Almost 25 Years Ago I Co-Developed A Prototype Of A Radiology Imaging Workflow System

Almost 25 years ago I co-developed a prototype of a radiology imaging workflow system at Shadyside Hospital in Pittsburgh. We published details in the 18th Annual Symposia on Computer Applications in Medical Care (SCAMC, now AMIA). I’ve been meaning to resurrect some of that detail for a long while. I finally have.

We’d been tasked with replacing a radiology information system from the sixties with a system based on what was then current tech. By the way, if you follow along the screens, you’ll see it is indeed a workflow. The next step would have been to control tasks and screens from a workflow engine, though we didn’t get that far. Anyway, this was when my interest in healthcare workflow management systems technology really gelled. SGML? Standard Generalized Markup Language, which predates HTML. This system was essentially a clinical domain-specialized web-browser (and back-end servers) before the advent of the World Wide Web.

Abstract

FELIX (FELIX Enables Limitless Information Exploration) provides a generic graphical interface for browsing medical and administrative information. FELIX relies on a large number of industry standards such as TCP/IP, X11R5, SQL and SQL-II, Postscript and SGML. In particular, the interface was developed using a high-level X-windows graphical scripting language called Tcl/Tk (Ousterhout, 1990, 1991,1994). We used real patient information and based our targeted applications on analysis of patient care processes at a local urban community referral hospital. We intended FELIX to be a vision of what is possible, a prototype to force us to confront the necessary integration of disparate technologies, and an inducement for clinicians and administrators to press for open systems file formats, programmatic interfaces and network protocols.

felixradiology

A magnetic resonance image scan has been completed and is ready for interpretation.

felixaudio

By pushing the button titled “Record Report”, a tape recorder with the standard buttons appears on the screen, which allows the physician to verbally enter their findings.

felixtext

A document that looks like a “document” (left), but which is actually derived from a database, can be printed, FAXed, or electronically mailed.

felixrealtime

Patients are tracked into and out of rooms using bar code readers on a network and the information is periodically used to update bar charts. Each bar represents a room. Height represents length-of-stay. Red indicates length-of-stay larger than an adjustable threshold.

felixpathology

The digitized image of a peripheral blood smear has annotated areas that correspond to high-lighted phrases in the textual clinical report.

felixschedule

This resource scheduler represents doctors, nurses, rooms, and equipment across the top, and times down the side. Constraint processing indicates in green the times during which resources are available to be committed together.

felixtrends

On the left is a list of procedures and referring physicians, which can be used to plot procedure volume over time. Decreasing rates of referral may suggest need to intervention.

Google Glass Is Not The Only Wearable: A Partial Long List

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Now, last year I gave a presentation on Google Glass at the conference, but I want to tell folks here that Google Glass is not the only wearable. In fact, there are hundreds and hundreds of wearables on just basically every part of the body, every layer of clothing. There are smart shoes, that the left or the right will vibrate when they’re connected to GPS. They will give you a tour of the city, where someone who is blind can rely on them. There are of course, the smart watches. Last week, the Apple Watch has really raised those profiles. Of course, Android Wear watches have been out for a year or so. There are the bracelets, I wear the Jawbone activity monitor. Gloves, rings, how about this!
Now I’m not going to go through all of these, but I just want to say that about a month and a half ago, there were 2 major wearable technology conferences; one was in New York, one was in Los Angeles, and Google Glass was only a minority of all of those presentations. There’s even smart rings. The smart ring is connected to your smartphone and it vibrates, and it’s connected by Bluetooth. Basically if you have a very high priority person that you only … If you get an email and you want to answer that, they’ll vibrate. Some of them even have little LCD screens to show you a symbol.

Workflow-Related #AMIA2014 Papers and Posters

I looked at every instance of the use of the word “workflow” in the 2012 page proceedings for the American Medical Informatics Association 2014 Annual Symposium. I found these 45 papers and posters. For each I created a short blog post (links below) so I can tweet them.

Why?

Because health IT (of which medical informatics is an influential tributary) must adopt more workflow technology. Workflow tech includes a variety of process-aware technologies, including workflow management system, business process management, and dynamic/adaptive case management. By highlighting specific medical informatics topics, such as clinical pathways, checklists, situational awareness, process maps, and time-and-motion studies, I hope to highlight specific potential contributions of workflow technology to dealing with healthcare and health IT’s manifold usability, interoperability, productivity, and patient safety workflow problems.

If you’re interested in healthcare workflow technology, I hope you’ll read my five-part series on the subject, or watch my 42-minute webinar, archived as a YouTube webinar and embedded in the following tweet.

There’s a lot material below. So, you just want to read my comments about the top five papers or posters (from my extremely workflow-centric point of view), just look for the big ol’ Top Five!

