Month: September 2009

Short Link: http://j.mp/6ke8Y5

Whenever I need help thinking outside the box I call on Dave Hubbard. For example, a few months ago I was trying to think of a good analogy to workflow in a medical office and Dave and I ended up co-writing about similarities between football plays and medical workflow. It’s been a popular post, web traffic wise.

Recently I considered the value of a positive customer experience of implementing a EMR and the beneficial transformations that can be achieved. I drafted a blog post, but it was, frankly, a dry exposition about economics of EMRs as commodities, goods, services, experiences, versus opportunities for transformation. (Entirely what you would expect though, from a premed Accountancy major.)

Dave Hubbard and Parachute

To liven it up, I again called on Dave.

Inside the Box (Or You Can Just Skip to Out-of-the-Box Fun Part)

So, as I said, I was thinking about EMR cost, value, experience, and transformation, and then stumbled on The Experience Economy, in which Joseph Pine II and James Gilmore distinguish among five levels of customer value (see below).

Which of the following kinds of product value can an EMR deliver?

That of:

• Undifferentiated stuff (commodities: flour, gas)
• Tangible things (goods: vehicles, furniture)
• Activities executed for a customer (services: tax returns, dog walking, legal services)
• Time spent with a customer (memorable experiences: theater, tour guide)
• Demonstrated customer outcomes (transformations: personal trainer, psychiatrist, productivity improvement)

If EMRs are interchangeable (many practically are, though not yet from an interoperability point of view), they are commodities. Delivered as a complete system of software and hardware, an EMR resembles a tangible good. And some EMRs are delivered as a service over the Web, though many such services also eventually become commodities.

What about the value of experiences and transformations created during implementing, going live, and optimizing an EMR workflow system?

Recent EMR market trends highlight EMR experience, or usability, as a key product differentiator. Is an EMR easy, even fun, to use?

Further, what about the ability of a EMR to transform?

Going Live with an EMR is as Easy as Jumping Out of an Airplane

“It was a beautiful summer day in northern California – 1982. I was about to embark on the adventure of a lifetime. Our instructor was an ex-Vietnam jumper and had thousands of jumps behind him. Jumping was his life. He had been teaching people how to jump for years, five days a week at this location. He had never had a mishap. It would take almost a full day of training for each of us to gain the knowledge and the confidence we would need to step out of that airplane…”

So began a new chapter in Dave Hubbard’s life. To give away the ending, Dave’s chute did not open, but he survived to tell his story. Since that moment, Dave has told and retold his story, applying it to a wide variety of subject matter across scores of industries, to inspire and motivate.

An All-American collegiate athlete who played professional football in the 1970’s for Hank Stram of the New Orleans Saints and then the Denver Broncos, Dave is familiar with healthcare professionally (serial entrepreneur) and personally (after all, he broke his back jumping out of a perfectly good airplane!). Combining an appreciation of team spirit and performance with an understanding of information technology, Dave has inspired thousands to better confront their fear and prepare for success.

Adopting an EMR is increasingly about the total EMR rollout and go-live experience rather than merely achieving specific EMR functional goals. (And skydiving is all about experience; after all, you’re already on the ground.) EMR rollout and go-live experience includes two components: emotion and meaning. “We were afraid but also eager and curious; we confronted our fears, overcame all obstacles, and grew individually and as a team.” This process of working through emotion to meaning is the great intangible key to EMR rollout and go-live success.

Analogies between skydiving and adopting an EMR include:

Murphy’s Law applies to both. (“Anything that can go wrong will go wrong.”) Therefore imagine everything that can go wrong to prevent it; survive problems before they happen.

Preparing to go live with your EMR is like packing your chute. (And your implementation coordinator is like your jumpmaster!)

Dealing with anxiety about taking a step into the relative unknown (to you) is like making your first move out the airplane door. (“Feet out! Get out! Go!”) Your EMR vendor, like your pilot, will do everything possible to drop you on the target, but it’s up to you to steer and land. It’s a cooperative effort.

