What is your EMR documentation index costing you?

It's all about the details. One of the things that I really love about front-line clinical Informatics is the remarkable insights you get into clinical operations - and how the tiniest, seemingly trivial design elements can strongly influence the cost and quality of patient care, as well as the cost of maintaining your EMR. 

When I first started, I didn't fully understand this relationship, and the focus of my attention was less on the names of notes and order sets, and more on their content. Fortunately, a respected Informatics colleague gave me this advice, early on :  "If you haven't struggled with designing a naming convention or a documentation index, you haven't done your job." 

It took me a while to understand exactly what this meant, but through years of experience, it's become much more clear to me. So for educational purposes, I thought I would share the story of how I was recently reminded of this lesson, when I saw the following posting on a popular Informatics listserver (paraphrased here for brevity):

'I would appreciate your input on the approach you have taken to your folder or ‘hierarchy’ structure for documentation mapping.
We have robust use of our EMR in both the inpatient and outpatient setting. I have seen both ends of the spectrum when it comes to hierarchies:  Minimal number of note types to a very high level of specificity. We fall in the latter category and are always looking for ways to streamline and strike the right balance. Can you share the approach your organization has taken in this space? 
This may, in part, depend on how robust the search tools are within each EMR but I have some basic questions:

• Do you have Outpatient notes separated from Inpatient Notes?
• Do you separate notes by medical specialties?
• Do you distinguish between a Resident and a Staff note? What about a Medical Student Note? (Do you take an alternate approach to distinguish between these such as the ‘signature line’ in the note proper or the template used for the note?)'

My response reminded me about how much the years of experience had taught me about designing naming conventions and documentation indexes. My paraphrased response is below : 

[ START OF RESPONSE ] 

This is a great question! You have a great opportunity in front of you - This is the essence of what we do - Make it intuitive for people to understand and find their notes in the vast sea of information that is an EMR!

I’ve never been given the same challenge (although it would be a good one!), but I think I would start with a few guiding design principles : 

1. The name of the note should follow a standard naming convention.

2. The index of the note should be intuitive enough for both users and managers to be able to quickly find the information they need.

With those principles in mind, I might then use the Bell Labs North American geographic telephone number model (e.g. (xxx) xxx-xxxx (area code - prefix - identifier)) for paradigm inspiration, and start by [DRAFTING] an index like this: 

Document Name = [ Geographic level-of-care ] + [ Setting ] + [ Role ] + [ Name of note ]

Where :

• Geographic Level-of-care = Where the patient is registered, e.g. Inpatient or Outpatient,
• Setting = What unit the patient is registered in, e.g. Med/Surg, Cardiac Telemetry, ICU, Childbirth, Nursery, Pediatrics, Psych/Behavioral Health, etc
• Role = Role of the documenter, e.g. Adult Hospitalist, Pediatric Hospitalist, Intensivist, ED Nurse, ICU Nurse, Med/Surg Nurse, etc.
• Name of Note = Common name of note, e.g. Admission H&P, Daily Progress Note, Discharge Summary, Consult Note, etc.

So, for example, you could use this naming convention to design a document index like this :

• Inpatient - Med/Surg - Adult Hospitalist - Admission H and P
• Inpatient - Med/Surg - Adult Hospitalist - Daily Progress Note
• Inpatient - Med/Surg - Adult Hospitalist - Discharge Summary
• Inpatient - Med/Surg - Adult Hospitalist - Medical Consultation
• Inpatient - Med/Surg - General Surgeon - Admission H and P
• … etc…

The reason I would probably avoid specialty, and instead use role, is because some specialties fill multiple roles (e.g. Med/Peds specialists might work one day in the role of an Adult Hospitalist, and the next day in the role of a Pediatric Hospitalist) - 

So if you decide to use this format, then, the strategic question will become : What exactly is your organization's list of roles? 

