Could Healthcare use a SimHospital?

It's July, 2014. Meaningful Use Stage 2 is underway, ICD-10 has been delayed again, the Affordable Care Act is happening, and healthcare is reforming at a pace it's never been subjected to. Change is afoot. So this has been keeping me quite busy.

So I thought I'd write a bit about the potential value of gaming and simulation in healthcare reform.

As a CMIO in a community hospital, you sometimes fill a lot of roles - Physician informaticist, project manager, trainer, workflow analyst, policy writer, regulatory guru, strategist, and practicing physician all in one. I think this is one of the reasons the CMIO role continues to expand and evolve nationally - It's helpful to have someone who sees so many facets of your care delivery system.

And as an Informaticist, to help the REAL world, you end up spending a lot of time in a VIRTUAL world, with dummy patients, dummy lab tests, and dummy tools, trying to test things in a virtual TEST environment, to make them work properly before they go into the LIVE environment. Sometimes I'm very surprised at what this virtual world teaches us about the real world. (For some Hollywood context, see Gary Sinise playing astronaut Ken Mattingly in the movie Apollo 13, where they work out problems in the virtual training environment that help save the real-life astronauts.)

Anyway, with all of the change going on in healthcare, we need to identify and train future healthcare leaders who will help see healthcare through these changes. Here is where gaming comes in.

Gaming could help healthcare, by allowing our future healthcare leaders to learn strategy in a safe, dummy, TESTING environment - No real workers, no real patients, no real budgets. If pilots can practice flying and landing planes in a simulator, why can't healthcare leaders? What if they could really experiment with revolutionary efficiency and cost-cutting strategies in a safe, TEST environment, where they wouldn't have to worry about departments or hospitals shutting down?

One thing I've learned from studying workflows is that most people behave in fairly predictable ways. Most people want to do the right thing - They want to practice their trade, make a living doing it, and be proud of their work - so if you give them enough structure and reinforcements, they will do it fairly predictably. In other words, predictable things happen predictably.

So if you were designing a healthcare simulator, it probably wouldn't be too hard to develop some common clinical and administrative avatars :

1. [ CLINICAL ] Nurse avatars
2. [ CLINICAL ] Physician avatars
3. [ CLINICAL ] Pharmacist avatars
4. [ CLINICAL ] Ancillary staff avatars (e.g. Respiratory, Dietary, Rehab, Case Management, etc.)
5. [ ADMIN ] Manager-type avatars (e.g. Nursing, Providers, etc.)
6. [ ADMIN ] Director/Chief avatars
7. [ ADMIN ] Executive avatars
8. [ ADMIN ] Board Member avatar

And in this game, with simulated budgets, each of these avatars would generally conduct themselves with a predictable degree of certainty, based on what I think are a few key environmental variables, which are all related to each other : 

1. Amount of Education/Training (includes everything from formal, professional education to organizational orientation to continuing ed)
2. Strength of Operational Infrastructure (includes everything from policies to governance to committee structure to supervision to technology to organized change management)
3. Quality of Documentation (includes everything from contracts to job descriptions to committee charters to bylaws)
4. Efficiency and Flexibility in Finance/Budgeting (includes everything from salaries to budgets to facilities and equipment)
5. Effectiveness of Communication (includes everything from emails to committee meetings to reporting structure to internal/external posters and publicity)

So in a virtual, gaming scenario, you could potentially build a virtual SimHospital, from the ground up, full of these avatars. And if you wanted it to be successful - Or really successful -  you would probably want your virtual avatars to have the highest amount of education, strongest operational infrastructure, highest quality documentation, most efficient and flexible finance/budgeting, and most effective communication.

But the real world doesn't work like that - you can't have the highest degree of all of them. You have to make compromises. Usually limitations come in the form of time, resources, or both. So to be successful, most organizations constantly work to maximize all five of those factors.

But the virtual avatars in this virtual hospital would all be continuously responding to these environmental variables, and in this way, one could build this SimHospital - A virtual environment in which the goal is to make a working, functional, and financially viable hospital. You make the decisions, you juggle the variables, and the avatars and budgets will respond to your decisions. You could be your own virtual board member.

