The Well-Tempered #HealthIT Department Index

Hi fellow CMIOs, CNIOs, workflow gurus, and other Applied Clinical Informatics friends,

I'm writing today to share an interesting design I developed to help HealthIT departments to better organize, understand each other, and share information in a more organized way.

Animated GIF for easy sharing

Coming up with an organizational index like this requires a lot of thought about :

• Q1 : What does it take to run a standard HealthIT department (for both large Academic Medical Centers that often conduct research/clinical trials, and non-Academic, community health centers)?
• Q2 : Who are the common team members (and teams), and how are they organized?
• Q3 : How do they work together?
• Q4 : Who do they serve, and how?
• Q5 : Is the departmental model scalable/expandable, as an organization grows (or partners with other organizations)?

In short - Many #HealthIT departments have a group demand for a lot of information sharing, but there's not a lot of consensus on exactly how to do this. While I've seen different attempts at 'organizing this closet', many of the designs I've seen are either : 

• [   ] too coarse (everything in one disorganized, central file space, with people using alpha-search and AI to try to find files)
• [   ] too granular (everything in filed in many separate, distributed folders, sometimes down to the individual user, with people using alpha-search and AI to try to find files)

The challenge is to find the 'goldilocks' folder structure, just intuitive enough that everyone can find their way around, and yet flexible enough to scale as an organization grows. Neither too many folders, nor too few, are desirable.

*Interesting side-note : For those of you who might be classical music fans - This indexing challenge is somewhat reminiscent of Bach's Well-Tempered Clavier, which was his answer to the 1700s question of 'Exactly how many notes do we need in a scale?' For more on this fascinating challenge, and how Bach solved it - and its long-standing impact on modern music - see this YouTube video : https://youtu.be/NCMrHkMCeXk 

So after a lot of discussion, review, and validation with other HealthIT and other Clinical Informatics leaders, I think I've come up with a fairly reasonable design for organizing all of this that is fairly simple, organized, intuitive, and scalable as an organization grows.

It's a simple hub-and-spoke model - One hub, and nine spokes. Remember - This is just a proposed model, and your mileage may vary. Let's look at them in more detail, for your consideration and feedback : 

A. THE HUB : Your #HealthIT Department (Leadership) Homepage

This is the primary welcome page for your staff to arrive in your departmental development space, and gives everyone one-step, easy-access to common departmental materials like :

• Important news and departmental announcements
• IT Portfolio
• IT Roadmaps (including Administrative, Clinical, Research, and Academic)
• IT Policies, Standards, Templates, Forms, and Terminology (this also includes departmental file naming conventions)
• AI Strategy, Governance Committees, and Oversight
• IT Intake and Procurement
• IT Org Charts

A1. SPOKE 1 : Your Administrative IT Application Dev/Support Homepage

This is where your Administrative IT Application team will support common Administrative systems, like : 

• Email Server
• Web Services (includes Intranet and Extranet services)
• Safety / Security Systems
• Human Resources (Timekeeping, Payroll, etc.)
• Official Document Management (e.g. Policies, Bylaws, Guidelines, Protocols, etc.)
• Finance Systems
• Revenue Cycle
• Billing Systems
• Provider Credentialing / Med Staff Office systems
• Other Credentialing / Human Resources
• Contracting
• Facilities Management
• Supply Chain / Procurement
• ... and other Administrative Systems

A2. SPOKE 2 : Your Clinical IT Application Dev/Support Homepage

This is an important page, and based on the informal, de-facto NIST/HITRUST-supported criteria for Academic Medical Centers, this is likely to contain support for : 

• Your Tier 0 systems (downtime tolerance=minutes), including your central Bed Monitoring, Telemetry, Secure Chat, Core EHR production, Pharmacy Systems (order verification, dispensing), Radiology PACS/Imaging Views, Laboratory Systems (e.g. critical analyzers), ADT/Identity/Registration services, and Clinical Authentication (SSO, badge-tap)
• Your Tier 1 systems (downtime tolerance=few hours), including your clinical documentation modules, OR scheduling systems, ED tracking boards, Clinical Decision Support engines, routine (non-STAT) results reporting, and Interface engines supporting clinical data flow
• Your Tier 2 systems (downtime tolerance = few days), including your Revenue cycle systems, billing and claims, Enterprise Resource Planning / Supply Chain, non-clinical scheduling, Data warehouses
• Your Primary EHR and common support teams, including core and 3rd party Pharmacy, Lab, Radiology, and other specialty systems for Inpatient, ED, Perioperative, Ambulatory Procedural Suites, Ambulatory Clinics, and Homecare functions
• Your 3rd Party ('bolt on') Applications in your various clinical areas, and the administrators / developers for each one
• Your Applied Clinical Informatics / Workflow Analyst Development Spaces (e.g. for your Ordering/CPOE projects, Workflow Projects, and Clinical Decision Support (CDS) project analyses)

