The bad news about CPOE and clinical protocols

So this week, the ONC released the final "Meaningful Use" rules. I'm still going through them, but in general, the response has been pretty warm. A lot of the regulations have been relaxed. Still, the overall message : Your hospital will still have to meet "Meaningful Use" if it expects to benefit from the government reimbursements.

So since I had a few free minutes, I thought I'd share the bad news about the conversion to CPOE. Wait - You probably already know. It's hard.

To get CPOE running effectively, you need complete organizational buy-in :

1. Front-line buy-in, to help design meaningful order sets and implement them.
2. Administrative buy-in, to help redesign committee structures and EMR governance, enforce the new rules, and help develop the flexible budgeting required for successful implementation.

And here's the hard part - CPOE is a major culture change for the culture of medicine. Some of our most sacred traditions start to fall apart in a CPOE culture.

"Like what?", you ask?

1. The order "Advance diet as tolerated" - You may have read this in medical school, or in your nursing textbook, but the truth is, this is essentially a protocol. In the paper world, it works reasonably well, because in most patients, nurses can figure out how to advance a diet, and what kind of diet to advance to. In the CPOE world, however, this generally becomes a clinical protocol. In the end : You may need the governance structure to build and approve this protocol.

2. The order "Up ad lib" - You may have also read this in medical school, or in a nursing textbook, and many nurses will tell you "That's part of our practice" - The problem is, in the CPOE world, this also becomes a bit of a clinical protocol. Again, it generally works in the paper world, because in most patients, nurses know how to ambulate someone safely. But in the CPOE world, it requires a better level of definition, and also often becomes a protocol. In the end : You may need the governance structure to build and approve this protocol.

3. The order "These orders only are active in the ED" - This type of order is also really a protocol, which basically instructs : "If the patient leaves the ED, then someone needs to discontinue these orders". This works in the paper world, because nurses (seeing this in an order section of a paper chart) will generally know which orders this statement refers to, and nurses elsewhere will then ignore those orders automatically. In the electronic CPOE world, however, it requires a protocol to make sure someone has discontinued the orders properly. In the end : You may need the governance structure to build and approve this protocol.

Yes, some of these most cherished traditions start to fall apart in the CPOE paradigm. See any of them in your current paper order sets? You can translate them to the CPOE world, but you will need to build a more robust way of accomplishing this same functionality - Unfortunately, it's not that easy to find evidence-based rules for developing these protocols.

Your alternative is to develop order sets without any clinical protocols. These will be easier to implement in clinical specialties which are in-house 24 hours/day (e.g. Hospitalists, ED, ICU, etc.), but will be more challenging for surgical specialties and others who manage outside practices. (E.g. they will get phone calls that they weren't used to in the paper world.)

This is why you will need workflow experts in your organization to help understand the exact details of these workflows, and help you develop your clinical protocols along with your order sets and CPOE. Doing them separately is a much more complex process.

So how does a small hospital tackle these challenges? This is tough! The government (and vendors) don't talk a lot about this part of the process - I can only repeat the mantra : "Installing an EMR is nothing at all like installing Microsoft Word into your home computer" - You should be prepared for significant cultural and organizational changes.

In the end, my honest feelings : An EMR will definitely help you organize and understand your own clinical processes. The lessons you learn are invaluable. The quality and control it can bring you are priceless. But you have to be prepared for the level of change. Are you prepared?

In the end, an experiences CMIO or other informatics professional can help you organize all of these changes. My advice : Doing this without expert help is a little bit like turning a battleship around in a bathtub - You *can* do it, but it's much easier to do with an experienced and knowledgeable navigator.

Hospital Administrator Informatics Tools

So it's been almost a week now, and I'm still trying to find good definitions for :

1. Clinical Protocols (to help automate a clinical process, e.g. Heparin or Insulin drips)

2. Clinical Policy

3. Clinical Documentation

4. Clinical Order Set

5. Clinical Templates

6. Staff Education Module

7. Patient Education Module

8. Clinical Staff Schedule

Each of these tools requires a delicate process to build, develop, approve, and publish them.

