Sunday, October 25, 2020

Optimizing Lumbar Punctures, Part I

Hi fellow Clinical Informaticists, CMIOs, CNIOs, #workflow gurus, and other #HealthIT friends,

How do you say 'Lumbar Puncture' in CPOE? Today, I'm writing to share the translation of one of the oldest, most common medical procedures that's routinely done in modern healthcare : The lumbar puncture, sometimes referred to as an 'LP'.

Lumbar punctures (LPs) are routinely performed to help look for infections, look for malignancy, and look for antibodies and other markers of neurologic disease. While they are a common mainstay of modern healthcare, building them electronically can be quite a challenge. 

Want to reduce clicks when ordering your LPs? It helps to first have a solid understanding of the most common LP workflows in healthcare, so you can build your order sets with the most common studies, priorities, indications, and order statuses all properly built and correctly defaulted.

So in this post, I figured I'd share some secrets about the four most common lumbar puncture workflows, and how to build them into an EMR, in a really gourmet fashion - for the best diagnostic yield, fewest clicks, and maximal success. 

1. THE WORKFLOWS

Lumbar punctures are commonly done for diagnostic purposes, but can also sometimes be done for therapeutic purposes. But as it turns out, the LP is not just one workflow - It's actually four different workflows


In each of these scenarios, there are different clinical specialties using the LP, commonly for different purposes : 


In addition to these workflow descriptions, some helpful notes : 
  • In workflows #2 and #3 above, there is a often a communication challenge between the ordering provider and the Interventional Radiologist, who has to collect, label, and transport the samples to the lab, and also report back some findings to the ordering provider (e.g. opening pressures, turbidity, etc.)
  • In workflow #3 above, there is also sometimes a patient education challenge, whereby the patient needs to come before the scheduled IR LP to have 'pre-procedure' labs drawn (e.g. CBC, BMP, PT/INR) to help ensure that the LP can proceed without problems. 

2. THE STAKEHOLDERS

Given the above workflows, the physician specialties most commonly involved with lumbar punctures then include :

  1. Emergency Medicine
  2. Inpatient Physicians - Pulmonary/Critical Care (Intensivists)
  3. Inpatient Physicians - General Inpatient Medicine (Hospitalists)
  4. Interventional Radiologists (IR)
  5. Ambulatory/Inpatient Specialists - Infectious Disease Physicians
  6. Ambulatory/Inpatient Specialists - Neurologists - General
  7. Ambulatory/Inpatient Specialists - Neurologists - Movement Disorders
  8. Ambulatory/Inpatient Specialists - Neurologists - Multiple Sclerosis
  9. Ambulatory/Inpatient Specialists - Neuro-ophthalmologists
  10. Ambulatory/Inpatient Specialists - Hematology/Oncologists

If we include :

  • the Registered Nurses (who have to help care for the patient before/after lumbar punctures), 
  • the pharmacists (who help provide the medications the provider has ordered for sedation/anesthesia)
  • the laboratory workers (who receive the fluid, provide the on-site analysis of certain labs, and send out other labs to external labs) 
  • the IT/Informatics workers (who connect with stakeholders, map the current state, and work with the clinical stakeholders to design, build, and test the future state)
... then this gives us a fairly long list of stakeholders in the most common lumbar puncture workflow discussions : 
  1. Emergency Medicine Providers
  2. Inpatient Physicians - Pulmonary/Critical Care (Intensivists)
  3. Inpatient Physicians - General Inpatient Medicine (Hospitalists)
  4. Interventional Radiologists (IR)
  5. Ambulatory/Inpatient Specialists - Infectious Disease Physicians
  6. Ambulatory/Inpatient Specialists - Neurologists - General
  7. Ambulatory/Inpatient Specialists - Neurologists - Movement Disorders
  8. Ambulatory/Inpatient Specialists - Neurologists - Multiple Sclerosis
  9. Ambulatory/Inpatient Specialists - Neuro-ophthalmologists
  10. Ambulatory/Inpatient Specialists - Hematology/Oncologists
  11. Nursing - Interventional Radiology
  12. Nursing - Floor/Bedside
  13. Nursing - Clinics
  14. Laboratory
  15. Pharmacy
  16. Clinical IT/Informatics
... and you'll quickly see why you it's helpful to have a good clinical informatics and project management team available, to help coordinate all of the meetings, discussion, architecture, building, testing, and approvals before you can go-live. In shortOptimizing LP order sets is usually a significant project effort, requiring many meetings.

3. THE LABS

With regard to the actual laboratories, it's helpful to keep in mind that workflows #1 and #2 are general-purpose LPs, usually for the emergent ruling out of CNS infection. It typically doesn't get much more complicated than that. So for Inpatient/ED purposes, the most common studies include : 

  • CSF Cell Count and Differential
  • CSF Gram Stain and Culture
  • CSF Protein
  • CSF Glucose
  • (Occasionally CSF HSV PCR, if clinically indicated)
But for workflows #3 and #4, they are more specialty-oriented, so their labs may include the general labs above, but also include a number of complex, high-cost specialty panels, antibodies, proteins, and pathology / flow cytometry. 

