Month: March 2010

Short Link: http://j.mp/bUmHkC

A great pediatrician or primary care physician (family medicine, obstetrics & gynecology, or general internal medicine) is caring, attentive, available and knowledgeable; a great pediatric or primary care office is full of people with these qualities; and a great pediatric or primary care EMR/EHR (electronic medical/health record) allows the doctor and staff to show what makes them great. For example, being able to express a caring persona by adding an alert to a child’s record (reminding to ask about Tigger, the family cat) may seem like a small thing, but the family sees this as a good quality.

Key to supporting a great pediatric, family medicine, obstetrics & gynecology, general internal medicine team is a new kind of EMR software, called clinical groupware. In contrast to traditional EMRs and EHRs based on a “singleware” approach, clinical groupware is

“intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate the care team’s work.”

Clinical groupware could be called clinical “teamware,” since it helps you coordinate your work with your staff and with other primary care specialists or subspecialists as part of a high performance medical home. It frees resources, manages interruptions, and reduces distraction to help you better know, care, and attend to your patients.

How does clinical groupware do this?

Large Colorful Buttons Help Navigation
and Data Entry Using Peripheral Vision

Let’s consider the remaining adjectives that apply to a great pediatric or primary care office: attentive, available, and knowledgeable.

Clinical Groupware Allows a Primary Care Physician to be More Attentive

One Georgia pediatrician, winner of the HIMSS Davies Ambulatory Care Award of Excellence (the most prestigious award for use of an EMR), shows his attentiveness using one hand to steady an energetic child and the other hand to enter data and orders out of the corner of his eye, made easy by large colorful buttons. A workflow engine pushes screens in preprogrammed sequences so he is not distracted by screen-to-screen navigation. Workflow-driven clinical groupware allows him to enter orders and automatically add work items (such as assembling educational materials or vaccination trays) onto staff to-do lists without interrupting patient-physician interaction. His focus remains uninterrupted and attentive to the concerned parent. Families like to see the doctor focus on them.

Clinical Groupware Allows a Primary Care Physician to be More Available

Taking a call from a patient and accessing an EMR from home is powerful availability. Spending more time with each patient is another form of availability. Clinical groupware makes a primary care office more efficient through (1) automated workflows and (2) keeping staff constantly aware of what you, the physician, are doing and intends to be done as well as keeping you aware of they are doing and their outstanding tasks. Clinical groupware makes “shared situational awareness” possible. Another Chicago pediatrician, who also won the HIMSS Davies Award, notes that customizable workflow has made his office so much more efficient that he can see more patients and spend more time with each patient. Efficiency frees time to be more available to parents and patients.

Clinical Groupware Helps a Primary Care Physician be More Knowledgeable

Obviously, a primary care physician should be perceptive and know his or her medicine. Conveniences include reminders of needed immunizations, a graph of growth relative to a norm, and a calculated drug dose. But there is something even more important: a pediatric, family medicine, obstetrics & gynecology, general internal medicine EMR should show the physician, at a glance, patient assessments, problems, flow sheets, current medications and treatments. When the physician can, at a glance, “know” a child, mother-to-be, or other family member’s current information, this is the most important kind of knowledge of all.

Briefly turning to pediatric-specific functionality one pediatric EMR workflow system includes premature, infant and child growth charts; vaccination tracking; functional development; Barton Schmitt pediatric protocols for telephone triage; and direct integration of vitals and spirometry instruments from Midmark Diagnostics Group and Welch Allyn. Areas of the record can be configured to be inaccessible by patients or guardians. Pediatric-specific reporting includes School Immunization, School Absence and Camp forms; Parent Take Home, Overdue Health Maintenance and a variety of signed immunization reports. The documentation for a HEDIS audit is as simple as the touch of a button.

