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.

What can Cardiac Myocytes teach us about Teamwork and Workflow?

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

Today's post is short, but one that I think most clinical friends will understand and appreciate. For conceptual teaching purposes only, I'm going to ask the question : 

"Q : What can Cardiac Myocytes teach us 

about Teamwork and Workflow Design?"

Here's my theory : Clinicians may actually have an advantage here. If you've ever studied the human heart - it's anatomy, it's functions, its biology, and its electrophysiology - You already know a lot about teamwork, workflow design, clinical operations, and essentially how to get things done. 

After all, cardiac myocytes and humans (clinical leaders and team members) both work towards a common goal. We both can function as individual units, but we function even better together as a well-organized, well-synchronized team : 

[ DRAFT ] TABLE - A tongue-in-cheek but honest comparison of Myocytes with Humans (Clinicians)

Let's face it, healthcare is a team sport. So when I'm working with other clinical leaders, especially new ones - For support, I often remind them of the importance of the infrastructure and tools that, especially as clinicians, we sometimes take for granted - Good : 

• Regulations (both Federal and State)
• Governance (e.g. Committee structures)
• Leadership
• Direction
• Management
• Communication
• Bylaws
• Policies/Procedures
• Training / Onboarding
• Continuing Education
• Offboarding
• Teamwork

After all, when growing a plant - it's not just the seeds you need to worry about, it's also the soil. So without enough of this 'supporting soil' (the tools above) in place, it becomes very easy to run into problems growing the seeds - And so for end-users, managers, directors, leaders, and executives alike, this can sometimes result in loss of efficiency, frustration, disorganized workflows, problems not getting solved in a timely basis, etc.

Typically, these tools don't get enough attention from new clinical leaders, because until they are in a leadership position - their focus has largely been on 'clinical things' like working with patients, diagnosing and treating diseases, performing operations and procedures, etc. While those are all the reasons we are in healthcare, it's still important to understand the many 'non-clinical' tools that make those things happen. (In truth, those tools are just as clinical as penicillin - But due to time constraints, they usually don't teach much about them in medical schools.)

What I find especially interesting is that, as a physician who during my career has treated cardiac tachyarrhythmias at the bedside (using beta-blockers, calcium-channel blockers, adenosine, cardioversion, etc.) - There are often similar analogous ways to treat these same 'human tachyarrhythmia' problems on project teams : 

So when I have the opportunity to teach a new clinical leader about how to solve problems and function in teams, I simply remind them that modern human biology has evolved over thousands of years to solve these same sorts of problems that we experience in healthcare today - And so sometimes, looking inward with a microscope is just as helpful as looking outward with a telescope. 

Finally, one of my clinical informatics colleagues and good friend Stefanie Shimko-Lin, BSN RN CD-L CD-PIC FHIMSS once shared this cardiac analogy with me : "Collateral circulation is a workaround, that happens when the desired workflow doesn't work. If you make it easy to do the right thing, people will do it."

These analogies may all seem a bit peculiar and tongue-and-cheek, but if you're a clinical leader - I hope this blog post helps to spark helpful discussion and learning with your own clinical leadership and project teams, so that you can better solve the workflow and operational issues you might encounter in your daily clinical routines.

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any other helpful analogies or advice for new clinical leaders? Feel free to share them in the comments section below!

How I Became a 'Document Whisperer'

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

I'm writing today to share some stories from my career path in Applied Clinical Informatics, and how I became a 'document whisperer' with regard to clinical workflow design. This post stems from a common question I get asked: 

'If you care so much about clinical workflows - Then why do you seem to care so much about bylaws, policies, procedures, guidelines, protocols, bylaws, charters, order sets, and other documents? Why don't you just worry about the things inside the EMR?' 

The reason is because all of these documents (whether they are inside or outside an EMR) work together to shape clinical workflow. 

To explain, I need to first offer some context. 

Back in 2007 when I first started my formal clinical informatics career, like most newcomers, I didn't yet have enough experience to fully understand my role. I figured my job was to 'help with the electronic medical record', so naturally, I focused mainly on the things that doctors interacted with inside the EMR. 

After a while, however, I started to see challenges we had with some of our projects. There were order sets that, after we built them, didn't get used. There were order sets that created turbulence with other workflows when we rolled them out. I received complaints from doctors who felt the computer was 'too clunky' and that 'it takes too long to get things done'. 

Initially, I wondered if this was simply a matter of an EMR just being more difficult to use. There were some people who told me, 'Oh, some doctors are just resistant to change' (which is partly true), and others who told me, 'Computers are just complicated and finicky' (which can also sometimes be true).

