Find any document in your hospital in five clicks?

It's December. The squirrels have gathered their nuts. The leaves have fallen. People are having their holiday parties. It's a time for reflection, as we anticipate the new year 2011 that lies ahead. Healthcare is changing faster than ever before, and those who want to survive, need to keep up.

I've spoken in previous blog posts about the tools we commonly use to deliver care in modern healthcare. So as I've been thinking about how to streamline organizational efficiency in healthcare, one of the major challenges most hospitals face is : How do we manage all of this information?

Some people will immediately look to IT for solutions, since we think of information as living inside a computer, but IT can only build a system as organized as you ask them to build. The problem is : If you had chaos before, making things electronic will only perpetutate the confusion.

(I've spoken to plenty of healthcare informatics types who complain about not being able to navigate their web sites, shared electronic folders that never get updated, and not having "intuitive" organization of their information.)

I find the comment, "We don't have intuitive organization of our information" particularly interesting. Everyone seems to have a different idea of what is intuitive.

All of this speaks to the need for standardization in healthcare, and education to support those standards. (Nobody teaches this stuff in medical school, nursing school, or pharmacy school.)

So I hope I've attracted your attention with the title of this blog. My proposal : We develop a standard "document tree" that can be used to organize virtually all of your hospital's information. (Except emails, of course, which generally are private and not shared.)

The Healthcare Informational Tree

So I thought about all of the common tools we use in healthcare (the CMIO's Checklist and the Informatics Toolbelt), and sorted them first by function and then by division (Clinical versus Administrative) - And this is what I got as a final list :

1. Telephone Numbers - Tools to contact a person
2. Emails, Screen Savers, and Posters - Tools to help send a short message
3. Schedules - Tools to show who is responsible at what date/time
4. Policies and Procedures - Tools to learn organizational standards and how to achieve them
5. Guidelines - Tools to help educate and guide staff towards a desirable outcome
6. Documentation - Tools to record and transmit information
7. Orders - Tools to document and transmit instructions to deliver care
8. Order sets - Tools to standardize and expedite the ordering process for a common clinical scenario
9. Clinical Protocols - Tools to standardize and automate a clinical process
10. Clinical Pathways - Tools to standardize care for a diagnosis throughout a hospitalization
11. Education Modules - Tools to help educate patients/staff
12. Templates - Tools to help make a document
13. Wikis - Tools to organize information / links for a department
14. Committee Charters - Tools to assign committee duties and responsibilities
15. Committee Minutes - Tools to record committee activities
16. Glossary of Terms - Tool used to learn definitions for common organizational terms

I believe that by using the above directory/tree hierarchy, you could arrange your tools on your intranet in a way that you can essentially find any document in your hospital in five clicks - Each link, from this main page, then divides up into clinical and administrative divisions, e.g. :

• Clinical Templates = e.g. Admission H&P template, Procedure Note template, Transfer Summary template, etc.
• Administrative Templates = e.g. Policy and Procedure template, employee evaluation template, etc. 

or

• Clinical Documentation = e.g. Admission H&P, Procedure Note, Transfer Summary, Vitals Flowsheet
• Administrative Documentation = e.g. Employee Evaluation Form, Room Change Form, Maintenance Request Form

or

• Clinical Policies = e.g. Pharmacy Policies, Infection Control Policies, Nursing Care Policies, etc.
• Administrative Policies = e.g. Human Resources Policies, Safety Policies, etc.

The interesting thing about making such a tree is it shows you, pretty quickly, how much work you are actually doing in your hospital, how much it actually takes to run a hospital, and why you need people to worry about all of these tools.

It also can help you find your work products much quicker, and it interfaces nicely with the tools that you need to make a change in the clinical setting.

Adopting such a tree is not a small project, but it sure can tidy up your intranet homepage. It also helps reinforce informatics education by making almost everyone in your organization review the basic tools you use, and what they do, every time they look for something. By having centralized publishing, this also helps keep your intranet a "high-value" site that people will use to find things.

As someone who wants to see American healthcare be the best that it can be, I think it's an admirable goal. Those of us working to organize Health2.0 should be keeping this tree in mind as we develop our healthcare informatics policies.

Remember, my advice is free, and you get what you pay for. Your mileage may vary. :)

Would love to hear comments about potential additions/changes you would make to the tree at your organization! :)

What is Medicine Reconciliation, anyway?

