Clinical Terminology : What is a History and Physical (H&P)?

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

Today, I'm sharing more on the importance of terminology, in untangling and streamlining clinical workflows. 

In day-to-day healthcare, effective communication is the bedrock of success. Ensuring accurate and efficient communication in healthcare settings hinges on the use of standardized clinical terminology and documentation practices.

So to better understand the importance of standardized terminology in untangling and optimizing clinical workflows, we will look at one of the most common anchors of clinical workflow - the History and Physical (H&P). 

The History and Physical (H&P) is one of the first things medical students learn to perform in medical school. (Since around 1968, it's been generally written in the same structure as the SOAP note by Larry Weed, MD.) Asking ChatGPT40 for a summary on 11-10-2024, I got this :

A History and Physical (H&P) is a comprehensive document that records a patient's medical history and a detailed physical examination performed by a healthcare provider. This documentation is typically created at the time of a patient’s hospital admission, outpatient clinic visit, or before a surgical procedure. The purpose of the H&P is to provide a structured, thorough assessment of the patient’s health status, which helps guide diagnosis, treatment, and ongoing care.

The H&P typically includes the following elements:

1. Chief Complaint (CC): A brief statement summarizing why the patient is seeking care, often in the patient’s own words (e.g., “chest pain”).

2. History of Present Illness (HPI): A detailed description of the patient’s current symptoms or concerns, including onset, duration, characteristics, associated symptoms, and any factors that worsen or improve the condition.

3. Past Medical History (PMHx): Information about any prior illnesses, surgeries, hospitalizations, and chronic conditions, as well as any ongoing treatments or therapies.

4. Medication History: A list of current medications, including prescriptions, over-the-counter drugs, supplements, and dosages.

5. Allergies: Details of any known allergies to medications, foods, or other substances, along with reactions.

6. Family History: Information about the health of immediate family members to identify any genetic or hereditary conditions.

7. Social History: Insights into the patient’s lifestyle, including smoking, alcohol use, occupation, living situation, and exercise habits, which may impact their health.

8. Review of Systems (ROS): A systematic check of the patient’s body systems (e.g., cardiovascular, respiratory, gastrointestinal) to identify any other symptoms that may not have been initially reported.

9. Physical Examination: A head-to-toe assessment performed by the healthcare provider, covering major organ systems and noting findings like heart rate, lung sounds, and any abnormalities.

10. Assessment and Plan: Based on the gathered information, the provider lists diagnoses (or differential diagnoses) and outlines a plan for treatment or further evaluation.

The H&P is essential for creating a baseline of the patient’s health status, supporting diagnosis, guiding treatment, and facilitating communication among healthcare providers. In electronic medical records (EMRs), standardized templates often guide providers through completing these sections thoroughly and consistently.

While ChatGPT40 gives us a reasonable starting point that most medical professionals will quickly recognize, I'd like to add that it did not explicitly call out Surgical history (SurgHx), Psych history (PsychHx), or OBGYN History (OBGYNHx), which are often separately called out in certain H&Ps.

So in addition to the PMHx, PSurgHx, SocHx, PsychHx, and OBGYNHx, the foundations of Larry Weed's SOAP note can be found in most H&Ps : 

• SUBJECTIVE (S) = What is the patient telling you? (e.g. CC, HPI, ROS, etc.)
• OBJECTIVE (O) = What do you see? (e.g. Physical Exam, Vitals, Labs, Radiology, etc.)
• ASSESSMENT (A) = How do you interpret this, and what do you think the patient needs?
• PLAN (P) = What is your plan to address these issues?

While this gives us a helpful framework to start from - it doesn't really clarify the eleven (11) different types of H&Ps that are commonly used in healthcare. Let's start off our journey by looking at the first four : 

I want to call out these first four (4) H&Ps because they are sometimes confused in elective pre-operative (and pre-procedural) workflow discussions : 

1. Primary (General) Pre-Operative (or pre-procedure) H&P and Risk Evaluation - That general pre-operative or pre-procedure H&P that is commonly done by a Surgeon, Proceduralist, or Primary Care Provider (e.g. Internal medicine, Family medicine, Geriatrics, Pediatrics, or OBGYN), which includes a pre-operative (or pre-procedure) risk evaluation and optimization plan.
2. Secondary (Focused) Specialist Pre-Operative (or pre-procedure) H&P and Risk Evaluation - That secondary, focused pre-op or pre-procedure risk evaluation that might be needed for patients with complex histories, typically done by one or more specialist(s) at the request of the Surgeon, Proceduralist, or Primary Care Provider doing the Primary (General) Pre-Operative (or pre-procedure) H&P and Risk Evaluation.
3. Interval H&P - That H&P where the Surgeon or Proceduralist briefly reviews, within 24h of surgery/procedure, the pre-operative H&P(s) - including the data elements PMHx, PSurgHx, FamHx, SocHx, Med List, Allergies, ROS, PE, and relevant labs and radiology -  and acknowledges that the information is all correct and accurate and that no changes or updates are needed prior to surgery/procedure, usually with a simple attestation : "I have read and reviewed the patient's pre-operative H&P and no changes or updates are required."  
4. Admission H&P - That H&P done by the Admitting Attending (or their clinical delegate) at the time of admission, usually to describe the patient's condition, reason(s) for admission, admission status, admitting team, admission active problem list and management plans, and contingency plans.  

