Thinking in Hammers and Nails: Problem-Based Approaches to Healthcare IT Implementation Paul...

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Thinking in Hammers and Thinking in Hammers and Nails: Nails: Problem-Based Approaches to Problem-Based Approaches to Healthcare IT Implementation Healthcare IT Implementation Paul Biondich, MD, MS Paul Biondich, MD, MS Asst. Professor of Pediatrics / Asst. Professor of Pediatrics / Informatics Informatics Regenstrief Institute… Regenstrief Institute… Indianapolis Indianapolis

Transcript of Thinking in Hammers and Nails: Problem-Based Approaches to Healthcare IT Implementation Paul...

Thinking in Hammers and Thinking in Hammers and Nails: Nails:

Problem-Based Approaches Problem-Based Approaches to Healthcare IT to Healthcare IT ImplementationImplementation

Paul Biondich, MD, MSPaul Biondich, MD, MS

Asst. Professor of Pediatrics / Asst. Professor of Pediatrics / InformaticsInformatics

Regenstrief Institute… IndianapolisRegenstrief Institute… Indianapolis

Current State of Affairs?Current State of Affairs?

““If the only tool you have is a If the only tool you have is a hammer, you tend to see hammer, you tend to see every problem as a nail..”every problem as a nail..”

- Abraham Maslow, Cognitive - Abraham Maslow, Cognitive PsychologistPsychologist

Hammers and NailsHammers and Nails

Full personal disclosure: infatuated with Full personal disclosure: infatuated with computers and information technologycomputers and information technology

Taking a leap: some of you are as well, Taking a leap: some of you are as well, or else you wouldn’t be here..or else you wouldn’t be here..

As a result, we are proactive As a result, we are proactive “technology users” .. and we “technology users” .. and we understand how these technologies understand how these technologies likely have positive impact on likely have positive impact on healthcarehealthcare

Hammers and NailsHammers and Nails

As a result, its easy to appreciate As a result, its easy to appreciate (become enamored with) the latest (become enamored with) the latest and greatest “hammers”:and greatest “hammers”:– Smart CardsSmart Cards– Wireless communicationWireless communication– Speech RecognitionSpeech Recognition– PDAs / Cell Phone HybridsPDAs / Cell Phone Hybrids– Portable Computing (Tablets, Wearable Portable Computing (Tablets, Wearable

Computing)Computing)

The Problem with HammersThe Problem with Hammers

Also easy to fall into trap of thinking Also easy to fall into trap of thinking that the technology that the technology itselfitself that can that can improve healthcare provisionimprove healthcare provision

Current “HIT euphoria” has further Current “HIT euphoria” has further exacerbated these myopic exacerbated these myopic perspectives..perspectives..

““PDAs could give pocket access to a PDAs could give pocket access to a patient’s medical record!”patient’s medical record!”

Looking for nails..Looking for nails..

Clinical Results via PDA

Gopher on Real Wireless Gopher on Real Wireless PDAPDA

Yet another Gopher PDAYet another Gopher PDA

The Popcorn Woman

What’s next?!What’s next?!

Problem-based frameworksProblem-based frameworks

Health IT is a tool no different than a Health IT is a tool no different than a tongue depressor or an otoscopetongue depressor or an otoscope

Identifying healthcare problems allows Identifying healthcare problems allows one to consider tailored solutionsone to consider tailored solutions

HIT might not be best answer?HIT might not be best answer? Stating the specific problem -> harder Stating the specific problem -> harder

than it sounds… typically an iterative than it sounds… typically an iterative processprocess

Identifying your nails..Identifying your nails..

““In the correct formulation of In the correct formulation of the question, lies the key to the question, lies the key to the answer.”the answer.”

- Nobelist Max Planck- Nobelist Max Planck

Iterative Problem Iterative Problem IdentificationIdentification

High level problem: need to improve High level problem: need to improve patient safetypatient safety

Focused on a topic: medication safetyFocused on a topic: medication safety Focused on a clinical problem: Focused on a clinical problem:

adverse drug eventsadverse drug events Focused on a specific clinical problem: Focused on a specific clinical problem:

severe drug interactions severe drug interactions Atomic problem: digoxin and Atomic problem: digoxin and

cyclosporine drug interactioncyclosporine drug interaction

Next questions..Next questions..

Who elicits the problem?Who elicits the problem? What is the prevalence of the What is the prevalence of the

problem?problem? Where is the problem occurring?Where is the problem occurring? When does the problem occur within When does the problem occur within

clinical workflows?clinical workflows? How can I “manually” fix the How can I “manually” fix the

problem?problem?

Typical ResultsTypical Results

Process often leads to surprising Process often leads to surprising solutionssolutions

Information gathered during the Information gathered during the process significantly informs how the process significantly informs how the solution can be customizedsolution can be customized

Specified tons more problems than Specified tons more problems than you immediately imagined.. how you immediately imagined.. how does one prioritize?does one prioritize?