Surviving the inevitable ups and downs (and then ups) of implementing, training, and getting back to previous levels of productivity takes mental preparation that begins *before* you set in motion events for which there is no “Undo.”

Make Dave’s story your story…

“It was a beautiful summer day in my hometown – 2010. I was about to embark on the adventure of a lifetime. Our instructor was an ex-EMR user and had hundreds of EMR implementations behind her. Helping people make the jump to an EMR was her life. She had been teaching people how to use EHRs for years, five days a week all over the nation. She had never had a mishap. It would take almost a full day of training for each of us to gain the knowledge and the confidence we would need to use our new EMR to see our first patient…”

Epilogue

What’s my point?

The true value of an EMR (workflow system) is not in specific product features and services available, but rather, it is in the transformational experience that can happen to you and your medical practice.

Short Link: http://j.mp/6CYRaS

Our new website for the High-Usability EncounterPRO Pediatric EMR Workflow System is just a bit more than a month old and we are pleased.

Some Recent Web Statistics

Before we published our new content I checked our search engine result position on Google and we did not appear on any of the first 10 search engine result pages (that’s 10 pages times 10 links per page). Four weeks later, for the Google search terms “pediatric” + “emr”, EncounterPRO.com moved from heavens knows where to the first page returned by Google (as of the date of this post; nothing except my crossed fingers guarantees we’ll stay there).

http://www.google.com/search?q=pediatric+emr

By the way, at this very moment we’re also on the first result page returned by Bing

http://www.bing.com/search?q=pediatric+emr

and Yahoo.

http://search.yahoo.com/search?p=pediatric+emr

Again, given the perverse logic of the Web, where for every action there is an opposite and unintended consequence, who knows what the effect of me even writing about this topic  here will do, or undo.

Compared to the same four weeks in 2008 our traffic is up more than threefold (not counting this blog), and our leads are up almost fivefold. During what is usually a slow month (Pediatric EMR leads and sales are cyclic), we’ve had more leads during the last four weeks (28 days) than any previous month.

A Bigger and Better Website

In 1993 I storyboarded a future EMR workflow system. I borrowed some screenshots from an existing workflow management system and replaced icons and text labels with medical content. I painted a picture of a future work environment in which non-programmers familiar with office workflow create and customize their own their own high-usability EMRs. Later I chanced upon the EncounterPRO Pediatric EMR Workflow System, based on the EncounterPRO EHR Workflow Management System. Here was the EMR workflow system that I storyboarded years ago.

There are advantages and disadvantages to being so far ahead of the curve. One disadvantage is that while many people know what to expect from an EMR, they don’t know what to expect from an EMR workflow system. In fact, folks often ignore or discount “workflow system” and categorize EncounterPRO as a mere EMR. This is why I continually stress differences between traditional hunt-and-peck EMRs and anticipatory EMR workflow systems.

The basic problem is this: how to compress EncounterPRO’s unique selling proposition to a sound bite that gets past preconceived market notions and traditional EMR stereotypes. Marketing types have asked me to express in ten words or less what makes EncounterPRO different and better. I’ve replied that, unfortunately, it would take a textbook on human factors and workflow automation to first educate and then make that case.

The new 33,000 word product website (and this 60,000 word blog) *is* that textbook. However, it is a textbook that has been chopped up, illustrated, and cross-linked so as to create two mutually supporting websites. One, this blog, educates (but occasionally promotes); the other, the product site, promotes (and occasionally educates, but relies on this blog for in-depth educational exposition).

In effect, since Google (and Bing and Yahoo and other search engines) like words so much, I’ve turned a disadvantage into a disadvantage:

• Disadvantage–the inherently necessary “wordiness” of our unique selling proposition.
• Advantage–lots of useful, information-rich, pages that clearly and accurately describe our unique selling proposition (as Google’s own advise).

The Future of Pediatric and Primary Care EMRs

OK. An improved website generates improved Web stats and leads. What about the “Future of Pediatric and Primary Care EMRs” in this post’s title? To what do I refer? To EHR Workflow Management Systems, of course.

