Virtually Priceless Thoughts

Reflections on Health, Informatics, and Research

Archive for the ‘Informatics’ Category

FutureMed – Half Way

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Half way through the FutureMed conference — it seems like there is barely time to process what’s being presented, but each morning I wake up with some new neural connections spinning into an idea.

Saw the WIMM Lab’s WIMM One device and saw several possibilities for research studies. This is a little android device with a 1 inch square touch screen and a bunch of other tech. Not as full featured as a smartphone, but smaller and cheaper and easier to ask people to keep with them.

The talks have been great and wide ranging from abundance to aging to genomics and proteomics — we are seeing and discussing some cutting edge topics with people working in these fields. I really felt the conference has been picking up speed exponentially since day 1.

Last night was the unconference and there were so many topics from around the world, it was great. Topics ranged from product ideas (web, mobile, medications, health system changes) to sharing global experiences to “let’s design how to improve the health of a city”. Great and heady stuff that went on way past my usual bedtime (not hard to do for those of you who know me).

Ironically, they everyone received a Lark. A sleep monitor! At first I thought how ironic (activities here start at 6:30 and last night didn’t wrap up until 11ish). Then I realized the sleep monitor (I scored a 9.4 / 10 for sleep quality last night but was scolded for quantity) wasn’t the business model – the alarm was. It is also a high tech alarm. I’m guessing Daniel Kraft had a hard time getting last year’s attendees to the first sessions on time. 😉

 

Written by priceless

February 9th, 2012 at 7:56 am

Posted in Informatics

FutureMed – Day 1

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This week I am at FutureMed at Singularity U. Starting off as a great conference with an amazing group of attendees from all over the world (especially Brazil).

Dr. Peter Diamandis gave the keynote — a positive speaker with his new book, Abundance, about to come out. Very future focused and inspiring.

Some themes and thoughts from today:

  • Capacity – we have seen a lot of growth in capacity in many areas. How do we develop huge amounts of capacity for health? The current models do not seem able to scale. We need to really innovate in models of care.
  • Challenges of mis-alignment between regulation / payment vs innovation – there needs to be ways to foster innovation and adoption.
  • Analytics and feedback are going to be key to the future acceleration. Particularly passive capture with quick feedback loops. For both providers and patients appear to be effective. Asthmapolis is an interesting example.
    • GIS could help us better understand patterns of illness and its environmental causes
  • Cracking the behaviour change problems – a lot of what we struggle with in health isn’t the need for synthetic, 3D printed organs, it’s the need to get people moving, eating, and taking care of themselves. I am looking forward to more discussion on this as this is where I hope we can see major changes supported through consumer social health.
  • Integration across the silos. Generalism or working across the “ologies” (endocrinology, ophthalmology etc.).
  • Incubators – there are a lot of them around here in Silicon Valley. I have not seen similar support / interest in Canada.
  • Big and Small: Global and Mobile Health.
  • And of course, exponentials. Personalized medicine – genomics as an example.

These are just some quick thoughts, not capturing everything.

Written by priceless

February 6th, 2012 at 10:20 pm

Posted in Informatics,Medicine

Publication: EMR Adoption

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Electronic Healthcare just published one of our papers on EMR Adoption

Great to see it in print!

Written by priceless

May 11th, 2011 at 12:45 pm

Types of Questions to Ask A Research Network

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Here’s the question:

What would your question be of a practice based primary care research network?

Consider that you are involved in establishing some of the first research questions that would be answered by a group of engaged, networked, and interested primary care practices – what would those questions be?

For this thought experiment, you could be a funder or a participant (clinician or patient) or an outside researcher.

Assume the network could collect whatever kinds of data you would need to answer your question.

Assume, also, for your quantitative types, that the network has 80 primary care providers (mostly family doctors, some nurse practictioners) across multiple sites both rural and urban and that these were full service primary care practices. Amazingly, all patients consent to participate and there are 120,000 patients. All practices are using an EMR and data from the charts would be encoded to support your question(s).

I will start with one of my questions:

What is the impact on overall capacity* of practices where patients with mental illness (mood disorders such as depression and anxiety) are given a proactive program and the tools to self manage their condition through a Personal Health Record (PHR)? Is there a difference if the PHR is integrated with their primary care provider’s practice EMR? Does self management also change quality of care (perceived and objective) for the patients involved?

* capacity should be examined both in terms of financial cost to the practice to run the program and changes in number of patients seen by providers over time compared to matched controls.

