tag:blogger.com,1999:blog-11147887147177953952024-02-20T04:36:36.863-05:00CKM BeatThe pulse of Clinical Knowledge ManagementJohn Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.comBlogger32125tag:blogger.com,1999:blog-1114788714717795395.post-56495633774853906452014-03-15T12:03:00.000-04:002014-03-15T14:11:45.102-04:00Does Your Analytics Vendor Deliver Long-term Value?<div dir="ltr" style="text-align: left;" trbidi="on">
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnsRyYAkt56scl-wrnOGhL8oNsLulSnqN5PeXv8aKCPaAPC0-HqAYOlV-AaAP511mA12sRY_SGz77leFsaMFVv-cZMQd-w-muOniDpeQ_ow-1zC-8ZxtbYDbCuMcWCtTl792UIQxvr8_-9/s1600/analytics.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnsRyYAkt56scl-wrnOGhL8oNsLulSnqN5PeXv8aKCPaAPC0-HqAYOlV-AaAP511mA12sRY_SGz77leFsaMFVv-cZMQd-w-muOniDpeQ_ow-1zC-8ZxtbYDbCuMcWCtTl792UIQxvr8_-9/s1600/analytics.jpg" height="247" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="https://www.viralheat.com/wp-content/uploads/2012/09/analytics.jpg" target="_blank">Source</a></td></tr>
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<span style="font-family: Calibri;"><span id="goog_695929796"></span><span id="goog_695929797"><br /></span></span></div>
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<span style="font-family: Calibri;">Walking through the vendor area at HIMSS14, it was
impossible to avoid being bombarded with analytics, analytics, analytics; everywhere
you turned a vendor was advertising and pushing analytics. Unfortunately, most
were overselling an underwhelming product. They look pretty, but they only
scratched the surface of analytics and they will not be the partner that will
carry your organization forward for the long run.</span></div>
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<div style="margin: 0in 0in 10pt;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Calibri;">Before you pick an
analytics partner and make a significant investment of time and money, you need determine if your vendor will be able to deliver long-term value. To do that, you need to understand the three phases of analytics and determine if your vendor will
be able to support all three.</span></b></div>
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<span style="font-family: Calibri;"><b style="mso-bidi-font-weight: normal;">The first phase of
analytics</b> is descriptive analytics. Descriptive analytics use data visualization,
statistics and mathematical models to show the current or historic state of an organization
or population. The math may be fancy, but it only shows what <i style="mso-bidi-font-style: normal;">has or is</i> happening. This phase of
analytics is best used for identifying patterns and correlations and is often
used in management decision making. If your health system does not have
transparency into its data, descriptive analytics can be a very powerful step
forward. However, it is only phase one.</span></div>
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<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><b style="mso-bidi-font-weight: normal;">Predictive analytics</b>
is the second phase. We are all familiar with predictive analytics even if we
don’t realize it. According to my phone, tomorrow is supposed to be sunny with
a high of 70 degrees. Meteorologists have been using predictive analytics for
decades, but it is relatively new technology to healthcare delivery. Predictive
analytics are best used for relatively short term predictions of future state.
In healthcare, that may mean predicting the number of nurses needed to staff a
unit based on the number of expected admission and discharges, or risk
stratification of an individual patient. I saw very few vendors that could
clearly demonstrate meaningful predictive analytics.</span></div>
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<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><b style="mso-bidi-font-weight: normal;">The third phase</b>
is prescriptive analytics. Prescriptive analytics combines predictive analytics
with pre-defined actions (or rules). The best known use of this type of
analytics is automated trading on the stock market. The predictive algorithm
predicts the price of the stock will rise if x or y occurs, so when x or y does
happen the computer buys a predetermined amount of stock without human
intervention. <span style="mso-spacerun: yes;"> </span>Similar types of
algorithms are used by Amazon to give you suggestions while you shop. No human
is involved when they recommend you buy conditioner to go with your shampoo.</span></div>
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<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;"><span style="mso-spacerun: yes;"> </span>There is extremely
limited use of prescriptive analytics in healthcare, but its use will grow as
we get better at population health. <span style="mso-spacerun: yes;"> </span>At
this time, the best use of prescriptive analytics is to identify a high risk
population and then automate a low risk intervention. For example, if you were
able to identify a group of patients at high risk for a heart attack you could
then use an automated calling system to screen them for evidence of chest pain
or shortness of breath. Those that screened positive could receive follow-up
care and those that screened negative had a very low risk intervention.</span></div>
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<div style="margin: 0in 0in 10pt;">
<span style="font-family: Calibri;">As you consider an analytics vendor, look past the
how pretty their graphs are and determine if they will be able to carry you
through to prescriptive analytics. It will be hard to justify why, <span style="mso-spacerun: yes;"> </span>after months of developing data models and
making charts you need to do it again with a different vendor because your
first one only did descriptive analytics.</span></div>
</div>
John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com8tag:blogger.com,1999:blog-1114788714717795395.post-572239456951701912014-02-27T23:34:00.001-05:002014-02-27T23:34:33.029-05:00HIMSS14 Highlights (Vlog)<div dir="ltr" style="text-align: left;" trbidi="on">
In addition to the incredibly powerful closing session by <a href="http://www.touchthetop.com/" target="_blank">Erik Weihenmayer</a> (@ErikWeihenmayer), <a href="http://leighmichele.com/" target="_blank">Leigh Williams</a> (@leightw) and I are bringing you our highlights from HIMSS14.<br />
<br />
<br />
<iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/lTiEk23XJeY" width="560"></iframe>
<b><br /></b>
<b>What were your highlights from HIMSS14? What would you like to see changed for HIMSS15?</b><br />
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John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-36363652926861958602012-11-26T10:00:00.000-05:002012-11-26T10:00:11.079-05:00Synergy in Health Care and Technology<div dir="ltr" style="text-align: left;" trbidi="on">
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<div class="header" style="background-color: white; color: #333333; font-family: verdana; font-size: 13px; margin: 0px; padding: 0px 0px 2px; word-wrap: break-word;">
<h2 class="me" style="color: black; display: inline; font-family: 'Arial Unicode MS', Arial, Helvetica, sans-serif; font-size: 18px; margin: 0px; padding: 0px;">
<a href="http://dictionary.reference.com/browse/synergy" target="_blank">syn·er·gy</a></h2>
<sup style="bottom: 1ex; font-size: 0.75em; height: 0px; line-height: 1; position: relative; vertical-align: baseline;"></sup> </div>
<div class="body" style="background-color: white; color: #333333; font-family: verdana; font-size: 13px; margin: 0em 0px 0em 0em; padding: 0px;">
<div class="pbk" style="font-size: small; margin: 0px; padding: 0px;">
<span class="pg" style="display: inline; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: italic; font-weight: bold; padding-right: 3px;"><span id="hotword"><span id="hotword" name="hotword" style="cursor: default;">noun,</span> </span></span><span class="pg" style="display: inline; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 13px; font-style: italic; font-weight: bold; padding-right: 3px;"><span id="hotword"><span id="hotword" name="hotword" style="cursor: default;">plural</span> </span></span><span class="secondary-bf" style="display: inline; font-size: 13px; font-weight: bold;">syn·er·gies.</span><div class="luna-Ent" style="background-image: none; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 1em; margin: 0px; padding: 0px 0px 5px;">
<span class="dnindex" style="color: #7b7b7b; display: block; float: left; font-weight: bold; width: 28px;"><span id="hotword">1.</span></span><div class="dndata" style="font-family: verdana; font-size: small; margin: 0px; padding: 0px 0px 0px 37px;">
<span id="hotword"><span id="hotword" name="hotword">the</span> <span id="hotword" name="hotword" style="cursor: default;">interaction</span> <span id="hotword" name="hotword">of</span> <span id="hotword" name="hotword" style="cursor: default;">elements</span> <span id="hotword" name="hotword">that</span> <span id="hotword" name="hotword">when</span> <span id="hotword" name="hotword">combined</span> <span id="hotword" name="hotword">produce</span> <span id="hotword" name="hotword">a</span> <span id="hotword" name="hotword">total </span><span id="hotword" name="hotword">effect</span> <span id="hotword" name="hotword">that</span> <span id="hotword" name="hotword">is</span> <span id="hotword" name="hotword">greater</span> <span id="hotword" name="hotword" style="cursor: default;">than</span> <span id="hotword" name="hotword" style="cursor: default;">the</span> <span id="hotword" name="hotword" style="cursor: default;">sum</span> <span id="hotword" name="hotword">of</span> <span id="hotword" name="hotword">the</span> <span id="hotword" name="hotword">individual</span> <span id="hotword" name="hotword">elements,</span><span id="hotword" name="hotword">contributions,</span> <span id="hotword" name="hotword">etc.;</span> <span id="hotword" name="hotword">synergism.</span></span></div>
</div>
<div class="luna-Ent" style="background-image: none; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 1em; margin: 0px; padding: 0px 0px 5px;">
<span class="dnindex" style="color: #7b7b7b; display: block; float: left; font-weight: bold; width: 28px;"><span id="hotword">2.</span></span><div class="dndata" style="font-family: verdana; font-size: small; margin: 0px; padding: 0px 0px 0px 37px;">
<span class="labset" style="display: inline;"><span class="ital-inline" style="display: inline; font-family: Georgia, Verdana, Arial, Helvetica, sans-serif; font-style: italic;"><span id="hotword"><span id="hotword" name="hotword">Physiology,</span> </span></span><span class="ital-inline" style="display: inline; font-family: Georgia, Verdana, Arial, Helvetica, sans-serif; font-style: italic;"><span id="hotword"><span id="hotword" name="hotword">Medicine/Medical</span> </span></span><span id="hotword">. </span></span><span id="hotword"><span id="hotword" name="hotword">the</span> <span id="hotword" name="hotword" style="cursor: default;">cooperative</span> <span id="hotword" name="hotword">action</span> <span id="hotword" name="hotword">of</span> <span id="hotword" name="hotword">two</span> <span id="hotword" name="hotword">or </span><span id="hotword" name="hotword">more</span> <span id="hotword" name="hotword">muscles,</span> <span id="hotword" name="hotword">nerves,</span> <span id="hotword" name="hotword">or</span> <span id="hotword" name="hotword">the</span> <span id="hotword" name="hotword">like.</span></span></div>
</div>
<div class="luna-Ent" style="background-image: none; font-family: Verdana, Arial, Helvetica, sans-serif; font-size: 1em; margin: 0px; padding: 0px 0px 5px;">
<span class="dnindex" style="color: #7b7b7b; display: block; float: left; font-weight: bold; width: 28px;"><span id="hotword">3.</span></span><div class="dndata" style="font-family: verdana; font-size: small; margin: 0px; padding: 0px 0px 0px 37px;">