P.S. Here are our website pages in high to low order of popularity:

1. The High-Usability EncounterPRO Pediatric EMR Workflow System
2. Contact: EncounterPRO Pediatric EMR Workflow System
3. Screenshots: EncounterPRO Pediatric EMR Workflow System
4. Management: EncounterPRO Pediatric EMR Workflow System
5. Pediatric-Specific Features of The High-Usability EncounterPRO EMR Workflow System
6. Chart Quickly: EncounterPRO Pediatric EMR Workflow System
7. EncounterPRO Pediatric Practice Management System
8. Workflow and BPM: EncounterPRO Pediatric EMR Workflow System
9. E-Prescribing Through Surescripts: EncounterPRO Pediatric EMR Workflow System
10. National Awards: EncounterPRO Pediatric EMR Workflow System
11. Family Medicine, Obstetrics and Gynecology: EncounterPRO EMR Workflow System
12. Health Information Exchange: EncounterPRO Pediatric EMR Workflow System
13. Rollout & Go-Live SYSTEM: EncounterPRO Pediatric EMR Workflow System
14. High-Usability: EncounterPRO Pediatric EMR Workflow System
15. Blog: EncounterPRO Pediatric EMR Workflow System

Thank you for your interest!

Short Link: http://j.mp/6V1KK6

American Academy of Pediatrics National Conference & Exhibition
Oct 17-20, 2009
Washington Convention Center
801 Mount Vernon Pl NW
Washington DC

• View a live demo of the EncounterPRO Pediatric EMR Workflow System at booth 1543 (directions to booth below).

Exhibit Hall Hours

Saturday, October 17 12:15 pm – 4:00 pm
Sunday, October 18 10:00 am – 4:00 pm
Monday, October 19 8:00 am – 2:00 pm

• Meet representatives from EncounterPRO Healthcare Resources.
• Attend the Pediatric Documentation Challenge at the Technology Learning Center, Saturday, October 17, 2:00-5:45.
• “Testkick” a Kickbike outside the Washington Convention Center. They’ll be locked to a bike rack at the corner of 7th and L streets if you’d like to “inspect” them first (directions to kickbikes also below). Then visit our booth to arrange for a personal tour (I live nearby, that’s the Washington National Cathedral in the background of the photo that appears in the upper right of this blog) of the Chinatown/Mt. Vernon (though not *that* Mt. Vernon) neighborhood around the convention center.

(10/16/09 Update: Kickbiking looks like it’s going to be rained out this weekend, but Monday is predicted to be clear and cool–perfect! Check back. CWW)

I look forward to meeting you!

Short Link: http://j.mp/84ujmB

An interruption–is there anything more dreaded than, just when you are beginning to experience optimal flow, a higher priority task interrupts your concentration. This is ironic, since so much of work-a-day ambulatory medicine is essentially interrupt-driven (to borrow from computer terminology, see also). Unexpected higher priority tasks and emergencies *should* interrupt lower priority scheduled tasks. Though at the end of the day, ideally, you’ve accomplished all your tasks.

In my last post on aviation human factors and EMR workflow and usability I described an interruption-based action loop in which staff routinely by step away from one sequence of tasks to work on another higher priority sequence of tasks. Staff eventually do accomplish lower priority interrupted tasks through reliance on colorful information-packed items in what’s called a “radar view” by usability engineers). A continually updated number, the number of minutes since the task began, helps prioritize order of task accomplishment.

Example of a Radar View in an EMR Workflow System

Interruption Theory is an important area of research and the medical domain is well represented there. For example, here are over 600 research papers on the topic (many of which are aviation or medically related). Interruptions can lead to failures to complete medical tasks, which may lead to errors that affect patient safety.

