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!


David Toohey said...

Dirk. This is a very good parsing of the issues and challenges......but also suggestive of the power of getting it right with IT-enabled solutions. "Paper-to-Glass" is an abomination but all too common. It is a lazy, 'quick-and-dirty' response to a requirement to go paperless. What is needed instead is to work with the stakeholders to devise a solution that uses the power of informatics optimally.....not slavishly copy the paper forms. When done right this can deliver major benefits in terms of error-avoidance, safety, productivity/efficiency, remote-access, completeness/accuracy and compliance. It can also provide excellent traceability and auditability. Avoiding a Frankenform requires significant and insightful work......a price many don't seem prepared to pay.

Dirk Stanley, MD, MPH said...

David - I couldn't agree more. But if you buy the car, you have to be prepared to pay for the gas too. This is one of the "hidden costs" of EMR implementation that is hard to budget for, unless you have an experienced Informaticist on board early to help evaluate the state of the current paper documentation prior to electronic conversion. Unfortunately, without recognizing Frankenforms, organizations will struggle when they try to just build electronic versions of their current paper documentation. As someone who believes in the potential for IT to improve and streamline care, I think it's important to understand these issues prior to EMR conversion. Thanks for your feedback! :)