<span class="labset" style="display: inline;"><span class="ital-inline" style="display: inline; font-family: Georgia, Verdana, Arial, Helvetica, sans-serif; font-style: italic;"><span id="hotword"><span id="hotword" name="hotword">Biochemistry,</span> </span></span><span class="ital-inline" style="display: inline; font-family: Georgia, Verdana, Arial, Helvetica, sans-serif; font-style: italic;"><span id="hotword"><span id="hotword" name="hotword">Pharmacology</span> </span></span><span id="hotword">. </span></span><span id="hotword"><span id="hotword" name="hotword">the</span> <span id="hotword" name="hotword" style="cursor: default;">cooperative</span> <span id="hotword" name="hotword">action</span> <span id="hotword" name="hotword">of</span> <span id="hotword" name="hotword">two</span> <span id="hotword" name="hotword">or </span><span id="hotword" name="hotword">more</span> <span id="hotword" name="hotword">stimuli</span> <span id="hotword" name="hotword">or</span> <span id="hotword" name="hotword">drugs.</span></span></div>
</div>
</div>
</div>
</blockquote>
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<a href="http://buyhomesindetroit.com/wp-content/uploads/2011/10/are-you-a-detroit-real-estate-investor-lets-start-working-together.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://buyhomesindetroit.com/wp-content/uploads/2011/10/are-you-a-detroit-real-estate-investor-lets-start-working-together.png" /></a></div>
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Synergy is often listed as one of the most hated words in the corporate world. However, achieving synergy between clinicians and health care technology is a crucial element in achieving return on investment.<br />
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I have rarely been in discussions, meetings, or presentations where people are discussing how clinicians and technology are going to work together to produce the best outcomes. Most commonly, the discussion is centered on how we are going to tweak the technology to suit the clinicians... or motivate the clinicians to use the existing technology. Sometimes, the impact on the patient is part of the discussion, but rarely- if ever- is the benefit to the institution included. The content of these discussions are exactly why most institutions have not seen the return on investment that they expected from their health care technology.<br />
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Achieving synergy between clinicians and technology is absolutely necessary. Here's why. Clinicians are good at being clinicians: ambiguity and the unknown are acceptable and expected parts of their decision making. Computers, on the other hand, are good at being computers: they excel at making consistent and accurate decisions when provided with a full set of data. Most health care delivery involves decision making on both ends of this spectrum. When computers provide consistent and accurate information to clinicians they are freed to make better decisions about the unknown. This facilitates optimal patient care, which of course benefits not only patients but creates value for institutions.<br />
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For anyone who has sat in a meeting like I described above, creating this needed synergy between clinicians technology may seem unlikely or even unattainable. The good news is that it is completely possible.<br />
<br />
When I was involved in the <a href="http://www.johnshowaltermd.com/2011/04/success-story-vte-reduction.html" target="_blank">project to decrease venous thromboembolism</a> (VTE), it was clear to the team that interactions between clinicians and the EHR were synergistic. <a href="https://hospitalpracticemed.com/doi/10.3810/hp.2012.08.984" target="_blank">Recent research</a> into the clinical decisions support tools we developed has actually quantified the effect of the synergy between providers and the EHR. While a computer-based algorithm could have been used to create reminders for clinicians about VTE prophylaxis, it would have only been 70% accurate in the population studied. However, without clinical decision support, providers were under-prophylaxing patients. By combining provider-based risk assessment with CDS to facilitate ordering prophylaxis, a greater than 50% reduction in nosocomial VTE was achieved. The synergy between clinicians and technology clearly improved care and outcomes for patients while also providing value to the institution by reducing never events.<br />
<br />
Despite the sometimes negative connotations of the term "synergy," it needs to be on the agenda for any meeting discussing how clinicians and technology will work together to create the best outcomes.</div>
John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com11tag:blogger.com,1999:blog-1114788714717795395.post-5436445974077176432012-08-20T09:00:00.000-04:002012-08-20T09:00:01.241-04:00Prioritizing End Users<div dir="ltr" style="text-align: left;" trbidi="on">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8fKEnpVPqIQZ96cRkJCOlAfZ_sW2eA3S740JdsgQAesNJ-I1i-_fACZvwXvI9kDrnGVzJSyhsYJ_cU06F_CV77chLOUN8xWOsAvr-jUUofxlh85Bed9DxHOtUOFXCS0Xnjho9LyKWbAG6/s1600/6334480931_957b516e13_b.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg8fKEnpVPqIQZ96cRkJCOlAfZ_sW2eA3S740JdsgQAesNJ-I1i-_fACZvwXvI9kDrnGVzJSyhsYJ_cU06F_CV77chLOUN8xWOsAvr-jUUofxlh85Bed9DxHOtUOFXCS0Xnjho9LyKWbAG6/s400/6334480931_957b516e13_b.jpg" width="223" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><h1 class="photo-title" id="title_div" property="dc:title" style="background-color: #fefefe; font-family: Arial, Helvetica, sans-serif; font-weight: normal; line-height: 1.3em; margin: 12px 0px; padding: 0px; text-align: center;">
<span style="font-size: xx-small;">Via <a href="http://www.flickr.com/photos/taedc/6334480931/" target="_blank">tedytan</a> on Flickr</span></h1>
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Implementing an <a href="http://www.johnshowaltermd.com/2012/05/what-is-livethegolive.html" target="_blank">integrated electronic health record</a> invariably results in competing priorities and competing end users. I've written before that I believe <a href="http://www.johnshowaltermd.com/2011/03/who-is-end-user.html" target="_blank">patients are the most important end user</a>. However, that still leaves clinicians, technicians, support and ancillary staff- and the often-ignored institution- competing for high ranking in decision making and resource allocation.<br />
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In order to assist in decision making and set system-wide strategy, I utilize a three-tiered approach to ranking these needs. Growing up with a strong Star Trek influence, I've come to agree with the Vulcan notion that "the good of the many outweighs the good of the few."<br />
<br />
With this belief in mind, <i>patients</i>, as a group, represent the top tier of importance. This means that with every decision that we make, we are asking "is this what is best for our patients?" If the answer is no, than another path must be chosen.<br />
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The second tier is the <i>institution</i>. The reasoning is two-fold.<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsBIJ0W2zzDOOm6wboQpbgPjLHg02t_0IX0Ak6gSAt61RHRogIHqL83tjd8zBFCRsmMf1pMNfQpo17rFqtV0VY9gd7WdSuyGm2OgS15TUbIrzVR5khkTsofGH_Ol15PlUf9H4Is8gxU5Vs/s1600/6339304142_4fe95167d7_b.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsBIJ0W2zzDOOm6wboQpbgPjLHg02t_0IX0Ak6gSAt61RHRogIHqL83tjd8zBFCRsmMf1pMNfQpo17rFqtV0VY9gd7WdSuyGm2OgS15TUbIrzVR5khkTsofGH_Ol15PlUf9H4Is8gxU5Vs/s400/6339304142_4fe95167d7_b.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Via <a href="http://www.flickr.com/photos/puuikibeach/6339304142/" target="_blank">puuikibeach</a> on Flickr</td></tr>
</tbody></table>
<br />
First, the patients are best served through the success of high-quality institutions. The era of the individual physician providing comprehensive care is coming to a close in the US; it's simply too difficult for a single physician to organize and orchestrate the multiple facets of a patient's care. Although many are nostalgic for the days when a doctor made house calls with his stethoscope and bag, modern health care requires advanced diagnostics, multiple providers, nurse coordination, complex billing and an increasing technology.<br />
<br />
Second, the institution exists as the governing body of the multiple individuals involved in delivering patient care. A successful institution will create an environment where conflicts are resolved and effective collaboration for the benefit of the patients is possible. The institution can arbitrate the wants and desires of individuals and groups of individuals to meet the ultimate goal of serving the patient.<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhljyF-mLtW7T3olJJLgCyW-Ea38uBWCl9X4XbANnJ6eZdTCP6zZsH6EGcQOSKO-cRKFMsuCABj_L1Zmt7kTOjC0ZN7hdMMjudYhZykBYTuQd8X75pBQ30hDuCPifCudsIds9HEAPappIEZ/s1600/1216721481_7c60e3e41f_o.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="241" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhljyF-mLtW7T3olJJLgCyW-Ea38uBWCl9X4XbANnJ6eZdTCP6zZsH6EGcQOSKO-cRKFMsuCABj_L1Zmt7kTOjC0ZN7hdMMjudYhZykBYTuQd8X75pBQ30hDuCPifCudsIds9HEAPappIEZ/s400/1216721481_7c60e3e41f_o.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Via <a href="http://www.flickr.com/photos/8725928@N02/1216721481/" target="_blank">janwillemsen</a> on Flickr</td></tr>
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<br />
The third tier are the <i>individuals </i>that are employed by or contracted by the institution. Many have tried to rank the importance of individuals and groups within this tier, suggesting that the desires of clinicians should receive greater weight in decision making than support and ancillary staff. However, in order to best meet the needs of the patients, the needs of these individuals must remain balanced. For instance, it does not serve the patient to purchase the fancy equipment requested by clinicians if it cannot be adequately disinfected by environmental services. Ultimately, the collective actions of every individual in the institution determine the quality of care that patients receive.<br />
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In order to realize the potential return on investment from integrated electronic health records, this tiered model must be embedded as a core value of healthcare institutions. By focusing efforts on benefiting patients, we will learn to use EHRs in ways that improve care and decrease cost, resulting in benefits for institutions and individuals.</div>
John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com1tag:blogger.com,1999:blog-1114788714717795395.post-36447935037876410812012-05-14T16:54:00.000-04:002012-05-14T16:54:11.697-04:00For Immediate Release: #LiveTheGoLive via Live Tweeting<div dir="ltr" style="text-align: left;" trbidi="on">
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<div class="MsoNormal">
<b>Chief Medical Information
Officer Invites Public Inside Go-Live Experience Via Social Media<o:p></o:p></b></div>
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<i>Dr. John Showalter,
Chief Medical Information Officer at the University of Mississippi Medical
Center is preparing to implement a fully integrated electronic health record on
June 1, 2012. Thought to be the largest single-day go-live to date, 20+
applications will be implemented at 5 hospitals and 95 clinics throughout
central Mississippi. As June 1 approaches, Showalter is sharing his experiences
and insights on popular social media sites in an effort to demystify the “big bang
go live.”<o:p></o:p></i></div>
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May 14, 2012 <o:p></o:p></div>
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JACKSON, Miss. – John Showalter, MD will be live Tweeting
his experiences as CMIO during the upcoming big bang go-live. On June 1, 2012, Showalter
will lead the implementation of 24 applications at 5 hospitals and 95 clinics
with over 6,500 users in the University of Mississippi Health System.<o:p></o:p></div>
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Showalter will be Tweeting from @JohnShowalterMD and using
#LiveTheGoLive to convey the experience of the CMIO before, during, and after a
go-live. He will also be fielding questions submitted via Twitter and engaging
in discussions on Facebook at <a href="http://www.facebook.com/johnshowaltermdblog">www.facebook.com/johnshowaltermdblog</a>.