Why would someone want to play this game? To learn safely. To experiment. To try new ideas without people getting hurt. Heck, you could even make it fun and award points for things like delivering a quality procedure without complications, or saving money. What if healthcare administrators played this game at home, competitively, trying to see who could get the highest score?

Let's face it, running a healthcare corporation isn't easy, with these many complex internal and external environmental variables that are constantly changing. But helping leaders to understand the these changing variables in a safe, TEST environment, would have enormous educational value to future healthcare leaders.

After all, if pilots have virtual simulators for flying a plane, why not a virtual simulator for running a healthcare organization?

The challenge with this whole gaming idea, of course, would be deciding : What would you award points for, exactly? Would it be :

1. Financial Profitability?
2. Quality of Care?
3. Quantity of Care?
4. All of the above?

Whatever the scoring schema is, a place for healthcare leaders to learn managerial and leadership skills safely, and try out new ideas without risk, would be a tremendous help in training the leadership we will need to see our industry through the next ten years.

What would you award points for? Leave your thoughts in the comments below! Remember, this post is for educational purposes only, and to stimulate discussion about new and innovative ways to help improve the delivery of healthcare. 

Cutting Healthcare Costs by Making A Better Brick

1. THE BRICK

An interesting question I get asked is, "Why don't all order sets look the same at every hospital, even for the same disease?"

This question can be posed in several other ways, including :

1. "Why can't we just use order sets from someone else?"
2. "Why can't we just use canned order sets without editing them?"
3. "What do your policies look like?"
4. "Why can't we just use canned policies?"
5. etc...

But all of these basically ask the question, "Why isn't this standard?" and, of course, the follow-up question is, "Why is every hospital re-inventing the wheel?".

For inspiration to answer this question, I'd like to first explain a little bit about a wonderful thing : The brick.

According to the Wikipedia article, bricks have been in use since about 7500 BC to help construct things. (It's actually a really interesting article - If you appreciate human civilization, the brick has played a big role in building our streets, aqueducts, houses, walls, etc...)

The reason the brick is such a useful thing, from a design standpoint, is because it has two features :

1. A brick has a fairly predictable shape that allows you to easily arrange them to connect two or more places in space.
2. A brick is designed to withstand a particular load.

You'll notice these two features are helpful when designing any system - Having basic units engineered in a predictable manner, which can be assembled to make a bigger, more complex system that achieves a certain goal.

Hospitals contain systems that are also made of smaller units - Order sets are made of orders, clinical pathways are made of order sets, charts are made of notes, policy manuals are made of policies, etc. 

Unlike a physical brick, however, all of these basic units are conceptual - They are mostly complex documents - not physical objects - so it's a little harder to tell how predictable they are - e.g. to know if they're not engineered exactly the same.

For example, with physical bricks, it's much easier to tell if one hasn't been engineered exactly the same as the others :

You can immediately and obviously see the entire system is off, and locate the offending brick quickly.

But real bricks are not 100% predictable - They all have some degree of imperfections between them -As a kid, I occasionally ran into bricks behind our grade school, or around landscaping projects - I think I could only stack about 10 of them on top of each other before they start to fall over. (Legos are about the only bricks I can think of that are engineered to such a high standard that you can stack virtually hundreds of them on top of each other and still have practically a straight wall.)

But because regular bricks in the real world have subtle imperfections, humans have developed a tool we can use to compensate for these imperfections : Mortar, or cement.

Mortar/cement only works, however, to help straighten out the system when our brains get involved - We see the system leaning, so we set up guidelines/markers to help determine what is straight, and we put down the mortar/cement to compensate and correct the system. Again, the compensation depends on our human brain.

Because documents are not physical objects, we may not see the system leaning - But it can lean the same way in a conceptual manner. Fortunately, our brains can still compensate for a lot of conceptual leaning. 

So in my job in clinical informatics, I look at the standards by which the "document" bricks are built - To determine just how standard they are, and how much people's brains are compensating.

