Sunday, February 17, 2019

Using CPOE Order Modes to Streamline Workflows

Hi fellow CMIOs, CNIOs, and other Clinical #Informatics enthusiasts,

This month, I thought I'd help demystify a common Computerized Provider Order Entry (CPOE) issue, that actually has a big impact on clinical workflows - Order modes.


Having a good understanding of order modes is essential to resolving many clinical workflow issues. If you've ever asked yourself : 

  • When is it appropriate to use telephone orders?
  • When is it appropriate to use verbal orders?
  • When is it appropriate to use written orders?
  • When is it appropriate to use protocol orders?
... then you've shared in the very common struggle with CPOE order modes

Order modes don't need to be confusing. One of the most common sources of confusion stems from the use of the term 'Computerized Provider Order Entry', or 'CPOE'. 
On selecting an EMR, some organizations assume that having a 'CPOE system' implies that all orders will be entered directly by a provider (The POE in 'CPOE') - And that once it is up-and-running, that there will no longer be any reasons for anyone else to enter orders. Some of those organizations may recognize the need to maintain telephone and verbal orders, for emergency purposes, but don't appreciate the same need for written or protocol orders. 
The truth is that while providers entering their own orders is a best practice, ideal and applicable in almost all ordering scenarios - It is not useful, or even possible, in all scenarios. For this reason, out of necessity, most EMRs recognize a few different ways that orders get entered into the EMR. 

I'm hoping this post will help generate more clarity around their use, and how they can help you streamline, and even improve, your clinical workflows. 

A. Order Mode Basics
To better understand order modes and how they help streamline and support workflows, it's first helpful to understand the difference between an order mode, and order status


(Click image to enlarge)

Basically :
  • Order Status - Tells you whether or not you should be executing ('following') the order
  • Order Modes - Tells you how the order got into the computer
The following slide gives a basic summary of the common order statuses and order modes, found in most electronic medical records : 

(Click to enlarge image)

It's again important to note that direct provider order entry ('CPOE') may be a best practice in almost all clinical scenarios - But the other order modes exist to support order entry in scenarios where it is impossible or even undesirable for the provider to enter the order directly. So to make sure you're only using those other order modes for the right scenarios, you'll want organizational policies in place to make sure they are being used appropriately and safely. The following policy discussion sheds more light on these scenarios, and at the end I've provided a nice summary table. 

