Sunday, December 20, 2015

How to spot and fix a Frankenform

Hi readers - As I write this last post for 2015, I'm going to explore one of the most common questions that Informatics professionals get asked : "Why can't you just make this paper form electronic?" - 

The most common answer that Informatics professionals respond with is, "Well, you just can't", usually followed by some sort of an awkward smile and an answer that sounds like, "You know those computers, they are always so difficult." 

But there is a real reason, with a better answer. To help explain that answer, I'd like to introduce a new concept - The Frankenform.


Before we go on, I just wanted to review some DRAFTED definitions of a few common archetypes we all use in healthcare. They include : 
  1. POLICIES - Tools used to describe an organizational standard
  2. PROCEDURES - Tools used to describe a series of actions conducted in a certain order or manner
  3. GUIDELINES - Tools used to educate staff about how to achieve a desired outcome
  4. ORDERS - Tools used to document an instruction to deliver a defined type of care to a defined patient at a defined date/time in a defined manner (sometimes for a defined reason)
  5. ORDER SETS - A collection of ORDERS used to standardize and expedite the ordering process for a common clinical scenario
  6. CLINICAL PATHWAYS - A collection of ORDER SETS used to standardize the care for a common clinical diagnosis
  7. PROTOCOLS - Tools that allow a nurse, pharmacist, or other licensed medical professional to start/modify/stop a patient care order on behalf of a licensed physician.
  8. DOCUMENTATION - Tools used to record and transmit information
  9. STAFF/PATIENT EDUCATION - Tools used to educate staff/patients about a particular topic
  10. STAFF SCHEDULES - Tools used to determine who is responsible at a particular date/time
  11. BUDGETS - Tools used to allocate resources for a project or initiative
These definitions will be helpful in spotting Frankenforms - Forms that often combine these functions.


So what exactly is a "Frankenform"? It's a term that Informaticists sometimes use, loosely, to describe paper forms that combine more than one of the above functions, or are used by different people in different scenarios. If I had to write a better definition, it might be described as : 
Frankenform (n.) - a form or document that is designed with more than one archetype, role, or scenario in mind.
Frankenforms existed all over in the paper world. While they are often convenient (having everything in one place), they generally don't behave well in the electronic world because : 
  1. They contain documentation recorded from two different roles. (e.g. the dietitian and physician both signing off on one TPN order)
  2. They contain two different archetypes (e.g. part-policy-part-order-set, or part-policy-part-guideline, or part-documentation-part-order-set, etc.
  3. They contain documentation from two different scenarios. (e.g. the sometimes-seen, all-encompassing "antibiotic order set" which contains antibiotics to cover all scenarios, from pre-op antibiotics to treatment of sepsis) - These all-encompassing tools are sometimes also called "pick lists", because they can be used in almost any scenario.)
Electronic medical records generally will not allow you to build Frankenforms into their systems because of these three reasons :
  1. They enforce legal-grade authentication - So a form used by two different people must be re-engineered to find out who-is-filling-out-what-part-of-the-same-form
  2. They are engineered to enforce archetypes - Generally, order sets are found in the order set section of the software, documentation is found in the documentation section, and guidelines and protocols may not be contained in the software at all. So while you can link from your clinical documentation TO your order set, or link your order set to a set of clinical guidelines, you can't actually put documentation and orders in the same part of the software.
  3. Taking advantage of good, electronic Clinical Decision Support (CDS) generally depends on a clear, linear workflow.
Interestingly, most EMRs will still allow you to make orders, order sets, or documentation to address two or more different scenarios - While it's quite not as unorthodox, it still can lead to very lengthy documents/order sets with poor decision support that can frustrate users in the long run because they require a lot of clicking to complete them.

So let's now look at these three different types of Frankenforms in a little more detail.


A common workflow challenge is when two different roles are involved in ordering/documenting in the same workflow. The classic example of this is the Dietary TPN order, which is usually one order with many fields - Some are filled out by the physician, and some are filled out by a Registered Dietitian

You can often spot these forms because they have multiple signatures on them. While it's important to have both signatures before processing the order (often for safety/billing reasons), having two different signatures can cloud the workflow that led to the completion of the order - Who filled out which field? Did the dietitian enter the potassium, or did the physician? If the potassium needs to be raised, who does a nurse call? The physician? Or the dietitian?

