Sunday, March 21, 2021

Another Trick for Untangling Workflows - Improved Document Design

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

In my last blog post, I shared some slides from a recent talk I gave to a group of newcomers to the world of Applied Clinical Informatics, and shared my first trick for untangling and controlling workflows - technical procedure writing ('the Cupcake Test')

For today's blog post, I'd like to share another helpful trick for untangling and controlling workflows - Designing documents, both inside and outside of your EMR, to help clarify and improve workflow.

There's a common saying in both Applied Clinical Informatics and technical document writing : "Control your documents, before they control you." This is basically how I learned to love documents - They actually do create standards, but only if you know how to use them properly

Documents are tools used to record and transmit information. To help better explain the power of documents, it's helpful to look back at patterns set into motion by our earliest human ancestors, when they first learned to document on the walls of caves. Their ideas could be turned into images and symbols, that would in turn put information into other heads. It was the first time that humans really learned the power of documentation

And so, an organization is simply four walls, into which a bunch of people and documents have been placed : 
  • If the documents are clear and easy-to-find, your staff will use them to understand your values and needs, and will create predictable patterns and outcomes
  • If the documents are vague or not easy-to-find, your staff will not use them to understand your values and needs, and will not create predictable patterns or outcomes
Interesting to note is that if you were to create a whole new hospital, from scratch - you would need about 24 document types to effectively run any hospital - About 12 are commonly found inside your EMR, and about 12 are commonly found outside your EMR

So if we assume that all of healthcare depends on these 24 document types to run, then this helps us simplify change management into three key steps : 
  1. STEP 1 : Define your current-state worfklow. ("Point A"
  2. STEP 2 : Design your desired future-state workflow. ("Point B")
  3. STEP 3 : Identify which of the 24 tool(s) (both inside the EMR and outside the EMR) you need to get FROM the workflow defined in step #1 above, TO the workflow defined in step #2 above. 
Another nice side-benefit to improving your document design is the opportunity to help get people better aligned in their understanding of commonly-used tools and concepts. 

For example, let's say you'd like to help get clinical staff better aligned in their understanding of the term "PROTOCOL". It's a term that is particularly difficult to nail down and define, so many people have slightly different interpretations of what-exactly-a-protocol-is-and-what-it-does : 

After first reviewing your State and Federal regulations, and then your own operational needs, you can then use these four steps to increase clarity and understanding : 
  1. STEP 1 : DEFINITION - Write a clear, simple, one-sentence, policy-grade definition to answer the question, "What is a protocol, and what does it do?"
  2. STEP 2 : TEMPLATE - After you have a good working definition, design a template for creating protocols. 
  3. STEP 3 : PROCEDURE - After you have a good working definition and template - design a good procedure for drafting, reviewing/vetting, approving, publishing, monitoring, and archiving protocols. 
  4. STEP 4 : EDUCATION - After you have the procedure in step #3 nailed down, you can start to educate your staff about your new definition, template, and process - And soon people's common understanding will increase, with this new foundation and support for this important document. 
This kind of foundational work is especially helpful when trying to get teams of people to work on complex clinical workflows. 

Need some guidance about how to go about writing clear, simple, one-sentence, policy-grade definitions (as in step #1 above)? - For this, I first recommend first working with your legal, regulatory, and compliance staff to review the applicable Federal, State, and local regulations. After reviewing the regulations, you can then use a spreadsheet to draft a "CMIO's Checklist", which is very helpful in creating definitions that meet or exceed these regulations : 

You can use this type of spreadsheet to work on elevating your definitions, for presentation back to your legal and compliance team, for their review and final approvals. With improved definitions comes improved understanding

In my next post, I'll share two more helpful tricks (from my recent presentations) that clinical leaders and informaticists can use to help untangle workflows. 

Remember - This blog is for education and discussion purposes only - Your mileage may vary. Always review with your Clinical Leadership, Legal/Compliance teams, and Informatics leadership before publishing or changing any definitions or document templates. 

Have any experience with redesigning document archetypes to enhance clarity or understanding? Feel free to leave in the comments section below!