But I kept looking for a better answer - There must be some sort of symmetry here that I was missing. 

And then, over the next 2-3 years, I experienced two important things : 

1. I once worked on a complex titration protocol, which required an extensive analysis to fully build out the protocol, and...
2. One day, a Registered Nurse complained to me about a policy that would need to be updated, in conjunction with a project we were actively working on.

So it was while confronting the question of 'How exactly do you write a protocol?' that I started to really confront the question : "What exactly is a protocol?" This led to even more questions, like : 

Trying to find more concrete answers, I looked to various potential sources, including various regulations, the International Standards Organization (ISO), the National Institute of Standards and Technology (NIST), the CMS web site, various HealthIT/Informatics societies, ITIL, and even Black's Law Dictionary, without much help. 

So around 2010, I decided to look at this from a more analytical, design-thinking standpoint : 

"If we gathered every document in healthcare, both those sitting on desks and on hard-drives - what would they be, and what would they look like?"

This led me to scribbling down some commonly-used words people use in healthcare, putting them into a spreadsheet, and in 2010 I came up with my first CMIO's Checklist : 

[ FIRST DRAFT ] Note : My workflow definitions have evolved since this 2010 version.

[ FIRST DRAFT ] Note : My workflow definitions have evolved since this 2010 version.

... which turned out to be my first real foray into clearly-defined terms, tools, and functions. Yes, a sample size of one - based only on my own clinical and administrative experiences - but a fairly comprehensive function-based analysis, nonetheless, that helps to clarify concepts and increase shared understanding.

(What good, functional, policy-grade definitions do to clarify concepts

and increase shared understanding - Hit PLAY to see animation)

Now with this new function-based analysis in hand, I stumbled into two interesting [DRAFT] functional definitions : 

Template (n.) - A tool used to standardize and expedite the creation of a document. 

... and ...

Document (n.) - A tool used to record and transmit information.

... both of which shed light on an important concept - For many of you, this may be common-sense or trivial, but for me it was a 'eureka' moment : 

• Definitions can be used to create templates.
• Templates can be used to create documents.
• Documents can be used to store and transmit the information needed to support workflows.

So around 2015, this led me to the realization that these concepts all depend on each other. And so, realizing that workflow inconsistencies sometimes arise from misalignment of these concepts, I wrote this blog post about workflow management and the Clinical Informatics domain : 

[ SCREENSHOT ] From Informatics Domain and Workflow Management, 2015

 

This also led me to the realization that all of the documents and tools contained in drawer #4 above :

• needed to be aligned with the workflows, goals, and mission above it, and... 
• were shaped by the concepts contained in #5, #6, #7, and #8 below it. 

It also revealed to me that some of the documents and tools that support workflows are typically contained inside the EMR, and others were contained outside the EMR : 

So now being able to mentally visualize this conceptual structure (above), I also realized that : 

• Workflow depends on all of these tools (above) for support. 
• Changing workflow means changing all of the tools (both inside and outside the EMR) that are used to support the workflow.

... and so effective workflow change management means : 

1. Clearly understanding each deliverable (tool) above.
2. Identifying the deliverables (both inside and outside the EMR) that are needed (or need to change) to support the desired workflow. 
3. Quickly drafting those deliverables, to demonstrate to users and HealthIT professionals how the deliverables need to fit together,
4. Reviewing those draft deliverables with clinical stakeholders, to confirm their needs/expectations before committing them to a formal build, and to help get their input and align expectations.

So to help quickly draft the deliverables in step #3 above, I had to quickly make templates for these roughly 24 documents that we commonly use in healthcare. And this brought me back to my pursuit for high-quality, high-grade definitions so that my workflow templates were quick, easy-to-use, and maybe most important - functionally sound. 

And this is essentially how I became a document whisperer for good clinical workflow design and EMR support. Using this deeper understanding of how these common concepts are related has helped me to quickly draft the 'workflow blueprints' that help to outline workflows, identify deliverables, identify stakeholders, create clarity, develop understanding, and align expectations before beginning a project. (This understanding has proven especially useful when scoping/analyzing clinical project requests prior to approval.)

 

I hope sharing this journey helps give you a roadmap for your own journey, and helps you develop your own definitions, templates, and tools for rapid workflow analysis and scoping before undertaking any significant projects. 

Remember this blog is for educational purposes only - Your mileage may vary. Have any anecdotes or stories to share about workflow analysis or development? Feel free to leave them in the comments section below!

Teaching Example : The Ice Cream Order Set

Hi fellow #ClinicalInformatics, #Informatics, #HealthIT, #CMIO, #CNIO, #CPOE, #workflow, and other #design thinking friends, 

Order sets - If you work in Clinical Informatics, you probably have a lot of experience with them. 

