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

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

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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!

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

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

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

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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EHR Workflow System, Like OR Nurse, Hands Right Screen to Right Person At Right Time

A competent OR nurse hands the right instrument, forceps, scalpel, in the right orientation to the right person at the right time. An EHR workflow system hands the rights screen, which could have data or order entry options, to the right person at the right time. How does it do that? EHR workflow systems have what’s called a workflow engine; this is a Corvette engine; and it’s executing a workflow. If you think about the bad old days; with some of which are still around, 15 or 20 years ago; you had to navigate through an incredible thicket or menu hierarchy in order to move from screen to screen.

Now, we have to do a lot of clicking to move from tab to tab. A lot of physicians complain about not wanting to be data entry clerks. I don’t think the issue is so much data entry or order entry, it’s all the navigation to find what you need. I heard the other day; this guy said he had to look at 10 different places in the system to find the information for to write a note.

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EHR Workflow Engine Executes EHR Workflow Definition, Performing Work For EHR Users

Here we have a very basic workflow. Let’s say the patient’s been taken to the exam room and the nurse asks about allergies, medications, take some vitals, information and initial chief complaint, reason for visit. Then, another person or role takes over; the physician conducts a physical exam, makes an assessment, prescribes something, okay some codes to go off to the billing system. That’s a very, very basic ambulatory workflow. Instead of the user having to drive the screens from screen to screen and find the right screen or find the right person or figure out that they are the right person, the workflow engine is putting up the right screen at the right moment for the right person. That is part of the magic or the intelligence of the workflow.

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EHR Workflow Driven By Workflow Engines Consulting Workflow Definitions Created By Non-Programmer EHR Users

How does the workflow engine know which screen to present to which person? The workflow engine consumes a definition of workflow. Down here, definition is a short description of a thing by its properties. That’s actually a 400-year old definition of definition from the first dictionary. Over here on the right, we have the human editor; the human editor can change the order of those steps, change a little bit of the business logic. This is no longer optional, this is now mandatory. Within five minutes or 10 minutes, if it’s not done, I want it to escalate. All of that can be specified by someone who is not a Java programmer, not a C# programmer, not a MUMPS programmer.

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Not There Yet, But Physicians Will Design EHR Workflows Dragging And Dropping Tasks

We’re not here yet, but this is where we’re headed. Imagine most tasks are associated with screens. There are screen-less tasks, those are the little dotted lines, but some of these screens are going to have data such as the last physical exam or the most recent lab values. Some of these screens are going to be order entry screens such as entering an assessment or a prescription. Imagine you can drag and drop them into your workflow model that’s going to be executed by the workflow engine and then do you double click on them. Say, this one, I don’t want to be optional, I want it to be mandatory and if the patient literally cannot be checked out of the office if it is not accomplished and it will escalate to a supervisor.

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EHR Airport Control Towers, Automobile Engines, And Aviation Cockpits: Analogies & Metaphors

We’re going to talk about visibility. Before we talk about the relationship between customizable workflow, workflow engines and task visibility, we need to lay a little bit of groundwork. 15 years ago, at HIMSS in Atlanta. HIMSS00 at AT., this was one of my presentations and was called Workflow enabled CPRs. This is even before people called systems electronic health records or electronic medical records, these were computerized patient records. In the middle, you have that engine that I’m talking about, the engine that consumes instructions. Over on the right, you have the aviation cockpit. I spent a year in aviation human factors at the University of [inaudible 00:08:54] and I graduate a degree in Industrial Engineering, one of the top programs in the world.

I learned about Fitts’ law and Hick’s law. Fitts’ law is the larger the target is, the larger a button is, the easier it is to hit accurately and quickly. Hick’s law is the number of options on the screen. The fewer there are, the more likely you can select the right one. It’s the job of the workflow engine consulting the workflow model to put the right buttons on the right screens and to filter out all of the extraneous, irrelevant content. If you don’t have that workflow engine, you get an explosion of the space you have to search in order to figure out what to do next.

Even if you have a workflow engine and you have a user customizable and improvable workflow model that’s being executed, sometimes tasks still fall between the cracks. Over on the left is the control tower of an airport. In that tower, you have what the usability engineer calls a ‘radar view’. You can see all of the patients and all of the planes, how long has they been waiting in their exam rooms on the runways or stacked up. You know how many minutes of fuel they have left. You can note exceptional circumstances and jump in there and fix them so that maximized throughput, while preserving safety. That’s actually called BAM or business activity monitoring in the business process management world, which I’ll go talk about briefly at the end.

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