• The more roles you have, the more expensive it will be to maintain your documentation, but the happier your docs will be having documentation designed just-for-them, and the easier it will be to collect role-specific quality indicators.
• The less roles you have, the cheaper it will be to maintain your documentation, but your docs may not be as happy having to accommodate to a one-size-fits-all approach, and the harder it will be to collect role-specific quality indicators.

So you will need to strike some sort of balance between the two. On the most cost-effective, conservative side, you might have very generic roles like : 

1. Inpatient - Med/Surg - Attending - Admission H&P
2. Inpatient - Med/Surg - Attending - Daily Progress Note
3. Inpatient - Med/Surg - Attending - Discharge Summary
4. Inpatient - Med/Surg - Consultant - Consult Note

And in the happy-medium, make-the-docs-happier and collect-more-role-specific-quality-indicators range, you might have roles like : 

1. Inpatient - Med/Surg - Adult-Hospitalist - Admission H&P
2. Inpatient - Med/Surg - Adult-Hospitalist - Daily Progress Note 
3. Inpatient - Med/Surg - Adult-Hospitalist - Discharge Summary
4. Inpatient - Med/Surg - Adult Hospitalist - Consult Note

And finally, on the most-expensive, docs-might-love-it-but-nobody-can-afford-it side, you might have roles like : 

1. Inpatient - Med/Surg - Adult-Hospitalist - Dr. Stanley - Admission H&P
2. Inpatient - Med/Surg - Adult-Hospitalist - Dr. Stanley - Daily Progress Note 
3. Inpatient - Med/Surg - Adult-Hospitalist - Dr. Stanley - Discharge Summary
4. Inpatient - Med/Surg - Adult Hospitalist - Dr. Stanley - Consult Note

For provider satisfaction reasons, I generally wouldn't recommend the first approach, and for cost reasons, I generally wouldn't recommend the third approach. Naming conventions and document indexes with provider names means you will be spending a lot of time and resources maintaining a much larger set of order sets or documentation than you might have budgeted for.

Whatever strategy you decide to employ, you will be living with the decisions for a long time, so I recommend really spending some time, drafting your naming convention and documentation index, and present it to both your clinical and administrative leadership for approval, before moving forward.

Hope this helps! Good luck!

- Dirk :)

[ END OF RESPONSE ] 

So gradually, you start to learn how these tiny, seemingly trivial design details impact the cost of care and maintenance of your EMR, and so you look out for them and look for ways to help cut costs and still maintain provider satisfaction. 

Please note : Other responses to this question included recommendations about using LOINC coding standards to assist with developing industry-standard file naming conventions. This is great advice, and helpful in achieving documentation harmony, especially if you are planning on a HIE or exchanging documentation with other organizations. You can read more about LOINC by going to their web page : 
http://loinc.org/international

Anyway, this was just a very basic introduction to some EMR design issues, and how they impact the cost of EMR maintenance - but I hope this story will be helpful to you in tackling your own naming convention and documentation indexing challenges!

Clinical Linguistics and EMR Interoperability

Hi fellow Informaticists, CMIOs, CNIOs, and other #HealthIT enthusiasts,

For today's post, I wanted to muse on a favorite subject : What can language management teach us about design of clinical documentation and EMR interoperabilty?

To answer this, it's helpful to first understand the three common models of communication used in clinical settings : 

1. Synchronous Communication - Undocumented, real-time communication, where both sender and recipient are sharing the same moment in time - E.g. face-to-face conversations, telephone conversations, video chats, or meetings
2. Asynchronous Communication - Documented communication, where both sender and recipient are separated in time - E.g. EMRs, HIEs, Notes, charts, graphs, videos, recordings, videos, voicemails
3. Hybrid Communication - Shares features of both, e.g. Texting, social media, Twitter, recorded phone calls, etc.

Professional interpreters and translators (like you might find at the U.N.) have worked for years to manage communications across these models - What can healthcare learn from them?

To help answer these questions, I've developed the following 14-minute-3-second video, for your consideration : 

I hope you enjoyed it - Leave your thoughts or feedback in the comments section below!

Can we do better than SOAP?