So recently I've been hearing and reading a lot about medicine reconciliation.

Medicine reconciliation is the safety practice that, it seems, The Joint Commission has recently announced they will set new expectations for.

A friend of mine, who went to an IHI conference last year, told me that on a wall full of posters of "problem subjects", the "Med Reconciliation poster" seemed to have the most hospitals reporting challenges.

So what is this Med Reconciliation thing, anyway?

• Is it a mythical creature that people see, but nobody ever really gets a picture of?
• Is it something that inspires poets and artists, because it's so intangible?
• Is it something that we can even achieve?

Most practicing physicians learned in medical school that it's "good practice to rip up and re-write all the orders when a patient comes out of the OR". Most practicing physicians are also used to documenting the patient's home medication list in an admission H&P. The interesting thing : These are both different facets of the same med reconciliation picture.

So then, I think one of the biggest challenges in implementing "Med Reconciliation" is that it's so hard to nail down. What is it, exactly? Who does it? And how? 

So I thought I'd share some answers.

WHAT IS MED RECONCILIATION?

I. THE PREMISE :
 First, the premise is simple : It's all about safety.

Med reconciliation is built on the basic premise that a physician and a patient work best together, when they're with eachother. For the purposes of this discussion, I've lovingly decided to call the "place where they work with eachother" the "Patient Care Cubicle" (instead of the industry term, "Level of Care" which is a little confusing.).

The process is then pretty simple. To perform med reconciliation, a physician needs two separate documents :

1. The 'home medication list', to know what the patient is 'usually on'.
2. The 'active medication list', to know what the patient is 'currently on' while sitting in this "patient care cubicle".

And the steps for doing med reconciliation? A doctor should basically follow these four steps :

1. Look at the Patient
2. Look at the HomeMedList
3. Look at the CurrentMedList
4. Make a new CurrentMedList!

This allows a physician can make the decision : What meds does the patient need to be on right now.

So remember, the recipe for med reconciliation needs these four ingredients :

   MED RECONCILIATION = [ Patient ] + [ Physician ] + [ HomeMedList ] + [ CurrentMedList ]

(While they are connected, remember - Med reconciliation is NOT the process of collecting the home med list - But you will need to collect the home med list before a doc can do med reconciliation.)

So... when does a physician actually do these four steps of "med reconciliation"? Optimally, it happens at two times :

1. When the patient appears in your cubicle (in hospital terms this is known as a "change in level of care")
2. When the patient has had some significant event (like delivering a baby, a code blue, a surgery, etc.)

So far, so good. Now comes the implementation challenges.



B. THE BASIC IMPLEMENTATION

The first thing you might do to map out the implementation of med reconciliation, is to make a general map of all of the "patient care cubicles" your patient might pass through, when he/she goes through your hospital. Typically, this map will start with the outpatient cubicle, and end with the outpatient cubicle. (On discharge, then, you need to do med reconciliation one last time to define the "new home med list", aka the "discharge medication list").

So if each "cubicle" has the patient and a physician :

1. The physician covering the "outpatient cubicle" is the primary care physician.
2. The physicians covering the other cubicles are the ones you assign.

And so if you need two lists - The home med list, and the current med list - To perform med reconciliation, you can see by the above slide that the first challenge will be getting the home med list available in your ED.

This brings us to some challenges with med reconciliation...



C. THE FOUR BIG CHALLENGES

The first challenge is just getting the home med list in your ED. How long does it take to actually assemble the list of home medications? (Remember : THIS IS NOT MED RECONCILIATION YET - Collecting this list is probably the thing most commonly confused with the term "med reconciliation".)

I did an informal study of this, while working clinically last year, and found that my median time for most adult medical inpatients was about 20 minutes. About 2/3 of my population was less than this, but about 1/3 of my patients were more than this, and there were some significant outliers - some patients took up to 45 minutes or more. (While slightly tongue-in-cheek, I called the standard I used the "mother standard", figuring I would work to achieve the same accuracy I would expect for my own mother.)

