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. 

Note that the American College of Radiology (ACR) and American College of Emergency Physicians (ACEP) just 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' : 

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!

Using AI to write a Scrubs Parody about Clinical Informatics

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

If you follow the #HealthIT industry, you're probably already aware that many people are writing about ChatGPT, the Artificial Intelligence (AI) tool (only released in November 2022) that has already spawned a number of other AI tools.

Curious about this new technology, I created an account. And when I was finally offered the opportunity to try ChatGPT on my own, I of course asked it something really important, something I thought might provide insight and be really helpful in helping to reform healthcare : 

"Write a Scrubs episode with a new Clinical Informatics character."

I asked it this because I'm always looking for ways to make Clinical Informatics more tangible, practical, and friendly - and to help explain the many benefits of having a Clinical Informatics team in successfully implementing and maintaining electronic health records (EHRs). So with sincerest apologies (and flattery!) to Bill Lawrence and the cast of Scrubs, I'd like to share these educational, AI-created parodies below.

Interestingly, the first time I asked it this, ChatGPT wrote the following - I'll call it "Episode A" : 

Title: "The Informatics Consultant"

Act 1:

The episode opens with JD and Turk in the hospital cafeteria discussing their recent struggles with the hospital's outdated electronic health record system. Suddenly, a new character walks in, a Clinical Informatics consultant named Rachel. She overhears their conversation and offers to help them with their issues.

Act 2:

Rachel begins to work with JD and Turk, showing them how to optimize their workflows and use the EHR system more effectively. JD becomes infatuated with her intelligence and wit, but is too nervous to express his feelings.

Act 3:

Meanwhile, Dr. Cox becomes increasingly frustrated with the hospital's EHR system and demands that it be fixed. Rachel agrees to help him, but clashes with him over his reluctance to change his ways. Eventually, they find a compromise and Dr. Cox begins to appreciate Rachel's insights.

Act 4:

As Rachel continues to work with the staff, she discovers that the hospital's EHR system has several security vulnerabilities. She works with the IT department to develop a new security protocol, but her efforts are met with resistance from a group of doctors who don't want to change their habits.

Act 5:

In the final scene, a hacker gains access to the hospital's EHR system and threatens to release private patient information unless they pay a ransom. Rachel, JD, Turk, and Dr. Cox work together to stop the hacker and protect their patients' privacy. In the end, they succeed in preventing the data breach, and Rachel is hailed as a hero by the staff. JD finally works up the courage to ask her out on a date, and she accepts. The episode ends with them walking out of the hospital together, hand in hand.

And the second time I asked it this, it wrote the following - I'll call this one "Episode B" :

Title: "Data Doctors"

Act 1:

The episode opens with J.D. and Turk at the hospital cafeteria, discussing the latest technology trends in healthcare. As they talk, a new character walks up to them and introduces herself as Dr. Rachel Lee, the new Clinical Informatics specialist at Sacred Heart Hospital. She explains that her job is to use data and technology to improve patient care and safety.

Act 2:

Dr. Lee shows J.D. and Turk how to use the hospital's new electronic health record system. J.D. is initially skeptical and finds the system cumbersome, but Dr. Lee patiently guides him through the process and shows him how the system can help him make more informed clinical decisions.

Act 3:

Meanwhile, Elliot is struggling to keep up with the demands of her patient load. Dr. Lee offers to help by analyzing the hospital's data on patient flow and identifying ways to improve efficiency. With Dr. Lee's help, Elliot is able to streamline her workflow and spend more time with her patients.

Act 4:

Dr. Cox is initially dismissive of Dr. Lee's role at the hospital, but when he sees the improvements in patient care and safety that result from her work, he begins to appreciate her contributions. He even agrees to help her analyze some of the hospital's more complex data sets.

Act 5:

At the end of the episode, Dr. Lee presents her findings to the hospital's board of directors. She shows them how her work has led to significant improvements in patient outcomes and reduced costs. The board is impressed and agrees to provide more resources for Clinical Informatics at the hospital. J.D. and Turk, impressed with Dr. Lee's work, ask her to join them for drinks after work.

