2006 EHR WfMS Tutorial Slides 67-71: Doughnut Baking Automation Analogy, Workflow Reference Model, Patient Encounter

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From EHR Workflow Management Systems: Essentials, History, Healthcare, TEPR Conference, May 19, 2004, Fort Lauderdale.

The Workflow Reference Model described a common vocabulary about workflow, a workflow management architecture that was technology and vendor neutral, and key interfaces that required standardization.

The Workflow Reference Model is reminiscent of the electronic health record reference model being defined today. So, it is natural to connect these two efforts when presenting the concept of electronic health record workflow management systems. In fact, a recent paper examining the legacy of the original reference model concludes by saying that the core legacy may be that “it has provided a common framework for people to think about Workflow and BPM (Business Process Management) and ten years of fascinating discussions!” [3] I hope and believe the same will be true of electronic health record workflow management systems, too! (By the way, there remains a residual of terminological variation, such as process definition versus workflow definition.)

Well, so much for that prediction! Nonetheless, it is eight whole years later and EHR workflow management systems, process-aware health information systems, business process management in healthcare do seem to be gaining some credence and ground…

I use(d) an analogy to a partially-automated, partially manually-operated donut shop near where I used to live in Atlanta to explain the Workflow Reference Model. Patients aren’t widgets or doughnuts. However this whimsical analogy introduce some serious technical ideas about patient encounter workflow.

I used to live near the donut company’s flagship store in Atlanta. There was a long glass wall through which you could follow an “extruded” bit of dough, watch is rise, fry on one side, flip to fry on the other side, and then receive its glaze. From mix to fix in just a few minutes, up to 3000 doughnuts an hour.

Photos:

• raising yeast on automated trays in warming oven
• doughnuts floating on hot oil
• doughnuts flipped on hot oil
• doughs being glazed

• Cooking Process
  • (defined by) Cookbook (used to manage Dessert Creation)
    • (composed of) Activities (during execution represented by activity instances)
      • Manual Activities
        • Mixing ingredients
        • Placing in oven
        • Adding glaze
      • Automated Activities
        • Programmable mixer
        • Conveyor belt oven
        • Automated icers
  • (managed by) Kitchen Staff
    • Dessert Creation
      • Activity Instances
        • Work Items
        • Invoked Applications

Here is a cooking analogy. Near where I live in Atlanta is the flagship donut shop for a major chain. In there they have the most amazing cooking process. They have this programmable mixer that is extruding donuts. This conveyor belt oven with glass on the side that allows you to see the donuts make their course through the oven. They emerge and float across some hot oil and then there is this automated icer that squirts the icing on them. On the other site of a wall from them is a line of kids, plus myself, and it’s quite fun to pick out your donut and then to eat it, having seen all the steps of its creation. Around the corner is the most amazing Buck Rogers wall full of dials, levers, and gauges. Its all very retro and very fifties and very fun.

• Business Process
  • (defined by) Process Definition (used to manage Process Instances)
    • (composed of) Activities (during execution represented by activity instances)
      • Manual Activities
        • Mixing ingredients
        • Placing in oven
        • Adding glaze
      • Automated Activities
        • Programmable mixer
        • Conveyor belt oven
        • Automated icers
  • (managed by) Workflow Management System
    • Process Instances
      • Activity Instances
        • Work Items
        • Invoked Applications

• Business Process
  • (defined by) Process Definition (used to manage Process Instances)
    • 1. Get Patient
    • 2. Vital Signs/CC
    • 3. Allergies
    • 4. Current Meds
    • 5. Examination
    • 6. Assessments
    • 7. Orders
    • 8. E&M (Evaluation and Management billing codes) Coding
    • 9. Approve Billing
  • (managed by) Workflow Management System
    • Process Instances
      • 1. Actually get B Smith on 2/10/04
      • 2. Actually capture his vitals and chief complaint
      • 3. Actually note his allergies
      • 4. Actually medications
      • 5. Actually examine him
      • 6. Actually diagnoses his problem
      • 7. Actually prescribe a medication
      • 8. Actually calculate an E&M level
      • 9. Actually bill his payer

We see that the process definition, or encounter definition, is composes of activities. Some of these activities are manual activities such as entering or reviewing data or entering orders. Others of these activities are automated activities such as when the electronic health record workflow management system invokes and manages communication with a devices such as an EKG machine, or starts up Primetime Instant Medical History so that the patient can enter their own history and then communicate that data back to the electronic health record. And then of course there are the communications with the outside world such as checking for lab values with the lab information system.

Just as with the cooking process, there is a mix of manual activities (entering and reviewing data, entering orders) and automated activities (communication with devices such as vitals and spirometers, other appliecations such as patient interview software, and other systems such as vaccine registries, clinical laboratories such as Quest and LabCorp, and pharmacies over the SureScripts e-prescribing network).

• Business Process
  • (defined by) Process Definition (used to manage Process Instances)
    • (composed of) Activities (during execution represented by activity instances)
      • Manual Activities (value added)
        • Entering and
        • Reviewing Data
        • Entering Orders
      • Automated Activities
        • Devices
        • Communication
        • Decision Support
        • Etc.
  • (managed by) Workflow Management System
    • Process Instances
      • Activity Instances
        • Work Items
        • Invoked Applications

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