The KHIT Blog: Back to the health IT tech stuff: NISTIR 7988

Monday, June 30, 2014

Back to the health IT tech stuff: NISTIR 7988

Executive Summary
Adoption of Electronic Health Record (EHR) systems in hospitals and outpatient clinics is accelerating. EHRs can support and revolutionize the way information is used to provide high-quality and safe patient care. At the same time, however, issues with workflow integration have contributed to slow rates of EHR adoption in some settings, including ambulatory outpatient care. Workflow is a set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal. Workflow analysis is an integral part of the early stages of the User-Centered Design (UCD) process. UCD is an approach to designing systems and employs both formative and summative methods in order to achieve systematic discovery of useful functions grounded in an understanding of the work domain.

In response to workflow integration challenges with EHRs, clinicians often develop workarounds to complete clinical tasks in ways other than were intended by system designers. A frequent workaround, for example, is copying and pasting text from a previous progress note for a patient to serve as a draft for the current progress note. In this report, two human factors workflow modeling tools, process mapping and goal-means decomposition, were used to collect, visualize, and document insights and the end-user needs to improve EHR workflow for clinicians in outpatient care settings. The findings identified clinical activities that require more relevant and flexible workflows in EHR designs to support end users’ needs. Based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created process map visualizations and a goal-means decomposition diagram...

39 pages. Well worth your time. Link to the full document here (pdf).

Figure 1. The SEIPS framework for work system elements

From our literature review, workflow, workaround, and work system are defined as follows:

Workflow: A set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal.

Workaround: Actions that do not follow explicit rules, assumptions, workflow regulations, or intentions of system designers.

Work system: The five main elements from the Systems Engineering Initiative for Patient Safety (SEIPS) model are used to define the work system (Figure 1): 1) people (individuals and teams), 2) physical environment, 3) tools and technologies, 4) tasks, and 5) organizational characteristics.

Below, one of my graphical takes on workflow.

Click to enlarge it it's difficult to read. Interesting, "the Systems Engineering Initiative for Patient Safety." Recall one on my earlier posts regarding "Systems Engineering." The "SEIPS model" publication is firewalled, so I've not yet been able to find it and read it without paying (cheapskate), but I bet it's safe to say it contains zilch about the cultural "workforce engagement" impediment that I've been discussing of late. You instead get stuff like this:

There is immense literature on workflow modeling in general, including agent-based modeling and other “humans-not-in-the-loop” modeling. In our review, we focused on approaches to analyzing and depicting workflow from a human factors perspective. Human factors is defined as “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance.” Human factors modeling methods are based primarily upon extraction of process flow and insights about challenges and variation from Subject Matter Experts (SMEs) during collegial discussions...

"...the understanding of interactions among humans..."

To include psychosocial workplace toxicity? 'eh? Do we not need to understand that factor?

Another of my workflow graphics.

Again, click to enlarge it it's difficult to read.

My graphics are better. :)

OK, I've just read all of it. Very good elucidation of the problems bedeviling EHR use in clinical workflow. Again, worth your (and my) time.

Conclusion
In response to workflow integration challenges with ambulatory physicians using EHRs, we have employed standard human factors methods in order to identify insights for EHR developers and ambulatory care centers. The methods illustrated in this document are process maps and goal-means decomposition diagrams informed by goal-oriented individual collegial discussions with physician Subject Matter Experts to walk through the typical workflow of a returning patient in an ambulatory care setting. We have identified a wide variety of potential opportunities to improve workflow with EHRs from a physician perspective. We anticipate that improving workflow might require an expansion in focus from the historical goal of supporting reimbursement to also improving quality of patient care as well as the quality of work-life for physicians. In order to increase the ease of implementing our insights, we provide a set of targeted recommendations.

Yeah. Blah, blah, blah. All necessary and good, but, nothing really new here. And, nothing whatsoever on the implicit, fundamental (albeit overlooked) "cultural/interpersonal" aspects of "Human Factors."

Another of my Photoshops.

Clinical practice is an irreducibly "high cognitive burden" enterprise requiring accurate and effective ongoing n-way communication between all participants. High performance teams have to be healthy -- in every sense of the word.

Re-read my little recent trilogy:

On healthcare system improvement: are the Feds proposing the building of a two-legged stool?

Continuing on the three-legged stool riff: more on "Just Culture," workforce engagement, and leadership in healthcare.

The "Talking Stick" and the three-legged stool of sustained, transformative healthcare QI

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ERRATUM

In which my friend Dr. Leslie calls me out. And, my response:

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More to come...

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
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"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
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"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
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"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
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"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
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"'Solutions' exist only in mathematics."

- Karen Martin
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"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
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"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Monday, June 30, 2014

Back to the health IT tech stuff: NISTIR 7988

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