Sunday (all at 3:30! How to choose? Click through to see what I quoted…)

Impacts of EHR Certification and Meaningful Use Implementation on an Integrated Delivery Network
The Impact of HIT on Cost and Quality in Patient-Centered Medical Home Practices
Squaring the circle: Managing local healthcare terminologies in the age of standardization
Missing Evidence for HIT Transformation in a Review of the Literature
ED Noise & Cognition Interruptions: Do We Have a Jackhammer in the Cockpit?


Monday

SMART on FHIR
The EHR’s roles in collaboration between providers: A qualitative study
Developing an Electronic Health Record for Google Glass: Challenges and Use Cases
Using EHR Timestamps for Analyzing Ophthalmology Clinic Workflows
Tissue-Experiment Inventory: A System to Enable Cataloguing of Experimental Results in Association with Tissue and Participant Information
The Need for a Nimble Decision Support Tool for Implementing Clinical Pathways in Oncology
Examining the Multi-level Fit between Work and Technology in a Secure Messaging Implementation
Using TURF to Understand the Functions of Interruptions
A Framework for Incorporating Patient Preferences to Deliver Participatory Medicine via Interdisciplinary Healthcare Teams
Effect of Obesity and Clinical Factors on Pre-Incision Time: Study of Operating Room Workflow
Coordination of Care for Complex Pediatric Patients: Perspectives from Providers and Parents
Clinical Workflow Observations to Identify Opportunities for Nurse, Physicians and Patients to Share a Patient-centered Plan of Care
Cognitive design of a digital desk for the emergency room setting
Integration of Generic Electronic Health Records: Moving from Technology Acceptance to Adaptive Structuration to Reciprocal Coordination
An Electronic Patient Safety Checklist Tool for Interprofessional Healthcare Teams and Patients
Enhancing the TURF Framework with a Workflow Ontology
Applied Clinical Informatics Best Practices in support of Clinical Next Best Practices: Integrating Knowledge Discovery to Delivery into Workflow
Engineering for reliability in at-home chronic disease management


Tuesday

An Extensible Integration Framework for Clinical Decision Support Applications
A Time-and-motion Study of Clinical Trial Eligibility Screening in a Pediatric Emergency Department
Google Glass for clinical procedures reference. Perception of optimal UI (user interface) and functionalities
A Comprehensive Simulation Modeling Methodology to Reduce Health Care Process Redesign Risk
Automating Extraction and Calculation of Daily Dose and Duration for Medications in EHRs
Differences in Occurrence and Recorded Times of Care Delivery Events as Documented in Electronic Health Records
Attitudes Towards Electronic Medical Records in Intensive Care
Workflow-based modeling of cancer care trial protocols
Challenges Faced When Designing and Conducting Time Motion Studies in Health Care Environments
User Experiences of Speech Recognition Technology (SRT) by Physicians: A cross-sectional survey study
Check it with Chex: A Validation Tool for Iterative NLP Development
Problem Management Module: An Innovative System to Improve Problem List Workflow
An Analysis of Medication Adherence of Sooner Health Access Network SoonerCare Choice Patients
HIE Enablers: A Crucial Need for Care Coordination Communication Among Long-Term and Post-Acute Care Front Line Nursing and Other Staff
Going Digital: Transforming Medical Checklists for Improved Patient Care
Safety-Enhanced Design as a Meaningful Use Objective: Evaluating and Advancing the Usability of Electronic Health Records
Considerations of dual process theories for EHR design
Integrated Data Management System for Medical Registries: A Case Study using RexDB
How Can We Partner with Electronic Health Record Vendors on the Complex Journey to Safer Health Care?
Analyzing and Comparing Clinical Work Systems with Cognitive Work Analysis: Lessons Learned


Wednesday

Patient-Centered Appointment Scheduling Using Agent-Based Simulation
Trends in Publication of Nursing Informatics Research
Characterization of a Handoff Documentation Tool Through Usage Log Data

Participatory Design and Development of a Patient-centered Toolkit to Engage Hospitalized Patients and Care Partners in their Plan of Care

PS I’ve not yet assigned papers to the top five workflow paper category! Come back to see! 🙂

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Transcribed Slides For My 42-Minute Webinar on Ebola, EHR Workflow Engines, Editors, and Visibility

(This is a full-text transcription of one slide from my November 5th 42-minute webinar on Ebola and EHR Workflow Engines, Editors, and Visibility. Please excuse occasional “typos” as I’ve not proofed every word. Consider watching the Youtube video. My original post announcing the webinar includes motivating context and an outline. Thank you!)

slide011

My name is Charles Webster. I’m @wareFLO on Twitter, W-A-R-E-F-L-O. All of my slides are tweets. People sometimes say they think I’m tweeting PowerPoint slides. That’s what I use them for. If you are on Twitter, please use #EHRworkflowNov5.

