People at Work – Myth vs. Reality

March 31, 2014

Matthew Loxton:

People at Work – Myth vs. Reality, from Jeff Saltzman

Originally posted on Jeffrey Saltzman's Blog:

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People at Work – Myth vs. Reality

Tuesday, April 22nd, 2014  at 12:30 PM EDT, 9:30 AM PST

Presented by: Jeffrey Saltzman

Everyone has various traits which could be described as strengths or shortcomings. Some of them are known to us and some are hidden, despite, perhaps, being quite obvious to others. Some of these traits have their origins in how we have evolved as a species and how our psychology developed. Our tendency to see intelligent intent where there may be none is one such trait. And our ability to form up into groups to better accomplish tasks which we would have difficulty accomplishing alone is another. This ability to form up into groups, using our social instincts, led to the very first human organizations and later on to the complex organizations we…

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The Connected Patient: My Adventures as an ePatient

March 26, 2014

Introduction

Firstly, let’s talk about what this is.

This is a blog – not an academic or research paper, not a product analysis, and not a study on healthcare.
It describes my experiences as I have pieced together one approach to connected health, and how I went about that.

With that disclaimer, here we go.

One of the big themes in healthcare over the last year has been the concept of “Connected Health” and the “ePatient“, and considerable hope is pinned on the idea that if patients are more active (and discerning) in the monitoring and maintenance of their own health, and use of healthcare services, population health will improve and healthcare costs will drop.
The premise being that autonomy and control will lead to better health outcomes at a lower cost. It all happens at the corner of individual responsibility and public health.

There is a lot of talk in the industry about a patient driven revolution, one that acknowledges that patients understand the impact of their disease and the associated treatments, that sees an urgent need for clinicians and patients to work in partnership , and accepts a need to challenge the status quo of practices and behaviors. (BMJ 2014;348:g1209). Tessa Richards, blogger at the BMJ, speaks to this with regard to patient data, and the role of the patient as an active participant, rather than just the subject of data within an EHR.

Part of this puzzle of improving healthcare is the concept of patient generated data (PGHD), and the idea that data on vitals, diet, and exercise, immunizations, sleep, and use of medications can be monitored by the individual to guide their own choices, and also be sent to their primary healthcare provider (HCP) – typically the person’s general practitioner. These data would fill in a more complete health picture, and the HCP could monitor and see patterns emerge that allowed lower-cost interventions to prevent or mitigate chronic disease. There could be fewer office visits, lower probability of emergency room (ER) visits, hospitalizations, or readmissions.

The three salient components of this view are:

  • Increased autonomy and control lead to improved health choices by the individual
  • More data over longer periods in the hands of HCPs lead to more focused and timely interventions, that will lower the use of high cost medical services
  • Monitoring of basic health and chronic conditions can enable better and cheaper care

So far, so good.

There are some behaviors that this is likely to give rise to, mostly for the better.
If providers know that their notes are going to be shared by their EHR with the patient’s PHR, they are going to take more care and be more complete than if they think only they will ever read them. This also drives patient compliance since the connected patient will be able to re-read the notes and instructions rather than walk out of the consultation room in a daze and then try to remember all the things the provider told them. The implications for patient safety are also important – being able to actually read the provider’s instructions are a vast improvement over trying to recall them from memory.
If patients think that skipping on walking for a few days or eating five burgers in a week is going to wind up alerting their doctor, they might be motivated to behave in a slightly better fashion.
It isn’t that this knowledge stops unhealthy behavior on both sides, they could simply not report, or think “what the heck”, but it certainly is likely to have an effect to the better, and for many problems, just a small change in behavior will be effective.
On the cost side, it means that instead of only showing up at the provider when there are symptoms, unhealthy behaviors and emerging signs and symptoms can trigger an alert to the provider to intervene. A single provider can handle a great many more patients by exception than in person. Monitoring a hundred patients in this way is far cheaper than seeing a hundred at the office, and far cheaper both in terms of time and the level of intervention.

In practical terms, a nurse practitioner could monitor for values coming across from the PHR to their EHR that exceed upper or lower control parameters of a large number of health metrics, ranging from exercise and sleep to compliance with meds, diet, or blood pressure and glucose measurements carried out by the patient. These alerts can trigger them to look closer at what is going on in the data over time for a specific patient, and either respond directly to the patient with suggestions or make a recommendation for an office appointment. They could also routinely examine individual patient records and reach out to the patients with encouragement or suggestions. Since the data include a large number of population health markers, new discoveries in medicine or changes in protocols could lead to a targeted outreach to patients with new information, suggestions, or closer monitoring.

