthcare organizations of the future will use midlevels with a solid oversight and supervision model, that allows them to give high quality care for less.

Any dissenting opinions? Feel free to comment below!

Secrets of EMR Governance

The following is essentially a repost of the piece I wrote for the June 2012 HIMSS Insider, with some slight modifications for my blog. (My apologies - my blog allows a higher word count!) :) :

Implementing an Electronic Medical Record (EMR)? Then you’ll want to know something about EMR governance. It’s a subject that’s not well-understood, but in this article I’ll try to provide some background. EMR governance is the process by which you standardize your clinical practices and set them up to work electronically. Without predictable clinical practices, you won’t be able to get predictable clinical outcomes - and because computers are programmed to behave predictably, your EMR implementation will be challenging.

What is governance? 

Although the Oxford dictionary defines governance as “the action or manner of governing,” a quick Google search reveals this NIST (National Institute of Standards and Technology) definition:
“…the controls and processes that make sure policies are enforced.”
So why should clinical professionals worry about policies? After all, aren’t they documents that administrators are paid to worry about?

What is a policy? 

The reason clinical professionals should care about policies is because they are the central nervous system that quietly controls your organization.

Policies are essentially your organization’s standards. They reflect your values and describe, in writing, what you’ve decided to do. If your standard is to give all patients a gluten-free, diabetic cupcake on admission, then your organization could decide to write that standard down on a piece of paper :

“All patients will get a gluten-free, diabetic cupcake on admission.”
Of course, you may decide to pursue more meaningful standards, but for now we’ll use this simple policy as a teaching example.

What is a procedure? 

If a policy describes what you do, then the procedure describes how exactly you go about doing it.

A good model for a procedure is a food recipe. Every line contributes to the end result. For example, to describe how to achieve the cupcake policy above, you might write this procedure:

  1. Kitchen staff will bake 100 gluten-free, diabetic cupcakes daily.
  2. Couriers will bring cupcakes to floor.
  3. Nurses will give cupcakes to patients on admission.
You’ll notice a common theme in the procedure above: Each line answers, at a minimum, the who and what, but also can explain the when, where, why, and how
PLEASE NOTE : Some legal advisors recommend avoiding “will” and substituting other terms like “should” and “may.” Check with your legal counsel for advice before writing policies.

Then by having the directors of the Kitchen staff, Couriers, and Nurses review the policy before it gets approved, it allows them to :

  • Review the expected workflow - so they can educate it to their staff once the policy is approved, and 
  • Budget for it - Do they have the staff and material resources to uphold their part of the workflow?
You will want the directors and their staff to review the drafted policy before it gets approved, so be prepared to spend some time reviewing it with them before it goes for final approval.

When do I write a policy and procedure? 
By writing your policy standard and a procedure describing exactly how to achieve that standard, you now have a very valuable document. Together, these documents give you a meaningful change management mechanism.

Some people, when they learn about policies and procedures, suddenly want to develop policies for everything. Try to resist this urge. Too many policies can make it hard for employees to comply with them. On the other hand, too few policies might mean you’re not standardizing your operations. Ideally, you want a happy medium.

And so, you should only write policies when:

  • The policy is required to meet a legal, regulatory, safety, or operations need.
  • The policy addresses a common occurrence or practice.
  • You have the resources to implement the policy.
  • You can enforce the policy.
And, you should only write good policies.

What’s a good policy? 

A good policy is one that creates clarity and harmony in your organization. End-users should be able to find it, read it, and immediately understand your expectations. It should be a valuable management tool for leaders and directors, and should always reflect your values and current practices.

A bad policy is one that creates confusion, chaos, or in a best-case scenario, changes absolutely nothing. A bad policy conflicts with your values, does not reflect practice, is published where few people can find it, and many employees don’t know it exists.

So what about hospital governance? 

Before discussing IT and EMR policies, it helps to understand a little about the difference between administrative and clinical policies.

Let’s say you were building a hospital from scratch—you would need two teams to help you :

  1. A clinical team, who know all about giving care, treating diseases, and doing surgeries and procedures
  2. An administrative team, who know all about finance and operations and regulations and legal issues.
Neither team can live without the other; virtually all hospitals need both. So we generally divide their standards into:
  1. Clinical policies – Those that define patient care and clinical standards.
  2. Administrative policies – Those that define employee and administrative standards.
The key ingredient needed for these two teams to work together harmoniously is good communication at all levels of your organization.

So what about IT and EMR Governance? 

After you have a good understanding of your organization’s policy and committee structure, you can go about examining your current standards. Do you have any documents that spell out basic clinical practices such as:
  • Electronic Documentation – How/when to create it, sign/authenticate it, use it?
  • Medication Order Standards– How/when to order certain medications? Non-formulary medications? In code blue/emergency situations? Over the phone?
  • Standards for lab/radiology orders– How/when to order certain tests?
  • Training standards – How do you train new employees? Existing employees?
  • Clinical Tool Development – How do you develop order sets? Policies? Procedures? Protocols? Documentation? Downtime documentation?
Look for these documents because you will need to examine them and probably modify them after your EMR implementation to help make your processes more efficient. In general, the standards get tighter, and the demand for resources increases after your EMR go-live.

Finally – A common question I hear is, “Where should I publish my IT and Informatics policies? In the administrative or clinical policy manual?” Surprisingly, most informatics and clinical IT policies belong in the clinical policy manual. While it’s tempting to think of them as administrative issues, most of them have a strong impact in clinical functions and strongly impact the day-to-day operations of clinicians. When in doubt, ask yourself: “Who is the end-user of this policy?

10 DOs and DON’Ts to remember with EMR and Health IT Governance

  • DON’T: …write policies in a rush. The more time you spend on them, the clearer and more effective they will become.
  • DON’T: …write too many policies. They should only be for things that address absolutely necessary legal, regulatory, or workflow issues, and those that you have resources to monitor and implement. 
  • DON’T: …make policies automatically punitive. Non-compliance with a policy should give a leader a reason to pause and reflect: Why didn’t the policy help reinforce the desired outcome?
  • DON’T: … forget to document reasons why you knowingly didn’t comply with a policy. They carry legal risk and weight, so any non-compliance should be well-documented and discussed with leadership.
  • DON’T: … keep policies hidden! For them to work best, it helps to keep them in a common place where everyone can find them.
  • DO: … practice writing policies, and have end-users look them over to help check for clarity.
  • DO: … spend time learning your organization’s governance structure, including your bylaws, policy manuals, policy writers, reviewers, and approval bodies.
  • DO: … keep reading more and look for classes on operations and policy development.
  • DO: … consult legal counsel when needed, especially to tackle tricky, high-risk or other compliance issues.
  • DO: … network with other healthcare technology colleagues, to share tips, tricks, and lessons learned.