Optimizing Lumbar Punctures, Part II

 Hi fellow Clinical Informatics, CMIO, CNIO, HealthIT, and other #workflow friends,

Sorry about the delay in following up my last post - As most people can probably understand, the COVD-19 pandemic has been a very busy time in healthcare.

Anyway, in my last blog post - I introduced the surprising complexity of a lumbar puncture - Not to complicate a fairly simple bread-and-butter clinical procedure that's performed in healthcare settings every day, but to help create clarity and understanding, set expectations, and help reduce clicks while delivering a great user experience that your providers can use to deliver great patient care. 

To help understand the complexity of this workflow, I thought I'd even share this academic poster which was developed by Deandra 'Uju' Momah, MS4, an outstandingly talented medical student from UConn Med who I've had the honor to work with. At a recent AMIA conference, Uju presented her academic poster which very nicely summarizes the workflow issues : 

(Academic poster by Deandra 'Uju' Momah, MS4 - Click to enlarge)

The take-home point : Diagnostic LPs are not one workflow - They are at least four. (That is, if you carve out intrathecal chemotherapy, epidurals, blood patches, and therapeutic LPs.)

I recently had the opportunity to discuss LPs to an online audience of new Informaticists - below are some of the slides from my presentation, which I'll borrow and annotate here for clarity and educational purposes. 

First - A review of some of the complexities of designing a Lumbar Puncture order set : 

Again, it's very important to remember that Lumbar Punctures are not just one workflow - Diagnostically, there are at least four. So for now, we will focus on the third of four below, the outpatient ID/Specialist LP, where in many institutions this is commonly collected by Interventional Radiology: 

Now before we can examine this in more detail, I thought I'd share the large (complex) set of stakeholders who all have an interest in how LPs are ordered, performed, and resulted in your organization : 

In my current role, I'm very fortunate to be able to work with the great Karen Gurba, RN MS, an experienced and outstanding Clinical (Nurse) Informaticist who I partner with to help investigate and design workflows. (Remember, Applied Clinical Informatics is a team sport!) Karen and I have done a number of interviews with the stakeholders in the list above, and through repeated iterations of blueprints, reviews, discussions, and updated blueprints - The picture starts to become more clear. 

In each of these cases, there are a six main features that almost all clinical staff seem to generally agree on : 

1. There are some PRE-LP labs, that are typically collected 24 hours before the procedure, to help establish that it's safe to proceed with the lumbar puncture lab. (They often include a simple BMP, CBC, and PT/INR.)
2. There are other PRE-LP serology labs, that are typically collected 1 hour before the procedure, for diagnostic purposes. (They often include a serum glucose, serum protein, and in some cases, oligoclonal banding.)
3. There is the LP procedure order itself, used to schedule the procedure and plan charges for doing the procedure. 
4. There are four BASIC LP labs, that most docs use for general purposes, including a CSF cell count and differential, a CSF gram stain and culture, a CSF glucose, and a CSF protein. 
5. There are some additional speciality-specific CSF labs, which can be very complex and specialty-specific. (Some of these can be very expensive, and so care should be taken so that they are not ordered unnecessarily or by accident.)
6. Finally, there are a limited number of nursing orders, mostly importantly a nursing communication order that allows the ordering provider to give the Interventional Radiology nurses a 'heads up' on any unique patient needs. 

 The problem is - When you have so many specialties needing access to specific labs in #5 above, how exactly do you build this out?

And so, now I'd like to present a mockup of an Outpatient LP via Interventional Radiology (IR) order set, that helps address all of these needs in one coherent order set, that relies on cascading logic to help guide the ordering provider to the best-practices for their unique clinical needs. (Pardon my amateur cartooning, which I used to customize my presentation.)

And the order set starts with the first clinical decision - Is the ordering provider ordering a DIAGNOSTIC LP, or a THERAPEUTIC LP?

Let's say in this case, the provider is ordering a DIAGNOSTIC LP : 

This then brings up four choices, seen above : 

• FOR ATTENDINGS, FELLOWS, AND RESIDENTS - Routine diagnostic LPs - Mon-Fri 8am-5pm
• FOR ATTENDINGS AND FELLOWS ONLY - ROUTINE Malignancy Evaluations - Mon-Thurs 8am-12pm
• FOR ATTENDINGS AND FELLOWS ONLY - URGENT Malignancy Evaluations - Friday-Sunday 8am-12pm
• FOR ATTENDINGS AND FELLOWS ONLY - PRION Disease Evaluations - Mon-Fri 8am-5pm

 This gives us the opportunity not only to confirm the role of the ordering provider, but also to stratify the routine diagnostic workflow from the more complex workflows that require additional notifications or supervision before ordering. This helps us to make sure that unnecessary orders are not added to the workup. 