The reason it can take some time to assemble is this : There are up to seven data sources a person can use to assemble the home medication list. They include :

1. The patient - Who usually knows their home med list... but not always.
2. The family - Who is often helpful at establishing an accurate med list, but not always
3. The PCP - Who is usually accurate, as long as the office is open and they know what the specialist might be prescribing, so...
4. The specialist - Who sometimes needs to be contacted for clarification about new specialty medications
5. The outpatient pharmacist - Can be helpful to get a broad view, assuming the pharmacy is open and the patient doesn't use a mail-order pharmacy
6. The previous chart - Can also be helpful, assuming the last visit wasn't too long ago
7. The "insurance-based electronic prescription database", available at some hospitals - Which also still sometimes takes time to sort through, and you have to make certain assumptions...

So if the first step is to assemble this list in the ED, then the first challenge is to figure out who will assemble this list, and how?

Curiously, if you examine med reconciliation needs in the ED department, it usually falls along these steps :

1. Triage desk Officer : Generally drug classes are most important, not actual drug names. (E.g. a triage officer may consider bringing someone in if they are on blood thinners, or antibiotics.)
2. ED physicians : Generally drug names are most important, sometimes doses. Most ED visits are short, so there has not traditionally been much focus on doing med reconciliation in the ED. Of course, if we expect ED physicians to perform med reconciliation, they will need more information. (Some patients do miss medication doses while waiting for care in the ED.)
3. Inpatient Physicians : Here is where the drug, dose, route, frequency, indication, and last dose are most important, because the patient staying in-house will need to continue the right medications at the right times.

Because of these varying needs, at these different levels, it's sometimes hard to figure out who's responsible for how much of the puzzle.

The second challenge, assuming you can get the home med list assembled in the ED, is figuring out : Which physicians will be responsible for actually doing med reconciliation in each cubicle?

While it's tempting to answer :

1. ED - Would be performed by ED physicians, 24/7
2. Floor - Would be performed by hospitalist physicians, 24/7
3. ICU - Would be performed by intensive care physicians, 24/7
4. Etc...

...the PreOP setting/OR/PACU usually presents some unique challenges (challenge #3)

The challenge for many ORs/PACUs is this : Operating room schedules are tight. Hospitals count on maximum efficiency in an operating room. Even small delays can be magnified into cancelled procedures if everything doesn't run like clockwork. Also : Surgeons and anesthesiologists spend a good part of their day in procedures that simply can't be interrupted. Briefly pulling a hospitalist out of a family meeting to "do med reconciliation" will have a very different cost than briefly pulling a surgeon / anesthesiologist out of a surgery.

To accommodate with these demands, many anesthesiologists focus mainly on anesthesia meds, and many surgeons write post-operative orders in the PACU. If the patient goes up to the floor, after the PACU, then the nurses depend on the post-op orders written by the surgeons in the PACU. Unless you create a cubicle where the PACU has the same level of care as the floor, you might have to do med reconciliation again after the patient reaches the floor.

Figuring out this workflow can be very challenging. It's why my friend, going to the IHI conference last year, saw Med Reconciliation as one of the 'top challenges' hospitals face.

The fourth, and final challenge, is deciding on the "triggers" you will use for med reconciliation. As described above, there are typically two things that should trigger a physician to actually perform med reconciliation :

1. Patient arrives in your patient care cubicle (aka "Change in level of care") - This is usually pretty easy to enforce electronically.
2. Patient has a significant change in status (e.g. delivery, surgery, code blue) - This can only be enforced by a policy/clinical practice.

So you will need to decide on these two triggers, knowing that

1. For your EMR to trigger med reconciliation electronically, you will need to organize your levels of care and their relationship to your patient locations.
2. For your staff to trigger med reconciliation during a significant patient event, you will need good policy design and education.

D. THE NEXT STEPS / SOLUTIONS

Fear not, my reader! This may seem daunting, but the problem can be solved! Many hospitals have started down this pathway already, and many more will continue as The Joint Commission and other regulatory bodies reinforce med reconciliation practices.

To help you, I've offered the following recommendations and steps you can take to advance the discussion in your own hospital.

