“Meaningful Use” and EHR Business Process Management

Short Link: http://j.mp/5wN38z

I attended the National Committee on Vital and Health Statistics hearing on “Meaningful Use” on Tuesday and Wednesday of this week. The NCVHS advises HHS on EHRs, among other things. The recent ARRA bill included billions for HIT but stipulated that only “meaningful use” of EHRs should qualify for financial incentives. However, the bill kicked the can of what meaningful use meant down the road. This hearing was about picking up the can and doing something useful with it. There were a lot of workflow and workflow-related ideas discussed.

I most liked this definition of meaningful use (from John Halamka, MD, a Boston CIO): Meaningful use is (or should be) “Processes and workflow that facilitate improved quality and increased efficiency.”

What struck me is that “processes and workflow that facilitate improved quality and increased efficiency” is essentially business process management applied to healthcare. The “business process management” industry is what the “workflow management systems” industry evolved into. EHR users need more than automated workflow; they need ability to systematically optimize the effectiveness, efficiency and flexibility of that workflow.

Optimizing clinical outcomes, optimizing patient satisfaction and optimizing practice productivity—are all forms of business process management applied to medical practice. An EHR “workflow management system” automates workflow; An EHR “business process management system” optimizes that workflow along dimensions that matter most to office-based physicians in private practice: clinical outcomes, patient satisfaction, and practice profitability.

You can think of this triad of clinical outcomes, patient satisfaction, and practice profitability as conceptually similar to what is called an objective function in operations research (of which I took a few courses as part of my Industrial Engineering degree). An objective function is the combination of things that need to be maximized, although sometimes at expense of each other (the trick is to find the workflow changes that are win-win-win in the sense that these tradeoffs are ameliorated or eliminated). You can think of automated workflow as a decision variable that is manipulated in order to find better workflow that will maximize the objective function value within a given environment (the set of constraints bounding the practically possible set of workflows).

Non-workflow-management-system-based EHRs are difficult to optimize in a business process management sense. Their workflows (decision variables) are highly constrained by the initial design decisions of the programmer. Their lack of easily changed workflow or process definitions makes it more difficult to systematically improve workflow in order to systematically improve clinical outcomes, patient satisfaction, and practice profitability.

To make this a bit clearer I’ve adapted a diagram from Process Aware Information Systems: Bridging People and Software Through Process Technology (Wiley-Interscience, 2005)

EHR business process management adds EHR management and modeling tools to the EHR workflow management system portion of this diagram.

From page 11 of Process Aware Information Systems: Bridging People and Software Through Process Technology:

In the design phase, processes are designed (or redesigned) based on a requirements analysis, leading to process models. In the implementation phase, process models are refined into operational processes supported by a software system. This is typically achieved by configuring a generic infrastructure for process-aware information systems (e.g., a WFMS, a tracking system, a case handling system, or an EAI platform). After the process implementation phase (which encompasses testing and deployment), the process enactment phase starts—the operational processes are executed using the configured system. In the diagnosis phase, the operational processes are analyzed to identify problems and to find aspects that can be improved.

In order for EHRs to become business process management systems, capable of systematically optimizing clinical outcomes, patient satisfaction, and practice productivity, they must first become “process-aware.” The most logical process-aware information system foundation on which to implement an EHR is a workflow management system. EHRs capable of true meaningful use, that is, capable of “processes and workflow that facilitate improved quality and increased efficiency,” will need to incorporate both workflow management system and business process management technology into their designs.