While these contain many of the same data elements, they also contain different elements, and are authored by different provider(s) at different times. Mislabeling all of them as just "H&P" leaves potential room for confusion - For example, if post-operatively Inpatient Nurses seeking post-operative orders were to try to contact the PCP instead of the Surgeon, because the Pre-Op H&P and the Admission H&P are both labeled "H&P".

Similarly, distinguishing the Primary (General) Pre-Op H&P and Risk Evaluation from the Secondary (Specialist, focused) Pre-Operative H&P(s) is necessary to clarify who has the primary responsibility and what other specialist(s) might need to be involved in assessing a patient with a complex history (e.g. pulmonary, cardiac, renal, endocrine, or other complex medication, allergy, or anesthesia needs). Labeling both of these as an "H&P" just leaves room for confusing the two (e.g. a Surgeon sending the patient to a cardiac specialist for a primary risk evaluation.) 

If you have ever tried to create structured documentation, to encourage users to complete the data field(s) that are necessary and unique to each of these note types - You will quickly see why it's important to label each of these notes correctly. 

In short : Trying to 'keep it simple' by labeling them all as "H&P" only confuses users and makes it a challenge to structure your workflows. My advice : Call it what it is.

Just to be complete, I thought I'd share some of the other common types of H&Ps used across healthcare : 

These include : 

• 5. The Emergency Department (ED) H&P - That focused H&P that is commonly done by Emergency Medicine doctors, usually as part of their routine visits. (In some organizations, this is labeled an 'ED Progress Note.)
• 6. The Discharge Summary H&P - That H&P that is usually done by the Attending Provider (or their clinical delegate) at the time of discharge, to provide a synopsis of the patient’s hospital stay, covering the course of illness, treatments provided, and recommendations for follow-up. These also often include the admission reason, key findings, procedures done, discharge medications, patient's condition on discharge and instructions for aftercare, and they help enable a smooth handoff to outpatient providers to help ensure continuity of care and provide clear guidance for post-discharge recovery.
• 7. The Consultation H&P - That H&P that is often done by a specialist, either as part of an inpatient consult or an ambulatory referral, at the request of another provider seeking specialty evaluation.
• 8. The Annual Physical H&P - That H&P commonly done by a Primary Care Provider as part of an annual evaluation of a patient's overall health status and needs. These are often preventative in nature (rather than problem-focused) and usually cover the entire spectrum of a patient's health, including lifestyle factors, preventive screenings, immunizations, and a physical exam.
• 9. The Employee Physical H&P - That H&P commonly done by an Employee Health Provider as part of a pre-employment evaluation, fitness-for-duty evaluation, or workplace injury.
• 10. The Sports Physical H&P - That H&P commonly done by a Primary Care Provider, Cardiologist, or other Sports Medicine provider, to evaluate an athlete prior to playing competitive sports or engaging in other demanding physical exercise regimen.
• 11. The Insurance H&P - That H&P typically done by a Primary Care Provider or Insurance Provider to help evaluate a patient prior to completing agreements for an insurance policy.

... each of which also has unique authors and unique data elements for unique purposes - So if you want to structure these notes, they will also require unique (descriptive) names. 

IN CONCLUSION : 

Terminology is important. The accurate capture of H&Ps relies heavily on standardized clinical terminology. From admission to discharge, the use of consistent terms and codes across each H&P type ensures that information is unambiguous and interoperable within the healthcare system. Applied Clinical Informatics professionals play a crucial role here, by:

1. Creating Templates and Standardized Workflows: Clinical informatics teams often design templates that incorporate standardized terminologies, improving the quality and consistency of documentation across providers and specialties.

2. Supporting Clinical Decision Support (CDS): By ensuring that H&P documentation aligns with clinical terminology standards, CDS tools can better identify risk factors, suggest interventions, and flag potential issues based on coded data from H&Ps.

3. Optimizing for Billing and Compliance: The use of terminologies like ICD-10 and CPT in H&P documentation is vital for billing accuracy. Standardized language not only supports coding but also ensures compliance with regulations.

So my four key take-home messages for this post include : 

• There are at least eleven (11) H&Ps commonly used in healthcare - If you are a clinical provider, a medical records professional, a billing/coding person, or a clinical informaticist, it is helpful to familiarize yourself with all of them.  
• Many federal and state regulations only refer to them as an "H&P" - This, and the common saying "An H&P is an H&P..." potentially only causes confusion and workflow challenges.
• The right naming conventions / labeling can help you structure your documentation, and clarify and optimize your clinical workflows. 
• Remembering the mantra, "Call it what it is" will help you reduce confusion and untangle even your most complicated workflows.