Worth mentioning is that the connected patient is very important to the industry move towards patient care teams and initiatives like the patient centered medical home.

(My) Technology Approach

Of course there are technical and logistical considerations, such as whether people are able to generate health data without undue complexity and effort, whether they are able to get the relevant data into the hands of the HCP, and whether the HCP has the technology to do something with the data.

As an experiment, I put together components of PGHD to monitor some basic health data of my own. I selected a relatively low-cost approach, and one that at face value I would be likely to be able to sustain over a potentially indefinite period.

Firstly, I experimented with a range of fitness apps on the Android platform, and various Personal Health Record (PHR) applications both on the device and cloud based.
Some I rejected after only a short while due to stability issues or ineffective functionality, and I gradually arrived at some specific requirements based on hands-on experience.
I selected, and then signed up for, a Microsoft HealthVault account as my primary PHR, since this provided a fairly comprehensive set of health records in a free, cloud-based solution.
This choice naturally limited the usefulness of many of the Android apps, but since interoperability with a secure and extensive cloud-based repository is important, the remaining apps are more realistic than ones that are standalone and can only store health data on the device.

Health Records

Health records span an enormous field, from diet, through exercise, to medical records such as conditions, medications, and labs.
To give you an idea of the breadth of the health records that can be stored to HealthVault, here is a snapshot of the fields that can be shared from HealthVault and a carer or an HCP. This is but a small drop in the ocean of data that could be collected on a person’s health, and a truly quantified self would be an epic undertaking, far beyond what we can currently achieve with any sort of scalability.

Figure 1. HealthVault Sharable Data

My next step was to transition from the somewhat inaccurate (but free) step-counters and fitness apps that I could download onto my smartphone, and buy a FitBit Flex.
The Flex was chosen according to:

  1. Interoperability with HealthVault
  2. Price
  3. Features and reputation

The FitBit Flex tracks some things automatically, and more things manually.

Automatic Manual
Step count Weight goal
Distance walked Food consumed
Calories burned Water consumed
Very Active Minutes Sleep Activity*
Sleep Activity* Exercise
Calories remaining

 

Sleep activity is one of those that is partly automated and partly manual input, and here’s how it works.
Since the Flex can’t tell if you are awake or not, you have to put it into “sleep” mode manually, and then take it out of sleep mode again when you wake up. This of course leads to some days of missed data because you either forgot to put it into sleep mode or to take it out again. The way in which it is done also presents a few challenges – it works by tapping on it three times in rapid succession, and this is mimicked by some day to day actions like knocking on a door, clapping, or some kitchen activities.

So if you applaud during a show, you have to verify that the Flex doesn’t think you are sleeping.

To get the data into HealthVault requires setting up the FitBit smartphone app and configuring HealthVault to receive data from FitBit.
This process was fairly smooth, but not without its share of oddities, like waiting 24-48 hours for the first upload. Initially I thought I must have misconfigured and wasted a lot of time troubleshooting a working configuration.

Obviously not all fields are interoperable between FitBit and HealthVault, and even within a single concept, not all the field dimensions are interoperable or visible to the user.
For example, sleep and exercise data are transferred but there isn’t a perfect match of fields.

Sleep

FitBit Field FitBit Value HealthVault Field HealthVault Value
Time 20:58 Bed Time 8:58:00.000 PM
Time 06:01 Wake Time 6:01:00.000 AM
Sleep Time 8h 20min Sleep Minutes 500
? ? Settling minutes 7
Wake State fully awake
Restless 18 min x 13
Awake 11 min x 2

 

Some values captured by FitBit, such as the Restless and Awake periods are not being used by HealthVault, while two of the values that HealthVault evidently received don’t appear to match anything that the FitBit app displays. “Settling minutes” is either received or calculated by HealthVault, but doesn’t show up in the FitBit app, and the meaning of “Wake State” is unclear and doesn’t obviously map onto anything in the FitBit app.

Exercise

FitBit Field FitBit Value HealthVault Field HealthVault Value
Distance 4.92 miles Distance 4.92 miles
Calories burned 2,544 Calories burned 2544 Calories
Steps 10,157 Number of steps 10157 Steps
Very Active Minutes 67

 

The exercise interoperability maps slightly better, but also has a field in the FitBit side that doesn’t map to anything on the HealthVault side.