As the episode closes, the three of them walk off, discussing the future of healthcare technology and the important role that Clinical Informatics will play in it.

As far as fan fiction goes, which episode is better? It's fascinating to me that ChatGPT somehow offered two different responses to the same question - perhaps considering that my asking again meant its initial response was not exactly what I was looking for?

Anyway, if you're both a Clinical Informatics leader and a Scrubs fan, I thought I'd share this experiment with you for your own insights and feedback. Which episode do you like better? And could medical dramas include Clinical Informatics characters, to help better introduce their role in modern healthcare?

Remember, this blog is for educational and discussion purposes only - Your mileage may vary. Sincerest apologies and heartfelt appreciation to Bill Lawrence and the entire cast of Scrubs for making a show that clinical people could relate to. 

Have an opinion about using AI in healthcare? Or want to comment on which episode you would want to see? Feel free to leave it in the comments section below!

Ten Ways to Help Reduce Frustration and Burnout

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

With all of the recent discussions about 'burnout' (moral injury) among clinicians and other struggles with healthcare technology, I thought I'd take a moment to share some lessons about what you can do to help reduce frustration and burnout, based on my own experiences and lessons I've learned (sometimes the hard way!) over the last sixteen years I've worked in Applied Clinical Informatics. 

10. Worry about the details.

Most providers are acutely aware of the effect of the problem, but not the cause. So when you are looking at workflow problems, try hard to resist the temptation to get overwhelmed with the details - they are very important. You can sometimes tell when people get overwhelmed, because they sometimes say things at meetings like : 

• "You can't boil the ocean!"
• "We can't get too into the weeds here."
• "Let's just look for some quick wins / low-hanging fruit!"
• "Don't fall victim to analysis paralysis!"
• "Perfection is the enemy of good!"
• "We don't have time to plan!"

Unfortunately, anything that prevents important details from being reviewed and discussed can lead to workflow problems, so it helps to set expectations early and accept that details are important - and so you should always look for ways to discuss them easily, openly, and honestly.

9. Have organized, well-developed project intake and project management processes. 

Healthcare is complicated. The need for change could come from any one of a number of different directions: 

... so you will need to plan for how to manage all of these stakeholders above. Developing an organized project intake, prioritization, and management process for all of your stakeholders to participate in will help them to see the big picture, better negotiate conflicts when they arise, and provide transparency to end-users.

8. Have an organized, well-developed change management process. 

People like predictable outcomes. While it might take some time and resources to do :

• formal evaluations of change/project requests, along with...
• the necessary policy/regulatory searches, 
• identification of best practices (e.g. through literature search, site visits, and interviews), 
• current-state/future-state ('gap') analysis, 
• design of organized blueprints, and ...
• proper identification of stakeholders and deliverables, 

... but it always pays off in smooth workflows, smooth implementations, predictable outcomes, and happy users/patients. So the answer is not to skip these necessary analysis and planning steps - The answer is to have a clear, consistent, well-developed, and well-supported change management process that - not unlike a factory assembly line - lets you accomplish all of these important steps in a smooth, well-oiled process throughout the intake, analysis, design, build, approval, training, implementation, and support phases of your projects.

7. Have standardized definitions and templates for common tools (both inside and outside the EMR).

Creating an organizational glossary (with policy-grade definitions!) and developing standardized templates for common tools will decrease training and development times, increase standardization and functionality, increase predictable outcomes, and improve user satisfaction. A common source of workflow inconsistency happens when development teams focus on developing only the tools inside the EMR (on the right below), while letting someone else worry about the tools outside of your EMR (on the left below) : 

You can help avoid those unnecessary workflow inconsistencies by using both the red and grey lists above (as a checklist!) when identifying the deliverables necessary for your requested clinical workflow implementations/updates. 