1. Define who is responsible for collecting the home med list in the ED
2. Define what home medication information they will collect, and how? (It's challenging to figure out how many of the seven potential data sources to use, but until our whole country is wired together electronically, your organization will need to decide this.)
3. Define where this home med list will be kept, once assembled, so that every doctor in the "chain of cubicles" will be able to access it and use it to perform and document "med reconciliation".
4. Define your "patient care cubicles", where your EMR can help trigger the med reconciliation process.
5. Define your policy that will help educate physicians about clinical scenarios in which you expect med reconciliation to be performed (e.g. delivery, code blue, surgery, etc.)
6. Define which physician's will be responsible for the med reconciliation process in each cubicle, 24/7.

Regarding the unique challenges that most Operating Rooms/PACUs present, this is a very common challenge, but I'll present the following possible scenarios I came up with :

1. Your hospital might consider asking the surgeons to perform med reconciliation after the patient arrives back up on the floor. (This may cost your hospital in OR time/efficiency.)
2. Your hospital might consider transferring all post-op patients to your hospitalist group, to allow the hospitalists to perform med reconciliation on the floor. (This may cost your hospital by needing more hospitalists to care for these patients.)
3. Your hospital might consider hiring a Physician's Assistant (PA) or Nurse Practitioner (NP) to assist the surgeons with the med reconciliation process. (This may also cost money, but I believe in most settings this would be more affordable than option #1 or  #2 above.)

Enjoy - I hope this discussion has been helpful. A good sample policy to support med reconciliation is available here from the University of Wisconsin Hospital and Clinics.  Again, I'm eager for any feedback folks have. Feel free to leave your own stories about tackling med reconciliation! :)

Converting paper order sets to electronic

If you're reading this, I hope you're the person in your institution trying to "convert the paper order sets to electronic ones".

Don't worry - you're perfectly normal. The job is usually a lot harder than it looks. And no, you're not the only one who hears, "Why can't you just take the paper order sets and put them on the screen?"

(Most people think it's simple, until they actually start to dissect the order sets.)

First, let's start with some of the challenges of paper order sets :

1. Paper order sets generally keep multiplying - Let's say you decide to fix the paper order sets, and so you need to take the old versions "off the shelves". Beware - People tend to make copies of paper order sets. So the old ones can turn up weeks and months later.
2. Paper order sets are often engineered differently - In the electronic (CPOE) world, orders are very concrete. You may have specific safety features put into your electronic PCA (Patient-Controlled Anesthesia) order. How will you put those safety features into your paper order set? You may also have hidden "protocols" in your paper order sets. What will you do with those protocol (conditional) orders? 
3. Paper order sets are sometimes ignored, after a hospital "goes electronic" - If you ignore your paper order sets, what will your hospital use during electronic downtimes? Can you afford not to have paper backup order sets, if your OR/ED are busy?

Believe it or not, how you address these paper-order-set problems will be vitally important in your long-term electronic success. Ignore the paper order sets, and you will miss an opportunity to really set up a robust electronic platform.

Let's look at each of these issues in a little more detail :

1. The "Multiplying paper order sets" -

This is a phenomenon many organizations struggle with. The solution : Centralize all of your order sets on one common electronic web site, and publish them as non-editable .PDF files. Create a clinical policy where "If it's not on this site, it's not an acceptable order set".  It will take you a while to get the site together, and organize all of your paper order sets there, but in the end, you will have a way of controlling the paper order sets in use. 

2. The "Engineering differences" between paper and electronic order sets

Some organizations, on going electronic, focus on developing electronic order sets, while the paper order sets continue to be produced in the way they "always have been built". If you have two separate processes (an electronic and a paper process), the problem is that you will start to have significant engineering differences between the two. 

If you have different paper and electronic order sets, you will then encounter :

• Paper order sets that don't meet the engineering standards needed for order entry in your EMR, so they will be very hard to "send-to-pharmacy-so-someone-else-can-do-the-order-entry"...
• Paper order sets that don't match the electronic order sets
• Two cultures : Docs who use electronic order sets, and docs who use paper order sets. (If your organization does a "flip-the-switch" approach to EMR/CPOE, then this won't apply to you. If you do a "gradual conversion", then this will apply to you.)

The way you fix this, of course, is to develop simultaneous paper and electronic order sets. Set up your informatics platform, update your policy on order set development (to include paper and electronic order sets), and ask your informaticists to develop the paper and electronic order sets simultaneously. Have them tested by the same people, and approved by the same committee. This will ensure that they match, and even if you are a "100% CPOE" organization, you will still appreciate having matching paper order sets during electronic downtimes.

