Rethinking electronic documentation filters

"Life is a series of hellos and goodbyes, I'm afraid it's time for goodbye again..."
- Billy Joel, Songs in the Attic, 1981

So I was thinking more about the challenges with electronic documentation. As I mentioned in my last post, I'm thrilled that people are going to be seeking ways to transmit notes to each other, but I'm just not convinced we have agreement about *what* to send and *when*.

The problem is that healthcare reform is going to center around documentation. So documentation is going to become more important than ever. Knowing :

1. What and when to document - and...
2. How to find the right information quickly

... is becoming a key survival skill for hospitals and doctor's offices.

So for today, I wanted to ponder #2 above - (I'm going to ponder on #1 in my next post...)

As part of my job, I teach docs about how-to-find-the-information-they're-looking for. Most EMR software has some system of "filters" you use to narrow down your search to exactly what-you-need.

Sometimes those filters, and learning to use them, can be a little complex, and it's not always the most intuitive. So I wondered - How can we make it more intuitive? I wondered how *I* would graphically re-think a chart - If the chart is all about a patient's life, then why not start with a simple timeline?

(Of course, since we don't really ever know when the end will be, we can just assume the line will have "TODAY" listed on the other side from "START".)

Anyway, during our lifetimes we will all have interactions with people - That's what we want to record. The goal of the medical chart is to document all those interactions.

Some relationships will last for varying lengths of time, all generally starting with a "HELLO" and a "GOODBYE".

It's funny - I think as human beings, our brains tend to remember the "Hellos" and "Goodbyes" much more than we remember the stuff in-between. Anyway, in clinical terms, that "HELLO" is either an "Admission H&P", an "Intake Note", or some sort of a "Primary Evaluation" - And the "GOODBYE" is a "Discharge Summary", "Transfer Note", or some other type of "Signoff Note"  :

But of course, if you're following that person regularly, you check in from time-to-time throughout the duration of your relationship. In "best-friend" terms, that's a "stop-by-for-a-visit" or "chat on Facebook". But in clinical terms, these "check-ins" are your progress notes :

The challenge then in documenting your life is that you will have to manage the information about these sorts of ongoing relationships for many people in your life :

And so if they all have an Admission-type note, several progress notes, and a discharge-type note - You already have a large amount of data to keep track of.

And making things more complex is that other people in your life will only be brief but still-important encounters - The cashier you met while withdrawing money while on vacation, the dermatologist you saw once to burn off a wart... Some of the people you interact with in your life will just be single encounters :

Finally, I think it's also important, when re-thinking the medical record, to remember that a patient's life will be punctuated by changes in level-of-care. As long as you have some kind of health coverage, you will always be in one level-of-care or another. (It's even debatable - If you have no insurance, could you still be in an "outpatient setting"? Deep philosophical questions for the healthcare informaticist!) So if we look at the patient's life from this level-of-care perspective, there are definite punctuations which are immediately useful at understanding clinical activities in time :

And so, whoever tries to comprehensively document the life of a patient will have a very complex issue to untangle - Who documented what, and when? :

Fortunately, I think most people think intuitively when inquiring about a patient's life - You either want the whole story, or a part of it. And how much you ask for will depend on your need. Want to admit them for a psychiatric admission? You might be interested in their first childhood pediatric notes. Have a "frequent flyer" you know well? You might just want the notes from the last few levels-of-care. And with computers, it's fairly easy to draw a box over the time period and notes (colors) you want :

Of course, this is somewhat of a jumbled mess - But if the user could help arrange the order of the colors they wanted, they could sort out the mess (by their own individual preference), and then by dragging one box :

... you could quickly select :

1. The timeframe you need (X-axis)
2. The notes you need, by your general and immediate preference (Y-axis)

Of course, the colored lines above make it sort of complicated (would some users interpret this to mean the patient had all of these people in their lives throughout the duration of time?), so maybe you would prefer to be able to check off the notes (by profession) you want, as you make your query for documentation :

... and so in this way, you could quickly get to the notes you want - In time, using levels-of-care as a marker, and by specialty. (But remember a common problem with electronic documentation : Sometimes you WANT the doc to see "REALLY IMPORTANT" stuff from a specialty they didn't think to look for, e.g. Case Management, physical therapy, chaplain services - In the paper world, those "REALLY IMPORTANT" things were usually done as a "sticker on the chart" or something like that... It's a little trickier to do that sort of thing with an electronic chart. Who gets to decide what's "REALLY IMPORTANT"?)

