Virtually Priceless Thoughts

Several years ago I discovered Christopher Alexander’s work on Architectural Patterns and have been meaning to write about it here for some time — so here goes.

In “The Timeless Way of Building” and his other books, the author describes and illustrates universal solutions to architectural design problems in a way that allow for reuse and flexibility to be adapted to specific situations. Patterns were designed to allow communication between users / dwellers and the builders in a way that they could be a lingua franca. Alexander’s work has had an influence on software engineering, where patterns are commonly discussed. Alexander pushes the idea from patterns to a Pattern Language, that includes a complete set of options for the space. Knowing the patterns in the language allows you to speak completely. Several groups have reflected on the concept of patterns and adapted it to domains outside of physical architecture.

In Software engineering, the patterns are used for discussion more between developers than with users / clients. In usability and user interface design, patterns have been applied as well in multiple settings. Here, the sense of the lingua franca is back — showing users standard approaches in wireframes / sketches allows the client / user to be able speak with the designers on a more equal playing field. There has been some recent thoughts are Creativity Patterns from Merlin Mann and Productive Patterns, based on some of David Allen’s Getting Things Done approaches. These tend to be collections of patterns rather than the more ambitious languages.

I have been collecting “EMR Patterns” in a little black book — approaches to repeatable problems faced in the EMR or EHR. The NHS CUI program has developed many good solutions to address some of the challenges of the management / viewing / input of clinical data. Several EMR vendors have good solutions to address specific problems.

Patterns scope is quite varied – Alexander’s range from patterns for organizing large geographic regions to (#2. The Distribution of Towns) to quite specific (#252 Pools of Light). So, too, can EMR Patterns. Patterns could range, especially for the larger regional EHR tools, to address problems at many layers and aspects of care provision, care planning, organizational management, etc.

As a practitioner, I have been more focused on the aspects of point of care and point of reflection patterns.

Patterns, with sufficient evidence behind their usefulness, may well be a mechanism to quantify requirements such as “EMR is easy to use” “Consistent User interface” and “Displays information required to address common problems in a safe manner”. Ongoing development of evidence will need to come from review of current published literature and the exploration, through a variety of studies, including usability testing, outcomes measurements, etc.

With patterns at the right levels, users can also engage in discussions with their vendors / software developers — they can have a lingua franca to discuss issues such as “Refilling Prescriptions” “Processing Incoming Test Results,” etc. These patterns could provide benefit to those discussions and improve ongoing standardization of functions, reducing errors, need for retraining, etc.

A simple example EMR pattern is below:

Patient Banner

Problem Addressed

Safety and privacy issues of reviewing / accessing / documenting on the wrong patient chart. Documentation on the wrong chart / reviewing information on the wrong patient by accident can lead to significant clinical errors and adverse events.

Example

Solution Description

By displaying, clearly, at the same position on the screen key patient information that is required for positive identification, users are able to quickly identify the patient. This should be displayed on all screens and not be able to scroll off the screen.

Data elements should include: name, date of birth, gender and patient ID at a minimum. Picture would also be helpful, if supported. In the second layer of the banner, additional information can be made available, including address and contact information. The Patient banner can be used to support clinical safety issues in other ways. By displaying the presence of Allergies and Alerts, clinicians are made aware of these elements from any screen. Allergies, alerts, etc can be accessed from the panner by a simple click.

Rationale

Positive patient identification is a key requirement to the safe use of Clinical Information Systems. The Patient Banner supports identification and additional safety activities, such as check allergies and alerts.

Discussion

The NHS CUI project has done considerable work on the patient banner and their understandings have greatly influenced this pattern.

Related Patterns  

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This is a follow on to my previous post on forms. I am working with a group now to design some clinical documentation and the information captured will be used in several very different environments. These locations are “hybrid” in that some information is electronic and other information is still on paper. A further wrinkle is that the evolution from paper to digital is not going to happen across the entire organization at the same rate, so we need to design a solution that will support various modalities as patients move in their journey.

Right now, the current practice for pre-admission work for elective surgeries is: store electronic results and transcribed documents electronically in a regional system that is accessible in multiple environments. The paper workflow is a little different. There is one paper chart – designed for inpatient care – and it is moved (or bits of it are moved) around to the various locations where a patient will be assessed over the up to 8 months prior to entering the hospital and the collect it all, make sure it is in the right order, and send it to the hospital just before the patient is scheduled to be admitted.

Many challenges here, not the least of which is the workflow associated with completing forms that are not designed for you to do your assessment, but are designed to support inpatient workflows pre and post operatively.

What we are looking at now is how to support two very different workflows in a manner that allows for standardization and flexibility at the same time. Flexibility in the sense that each workflow needs to be supported. Standardization in that the data needs to be captured in a way that allows logical reuse throughout the care process. With the wrinkle that some of that reuse will have to be that the data captured electronically needs to be able to recreate the inpatient PAPER chart through a report writer as the inpatient world will not be changing to electronic documentation at the same time as our pilot sites in the outpatient world.

Interesting times! I will post more on our approaches as we move forward.