2018-11-20

When does Clinical System Design stop?

The enthusiasm, energy and productivity of Area Councils (AC) and Specialty Workgroups (SWG) continues to amaze us. Alberta Health Services (AHS) witnesses extraordinary collaboration, reduction of unhelpful variation and informational integration. Indeed, more important than any clinical information system (CIS) configuration may be the principles, relationships, and processes learned through clinical system design (CSD). Growing new ways of designing and optimizing clinical content (documentation, decision and inquiry supports) helps AHS mature as a learning healthcare organization.

ACs and SWGs understand that essential specialty CSD should wrap up as 2018 comes to a close, leaving January 2019 for unfinished or deferred issues. All specialty CSD decisions need to be recorded by a hard deadline of February 8, 2019. This milestone is critical to readying the CIS for testing and training.

So, if specialty CSD must deliver by February 8, 2019 and the value of specialty CSD is as an enduring process, then what becomes of CSD once testing and training start? The short answer is that CSD continues indefinitely. It must. There is no other way to ensure that the CIS grows with AHS, both helping AHS to learn and optimizing what works best.

Appreciating that CSD is a core Connect Care activity, today’s time-boxed work just gets us to a starting line. It allows a basic CIS to be built; enough to illustrate the value of CSD and to teach skills for meaningful use.

The really valuable CSD work begins once the CIS is deployed. Accordingly, we have begun planning systematic processes for tackling all the “parking lot” issues left over from CSD build; and anticipating all the new needs arising post-launch. The appetite for new uses of CSD tools will be great, priorities must be set and design capacity must continue to grow.

2018-11-19

In-System Inquiry guided by the Clinical Improvement Lifecycle

We've previously posted about how Connect Care in-system inquiry tools can help AHS grow as a learning healthcare organization.

Key characteristics of a health system that can learn include:

  • Every patient’s characteristics and experience are available for study
  • Best practice knowledge is immediately available to support decisions
  • Improvement is continuous through ongoing study (closed loop)Inquiry happens routinely and economically
  • Curiosity and inquiry is valued and embedded in organizational culture
Connect Care in-system reporting and analytics tools will provide AHS staff with the ability to create and use real time data about patients, populations and the health system as a whole. This data can then be transformed into information that guides evidence-informed decisions in service of continuous clinical improvement.

Clinical information system (CIS) facilitated clinical improvement emulates continuous quality improvement lifecycles. Today’s internal and external evidence generates tomorrow’s ideas which are then critically examined to evaluate the impact of the change and stimulate ideas for further clinical improvement. A simple clinical improvement lifecycle can help guide Connect Care planning for in-system inquiry.

2018-11-18

What level of in-system inquiry maturity do we need?

As part of Reporting Content Review, Alberta Health Services (AHS) analysts help clinical information system (CIS) users design reports, dashboards and visualizations that will be deployed through self-serve, in-system, analytics tools supporting decision making. The possibilities are limitless... early configuration work is intimidating to say the least.

It can help to envision a stepwise progression towards the reporting maturity AHS needs to attain HIMSS Level 6 and 7 recognition. Early in-system reports, dashboards and visualizations should focus on gaining insight about user on-boarding and adoption. Soon, data becomes available to support tracking minimum acceptable CIS use. Once use is solid, attention can shift to indicators of meaningful use and charting quality. Thereafter, gaining insight from internal evidence about health processes and outcomes becomes possible. Appreciating this can help prioritization of in-system reporting capabilities for launch and the months that follow.

2018-11-17

How does Connect Care align with AHS strategic analytic priorities?

The Strategy for Research, Innovation and Analytics (RIA) lays out Alberta Health Services (AHS) roadmap for becoming an organization skilled at helping its people create, acquire and transfer knowledge to raise the standard of healthcare delivered to all Albertans. Connect Care is a key enabler. The Connect Care clinical information system (CIS) promotes curiosity, inquiry and research with in-system tools for data exploration, practice surveillance and hypothesis testing.

Connect Care aligns directly with the AHS RIA Roadmap by:
  • Making real time data available to care providers and managers
  • Providing front end access to analytics tools
  • Building analytics literacy and frontline interpretive capacity
  • Stimulating curiosity and question formulation
  • Providing effective ways to capture, translate and apply knowledge at the point of care
  • Allowing innovation in care to be introduced with changes in behavior and outcomes measured in real time
AHS builds improvement capacity in the workforce by allowing it to use its own data and identify opportunities to improve; where improvement is about the experience of healthcare as much as patient, organizational and system outcomes.

