Where's the Clinical Informaticist?

Hello fellow CMIOs, CNIOs, and other Applied Clinical Informatics friends,

This month I'd share some cool discoveries I've made with some friends recently, in a helpful blog post about finding the Clinical Informaticist(s) in your organization, and/or identifying the need for them.

One of the common challenges of Applied Clinical Informatics is that Informaticists can sometimes be hard to find. Typically due to a number Human Resources (HR) and other industry issues, they can sometimes be hidden behind : 

• FALSE NEGATIVES - E.g. People who actually do Clinical Informatics work, but aren't necessarily titled "Clinical Informaticist" in their job title, or aren't recognized as doing Clinical Informatics work at all.
• FALSE POSITIVES - E.g. People who are called "Clinical Informaticist", when they don't necessary do the work that might commonly fall under the domain of the Clinical Informaticist (or they only do a specialty branch on the larger 'tree' of Applied Clinical Informatics - See below.)

While some have tried to tackle these HR challenges, concrete job descriptions are hard to find since there is such a wide variation of practice, in the general 'tree of Informatics' - which spans a number of disciplines related to both data storage ('data in') and data retrieval ('data out') functions : 

If your search for a Clinical Informaticist turns up negative, you will probably need to establish the need to hire one (or more) to help with your clinical workflow analysis and development. Historically, there have been two common approaches to doing this in #Healthcare - the 'Clinical Choir' approach, and the 'Executive/Financial' Approach: 

Each of these historic approaches come with some pros and cons : 

1. The 'Clinical Choir' Approach - Where the Clinical Staff recognizes the need for workflow updates and redesign, and collectively asks for Applied Clinical Informatics resources. PROS : Support from clinical end-users can be very helpful to support the allocation of FTE(s) for Clinical Informatics. CONS : Difficult to execute. Most clinical end-users aren't familiar with the potential role of Applied Clinical Informatics in their day-to-day workflows, so it's not easy to get them to ask for it by name. 
2. The Executive / Financial Approach - Where the Executive / Finance teams recognize the need for improved Return on Investment (ROI) and overall improved stewardship of technology investments, and so they collectively ask for Applied Clinical Informatics resources. PROS : Support from Executives and Finance officers can also be helpful to support the allocation of FTE(s) for Clinical informatics. CONS : Most ROI from workflow design and improvement falls under the category of 'soft ROI' which could easily be attributed to other departments, or it falls into the category of cost reduction rather than revenue improvements. (Both will help your organization, but one is easier-to-identify.) So putting a hard number to ROI or cost reduction that stands up to scrutiny will require some real pre-planning before you execute your improvement projects.

So for today, I'd like to share a new approach that I recently discovered, when I worked with some of my trusted Project management and Compliance colleagues (Jim McGennis and Elle Box) to combine my 10-step change management recipe with a Responsibility Assignment (RACI) Matrix :

First, a brief reminder that my recommended ten steps for clinical change management (originally published back in 2018) helps to create consistent outcomes through the thoughtful analysis, scoping, development, and planning of workflow changes (both big and small) :

After combining these ten change steps (above) with a Responsibility Assignment (RACI) Matrix (typically used by experienced Project Managers for assigning responsibility for various tasks), new discoveries were made and additional clarity was achieved. (Note : If you're new to Responsibility Assignment / RACI matrices, please see this Wikipedia article for a helpful introduction. And special thanks to PM guru Jim McGennis, for introducing me to this powerful tool.)

The basic premise of a RACI matrix is that you create a grid (spreadsheet) of roles versus steps, and then assign these four categories in each step : 

• (R)ESPONSIBLE (also recommender) - The one (or more) person(s) who are responsible to complete the task.
• (A)CCOUNTABLE (also approver or final approving authority) - Who is ultimately answerable for the correct and thorough completion of the deliverable or task, who also ensures the prerequisites of the task are met, and delegates the work to those responsible.
• (C)ONSULTED (sometimes consultant or counsel) - Those whose opinions are sought, typically subject matter experts (SMEs), and with whom there is two-way communication
• (I)NFORMED (sometimes informee) - Those who are kept up-to-date on progress, often only on completion of the task or deliverable, and with whom there is just one-way communication.

