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A Leader at the Intersection of IT and Clinical Workflow

September 11, 2013
by Gabriel Perna
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Jonathan Teich, M.D., is in a unique position to comment on the intersection of IT and physician workflow. Dr. Teich is not only a practicing emergency physician at Brigham & Women’s Hospital in Boston, but he is also the CMIO at Elsevier, which is an Philadelphia-based healthcare information and software provider.

These two elements have put Teich at the forefront of the industry. He has served in a number of leadership positions, including co-chair of the panel responsible for the Department of Health and Human Services (HHS)-sponsored Roadmap for National Action on Clinical Decision Support and board member of the eHealth Initiative. Further, his primary goals at Elsevier involve developing information systems that will improve clinical care, prevent adverse events, and yes, streamline clinical workflow.  

As Teich tells it, this is something he has been interested in throughout his entire career.  He recently talked with HCI Associate Editor Gabriel Perna about a few of his thoughts on health IT, specifically clinical decision support (CDS) systems, and how they fit into the workflow of a clinician. He talked about the problem of alert fatigue and how clinician culture is changing for the better. Below are excerpts from that interview.

Jonathan Teich, M.D.

How did you get interested in the technical aspect of healthcare IT and clinical decision support in particular?

I’ve been intrigued by the way clinicians can use technology for clinical decision support (CDS) and evidence-based medicine throughout my career.  The healthcare industry is faced with an explosion of medical knowledge, along with escalating demands for clinical, operational and financial data and information, to improve performance and outcomes and move the needle on population health management and accountable care.  Clinicians need trusted information and professional insights to make timely, accurate, evidence-based decisions at the point of care.  It's really all about the ideal partnership between the computer's best capabilities and the clinician's.  

Health information technology (HIT) compensates for clinicians’ limited ability to remember details and make associations.  At the same time, HIT exploits the clinicians’ skill in making inferences and decisions based on seemingly disjointed pieces of information.  By relying on the enabling power of HIT, clinicians can prevent errors and deliver on the basics of care. HIT liberates clinicians to focus on more creative, thoughtful and personalized approaches to patient care.  In medicine, this is what computers should be used for -- to help supplement our poor memory and association-finding, and work with our superior inference and gestalt decision making. 

The most important benefit is to help prevent mistakes and keep clinicians grounded on routine care so that we can focus on creative and thoughtful care to improve patient outcomes.  The result, I believe, is a higher level of engagement for clinicians, patients and family members, as well as an enhanced care experience.

One of the biggest complaints about IT I’ve seen is how it fits into the clinical workflow. As a practicing physician, what do you make of this? 

While it’s possible for technology to interfere with clinical workflow, it’s also clear that HIT helps improve and streamline workflow; naturally, those situations don't generate as much controversy and news.  The key rests in developing HIT systems that fulfill the criteria of intelligence, accessibility, value, and usability.  Clinicians perceive value when HIT systems are relatively easy to use and firmly integrated into the preferred workflow. We are also seeking systems that inform and support our diagnostic and treatment decision making at the point of care. HIT producers do best when they pay attention to multiple factors, including system design and interaction, screen display, intuitive features and functions and flexible, efficient workflows.  Clinicians want systems that make them better clinicians—whether that involves error identification, recommendations on the best evidence-based treatment options, or sharing a nuance that the majority of clinicians would never have considered on their own. 

When I work in the emergency department, when the system points out an error to me, or when it reveals a best option upon my request, or when it informs me of a nuance I did not think to ask, it's making me a much better doctor. 

CDS has the power to change the quality of care for the better, but problems like alert fatigue have popped up, how can systems be designed to address this issue?

We need to realize that CDS involves far more than alerts.  CDS embraces many other methods, including intelligent data displays and intelligent knowledge delivery.  To that point, CDS can offer clinicians insight into the questions we tend to ask most:  What do I really need to know about this patient?  What do I need to do next?  Am I taking the best, most appropriate action right now? Over my last 500 patient encounters? 

These can be delivered in many workflow-friendly ways that help, rather than hinder, workflow; we spend a lot of time in the Improving Outcomes with CDS book describing just how to make that happen.  Providers can benefit from more insight into how different CDS methods compare in terms of information quality and completeness, speed of access, timeliness and usability.  Clinicians also need to be aware of how well these methods support them in making accurate, evidence-based diagnostic, treatment and prevention decisions, and how they help clinicians accomplish tasks, including data entry, review and assessment. 
How much does physician culture play into CDS struggles – the physician attitude that no one will tell me how to practice? Or is that a non-factor, do physicians want the information a CDS can provide? 

I think that physician culture has changed substantially.  The entire world is now seeking information, seeking it often, expecting it to come back quickly, and taking action based on it.  Most importantly, people expect to make decisions and take action on the information retrieved.  Clinicians are no different.  They want data, information and insight, but delivered in an actionable, workflow-supportive way, based on the particular patient as well as on general principles.  In an ideal scenario, such content extracts information from multiple sources and encodes knowledge into easy-to-use pieces of information.  The role of CDS is not to restrict clinical practice; in fact, CDS shouldn't be making policy at all, but simply presenting information and decisions that humans have agreed on previously.  When done this way, CDS is not "telling a physician how to practice", but making it easier for the physician to do the practice they already want to do.

Instead of constraining clinicians, CDS can liberate them to focus on overall treatment planning,  patient engagement and education -- improving both patient and physician satisfaction.  The near future will see improving and increasing CDS tools directed toward care coordination, driven by ever-increasing regulatory and payment drivers.  Providers will improve care coordination by applying CDS communication tools and more highly interactive multidisciplinary care plans.  CDS assessment and management tools are being built with greater attention to possible variations in the patient’s progress and response to treatment, which have often bedeviled efforts to regularize coordinated care.  Government and payer programs will continue to recognize that coordination is vital for efficient, effective, safe and timely healthcare, and those programs will support it and require it.  HIT is one very important part of the toolset that providers need to make this happen.  HIT tools can be expected to become more prevalent, more usable and more valuable to the effort.

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