For Clinical Informatics professionals, understanding these elements is critical to optimizing workflows, enhancing patient care, and contributing to the data-driven future of healthcare. By promoting accurate and standardized documentation, we can facilitate the development of a healthcare system that is not only more efficient but also more responsive to the needs of patients and providers alike.

I hope this helps you plan your document index and naming conventions, to help streamline your clinical processes. If you have any feedback or other comments, please leave them in the comments section below!

Have any experience with naming conventions for your clinical documentation? Feel free to share and leave other feedback in the comments section below. 

Remember, this blog is [ DRAFT ] guidance for discussion and educational purposes only - Your mileage may vary. Always check with your Clinical Leadership and your own Legal, Compliance, Regulatory, and Informatics leaders before adopting any definitions or new clinical standards.

Advice from a Wise Business Leader

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

A brief pause from Applied Clinical Informatics, just for a moment. 

Today's post is related to some helpful business ethics advice I once received from a wise and successful businessman my mother used to work for. His name was James ('Jim') Everett Robison (11/22/1915 - 2/21/1998), and he was a very successful businessman and Harvard Business School graduate who, in addition to having a wonderful and loving family, also counted Roy Little and Thomas J. Watson, Jr. as some of his business associates and friends.

(L) James E. Robison as an Air Force pilot circa 1940s, and (R) as a successful business leader circa 1990s.

A retired and decorated WWII Air Force Major (who flew 63 completed missions, 402 combat hours, 26 squadron leads, 7 group leads, and 1 wing lead!), Jim Robison lived and breathed integrity.

Growing up, I would run into Mr. Robison occasionally, while my mother was working for him in Armonk, NY back in the 1980s and 1990s. During one of my visits to my mother's workplace, he shared a message with me - one that he apparently also shared with many other people - about the importance of honesty, integrity, and ethics in business.

His message was once captured beautifully by his good friend Charles Osgood, who shared it in his November 24th, 1992 Osgood File message. 

The message is still so important and relevant, that I think it bears repeating today. Transcribed from an old cassette tape I found in my attic, here it is : 

TRANSCRIPT :

Charles Osgood

CBS 880 AM Radio 11-24-1992

[ Start of Transcript ]

The Osgood File, sponsored in part by ______ Heating and Cooling. I'm Charles Osgood.

Last night at the University Club in New York, I attended a reunion dinner of sixty (60) people who used to work for the same company my late father did. There were books of pictures, and in some of them I could hardly recognize dad because he was so much younger then, than I am now. It made me feel like Michael J. Fox in "Back to the Future".

And amongst the memorabilia I found something that impressed me so much, I wanted to share it with you, which I will do, in a moment. Stand by.

My father was in the textile business. His boss, at a company called Indianhead Mills, was a dynamic young man by the name of Jim Robison. Dad thought the world of Jim, not only because he was so smart and so successful, but also because he was such a straight shooter. Robison never wanted to outdo or get the better of anybody in a business deal. If both parties didn't benefit from the deal, he didn't want to do it.

My dad died several years ago, but last night I was invited to a reunion of Indianhead people, some of them I hadn't seen since I was a kid. Jim Robison was there, retired now and no longer a young man, but still sharp as ever. And looking through some materials they had there, I came on a company policy statement that he had issued 40 years ago. And I took a copy of it because I wanted to share it with you this morning. Here's what it said :

"There is one basic policy, to which there will never be an exception made by anyone, anywhere, in any activity owned and operated by Indianhead. That policy is as follows," Jim Robinson wrote. "Play it straight, whether in contact with the public, stockholders, customers, suppliers, employees, or any other individuals or groups. The only right way to deal with people is forthrightly and honestly. If any mistakes are made, admit them and correct them. Our commitments will be honored, and we have a right to expect the same performance from those people with whom we do business.

This is fundamental. We will not welch, weasel, chisel, or cheat. We will not be a party to any untruths, half-truths, or unfair distortions. Life is too short.

It is perfectly possible to make a decent living without any compromise with integrity."

I think I'm going to frame that and put it on the wall.

The Osgood File, Charles Osgood on the CBS Radio Network.

[ End of Transcript ]

I agree with Charles Osgood - I think I'm going to frame that and put it on the wall.

I hope this timeless message inspires you too!

Remember, this blog is for informational and educational purposes only - Your mileage may vary! Have any experience with studying business ethics? Please feel free to share in the comments below!

Applied Clinical Informatics Progress Bar Video

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

I recently put together a quick animation, help tell the story of Applied Clinical Informatics in a short (2 minute 38 second) YouTube video.

There's not much to say, other than it frames one potential journey - from beginning to end - and the progress that eventually leads to improved engagement, improved usability, improved return-on-investment, and most importantly - improved patient care.  

YouTube Link : https://youtu.be/mFL6WkPaog4

At the end, the bar suddenly returns to the very beginning - Letting the viewer consider their own journey. 

Feel free to share with anyone who's looking to better understand the Applied Clinical Informatics journey, and the many benefits it (and #BlueprintsBeforeBuild) can bring. 

