Find any document in your hospital in five clicks?

It's December. The squirrels have gathered their nuts. The leaves have fallen. People are having their holiday parties. It's a time for reflection, as we anticipate the new year 2011 that lies ahead. Healthcare is changing faster than ever before, and those who want to survive, need to keep up.

I've spoken in previous blog posts about the tools we commonly use to deliver care in modern healthcare. So as I've been thinking about how to streamline organizational efficiency in healthcare, one of the major challenges most hospitals face is : How do we manage all of this information?

Some people will immediately look to IT for solutions, since we think of information as living inside a computer, but IT can only build a system as organized as you ask them to build. The problem is : If you had chaos before, making things electronic will only perpetutate the confusion.

(I've spoken to plenty of healthcare informatics types who complain about not being able to navigate their web sites, shared electronic folders that never get updated, and not having "intuitive" organization of their information.)

I find the comment, "We don't have intuitive organization of our information" particularly interesting. Everyone seems to have a different idea of what is intuitive.

All of this speaks to the need for standardization in healthcare, and education to support those standards. (Nobody teaches this stuff in medical school, nursing school, or pharmacy school.)

So I hope I've attracted your attention with the title of this blog. My proposal : We develop a standard "document tree" that can be used to organize virtually all of your hospital's information. (Except emails, of course, which generally are private and not shared.)

The Healthcare Informational Tree

So I thought about all of the common tools we use in healthcare (the CMIO's Checklist and the Informatics Toolbelt), and sorted them first by function and then by division (Clinical versus Administrative) - And this is what I got as a final list :

1. Telephone Numbers - Tools to contact a person
2. Emails, Screen Savers, and Posters - Tools to help send a short message
3. Schedules - Tools to show who is responsible at what date/time
4. Policies and Procedures - Tools to learn organizational standards and how to achieve them
5. Guidelines - Tools to help educate and guide staff towards a desirable outcome
6. Documentation - Tools to record and transmit information
7. Orders - Tools to document and transmit instructions to deliver care
8. Order sets - Tools to standardize and expedite the ordering process for a common clinical scenario
9. Clinical Protocols - Tools to standardize and automate a clinical process
10. Clinical Pathways - Tools to standardize care for a diagnosis throughout a hospitalization
11. Education Modules - Tools to help educate patients/staff
12. Templates - Tools to help make a document
13. Wikis - Tools to organize information / links for a department
14. Committee Charters - Tools to assign committee duties and responsibilities
15. Committee Minutes - Tools to record committee activities
16. Glossary of Terms - Tool used to learn definitions for common organizational terms

I believe that by using the above directory/tree hierarchy, you could arrange your tools on your intranet in a way that you can essentially find any document in your hospital in five clicks - Each link, from this main page, then divides up into clinical and administrative divisions, e.g. :

• Clinical Templates = e.g. Admission H&P template, Procedure Note template, Transfer Summary template, etc.
• Administrative Templates = e.g. Policy and Procedure template, employee evaluation template, etc. 

or

• Clinical Documentation = e.g. Admission H&P, Procedure Note, Transfer Summary, Vitals Flowsheet
• Administrative Documentation = e.g. Employee Evaluation Form, Room Change Form, Maintenance Request Form

or

• Clinical Policies = e.g. Pharmacy Policies, Infection Control Policies, Nursing Care Policies, etc.
• Administrative Policies = e.g. Human Resources Policies, Safety Policies, etc.

The interesting thing about making such a tree is it shows you, pretty quickly, how much work you are actually doing in your hospital, how much it actually takes to run a hospital, and why you need people to worry about all of these tools.

It also can help you find your work products much quicker, and it interfaces nicely with the tools that you need to make a change in the clinical setting.

Adopting such a tree is not a small project, but it sure can tidy up your intranet homepage. It also helps reinforce informatics education by making almost everyone in your organization review the basic tools you use, and what they do, every time they look for something. By having centralized publishing, this also helps keep your intranet a "high-value" site that people will use to find things.

As someone who wants to see American healthcare be the best that it can be, I think it's an admirable goal. Those of us working to organize Health2.0 should be keeping this tree in mind as we develop our healthcare informatics policies.

Remember, my advice is free, and you get what you pay for. Your mileage may vary. :)

Would love to hear comments about potential additions/changes you would make to the tree at your organization! :)

Who works in Health Informatics?

So I have had a number of people recently talk to me about health informatics jobs. Being a physician, they are mostly physicians looking for informatics jobs.

The interesting thing is, I get the sense the healthcare industry NEEDS informatics, but isn't really ready for it. The CMIO position, despite being almost 20 years old, is still too new to most healthcare administrators, and from what I see and hear, many hospitals don't really know what to do with one. The job functions, from hospital to hospital, vary so widely.

And then there is the question about exact titles - what's the difference between a "CMIO", a "CNIO", a "Physician or Nurse [Embedded] Informaticist", a "Physician Champion", and a "Superuser"?

