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.

Top 15 Signs You May Work in Clinical Informatics

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

Over the last 10 years, I've blogged a lot about different topics in applied Clinical Informatics, from change management to glossary development and workflow terminology management, to order set development. And yet, across the industry, it can sometimes be a challenge to find the other people who do this type of work, partly because: 

• There are some people who 'do Clinical Informatics work', but are not labeled Clinical Informaticists / Clinical Informaticians in their job title. (Some are labeled CMIOs, CNIOs, Directors of Clinical Informatics, Clinical IT Analysts, Business Analysts, etc.)
• There are some people who do have a job title like 'Clinical Informaticist/Clinical Informatician', but focus their efforts mostly on a particular branch of Informatics, without clear support for the other branches (often due to resource limitations).
• Some 'Clinical Informatics' people focus their work for only their clinical specialty (e.g. 'Physician Informaticist', 'Nurse Informaticist', etc.)

So since in some regions, applied Clinical Informatics in 2020 still seems to be an emerging field, one that is fortunately becoming more formal and structured with the advance of more formal training and certification programs - I decided to spontaneously write a humorous piece on Twitter that could appeal to the 'Clinical Informaticist' (or 'Clinical Informatician') in all of us : 

Feel free to share with any Clinical Informaticists (or Clinical Informaticians) you know with a sense of humor! :)

Remember, this blog is for education and discussion purposes only - Your mileage may vary. Have any helpful humor or insights about Clinical Informatics, job titles, and professional development? Feel free to leave them in the comments box below!

Great NEJM Catalyst piece about HealthIT Implementations

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

Short post - Just wanted to share this great piece about HealthIT implementation from the October 2nd New England Journal of Medicine (NEJM) Catalyst, by Christina Pagel, PhD, David W. Bates, MD MSc, and Donald Goldmann, MD : 

"How to Avoid Common Pitfalls of Health IT Implementation" 

LINK : https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0048 

This is a super-helpful piece that includes cartoons (!) to help explain common issues in HealthIT implementations.

Since many of you know I'm a big fan of educating using cartoons, I just had to share. Feel free to share this great piece with your colleagues. 

Remember, this site is for educational and discussion purposes only - Your mileage may vary. Have helpful tips or other lessons you've learned from HealthIT implementations? Feel free to share 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!

How to Untangle a Complex Clinical Workflow

Hi to my fellow #CMIO, #CNIO, #ClinicalInformatics, #Design, #Designthinking, #workflow, and #HealthIT friends,

For today, I thought I'd share an easy trick for untangling even the most complicated clinical workflows. 

Let's say you're asked to help troubleshoot a particularly complicated workflow, where the end-users tell you things like 'It's so complicated, I can't even describe it!', or 'It's very non-linear'. You want to help, but aren't sure where to start. 

Here's my tip : Start by just writing procedures. 

While many people in the industry commonly write their workflows as 'swimlane' workflow diagrams, I find that these can sometimes quietly have room for error. In the wrong hands, with an untrained eye, it's possible to draw up a swimlane diagram with 'hidden gaps' that are hard-to-spot until you talk through each step in the process, usually with a group of end-users.

Indeed, swimlanes are the usual industry standard for planning or troubleshooting complex workflows, but writing good procedures can be equally as effective, with some added benefits : 

• Procedures can usually be edited dynamically, on-the-fly, with a group of people (e.g. in a video conference), as an easy way of quickly collecting their understanding of their workflow/process. 
• Procedures also make it easier to spot missing pieces - If you use my format above, you'll always know when the WHO (stakeholder) is missing, when it's not clear what's a REQUIRED (will) task or an OPTIONAL (may) task, or what exactly the task is. 
• Procedures can also usually be easily converted into policies or education, for those times when you want a policy to help back up and reinforce your important procedure, or educate it out to the people who need to follow your new workflow/procedure.
• Procedures are also generally 'naturally lean'. Missing pieces, redundancies, or design problems usually become obvious as you write out the procedure, allowing you to address those questions before you build your new process. 

If you use the procedure outline above, with the optional modifiers - you can even estimate the time it takes to do each task, allowing you to estimate the total time, people, and resources you will need to achieve your desired outcome. This can even be helpful in developing a Total Cost of Ownership (TCO) and Return-on-Investment (ROI) for your workflow.

And it's generally easier to stitch procedures together than it is to try to stitch swimlane workflows, which can take some time to move objects around, edit text, and reformat the diagram. 

Finally - For extra clarity, you can even name your procedures exactly what they are, e.g. : 

• DRAFT - CURRENT STATE - How to cook good food
• FINAL - CURRENT STATE - How to cook good food
• DRAFT - FUTURE STATE - How to cook even better food
• FINAL - FUTURE STATE - How to cook even better food

If you have any tips you'd like to share for documenting or troubleshooting workflows, feel free to leave them in the comments section below!

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Please check with your Clinical Informatics, Legal/Compliance, or Clinical Operational leadership before documenting any of your own workflows. If you have any feedback, tips, or tricks you'd like to share - Feel free to leave them 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!