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

Better Patient Experience Through Structured Messaging and Workflow Technology

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Hello. My name is Chuck Webster. Welcome to my webinar, Wellness Through Workflow: Structured Messaging Contributes to Better Patient Experience. An alternative title could be Structured Workflow Contributes to Better Patient Experience, but I will be using the specific example of structured messaging.

Here is the outline. A little bit about who I am. Then this idea called the system behind the smiles, the relationship between patient experience and healthcare workflow, what I call healthcare’s “workflow wall”. Finally, how can structured messaging help?

I’m an odd duck, I have a lot of degrees. My mother says I’m killing myself by degree. Medical degree, I also have a Master’s in Industrial Engineering, where I focused on workflow usability productivity. My Medical Informatics degree was in Intelligent Systems, and I’m the only premed Accountancy major I ever met, or I majored in Cost Management Systems and MIS. I did design the first undergraduate degree in Medical Informatics, and I was Chief Medical Informatics Officer for an EHR vendor for over a decade, where I helped the three medical practices win the first three consecutive HIMSS Davies Awards.

I’m extremely active on Twitter, and there’s a kind of a virtual drinking game, where if someone’s at a conference, or they read something, and it’s about workflow or healthcare workflow, or healthcare workflow technology, they tweet about it and they mention me, .

What we have here is a hashtag, which I have been using for about four years, and I also have various social badges. #POWHIT, People and Organizations Fixing Workflow with Heath IT. That’s kind of a reference to the old Batman show, pow, hit. If you tweet about this webinar, or during the blab, I hope you’ll use #POWHIT. I’ve got about half a dozen folks, now, who are starting to use it, and it’s all about the folks in the white hats that are rushing to fix workflow in healthcare.

At the top of the hour, join a blab. It’s kind of like Google Hangouts and Twitter had a beautiful baby. It’s a lot of fun. All of this, the , blab workflow, HIT #POWHIT will be in all of the slides, works best in Chrome. That’s that middle URL, and I hope to see you there, because you can actually take a seat and tell us a little bit about yourself. The subject, this just an example, but the subject is any aspect of healthcare workflow and patient experience.

Take me to the next post in this series: The Systems Behind The Smiles: Patient Experience.

The Systems Behind The Smiles: Patient Experience

There is this idea, in the hospitality industry, in the hotel industry, luxury hotel industry where my wife works, and it’s called The System Behind the Smiles. When you arrive at that hotel, you walk in, the bellman greets you by name. You walk to the front desk, you’re in you’re room in ten minutes, everything works perfectly. All of the staff is well-trained, radar on, antenna up, they can see anything that you need and it’s right there. Well, guess what? There’s an incredibly system behind the scenes of databases and workflows that make this all possible, and that’s The System Behind the Smiles.

The System Behind the Smiles comes from a book, in 1990, called Customers for Life: How to Turn that One-Time Buyer into a Lifetime Customer, by Carl Sewell. This is the only thing I’m going to read word-for-word, quote-wise. “What’s needed in restaurants, car dealerships, department stores, and every place else is systems–not just smiles–that guarantee good service. Every business is composed of systems. These systems must work together to create a process that is efficient and responsive to a customer’s wants.”

About fifty percent, roughly forty to sixty percent, of customer experience, patient experience, is due to the actual, face-to-face or on the phone, interaction with some staff member or customer service member.

That means that the other fifty percent, forty to sixty percent, is due to things that are not under the control of that front-line staff person. These are the workflows and the systems that are behind the smiles. These are the backroom enterprise transaction systems. When you make a reservation at the hotel, you make a reservation online for the airline. You go there, the reservation is in place, you get your seat, you get your room. All of that has to work, that is absolutely critical to making sure that the folks on the front of the line can deliver, are free to basically live the visions and ideals of their organizations. They can count on these workflows working every time.

Take me to the next post is this series: The Workflow Behind The Smiles: Patient Experience.

The Workflow Behind The Smiles: Patient Experience

Today, industrial engineers, and I have a Master’s in Industrial Engineering, they’re changing their name to Systems Engineering. When you’re a systems engineer, and you start talking about improving systems, basically, what systems engineers do, is they replace every word that is “systems” with the word “workflow”, because as soon as you start talking about workflow, you’re starting to talk about actual sequences of things. There’s all kinds of tools to help you improve those workflows.

