Wednesday, September 23, 2020

Using Artificial Intelligence to Help the Clinician Make the Right Decision

Physicians and Advanced Practitioners work hard to make the correct diagnosis and help each patient. They use their knowledge and experience to decide what information to gather, but we are all human and imperfect. No one can know everything, and everyone has biases in their reasoning. 

There are many studies showing that clinicians often don’t order the best imaging studies given the patient’s signs and symptoms. Sophisticated imaging studies like CT scans and MRI’s are priced fairly high because of the many associated expenses, and therefore the total cost to payers is enormous. When an inappropriate test is ordered, it is a prime example of waste. 

The Protecting Access to Medicare Act (PAMA) of 2014 established a program to increase the rate of appropriate advanced diagnostic imaging studies provided to Medicare beneficiaries. Examples of advanced imaging studies include:

Computed tomography (CT)
Positron emission tomography (PET)
Nuclear medicine, and
Magnetic resonance imaging (MRI).

The legislation requires that whenever a practitioner orders an advanced imaging study, he or she must use “a qualified Clinical Decision Support Mechanism (CDSM) with appropriate use criteria (AUC).” The CDSM is an interactive electronic tool that provides a determination of whether the order adheres to the AUC. It takes the input from the clinician and provides analysis and feedback to the ordering provider about whether the test is appropriate. This requirement is currently in the testing and education phase and will be fully implemented in January 2022.

At GBMC, we have used our core competency of redesigning care and made numerous enhancements to our CDSM/AUC workflow. By analyzing our data, we identified that the use of “free text” indications accounted for most of the non-compliant/indeterminate orders. We learned from discussion with providers that the “free text” field is used when a patient's condition did not match the available displayed diagnosis. We also learned that it is used to provide additional clinically-relevant information to the radiologist reading the study.

By working with the vendor of our CDSM software, we deployed their artificial intelligence tool to streamline the ordering workflow and to move us closer to our aim of increasing the rate of appropriate advanced imaging studies. The new artificial intelligence tool reads the “free text” field and presents discrete diagnoses to the provider so that he or she can pick one during the process of ordering advanced imaging tests. The pilot was done with providers in the Emergency Department because they had the highest utilization of the “free text” field. 

The chart below shows the “special cause” improvement in reducing the number of indeterminate studies in the pilot. This test of the use of level 2 mistake proofing  (a reminder in the moment or an affordance) shows that the use of artificial intelligence significantly improved ordering. 

My hat goes off to my colleagues in Radiology and in the Emergency Department for this great use of the Model for Improvement in moving us closer to our vision! 

Wash Your Hands
This week is International Clean Hands Week. It’s a good time to remind ourselves of the importance of good hand cleaning habits. We all know that proper hand hygiene is one of the most effective actions to reduce the spread of pathogens and prevent infections, including the COVID-19 virus. So please, wash your hands. Thank you!

Friday, September 18, 2020

Visual Prompts & Level 2 Mistake Proofing

Our daily lives seem to be getting more and more complex. We must remember so many things (taking our car keys, remembering all of our passwords, etc.) it is no wonder that we make mistakes. It is difficult to remember things that we don’t do regularly. With all the distractions that come at us daily, we frequently “slip” and forget to do something. 

When that the “slip” is minor (recently I had to return to my office to get my car keys before heading home) we shouldn’t worry about it too much. But, if the error could result in significant harm to someone, then that is a different story. 

Experts in safety list THREE levels of error prevention. The first level is education. So, when a young clinician or nurse forgets to do something, we might meet with them and remind them of the importance of the task that they did not do. If, in fact, they did not know the importance of the task, this may solve the problem. However, if they already knew of the importance, but got distracted in their work and just forgot to do it, then re-educating them about the task is not a very powerful way to prevent the “slip” from re-occurring. 

The second level of mistake proofing includes reminders in the moment. In the example of the clinician or nurse who forgot to do something important, this may be a BPA (best practice alert) that flashes on their computer screen to remind them to do something. It makes it harder to forget. Unfortunately, the clinician could ignore the alert (perhaps because he or she is getting too many alerts) or could see the alert, intend to do the work, but then get distracted and not complete the task. These reminders in the moment are sometimes called affordances. 

I am writing again about mistake proofing in this week’s blog because I saw three interesting uses of affordances on rounds this week. The first two were clever ways to get people to clean their hands before entering a patient’s room. The second was on the floor in the corridor outside of the Pediatric ED, in a place where people frequently leave beds, stretchers, and wheelchairs. This is a serious safety hazard. If there was a fire and we had to quickly move children out of the ED, we would have to move the misplaced equipment first. Recently, we put red tape on the floor in the places where the equipment is usually left. This is a great test of change. We believe that the red tape on the floor in front of the medical gas shutoff valves is the main reason why people don’t block the valves with equipment. Why not try the same method to keep equipment from being left in a narrow corridor? Please see the photos of the three new affordances that I saw this week below.

The third level of mistake proofing is the most powerful. It blocks the error by not letting you get to the next step without doing the important task. Think of a device on my office door where it would not let me open the door to leave unless I had my car keys in my pocket. A real-life example of this happens when you try to buy something online, but forget to enter the CVV number. The software won’t let you get to the next step. Level 3 mistake proofing methods are often called constraints. The more serious the potential harm from an error, the more important it is to get to level THREE. 