All in all, the average user should be able to navigate and configure this without help, and can get some basic health data uploaded from a device like FitBit to HealthVault.

Medical Images

Medical images are a challenge, and typically if you want to provide images to your provider or upload to HealthVault just for your own record, you need a third application that can convert jpeg or png images to Digital Imaging and Communications in Medicine (DICOM) format. It isn’t as simple as taking a photo of the lump on your hand and uploading. Firstly you need to get the photo as a jpeg (easy with a smartphone), upload to an application such as MIPAV and then navigate around a fairly large number of fields to be filled in that are part of the DICOM metadata standard. Some DICOM apps are somewhat inscrutable and at this point they probably assume you are a radiologist or somebody in the field. Typical data you will need to enter include Date, Patient Name, Description, Study Instance UID, Referring Physician, Study Type, and Body Part. It was obvious that the apps were geared towards practitioners rather than patients doing their own imaging.

In my case it took quite a few attempts, and I had to get HealthVault Support (thanks guys) to help troubleshoot. It turned out that the MIPAV app was incorrectly packing a certain required field with spaces that was meant to be null, and HealthVault was applying the standard rigorously and rejected the image. As a workaround I first converted the image to jpeg-2000, and then into DICOM, and that allowed it to upload.

In terms of general usability and maturity, I would say that image uploads are not yet ready for the average user.

Providers

The next challenge is to transfer the data from HealthVault to your healthcare providers or to get your medical images and data from your provider.
For this I set up the HealthVault Message Center, and there are a number of options.

At the lowest level of interoperability, you can simply print out the health record from HealthVault and take it with you to the provider appointment, and then get paper records back from them after the appointment and re-enter the data into HealthVault or scan them and load them into HealthVault– not very satisfactory either in terms of efficacy or security. Losing a piece of paper is a very real possibility for some of us. Scanning them in is fairly simple if you have a scanner, and you can upload them either as a Continuity of Care Document (CCD) or a Continuity of Care Record (CCR), This is a bit of a cheat, since CCR and CCD are actually competing healthcare record standards, and have specific fields and meanings that would not be parsed into computable health data from just uploading a scanned document. However, it is better than leaving the paper lying around in a file folder, and if they are in HealthVault you at least have an opportunity to find them again and nobody else will chance upon them while looking in your filofax for the electric bill.

A second option is to set up a provider or custodian in the Message Center, provide their email address and optional password, and then select which of the data in Figure 1 you wish them to be able to see. This however requires a provider to navigate to the website and to go through the login process. It is more secure, under the patient’s control, but requires a fair amount of effort on the side of the provider, who will need to keep a record of the login details for each ePatient. This is not really a scalable model since from the provider’s side it would require them to keep a record of each patient’s chosen PHR, the login procedure, and login credentials. Not all patients will share the same things, and not all PHRs will have the same fields available or in the same format, so it would be a very complicated world for the provider once significant numbers of patients share in this manner. It is the flip side to the mistaken idea that patient portals are a solution, but in that case each patient would have to keep a record of multiple provider portals, logins, etc. Since the average person has ~4 providers, and patients with chronic illnesses have ~15, portals simply don’t scale well.

The most integrated option I had was to set up a Direct account in HealthVault that gives you a <yourname>@direct.healthvault.com address.
This address only sends between Direct addresses, and is encrypted – so no spam and pretty secure. No paper records lying around, no manual portal-surfing, and no proliferation of user codes and passwords to remember. The patient sees everything in their chosen PHR and the provider sees everything in their EHR.

HealthVault even provides you with a natty little printout or email that you can give to your provider that tells them what to do:

If you are using an electronic health record (EHR) system that is certified for Meaningful Use Stage 2, then your software may be able to generate a CCDA and send it to me using the Direct protocol. (As you may know, Direct is a security-enhanced health messaging protocol designed to help protect health information when it is sent from one computer system to another.) Your EHR software vendor should be able to provide instructions. If you can’t yet send information via Direct, can you give me electronic records another way, such as on a disc? HealthVault accepts structured information in CCDA, CCD, CCR, and BlueButton formats, as well as information in unstructured files such as images, PDFs, and text. You can find more information about HealthVault and how it supports Meaningful Use Stage 2 at http://www.healthvault.com/providers.