And the interesting thing? We don't seem to have a standard policy definition! The SKTM Glossary (http://www.skmtglossary.org) seems to offer mostly technical definitions, and various other web sites seem to have different definitions/labels for this very common tool in healthcare. (Most of the other definitions are related to clinical trials.)

I'm honestly surprised The Joint Commission and CMS haven't stepped in to offer a definition that could be very useful in healthcare policy development and educating healthcare administrators internationally. (Is anyone from CMS or TJC a reader? Email me!)

There are also a bunch of automated software packages and companies that provide automated policy management - Just Googling the options will give you lots and lots of choices. (This must be a big business!)

In the meantime, I keep trying to keep the Wikipedia entry alive :

http://en.wikipedia.org/wiki/Health_informatics_tools

(Perhaps I should write the first "Healthcare Administrator's Toolbook", so I can use myself as a citation?) :P :)

Common EMR Training Tools

So now, back to my post about common EMR training methods.

When you plug in an EMR into your hospital environment, one of the biggest mistakes (challenges?) is the underestimation of training needs. Hospitals sometimes budget for money around the go-live. In reality, the training budget usually increases as time goes on. (This is one of those "Hidden costs of EMR implementation" that many hospitals don't prepare for.)

So I thought I'd talk about what some common educational tools are, that front-line informatics departments use to accomplish this feat. They include :

1. Department meetings

2. Emails / Paper mailings

3. Posters / Screen savers / Billboards

4. CBT (Computer-based testing)

5. Clinical Superusers

6. Train-the-trainer

7. Classroom instruction

8. One-on-one instruction

9. Electronic Decision Support (Alerts / Order Sets)

10. Clinical Managers / Directors

Each of these tools has distinct advantages and disadvantages. I thought I'd go through each one and offer some insight.