I will attempt to wax philosophic here, just in the name of starting the discussion on formal titles and formal job descriptions - which the healthcare industry needs badly, if it wants to take advantage of informatics help. Perhaps eventually this will turn into the holy grail of formalization - An actual Wikipedia page. :)

1. The CMIO (Chief Medical Informatics Officer) - Yes, you do informatics, so you have to believe in political neutrality. Yes, you try to guide the rest of the hospital about informatics issues.  You talk about EMR strategy, you help discuss budgeting issues for a solid informatics platform, you stress the importance of proper training. You monitor and guide the politics of CPOE and EMR in the Medical Executive Committee. You worry about administrative, physician, and nurse buy-in. You may do some training, but mostly you guide the education process. You may do some data mining and quality work. You get involved in project management, and help develop physician and nurse informaticists to work with you. This position is heavily involved in policy, however, and you should prepare to analyze and write a great deal of clinical policies. Lots of regulatory work too. In a smaller hospital, your salary line will probably come from a clinical line, and you will still work clinically. In a larger multi-system hospital, your salary line may come from an IT line, or other administrative line, and you probably won't be working clinically anymore.

2. The CNIO (Chief Nursing Informatics Officer) - The nursing equivalent of the CMIO. Yes, there is a big need for this role. The CNIO worries about administrative and nursing buy-in, and continues to work clinically.

3. The Physician or Nurse Informaticist (aka Embedded Informaticist or my affectionate term, Clinical Jedi Informaticist) - Think a mini-CMIO, but in an individual department. A physician informaticist (or nursing informaticist) is a slightly broader term, and could be an outside consultant called in to help the informatics development of a department in your hospital. The much cooler (and reliable and useful position) is the Embedded Informaticist, the doctor/nurse in a clinical tribe whose paid responsibility it is to develop the informatics platform for their clinical tribe. If the CMIO still works 25% clinically, the embedded informaticist works 75% clinically (and 25% informatics). In an ideal world, the hospital CMIO gets to work with an embedded informaticist in each clinical tribe, to coordinate the workflows between different departments. The embedded (physician or nurse) informaticist then analyzes their own tribe's workflows, maps them, redesigns them, and sees the changes through committees, policy work, and brings them to the Clinical IT staff to make it happen. Since they are embedded, they can also easily train and support the new workflows in their tribe. And because they are embedded, buy-in is never a challenge. The EMR works better, the docs and nurses feel more loved. This is an extremely effective model, by my experience. (If it's supported by administration.) This, I think, is the position that is going to explode in demand in the next year or two. Look out for it. The AMIA 10x10 class will train most of these embedded informaticists. 

4. The Physician Champion - This is a physician who is asked, or paid, to rouse the troops. Your main mission is to be a cheerleader. You encourage the docs around you, and you may get involved in training directly. Exposure to policy and strategy discussions will probably be minimal. You probably won't have the pay or time budget to do much data mining, and you won't be managing other informaticists. Your ability to motivate is much more important than knowing every detail of every workflow. For reasons I don't understand, nursing usually doesn't need a champion, but this may change.

5. The Superuser - This is probably the most misunderstood positions in healthcare informatics today. The superuser is a really, really advanced, highly-skilled educator. They need to know the details of the software and every detail of every workflow. Think of the superuser as an embedded informaticist without the workflow redesign responsibilities. Superusers have to be patient and love education. They don't get involved in the politics or budgeting discussions. And they need to be available, especially at the time of new software or hardware rollouts, to help smooth the transition between classroom training and the clinical front. Superusers are worth their weight in gold, and you can never have enough of them. Not having well-trained superusers makes any clinical go-live a challenge.

Unfortunately, these are all roles in healthcare informatics, but only the CMIO has any semi-reliable job descriptions and pay data. (And trust me, even for CMIOs, the human resources data is still pretty scarce.) Eventually, these all should be recognized, formal roles, but I'm having a hard time imagining a want ad saying :

"WANTED - SUPERUSER FOR #EMR GO-LIVE AT LARGE UNIVERSITY HOSPITAL THIS JANUARY. APPLY WITHIN."

So until we formalize the CMIO, the CNIO, the physician and nurse informaticist, the physician champion, and the superuser - Healthcare won't really be able to take advantage of these very important positions.

In the meantime, I'll keep working on it. :)

Hospital Administrator Informatics Tools

So it's been almost a week now, and I'm still trying to find good definitions for :

1. Clinical Protocols (to help automate a clinical process, e.g. Heparin or Insulin drips)

2. Clinical Policy

3. Clinical Documentation

4. Clinical Order Set

5. Clinical Templates

6. Staff Education Module

7. Patient Education Module

8. Clinical Staff Schedule

Each of these tools requires a delicate process to build, develop, approve, and publish them.

And the interesting thing? We don't seem to have a standard policy definition! The SKTM Glossary (http://www.skmtglossary.org) seems to offer mostly technical definitions, and various other web sites seem to have different definitions/labels for this very common tool in healthcare. (Most of the other definitions are related to clinical trials.)

I'm honestly surprised The Joint Commission and CMS haven't stepped in to offer a definition that could be very useful in healthcare policy development and educating healthcare administrators internationally. (Is anyone from CMS or TJC a reader? Email me!)

There are also a bunch of automated software packages and companies that provide automated policy management - Just Googling the options will give you lots and lots of choices. (This must be a big business!)

In the meantime, I keep trying to keep the Wikipedia entry alive :

http://en.wikipedia.org/wiki/Health_informatics_tools

(Perhaps I should write the first "Healthcare Administrator's Toolbook", so I can use myself as a citation?) :P :)