Virtually Priceless Thoughts

Here’s a wonderful You Tube video that relates too well to my life and work – both tongue and cheek and spot on.

I came across this little slide show that I quite liked this morning on visual thinking. I like the 4 Ms and 6 steps of visual thinking (starting on slide 21).

This is a follow up to my earlier post on the challenge of writing my dissertation.

For 25 days this summer, I counted my days by the word. I set myself the task of writing 1,000 words per day on my dissertation.

That was the minimum I could write. I could write more, but not less — and no banking of words. And contrary to my earlier post on pictures being worth 1,000 words, they didn’t count.

I had to write at least 1,000 words a day.

Every. Day.

My idea was to set up a chain of accomplishments so that even when I was waning, I would not want to break the chain by missing a day. I had to reach 1,000, then I could stop and rest. Or edit. Or revise a picture. Or re-review my findings. Or do something else. Anything, as long as I wrote my 1,000 words.

25 days later and I was at the end of my 1,000 word days. The body of my dissertation was drafted. 228 pages, over 66,000 words.(1)

This proved to be a successful approach for me to get through my draft and one I will likely use again in future projects.

I think the trick to find the right metric that is an accomplishment that is significant for a day without being overwhelming that cannot be achieved. For me, last month, 1,000 words a day worked.

Since then I have started the editing process. I have shifted metrics to a set of tasks, determined based on a review cycle and laid out over a week. Not as clean as the 1,000 word metric, but that’s the nature of editing.

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1. Yes, 66,000 / 25 is more than 1,000 words a day. I was working on my draft prior to July 30th, so I had several chunks completed before I started (that I didn’t count in my 1,000).

Right now I’m in the deep, dark part of the PhD – the dissertation writing. Having cleared away everything else, but the blank papers in front of me, I have no excuses but to write.

Well I have actually discovered plenty of excuses… that is the nature of writing, isn’t it?

I am moving steadily along and feel like I have a handle on where I need to go. I have done enough of the analysis work before now that this is mostly about writing, instead of doing the conceptualizing / analysis in parallel with the writing. That definitely seems to help.

I have my daily and weekly goals and that’s good.

One of my touch points is volume of words. The target is at least 1,000 words a day. I feel like I have accomplished something if, among the other pieces (e.g. editing, etc) that I have generated 1,000 words. It’s not the only measure, but it is one metric to work against (to quote Monty Python:

Sir Edwin: Ah, well, I don’t want you to get the impression it’s just a question of the number of words… um… I mean, getting them in the right order is just as important. Old Peter Hall used to say to me, “They’re all there already– now we’ve got to get them in the right order.”

But number of words is a good metric. It’s clear and measurable. And I start to create a chain of activity that I don’t want to break — every day, 1000 words. What if I miss a day? Can’t do that, I’ve had 9 1000 word days in a row. Gotta make it ten. That works well.

In a break today I started thinking about ways to keep the chain and slack off (the human mind never ceases to amaze me). “Never fear, I can count my pictures… that’s right. A pictures worth a thousand words, isn’t it? If I miss a day, I’ll count one of those…” My dissertation is full of pictures. Excellent! My brain has found a way around my own self imposed productivity standards… but maybe pictures are really worth a 1,000 words.

So I surfed and – even better – I came across this image:

It appears there was an error in translation – 10,000 words! I can take off the whole week and still make quota! Ah, I love August by the lake… but alas, no matter how I count my actions, I still have to reach “done” as defined by my supervisor and my committee in fairly short order and cannot bask in the warm shade much.

Also, it turns out that there were a couple of errors in the translation of the chinese proverb, actually. As Paul Lester explains:

In fact, the literal translation is: A Picture’s Meaning Can Express Ten Thousand Words.

He goes on to explain that:

With the correct interpretation of the proverb, words and pictures live in harmony as they are both used equally in order to understand the meaning of any work that uses them both.

This is a wonderful interpretation that works well with my dissertation. I’m sure to find a use for it somewhere as much of the work in the study relies on visual communication of findings through pictures and (visual) models.

Until then, however, I am either going to have to change my metrics (1000 words, and 1 picture) or I am going to have to up my daily quota for words, otherwise I am sure I am going to find myself slacking off, counting pictures as 10,000 words each.

“Across VIHA Regional Clinical Information Systems, clinical information must have a defined Source of Truth, be up to date, and consistently available.”