B. Sample Policy Definitions
Since order statuses represent the different states that an order can have inside most EMRs, some [ DRAFTED ] policy-grade definitions for these four common order statuses ('states') might look like this : 
  • ACTIVE orders - Orders which HAVE been submitted and signed by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. These orders are ACTIVE and should be executed in a timely manner, according to the details contained inside the order. Outcomes from all active orders are attributed to the licensed prescriber.
  • PENDED orders - Future orders which HAVE been submitted and signed by a licensed prescriber, in anticipation of planned future release ('activation') at a future date/time by the licensed prescriber, or by a well-trained, delegated clinical team member on behalf of the licensed prescriber as part of a clear, standardized, well-developed protocol approved by nursing, provider, and pharmacy leadership. These PENDED orders are NOT ACTIVE and  SHOULD NOT be executed until they are released ('activated') into ACTIVE order status by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. Outcomes from all pended orders are attributed to the licensed prescriber.
  • HELD ordersPreviously ACTIVE orders which have been placed on hold ('paused') by a licensed prescriber, or by a well-trained, delegated clinical team member on behalf of a licensed prescriber as part of a standardized, clear, well-developed protocol approved by legal nursing, provider, and pharmacy leadership. These HELD orders are NOT ACTIVE and SHOULD NOT be executed until they are again released back into ACTIVE order status by the licensed prescriber, or by a trained, delegated clinical team member on behalf of the licensed prescriber as part of a standardized, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. Outcomes from all held orders are attributed to the licensed prescriber.
  • DISCONTINUED ordersPreviously ACTIVE, PENDED, or HELD orders which have been discontinued ('deactivated') by a licensed prescriber, or on behalf of the licensed prescriber by a well-trained, delegated clinical team member as part of a clear standardized, well-developed protocol approved by legal, nursing, provider, and pharmacy leadership. These discontinued orders must be retained as part of the legal medical record but must NO LONGER be executed for patient care purposes. Outcomes from all discontinued orders are attributed to the licensed prescriber.
And if the order MODES include the different ways that those orders can get into the computer, then some [ DRAFTED ] policy-grade definitions for these different order modes might look like this : 
  1. CPOE ('PROVIDER') order MODE - Routine orders originated, entered directly, reviewed, and immediately signed (authenticated) by a licensed prescriber, allowing the prescriber to follow decision support rules and order designs that guide best practices and identify errors before they occur. 
  2. TELEPHONE order MODE - Orders originated by a licensed prescriber via direct telephone ('voice-to-voice') communication, and transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member on behalf of the originating licensed prescriber according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership. Telephone orders must be signed by the originating licensed prescriber within _?12_?24_ hours.
  3. VERBAL order MODE - Orders originated by a licensed prescriber via direct verbal ('face-to-face') communication, transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of the licensed prescriber, according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership. Verbal orders must be signed by the originating licensed prescriber within _?1_?2_?6_ hours.
  4. WRITTEN order MODE - Orders originated by a licensed prescriber via a pre-approved paper form (approved by legal, nursing, pharmacy, and provider leadership), and transcribed by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member (according to a well-developed plan approved by legal, nursing, pharmacy, and provider leadership). Since these paper orders must be signed prior to transcription, they [ usually ] do not require re-authentication ('re-signing') after transcription. The original paper orders are part of the legal medical record and should be retained for quality-control purposes. 
  5. PROTOCOL - WithOUT SIGNATURE order MODE - LOW-risk patient care orders which are activated, modified, or discontinued by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of an attending prescriber, as part of a standardized, clear, well-developed protocol approved by legal, nursing, pharmacy, and provider leadership. By policy, all child orders from these low-risk patient care protocols are attributed to the attending provider, and do not require signature.
  6. PROTOCOL - WITH SIGNATURE order MODE - HIGH-risk patient care orders which are activated, modified, or discontinued by a Registered Nurse, Registered Pharmacist, or other registered, licensed, and trained, delegated team member, on behalf of an ordering prescriber, as part of a standardized, clear, well-developed protocol approved by legal, nursing, pharmacy, and provider leadership. By policy, all child orders from these high-risk patient care protocols are attributed to the ordering provider, and require signature within __?12_?24__ hours.
You'll notice in the above [ DRAFT ] definitions : 
  • These are all just [ DRAFT ] definitions - You'll want to check with your own legal team before you consider them and approve them for use in your own organization.
  • There are several signature timeframes which are unidentified (E.g. "__?__ hours") - You will want to review them with your own risk, legal, nursing, provider, and pharmacy leadership to decide on an organizational standard for these. Since these orders all carry risks of miscommunication, you will want to set these timeframes to as short a time period as possible. 

COMMON QUESTION : 
Q: Will every provider sign these orders within the assigned timeframes? 
A: Probably not. But you will want to regularly monitor compliance with your organizational standard, and that probably includes provider report cards for CPOE compliance. Some organizations find that connecting these CPOE statistics to compensation helps improve compliance with organizational standards. 

C. The Summary Table
Confused by the above definitions? Don't like the policy mumbo-jumbo? To help make more sense out of these order modes, and how they impact workflow, I've put together a little summary table which should help clarify them. It includes a summary of the order modes, WHEN to use them, their risks/benefits, and helpful ways to minimize the risks : 

(click to enlarge image)

Remember, it's all about safety and great patient care. Using the right order modes is essential to designing and implementing workflows that deliver that safe, great patient care. Once you have that good understanding of these modes, and the organizational policies to back them up, it becomes much easier to design clinical workflows that meet the needs of your patients, providers, nurses, pharmacists, and other ancillary staff. 

Hope this was a helpful summary! If you have any questions or feedback, please leave them in the comments section below!

Remember, this post is for educational and discussion purposes only - Your mileage may vary. Do not use any of these standards or definitions without first consulting with your informatics team and legal counsel!

Have your own tips for educating CPOE order modes, or anecdotes about how they improved your workflows? Feel free to leave them in the comments section below!