1. Department Meetings - Department meetings are a good way of getting people to your training - They're not good for much more than that. Trying to communicate how to operate a particular software feature, at a meeting when most physicians/nurses are coming in late, or looking for coffee, is generally a poor way to get across proper EMR technique.
2. Emails / Paper Mails - Like Department Meetings, emails suffer from a few challenges. First, many doctors have such a high noise-to-signal ratio that emails and paper mails almost never get through. (Notice the stuffed paper mailboxes? Physician email boxes are usually pretty similar.) Next, mail suffers from a lack of feedback - Did the physician actually learn the educational objective? How do you know they spent the time to actually properly understand the objective you were trying to get across? As a result of these problems, both paper and emails are notoriously bad for trying to use as an educational tool. My advice : At best, use them to get your staff to the training you set up. Don't mistake them for a training device.
3. Posters / Screensavers / Electronic Billboards - It's tempting to consider screensavers and electronic billboards for training - One powerpoint slide, seen intermittently around the hospital, might communicate the educational objective! The problem : You can't really guarantee it's seen by everyone. If the electronic billboard is in your cafeteria, then you'll miss employees who don't get lunch in your cafeteria. If the billboard is by the front entrance, then you'll miss employees who go in the back entrance. And like email, there's no way to know if your clinical staff learned the educational objective. Posters take more time to create, but work by the same principle as screensavers and electronic billboards, and so they suffer from the same geographic limitations, and also don't have a way to determine if the educational message has been received by your clinical staff. My advice : At best, use them to augment your training. Don't mistake them for a training device.
4. CBT (Computer-based testing) - Computer-based testing (e.g. having little computer-designed tests on your web server) is amazingly tempting. Clinical staff can do the tests at work, or at home. The software packages usually let you track which employee has completed which module, so you'll have great data on who completed their training. The downside is that the development of CBT (Computer-based tests) is much harder than it looks. There is a lot of programming and media development that goes into making a single CBT. So while most people dream of being able to save on teachers, usually they end up paying for people to develop the CBT. My advice : This can be very effective, if you plan resources to set up and maintain the CBT site. Don't underestimate the challenge.
5. Clinical Superusers - This is one of the most misunderstood terms in EMR education. Some people perceive "superusers" as non-clinical staff who wander around your hospital, usually during the month before and after your EMR go-live, to help "answer questions" and provide on-the-spot remediation. Other people perceive "superusers" as clinical staff who are just "really good with computers" and maybe got "extra training", so they could help the clinical staff who aren't as quick to learn. My advice : If you plan on using superusers, plan their time budget carefully. If your superusers are clinical people, and they have a full clinical load, they will not have much time to help your other staff. If they are non-clinical people, it will cost you money. Prepare a superuser strategy carefully, and prepare to spend money on them.
6. Train-the-trainer - This is also often mistakenly confused with "superusers". Train-the-trainer, done properly, can be a very effective way at educating a large number of clinical staff quickly. It involves a single person developing an educational tool (e.g. a quiz, usually with 4-5 questions, which tests whether or not a clinical member understood the training. Then the primary trainer needs to go out and find, usually, 5-10 secondary trainers. The primary trainer then teaches the secondary trainers how to teach the educational objectives, and give the clinical staffmembers the quiz designed by the primary trainer. The secondary trainers then go out, and usually complete this short education module with another 5-10 clinical staffmembers each. In the end, it distributes the teaching load, and as each secondary trainer comes back with successful quizzes, they bring it back to the primary trainer who can then keep track of "What percent of our staff completed the educational objectives?". My advice : This is a little like guerilla training. It can be very effective if done properly, but try to save it for the emergency, "Every-doc-has-to-know-this-feature-by-next-month-or-they-won't-be-able-to-sign-into-our-system"-type problems.
7. Classroom Instruction - Classroom instruction seems like a good way to train clinical staff. The problem is that often it's hard to get the clinical staff to the classroom, and if they don't have non-clinical time budgeted, their attention span and patience will be minimal. If you plan on using classroom time, make sure you have a well-developed curriculum, and you budget time and resources so that your clinical staff can learn in a relaxed atmosphere. Another challenge with classroom instruction, in the modern hospital, is that you generally end up running classes at all shifts - Don't forget your night staff if you're doing classroom instruction. My advice : This is a mainstay of teaching in hospitals, but it has its flaws and problems. Make sure you budget time and resources effectively, and develop a good educational curriculum, and keep it short and concise. My advice : Use this as a workhorse-type solution, but don't think it's going to solve all of your training needs.
8. One-on-One Instruction - This is often perceived as a nightmare (How can we have the time and budget to have a trainer do one-on-one instruction with all of our clinical staff?), but in the hands of a real teacher, this can be enormously effective. It involves one teacher sitting down with one clinical staffmember, and going through a set of educational objectives. Think of it as "your tutor" in high-school. One-on-one is certainly not good for large-scale training (e.g. all your clinical staff in the next month), but can be useful for small amounts of very intense, personal training. In my experience, one-on-one can be very helpful because as a teacher you can really perceive the learning problems and adjust accordingly. You'd be amazed what clinical staff will confess when they are learning one-on-one. My advice : This is good for "problem cases", and good for "brush-ups", but definitely won't work for major software updates or major workflow changes.
9. Electronic Decision Support (alerts / order sets) - Some people point to alerts in the software as an educational tool, e.g. "We'll just make a pop-up window that tells the doctors what not to click on". This is a major mistake. A pop-up window is not training. At best, it can help educate a doctor about a possible problem. At worst, your clinical staff may be suffering from alert fatigue, and ignore the alert entirely. Some people look for other electronic decision support (e.g. order sets) as a possible educational tool. While some order sets can be useful in educating your staff (e.g. is there a new antibiotic that you should be using for UTIs? Change the UTI order set to the new antibiotic!) - The problem is generally that EDS is not well-understood by most hospitals, and at best it helps guide clinical staff towards successful navigation of a small workflow issue. My advice : It helps a little, but definitely don't count on alerts or order sets to educate your clinical staff.
10. Clinical Directors / Managers - While some people don't focus training on clinical directors or managers, mistakenly thinking "only the front-line staff will need to know how to use the EMR!", I can tell you this is a big mistake. Clinical Directors and Managers are exactly the support people that the front-line staff go to for help. If your clinical directors and managers aren't familiar with your EMR software and workflows, then they won't be an effective resource for your front-line staff. My advice : Make sure you have a teaching strategy set up for your clinical directors and managers, and make sure they learn your EMR software. They can be a tremendous asset to the educational process, and in general, departments where the manager feels "I don't need to learn to use the software!" have very poor EMR implementations. The directors need to learn the software so they can be an educational resource for front-line staff.