Fixing these, to make them electronic, can be very complicated - and often means a good deal of workflow analysis and redesign. The electronic solution will typically have electronic orders and documents with electronic co-signatures, but will often mean a more rigid workflow (e.g. having to decide who starts off the workflow, the doctor or the dietitian? And who cosigns the order? And how do they attribute the cosignature to the right person?)


This is the scenario where a paper form with one signature actually contains components from two different tools, e.g. an "ED Nursing Protocol" which is part-documentation, part-orders, and part-guidelineAgain, these were very convenient in the paper world, because you could have all-the-information related to the workflow in one place. 

While these are sometimes easier to build in an electronic environment (provided they really only have one stakeholder), they still generally require separation of the tools into their electronic components - E.g. the documentation in one place in the software, LINKED to the guidelines for review, LINKED to the orders that get activated. 

Often, while dissecting these Frankenforms into their separate components, workflow questions arise which must be looked at to ensure safety and regulatory compliance. Again, this is usually not hard to overcome, but it should be expected that converting these paper forms to an electronic workflow will take some additional time and resources. 


(Also sometimes referred to as "pick lists") - While this Frankenform looks fairly innocent (who wouldn't want all of their antibiotics on one order set?), it's generally a sign of a larger workflow issue. These Frankenforms, seeking to address many-different-clinical-scenarios-with-one-tool, can require the most time to redesign because they usually raise larger workflow questions, bigger than the form itself.

For example, having a broad "ED Antibiotics Order Set" means you are missing opportunities to develop disease-related, evidence-based order sets, which often involve more than just antibiotics. While in the short-run, physicians may like having all of their antibiotics in one place, they may get frustrated looking for other medications related to disease management, and/or miss other quality indicators. 

The solution to this type of Frankenforms is generally the construction of a larger library of disease-related, evidence-based order sets, focused on common disease pathways that doctors are responsible for initiating after they reach a diagnosis. (And so you might even want a separate library of order sets used to work up common chief complaints, to help them reach this diagnosis!)

While creating (and maintaining!) this larger library can take time and resources, it generally results in shorter, disease-related order sets, which are focused on the total management of the patient in an evidence-based manner, with better decision support, better provider satisfaction, better quality compliance, and better overall time savings. 


If 'going electronic' means that you will need Informatics resources to identify and fix existing Frankenforms, then budgeting for a successful EMR implementation generally means : 
  • Conducting a complete review of all current clinical documentation and forms.
  • Developing a good understanding of your current workflow issues by estimating the number (and type) of Frankenforms currently in use
  • Planning and budgeting for the informatics resources necessary to fix (and maintain!) your solutions.
And so the first step in solving these issues is finding an experienced Informatics or workflow professional, and asking them to do a good current-state and needs analysis. The answer will help determine your success and satisfaction with your new EMR implementation!

I hope this post has been helpful in creating understanding and clarity. Thank you so much for reading my blog, and many happy wishes for 2016!

Have any thoughts about workflow redesign and optimization? Leave them in the comments section below!

Thursday, November 19, 2015

Informatics Domain and Clinical Workflow Video

Hi readers,

After my last post, some people asked me if I could put it into a video form, to help share with other people.

I was able to condense it into this 7-minute, 23-second video below.

So for anyone who has ever struggled to explain the Informatics domain, how it is related to clinical workflow development, and how it can help create smooth, predictable, reliable, and non-disruptive workflows - I offer up the following : 

Hope it was helpful! Leave your comments and feedback in the comments section below!

Wednesday, November 18, 2015

The Informatics Domain and Workflow Management

Hi readers,

For today's post, I'd like to offer some insight about two common questions I get - What is clinical informatics, really? And just how is informatics related to workflow development in the EMR world?

