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NIST Dissects Workflow: Is Anyone Biting?

Note: This was first published on emrandehr.com
Psst. Hey, Buddy, wanna see an EHR, visit’s workflow? Here it is, thanks to the National Institutes of Standards and Technology’s (NIST) new report, NISTIR 7988, Integrating Electronic Health Records into Clinical Workflow, etc.

Returning Patient Ambulatory Workflow NIST

What It Represents

NIST wants to make EHRs usable and useful. It first took aim at patient safety EHR functions that endangered, confused users or were error prone. To counter these, it developed and recommended EHR usability protocols.

Now, in an extensive report, it’s tackled EHR workflow to determine where problems occur. The result is a comprehensive work with significant findings and recommendations. The question is: Is anyone listening?

NIST’s Analytical Approach

NIST decided to create a typical workflow by interviewing knowledgeable physicians, who it calls Subject Matter Experts, SMEs. The physicians had different specialties and used different EHRs, though who they were, NIST doesn’t say.

From their discussions, NIST’s analysts created the above chart, NIST’s Figure 2. NIST’s authors recognize that actual workflows will vary based on setting, sequences, staffing, etc., but that it provides a useful way to look at these issues.

What They Did With It

Working with their physicians, NIST’s analysts broke down the workflow into three sections: before, during and after the visit. Then, they broke down, or decomposed, each of those sections, like opening nested Russian dolls. For example, they segmented the physician’s encounter, below, and once again, broke each down into its functions.

Returning Patient, Physician Encounter - NIST

What They Found

It was at this stage the analysts found significant variations among the EHRs used by their physicians,

[T]here appeared to be high variation in whether and how the EHR was used during this period, how extensive each of the activities typically were for each SME, different based upon the type of patient, how complex the patient was, context of how busy the day was, and other factors. NSTIR 7988, p 18.

Despite these differences, the physicians identified two issues that crossed their EHRs:

  • Working Diagnoses. The physicians wanted systems that let them create a working diagnosis and modify it as they worked until they made a final diagnosis. Similarly, they wanted to be able to back up and make changes as needed, something current systems make hard.
  • Multiple Diagnoses. Diagnoses usually involve multiple causes, not single factors. They wanted their EHRs to support this.

These types of issues aren’t new to those familiar with EHR problems. What’s new is NIST, as an independent, scientific organization, defining, cataloguing and explaining them and their consequences.

What They Recommended

From this work, NIST’s analysts developed extensive and persuasive recommendations, in three categories:

  • EHR Functions
  • System Settings, and
  • System Supports

EHR Functions

NIST’s recommends reducing practitioner workload, while increasing their options and supports. For example, they suggest:

  • Workload Projections. Give practitioners a way to see their patient workloads in advance, so they can plan their work more effectively
  • Notes to Self. Let users create reminder notes about upcoming visit issues or to highlight significant ,patient information. These would be analogous to their hand written notes they used to put on paper charts.
  • Single Page Summaries. Create single page labs summaries rather than making users plow through long reports for new information.
  • Single Page Discharge Summaries. Eliminate excessive boiler plate with more intelligent and useful discharge sheets.
  • Highlight Time Critical Information. Segregate time critical information. Often they get mixed in with other notices where they may be overlooked or hard to find.
  • Allow Time Pressure Overrides. When time is critical, EHRs should allow skipping certain functions.
  • System Settings

NIST recommendations echo the familiar litany of issues that characterize poor implementations:

  • Allow Patient Eye Contact. Exam room designs should put the doctor and patient in a comfortable, direct relationship with the computer as a support.
  • Login Simplification. Allow continuous logins or otherwise cut down on constant login and outs.

System Supports

The physicians recognized they often caused workflow bottlenecks. NIST recommended off loading work to medical assistants, nurse practitioners, physician assistants, etc.. For example, physician assistants could draft predicted orders for routine situations for the physician to review and approve.

Progress Note Frustrations

In the thorny area of clinical documentation, the report details physician frustration with their EHRs. All experienced excessive or missing options, click option hell, excessive output, puzzling terms, etc. These were compounded by time consuming system steps that did not aid in diagnosis or solving patient problems. The report discusses their attempts at improving documentation:

Several of the SMEs had attempted and then abandoned strategies to increase the efficiency of documentation. One SME reported that copying and pasting and “smart text” where typing commands generate auto-text had a “vigilance problem.” The issue was that it would be too easy to put the wrong or outdated information in or in the wrong place and not detect it, and then someone later, including himself, could act on it not realizing that it was incorrect.