<o:p></o:p></div>
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‘While many healthcare leaders realize that a big bang
go-live is technologically best for their institution, they remain apprehensive
because of the operational challenges,’ Showalter said. ‘I am sure we will have
our share of challenges, but I hope that by being open and honest about my
experience, others will have less anxiety about large scale go-lives. Ultimately,
it’s about doing what’s best for our patients and the community we serve.’<o:p></o:p></div>
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Showalter’s Twitter and Facebook communications will be
separate from the official UMMC Twitter and Facebook updates. <o:p></o:p></div>
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Showalter has already begun Tweeting his take on the
implementation process. He will continue to dialogue on both Twitter and
Facebook leading up to and following go-live on June 1, 2012.<o:p></o:p></div>
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About John Showalter:<o:p></o:p></div>
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Showalter is a board certified Internal Medicine physician.
He also holds a Master’s Degree in Information Systems and completed fellowship
training in Medical Informatics. Showalter joined the University of Mississippi
Medical Center last year to assist in leading the implementation of the
electronic health record. He also practices Internal Medicine as a hospitalist.
<o:p></o:p></div>
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Contact:<o:p></o:p></div>
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John Showalter <o:p></o:p></div>
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JohnShowalterMD.com<o:p></o:p></div>
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<a href="mailto:JohnShowalterMD@gmail.com">JohnShowalterMD@gmail.com</a><o:p></o:p></div>
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@JohnShowalterMD<o:p></o:p></div>
</div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-45494477506350596502012-05-10T23:20:00.000-04:002012-05-10T23:20:02.873-04:00What is #GoLiveGetCKM?<div dir="ltr" style="text-align: left;" trbidi="on">
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTjvpGCgILjaptm2Ac7jcTPNv8wp8zLslXwM6U4pv6rHgwW39xxhGfvrQHt5xR4bUBJs6x_NMtI7vH_2i2JRDt-Vy-olGpMNivbYq91PJY_5Yt610GUs2rzQIvEdsuJQlzsJyX3hlS56JF/s1600/recovery-billboard-smith.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="283" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhTjvpGCgILjaptm2Ac7jcTPNv8wp8zLslXwM6U4pv6rHgwW39xxhGfvrQHt5xR4bUBJs6x_NMtI7vH_2i2JRDt-Vy-olGpMNivbYq91PJY_5Yt610GUs2rzQIvEdsuJQlzsJyX3hlS56JF/s400/recovery-billboard-smith.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Doctor, Patient, and EHR. <a href="http://www.hhs.gov/recovery/programs/healthittexas.html" target="_blank">Source</a></td></tr>
</tbody></table>
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Going live with 20+ applications at 5 hospitals and 95
clinics is a big deal. But a fully integrated electronic health record isn’t
the end game. <o:p></o:p></div>
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#GoLiveGetCKM is about keeping the patient in the forefront
of our minds during the intensity and mayhem of a big-bang go-live.<o:p></o:p></div>
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#GoLiveGetCKM is what happens when we leverage our EHR in
every way possible to benefit our patients through research, practice-based
evidence, improved efficiency, improved quality and decreased cost. <o:p></o:p></div>
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#GoLiveGetCKM is not about getting the system working, it’s
about working the system.<o:p></o:p></div>
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<a href="http://twitter.com/#!/johnshowaltermd" target="_blank">Follow me on Twitter</a> and follow <b>#GoLiveGetCKM</b> to see where
we are headed!<o:p></o:p></div>
<!--EndFragment-->
</div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-50321061620160732422012-05-10T23:12:00.000-04:002012-05-10T23:12:27.339-04:00What is #LiveTheGoLive?<div dir="ltr" style="text-align: left;" trbidi="on">
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There are go-lives. There are big go-lives.<span style="mso-spacerun: yes;"> </span>There are really big go-lives.</div>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJkYPfYibZxzoesMr8rf4XJ7gwiiqihO1g8hFGGlQwcbJPsQBJtBlk9eqUsrOYLMG0exqFY-tWoeEKopH69uDiVocLtgukoVkDxt5P5_gM-DHzAQBVZKopVRjVD5B7jXtyBEs8w0eyv8Bp/s1600/big_bang_by_darkshadowinme-d3a5jz1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJkYPfYibZxzoesMr8rf4XJ7gwiiqihO1g8hFGGlQwcbJPsQBJtBlk9eqUsrOYLMG0exqFY-tWoeEKopH69uDiVocLtgukoVkDxt5P5_gM-DHzAQBVZKopVRjVD5B7jXtyBEs8w0eyv8Bp/s400/big_bang_by_darkshadowinme-d3a5jz1.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Big Bang <a href="http://darkshadowinme.deviantart.com/art/Big-bang-198453853" target="_blank">Source</a></td></tr>
</tbody></table>
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<o:p></o:p></div>
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And then there are truly <b>EPIC</b> go-lives.<o:p></o:p></div>
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June 1, 2012 will be the dawn of an EPIC go-live at the
University of Mississippi Medical Center. At 5am CST we are going live with 20+
applications in 5 hospitals and 95 clinics with over 6,500 end users.<span style="mso-spacerun: yes;"> </span><o:p></o:p></div>
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As the CMIO, I will be on the front-lines as we
revolutionize health care in Central Mississippi. I will be live tweeting my
experiences with this EPIC go-live. I am sure there will be challenges, but I’m
also sure our team is poised for victory. <a href="http://twitter.com/#!/johnshowaltermd" target="_blank">Follow me on Twitter</a> and follow
<b>#LiveTheGoLive</b> to get the latest scoop!<o:p></o:p></div>
<!--EndFragment-->
</div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-2926977910189467142012-04-20T22:09:00.000-04:002012-04-20T22:09:26.061-04:00Featured Post at Health Data Management Magazine<div dir="ltr" style="text-align: left;" trbidi="on"><blockquote class="tr_bq" style="text-align: -webkit-auto;"><div style="background-color: white; color: #333333; line-height: 20px; text-align: center;"><em><span style="font-family: inherit;">“Know the enemy and know yourself, and your victory will never be endangered; know the weather and know the ground, and your victory will then be complete.”</span></em></div><div style="background-color: white; color: #333333; line-height: 20px; text-align: center;"><span style="font-family: inherit;"> <strong>Sun Tzu 500 B.C.</strong></span></div></blockquote><br />
<span style="font-family: inherit;"><i><span style="background-color: white; color: #333333; line-height: 24px; text-align: -webkit-auto;">Twenty-five hundred years ago, Sun Tzu asserted that with sufficient knowledge about yourself, your opponent and the environment, your victory would be assured. In our battles against rising health care costs and medical errors, this wisdom has been lost...</span></i></span><br />
<span style="font-family: inherit;"><i><span style="background-color: white; color: #333333; line-height: 24px; text-align: -webkit-auto;"><br />
</span></i></span><br />
<div style="text-align: -webkit-auto;"><a href="http://www.healthdatamanagement.com/blogs/EHR-CDS-research-healthcare-knowledge-generation-44346-1.html" style="text-align: left;" target="_blank">Read more</a><span style="text-align: left;"> over at </span><a href="http://www.healthdatamanagement.com/" style="text-align: left;" target="_blank">Health Data Management Magazine</a><span style="text-align: left;">.</span><span style="text-align: left;"> </span></div></div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-42350656316236993302012-03-28T08:00:00.001-04:002012-03-28T08:00:06.215-04:00PapPap, the Talking Scale, and Readmissions<div dir="ltr" style="text-align: left;" trbidi="on"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuz0FHU2bGUcab6vaP1AsXytnG3LmdBDyuhzM8MyX30NvcubYj4ZL2ltdeikVIQVaY2ZOWrq0thyi18953v8TYM_z3Ru_o2Kq-tNGtHl_3cbygzS5rPOkcIJ-h12P-KN3CJYcb34h0JBze/s1600/IMG_0449.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjuz0FHU2bGUcab6vaP1AsXytnG3LmdBDyuhzM8MyX30NvcubYj4ZL2ltdeikVIQVaY2ZOWrq0thyi18953v8TYM_z3Ru_o2Kq-tNGtHl_3cbygzS5rPOkcIJ-h12P-KN3CJYcb34h0JBze/s400/IMG_0449.JPG" width="300" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">My PapPap and my son. October, 2010</td></tr>
</tbody></table><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Geisinger Health Plan recently reported that <a href="http://www.healthcarepayernews.com/content/geisinger-health-plans-remote-monitoring-program-cuts-readmissions-44-percent">the use of interactive voice response and telemonitoring technologies facilitated a 44% reduction in hospital readmissions</a> for patients with congestive heart failure, diabetes, and hypertension. This reduction was demonstrated in a clinical trial studying the technologies above versus the standard post-hospitalization follow-up. My PapPap happened to be a participant in the pilot group that led to this study. </div><br />
Upon discharge from the hospital, my PapPap was given a "talking scale" and instructed to plug it into the power socket and phone line (the pilot group was not wireless.) Each morning, he was to stand on it and have his weight measured. Each morning, the scale would capture his weight and ask him a series of standard questions about how he was feeling.<br />
<br />
This led to a great deal of cursing.<br />
<br />
Being the man he is, my grandfather attempted to have a conversation with the scale. He wasn't trying to be difficult... he was just being himself. Let me replay a typical exchange between my PapPap and the scale:<br />
<br />
<i>Scale</i>: Are you short of breath?<br />
PapPap: Naw, my breathing's fine.<br />
<i>Scale</i>: Are you short of breath?<br />
PapPap: I already told you my breathing's okay.<br />
<i>Scale</i>: Are you short of breath?<br />
PapPap: Bernice! This damn thing's not working!<br />
<i>Scale</i>: Are you short of breath?<br />
PapPap: Bernice! Call Elaine and tell her this idiot scale's not working again!<br />
<i>Scale</i>: Are you short of breath?<br />
PapPap: No! Now, how many times do I have to tell you?<br />
<i>Scale</i>: Okay. Do you have any swelling?<br />
<br />
This type of exchange happened fairly routinely until we explained to him that the scale only wanted yes and no answers. After several days, my PapPap and the scale came to an understanding. One day, his weight and responses were outside of the acceptable standards and he received a call from his nurse. He was instructed to make some changes to his medications.<br />
<br />
This type of early and personalized response kept him and patients like him from needing to return to the hospital. Yet, it wasn't the <i>scale </i>that kept him out of the hospital. It was the way Geisinger Health Plan managed the <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">knowledge </a>about his condition.<br />
<br />
Through the use of the talking scale, GHP collected standardized data at regular intervals to create information about PapPap's clinical course. That information was combined with algorithms to create knowledge about his clinical condition and generate clinical alerts that notified his providers about the change in his condition. These alerts represent actionable knowledge that allowed for early interventions to be performed and prevent further clinical decline in each patient.<br />
<br />