In this case, clicking the first option (ROUTINE DIAGNOSTIC LUMBAR PUNCTURES) would then produce the list of specialties that commonly use this order set : 

And here, if an Infectious Disease provider were to click their section, the order set can now produce the tailored, specialty-specific orders that the provider needs : 

Using this naming convention and design, we now know : 

• Scenario = Specialty, outpatient LP for collection in IR
• LP type = Diagnostic
• User = Attending, Fellow, or Resident
• Specialty = Infectious Disease

... and so now the order set can allow a tailored, specialty-specific palette of orders that are most commonly used for the user's needs. 

And with that, a significant reduction in clicks and improvement in utilization, diagnostic accuracy, and diagnostic yield. 

We are now working with our department Chiefs to help confirm the final orders (to appear in the fifth section of each specialty-specific area), and maybe once they are completed, I can help publish the final result here. 

Until then, I hope this helps you develop your own strategy for ordering Lumbar Punctures! If you have any secrets or feedback you can share, please leave them in the comments below!

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any recommendations or tricks to share about designing lumbar puncture workflows? Feel free to share in the comments box below!

Optimizing Lumbar Punctures, Part I

Hi fellow Clinical Informaticists, CMIOs, CNIOs, #workflow gurus, and other #HealthIT friends,

How do you say 'Lumbar Puncture' in CPOE? Today, I'm writing to share the translation of one of the oldest, most common medical procedures that's routinely done in modern healthcare : The lumbar puncture, sometimes referred to as an 'LP'.

Lumbar punctures (LPs) are routinely performed to help look for infections, look for malignancy, and look for antibodies and other markers of neurologic disease. While they are a common mainstay of modern healthcare, building them electronically can be quite a challenge. 

Want to reduce clicks when ordering your LPs? It helps to first have a solid understanding of the most common LP workflows in healthcare, so you can build your order sets with the most common studies, priorities, indications, and order statuses all properly built and correctly defaulted.

So in this post, I figured I'd share some secrets about the four most common lumbar puncture workflows, and how to build them into an EMR, in a really gourmet fashion - for the best diagnostic yield, fewest clicks, and maximal success. 

1. THE WORKFLOWS

Lumbar punctures are commonly done for diagnostic purposes, but can also sometimes be done for therapeutic purposes. But as it turns out, the LP is not just one workflow - It's actually four different workflows : 

In each of these scenarios, there are different clinical specialties using the LP, commonly for different purposes : 

In addition to these workflow descriptions, some helpful notes : 

• In workflows #2 and #3 above, there is a often a communication challenge between the ordering provider and the Interventional Radiologist, who has to collect, label, and transport the samples to the lab, and also report back some findings to the ordering provider (e.g. opening pressures, turbidity, etc.)
• In workflow #3 above, there is also sometimes a patient education challenge, whereby the patient needs to come before the scheduled IR LP to have 'pre-procedure' labs drawn (e.g. CBC, BMP, PT/INR) to help ensure that the LP can proceed without problems. 

2. THE STAKEHOLDERS

Given the above workflows, the physician specialties most commonly involved with lumbar punctures then include :

1. Emergency Medicine
2. Inpatient Physicians - Pulmonary/Critical Care (Intensivists)
3. Inpatient Physicians - General Inpatient Medicine (Hospitalists)
4. Interventional Radiologists (IR)
5. Ambulatory/Inpatient Specialists - Infectious Disease Physicians
6. Ambulatory/Inpatient Specialists - Neurologists - General
7. Ambulatory/Inpatient Specialists - Neurologists - Movement Disorders
8. Ambulatory/Inpatient Specialists - Neurologists - Multiple Sclerosis
9. Ambulatory/Inpatient Specialists - Neuro-ophthalmologists
10. Ambulatory/Inpatient Specialists - Hematology/Oncologists

If we include :