One physician described an attempt to use automated speech recognition for dictation for a patient with scleritis, which is inflammation of the white of the eye. He stopped using the software when what was documented in the note was “squirrel actress.”

Another SME described that colleagues relied upon medical assistants to draft the note and then completed it, but they did not like that approach because it was too tempting to rely upon what was typed without reviewing it, and he felt the medical knowledge level was not high enough for this task.

One SME described a reluctance to use any scribe, including a medical student, because the risk would be too high of misunderstanding and thus not correctly documenting the historical information, diagnosis, and treatment plan. This was particularly problematic if the physician had information from prior visits, which contributed to these elements, which were not discussed in detail during the visit. NSTIR 7988, p. 28

Coding their diagnoses into progress notes also came in for criticism:

All SMEs described frustration with requirements to enter information into progress notes, …, which were applied to the notes in order to have sufficient justification to receive reimbursement for services. Although all of the SMEs acknowledged the central importance of receiving reimbursement in order to function as a business, this information was often not important for clinical needs. NSTIR 7988, p. 28

 

Role Based Progress Note

Unlike other areas of the report, the doctors could not agree on what to do, nor does NIST offer any specific cures for documentation problems. Instead, NIST recommends using a new, role based, progress note:

[T]he progress note for a primary care physician would have a different view from a specialist such as a urologist physician, who might not need to see all of the information displayed to the primary care physician. Similarly, the view of the note for primary care providers could differ from the view of a billing and coding specialist. … NSTIR 7988, p. 28

Will ONC Respond?

In this and its prior reports, NIST covers a lot of EHR issues making sensible recommendations that not only improve functionality, but more importantly improve patient safety. However, NIST’s recommendations are just that. It’s not a regulatory agency, nor is supposed to be one. Instead, its role is to work with industry and experts to develop usable, practical approaches to tough technical, often safety related, problems. To its credit, it’s done this in a vast number of fields from airplane cockpits, nuclear reactors, and atomic clocks to bullet proof vests.

However, its EHR actions have not gained any noticeable traction. If any EHR vendor has implemented NIST’s usability protocols, they haven’t said so. They are not alone.

Notably ONC, one of NIST’s major EHR partners, refuses to incorporate any of NIST’s usability recommendations. Instead, ONC requires vendors to implement User Centered Design, but does not define it, letting each vendor do that for themselves.

NIST has many answers to common EHR workflow and usability problems. The question is, who will bring them to bear?

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An Eclectic Gathering of EHR Usability and Project Resources

Note: This was first published on emrandehr.com
Here are a few resources that I use to solve a variety of design, project management and other problems. Some, such as NIST’s protocols, are directly EHR related; others aren’t, but easily apply to EHR problems.

So here, as was once said, are a few of my favorite people and things:

  • Dan Bricklin. Hopper and Jobs are gone. Woz is a sage. Gates, Kapor and Norton long ago stopped being systems innovators in favor of being philanthropists. Bricklin, however, the electronic spreadsheet’s inventor, soldiers on. His personal site has much to offer, especially his video on interface development for different types of devices and users.
  • Donald Norman. If you only read one of Norman’s many works on usability, make it The Design of Everyday Things. When you do, you’ll find one of the most cogent, funny and thoughtful studies of user centered design. From his account of slide projectors from hell, to post office doors that trap the unwary, to the best ways to arrange light switches, Norman has good advice for all of us. I first read this twenty years ago, but the advice still resonates. He’s recently revised it and added a free on-line course. After Norman, you won’t look at doors, appliances, much less screens the same way again.
  • Jakob Nielsen. There are people who think if you know Nielsen’s usability approach, you need little else. Then, there are those who think if you know Nielsen’s approach, all hope is lost. No one has a monopoly on good interface design, but Nielsen’s site is a place to stop for tons of notable examples.
  • NIST Protocols. NIST works with the private sector to solve major, operational problems. After Three Mile Island close call NIST redesigned all US nuclear power plants’ control rooms. Recently, they’ve developed EHR usability standards. These are the best, most comprehensive treatment of what not to do. You’ll find them in an appendix in their publication, NISTIR 7804.
  • ONC Repository. Most those in the EHR field know ONC, for better or worse due to its Meaningful Use standards. There’s a lot more. Buried on ONC’s site is its Implementation Resources. The repository has dozens of videos, guides, white papers, toolkits and templates all centered on improving EHR selection, implementation and use.
  • Ross Koppel. Koppel is a grouch. He grouches about the dozens different ways EHRs record simple things, such as, blood pressure. Writing often in JAMA, he notes how health IT systems spawn workarounds, confusion and give users choices that are false, misleading or illogical. In short, he’s produced a treasure trove of frightening observations, embarrassing questions and pointed observations, but his bête noire findings also include correctives. All of this is written in a careful, thoughtful style that makes the subject compelling and chilling.
  • Tom Demarco. Demarco of the Atlantic System Guild has produced a wealth of insightful books, lectures and articles on project management. In the 60s, DeMarco asked himself, if a civil engineer can build a bridge from requirements to operation, why can’t we do the same thing with software. His first take was Structured Analysis and System Specification. It’s still in print and full of practical advice and approaches for project managers. Other works include Peopleware: Productive Projects and Teams, where he takes the odd position that you should treat your staff like people and help them be productive. I especially love his The Deadline: A Novel About Project Management in which the main character is kidnapped and forced to manage a project under threat of death. It’s a comedy.