Remember, the solution isn't to make electronic orders that mirror your bad paper processes. Make good, solid, and safe electronic orders, and then use those in your updated paper order sets.

A final tip : Embedded "protocol" (conditional) orders generally need to get pulled out of the paper order sets, before you can "make them electronic" - and you will need to decide what to do with those : A. publish them as new protocols, or B. throw them out. This will take work and can be politically challenging. 

3. The "Ignored Paper Order Sets"

Some organizations, on going electronic, ignore the paper order sets, thinking, "We don't need them anymore, right?". My advice : Don't ignore them. Not only will you need to figure out what your pharmacy will do if they end up getting faxed paper orders, but you will still need them for computer downtimes.

If all of this sounds complicated, and it sounds like a lot of work, you're right - It is. This is why order sets are the political and organizational challenge that they are. A good informaticist can help sort out the issues and put a plan and process into place for your organization, where it doesn't have to be too painful. Unfortunately, because healthcare doesn't have standards in clinical processes, every organization handles this conversion differently, and as a result, order sets are notoriously hard to standardize. (Think of them as a "custom-fitted suit".)

One last tip : Beware the "quick fix" - There are consultants who will "easily and quickly convert your paper order sets to electronic ones". The way they usually do this is by taking the paper orders, no matter how they are engineered, and simply build new electronic orders that match them. In the short term, this may appear to work, but in the long term, it may leave the nurses with orders which are unclear (and may create extra pages to doctors to clarify), since some paper orders are not as well-defined as their electronic counterparts. You may also miss out on the opportunity to streamline your clinical processes, and miss out on the time and cost savings that an EMR can really bring. My recommendation : Build the new paper order sets to match the engineering standards of your electronic order sets - Not the other way around. 

As always, my advice with order sets : There are no quick fixes. Hire a good informaticist to help you with this. :)

Hey, by the way, I'm open for questions - If anyone has any EMR conversion or informatics questions that you'd like to chat about, feel free to leave a comment here or email me. I'll try to devote my next posts to reader questions! So send me stories, questions, or whatever else you'd like to discuss in upcoming posts - I look forward to hearing from folks! :)

What's in the Informatics Toolbelt?

QUESTION : Dirk... How do I make change in a clinical setting?

A lot of modern healthcare asks for standardization. Common questions I get asked are focused on change and standardization, such as:

1. "How can we make sure the doctors use the order sets?"
2. "How can we make sure the doctors document ______ properly?"
3. "How can we make sure the doctors enter orders for ventilator changes?"
4. "How can we make sure the nurses document the vitals properly?"
5. "How can we make sure the pharmacists document the medication substitutions properly?"

The first tool most people reach for, to standardize care, is the order set. As a result, order sets are notoriously political. In the paper world, they generated enough debate, but in the electronic world, it often gets worse, as the political power shifts from a physician-centered process to a more organization-wide process.

Question : Huh? Dirk? Electronic order sets have a different political structure than paper order sets?

The short answer is yes. Why?

In a paper order set, most hospitals let doctors type their commonly-used orders on a piece of paper, put little check boxes next to each order, and a committee reviewed them - if the group of orders looked safe and met the right formatting requirements, and didn't have any unapproved abbreviations, the order set was generally approved, and the doctors could use them. End of discussion, for the most part, until the order set had to be updated. The doctors wrote what they wanted, and the organization approved them as long as there wasn't any major safety or organizational problem.

In an electronic order set, every electronic order (in the order set) has to be built by a programmer. So quite often, those programmers design the orders with extensive safety in mind. To figure out how to make them safer and more effective, the programmers ask the entire team (not just the doctor) for advice on how the order should be built. So programmers may ask the pharmacists, "How can we make this order safer?". They may ask the respiratory therapists, "What should this order look like?". They might ask the nurses, "What should the doctors really be asking for in this order?". They might ask the dietitians, "What should a diet order look like?". They might even add evidence-based links to the orders, on the order sets, to help guide the physicians about when best to use which orders.

As a result of these discussions with all of these different parts of the hospital, it's not uncommon for the programmers to design the electronic orders to look and behave differently than the paper orders did.