Remember - This blog is for academic and discussion purposes only - Your mileage may vary!

Have any experience from your own journey that you would like to share? Feel free to leave in the comments section below!

Welcome to Healthcare!

Hi fellow CMIOs, CNIOs, Clinical Leaders, and any healthcare newcomers,

Today's post came after I recently had someone actually thank me (!) for quickly explaining the fundamentals of healthcare to them. 

After this conversation, it dawned on me that I've never really found a good welcome introduction to healthcare, this industry that I've worked in for years. It's been open for business, 24/7, for roughly 250+ years, but has never had a good opportunity to pause and ask itself : What we are doing, and how we are doing it? 

If you're a newcomer to healthcare, the welcome can sometimes seem a little cold and informal, something like this graphic :

While there are some reasons why seasoned healthcare professionals might greet newcomers this way, it doesn't actually help newcomers to understand healthcare. Sure, it's an industry that saves lives and treats diseases - but it can also make technology companies throw in the towel, and can frustrate politicians, providers, and patients alike. We could probably all benefit from newcomers having a good understanding of it's inner workings, before they get started.

So as a Clinical Informaticist, clinical translator, and general 'tour guide', I thought I'd write a friendlier, more explanatory piece, to help newcomers succeed by better understanding the fundamentals of this industry.

First, let's start with a sample diagram showing the overall structure of a typical healthcare organization :

*Note : This is a sample general-purpose structure - Many healthcare organizations will differ

 from this structure, based on their mission and other local legal, financial, operational, or regulatory needs.

*Also note : To help keep the chart simple, the Board of Directors is not depicted in the slide above. 

If I actually did a walking tour of this 'House of Healthcare' (not an org chart!), it might actually sound like this :

1. THE ADMINISTRATIVE ROOM

Walking into the administrative room, you can look around to see a lot of departments here, collectively tasked with running the organization and providing services to the areas below them. From here, some of the departments you can see include : Finance, Human Resources, Legal/Regulatory/Compliance, Privacy and Information Security, Contracting/Procurement, Employee Health, Facilities Management / Physical Plant, Public Safety/Security, Staff Education, the Switchboard/Operator, the Staff Directory, Public and Internal Communications, Enterprise IT/Informatics, Enterprise Project Management, Enterprise Analytics and Data Governance, and even the Library!

These departments are all busy providing the day-to-day support necessary for the Academic/Education, Research, and Clinical domains below them - And that means understanding both the common and unique needs of these three areas. (This is no small task!)

1.a. THE ACADEMIC / EDUCATIONAL ROOM

Walking down the path from the Administrative area, the Academic/Educational room often has a lot of schools/departments here, including Medical, Nursing, Dental, Pharmacy, and other Ancillary types of schooling. While these students and staff may also do research, and may provide clinical support (work) to the clinical enterprise, the main focus of this area is academics and education. So, for example, a Medical school might have several divisions : 

• Undergraduate Medical Education (UME)
• Graduate Medical Education (GME)
• Continuing Medical Education (CME) 

Before you think that these academic areas have it easy, keep in mind that clinical care and technology are constantly changing at an increasingly rapid pace. What was once considered desirable in the past - Memorizing textbooks full of science and clinical information - Is now considered passé, since a student who rotely memorizes facts is only memorizing clinical information that is rapidly outdated. Modern clinical educational thinking depends on not only learning a great deal of foundational knowledge, but also incorporating electronic databases and real-time decision-support tools into daily practices, with the goal of producing clinicians (doctors, nurses, and pharmacists) who continuously improve their knowledge while making decisions. 

Finally - Since the Research and Clinical Enterprises often depend on the students and staff from these Academic areas - They are a cornerstone of many healthcare institutions. (Except non-academic institutions, which do not have an academic/educational mission.)

1.b. THE RESEARCH ROOM

Walking up from the Academic/Educational room, you can walk down the hallway to the Research room, where you'll find a lot of very important departments, including : The Independent Review Board (IRB), Grant Management, Research Centers, Research Laboratories, Research Compliance, Research IT, Research Analytics and Translational science, and of course - a lot of highly-educated Researchers and Research Assistants!

This research is very important to us as a society, since it drives the foundations of medicine by creating the therapies and understanding that we all depend on. 

1.c. THE CLINICAL ENTERPRISE ROOM

Now walking from the Research Enterprise to the Clinical Enterprise, you'll notice some sudden, palpable cultural changes : 

• The Clinical Enterprise is largely open-for-business 24/7, so many of the staff are used to working in shifts and on holidays. 
• Patient safety is a constant focus of the workers here.
• A lot of people in these areas are wearing scrubs or white coats, and the air often smells faintly of antiseptic cleaning fluids.
• The fault tolerance is suddenly a lot less - requiring higher standards for hiring, budgeting, training, and implementing new tools. 
• Because it never gets to shut down for maintenance, and the low fault-tolerance - both the change management and project management are higher-caliber and noticeably different.
• The staff are often highly-educated, many with large amounts of student debt, so the salaries are suddenly higher. 
• The language and culture change, and may sometimes overlap or be different than the culture and language of the Academic/Educational or Research enterprises.. 
• Navigating the 'quasi-military' style clinical roles and responsibilities can sometimes be very complicated.

