The Informatics Domain and Workflow Management

Hi readers,

For today's post, I'd like to offer some insight about two common questions I get - What is clinical informatics, really? And just how is informatics related to workflow development in the EMR world?

So to really answer these questions, I'd like to propose three goals for this post :

1. To describe how operational tools and workflows are developed and directed in an organization.
2. To describe the informatics domain.
3. To demonstrate how the informatics domain is vital in developing and directing workflows in the electronic (EMR) realm.

And by accomplishing those goals, I hope I can offer some insights into how to build a successful informatics platform. So, let's start off with a diagram I have lovingly named the "operations pyramid" :

I created this diagram to help explain how predictable operations are created. First, let's look at two important features of the diagram : 

1. At the top is the Mission/Vision - This is essential for setting the tone and direction of the organization, creates goals and targets, and is necessary to align the rest of the operations with successful outcomes. Typically, senior leadership has the responsibility for defining this very important part of the operations pyramid.
2. At the bottom is the Organizational Support - Because nothing happens in an organization without good support.

Between these two parts of the pyramid are a number of steps which all build on each other to predictably support the Mission/Vision of an organization. First - From the bottom-up, let's step through them - The : 

• Organizational Support (needed for everything) helps create the...
• Concepts (or in Informatics lingo, Ontologies) which shape the fundamental understanding and principles that the the organization uses to function, which then supports the... 
• Definitions / Terminology / Standards the organization uses to write and speak predictably to each other, which then support the...
• Templates / Archetypes the organization uses to support the creation of predictable...
• Documents / Tools which the organization uses to support the...
• Workflows / Processes the organization needs to support the ...
• Goals / Regulations the organization seeks to support the ...
• Mission / Vision of the organization.

Even when it's not fully appreciated, every organization has this pyramid at work, creating predictability and infrastructure - or not, if it's not well-understood.

This brings us to the Informatics domain, and why it's suddenly become an important part of operations in the EMR world. Informaticists are people who work to create predictable outcomes by focusing their attention on parts 3-7 of this pyramid : 

So to be successful at creating predictable workflow/process outcomes (#3), Informaticists must also concern themselves with steps 4-7.

Now, keep in mind that the part that's most visible in most organizations - the traditional documents/tools (deliverables) that we think of as 'what we need to operate' (e.g. documentation, order sets, etc) - is really only step 4 in this pyramid :

So you'll notice that in the entire Informatics domain, these documents/tools that are seen as the traditional deliverables are only small piece of the domain :

... and so conflicts can arise if it's not well-understood :

1. ...that these deliverables are only a piece of the entire Informatics domain, and
2. ... the depth/breadth of these of deliverables. 

So to better understand the challenges organizations may face when developing a successful Informatics framework, let's look at this line #4 (Documents/Tools) in a little more detail, and see how it related to workflow development.

To create workflows that are smooth, predictable, reliable, and non-disruptive, requires a significant amount of deliverables - The list continues to grow as technology advances. One common source of confusion : Only some of them are inside the EMR, which is another potential source of conflict for the Informaticist who is seen as only needing to occupy their time with the 'EMR issues'. So let's look at these deliverables in more detail : 

In the above slide, I've largely separated the workflow deliverables into :

1. The ones generally outside the EMR are ones that are traditionally seen as the responsibility of other departments, such as quality, nursing, IT, HR, or finance. (e.g. policies/procedures, guidelines, interfaces, schedules, etc.)
2. The ones generally inside the EMR are ones that are traditionally seen as the responsibility of Clinical IT/informatics departments (e.g. clinical documentation, orders, order sets, etc.)
3. The ones that span both (largely the emerging workflow technology which is created to help automate clinical workflow management).

The challenge that some organizations face in developing a successful informatics platform, however, is the understanding that whether they are inside the EMR or outside the EMR, or both - These deliverables all impact workflow.

So to avoid conflict, it's important to consider breaking with tradition, and developing a newer governance model which integrates your informatics leadership with the leadership of these other departments (e.g. quality, nursing, IT, HR, and finance). If the workflows that the organization needs depends on all of the deliverables, together, then it's important that the leaders of all of these areas work together to manage these deliverables as a team.

