Some Factors Underlying Efficient Change Management

Recently I had a great discussion with a non-healthcare person about the role of Informatics in EMR implementation, and what kind of things CMIOs look for to estimate whether a particular EMR implementation will be successful or not.

The discussion was a great opportunity for me to really think about the big picture issues, and try to distill them into something more tangible to a non-healthcare, non-informatics audience. 

What it finally came down to, for me, was the successful planning and budgeting for the whole EMR implementation - both the go-live, and the eventual optimization and continued maintenance that come afterwards. It's not unlike buying a car - To be successful at car ownership, you have to budget for both the car (necessary at go-live) and the gas/maintenance (necessary after go-live to make the car go forward) :

While researching for this blog post, I found out this is one of the reasons why the mandatory price stickers on all new cars (known as the Monroney sticker) must contain both the price of the car and an estimate of the gas mileage :

Not only does this allow consumers to select cars with better fuel efficiency, it also helps a consumer answer the question "Can I afford this car?" before they actually buy it - A major factor for successful car ownership.

With most healthcare technology, it's pretty easy to budget for the car - vendors know this number well - but it's not as easy to budget for the gas. Vendors will often estimate the cost of optimization, upkeep, and maintenance for you, but how do you really know if their estimate is correct? Will you see the same gas mileage in your experience?

This then raises the question - What exactly are the factors that go into 'gas mileage' for an EMR? CMIOs, CNIOs, and other Informatics professionals struggle with these questions all the time, because they are important to help budget for successful EMR implementation :

• Budget well for the ongoing optimization, maintenance, and upkeep - And your EMR implementation will likely be successful.
• Budget poorly for the ongoing optimization, maintenance, and upkeep - And your EMR implementation may be fraught with struggle.

What experienced Informatics professionals know is that a large part of the 'fuel-efficiency' of EMR ownership comes from the organizational change management - How well-suited is the organization to make change? Does it contain the infrastructure and configuration needed to support efficient change management? 

These change management issues are so key to EMR implementation that in 2013, the website www.HealthIT.gov published this great primer on EHR change management :

https://www.healthit.gov/sites/default/files/tools/nlc_changemanagementprimer.pdf 

 ...which provides a great high-level overview about change culture, along with some fantastic references. (A helpful document and a must-read for any healthcare executive considering an EMR installation or replacement!)

But what are the other factors that experienced informatics professionals look for in change management? Are there other factors to look for that help better estimate your gas mileage, and thus your eventual cost of ownership? To help share some insights, I've created the following table, with some factors that I believe influence an organization's ability to manage change efficiently - In estimating the price of your gas, some factors to consider (in no particular order) include : 

While this list is by no means comprehensive, these are some of the bigger factors that experienced Informatics professionals consider before advising organizations how to best budget for their EMR implementations.

In the end, enterprise EMR success depends on correctly budgeting for the purchase, maintenance, and upkeep of your technology. It's not just your go-live that matters. Knowing the price of both the car and the gas before you invest will help you have a successful long-term implementation.

This post is for educational and discussion purposes only - Please consult your own Informatics professional before budgeting for any technology purchases. If you have any feedback, thoughts, or other factors to consider, please leave them in the comments section below!

Problem Lists - What exactly is the "Past Medical History"?

Hi readers,

Happy 2016! For today, I'm going to try to tackle an interesting conceptual and terminology issue around problem list management, and how it relates to the Past Medical History (PMHx).

Many people, working to optimize their EMRs, work hard to try to 'curate the problem list' - WIthout good curation, problem lists can become very lengthy, and include issues like "Cough" under Past Medical History - 

1. Some people see this as a failure of HealthIT ("Why is cough under the Past Medical History, when it's not a diagnosis?") - 
2. Other people see this as a failure of the doctors using the system ("Why didn't anyone remove cough from the Past Medical History?") - 

What I find particularly interesting about this discussion is the wide variation in practice, when I read admission history and physicals. I think most docs, billers, and coders believe that, on admission, the doctor should document whatever the 'acute medical issues' or 'active medical issues' are - But what do these terms mean, exactly?

1. If a patient with stable diabetes is now admitted with cellulitis, and the doc continues the diabetic medication - Should diabetes be on the active medical issues list?
2. Or should the doc only code for the cellulitis?

In discussing this many times over the years, I find that many docs use the terms 'active medical issues' and 'acute medical issues' almost interchangeably. Are they really interchangeable?

So I Googled the terms "Active Medical Issue" and "Acute Medical Issue", and found a number of good articles, including this 2010 post by A Country Doctor on Kevin MD and this excellent 2005 discussion on Past Medical History by John Gazewood, MD. Finally, the US National Library of Medicine offers this good explanation of acute versus chronic conditions.

But how are acute and active medical issues different? While these are are all good treatises on medical issues, I was wondering if I could approach this from a design standpoint, as a physician informaticist, with good conceptual definitions for the terminology, to make sure there is real clarity around the discussion. 

So, in trying to tackle this informational design issue, I've hammered out the following DRAFTED definitions, depicted on the following two slides, for your examination and discussion (the same concepts are on both, but each is displayed slightly differently) :

Slide 1 - "Bucket" depiction

Slide 2 - Same concepts, different depiction

I created these slides to try to create conceptual 'buckets' that problems/issues could easily fall into, allowing physicians to move items from one bucket to another as the patient moves from one provider to another - And then labeled them with terminology (and synonyms) that I believe best fit the concepts. (Please use your own judgment before adopting any of this terminology.)

What these slides do, however, is shed some light on why maintaining the problem list is more challenging than you might expect. It requires enormous clarity just to discuss the issues, and then when you examine the concepts in detail, there seems to be some breakdown in the definition of "Past Medical History". 

For example, in the scenario where the patient with stable diabetes is admitted for cellulitis - On writing the admission H&P, a doctor might code for both the Unstable (Acute) issue ("Cellulitis"), and the Stable (Chronic) Issue ("Diabetes, Type 2, Controlled"), since he/she has made the active medical decision to continue the diabetic medication while treating the cellulitis. 

However, on discharge, what do you do with these two Current(Active) issues (Stable and Unstable) in the EMR? 

• The cellulitis might be moved to the Prior(Inactive, Resolved) Issue list, but 
• the diabetes is still a Stable (Chronic) issue - which falls under the category of Current(Active) issues - 

So the problem is that, I suspect, most doctors would conceptually define "Past Medical History" as the items found in these three buckets : 

1. Prior Procedures
2. Prior (Inactive, Resolved) Issues
3. Stable (Chronic) Issues - which conceptually falls under the category of Current (Active) Issues - 

It's the incongruence between "Past Medical History" and "Current (Active) Issues" that I find most interesting - Past isn't really in the past, if it's still in the present. 

It's also interesting to note that the commonly-used term "Reason for Admission" typically only includes issues that would fall under the Unstable (Acute) issues bucket - But the Admission H&P typically includes more issues, especially if they involve active medical decision-making (E.g. both Unstable (Acute) issues + Stable (Chronic) Issues)

In practice, I find many docs will only include as many Stable (Chronic) issues as time (and patient census) allows - It's interesting to ponder how this impacts coding and billing on the national level.

Finally - I believe these slides support the argument that the terms "Active Medical Issues" and "Acute Medical Issues", although related, are in fact not interchangeable. (I suspect that Acute is really a sub-type of the concept of Active medical issues.)

While my post today doesn't have any great answers, I hope these slides, and this discussion, have at least shed some light on the concepts and terminology surrounding problem list management, and how they impact EMR usage, coding, and billing on the national level.

Have any thoughts about problem list management? Leave them in the comments section below!