In this first top 1.c Clinical Enterprise box, we can see the many Clinical Enterprise Departments that support the patient care activities of all of the areas below them, including : Credentialing, Medical Staff Office, Nursing Department, Pharmacy & Therapeutics Department, Laboratory & Pathology Department, Diagnostic Radiology, Interventional Radiology, Non-Invasive Cardiology, Interventional Cardiology, Dietary/Nutrition, Physical Therapy, Occupational Therapy, Speech Therapy, Case Management / Social Work, Health Information Management, Registration, Access Management, Revenue (Billing/Coding), Housekeeping, Call Center, Scheduling, Clinical IT/Informatics, and Biomedical Engineering.

While many of these Departments above might be physically located inside the Hospital, it's important to note that the majority of these departments serve the needs of :

• the Hospital-based care areas, and...
• the Clinic-based care areas, and even ...
• the Nursing Home / Patient Home care areas.  

Let's now take a walk through the first of our patient care areas, the Hospital-based patient care locations...

1.c.i. THE HOSPITAL-BASED PATIENT CARE LOCATIONS

Walking through here, we can see a number of hospital-based departments / patient care areas in this room : 

• Emergency Department (technically an outpatient area!)
• Inpatient Unit - Med/Surg
• Inpatient Unit - Intermediate Unit (often Cardiac Telemetry)
• Inpatient Unit - Intensive Care Unit (ICU)
• Inpatient Unit - Labor and Delivery
• Inpatient Unit - Nursery
• Inpatient Unit - Pediatrics
• Inpatient Unit - Psychiatry 
• Perioperative Services (Pre-Op, OR, PACU) (technically all outpatient areas!)
• Ambulatory Procedural Suites (e.g. Endoscopy, Bronchoscopy, Interventional Cardiology, Interventional Radiology, sleep labs, EKG/Echos, etc.) (technically all outpatient areas!)
• Chemotherapy and Infusion Suites (note : in some organizations these are not hospital-based areas)

A lot of care is delivered in these hospital-based patient care areas! And keep in mind, it's a common mistake to either under- or over-estimate the acuity, complexity, or importance of these hospital-based areas - 

• The clinic-based areas can be every bit as acute, complex, and important!
• Many workflows start in the ambulatory clinic-based areas, and end in the Inpatient/ED (hospital)-based areas - And vice-versa! 

So understanding these many hospital-based patient care areas is only a part of the story.

1.c.ii. THE AMBULATORY (CLINIC) BASED LOCATIONS

In the Ambulatory (Clinic) based locations, you can find a lot of ambulatory clinics, along with sometimes some remote radiology services, blood draw services, and even some procedural and infusion services. For example, you'll commonly see Primary Care and clinics including : 

• Neonatology / Maternal Fetal Medicine
• General Pediatrics
• Family Medicine
• Medicine - General Internal Medicine
• Medicine - Geriatrics
• Medicine - Cardiology (General non-invasive and invasive/interventioal)
• Medicine - Endocrinology
• Medicine - Gastroenterology
• Medicine - Pulmonary / Sleep Medicine
• Medicine - Rheumatology
• Neurology - General
• Neurology - Movement Disorders
• Surgery - General
• Surgery - Neurosurgery
• Surgery - Ophthalmology
• Surgery - Plastics
• Surgery - Otolaryngology (Ear, Nose, & Throat, or ENT)
• Surgery - Orthopedics (Bone & Joint)
• OBGYN
• Maternal Fetal Medicine
• Psychiatry - General Adult
• Psychiatry - Pediatric and Adolescent
• Dermatology - General Dermatology
• Dermatology - Mohs Surgery
• Hematology and Oncology (often divides up into several specialty subdivisions of care)
• Radiation Oncology
• Genetics Counseling
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Diet/Nutrition
• Anesthesiology / Perioperative Medicine
• Urgent Care

... and more!

While they are generally only open during business hours, these ambulatory clinics provide a tremendous amount of care to a tremendous number of patients, and often have acuity, complexity, and safety issues on par with the hospital-based areas.

1.c.iii. THE OFF-SITE (NURSING HOME) or HOME CARE LOCATIONS

For our final stop in our tour of the 'House of Healthcare', we'll be stopping at the nursing-home and patient-home-based care. Yes, house visits still exist! These are growing areas for many healthcare institutions, and especially since COVID, this segment is only expected to grow in the near future. It often requires providers with unique documentation/billing practices, but this is an important source of care for hospice, homebound, and nursing home patients. 

SOME FINAL WORDS

Before we wrap up our walking tour, it's important to note that Population Health is a growing trend, which ties reimbursement strategies to improved health and improved patient outcomes. While much of the focus is on outpatient/ambulatory clinics, it can also impact a number of hospital-based workflows, and so it's important for everyone to understand the role that Population Health plays.

