2006-Tutorial – Healthcare Business Process Management Blog by Chuck Webster, MD, BSA (Accountancy), MSIS (Intelligent Systems), MSIE (Industrial Engineering), #HIMSS18 Social Media Ambassador

2006 EHR WfMS Tutorial Slides 103-108: To Be, or Not to Be (the Workflow Engine) That is the Question

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These are the closing slides from the 2006 EHR Workflow Management Systems: Key to Usability slide deck. They are dense. But, if you’ve referred all or most of the preceding slides they should make complete sense.

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Workflow Engine (1)

Provides run-time execution environment for workflow instance
Interprets process definition
Controls [sic] of process instances – creation, activation, suspension, termination, etc.
Navigates between process activities, including sequential or parallel operations, deadline
Schedules, interprets workflow relevant data
Signs-on/off specific participants

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Workflow Engine (2)

Indentifies workitems for user attention and an interface to support user interactions
Maintains workflow control data & workflow relevant data, passing workflow relevant data to/from applications or users
Interfaces to external applications and links any workflow relevant data/li>
Supervises actions for control, administration and audit purposes

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Workflow Engine Uses Process Definition to Reason About…

Who (Dr. Jones: personal preferences)
What (role: physcian, nurse…)
Why (vist reason: well child, chronic Rx)
When (position in workplan [AKA process definition])
Where (exam room, tech station…)
How (specialty-specific)

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EMR EHR Workflow Engine Presents Right Screen & Data & Order Entry Options…

Present the right screen
To the right person
At the right time
Containing the right data
Right order entry options
(and to execute many tasks automatically without need for any user intervention)

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Ask Yourself…

Who or what is the workflow engine?
- If the answer is “who”…(Bad)
- If the answer is “what”…(Good)

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Discussion after the tutorials was interesting. What stands out are the number of people from the workflow management systems AKA business process management industry who attended the tutorial and came up afterwards. They, or the organization that sent them, saw an opportunity to bring workflow automation to healthcare, but actually seemed dismayed. They saw a lot of session titles that used the word workflow but when they attended the presentation they noted that “workflow” in healthcare didn’t seem to be used the same way as it was and is in the workflow/BPM industry.

In each case I would sympathize. And I would tell them that they were not alone in this puzzlement. Wil van der Aalst is a well known business process management researcher, about which I’ve written:

Prof. van der Aalst gave one of the main keynotes at the 2004 MedInfo conference in San Francisco where he said that while he had looked through the two thick volumes of 300 hundred or so medical informatics papers and saw the word “workflow” a lot, it did not seem to be used in the way in which it is usually understood within workflow management systems research and industry. (By the way, I did catch up with Prof. van der Aalst afterward to confirm that my paper and poster did indeed discuss workflow in the workflow management systems sense.) This is consistent with my own experience.

Source: (EHR) Workflow Management: Models, Method & Systems (on chuckwebster.com)

Process-aware technologies, from workflow engines to process definitions and process mining are diffusing into healthcare. The technology has had great promise for a long time. This potential has been written about for two decades. I think we are finally getting close to critical mass. There are wide array of usability and productivity problems with EMRs and EHRs that are due to the fact that most EMRs and EHRs are not particularly (if at all) process aware. At the same time, workflow/process researchers better understand these problems and how to articulate the potential benefits of process-aware information systems for what ails healthcare and healthcare IT. To follow this increasing activity, check out The EHR.BZ Report on EMR and EHR Workflow, Usability, and Productivity. There are more and more headlines (linked to sources) that implicate EMR and EHR usability and productivity problems, but, at the same time, more and more headlines (again, linked to sources) that illustrate how process-aware EMR and EHR technology can address these very issues.

The End!

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2006 EHR WfMS Tutorial Slides 98-102: More Workflow Definitions (No Pun Intended) Applied to Patient Encounter

Get it? Sorry. “Workflow Definition” could refer to either process definitions, executed by a worklflow engine, or a definition of some word or phrase related to EMR and EHR workflow such as workitem, enactment, etc.