OF COURSE, making this sort of a search filter available for your own medical record would depends on some of the following factors :

1. Having a common (or at least steady) patient identifier, so that someone will be able to assemble all the documentation from all of these different clinical people you interact with.
2. The ability to mark documentation with not only the author, but the profession/specialty they represent.
3. Being able to mark changes in level of care across a healthcare delivery system.

... so I'm not counting on seeing this in any software tomorrow - But I think it's potentially another way to look at the mass of information about a patient and quickly get what you want in an intuitive way.

REMEMBER : WITH FREE OPINIONS, YOU GET WHAT YOU PAY FOR. :) Always glad to hear from people - Feel free to leave thoughts and comments! :) In my next post, I'm going to ponder about "How much documentation is enough?" - Stay tuned! :)

Common EMR Training Tools

So now, back to my post about common EMR training methods.

When you plug in an EMR into your hospital environment, one of the biggest mistakes (challenges?) is the underestimation of training needs. Hospitals sometimes budget for money around the go-live. In reality, the training budget usually increases as time goes on. (This is one of those "Hidden costs of EMR implementation" that many hospitals don't prepare for.)

So I thought I'd talk about what some common educational tools are, that front-line informatics departments use to accomplish this feat. They include :

1. Department meetings

2. Emails / Paper mailings

3. Posters / Screen savers / Billboards

4. CBT (Computer-based testing)

5. Clinical Superusers

6. Train-the-trainer

7. Classroom instruction

8. One-on-one instruction

9. Electronic Decision Support (Alerts / Order Sets)

10. Clinical Managers / Directors

Each of these tools has distinct advantages and disadvantages. I thought I'd go through each one and offer some insight.