Interested in EHR usability? Join my LinkedIn group: EHRUsability.

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Drop In Clinics: Another EHR Quandary

Note: This was first published on emrandehr.com

If you go to a walk in health clinic, you’re in good company. These clinics and their users are growing rapidly. So, too, is their using EHRs to document your stay. That EHR use is both good and bad news.

 Clinic Types

There are two basic types of these no appointment, walk in clinics: Retail Health and Urgent Care:

  • Retail Health. These treat minor problems or do basic prevention that usually doesn’t require a physician visit. For example, they give flu shots, treat colds, ear infections, and strep throat, etc. The clinics are often one person operations staffed by a nurse practitioner. You can find them in stand alone settings, but more frequently now they are in major, retail chains such as Target, Wal-Mart, CVS, etc. In addition to their location accessibility, these clinics usually have evenings and weekend hours.
  • Urgent Care Clinics. These perform all the services of retail clinics, and also have extended hours. Importantly they add physician services. For example, they will treat burns, sprains, or run basic lab tests. These clinics usually are part of a clinical chain or may be associated with a local hospital. Unlike retail health clinics, they generally are in their own store fronts.

While their services and settings differ, both accept health insurance. With the projected growth of the insured population under the ACA, their managers are expanding their networks.

Clinic EHR to PCP EHR Problem

Unlike practices and hospitals that have undergone, often painful, transitions from paper to EHRs, these clinics, skipped that phase and have, by and large, used EHRs from the start.

EHRs give them a major advantage. If you visit Mini-Doc Clinic in Chamblee, Georgia and then go to one in Hyattsville, Maryland, the Maryland clinic can see or electronically get your Georgia record. This eliminates redundancy and gives you an incentive to stay with a service that knows you.

If you only go to Min-Doc for care, then all your information is in one place. However, if you use the clinic and see you regular doctor too, updating your records is no small issue. Coordination of medical records is difficult enough when practices are networked or in a HIE. In the case of a clinic, especially one that you saw away from home, interface problems can compound.

With luck, the clinic you saw on vacation may use the same EHR as your doctor. For example, CVS’ Minute Clinic uses Epic. However, your clinic may use an EHR tailored to walk ins. Examples of these clinic oriented, tablet, touch optimized EHRs are:

Your physician may not have the technical ability to read the clinic’s record. Getting a hospital to import the clinic’s data would require overcoming bureaucratic, cost and systems problems for what might be a one time occurence. Odds are the clinic will fax your records to your doctor where they will be scanned or keyed in, if at all.

This is not a hypothetical issue, but one that clinic corporate execs, patient advocates and physicians are concerned about. There is no easy solution in sight.

Recently, on point, NPR’s Diane Rehm show had a good discussion of the clinic phenomena, and included the clinic to PCP EHR record issue. You can hear it on podcast. Her guests were:

  • Susan Dentzer. Senior Policy Adviser, The Robert Wood Johnson Foundation and on-air analyst on health issues, PBS NewsHour.
  • Dr. Nancy Gagliano. Chief Medical Officer, CVS MinuteClinic.
  • Dr. Robert Wergin. Family Physician, Milford, Neb., and President-elect, American Academy of Family Physicians, and
  • Vaughn Kauffman. Principal, PwC Health Industries.

All the actors in this issue know that the best outcome would be transparent interoperability. However, that goal is more honored in the breach, etc., for EHRs in general. The issue of clinic to PCP EHR is only at a beginning and its future is unknown.

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