The following table is adapted from the associated 2004 proceedings paper EHR Workflow Management Systems: Essentials, History, Healthcare, TEPR Conference, May 19, 2004, Fort Lauderdale.

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Glossary of EMR / EHR Workflow Terminology

Phrase	Definition	Medical Example
Work Item	Task to perform	Vitals signs awaiting performance during a patient encounter
Workflow/ Process Definition	Description of a process detailed enough to drive EMR / EHR behavior. van der Aalst refers to this as a formal process model, that is, one that can executed.	Get the Patient, Take Vitals and a Chief Complaint, Review Allergies, Review Medications, Review of Systems, Examination Screen, Evaluation and Management, Billing Approval
Worklist	List of tasks to perform	A nurse’s To-Do list
Case	Particular application of a EMR / EHR workflow management system / business process management suite	A particular patient’s encounter managed by EMR / EHR workflow management system /business process management system
Process	Order (though not necessarily sequence) of tasks to be performed and resource requirements	A Well Child pediatric visit
Resource	Something that accomplishes tasks (often a user)	A physician, nurse, technician
Role	Set of related skills accomplished by a resource	The role of nurse or physician
Routing	Types of routing include sequential, parallel, conditional, or iterative task execution	Routing a recording to a transcriptionist and the report back to the physician
Task	Unit of work carried out by a resource	Obtain vital signs
Trigger	An event that changes a work item into an activity	Starting to accomplish the task of responding to a phone message by selecting a To-Do list item
Workflow	A process and its cases, resources, and triggers	The tasks and people involved in accomplishing a patient encounter
Workflow/ Process Definition Editor	User application or interface for creating workflow/ process definitions	An ordered picklist or flowchart diagram representing Get the Patient, Take Vitals and a Chief Complaint, Review Allergies, Review Medications, Review of Systems, Examination Screen, Evaluation and Management, Billing Approval
Activity	Performance of a task	Obtain vital signs within a patient encounter

Related to this table is the Electronic Health Record Workflow Management Systems Features & Functions Survey that I wrote for the 2003 Advance for Health Information Executives EHR Workflow Management Systems Survey.

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Definition of Workflow: Workflow Management Coalition

“The automation of a business process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules.”

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Definition of Workflow Management System: Workflow Management Coalition

“A system the defines, creates and manages workflows through the use of software, running on one of more workflow engines, which is able to interpret the process definition, interact with workflow participants and, where required, invoke the use of IT tools and applications.”

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This slide is from the 2004 slide deck [link].

Practical Distinction

If you don’t have an EHR workflow management system…
…you can’t change or manage your EHR workflow system…
…and everyone’s workflow is different!

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Process Definition

A network of activities and their relationships, criteria to indicate the start and termination of the process, and information about the individual activities, such as participants, associated IT applications and data, etc.

From EMR Workflow Systems vs. EHR Workflow Management Systems:

Just as workflow management systems are used to create and manage workflow systems–as discussed in Prof. van der Aalst’s book on workflow management systems–EHR workflow management systems are used to create and manage specialty-specific EMR workflow systems. This is similar, by analogy, to the way in which database management systems are used to create and manage database systems. Your baseball card collection database is a database system; it was a database management system, such as MS Access, that created and manages it.

“A workflow management system is a software package for the implementation of a workflow system. The term refers to a universally applicable system; in other words, a workflow management system is not customized to a specific business situation. By configuring such a system, it is turned into one which supports specific workflows. Unlike a workflow system, a workflow management system is a generic application.” (Page 357, Wil van der Aalst, Kees Max van Hee, Workflow Management: Models, Methods, and Systems, MIT Press, 2004.)

“A workflow system is one that supports the workflows in a specific business situation. Unlike a workflow management system, a workflow system usually consists of a workflow management system plus process and resource classification definitions, applications, a database system, and so on. We can compare the difference between a workflow management system and workflow system to that between a database management system and a database system.” (Page 357, Wil van der Aalst, Kees Max van Hee, Workflow Management: Models, Methods, and Systems, MIT Press, 2004.)