Saturday, January 12, 2019

Building your #Workflow Glossary

Hi fellow Clinical #Informatics and other #workflow enthusiasts, 

Happy 2019! While I continue to work on compiling the business case for Clinical Informatics, I thought I'd take a minute to talk about #workflow terminology

A. THE BACKGROUND :
Simply put - words matter. Any bilingual person who has ever tried to translate the phrase 'scram' or 'hit the road' into another language knows that a word-for-word translation does not always work. (Really? Hit the road..?) One might try to translate it as 'it's time to leave', but even that fails to convey the certain informal, vernacular quality that the phrase 'hit the road' conveys so well. So my advice to anyone working in a translational role - Do your best, but always translate at your own risk

In healthcare, we have a number of terms that people generally understand, but their exact definitions may vary from organization to organization. They include such common terms as : 
  • Order
  • Order Set
  • Protocol
  • Policy
  • Procedure
  • Guideline
  • Standing Order
  • Clinical Pathway
  • Documentation
  • Templates
  • ... and more!
While almost all clinical staff have a general sense of these terms, their true understanding may not be exactly the same - And so, with regard to the term ‘protocol’, for instance, they may quietly have overlapping circles of a common understanding :

The problem is that these differences in understanding may result in dramatically different expectations about how exactly a 'protocol' works, and what it can do to help their workflow : 
  • Can a protocol be used to allow a Registered Nurse to titrate an IV heparin drip?
  • Can a protocol be used to allow a Registered Nurse to give a pneumonia vaccination?
  • Can a protocol be used to allow a Respiratory Therapist to titrate the settings on a ventilator in the ICU?
  • Can a protocol be used to allow a Registered Dietitian to modify a diet for an inpatient?
  • What is the difference between a protocol and a standing order?
To increase the amount of common understanding, it's helpful to look at your federal and state regulations, along with your own safety and operational needs, to see if they offer any definitions that help clarify the answers to these questions :

After all, once there is a clear definition - then you can create a standardized template, development procedure, and staff education to give everyone on your team a greater, more standardized understanding of the tool and what it can do. Remember - It all starts with the definition.

B. THE PROBLEM :
Healthcare faces some challenges in harmonizing this terminology - What a protocol can do in some organizations is different than what a protocol can do in others. And despite CMS regulations which refer to the use of protocols, many federal and state regulations use these terms interchangeably - See this 2013 letter from the Centers for Medicaid Services (www.cms.gov), page 4 : 
Standing orders: Drugs and biologicals may be prepared and administered on the orders contained in pre-printed and electronic standing orders, order sets and protocols (collectively referred to as “standing orders” in our guidance) only if the standing orders meet the requirements of the medical records CoP.
And this, from the Interpretive Guidelines §482.24(c)(3) on page 78 : 
There is no standard definition of a “standing order” in the hospital community at large (77 FR 29055, May 16, 2012), but the terms “pre-printed standing orders,” “electronic standing orders,” “order sets,” and “protocols for patient orders” are various ways in which the term “standing orders” has been applied. For purposes of brevity, in our guidance we generally use the term “standing order(s)” to refer interchangeably to pre-printed and electronic standing orders, order sets, and protocols. However, we note that the lack of a standard definition for these terms and their interchangeable and indistinct use by hospitals and health care professionals may result in confusion regarding what is or is not subject to the requirements of §482.24(c)(3), particularly with respect to “order sets.” 
Making it even worse is when Informatics professionals then have to compare this with their state regulations :


... which may have slightly different understandings and definitions of these terms.

Fortunately, there are some very talented medicolegal and compliance experts out there, who can help an organization to develop a strategy for navigating these regulations, while planning their workflows, both before and after an EMR implementation. One of the best I've seen is Sue Dill Calloway, BSN MSN JD, who has a fantastic series of lectures on the importance of this terminology, for regulatory, financial, and patient safety reasons.

But in the absence of a simple, standardized national glossary, with good functional definitions of these tools - It can be very hard to develop the templates, development procedure, and education you need for your team. 

