Virtually Priceless Thoughts

Some months ago now I posted on the idea of creating patterns for EMRs akin to the work that others have done in User Interface design and other areas, all based on Christopher Alexander’s work. We are close to embarking on attempting to build some specific documentation patterns now at the Health Authority. Not the full blown vision with breadth and depth of Alexandrian patterns, but specific, fairly uniform sections of reusable electronic clinical documentation.

These are sitting somewhere in between openEHR archetypes and templates in terms of scope and size. The hope and plan is that these can be designed in a way that they will form the building blocks for the various e-Forms in the multiple clinical information systems, increasing interoperability and care standardization while decreasing rethink for common items. Each pattern will be designed to be a clinical cluster of content that is part of a reusable assessment.

These documentation patterns can managed by a central group (in this case the CARB – Clinical Architecture Review Board) and used, with simpler guidelines, by documentation teams in each application design team. Request for new patterns would come back to the CARB so they can be reviewed and ensure that they are consistent.

Some example patterns include:

• Problem List
• Past Medical History
• Allergies
• Glasgow Coma Scale
• Vital Signs

Some patterns will likely have multiple versions. This could be for a few reasons: evolution of the pattern or there are needs to have different levels of detail in different settings. Patterns evolve over time with improved design: initial design included minimal structure, now it should be more structured and we know how better to structure it. Patterns in different context may need more or less information. Vital Signs is a good example of this – vitals in an ambulatory clinic are much simpler than they are in the ICU. Still the information that does overlap should be the same (e.g. weight, BP, etc). These would be multiple versions of the pattern. Neurovitals will likely be a separate pattern to complement vital signs.

We are early days now, just starting to ramp up the necessary clinical and informatics skills to do this work. The two daunting aspects are: can we crack the clinical content into a sufficient number of truly reusable patterns to make this useful? (and related) how are we going to standardize clinical documentation across a large region that is actively using multiple documentation standards (including many ‘local’ standards) across several care settings and professions.

Jim Collins talks about acquiring the skills of a level 5 leader. A level 5 leader, in Jim Collins’ book Good to Great, is a leader who puts “ambition first and foremost for the company and concern for its success rather than for one’s own riches and personal renown.”

His example of Lou Gerstner resonated with something I sketched in my notebook a few years ago. Jim Collins describes how he interprets Lou’s evolution to a level 5 leader. With a very poignant quote from Lou about IBM. Lou Gerstner “fell in love with IBM” – and that was the point in which he transformed into the highest level leader.

Accidental Creative is an online community that I have been a member of for several years. In a discussion some years ago on the importance of engagement, Todd Henry sketched out an idea much like the one illustrated here. Ensuring engagement in the creative process is key to productivity. Allowing for ebbs and flows and exploratory activities keeps the engagement high, as well as many other things like belief in the value of the project, it’s goals, etc.

I quite like the terms he uses. (There is such a wonderful distinction between willing compliance and malicious obedience.) One of the gaps for me in the model was the context of the work. I think that is useful to think about a level of engagement in both the content of your work and the context of your work.

This is true for medicine. I move up and down the arrow (mostly near the top I am happy to say) in terms of my passion for healthcare and my work in the inner city. I would not be able to sustain that level of commitment without also having similar engagement with the context of my work – the organization and the people. Perhaps that is part of what is needed in the sustainable transformation of level 5 leaders. There is a creative excitement to both the content of your work (doing the right work) and to the context of your work (doing the work in the right way and in the right place). Perhaps this is what Lou Gerstner discovered at IBM.

Yesterday I was lucky enough to be invited to give the opening Keynote for the Software Engineering in Health Care Workshop at ICSE 2009 and spend the whole day with a very thoughtful group of software engineers from around the world as we discussed issues related to designing software for healthcare. It was a very refreshing conversation with a slightly different perspective from the group. Some interesting activities and good people.

One of the topics that came back through the day was the issue of leveraging the context of data. This seemed to resonate in our discussions as a way to enhance current systems in new ways. The challenge is to define what those context could be and how they would support activities. The 5 W’s and 1 H are all important (who, what, when, where, why, and how). I’ve illustrated a few more specific elements in the diagram, but there are certainly more. Also important to consider which context we are talking about. So far, there are at least two distinct contexts that need to be considered:

1. Point of Capture – where the datum was documented. The context of that point in time is obviously important.
2. Point of (re)use – where the datum is being accessed. This might be future point of care activities, or it might be point of reflection activities (such as quality improvement or health planning, etc).

Model driven design and the overall socio-technical complexity of healthcare were also two additional resonating themes for me today. The challenge of the combination of these two (and our relative rates of failures of systems in healthcare in general) does lead one to look for new methodologies for system design and implementation. More explicit modeling of context into systems to provide more reusable information (as opposed to data) might be part of the answer.

A great workshop and I wished I could stay for the two days.