In order to achieve consistent and comprehensive information across VIHA’s regional CISs, clear delineation of the sources of truth is required, both for individual data elements (author) and for types of information (system).

Information will be available to users (in accordance with access policies) consistently in each regional CIS. Information accessed in each system should be consistent in terms of content, currency, and presentation. This is important for safe practice and to ensure continuity. There are several approaches to ensuring consistency:

1. One integrated system – no sharing needed. Display, functionality and content are consistent. This is the preferred approach in VIHA.
2. Information will be shared between such that each piece of clinical information is stored only once. The other system accesses and displays that information through background messaging. Functionality (e.g. CDSS rules) will need to be duplicated and display standards will be required to ensure consistency and safety. This is the second preferred option.
3. The less desirable approach would be to duplicate information and have copies of data stored in each system. Full multi-directional synchronization will be required for clinical information documented in more than one system (e.g. if allergies were to be documented in three systems).
4. The final option is that some information is not available through one of the CISs. In this case, providers may view or use the other regional system as needed (links may be provided). This is not interoperability.

It is not acceptable to have similar information captured in multiple systems without any form of syncing. The risk of not clearly defining sources of truth is that some systems may have partial information; the information is not up to date, or conflicting. Providers will not know what information is missing. Gaps in continuity of information will occur. The risk is that clinical decision-making will suffer due to incomplete / inaccurate information. This is a safety issue.

Commentary:

There are some strong words in this last principle. They speak to the dangers and safety issues when having information in silos that are inappropriately inaccessible. I realize that “option 5″ (not shown, but is basically disconnected systems that are not accessible) is very common practice today, at least in Canada. Still, the intent of the principle is to put a stake in the ground, or some writing on a page, that can be pointed to when another isolated system is requested or when IM/IT project teams are looking for guidance on how to prioritize how systems are selected / configured. Thus some strong words seemed important.

The ranking of options was debated. Specifically 2 and 3 were heavily discussed. The very real issue that many disparate systems cannot realistically support option 2 was debated over, what I have begun to call the “Syncing Calendar Issue”(1) that would plague option 3. In the end, from a principle perspective, we agreed that 2 outranked 3. We also agreed would likely see more HL7 messages floating around copying and syncing content than shared tables, from a practical perspective. Shooting for option 3 is never my favorite target (nor is it Seth Godin’s) and I would like to push for option 1.

This principle is focused on information continuity. It does not really speak to the workflow issues of having multiple systems and the challenges providers face in trying to manage multiple systems with overlapping content. We were leaving that for part 2 – a set of clinical business process principles.

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1. Syncing Calendar Issue: Every once in a while, my calendar syncing goes awry. Somewhere between the cloud, my desktop, my phone, my laptop, and some (I think) edit to a recurring series from exchange, my syncing gets a bit broken. I have to decide which calendar is the “best”, manually make changes to make sure “best” is accurate and then push that calendar back to my other devices. I’m sure many of us have this problem – and patient records are much more complex than our schedules.

“Approved vocabularies will be consistently adopted wherever appropriate in all regional Clinical Systems.”

One of the benefits of using Clinical Systems is that passive data, previously found in paper charts, can become active and actionable. It can be reused to display in different contexts and it can be used to support Clinical Decision Support (such as proactive care delivery) and Health Planning (at multiple levels). In order to achieve this level of activity, information needs to be coded in a way that can be consistently interpreted both by users and by the information systems. Thus, standardized vocabularies are desired to provide that consistency.   There are three levels of vocabularies that can be considered.

Reference Vocabularies are designed to have maximum details in to support the information needs of clinical care. SNOMED CT is recommended as one of the primary clinical coding terminologies. It is supported by provincial and national standards and is actively developing on an international level. Additional reference vocabularies will be included where SNOMED CT does not have sufficient clinical coverage.

For Health Planning and Reporting activities, Classification Vocabularies and Group Vocabularies will be used, as they are today. ICD 10 is currently used for chart abstraction functions and various reporting as a Classification Vocabulary. The level of detail in ICD-10 is not truly sufficient for clinical documentation but provides useful data at an aggregate level. Mapping from reference vocabularies to classification vocabularies is possible and recommended to reduce manual re-coding of information.

Commentary:

Here, the focus is on the need to develop a nomenclature approach and leverage the right detail level of existing standards for their purposes. This principle relates to Principle 3 in that data should be captured at a granularity level for appropriate clinical purposes and then can be mapped up to the higher level reporting needs.

