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

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 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.

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 (, 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. 

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) : 

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!