| The following is a blog article originally written for the Health Information Technology Resource Center (HITRC) portal—which is a tool for health IT RECs across the country to collaborate with each other. The article is in response to the Office of the National Coordinator for Health IT''s (ONC) request that RECs share what "meaningful use" means to them. Jeff Hummel, MD, MPH is the Medical Director for Health Informatics at Qualis Health. He collaborates with the ONC and the other RECs through the meaningful use community of practice. My daughter is an aerialist. That means she performs graceful ballet-type acts in the air usually with silks, but occasionally on a trapeze. Her actual professional training is in musical theater, but like me she harbors a romantic attraction for the lifestyle of people who used to travel with circuses. After a recent show in which she performed, I commented that the changeover after her silks act appeared a little clumsy. The stage crew didn’t seem to have a plan for attaching a rope to the silks to pull them out of the way, and the karabiner ended up sliding all the way to the ceiling and stuck in a pulley.
She explained to me that scene changes in variety shows, with jugglers, sword swallowers, acrobats, and the like are usually ad hoc, meaning that no one puts much energy into planning the transition between the segments of the show. This, she pointed out, is in complete contrast to professional musical theater in which the adage is, “sloppy set changes will kill a show.” She should know; she just finished four years in a serious fine arts conservatory where she learned among other things from Broadway performance artists how a tightly choreographed set change can be done so smoothly that the performance can literally proceed uninterrupted as the background is transformed to a new scene. In other words, the set changes are as carefully rehearsed as the scenes themselves.
We had this conversation shortly after I had finished a string of consulting jobs with multiple different primary care clinics including my own, all of which were struggling to assure that every patient who passed through our clinics would leave with his or her vaccination status addressed. I couldn’t help but be struck with the similarities between commonplace primary care workflows and the set changes in a variety show. Giving an immunization may not seem at first glance to share many characteristics with juggling or aerial acrobatics, but the more I thought about it the more I was impressed with the similarities. Someone, usually the doctor, has to remember to decide whether the issue of a patient’s immunization status should even be addressed in the midst of juggling all the other issues that demand attention in the exam room. Once the topic is addressed the decision requires assembling information from multiple sources to determine if a vaccine is due. Then the order must be entered into the computer correctly, and the medical assistant must be made aware that the order has been placed so she can draw up the vaccine and administer it before the patient leaves having forgotten that it was part of the plan. Lastly, the fact that the vaccine was given has to be entered into the electronic record correctly so the information is available in the EHR when it is needed to run the rules engine that triggers health maintenance alerts, and can be sent to the State registry.
The ad hoc way in which such issues are left to chance has many similarities to the sloppy set changes of variety shows as described by my daughter. Mostly the doctor forgets to even think about immunizations except as part of a physical exam or during flu season. Frequently each physician even in the same clinic has a different way of ordering it, some still on paper forms, some in the EHR although often incorrectly, and some on yellow sticky note messages to the Medical Assistant. Each Medical Assistant must respond to this variation, and then navigate the multiple data entry fields in every EHR I’ve seen, which seemed to call out, “enter the information here”. Yet as it turns out, usually only one of these similar-appearing data entry fields actually feeds the information into the rules engine that runs the decision support alerts telling the healthcare team when a patient is overdue. The rest of these look-alike data entry fields resemble booby traps, and commonly no one on the care team is sure which is the correct field. The net effect is a performance that might be considered acceptable for a carousel act, but not in professional theater.
I’ve always considered medicine to be performance art; after all, medical students learn bedside manner and interviewing skills to allow them to gain the confidence of their patients by exhibiting empathy and displaying confidence. We learn to do this even when we’re tired, hungry and stressed. We are however, kidding ourselves if we think it is a one-man (or woman) show and the others on our team are simply stagehands. The show, of which they are a part just as much as we, is as vulnerable to sloppy set changes as is professional theater.
Implementing an EHR is all about standardizing workflow, as the example of immunizations demonstrates. There is little value to the patient in implementing an EHR without standardizing workflows to assure that: - every patient who comes to the clinic has his or her immunization status addressed,
- every immunization that is given is entered correctly into the EHR, so that,
- immunization data are sent to a State or regional registry.
While only the last step is officially a meaningful use element, for the process to be meaningful the first two steps are essential.
What does this have to do with set changes, or changeovers as they are referred to in the workflow literature? Every patient who comes to the clinic has different gaps in their care. Some are missing immunizations, some are missing cancer-screening tests while others have a chronic illness and are missing key monitoring activities or evidence-based treatments. A team must practice and perfect their set changes so that the mini-workflows for detecting and closing these gaps can be seamlessly inserted into the main act of the office visit. This requires teamwork and planning, usually in the form of a huddle in which the EHR chart is reviewed before clinic starts so that providers and other care team members understand their roles in coordinating the gathering of information and acting on it using clinical protocols for preventive and chronic illness care. The goal should be for a musical theater professional to applaud, or better yet, not even notice, the little set changes that we now so often leave to chance. |