Carefully planning this Clinical IT page, with cross-referencing hyperlinks, can turn this page from a file storage area into a knowledge base and tool of learning and understanding. 

A3 : SPOKE3 : Your Research IT Application Dev/Support Homepage

If you are an Academic Medical Center that does clinical research (clinical trials), this is the page for your team members who support your Research IT applications, including :

• Your Core Research Labs/Areas
• Your Independent Review Board systems
• Your Clinical Trials Management (CTMS) system(s)
• Your Research Compliance
• Your Research Committees and Governance
• Your High-Performance Computing (if available)
• Your Research Analytics Systems
• Your Data Science / Translational Science Systems
• ... and other Research systems

A4 : SPOKE4 : Your Academic IT Application Dev/Support Homepage

If you are an Academic Medical Center with an academic mission, this is the page for your Academic IT systems including : 

• Academic Administration Systems
• Academic Registration Systems
• Academic Scheduling Systems
• Academic Grading/Scoring Systems
• Learning / Simulation Systems
• Graduate Medical/Dental/Nursing/Pharmacy Education
• Continuing Medical/Dental/Nursing/Pharmacy Education
• Undergraduate Medical/Dental/Nursing/Pharmacy Education
• ... and other Academic IT systems

A5 : SPOKE5 : Your IT Project Management Office (PMO) Homepage

Most HealthIT departments of sufficient size have a formal Project Management Office (PMO). If you have a PMO, you will need a page for PMO team members (and the many people who interact with the PMO and active projects), so this page could include : 

• Project Intake
• Prioritization Rubrice
• Project Governance
• Project Utilization Dashboards
• Project Templates
• Project Development Folders/Spaces
• Other Project Management Office (PMO) Tools

A6 : SPOKE6 : Your Enterprise Technology (Infrastructure) Dev/Support Homepage

This is where your Enterprise Technology (Infrastructure) Development and Support teams could easily find folders and supporting materials for : 

• Platform & Middleware Layer Applications (e.g. Windows/OS, Citrix, Virtualization/VM Ware, Interface engines, batch jobs, schedulers, and data warehousing)
• Identity and Security Layer Applications (e.g. Active Directory, SSO/MFA, Certificate services, etc.)
• Network and Firewall Layer Applications (e.g. Wireless, switches, routers, VPN, firewall, etc.)
• Physical Layer Applications (e.g. HVAC, cooling systems, fire suppression, telecom, elevators, electric grid, backup generators)

A7 : SPOKE7 : Your Business Intelligence, Reporting, and Analytics Homepage

This is where your Business Intelligence, Reporting, and Analytics team members could support your : 

• Administrative Reporting and Analytics - E.g. for HR, Legal, Finance, Compliance, or other Administrative purposes
• Clinical Reporting and Analytics - E.g. for Clinical, Quality, Operational, Scheduling, or Billing/Operational purposes
• Research Reporting and Analytics - E.g. for Research purposes, Clinical Trials, IRB support, Research Compliance support, etc.
• Academic Reporting and Analytics - E.g. for Academic/Educational purposes, Academic research projects, etc. 