So I've recently been looking at some of the most important standards we have, that few people appreciate. Some standards that I've recently been admiring the beauty of :

1. The 110-volt AC plug in America - Thank goodness for this! Imagine if you had to worry about which coffee maker you could or couldn't buy because it didn't have a plug that fit your house! (Or even better, think about how challenging it is to travel with that same coffee maker to a different country!)
2. Traffic lights - Thankfully, they all behave the same in our country. Imagine if driving from Maine to Florida meant having to learn different traffic signal patterns?
3. Traffic patterns - We all drive on the right side of the road in the U.S. - Imagine having to change as you drove state-to-state? (I wonder how they handle this in the Chunnel between France and England?)
4. Train tracks - Snopes.com has this interesting debunking about railroad gauge, that includes a mention of how during the American Civil War, the northern railroads had one gauge while southern railroads had multiple gauges -  this was argued by historian James McPherson to be one of the logistical factors that contributed to the Union army winning over the Confederate army. (And interestingly, after the North won the war, many of the southern railroads were rebuilt by the North, giving us the American standard of 4 feet, 8.5 inches.
5. The Apple iPhone/iPad/iPod charger - Although Apple toyed with some of the charging pins since the iPhone 3G, the plug has essentially been the same since the original iPod in 2001. Now it seems that since the iPhone 3G, you can use the same plug to charge your iPhone 3G, iPhone 4, iPhone 4S, iPad, iPad2, iPod Touch, and various other apple devices. I suspect this is why the plugs are becoming so ubiquitous that most of my friends now seem to have one in the kitchen just to let visitors charge their Apple devices.
6. American Standard Code for Information Interchange (ASCII) - This is arguably much larger than just an American standard - Although Unicode has expanded the ability for designing documents, ASCII is probably the most widely-used standard in computing.  Can you imagine if your processor didn't know you pressed the "A" key on your keyboard? What if that "A" didn't show up on the screen? What if you sent an email and the "A" didn't arrive?
7. Internet Protocol (yes, both versions 4 and 6) - The Internet would not be possible without a standard Internet Protocol. 

So I think we can all agree that these standards are good for us - And thankfully for healthcare, the ANSI (American National Standards Institute) created a new HITSP chapter in 2005 after the ONC recommended someone start working on healthcare IT standards. (A shout out and thanks to John Halamka, MD for taking on this labor of love!) :)

Anyway, I think the take-home message about healthcare IT standards is that we're still really early in the process. (As of this writing, the HITSP has only been around for about 6 years!)

So because a lot of my work as an informaticist deals with the struggles to achieve standards, I think a lot about the final objective of informatics : Getting the right information to the right person in the right place at the right time in the right way. (It's easy to get 2 or 3 of those right, but getting all 5 right is much more difficult.)

Anyway, so it's nor surprising that I eagerly await the day when the Regional Extension Centers (RECs) and Implementation and Optimization Organizations (IOOs) finally make the HIEs that smoothly link our electronic medical records - ... But what then?

A WORD ABOUT STANDARDS FOR CLINICAL DOCUMENTATION

In my quest to get the right information to the right person in the right place at the right time in the right way, it dawns upon me that the best technical solutions may still fall short of expectations because of this : There aren't really any good standards for the content of electronic documentation.

In fact, I started to ponder - What standards are there, at all, for clinical documentation?

Most practicing physicians can pretty quickly think of one real standard - The SOAP note. It stands for "Subjective, Objective, Assessment, and Plan", and is a rough outline for how you write a note in a logical way :

S - Subjective - What you heard from the patient (history, opinions, and answers)
O - Objective - What you saw about the patient (measurable things or physical findings)
A - Assessment - What you believe is currently going on with your patient
P - Plan - What you and your patient are going to do about it

The SOAP note is also a cognitive framework for how we think and communicate about patients - When you sign out to another physician, the SOAP note influences our thinking and what we say or write about our patients. By forcing a physician to confront the evidence (S, O) before rendering an opinion (A) and plan (P), it has had a remarkable impact in improving the quality of care and communication about that care.