For example, a common safety tool used by programmers, after these discussions, is to build mandatory fields into the orders, that the doctors have to complete for the order to be accepted. As a result, the doctors are suddenly forced to think differently about these electronic orders, than they used to think about the paper orders.

I know it's still still sort of complicated, but a good example of this phenomenon is the diet order.

1. In the paper world, most paper order sets simply refer to an order, "REGULAR DIET".
2. In the electronic world, however, after discussion with speech therapists and dietitians, many electronic diet orders are built with mandatory fields for texture and liquid modification, so a doctor HAS to think about texture and liquid modification just to be able to enter a diet order. As a result, many electronic diet orders, on an electronic order set, will refer to the diet order, "REGULAR DIET, NO TEXTURE MODIFICATION, NO LIQUID MODIFICATION".

So doctors moving from the paper world to the electronic world will generally sense this loss of control - Suddenly, dietitians and pharmacists and radiologists can have enormous impact on the way they order something. In the paper world, doctors could simply write whatever they felt was best.

As a natural result of this political shift, electronic order sets often generate even more political discussion and debate than the paper order sets did. And this is another reason you may want to hire a CMIO, to help guide your doctors past the political debates and focus on good patient care.

Question : Aha. Interesting... Never thought about that. So what about this "Informatics Toolbelt" you mentioned?

The reason I bring up the "Informatics toolbelt" is because, as a hospital tries to standardize care by crafting workflows, everyone seems to reflexively reach for one tool : The order sets. By fixing the order sets, we can standardize care, right?

While order sets are certainly a good tool to help standardize care, they are not the only tool. Just to remind you that there are other tools, I present the following list of tools which I think sit in the Informatics Toolbelt : (Remember, most of these tools can be published either on paper or electronically...)

1. An order - A medicolegal instruction to provide a defined portion of patient care, via a defined route, at a defined rate, for a defined period of time. (Remember, in the paper world, you didn't have to "build" orders - In the electronic world, you have to "build" them, so you can actually engineer them to your advantage - The source of much political debate.)
2. An order set - A grouping of orders, to help standardize and expedite the ordering process for a common clinical scenario. Physicians generally start, modify, and stop the orders on an order set.
3. A protocol - A document that allows a nurse or pharmacist to start, modify, or stop orders based on a well-defined clinical condition.
4. A guideline - (aka care plan, etc.) A document that educates care team members about desired outcomes and processes, but generally carry less medicolegal weight than a protocol or policy, more negotiable, so they are engineered differently.
5. A policy (clinical or administrative) - A defined organizational goal or rule. 
6. A procedure - The steps requires to achieve a goal (or policy).
7. Documentation - (aka a forms, a flowsheet, etc.) - A permanent recording of patient status, activities, responses, and outcomes in time, authenticated by the signature of a licensed medical professional.
8. A patient education module - A document with media (written, video, or other) that explains a defined set of educational objectives to patients.
9. A staff education module - A document with material (written, video, or other) that explains a defined set of educational objectives to staff members.
10. A committee charter - By creating a charter, you can create a committee that helps standardize your care and monitor your processes
11. Committee minutes - By creating minutes, you can show effective supervision and committee activity to meet the organization's goals.
12. A staff meeting - Can be helpful for education and organizational purposes.
13. Email, paper mail - Can also be helpful for educational purposes.

There are probably other tools to put into the Informatics Toolbelt, but these are the most common ones. And a good informaticist can help you figure out the right mix of tools to craft the workflows you want to create to improve safety and standardize care.

(Using these tools to craft a workflow, in the electronic world, is an art known as electronic decision support. This is why a clinical informaticist is a key role in managing your clinical processes in the electronic world.)

Hope this helped remind you that order sets are a good tool to help craft a workflow and standardize care, but not the only tool. If you forget about the other tools, you may be missing out on other opportunities. A good clinical informaticist will help you figure out which tools to use for which scenarios. :)

A Few Words About Education in Healthcare and Life

So I recently got a very nice email from a person at a healthcare informatics consulting company, asking me to participate in a webinar on healthcare informatics. Two pieces of the email that really made me smile :

"Your blog was sent to me by a colleague who found it extremely educational on the topic of medical informatics. I quickly agreed; you discuss what can be very complicated systems and the politics of implementing an EMR in terms a layperson such as myself can easily understand. It has become a great resource for our staff as we continue to learn and grow within the HIT community."

and

"We were very impressed by the information in your blogs along with your conversational style..."