1. “Rothschild et al….found that over 50% of all healthcare errors noted were slips and lapses, such as not executing an intended action.” (see below)

Interruption theory and research in healthcare primarily addresses medical errors and patient safety. However, much about what we understand about interruptions also applies to achieving fast, accurate data and order entry in EMR workflow systems. Simply put, the faster and more accurately one can enter data and orders into an EMR, in the face of interruptions that threaten this speed and accuracy, the fewer errors. Whatever contributes to fast, accurate use on one hand and fewer errors on the other usually serves both goals.

Interruptions in Healthcare: Theoretical Views

A good place to start is “Interruptions in Healthcare: Theoretical Views,” by Grundgeiger and Sanderson (by the way, I took an excellent class on human factors from Dr. Sanderson when I was a graduate student in industrial engineering). The results of interruption research support an especially compelling argument for EMR workflow systems.

First G&S describe prospective memory (PM), which occurs when “a person must recall an intention or plan in the future without an agent telling them to do so.” There are two dominant views of PM:

2. “The monitoring view proposes that when a person forms an intention…to monitor the environment for a specific cue that will remind them to act….”

3. “[T]he automatic associ­ation view proposes that when a person forms an intention, an association is formed automatically between the intention and the reminding cue….When the cue is later encoun­tered, a spontaneous retrieval process brings the intention into mind.”

And:

4. “[N]urses ‘stack’ activities in memory—moving on to a next activity and coming back to stacked activity later—to prevent down times”

From a section entitled Interruptions in the medical and aviation domain G&S write:

5. “Similarities between the domains have been shown in tasks consisting of multiple well defined steps.”

6. “Pilots have a highly structured workplace that supports the use of workflow tools and check­lists”

(I am reminded of this blog post by a physician reflected on the checklists used by her pilot husband.)

In their section entitled Informatics implications of prospective memory G&S advise:

7. “IT systems could remind people what they were doing before the interruption by providing cues on the display.”

8. “IT systems either should be designed in a way that makes them sensitive to the possibility of interfering with working memory processes or they should use non-interfering means of output.”

9. “[O]ffer solutions that help healthcare workers execute plans. For example, electronically accessible work lists that integrate system inputs from different healthcare workers in a timely fashion would provide non-disturbing reminders.”

10. “[S]upport tailoring—the possibility for the user to make modifications that preserve awareness of intended actions or that produce reminders on demand”

11. “[M]itigate memory limitations by providing cues or explicit reminders.”

12. “Distributed cognition is a promising approach in understanding and designing support for many kinds of tasks involving PM.”

13. “[N]otify a person without interrupting him, so removing the load of remembering from the sender and creating a reminder for the recipient.”

14. “Currently, attention aware systems may not be as helpful in healthcare as context-mediated social awareness.”

15. “[H]ealthcare IT systems should be designed and evaluated with regard to their potential disruptiveness (especially on working memory processes) and their potential to provide cues and non-interruptive reminders for intended tasks.”

16. “[A]rtifacts used to manage the effect of interruptions might be useful for designing new technological products. For example, IT products could support cognitive processes disrupted by interruptions or the results could be used for interruption management”

And finally:

17. “[M]ake the workplace resilient to the effects of interruptions. This recommendation has the advantage of preserving the potential positive effects of interruptions, because it does not prevent interruptions. Resilience is enhanced if the burden of resuming an interrupted task is not the PM task of just a single person (e.g., a nurse), but of the interrupter as well, or of the unit as a whole. The PM task needs to be a distributed prospective memory task in the sense that multiple agents (other nurses, equipment, IT) remind the nurse of the intended task. “

Interruption Management Using an EMR Workflow System

Consistent with the ideas and advice in G&S (numbers in parentheses correspond to previous quotes), an EMR workflow system:

Provides environmental cues to remind automatically (via the radar view) pediatric and primary care staff to resume interrupted tasks (2, 3).

Represents “stacks” of nursing tasks so the entire care team works together to make sure that interrupted tasks are eventually and appropriately resumed (4).

Transforms the pediatric and primary care domain into one that more closely resembles the aviation domain, with its well-defined steps, checklists, workflow tools (5, 6).

