Adaptive Case Management, Clinical Groupware, and Routine vs. Non-Routine Workflow in Medical Practice

Shot Link: http://j.mp/bNdXHu

I recently attended the Process.gov conference, specifically to attend a track about Adaptive Case Management. Before I tell you about adaptive case management and its relevance to clinical groupware and pediatric workflow, here’s some background and why I went.

Clinical groupware applications arrange along a spectrum from informal and ad-hoc groupware collaboration tools to formal process model-driven EMR workflow systems. When I researched the historical roots of clinical groupware in groupware and workflow systems I noted:

“[There is a spectrum] between well-structured and ill-structured cooperative problem solving, and the kinds of groupware needed to facilitate computer-supported cooperative work in healthcare. Both kinds of cooperative problem solving require clinical groupware. EMR workflow systems fare especially well on well-structured care coordination problems. The EncounterPRO Pediatric EMR handles both ends of the spectrum well: a workflow engine to handle routine group workflows and the Office View to handle non-routine group workflows.” (Clinical Groupware, Care Coordination, and EMR Workflow Systems: Key Ideas)

Over the last decade workflow management systems (the source of this blog’s name) evolved and became business process management (BPM; I’ll keep the blog name, for now). During the same time, the EMR/EHR industry evolved more slowly, mostly adding features and functionality atop patient clinical data models. The user enters data, navigates to screens, and reviews data and enters orders (and many other people benefit from this effort). The user is, in effect, a workflow engine who pushes and pulls the traditional EMR through a patient encounter.

ehr-wfms-bpm-collision1

Convergence of Concerns between
Clinical Groupware and Adaptive Case Management

This year’s Process.gov theme was “Adaptive Case Management,” a movement within the business process management community resembling, in some ways, the clinical groupware movement within the health information technology community. Both are innovative “outside-the-box” reactions to the traditional software and orthodoxy within each’s respective industry. I think both seek to return to the collaborative human-centric roots of groupware as it was originally envisioned. The big difference now, and potential advantage, is that we have an additional three decades of engineering and cognitive science ideas and technologies to realize this vision.

I went to Process.gov to try to capture some of the essence of adaptive case management ideas as they apply to creating a new generation of process-aware, but also human-centric, clinical groupware. As an emissary from the health information technology industry, my interest in combining ideas from clinical groupware and adaptive case management felt welcomed and reciprocated.

By the way, I used Twitter to record my Process.gov conference notes at @EMRGroupware (reserved for high-frequency, event-related, real-time note taking, to not flood @chuckwebster followers with minutia). If this post piques your interest, feel free to browse this archive.

What is Adaptive Case Management?

To answer this question I will have to pick and choose, because the answer was subject to spirited debate at Process.gov. So I will highlight what I think will be most accessible to the EMR, EHR, and clinical groupware overlapping communities.

I’m a fan of workflow engines, embedded in EMRs, executing process definitions to reduce the amount of work users have to do in order to use an EMR. These are the executable process models I’ve referred to in recent posts. However, I’m not a fan of making any EMR user, in any sense, subservient to predefined process models, because healthcare is chock-full of exceptions. Users have to be free to jump off the happy path, so to speak, and deal with the unexpected–to creatively improvise.

In 2004 I wrote (mentally replace “workflow management systems” with “business process management system or suite”):

“Evident throughout this article is a tension between straightforward, predictable, repetitive, high volume episodes of patient care versus more complex, less predictable, one-of-a-kind episodes, each of which is unique and therefore infrequent, but all of which taken together constitute a significant and important part of the ecology of health care. Traditional workflow management systems excel at what has been called ‘straight through processing’ (STP) in the banking and finance industries. For example, an order to sell shares in a publicly traded stock should ideally happen in a very short interval (that is, before the stock price changes materially). STP seeks to eliminate the human element that slows down stock trades, to only rely on humans for handling exceptional circumstances, and to reduce exceptional circumstances to an absolute minimum (if not altogether!). However, in health care exceptions happen all the time. Medical care is exception rich because abnormal states are, in effect, normally encountered occurrences.

Healthcare processes, and especially core patient-driven processes, are rife with exceptions—from the appointment no-show to the abnormal laboratory value to the undeniably unique history of present illness. And yet, these are in a way predictable and therefore categories and rules and workflows can be defined to facilitate execution of core clinical and administrative processes. Workflow management in health care, especially in and around the EHR, will be workflow with healthcare characteristics. While this may seem obvious, it also means that workflow management systems technology and concepts borrowed from other industries must necessarily be considerably adapted to become successful components of the next generation of electronic health records.” (EHR Workflow Management Systems: Essentials, History, Healthcare, 2004)

“Workflow with healthcare characteristics” was essentially a code phrase for the kind of ad-hoc, improvisational activities that I hoped to hear discussed in the Case Management track at Process.gov. And I did!