Interestingly, the history of the SOAP note goes back to this seminal paper written by Dr. Lawrence Weed, published in the March 14th, 1968 edition of the New England Journal of Medicine. (Click on the link above to read the actual article.) 

** IF YOU WORK IN HEALTH INFORMATICS, YOU SHOULD READ THE ORIGINAL ARTICLE IN ITS ENTIRETY. **

One of the fascinating parts about this article is in its opening paragraphs - The purpose of this paper, in 1968, was "...to develop a more organized approach to the medical record, a more rational acceptance and use of paramedical personnel and a more positive attitude about the computer in medicine." Snark Alert : Amazing how far we've come in the last 43 years!

But getting back to serious discussion, the paper highlights many of the struggles we have had with implementing EMRs in the last 40 years - And still continue to struggle with today. When you read the article and see how notes were structured BEFORE the SOAP structure, you can see why some people argue he should win a Nobel Prize for Medicine. 

It's also good to know Dr. Weed is still developing his argument, as published in this 1997 British Medical Journal article. (THANK YOU DR. WEED!)

But then I thought : We have the SOAP note - But do we have anything else to help guide us?

Since most medical schools teach little about clinical documentation (you're usually too busy learning about diseases), many doctors finally learn about note writing from pocket books like the Washington Manual Intern Survival Guide. (Similarly-themed but shorter "Intern Survival Guides" can be found here and here, just to get an idea of what I'm talking about.)

So if most of our education for physicians about writing notes falls down to these pocket guides, and the notes are often specialty-dependent but built on the SOAP framework - It's no wonder we all struggle with electronic documentation.

A WORD ABOUT THE STRUGGLES OF ELECTRONIC DOCUMENTATION

Anyone who has worked on electronic documentation will tell you : It's hard to build, and hard to maintain.

The first challenge is getting a note built - What exactly will you use the note for? What will you name it? What do you want to include in the note?

Looking for answers to these questions often depends on :

1. The planned clinical scenario
2. The physician's experience
3. The physician's pocket guide they learned from in Internship
4. Regulatory and compliance issues (the stuff that insurers and other regulators want to read about)

The funny thing is, every hospital is working on this same problem separately - Often coming out with similar but slightly different results. It's a great example of "everyone rebuilding the wheel".

Why can't all Medicine History and Physicals look the same? In my experience, most of them approximate the same SOAP format, but I've even heard the argument, "I'd like to see the Plan at the TOP of the note when I read it." This speaks to a challenge of documentation in general - 

1. Documentation is closely tied with our cognitive processes.
2. Our cognitive processes, while similar, are not entirely standardized.
3. Regulations, insurer demands, and clinical practices change frequently, making it important to maintain notes after they're built.

So in the end, clinical documentation is more expensive to build and maintain than most people imagine - And every hospital is having the same struggles together.

And because the notes may vary in their end result - An electronic note sent from a doc in one hospital one day may not have the best reception by the physician at another hospital.

In other words : I'm thrilled we're working to link our EMRs - But will the notes we send be equally effective at another hospital?

THE INTERSTATE-91 INFORMATICS PROJECT

So we have a new, small, informal group of volunteer healthcare informaticists here along the Interstate 91 Corridor that stretches between New Hampshire/Vermont, all the way down through Massachusetts to New Haven, CT. We meet informally every 3-4 months for dinner to discuss healthcare informatics, and I'm glad to report we recently obtained a donated website, which we hope to develop. 

I'm hoping at our next dinner to propose a few crazy ideas to our group : 

1. What if all of our documentation looked the same? (for the same clinical scenario...)
2. Could all of our clinical documentation look the same? (for the same clinical scenario...)
3. Could we develop a standard for content of electronic documentation?
4. Could we help further develop the SOAP note, to provide a logical and cognitive standard that helps improve care and reduce costs for all of us?
5. Could this framework be used as a teaching tool about clinical documentation in medical schools and residency programs?