A8 : SPOKE8 : Your IT Security and Privacy Team Dev/Support Homepage

This is where your IT Security Team could find and develop important IT security materials including : 

• Role-Based Security Templates
• Incident Reporting
• Account and Access Security (includes Onboarding/Offboarding and Role Changes)
• Security, Privacy, and Data Protection Policies
• Governance Committees and Leadership
• Multifactor Authentication (MFA) support
• Single Signon (SSO) support
• Security Training and Awareness Materials
• Other IT Security applications and files

A9 : SPOKE9 : Your IT Customer Service & Support (Service Desk)

This is where your IT Customer Service and Support (IT Service Desk) Team members (and others) could easily access helpful materials like : 

• IT Support Ticketing Systems
• Triage protocols
• Self-Service / Quick fixes
• Escalation Pathways
• Major Incident Board
• Status Board
• Outages / Alerts
• Known Issues
• Requests & Lifecycle Services
• Lost Equipment Reporting
• Data breach Reporting systems
• Planned Downtime Policies
• Unplanned Downtime Policies

SCALING / GROWTH : 
Assuming your team chooses to adopt this model for your organization, you could easily expand/scale this model to additional partner organizations, through a simple set of hyperlinks from these pages, e.g. : 

• [ Organization A : Project Management Page ] 
• [ Organization B : Project Management Page ] 
• [ Organization C : Project Management Page ] 

In this way, each organization would have a clean page for their own unique needs, while keeping all of the Project Management pages closely linked and aligned in expectations. (This would allow you to gradually continue to align, as organizations mature.)

SOME FINAL THOUGHTS : 

This is just a sample model, that I thought I'd share for friendly review, discussion, and feedback. If nothing else, I hope this has been a fun and helpful journey navigating through the most common functions, teams, and roles of #HealthIT, and welcome feedback or comments from others who have already explored this journey.

Remember : This blog is for academic and educational discussions only - Your mileage may vary. Have any feedback or suggestions? Leave in the comments section below!

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.

Why Healthcare needs Clinical Architects

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

Some of you might already be familiar with #BlueprintsBeforeBuild, the hashtag I started several years ago (on X/Twitter, LinkedIn, and elsewhere) to help create awareness of the need for good workflow design in healthcare technology. 

You might also be aware of the value of having an Applied Clinical Informatics ('Clinical Architecture') team in Healthcare, to assist with things like : 

1. Project Intake or Procurements that require additional support or workflow evaluations, to help ensure the technology does not already exist, and to help ensure proper scoping, budgeting, stakeholder identification, resource allocation, necessary safety, compliance, and regulatory reviews, and expected outcomes.
2. Special Event Workflow Planning (e.g. Planned upgrades and maintenance, unplanned downtimes, project go-lives, etc.)
3. Complex IT Tickets that require workflow updates or modifications (which often span multiple areas with multiple stakeholders)
4. Complex Projects that require clinical translation, terminology work, stakeholder alignment, or other workflow updates/modifications
5. Ongoing Maintenance of existing configuration / workflows to meet CMS/TJC regulations, that require continuous staff engagement with multiple stakeholders across different areas and specialties. 
6. Helping to ensure clinical workflows are aligned with the Clinical, Administrative, HIM, Regulatory/Compliance, coding/billing, and revenue capture needs of the organization. 

So while my last post helped to ask and answer the question, "Where is the Clinical Informaticist?", this month's post is related to my support of an easy way to make Applied Clinical Informatics more familiar and tangible for newcomers - Instead of "Clinical Informatics", consider using the synonyms "Clinical Architect" and "Clinical Architecture" :

 

While some organizations have clinical staff (MDs, RNs, APRNs, PAs, Pharmacists, Lab/Radiology staff, and others) who are trained to configure computers, other healthcare administrators might question the reasons for paying a clinical team member to do this sort of configuration (building) : 

Q : "Why should we pay a doctor (or RN, APP, or other clinical role) to do this?"

In addition to the six deliverables mentioned above, there are other good reasons to pay clinical staff to be involved in your EMR go-live, configuration, and ongoing maintenance, including :

• Improved user satisfaction and workflow design (See this recent AMA article for a success story from TSPMG on the benefits of improved user engagement!)
• Improved upkeep of technology (to reflect continuously-changing medical literature and other clinical, regulatory, and billing standards)
• Improved utilization (ROI) and stewardship of your technology
• Improved quality metrics and revenue capture
• Improved patient care
• Improved patient satisfaction

... where clinical staff play an essential role in experiencing and understanding their workflows, translating their workflows, and maintaining their workflows. The questions then become : 

• Q : "Do we need clinical staff to build configurations?" ('Clinical Builder')
• Q : "Or do we need them to architect clinical workflows?" ('Clinical Architect')

While many clinical staff begin their HealthIT journeys focused on build - I would argue that there is a value in focusing their efforts on clinical architecture, rather than construction. Here's why.