Putting my 2018 clinical change management recipe together with the RACI matrix has been remarkably helpful and enlightening. And with some help from Compliance colleages (thanks to Compliance guru Elle Box for her help reviewing and refining the descriptions), the first thing I began to notice was the number of roles that participate in one or more steps of change management : 

Roles that participate in one or more steps of clinical change management

 

Roles that participate in one or more steps of clinical change management

... as well as the details of exactly who is (R)esponsible, (A)ccountable, (C)onsulted, and (I)nformed at each step. (*Note : In the slide above, you'll notice that the Applied Clinical Informaticist already has a different set of roles and responsibilities than the Clinical IT Analysts. More to come on this shortly...)

When we look at the first phase of the change recipe (documentation of request and expectations, or intake) it's easy to see who has primary and secondary (R)esponsibility - Both the clinical end-user and the official requestor - their supervisor, director, chair, or chief - who needs to help support the request : 

First phase of change : Documentation of Request and Expectations ('Intake')

First phase of change : Documentation of Request and Expectations ('Intake')

As we move to the second phase of the change management recipe (Analysis, scoping, prioritization, resource allocation, and project approval), we can see that suddenly the Chief Information Officer picks up (A)ccountability, while the Applied Clinical Informaticist has primary (R)esponsibility for the literature search, sponsor identification, workflow gap analysis, workflow development, scoping of deliverables, and identification of stakeholders. Together with a number of (C)onsultants including Clinical IT Analysts, Medical Librarians, Compliance, Regulatory, and Finance, they will also help review regulations and estimate a Total Cost of Ownership (TCO) and Return-on-Investment (ROI), providing much more helpful information for Senior Executives who will need to prioritize and approve this project before it can be assigned. (*Note : By serving this important workflow analysis role, the Applied Clinical Informaticist will also become a subject matter expert (SME) for other experts who will be (R)esponsible for later steps in the change recipe.)

Second phase of change : Analysis, scoping, prioritization, resource allocation, and project approval

Second phase of change : Analysis, scoping, prioritization, resource allocation, and project approval

When we arrive in the third (Project Planning) phase, now the Executive Sponsor has picked up (A)ccountability, while the Project Manager has primary (R)esponsibility for working with the Applied Clinical Informaticist, Clinical IT Analyst, and others to plan the necessary parts of the project, including Gantt charts, RACI Matrices, and/or other formal project plans :

Third phase of change : Project Planning and RACI Matrix / Gantt Chart Development

 

Third phase of change : Project Planning and RACI Matrix / Gantt Chart Development

Assuming all of the above phases have been completed, this now brings us to the fourth phase of change - The drafting of workflows, for which the Applied Clinical Informaticist has primary (R)esponsibility, typically in conjunction with the Clinical IT Analyst, Compliance, and the End-users. 

Fourth phase of change : Drafting of Workflows

Fourth phase of change : Drafting of Workflows

While some organizations may not yet have implemented blueprints in their development process, this step can be very helpful because :

• Blueprints help to create understanding, align clinical stakeholders, let you conduct tabletop workflow discussions and reviews, and obtain preliminary approvals before the Clinical IT Analysts begin their build (in the next step).
• Once approved, and with a few small changes, blueprints can also become your downtime forms, in case your electronic system is ever down for planned maintenance or other unplanned reasons.

This now brings us to the fifth and sixth phases of change, the building of deliverables and testing of workflows, where the Clinical IT Analyst now has primary (R)esponsibility to build and test the deliverables, typically in conjunction with the Applied Clinical Informaticist and the End User (for end-user acceptance testing).