Microsoft provides ample educational and instructional materials for providers, such as this overview on sending health information to patients

This option allows health records to be sent securely and effectively from the provider’s EHR to your HealthVault account and vice versa, with no extra work on the providers side, and only one login to your HealthVault account to you as the patient.

So far so good.

Unfortunately for me, this is where the wheels come off because of my four healthcare providers, none are able to use Direct.

  1. General Practitioner in Colorado: Only has paper health records
  2. General Practitioner in DC: Has an EHR, but staff don’t know how to get it to work to provide electronic records. (They spent huge money for an EHR but still print records)
  3. Dentist: has an EHR, but doesn’t have the functionality to work with Direct. Instead sent me my dental images over unencrypted email (!)
  4. Optometrist: has images on a standalone machine that doesn’t connect to anything, and all other records on paper

So at the moment I have limited ability to do any real work as an ePatient or be part of a meaningful care team with my providers. The technology is ready enough, cheap enough, and usable enough to support at a minimal level, but my providers are just not there yet. The question that occurs to me on many of the #bioethx, #hcldr and #hcsm tweet chats, is that at some point I might start looking for providers that are further along the curve, and are willing and able to connect. From a provider perspective, this might be a competitive advantage issue, and providers that aren’t able to offer ePatients a workable data exchange schema may find that their patient population is dwindling and they are left with high-cost low profit patients.

Conclusion

So what did I learn?

Firstly, you can get basic health info including allergies, insurance details, vitals, and essential fitness data into a handy, secure, and easy to use PHR.
Secondly, if you are conscientious, you can keep track of things like blood pressure, diet, water consumption, alcohol and smoking, etc. in the PHR, but you will have to stick with it and remember to keep inputting the data.
Thirdly, if you have a participating provider, and they are also ahead of the curve, you can start transferring some pretty useful health data to them, and get responses back with useful guidance. This should enable you to have better health, get expert advice, and do so cheaper and more efficiently.

The future looks better though – and probably just in time for Meaningful Use 3: weight, blood pressure, sleep, etc. will be things that can automatically be sent to a provider.
The ability to collect and share health data with a virtual team of providers is a game changer, and is allied to the ability to set personal targets, monitor dietary intake and exercise, collect vitals over time, through the combination of wearable tech and Meaningful Use.
It occurs to me when I wait for my turn in a provider’s waiting room, that the bulk of visits to the provider could be done remotely with these tools, and my provider team need not be in the same practice, town, or even the same country. There is nothing at this point that should stop the ePatient from building a care team themselves that might span the globe, and achieve better healthcare, cheaper. A big artifact of the connected patient may be the mass customization and commoditization of healthcare that many other industries have experienced over the last 30 years.

Perhaps it is time.

Justine Sacco and IAC: How Not to do Social Media

December 23, 2013

I usually blog on knowledge management and business, and for the last year mostly on the intersection with healthcare. This post is about how companies keep getting social media wrong and how huge opportunities are missed out of fear and cowardice. I was drawn into the Justine Sacco scoldgasm by a tweet by Dr. Ben Goldacre, world renowned for his fight against bad pharma and the need for transparency in clinical trials. I got to thinking about the Justine Sacco situation after seeing her employer’s response and a tweet by another doctor. The imbroglio of Justine’s ill-considered tweet garnered world attention, and drew comments from people as far apart as Dr. Richard Horton, editor of the premiere medical journal, The Lancet, and newspapers in Johannesburg. Here are the pertinent facts from my perspective:

  1. Justine hit send on a really bad tweet – who knows why.
  2. She was incommunicado for the next 12 hours enroute to Cape Town
  3. Twitter exploded
  4. Her followers went from 400 to 8,000
  5. The world’s attention was focused on her and her employer