• the Registered Nurses (who have to help care for the patient before/after lumbar punctures), 
• the pharmacists (who help provide the medications the provider has ordered for sedation/anesthesia)
• the laboratory workers (who receive the fluid, provide the on-site analysis of certain labs, and send out other labs to external labs) 
• the IT/Informatics workers (who connect with stakeholders, map the current state, and work with the clinical stakeholders to design, build, and test the future state)

... then this gives us a fairly long list of stakeholders in the most common lumbar puncture workflow discussions : 

1. Emergency Medicine Providers
2. Inpatient Physicians - Pulmonary/Critical Care (Intensivists)
3. Inpatient Physicians - General Inpatient Medicine (Hospitalists)
4. Interventional Radiologists (IR)
5. Ambulatory/Inpatient Specialists - Infectious Disease Physicians
6. Ambulatory/Inpatient Specialists - Neurologists - General
7. Ambulatory/Inpatient Specialists - Neurologists - Movement Disorders
8. Ambulatory/Inpatient Specialists - Neurologists - Multiple Sclerosis
9. Ambulatory/Inpatient Specialists - Neuro-ophthalmologists
10. Ambulatory/Inpatient Specialists - Hematology/Oncologists
11. Nursing - Interventional Radiology
12. Nursing - Floor/Bedside
13. Nursing - Clinics
14. Laboratory
15. Pharmacy
16. Clinical IT/Informatics

... and you'll quickly see why you it's helpful to have a good clinical informatics and project management team available, to help coordinate all of the meetings, discussion, architecture, building, testing, and approvals before you can go-live. In short : Optimizing LP order sets is usually a significant project effort, requiring many meetings.

3. THE LABS

With regard to the actual laboratories, it's helpful to keep in mind that workflows #1 and #2 are general-purpose LPs, usually for the emergent ruling out of CNS infection. It typically doesn't get much more complicated than that. So for Inpatient/ED purposes, the most common studies include : 

• CSF Cell Count and Differential
• CSF Gram Stain and Culture
• CSF Protein
• CSF Glucose
• (Occasionally CSF HSV PCR, if clinically indicated)

But for workflows #3 and #4, they are more specialty-oriented, so their labs may include the general labs above, but also include a number of complex, high-cost specialty panels, antibodies, proteins, and pathology / flow cytometry. 

Commonly, the occasional ordering of these specialty studies (commonly from workflows #3 and #4 above) in the Inpatient/ED settings (commonly workflows #1 and #2 above) can generate a lot of discussion. For reimbursement reasons, it's helpful to stratify these workflows, but keep in mind - In complex cases, there may still be reasons to order the more complex outpatient labs on an inpatient, but generally they should only happen with specialist review and approval.

4. THE ORDER SETS

So now you're faced with the question - One order set, or four order sets?

If you do one order set, you'll probably end up needing to stratify them (with radio buttons!) into the four different workflows, e.g. : 

Or, more likely for operational, culture, and other EMR configuration reasons, you may end up with four different order sets - In which case you will want to choose your naming convention very carefully, e.g. : 

1. LUMBAR PUNCTURE (LP) - INPATIENT/ED - AT BEDSIDE
2. LUMBAR PUNCTURE (LP) - INPATIENT/ED - IN IR
3. LUMBAR PUNCTURE (LP) - AMBULATORY/OUTPATIENT - IN IR
4. LUMBAR PUNCTURE (LP) - AMBULATORY/OUTPATIENT - IN CLINIC

Even though #1 and #2 above are typically used by generalists, and #3 and #4 above are typically used by specialists - You'll still want to have specialty input into #1 and #2, to help make sure that the common specialty scenarios can still be addressed (when they arise) in the inpatient settings. (E.g. Having Infectious Disease provide input into #1 and #2 can help make sure your ED providers/Hospitalists/Intensivists are ordering the right ID labs for the right scenarios.)

In my next post, we will look at these four LP workflows in more detail, and discuss some of the common educational, operational, and ordering challenges that organizations may come across when building out and optimizing these order sets. 

Have any thoughts, comments, feedback, or stories to share about building highly-optimized (gourmet!) lumbar puncture workflows? Feel free to leave in the comments section below!

Remember, this blog is for educational / discussion purposes only, and does not constitute medical advice - Your mileage may vary. Always consult your clinical leadership, your clinical informatics team, and your medical specialists before building out any order sets in your own organization.