When you fill an EHR workflow management system with specialty-specific content (such as specialty-specific picklists of symptoms, physical findings, assessments, treatments and so on), add specialty-specific screens for (using pediatrics for example) immunization management, growth tracking, developmental checklists, rely on pediatric-specific functionality such as pediatric dosing and data norms, *and* create the necessary pediatric-specific workflow definitions (also known as process definitions), the result is a pediatric EMR workflow system. Different specialty-specific picklists, screens, other functionality, and workflow results in a different specialty-specific EMR workflow system.

So far I think I’ve done a good job of posting about the general (that is, universal) characteristics of EHR workflow management systems (for example, “What’s So Special about EHR Workflow Management Systems?” and “Litmus Test for Detecting Frozen EHR Workflow”) while touching on EHR business process management as well. However, while EMR customizers (“customizers”, not “customers”) interact directly with an EHR workflow management system (three words!), physicians, physician assistants, nurses, technicians, and administrative staff typically do not. They interact directly with the EMR workflow system (two words!) that pops out when you turn the crank on the EHR workflow management system.

That’s the difference between an EMR (or EHR) workflow system and an EHR (or EMR) workflow management system.

2006 EHR WfMS Tutorial Slides 90-97: Hospital EMR/EHR BPM: A Case Study

This portion of my three-hour tutorial EHR Workflow Management Systems: Key to Usability draws from a presentation I attended at the 2005 HIMSS conference in Dallas: What a Concept! Automate Manual Processes Using a Workflow Management Engine. By the way, I presented a 50 minute version of my three hour tutorial at this HIMSS: EHR Workflow Management Systems in Ambulatory Care

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[Typo! “Staphyloccus” should be “Staphylococcus” :)]

Combating MRSA Infections with Workflow Management

Methicillin Resistant Staphylococcus Aureus
3% of admissions, 7% of patient days
Strict regulatory guidelines
High cost per patient/day
Traditional approach (flowcharting, improving a manual process)
Workflow Management System approach…

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Characterizing the Problem

Many time consuming manual steps
Steps were missed
Haphazard inconsistent documentation
Some patients should be removed form isolation weren’t
Some patients who should be removed from isolation weren’t

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Workflow Management System Approach

Document existing process
Optimize desired process
Diagram desired process in process definition editor
Test sub processes
Test whole process for possible inputs (testers execute steps, alerts to reviewers)

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Here is Soarian’s graphical workflow editor. You can see that it resembled MS Visio, but with a major difference. Diagramed workflows are executable. This is what I mean when I refer to executable process model elsewhere. Instead of a Java or C# programming writing code that is incomprehensible to users who best know their workflows, the “code” is this is based on this diagram, which is comprehensible to users who best understand their workflows. The workflow is constructed from clinical workflow domain-specific terminology:

Admission Kickoff
Lab Kickoff
Manual Kickoff
Check Results Last 6 Weeks
Order MSRA Screen
Call RN Supervisor
Write to MRSA Db
Send Alerts Procedure
Etc….

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Triggering MRSA Workflow

Does patient have MRSA history (in system)
- Do they have any lab results in last six weeks?
Does patient have MRSA history (not in system -> manually triggered)
Generates alert for MRSA screen

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Forward Items on to To Do Lists

Infection Control
Central supply (isolation kit)
Laundry (extra gowns)
Dietary (disposable protocol)
Housekeeping (resource allocation)

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Dischare/Removal from Isolation

Bed manager (bed availability)
Nurse (documentation)
Laundry (stop extra gowns)
Housekeeping (clean bed, trigger discharge workflow)

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Results

Improved ability to verify proper isolation status
Eliminated 12 manual steps by automating them
Execution is consistent and complete
Documentation better demonstrates compliance with regulation

Just as was the case in the results to the previous survey of twenty practices implementing an EHR workflow management system, good things increased and bad things decreased.

2006 EHR WfMS Tutorial Slides 82-89: Hospital EMR/EHR BPM: Usability, Workflow, Analytics

From (EHR) Workflow Management: Models, Methods, and Systems.