C. THE SOLUTION :
Given the lack of clarity about these terms, what's the average CMIO, CNIO, or clinical informaticist to do? Fortunately, there is a strategy you can employ, and that is expanding upon a fairly simple template for functional definitions : 
[ TermWhat It's Called ] - [ Functional Definition: What It Does
This simple template is helpful in separating terminology for tools that have slightly different functions, e.g. : 
Term1 - FunctionalDefinition1
Term2 - FunctionalDefinition2
 ...and so on...
So if we can accept this simple template for separating terminology and function, we can then start to draft a 'conceptual map' for these common terms in healthcare (click the image below to enlarge) : 
(REMEMBER - THIS GRID IS JUST A DRAFT AND IS NOT COMPLETE!)

As you start to do this exercise, you'll see that there are some terms which have very similar functions, and other terms which don't
  • Guidelines and Policies initially look like they might have similar functions - until you consider that policies might result in root cause analysis and disciplinary action, and guidelines don't. (Policies=rulesguidelines=suggestions).
  • Protocols and Standing Orders seem to have very similar functional definitions, so we need to figure out if they are true synonyms, or if there is some kind of a difference between them.
  • Procedures and Plans also have similar definitions - So we will need to figure out how to separate them. In this case, I've taken the liberty of separating them in time, suggesting that procedures describe current tasks, and plans describe future tasks
Given the similarities between protocols and standing orders, it's helpful to separate them by considering their risk - and thus their initiation/triggering mechanisms, FOR EXAMPLE
  • Standing Orders = Used for common, LOW-risk clinical scenarios in which the benefit to the patient of rapid evaluation and care outweighs any known risks. Standing orders may be initiated ('triggered') by a clinical POLICY (e.g. 'All clinic patients will be screened and potentially administered for pneumonia vaccination, according to the Standing Orders for Pneumonia Vaccination.) All orders and outcomes of standing orders will be attributed to the attending provider.
  • Protocols = Used for common, HIGH-risk clinical scenarios in which the benefit to the patient of improved care standardization outweighs any known risks. All protocols must be initiated ('triggered') or discontinued by an ORDER (e.g. 'Initiate Ventilator Liberation Protocol' or 'Discontinue Ventilator Liberation Protocol'). All orders and outcomes of clinical protocols will be attributed to the ordering provider.
While you undergo this exercise, it's important to look at your regional, state, and federal regulations, and to speak to experts (like Sue Dill Calloway, BSN MSN JD as I mentioned above). If there are no regulations to guide you in this grid, then you and your clinical and administrative leadership will have to make local decisions about how your organization wants to define these tools.  

As you work on these definitions, keep in mind other things you can do to improve safety and clarity, e.g. "Orders are documented instructions [ that ] must be signed within 24 hours."

As you start to build out this grid for your own organization, talk to people who use these tools, and you'll start to better understand the form, function, and other issues related to their design. And once you think your grid is complete? Bring it back to your senior leadership for review, discussion, and formal approval. Voila! You now have your own organizational glossary that will help you develop the templates, procedures, and education that create a greater understanding, and improved standardizationpredictability, and efficiency, for both your clinical and administrative teams. 

Hope this is helpful in guiding you to build your own workflow glossary! If you have any other tips, suggestions, or comments, leave them in the comments section below!

Remember - This blog is for educational discussions only. Do not use any of these definitions without formal review and discussion with your own informatics, legal, administrative, and clinical teams. Have any other clinical terminology tips you'd like to share? Feel free to leave in the comments below!

Thursday, December 27, 2018

Building a Business Case for Clinical Informatics

Hi fellow Informatics leaders,

After my last post on The Offerings of Clinical Informatics, I'm planning a follow-up post on the business case for Clinical Informatics.

After all, we all know the clinical case - More predictable workflows, better clinical decision-support strategies, better data management, better engagement of clinical staff, and better prioritization of clinical improvement projects - But what exactly is the business case? Does having certified, well-trained, and well-supported clinical informatics professionals actually save money? Improve charge capture? Improve efficiency? If so, how much?

Sure, there are plenty of industry anecdotes - but I'm searching for published data too.

If you have any good anecdotes, and would be willing to share them for my next post, please leave a comment below, so I can compile them and share your story. And if you are aware of any good published data, please feel free to leave that too. 

More to come soon, and thank you all for your help.