While many are lauding the technologies used in this study, it was not the the Bluetooth, the interactive voice recognition software nor the talking scale that produced such dramatic improvements. It was the generation of <i>individualized actionable knowledge</i> for each participant that led to GHP's success and my PapPap's continued recovery.<br />
<br />
Although, to hear him tell it, that damn idiot scale had nothing to do with it! </div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com1tag:blogger.com,1999:blog-1114788714717795395.post-22736977794478910292012-03-10T00:02:00.000-05:002012-03-10T00:02:41.960-05:00EMR Implementation Interview<div dir="ltr" style="text-align: left;" trbidi="on">Last month at <a href="http://www.himss.org/ASP/index.asp">HiMSS</a>12 I gave a brief interview to <a href="http://hitexchangemedia.com/">HIT Exchange</a> about the <a href="http://www.epic.com/">Epic </a>implementation I am leading.<br />
<br />
You can check out the interview <a href="http://hitexchangemedia.com/video/OGJsLwT7t_k">here</a>.<br />
<br />
(If you think I'm looking tired, it's because the HiMSS exhibit space was massive- you could walk for days!)<br />
<br />
(And also, I was in Vegas.)</div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-36043236069221864722012-02-29T01:23:00.000-05:002012-02-29T01:23:23.323-05:00Patients Need Actionable Knowledge<div dir="ltr" style="text-align: left;" trbidi="on"><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: left;">Meaningful use has defined <a href="http://www.aappm.org/docs/13ClinicalSummaries.pdf">the data that should be included in a clinical summar</a>y. According to Stage I, the following demonstrates the minimum requirement necessary to qualify for this measure.</div><div class="separator" style="clear: both; text-align: center;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_z80jz7axD1q54p38pjpjBTnXb_UnejdjTIOKqDWymnUy_Sg0H8I1K-wMqAyuxrslvD6wcMqQWVTJH0nS02UecLtnoTerbfyGZCpu7CFFXD7zdXKse9RDqbv9qBco8lu80tVdHbHo59Mq/s1600/MU+AVS.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_z80jz7axD1q54p38pjpjBTnXb_UnejdjTIOKqDWymnUy_Sg0H8I1K-wMqAyuxrslvD6wcMqQWVTJH0nS02UecLtnoTerbfyGZCpu7CFFXD7zdXKse9RDqbv9qBco8lu80tVdHbHo59Mq/s640/MU+AVS.jpg" width="494" /></a></div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">"Just the facts, ma'am." That about sums it up. This summary includes the required data and can easily be extracted from the EHR.</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">But it doesn't do much else. It certainly doesn't engage the patient, provide them with actionable knowledge or meet the spirit of the meaningful use measure.</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">However, with minimal provider data entry, well thought out templates and re-formatting with the goal of patient engagement, the clinical summary can be packed with actionable knowledge. That same visit could produce something like this:</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7H61FIlceeVgDasKXDjuW4rK9tYO-1BblPRG-6S8wnx7zf68XG4ViZc0sGv0NV_mjyw7j0FJtIdeMkYIScHqh_VW2IR3I0lkkEU_esEOKx-fC6dJtm8ExB0ghMCnYEIZHDN8W6z_EkFCc/s1600/Pt+Knowledge+AVS.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7H61FIlceeVgDasKXDjuW4rK9tYO-1BblPRG-6S8wnx7zf68XG4ViZc0sGv0NV_mjyw7j0FJtIdeMkYIScHqh_VW2IR3I0lkkEU_esEOKx-fC6dJtm8ExB0ghMCnYEIZHDN8W6z_EkFCc/s640/Pt+Knowledge+AVS.jpg" width="494" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXBv4lAzl9rLrWE2InbQt1aatV81QewBhfqTt9zoPOMQGYWUmkAu70HMFkMT0vkcNZARjFpywjb4ntGgxOOuUNVa3YeMVSEU9ecF6xyPRjECeKGP82XnxYGoA7uPofvemEQFKP4K47uOWj/s1600/Pt+Knowledge+AVS+II.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhXBv4lAzl9rLrWE2InbQt1aatV81QewBhfqTt9zoPOMQGYWUmkAu70HMFkMT0vkcNZARjFpywjb4ntGgxOOuUNVa3YeMVSEU9ecF6xyPRjECeKGP82XnxYGoA7uPofvemEQFKP4K47uOWj/s640/Pt+Knowledge+AVS+II.jpg" width="494" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglZ0ZwdEQgEixrOOl7w6JZH_vnYTMvAO7s-79g7dqjWhcWFIC8OMAaDVvsOepkNHCWcACeDYQe-jvwiiS-ZONJPcwI1CZcEAXAqiuNkSN3uYpGFBRRXq1rd5eLd8lseRIPnw5fmLL9B7ud/s1600/Pt+Knowledge+AVS+III.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglZ0ZwdEQgEixrOOl7w6JZH_vnYTMvAO7s-79g7dqjWhcWFIC8OMAaDVvsOepkNHCWcACeDYQe-jvwiiS-ZONJPcwI1CZcEAXAqiuNkSN3uYpGFBRRXq1rd5eLd8lseRIPnw5fmLL9B7ud/s640/Pt+Knowledge+AVS+III.jpg" width="494" /></a></div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;">Presenting patients with knowledge about their health is a key in engaging them as active participants in their care. As medical providers, we need to demand that EHR vendors provide us with tools that will meet this need.</div><div class="separator" style="clear: both; text-align: left;"><br />
</div><div class="separator" style="clear: both; text-align: left;"><a href="http://www.ofr.gov/OFRUpload/OFRData/2012-04443_PI.pdf">Meaningful Use Stage II</a> comment period opens next week. We need to provide feedback so that loopholes like the one above are eliminated. <b>What good is meeting program requirements if we haven't met the needs of the patient?</b></div></div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com1tag:blogger.com,1999:blog-1114788714717795395.post-58185960819227531452012-02-09T08:56:00.004-05:002012-02-09T08:56:00.851-05:00Meaningful Use and CKM<div dir="ltr" style="text-align: left;" trbidi="on"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://www.tedeytan.com/wp-content/uploads/2010/08/LygeiaWordle-300x202.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="269" src="http://www.tedeytan.com/wp-content/uploads/2010/08/LygeiaWordle-300x202.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://www.tedeytan.com/2010/08/03/5927">Source</a></td></tr>
</tbody></table><br />
<b>Meaningful Use: What Is It?</b><br />
<br />
<ul style="text-align: left;"><li>By <a href="http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives">definition</a>, <a href="https://www.cms.gov/EHRIncentivePrograms/30_Meaningful_Use.asp">meaningful use</a> refers to the use of certified electronic health record technology to perform certain tasks.</li>
<li>Meaningful Use Stage I is ultimately an outline for better and more affordable healthcare</li>
<li>While not yet established, it is hoped that Stage II and III will complete the first chapters of better and more affordable healthcare</li>
<li>Meaningful Use is an important infrastructure for improving healthcare</li>
<li>Meaningful Use limits its focus to using technology</li>
</ul><b><b><br />
</b><br />
Meaningful Use: What <i>Isn't</i> It?</b><br />
<br />
<ul style="text-align: left;"><li>Meaningful Use is not a comprehensive plan to leverage technology for healthcare improvement</li>
<li>Meaningful Use is not focused on the <i>use </i>of data</li>
<li>Meaningful Use is not <a href="http://www.johnshowaltermd.com/p/what-is-ckm.html">Clinical Knowledge Management</a></li>
</ul><div><br />
</div><div><b>Meaningful Use and Clinical Knowledge Management</b></div><div><br />
</div><div>Meaningful Use is focused on the collection, storage, and reporting of data, not the creation of <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">actionable knowledge</a>. While MU creates outlines, paragraphs, and chapters in data collection, Clinical Knowledge Management creates volumes of knowledge to improve all aspects of healthcare. These volumes of knowledge are needed if we are ever going to bend the cost curve in the US healthcare system. </div><div><br />
</div><div>MU needs to be built with this end in mind; if we don't take this opportunity to build the necessary infrastructure, we will not be able to generate the knowledge needed to make a sustainable US healthcare system. The conversations about MU need to expand beyond implementation dates, reimbursement, and vendor/physician concerns. We need to include discussions about which data needs to be captured to insure the generation of sufficient knowledge to allow optimal return from the investment in Meaningful Use.</div><div><br />
</div></div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-54978312562421137862012-02-06T20:35:00.000-05:002012-02-06T20:35:27.416-05:00Revealing Bias in Healthcare Decision Making<div dir="ltr" style="text-align: left;" trbidi="on"><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="http://ecx.images-amazon.com/images/I/51VcGBtiLTL._BO2,204,203,200_PIsitb-sticker-arrow-click,TopRight,35,-76_AA300_SH20_OU01_.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="http://ecx.images-amazon.com/images/I/51VcGBtiLTL._BO2,204,203,200_PIsitb-sticker-arrow-click,TopRight,35,-76_AA300_SH20_OU01_.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><a href="http://www.amazon.com/dp/0553386794/ref=rdr_ext_tmb">Source</a></td></tr>
</tbody></table><br />
I've recently been reading the Song of Ice and Fire series (Game of Thrones) by <a href="http://georgerrmartin.com/">George R. R. Martin</a>. While the plot is engaging and intriguing, one of the things I enjoy about the book is that it is written from the third person multiple perspective. Each chapter is limited to a specific character's perspective, but many characters get to tell the story. With this narrator point of view, the story develops with more layers and nuance than other perspectives. Each character's biases are revealed, and the reader is able to develop their own opinion of the events in the story.<br />
<br />
Bringing the bias of each character to the surface through the third person multiple perspective deepens the understanding of the setting of the book. Similarly, bringing the bias to the surface in healthcare decision making helps us develop better knowledge and make better decisions. Just as each character in the novel is limited by what they can sense and feel, so each type of healthcare knowledge is limited by the constraints of its data.<br />
<br />
These constraints make the exclusive use of any single type of healthcare knowledge unwise. We need to use multiple types of healthcare knowledge to better understand the current environment. For instance, in any single healthcare decision making process, knowledge can be garnered through:<br />
<br />
<ul style="text-align: left;"><li>Institutional knowledge</li>
<li>Quality knowledge</li>
<li>Research knowledge</li>
<li>Financial knowledge</li>
<li>Operational knowledge</li>
<li>Medical knowledge</li>
<li>Direct Care knowledge</li>
<li>Transactional knowledge</li>
<li>Analytical knowledge</li>
</ul><div>When we combine multiple types of healthcare knowledge we are able to develop a more layered and nuanced understanding of the challenge facing us and thus make better decisions and take more appropriate actions.</div><br />
<br />
</div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-34455990213823909432011-09-22T09:33:00.000-04:002011-09-21T23:53:43.099-04:00Structure, Process, Outcomes and CKM<div dir="ltr" style="text-align: left;" trbidi="on"><span class="Apple-style-span" style="background-color: white;"><span class="Apple-style-span" style="font-family: inherit;"></span></span><br />
