A Tale of Applied Clinical #Informatics, in Four Parts

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

Today I'm writing today to share a tale of Applied Clinical #Informatics, in four parts. (Or, "Why workflow analysis, naming conventions, indexing, and usability all really do matter.")

Feel free to leave comments at the end - Hope you enjoy it!

1. PART ONE - 

"I'm sorry, I don't have time to talk about workflow analysis, naming conventions, indexing, or usability - just give me everything I need in one place, and quick!!"

2. PART TWO - 

"Wait, that's not right, I can't use that. I still don't have time to talk about any of that workflow or usability stuff, but can you just put everything I need in one place so I can see it all and easily access everything I need with just one click?"

3. PART THREE - 

"Wait, that still doesn't look right, and I'm afraid I'm going to be scrolling forever. I still don't have the time to meet, but I heard there's some tool they use at another organization - Can you just find out what tool they use to do this, and then just put my stuff into whatever tool they use?"

4. PART FOUR - 

"OK, wait... I think I see the problem. Let's make some time to talk about workflow, including exactly what these tools do - Both what I use them for, and when I use them. Then let's talk about the naming conventions and indexing for each tool, so they all have a standard look and feel. Then let's talk about usability, so that I keep the most commonly-needed tools in one place, and the less common tools in a separate but nearby place. And then finally after you build it - I'll help test it to make sure it's both functional (what-we-need) and also easy-to-use."

"Eureka - That's it!" 

[ THE END ] 

Remember, this blog is for educational/discussion purposes only - Your mileage may vary. Have a good teaching example you'd like to share? Feel free to leave in the comments section below!

Why Terminology Matters

 Hi fellow Clinical Informaticists, CMIOs, CNIOs, and other HealthIT friends,

A short post this time - Just sharing how terminology management can impact EMR usability. 

Managing an enterprise EMR is a lot like owning a closet. Information is stored in certain virtual 'drawers', where people (users) get used to storing and finding the information they need to do their jobs.

The problem is, just like closets - Exactly where and how people like to store this information is an intensely personal, cognitively-driven process. If you have ever had to share a closet, you probably know how challenging it can be to share a closet with another person. 

Now, imagine having to share a closet with 500 people. The first step would be getting all 500 people together for a meeting, and discussing/reviewing : 

• Where should we keep the socks?
• Where should we keep the pants?
• Where should we keep the shirts?

Some people may have different opinions about where and how to keep things, but ultimately, you will need to make some final, group-based decisions. 

Still, some people may start working for your company after those group discussions/decisions are made, so it's helpful if you :

• ... have an easily-identifable pattern associated with your information storage and retrieval, and...
• ... if you label things correctly. 

Today's post is really about labeling things correctly. For teaching purposes, I sometimes simplify it as this : 

"Call it what it is."

It can sometimes be difficult to spot terminology issues, so I'll start with a simple hierarchy that helps explain the confusion that can create frustration for end-users :

Keep in mind that these are simple, real-world examples that we are using as proxies for more complicated, real-world clinical scenarios.

In any case - when labeling a button, folder, or other item in an EMR, it's important to have the appropriate level of granularity and accurate clinical terminology, or else you can lead to confusion for end-users : 

Suppose a user is looking for an apple. 

• In scenario #1 above, if we just refer to apples and oranges as "fruit" - users will need to spend time clicking through both boxes, looking for the apple. It might be in the left box, or the right box - They are both labeled "Box of Fruit", and fruit is not a granular enough term to identify the exact tool the user is looking for (an apple).

• In scenario #2 above, it's easy to find an apple. The first box is labeled, "Box of Apples".

So it's always very helpful to :

• understand and anticipate what the user will be looking for, and...
• understand the clinical terminology and associated hierarchies, and...
• call it what it is.

Some people might argue "Well, if both apples and oranges are fruit, why not keep them in the same 'fruit' folder?" For sure, there are some scenarios where this may make sense, especially if there are not many items to look for under a folder. 

However, keeping too many items in a folder can also lead to unnecessary time spent looking for things. 

So ideally, especially when storing a large number of items - It's helpful to understand the clinical role, the clinical context, the clinical terminology, and the higher/lower level concepts, to help identify the right term to label buttons in your EMR, for maximum efficiency and less clicks.

Hope this helps shed some light on common terminology issues that every organization has to manage as they configure their EMRs. If you're not sure about a term, reach out to your local Clinical Informaticist for guidance, tips on how to reduce clicks, and other common clinical workflow design issues.

Remember, this blog is for educational/discussion purposes only, and your mileage may vary. If you have any terminology tips or suggestions, please leave them in the comments box below!

Culture, Terminology, and EMR Usability

Hi fellow Informatics friends and colleagues,

When sharing the secrets of electronic medical record (EMR) usability, some people are surprised at how much culture and terminology impacts user satisfaction. Allow me to explain.

EMRs are essentially tools used to store and retrieve patient care information. When configuring an EMR, the most common mistake is thinking it's 'like paper', simply a bunch of words, lines, and boxes on a page. EMRs are different - Buttons open menus that lead to other tools and actions, so it's more helpful to think of it more like you are organizing a closet: 

• Socks go in the sock drawer.
• T-shirts go in the t-shirt drawer.
• ... and so on.

Only an electronic patient record literally contains hundreds of drawers, each containing as few as a handful, or as many as hundreds of documents, images, vitals, or other data elements. E.g. : 

... and when you click on the button "RADIOLOGY ORDERS", one would expect to find the orders related to diagnostic and therapeutic/procedural radiology modalities.

