My Comments on the NIST Report on Integrating EHRs into Clinical Workflow

The National Institute of Standards and Technology just published the report Integrating Electronic Health Records into Clinical Workflow: An Application of Human Factors Modeling Methods to Ambulatory Care (archived). I’ve just skimmed it so far, but I wanted to publish this blog post stub as a sort of tickler for me (and anyone else who wants to weight in) to remind me to write more about it later. In the mean time, off the top of my head, here were my initial reactions.

Yeah, strong, I know. In fact, I approve the general direction of this report, which is, we need to think hard and creatively to improve EHR workflow. While I approve of the general direction, I don’t think it goes far enough. In other words, it does not go on to what I think is a logical conclusion: If healthcare workflow is the problem; workflow technology is the solution.

Health IT is gradually getting used to the idea of actually modeling healthcare workflow. The next logical step after that is to actually execute those models of workflow. Well, what to do you use to execute a model of workflow? A workflow engine.

I hope health IT doesn’t try to reinvent the wheel, as it has done so for operating systems and programming languages. Workflow engines (and related technologies such as activity monitoring, event processing, workflow editors, and workflow analytics, and even alternatives to classical workflow management systems such as case management systems) are part of the what is now called the Business Process Management industry. There are many excellent workflow platforms on which to build truly process-aware health information systems.

Or, if we have to essentially “work around” the workflow-oblivious EHRs and HIT systems we’ve subsidized into place, see my From Syntactic and Semantic to Pragmatic Interoperability blog post that recently generated so much reaction on Twitter.

Addendum

[The following are quotes from the report. I pulled out the ones I think will be of most interest to workflow management systems, business process management suite, and dynamic/adaptive case management professionals and analysts. Be sure to check out the actual process maps in the report. My comments are shown within brackets. I’ll likely keep adding comments over time. Some are sort of me thinking out loud or reminders to myself to elaborate a reaction to the quote.]

“issues with workflow integration have contributed to slow rates of EHR adoption”

“Workflow is a set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal.”

“Workflow analysis is an integral part of the early stages of the User-Centered Design (UCD) process”

[Opportunities]

  • “At-a-glance overview displays to enable physicians to adapt patient schedules to smooth out predicted workload and better meet work-life balance objectives
  • Support for remembering tasks to accomplish during a subsequent patient visit
  • Redacting and summarizing laboratory results
  • Drafting predicted orders a day before a patient visit to reduce the time to complete the orders during the visit
  • Supporting moving from initial working diagnoses to formal diagnoses
  • Supporting dropping or delaying tasks under high workload conditions
  • Supporting different views of a progress note based upon role
  • Distinguishing new documentation in a progress note from copied information from a different progress note
  • Supporting communication with specialist physicians about referrals and consultations
  • Tracking scheduled consults and review of laboratory results”

“recommendations … to improve workflow integration with EHRs are proposed to increase efficiency, allow for better eye contact between the physician and patient, improve physician’s information workflow, and reduce alert fatigue”

“recommendations point the way towards a ‘patient visit management system,’ which incorporates broader notions of supporting workload management, and supporting the flexible flow of patients and tasks.”

[CW: “patient visit management system” equals patient workflow management system]

“Usability has traditionally been defined as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use.”

“In order to achieve usability in such systems, it is critical to design for usability using best practices from User-Centered Design (UCD).”

“summative usability tests of EHR software as a part of implementation.22 An acknowledged limitation of this approach is that it is difficult to identify workflow challenges arising from local implementation decisions and from the variation in the distribution of work across types of users”

“Workflow has emerged as an issue for EHR adoption, productivity,25 and professional satisfaction for physicians.”