<div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Over 40 years ago, Donabedian described a model of assessing quality within a system. The model had three components: structure, process and outcomes. AHRQ has a detail description of <a href="http://www.ahrq.gov/qual/medteam/medteam4.htm#donabedian">Donabedian’s Model</a>. In short, it states that a system’s outcomes are based on its processes and its processes are bound by its structure. In order to have a long lasting effect on outcomes of interest you need to make changes to the system’s structure and processes. </span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">An understanding of this system is essential to clinical knowledge management because each component of the model represents a different knowledge type and often a different knowledge source. Knowledge about all three is needed to reach the threshold for <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">actionable knowledge</a> when solving system-based quality problems. If the threshold of actionable knowledge is not met, you will be guessing at which parts of the system to change. In my opinion, the guessing of which parts of the healthcare system to change explains the limited success there has been with improving quality in healthcare.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">A stepwise process should be used to create actionable knowledge for system-based quality questions.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Step 1. Define, measure and benchmark the outcome of interest.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Step 2. Determine if the outcome of interest is at goal levels of performance. If not, go to step 3. Otherwise, spend you energy on a different issue.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Step 3. Define, measure and benchmark the processes driving the outcome of interest.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Step 4. Determine which process or processes are preventing the outcome from reaching goal levels.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Step 5. Define the structure of the processes identified in Step 4.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Step 6. Combine the knowledge developed in the previous steps to make actionable knowledge.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">Step 7. Now that you have completed the first step of the <a href="http://www.johnshowaltermd.com/2011/03/auri-cycle.html">AURI cycle</a> (analysis), complete the AURI cycle to develop appropriate system changes and track their effect.</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br />
</div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">This process was used to reduce sepsis mortality at my previous hospital. It was first determined that sepsis mortality was above goal. Two main <i>processes </i>were identified as driving the mortality: the identification of the presence of sepsis and the time it took to deliver antibiotics. The <i>structure </i>around the diagnosis process was that physicians and nurses did not receive standard education on recognizing sepsis and there were no job aids to help them identify patients. With regards to the delivery of antibiotics, one of the most popular antibiotics ordered for these patients had to be mixed in a sterile hood by a pharmacist and thus administration was delayed. </span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></div><div class="yiv2042587715MsoNormal" style="display: block; line-height: normal; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="Apple-style-span" style="font-family: inherit;">The structural changes made to improve the outcome were the standard education of nurses and physicians as well as the creation of posters that were posted in the emergency department on how to identify patients with sepsis. Additionally, a formulary change allowed an alternative antibiotic to be immediately available in the emergency department. These structural changes resulted in improved processes for identifying patients and delivering antibiotics more rapidly. The effect on the outcome has been a sustained 37% reduction in mortality for patients presenting to the emergency department with sepsis.</span></div></div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-1651766649736633712011-08-11T23:31:00.001-04:002011-08-11T23:35:03.934-04:00Freakonomics and CKM<div dir="ltr" style="text-align: left;" trbidi="on"><br />
<div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;">Asking the right questions and using the right analytics can lead to major knowledge breakthroughs. However, it is often difficult to know which questions are the <i>right </i>questions. <span class="apple-converted-space"> <o:p></o:p></span></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><br />
</div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;">Steve D. Levitt and Stephen J. Dubner, the authors of <a href="http://freakonomicsbook.com/">Freakonomics</a>, would argue that you should not focus on asking one <i>specific </i>question based on what is known, but instead ask a <i>variety </i>of questions and use the right analytics to discover hidden connections between seemingly unconnected variables. <span class="apple-converted-space"> </span>They reason that you will hit a number of dead ends and a number of questions won’t have clear answers, but some will be extremely revealing and meaningful.<o:p></o:p></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><br />
</div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;">The analytic approach they write about is based in economics with five major principles:<o:p></o:p></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"> <o:p></o:p></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"><i>“Incentives are the cornerstone of modern life.”<o:p></o:p></i></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"><i> <o:p></o:p></i></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"><i>“The conventional wisdom is often wrong.”<o:p></o:p></i></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"><i> <o:p></o:p></i></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in; text-indent: .5in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"><i>“Dramatic effects often have distant, even subtle causes.”<o:p></o:p></i></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .5in; margin-right: 0in; margin-top: 0in;"><br />
</div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .5in; margin-right: 0in; margin-top: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"><i>““Experts” – from criminologist to real-estate agents – use their informational advantage to serve their own agenda.”<o:p></o:p></i></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .5in; margin-right: 0in; margin-top: 0in;"><br />
</div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin-bottom: 0in; margin-left: .5in; margin-right: 0in; margin-top: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;"><i>“Knowing what to measure and how to measure it makes a complicated world much less so.”</i><o:p></o:p></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><br />
</div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;">Their book analyzes the drop in violent crime in the 1990s and cheating in sumo wrestling, among various other topics. <span class="apple-converted-space"> </span>One large subject area that was mostly absent from the book was healthcare. <span class="apple-converted-space"> <o:p></o:p></span></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><br />
</div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><span style="background-attachment: initial; background-clip: initial; background-color: white; background-image: initial; background-origin: initial;"><span class="Apple-style-span" style="font-family: inherit;">I believe that their approach could be very revealing when applied to healthcare quality improvement, or the relative lack thereof. <span class="apple-converted-space"> </span>Deep reliance on expert opinion rather than objective data, misaligned incentives that don’t support quality goals and limited ability to measure and understand the measurements of quality outcomes must play a role in the state of quality improvement. It would be fascinating to see the authors of the book explore this issue. With a robust health information system in place, many questions could be asked and efficiently answered, potentially revealing meaningful hidden connections to quality improvement in the healthcare setting.</span><span class="Apple-style-span" style="color: #454545; font-family: Arial, sans-serif;"><o:p></o:p></span></span></div><div class="yiv1589367518msonormal" style="background: white; margin-bottom: .0001pt; margin: 0in;"><br />
</div><iframe class="om-messageread-app" style="border-bottom-style: none; border-color: initial; border-left-style: none; border-right-style: none; border-top-style: none; border-width: initial; height: 1px; position: absolute; top: -5000px; visibility: hidden; width: 1px;"></iframe></div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-64525011308988479292011-08-04T08:37:00.003-04:002011-08-04T08:37:00.883-04:00Better Questions, Better Answers, Better Solutions<div class="MsoNormal" style="background: white; line-height: normal;"><span class="Apple-style-span" style="font-family: inherit;">Often, when we are struggling to make good decisions, the problem is not the quality of the <i>data </i>available… it is the quality of the <i>question</i>. This is because the threshold for achieving <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">actionable knowledge</a> is dependent on the question being asked. The more simple and specific you make the question, the easier it is to gather enough information to reach the threshold for actionable knowledge. If the question being asked is too broad, the question itself may prevent the creation of actionable knowledge.<br />
<br />
A perfect example of this in the medical field is the current discussion about salt intake. The main concern is the sodium component of salt. Diets high in sodium have been associated with increased rates of hypertension, which is clearly linked to an increased chance of heart attack and stroke. Because of these associations, there has been a public health campaign to advise adults in the US to reduce their salt intake. However, the campaign to reduce salt consumption has recently become controversial. This controversy stems from asking a question that is too broad to facilitate the creation of actionable knowledge. The question being asked is “What should we tell the US adult population about salt intake?”<br />
<br />
A <a href="http://archinte.ama-assn.org/cgi/content/abstract/171/13/1183">recent article</a> in the Archives of Internal Medicine demonstrated a reduction in cardiovascular mortality associated with lower sodium diets. The study was statistically adjusted to be a representative sample of the US population. This article gives the appearance of creating sufficient actionable knowledge to tell the US population to eat less salt. However, two other recent studies create serious doubts about that conclusion. The <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa0907355#t=abstract">first study</a>, published in the New England Journal of Medicine, was also a study modeling the US and showed that the mortality benefit for a lower sodium diet had a significantly larger impact for blacks than for whites. The <a href="http://jama.ama-assn.org/content/305/17/1777.abstract">second article</a>, published in the Journal of the American Medical Association, was a European study that only looked at a relatively young and healthy white cohort; this study demonstrated a large increase in mortality for the subjects with the lowest sodium diets.<br />
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These articles appear to disagree and there have been discussions about the methods of each study. No study is perfect and the conclusions from any of the three may be proven incorrect, but it is also possible that all three <i>may </i>be correct. It is possible that young and healthy whites in Europe may be harmed by a diet that restricts salt intake. Sodium is necessary for several biological functions. However, white, young, and healthy only represent a small group in a study that utilizing a sample representative of the adult US population. The potential harm to the white, young, and healthy cohort may be washed out by the benefits for other groups.<br />