Order sets offer great opportunity, and can really help streamline clinical processes and create predictable outcomes. Since they are a part of the medical record that every doctor uses (like Larry Weed, MD once said), they can help guide and teach. In my 13 years of designing them, I've seen remarkable standardization in processes, reduction in variation, and improved outcomes when they are designed well. 

For those who design and build them, however, here are the five most common challenges : 

1. People without solid order set experience often don't budget properly from them, from a time or resources perspective. (They often take more work than most people would initially imagine.)
2. Doing them well often requires a great deal of effort and coordination between multiple clinical stakeholders (Physicians, Nurses, Pharmacists, and often other ancillary services, operational leaders, finance, legal/compliance, etc.)
3. It's not just the effort to create them - It's also the effort to maintain them.
4. People often disagree about the best way to create, review, test, approve, and publish them. 
5. Managing expectations can take time, especially when people try to use them to solve complex training/education or utilization problems. 

There are actually best-practices for developing them, but they're often not well-understood. It often takes time to build them in a collaborative manner, to help ensure the best outcomes: Order sets that physicians will actually *use*, predictably, to achieve predictable outcomes. 

So recently on Twitter, my CMIO colleague Paul Fu, MD from UCLA shared a tweet about an EMR order for 'birthday cake', presumably from a pediatric hospital that had actually had built an order for pediatric patients who could tolerate a piece of birthday cake on their birthday.

While several Clinical Informatics friends chimed in to comment, I took the opportunity to create a tongue-in-cheek, general-purpose Ice Cream Order Set that could actually be used for teaching and discussion purposes : 

This [DRAFT] order set example above basically lets you prepare ice cream for your TV binge-watching purposes. Remember, It's not a real order set, but it's a decent teaching example to show just how complicated and workflow-dependent order set design can be. 

You'll notice that it's a general-purpose ice-cream order set, addressing some common scenarios : 

• It's fairly flexible, allowing you to eat as little as a single scoop in a bowl or cup, or as much as multiple pints.
• It does a decent job addressing common allergies (lactose, peanut, dairy, etc.)
• It uses fairly standardized units of measurement, which are reasonable for most ice-cream consumption purposes. 
• It lets you select a number of toppings - and even finishes with a cherry on top. 

You'll also notice that it has some limitations : 

• It only offers three flavors - Chocolate, strawberry, and vanilla. (Imagine trying to index an order set to offer more complex flavor combinations?)
• While it has decision-support built in to help guide an ordering provider to the right choices, it does require a doctor to order the ice cream differently, depending on the utensils and container (cup/bowl versus the ice-cream container)
• Some Clinical Informatics friends have suggested it should have some alerts and hard-stops for people with certain food allergies (e.g. should you be able to order peanuts if you have a peanut allergy?)

Of course, it's just ice-cream, but the order set is still fairly complex, and required the development of a new term ('unique container') to address the ordering workflow related to eating from bowls/cups versus the ice-cream container - Imagine creating order sets for complex or high-risk clinical workflows.

Feel free to share this teaching example for your own discussion or education purposes - If you don't use an EMR or don't use order sets, it's a friendly way of showing people the promise and complexity that order sets can present, both in development and use.

Remember this blog is for discussion and education purposes only - Your mileage may vary. What would you do to make this order set easier or offer more flavors? Do you have any tips or feedback about order set development or maintenance? Feel free to leave them in the comments section below!

Signal-to-Noise, Provider Communication, and Provider Education

Hi fellow CMIOs, CNIOs, Clinical Informatics, HealthIT friends, (and other Clinical Jedi!),

Happy 2020! May this year bring us all peace, happiness, and good clinical workflows.

Speaking of good clinical workflows, thought I'd introduce today's piece by sharing some recent #HealthIT Tweets - One I was connected with on January 1st came from the great Janae Sharp (@CoherenceMed), via her @SharpIndex account: 

(For those of you who don't know the Sharp Index, 

it's a 501c 3 non-profit dedicated to improving awareness and tools to combat physician burnout.)

In any case, it's an honor being mentioned in this group with other fantastic people who are working on the same or similar issues - So I figured I'd simply respond with: 

So with this 2020 goal in mind, let's get to today's post. 

Communication with your clinical providers is vitally important. Often when discussing provider communication, I get the question, "Why is it so hard to communicate with providers?", sometimes followed by some kind of joke, usually about providers not being able to read their email in a timely basis. 