The vaccine tracking and management module of the pediatric EMR workflow system has interfaces to state immunization registries (in those states that offer an automated upload option) as well as direct parent signature capture in exam rooms. The module relies on CDC guidelines for notification of when a patient is due for a specific vaccine and recommends a schedule of the remaining doses. It works for patients who are on schedule as well as those who have fallen behind. Access to the CDC guidelines is quickly available.

Clinical groupware is about more than just coordination of care; it is about coordination of knowledge too. An important feature of clinical groupware is the ability for specialists to create and manage new knowledge about what works and doesn’t work and share it with each other. For example, for new and useful reports and workflows created or customized locally, users should have the option of sharing with a larger community at other clinical groupware sites (see Addendum for further discussion in context of vaccine management).

Clinical Groupware Provides a Different Experience than Traditional EMRs

Family medicine, obstetrics & gynecology physician Dr. Jeffrey Harris wrote in his winning HIMSS Davies application (achieving a third win of the HIMSS Davies Award for a clinical groupware EMR):

“The EMR user interface is akin to the touch screen-oriented systems in restaurants: one screen at a time, with only the most relevant data displayed and options presented (although, of course, a user can always jump out of a particular screen sequence to accomplish an arbitrary task), and the sequences can be tweaked through the workflow management to make such occurrences infrequent…The workflow plans are tailored for each type of patient seen in the office (obstetrics, gynecologic, annual exams, family practice) assuring that key elements of the present illness, history and physical are addressed and documented. Work plans contain required laboratory tests for specific conditions, assuring that key tests are not forgotten.” (Dr. Jeffrey Harris, MD, Family Practice, Obstetrics & Gynecology)

Workflow-driven clinical groupware provides a different user experience than the clickity-clickity-click-click-click, hunt-and-peck style of interaction with traditional EMR singleware. In an EMR workflow system the computer is the workflow engine, not the physician.

Clinical Groupware is Ideal for High-Volume, Low-Margin Specialties

Family medicine physicians, obstetricians, gynecologists, and general internists have a lot in common with pediatricians. They all operate with narrow profit margins. Reducing costs, capturing charges correctly, and increasing the number of encounters can increase profit. For example, if a pediatrician cannot chart a routine otitis media encounter from start to finish in 30 seconds, the EMR will slow him or her down and reduce profit. Clinical groupware workflow engines push tasks to users as fast as they can perform them. Family medicine and obstetrics & gynecology versions of clinical groupware rely on family medicine- and obstetrics & gynecology-specific process definitions to tell workflow engines to push family medicine- and obstetrics & gynecology-specific tasks in family medicine- and obstetrics & gynecology-specific-sequences to achieve workflow automation induced productivity surges, decreasing encounter length and increasing patient volume.

Flexible Automatic Workflows plus Shared Situational Awareness

Clinical groupware emphasize flexible to-do lists and task tracking. Yes, many traditional singleware EMRs have to-do lists and task tracking, but they are not flexible. Their workflows are, in a sense, “frozen.” A clinical groupware workflow system has a workflow engine that automatically executes modifiable workflow definitions to save users time and effort. You don’t like your workflow? Change it! You can’t do this with traditional EMR singleware.

Various clinical groupware communication and follow-up tools assist a pediatrician, primary care physician, and the entire office team to better manage patients and tasks throughout the office. Visitors to office sites often comment on the quiet efficiency with which a clinical groupware-equipped office runs—the workflow system reduces the need for constant staff interaction about what needs to be done. Automatic task delegation to the right staff person, performed by a workflow engine executing a process definition, gets the job done.

Office View Tracks Patient, Task, and Provider Workflow in Real Time

Pediatricians and other primary care physicians and staff often struggle with office flow. Where are the patients? Where are the doctors? Where are the nurses? An office view lets users see patient location, which provider the patient is scheduled to see, tasks ordered for the patient, who is responsible for performing the tasks, and how long each task has been outstanding in minutes (updated continually in real time) – all in one multi-color coded screen. Usability engineers (the technical folks who make sure software is usable) call such screens “radar” views, because they resemble the radar screens in airport control towers. When every one of the staff can see a radar view of each other’s location and patient tasks the result is what usability engineers call “shared situational awareness.” In other words, office views track patients, tasks, and staff to make sure everything flows nicely and without collision.