Fifth and sixth phases of change : Building of deliverables and testing of workflows

 

Fifth and sixth phases of change : Building of deliverables and testing of workflows

For the seventh phase of change (Final workflow approval), the Applied Clinical Informaticist now assumes primary (R)esponsibility and works to secure the necessary final approvals in conjunction with Senior Leadership and a number of other stakeholders. (*Note that the Executive Sponsor still has (A)ccountability for this step.)

Seventh phase of change : Final Workflow Approvals

 

Seventh phase of change : Final Workflow Approvals

 

Finally, for the eighth phase (Communication and Education/Training), ninth phase (Implementation/Publication), and tenth phase (monitoring and support) of change, the Clinical IT trainers, Clinical Education / Training team, Communications Team, and End-Users now all share (R)esponsibility, and typically do their steps in conjunction with the Applied Clinical Informaticist and the Clinical IT Analysts.

Eighth, ninth, and tenth phases of change : Communication, Education, Implementation, Monitoring, and Support

 

Eighth, ninth, and tenth phases of change : Communication, Education, Implementation, Monitoring, and Support

IN CONCLUSION : 

What does this exercise (combining change management recipe with a RACI responsibility assignment matrix) teach us? Five helpful take-home points : 

1. Clinical change management is a team sport that requires the participation of a large number of stakeholders to work together in a clear, highly-detailed, highly-coordinated fashion, where different roles will be (A)ccountable for some steps, have primary (R)esponsibility in some steps, serve as a (C)onsultant in other steps, and need to be (I)nformed of other steps.
2. The roles of the Applied Clinical Informaticist and Clinical IT Analyst are separate and distinct roles that often work together, but serve in distinct and unique capacities, and thus should have separate and distinct job titles and descriptions.
3. Before projects are approved, the Applied Clinical Informaticist has primary (R)esponsibility for the analysis, scoping, prioritization, and resource allocation, typically in conjunction with (C)onsulting expertise from the Clinical IT Analyst, End-users, Compliance, Regulatory, Finance, Executive Sponsor(s), and Senior Leadership.
4. The Applied Clinical Informaticist also has primary (R)esponsibility for the drafting of workflows (blueprints of deliverables), typically in conjunction with (C)onsulting expertise from the Clinical IT Analysts, Compliance, and End-Users. These blueprints will help to create understanding and alignment, and later serve as downtime forms in the event of a planned or unplanned downtime. 
5. The Clinical IT Analyst often provides (C)onsulting expertise during earlier analysis and scoping phases of the change, but then assumes primary (R)esponsibility for the building and testing of electronic deliverables, before providing additional (C)onsulting expertise during the implementation phase of the change. 

I know there's a lot to unpack here, but I hope this review helps to demystify the process, and helps you look at your own change recipe and the roles that are (A)ccountable for,  (R)esponsible for, (C)onsulting on, and (I)nformed of each step. I also hope it helps to dispel the misunderstandings and confusion about the roles of the Applied Clinical Informaticist and the Clinical IT Analyst, two important roles that often work together but each of which require their own skill sets, job titles, job descriptions, and support.

Remember, the above is all a [ DRAFT ] and this blog is for educational and discussion purposes only - Your mileage may vary! Have any feedback or experiences you would like to share? Please feel free to leave comments in the comment section below!

Strong Recommendations for new Applied Clinical Informaticists, Part 2 of 2

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

Today, I thought I'd share the second half (next ten suggestions) of my general advice to new Applied Clinical Informaticists, and other people interested in smooth clinical #workflow design. 

Strong recommendation #11 (of 20) below involves understanding the inseparable, symbiotic relationship between Information Technology (IT) and Information Science (IS), the discipline that drives Applied Clinical Informatics. While it's tempting to think only one is more necessary or relevant than the other, they are both equally necessary and relevant - You cannot have one without the other. 