What’s the relationship to patient experience? Folks are developing mobile apps for patients to interact with, and folks are coming in and doing, kind of, sophisticated “Charm Schools” for the folks that are interacting with the patients. I’m going to talk about this back-end stuff, but let’s start with probably the most famous, and prevalent, and popular definition of patient experience, from the Beryl Institute. “The sum of all interactions, shaped by an organization’s culture, that influence patient perceptions across the continuum of care.” If you drill down on each of these four areas, Beryl also defines those.

Let’s take a look at the stuff in the middle here, the organization’s culture to influences patient perceptions. That culture is made up of vision and values, with then inform the attitudes, and demeanor, and training, and behavior of that front-line staff, interacting with the customer or the patient. The perceptions, that’s the other half, that’s the patient reacting, saying, “I recognize this, I understand this, I remember that.” Those are the smiles.

The systems is the rest of that definition. The sum of all the interactions across the continuum of care. If you drill down and grab the description of interactions, and the description of continuum of care, from the Beryl Institute, put them together, you get this. The orchestrated touch-points of people, processes, policies, communications, actions, and environment, before, during and after the delivery of care. The key word here is “orchestrated.” Orchestration is a very important word, it is a important part of the terminology of the workflow, and the workflow technology industry.

One way to understand orchestration is to contrast it with choreography. Orchestration implies some sort of central workflow conductor. You’ve got the conductor up there, they’re waving their want, and everybody is kind of doing what they’re told to do. In software, that’s often a workflow engine, which we’ll talk about in a little bit, but they can also be a human, a human care coordinator, who is facilitating these workflows. Choreography is about distributed workflow control, so there is no conductor, it’s like a jazz ensemble, and everybody has a set of, kind of, workflow rules in their heads, and they’re watching each other, and they’re doing a kind of a dance.

Modern workflow systems tend to be hybrids of orchestration and choreography. Some are very much toward orchestration, but they still have some choreography. Some are very much about peer-to-peer choreography of workflows.

Take me to the next post in this series: Health Information Technology’s “Workflow Wall”: Patient Experience.

Health Information Technology’s “Workflow Wall”: Patient Experience

We have invested tens of billions of dollars in health information technology and electronic health records over the last several decades. I believe that we have hit what I call the workflow “wall”. The workflow wall is the invisible workflows, that is, you can’t see task status, you don’t know what’s going on, all these black boxes around us.

The inflexible workflows, you can’t change them, because they’re hard coded into the software. They’re ineffective, they’re not achieving the goals we need them to achieve. They are inefficient workflows, that is, they consume too many resources when they are executed.

This has created what I call workflow discontents. If you go to a healthcare industry, or particularly a health IT industry conference, you may see people talking about workflow, it may be in some abstracts. For sure, when you walk down the hall, you will hear the word workflow, it’s like a cocktail party effect, where you hear someone mention your name across the room. You walk down the hall, and every thirty seconds you’ll hear “Workflow, workflow, workflow.”

Let’s say you have a problem, pollution, you have a pollution problem. Guess what, then you have pollution technology. Well, healthcare has a workflow problem, so we need to use workflow technology. In the academic research realm, the folks who study workflow technology, call these “process-aware information systems”. Process aware means that there’s some kind of model of the process or workflow, and aware basically means, not that the software has consciousness, but that it can inspect that model, and it can refer to that model, and it can reason with that model in order to facilitate, and make these invisible workflows visible, flexible, effective and efficient. Structured messaging is an example of workflow technology and process aware information systems.

This is the only slide that’s full of statistics, and it’s really to drive home the point, that this is an important problem, and there’s a way to characterize it.

First of all, fifty percent of all healthcare errors are due to slips and lapses, such as not executing some intended or an interrupted action. This is called perspective memory. Perspective memory is when you say, “I need to do something next, or eventually, and you intend to do it. Then later, you remember that you intend to do it, and then you do it. Obviously, if you forget to do it, that can be a problem.

Almost fifty percent of interruptions affect direct care tasks. About fifty percent of pages to physicians interrupt direct patient care, and almost fifty percent of pages are non-urgent. You’ve got almost fifty percent of pages, non-urgent, and they are causing interruptions, which can lead to healthcare errors. These errors may be serious, in terms of outcomes, but they also have dramatic impact on patient experience. “They forgot me,” or, “They forgot about this,” or, “This took too long.” Those affect patient experience, and that’s the system behind the smiles.