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AMIA2014 Workflow Paper (Monday) Engineering for reliability in at-home chronic disease management

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[CW: Great table! > Table 2. Summary of reliability system design strategies used by participants to enhance self-care reminders.]

3:30PM Sunday

“Prospective Memory as a Basis for Task Planning and Recall

Remembering to perform all the tasks expected for proper self-management requires effective recall of what has already happened and a continuous scan of what needs to happen in the near future. The process of remembering is frequently framed as either of two types: (1) retrospective memory that is concerned with the retrieval of past memories of people, events, and words, or (2) prospective memory that is concerned with remembering to perform a planned action or intention in the future11. The latter process includes short-term intentions—such as daily intake of a medication—as well as delayed actions—such as going to an annual checkup appointment—that could occur weeks or months in the future. Outlined in Figure 1, the process for realizing a delayed intention begins with encoding the future action, retaining the intention, and then retrieving the intention at the appropriate time to complete the action. This can occur through either an explicit reminder system or through spontaneous retrieval. Actions such as remembering to take medication at breakfast often rely on spontaneous retrieval of the intention that is triggered through environmental and physiological cues linked to daily routines. However, intermittent actions further out in time often involve a more explicit signaling cue—such as creating an alarm on a phone—to retrieve and execute the action at the right time12. In the case of an individual managing a chronic condition, the capacity to reliably shape and direct future behavior is critical to successfully managing the disease. The role of both explicit and implicit reminder systems within this memory process is the focus of this paper.
….
Designing for Human Error

Importantly for systems-thinking, our study highlights the variety of ways that failures can occur in remembering to perform self-care management activities. Therefore, the design of reminder systems to support self-management should account for errors by making it easier to detect, evaluate, and respond to failures when they do occur.”

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Outline: Ebola, EHR Workflow, Workflow Tech, Workflow Engines, Editors, and Visibility

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slide02
Overview, I’m going to talk a little bit about Ebola, EHR and workflow as in a torn from the headlines sort of way, then I’m going to talk about the basics. What is workflow, what is workflow technology and then a little bit more of length about engines, editors and visibility. By the way, that’s my main blog there, chuckwebster.com. Thank you for everybody who retweeted this outline over the last couple of weeks.

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“Poke the workflow bear” Refers To Mentioning Me On Twitter!

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slide03
Sometimes people call me the workflow bear and they’re talking about ‘poking the workflow bear.’ There in some conference and some guy or gal starts talking about workflow and EHRs and health IT, so they’ll take a picture of the slide, they’ll quote them and they’ll include my URL or my handle and I always respond. It’s like I’m a sleeping bear and you poke me and I wake up and I say something.

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Dallas Hospital Blames Flaw In Workflow For Release of Ebola Patient, Then Retracts

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slide04
On October 3rd, I woke up and I had hundreds of mentions and people emailing me, including health IT journalists, contacting me through contact forms of one of my blogs asking me about this headline which is “Dallas hospital blames ‘flaw’ in ‘workflow’ for release of Ebola patients.” I actually end up quoted in quite a few health IT publications and was exciting moment for me to see workflow up there in lights.

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Ebola Workflow, Nurse Workflow, Physician Workflow, EHR Workflow: Part 1

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slide05
Interestingly enough, the next day, the hospital retracted the statement that there was a flaw in the HRE workflow. The other half of the health IT community went ‘aha’, it was a human or user error. We’ll talk about that at the end of this presentation. On the second one, a PR release came out, which I read on the third, it talked about visibility of workflow. The nurse collected the information supposedly about travel from Africa and somehow, the result of this wasn’t part of the physician workflow, it wasn’t visible. All of this is going to a build-up to what does it mean, to have visible workflow, but I’m using a lot of analogy and metaphor.

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EHR Workflow Is A Series Of Steps, Consuming Resources, Achieving Goals

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Let’s start with the basics. I have looked at literally hundreds of definitions of workflow, some of which would fill multiple PowerPoint slides. This is my favorite definition, because I made it up: “A series of steps, consuming resources, achieving a goal.” If you’ve ever written out a workflow on a napkin, labeled boxes with little arrows to explain workflow to someone else, I’m sure you’re familiar with that. Consuming resources; each workflow step requires a widget from inventory or the time of some user or some access to some other system that’s talking to and it consumes these resources; it can’t perceive without those resources, but it also costs something. The amount of time the user spends interacting with, say a data entry screen is part of that. Finally, the workflow achieves a goal. That goal is the benefit of the workflow.

What we’ve connected up here is a series of steps to cost and benefit. If the cost and the benefit change, if the economics of the workflow change, you should be able to change the workflow. Unfortunately, many workflows and health IT and many EHRs are relatively frozen and that’s one of the sterling qualities that workflow technology brings to EHRs and health IT. It makes it easy to change the workflow when contexts change in order to make the users happier and more effective and efficient.

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