Here’s the quote that struck me:

Once you’re on the job, having a best friend at work is a strong predictor of success. People might define “best” loosely (think of this as kindergarten where you can have more than one “best” friend), but according to a Gallup Organization study of more than 5 million workers over 35, 56% of the people who say they have a best friend at work are engaged, productive, and successful while only 8% of the ones who don’t are.

Over the last twenty years – in what are really three different careers – I have been lucky to have many best friends at work. Indeed, I have often thought about how important it is to have them and have them as part of a team in order to get to the real work that needs to be completed.

I wanted to thank you, friends, and you know who you are, for being there and helping me engage in each of the major projects I have had the pleasure to work on. I could not have done these things without you.

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I have, on occasion, thought about how one can apply agile software develop methods to research projects and other non-IT projects. I have been thinking about how our groups and projects could benefit from some of the agile methods. This seemed like a good enough trigger for me to write about scrum and research.

Craig Brown (on Better Projects) lists the elements of scrum as follows:

1. Start with a goal. Break down the goal into incremental steps.
2. Discuss the steps with the team who needs to deliver the solution.
3. Set standard time boxes. Do your best to deliver something practical and useful each time boxed iteration.
4. The team needs to take instruction from the customer at the beginning of each iteration and report on what got ‘done’ at the end of each iteration.
5. The team must set aside a portion of time at the beginning of each iteration to plan their work.
6. The team needs to set aside a regular and brief portion of each day to communicate progress and problems to one another.
7. The team needs to commit to continuous improvement and should set aside a portion of time each iteration to reflect on what went well, not well and where they can improve.
8. The planning, review and reflection sessions, and the daily team update all need to be set at regular times to help the team achieve a sense of rhythm.

Let’s go through the eight elements, applying a research lens. I will be thinking about some of the evaluation of health information systems, rather than

1. Goal: Check. Research projects should have a clear question in the beginning. There’s a need to define a method, which really could be broken down into incremental steps.
2. Determine who is responsible for which work products: Check.
3. Research projects can be time boxed. The question of delivery is interesting and it depends on the methods. Some research protocols, such as randomized control trials do not lend themselves to using agile methods. They are more “waterfall” in their approach, if you will. You won’t know results until you have a large enough number of research subjects (although the set up activities can easily be time boxed). Other methods are more suited to thinking about them with agile methods.
4. Instruction from the customer: for some studies the “customer” is not explicit. Is it the granting agency? Is it the end user? The more engaged we as researchers are with our customer, the more likely the knowledge gained is knowledge applied. So we can benefit from defining a customer who is engaged.
5. Planning Time: Yes, this can be easily done. I would add, especially when working with students, that this is key and ties into #6 & #7.
6. Daily Progress Report: Typically, research projects are run more autonomously. One of the challenges we have of adapting scrum and the importance of daily team meetings is simply the timelines for some studies. There are often long pauses (ethics review) where things are on pause until approval is received. Does this require redesigning the research team structure (e.g. have an ethics rep on the team) or does it mean that scrum activities are bound to periods of higher activity? I am not sure.
7. Continuous Improvement: For all of us this is important. For students who are on such a trajectory of learning and growth, even more so. Regular reflection helps improve skills faster than just doing blindly. Here we can learn to better plan, assess our capacity for work, and highlight “hard parts” of projects. This helps the current project as well as future projects. I am a big supporter of reflection, so this is easy.
8. Regular times led to productive rhythms.

In truth, many of the action oriented approaches are similar. Soft Systems Methodology also recommends iterations and reflections.

I think it is time to start more formally bringing in some of these ideas into the research plans that I am building now.

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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.

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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.

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.

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What does discrete data capture mean to you as a physician? Is this different than structured text? And the difference from free text?

For me, discrete data means that information is being stored in a way that is predefined and has computable meaning. Discrete data could have a terminology behind it, such as a problem list with SNOMED codes or it could be data elements, such as birthdate, that have a singular value. Both of these can be acted on in a consistent manner using decision support engines, used to run practice level reports (how many diabetics over the age of 50 are in my practice?), etc.

Structured text is a way of standardizing and speeding up text entry by using some form of macro-like functionality. Type “_RESPN” and you get a long blob of text that outlines what you do in a respiratory physical exam, all with normal findings. (“…Breath sounds normal, no crackles or wheezes heard on auscultation…”). This text is not interpretable (with the exception of natural language processing) by the computer.

Free text is just ASCII or rich text that is typed / dictated / input by the user using phrases and sequencing that is up to the user.

