Sunday, April 28, 2019

The Tribes of Healthcare

Hi fellow Informatics friends,

#whyinformatics... This weekend I worked on a video little video, for a team building meeting, to try to explain the different 'Tribes of Healthcare', the clinical and administrative teams that work together to make patient care happen. 

As we've explored in prior posts, healthcare has a uniquely complex set of stakeholders, each with its own skill set, culture, and terminology. Together, they can make amazing things happen - Real advances in patient care and treatment of disease. Separately, they can struggle. 

It's intended to be a little tongue-in-cheek, but clinical informaticists may find this especially amusing, since informatics sits at the intersection of all of these stakeholders - working to translate their needs and concerns into actionable items, projects, and EMR configurations. If you're struggling to assemble these teams for an operational discussion, make sure to ask your local clinical informatics professional for help. :)

The video has a little introduction from one of my educational side projects, with the sound of a cardiac monitor during a code, so make sure your volume is low if you're using headphones. (Believe it or not, it was all created with some very common phone and laptop tools.)

The result is only about three minutes long, so enjoy!


(Click to open)

Remember - This blog is for educational discussions only - Your mileage may vary. Have any anecdotes you'd care to share? Feel free to leave them in the comments below!

Thursday, April 18, 2019

Culture, Terminology, and EMR Usability

Hi fellow Informatics friends and colleagues,

When sharing the secrets of electronic medical record (EMR) usability, some people are surprised at how much culture and terminology impacts user satisfaction. Allow me to explain.

EMRs are essentially tools used to store and retrieve patient care information. When configuring an EMR, the most common mistake is thinking it's 'like paper', simply a bunch of words, lines, and boxes on a page. EMRs are different - Buttons open menus that lead to other tools and actions, so it's more helpful to think of it more like you are organizing a closet
  • Socks go in the sock drawer.
  • T-shirts go in the t-shirt drawer.
  • ... and so on.
Only an electronic patient record literally contains hundreds of drawers, each containing as few as a handful, or as many as hundreds of documents, images, vitals, or other data elements. E.g. : 

... and when you click on the button "RADIOLOGY ORDERS", one would expect to find the orders related to diagnostic and therapeutic/procedural radiology modalities.

So a key design element to consider : 
  • How many items do you need to store in a chart, for patient care purposes?
  • In which 'drawers' will you store them?
And so when organizing a closet at home, most people realize they don't have room for a separate drawer for every piece of clothing, so they will use some categorization scheme (that makes sense to them) to combine related items in the same drawer, E.g. : 
  • Top Drawer = Undergarments (Socks, Underwear, and T-shirts)
  • Bottom Drawer = Outer garments (Shirts / Pants)
We don't consciously think about categorization schemes very much, but our brains do this naturally, to try to make sense of the world, and establish a pattern that will ultimately help us get dressed in the morning

Anyone who's ever had to share a closet, however, knows there can be disagreements about categorization schemes, resulting in some interesting household debates. If you have children, you also know it's helpful to label drawers, or explain the categorization scheme, so your kids can find their clothes in the right drawers. Food pantries and refrigerators are common sources of domestic debates, because different family members might have different ideas about ideal organizational schemes.

So it's no surprise that people who are responsible for configuring and organizing an EMR often stumble upon the many cultural differences in thinking and terminology between "healthcare tribes" - E.g. between physicians, nurses, pharmacists, radiologists, laboratorians, ancillary services, medical records, finance, etc.

Here's a good teaching example to better understand what I'm talking about, and how these terminology issues have real-world impact in user EMR satisfaction

Imagine it's the year 2050
You run a hospital with an EMR. It is suddenly discovered that tomatoes save lives, so you prepare to have tomatoes in your hospital, keeping them in your Pyxis machine, and create tomato orders in your EMR, to order and release the tomatoes for patient care (when needed). 

After meeting with your available subject matter experts (SMEs), many of whom, for scheduling reasons, just happen to be from clinical Tribe A - your analysts build the "Tomatoorderand make it available under the "Vegetable" menu choice below :

Shortly after building this, you suddenly get complaints from Tribe B users, who couldn't show up to the earlier meeting but say, "Hey wait, tomatoes are technically berries, which are technically fruit - Here is the evidence : https://en.wikipedia.org/wiki/Tomato - So they should be listed under the "Fruit" menu choice instead! Those of us who know this can never find the Tomato order!"

You also get complaints from Tribe C users, who say, "What's a Tomato? We've never heard of that. Oh, wait, you mean that red thing we put in our salads/sauces/sandwiches? We've been doing this for 20 years, and in our experience, we've always called it a Golden Cherry."

Do you :

  • OPTION 1. Listen to Tribe A, and file the tomato order under the "vegetable" menu, and educate Tribes B and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and most commonly thought of as vegetables?