1. Department Meetings - Department meetings are a good way of getting people to your training - They're not good for much more than that. Trying to communicate how to operate a particular software feature, at a meeting when most physicians/nurses are coming in late, or looking for coffee, is generally a poor way to get across proper EMR technique.
2. Emails / Paper Mails - Like Department Meetings, emails suffer from a few challenges. First, many doctors have such a high noise-to-signal ratio that emails and paper mails almost never get through. (Notice the stuffed paper mailboxes? Physician email boxes are usually pretty similar.) Next, mail suffers from a lack of feedback - Did the physician actually learn the educational objective? How do you know they spent the time to actually properly understand the objective you were trying to get across? As a result of these problems, both paper and emails are notoriously bad for trying to use as an educational tool. My advice : At best, use them to get your staff to the training you set up. Don't mistake them for a training device.
3. Posters / Screensavers / Electronic Billboards - It's tempting to consider screensavers and electronic billboards for training - One powerpoint slide, seen intermittently around the hospital, might communicate the educational objective! The problem : You can't really guarantee it's seen by everyone. If the electronic billboard is in your cafeteria, then you'll miss employees who don't get lunch in your cafeteria. If the billboard is by the front entrance, then you'll miss employees who go in the back entrance. And like email, there's no way to know if your clinical staff learned the educational objective. Posters take more time to create, but work by the same principle as screensavers and electronic billboards, and so they suffer from the same geographic limitations, and also don't have a way to determine if the educational message has been received by your clinical staff. My advice : At best, use them to augment your training. Don't mistake them for a training device.
4. CBT (Computer-based testing) - Computer-based testing (e.g. having little computer-designed tests on your web server) is amazingly tempting. Clinical staff can do the tests at work, or at home. The software packages usually let you track which employee has completed which module, so you'll have great data on who completed their training. The downside is that the development of CBT (Computer-based tests) is much harder than it looks. There is a lot of programming and media development that goes into making a single CBT. So while most people dream of being able to save on teachers, usually they end up paying for people to develop the CBT. My advice : This can be very effective, if you plan resources to set up and maintain the CBT site. Don't underestimate the challenge.
5. Clinical Superusers - This is one of the most misunderstood terms in EMR education. Some people perceive "superusers" as non-clinical staff who wander around your hospital, usually during the month before and after your EMR go-live, to help "answer questions" and provide on-the-spot remediation. Other people perceive "superusers" as clinical staff who are just "really good with computers" and maybe got "extra training", so they could help the clinical staff who aren't as quick to learn. My advice : If you plan on using superusers, plan their time budget carefully. If your superusers are clinical people, and they have a full clinical load, they will not have much time to help your other staff. If they are non-clinical people, it will cost you money. Prepare a superuser strategy carefully, and prepare to spend money on them.
6. Train-the-trainer - This is also often mistakenly confused with "superusers". Train-the-trainer, done properly, can be a very effective way at educating a large number of clinical staff quickly. It involves a single person developing an educational tool (e.g. a quiz, usually with 4-5 questions, which tests whether or not a clinical member understood the training. Then the primary trainer needs to go out and find, usually, 5-10 secondary trainers. The primary trainer then teaches the secondary trainers how to teach the educational objectives, and give the clinical staffmembers the quiz designed by the primary trainer. The secondary trainers then go out, and usually complete this short education module with another 5-10 clinical staffmembers each. In the end, it distributes the teaching load, and as each secondary trainer comes back with successful quizzes, they bring it back to the primary trainer who can then keep track of "What percent of our staff completed the educational objectives?". My advice : This is a little like guerilla training. It can be very effective if done properly, but try to save it for the emergency, "Every-doc-has-to-know-this-feature-by-next-month-or-they-won't-be-able-to-sign-into-our-system"-type problems.
7. Classroom Instruction - Classroom instruction seems like a good way to train clinical staff. The problem is that often it's hard to get the clinical staff to the classroom, and if they don't have non-clinical time budgeted, their attention span and patience will be minimal. If you plan on using classroom time, make sure you have a well-developed curriculum, and you budget time and resources so that your clinical staff can learn in a relaxed atmosphere. Another challenge with classroom instruction, in the modern hospital, is that you generally end up running classes at all shifts - Don't forget your night staff if you're doing classroom instruction. My advice : This is a mainstay of teaching in hospitals, but it has its flaws and problems. Make sure you budget time and resources effectively, and develop a good educational curriculum, and keep it short and concise. My advice : Use this as a workhorse-type solution, but don't think it's going to solve all of your training needs.
8. One-on-One Instruction - This is often perceived as a nightmare (How can we have the time and budget to have a trainer do one-on-one instruction with all of our clinical staff?), but in the hands of a real teacher, this can be enormously effective. It involves one teacher sitting down with one clinical staffmember, and going through a set of educational objectives. Think of it as "your tutor" in high-school. One-on-one is certainly not good for large-scale training (e.g. all your clinical staff in the next month), but can be useful for small amounts of very intense, personal training. In my experience, one-on-one can be very helpful because as a teacher you can really perceive the learning problems and adjust accordingly. You'd be amazed what clinical staff will confess when they are learning one-on-one. My advice : This is good for "problem cases", and good for "brush-ups", but definitely won't work for major software updates or major workflow changes.
9. Electronic Decision Support (alerts / order sets) - Some people point to alerts in the software as an educational tool, e.g. "We'll just make a pop-up window that tells the doctors what not to click on". This is a major mistake. A pop-up window is not training. At best, it can help educate a doctor about a possible problem. At worst, your clinical staff may be suffering from alert fatigue, and ignore the alert entirely. Some people look for other electronic decision support (e.g. order sets) as a possible educational tool. While some order sets can be useful in educating your staff (e.g. is there a new antibiotic that you should be using for UTIs? Change the UTI order set to the new antibiotic!) - The problem is generally that EDS is not well-understood by most hospitals, and at best it helps guide clinical staff towards successful navigation of a small workflow issue. My advice : It helps a little, but definitely don't count on alerts or order sets to educate your clinical staff.
10. Clinical Directors / Managers - While some people don't focus training on clinical directors or managers, mistakenly thinking "only the front-line staff will need to know how to use the EMR!", I can tell you this is a big mistake. Clinical Directors and Managers are exactly the support people that the front-line staff go to for help. If your clinical directors and managers aren't familiar with your EMR software and workflows, then they won't be an effective resource for your front-line staff. My advice : Make sure you have a teaching strategy set up for your clinical directors and managers, and make sure they learn your EMR software. They can be a tremendous asset to the educational process, and in general, departments where the manager feels "I don't need to learn to use the software!" have very poor EMR implementations. The directors need to learn the software so they can be an educational resource for front-line staff.

So what have we learned? "Dirk - None of these sounds that great...." You're right! None of them are perfect. This is why EMR training requires a combination of all of these tools. And to know how much money to devote to which tool, you'll need an EMR educational strategy, which generally includes EMR policy development in your institution.

And how will you develop that EMR educational strategy and EMR policy? By having a good clinical informaticist (or CMIO) to help you with the entire EMR implementation. Remember : Good informatics starts at the budgeting process. Make sure you get expert help early, and don't underestimate the challenge of training and education in the EMR environment. Remember, as I said - The challenges generally get harder after your EMR go-live. Outsourcing training generally doesn't work well, because only in-house trainers will really know your culture and know which tool to apply to which problem.

Hope this was a good overview for folks! Write me with any questions!

Why don't the order sets work anymore?

One of the most frequent questions I get asked is :

Q : Why is it so hard to make the paper order sets work in our electronic EMR?

