At 04:36 PM 4/14/2009, Dr Reynolds wrote:

Dear Rodolfo,

I visited the ACGME (Accreditation Council for Graduate Medical Education) website, read the OUTCOMES PROJECT material and printed it out for further thought and analysis. The "Healthcare Matrix" was inspired by the 2001 IOM (Institute of Medicine) report Crossing the Quality Chasm. I had known about that report during my years in California. I worked in the USA from 1983 to 2004. The last 5 years of that sojourn were spent as Chief of Ambulatory Care with Los Angeles County's facility in Lancaster and surrounding communities. I was involved in many projects related to quality of care. All of them, alas, were based on the paper medical record. The process was so time-consuming that major changes were difficult to implement.

The concept processor will be able to help the process of OUTCOMES IMPROVEMENT. As indicated in my essay (Attached), a Reminder to the physician of what to do and how to do it, can improve outcomes as well as the process of care.

Because Richard (and other readers) may not have seen the documents, I'll give a brief intro: The matrix has 6 Aims (which are listed across the top of the page) and 6 Competencies (which are listed down the left side of the page). These create 36 boxes, a 6 x 6 matrix. Each medical case under review will potentially have 36 items or facets.

The 6 Aims are: Safe, Timely, Effective, Efficient, Equitable and Patient-centered.

The 6 Competencies are: Patient Care (overall assessment- as "yes/no"), Medical Knowledge & Skills (What must we know?), Interpersonal & Communication Skills (What must we say?), Professionalism (How must we behave?), System-based practice (On whom do we depend and who depends on us?), and Practice-based Learning and Improvement (What have we learned? What will we improve?).

To give a concrete example of Praxis' role, let me refer to the case that was used in the ACGME Tutorial (which is itself a brilliant idea, since abstract concepts such as "Outcomes Improvement" have to be brought "down to earth" in specific cases, which is what the tutorial does).

In the section "Care of Patients with respiratory distress; Otolaryngology: Head and Neck Surgery," the reader sees the final, completed matrix dealing with an ENT case that had a bad outcome. ("Bad enough," you say, "the patient died.").

If you go across the top to "Efficient" and then down that column to "System-based practice," you find that the item says: "Inefficient system for tracheostomy care (i.e. supplies, specified Nursing Instructions)."

The next page shows an overlay stating: "After collaborating to create the complex matrix described above, the ENT resident was prompted to ask if there were standardized trach orders already in place throughout the hospital. There were, but the orders were out of date and few staff were aware they existed."

The Action Plan includes 4 items, 2 of which require creating written material and 2 of which require communication.

Comment: Using a paper-based system to improve the process of patient care (In this case "Determine what materials are best for tracheostomy tube change" and "Create new set of tracheostomy orders") is very inefficient. It would be much better to have a computer program that holds the "new set of tracheostomy orders," ready for any healthcare worker who needs access to them. That would also take care of the 2 Action Plan items which require communication.

Since I do not intend for this essay to contain a contrast between Praxis EMR with its concept processor and its competitors with their templates, I will comment on the capabilities of Praxis and leave it to others to comment on the capabilities of the template systems to handle these complex maneuvers.

Praxis already has an example of how to use such items as "New set of tracheostomy orders". If you look at my website www.reynoldsmedicine.com you will see that we have for license a complete textbook: The Manual of Rural Practice. This is not simply a textbook whose material has been "copied and pasted" into an EMR. I actually "deconstructed" the text from the document source (provided to me by the publishers) and "reconstructed" it within Praxis, using the SOAP system so familiar to physicians and other healthcare providers. Thus the Introduction (for example Chapter 4 "The Occasional Cricothyrotomy") has been put into Praxis under Assessment. The text material is in brown colored font, which means that it can be read by the User but will not print out in the case report. Similarly with the Complications. Hopefully there will be none, but if they do occur, the User will be able to document them simply by changing the color of the font from brown to black.

The actual instructions for the procedure (performing a cricothyrotomy) I placed in Procedure (Praxis actually uses SOPAP, meaning Subjective, Objective, Procedure, Assessment and Plan- see the Demo for details). The textbook also had a "Procedure Summary," for quick reference or memory refresh, so I put that into Praxis under "Procedure" too. If the User wishes to print out either "Procedure" or "Procedure Summary" he simply ensures that the text is in black font, and it will print out.

I placed the Figures in the Agents section. They can be called up instantly, to inform or remind the User where the cricothyroid ligament resides.

I placed the Index of Procedures into Praxis as a separate Assessment, for rapid review by the User. Similarly with the list of Equipment Sources (a feature which I have not found in any other textbook). That list contains instrument-specific suppliers with their names, addresses, email addresses, website and "price at date of publication of textbook". This is like "one stop shopping"!

Now you may say, what good is it to have this information in the computer?

1. Part of the answer is that if you put this information into the server, it is available to all users, 24/7 and at the point of care. If someone has need of a printed copy, it can be printed. A simple email to all users would alert them to the presence of this set of instructions (obtained, by the way, from a respectable and trusted source) and any updating can be done "at source" which is the Clinic's server.
   
   
2. Another major part of the answer is that the instructions become part of the case write-up, without the User having to do anything other than ensure that the text to be saved with that particular patient is in black font. If the provider performs a maneuver that is not in the Procedure, or is in addition to the embedded Procedure, he simply types that in and it becomes part of the case report for that patient.

The Query system in Praxis is being constructed following my theory of the 3Rs of healthcare quality: The guidelines (and in this instance the guidelines are the Procedures) are in the computer as a Reminder to the physician as to what to do. The case write-up, facilitated by the fact that much of the case report is already done, is the Record of what was done and any Review must match these other two features. The Praxis Query Engine can already extract a large amount of user-defined information. The Query Engine will be even more powerful after the upcoming version is perfected.

Imagine a program, whereby every User in a Clinic has the same guidelines at his fingertips. Those guidelines can be updated rapidly and efficiently. Compliance with those guidelines can be queried. And, eventually, automated performance reports (APRs) will be enabled.

Patient safety will be enhanced, just as recommended by IOM, because any Action Plan, no matter how complex, can be carried out by installing the appropriate guidelines as text material within the EMR.

Also, if a provider is getting ready for an academic exam (say in Rural Medicine) he only needs to have access to this program and 1 or 2 hours of "free" time, to review 40 different procedures, with their indications, contraindications and complications.

That's about enough for you to digest now, I suspect!!!

Please keep in touch. Perhaps you could describe your local situation more: number of providers in Clinics, number of patients seen annually, methods of reimbursement etc.

Clay