Better Care Through HCIT 101: Part Four, Reliable and Timely Care
If you need to cross over a body of water when driving a car, there had better be a bridge, tunnel or ferry of some sort.Occasionally, you can drive around it, or drive your 4x4 SUV straight through it. My point is, however, the practical solution is not to redesign the car so that it's amphibious!
In a wide variety of ways, this issue keeps rearing its head: What's our goal here with HCIT? Drive adoption of EMRs in the inpatient and outpatient world, or something subtly or dramatically different? Like our amphibious car analogy, we're not going to get reliable, timely, and cost-effective care by improving the EMR. Not through certification.Not through getting the definition of "meaningful use of an EMR" correct. And not through performance measures obtained through requiring amphibious cars, aka EMRs, being asked to cross gaps in our processes, gaps where we need to start at the total trip view. Moving from task thinking to process thinking provides that total trip view.Dr. Jim Walker at Geisinger describes how that's really working today, in two links in the conclusion section.
We've read Adrift in PolicyLand, where Anthony shared his family's experience receiving care; it left mom and dad sure that the care processes were not reliable and timely.
I've previously shared, in Relativity and Reality, my experience that the reliability and timelines of gettingcare for my daughter was horrible. The recommended care for the same problem at four institutions was radically different. Different diagnostic processes and different therapeutic recommendations were presented. Could they all be correct?
And this past weekend, a close friend took her son to the ED for what was determined to be a urinary tract infection. She and her son were sent home after testing, diagnosis and administration of a potent antibiotic, with instruction to follow-up the urine culture results. When she followed up, she was told that, somehow, they lost the urine culture, either the order or the specimen.Reliable care? Would an EMR have changed the reliability? Is putting in an EMR the solution (rhetorical; we don't have enough information)? Does the ED have control charts on the reliability of getting a "resulted urine culture on all applicable UTI visits?" Should that sort of thing come before installing an EMR?
Okay, you say, "Thanks Joe, but isn't that all a bit anecdotal, no offense?" Right! Great point. Okay, it's only a good point. For it to be a great point, I would need to have a previously prepared PowerPoint or blog post prepared to address it. I do, however, have exemplary data that is scientific:
In a multi-province Canadian study Olivotto et al, Canadian Medical Assocaition Journal 165, no. 3 (2001):277-283), 14,000 women were studied for the reliability and timeliness of follow-up from breast cancer screening. One group of women had 2.6 weeks test diagnosis (median) times; for other groups described in the article, it was weeks or longer, generally more than two months. A third group fell through the cracks completely, never receiving or documenting follow-up. This example comes from Walker and Carayon's Health Affairs article, and is offered with a solutions framework — design for processes, not simply tasks. Or in amphibious car language, plan for the whole trip, instead of solving for a ferry, when you really need a ferry, bridge, or aircraft.
Conclusion and Lessons?
To quote Anthony Guerra, there is broad concensus that "Electronic medical records, while critical, do not constitute a silver bullet." I think Walker and Carayon have it rightThere's a different mindset that occurs when the focus is moved to reliability and timeliness.It's the mindset of redesign around value-added processes of care. Paraphrasing a bit (sorry Jim and Pascale):
- Developing those processes, which requires
- Intelligent Observation and feedback Testing, monitoring
- Human-factors engineering principles, like team awareness (eg aviation lessons)
- Recognizing the added value possible in unstructured situations
- Workload management – sensitivity to overload and underload changes caused by HCIT
- Implications for Policymakers — Eight specific and proscriptive implications were elaborated
- Implications of Information-System Developers And Managers
- Profound workflow implications (sensitivity to operations, in Weick-speak, slide 21 here)
- Integrated Informatics (coordinating every team member)
- If knowledge management is "a systematic process to ensure that everyone knows what the best of us knows," then Integrated Informatics takes it one step further.So, for example, clinical decision support is a broader thought than something for the physician at order entry time, or the nurse during BCMA.It's about the care team, whether inpatient, ambulatory medical home, or something even more patient-centered.
For a more indepth treatment of this topic, see "From Tasks To Processes: The Case For Changing Health Information Technology To Improve Health Care --- Why we need a new model of health IT that supports value-added, patient-centered processes over individual tasks.
For a delightful video presentation of the topic at a high level, by a practitioner in the field, click here.
Other industries have successfully moved from amphibious car thinking, to total processes, including human factors, high reliability, and the equivalents of STEEEP care. So can we!