Let’s celebrate our outstanding Environmental Service Workers
This week is Environmental Services (EVS) and Housekeeping Week (Sept. 13—19) and I want to take time to recognize the contributions of our EVS staff. They work very hard to keep our facilities clean. In the face of COVID-19, our hospital colleagues have displayed an unwavering commitment to the health and safety of our patients and each other. They are playing a vital role in keeping everyone safe through proper cleaning and disinfecting.

Cleanliness is everyone’s job at GBMC, but our EVS staff members are the experts in cleaning and work tirelessly to get the job done. There are over 100 EVS associates working around-the-clock at GBMC in a variety of roles, servicing over 1.2 million square feet of facility. So, please join me in honoring all the men and women of EVS!

Neonatal Nurses Day...
This past Tuesday (9/15) was Neonatal Nurses Day. It’s a day to honor our nursing colleagues who care for our tiniest and most vulnerable patients. With more than 4,500 babies born at GBMC annually, we are very fortunate to have such a fabulous NICU team. Please join me in thanking them.

Friday, September 11, 2020

The Pandemic and the Complexities of Life

This week, many schools started the new academic year with virtual learning -- a situation that leaves many working parents trying to figure out how to work and take care of their children simultaneously. When the coronavirus outbreak led to school closures in the spring, parents had to figure out how to do their jobs while taking on the added roles of teacher, tutor, and at times, IT technician. We learned that managing the education of children without the help of schools is difficult for both parents and their children, especially for special education and elementary school students. 

My life has clearly been affected by the pandemic. At work, there are new issues to deal with that we haven’t encountered before, like the availability of test kits and personal protective equipment. But I have seen some upside in my time out of the hospital. During a typical late summer/early fall, I am at meetings and events at least three nights per week. This year, I am at home on those evenings since events and meetings are all virtual. This is clearly a benefit that allows me to better deal with what is happening at work. And, my children are adults, so I don’t have the added pressure of managing their education in addition to my “day job.” 

This is not the case for many of my GBMC colleagues, especially those who can’t work from home, which includes almost all of our clinicians. Somehow, they must keep “all the balls in the air” while juggling work and childcare responsibilities. And it’s no easy task for those who are able to work from home either. My colleague, Jenny Coldiron, our Vice President for Philanthropy and Marketing and Communications, told me that she was at a virtual meeting with a vendor this week, discussing a virtual event for this winter. During a one-hour meeting, the vendor was interrupted multiple times by her 6-year-old daughter who came into the room to say “Mommy, the computer isn’t working.” 

I understand how these pressures are pushing some to consider leaving the workforce until the pandemic is over. We are already having a difficult time staffing some areas. This has led me to wonder if there is something more that the GBMC HealthCare System can do as an employer that it isn’t already doing. I would love to hear your thoughts on this. Please comment below.

Let me end by thanking everyone for your efforts during the pandemic. I especially want to thank my colleagues who are parents of school-age children!

Remembering 9-11
As we remember the terrible tragedy that occurred 19 years ago on September 11 and the brave first responders who showed tremendous heroism in the hours, days and weeks thereafter, please remember to honor those whose lives were lost and to recognize the work of our first responders. When emergencies happen, they always answer the call. Thank you!

Thursday, September 3, 2020

Recognized Again!

Last week, we learned that the GBMC HealthCare System has again been selected for a site visit for the Malcolm Baldrige National Quality Award! This Presidential award is the highest national award for quality and is managed by The United States Commerce Department’s National Institute of Standards and Technology (NIST). Over the past several years, GBMC has been using the Baldrige Excellence Framework and participating in the award process. In the spring, we submitted a 50-page application responding to questions about our deployment of systems in the categories of leadership, strategy, customers, measurement, and knowledge of management, workforce, operations, and results. 

Of the 20 applications submitted for consideration this year, GBMC was one of only nine selected for a site visit and one of just three in the healthcare category! The site visit will take place the week of September 27 through October 6, when we will be joined by a team of highly-skilled and dedicated volunteer examiners. This year, due to COVID-19, the process will be completely virtual. During this visit, the examiners will validate the information we submitted in our application and provide feedback to help us to continue to improve. They will review all three of our work systems: Greater Baltimore Medical Center, Gilchrist, and GBMC Health Partners.

Following the site visit, the examiner team will submit a report to the Board of Judges. The judges will then determine if we achieve the award. 

Although we did not achieve the Malcolm Baldrige Quality Award in 2019, we were the only organization in the country to be recognized for a Category Best Practice in Leadership. The Baldrige judges identified the best practice in how our senior leaders and our Board of Directors guide and sustain the organization. They noted how we fulfill our mission by addressing and responding to community needs. GBMC is the only healthcare organization in Maryland to be recognized by Baldrige for a best practice.

I look forward to sharing our great work more fully with the examiner team during our meetings later this month. I am so proud of our organization and how we have matured in our use of the Baldrige Framework for Excellence. Thank you for your dedication as we move closer to our vision every day! 

Labor Day
As our country celebrates the hard work of the American people this Labor Day holiday, let me thank all my colleagues in our system for all that they do for our patients, especially during the pandemic. Some of us will enjoy a three-day weekend, but many of our people will be serving others in our hospital, hospice, and physician practices, so let me give a special thanks to the members of our team who will be at work during this holiday weekend.