“workflow challenges that have been identified in the literature review include:

  • having to log in to multiple systems separately,
  • extensive manipulation of keyboards to enter information,
  • the number of clicks involved in medication ordering processes,
  • difficulty in processing orders that are not standard,
  • difficulties in switching between different paths and screens to enter and retrieve information,
  • problematic data presentations such as patient medication profile design,
  • clutter of order and note screens,
  • difficulty seeing patient names on the screen, and
  • missing free text entry and other word processing functionalities”

“Workarounds are defined as actions that do not follow explicit rules, assumptions, workflow regulations, or intentions of system designers”

“systems that are poorly integrated into workflow may promote workarounds that bypass safety features”

“Modeling methods are needed to allow EHR software to accommodate the complexity of clinical environment workflows. Applying these methods will avoid contributing to patient safety issues31 directly through design flaws as well as indirectly through unsafe workarounds”

“Workflow: A set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal”

[contrast with my shorter definition of workflow]

“Workaround: Actions that do not follow explicit rules, assumptions, workflow regulations, or intentions of system designers”

“Human factors is defined as “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance”

[contrast with my post on Industrial Engineering, including Human Factors]

“Process mapping

Flowchart typical process flows with a sequence of process steps and frequently occurring branches as yes/no decision boxes”

“Goal-means decomposition

Means (how) for achieving (goals) are displayed visually in a concept map, which are derived from functional analysis”

“Hierarchical task analysis

A structured description of tasks that provides an understanding of the tasks users need to perform to achieve certain goals by interacting with software. Tasks are broken down into multiple levels of subtasks”

“Figure 2 is a generalized portrayal of workflow, and thus may vary when customized for different work settings. Choices about what staff perform what roles will modify workflow, and individual clinician preferences will influence what steps are performed in what order and by what personnel, thus the step sequence and order may vary”

“Figure 2. Overview process map for EHR use related to returning patient visit in ambulatory care”

“Figure 3. Process map for activities conducted before a returning patient visit with the EHR”

“looking at the size of a paper chart was a cue to how complex or challenging the patient was which is not typically displayed at the top-level view in EHRs with document icons which do not vary based upon length”

During the patient visit

“In Figure 4, the process steps related to activities occurring with the EHR during the visit are shown. These are:

  • Check in patient, obtain vital signs and chief complaint from patient,
  • “Warm up” and remember pertinent information,
  • Collect medication reconciliation data and review of systems data,
  • Get history, signs and symptoms, review of systems, make working or presumptive diagnosis,
  • Examine patient, physical,
  • Form initial treatment plan,
  • Review chart/research guidelines, informal consult,
  • Initiate intent to order medications, procedures, labs, consults,
  • Verify medications and allergies,
  • Pick diagnostic (ICD-9-CM, ICD-10-CM) and procedure (CPT) codes, verify insurance, investigate requirement for public reporting,
  • Verify dosage for some medications,
  • Explicit Orders: medications, procedures, labs, imaging, consults/referral,
  • Clinical Procedure,
  • Patient education,
  • Give patient summary,
  • Physician and/or others tells/reviews patient initial assessment, plan, and “to do” activities, motivates following plan,
  • Document relevant history, physical, assessment, plan,
  • Documentation to support billing,
  • Document medications reconciled, and
  • Documentation for others (legal, research, compliance, MU)”

“Variation was described in by typically:

  • Collects the Review of Systems data for the appropriate body functions,
  • Enters the information into the EHR,
  • Determines the diagnostic (ICD-9-CM, ICD-10-CM) and procedure (CPT) codes,
  • Determines whether insurance covers particular activities,
  • Verifies the accuracy of relevant medication types and dosages, and
  • Makes changes to the schedule during the day”

“Figure 4. Process map for activities conducted during a returning patient visit with the EHR”

“All SMEs believed that physicians were typically the bottleneck in the process flow in ambulatory care settings. All of them felt that there were aspects of how the EHRs were designed that increased the time spent during this bottleneck which had the potential for unintended consequences for patient care”

“In Figure 5, the process steps related to activities occurring with the EHR during a physician encounter are shown. These are:

  • Get history, signs and symptoms, review of systems, make working or presumptive diagnosis,
  • Examine patient, physical,
  • Form initial treatment plan,
  • Review chart/research guidelines, sideline consult,
  • Initiate intent to order medications, procedures, labs, consults,
  • Verify medications and allergies,
  • Pick diagnostic (ICD-9-CM, ICD-10-CM) and procedure (CPT) codes, verify insurance, investigate requirement for public reporting,
  • Verify dosage for some medications,
  • Explicit Orders: Medications, procedures, labs, imaging, consults/referral,
  • Clinical Procedure, and
  • Document relevant history, physical, assessment, plan”