Commonly, the occasional ordering of these specialty studies (commonly from workflows #3 and #4 above) in the Inpatient/ED settings (commonly workflows #1 and #2 above) can generate a lot of discussion. For reimbursement reasons, it's helpful to stratify these workflows, but keep in mind - In complex cases, there may still be reasons to order the more complex outpatient labs on an inpatient, but generally they should only happen with specialist review and approval.

4. THE ORDER SETS

So now you're faced with the question - One order set, or four order sets?

If you do one order set, you'll probably end up needing to stratify them (with radio buttons!) into the four different workflows, e.g. : 


Or, more likely for operational, culture, and other EMR configuration reasons, you may end up with four different order sets - In which case you will want to choose your naming convention very carefully, e.g. : 

  1. LUMBAR PUNCTURE (LP) - INPATIENT/ED - AT BEDSIDE
  2. LUMBAR PUNCTURE (LP) - INPATIENT/ED - IN IR
  3. LUMBAR PUNCTURE (LP) - AMBULATORY/OUTPATIENT - IN IR
  4. LUMBAR PUNCTURE (LP) - AMBULATORY/OUTPATIENT - IN CLINIC
Even though #1 and #2 above are typically used by generalists, and #3 and #4 above are typically used by specialists - You'll still want to have specialty input into #1 and #2, to help make sure that the common specialty scenarios can still be addressed (when they arise) in the inpatient settings. (E.g. Having Infectious Disease provide input into #1 and #2 can help make sure your ED providers/Hospitalists/Intensivists are ordering the right ID labs for the right scenarios.)


In my next post, we will look at these four LP workflows in more detail, and discuss some of the common educational, operational, and ordering challenges that organizations may come across when building out and optimizing these order sets. 

Have any thoughts, comments, feedback, or stories to share about building highly-optimized (gourmet!) lumbar puncture workflows? Feel free to leave in the comments section below!

Remember, this blog is for educational / discussion purposes only, and does not constitute medical advice - Your mileage may vary. Always consult your clinical leadership, your clinical informatics team, and your medical specialists before building out any order sets in your own organization.

Monday, October 12, 2020

Top 15 Signs You May Work in Clinical Informatics

Hi fellow CMIOs, CNIOs, Clinical Informaticists, Clinical Informaticians, and other #workflow and #HealthIT friends,

Over the last 10 years, I've blogged a lot about different topics in applied Clinical Informatics, from change management to glossary development and workflow terminology management, to order set development. And yet, across the industry, it can sometimes be a challenge to find the other people who do this type of work, partly because: 

  • There are some people who 'do Clinical Informatics work', but are not labeled Clinical Informaticists / Clinical Informaticians in their job title. (Some are labeled CMIOs, CNIOs, Directors of Clinical Informatics, Clinical IT Analysts, Business Analysts, etc.)
  • There are some people who do have a job title like 'Clinical Informaticist/Clinical Informatician', but focus their efforts mostly on a particular branch of Informatics, without clear support for the other branches (often due to resource limitations).
  • Some 'Clinical Informatics' people focus their work for only their clinical specialty (e.g. 'Physician Informaticist', 'Nurse Informaticist', etc.)
So since in some regions, applied Clinical Informatics in 2020 still seems to be an emerging field, one that is fortunately becoming more formal and structured with the advance of more formal training and certification programs - I decided to spontaneously write a humorous piece on Twitter that could appeal to the 'Clinical Informaticist' (or 'Clinical Informatician') in all of us : 



Feel free to share with any Clinical Informaticists (
or Clinical Informaticians) you know with a sense of humor! :)

Remember, this blog is for education and discussion purposes only - Your mileage may vary. Have any helpful humor or insights about Clinical Informatics, job titles, and professional development? Feel free to leave them in the comments box below!

Sunday, October 4, 2020

Great NEJM Catalyst piece about HealthIT Implementations

Hi fellow CMIOs, CNIOs, Clinical Informatics, and #HealthIT friends,

Short post - Just wanted to share this great piece about HealthIT implementation from the October 2nd New England Journal of Medicine (NEJM) Catalyst, by Christina Pagel, PhD, David W. Bates, MD MSc, and Donald Goldmann, MD

"How to Avoid Common Pitfalls of Health IT Implementation" 

LINK https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0048 

This is a super-helpful piece that includes cartoons (!) to help explain common issues in HealthIT implementations.

Since many of you know I'm a big fan of educating using cartoons, I just had to share. Feel free to share this great piece with your colleagues. 

Remember, this site is for educational and discussion purposes only - Your mileage may vary. Have helpful tips or other lessons you've learned from HealthIT implementations? Feel free to share them in the comments section below!