If this is interesting to you, add your own question as a comment or join the discussion by supporting / adding to other questions.

My goal here is to collect the types of questions people want answered not to focus on how to answer them (that comes later).

Written by priceless

March 27th, 2011 at 6:53 pm

Posted in Informatics,Medicine

Tagged with

Design Thinking

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Jess McMullin has a good slide deck where he describes (slide 9) five levels of Design Maturity. (1)

Those levels are (paraphrased):

  1. Default – Status quo determines design.
  2. Style – Changes to look and feel
  3. Function – Design improves use
  4. Problem Solving – Seeks current problems and changes
  5. Framing – Redefinition of the problem itself.

This is a good list to remember in healthcare.

The potential for improvement (and some types of risk) increase as you move from default to framing. Also, it is harder for users to conceptualize the changes as you move through. It’s easy for people to visualize “we are going to put this paper form on the computer”. It’s harder for them to consistently visualize “where we’re going you won’t need to document”, or large lists of requirements… As you move along the levels of design you need to rely on more iterative and visual tools to support shared and common understandings of the changes that are being considered.

1. I found a similarity to a list of maturity for Business Analysts that was on Better Projects. If you are a BA or work with BA, think about where you fit in this list of maturity for the various kinds of activities / projects you work on.

Written by priceless

December 31st, 2010 at 7:51 am

Using methods vs “The Method”

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I have been struggling recently between “using methods” to reach success and having to use “The Method”.

As organizations grow, there seems to be a tendency to standardize on The Methods. PMOs can often come up with “The Meth”, consulting firms will sell you their Method (either through hiring their consultants or directly). The Method provides standardized assessments and processes. You can make comparisons (useful for research / evaluation). You can scale up nicely by having everyone do the same thing.

Students learning and wanting to be successful want The Method. Something concrete to follow that will guarantee the end product is an “A”. Something that can be memorized and provides a level of safety in knowledge. I see this with medical students / residents as well as informatics / IT students.

It is also easier to teach about The Method. It is defined and discrete. 10 steps, 5 minutes / step = one, 50 minute lecture. Done, you are certified!

However, people with experience that have developed their skills use methods, not The Method. They have an approach and a toolkit. In complex problems and complex situations they reach for the tools that they think will work and, while using them, assess their fit and course correct. Their approach supports communication with others, their detailed actions change based on their understanding of the problem.

This is harder to teach, especially in 50 minute lecture blocks. It is easier to model with students in practice. Residents can learn this by watching and modelling their preceptors. informatics students can learn this (if they are lucky) from Co-Op terms. We can all learn this by reflecting, regularly, on what we do and why.

There is value in standardizing and having processes, definitely. They help us (a) reach common ground across team members and team and they (b) can cover our blind spots. For routine problems (complicated and simple, not complex), using the well tested and validated Method is better. Surgical outcomes benefit from using The Method, for example.

But they can also cause blind spots, if The Method is a poor fit or poorly applied. This is particularly true for complex problems, I feel.

With complex problems, it is impossible to know if a rigid method is a good fit until you are in the middle of it. Complex problems are, by their nature, unpredictable. So it is better to have a flexible, reflecting approach to these complex problems. Use aspects of your methods to help anchor you, as ways of reaching common understandings amongst team members and stakeholders, and then reach into your toolkit as needed when one method does not fit.

Written by priceless

May 23rd, 2010 at 8:59 am

Posted in Informatics,Software

The importance of health information

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This is a follow on the last post on health information. I actually started this one before I got the question, so maybe this is a prequel blog post…?

I have been thinking about the challenges that are going to face us in Canada as we move forward and start interconnecting EMRs (Electronic Medical Records) and sharing data. I am wondering:

What happens to health information when the EMRs of today are no longer “islands”(1) unto themselves?

Right now many EMRs are being used in relative digital isolation. Often EMRs have a laboratory results feed in to the practice, but very little comes out of the practice in digital form. Printing of referral letters and consult letters and patient summaries and prescriptions is the norm.