Will let you know how things turn out after our next dinner. Look out for the I91 Standards. :) (Ooh, another cliffhanger, I know!)

As always, I love to answer questions. Feel free to respond with thoughts, questions, ideas, or other discussions. Remember : Education is a priority! :)

What is an Order Set?

It's funny. When I first got involved with electronic medical records at the Albany VA Hospital, as a resident, I remember one of their informatics people telling me, "You have no idea how political order sets are. The arguments I have seen over whether to check or uncheck a box... It's unbelievable."

She was right.

After you go electronic, prepare for the political discussions about order sets. Lots of people have opinions, but not many are actually are involved with building, testing, or development of order sets or using them.

So I thought I'd present this primer, to help people understand - "It's not just a bunch of orders with boxes." :

What is an Order Set?

I. BACKGROUND

An order set is a grouping of orders, used to standardize and expedite the ordering process for a common clinical scenario.

Before an order set can be created, the goal of the order set must be clear. Any necessary orders, contained in the order set, must be built first. (Order sets for new or innovative workflows should first be examined for any new orders that need to be engineered first.)

Order sets should only contain orders. They should not be confused with :

1. PROTOCOLS - Conditional IF/THEN statements, allowing a nurse/pharmacist/other licensed medical professional to start/modify/stop orders on behalf of a licensed physician, to automate and standardize the care for a common clinical scenario.
2. CLINICAL PATHWAYS - Tools used to standardize the discussion and goals of therapy, during rounds, for a common clinical diagnosis.
3. CHECKLISTS - Documentation tools used to document, standardize, and expedite the screening process for a common clinical scenario.
4. POLICIES - Agreed-upon standards for your organization
5. PROCEDURES - Detailed steps about how to achieve a desired standard.
6. PATIENT EDUCATION MODULES - Documents that help educate a patient about a particular subject (e.g. diet, disease, procedure, or aftercare)
7. STAFF EDUCATION MODULES - Documents that help educate a staff member about a particular subject (e.g. diet, disease, procedure, or aftercare)
8. DOCUMENTATION - Tools that help record and transmit patient history, condition, activities, responses, laboratory values, radiology images, and notes
9. GUIDELINES - Educational tools to help educate a staffmember about a general clinical objective (more flexible and negotiable than a policy)

For maximum safety, order sets should be built :

1. With clarity and a standard layout (Please see the ISMP Guidelines).
2. With all necessary information required to safely complete the order set.
3. With only those automating features which are absolutely necessary. (Risks/benefits of pre-checking orders must be closely examined on each order. As a general recommendation, pre-checking orders should be avoided on medication orders.)
4. With evidence-based practices.
5. To reduce variation and unintentional oversight.
6. To prompt for all necessary information.

Order sets can range widely in complexity, from very simple convenience order sets, to very complex order sets used to trigger clinical pathways or protocols.

II. DESIGN / CATEGORIZATION

Order sets typically fall into one of two primary categories :

1. Charge Order Sets - Those used by nurses and other clinical staff to create charges for common clinical materials (e.g. gauze, dressings, etc.)
2. Physician Order Sets - Those used by physicians to standardize and expedite the ordering process for a common clinical scenario.

Physician Order Sets may vary widely in complexity, but typically come in one of several types :

1. Admission Order Sets - (Sometimes called "Venue-specific order sets") - Used to admit a patient to a particular attending, level-of-care, and service.
2. Transfer Order Sets - Used to transfer a patient to a particular attending, level-of-care, and service (rarely used in clinical practice, but hypothetically these could be used to standardize care on transfer of a patient)
3. Discharge Order Sets - Used to discharge a patient from a particular level-of-care
4. Workup Order Sets - Used to workup a particular condition of complaint
5. Treatment/Diagnosis Order Sets - Used to standardize and expedite care orders for a common clinical diagnosis.
6. Prep (aka Pre-procedure or pre-operative) - Used to prepare a patient for a procedure or operation.
7. Recovery (aka Post-procedure or post-operative) - Used to recover a patient from a procedure or operation.
8. Convenience Order Sets - Used for another common clinical scenario, other than those in 1-7 above (e.g. nursing protocols, heparin titration protocol, alcohol withdrawal protocol, insulin titration protocol, vent liberation protocol, etc.)

