Thinking in Hammers and Nails: Problem-Based Approaches to Healthcare IT Implementation Paul Biondich, MD, MS Asst. Professor of Pediatrics / Informatics Regenstrief Institute… Indianapolis

Current State of Affairs? “If the only tool you have is a hammer, you tend to see every problem as a nail..” - Abraham Maslow, Cognitive Psychologist

Hammers and Nails Full personal disclosure: infatuated with computers and information technology Taking a leap: some of you are as well, or else you wouldn’t be here.. As a result, we are proactive “technology users” .. and we understand how these technologies likely have positive impact on healthcare

Hammers and Nails As a result, its easy to appreciate (become enamored with) the latest and greatest “hammers”: Smart Cards Wireless communication Speech Recognition PDAs / Cell Phone Hybrids Portable Computing (Tablets, Wearable Computing)

The Problem with Hammers Also easy to fall into trap of thinking that the technology itself that can improve healthcare provision Current “HIT euphoria” has further exacerbated these myopic perspectives.. “PDAs could give pocket access to a patient’s medical record!”

Looking for nails..

Clinical Results via PDA

Gopher on Real Wireless PDA

Yet another Gopher PDA

The Popcorn Woman

What’s next?!

Problem-based frameworks Health IT is a tool no different than a tongue depressor or an otoscope Identifying healthcare problems allows one to consider tailored solutions HIT might not be best answer? Stating the specific problem -> harder than it sounds… typically an iterative process

Identifying your nails.. “In the correct formulation of the question, lies the key to the answer.” - Nobelist Max Planck

Iterative Problem Identification High level problem: need to improve patient safety Focused on a topic: medication safety Focused on a clinical problem: adverse drug events Focused on a specific clinical problem: severe drug interactions Atomic problem: digoxin and cyclosporine drug interaction

Next questions.. Who elicits the problem? What is the prevalence of the problem? Where is the problem occurring? When does the problem occur within clinical workflows? How can I “manually” fix the problem?

Typical Results Process often leads to surprising solutions Information gathered during the process significantly informs how the solution can be customized Specified tons more problems than you immediately imagined.. how does one prioritize?

Prioritization Factors P= Impact on individual patients’ care (e.g. quality, safety, cost) O= Organizational impact (e.g. regulatory compliance, resource use) C= Clinician impact (e.g. enhanced workflow) N= Number of patients positively affected G= Gap between ideal and actual behavior pertinent to the intervention D= Difficulty associated with implementing intervention C= Cost of intervention

Setting – “Enterprise” Pediatric Outpatient Clinic High patient volume (~200 patients/day) “Digital Divide” within patient population Diverse, large, and ever changing clinician population Urban setting not amenable to electronics in rooms Limited support staff to assist in data acquisition

The Problem / Motivation Need to capture data prior to physician encounters from both patients/parents and support staff to inform a new preventive care DSS. They move all over the clinic (waiting room, patient room, vitals area, etc) There were resource constraints ($) Management technology-phobic

Our 21st Century Technology Choice – Paper

Paper as a Computer Interface? Familiar Easy to work with Fully enabled Portable Cheap Computer can reliably read information off of paper when it is structured

Adaptive Turnaround Documents Data-driven, dynamically generated, computer interpretable paper forms Pre-Screening Form: Collects 20 most relevant risk factor observations from family, and also collects vital sign assessments from nursing

Sample Screening Form (PSF)

Nursing Observations / Vitals Real-time calculations: Body Mass Index (BMI), Growth Percentiles, Blood Pressure abnormalities, Abrupt changes between visits Nurse / Aide prompting: Better indication of when to do Screening Tests Reminder of previously abnormal values that need to be retaken

Parental Screening Questionnaire Forms are custom tailored to patient Questions are age specific Logic is sensitive to questions that are previously answered Questions are all prioritized.. Most clinically relevant and high-risk questions are asked first

Parental Screening Questionnaire Patients identify their own risk factors – physicians no longer spend time on “fishing expeditions” Parents are “activated” into thinking about relevant or misunderstood topics Triggers many decision support “tools”: “Extra Specific” reminders Just-in-Time Handouts Automated Orders

Sample Physician Worksheet Form

Vital Sign Calculations Screening Form (PSF) Doctor’s Worksheet (PWS)

Physician Preventive Care Reminders

Identifying Risk Factors Screening Form (PSF) Physician Form Reminder

Thinking Out of the Box… The London Times in 1834 “That it will ever come into general use, notwithstanding its value, is extremely doubtful because its beneficial application requires much time and gives a good bit of trouble, both to the patient and to the practitioner because its hue and character are foreign and opposed to all our habits and associations.”