- Dirk :)


Have any good anecdotes about the business case for clinical informatics? Or know of any published data? Feel free to leave information in the comments below!

Sunday, December 2, 2018

The Offerings of Clinical Informatics

Hi fellow readers,

If you are involved in electronic medical record (EMR) implementations, or healthcare technology in general - Someone has probably forwarded to you the recent November 12th New Yorker article by surgeon and innovative healthcare thinker Dr. Atul Gawande :


In the style of Dr. Gawande's excellent narrative and analysis, this is a well-written, thoughtful piece about the common challenges of EMR implementation, as told from the front lines of medicine: The surgeon who feels the EMR is controlling him, instead of vice-versa. The Internal Medicine Primary Care Physician (PCP) who spends hours fter her shift documenting her notes and managing problem lists. The rigidity of EMRs, compared with the fluidity of paper. The use of physician scribes, with questionable improvement in outcomes. And the patients who lose when their provider no longer focuses solely on them during a clinic visit. These are all real - but there is more to the story.

Dr. Gawande very eloquently describes these very real and common scenarios, why they happen, and their impacts on providers and patient care, both for good and for bad. I appreciate his storytelling, and how it educates people about some very real usability issues, which impact users all across the clinical spectrum - and the patients they serve.

So this is not a rebuttal, but more of a commentary on his piece in the New Yorker. As a clinical informatics professional, I was somewhat disappointed that nowhere in his essay did he share the term "clinical informatics" - The discipline that works to implement emerging technology in the safest, most sensible, and cost-effective manner possible.

Given the wide audience for this piece, it could have been a great opportunity to educate the general public about this underrated, poorly-understood, but very important clinical discipline. 

What is Clinical Informatics?

For those of us who work hard to implement these technologies, we often to struggle to explain this (still!) emerging discipline of information engineering, and how/why it impacts clinical workflows, safety, efficiency, and provider satisfaction.

To begin : Informatics is a branch of the academic field of information engineering. Taken from the current Wikipedia page on Informatics :
"It involves the practice of information processing and the engineering of information systems, and as an academic field it is an applied form of information science. The field considers the interaction between humans and information alongside the construction of interfaces, organisations, technologies and systems. As such, the field of informatics has great breadth and encompasses many subspecialties, including disciplines of computer scienceinformation systemsinformation technology and statistics. Since the advent of computers, individuals and organizations increasingly process information digitally. This has led to the study of informatics with computational, mathematical, biological, cognitive and social aspects, including study of the social impact of information technologies."
Informatics is a branch of information sciencenot information technology, that sits right in the intersection between healthcare (clinical medicine), our health system (clinical operations), and information technology and communication : 

If IT professionals need to focus on supporting the technology that will store and route all of this clinical information, then Informatics professionals are more focused on what information will be stored, and how it will be organized and used for clinical purposes. 

To do this, Clinical informatics professionals ('Informaticians') need to focus on what care is being delivered, and how exactly clinical staff is using (or planning to use) the information and new technology to improve outcomes :
  • How will the technology impact the delivery of patient care?
  • In which workflow(s) will clinical staff use the technology?
  • Is the technology safe, efficient, and well-configured?
  • Are any technical, process, or terminology standards needed to support the technology in a harmonious way?
  • Does the technology make it easier to deliver good patient care within the planned workflow(s)?
  • What kind of training will clinical users need to correctly use the technology?
  • What other things might be needed to achieve a successful implementation of the technology?
  • What research opportunities will the technology make possible?
So to accomplish their mission, clinical informaticists have to care about organizing both data in and data out : 
... and the breadth of workflows that clinical staff will use to deliver quality care. This means studying a wide variety of disciplines :
  • Clinical medicine, terminology, roles, and operations
  • Cognitive and behavioral science
  • Evidence-based design principles
  • Interface design, usability and interoperability
  • Data structure design (e.g. data indexing, archetypes, hierarchies, and logical functioning)
  • Heuristics
  • Process analysis and engineering
  • Linguistics and terminology management
  • Project management
  • Legal/compliance environmental analysis
... and more. It's this kind of detailed analysis and workflow ownership that is necessary to convert turbulent workflows into laminar workflows : 

I know this because I am one of the many physicians who is now board-certified in Clinical Informatics by the American Board of Preventive Medicine (ABPM), a program supported by the American Medical Informatics Association (AMIA). With over twelve years of practical, applied clinical informatics experience, I have seen the problems created by turbulent clinical workflows, and worked hard to make them laminar again - And seen the improved outcomes and provider satisfaction that informatics can offer.