Workflow management systems (and now business process management) ideas, terminology, and technology are finally beginning to gain traction in the health information technology industry. A great deal of credit for this progress is due to Soarian from Siemens, which is based on the TIBCO Staffware workflow management/business process management platform. Soarian’s use has won a major award from the Workflow Management Coalition.

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A Major EHR WfMS

“Soarian embeds workflow management technology, providing means to coordinate services between departments, and across the institution. If orchestrates care, coordinating all the services provide to each individual patient, and making optimal user of people and resources.” (electronmedica 69 (2001) no. 2)

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Siemens Soarian

Smart User Interface
Workflow Engine
Embedded Analytics

[connect smart to intuitive and intelligent]

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Smart User Interface

“Soarian permits intentional and optimized workflow process designs. It provides an intuitive graphical environment for designing reengineered workflow processes.” (electronmedica 69 (2001) no. 2)

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Workflow Engine

“Soarian enforces the execution of these reengineered processes. It tracks the progress of individual work steps, and automatically escalated failed or expired work steps to the appropriate individuals.” (electronmedica 69 (2001) no. 2)

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Embedded Analytics

“Soarian provides embedded analytics. It automatically gathers detailed information regarding process execution throughout the institution. This information enables the detailed analysis needed for further process refinement, and the completion of the Quality Cycle.” (electronmedica 69 (2001) no. 2)

[see my process mining post, paper, and video]

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Siemens on Workflow

“At Siemens, we define workflow as the process of moving patients, resources and information across the healthcare continuum… Our solutions track the sequence of next steps by eliminating manual tasks and departmental lines and handoffs. They proactively push information such as coverage and medical-necessity issues to people who need it, while driving clinical tasks — delegating work to the right person and the right time.”

Retrieved from (now broken link):

http://www.medical.siemens.com/webapp/wcs/stores/servlet/CategoryDisplay?storeIT=10001&catelogID=1&langId=1&categoryId=19021&catTree=100001,19021

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Finally, here is Soarian’s graphical workflow editor. You can see that it resembled MS Visio, but with a major difference. Diagramed workflows are executable. This is what I mean when I refer to executable process model [link] elsewhere. Instead of a Java or C# programming writing code that is incomprehensible to users who best know their workflows, the “code” is this is based on this diagram, which iscomprehensible to users who best understand their workflows. The workflow is constructed from clinical workflow domain specific terminology:

Triage Patient
New Neuro Deficit
Nurse EHR Evaluation
Nurse TPA Assessment
Thrombolysis Candidate?
Physician Eval
STAT CVA Eval
CVA Confirmed?
Thrombolysis Panel
CT Head r/o CVA
Stat IV
Hemorrhage
Physician TPA Decision

There’s a great potential fit between user-centered design and workflow-centered design (as I note at the end of my “straw man” article User-Centered EHR Design Considered Harmful (Try Process-Centered Instead)) Note the important role of psychologists and linguists in user-centered design of Soarian in the following passage.

A team of industrial psychologists, linguists, physicians, medical informatics and communication and indus- trial graphic designers developed the user interface for Soarian – its page, language and navigation design…The result is an interface that…will be easy to use and will require little training. The use of a common look and feel facilitates access from any device and supports collaboration across clinical disciplines. Soarian’s user-specific workflow design intents to present screens and data appropriate for each user’s job function and work to be performed…The main-goal of Soarian’s ‘smart user interface’ is to deliver a transparent user interface, which supports the users accomplishing their tasks. That means, ideally the users’ focus attention is only targeted at the task, not how to handle a system…The Soarian process has been added with the principles of user centered design methodology in addition to the wide spread object-oriented-approach (36, 37). This process allows task-oriented soft- ware design rather than feature/function driven…the task-oriented user interface work accompanies the whole solution lifecycle right from the beginning rather than being sent to a usability test after the design already took place…The ‘smart user interface’ is technically divided up in two aspects: the user interface concepts & design [and] the contributions of the workflow engine…This concept is in accordance with the modern understanding of workflow supporting systems and does not create any additional burden of learning or changes on the clinical end users.