And this is why informatics should not be confused with IT, tech support, or 'whatever's inside the EMR' - Workflow success depends on the integration of leadership from all of these areas, to ensure that the organization can build and fully support the workflows that are needed to support their operational goals and vision.

I hope this post has been helpful to you! Leave any comments or feedback in the comments section below!

What are Clinical Decision Support and Infobuttons?

Hi readers! I was very excited when I was recently asked to give a brief overview of Clinical Decision Support (CDS)! What is it, exactly? Since I enjoy sharing front-line #Informatics insights in this blog, for educational purposes,  I thought I would share some of the slides from my presentation : 

Clinical Decision Support (CDS) is a term that is commonly used in health technology circles. What it means, however, is somewhat more elusive, because it doesn't just represent one tool - It's a whole toolkit of tools, used to steer clinical people in the right direction at the right time : 

The take-home message of these slides is that CDS is :

• A very powerful and broad toolkit of tools that helps answer questions and guide people towards the right decisions at the right times.
• Not just pop-up alerts! E.g. CPOE or BPA (Best Practice Alerts)!

CDS comes with the noble goal of the "Five Rights" of CDS : 

... which, in practice, take significant work and thought to achieve all five goals. Some concerns people have voiced about CDS include : 

And just for educational purposes, I included these two very simple forms of decision support which people can easily relate to, both seen below : 

(You may recognize the actor Wilford Brimley above, who very effectively educates patients about the potential importance of medical therapies, allowing patients to then speak to their providers about potential therapies.)

In any case, I'm so thankful that the very talented Informatics leader Dr. Guilherme Del Fiol, MD PHD has already spent years researching and studying CDS, and in 2014 published this great study in JAMA about what happens with questions that arise, among physicians, during real clinical care :

What Dr. Del Fiol identified in this landmark paper is that almost half of patient interactions result in a question about clinical care - Either about drug treatment, symptoms, tests, or physical findings - And when these questions do arise, only about half of them get answered, often because of a clinical lack of time to research an answer, or doubt that a useful answer exists!

The implications of this research is that almost 60% of these information needs are not being met! Fortunately, there is enormous potential for infobuttons to connect providers to instant, context-sensitive education. A great, short video demonstrating the power of infobuttons can be found here : https://www.powtoon.com/t/fh5ISK1UWO8/0/ 

... and fortunately there is a large project underway to standardize and develop infobuttons, which can be found at http://www.opeinfobutton.org. In any case, Dr. Del Fiol and others have shown the real potential for infobuttons to reduce search times for information, and increase the accuracy of answers : 

... and through this strategy, the VA has seen a remarkable impact on the delivery of care : 

... which is why I believe Infobuttons will continue to grow and evolve as a clinical decision support tool. It not only provides clinicians with fast, real-time, context-sensitive information, but it has the potential to change the entire educational model for physicians : 

So my take-home messages about CDS and Infobuttons? 

And anyone wishing to pursue additional references : 

I hope this was a helpful introduction to the concepts and tools of Clinical Decision Support, and the role that Infobuttons play in that toolkit. Special thank you to Dr. Guilherme Del Fiol (and many other talented #Informatics leaders) for their work in publishing these very important studies, which help us understand opportunities to help improve the efficiency and accuracy of care delivery.

What are your thoughts about CDS? Do you have any favorite CDS tools? Feel free to leave comments section below!

Recipes for Success in Clinical Workflow Management

Hi readers,

I had the great fortune today, to collaborate on a presentation with the talented nurse informaticist and designer Andrea Hoffman, RN, to the Informatics team at a fairly large healthcare organization. What a humbling experience! We were in a room with a lot of bright people, working on some truly remarkable and groundbreaking stuff! (It's good to know that healthcare is really working on innovation!)

Anyway, we presented on patient safety ( #ptsafety ) and clinical #workflow management - How to make your own gourmet workflow kitchen! A few people have asked me if they could see the slides, so here they are!

Please note : To make clinical workflow design something real and tangible, and to convey our passion for great workflows, we decided to use a lot of food analogies - After all, the food service industry has a lot of lessons to offer in process design, workflow, and safety.

Enjoy, and feel free to leave any questions or thoughts in the comments section below.

Hope you enjoyed them! New posts to come soon!

- Dirk :)