And for the particular segment that I work in (IT/Informatics), it's important to note that there are essentially four IT/Informatics domains that cover the spectrum of a typical healthcare organization : 

• Administrative (Enterprise) IT/Informatics (often includes Analytics/Data Governance, and infrastructure like servers, network architecture, security, interface management, hardware/software procurement, life cycle management, desktop/application management, etc.)
• Academic/Educational IT/Informatics
• Research IT/Informatics
• Clinical IT/Informatics

... each with their own unique language, culture, regulations, needs, and stakeholders.

I hope this has been a quick, helpful virtual tour of a typical healthcare organization - Remember, many organizations will vary slightly, based on mission and local financial, legal, or regulatory needs. If you have any questions or comments, please feel free to leave them in the comments section below!

Remember, this blog is for educational discussion only - Your mileage may vary. Have any insights into healthcare structures, or emerging trends that are shaping healthcare? Feel free to leave them in the comments section below!

Getting from A to B : Project Management for Clinical Leaders

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

Change is important. As a clinical leader, you'll want to know how to make workflow changes, either to help fix a workflow that's not ideal, update a workflow that needs updating, or build a new workflow. (As long as there are new journal articles and conferences, there will be necessary updates to clinical practice to stay current.)

So this week, I thought I'd write about a topic that can help a clinical leader to feel comfortable with making changes in their area: 

"How to get from Point A to Point B"

I once alluded to a problem with making changes back in 2016, when I blogged about the Red Sneaker Problem - And How To Fix It. To help avoid frustration for you and your team, it's helpful to understand 'How does anything change?'. Without understanding the change process, it can be hard to make change. 

Although clinical leaders often need to focus primarily on clinical services, functions, and expertise - it's still helpful to know the basics about two important things, related to 'how things get done' : 

1. Project Intake / Scoping - Helps you secure necessary people, time, and resources before you start a change project.
2. Project Management - Helps you effectively use those people, time, and resources to get things done (accomplish the change)

Without understanding these two steps, it can be very hard to accomplish much change. And without regular, smooth, and predictable changes, clinical leadership can seem more daunting than it needs to be. 

So as a brief introduction for new clinical leaders, let's review these two items in a little more detail. Borrowing some slides from a recent presentation I did for a group of clinical leaders, I present some high-level overview below. 

1. PROJECT INTAKE / SCOPING - 

Making change is work. It takes people, time, and resources, to move your CURRENT state (Point A) to your desired FUTURE state (Point B). 

Ideally, to make sure you have the 'gas' needed to drive your 'car' to where you want it to go, you'll first need to understand the scope ('size') of your project. Conceptually, think of this as collectively driving your car (with your team inside it!) from :

• Your CURRENT state (Point A)
• Your desired FUTURE state (Point B)

This is why I always advise people to formally map the current and future states. The distance between these two points is what will determine the scope (size) of your project,  and the work effort (and resources) needed to accomplish your goal.

• If you have the time, people, and resources necessary to get from Point A to Point B - Great! 
• If you don't... Then you may feel frustrated.

So to make sure you have a thorough, well-documented analysis that you can share with your project team - it's very helpful to formally document, in a folder, your CURRENT state, and also formally design your ideal FUTURE state, one that is formally signed off by the clinical leaders who oversee the clinical staff who will live in this new future-state workflow. 

People sometimes ask me : "Do I need to do this much for every change I want to make?" My advice : You only need to apply as much rigor as you need to get the change accomplished. E.g. : 

• For small changes (e.g. making some small changes to a documentation template) --> Usually, less rigor is required
• For large changes (e.g. implementing electronic med reconciliation at all transitions of care) --> Much more rigor is required

This exercise will not only help you scope your project, and identify the people, time, and resources you will need to secure - It will also help you formally plan a project, estimate the return on investment (ROI), and secure the necessary approvals before beginning your project. 

2. CLINICAL PROJECT MANAGEMENT

Once you have secured the necessary people, time, and resources, and have the approvals of your leadership to move forward - It's helpful to identify a formal, trained, and experienced project manager to plan, orchestrate, and lead your project. For a high-level overview, you can see the Wikipedia piece : https://en.wikipedia.org/wiki/Project_management 

For planning purposes, many experienced project managers might develop a Gantt Chart ( see https://en.wikipedia.org/wiki/Gantt_chart ), a sort of ordered series of steps, with time estimates and dependencies, that will be needed to finish the project and achieve the desired outcome. Similar, but also helpful is a Responsibility Assignment Matrix, sometimes called a RACI Chart. 

Experienced clinical leaders, especially those who have worked with good project managers, can often help a project by anticipating steps and helping to answer questions before they arise. While there are different types of project management (from the more traditional waterfall model, to newer agile methodologies), I've stripped down some bare essentials that are helpful to think about before starting any clinical update or improvement project : 

These are the ten steps (above) that I commonly plan and follow for clinical projects, where the rigors of step two (2) above are often necessary to help adequately scope and plan clinical projects, and help ensure that there are no unanticipated surprises later in the project. Note: Clinical Informatics professionals often work in steps 2, 4, 5, 6, and 9 above, working closely with end-users, analysts, educators, and project managers.