Coming in at #12 is the strong recommendation (below) to understand the difference between the 'seeds' of good ideas, and the 'soil' (operational infrastructure) necessary to grow those seeds. While operational infrastructure is not always a high priority, neglected infrastructure can lead to frequent project delays, project failures, and inability to move forward. Take some time every year to look carefully at operational infrastructure, and make sure you devote the time and resources necessary to be able to grow the seeds of good ideas. 

Strong recommendation #13 (of 20) below sometimes becomes more visible after a few years in Applied Clinical Informatics, but it addresses the relationship between inconsistent or incomplete workflows, and burnout (moral injury). Especially in routinely high-risk, high-stress operations, your clinical teams will always appreciate having a smooth, predictable, well-understood pathway (workflow) from problem (point A) to solution (point B). Tangled, confusing, or incomplete workflows only create stress and confusion. Having well-designed, well-developed templates will help you make sure you're covering all of your bases, and that every step of your workflow is well-planned, clear, and complete.

My next strong recommendation (#14 of 20) below is just to be prepared to answer common questions about "Why do we need an interdisciplinary Applied Clinical Informatics team?" While there are many reasons, six of the most common include :

1. Project Intake / Procurements that require additional support or workflow analysis / evaluation to help ensure the technology doesn't already exist (in your organization), and to help ensure proper scoping, budgeting, stakeholder identification, resource allocation, alignment with safety or compliance needs, and expected outcomes. 
2. Special Event Workflow Planning (e.g. Planned maintenance or unplanned downtimes, planned upgrades, or project go-lives)
3. Complex IT Tickets that require workflow updates / modifications (often span areas with multiple stakeholders)
4. Complex Projects that require clinical translation, terminology work, stakeholder identification and alignment, or workflow updates/modifications.
5. Ongoing maintenance of existing configuration / workflows to meet CMS/TJC regulations (and other payer and user requirements), that requires continuous staff engagement with multiple stakeholders across different areas/specialties. 
6. Helping to ensure clinical workflows are aligned with the clinical, HIM, coding/billing, and revenue capture needs of the organization.

To have the skills and expertise necessary for these common functions, you will need an Applied Clinical Informatics team. Knowing some good reasons to have such a team will help support the discussions about how to build one. 

Strong recommendation #15 (of 20) for new Applied Clinical Informaticists (below) is to really care about design. Cooking food is not enough, you need to care about cooking great food. While discussing details is sometimes seen in healthcare as 'getting too into the weeds', our clinical teams need you to care about the details, so that you can develop the complete blueprints that will help technical teams to build great workflows. Also : Try to resist the urge to use short-term solutions for long-term problems - While they might temporarily help, they usually create workarounds that then need even more work to fix.

At #16 is my strong recommendation (below) to know the sixteen (16) most common (CPOE) order types. These are the basic building blocks that work together to build all of your clinical worfklows. It's very helpful to know what they are, what they do, how they work together, and when to use them. Many incomplete workflows come from not including one or more of these order types in an order set, order panel, or other ordering tool, so you can help improve workflow design by including all sixteen order types in an order set template, and then using that to guide the development of all of your order sets. *Note : Not every order set will use all sixteen order types, and you will only use the ones you need to address your desired clinical scenario. Having all sixteen types in a template (for developing your order set blueprints) will help create consistency and completeness for your clinical teams. 

My strong recommendation #17 (of 20) below is simply not to minimize the complexity of ordering tool ('order set') requests. I'm often fascinated by the small requests that have the largest operational impact, and thus require more time and effort to plan and execute than most people have budgeted for. Setting realistic expectations is the first step to good planning, so do your worfklow (gap, current-state-future-state) analysis early, and be prepared to inform your requestor when a project is larger than originally anticipated. 