More complex physician order sets may fall outside one of these categories.

III. OWNERSHIP

Order sets are typically owned by a defined clinical director.

IV.  CONSTRUCTION

Order sets should generally be constructed by a person trained/experienced in building order sets (e.g. clinical informaticist) in conjunction with a Subject Matter Expert (SME) and a Clinical IT Analyst.

V. TESTING

Order sets should be tested by all parties involved in the use and function of the order set. Generally, at a minimum :

1. One end-user physician should be able to understand and complete the order set
2. One end-user nurse should be able to understand and complete the orders from the order set

Additional users (e.g. Pharmacists, respiratory therapists, etc.) may be necessary for testing, depending on the type, complexity and goal of the order set. 

Testing needs shall be determined by the clinical Informaticist in conjunction with the chairperson of the Order Set Committee.

VI. APPROVAL

After testing is completed, the order set may be brought to a committee for approval. The chairperson of the Order Set Committee will put the order set on the agenda, and allow a period of comments from voting members before the order set is brought to a vote.

Voting will be conducted by the Order Set Committee Chairperson.

If the order set is approved by committee, the chairperson will forward the order set to the Clinical Analysts for publication.

In the event of a tie vote, the order set will be brought to the Medical Executive President for further discussion or placement on the Medical Executive Committee.

VII. PUBLICATION

After approval by committee, the order set will be published for use :

1. An electronic version will be published in the EMR Order Set Catalog.
2. A paper version will be published into the Emergency Downtime Order Set Folder
3. An electronic version will be published in the Printshop Order Set Catalog, for creation of any paper order sets needed for remaining paper functions.

VIII. EDUCATION

After publication, staff education on the existence, goal, and use of the order set is the responsibility of the owner.

It is helpful if users are made aware of order sets, how to use them, changes, and reasons for change.

IX. MONITORING

After publication, all order sets will be monitored by their owner.

X. CITATIONS

ISMP's Guidelines for Standard Order Sets : http://www.ismp.org/tools/guidelines/StandardOrderSets.pdf

The CMIO's checklist

So as someone who thinks a lot about the informational flows behind a hospital's day-to-day operations, I read a lot about people who are having challenges with "EMR governance issues".

The governance issues you hear about are basically related to change management and implementation issues. After you have an EMR, your training needs expand dramatically. You may need to engineer your paperwork differently. You have workflow issues to contend with, and decision support issues to tackle.

And the committee structure you had before your EMR may not hold up under the new workload demands. Make too small a committee, and you may not get the right input. Make too large a committee, and you may never be able to make a decision.

If the committee charters aren't well-designed, some committees will be overburdened, while others are looking for work to do.

And if you don't have the support to implement your basic tools, then the "ejection fraction" of your committees will drop. (E.g. the committee will decide on a new policy, but if nobody knows about the new policy, then the committee can make lots of decisions that don't really get executed on the floor.)

In short - it helps if you lay out a strategy for how to deal with all of these issues.

So I created this simple little tool, to help a CMIO (or CMIO-like person) figure out how to help orchestrate the "overhaul" to meet your new needs. I affectionately call it, "The CMIO's Checklist". (See the spreadsheet above for an idea of how to build your own.)