Why Clinical Informatics?

Clinical Informatics professionals are especially helpful when implementing electronic medical records because, as Dr. Gawande points out - EMRs enforce a certain sense of operational rigidity and role accountability that is difficult to identify (or enforce) in a paper-based clinical environment. If operational standards are not strictly enforced prior to EMR go-live, then these roles will be re-aligned after go-live : 

Given this realignment of roles and responsibilities, a significant amount of workflow analysis and engineering must occur for EMR configurations to align with user needs and expectations. Clinical informaticists ('Informaticians') are particularly adept at this sort of workflow analysis and design, translating the needs between the clinical and IT realms, and providing design and project management support.

Where are the Clinical Informaticists?

It can be difficult to identify the clinical informatics professionals on many EMR implementations, because there are often challenges in separating them out from other common HealthIT roles - few of which require clinical backgrounds. While these roles commonly overlap, and many people fill more than one role, here are some gross generalizations - As a caveat, your mileage may vary : 
  1. Clinical analysts - These are generally the professionals who work with end-users to analyze, build, test, and implement clinical content in an EMR. While analysts are the backbone and workhorses of configuration for most EMRs - they generally focus mainly on the tools inside the EMR, which occupies most of their time - and often do not have time or expertise to manage additional workflow tools that may be necessary outside the EMR. 
  2. Application Support Professionals - These are often the 'second-tier help desk' or 'second-tier support' professionals who work together with the help desk, to respond to more detailed user questions, troubleshoot issues, and provide elbow-to-elbow support to end-users who might need additional assistance.
  3. Clinical/credentialed trainers - These are the professionals who are experts at  studying clinical workflows, studying application features, developing training materials and curricula, and delivering that training in classroom and online settings. They also sometimes assist application support professionals in direct elbow-to-elbow settings.
  4. Project Managers - These are the professionals (many with PMP certificates), who are experienced at planning, budgeting, scoping, and leading projects. Their tasks include meeting frequently with stakeholders, developing detailed project plans, timelines, and deliverables, and keeping the work team on schedule and on budget.
  5. Analytics professionals / report writers - These are professionals who are focused on getting data out of the system, validating it, interpreting it, and displaying it in a meaningful way, to help advance clinical care and research needs.
  6. Process Improvement Specialists (E.g. Lean or Six Sigma- These are trained professionals who typically report to quality to study clinical processes, study outcomes, and improve upon them. They may or may not have clinical experience.

While clinical informaticists ('Informaticians') may work with all of the above, or fill some of all of these roles, the informatics role is unique in their ownership of implementing clinical workflows, change management, standards, clinical terminology and translation, information design, indexing, archetype analysis, usability, and clinical outcomes. Clinical informaticists are skilled at critically evaluating details of workflows and configuration, and adjusting them, when necessary. While it is not always necessary, most clinical informaticists come from clinical backgrounds, which is very helpful when trying to interface with clinical staff and navigate clinical terminology, roles, or processes : 



Despite their important role, there are other things that may make it more difficult to identify a clinical informatics professional:
  • For many years, clinical informatics was a poorly-understood, poorly-controlled term. Since clinical analystsapplication support professionalsclinical/credentialed trainers, project managers, analytics professionals/report writers, and process improvement specialists are all involved in information design and EMR support - some of them might refer to themselves as 'Informaticists' or 'Informatics professionals' - Unfortunately this loose association clouded the role for the new generation of clinical informaticists who come prepared with formal informatics training and certification
  • Clinical informatics often reports to IT departments, where there can be a competition for resources. (It can be challenging to budget for informatics when there are also valid and competing IT needs.) 
  • Some people seeking to lower the cost barriers-to-entry for their projects, may sometimes minimize the importance of having clinical informatics professionals available on projects to help support the clinical analystsclinical trainersreport writersapplication support professionals and process improvement specialists who help develop content and support end-users. 
  • Some organizations believe that 'sample content' can help save significant time by replacing clinical workflow evaluations and operational discussions with sample content that has already been developed by another organization. Unfortunately, these workflow evaluations and clinical discussions are still necessary for gap analysis and proper scoping, and to validate and align configuration with end-user needs, expectations, and training - and so there generally not much time saved from using sample content.
  • Many workers fulfill the role of clinical informatics, but with other vague job titles like 'solutions engineer' or 'clinical workflow analyst' or 'EMR implementation specialist'.
This somewhat-ironic 'Informatics terminology issue' was recently highlighted in this humorous (!) segment from the November 2018 AMIA conference in San Francisco, featuring AMIA President and CEO Douglas B. Fridsma : 