Strong recommendation #18 (of 20) below is simply to consider how you will manage the intake of maintenance tickets and new project requests, from a variety of stakeholders. Navigating HealthIT (and Applied Clinical Informatics) often means managing the competing interests of : 

• Software vendors
• Patient/Caregiver input/feedback
• User input (from multiple stakeholders)
• Contracting and Payer Updates
• Formulary Updates
• Practice Onboarding
• Institutional Decisions
• Federal, State, and Department of Public Health regulations
• Evidence-based best practices
• Institutional policies and bylaws
• Privacy and Security Needs
• Quality Reporting
• External advisory organizations (e.g. The Joint Commission, Leapfrog, etc.)
• Vendor choices

... so you will want to consider all of these potential sources of change in your intake and prioritization processes.

Nearing the end, my strong recommendation #19 (of 20) below is to learn the most common types of Computerized Provider Order Entry (CPOE) order modes. Ideally, providers would always enter their own orders, but there are some very important, very legitimate reasons (clinical scenarios) why they sometimes cannot (without delaying necessary patient care). Understanding these reasons (and scenarios) will help you create and support compliant and safe order entry workflows all across your organization.

Finally, my strong recommendation #20 (of 20) below is simply to empower a clinical leader. Whether they are a nursing leader, physician leader, APP leader, radiology leader, laboratory leader, pharmacy leader, or other ancillary staff leader - they are all important and deserve your support. Usually, they are already great clinicians - Help them learn leadership skills, and they will be better leaders, and help you solve more problems. Skills like : 

• Reading a bylaw / policy
• Writing a bylaw / policy
• Reading a budget
• Planning a budget
• Writing a charter
• Chairing a committee
• Planning an agenda
• Project and change management basics
• Documentation and coding basics
• Hiring a staff member
• Managing a staff member

... can go a long way to long-term success for any leader. If you see a new clinical leader, make sure you reach out to them and support them as they grow - This will help empower leaders to retain staff and solve problems.

Okay, along with my first ten recommendations, I think these additional ten above cover my top twenty (20) strong recommendations for new Applied Clinical Informaticists seeking to design smooth workflows. If you have other suggestions, please leave them in the comments section below!

Remember - This blog is for educational and discussion purposes only, and is not formal advice - your mileage may vary. Have any other helpful ideas, suggestions, or experiences you'd like to share? Feel free to leave them in the comments section below!

Strong Recommendations for new Applied Clinical Informaticists, Part 1 of 2

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

Today I thought I'd share the first ten (of 20) strong suggestions I put together into slides for other Applied Clinical Informaticists, or those considering a career in Applied Clinical Informatics. I'm hoping this helps shed light on the importance and value of this role in modern healthcare, and how it helps to evaluate, implement, and maintain clinical technology and content. 

First, my #1 advice to newcomers - Always map the CURRENT-STATE and FUTURE-STATE workflows. While some might argue this is an unnecessary step, this exercise will benefit you in some very important ways : 

• It will help you understand and relate to your end-users.
• It will help you determine just how much work it takes to get from your CURRENT STATE (Point A) to your FUTURE STATE (Point B), which is necessary to help plan and allocate resources.
• Finally, it will help you develop blueprints, develop downtime forms, identify stakeholders, and scope/prioritize your projects. 

Next, for my strong recommendation #2, I'd like to share how to write a good task, and then a good procedure. Learning to write a good task and procedure are so instrumental in building or untangling workflows, that it can even be used as a quick substitute for swimlane diagrams (e.g. when trying to quickly document a workflow during a video chat with clinical end-users) :

Strong recommendation #3 involves something that sounds dull, until you learn about how it impacts your infrastructure and operations - Document management. Learning how to create, edit, and archive documents can actually be a very powerful way of shaping or augmenting workflows in your electronic medical record. My mantra for newcomers : "Learn to control your documents, before they control you."

My next strong recommendation #4 is to learn the basic structure of healthcare operations, by understanding the relationship between Administrative, Academic, Research, and Clinical Enterprises (Note : Smaller community hospitals typically only have Academic and Clinical enterprises.) In short : Administration supports the needs of the Academic, Research, and Clinical Enterprises. Learning how to navigate the people in these areas will help you break down silos, untangle workflows, and improve collaboration.