Prioritization FactorsPrioritization Factors

PP= Impact on individual patients’ care (e.g. quality, = Impact on individual patients’ care (e.g. quality, safety, cost)safety, cost)

OO= Organizational impact (e.g. regulatory = Organizational impact (e.g. regulatory compliance, resource use)compliance, resource use)

CC= Clinician impact (e.g. enhanced workflow)= Clinician impact (e.g. enhanced workflow)

NN= Number of patients positively affected = Number of patients positively affected

GG= Gap between ideal and actual behavior pertinent = Gap between ideal and actual behavior pertinent to the interventionto the intervention

DD= Difficulty associated with implementing = Difficulty associated with implementing interventionintervention

CC= Cost of intervention= Cost of intervention

Setting – “Enterprise” Pediatric Setting – “Enterprise” Pediatric Outpatient ClinicOutpatient Clinic

High patient volume (~200 patients/day)High patient volume (~200 patients/day) ““Digital Divide” within patient populationDigital Divide” within patient population Diverse, large, and ever changing Diverse, large, and ever changing

clinician populationclinician population Urban setting not amenable to Urban setting not amenable to

electronics in roomselectronics in rooms Limited support staff to assist in data Limited support staff to assist in data

acquisitionacquisition

The Problem / MotivationThe Problem / Motivation

Need to capture data Need to capture data prior prior to to physician encounters from both physician encounters from both patients/parents and support staff to patients/parents and support staff to inform a new preventive care DSS.inform a new preventive care DSS.

They move all over the clinic (waiting They move all over the clinic (waiting room, patient room, vitals area, etc)room, patient room, vitals area, etc)

There were resource constraints ($)There were resource constraints ($) Management technology-phobicManagement technology-phobic

Our 21Our 21stst Century Technology Century Technology Choice – PaperChoice – Paper

Paper as a Computer Paper as a Computer Interface?Interface?

FamiliarFamiliar Easy to work withEasy to work with Fully enabledFully enabled PortablePortable CheapCheap Computer can reliably read Computer can reliably read

information off of paper when it is information off of paper when it is structuredstructured

Adaptive Turnaround Adaptive Turnaround DocumentsDocuments

Data-driven, dynamically generated, Data-driven, dynamically generated, computer interpretable paper formscomputer interpretable paper forms

Pre-Screening FormPre-Screening Form: Collects 20 : Collects 20 most relevant risk factor most relevant risk factor observations from family, and also observations from family, and also collects vital sign assessments from collects vital sign assessments from nursingnursing

SampleSampleScreening Screening Form (PSF)Form (PSF)

Nursing Observations / Nursing Observations / VitalsVitals

Real-time calculations:Real-time calculations:– Body Mass Index (BMI), Growth Body Mass Index (BMI), Growth

Percentiles, Blood Pressure abnormalities, Percentiles, Blood Pressure abnormalities, Abrupt changes between visitsAbrupt changes between visits

Nurse / Aide prompting:Nurse / Aide prompting:– Better indication of when to do Screening Better indication of when to do Screening

TestsTests– Reminder of previously abnormal values Reminder of previously abnormal values

that need to be retakenthat need to be retaken

Parental Screening Parental Screening QuestionnaireQuestionnaire

Forms are custom tailored to patientForms are custom tailored to patient– Questions are age specificQuestions are age specific– Logic is sensitive to questions that are Logic is sensitive to questions that are

previously answeredpreviously answered– Questions are all prioritized.. Most Questions are all prioritized.. Most

clinically relevant and high-risk clinically relevant and high-risk questions are asked firstquestions are asked first

Parental Screening Parental Screening QuestionnaireQuestionnaire

Patients identify their own risk factors – Patients identify their own risk factors – physicians no longer spend time on physicians no longer spend time on “fishing expeditions”“fishing expeditions”

Parents are “activated” into thinking Parents are “activated” into thinking about relevant or misunderstood topicsabout relevant or misunderstood topics

Triggers many decision support “tools”:Triggers many decision support “tools”:– ““Extra Specific” remindersExtra Specific” reminders– Just-in-Time HandoutsJust-in-Time Handouts– Automated OrdersAutomated Orders

SampleSamplePhysician Physician WorksheeWorkshee

t Formt Form

Vital Sign CalculationsVital Sign Calculations

Doctor’s Worksheet

(PWS)

Screening Form (PSF)

Physician Physician PreventivePreventive

Care Care RemindersReminders

Identifying Identifying Risk FactorsRisk Factors

ScreeningForm (PSF)

Physician Form Reminder

Thinking Out of the Box…Thinking Out of the Box…

““That it will ever come into general That it will ever come into general use, notwithstanding its value, is use, notwithstanding its value, is extremely doubtful because its extremely doubtful because its beneficial application requires much beneficial application requires much time and gives a good bit of trouble, time and gives a good bit of trouble, both to the patient and to the both to the patient and to the practitioner because its hue and practitioner because its hue and character are foreign and opposed to character are foreign and opposed to all our habits and associations.”all our habits and associations.”

The London Times in 1834