“Figure 5. Process map for activities conducted during a physician encounter with the EHR”

“elements of the provider exam were predictable based upon established diagnostic information”

“Every SME expressed enormous frustration that most elements of their EHRs assumed that a diagnosis was already established at a detailed level”

“Discharge

In Figure 6, the process steps related to activities occurring with the EHR during discharge are shown. These are

  • Explicit Orders: Medications, procedures, labs, imaging, consult/referral,
  • Clinical Procedure,
  • Give patient summary, and
  • Physician and/or others tells/reviews patient initial assessment, plan, and “to do” activities, motivates following plan”

“Figure 6. Process map for activities conducted during discharge with the EHR”

“Figure 6a: Workflow of Explicit Orders: Labs”

“Figure 6b: Workflow of Explicit Orders: Imaging”

“Figure 6c: Workflow of Explicit Orders: Medication”

“Figure 6d: Workflow of Explicit Orders: Consult”

“Figure 7. Process map for activities conducted during documentation with the EHR”

“In comparison with a paper-based system, clicking through an interface to document information and categorizing information into structured elements are primarily new tasks which largely did not exist in the previous systems”

“Supporting real-time documentation

The SMEs described three potential models relating to documentation during the actual patient visit:

1) No documentation during the visit. In this situation, the physician would review portions of the chart before seeing the patient, and do orders and documentation after the visit. In some cases, printed information would be taken into the room and handwritten notations would be made on the printout during the visit.

2) Draft documentation during the visit. In this situation, the physician would typically review new results with patient, do any simple orders during the visit, do consult requests that did not require extensive documentation, and create an initial draft of a note, typically employing a personal shorthand to increase efficiency and which would be replaced with a longer format after the visit.

3) Full integration of documentation during the visit. Only one SME used this approach. In this situation, he reviewed the last progress note immediately after greeting the patient (without showing this to the patient), entered data from the history real-time and from the physical immediately following the exam, did all orders and consult requests, finalized documentation which was done throughout the visit, signed the note, and then explained to the patient what steps to do next”

“the following opportunities to improve workflow were identified based on the discussions with several physician SMEs in ambulatory care:

  • Scheduling support with at-a-glance overviews of patients for the day,
  • Supporting remembering what to do during the patient visit,
  • Cognitive warm-up support,
  • Managing flow,
  • Identifying time-critical notifications,
  • Redacting and summarizing laboratory results,
  • Drafting predicted orders,
  • Transferring initiated tasks to another to complete,
  • Supporting established diagnosis-based workflow,
  • Supporting moving from working diagnoses to formal diagnoses,
  • Supporting reviewing changes to medications,
  • One-page patient summary,
  • Supporting handing off patient education,
  • Supporting dropping or delaying tasks under high workload conditions,
  • Reducing time spent on documentation of provided care,
  • Supporting different views of a progress note based upon role,
  • Distinguishing new documentation from copied information,
  • Supporting communication with specialist physicians about referrals and consultations,
  • Supporting real-time documentation, and
  • Tracking scheduled consults and review of laboratory results”

C. Managing conflicting goals: goal-means decomposition diagram

[find my notes on the BPMSExpo demo of BPM system representing conflicting goals]

“In Figure 8, for physicians in ambulatory care using EHRs to provide care to patients, we have identified three top-level goals: 1) patient care, 2) billing/reimbursement, and 3) physician quality of work-life”

“Figure 8. Goal-means decomposition diagram for EHR use by ambulatory physicians”

“5 Conclusion

In response to workflow integration challenges with ambulatory physicians using EHRs, we have employed standard human factors methods in order to identify insights for EHR developers and ambulatory care centers. The methods illustrated in this document are process maps and goal-means decomposition diagrams informed by goal-oriented individual collegial discussions with physician Subject Matter Experts to walk through the typical workflow of a returning patient in an ambulatory care setting. We have identified a wide variety of potential opportunities to improve workflow with EHRs from a physician perspective. We anticipate that improving workflow might require an expansion in focus from the historical goal of supporting reimbursement to also improving quality of patient care as well as the quality of work-life for physicians. In order to increase the ease of implementing our insights, we provide a set of targeted recommendations.”

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