Coming in at #5 is my strong recommendation to care about hard work, details, and precision. "In Healthcare, there are no shortcuts." While timelines are often short, and there is often pressure to move ahead, try to resist the temptation to serve workflows that are not complete. (They may get you across your project finish line, but you risk having to do the whole project again, especially if end-users are not satisfied with the results.)

Strong Recommendation #6 might be a surprise to some : When working in a team, file naming conventions really matter. Group files should be both easy-to-find and easy-to-identify. My own personal favorite is :

DRAFT/FINAL - ARCHETYPE - Descriptor - Created/Updated/Approved mm-dd-yyyy.ext

Where : 

• DRAFT / FINAL = Use DRAFT for documents in development, FINAL when approved
• ARCHETYPE = Describes the file type (e.g. Education, Budget, Order Set, Catalog, Index, Contract, Policy, Protocol, Guideline, Schedule, Bylaws, Notes, Slide, Screenshot, etc.)
• Descriptor = Describes a unique identifier for the file (e.g. "ICU DKA Treatment Discussion", "Meeting with Dr. Smith", "Malaria Workup", etc.)
• Created/Updated/Approved = Use CREATED when first creating a file, UPDATED when updating a file, and APPROVED when creating a final version
• mm-dd-yyyy = Describes when the file was created, updated, or approved
• ext = File extension (e.g. ".docx" or ".PDF", etc.)

My next Strong Recommendation #7 is to learn the twenty-four (24) basic tools that shape all clinical workflows - Twelve (12) are typically outside of the electronic medical record, and the other twelve (12) are found inside the electronic medical record. Understanding the basic functions and design of each of these tools will help you to better plan projects, identify deliverables, identify stakeholders, and create smooth, complete clinical workflows : 

Coming in at #8 is my general recommendation to all Applied Clinical Informaticists to care about the entire 'Informatics tree', including both the 'Data In' and 'Data Out' branches. While most people will gravitate toward one area, understanding the whole tree will broaden your perspectives and skill sets, and overall help you plan workflows :

Strong Recommendation #9 for Applied Clinical Informaticists seeking to design smooth workflows comes from this 2015 blog post, where I recommend learning the relationship between concepts, terminology, templates, documents, and workflows. In general : 

• Organizational Support (#8) is necessary to...
• identify the concepts and ontologies (#7) that help you...
• develop the definitions, terminology, and standards (#6) that you need to...
• develop the templates and archetypes (#5) that will help you...
• create the documents and tools (#4) that, combined, will help to...
• create and support the workflows and processes (#3) that, if designed properly, will...
• align with your goals and regulations (#2) which should...
• align with your Mission and Vision (#1).

Typically, after first understanding #2, Applied Clinical Informaticists will concern themselves with aligning levels #7-#3 of this pyramid. (Learning how pyramid levels #8-5 impact the documents in #4 can help you troubleshoot even the most complicated workflows in #3.)

Finally, my Strong Recommendation #10 for Applied Clinical Informaticists seeking to design smooth workflow is to care deeply about change management. While Kotter's 8-step change management model is an excellent foundation, I recommend beginning with a standard, linear waterfall project model and then expanding it slightly for healthcare purposes, to include :

1. Conception, Determination, and Documentation of Need for Change
2. Evaluation, Analysis, Scoping, Presentation, Prioritization, and Approval for Change
3. Project Planning
4. Drafting of Change
5. Building of Change
6. Testing of Change
7. Final Approval of Change (go / no-go discussion)
8. Communication and Education of Change
9. Implication / Publication ('Go-Live') of Change
10. Monitoring and Support of Change

Once you have these ten steps laid out, you can begin looking at the tasks beneath each step, and developing your own 'waterfall-meets-healthcare'-type change management strategy.

I hope this is a helpful set of slides for newcomers to Applied Clinical Informatics. Feel free to leave comments below with any thoughts or feedback. In my next post, we will look at another ten (10) of my strong recommendations for Applied Clinical Informaticists seeking to design smooth workflows!