So to really answer these questions, I'd like to propose three goals for this post :
  1. To describe how operational tools and workflows are developed and directed in an organization.
  2. To describe the informatics domain.
  3. To demonstrate how the informatics domain is vital in developing and directing workflows in the electronic (EMR) realm.

And by accomplishing those goals, I hope I can offer some insights into how to build a successful informatics platform. So, let's start off with a diagram I have lovingly named the "operations pyramid" :

I created this diagram to help explain how predictable operations are created. First, let's look at two important features of the diagram : 
  1. At the top is the Mission/Vision - This is essential for setting the tone and direction of the organization, creates goals and targets, and is necessary to align the rest of the operations with successful outcomes. Typically, senior leadership has the responsibility for defining this very important part of the operations pyramid.
  2. At the bottom is the Organizational Support - Because nothing happens in an organization without good support.
Between these two parts of the pyramid are a number of steps which all build on each other to predictably support the Mission/Vision of an organization. First - From the bottom-up, let's step through them - The : 
  • Organizational Support (needed for everything) helps create the...
  • Concepts (or in Informatics lingo, Ontologies) which shape the fundamental understanding and principles that the the organization uses to function, which then supports the... 
  • Definitions / Terminology / Standards the organization uses to write and speak predictably to each other, which then support the...
  • Templates / Archetypes the organization uses to support the creation of predictable...
  • Documents / Tools which the organization uses to support the...
  • Workflows / Processes the organization needs to support the ...
  • Goals / Regulations the organization seeks to support the ...
  • Mission / Vision of the organization.
Even when it's not fully appreciated, every organization has this pyramid at work, creating predictability and infrastructure - or not, if it's not well-understood.

This brings us to the Informatics domain, and why it's suddenly become an important part of operations in the EMR world. Informaticists are people who work to create predictable outcomes by focusing their attention on parts 3-7 of this pyramid : 

So to be successful at creating predictable workflow/process outcomes (#3), Informaticists must also concern themselves with steps 4-7.

Now, keep in mind that the part that's most visible in most organizations - the traditional documents/tools (deliverables) that we think of as 'what we need to operate' (e.g. documentation, order sets, etc) - is really only step 4 in this pyramid :

So you'll notice that in the entire Informatics domain, these documents/tools that are seen as the traditional deliverables are only small piece of the domain :

... and so conflicts can arise if it's not well-understood :
  1. ...that these deliverables are only a piece of the entire Informatics domain, and
  2. ... the depth/breadth of these of deliverables. 
So to better understand the challenges organizations may face when developing a successful Informatics framework, let's look at this line #4 (Documents/Tools) in a little more detail, and see how it related to workflow development.

To create workflows that are smooth, predictable, reliable, and non-disruptive, requires a significant amount of deliverables - The list continues to grow as technology advances. One common source of confusion : Only some of them are inside the EMR, which is another potential source of conflict for the Informaticist who is seen as only needing to occupy their time with the 'EMR issues'. So let's look at these deliverables in more detail : 

In the above slide, I've largely separated the workflow deliverables into :
  1. The ones generally outside the EMR are ones that are traditionally seen as the responsibility of other departments, such as quality, nursing, IT, HR, or finance. (e.g. policies/procedures, guidelines, interfaces, schedules, etc.)
  2. The ones generally inside the EMR are ones that are traditionally seen as the responsibility of Clinical IT/informatics departments (e.g. clinical documentation, orders, order sets, etc.)
  3. The ones that span both (largely the emerging workflow technology which is created to help automate clinical workflow management).
The challenge that some organizations face in developing a successful informatics platform, however, is the understanding that whether they are inside the EMR or outside the EMR, or both - These deliverables all impact workflow.

So to avoid conflict, it's important to consider breaking with tradition, and developing a newer governance model which integrates your informatics leadership with the leadership of these other departments (e.g. quality, nursing, IT, HR, and finance). If the workflows that the organization needs depends on all of the deliverables, together, then it's important that the leaders of all of these areas work together to manage these deliverables as a team.

And this is why informatics should not be confused with IT, tech support, or 'whatever's inside the EMR' - Workflow success depends on the integration of leadership from all of these areas, to ensure that the organization can build and fully support the workflows that are needed to support their operational goals and vision.