Nurses can easily identify unaccomplished patient care tasks. The office view helps staff manage higher patient volume more efficiently. Nurses can see patients in a real-time virtual waiting room and monitor phone calls posted in a telephone message room. In some offices, the office view screen (shown), waiting room view screen, and telephone message room view screen each has its own dedicated flat monitor, easily observed by any nurse or physician, to monitor progress and facilitate moment-to-moment workflow where necessary.

Clinical Groupware Improves Your Bottom Line

Implementing a pediatric, family medicine, or obstetrics & gynecology EMR workflow system has a big payoff. Average income per physician can increase substantially after implementation. Flexible and coordinated workflow, streamlined navigation and communication, and easy-to-create accurate documentation lead to seeing more patients, spending more time with each patient, or going home early (the particular emphasis depending on your own business or personal objectives). One solo pediatrician HIMSS Davies Award winner doubled his income by seeing more patients and overseeing more clinical staff who see more patients.

A good pediatric and primary care EMR has the necessary pediatric-, family medicine-, obstetrics & gynecology, and general internal medicine-specific screens, functions, and reports. A great pediatric and primary care EMR must be more than its parts. Clinical groupware for pediatric and primary care practice must and does maximize opportunity for pediatricians, family medicine physicians, obstetricians, gynecologists and their staff to demonstrate care, attentiveness, availability and knowledge—while making excellent business sense.

Clinical Groupware and the Multispecialty Medical Home

If you are a pediatrician, family medicine physician, obstetrician, gynecologist, general internist, or other primary care subspecialist, why should you care whether EMR/EHR groupware can handle the other primary care and related specialties?

To future proof your practice.

• You may eventually add another primary care specialty to your list of board certifications (some pediatricians are board certified in multiple specialties). Specialty-specific automated workflows will switch specialties when you do.
• Your practice may add a primary care physician who will complement your own specialty (many pediatricians work in multispecialty primary care settings). Specialty-specific workflows will allow you and your partners to each “Have It Your Way” while not stepping on each other’s toes.
• You may need to communicate and coordinate with other primary care specialists who join your practice, or other specialty-specific EMRs outside your practice as part of a high performance medical home. If so, your EMR will need to “know” more than just your specialty.

If you think any of these events may happen in your future, please consider getting a clinical groupware solution used by thousands of users, including primary care physicians in pediatrics, family medicine, obstetrics & gynecology, general internal medicine, and physicians in primary care-related subspecialties.

Summary

Clinical groupware for pediatric and primary care practice is a new kind of EMR software. It speeds up data review and entry, order entry, and coordination between you and your staff, to allow your clinical team to be great. By increasing efficiency and effective coordination among you and your staff, clinical groupware manages interruption, reduces distraction, and frees resources to make you more available to better know, care, and attend to your patients.

Short Link: http://j.mp/cmsisv

I received a cool looking document last week, the copyright certificate of registration for the EHR Workflow Management Systems survey of features and functions.

A fan of open source and open minds, I license everything on this blog (and we everything on our product website) under the Creative Commons Attribution 3.0 License.

I essentially registered the copyright to give you (or anyone) the right to adapt and use the EHR workflow management survey criteria (with attribution, of course!).

So, please feel free to use or adapt and use the EHR Workflow Management Systems survey of features and function for any purpose whatsoever, knowing that you have the right to do so.

Have fun!

Short Link: http://j.mp/aYkgbg

A while ago I proposed the following definition of clinical groupware:

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate a care team’s work.” (emphasis not in original)

I received a surprising number of suggestions (but: Post! Post!). All food for thought.