2018-11-16

What is a learning healthcare organization?

A Learning Healthcare System is a system in which, "science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the delivery process and new knowledge captured as an integral by-product of the delivery experience."
Learning healthcare organizations demonstrate both an ability to use 'external evidence' (arising from the study of populations other than one's own) and an ability to use 'internal evidence' (about what works best in one's own context).  They use this evidence to generate hypotheses, strategically apply change to clinical and operational practices and evaluate the impact of the change on outcomes and behaviours. Characteristics of a health system that can learn include:
  • Every patient's characteristics and experience are available for study
  • Best practice knowledge is immediately available to support decisions
  • Improvement is continuous through ongoing study (closed loop)
  • Inquiry happens routinely and economically
  • Curiosity and inquiry is valued and embedded in organizational culture
Connect Care in-system reporting and analytics tools will provide AHS staff and stakeholders with the ability to create and use real time data about patients, populations and the health system as a whole.  This data can then be transformed into information that guides evidence-informed decisions in service of continuous clinical improvement.

2018-11-15

Understanding Connect Care Reporting Tools

Connect Care Area Councils and Specialty Workgroups have begun a new stream of ​specialty clinical system design (CSD) work focusing on 'Reporting Content Review'. The work is covered in detail in the CSD updates blog.

For those not involved in CSD activities, this is still a good time to learn a little of the language and opportunity associated with powerful in-system inquiry support tools to be made available to users.

2018-11-14

Mackenzie Health Excels with Epic

It is encouraging to witness successes of other Canadian Epic clients.

Mackenzie Health (Toronto GMA in Ontario) launched just over a year ago, summer of 2017. They have since attained stage 6/7 in most areas and now have reached the coveted 7/7 EMRAM recognition in ER and ICU.

2018-11-13

Connect Care Physician Area Trainers

We have previously posted about Connect Care Provincial Physician Trainers (PPTs) and are thrilled to be screening a number of excellent applicants for these formal physician roles. New PPTs already progress through clinical information system (CIS) and curriculum courses and certifications. A few months from now, recruitment begins for the Area Physician Trainers (APTs) who will focus on the needs of specific clinical areas and specialties under the guidance of PPTs.

Prescriber training is facilitated by prescribers wherever possible. APTs fan out to make this possible across specialties and geographies. They support power users and super users (see informal physician contributions) while also directly helping Connect Care users through the launch and personalization stages of implementation (starting just under a year from now!).

The CMIO office will work with AHS Zones to determine the number of APTs required for successful launch. The APT cohort may include trainers who focus on a few specialties while others focus more on a few waves. Our current APT need estimates range from 25-30 per wave.

Further collaboration and planning with AHS zones will bring precision to the APT plan. Nonetheless, the time is right to think about persons who may be well suited to this role.

2018-11-12

Prescriber Training Primer

We have previously described Connect Care's training strategy for prescribers (including physicians).

Work is progressing well. An recent consultation with provincial medical leaders allowed validation of key principles and processes.

A new backgrounder provides an orientation to the emerging Connect Care Prescriber Training Program:

2018-11-11

Results & Reports Routing Workgroup Formed

A key Connect Care deliverable is de-fragmentation of AHS-managed health information flows. This includes “closed loop” results and report routing, where investigations and interventions are tracked from ordering to action, with verified delivery of the right information to the right person. Achieving informational continuity within AHS is essential. In addition, the right information needs to be routed to, received by and attested to by practitioners using non-AHS legal records of care.

Again, we have a complex area impacting diverse groups. Accordingly, a workgroup reporting to the Connect Care Portals Committee (which has multi-stakeholder connections) has started work. This will affect both configuration and change management. Sid Viner and Dominic Order co-chair, again with good clinician representation. Query cmio@ahs.ca as needed.

2018-11-10

Mobility Workgroup Formed

Recognizing the importance of mobile applications (Haiku for iOS and Android, Canto for iPads, Rover for iOS, Limerick for iWatch) to engagement and adoption, and that impacts cross all clinical and operational groups, Connect Care has established a Mobility Workgroup reporting to the Connect Care Council (cross reporting to Connect Care Infrastructure Committee). Chris White and Bart Mielczarek co-chair, and solid clinician representation has been arranged. The workgroup considers how personal and organizational devices can be best used, and how to optimize mobility application features to fit clinician workflows. Please direct questions to cmio@ahs.ca.