Source:

2006 EHR WfMS Tutorial Slides 80-81: Why Did Patient Volume Increase? Why Did Encounter Length Decrease?

We already covered much of the answer to this question. However, it’s worth returning to, after examining the results of the productivity survey.

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

Productivity Survey Discussion

Why did visit volume increase? The most likely reason is that encounter length decreased, freeing up resources to see more patients. Consider this hypothetical and simplified example. If average encounter length is 30 minutes, then resources such as waiting and exam rooms, as well as staff are tied up during
this time. However, if encounter length is reduced to 15 minutes, then resources are freed up that can be used to see another patient. Shorter visits incline toward greater visit volume. However, the real question is “Why did the encounter length decrease?” Three reasons: decreased non-value-added EHR activities, increased parallelism among value-added EHR activities, and better coordination among EHR activities.

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We previous covered elimination of non-value-added EHR activities and “parallelizing” value-added EHR activities.

Better coordinated value-added coordination remains to be discussed. Key here is the degree of activity transparency made possible by workflow management systems technology. The following is what usability engineers call a “radar view” (“office view” in this system).

You may recall this slide from our discussion of the supportiveness workflow usability principle.

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The following is a bit more legible.

officescreen-web

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

Now that so much is happening so quickly and at the same time, a coordination problem potentially arises, but workflow management systems have a solution for that as well. The real-time task tracking capabilities of workflow management
comes into play.

The workflow engine, in executing process definitions, keeps track of what activity is waiting, how long, where and for who. This information can be fed not only into To-Do lists, but also onto a status screen available to all EHR users. For example, in Figure 4 we can see an office status screen. We can see rooms, tech station, nurse station, exam room one and so on. In room one is Jessica Dalwart waiting for vital signs and several other tasks. Each task pending completion is tagged with a continually updated number representing the total number of minutes that have elapsed since that task was posted to the office view. These can be used to prioritize tasks when many are competing for attention. Patients are color coded according to physician; tasks are color coded according to who or what role is responsible for completing the task. So, at a glance, a nurse can see all pending nursing tasks or a physician can see all his or her patients.

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This animation requires some imagination on your part. Imagine the Begin Encounter bar in the upper right slowly moving downward toward the End Encounter bar. This represents patient encounter length getting shorter. At first non-valued EHR activities are eliminated (that’s the arrows in the upper left disappearing, in your mind’s eye). But then there are a bunch of EHR screens in the lower left (partially obscured by the radar view). This need to clump up, so to speak, parallel with each other. You can see this in the earlier representation of this animation from the 2004 tutorial. Thirdly we see the “radar view” to provides supportive transparency so all the member of the team can see what tasks have been waiting where for who and for how long.

2006 EHR WfMS Tutorial Slides 72-79: EMR EHR Workflow Survey: Usability, Revenue, Expense, Time & Quality

Well, I hope that I have made you interested electronic health record workflow management systems technology. It has a lot promise. But the proof is in the pudding.

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

In a survey of 200 practices using an EHR workflow management system, thirty-six responded. Of these, twenty practices practices had pre-existing operations, so they could compare their before and after experiences. The average practice had been on an EHR WfMS for 2.7 years, had 3.76 physicians, and 17.5 total staff. Their specialties were pediatrics (55%), family medicine and internal medicine (35%), obstetrics/gynecology (5%) and multi-specialty (5%) [CW: which is why the percentages add up to 105 percent]. The survey was a self-assessment survey which covered the categories of usability, revenue, expenses, time and quality.

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Cateories

Usability
Revenue
Expenses
Time
Quality

Survey questions covered five areas:

Usability–operationalized as time to competence, degree of paperlessness, and percent of physicians who use the EMR
Revenue–effects on exam rooms, patient volume, charges/visit, billing, denied claims, and total revenue
Expenses–staff reduction, staff/provide ratio, transcription costs, ROI
Time–waiting, charting, encounter length, to return calls and refill prescriptions
Quality–increase immunizations and quality review scores

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

Usability

Practices achieved competency in five weeks. Of the practices 85% had achieved a paperless office (except for printing paper destined for the outside world or scanning incoming documents). These offices took an average of eleven weeks to achieve this paperless state. Notably, 100% of physicians used the EHR.