At that point, I usually have to explain exactly why provider communication is particularly challenging. To help explain the unique challenges providers face, there's a little concept that's fairly well-known in engineering circles, that is not as well-known in clinical circles - So with this blog post, I thought I'd bridge the gap. 

It's called a signal-to-noise ratio, sometimes written in engineering circles as "S/N". And it's super-helpful concept in a lot of situations - from everything including tuning your car radio, to developing communication strategy in emergencies, to clinical workflow design, to provider communication and education strategies.

You can read more about the engineering principles behind a signal-to-noise ratio on the Wikipedia page ( https://en.wikipedia.org/wiki/Signal-to-noise_ratio ), where on this day I retrieved it (1/3/2020) it defines the signal-to-noise ratio as : 

Signal-to-noise ratio is defined as the ratio of the power of a signal (meaningful information) to the power of background noise (unwanted signal).

The Wikipedia article then has a lot of complex math and descriptions of modulation and decibels, but you don't need to understand any of that math to appreciate the concepts behind a signal-to-noise ratio: 

Slide 1 - Introduction slide showing signal-to-noise ratio

In any environment, as humans, we always seek meaningful information (signal). Sometimes, finding that meaningful information (signal) is easy, provided the surrounding noise is fairly low. And sometimes, finding the signal can be a challenge, especially when the noise is high.

You can experiment with signal-to-noise ratios by visiting a restaurant with a friend before routine dinner hours - and trying to have a conversation. 

Before dinner hours - your conversation may start with a relatively normal signal, where you can both hear each other fairly well, with only a limited amount of ambient noise in the background; perhaps from waitstaff speaking or preparing for the dinner rush: 

Slide 2 - Signal-to-noise ratio before dinner crowd arrives 

in restaurant

But as more people come into the restaurant, it starts the race-to-the-top. Gradually more people arrive, the noise in the restaurant goes up, and pretty soon you can't hear each other as well: 

Slide 3 - Signal-to-noise ratio as more people arrive, 

and it gets harder to hear conversation

At this point, it starts to become a little uncomfortable - So to compensate, you will both need to speak louder (increase your signal), to continue your conversation in the setting of increasing noise:  

Slide 4 - Both people start speaking louder, to hear 

signal above noise and continue conversation

But then eventually everyone in the restaurant starts speaking louder to hear each other, and the noise goes up again - So it starts to get more uncomfortable: 

Slide 5 - Everyone in restaurant is speaking louder, 

noise goes up, conversation is harder to hear.

And perhaps, just a few times, you can't actually hear what the other person is saying: 

Slide 6 - Noise in restaurant is higher than 

your friend's voice (signal) - Conversation fails.

So to keep talking to your friend, you will need to increase your signal, and raise your voice again: 

Slide 7 - To maintain conversation, you have to raise your 

voice again (increase signal).

... at which point you will start to shout, get a sore throat, or speak only in short sentences (because you can't get enough air to increase your signal above the noise). 

If you've ever experienced this, you probably know it can make for a fairly unpleasant dining experience. Eventually, you'll leave the restaurant, and the first thing you might experience is this: 

Slide 8 - First reaction on leaving the noisy restaurant, 

when everyone seems to be 'speaking loudly'

... after which your friend may say "You don't need to shout anymore!". Soon after, the dinner crowd will empty out, and the restaurant will go back to a more normal signal-to-noise ratio again: 

Slide 9 - The restaurant goes back to a normal signal-to-noise ratio - 

but may wonder why the diners report an unpleasant experience. 

This same principle applies to provider communication and email boxes, which often have an unusual signal-to-noise ratio when compared with other clinical and administrative roles. Whether it's by email, page/text, phone call, or other communications means, here's roughly what most providers and nurses have to contend with: 

Operationally, the above table looks something like this (in no particular order, and Nurses have a very similar-looking communications map) : 

... where you can imagine, being the operator/orchestrator at the center of this communications chain - It's easy for the signal-to-noise ratio to get out-of-hand. This is why, nationally, provider communications and education strategies are particularly challenging.

This is also why, when there are critical safety issues, and patient-care is on the line - The most reliable mechanism you can use to ensure proper communication (and confirm receipt of that information) is a direct telephone call. Other methods (pages, texts, emails, etc.) are all valid forms of communication, but they are asynchronous, and may be prone to delays, or worse yet, they may get lost in the signal-to-noise ratio the provider is currently experiencing. Telephone calls are synchronous, and if it fails - You know immediately that it has failed, so you can try another provider or try another mechanism.