2018-11-09

Physician Communication Channels

Finding and growing physician-friendly communication channels is a constant preoccupation. The imperative intensifies as we ramp up readiness work and prepare for wave 1 launch in November 2019.

Many physicians are well served by excellent communications provided for all Alberta Health Services (AHS) staff. However, many other physicians preferentially attend to non-AHS communication channels, such as zone and University clinical department, medical staff society or professional association news. With a first launch looming, now is the time to seek all possible help getting Connect Care communications integrated with stakeholder communications. All suggestions are welcome.

Please promote our current physician-oriented channels to partner organizations, healthcare education, research communities and professional associations!

2018-11-08

Where we are at

The herculean work to get essential Connect Care clinical content ready for testing and training has peaked. Area Councils and Specialty Workgroups will get through most clinical system design (CSD) work packages by year end, dealing with any deferred tasks in January, and concluding specialty CSD by February 8, 2019. Thereafter CSD continues but with a view to testing and optimization.

The full attention of our Area Councils will soon shift to readiness. Already the work of training curriculum design is well under way. Recruitment has already brought many clinician trainers into Connect Care, now working through certification. As training, testing and readiness activities ramp up, we’ll shift communications like these to what our stakeholder communities most need to know.

2018-11-07

What is Inquiry and Research to Connect Care?

We participate in inquiry when we ask questions about what we do; and perform research when we use systematic approaches to answer those questions.

Connect Care is, at its core, about inquiry and research. The vision is to better healthcare with better information. The means is curiosity, inquiry and research. The Connect Care clinical information system (CIS) supports those means with tools for systematic data exploration, practice surveillance and hypothesis testing.

2018-11-06

Patient and Family Centred Care Week

November 5-9 marks Patient and Family Centered Care week, and opportunity to acknowledge the wonderful work of our Connect Care community contributors!

Connect Care is about clinical transformation, with patients and families the intended beneficiaries. Remember who we’re building for: our parents, grandparents, friends, neighbours and colleagues – as well as the thousands of Albertans we’ll never meet.

As defined by the Institute for Patient and Family-Centered Care, “Patient and family-centered care is an approach to the planning, delivery, and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare providers, patients, and families.” Core elements include:
  • Respect and Dignity - We listen to and honour patient and family perspectives and choices and include patient and family knowledge, strengths, values, beliefs and cultural backgrounds in the planning and delivery of care.
  • Information Sharing - We communicate with patients and families to ensure they understand and receive timely, complete and accurate information to effectively participate in care and decision making.
  • Participation - We build partnerships with patients and families, and we encourage and support them in the participation  of their care and decision making, at the level they choose.
  • Collaboration - We collaborate with patients and families in policy and program development, implementation and evaluation.
Many Connect Care Patient Advisors have been with us since the first steps of our journey. They serve on committees, councils and advisory groups and have grounded us at all 6 direction setting and adoption & validation sessions. Please join us in celebration of their invaluable work!

2018-11-05

Why Doctors Hate Computers - a Surgeon's View

Our re-posting of Atul Gawane's essay, "Why Doctors Hate Their Computers", has generated a lot of discussion about what Connect Care needs to do in order to avoid the harms described. Thanks for the emails! Feel free to use the comment link on postings.

The following came in as 'Thoughts from a Surgeon':

I have gone over the Gawande essay, here are my reflections:

1. It's long piece and, like much of his writing, it meanders a bit and doesn't really reach a firm conclusion or suggest solutions, except to say that the adoption of digital health records may have some unanticipated side-effects that we should guard against.

2. The issue of user burnout related to clinical information system use is real and will probably hit clinic-based docs hardest.

3. It amazes me how much documentation I ignore or skip over in an average day. If I can't skip to the important stuff in a clinical information system (CIS) [Connect Care], my work is going to grind to a halt. The "Revenge of the Ancillaries" is a real risk and could lead to a bloated and unusable system.

4. Ensuring a good user/provider experience is the key to success. How will providers use the system efficiently every day?