As a clinical leader, you will want to help champion change and updated practices. While there is much more to be said about project intake, scoping, planning, and execution, I hope this little introduction will help my friends in clinical leadership see the value of good project managers, and good project planning, and the role they play in getting things done.

Remember, this blog is for educational purposes only - Your mileage may vary. Always ask your local Project Management and Clinical Informatics professionals for guidance, and work closely with your clinical leadership to review, prioritize, and approve your projects before initiating any changes.

Have any stories to share about clinical leadership in supporting clinical projects? Have any tips or tricks to share from your own clinical project management experiences? Feel free to leave them in the comments section below!

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. 

Determining COVID-19 Status in an EMR

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

For most of us, the last few months have been very busy. At no point during my medical education did I ever think we would all be working one day in the middle of a global, 1918-style pandemic.  And yet, here we are. For my fellow healthcare workers, I hope you and your families are all safe and healthy.

While there continues to be national debate about how best to manage our global crisis, there seems to be one thing most experts agree on - Having good data is key to planning and public health decision-making. 

So as a Clinical Informaticist with a background in public health and epidemiology, I'm always especially interested in the national (public) discussion about total numbers : 

• How many people have been infected with the SARS-2-Novel Coronavirus?
• How many people have active infections with the SARS-2-Novel Coronavirus? 
• Of those infected - how many display symptoms of COVID-19? How long after infection with the SARS-2-Novel Coronavirus, and for what duration?
• Of those infected - how many have COVID-19 illness that progresses to severe illness and/or death (case fatality rate)? How long after infection?

And yet, with all of these questions, here's one I find the most puzzling : 

"Q : How do you know if a patient has COVID?"

While this might seem like an easy question (A: read the chart!), in reality - it's anything but simple. 

FIRST - AN IMPORTANT POINT:

It's tempting to just look in a chart for "COVID" or "COVID-19", but it's important to consider that the virus is actually called the "Novel SARS-Covariant-2 RNA virus".

• "Novel SARS-Covariant-2 RNA virus" = The new coronavirus that actually infects people, reproduces inside their cells, and may/may not cause symptomatic disease.
• "COVID-19" = The constellation of symptoms that are caused by the Novel SARS-Covariant-2 RNA virus. 

So it's entirely possible to :

• be infected with the Novel SARS-Covariant-2 RNA Virus, with NO SYMPTOMS OR
• be infected with the Novel SARS-Covariant-2 RNA Virus, with symptoms of COVID-19 disease. 
• assume that patients with symptoms of COVID-19 disease should be tested for the Novel SARS-Covariant-2 RNA Virus, to determine if that is the cause of their disease symptoms.

And so when someone asks, "Q : How do you know if a patient has COVID?", it's first important to distinguish : 

• "Did you mean how many people are CURRENTLY Infected with the Novel SARS-Covariant-2 RNA Virus?" OR
• "Did you mean how many people total have been Infected with the Novel SARS-Covariant-2 RNA Virus, since the beginning of the outbreak?" OR
• "Did you mean how many people infected with the Novel SARS-Covariant-2 RNA Virus have developed symptoms of COVID-19 disease?"

Always remember, when reporting data, especially to researchers or regulatory agencies - it's very important to first make sure you know exactly what is being asked. 

WHERE IN A CHART CAN YOU LOOK?

To help answer the question, "Q: Does this patient have COVID?", there are a surprising number of different places you might look in a medical record : 