Sometimes, this is accompanied by stares of disbelief, or better yet, a suspicious glance, wondering if I'm 'just making this up'.

Here's the sad truth : No, you can't just put the paper orders on the computer screen and make them work.

Why that is, is a complex answer. I'm going to share two simple ways of looking at it.

THE LINGUISTIC ANSWER :

Some people have tried to equate the electronic world and the paper world as "two different languages" - Anyone who has ever tried to translate between two languages will show you how difficult it is to translate idioms. E.g. "Hit the Road!", "Drop Dead!", "Happy as a clam!" are all idioms that don't translate too well into other languages.

This is where you see the cultural differences between electronic medicine and paper medicine - It just doesn't translate well.

The problem with this example is that people who aren't bilingual won't really appreciate this difference. (Many people seem puzzled to find out that the best interpreters are only about 95% accurate... Usually, 90% is good enough for most communication, so it generally works.)

THE INFORMATICS ANSWER : (Easier to understand, trust me!)

The Informatics answer to this question requires one to understand some basic premises of information science.

1. An order set is a group of lab and medication orders which can either be ordered, or not, depending on a physician's or nurses's decision when they execute the order set.

2. Clinical Documentation is something your clinicians will write on a piece of paper, or a form, to document what's going on with the patient.

3. Clinical Protocols are essentially "if-then" instructions that tell your staff how to react in a particular patient situation, to achieve a certain goal.

So here's the problem most people face when trying to translate from the electronic world to the paper world : Most "paper-based" hospitals have paper order sets with pieces of documentation and clinical protocols built into them.

Q : Huh? How is that possible? My order sets have policies and documentation built into them?!?

The truth is often : Yes.

Q : How did that happen?

Basically - Paper is flexible. You can write anything you want on it.

Computers are much more fussy about :

1. Where protocols go (read-only)
2. Where documentation goes (read/write, for your clinicians to use)
3. Where order sets go

Q : I'm still not sure I get it.

Let's look at this another way.

• On paper : [Protocol + Order set + Documentation] = All on one sheet of paper, often labelled "Order Set"
• Electronic : [Protocol] + [Order set] + [Documentation] = All go in different places in your EMR.

Q : So what do I have to do, then, to make my paper order sets electronic?

It takes work - To fix this, then, means someone has to separate your paper order sets into :

1. Clinical Protocols
2. Order sets
3. Documentation (Notes, forms, etc.)

Q : Can you give me some examples?

Sure. Let's make up a hypothetical order set - Not based in reality, I assure you, but not uncommonly seen before a hospital "goes live with CPOE"...

Sometimes on a paper order set you will see things like this :

[Line 1] ( ) Tylenol 650mg PO q6 hours PRN mild (1-3) pain

[Line 2] ( ) Percocet 5/325 (1) tab PO q6h PRN moderate (4-6) pain

[Line 3] ( ) Morphine 2mg IV q30 minutes PRN severe (7-10) Pain

[Line 4] These orders are only to be used in Emergency Department!

[Line 5] ( ) If O2sat is less than 85% check ABG STAT and call MD.

[Line 6] Please assess vitals and assess respiratory rate : ________ breaths/minute

[Line 7] If patient respirations less than 10 then give Narcan 0.4mg IV x1 dose STAT and call MD.

Let's examine this hypothetical order set above...

• Line 1 = Fine order. No problem putting this into an electronic order set.
• Line 2 = Fine order. Again, no problem.
• Line 3 = Fine order. Glad to see pain levels specified for patient safety! Again, no problem.
• Line 4 = Problem. By saying "These orders are only to be used in the ED", this is technically a clinical protocol. Essentially, it tells a nurse : "If the patient is discharged from the ED, these orders must be discontinued by a nurse."
• Line 5 = Similar problem. This is actually a clinical protocol. Needs to be written into a separate document, instructing a nurse what to do if the O2sat drops below 85%.
• Line 6 = This is also a problem, because it's clinical documentation. Needs to go on a separate form to work with this order set.
• Line 7 = Another clinical protocol. It also suffers from the problem : How do you execute an order for Narcan at some point in the future, when you're running this order set now? Again - This needs to be a clinical protocol.

So to fix this paper order set would require designing new documentation and new clinical protocols to function with this order set. You typically end up making a whole lot of new clinical policies and documents and need the committee structure that can handle this in a nimble way. Phew!

Q : This seems like a lot of work, isn't there some simpler way to do this?

It is a lot of work! And there isn't a really simple way to do this. If there were, hospitals wouldn't often look for specialist help to convert to the electronic world.

Next article, we'll talk about "Why didn't the vendor give us order sets that work?!?!". Stay tuned. :)