6. Worry about document control and standardized document management. 

At first, it might seem like a trivial detail. Most people don't give it much thought, but having a single, centralized catalog (source-of-truth) for all of your important operational documents (policies, procedures, guidelines, protocols, forms, etc.) can help create a great deal of clarity, understanding, and collaboration. As the saying goes, "Control your documents, before they control you." - Without good document control and management, it's easy for project implementations to be delayed and/or result in unexpected outcomes. 

5. For those who write Federal/State regulations - You can help save time and frustration by fully understanding the subject matter, working from clear policy-grade definitions, and writing clearly and succinctly.

Some of the administrative complexities of modern healthcare can result from Federal / State agencies sometimes writing vague regulations, using vague definitions, sometimes with a vague understanding of the clinical workflows and subject matter. So if you write regulations, you can help organizations to save time and reduce administrative costs by using standardized, federal policy-grade definitions and writing regulations that are clear, short, and succinct. You could even help organizations to succeed by writing more than just regulations - Consider other tools necessary for success, such as sample workflows, best practices, educational curriculum, and sample policies : 

Finally, always have a plan for expiring/retiring or updating your regulations - Regulations with no planned expiration date may not get the necessary attention and updates they deserve.

4. Always have clearly written operational policies and procedures. 

Your operational policies are the standards of your organization, and your associated procedures describe how you will achieve those standards. Not only do good policies and procedures create clarity, harmony, and understanding - but they can be used to educate staff, answer questions, and even help plan/design workflows. While some believe the mantra 'don't paint yourself into a corner' , always remember - Good policies help to create clarity, improve understanding, improve accountability, encourage teamwork, and reduce risk of harm or unexpected outcomes.

3. Have an Applied Clinical Informatics team. 

When budgeting for technology, details are important. Total Cost of Ownership (TCO) and Return-on-Investment (ROI) are crucial to make smart business decisions. Applied Clinical Informatics professionals specialize in the analysis, planning, budgeting, design, development, implementation, and monitoring/support of technology implementations. So it's very helpful - if not essential - to have a multidisciplinary team of them available to help you with your most common clinical and business needs : 

... through not just your purchasing decisions, but also for your clinical workflow analysis/designs (#BlueprintsBeforeBuild), complex tickets/projects, special event planning, compliance, maintenance, and other strategic clinical and business needs.

2. Build clear, complete, and consistent order sets.

Physicians spend a lot of time ordering. Order sets connect all of the orders they need for all of their common clinical scenarios. Having inconsistent, incomplete, or unclear order sets only creates frustration, clicks, and unnecessary pages for your physicians. So to help reduce clicks, reduce frustration, and reduce unnecessary pages - you can help ensure your order sets are always clear, complete, and consistent by : 

• Making sure you have a standardized order set template for developing your ordering tools (in a consistent manner).
• Making sure you have the terminology necessary to clearly distinguish your order sets from your other common clinical tools like protocols, guidelines, templates, and clinical pathways.
• Making sure your organizational order set development, approval, implementation, monitoring/support, and update processes are clear, well-defined, and well-supported.
• Making sure you have organized naming conventions for all of your order set types.

1. Empower your clinical leaders. 

Supporting your Physician, Advanced Practice Providers (APPs), Nursing, and Pharmacy leaders might take time, planning, and resources - but expanding their skill set with helpful information about governance, committee chairing, policy writing, operations, finance, and/or project and change management will : 

• give your clinical leaders more satisfaction, understanding, and control of their workflows, while also ...
• empowering them them to play a more active role in problem solving, project development, and project implementation.

Remember - With the necessary Clinical Informatics support, support for/from your clinical leaders, and change and project infrastructure - you too can help create the clarity, harmony, efficiency, and predictable outcomes needed to help fully see the return on your technology investments. 

I hope this blog post helps spur some discussions with your own teams on how to help reduce frustration, reduce burnout, improve planning, improve analysis/design, improve usability, improve participation, and perhaps most importantly - improve patient satisfaction and patient care. 

Remember : This blog is for educational and discussion purposes only - Your mileage may vary! Have any other helpful suggestions for reducing frustration and burnout? Please feel free to leave them in the feedback section below!