This is also why a good provider communication/education strategy does not just rely on just one mechanism :

[ DRAFT ] LIST - Sample modes of provider communication/education

1. Telephone Calls - Directly to the provider
2. Pages - Requesting a call-back from a provider
3. Texts - Directly to the provider
4. Emails - To the provider's email inbox
5. EMR Inbox/Inbasket messages - To the provider's EMR inbox/inbasket
6. Posters - On the walls of the hospital, office, nursing unit, or staff bathrooms
7. Department Meetings - Scheduled meetings with the department members
8. Workgroup Meetings - Scheduled meetings with a select set of clinical staff
9. Committee Meetings - Regular meetings with selected committees
10. Face-to-face communication - Meeting in a common location (e.g. cafeteria, staff lounge)
11. Intranet - Creating a high-value communication/learning ecosystem for providers (containing high-value blogs, videos, and links to training and solutions)
12. Social Media - Creating easy links to high-value communication/learning (e.g. videos, blogs, and links to training)
13. Classroom Training / Web Instruction - Creating a defined curriculum and assessment tool, for use in a classroom or virtual web environment
14. Configuration / Clinical Decision Support - Embedding EMR alerts, order set templates, and other tools inside the common EMR workflows, to help guide staff to desired outcomes
15. Policies/Procedures - Tools used to define organizational standards and how to achieve them
16. Guidelines - Tools used to educate staff about how to achieve desired outcomes
17. Onboarding / Credentialing - Tools used to educate staff when they join your organization
18. Recredentialing - Tools used to educate staff at regular intervals (e.g. recredentialing)
19. Screen Savers - Tools on the computers in clinical and non-clinical areas that display important messages during periods of non-use
20. And more...

Each of these tools has it's own costs, risks, and benefits - And so which tools you use, and who you direct them to, requires thoughtful analysis and consideration of things like : 

• What exactly is the purpose of the communication?
• Who (exactly) is the desired recipient/audience for the communication? (Careful not to confuse provider service with provider specialty!)
• What is the criticality of the communication? (What if the communication fails to reach the desired recipient/audience?)
• What details need to be included in the communication? 
• When and how often does the communication need to be delivered? (Once? Before a project go-live? Or a series of emails leading up to the go-live?)
• Which of the above tools are likely to be most effective with the desired recipient/audience?
• How often will the communication need to be updated? (Is it a one-time communicaiton based on a particular project? Or trying to communicate a TJC standard that may be updated next year? Or trying to communicate a long-standing HR standard that is unlikely to change?)
• How often will the communication need to be delivered? (Once? In a sequence leading up to an event? Only during credentialing/onboarding? Yearly? Bi-yearly with recredentialing?)

And why I'd like to leave off with a few take-home points : 

• It's helpful to understand the concept of signal-to-noise ratios, when analyzing your clinical workflows and provider communication and education strategies.
• Some ways to help minimize noise include fully building out workflows (to minimize communications related to clarifications), changing the supervision model (to help off-load some communications to other members of the care team, e.g. APPs), or changing communications modes and timing (to better target communications and minimize disruptions during patient care hours.)
• Good provider communication and education strategies do not rely on a single tool - They are a toolbox of tools.
• The tool(s) you use for communications and education should depend on a thoughtful analysis of the exact message, the desired recipient(s), the timing, the criticality, the frequency, and the anticipated need to update the message(s) in the future.
• Every role will have a different communication map - You can streamline your workflows for any role by making a map and then working to streamline your communications.

Hope this is helpful in guiding your clinical workflow analysis and your provider communications and education strategies! If you have any thoughts or feedback, feel free to leave in the comments section below!

Remember, this blog is for educational discussion only - Your mileage may vary. Always discuss with your Clinical Leadership, Administrative Leadership, Legal/Compliance Team, and Senior Leadership before making any strategic changes to your clinical workflows or communications or training strategies.

Have any thoughts or feedback? Or other communications or educational secrets to share? Feel free to leave them in the comments section below!

Raising a Well-Supported Workflow

Hi fellow Informaticists and other clinical leaders,

Long time no post - But I'm glad that I had some time this weekend to catch up on my blog. Have several pieces in the works, but today's is a roughly 18-minute video I put together on "Raising a Well-Supported Workflow".

Having workflow challenges? Not sure what the impact will be if you change a document? I'm hoping this video will help. Remember, workflow design isn't hard, once you see the big picture. It's a lot like propping up a tent, pole-by-pole - The trick is to know what poles you will need to prop up your tent.

So with that, I'd like to offer up this video for your consideration. Special thanks to Charles Webster, MD from ChuckWebster.com for his awesome definition of "workflow"!

Hope this was helpful to you, our future healthcare leaders! If you have any thoughts or comments, please leave them in the comments section below!