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Thinking in Hammers and Thinking in Hammers and Nails: Nails:
Problem-Based Approaches Problem-Based Approaches to Healthcare IT to Healthcare IT ImplementationImplementation
Paul Biondich, MD, MSPaul Biondich, MD, MS
Asst. Professor of Pediatrics / Asst. Professor of Pediatrics / InformaticsInformatics
Regenstrief Institute… IndianapolisRegenstrief Institute… Indianapolis
Current State of Affairs?Current State of Affairs?
““If the only tool you have is a If the only tool you have is a hammer, you tend to see hammer, you tend to see every problem as a nail..”every problem as a nail..”
- Abraham Maslow, Cognitive - Abraham Maslow, Cognitive PsychologistPsychologist
Hammers and NailsHammers and Nails
Full personal disclosure: infatuated with Full personal disclosure: infatuated with computers and information technologycomputers and information technology
Taking a leap: some of you are as well, Taking a leap: some of you are as well, or else you wouldn’t be here..or else you wouldn’t be here..
As a result, we are proactive As a result, we are proactive “technology users” .. and we “technology users” .. and we understand how these technologies understand how these technologies likely have positive impact on likely have positive impact on healthcarehealthcare
Hammers and NailsHammers and Nails
As a result, its easy to appreciate As a result, its easy to appreciate (become enamored with) the latest (become enamored with) the latest and greatest “hammers”:and greatest “hammers”:– Smart CardsSmart Cards– Wireless communicationWireless communication– Speech RecognitionSpeech Recognition– PDAs / Cell Phone HybridsPDAs / Cell Phone Hybrids– Portable Computing (Tablets, Wearable Portable Computing (Tablets, Wearable
Computing)Computing)
The Problem with HammersThe Problem with Hammers
Also easy to fall into trap of thinking Also easy to fall into trap of thinking that the technology that the technology itselfitself that can that can improve healthcare provisionimprove healthcare provision
Current “HIT euphoria” has further Current “HIT euphoria” has further exacerbated these myopic exacerbated these myopic perspectives..perspectives..
““PDAs could give pocket access to a PDAs could give pocket access to a patient’s medical record!”patient’s medical record!”
Problem-based frameworksProblem-based frameworks
Health IT is a tool no different than a Health IT is a tool no different than a tongue depressor or an otoscopetongue depressor or an otoscope
Identifying healthcare problems allows Identifying healthcare problems allows one to consider tailored solutionsone to consider tailored solutions
HIT might not be best answer?HIT might not be best answer? Stating the specific problem -> harder Stating the specific problem -> harder
than it sounds… typically an iterative than it sounds… typically an iterative processprocess
Identifying your nails..Identifying your nails..
““In the correct formulation of In the correct formulation of the question, lies the key to the question, lies the key to the answer.”the answer.”
- Nobelist Max Planck- Nobelist Max Planck
Iterative Problem Iterative Problem IdentificationIdentification
High level problem: need to improve High level problem: need to improve patient safetypatient safety
Focused on a topic: medication safetyFocused on a topic: medication safety Focused on a clinical problem: Focused on a clinical problem:
adverse drug eventsadverse drug events Focused on a specific clinical problem: Focused on a specific clinical problem:
severe drug interactions severe drug interactions Atomic problem: digoxin and Atomic problem: digoxin and
cyclosporine drug interactioncyclosporine drug interaction
Next questions..Next questions..
Who elicits the problem?Who elicits the problem? What is the prevalence of the What is the prevalence of the
problem?problem? Where is the problem occurring?Where is the problem occurring? When does the problem occur within When does the problem occur within
clinical workflows?clinical workflows? How can I “manually” fix the How can I “manually” fix the
problem?problem?
Typical ResultsTypical Results
Process often leads to surprising Process often leads to surprising solutionssolutions
Information gathered during the Information gathered during the process significantly informs how the process significantly informs how the solution can be customizedsolution can be customized
Specified tons more problems than Specified tons more problems than you immediately imagined.. how you immediately imagined.. how does one prioritize?does one prioritize?