Sunday, March 7, 2021

Untangling Workflows - The Cupcake Test

 Hi fellow CMIOs, CNIOs, and other Clinical Informatics friends,

As I mentioned in my last post, I recently had the opportunity to share some workflow design tips with an online group of new physicians who are getting into Applied Clinical Informatics and workflow building. During my talk, I shared some helpful workflow tricks that I use to untangle even the most complex clinical workflows. Even though I've written about this one before, it's so useful I figured I should re-review and elaborate with this new audience. 

One of my favorite tricks is this very simple one with pretty impressive impact. It's basically just writing a technical procedure, but with a little more detail. I affectionately call it, "The Cupcake Test", because it uses good procedure writing to help answer the metaphorical question - Does this 'cupcake recipe' (or 'cupcake workflow') actually bake a cupcake?

Writing a good technical procedure can be a helpful substitute for the common Visio swimlane diagram that seems to be more of a popular industry standard. From my recent presentation : 

To understand how good procedure writing can be used as a substitute for Visio swimlanes, I need to first explain two important concepts that are necessary to understand before writing a procedure that passes the 'Cupcake test' : 
  • What is a TASK?
  • What is a PROCEDURE? (Synonyms : Workflow, recipe, process)
And so from my presentation, my slide showing the definitions of both : 
Using these two definitions, and the procedure template outlined above, we can now write a simple and clear technical procedure, and even color code it to help quickly identify and align concepts. Here's a sample of what it looks like : 

While this approach is not exactly an industry standard, there are some pros and cons to using it : 
And in my experience, a good procedure can usually be quickly and easily converted to a good swimlane diagram - But sometimes swimlane diagrams can't be as easily converted into good technical procedures that pass this 'Cupcake Test'. That is, they are not written with the template : 
TASK = [WHO] will/may [WHAT] {how} {where} {when} {why}
... in each line of the procedure

Not only does this approach include the benefits listed in the slide above, but it's easy to teach, and it also helps you easily generate cost estimates of workflows/procedures before you build them.

Next time you have a complex workflow you're trying to figure out - just start by writing good technical procedures, and the workflow will start to immediately reveal itself right in front of you. If you have any experience with using this approach, please leave it in the comments section below.

Remember - This blog is for educational and discussion purposes only - Your mileage may vary. If you have any feedback or questions, or experiences writing workflows or technical procedures, feel free to share them in the comments section below. 

Saturday, March 6, 2021

Optimizing Lumbar Punctures, Part II

 Hi fellow Clinical Informatics, CMIO, CNIO, HealthIT, and other #workflow friends,

Sorry about the delay in following up my last post - As most people can probably understand, the COVD-19 pandemic has been a very busy time in healthcare.

Anyway, in my last blog post - I introduced the surprising complexity of a lumbar puncture - Not to complicate a fairly simple bread-and-butter clinical procedure that's performed in healthcare settings every day, but to help create clarity and understanding, set expectations, and help reduce clicks while delivering a great user experience that your providers can use to deliver great patient care

To help understand the complexity of this workflow, I thought I'd even share this academic poster which was developed by Deandra 'Uju' Momah, MS4, an outstandingly talented medical student from UConn Med who I've had the honor to work with. At a recent AMIA conference, Uju presented her academic poster which very nicely summarizes the workflow issues : 

(Academic poster by Deandra 'Uju' Momah, MS4 - Click to enlarge)

The take-home point : Diagnostic LPs are not one workflow - They are at least four. (That is, if you carve out intrathecal chemotherapy, epidurals, blood patches, and therapeutic LPs.)

I recently had the opportunity to discuss LPs to an online audience of new Informaticists - below are some of the slides from my presentation, which I'll borrow and annotate here for clarity and educational purposes. 

First - A review of some of the complexities of designing a Lumbar Puncture order set : 
Again, it's very important to remember that Lumbar Punctures are not just one workflow - Diagnostically, there are at least four. So for now, we will focus on the third of four below, the outpatient ID/Specialist LP, where in many institutions this is commonly collected by Interventional Radiology
Now before we can examine this in more detail, I thought I'd share the large (complex) set of stakeholders who all have an interest in how LPs are ordered, performed, and resulted in your organization : 

In my current role, I'm very fortunate to be able to work with the great Karen Gurba, RN MS, an experienced and outstanding Clinical (Nurse) Informaticist who I partner with to help investigate and design workflows. (Remember, Applied Clinical Informatics is a team sport!) Karen and I have done a number of interviews with the stakeholders in the list above, and through repeated iterations of blueprints, reviews, discussions, and updated blueprints - The picture starts to become more clear. 