And this is why hospitals all have order sets that look and behave slightly differently - Because there aren't national standards by which their bricks are engineered. Fortunately, human brains are filling in the mortar.

What would it take to get all hospitals to engineer exactly the same bricks? The same engineering standards at all hospitals. 

And what would it take to get all hospitals to engineer bricks as well as Legos? An engineering process that was detailed enough to ensure that every brick looked virtually identical.

So why don't all hospitals have the same engineering standards and engineering process? Because documents, unlike bricks and Legos, are not as easily understood/studied/observed as physical objects. And because, for better or for worse, human brains can compensate extremely well - So there is little pressure to engineer them exactly the same. 

So as a result : Every hospital is re-inventing the wheel when it comes to their processes and their documents. In almost every hospital, they are looking to achieve exactly the same goal (in brick terms, "bear the same load") - Delivering standardized but customizable, evidence-based, high-quality care. But because the engineering standards and processes are not defined nationally, their tools are all ever-so-slightly different, and so virtually every hospital has to engineer them slightly differently.

2. A NEW IDEA ON CUTTING HEALTHCARE COSTS

The number of people employed to re-engineer all of these tools is remarkable. And it doesn't just include order sets - It includes every document in a hospital, virtually everything I mentioned in the CMIO's Checklist - Order sets, policies, protocols, documentation/forms, templates, etc. And all of these tools have to be continuously updated to reflect best practices, new technology, new evidence, etc.

These operations have become part of the price of healthcare - Continuously re-engineering all of these tools, so that the front-line doctors and nurses have the best and most up-to-date :

• Policies and Procedures to learn from and operate by
• Orders to take care of patients and deliver care
• Order sets to standardize and expedite the ordering process for a common clinical scenario
• Clinical Pathways to standardize care for a common clinical diagnosis
• Protocols to standardize and automate care for a common clinical scenario
• Guidelines to help standardize outcomes for a common clinical scenario
• Documentation tools to record and transmit data about care, and guide their thinking
• Templates to help them standardize and expedite the documentation process
• etc...

Unfortunately, keeping up with all of this information, and managing it, is very challenging for most hospitals. The professional industry term for this is "document management", and hospitals that do this well will probably have an easier time in the next five years than hospitals that do this poorly.

So to help hospitals struggling with this, I have often wondered why nobody publishes national, standard definitions of these tools, so that we could at least have the same engineering standards, and maybe then the same engineering processes - So that the order sets would all look the same - And you could truly use the same order set at any hospital...?

I suspect the reason that no regulatory body currently wants to offer these standard definitions is this : Anyone who tries to introduce these definitions and engineering standards nationally will have a big operational and financial challenge : 99% of hospitals would suddenly have to re-tool all of their documents to meet these national standards. Imagine the cost to healthcare nationally.

But so then I wondered - could we do something like this on a much smaller basis, in a much slower, more controlled manner?

Again I'll mention our Interstate 91 Informatics project - Where a bunch of volunteer Informaticists along the Interstate 91 Corridor here in New England are starting to meet regularly to talk about our common informatics issues. As I mentioned in a previous post ("Can we do better than SOAP?"), we are going to start talking about ways to standardize our documentation on a regional level. I'm interested to hear people's responses because it could be very interesting if, in the next step, we looked at standardizing our definitions, engineering processes, and engineering standards. Would it allow us to share resources that ultimately saved all of our hospitals money, and reduced the cost of operations and care in the entire region?

Stay tuned!

My belief is that we are all both teachers and students our entire lives - So I love to hear people's feedback and thoughts. Feel free to leave comments or questions - Always glad to entertain any new or interesting ideas!

Formal entry into CMIO blogging

Okay...

I realized, after I posted a bunch of stuff on Twitter this week, that people actually read what I posted.

As in, they asked me to make some sense of the chaos that I posted, because people were curious if I had any tips about good EMR implementation.