What IAC and Justine did next was the second worst thing possible. With world attention on them, IAC semaphored their intentions – (a) to distance themselves from the situation, and (b) to punch Justine in the face as soon as they could. When Justine switched on her phone in Cape Town, and probably feeling isolated, embarrassed, and terrified, she went into fight/flight mode, and deleted her twitter and FaceBook accounts. IAC, true to their signaled intentions, duly punched her in the face by firing her, along with the lukewarm rejoinder that she really is a nice person at heart. #Fail With the world’s attention, they both killed the stage lights, shrieked, and scuttled off the stage. Justine had 2,000% more followers on twitter, her name was irrevocably linked to AIDS, and www.justinesacco.com was created to link to an AIDS charity. The twitterverse was focused on her next move. As many tweeps said, she dropped the mic. But that’s not all – while firing her effectively placed a distance between IAC and the scandal, IAC also sent a clear and stentorian message to its business partners and current and prospective employees. That message is “If you screw up, we won’t help you, we will stab you in the kidney”. Right now, over Christmas and New Year, you can bet that IAC employees are brushing up their resumes, updating their LinkedIn accounts, and browsing Monster.com. Likewise investors are looking at them as tainted goods. For Justine it is a disaster too, she got publically fired and humiliated just before Christmas, her life is a wreck, and her employability is rock bottom. It has fueled more fear about social media, and in some people’s minds has reinforced two nasty stereotypes – that women shouldn’t have jobs like that, and that social media is bad for companies. What a wonderful outcome – NOT So what if instead of fight/flight mode, they had gone into tend/befriend? What if they had planned for this kind of mistake. What if IAC had been supportive, and said that they would work with Justine to make amends and to apologize properly as soon as she landed. What if they had SMS’d Justine to tell her they would stand by her, and she should talk before doing anything. She could have kept the 8,000 followers, she could have embraced the charity, she could have become relevant. What if her next tweet (in keeping with her style on twitter) was something like: “OMG, totally screwed up, I am such an airhead sometimes! Tried to recycle Sarah Silverman joke, badly, hurt people, sorry sorry sorry!!!!” What if she asked for people to give her a moment to think it through, and asked for suggestions. There would have been the usual flaming and slut-shaming responses ranging from that she should be fired to she should kill herself, but there was a real opportunity for outreach, and there would have been real, thoughtful responses as well. One of them perhaps being that now that www.justinesacco.com already exists, she could take on a role in promoting AIDS awareness, and champion the cause. IAC instead took a cowardly and thoughtless path, and have lost an opportunity to show that they care and that they are supportive. That’s a shame, especially since they could have done good work against a horrifying disease that breeds on fear and ignorance, and is burning up millions of people across the world. That’s a shame.

Connecting across media

November 28, 2013

Dear Reader, 
I am conducting a small experiment to see what overlap I have across the blog,  my LinkedIn connections, and my Twitter followers.

If you read my blog,  please also connect with me on LinkedIn at http://linkedin.com/in/mloxton, and follow me on Twitter at @mloxton

If you arrived here as a result of my LinkedIn or Twitter requests,  welcome!
I hope you find the content interesting,  and please comment.

Best regards
Matthew

The HealthCare Blockbuster Trio: Workflow + EHR + Activity-Based KM

November 19, 2013

The Emergency Room (ER) is a dangerous place to be, and the less time a patient spends in one, the better their chances of an optimal outcome.

This is a simple unpleasant fact, and one reason is a simple truism – people who really need to be in the ER tend to be very ill and if you are one of them, your odds are already sub-optimal.
Other than the rare hypochondriac with Munchausen’s syndrome, most patients in the ER are not in a good way – otherwise they would have fixed it themselves or gone to their general practitioner.
The other reason is both more sinister and complex: ERs tend to get crowded, chaotic, and triaged. The chaos is a result of a combination of crowding, acuity, variation, and stressed processes. Many ER patients really should be treated by a primary care physician, but go to the ER instead because they lack health insurance, don’t know how to gauge their condition, or their primary care provider is not open after hours or on weekends. The ER increasingly supports primary care by performing complex diagnostic workups not provided by primary care facilities, handling primary care overflow, and after hours care. (1)

The fact that ER triage’s patients is a frank (and normal) admission that demand has outstripped supply of services, but ER crowding is mainly a function of idiot politicians and a Gordian knot of infrastructure, policies, processes, technology, and people.

Let’s deal with the simplest but most unappetizing part first

Idiot Politicians

Politicians are those kinds of people who are vaguely of the opinion that laws can reduce the duration of gestation, change the behavior of pathogens, or turn aside hurricanes, typhoons, and tornadoes. I am not sure if this is the result of repeated head injuries on their part, bad genes, or just a lack of scientific training. The problem is that they will enact silly laws to satisfy donors, and these laws will tend to cut funding to primary care, education, nutrition, environment, safety, and a host of other epidemiological causes of injury, disease, and ill health. This not only increases the burden of sickness in the net number of patients, but also means that they will tend to have more serious health incidents, not address illness early on, and present in greater numbers, with more complex conditions, more often than would be the case in the null hypothesis in which there was no stupid politician making these laws.