So what have we learned? "Dirk - None of these sounds that great...." You're right! None of them are perfect. This is why EMR training requires a combination of all of these tools. And to know how much money to devote to which tool, you'll need an EMR educational strategy, which generally includes EMR policy development in your institution.

And how will you develop that EMR educational strategy and EMR policy? By having a good clinical informaticist (or CMIO) to help you with the entire EMR implementation. Remember : Good informatics starts at the budgeting process. Make sure you get expert help early, and don't underestimate the challenge of training and education in the EMR environment. Remember, as I said - The challenges generally get harder after your EMR go-live. Outsourcing training generally doesn't work well, because only in-house trainers will really know your culture and know which tool to apply to which problem.

Hope this was a good overview for folks! Write me with any questions!

Policy definitions for common front-line informatics tools?

First, this week, I thought I'd offer up an interesting problem. You can help solve the problem.

I put up what I think are "Nine common front-line Health Informatics Tools" on Wikipedia :

http://en.wikipedia.org/wiki/Health_informatics_tools

These are nine tools that almost every hospital uses, to accomplish their day-to-day operations.

The curious thing is that there seems to be little national consensus on the definitions of these tools.

I looked through the Joint Commission, CMS, AMIA, and HIMSS web sites, and was unable to find good policy definitions of these tools.

Most hospitals have as one of their primary administrative policies, a policy that spells out the use of one or more of these tools. But since there is little national consensus, it seems most hospitals have to write that first administrative policy from scratch. (Do I have any readers who can comment more about this?)

So I took my first stab at writing a middle-of-the-road definition of these tools, and put it up on Wikipedia. And within 5 minutes, the Wikipedia editors rightfully told me these entries would be taken down in 7 days if I could not produce proper citations for these tools.

I sought more sources, and was able to find some help on clinical order sets through the Institute of Safe Medication Practices web site (http://www.ismp.org) -

But unfortunately, I'm having significant challenge in finding additional sources.

If you have time, feel free to go to Wikipedia and contribute either sources or edits that could help shape the political, legal, and cognitive framework on which all front-line informatics tools may be built in the future. :)

(In the meantime, I've approached some big people in the Informatics Industry - We'll see where we can get in the next seven days. Talk about a challenge!) :)

Stay tuned - Next post will be the training post I promised. :)

Preparing budgets for the jump to "going electronic"

I was a child of the 80s, really, so I don't remember what the hubbub was about Bob Dylan "going electric". Wikipedia has an article about the incident, including the public reaction. Apparently it caused enough of an uproar for there to be a whole article devoted to the incident.

Anyway, getting your hospital to "Go Electronic" is probably just as shocking. It's not just a "software update".

First, there are "hidden costs" to going electronic, that vendors can't really tell you about, including :

1. IT/Software Maintenance costs
2. Changing hospital managerial structure / governance
3. Updating hospital policies
4. Developing Informatics platform
5. Developing robust training platform (for doctors, nurses, pharmacists, and all clinical staff)
6. Policy / Protocol / Order set / documentation building and development

... among other things. The hard part : You should plan for these "hidden costs". (Vendors don't generally bring these up before a sale, I think because a) it might cause you to think twice, and b) they often sell consulting services to help fix this stuff later.)