  • OPTION 2. Listen to Tribe B, file the tomato order under the "fruit" menu, and educate Tribes A and C that tomatoes are red fruit that grow on a vine, are commonly used to make sauces/salads/sandwich toppings, and correctly categorized as fruit

  • OPTION 3. Listen to Tribes A and C, rename the tomato order to a golden cherry order, file it under "vegetable", and educate Tribe A that tomatoes will now be referred to as a golden cherry and will be filed under the vegetable menu? 
  • OPTION 4. Listen to Tribes B and C, rename the tomato order to a golden cherry order, file it under "fruit", and educate Tribe B that tomatoes will now be referred to as a golden cherry, and will be filed under the fruit menu? 
  • OPTION 5. Bring Tribes A, B, and C together for a meeting, review the concepts, terminology, and taxonomy of tomatoes together, and agree to a functional definition (for your glossary!) that meets the needs of all three tribes

Tomato ('golden cherry') - A common red fruit/vegetable that grows on a vine in temperate climates, that is commonly used to make salads, sauces, and sandwich toppings. 
... and then build the tomato order, attach a synonym of 'golden cherry', and then file it under :
  • the "vegetable" menu choice? 
  • the "fruit" menu choice? 
  • BOTH the "vegetable" and "fruit" menus? (making Tribe A complain that it shouldn't be making the fruit menu look messy, and Tribe B complain it shouldn't be making the vegetable menu look messy
  • Or build a hybrid "vegetable/fruit" menu choice? 
... or more options we haven't considered yet?

How these terminology, taxonomy, and conceptual issue get managed will ultimately impact the satisfaction of users who are trying to find a tomato ('golden cherry') in the EMR for patient care.

Hope you enjoyed chewing on this interesting EMR terminology challenge! If you think terminology issues might be impacting your workflow, feel free to ask your local clinical informaticist for help! (#whyinformatics!)

Remember this blog is for education and sharing purposes only. Have other examples of terminology and classification systems impacting EMR usability and satisfaction? Or have you struggled with this yourself? Feel free to share in the comments section below!

Monday, April 1, 2019

Highlights From The Last 250 Years of Healthcare

Hi fellow #Informatics enthusiasts, physician leaders, CMIOs, CNIOs, and other #healthcare junkies,

So I'm working on a blog post about physician leadership and healthcare traditions, but before I can write that blog post, I had to research some about our history in healthcare - When major things happened, how we got here, and how those discoveries years ago helped to shape our modern healthcare landscape today.

Initially, I thought I'd go back 100 years, to see what the major achievements were - and how they impact us in today. And then I found out - there were several achievements way before that, that I needed to include, because they are still shaping modern healthcare. 

The healthcare environment we think of today is largely the result of many decisions, discoveries, and role developments, some serendipitous, that occurred slowly over the last 250 years.

So I thought I'd document some of the major highlights here, for review and discussion, before I plan my next blog post. Feel free to review and enjoy - And if you see items that need to be added, please leave them in the comments section below!