A good way to explain the relevance of Adaptive Case Management ideas to clinical groupware is to go through a representative list of adaptive case management ideas and show how the EncounterPRO Pediatric EMR Workflow System implements each idea. The left-hand column of the table in the next section is adapted from the 14th and 15th slides in Jacob Ukelson’s excellent presentation, “What to do When Process Modeling Doesn’t Work” (slides posted here, based on a chapter by the same name in the timely new book Mastering the Unpredictable, put together by Keith Swenson and launched at Process.gov). The right-hand column maps each idea to a way in which the EncounterPRO Pediatric EMR Workflow System (AKA EncounterPRO Pediatric EMR BPM System, AKA EncounterPRO Pediatric EMR Adaptive Case Management System) implements the idea.

How the EncounterPRO Pediatric EMR Workflow System Implements Business Process Management *and* Adaptive Case Management

In this representative sequence of EncounterPRO screenshots are two screens that directly illustrate EncounterPRO’s hybrid combination of business process management and adaptive case management.

  • EncounterPRO’s Workplan Editor (analogous to business process management’s process definition editor) and
  • EncounterPRO’s Office View (analogous to adaptive case management’s case folder).

The manner in which EncounterPRO implements each of the following additional adaptive case management ideas can also be directly or indirectly illustrated by a relevant screenshot. However, this post is already too long, so I’ll publish those screenshots in a future post.

(The following table really gets into the weeds, so to speak. If you’d rather skip the table and remain on the fairway click here. Or, just read the bold stuff.)[TABLE=7]

I frequently blog about EncounterPRO’s workflow engine and workplans/process definitions, and how they can make routine pediatric patient encounters simple and easy (“Pick a post, any post!”). Much of ambulatory pediatrics is sufficiently routine (“If I can’t chart a routine otitis media encounter in under 30 seconds, I know something is wrong!”) that EncounterPRO’s executable process model can do much of work for the user that the user would otherwise have to do for themselves to operate a traditional pediatric EMR. However, even in a high-volume, low-margin businesses like primary and pediatric care, the non-routine does happen. In fact, I wrote an entire (and longish) post about interruption theory and how EncounterPRO compensates for the “routine” non-routine interruptions that threaten completing all the necessary hand-offs and tasks of pediatric care.

EncounterPRO’s Office View is the key.

EncounterPRO’s Office View is a Set of “Case Folders” Where Each Room is a “Case Folder”

The single most salient aspect of the user interface of a case management system is the case folder. It holds all the pending tasks for a case, details about their status, and means for users to take over and complete a task.

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EncounterPRO’s Office View Leverages
Case Folder = Exam Room Metaphor
(From Ten Years Ago, Dallas HIMSS: Landmark Presentation
on Modular Pediatric EMR Workflow Groupware
)

The single most salient aspect of the user interface of the EncounterPRO Pediatric EMR Workflow System is the Office View (click previous screenshot to see animation). Each room in the office view is equivalent to a case folder in a case management system. In the Office View animation, patients and tasks appear (automatically due to workplan execution or optionally due to ad-hoc user initiated activity) and disappear (started and completed by users). In contrast to the animation, in which activity systematically proceeds from upper-left to lower right, in a real-world pediatric office tasks appear and disappear less systematically–to the eye. Each of the colorful little bricks indicates who, what, why, when, and where details that are continually updated over time. And each of these colorful little bricks is also a big fat target that, when clicked or tapped, brings up the screen necessary to accomplish the task (making it disappear from the “case folder,” that is, “room’).

[flv:http://www.chuckwebster.com/video/interview_EMR_WFMS_BPM/interview_dr_G_040809.flv 320 240]

Pediatrician Dr. Armand Gonzalzles MD
on Leveraging Business Process Management
in his Busy Chicago Pediatric Practice

You may think that business process management and adaptive case management are the sole preserve of large organizations with sophisticated IT staffs. However, listen to this eight minute interview with a solo pediatrician who uses workflow management and business process management to run his busy pediatric practice. If you are interested, this post describes the context in which the interview took place.

Eventually, all EMRs in high-volume, low-margin specialties like pediatrics, family medicine, and obstetrics/gynecology, will require process-aware clinical groupware that makes the routine fast and easy (through reliance on executable process models) but also makes the non-routine “ownable,” trackable, visible, accomplishable, and subject to deadline and escalation. There simply won’t be any other way to inject mission-critical clinical information systems into these fast-paced, chaotic environments, than to use ideas from business process management and adaptive case management, adapted to “workflow with healthcare characteristics” of course!

P.S. While we’re on the subject of successfully completing scheduled tasks, I’m reminded of a short anecdote. Around 1995 my wife opened an international hotel in Russia (four years after the dissolution of the USSR). She bought a book about Russian toasts and etiquette. With her background in quality control and continuous improvement, and mine in industrial engineering, we were quite taken with one toast in particular, “To the success of the scheduled tasks!” It sounded so, well, Soviet. One of the graduate students in the Health Management Systems program at Duquesne University had emigrated from Russia. He blanched when I jokingly offered the toast. “Where did you hear that?” It turns to apparently be the official toast of the Young Communists, which he’d been forced to join, the sort of thing that he left Russia to avoid.

So, with respect to this blog’s tasks, to encourage a conversation between the worlds of EMRs/EHRs/clinical groupware and workflow management systems/business process management/adaptive case management: “To the success of the scheduled tasks!”

(Sorry about that, Gregory!)

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