Many clinicians, from what I have observed, still think of their EMRs as “EPRs” – Electronic Paper Records. They use them as legible, remotely accessible paper charts and work around limitations as they would in paper. For example:

  1. Prescription writer or lab form is too complex?
    No problem, write it in free text and use the paper forms still in your office.
  2. EMR have a problem with not putting significant past medical and surgical history on your referral note?
    No problem, just put it in the problem list. The problem list prints on the referral note automatically.
  3. Not able to code procedures correctly (because you are using the problem list as in #2)?
    No problem, do not worry about the code, just pick something close and edit the display name so it is accurate to what you are trying to say.
  4. Do not have a place to document housing issues? No problem, just create a new data element in the problem table for “unstable huosing – living under Main St Brige”(2)
  5. Problem list not specific enough for you?
    No problem, create a new value in your code set that is more specific.
  6. Difficult to write that complex dosing regime of one pill twice a day and two pills at night?
    No problem, put anything in the main field but make sure you use the comments field to say what you really want, the pharmacist will figure it out when she reads the printed prescription.
  7. Want to speed up your new patient visit? No problem, the EMR makes it easy to make your own templates. Just make a new template with tick boxes for “All immunizations up to date”, “NKDA” and others. OR you can just make a text macro that gives you a nicely formatted few paragraphs that you can edit only where you need to.

You can see where things are going, right? All of those are real examples and all of these are uniquely solved in each practice. Oftentimes they are uniquely solved many different ways in one practice.

Now fast forward a few years and start linking up EMRs, through Infoway’s EHR or through a standardized referral system or even through a custom interface from the vendor (it doesn’t really matter) and what happens?

As patients move around, EMR data in each practice becomes a mosaic. Local fixes are copied from one system to another. Each one different, just like the old paper charts. Specialists will have a worse time of it as they will be getting referrals from many sources, each one customized.

Clinical decision support will fall apart — how many people are missing their H1N1 vaccination? Don’t know, some of these records are using this field “immsuptodate” and others code it in the problem list as “053, injection, other” with a display name of “H1N1”, another few have this field called “immunizations_UTD_2009″…

The default approach would be to leave free text alone and only consider coded values, but this does not help when clinicians have co-opted terms for their own use.

This scares me. I do not think we have thought deeply enough yet on how to manage this issue. dreamstimemaximum_766576.png

It is going to be a huge clean up activity to get existing information standards compliant. To be fair to the EMR vendors and clinicians, there is not a supported “right” way to store health information in EMRs yet. We have some standards in Canada, but the bulk of the clinical information has been recorded without those standards in mind. The local “work arounds” were/are required to get the job of providing care done.

What tools should we start seriously considering in order to improve our health information as it moves off the isolated islands? Maybe we just need more duct tape?

Harmonizing our standards and redesigning EMRs to be standards compliant are only part of the process.

__________________________

1. This is a popular term here in BC and likely elsewhere – a standalone EMR with few electronic connections to the outside world would be an island. Much of the data coming in and out is via paper (printing and scanning). It is an appropriate analogy as information is evolving more rapidly on islands.

2. Typos intentional to prove a point. Note also that there could be no code associated with this if the EMR allowed for codeless terms.

Written by priceless

April 4th, 2010 at 7:49 am

Posted in EMR,Informatics

Tagged with ,

Clinical Archtect and User Centred Design

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NOTE: This post is a follow up from the overall post on what does a clinical architect need to know.

Usability of systems in an important issue. Although it is not one that is first thought of when one thinks of architecture, which is a shame. User Centredness really should be a large part of what a Clinical Architect considers during design.UserCentredDesign.graffle.png

Of course, detailed user centred design work is not something that the clinical architect can do single handedly, especially in large organizations. Keeping the mantra in the forefront is important to making workable systems and that is something the Clinical Architect should do.

I think about user centredness at a few levels:

  • The single user interacting with one information system
    • How do the screens flow, does that support the work, is the right information where it is needed, are movements from keyboard to mouse and back streamlined, etc.
  • The single user interacting with systemS (plural) or the greater system –
    • Where does a user need to go to get information, what does their day look like, etc. Are they interfacing witn 3 systems to do one job, what are the greater outputs, are they hand modifying those outputs and why.
  • The multi-user system –
    • How does the CIS impact provider – patient interactions and how does it impact provider-provider interactions? What intentional changes are occurring and what UNintentional changes are occurring (or could occur) with the implementation.

Together these views can give an Architect a good view into how the systems work as a whole for a user in their day to day work. Typically, one would consider

I’ve written about the bio-psycho-social approach to usability before and it is a useful framework to consider usability as well as user centred design.

In healthcare, there is also the idea of being patient centred as well. This is an extremely important perspective to consider. My recent research has shown how fragmented a patient’s care is and how they information can be scattered across literally dozens of records (see broken records).

As a final note, here is a recently ISO / IEC 62366 summary from User Focus that discusses usability of medical devices.

Written by priceless

March 19th, 2010 at 11:43 am