So yes, the three are different — structured text is a quick input method for free text, but it also triggers some standardization in verbage and action (you cannot say what you did not do).

That would answer the question. There are some other aspects to talk about – and some of these might be relevant.

First, discrete data does not mean standardized data. A common EMR feature (and HIS feature) is the ability to locally define data elements – nicely formed discrete data. Data that does not have to conform to any standard. Thus, there are many discrete data elements that cannot be shared, even between users of the same EMR.

Also, one could have another definition of structured text – that would be text that is marked up. Mark up provides some discrete data, if the EMR supported it. Think of how XML works. Readable text can be marked up with meaning. A sentence like:

“The blood pressure is 130/80.”

could actually be marked up behind the scenes like this:

The blood pressure is <systolic blood pressure>130</systolic blood pressure> / <diastolic blood pressure>80</diastolic blood pressure>

The user may not be aware of the mark up or they may do it with key phrases, but the data is then available elsewhere for graphing, trending, etc. and it seems like free text mark up. (NOTE: this may be what some people talk about when they talk about structured text, I am not sure.)

Finally, these categories, no doubt, are somewhat arbitrary and people will either say “what about X” which doesn’t fit into the boxes above or present another way of breaking down types of information. And that, friends, is exactly why I have comments enabled.

Hope this helps.

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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.

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.

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I am a fan of modelling systems to describe and reason about complex problems. Modelling systems allows you to describe an aspect of the real world as a connected whole, consider changes to the model, and then reflect on how those changes might impact the real world.
Models can be mathematical simulations. I have more experience with visual models of systems. I think that these can be helpful in exploring and developing understanding of problems and their solutions. If we think about models selection in terms of cognitive fit (See picture below), the closer the external representation is to the problem solving task, the better the overall performance, all other things being equal.

There are many types of notations and different notation standards that can be used. Many people (myself included) often invent their own for specific projects. There is an important role for personal notations in describing specific issues. There is also a role for standardizing on a subset of notations within an organization so that people who work across multiple projects are able to consistently glean information from the visual models rather than spend time translating visual notations in their head. That is, consistency of the notation allows people to think more about the problems / solutions than about the picture, which is why one would adopt a visual notation in the first place.
A Clinical Architect should promote standards, ensure that people are familiar with the standards, and that the appropriate tools are selected for the right tasks. I have found BPMN, UML and other open standards to be useful. Keep the notations simple, however. You do not want clinicians to have to spend a lot of time learning the details of the notation.
To follow along on that thought on keeping things simple, models are only models. They are not complete descriptions of the real world – they are selectively simplified illustrations of particular views of the real world to help us reason about the problem situation and how we can change the situation. It is important for us to keep that in mind. Sometimes the model becomes end and it is not, it is a means to an end, which is improving the real world. Models, then, should highlight aspects of processes, information, etc. that need to be highlighted, that are directly relevant to the changes being implemented, and that provide context to the decision making process.

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A Clinical Architect should be able to design requirements, even though that might not be a day to day activity.

I prefer terms like requirements design or requirements engineering as I don’t think requirements are just out their to be picked off trees. Requirements elicitation, for example, suggests you just have to ask users. I do not think requirements design consists of pulling some people into a room and asking them what they need. Or at least, I do not think that is the only thing required.

While the user is never wrong, the user is not always right. Especially in a meeting room, away from their daily work when they haven’t been trained to think about requirements. You can often get suggestions for solutions (just trying to be helpful!) and a lack of understanding of the needs.

“I need a soft ware for electronic call schedule management”

“I need secure email”

“I need… version 9 of the EMR Cardiology Suite by MegaCorp”

With these statements, one isn’t sure why they need these solutions – what are the solutions addressing? Was it that that EMR Cardiology Suite was seen at a conference? Or were the reasons for secure email really about an integrated electronic solution for referral management?

Complex problems and their “solutions” are intertwined (see Wicked Problems), but it is important to have the context of the problem somewhat understood before exploring solutions (and then re-describing the problems being addressed).

A Clinical Architect’s role here is two-fold. First, to have an understanding of the process used to engineer requirements and be able to articulate it. Second, to ensure that potential solutions are reviewed in the broader context of the organization: how can the solution be reapplied to other settings? how aligned in the solution to other aspects of care delivery? how much patient information is being locked away in an isolated clinical information system that would be useful to other providers or the patient in other settings? These are the types of broader questions that should be explored with the organization’s clinical architect during project scoping and in the more detailed requirements engineering activities.