Given these terminology, budget, and support challenges, many HealthIT projects and EMR implementations occur with little or no significant informatics support. 

The Cost of No Informatics

The easiest way to demonstrate the importance of clinical informatics comes from an examination of a best-practice model for implementing clinical workflow changes : 

The change management procedure outlined above is a sort of 'best-practice' series of steps which, only if performed in order, will help ensure that a new workflow is safe, best-practice, compliant, and efficient before it is built, tested, and expertly delivered with a minimum of disruptions. It will also help engage users, ensure that testing is complete, align expectations, and ensure that users are properly trained and supported during go-live. 

Making great clinical configuration, workflows, and outcomes is a great deal of work. Many organizations struggle to have the time or resources to fully complete all steps, so to meet project deadlines, they often have to make compromises - while still trying to fulfill as many of the steps as possible. 

Without well-trained, well-defined clinical informaticists there to support the project team, a few things become clear :
  1. It is usually difficult to manage all of the steps of a 'best-practice' change control and project management process. This can result in user dissatisfaction, lack of engagement, and unplanned outcomes.
  2. Terminology and naming conventions may be difficult to manage. This can result in reporting challenges, and difficult validation of data.
  3. Other roles (clinical analystsapplication support professionalsclinical/credentialed trainers, project managers, analytics professionals / report writers, and Performance Improvement specialists) may have translational challenges when trying to engage with clinical staff.
  4. Prioritization of projects may be difficult, without an accurate assessment of needs, and proper scoping and prioritization.
  5. Without adequate analysis, scoping, prioritization, and design pre-work - analysts may spend time re-building workflows that require frequent adjustments.
In my experience, organizations that support the role of clinical informatics to augment their project team generally see better use of their technology, improved user satisfaction, better staff engagement, and improved outcomes.

To help improve physician satisfaction...

To help clinical staff in Dr. Gawande's organization better utilize their technology, it's important to critically assess the configuration and workflows that the providers and their teams are working in every day :  

... and ask some of these questions : 
  1. Have all of the steps of this workflow been properly organized, designed, and budgeted? 
  2. What is the clinical governance like? Is it shared or siloed? And how does it interact with administrative governance?
  3. Healthcare is a team sport - Do the physician, nursing, and pharmacy leaders need to meet to critically assess and re-evaluate their shared clinical goals and needs?
  4. Have the current-state and future-state workflows in all service lines been well-documented?
  5. Are there templates for common operational tools and documents found both inside and outside the EMR?
  6. Do directors and clinical chiefs have adequate support for their participation in EMR discussions (analysis, design, and testing)?
  7. What is the request intake, prioritization, and project management process like?
  8. How many ways can users find solutions? Is end-user education easily available on the organizational intranet?
  9. How is clinical terminology managed and harmonized?
  10. How many clinical staff have been trained in workflow development, project management, or document writing (e.g. policies, orders, order sets, protocols, guidelines, clinical documentation, clinical decision support, etc.)?
And : Are there trained clinical informatics professionals available to help educate, evaluate, and oversee all of the above?

FINALLY - A big thank you to Dr. Gawande for writing such a great, real, and thought-provoking piece. Provider burnout is a real issue, and we need to work together to combat it. I hope my discussion helps shed light on how clinical informatics can help change the environment for both providers and patients. 

Remember, the above discussion is for education purposes only. Your mileage may vary. What are your thoughts? Are there other ways to improve clinical workflow and provider satisfaction? If you have any comments or feedback, leave them in the comments box below!