Some Highlights From The First 250+ Years of Healthcare :
1700s
  • 1765 - First US Medical School opens, the College of Philadelphia (now the University of Pennsylvania). Ben Franklin recommends documenting care, and creates first medical record.
1800s - 1850s
  • 1800s -1900s - While German and British healthcare models grow in Europe, most American ‘healthcare’ exists largely as a mix of voluntary, religious, and charitable alms houses, along with some battlefield doctors and nurses tending to the wounded.
  • 1846 - Hungarian doctor Ignaz Semmelweis recommends hand washing to help prevent the spread of disease. 
  • 1846 - Dentist William T. Morton and Surgeon John Collins Warren do first surgical procedure with anesthesia at Mass General Hospital.
  • 1854 - Florence Nightingale documents first Quality Improvement project during Crimean war, reducing mortality rate in Crimean War from 42% to 2% - Registered Nursing soon becomes a profession, with formal hospital-based training programs.
  • 1854 - Cholera outbreak occurs in London, and John Snow investigates and practically invents Public Health
1860s 
  • 1860 – 1960 – Deliberate Quality Improvement efforts take a foothold in other industries (eg. automobile manufacturing, etc.)
  • 1861 – 1865 – American Civil War
  • 1862Louis Pasteur develops pasteurization.
1870s - 1890s 
  • 1879 – French physician Charles Chamberland develops sterilization technology.
  • 1881Louis Pasteur develops anthrax vaccine.
  • 1883 - German Chancellor Otto Von Bismark develops first state-run medical insurance program.
  • 1885Louis Pasteur develops rabies vaccine.
  • 1895 - William Conrad Roentgen accidentally discovers X-rays, wins Nobel in 1901.
1900s - 1920s 
  • 1910 - Flexner Report formalizes and standardizes medical education to 4-years plus residency.
  • 1914 – 1918World War I
  • 1916 - After isolating it from canine liver cells, heparin discovered by surgeon Jay McLean and physiologist William Henry Howell, but not available for clinical trials until 1935.
  • 1918 - Influenza Pandemic kills millions worldwide. Surgeon General Dr. Rupert Blue uses public health tools and documentation to save lives.
  • 1920s – 1980s - A predominantly employer-based fee-for-service health insurance system develops in the US, in a very fragmented, decentralized manner - with private insurers and the government eventually filling some, but not all of the gaps.
  • 1928 - Sir Alexander Fleming accidentally finds an empty circle around some mold on a staphylococcus culture plate, and discovers the "wonder drug" penicillin.
  • 1928 - First MCAT Test.
1930s - 1950s 
  • 1930President Hoover creates Veterans Administration and first VA Hospitals.
  • 1935 - Heparin first available for clinical trials.
  • 19411945World War II
  • 1942 - William Beveridge publishes "Beveridge Report" which advocates for England to build a "National Health System"
  • 1942 - After noting that WWI mustard gas was a potent suppressor of hematopoeisis, nitrogen mustards were further developed during WWII at Yale University and were given by vein (instead of inhaling irritant gas) to several patients with advanced lymphomas who had temporary but notable improvements, in what was the first chemotherapy regimen
  • 1945 - Industrialist Henry Kaiser builds first pre-paid health program for his employees which becomes "Kaiser Permanente"
  • 1945 – 1950Penicillin becomes more widely available. Narcotic analgesia also becomes available.
  • 1950sJonas Salk develops polio vaccine. Nursing training programs begin to move from hospitals to colleges and universities.
  • 1950s - Physicist Gordon Brownell and neurosurgeon William Sweet from Mass General use first PET scanner to detect brain tumors using sodium iodide.
  • 1951Joint Commission establishes itself as “The Joint Commission of Accreditation of Hospitals”, but accreditation has no significant impact until 1965 (see below).
  • 1951 - American College of Obstetricians and Gynecologists (ACOG) formed, formalizing specialty training for obstetric care and Women's Health.
  • 1952 - American Psychiatric Association publishes first Diagnostic and Statistical Manual (DSM) of Mental Disorders, standardizing and formalizing diagnostic criteria for patients with mental health needs.
  • 1953 - Although they did not 'discover DNA', James D. Watson and Francis Crick build upon X-ray crystallography work by Rosalind Franklin and Maurice Wilkins to publish description of double-helix structure of DNA.
  • 1955 - Chemist Leo Sternbach invents benzodiazepines when he accidentally discovers chlordiazepoxide (Librium), first available for clinical use in 1960.
  • 1956 – 1958 - Dr. Peter Safar develops A-B-C technique for CPR, convinces Baltimore Fire Department to have first ambulance staffed with Emergency Medical Technicians, and creates first 24-hour ICU.
1960s - 1980s 
  • 1960 - First oral contraceptive pill, Enovid, is approved by FDA.
  • 1964 - First loop diuretics ethacrynic acid and furosemide approved for use. 
  • 1965Centers for Medicare and Medicaid Services (CMS) established, and establishes Joint Commission accreditation as a Condition of Participation (CoP).
  • 1967 - South African surgeon Christiaan Barnard does first heart transplant.
  • 1968 - First 911 call made in Haleyville, Alabama to the Fire Chief, starts first US 911 service.
  • 1968 - NEJM publishes 'Medical Records that Guide and Teach' by Larry Weed, MD, creating the first SOAP note allowing easier transfer of patients between providers.
  • 1971 - First CT scan used to image a living brain.
  • 1970s - 1980s – Most US patients continue to receive care in Fee-for-Service. 911 service continues to expand.
  • 1973 – Rising healthcare costs spur President Nixon to sign Health Maintenance Organization (HMO) Act, opening way for development of for-profit hospitals and private HMOs.
  • 1975 - First whole-body CT scanner was built.
  • 1977 - American physician Dr. Raymond Damadian does first MRI to diagnose cancer.
  • 1979American Board of Medical Specialties votes to create American College of Emergency Physicians, formalizing the training and role of Emergency Medicine physicians. Many hospitals go from having daytime ‘Accident Rooms’ to formal, 24/7 ‘Emergency Departments’.
  • 1980s - AIDS epidemic discovered to be caused by HIV virus, nationally changing infection control procedures and safety standards for blood supply.
  • 1980s - 1990s – HMOs and Payment Reform start to significantly change the billing landscape and increase demands on physician documentation.
1990s 
  • 1996Health Insurance Portability and Accountability Act (HIPAA) first signed into law (with updates in 2004, 2005, 2009, and 2013). NEJM Publishes first article describing new specialty of Hospitalist Medicine.
  • 1999Institute Of Medicine (IOM) releases report To Err Is Human : Building a Safer Healthcare System.
2000s - 2010s
  • 2000 - 93% of the US Population has access to 911 service, and WHO ranks Britain 18th, Germany 25th, and America 37th best in the world.
  • 2008 – Global financial crisis leads to US American Reinvestment and Recovery Act (ARRA), including HITECH Act with $19.3 Billion for Meaningful Use. EMRs become ubiquitous across healthcare landscape.
  • 2017More female candidates than male candidates enroll in American medical schools.
[ End of List ]

Remember : This list is not comprehensive - Have anything you'd like to add to this list? Leave comments in the comments section below! Remember, this blog is for only for educational/discussion purposes only!