So a key design element to consider : 

• How many items do you need to store in a chart, for patient care purposes?
• In which 'drawers' will you store them?

And so when organizing a closet at home, most people realize they don't have room for a separate drawer for every piece of clothing, so they will use some categorization scheme (that makes sense to them) to combine related items in the same drawer, E.g. : 

• Top Drawer = Undergarments (Socks, Underwear, and T-shirts)
• Bottom Drawer = Outer garments (Shirts / Pants)

We don't consciously think about categorization schemes very much, but our brains do this naturally, to try to make sense of the world, and establish a pattern that will ultimately help us get dressed in the morning. 

Anyone who's ever had to share a closet, however, knows there can be disagreements about categorization schemes, resulting in some interesting household debates. If you have children, you also know it's helpful to label drawers, or explain the categorization scheme, so your kids can find their clothes in the right drawers. Food pantries and refrigerators are common sources of domestic debates, because different family members might have different ideas about ideal organizational schemes.

So it's no surprise that people who are responsible for configuring and organizing an EMR often stumble upon the many cultural differences in thinking and terminology between "healthcare tribes" - E.g. between physicians, nurses, pharmacists, radiologists, laboratorians, ancillary services, medical records, finance, etc.

Here's a good teaching example to better understand what I'm talking about, and how these terminology issues have real-world impact in user EMR satisfaction : 

Imagine it's the year 2050. 

You run a hospital with an EMR. It is suddenly discovered that tomatoes save lives, so you prepare to have tomatoes in your hospital, keeping them in your Pyxis machine, and create tomato orders in your EMR, to order and release the tomatoes for patient care (when needed). 

After meeting with your available subject matter experts (SMEs), many of whom, for scheduling reasons, just happen to be from clinical Tribe A - your analysts build the "Tomato" order, and make it available under the "Vegetable" menu choice below :

Shortly after building this, you suddenly get complaints from Tribe B users, who couldn't show up to the earlier meeting but say, "Hey wait, tomatoes are technically berries, which are technically fruit - Here is the evidence : https://en.wikipedia.org/wiki/Tomato - So they should be listed under the "Fruit" menu choice instead! Those of us who know this can never find the Tomato order!"

You also get complaints from Tribe C users, who say, "What's a Tomato? We've never heard of that. Oh, wait, you mean that red thing we put in our salads/sauces/sandwiches? We've been doing this for 20 years, and in our experience, we've always called it a Golden Cherry."

Do you :

• OPTION 1. Listen to Tribe A, and file the tomato order under the "vegetable" menu, and educate Tribes B and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and most commonly thought of as vegetables?

• OPTION 2. Listen to Tribe B, file the tomato order under the "fruit" menu, and educate Tribes A and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and correctly categorized as fruit? 

• OPTION 3. Listen to Tribes A and C, rename the tomato order to a golden cherry order, file it under "vegetable", and educate Tribe A that tomatoes will now be referred to as a golden cherry and will be filed under the vegetable menu? 

• OPTION 4. Listen to Tribes B and C, rename the tomato order to a golden cherry order, file it under "fruit", and educate Tribe B that tomatoes will now be referred to as a golden cherry, and will be filed under the fruit menu? 

• OPTION 5. Bring Tribes A, B, and C together for a meeting, review the concepts, terminology, and taxonomy of tomatoes together, and agree to a functional definition (for your glossary!) that meets the needs of all three tribes : 

Tomato ('golden cherry') - A common red fruit/vegetable that grows on a vine in temperate climates, that is commonly used to make salads, sauces, and sandwich toppings. 

... and then build the tomato order, attach a synonym of 'golden cherry', and then file it under :

• the "vegetable" menu choice? 

• the "fruit" menu choice? 

• BOTH the "vegetable" and "fruit" menus? (making Tribe A complain that it shouldn't be making the fruit menu look messy, and Tribe B complain it shouldn't be making the vegetable menu look messy) 

• Or build a hybrid "vegetable/fruit" menu choice? 

... or more options we haven't considered yet?

How these terminology, taxonomy, and conceptual issue get managed will ultimately impact the satisfaction of users who are trying to find a tomato ('golden cherry') in the EMR for patient care.

Hope you enjoyed chewing on this interesting EMR terminology challenge! If you think terminology issues might be impacting your workflow, feel free to ask your local clinical informaticist for help! (#whyinformatics!)

Remember this blog is for education and sharing purposes only. Have other examples of terminology and classification systems impacting EMR usability and satisfaction? Or have you struggled with this yourself? Feel free to share in the comments section below!

Clinical Linguistics and EMR Interoperability

Hi fellow Informaticists, CMIOs, CNIOs, and other #HealthIT enthusiasts,

For today's post, I wanted to muse on a favorite subject : What can language management teach us about design of clinical documentation and EMR interoperabilty?

To answer this, it's helpful to first understand the three common models of communication used in clinical settings : 

1. Synchronous Communication - Undocumented, real-time communication, where both sender and recipient are sharing the same moment in time - E.g. face-to-face conversations, telephone conversations, video chats, or meetings
2. Asynchronous Communication - Documented communication, where both sender and recipient are separated in time - E.g. EMRs, HIEs, Notes, charts, graphs, videos, recordings, videos, voicemails
3. Hybrid Communication - Shares features of both, e.g. Texting, social media, Twitter, recorded phone calls, etc.

Professional interpreters and translators (like you might find at the U.N.) have worked for years to manage communications across these models - What can healthcare learn from them?

To help answer these questions, I've developed the following 14-minute-3-second video, for your consideration : 

I hope you enjoyed it - Leave your thoughts or feedback in the comments section below!