Have any helpful advice for newcomers to Applied Clinical Informatics? Are there any tips or tricks that were important to you? Please feel free to leave in the comments section below!

Definitions, Templates, Documents, and Workflow Design - the Video!

Hi fellow CMIOs, CNIOs, and other Informatics friends,

I'm writing today to share a video adaptation of a lecture I did last year for a Physicians in AMIA meeting (thanks to Dr. Richard Schreiber!), where I shared a bunch of the lessons I've learned during my 16-year career as an Applied Clinical Informaticist and CMIO. 

If you're interested in Applied Clinical Informatics or workflow design, I think you'll like this video. My adapted version is about 26 minutes long, but it contains as much information and background as I could fit. And with a standard YouTube format, you can now pause and resume on any slide!

(Click above icon to open)

So if Applied Clinical Informatics, workflow design, or reducing clicks and burnout are your thing, I hope this video helps you. Please feel free to leave questions or feedback in the comments section below!

And for those of you who prefer printed slides, instead of video - I'm also working on a printed version of this presentation shortly!

Have any helpful experiences in developing clinical workflows? Or just want to share any lessons learned? Feel free to leave feedback in the comments section below!

What are Incidental and other Actionable Findings?

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

I'm writing today to share some helpful insights into one of those clinical operations things you don't usually learn much about during clinical education and training : Incidental and other actionable findings. 

First, some literature review. Before we dive into this, I'd like to share this excellent 2014 groundbreaking paper from the Journal of the American College of Radiology (JACR) Actionable Findings Workgroup, including Larson MD, Berland MD, Griffith MD, Kahn Jr MD, and Liebscher MD:

Actionable Findings and the Role of IT Support : Report of the ACR Actionable Reporting Workgroup

Also note that the American College of Radiology (ACR) and American College of Emergency Physicians (ACEP) recently published a joint piece in the March 2023 Journal of the American College of Radiology (JACR), an excellent white paper (click here to open it) about "Best Practices in the Communication and Management of Actionable Incidental Findings in Emergency Department Imaging" (Christopher L. Moore, MD , Andrew Baskin, MD , Anna Marie Chang, MD, MSCE , Dickson Cheung, MD, MBA, MPH , Melissa A. Davis, MD, MBA , Baruch S. Fertel, MD, MPA, Kristen Hans, RN, MS, Stella K. Kang, MD, MSc, David M. Larson, MD, Ryan K. Lee, MD, MBA, Kristin B. McCabe-Kline, MD, Angela M. Mills, MD, Gregory N. Nicola, MD, Lauren P. Nicola, MD, JACR Mar 13, 2023). However, since this is an important discussion, I thought I'd share some broader insights into these important workflows from an Applied Clinical Informatics perspective. 

It all starts here : In healthcare, there are the routine clinical scenarios, and then there are the unusual, unexpected clinical scenarios. Most of the time, laboratory studies are generally within normal or anticipated ranges, and radiologic studies (X-rays, ultrasounds, CT scans, and MRIs) produce expected or anticipated results. 

So when labs or radiology are unanticipated, unusual, or abnormal - they can come in different levels of abnormal : 

• Mildly abnormal - Something is unusual that requires special but not-urgent clinical attention (within days)
• Moderately abnormal - Something is unusual that requires urgent clinical attention (within hours)
• Severely abnormal - Something is unusual that requires immediate clinical attention (within minutes)

In all three cases, it's not enough to just deliver the routine results of the lab or radiology to the ordering provider. For patient care and safety reasons, some type of extra communication is warranted.

The three most common reasons for these extra communications all fall under a general category known as 'Actionable Findings' - Note these categories align with the findings from the 2014 JACR Actionable Results Workgroup above : 

Now the interesting challenge of these additional communications is the urgency of these additional messages and how they can sometimes conflict with real-world scenarios : 

• What if the ordering provider was a resident who has gone home at the end of their shift?
• What if the attending has also gone home at the end of their shift?
• What if both the resident and attending have turned off their phones/pagers or are asleep?
• Who is the covering provider? 
• What if the covering provider is busy with urgently caring for another patient? 

