Wednesday, May 26, 2010

The problem of "Feature Bleed"

Another common question I get asked is, "What can we do to prepare for 'going electronic'?"

Most hospitals will, in these times, gather their order sets, in the hope of "making them electronic".

It's then, that you may notice the first problem. I like to call it "Feature Bleed".

"Feature Bleed" is when you have order sets that have pieces of :
  1. Order sets
  2. Protocols
  3. Documentation

This is VERY, VERY common - Most paper-based hospitals aren't disciplined enough to have their order sets and protocols and documentation well-separated.

Take a look at your paper order sets - See something called "Advance Diet as tolerated" or "Up ad lib" or "Do not start any other CNS depressants without checking with the anesthesiologist first"? These are all protocols!

Take another look at your paper order sets - See something like "Write patent's PTT here : ___ ___ ___" or "Write patient's neuro checks q6h here : ____ ____ ____" - These are all documents!

Take one last look at your paper order sets - Are they labelled something like "Alcohol Withdrawal Protocol / Order set / Flowsheet"? This is a sign that you may have feature bleed. (Ask yourself which tab in the paper chart you have been putting this order set into - If you're not sure, that's a warning sign of "Feature Bleed")

How does this happen, and why is it so common? In the paper world, it's very easy to make an order set where :

[ Order set ] = [ Order set ] + [ Documentation ] + [ Protocol ]

The problem is, when you go electronic, you will have different places ("buckets") where you need to organize those things.

  1. The "Order set" bucket
  2. The "Protocol" bucket
  3. The "Documentation" bucket

And to organize this, it will mean :

  1. Significant redesign of your paper order sets
  2. Significant redesign of your clinical protocols
  3. Significant redesign of your clinical documentation

And to handle this? You'll need to define, for each of these informational tools :

  1. A good policy definition of the informational tool (to help guide builders in the right direction and prevent future "Feature Bleed")
  2. How will the informational tool be built? (By who, and how? What format?)
  3. How will the informational tool be tested before it "goes live"?
  4. How will the informational tool be approved in your organization?
  5. How will the informational tool be published
  6. How will the informational tool be tracked.

If your organization was very disciplined in the paper world, and you have good policy definitions of these tools, your conversion to EMR will go a lot easier.

And if not, you're like about 80% of the places I talk to. :) Just be prepared to deal with this organizational redesign issue at some point - Preferrably earlier, rather than later.

Thursday, May 6, 2010

Why don't the order sets work anymore?

One of the most frequent questions I get asked is :

Q : Why is it so hard to make the paper order sets work in our electronic EMR?

Sometimes, this is accompanied by stares of disbelief, or better yet, a suspicious glance, wondering if I'm 'just making this up'.

Here's the sad truth : No, you can't just put the paper orders on the computer screen and make them work.

Why that is, is a complex answer. I'm going to share two simple ways of looking at it.

Some people have tried to equate the electronic world and the paper world as "two different languages" - Anyone who has ever tried to translate between two languages will show you how difficult it is to translate idioms. E.g. "Hit the Road!", "Drop Dead!", "Happy as a clam!" are all idioms that don't translate too well into other languages.

This is where you see the cultural differences between electronic medicine and paper medicine - It just doesn't translate well.

The problem with this example is that people who aren't bilingual won't really appreciate this difference. (Many people seem puzzled to find out that the best interpreters are only about 95% accurate... Usually, 90% is good enough for most communication, so it generally works.)

THE INFORMATICS ANSWER : (Easier to understand, trust me!)
The Informatics answer to this question requires one to understand some basic premises of information science.
1. An order set is a group of lab and medication orders which can either be ordered, or not, depending on a physician's or nurses's decision when they execute the order set.
2. Clinical Documentation is something your clinicians will write on a piece of paper, or a form, to document what's going on with the patient.
3. Clinical Protocols are essentially "if-then" instructions that tell your staff how to react in a particular patient situation, to achieve a certain goal.

So here's the problem most people face when trying to translate from the electronic world to the paper world : Most "paper-based" hospitals have paper order sets with pieces of documentation and clinical protocols built into them.

Q : Huh? How is that possible? My order sets have policies and documentation built into them?!?

The truth is often : Yes.

Q : How did that happen?

Basically - Paper is flexible. You can write anything you want on it.
Computers are much more fussy about :
  1. Where protocols go (read-only)
  2. Where documentation goes (read/write, for your clinicians to use)
  3. Where order sets go
Q : I'm still not sure I get it.

Let's look at this another way.
  • On paper : [Protocol + Order set + Documentation] = All on one sheet of paper, often labelled "Order Set"
  • Electronic : [Protocol] + [Order set] + [Documentation] = All go in different places in your EMR.
Q : So what do I have to do, then, to make my paper order sets electronic?

It takes work - To fix this, then, means someone has to separate your paper order sets into :
  1. Clinical Protocols
  2. Order sets
  3. Documentation (Notes, forms, etc.)
Q : Can you give me some examples?

Sure. Let's make up a hypothetical order set - Not based in reality, I assure you, but not uncommonly seen before a hospital "goes live with CPOE"...

Sometimes on a paper order set you will see things like this :
[Line 1] ( ) Tylenol 650mg PO q6 hours PRN mild (1-3) pain
[Line 2] ( ) Percocet 5/325 (1) tab PO q6h PRN moderate (4-6) pain
[Line 3] ( ) Morphine 2mg IV q30 minutes PRN severe (7-10) Pain
[Line 4] These orders are only to be used in Emergency Department!
[Line 5] ( ) If O2sat is less than 85% check ABG STAT and call MD.
[Line 6] Please assess vitals and assess respiratory rate : ________ breaths/minute
[Line 7] If patient respirations less than 10 then give Narcan 0.4mg IV x1 dose STAT and call MD.

Let's examine this hypothetical order set above...
  • Line 1 = Fine order. No problem putting this into an electronic order set.
  • Line 2 = Fine order. Again, no problem.
  • Line 3 = Fine order. Glad to see pain levels specified for patient safety! Again, no problem.
  • Line 4 = Problem. By saying "These orders are only to be used in the ED", this is technically a clinical protocol. Essentially, it tells a nurse : "If the patient is discharged from the ED, these orders must be discontinued by a nurse."
  • Line 5 = Similar problem. This is actually a clinical protocol. Needs to be written into a separate document, instructing a nurse what to do if the O2sat drops below 85%.
  • Line 6 = This is also a problem, because it's clinical documentation. Needs to go on a separate form to work with this order set.
  • Line 7 = Another clinical protocol. It also suffers from the problem : How do you execute an order for Narcan at some point in the future, when you're running this order set now? Again - This needs to be a clinical protocol.
So to fix this paper order set would require designing new documentation and new clinical protocols to function with this order set. You typically end up making a whole lot of new clinical policies and documents and need the committee structure that can handle this in a nimble way. Phew!

Q : This seems like a lot of work, isn't there some simpler way to do this?

It is a lot of work! And there isn't a really simple way to do this. If there were, hospitals wouldn't often look for specialist help to convert to the electronic world.

Next article, we'll talk about "Why didn't the vendor give us order sets that work?!?!". Stay tuned. :)