I hope this post has been helpful to you! Leave any comments or feedback in the comments section below!

Friday, October 30, 2015

What are Clinical Decision Support and Infobuttons?

Hi readers! I was very excited when I was recently asked to give a brief overview of Clinical Decision Support (CDS)! What is it, exactly? Since I enjoy sharing front-line #Informatics insights in this blog, for educational purposes,  I thought I would share some of the slides from my presentation : 

Clinical Decision Support (CDS) is a term that is commonly used in health technology circles. What it means, however, is somewhat more elusive, because it doesn't just represent one tool - It's a whole toolkit of tools, used to steer clinical people in the right direction at the right time

The take-home message of these slides is that CDS is :
  • A very powerful and broad toolkit of tools that helps answer questions and guide people towards the right decisions at the right times.
  • Not just pop-up alerts! E.g. CPOE or BPA (Best Practice Alerts)!
CDS comes with the noble goal of the "Five Rights" of CDS

... which, in practice, take significant work and thought to achieve all five goals. Some concerns people have voiced about CDS include : 

And just for educational purposes, I included these two very simple forms of decision support which people can easily relate to, both seen below : 

(You may recognize the actor Wilford Brimley above, who very effectively educates patients about the potential importance of medical therapies, allowing patients to then speak to their providers about potential therapies.)

In any case, I'm so thankful that the very talented Informatics leader Dr. Guilherme Del Fiol, MD PHD has already spent years researching and studying CDS, and in 2014 published this great study in JAMA about what happens with questions that arise, among physicians, during real clinical care :

What Dr. Del Fiol identified in this landmark paper is that almost half of patient interactions result in a question about clinical care - Either about drug treatment, symptoms, tests, or physical findings - And when these questions do arise, only about half of them get answered, often because of a clinical lack of time to research an answer, or doubt that a useful answer exists!

The implications of this research is that almost 60% of these information needs are not being met! Fortunately, there is enormous potential for infobuttons to connect providers to instant, context-sensitive education. A great, short video demonstrating the power of infobuttons can be found here : 

... and fortunately there is a large project underway to standardize and develop infobuttons, which can be found at In any case, Dr. Del Fiol and others have shown the real potential for infobuttons to reduce search times for information, and increase the accuracy of answers : 

... and through this strategy, the VA has seen a remarkable impact on the delivery of care : 

... which is why I believe Infobuttons will continue to grow and evolve as a clinical decision support tool. It not only provides clinicians with fast, real-time, context-sensitive information, but it has the potential to change the entire educational model for physicians : 

So my take-home messages about CDS and Infobuttons? 

And anyone wishing to pursue additional references : 

I hope this was a helpful introduction to the concepts and tools of Clinical Decision Support, and the role that Infobuttons play in that toolkit. Special thank you to Dr. Guilherme Del Fiol (and many other talented #Informatics leaders) for their work in publishing these very important studies, which help us understand opportunities to help improve the efficiency and accuracy of care delivery.

What are your thoughts about CDS? Do you have any favorite CDS tools? Feel free to leave comments section below!

Wednesday, September 9, 2015

Recipes for Success in Clinical Workflow Management

Hi readers,

I had the great fortune today, to collaborate on a presentation with the talented nurse informaticist and designer Andrea Hoffman, RN, to the Informatics team at a fairly large healthcare organization. What a humbling experience! We were in a room with a lot of bright people, working on some truly remarkable and groundbreaking stuff! (It's good to know that healthcare is really working on innovation!)

Anyway, we presented on patient safety ( #ptsafety ) and clinical #workflow management - How to make your own gourmet workflow kitchen! A few people have asked me if they could see the slides, so here they are!

Please note : To make clinical workflow design something real and tangible, and to convey our passion for great workflows, we decided to use a lot of food analogies - After all, the food service industry has a lot of lessons to offer in process design, workflow, and safety.

Enjoy, and feel free to leave any questions or thoughts in the comments section below.

Hope you enjoyed them! New posts to come soon!

- Dirk :)