Thursday, August 31, 2023

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!

Friday, August 18, 2023

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!