So I'm thrilled that someone picked up on what I try to do - Educate in a painless, simple way that people actually enjoy. A great example of this style can be found in the NPR Radio Show This American Life, where every week Ira Glass and various other writers/readers tell stories that are actually very educational. On This American Life, they have recently tackled subjects as complicated as the economic meltdown, credit default swaps, and other hairy political, legal, and financial issues, all told through stories that people share about their lives.

A great example of painless education told through story is their show about the financial meltdown, called The Giant Pool of Money. This is a true educational masterpiece. Every sentence in the show show lures you in, grabs you, and explains world banking and finance in a way that is totally tangible and palpable by the masses. You leave the piece feeling full of amazement at what you just learned.

This is the style of education I try to emulate in healthcare informatics. There are a lot of discussions in healthcare that are full of drama and intrigue, worthy of a Shakespearean drama. I try to convey it that way. :) (Although admittedly, I don't have as much time, creativity, or talent to emulate the TAL writers.) :)

Anyway, this gets me to my subject of education in healthcare, and in life.

Education is not something that has to be painful. It just has to require work. The first step is approaching a subject with :

1. An open mind
2. Eagerness to learn
3. The humility to admit you might not understand something

If you can achieve that, then you will be a great student and will learn a great deal, in school and in life. As social human beings, I think it's our nature to be BOTH a teacher and a student, as long as we live, and we have that responsibility to play both roles to keep our society intact.

I think part of the educational problem is that people don't appreciate how much work it takes to make education painless. Good teachers are worth their weight in gold and platinum. We also think of education as ending after high school, or after college. Yes, we pay attention to higher education too, but there are many, many ways we educate eachother, as humans :

1. We go to grade school, high school, and college
2. We talk to our friends and neighbors
3. We watch eachother and watch our children play on a playground
4. We tell stories at family reunions
5. We ask questions (to learn and to teach!)
6. We scribble ideas on cocktail napkins
7. We create and watch movies and videos
8. We write and read books and web pages
9. We write and listen to songs.
10. We write laws and policies.

Although the law, and most discussion centers around #1 as an educational medium, there are many other ways to achieve an educational goal.

One of my favorite stories I collected during medical school was when my parasitology professor, Dr. Calum Macpherson, told us about his time spent fighting parasitic diseases in Africa. In one story, he described a particular disease, echinococcus, which was causing disabling and life threatening liver and abdominal cysts in animals and people in a particular region.

The challenge to him and his team, he reported, was preventing the behavior where people would feed pieces of these large, salty, abdominal cysts from dead animals to the dogs in the neighborhood. (Gruesome, perhaps, but when you have dead animals, and hungry dogs, it only makes sense.) This behavior, unfortunately, perpetuates the life cycle for the parasite, and the disease continues to spread.

So how to prevent the behavior of feeding these cysts to neighborhood dogs? One way: To educate the village. So they developed a creative solution. Working with local people, they created a children's song that could be performed and sung at a playground, during playtime. They made the song catchy enough that kids liked to sing it.

Apparently, many years later he went back, and still found the kids on the playground singing the song they wrote about "not feeding cysts to dogs".

A creative approach, and effective. Perhaps the first example of a viral idea.

In conclusion : Don't let education intimidate you. It takes work, but it doesn't have to be painful. :)

Why not let docs have their own order sets?

Last week, I was asked a question I'd been asked many times before, by someone who was helping another hospital set up their EMR :

"Why shouldn't we let our docs make their own order sets?"

The reason I was asked this is because many EMR packages have this feature, where docs can make their own order sets for their own convenience. 

REASONS TO LET DOCS MAKE THEIR OWN ORDER SETS :

1. Every doc struggles with efficiency, and making your own order sets certainly is tempting. Why not make order sets that accomplish exactly what you want? After all, if I'm a practicing physician, and I know what orders I 'always put in' in certain scenarios, why shouldn't I be able to make my own order sets?
2. We could save so much committee time if the docs could just make their own order sets!
3. If the docs could make their own order sets, they would probably feel "more comfortable" with order sets and CPOE, in general - Wouldn't this help us with our EMR implementation? Wouldn't we get a higher CPOE rate faster?
4. It would save the time and labor of converting their old paper order sets - (Which, as I've discussed in past postings, are often loaded with embedded protocols which are expensive and time-consuming to engineer out!) - Just let the doctors make their own order sets!
5. If docs could make their own order sets, then they probably wouldn't blame some poor informaticist for making a bad order set for them.