Take me to the next post in this series: The Workflow Technology Prescription: Patient Experience.

The Workflow Technology Prescription: Patient Experience

Over the last couple of decades, I’ve noticed that whenever there’s a big, sort of, societal problem, someone will eventually get around … The problem is called “X”, and someone will write a book called The “X” Prescription, how are we going to solve the problem. I often tweet this picture of The Workflow Prescription. What is the workflow prescription?

Let’s start with what is workflow. I have seen literally hundreds of definitions of workflows, over the two or three decades that I’ve been interested in the topic. I have seen definitions that would span two PowerPoint slides and used tiny font. The very simplest is simply, a series of steps. I like this definition, it’s mine, and it is workflow is a series of steps, consuming resources, that’s cost, and achieving a goal, that’s benefit.

Let’s break it down. Series of steps, tasks, activities, so they’re called different things. If you’re an anthropologist, and you go into someone’s home, and you are diagramming their life flows, and they create process maps when they’re trying to understand how folks, for example, are using various products. They may not call them tasks, they may call them activities.

Consuming resources, or costs. These costs are not just the healthcare system’s cost, but these are the patient’s money, attention, and time costs.

Then you’ve got goals, these are the benefits, costs and benefits. Workflows exist in an economic environment. When that economic environment changes, the workflows need to change. However, there are many reasons why it’s difficult to change healthcare workflows, in the ways that would maximize the ROI, maximize the benefit/cost ratio.

By the way, process and workflow are often used synonymously, not always, and the meaning is usually clear, from context.

That was workflow, what is workflow technology? Generally, informally speaking, any technology that intentionally facilitates workflow is workflow technology, but narrowly, technically, if you’re a workflow professional, a workflow technology person, workflow technology involves models of work. These models of work are executable, meaning a computer program can look at that model and execute it just like some computer code, just like an if/then or case statement. The models can be of work or workflow, workflow tends to be sequences of things, work tends to be hierarchies of goals. Consultable means these models can be understood and consulted by a human, so that you can look at it, and inspect it, and say, “Oh, I see what the status of this task is,” or, “I see what needs to change in the design of the work or the workflow.” Consultable also means by the computer, because even if it’s not executing the model, the computer may use some model of work to interpret, for example, analytics.

These models can usually be visually represented. In the business process management industry, you have lots of systems that allow you to draw workflow diagrams, and you turn a crank, and an application comes out. Instead of writing Java, C# and MUMPS code, you draw the workflows. Workflow technology also includes calendar systems, where non-programmers are creating rules, that are running against the calendars, to route messages and escalate, and also dynamic checklists. Checklists are big in healthcare, but if you implement those checklists in such a way that all of the items are smart, and they can detect which things have to occur in a different order, that’s an example of workflow technology, too.

What’s the difference between workflow technology and information technology? Information technology certainly influences workflow, every piece of software has “workflow”. My mother, who was an English teacher, drilled into the difference between affect and effect. Affect means to influence something, maybe positively, maybe negatively. Some software makes workflow better, in healthcare, some software does not. Workflow tech is intentionally designed to effect workflow, that is, it drives workflow, it pushes tasks to the right person, checks to make sure that they’re done, and so forth. It’s kind of like Jean-Luc Picard, in Star Trek, saying, “Make it so.” That’s workflow technology.

Here’s another difference. Information technology in health IT often hardcodes workflow. What does that mean for workflow to be hardcoded? It means that, after you compile the program, in the software factory, back at the vendor, and then you send it out, and it starts to execute. All of it’s behaviors are already inside the program, they’re already compiled down. It doesn’t consult much in its environment when it executes.

Softcoded software, such as workflow technology, softcodes workflow, so as the program executes, instead of just consulting some value that’s hardcoded into the program, it reaches out into a database, or reaches out into the environment, and at run time, this changes the order of things, this changes the business logic. People who aren’t programmers, people who aren’t Java, C# folks, can change the workflow behavior after you implement the system. It’s important to get the folks in the workflow, the clinicians and so forth, involved in the design at all aspects, not just before you implement, but even after to implement it. In order for that to be true, the software has to softcode workflow, so that those changes can be tweaked after the implementation.