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These studies create debate because the question being asked is too broad. If you believe that eating less salt will harm a cohort of people, it is unethical to tell them to do so. If you are then trying to take action based on the question “What should we tell the US adult population about salt intake?” you have quite a dilemma. <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: normal;"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></div><div class="MsoNormal" style="background: white; line-height: normal;"><span class="Apple-style-span" style="font-family: inherit;">I suggest in these cases you don’t try to solve that dilemma with <i>more </i>data, information and knowledge. <b>You solve it by changing the question</b>. If some groups are helped by an action and others harmed, the question should <i>not </i>be “what advice do we give the whole population?” The question <i>should </i>be “how do I advise each cohort in the population?” <o:p></o:p></span></div><div class="MsoNormal" style="background: white; line-height: normal;"><span class="Apple-style-span" style="font-family: inherit;"><br />
</span></div><span style="line-height: 115%;"><span class="Apple-style-span" style="font-family: inherit;">With regard to salt intake, we should stop asking “what should we tell the US adult population about salt intake?” and start asking "who in the US do we need to tell to eat less salt?"</span></span>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-78385707475438662842011-08-01T10:12:00.008-04:002011-08-01T10:12:00.437-04:00Health Information Exchanges and CKM<a href="http://searchhealthit.techtarget.com/definition/Health-information-exchange-HIE">According to SearchHealthIT</a>, health information exchange is "the transmission of healthcare-related data among facilities, health information organizations (HIO) and government agencies..." Health information exchanges have been suggested as a tool to improve the delivery of care, especially in emergency departments and other acute care settings. However, there has been little evidence that proves they create <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">actionable knowledge</a>.<br />
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One study that indicates HIEs do produce actionable knowledge was presented at the <a href="http://www.sgim.org/">Society of General Internal Medicine</a> Annual Conference earlier this year. Dr. Lisa Mabry and colleagues presented a poster entitled "Does Health Information Exchange Use Improve Adherence With Evidence-Based Guidelines for Neuroimaging in the Emergency Evaluation of Headache?" Their study investigated whether ED staff use of the <a href="http://www.midsoutheha.org/">MidSouth e-Heatlh Alliance</a> HIE, a health information exchange in the greater Memphis area, reduced the use of neuroimaging in patients presenting with repeat episodes of headache. Their results showed that although the HIE was only used in 21.8% of encounters, when it was used, it was associated with a 76% decreased odds of neuroimaging. Additionally, adherence to evidence-based guidelines was improved.<br />
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These results indicate that, at least with regard to headache, the HIE does provide the user with actionable knowledge. If the HIE was used more frequently, unnecessary cost, testing, and radiation exposure could be avoided.<br />
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As creation and utilization of health information exchanges expands, it is important to design them in a fashion that assists users in reaching the threshold for actionable knowledge. Focusing on overcoming technical challenges to allow for the transmission of data within HIEs rather than insuring their ability to communicate actionable knowledge will limit the effectiveness and relevance of this technology.John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-66061349236516005422011-07-28T05:15:00.000-04:002011-07-28T05:15:00.645-04:00CKM and Positive Deviance<a href="http://www.positivedeviance.org/about_pd/index.html">Positive deviance</a> is a strategic approach to identifying top-performing individuals or groups, and disseminating their special knowledge to the remainder of the group. If you've read <a href="http://www.gladwell.com/outliers/index.html">Malcolm Gladwell's book Outliers</a>, you are familiar with the concept of positive deviants; positive deviance identifies these outliers for the basis of process change and improvement. Historically, positive deviance was used to improve conditions in the developing world, including malnutrition and peri-natal mortality. Recently, positive deviance has been <a href="http://www.positivedeviance.org/pdf/publications/Positive%20Deviance%20-%20A%20new%20strategy%20for%20improving%20hand%20hygiene%20compliance%20ICHE%202010-1.pdf">applied to quality improvement in health care.</a><br />
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Positive deviance can play an important role in health care. The process not only identifies the positive outliers but also provides the framework for disseminating their knowledge. However, until recently, identifying individuals and groups with significantly better outcomes has been difficult in health care.<br />
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As organizations increasingly implement robust HIS systems, the systematic identification of positive deviants has become possible. From this starting point, <a href="http://www.johnshowaltermd.com/2011/03/auri-cycle.html">the AURI cycle</a> can be used to create <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">actionable knowledge</a> which can be disseminated and implemented. This is why clinical knowledge management is an excellent platform for quality improvement.<br />
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To use positive deviance in the <a href="http://www.johnshowaltermd.com/2011/03/process-of-ckm.html">CKM process</a> for a QI project, the "analyze" step of the AURI cycle is divided into three actions:<br />
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<ol><li>Identify individuals or groups with significantly better performance in your outcome of interest</li>
<li>Utilize quantitative techniques to determine differences in care delivery between positive deviants and others</li>
<li>Utilize qualitative techniques to determine differences in care delivery between positive deviants and others</li>
</ol><div>During the "understand" step of the AURI cycle, the differences in care delivery identified in the "analyze" step are examined to determine which are most significant. These significant differences are then incorporated in the "redesign" step. During the "implement" step, these differences in care delivery and their importance to the redesign are communicated to the group. The cycle continues by analyzing whether the remainder of the group has adopted the new care processes and if they have had the desired impact on outcomes. </div><div><br />
</div><div>By using positive deviance in conjunction with the CKM process, quality improvement projects can demonstrate rapid improvement. </div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com2tag:blogger.com,1999:blog-1114788714717795395.post-43348006127260531252011-07-25T04:52:00.000-04:002011-07-25T04:52:00.142-04:00CKM and ReadmissionsThe <i><a href="http://www.springer.com/medicine/internal/journal/11606">Journal of General Internal Medicine</a></i> recently published <a href="http://www.springerlink.com/content/46312r2224861652/">my paper</a> examining the effects of standardized discharge instructions on readmission. Readers may be surprised that standardizing our discharge instructions to meet consensus recommendations did <i>not </i>reduce readmissions.<br />
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However, in light of the necessity of providing <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">actionable knowledge</a> to improve decision making, these findings begin to make sense.<br />
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The standardization of the discharge instructions focused on insuring that a set of recommended components (ie: discharge medications, follow-up appointments, contact information, etc.) were always provided to the patient at the time of discharge. On the continuum from data to actionable knowledge, these components are information. Although patients can often synthesize these various information points into knowledge, good decision making is born of actionable knowledge. To move from information, to knowledge, to actionable knowledge, you first have to understand the question that discharge instructions are trying to answer: <i>how should I take care of myself outside of the hospital so that I don't have to come back? </i><br />
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In light of this question, actionable knowledge is based on an understanding of the patient's own health and disease processes as well as the actions necessary to maintain their health. The capacity to understand and perform these actions is highly variable among patients. Therefore, interventions to prevent readmission need to be <i>customized </i>to each individual patient rather than <i>standardized</i>.<br />
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Whether these customized interventions will be time efficient and cost effective has not yet been determined. However, in my opinion, discharge interventions that are not customized to the patient will continue to show lackluster results.John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-91211575970817363802011-06-29T22:55:00.001-04:002011-07-24T23:08:12.679-04:00CKM and Serenity<span class="Apple-style-span" style="font-family: Georgia, serif;">Clinical informatics and electronic health records are often offered as the path to high quality medical care and reduced adverse events. However, technology can only help deliver the best care medical knowledge can achieve. Frequently, even with the best implementation, technology can only get adverse events and complications of care to an irreducible minimum. After that new medical knowledge is needed. This is where CKM can be extremely important. Even when CKM doesn’t provide new knowledge for medical advancement, it can provide a clear indication if an irreducible minimum has been meet.</span><br />
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</div><div class="MsoNormal"><span style="font-family: Georgia, serif;">When considering this, I often think of the Serenity Prayer.</span><br />
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</span></div><div align="center" class="MsoNormal" style="text-align: center;"><span style="font-family: Georgia, serif;">God grant me the serenity <br />
to accept the things I cannot change; <br />
courage to change the things I can;<br />
and wisdom to know the difference.</span></div><div align="center" class="MsoNormal" style="text-align: center;"><br />
</div><div class="MsoNormal"><span style="font-family: Georgia, serif;">CKM can help provide the wisdom to know the difference. Well designed CKM can determine if patients received ideal care for specific disorders, i.e. early goal directed therapy for sepsis. If 100 patients all received perfect care and 20 died then there is nothing to change. However, if 100 patients received less than perfect care and 30 died, we need to have the courage to change the system. </span></div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-73547005715386959872011-04-25T08:19:00.003-04:002011-07-24T23:08:42.096-04:00American Airlines and CKMThe other morning I was sitting in a meeting and a question was raised. That question was "do we really know that understanding our data better, and using tools such as data visualization, will really improve healthcare?"<br />
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Only in healthcare would this question still be asked in 2011.<br />