I do have a list of what I like and a list of what I think is possibly problematic about the definition. “plus the” and “tools” are on my second (possibly problematic) list.

I’m tempted to replace “plus the” with “using,” or reverse the order of the primary clauses and use “applied to.” However I’d like to pay respect to the Johnson-Lenzs’ pioneering definition of groupware. I definitely *want* someone from the larger groupware industry and academic community to *recognize” this relatively well know construction. Nonetheless, I did replace “+” with “plus” because, well, “+” is just not a word.

“Tools” was on the second list too, not so much because “tools” is vague (and even if it was vague, that’s not necessarily bad); it’s that it is too general (too high up the knowledge representation abstraction hierarchy, using artificial intelligence-speak, therefore violating the third requirement for a good definition). It might admit “examples” of clinical groupware that we don’t want to be counted as examples. A rock can be used to compel coordination. But it’s not nice.

“Communication technology” is very close to what I had in mind. It implies information processing too, I think. However, successful communication does not ensure successful coordination to achieve common goals. Diplomatic instances of this give rise to the euphemism “a frank and constructive exchange of views.”

I considered all the possible combinations of “information,” “processing,” “communication, “digital,” and “technology” but wasn’t happy with any of them. So I decided to leave it “tools” until I came up with better. I’d rather gradually tighten the definition to exclude false positive examples of clinical groupware than untighten to include false negative examples of clinical groupware.

I’m also looking for a level of abstraction slightly higher than computer code-based clinical groupware. Examples of codeless coordination technology include the electrical lights and signal systems used in medical offices to represent who is where–with what priority–in real-time. EncounterPRO’s Office View is a digital example of this kind of radar view, albeit with much more task status information and driven automatically by the workflow engine.

Some computers don’t rely on electrons at all (at least directly). They are physical machines that operate deterministically according to the laws of Newtonian physics (not the laws of a computer language). A problem to be computed is mapped to their physical state, the machines move to equilibrium or quiescence, and the solution is mapped back out. I used to build gadgets out of tinker toys and punch cards that would play Tic-Tac-Toe. It blows my mind to think of how different today’s world might be if Babbage had succeeded to build a computer based on gears and powered by steam.

Physical machines can also be used to communicate (and I’m not talking  tin cans and string here). I recall that Leonardo De Vinci designed a mechanical means to convey a pixel-image from one location to another. Black and white squares in a grid are flipped, drive cords running over pulleys, which flip corresponding squares in another room. I don’t know if he built it and I can’t find it on the Web (keep coming up with television shows about his inventions instead of his invention of the television–or maybe I have the wrong inventor).

If all this seems a bit far afield from clinical groupware, I’d stress that this definition needs to be “extensible.” It needs to be compatible with innovative approaches to coordinating patient care we haven’t even imagined yet.

Technology is about more than digital computers. Finding the right representation for a coordination problem can be most of the battle. Annotating that representation, or moving physical tokens around on it, can be a groupware solution. Many board games are based on this idea. I’d like the definition of clinical groupware to be compatible with any such fiendishly clever annotatable or mutable physical representation (such as the common grease board). Codeless clinical groupware prototypes may be part of a developmental process in which some step will be to digital format.

So far, the best phrase I’ve come up with to specialize “tools” and tighten up the definition is “coordination technology.” It captures what I think needs to be captured, and resonates nicely with current discussions about “care coordination.” 

So here is another candidate for a definition for clinical groupware (version 2.0):

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the coordination technology designed to support and facilitate a care team’s work.”

Just one problem though, it violates the fourth requirement for a good definition: Avoid obscurity. Coordination technology is not a commonplace and widely understood phrase. The interesting thing is that if I define coordination technology to be “tools designed to support and facilitate a (care) team’s work,” I end where I started.

So, for now at least, I think I’ll stick with my original definition for clinical groupware:

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate a care team’s work.”

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