Take me to the next post in this series: Four Benefits Of Structured Workflow and Messaging: Patient Experience.

Four Benefits Of Structured Workflow and Messaging: Patient Experience

What is structured messaging, which is an example of workflow technology? You pre-build these message structures, and you can think of these message structures as kind of like simplified forms, that folks are very familiar with in healthcare. You send that securely over the internet, and these messages can occur in strings, back and forth, conversations. These are the workflows, these are the steps, tasks, activities.

Because you are using the same set of structures over and over again, same message types, over and over again, folks become familiar with them. When it arrives, they know exactly where to look to find the information they need, if the workflows and the forms are designed correctly. They can be, because you can change them, even after you’ve implemented.

All of this familiarity leads to both speed and accuracy. Speed is important because the faster you interact, the more throughput you can get. For example, if it takes, instead of four hours, from beginning to end of a workflow, from beginning to end of a case, if you move that to two hours, you’ve effectively doubled your capacity. Accuracy, it’s more consistent, and because you can track the task status, you can make sure that nothing languishes, or fails to be done. This combination of structured data and structured workflow facilitates automation through workflow technology.

The three major components, pieces, of structured messaging, in a calendar model, are forms, these are the forms that I just talked about. You’re sending these out, and instead of people having to type a lot of text, and then to remember what it is they need to type, and then they have to look at it and they have to interpret it, because it is structured, you have what’s called recognition memory instead of retrieval memory. Retrieval memory, you have to remember what to create. In recognition memory, you have an enumerated list of possibilities, and you choose whichever one you recognize to be correct, it might be yes, no, please ask me again when I get back to the office, that sort of thing.

Then you have the calendar. Shared mental models are so important for team behavior. If you’ve ever talked to someone about your calendar, even though there’s no calendar in front of them and there’s no calendar in front of you, there’s calendars in both of your heads, they’re like virtual calendars, and you’re using it as a shared mental model, to talk about whether you can meet up or not. Shared mental models need to be shared, not just among the humans, they also need to be shared with the software. It needs to be at high enough level that the humans can understand it, but low enough level that the workflow engine can consult it, and a calendar is an ideal model for that.

Then you’re got the rules. The rules are proactively watching for certain conditions to happen. Someone needs some care, and you check in the calendar, you see who’s available, if they’re not available, you use a rule to route it to the back-up, and then you check later to see if they answered, and if not, you escalate, those are the rules. Forms, calendars and rules.

This is kind of a pictorial representation of that. On the left we’ve got the calendar. This is the shared mental machine model. On the right we have these forms, and these forms aren’t just about text, they can also contain images, audio. These rules and these forms, the user interface and the workflow, is softcoded, so that means that once you implement it, folks who aren’t programmers can change the workflow behaviors.

What are the major benefits of structured workflow? Number one, automaticity. Because you have a workflow engine, and it’s in the software, instead of a human workflow engine, it’s a software workflow engine. It can recognize and be triggered, and do things without manual human intervention, although this can be overwritten. If the workflow engine consults a rule and sends you something, and maybe someone didn’t code something right, you can always say, “Well, no, that doesn’t apply to me.” If you don’t, then there are fallback rules in this logic.

Then you have transparency. Because every task goes through the workflow engine, that means the task is both time-stamped, and the workflow engine keeps track of the status. “Is it pending? Is it in process? Has it been completed? Is it languishing? Has it been forwarded to someone else? Has it errored out? Has it been cancelled?” All this information is available, and it can be viewed by the members of the team, that can see, “Okay, I see this task in our group, and Joe, who usually does it, didn’t do it, so I guess I’ll have to do it.” The workflow status can be viewed in reports by the supervisor, so they can say, “Show me all the outstanding tasks that have languished more than five minutes,” and they can be seen by the administrators, who are keeping the system running well.

It is this task transparency that allows you to compensate for interruptions. Instead of a human saying, “Oh, I need to do this later,” and they forget, the workflow engine knows that you haven’t done it, and it can remind you.

Flexible. Workflow engines don’t just do what workflow engines do, they consult these workflow rules. These workflow rules are out there in the environment. They can be changed by the administrators and the supervisors. They tell the workflow engine what to do, they are softcoded. Therefore, when you change them, the workflows change.