Effective, predictable change management generally begins with a ten step process :

Generally speaking, these ten steps include : 

1. Documenting and understanding the change.
2. Analyzing, evaluating, designing, and scoping the change.
3. Prioritizing and approving the change project.
4. Building the project team (including stakeholders, deliverables, and timelines).
5. Designing blueprints for all EMR/Non-EMR deliverables (for discussions, tabletop exercises, edits, and to secure necessary buy-in and approvals)
6. Building the change (Analyst)
7. Testing and approving the change (future-state workflow)
8. Communicating and educating (training) the change
9. Implementing the change
10. Monitoring and supporting the change

After reviewing these steps, the questions then become : 

• Who supports each of these steps?
• Do your IT Analysts typically support step #6?
• If so, are your clinical staff then more useful in step #6, or in steps #2 and #5?
• Could any analyst time be saved in #6 with more informatics time spent in #2 and #5?

This may seem somewhat paradoxical at first, since many clinical staff initially gravitate towards building when they first get involved in healthcare technology. After all, it seems like a good way to get involved, learn about data structures, and get some control over the systems they use to deliver care to patients. 

But on closer inspection, I believe there's real value in focusing your clinical staff on architecture, rather than construction (build) : 

From Wikipedia : Architecture is the art and technique of designing and building, as distinguished from the skills associated with construction. And what connects architecture to construction is blueprints. (Note : For more about architecture, please also see this helpful Brittanica article.)

So for most clinical staff first getting involved in HealthIT, having some experiences with construction is very helpful. Unless they have some kind of a background in computer science, it's still very helpful (foundational) to learn about data structures, relational databases, indexing, and coding. 

But once they have this foundational understanding, I personally think their bigger value comes from using their clinical expertise to architect workflows using blueprints, rather than building (configuring) workflows. Here's why : The value of blueprints in construction is typically underestimated :

• Blueprints allow you to quickly mock up deliverables (e.g. the EMR and non-EMR deliverables that work together to support your desired workflow)
• They let you share your mockups with other clinical staff, to discuss, review, create tabletop exercises, make edits, and secure necessary buy-in and formal approvals.
• They let you then share your approved blueprints with your IT analysts (who can then quickly create the electronic deliverables in your EMR, e.g. orders, order sets, clinical documentation, alerts, charges, etc.)
• They let you share your approved mockups with other Clinical Leaders (who can then help create the non-EMR deliverables, such as policies, guidelines, protocols, schedules, training, budgets, etc.)
• Finally, blueprints can also help save analyst time while synchronizing your electronic (EMR) deliverables with your paper deliverables (downtime forms).

How can blueprints help save analyst time, while synchronizing your electronic and paper deliverables (for planned EMR maintenance / unplanned EMR downtimes)? They can do this because blueprints help to create clear understanding and discussions, and allow clear edits and revisions, that are necessary before you can secure the necessary buy-in and final approvals - Not just from your clinical staff, but also from your Legal/Compliance/Regulatory staff, Pharmacy staff, Nursing staff, Radiology staff, Laboratory staff, HIM staff, Billing/Coding staff, Clinical Leadership, IT leadership, etc. 

Having that level of clarity, understanding, and buy-in is very difficult to achieve after something has been built. (This is a common reason for IT Analyst complaints of having to build and re-build something before it's right.) So why not put your Clinical Architects (Clinical Informaticists) to work on blueprints, rather than build?

And so once your IT analysts are working on the electronic (EMR) deliverables, blueprints are then also very easy to convert to paper downtime forms :

So that process for creating synchronized EMR deliverables (from an IT Analyst) and paper downtime forms (from a Clinical Architect / Clinical Informaticist) can then look like this : 

How to use blueprints to create matching paper and electronic tools : 

1. Clinical Architect (Clinical Informaticist) will study and design the desired (future-state) workflow. 
2. Clinical Architect (Clinical Informaticist) will use templates to quickly mock-up blueprints for all deliverables. 
3. Clinical Architect (Clinical Informaticist) will use blueprints to review and share with staff and other stakeholders, conduct tabletop exercises, lead clear discussions, make necessary edits/changes based on feedback, and secure the necessary buy-in and approvals.
4. Clinical Architect (Clinical Informaticist) will share and discuss approved blueprints with IT Analyst, for building and testing of electronic deliverables.
5. Clinical Architect (Clinical Informaticist) will convert blueprints to paper downtime forms.