Some more conspiracy-minded folks, when they figure this out, will accuse the vendors of "Not fair! You didn't mention those costs!" - But in all fairness to the vendors, these costs are a hard discussion to have.

Why? Not only are there conflicting financial interests, but vendors often can't gauge your hospital clinically. After all, they are software companies, not hospitals, and so they have trouble giving accurate opinions about your clinical operations.

What I mean is this : If you actually study those "hidden costs" in detail, you'll notice they all depend on how you run your clinical ship. Let's review some of these "hidden costs" again :

1. IT/Software maintenance costs - Depends on your clinical staff, how they use the system, how often they want things fixed/updated - Every hospital is different. Software companies can't really gauge this for you.
2. Changing hospital structure / governance - Depends on your hospital's culture, some hospitals have an easy time adjusting, others don't. Software companies can't really gauge this for you.
3. Updating hospital policies - Depends on your hospital's clinical policies - Some hospitals require only minor updates, other hospitals require heavy changes. Software companies can't really gauge this for you.
4. Developing an informatics platform - Depends on your hospital's budget and understanding of the term "informatics". Some hospitals will adapt quickly and assign these roles formally. Others will try to do this in small increments. Software companies can't really gauge this for you.
5. Developing robust training platform for all clinical staff - Depends on your hospital's pre-existing training platform. Some hospitals will require significant changes, others will only need a little help. Software companies can't really gauge this for you.
6. Policy / Protocol / Order set / documentation building and development - Depends on your hospital's already-existing policies, protocols, order sets, and documentation. Hospitals with good design will have an easier time converting them to electronic. Hospitals that mix their policies / protocols / order sets / documentation will have a harder time. Again - Software companies can't really gauge this for you.

I think one of the hardest things about preparing for the jump, is that to answer these budgeting questions accurately reqires getting an honest assessment of your clinical staff, so that you can plan a good budget.

A good CMIO can help guide these budgeting discussions and decisions before, during, and after your go-live. Most CMIOs continue to practice clinically, so they can learn your hospital and give you an honest assessment of your clinical workflows.

If you don't have this discussion before go-live, you may find yourself with unrealistic early budget decisions which eventually hamper your eventual growth electronically. It's always better to start this discussion and planning process early.

Next post, we'll talk about developing meaningful training mechanisms for both before and after your go-live.

Denial, Anger, Bargaining, Depression, and Order Sets

More answers to questions about order sets.

Another common question I get asked, actually usually comes to me in one of three flavors :

1. "You mean we spent all of this money on an EMR, and they don't even give you decent order sets?"
2. "Can't we just copy order sets from ______ hospital? I have a friend there!"
3. "Can't we just scan the paper order sets and make them electronic?"

These are all variations on the same theme - What you purchased doesn't seem to fit, and there MUST be an easier way to do this.

I get this fairly commonly.

Many EMR vendors will sell you some sort of package of "Pre-made order sets". Beware! What vendors think of as "pre-made order sets" and what most administrators/clinicians think of as "pre-made order sets" are very different.

Pre-made order sets from a vendor are typically built around common clinical scenarios that most hospitals share in common - The CHF exacerbation, the pneumonia, the chest pain, the pre- and post-op patients.

The problem : A vendor has no way of knowing the exact idiosyncracies of your hospital or office. So they design something in a "one-size-fits-all" kind of way. (Think of it as a "one-size-fits-all" suit - Yes, it'll be too big for most people, but at least everyone can fit into it.)

So typically, these order sets tend to be VERY long, including EVERY evidence-based test and study and medication you can possibly think of.

When most doctors look at these lengthy, one-size-fits-all order sets, however, their first reaction is often : "What?!?! This is WAY too big!! We don't need all this stuff!!"

So the only way you end up trimming this order set to your particular hospital's culture is to go through the entire order set, line-by-line, and checking to see what you need and what you don't.

In the end : You usually end up doing the same amount of work you would as if you started from scratch.