REASONS NOT TO LET DOCS MAKE THEIR OWN ORDER SETS :

1. If every doc can make their own order sets, you have no centralized mechanism for clinical decision support. For example, if your pharmacy previously paid a lot for omeprazole, and it suddenly gets a good deal on pantoprazole, you will probably want all of your doctors to take advantage of the cost savings by steering them towards pantoprazole (when backed by good evidence) - If they all have their own order sets, you won't be able to help guide physician behavior and take advantage of this cost savings. 
2. If every doc can make their own order sets, you also have no centralized mechanism for standardizing care. E.g. an appendectomy could get very different care, depending on which physician was using which appendectomy order set. (Most hospital administrators are trying to standardize care to improve quality and reduce costs.)
3. Order sets need to be maintained regularly, to be kept safe, evidence-based, and efficient. If every doc can make their own order sets, you may quickly end up with many, many different order sets which can be a challenge to maintain, from a technical standpoint. What are you going to do when new guidelines suggest you should be using different drugs to treat pneumonia? How will you find which order sets you need to update? Do you have the resources to keep ALL of your order sets updated? 
4. If every doc can make their own order sets, you will miss out on the opportunity to teach your physicians what informatics is, and how they can improve their own care through evidence-based practice and standardization of processes.

I will admit, as a practicing physician, myself, there are times where I wish I could just make my own order sets. But I will also admit that being challenged on my own order sets is a great learning experience, and ultimately, sharing the discussion with my colleagues, and reviewing the literature is the best learning experience of them all. 

(Apparently I'm not the only one who frowns on personal order sets - A final web page, worth reading even though the author is unclear and this looks more like a comment than a legitimate argument : 

http://www.informatics-review.com/wiki/index.php/Personal_Order_Sets) 

Ultimately, every hospital will need to make this decision for themselves, but remember, as I said - With order sets, there are no free lunches. The rule still applies. :)

Top things to do with your new CMIO

Dear CMIO-owner,

Congratulations on your new CMIO! With a few simple care instructions, your CMIO will serve you well and last a long time.

Here are some of the things you can do with your new CMIO :

1. Ask him/her to help design and develop an informatics platform for your healthcare organization.
2. Ask him/her for advice on how to budget for your next clinical IT project.
3. Instruct him/her to do clinical workflow analysis before you implement your next EMR rule.
4. Ask him/her for expert advice on clinical decision support - What it is, and why it could help your hospital.
5. Ask him/her to help fix and update your order set process to include evidence-based order sets.
6. Ask him/her to help dissect and improve your paper order sets.
7. Ask him/her to help design training curriculum for your physicians, and develop a training plan.
8. Ask him/her about "EMR Governance" and why people seem to write so much about it.
9. Instruct him/her to attend your Medical Executive Committee meetings and give expert input about clinical workflow issues.
10. Ask him/her to develop ARRA/HITECH educational summaries for your senior leadership.
11. Ask him/her to develop EMR implementation strategy.
12. Ask him/her for policy help in developing policies needed to support your EMR.
13. Ask him/her "What is informatics?" and "Do we need it?" and "Is this something other people should know about?"
14. Ask him/her to help develop physician buy-in for CPOE, Order Reconciliation, and other enterprise-wide EMR projects.
15. Ask him/her to build approval policies for your clinical tools.
16. Ask him/her to manage software upgrade projects.
17. Ask him/her to design informatics education materials for your department directors.
18. Ask him/her to network with other CMIOs to look for workflow solutions that meet the tough compliance questions.
19. Ask him/her to develop datamining solutions, so you can get quality data OUT of your EMR.
20. Ask him/her to work with your Chief Medical Officer (CMO), Chief Nursing Officer (CNO), and other leaders to fully implement your EMR and the order sets, protocols, and policies needed to support it.

We recommend keeping your CMIO out of direct sunlight, make sure he/she has a warm place to sleep, and most of all, never feed him/her after midnight.

Sincerely,

The Manufacturer