With this tool, you first have to come up with a list of your common paperwork design challenges. As an example, most hospitals generally struggle with the timely design, testing, approval, publication, and implementation of the following :

1. Clinical Policies (ALWAYS ON) - A statement describing an organizational standard. Commonly fall into standards for patient care (clinical policies) and employees/non-clinical functions (administrative standards). Typically published through a printshop or an electronic site.)
2. Procedures - Tools which include the detailed steps on how to achieve an organizational standard or defined goal. Typically published attached to a policy statement or in a separate procedure manual.
3. Guidelines - Tools more flexible and negotiable than a policy that are used to outline desired actions and outcomes of therapy.  
4. Clinical Protocols (ON/OFF) - Tools used to standardize and automate care for a common clinical scenario, containing those conditional (IF/THEN) statements that allow a nurse, pharmacist, or other licensed medical professional to start / modify / stop a patient care order on behalf of a physician. All conditional (IF/THEN) statements in a protocol should refer to a discrete, well-defined data element. Protocols are primarily activated/deactivated by a physician order, or in some scenarios by a clinical policy. Common examples include : Heparin Protocol, alcohol protocol, PPI substitution protocol, etc. Protocols are typically published through a printshop or an electronic site.
5. Order Sets -  Tools which include a grouping of orders which can be started / modified / stopped by a physician, used to standardize and expedite the ordering process for a common clinical scenario. Typically categorized as either admission order sets, diagnosis order sets, or convenience order sets, and commonly published either through a printshop or an EMR.
6. Orders - Tools used to instruct a licensed person to deliver a defined type of care to a defined patient at a defined time in a defined manner for a defined duration. Medication orders, referring to the delivery of medications, are typically compiled in a medication formulary and are commonly published via printshop, electronic site, or EMR.
7. Clinical Documentation - Tools used to record and sometimes transmit information about a patient's history, activities, therapies, and responses in time, legally authenticated by a licensed medical professional. Commonly includes notes, checklists, forms, flowsheets, tables, fields, images, movies, and other media. Clinical documentation is typically published through a printshop or an EMR.
8. Templates - Tools that help expedite and standardize the creation of a document.
9. Staff Education Modules - Tools used to educate staff about a common clinical scenario, often including text, slides, videos, recordings, and other media. All staff education modules will include at least three competency questions. Typically published through a printshop or an electronic site.
10. Patient Education Modules - Tools used to educate patients about a common clinical condition or activity, often including text, slides, videos, recordings, and other media. Follow-up questionnaires are recommended. Typically published through a printshop or an electronic site.
11. Staff Schedules - A tool used to define which staff member(s) is/are responsible for a specific type of care at a defined date and time. Typically published through a printshop or an electronic site.

Then, going down the left-hand border of the CMIO checklist spreadsheet, are the following questions that everyone goes through when creating any tool:

1. What is the definition and main purpose of this tool?
2. Who owns this tool?
3. Who builds this tool?
4. Who tests this tool? (Director of Regulatory Affairs? MD? RN? Clinical Director? Risk Management representative? CMO? CNO? COO? What committee(s)?)
5. Who approves this tool? (Med Exec Committee? Forms committee? P&T?)
6. Who codes this tool? (Who comes up with the coding scheme for this tool?)
7. What coding schema do you use? (E.g. a number like #2.12 or ABC-123?)
8. Who publishes this tool? How will your staff be able to find it to use it? In a common place?
9. Who tracks this tool? (What database tracks the tool, it's code, and its approval date?)
10. Who educates/implements this tool? (Who is responsible for spreading the word that a new tool has entered your clinical arena?)
11. Who monitors this tool? (Who looks at the tracking database and checks your quality data to look for problems with the tool or its design process?)

Building and completing a CMIO's checklist is a good way to :

1. Generally figure out where your informatics issues may arise, after you go-live with your EMR.
2. Generally figure out what committee(s) you will need to approve the maintenance of these tools, and how to build those committees.
3. Help your committee chairpeople to better define their charters.
4. Help your middle managers know who is responsible for each part of each tool, when they need to make changes to the clinical setting.
5. Help the people who design these tools understand the definitions, so that you don't have the "feature bleed" problem I've talked about in previous posts.
6. Help employees understand the role(s) they play in the overall functioning of your organization.

You will probably want to try completing one of these BEFORE you go-live with your EMR. If you don't, you may have to adjust your governance issues AFTER your go-live.