Just for reference:

BABOK 2.0 is now available free on Google Books. To be shared with BAs, absolutely, but also adapted to the organization so that there is local expertise in a subset of approaches. (They also speak of requirements elicitation…)

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I think understanding some of the common approaches to software engineering is important for a clinical architect. At the least, you’ll need to participate in a process. Likely, you’ll have some influence on that process. As Clinical Architect you may be called upon to help (re)define some or all of the process of development of a Clinical Information System, especially if you have worked on the Enterprise Architecture.

One does not need to be a guru in RUP or a SCRUM master, but it helps to know the differences between waterfall approaches, agile methods, and even some of your vendor’s processes (where there is a dominant vendor in the organization and the system is not locally built).

The waterfall approach to development has a fantastic elegance to it. (See figure on left) You move from top to bottom, completing each step in logical order. You completely define your requirements before moving on to design. That way nothing is missed and effort is not wasted building pieces incorrectly.

Only thing is, it does not work.

Especially in healthcare, where there are complex systems in play with complex systems, it is not possible to “complete” a step. That is, you will never define all your requirements. You cannot get all your requirements “correct” as they are attempting to define ill defined needs that are often in conflict between groups or users (e.g. health planners may need something that providers do not need). Get a requirement wrong early in a pure waterfall approach and you do not realize it until later. Later means more expensive to fix. Often much more. Sometimes more than can be afforded at the end of a project (especially when the planning does not include changes of that magnitude).

Iterative approaches, of various kinds, begin with the admission that you cannot know it all. You have to learn through action. Thus, you iterate through increasingly refined understandings of the problem and solution space. High impact / high risk areas are addressed first, so those have the most time to be refined and improved. Approaches are used that lessen the impact of rework.

How you iterate depends on the approach. Most groups adopt aspects of different methods into their own custom fit agile method. I think that is a good idea. It is hard to justify a truly extreme programming approach in healthcare that includes putting semi-functional content into production with live patients. However, being able to iterate aspects of systems, test them, refine assumptions, work with providers to allow them to provide feedback and to mentally adapt to new ideas is key. Iterative approaches can support that process. It can be done in pre-production environments or even offline (paper prototyping can even work), and then allow for careful testing prior to production go-lives.

The challenge with iterative approaches is they often do not fit well into waterfall thinking. As I said earlier, waterfall is elegant. That elegance is easily understood by steering committees and executive sponsors. Why wouldn’t you plan out everything in advance and then just build it right the first time? I mean, that’s what they did when then built the bridge, isn’t it? Software is different, and that is especially true at this stage in the evolution of clinical information systems. We do not have the same experience as a bridge builders and there are more variables to consider.

One of the roles, then, of a Clinical Architect, is to ensure that the right process for the job is used, that standards are adhered to, that content is appropriately tested, AND that sponsors understand why projects should iterate and why it is important to learn through action.

Finally, if your organization has a dominant vendor product (e.g. your hospital information system is a vendor product), you will need to know their development processes. This is important to be able to make suggestions / feature requests, but also incase you are hiring / contract additional services.

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Being able to consider the full scope of design is, I think, an important piece for someone who – as an organization’s Clinical Architect – is leading the decision making around how the clinical systems fit together (or consciously do not fit together) to meet the organization’s goals.

While clinical leaders often think of systems from a care perspective, they often have not had training in the areas of information systems. With the complex CISs in play in many large organizations today, this kind of structured thinking is key.

Enterprise Architecture is the logic, processes, and products that connects the organization’s operations to its ICT infrastructure design.

This architecture should span the organization, not just IM/IT.

National Institutes for Health have their description of Enterprise Architecture.

There are many approaches to Enterprise Architecture. For organizations that are developing their architecture capabilities, it does not make sense to go too heavy, nor invest in a proprietary approach when there are good, published, open approaches. TOGAF, for example, is a good, open standard to enterprise architecture. It can be tailored to be light enough for early use and can the grow with organizations as they are ready to grow. Version 9 is available online. The figure on the side is a nice cyclical approach to EA management from TOGAF.

The Zachman Framework (wikipedia link) was developed in the 1980s at IBM and has been adopted, adapted, and revised since then. The Enterprise Architecture Center of Excellence now is its home. There are several tools to members (I am not a member). I have always thought of the Zachman Framework as something that is heavier to implement than other frameworks, such as TOGAF. I do like how the Zachman Framework ensures goals are explicit in the modelling processes.

I think what is important to keep in mind, for me, is that this level of architecture is much more socio-technical in its approach than simply a technical architecture.

There are others, certainly, but I thought I would list two. Please suggest others that you think are applicable to healthcare.

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