Simply put, politicians as a class are a health hazard, and sadly, there is no cure for them.

Infrastructure and policies

Somewhat caused by idiot politicians, a sub-optimal infrastructure is often the result of policies that shape themselves to the laws that exist (see above).
Often the policies serve people with money rather than those with need, and as a result the infrastructure caters to heroic and epic conditions rather than those that cause the most harm and suffering to patients. This is somewhat because the people who get sickest and sicker more often tend to live lives that do this to them. They live in places that are more dangerous, have work that is more dangerous, have less education, nutrition, and access to primary care than the wealthier members of society. Low Socio Economic Status (SES) is generally speaking, also a health hazard.

As an example, let’s look at a very fancy cardiac unit, a world famous one.
The first successful human to human heart transplant was carried out by the pioneering surgeon, Dr. Chris Barnard at Groote Schuur hospital, in South Africa.
That’s right, not the US nor the UK or France, but South Africa.
In 2001, there were serious moves by the Western Cape government to close the transplant unit, and in the subsequent public and international uproar, one of those involved in the considerations made a rude, surprising, and very accurate argument. South Africa simply couldn’t afford a fancy 1st world cardiac unit serving mainly privileged white men who tended to have long histories of medical self-neglect as the result of over indulgence, when at the same time, thousands of low SES people were dying of entirely curable and preventable diseases like Tuberculosis. During the various brawls over the unit’s fate, the uncomfortable fact was that although the cardiac unit was a heroic and epic institution, it was far less clear if this was the best use of available resources. For every life saved by heroic attempts in the transplant unit, at least an order of magnitude more died because those funds and expertise were not being applied to the things that were killing far more people in South Africa.

Healthcare is often brutal in this way, and the example perhaps exemplifies how the diseases of influential people are more represented in the policies, and thus the infrastructure of a healthcare system than one might notice at first glance. Policies often translate into more and sicker people coming to the ER, and also less funding to address both the causes of the illness and technology and resources to address them.

Processes, Technologies, People

ER is a compression zone in the flow of patients, since many routes lead into ER, and frequently the wisest course when in doubt over severity and acuity of a condition, is to process them through the ER just in case the quietly seated patient quietly dies because nobody took a really good look with the right level of technology and expertise.

All clinician roles are stressful; let that be said before I draw the ire of opticians, dentists, and dermatologists. ER clinicians however are right up there with the highest stress roles in healthcare. Although it must be admitted that ER clinicians generally get to see better outcomes than some specialties, ER clinicians are usually presented with life in its raw state. Torn flesh, broken bones, and mangled people, some still with the smell of gasoline and tire rubber on their bodies, the smudges of nitrocellulose propellant from gunshot wounds on their skin, and lots of vomit, blood, and tears. ER departments are not restful, tranquil, or serene, and no amount of feng shui, fragrance sticks, or furnishings can change that. ER departments have to sort people rapidly into categories and actions to be taken, often in exact opposite order to instinct. Quiet and blue takes precedence over bleeding and screaming, necks take precedence over hands, clear fluids over blood in the ear.

As a result, ER departments have an urgent need to have supporting technologies such as ED Patient Tracking Systems and  Electronic Health Records (EHR), that can remember and track patients that might easily get lost or forgotten, and whose history will be collected accurately and quickly as they transition from the ambulance to the first-look nurse, then triage team, the nurse, perhaps more than a few doctors, specialty care, radiology, laboratory, and yes, accounts. Have they seen this patient before, are there allergies or prior conditions to consider, are they already taking any medications?
However just having an EHR system does nothing unless there is an underlying workflow, and the EHR integrates perfectly with that workflow.

ER workflow is both physical and virtual, and it comprises rules, procedures, activities, equipment, spaces, places, and people. Although some of the people can switch roles in an instant, they are deployed according to a process, licensure, and how the ER facility is physically structured. The very first person must rapidly assess where the patient most needs to go at that instant in order to get them to the right level of care the fastest, and to maximize the use of the very expensive and scarce resources available. The resuscitation team should receive the person with the cardiac arrest; the trauma team gets the one with the bones coming out of the wound, and so on. No sense in blocking the resuscitation bed with the patient with the broken arm. The workflow has priorities, and activities that have primary and secondary actors, and various technologies including equipment, medical gases and fluids, medications, and consumables such as needles, gloves, and dressings.