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Industries of all types have learned over the last 20 years the power of developing knowledge based on their actions and the actions of their customers. Many of these industries are not as complicated as healthcare. But I believe that the idea that healthcare is the most complex industry is erroneous; however, it's been my experience that this idea is deeply rooted in the culture of medicine. It seems to be felt that since there are so many uncontrollable factors such as patient complexity, patient compliance, variations in disease presentation, and the intricate web of payers and delivery systems, it is not possible to understand the "healthcare system" with data. I do not believe this is true, and in support of my position, I'd like to present a case from an industry that is at least as complex as the healthcare system: the airline industry.<br />
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Within the airline industry, the uncontrollable variable range from mechanical problems to passenger behavior to natural disasters to terrorist attacks... to the most unpredictable of all- the weather! Despite all of these variables, there are many examples of how the airline industry has transformed data into knowledge, improved service, and remained profitable.<br />
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Take, for example, the <a href="http://www.gleanster.com/images/success_stories_pdf/Gleanster-AmericanAirlines-BI.pdf">recent case study reported by American Airlines</a>. American Airlines had identified fraud as a major cost to their business. However, they had no data warehouse technology or knowledge management plan for addressing fraud in their system. It was originally estimated that an effective data analytics system would save the company $150,000 per year. Using an "off-the-shelf" data warehouse solution, great gains were immediately seen, and ultimately saved the company $5 million over 5 years. The success was credited to the new system's ability to identify forms of fraud that the company never knew existed and giving the company the ability to make changes to eliminate those causes.<br />
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While it is true that we may be many decades away from being truly knowledgeable about how the US healthcare system works, it is also true that there are many technologies available today that, if utilized in healthcare, could have immediate and meaningful impact. Targeted solutions can quickly exceed expectations when we focus on creating new actionable knowledge with current technologies.John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-51566967730382573932011-04-14T21:16:00.000-04:002011-04-14T21:16:47.410-04:00CKM and Spaghetti Sauce<div class="MsoNormal" style="font-family: inherit;"><span style="font-size: small;">One of the key components to <a href="http://www.johnshowaltermd.com/p/what-is-ckm.html">clinical knowledge management</a> is the discovery of <a href="http://www.johnshowaltermd.com/2011/03/data-information-and-knowledge.html">actionable knowledge</a>. The process of discovering knowledge is often more of an art than a science. A complex part of the art is asking the <i>right</i> question. The knowledge discovered and developed through data driven techniques such as data mining and statistical hypothesis testing are always framed by the questions being asked. Ask the wrong question, generate the wrong knowledge. Unfortunately, unless you <i>know </i>you are asking the wrong question you <i>assume </i>you are working with the <i>right </i>knowledge. </span></div><div class="MsoNormal" style="font-family: inherit;"><br />
</div><div class="MsoNormal" style="font-family: inherit;"><span style="font-size: small;">Gains can be made when making decisions with the “wrong knowledge,” but they will be less than the gains made if decisions were made from the right knowledge. An excellent example of how knowledge is improved when you ask the right question is described by Malcolm Gladwell in his TED talk about the food industry and a spaghetti sauce breakthrough.</span></div><br />
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<div class="MsoNormal" style="font-family: inherit;"><span style="font-size: small;">Gladwell describes how chunky spaghetti sauce revolutionized the food industry… because companies stopped asking their research teams to find <i>the perfect food</i> and started to ask them to find <i>the best food for a cluster of people</i>. The right question was <i>not </i>“what is the perfect spaghetti sauce?”(or mustard or soda.) The right question was “which varieties of spaghetti sauce greatly appealed to large groups of people?” The result was more food options, happier customers and increased revenue.</span></div>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-72006544299607872322011-04-11T10:15:00.036-04:002011-04-11T10:15:01.144-04:00Communication: Changing BehaviorsI just received my copy of the Journal of the American Medical Informatics Association. In it, I found an article that is very revealing with regard to communication: Actionable reminders did not improve performance over passive reminders for overdue tests in the primary care setting (<a href="http://jamia.bmj.com/content/18/2/160.abstract">abstract</a>). In the article, El-Kareh et al. investigated the impact of altering a passive reminder to be a passive reminder that facilitated direct ordering of recommended tests. The reminders created highly sensitive and specific actionable knowledge from the clinic's electronic health records. The new "enhanced" reminders had absolutely no affect on the screening rates of bone density exams, HgA1C, and LDL monitoring; in fact, they may have decreased the rate of screening mammograms.<br />
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From a health IT standpoint, this outcome makes no sense whatsoever. The software provided streamlined functionality to place orders and reminders were based on reliable knowledge. However, a psychology major would have predicted these results. So, why didn't the enhanced alerts work?<br />
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They did not work because they did not effect the physician's intention to perform the preventative services. But in order to understand this, you must first understand the theory of planned behavior.<br />
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The theory of planned behavior, like most psychological theories, is fairly complex. I like how Wikipedia <a href="http://en.wikipedia.org/wiki/Theory_of_planned_behavior">explains it here</a>, if you are interested, but basically, what it comes down to is this: when a person has the option of whether or not to do an action, their choice to act or not act is dependent upon their intention to act. <br />
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The intention to perform a behavior is the summation of three components: a person's attitude towards the behavior; the subjective norm; perceived behavioral control. Increasing someone's <i>intention </i>to perform the behavior increases the <i>frequency </i>of the behavior. So how do you increase a person's intention to perform a behavior? By changing their <i>attitude </i>towards the behavior, their <i>perception </i>of how others view the behavior, and the <i>beliefs </i>about their ability to complete the action.<br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxLqxY2ElfDNxH3atMrebWoLVqRpvnM95hyOifUSDnw-p-GAOZucuyhDML_xvZsYTR3dZ55cWm9c4psjv6InlfhTj8yVSQAKcCZNFAs0T1xzVyv3kmhqrIbsfLMuD4_ypDq3aoVvTRArjO/s1600/TPB+Graphic.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="353" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxLqxY2ElfDNxH3atMrebWoLVqRpvnM95hyOifUSDnw-p-GAOZucuyhDML_xvZsYTR3dZ55cWm9c4psjv6InlfhTj8yVSQAKcCZNFAs0T1xzVyv3kmhqrIbsfLMuD4_ypDq3aoVvTRArjO/s640/TPB+Graphic.jpg" width="640" /></a></div><br />
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The "enhanced" reminder studied by El-Kareh et al. did not alter any of the three components needed to increase intention. Both the basic reminder and the enhanced reminder were passive meaning the physician's <i>perception </i>of how colleagues felt about him/her completing preventative screening would not have changed. Streamlining the ability to place orders would not effect the physician's <i>attitude </i>towards providing screening to his patients. It is possible that the<i> perceived ability</i> to complete screening would have been increased due to increased ease of placing orders; however, the authors report that 79% of the physicians almost never used the system or were unaware of the functionality, despite receiving training on the new reminders. Thus, it is not surprising that the enhanced reminders did not result in improved care.<br />
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When you are sharing actionable knowledge with the intention of effecting behavior, you will be most effective when you keep the three tenets of intention in mind. For instance, in our <a href="http://www.johnshowaltermd.com/2011/04/success-story-vte-reduction.html">VTE project</a>, we purposely addressed each of these tenets in our interventions. We instituted a major, mandatory education program to change the <i>attitude </i>of providers. We used forcing functions and pop-up alerts to change the <i>perception </i>of VTE prophylaxis and reinforce the perceived importance of stratifying and prophylaxing patients. We embedded guidelines for risk stratification in the risk assessment tool and allowed order entry with a single click from the pop-up alerts to impact <i>beliefs about the ability</i> to complete the behavior.<br />
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Using the theory of planned behavior to optimize communication will only be effective if the health information system is designed to be functional for the provider. However, as El-Karah et al. demonstrated, improved functionality without improved communication is often ineffective.John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-44161418795077674562011-04-07T09:06:00.003-04:002011-04-07T09:06:00.140-04:00Communication: The BasicsOne of the most fundamental elements of communication is using the same vocabulary so that each participant can understand the others. The best example I have of this comes from my 3 year old daughter.<br />
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She was walking all kinds of funky across the living room. I called to her, "Anna, do you have a wedgie?" She turned around, looked me square in the eye, and with all the will in her little body corrected me, "No! My panties are stuck in my butt!"<br />
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Clearly, this was a situation where we were not communicating well because we did not have a shared vocabulary. Whether evaluating information to make knowledge, sharing knowledge to effect behavior, or developing understanding in the <a href="http://www.johnshowaltermd.com/2011/03/auri-cycle.html">AURI cycle</a>, all parties involved must have a shared vocabulary. In my experience, this is a common pitfall in HIS implementations and data-driven quality improvement.<br />
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So, how do you establish this shared vocabulary in teams utilizing clinical knowledge management processes or quality improvement initiatives, such as with the AURI cycle? Defining terms and establishing metrics must be your first order of business in any of these projects; there's really no point in participating in these processes if the participants are not able to equally engage and speak with a common vocabulary.<br />