5. Proving room for innovation and customization inside the system is also going to be essential.

Here is a detailed list of the actual clinical documentation I do in my own practice:

in clinic space
- see patient, scribble illegible note on health organization paper
- occasionally write a prescription on paper pad

in the office after clinic
- dictate my own detailed letter, copy and paste text into my electronic medical record (EMR)
- complete OR booking form, H&P and pre-op orders in CIS, medical office assistant sends to the OR
- check lab results in EMR
- enter billing codes in EMR

day of surgery
- dictate OR note at end of procedure (unless resident does it)
- resident does post-op note and orders, I rarely do this.

on the ward
- I never write in the chart, residents do all of that
- occasional verbal orders
- dictate discharge summaries which make their way to the provincial electronic health record (EHR)

in endoscopy suite
- scribble illegible note on health organization paper
- dictate my own endoscopy note for attachment to the provincial EHR

At home
- I never do any clinical documentation from home, I don't even have EHR or EMR access and I don't want it!

As you can see, I have developed what I think is a highly-efficient system designed to minimize the time I spend on clinical documentation. I bet most of my colleagues do something similar. I'd love to see what our new workflow will be like in the Connect Care CIS...

Why Doctors Hate Computers

To find Atul Gawande's New Yorker essay on "Why Doctors Hate Computers" in my morning newsfeed gives instant jolt. A worrying read.

We took care to capture and characterize clinician fears early in the Connect Care journey. Every one of those fears is explored by Dr Gawande. He gifts Connect Care with a potent reminder of our purpose... to enable better health with better information. Any informational process that gets in the way must be questioned.

The timing could not be better. As we work through the final months of essential clinical system design, our councils and committees navigate more and more demands for mandatory data entry during test ordering, procedural documentation and communications management.  Our Connect Care oversight has strong clinical input. Now more than ever, we need those clinicians present and focused. Their advocacy can keep sensible workflows front of mind while testing design decisions for prospect of making things better, not worse, for our busiest healthcare providers.

The essay is not a short read; but well worth the hour we gained falling back from daylight savings time yesterday. We'll return to each of Dr Gawande's challenges, hoping to avoid the more preventable clinical information system harms, especially those associated with imbalances between administrative and clinical purpose.

And we must invest like never before in preparing clinical communities with the information literacy, norms and professionalism needed for better information to improve both the provision and experience of health care.

Every additional click, screen element or data demand potentially puts Connect Care at risk. We must remember this and continually push for the simplest, leanest and most straightforward configuration possible. There will be ample time later to consider the many decision, documentation and inquiry supports that could make us grow to love Connect Care, if not computers.

2018-11-04

Connect Care Lingo - Testing

Even as we accelerate remaining Connect Care clinical content development, enough clinical information system (CIS) build has occurred that testing can begin. This will preoccupy us for most of the next year.

To help make sense of expected communications, we'll keep the eHealth glossary updated with new terms and acronyms.

2018-11-03

Falling Back

Twice a year we warp time... and frustrate clinical time keeping. Yes, tonight the clocks fall back an hour as daylight saving time retires for another year.

The DST experiment started about 100 years ago to see if energy consumption (principally coal) would be reduced by bringing more work into daylight. We've learned that the opposite happens. Worker productivity suffers as well.

Whatever our gripes about gaining or losing an hour's sleep, serious information management problems confront those caring for patients when 02:00 becomes 01:00. For example, whether a change in blood glucose occurs over an hour, or a minute, can radically affect insulin drip protocols.

With a clinical information system in play, time distortions also distort medication administration records, clinical decision supports, and countless other digital details; especially if interoperating and interfaced systems handle DST-adjusted timestamps differently.

The biannual DST challenge is not handled consistently by health information systems. We'll need to plan and train for how Connect Care will cope (and vote against DST anytime the opportunity arises!).

2018-11-01

Connect Care Privacy Impact Assessment

Information sharing is about how health data is collected, accessed, used, disclosed and exchanged. The Connect Care Clinical Information Sharing Approach (CISA, ahs-cis.ca/cisa) guides Alberta Health Services (AHS) as its provincial clinical information system (CIS) is designed, built and prepared for launch just one year from now.

CISA promotes responsible information sharing to improve health care and the health care system. This includes uses for training, administration, quality improvement, outcomes tracking, research and instruction. As custodian of the Connect Care CIS, AHS bears responsibility for a wide range of processes to ensure that information sharing is both productive and protective.

AHS responsibilities include preparation of a Privacy Impact Assessment (PIA) for submission to the Office of the Information and Privacy Commissioner (OIPC). A PIA demonstrates that AHS, as a custodian of health information under the Health Information Act (HIA), has considered the privacy risks associated with implementing a provincial CIS and has implemented strategies to mitigate those risks.

We highlight this important work now because the first PIA sections are submitted in October 2018.