“[Re]mind[s] people what they were doing before the interruption by providing cues on the display” (7)

“[U]se[s] non-interfering means of output” (8)

“Help[s] healthcare workers execute plans” (through use of what are called workflow or process definitions in the workflow and business process management industry) (9)

“[S]upport[s] tailoring—the possibility for the user to make modifications that preserve awareness of intended actions or that produce reminders on demand” (an EMR workflow system allows workplan customization as well as user actions affecting workplan execution: postpone, cancel, forward, etc.) (10)

Exploits distributed cognitive processes (see below) (12)

Notifies without interrupting (via radar view and To-Do lists) (13)

Promotes “context-mediated social awareness” (through use of the radar view and user awareness of consistently executed workflow process definitions) (14)

Supports cognitive processes with non-interruptive reminders (15, 16)

Enhances the resilience of the entire pediatric and primary care human-computer cognitive system by “preserving the potential positive effects of interruptions.” An EMR workflow system converts a prospective memory task into a “distributed prospective memory task.” Each member of the healthcare team efficiently and effectively resumes and accomplishes previously interrupted tasks. (17)

I am reminded of what I wrote (in the proceedings of the 2004 TEPR conference, and exercising the blogger’s prerogative to quote myself) about the important connection between distributed cognition and EHR workflow management systems:

[begin 2004 TEPR quote]

EHR Workflow Management Systems: Essentials, History, Healthcare

…

Workflow Management and EHR Usability

EHR workflow management concepts mesh with research initiatives to improve EHR usability. For example, Human-Centered Distributed Information Design [6] (there applied to EHR usability issues) distinguishes four levels of distributed analysis: user, function, task, and representation, which correspond well to workflow management architectural distinctions. Distributed user analysis can be interpreted to include allocation of tasks, relationship between roles, and task-related messaging, all of which are important workflow management concepts.

Distributed function analysis involves high-level relationships among users and system resources. From a workflow management perspective, this includes who reports to whom and who is allowed to accomplish what.

Distributed task analysis roughly corresponds to the creation of process definitions that in turn drive EHR behavior: What is to be accomplished by whom, in what order, and what needs to happen automatically.

Distributed representational analysis corresponds to something that workflow management systems intentionally do not address. Workflow management system design tends to be agnostic about how information is displayed to, transformed, or collected from the user. The underlying workflow engine is intended to be a general purpose tool that can be used to sequentially launch whatever screen or initiate whatever behind the scenes action that the implementer of the workflow system deems most apt as part of workflow analysis and design. However, by remaining orthogonal to the choice of screen, by not mandating or hard coding, the designer/implementer is free to bring to bear the powers of representational analysis to use whatever screen and attendant representation is most appropriate.

Thus, workflow management concepts are consistent with human-centered distributed information design, an important emerging area of medical informatics research. “Task-specific, context-sensitive, and event-related displays are basic elements for implementing HCC [human-centered computing] systems,” (p. 46 [6]) and they are the basic elements provided by EHR workflow management systems, too.

…

References

…

[6] Zhang J, Patel V, Johnson K, Smith J, Malin J. Designing human-centered distributed information systems. IEEE Intelligent Systems 2002: Sept/Oct: 42-47.

[end 2004 TEPR quote]

Conclusion

I don’t think you will be able to find a more compelling, research-based argument that ‘anticipatory’ EMR workflow systems are superior to traditional ‘hunt-and-peck’ EMRs. Traditional EMRs soak up scarce attention and memory and interfere with prospective memory processing. EMR workflow systems free up attention for prospective memory processing while reducing interruptions and providing unobtrusive future cues to resume previously interrupted tasks efficiently and effectively.

You can retrieve the complete PDF for the “Designing human-centered distributed information systems” article here.

The complete reference for Grundgeiger and Sanderson paper that triggered this post is:

Grundgeiger T. & Sanderson P. (2009) Interruptions in healthcare: Theoretical views, International Journal of Medical Informatics, 78 (5), 293-307.

And their complete PDF article is here.