So to summarize, some key take-home points from today's discussion :

• There is real value in having (some) clinical staff engaged in the development and ongoing maintenance of your EMR and downtime processes (e.g. improved outcomes, improved user and patient satisfaction, improved quality metrics, improved revenue capture, etc.) 
• Clinical architecture (Clinical Informatics) is the art and technique of designing and building clinical workflows, a specialty distinct from (but intrinsically related to) IT Analysts (who commonly focus their primary efforts on construction).
• Clinical staff commonly begin their HealthIT career journey focused on building in an EMR, but their value can increase when they focus their efforts on clinical architecture (Clinical Informatics) and blueprint development.
• Blueprints can help save project and IT analyst time by creating the necessary discussions, understanding, buy-in, and approvals before beginning construction.
• Blueprints can also help synchronize your electronic deliverables with your paper downtime forms (by making it easy to create downtime forms with the same appearance, format, and cadence as your electronic deliverables).
• An easy way to improve clinical workflow design, improve outcomes and user satisfaction, save time, create clarity and understanding, and develop smooth downtime processes is to develop a Clinical Informatics (Clinical Architecture) team, and remember the hashtag #BlueprintsBeforeBuild!

For many of you, this discussion is probably just a refresher. For others, I hope this was a helpful discussion, for you and/or your clinical informatics teams. Please let me know your experiences, and feel free to leave comments and feedback in the comments section below!

Disclaimer : Remember, this blog is for educational, discussion, and information-sharing purposes only - As always, your mileage may vary! Remember to always have your clinical leadership, IT, and legal/compliance teams review any changes to processes before you initiate them. Have any related experiences, or other suggestions for improving clinical workflow design? Leave your comments and feedback below!

Strong Recommendations for new Applied Clinical Informaticists, Part 2 of 2

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

Today, I thought I'd share the second half (next ten suggestions) of my general advice to new Applied Clinical Informaticists, and other people interested in smooth clinical #workflow design. 

Strong recommendation #11 (of 20) below involves understanding the inseparable, symbiotic relationship between Information Technology (IT) and Information Science (IS), the discipline that drives Applied Clinical Informatics. While it's tempting to think only one is more necessary or relevant than the other, they are both equally necessary and relevant - You cannot have one without the other. 

Coming in at #12 is the strong recommendation (below) to understand the difference between the 'seeds' of good ideas, and the 'soil' (operational infrastructure) necessary to grow those seeds. While operational infrastructure is not always a high priority, neglected infrastructure can lead to frequent project delays, project failures, and inability to move forward. Take some time every year to look carefully at operational infrastructure, and make sure you devote the time and resources necessary to be able to grow the seeds of good ideas. 

Strong recommendation #13 (of 20) below sometimes becomes more visible after a few years in Applied Clinical Informatics, but it addresses the relationship between inconsistent or incomplete workflows, and burnout (moral injury). Especially in routinely high-risk, high-stress operations, your clinical teams will always appreciate having a smooth, predictable, well-understood pathway (workflow) from problem (point A) to solution (point B). Tangled, confusing, or incomplete workflows only create stress and confusion. Having well-designed, well-developed templates will help you make sure you're covering all of your bases, and that every step of your workflow is well-planned, clear, and complete.

My next strong recommendation (#14 of 20) below is just to be prepared to answer common questions about "Why do we need an interdisciplinary Applied Clinical Informatics team?" While there are many reasons, six of the most common include :

1. Project Intake / Procurements that require additional support or workflow analysis / evaluation to help ensure the technology doesn't already exist (in your organization), and to help ensure proper scoping, budgeting, stakeholder identification, resource allocation, alignment with safety or compliance needs, and expected outcomes. 
2. Special Event Workflow Planning (e.g. Planned maintenance or unplanned downtimes, planned upgrades, or project go-lives)
3. Complex IT Tickets that require workflow updates / modifications (often span areas with multiple stakeholders)
4. Complex Projects that require clinical translation, terminology work, stakeholder identification and alignment, or workflow updates/modifications.
5. Ongoing maintenance of existing configuration / workflows to meet CMS/TJC regulations (and other payer and user requirements), that requires continuous staff engagement with multiple stakeholders across different areas/specialties. 
6. Helping to ensure clinical workflows are aligned with the clinical, HIM, coding/billing, and revenue capture needs of the organization.