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

Expenses (and related figures)

Total staff decreased from 17.5 to 16.7 fulltime equivalents. The staff to physician ratio decreased 12%. (Which is good because physicians generate revenue while staff generate expenses.) Transcription costs decreased 67%. And (in conjunction with the previously described increase in revenue) the estimated pay back period for EHR software and hardware was fifteen months. Visits per day increased 13.5%. Exam rooms increased 34%. Charges per visit increased $17. Billing increased 30%. Denied claims decreased 61%. And revenue increased 24%.

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

Expenses (and related figures)

Total staff decreased from 17.5 to 16.7 fulltime equivalents. The staff to physician ratio decreased 12%. (Which is good because physicians generate revenue while staff generate expenses.) Transcription costs decreased 67%. And (in conjunction with the previously described increase in revenue) the estimated pay back period for EHR software and hardware was fifteen months.

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

Time and Quality

Time and quality have a very interesting relationship. Before the quality management movement, most people assumed that one must increase the amount of time spent on a product or service in order to increase its quality. (This is not necessarily true.) More to the point, patients see timeliness and convenience as an important element of the quality of care. If they do not have to wait or the encounter is shorter and allows them to get back to work on time, this is perceived as increased quality. These practices estimated a 13.5 minute decrease in patient wait, a six minute decrease in charting time, and a 16 minute decrease in overall encounter length. The amount of time to return a phone call to answer a question or to refill a prescription decreased by two hours and 45 minutes and four hours, respectively. Finally, in spite of a higher volume of shorter visits, immunizations increased by 25% (in pediatric practices) and quality review scores increased by 17%.

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To summarize the results of this survey, good things increased, bad things decrease, and the EMR workflow system paid for itself in 15 months. And presumably, next 15 months generated enough to purchase the EMR workflow system again, but since the practices already had on, this flowed directly to the bottom line.

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

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.

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Photos:

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

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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.

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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

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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).

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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

2006 EHR WfMS Tutorial Slides 64-66: Parallelizing EMR EHR Value-Added Steps

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

Reduction of non-value-added activities can go only so far in reducing encounter length. Once the non-value-added activities are eliminated, there are still value-added activities, and these cannot be eliminated without reducing the overall value to the patient. However, many value-added activities can be accomplished at least partially in parallel. While it is true that the patient can only be one place at one time, and this imposes a certain requirement for the serial accomplishment of activities that require interaction with the patient, there are preparatory portions of these activities that can indeed be accomplished in parallel—if only the people needed to accomplish them can be informed of the need at the earliest possible moment during the encounter.

Printing and assembly of educational materials to be delivered to the patient or setting up trays of materials necessary for obtaining a specimen or administering a vaccination can be accomplished before the physician even leaves the exam room. While the physician is seeing the patient, orders can be entered and forwarded into To-Do lists or onto real-time task status screens and staff can accomplish these preparatory steps. When the physician walks out of the room, procedure trays are ready and staff members are waiting at the door to do whatever they need to do with the patient.

I don’t really like “Parallelize”. It’s awkward to pronounce (and sounds too close to paralyze!). “Collimate” (as in collimated light, as in LASERs) is more accurate, as it means to make parallel. But that would be an uphill fight, wouldn’t it? So I’ll just stick with parallelizing EMR EHR value-added steps and workflow.

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This first slide is the same as the previous collection of 2006 slides pertaining to elimination of non-value-added steps.

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Instead of eliminating step 2, we’ll “parallelize” (yuck!) steps 2 and 3.

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This and the next slide show effects of parallelization cycle time and accumulated value.

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Here steps 2 and 3 are carried out end-to-end.

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Here steps 2 and 3 are carried out at the same time, resulting the same accumulated customer value as before, with a reduced cycle time. At the extreme, cycle time is reduced by the length, or duration, of the shorter step.