1. The Chief Complaint, (e.g. "cc: COVID symptoms" or "cc: Fever, Respiratory Symptoms" or "cc: Suspected COVID" or "cc: Suspected Pneumonia") - This gives you some insight about what type of symptoms the patient might have had on arrival. 
2. The History of Present Illness (e.g. "75M with recent travel to country with high COVID activity and recent exposure to known COVID patient (8d ago), who now presents with home temp of 103 and worsening shortness of breath x1 day.") - This helps further establish the likelihood of COVID-19 disease, but may not always be conclusive.
3. The Review of Systems (e.g. "+Fever, +Chills, +Cough, +Worsening exertional dyspnea, +Weakness") - Again, like the History of Present Illness, this is suggestive, but not conclusive of disease.
4. The Vital Signs (e.g. "HR=120, BP=100/60, O2sat=75% on RA") - This also helps build the case that the patient has COVID-19 disease symptoms, especially the low O2 sat, which has been a hallmark of disease in patients with severe symptoms. But keep in mind : Normal vitals do not exclude disease. 
5. The Radiology (e.g. Chest X-ray or CT Scan showing bilateral ground glass opacities, CT Angio showing pulmonary embolism, or ultrasounds showing DVT/VTE) - This further helps establish clinical suspicion of COVID-19 disease and SARS-CoV-2 RNA Virus Infection - But is not confirmatory. 
6. The Routine Labwork (e.g. Lymphopenia, elevated Ferritin, elevated D-Dimer, Renal Insufficiency, Transaminitis) - This pattern helps establish suspicion of SARS-CoV-2 Infection and possibly COVID-19 disease, but is not confirmatory.
7. The Diagnostic Labwork - Nasal Swabs (e.g. Positive SARS-CoV-2 RNA PCR Nasal Swab) - This is helpful and confirmatory, to determine if your patient has COVID-19 disease symptoms caused by the Novel SARS-2-CoV RNA Virus - But remember that most nasal testing, as of this post, is only about 90% sensitive. So about 1 in 10 people with a negative result may in fact actually have the disease. (As of this writing, I'm not entirely sure if this refers to testing patients WITH symptoms, or testing patients WITHOUT symptoms - If you have a good answer to this, please feel free to comment below!)
8. The Diagnostic Labwork - Antibody Serologies (e.g. Positive IgG antibodies to the SARS-CoV-2 RNA virus) - This can help determine a prior infection, provided the patient has enough time and immune response to develop antibodies. (I'm not sure if anyone has good data on timeframes for developing antibodies - If you have a good answer to this, please feel free to comment below!) Presuming the test is a reliable one, having antibodies suggests that the patient was at least exposed to the virus. Not having antibodies is not as helpful diagnostically. 
9. The Admission Diagnosis (e.g. "Respiratory Symptoms" or "Pneumonia" or possibly "COVID-19") - This can be very helpful, and it is a required data field in most hospital admissions. If the clinical suspicion from the initial workup is high enough, and there is maybe even laboratory confirmation of SARS-2-CoV RNA Virus infection, it's possible this might list "COVID-19" disease as an admission diagnosis. Keep in mind that during most hospitalizations, often because of the incomplete information on admission, the admission diagnosis is not as accurate as the discharge diagnosis. (E.g. Some doctors might not be willing to call it "COVID-19 disease" until the laboratory confirmation has returned.)
10. The Discharge Diagnosis (e.g. "COVID-19" or "Suspected COVID-19" or "Suspected SARS CoV-2") - This can also be very helpful, and is also a required data field in most hospital discharges. Remember that because of the additional data obtained during a hospitalization, the discharge diagnosis is usually more accurate than the admission diagnosis. 
11. The Active Problem List (e.g. "COVID-19" or "Suspected COVID-19" or "Confirmed COVID-19") - This can be very helpful, since doctors usually have to manually add it to the list - So if it's there, it usually means a doctor had enough clinical suspicion and laboratory confirmation to label the patient as having COVID-19 disease. Keep in mind that some doctors might not put it in the active problem list, and instead put it in their progress notes. 
12. The ASSESSMENT/PLAN on the Admission H&P, Daily Progress Notes, and Discharge Summary (e.g. "Assessment : Patient with COVID-19 disease, hospital day #2, improving steadily." or "Plan : COVID-19 - Continue current therapy") - This can also be very helpful, since the Admission H&P, Daily Progress Notes, and Discharge Summary are usually the most intimate notes that doctors write in a chart. Depending on the clinical information available when they were were written, they might not confirm COVID-19 disease until later in the hospitalization.
13. The Death Certificate (e.g. "Primary Cause of Death = Cardiopulmonary arrest, Secondary Cause of Death = COVID-19 Disease, Tertiary Cause of Death = Novel SARS-CoV-2 Infection) - This would be an ideal source of data and mortality, but this can be dependent on the time of death - Death immediately on arrival may not have the symptoms/laboratory confirmation/clinical information available as a death after several days of hospitalization and data gathering. (It may also be dependent on what exactly a doctor writes on the death certificate, e.g. "COVID-19 disease" or "Suspected COVID-19 disease" or "Confirmed COVID-19 disease" or "Novel SARS-CoV-2 Pneumonia") 

What does this analysis suggest? That determining a patient's Novel SARS-CoV-2 Infection status or COVID-19 disease status in a medical record (electronic or paper) is not as easy and straightforward as one might imagine. And so, writing data reports for local or national reporting purposes is not easy. 

SOME FINAL THOUGHTS : 

If that's true, then how do you develop accurate reports for local and federal reporting purposes? It takes work, but here are a few suggestions I wanted to share : 

• Before you develop any reports, make sure you familiarize yourself with the different elements of a medical record, and work closely with clinical staff to develop those reports.
• Try to avoid using a single data point as your source-of-truth.
• Work closely with your clinical staff to help regularly review and validate your reports.
• Maintain open discussions about these issues with your report writers, your clinical staff, your legal/compliance team, and your HIM team. 
• In the absence of manual chart reviews - it would be helpful if software vendors could look at algorithms and artificial intelligence to help review all of these data sources and make a predictive analysis that could be used for reporting purposes.

I hope this helps you better understand the complexities of reporting on both Novel SARS-CoV-2 RNA Virus infections and COVID-19 disease. If you have any tips or tricks you'd like to share, please feel free to leave in the comments section below!

Remember, the information in this blog above is for educational purposes only - Your mileage may vary. If you have any reporting tips or tricks you'd like to share, feel free to leave in the comments section below!