In figure 1 the fundamental structures of activities within a workflow are shown for typical industrial or business settings  (2), but these map directly to their medical counterparts. Tools relate to equipment and instruments, materials to medications, fluids, and consumables, while utilities relate to medical gases, suction, irrigation, and electrical power.

fig1

Figure 1. Workflow activity substructures

The implication of workflow is that knowledge is applied to the activities by actors in relation to the tasks they carry out and the requisites they use in doing so. As such to have a functional workflow that is supported by an EHR, the ER also needs to consider who knows what and how they will best come by this knowledge in order to apply it effectively at the point of care. The application of knowledge management principles to ER workflow expands this as illustrated in figure 2.

fig 2Figure 2. Knowledge Sources

All things being equal, the ER staff, deployed in space and sequence in a carefully monitored and calculated fashion will quickly identify urgency and action to stabilize, treat, and often admit patients with the maximum efficiency, because in illness, time counts.
However, even a perfect ER, operating at 100% efficiency, will swiftly overcrowd unless the patients can be routed to the next appropriate level of care as efficiently. Whether the next point of care is the patient’s home, their local hospital, or Intensive Care (ICU), the time it takes to process the necessary documentation and route them is not infinitely small, and results in backlog and patients piling up in holding areas in and around ER, and people die in these interstices of care.

The workflow thus needs to integrate with care beyond the ER, so that patients can be drawn off to the next point of care at least as fast as they are processed by ER, and this is where the integration of EHR across the institution comes into play. The workflows at the perimeter of ER can only effectively integrate with those of other services and points of care if the EHR enables seamless transition.

An example of this is the bed management system for inpatient registration. An ER patient that requires definitive care as an inpatient can only be transported to a ward if there is an open bed suitable for the level of care required. To achieve this, the ER clerk must be able to see with great reliability which wards have a currently open and clean bed that has the right associated services, technologies, and level of care. A patient requiring 24hr surveillance may require a telemetry bed, patients with mental health conditions may require special services, and fall-risk patients, and infectious patients have still other bed and location requirements. To complicate matters, ward configurations change, policies changes, and new medical norms arise, requiring the systems and the people to adapt smoothly to changes.
Reflecting on figure 2 one can usefully ask how the ER clerk would know what the current policies are with regard to the patient needs and available beds. The answer is that it will be a combination of embedding the knowledge in the EHR, recruiting people with the right prior application and hospital knowledge, training  on the EHR and the policies, and job aids that are either embedded in the EHR or available in conjunction with it.

Throughout the process from registration to discharge, the integrity of the patient’s record must track smoothly across transitions and locations of care, including follow-up and outpatient care.

Conclusion

Integration of workflow, EHR, and knowledge management methods can provide significant improvements in patient flow management in a hospital, and this can be seen in what is perhaps the starkest situation- the ER. Workflow ensures that the right things are occurring with the right actors and at the right time, while EHR avoids medical mistakes by tracking the patient and their health throughout the system. Knowledge management asks the important question of how all the actors know how to do what they are expected to do. This applies to all the actors involved, whether they are clinicians, administrative staff, the patients themselves, or those that care for them.

Acknowledgement: For his invaluable input on ED Tracking, ER operations, and crowding, special thanks are due to “Mr. BMS” Hub Freeman, MSA, RN, Nurse Executive – BC, Clinical Director for Systems Efficiency and Flow Improvement, Veterans Health Administration

References

1. Hospital Emergency Department Use, Importance Rises in U.S. Health Care System. Hospital Emergency Department Use, Importance Rises in U.S. Health Care System. RAND May 2013.

2. Loxton, Matthew. Knowledge Auditing: An Activity-Based Method for Organisational Success. s.l. : Ark Group, 2013. ISBN: 1783580755.

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Matthew Loxton is a certified Knowledge Management practitioner, and is a peer reviewer for the Journal of Knowledge Management Research & Practice. Matthew works at WBB as a senior analyst applying KM principles to Health IT implementation. Matthew holds a Master’s degree in Knowledge Management from the University of Canberra, and provides pro-bono consulting in Knowledge Management and IT Governance to various medical institutions.


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