SNOMED CT is called out explicitly in this principle to ensure that energy and resources are applied to gaining knowledge about this powerful – but complex – terminology.

“Documentation will be constructed from standardized building blocks or “patterns” that are interactive and support decision-making.”

A “pattern” is a collection of clinical content and system functionality that supports a specific care activity that is part of an overall assessment (e.g. vital signs, Glasgow Coma Scale assessment). Patterns are reused across the region.   Patterns will be used as building blocks.

Pattern development, including the creation of resulting detailed data models and data definitions will be tightly controlled by the CARB. Patterns will be approved by EHR SC. The design will consider current documentation standards, redesigned care processes, and advanced EHR functionality, such as CDSS. Patterns will be applied to all regional systems in VIHA. Patterns will be shared.

There will be several versions of some patterns to support variable needs of providers across the region. They will have varying levels of detail, depending on clinical need (e.g. Vital Signs may have 4-5 patterns, depending on details required, context, and user). Amount of structure in patterns will vary.

The collection of patterns and their various versions will constitute VIHA’s “Pattern Collection”. Specific clinical electronic tools (e.g. electronic documentation) can be built up through the selection of patterns that best fit the best practices for specific programs. There will be a recommended order for patterns, such as SOAP.

Not adopting a pattern approach will result in increase work as common assessments are repeatedly rebuilt across the region. Continuity of care, user training, and health planning would all be affected if data is not consistently captured and stored.

Commentary:

I have written about this concept before here and here.

For VIHA, the concept of patterns is very focused — this principle describes a new way for VIHA IM/IT to consider how to develop electronic documentation, not other aspects of their clinical information systems. Instead of building unique (or similar) forms for each particular need, forms can be thought of a collection of building blocks (called patterns). Patterns could be Vital Signs, ADLs, etc etc. Once they are designed, they can be reused throughout the organization and perhaps shared more broadly. This is not that dissimilar to the openEHR design, especially if you notice on the diagram where there are also models that relate the various data elements.

This structure and reuse should (a) make the data more consistent and (b) speed form design one the patterns are developed. The patterns are meant to be designed independently of a particular system, so they can be replicated in the various CISs in VIHA.

The tricky part for VIHA is to find the natural joints or break points in clinical content so that reuse is maximized. If too many unique patterns are developed, then the work to maintain these external to any system is negated.

“Core Patient Information will be stored and maintained in Cerner so that advanced EHR features can be properly supported in VIHA.”

VIHA is deploying advanced EHR functionality to support clinical decision-making, improve quality and patient safety through proactive care planning and clinical decision support. VIHA aims to achieve this in a multi-system environment with limited resources.

In order to provide advanced functionality within VIHA, in a timely and reasonable fashion, a set of interprofessional Core Patient Information (CPI) will need to be defined and reside in VIHA’s primary EHR, Cerner.

Other regionally supported systems will need to be able to interoperate with the Primary EHR to ensure that this data is up to date within Cerner.

What is considered Core Patient Information will evolve over time (see current categories on the left). Additional information, such as Patient Alerts, Social History, and Family History, will be considered. These will be added when there are suitable structures to support them and regionally agreed to use and definitions. Diagnostic data, such as lab and medical imaging are already captured in Cerner.

Without a clear understanding of the CPI, VIHA risks reduced interoperability, hiding key patient information in electronic silos, and not being able to achieve the benefits of electronic health records.

Focusing on the limited scope of the CPI necessary, due to resource demands, complexity, and capability of systems. However, there is a risk that if the CPI is too small, VIHA will be limited in its ability for advanced functionality. Additional standardization of content across systems will also be required.

Commentary:

There are several clinical systems in VIHA and the content that will be stored in each is not yet clear. This principle starts to hammer out a set of fundamental information that will be stored in the primary patient record inside of Cerner. This means that interfaces will need to be created to import data or share data from other systems inside VIHA that contain similar medication. This is deemed the minimum set of content to ensure future clinical decision support.*

The other aspect of this list is that we promoted components that we knew had reasonable models inside the VIHA instance of Cerner. Family History, for example, while useful, was excluded at this time as it would require VIHA to spend time developing that content internally, and there is an expectation that this feature will come from Cerner in the future. This list alone will likely keep VIHA busy for a while. So this list is targeted and will grow as is practical.

*NOTE: laboratory results and medical imaging are already in Cerner and thus were not added to this, but would need to be considered for other organizations where labs were in one or more other systems.