It was then that I decided I needed to actually start to write something a little better organized. So I'll try writing more on this blog - Mainly, for those of you who want/need a CMIO, but don't have one yet - I'll try to give you the little tips and tricks that I think can help a hospital have a good EMR implementation.

My little pithy blog is no substitute for an actual CMIO in your hospital, but until then, you'll have to read on.

Now, without further delay, my EDITED list of tips for good EMR implementation :

#CMIO tip #1 for DOCS wanting to fit into the new #EMR paradigm WELL: Learn to type, even a little, or learn to use Dragon well. Your thoughts are too important to be lost to handwriting.
#CMIO tip #2 for DOCS wanting to fit into the new #EMR paradigm WELL: prepare to redesign yourself. You won't be Dr. Kildare or Dr. Welby or Dr. Auslander or Dr. Dorian or Dr. McDreamy when you're done -
You'll be a whole new doctor. Same look, same skills, same caring, same name, new doctor.
#CMIO tip #3 for successful #EMR implementation : the EMR isn't "an IT thing", or an "MD thing", or a "RN thing" - it's everybody's thing.
#CMIO tip #4 for successful #EMR adoption : Patience, part II: Like humans, no product is perfect. You will always question if you made the right choice. The truth : it probably was.
#CMIO tip #5 for successful #EMR adoption : Patience. Realize that government, vendors, docs, administrators, and patients are "still trying to figure it all out"
#CMIO Tip #6 for a successful #EMR implementation : Persistence. Never stop pruning, weeding, and gardening. Have a good gardening team.
#CMIO Tip #7 for successful #EMR implementation : Learn that no doc, nurse, pharmacist, administrator, IT person, or consultant knows the whole story. You need them all to work together before you'll understand.
#CMIO tip #8 for a successful #EMR implementation : plan your budget well. Then increase your budget for training and support.
#CMIO tip #9 for a successful #EMR implementation : Plan your data needs for go-live. Then prepare for them to increase exponentially after go-live.
#CMIO tip #10 for a successful EMR implementation : Break down the wall between IT and clinical worlds. Promote both sides together.
#CMIO tip #11 for a successful EMR implementation : Prepare to cringe every time you hear "Why can't we just _____?" Generally this is NEVER the answer.
#CMIO tip #12 for a successful EMR implementation : Plan for docs in the middle ground. Aim for happy mediums. Walk before you run.
#CMIO tip #13 for a successful EMR implementation : don't just plan for your inpatient docs, plan for your outpatient docs EARLY. Doing this well can be strategic as long as you stay within Stark laws.
#CMIO tip #14 for a successful EMR implementation : Leave your emotions and personal baggage at the door when redesigning clinical workflows. Focus on good patient care.
#CMIO tip #15 for a successful EMR implementation : Recognize the tribal culture of medicine, but don't be limited by it.
#CMIO Tip #16 for a successful EMR implementation : try to avoid the four-letter word : "INTERFACE". Use only when absolutely needed.

#CMIO tip #17 for a successful EMR implementation : Plan staffing for an initial reduction in efficiency. Develop measurable metrics.
#CMIO tip #18 for a successful EMR implementation : be prepared for more training AFTER go-live.
#CMIO tip #19 for a successful EMR implementation : Have a politically neutral, teambuilding, personable, persuasive, and creative CMIO.
#CMIO tip #20 for successful EMR implementation : Dont be discouraged. Even a flat #CPOE rate will respond to nurturing and TLC.
#CMIO tip #21 for a successful EMR implementation : make sure you work on building allies early, before purchasing software.
#CMIO tip #22 for a successful EMR implementation : The secret to physician involvement - give them a chance. A good CMIO will help.
#CMIO Tip #23 for a successful EMR implementation : Grow a crop of clinical "Jedis" who KNOW your clinical workflows,can help bargain and teach them, and help reinforce good IT behaviors. (Clinical "Jedis" : they're not just superusers. They investigate workflows and datamine. They're your best management consultants.)
#CMIO: Tip #24 for a successful EMR implementation : work hard to make a comfortable environment for change. Bad blood slows progress.