Yes, this leaves many doctors and administrators frustrated. Some will complain to the vendor about this.

A vendor *could* try to help, and take a "best-guess" approach, and try to trim their "standard CHF admission" order set down - But this would leave 1/2 of their customers more happy, and 1/2 of their customers less happy. (Now, think of it as the vendor trying to make a smaller suit - It'll fit 1/2 of their customers better, but 1/2 won't be able to fit in the suit at all.)

Again - This is why the pre-built order sets often leave doctors and administrators frustrated.

After experiencing this phenomenon, clinicians and administrators will often go into "bargaining mode" - You may hear things like "I have a friend who can give us their order sets!" or "I found a web site with order sets!" or "Can't we just scan our paper order sets?"

The problem is - These order sets generally suffer from the same problem as the "best-guess" approach I described above - The suit may fit, if you're lucky, but it also may not. Often, getting order sets from a friend, or from a web site, or from your old paper version is a lesson in frustration, and again you have to tailor it to your hospital with your culture and your clinical circumstances.

In short : Thinking there is a "quick fix" to your order set problem is like thinking there's a "quick fix" to having a custom-made suit. Order sets, like a well-fitting suit, need to be tailored and adjusted and updated regularly.

Remember - It's the custom-fitted suits that look good - In the same way, custom-fitted order sets are the ones that doctors will *want* to use, will help increase your efficiency the most, and ultimately help cut your hospital's operating costs.

So ask yourself before you buy an EMR - Do I need a tailor to help build and adjust these order sets? Or can I get copies from other people, and hope they'll fit?

My advice : Make sure you have a tailor when you go electronic! :)

The problem of "Feature Bleed"

Another common question I get asked is, "What can we do to prepare for 'going electronic'?"

Most hospitals will, in these times, gather their order sets, in the hope of "making them electronic".

It's then, that you may notice the first problem. I like to call it "Feature Bleed".

"Feature Bleed" is when you have order sets that have pieces of :

1. Order sets
2. Protocols
3. Documentation

This is VERY, VERY common - Most paper-based hospitals aren't disciplined enough to have their order sets and protocols and documentation well-separated.

Take a look at your paper order sets - See something called "Advance Diet as tolerated" or "Up ad lib" or "Do not start any other CNS depressants without checking with the anesthesiologist first"? These are all protocols!

Take another look at your paper order sets - See something like "Write patent's PTT here : ___ ___ ___" or "Write patient's neuro checks q6h here : ____ ____ ____" - These are all documents!

Take one last look at your paper order sets - Are they labelled something like "Alcohol Withdrawal Protocol / Order set / Flowsheet"? This is a sign that you may have feature bleed. (Ask yourself which tab in the paper chart you have been putting this order set into - If you're not sure, that's a warning sign of "Feature Bleed")

How does this happen, and why is it so common? In the paper world, it's very easy to make an order set where :

[ Order set ] = [ Order set ] + [ Documentation ] + [ Protocol ]

The problem is, when you go electronic, you will have different places ("buckets") where you need to organize those things.

1. The "Order set" bucket
2. The "Protocol" bucket
3. The "Documentation" bucket

And to organize this, it will mean :

1. Significant redesign of your paper order sets
2. Significant redesign of your clinical protocols
3. Significant redesign of your clinical documentation

And to handle this? You'll need to define, for each of these informational tools :

1. A good policy definition of the informational tool (to help guide builders in the right direction and prevent future "Feature Bleed")
2. How will the informational tool be built? (By who, and how? What format?)
3. How will the informational tool be tested before it "goes live"?
4. How will the informational tool be approved in your organization?
5. How will the informational tool be published
6. How will the informational tool be tracked.

If your organization was very disciplined in the paper world, and you have good policy definitions of these tools, your conversion to EMR will go a lot easier.

And if not, you're like about 80% of the places I talk to. :) Just be prepared to deal with this organizational redesign issue at some point - Preferrably earlier, rather than later.