Prioritization FactorsPrioritization Factors
PP= Impact on individual patients’ care (e.g. quality, = Impact on individual patients’ care (e.g. quality, safety, cost)safety, cost)
OO= Organizational impact (e.g. regulatory = Organizational impact (e.g. regulatory compliance, resource use)compliance, resource use)
CC= Clinician impact (e.g. enhanced workflow)= Clinician impact (e.g. enhanced workflow)
NN= Number of patients positively affected = Number of patients positively affected
GG= Gap between ideal and actual behavior pertinent = Gap between ideal and actual behavior pertinent to the interventionto the intervention
DD= Difficulty associated with implementing = Difficulty associated with implementing interventionintervention
CC= Cost of intervention= Cost of intervention
Setting – “Enterprise” Pediatric Setting – “Enterprise” Pediatric Outpatient ClinicOutpatient Clinic
High patient volume (~200 patients/day)High patient volume (~200 patients/day) ““Digital Divide” within patient populationDigital Divide” within patient population Diverse, large, and ever changing Diverse, large, and ever changing
clinician populationclinician population Urban setting not amenable to Urban setting not amenable to
electronics in roomselectronics in rooms Limited support staff to assist in data Limited support staff to assist in data
acquisitionacquisition
The Problem / MotivationThe Problem / Motivation
Need to capture data Need to capture data prior prior to to physician encounters from both physician encounters from both patients/parents and support staff to patients/parents and support staff to inform a new preventive care DSS.inform a new preventive care DSS.
They move all over the clinic (waiting They move all over the clinic (waiting room, patient room, vitals area, etc)room, patient room, vitals area, etc)
There were resource constraints ($)There were resource constraints ($) Management technology-phobicManagement technology-phobic
Paper as a Computer Paper as a Computer Interface?Interface?
FamiliarFamiliar Easy to work withEasy to work with Fully enabledFully enabled PortablePortable CheapCheap Computer can reliably read Computer can reliably read
information off of paper when it is information off of paper when it is structuredstructured
Adaptive Turnaround Adaptive Turnaround DocumentsDocuments
Data-driven, dynamically generated, Data-driven, dynamically generated, computer interpretable paper formscomputer interpretable paper forms
Pre-Screening FormPre-Screening Form: Collects 20 : Collects 20 most relevant risk factor most relevant risk factor observations from family, and also observations from family, and also collects vital sign assessments from collects vital sign assessments from nursingnursing
Nursing Observations / Nursing Observations / VitalsVitals
Real-time calculations:Real-time calculations:– Body Mass Index (BMI), Growth Body Mass Index (BMI), Growth
Percentiles, Blood Pressure abnormalities, Percentiles, Blood Pressure abnormalities, Abrupt changes between visitsAbrupt changes between visits
Nurse / Aide prompting:Nurse / Aide prompting:– Better indication of when to do Screening Better indication of when to do Screening
TestsTests– Reminder of previously abnormal values Reminder of previously abnormal values
that need to be retakenthat need to be retaken
Parental Screening Parental Screening QuestionnaireQuestionnaire
Forms are custom tailored to patientForms are custom tailored to patient– Questions are age specificQuestions are age specific– Logic is sensitive to questions that are Logic is sensitive to questions that are
previously answeredpreviously answered– Questions are all prioritized.. Most Questions are all prioritized.. Most
clinically relevant and high-risk clinically relevant and high-risk questions are asked firstquestions are asked first
Parental Screening Parental Screening QuestionnaireQuestionnaire
Patients identify their own risk factors – Patients identify their own risk factors – physicians no longer spend time on physicians no longer spend time on “fishing expeditions”“fishing expeditions”
Parents are “activated” into thinking Parents are “activated” into thinking about relevant or misunderstood topicsabout relevant or misunderstood topics
Triggers many decision support “tools”:Triggers many decision support “tools”:– ““Extra Specific” remindersExtra Specific” reminders– Just-in-Time HandoutsJust-in-Time Handouts– Automated OrdersAutomated Orders
Thinking Out of the Box…Thinking Out of the Box…
““That it will ever come into general That it will ever come into general use, notwithstanding its value, is use, notwithstanding its value, is extremely doubtful because its extremely doubtful because its beneficial application requires much beneficial application requires much time and gives a good bit of trouble, time and gives a good bit of trouble, both to the patient and to the both to the patient and to the practitioner because its hue and practitioner because its hue and character are foreign and opposed to character are foreign and opposed to all our habits and associations.”all our habits and associations.”
The London Times in 1834