In each of these cases, there are a six main features that almost all clinical staff seem to generally agree on : 
  1. There are some PRE-LP labs, that are typically collected 24 hours before the procedure, to help establish that it's safe to proceed with the lumbar puncture lab. (They often include a simple BMP, CBC, and PT/INR.)
  2. There are other PRE-LP serology labs, that are typically collected 1 hour before the procedure, for diagnostic purposes. (They often include a serum glucose, serum protein, and in some cases, oligoclonal banding.)
  3. There is the LP procedure order itself, used to schedule the procedure and plan charges for doing the procedure. 
  4. There are four BASIC LP labs, that most docs use for general purposes, including a CSF cell count and differential, a CSF gram stain and culture, a CSF glucose, and a CSF protein
  5. There are some additional speciality-specific CSF labs, which can be very complex and specialty-specific. (Some of these can be very expensive, and so care should be taken so that they are not ordered unnecessarily or by accident.)
  6. Finally, there are a limited number of nursing orders, mostly importantly a nursing communication order that allows the ordering provider to give the Interventional Radiology nurses a 'heads up' on any unique patient needs. 
 The problem is - When you have so many specialties needing access to specific labs in #5 above, how exactly do you build this out?

And so, now I'd like to present a mockup of an Outpatient LP via Interventional Radiology (IR) order set, that helps address all of these needs in one coherent order set, that relies on cascading logic to help guide the ordering provider to the best-practices for their unique clinical needs. (Pardon my amateur cartooning, which I used to customize my presentation.)
And the order set starts with the first clinical decision - Is the ordering provider ordering a DIAGNOSTIC LP, or a THERAPEUTIC LP?

Let's say in this case, the provider is ordering a DIAGNOSTIC LP

This then brings up four choices, seen above : 
  • FOR ATTENDINGS, FELLOWS, AND RESIDENTS - Routine diagnostic LPs - Mon-Fri 8am-5pm
  • FOR ATTENDINGS AND FELLOWS ONLY - ROUTINE Malignancy Evaluations - Mon-Thurs 8am-12pm
  • FOR ATTENDINGS AND FELLOWS ONLY - URGENT Malignancy Evaluations - Friday-Sunday 8am-12pm
  • FOR ATTENDINGS AND FELLOWS ONLY - PRION Disease Evaluations - Mon-Fri 8am-5pm
 This gives us the opportunity not only to confirm the role of the ordering provider, but also to stratify the routine diagnostic workflow from the more complex workflows that require additional notifications or supervision before ordering. This helps us to make sure that unnecessary orders are not added to the workup. 
In this case, clicking the first option (ROUTINE DIAGNOSTIC LUMBAR PUNCTURES) would then produce the list of specialties that commonly use this order set : 

And here, if an Infectious Disease provider were to click their section, the order set can now produce the tailored, specialty-specific orders that the provider needs : 
Using this naming convention and design, we now know : 
  • Scenario = Specialty, outpatient LP for collection in IR
  • LP type = Diagnostic
  • User = Attending, Fellow, or Resident
  • Specialty = Infectious Disease
... and so now the order set can allow a tailored, specialty-specific palette of orders that are most commonly used for the user's needs. 
And with that, a significant reduction in clicks and improvement in utilization, diagnostic accuracy, and diagnostic yield. 

We are now working with our department Chiefs to help confirm the final orders (to appear in the fifth section of each specialty-specific area), and maybe once they are completed, I can help publish the final result here. 

Until then, I hope this helps you develop your own strategy for ordering Lumbar Punctures! If you have any secrets or feedback you can share, please leave them in the comments below!

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any recommendations or tricks to share about designing lumbar puncture workflows? Feel free to share in the comments box below!