Given these scenarios, the communication workflow can be a bit difficult to dissect - but I'm happy to share a basic breakdown of what to consider. Hint : It stratifies along the lines of acuity (low, medium, and high), patient location, and ordering provider.

Let's take a closer look at these important scenarios.

1. LOW ACUITY - THE INCIDENTAL FINDING

In this scenario, there is something important that needs to be communicated to the ordering provider but also usually the Primary Care Provider (PCP), usually because there was something unexpected that requires additional follow-up, e.g. an unexpected nodule. 

While it's tempting to think that low-acuity (incidental) findings are somehow less important than moderate-acuity (urgent) findings or high-acuity (critical) findings - the truth is that they are every bit as important, only the time needed to address the issue is a little longer. 

Stratifying this first low-acuity (incidental) finding scenario by patient location then looks like this : 

(Sample workflow for delivering low-acuity, incidental findings)

Since incidental findings require follow-up, it's very important to close the loop with the PCP to ensure the proper follow-up studies have been ordered and the patient/caregiver are aware of the need for follow-up. (New rules from the 21st Century CURES Act and open sharing via the patient portal make this much more transparent for patients today.) To help, some EMR software will record exactly when the PCP has acknowledged receipt of this important message, with important instructions.

2. MODERATE OR HIGH ACUITY - THE URGENT AND CRITICAL FINDINGS

In these scenarios, there is something urgent or critical that needs to be communicated to the ordering or covering provider, usually within an hour or less. Typically, direct provider-to-provider communication is best to help ensure the message has been transmitted and received properly, and an urgent/emergent plan has been put in place. 

Communication in these scenarios can sometimes be stymied by schedule/change-of-shift, so an escalation process is especially important for these urgent/critical scenarios : 

(Sample workflow for delivering medium-acuity (urgent) and high-acuity(critical) findings)

The exact escalation process you build for your own organization will probably depend on a number of factors, including whether you are a community hospital, teaching hospital, or critical-access hospital. For a great example of a well-developed escalation process, see pages 7-11 of this helpful policy,  "Reporting of Critical Results to Providers" from the University of Texas Medical Branch. (Thank you to UTMB for sharing your process for teaching purposes and the betterment of healthcare!)

What's interesting about this escalation process is that it will often depend on a provider schedule; So having access to a centralized, up-to-date provider on-call (coverage) schedule is often helpful in identifying covering providers for various services and clinics, especially when trying to communicate actionable findings after change of shift : 

Also, depending on the scenario, having a complete and accurate provider directory is very important, one that properly considers both a providers' clinical specialty/subspecialty (training) and clinical service(s) : 

Since most providers will arrive through your Credentialing/Medical Staff office, and most residents/fellows will go through your Graduate Medical Education (GME) office, you will want to collect this information at onboarding, and help maintain it at regular intervals (e.g. recredentialing or yearly assessments.)

And after an urgent/critical provider-to-provider communication has been completed, both providers should document the discussion in their clinical documentation to help ensure the loop has been closed and a plan is in place. 

Finally, for providers external to your institution - When designing your forms for ordering labs or radiology, you might consider adding the following language : 

(Sample language for external ordering forms, to plan for all actionable finding scenarios)

Having this information somewhere handy (e.g., on the ordering form) will help you prepare for these scenarios when they occur with external providers. 

Yes, these are a lot of scenarios to think about - but with the right planning and tools, you can help your staff reach ordering or covering providers to communicate these important messages and close the loop on important patient care. 

Remember, this blog is for educational purposes only - Your mileage may vary. Have any experience with these workflows, or experience building them? Or have a perfect escalation process? Feel free to leave comments, feedback, and suggestions below!