Remember - Every hospital will have slightly different definitions of these tools, and fill in different titles and committees into each of these boxes. Why? Because unfortunately, there are not universally standard policy-worthy definitions for each of these tools - CMS and Joint Commission curiously don't seem to endorse definitions - I'm not sure why. (What I've written above is just my own example - You may need to adjust the definitions to suit your needs.)

Enjoy! Hope it helps! Remember, your mileage may vary!

The bad news about CPOE and clinical protocols

So this week, the ONC released the final "Meaningful Use" rules. I'm still going through them, but in general, the response has been pretty warm. A lot of the regulations have been relaxed. Still, the overall message : Your hospital will still have to meet "Meaningful Use" if it expects to benefit from the government reimbursements.

So since I had a few free minutes, I thought I'd share the bad news about the conversion to CPOE. Wait - You probably already know. It's hard.

To get CPOE running effectively, you need complete organizational buy-in :

1. Front-line buy-in, to help design meaningful order sets and implement them.
2. Administrative buy-in, to help redesign committee structures and EMR governance, enforce the new rules, and help develop the flexible budgeting required for successful implementation.

And here's the hard part - CPOE is a major culture change for the culture of medicine. Some of our most sacred traditions start to fall apart in a CPOE culture.

"Like what?", you ask?

1. The order "Advance diet as tolerated" - You may have read this in medical school, or in your nursing textbook, but the truth is, this is essentially a protocol. In the paper world, it works reasonably well, because in most patients, nurses can figure out how to advance a diet, and what kind of diet to advance to. In the CPOE world, however, this generally becomes a clinical protocol. In the end : You may need the governance structure to build and approve this protocol.

2. The order "Up ad lib" - You may have also read this in medical school, or in a nursing textbook, and many nurses will tell you "That's part of our practice" - The problem is, in the CPOE world, this also becomes a bit of a clinical protocol. Again, it generally works in the paper world, because in most patients, nurses know how to ambulate someone safely. But in the CPOE world, it requires a better level of definition, and also often becomes a protocol. In the end : You may need the governance structure to build and approve this protocol.

3. The order "These orders only are active in the ED" - This type of order is also really a protocol, which basically instructs : "If the patient leaves the ED, then someone needs to discontinue these orders". This works in the paper world, because nurses (seeing this in an order section of a paper chart) will generally know which orders this statement refers to, and nurses elsewhere will then ignore those orders automatically. In the electronic CPOE world, however, it requires a protocol to make sure someone has discontinued the orders properly. In the end : You may need the governance structure to build and approve this protocol.

Yes, some of these most cherished traditions start to fall apart in the CPOE paradigm. See any of them in your current paper order sets? You can translate them to the CPOE world, but you will need to build a more robust way of accomplishing this same functionality - Unfortunately, it's not that easy to find evidence-based rules for developing these protocols.

Your alternative is to develop order sets without any clinical protocols. These will be easier to implement in clinical specialties which are in-house 24 hours/day (e.g. Hospitalists, ED, ICU, etc.), but will be more challenging for surgical specialties and others who manage outside practices. (E.g. they will get phone calls that they weren't used to in the paper world.)

This is why you will need workflow experts in your organization to help understand the exact details of these workflows, and help you develop your clinical protocols along with your order sets and CPOE. Doing them separately is a much more complex process.

So how does a small hospital tackle these challenges? This is tough! The government (and vendors) don't talk a lot about this part of the process - I can only repeat the mantra : "Installing an EMR is nothing at all like installing Microsoft Word into your home computer" - You should be prepared for significant cultural and organizational changes.

In the end, my honest feelings : An EMR will definitely help you organize and understand your own clinical processes. The lessons you learn are invaluable. The quality and control it can bring you are priceless. But you have to be prepared for the level of change. Are you prepared?

In the end, an experiences CMIO or other informatics professional can help you organize all of these changes. My advice : Doing this without expert help is a little bit like turning a battleship around in a bathtub - You *can* do it, but it's much easier to do with an experienced and knowledgeable navigator.