To have the skills and expertise necessary for these common functions, you will need an Applied Clinical Informatics team. Knowing some good reasons to have such a team will help support the discussions about how to build one. 

Strong recommendation #15 (of 20) for new Applied Clinical Informaticists (below) is to really care about design. Cooking food is not enough, you need to care about cooking great food. While discussing details is sometimes seen in healthcare as 'getting too into the weeds', our clinical teams need you to care about the details, so that you can develop the complete blueprints that will help technical teams to build great workflows. Also : Try to resist the urge to use short-term solutions for long-term problems - While they might temporarily help, they usually create workarounds that then need even more work to fix.

At #16 is my strong recommendation (below) to know the sixteen (16) most common (CPOE) order types. These are the basic building blocks that work together to build all of your clinical worfklows. It's very helpful to know what they are, what they do, how they work together, and when to use them. Many incomplete workflows come from not including one or more of these order types in an order set, order panel, or other ordering tool, so you can help improve workflow design by including all sixteen order types in an order set template, and then using that to guide the development of all of your order sets. *Note : Not every order set will use all sixteen order types, and you will only use the ones you need to address your desired clinical scenario. Having all sixteen types in a template (for developing your order set blueprints) will help create consistency and completeness for your clinical teams. 

My strong recommendation #17 (of 20) below is simply not to minimize the complexity of ordering tool ('order set') requests. I'm often fascinated by the small requests that have the largest operational impact, and thus require more time and effort to plan and execute than most people have budgeted for. Setting realistic expectations is the first step to good planning, so do your worfklow (gap, current-state-future-state) analysis early, and be prepared to inform your requestor when a project is larger than originally anticipated. 

Strong recommendation #18 (of 20) below is simply to consider how you will manage the intake of maintenance tickets and new project requests, from a variety of stakeholders. Navigating HealthIT (and Applied Clinical Informatics) often means managing the competing interests of : 

• Software vendors
• Patient/Caregiver input/feedback
• User input (from multiple stakeholders)
• Contracting and Payer Updates
• Formulary Updates
• Practice Onboarding
• Institutional Decisions
• Federal, State, and Department of Public Health regulations
• Evidence-based best practices
• Institutional policies and bylaws
• Privacy and Security Needs
• Quality Reporting
• External advisory organizations (e.g. The Joint Commission, Leapfrog, etc.)
• Vendor choices

... so you will want to consider all of these potential sources of change in your intake and prioritization processes.

Nearing the end, my strong recommendation #19 (of 20) below is to learn the most common types of Computerized Provider Order Entry (CPOE) order modes. Ideally, providers would always enter their own orders, but there are some very important, very legitimate reasons (clinical scenarios) why they sometimes cannot (without delaying necessary patient care). Understanding these reasons (and scenarios) will help you create and support compliant and safe order entry workflows all across your organization.

Finally, my strong recommendation #20 (of 20) below is simply to empower a clinical leader. Whether they are a nursing leader, physician leader, APP leader, radiology leader, laboratory leader, pharmacy leader, or other ancillary staff leader - they are all important and deserve your support. Usually, they are already great clinicians - Help them learn leadership skills, and they will be better leaders, and help you solve more problems. Skills like : 

• Reading a bylaw / policy
• Writing a bylaw / policy
• Reading a budget
• Planning a budget
• Writing a charter
• Chairing a committee
• Planning an agenda
• Project and change management basics
• Documentation and coding basics
• Hiring a staff member
• Managing a staff member

... can go a long way to long-term success for any leader. If you see a new clinical leader, make sure you reach out to them and support them as they grow - This will help empower leaders to retain staff and solve problems.

Okay, along with my first ten recommendations, I think these additional ten above cover my top twenty (20) strong recommendations for new Applied Clinical Informaticists seeking to design smooth workflows. If you have other suggestions, please leave them in the comments section below!

Remember - This blog is for educational and discussion purposes only, and is not formal advice - your mileage may vary. Have any other helpful ideas, suggestions, or experiences you'd like to share? Feel free to leave them in the comments section below!