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As clinicians, we all understood what a VTE was, but in the first meetings of the <a href="http://www.johnshowaltermd.com/2011/04/success-story-vte-reduction.html">VTE team</a>, we had to define VTE clearly and establish which VTEs would be included in our metrics. For instance, would we count hospital-acquired VTEs in upper extremities that were associated with PICCs or other central lines as nosocomial VTEs and include them as a target of our interventions? We also had to decide if we would include VTEs discovered as outpatients and during readmissions or only those discovered during a single hospital admission as part of our intervention. Ultimately, we chose to include all VTEs, regardless of physical location or the clinical setting in which it was discovered.<br />
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As you can see, making another choice would have changed our evaluation of metrics, knowledge, and understanding. The interventions described in the VTE project were the result of the definitions and metrics we agreed upon as a team. If we had not established a common vocabulary, we would have experienced significant delays in the progress of our project, and possibly have been significantly less successful than we were.<br />
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Keep in mind that communication is dynamic and anytime a new member enters, you need to ensure you re-establish the shared vocabulary. For instance, when writing out the above story, my 8 year old daughter read it. Then she turned to her mother and asked, "Momma, what is a weed-ghee?"<br />
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In my next post, I will outline the science behind communicating with the goal of effecting volitional behavior.John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0tag:blogger.com,1999:blog-1114788714717795395.post-9728802352952346802011-04-04T12:44:00.011-04:002011-04-04T12:44:00.566-04:00Success Story: VTE Reduction<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">As part of the <a href="http://www.bcbs.com/issues/uninsured/highmark-blue-cross-blue-shiel.html">QualityBLUE Pay for Performance</a> partnership between <a href="https://www.highmarkbcbs.com/chmptl/chm/jsp/Splash.do?site=hbcbs">Highmark Blue Cross Blue Shield</a> and Penn State Hershey Medical Center, hospital-acquired venous thromboembolism (VTE) was identified as an area for quality improvement. This coincided with the release of the latest <a href="http://chestjournal.chestpubs.org/content/133/6_suppl">ACCP Guidelines on Antithrombolytic and Thrombolytic Therapy (8th Ed.)</a> in the summer of 2008.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">An interdisciplinary team of nurses, physicians, pharmacists, quality improvement specialists, and informatics specialists was assembled to determine how to implement the new guidelines at HMC. Through the use of <a href="http://www.johnshowaltermd.com/p/what-is-ckm.html">Clinical Knowledge Management</a> and th<a href="http://www.johnshowaltermd.com/2011/03/auri-cycle.html">e Analyze-Understand-Redesign-Implement cycle</a>, we made tremendous gains in this QI project, including a sustained 25% reduction in nosocomial VTEs, reduced mortality associated with nosocomial VTEs, and cost avoidance estimated at $2-4 million annually. Let me walk you through the use of the <a href="http://www.johnshowaltermd.com/2011/03/process-of-ckm.html">CKM process</a> and the AURI cycle in this QI initiative.</span><br />
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<b><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: large;">The CKM Process</span></b><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Capturing & Classifying</u></b>: At the time of the project initiation, HMC had been using an electronic medical record (EMR) with computerized physician order entry (CPOE) for greater than two years. This mean that in addition to the best practices outlined in the ACCP Guidelines, we also had data from greater than 50,000 inpatient visits available to us. This included: risk stratification data like demographics and clinical conditions; use of pharmocologic and non-pharmocologic prophylaxis; time elapsed from admission to first prophylaxis dose; rate of occurrence of nosocomial VTE.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Retrieving</u></b>: Queries were developed to gather information about current VTE prophylaxis behavior from HMC's clinical database. Results from the queries were transferred into Excel spreadsheets.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Evaluating</u></b>: Rates and timing of appropriate prophylaxis and rates of development of nosocomial VTEs were determined to identify gaps between current recommendations and current HMC practice. Underutilization of risk-scoring at admission as well as underutilization of pharmacologic and mechanical prophylaxis were identified. Inappropriate risk stratification was common as was inappropriate use of prophylaxis. </span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Concurrently, the pharmacists and clinicians from both Medical and Surgical services condensed the ACCP Guidelines to an easy-reference pocket card that contained risk stratification guidelines and appropriate treatment options.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Sharing</u></b>: Required education for all pharmacists, physicians, and nurses was provided along with the quick-reference pocket cards. The education reviewed the new ACCP Guidelines as well as required changes to HMC practice.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Action</u></b>: Based on the education and availability of the pocket cards, there was a modest improvement in guideline compliance and a slight decrease in hospital acquired VTEs. </span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">A second cycle of the CKM process was then initiated. The data that was <i>captured </i>and <i>classified </i>after the roll-out of the education and pocket cards was <i>retrieved </i>and <i>evaluated</i>. It was determined that significant opportunities for improvement were as of yet untapped. It was also determined that a more structured and standardized approach was needed to accommodate the resident learning curve.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The <i>sharing </i>step was multifaceted. A clinical decision support (CDS) tool was created that included forcing functions at the time of admission that required VTE risk stratification on all patients. Residents were provided with the stratification criteria at the time of the risk assessment. Interactive alerts were developed to present providers with prophylaxis guidelines based on patient risk stratification at the time of order entry. Providers were required to either place appropriate prophylaxis orders or document contraindications.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The resulting <i>actions </i>from the providers were immediate. There was an increase in appropriate prophylaxis and a decrease in nosocomial VTEs. This reduction has been sustained for two years and through two intern classes. <a href="http://smdm.confex.com/smdm/2010on/webprogram/Paper5708.html">Partial results were presented</a> at the Society of Medical Decision Making Annual Conference in October, 2010.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif; font-size: large;"><b>The AURI Cycle</b></span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">As you can see from the above, the traditional Plan-Do-Study-Act (PDSA) cycle was not followed during this initiative. Most notably, no system changes were made until the data was carefully analyzed and understood by all team members. However, the AURI cycle was extremely effective in producing sustained behavioral change and improved outcomes. Let's examine how the steps of the CKM process fit into the AURI cycle.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Analyze</u></b>: The <i>retrieval </i>and <i>evaluation </i>of both internal and external data to create new knowledge comprises this part of the AURI cycle. In this QI project, retrieving and evaluating data from HMC's EMR and studying and condensing the ACCP Guidelines represents the analyze component. The new knowledge gained from the analyze phase was three-fold: the correct prophylaxis choices were often clear to experienced clinicians but not to inexperienced residents; ideally, a single drug would be suggested for pharmacoprophylaxis; risk stratification was rarely performed at admission.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Understand</u></b>: <i>Sharing </i>the new knowledge derived from the analysis phase with the quality improvement team comprises this part of the AURI cycle. The team identified barriers such as baseline resident knowledge, inability to use a single low-molecular weight heparin, insufficient availability of mechanical prophylaxis devices, and concerns for the feasibility of improvement with voluntary compliance.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Redesign</u></b>: The redesign phase is a <i>result </i>of the CKM process rather than a <i>step </i>in the CKM process. The new standard of practice at HMC that involved risk stratification of all patients at the time of admission based on a standard risk stratification system as well as the</span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"> testing of multiple models of mechanical prophylaxis devices by the Department of Nursing comprises this part of the AURI cycle.</span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"> </span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><b><u>Implementation</u></b>: </span><i style="font-family: Arial, Helvetica, sans-serif;">Sharing </i><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">new knowledge derived from the analysis phase with all clinicians and other stakeholders comprises this part of the AURI cycle. The first barrier to success, baseline resident knowledge, was tackled during the roll-out of required education. Additionally, the Operations Department purchased an adequate number of machines and made them easily accessible. The EHR was modified to capture the use of mechanical prophylaxis devices and the use of pharmacoprophylaxis continued to be captured. We were not able to capture the timing of the risk assessment, which unfortunately, had to be done manually on a small sample of the patients.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Despite seeing modest gains, a second AURI cycle was needed to address the remaining two barriers. As noted above, the <i>analysis </i>phase identified the need for a more structured, standardized approach. The <i>understanding </i>phase led to the new knowledge that risk assessment needed to be required instead of voluntary, prophylaxis needed to be simplified, and appropriate guidelines needed to be shared in real-time with residents. The <i>redesign </i>phase resulted in the clinical decision support tool described above as well as a policy change that Pharmacy would substitute appropriate low-molecular weight heparin for patients with renal failure. The <i>implement </i>phase was the education and go-live of the CDS tool.</span><br />
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<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">The time elapsed from the beginning of the first AURI cycle to the implementation of the second AURI cycle was only 9 months. As you can see, the CKM process and the AURI cycle can allow for rapid institutional improvement and identification of barriers to improvement. The success of this project highlights the way that efficient quality improvement methodologies result in significant financial gains as well as reduced morbidity and mortality.</span>John Showalter MDhttp://www.blogger.com/profile/14447368653045477652noreply@blogger.com0