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Dec 21 2011   2:37PM GMT

Learning from “Moby Duck”: Lessons in health care variation

Posted by: Jenny Laurello
EBM, EHR, EHR implementation, EMR, Evidence-based medicine, Health care variation, RAC audits, Variation, Wendy Whittington

Guest post by: Wendy Whittington, MD, MMM, Chief Medical Officer, Anthelio Healthcare Solutions, Inc.

Chances are you don’t remember hearing about Moby Duck.  It’s the name of a book that describes the journey of a high school teacher/journalist who quit his job to follow a story.  The story starts in China with the manufacturer of bathtub toys including yellow duckies, green frogs, blue turtles and red beavers.  A shipping container holding more than 28,000 of these four toys fell overboard in a raging storm in the north Pacific in 1992 and the toys scattered throughout the ocean.  When they begin showing up on the beaches of Alaska, the story begins.

The teacher/journalist tells their story.  He followed the toys all over the oceans, beaches, ice flows, islands and rocky shores trying to determine how they can start in the same place and end up all over, including the coast of Maine.  He says, “I’m becoming a devout driftologist. The only essential difference between rock, water, air, life, galaxies, economies, civilizations, plastics – I decide, standing on the deck, totally sober, watching the fog make pretty shapes above the trees – is the rate of flow.”   The book describes how to look at an ocean and tell from the flat spaces where the winds will have less effect because of small differences in salinity or temperature. This is the “butterfly effect” to an amazing degree.

The idea of the rate of flow really hit me.  We are always talking about variation in health care and how seemingly small differences in practice can cause large differences in cost.  Protocols, core measures, evidenced-based medicine, etc. are all efforts to reduce the variations in practice.  I have to wonder to what degree variations in healthcare are caused by the rate of data flow.

You wouldn’t have to walk around a health facility long to hear someone talking about missing information: a missing lab report, a missing chart, a misfiled consultant report, an un-done H&P and the list goes on.  Electronic or paper, the rate of flow of information to the patient chart makes a huge difference.

A clinic that I have worked with on implementing an EMR system shaved two minutes off each patient by paying attention to their patient flow.  That meant that they could see an extra two patients per day, ten per week, without lengthening their work day.  This made a significant difference not only to the clinic, but to the patients.  Remember that the last patient of the day waited about twenty minutes less!

Too few administrators worry about workflow when implementing their EHRs.  While efforts are made to map the workflow in specific areas, such as this article on the impact of EMR on obstetric charts, I don’t think there is generally enough emphasis placed on rate of flow.

How often have you heard administrators talk about their rate of cash flow?  They know that ICD-10 is going to affect their rate of cash flow and studies have been done on what to expect.  They know about other factors affecting cash flow such as RAC audits.  The American Hospital Association (AHA) issues quarterly reports on RAC audits.

But do they know how long it takes for lab or radiology results to appear in the record? Do they know what percentage of the results will make it in two hours?  Four hours? Eight hours? Do they know what factors affect the flow? Can they identify their wind, salinity, temperature or butterfly wings?

I’m a strong proponent of electronic medical records.  Since they are template-based, they have far less variation than a paper chart. Converting a health facility to electronic records is huge, but doing it right is crucial.  Administrators are not expected to be experts in workflow mapping and testing, but their IT folks or consultants should be. Interfaces and other forms of interoperability affect data flow.  Do you know who is monitoring your interfaces? What about your physician portal? Are you alerted when your rate of flow changes?  If not, this might be a good time to call your preferred health care IT solutions and services provider.

Please visit Anthelio Healthcare Solutions Inc. for more information on Dr. Whittington and the Anthelio blog.   

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