Below we show parallelization of EHR tasks, each represented by a screen. Tasks are often, but not always, associated with screens. Screenless tasks also exist. This animation is a continuation of the animation that began at the end of the previous collection of screenshots.

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Animation step 8

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Animation step 9

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Animation step 10

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Animation step 11

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Animation step 12

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Animation step 13

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Animation step 14

2006 EHR WfMS Tutorial Slides 60-63: Eliminating EMR EHR Non-Value Added Workflow Steps

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

Value-added activities are typically those that someone will pay for. To use a manufacturing example, an automobile buyer may willingly pay for a leather interior but will be loath to pay for fixing a defect that shouldn’t be there in the first place. Encounter length is determined by a combination of value-added and non-value-added EHR activities. EHR value-added activities include entering data that may be used in a future decision or making a decision that affects the welfare of the patient. Non-value-added activities include navigation from screen to screen and searching for the next person to handover the next activity in the encounter. If these non-value-added activities, and the time required to accomplish them, can be eliminated, encounter length can be reduced.

Process definitions can be used by the workflow engine to accomplish exactly this. Instead of users having to proceed through multiple clicks to search for the next data or order entry screen, the workflow can be controlled by the process definition and the user merely needs to click ‘Next’, ‘Next’, ‘Next’…. (Of course, a user always has the option of jumping out of an executing definition to manually access a different screen than the one presented. Over time, with process definition refinement, this usually happens less and less.) Similarly, instead of a user having to find the next user to hand off the next activity, the workflow engine can do this instead, perhaps by forwarding items into a user’s To-Do list or onto a generally available status screen of pending tasks.

A general strategic principle is to shift as many value-added, and non-value-added activies from the manual to the automated category, while preserving and enhancing value-added manual activies that increase effectiveness, efficiency, and (user and patient) satisfaction.

wfms-usability-ehr-015

Here is a generic representation of a workflow or process. Tasks/activities are the circles and arrows combos. Processes are networks (in this case a very simple network) of interconnected activities. Roles are kinds of resources required to accomplish each step. There are different kinds of resources, some human and some automated. The role is a container and that person (or other resource) must fit, but as long as a resource fits it is interchangeable with other resources.

By the way, this is my own dead-simple notation, intended to convey basic ideas about EHR workflow. Business process management, research and industry, is full of notations (such as Petri nets and BPM Notation) and machine readable formats. My purpose and method here is to emphasize relevance to EHR usability and eschew methodological complexity. This is what I call my cat-dog-tree approach: what are the simplest ideas expressed most simply that only combine in one simple manner.

Suppose step two is navigating from screen to screen or searching for the next person required to complete the process or an opportunity to acomplish the task automatically without relying on expensive manual human labor.

wfms-usability-ehr-022

Now the following is a little complicated. I included a number of animations in the original EHR Workflow Management Systems: Key to Usability PowerPoint slides. It was easy to trigger the animations and talk about them. It’s a little different here on the Web. There are ways to include embed animations in web pages. I’ve done elsewhere on this blog. However, I’ve found, these are not usually very cross-platform friendly, and especially so with advent of smartphones. So I decided to screen-capture intermediate animation states and publish a series of screen captures from the original slides.

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The slide generically shows customer value incrementally growing during execution of workflow. I’ve only labeled the three steps from the previous slide. Steps 1, 3, and (implied) 5 are value-added so their execution moves graphed customer value up and to the right. Steps 2 and (implied) 4 (in green) consume resources and, especially, time, but do not contribute to accumulated customer value.

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This is just a visual representation of the previous paragraph. The phrase “Value-Added” points to steps 1, 3, and 5. The phrase “Non-Value-Added” points to steps 2 and 4. (If this slide reminds you of Value Stream Mapping. It should.)

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In the original slide animation steps 2 and 4 disappeared and steps 3 and 5 slipped to the left. The result is a graph that shows steadily increasing accumulated EHR value during execution of workflow and a new, shorter, cycle time (length of patient encounter).

The following slides depict intermediate animation states showing essentially the same idea as above: elimination of non-value added EHR steps results in a shorter patient encounter. The slides look different because I took them from the 2004 tutorial slides.

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