When you put together transparency and flexibility, you arrive at improvability, because you’ve got this time-stamped task data out there, you can use it, using a variety of tools, to find and eliminate bottlenecks, rework or redundancies, doing things over and over again. This can be used both to improve cycle time, reduce the workflow from four hours to two hours and double your capacity, and increase consistency, that is vastly increase the likelihood that the task will eventually be accomplished within a certain window of time.

Those are kind of essential aspects of architecture, but you also have to be concerned about these sort of value added ons. It’s not just text in the form, you also have voice, images, radiology images, for example. Then you need to able to convert, so if you try one channel, by voice, and they don’t respond, well, maybe you need to text them.

As is the case with many add-ons today, you’ve got to integrate with EHR, that’s happening. Particularly, tasks that happen in the EHR may need to cause things to propagate up through the structured messaging system.

Of course you need HIPAA compliance. Then, there’s cross-platform. Because these systems are sending data to either Android, or iOS, or to the desktop, you have the option to use your own device, that’s the bring your own device phenomenon.

Finally, this may seem redundant, so why am I mentioned intelligent message routing and escalation again? Well, you want content. Just like picklists of drugs and codes are content, workflows are content, too. When you get that structured messaging system, you want to have a set of routing and escalation workflows already, sort of … Other people have been using them, and they work great, and then they work great for you, you don’t have to create them from scratch, and you can tweak them further.

Take me to the next post in this series: What If We Had Automated Workflow Before Data? Patient Experience.

What If We Had Automated Workflow Before Data? Patient Experience

Here’s a thought experiment, I think what Einstein called a “gedankenexperiment”, and that is, what if … Take a time machine back ten years ago. What if we had started automating workflow instead of data? What an absurd idea. I mean, how is that possible? Don’t we have to have all this data? Well, in fact, I’ve done some consulting internationally, and there are a lot of companies that have watched what has happened in the United States over the last couple of decades, and they’ve kind of, just like in the model of you skip the telephone poles, and go directly to satellite phones? Some of them are saying, “You know what? What we need to do is understand the workflows first, and then only gather the data we need to accomplish the workflows.”

Today, we have all of this data and all of these databases, basically, EHRs are kind of databases with UIs slapped on them. We have this data, and people are saying, “I don’t want all this data, I want actionable data.” Whenever you hear the word actionable data, think workflow technology.

This is consistent with the famous advice from Covey, 1989, “Begin with the end in mind.” This is exactly the way industrial engineers are trained. You go into the factory, you figure out, “Here is the product, in the box, that’s being sent to someone. Now we work backwards.”

Down at the bottom here we have data, which is a very important resource. It costs money to obtain it, it costs money to stick it into the workflow. On the right, here, we have goals and benefits. That’s the end in mind. We’re trying to lay down, across all of this data, a whole bunch of workflows, to take advantage of it.

If we had done it differently, we would have done it this way. We would have started with the end in mind, we would have said, “What is the penultimate step, before the end, and what is the data that we need?” Then you say, “What is the step before that, and what is the data we need?” Then you finally get to where you are, or where you typically would be.

Instead, what we have is this situation. We’ve got all of these databases out there, we’re collecting all of this data at the point of care, and we’re trying to lay down on top of it a set of workflows to take advantage of it. It’s a lot harder to lay down all this patchwork workflow, kind of whole cloth, without following that end to start model.

What order makes sense? I’d argue adding data to workflow, but we’re kind of stuck, right now, with adding workflow to data. That means we need extremely flexible workflow technology to adapt, to lay down, to compensate for and take advantage of all of this existing data investment. This is an excellent argument for structured messaging, for example as a platform. A platform is a set of constraints and resources that you can just count on, when you’re building some other system on top, and that is the workflow platform that, I believe, in the next five years, we’re going to see dramatic investments in a variety of workflow platforms, kind of laid down on top of the data systems we have in place, and structured messaging is one of them.

Take me to the next post in this series: Workflow Engineering Patient Experience & Engagement.

Workflow Engineering Patient Experience & Engagement

I could have drawn these diagrams, but I wanted something a little more vivid, so you may recognize some of the folks, there, in the lower left, we’ve got Dr. Nick Cullen and John Lind. That’s a drawing of the relationship between patient experience and patient engagement. Now, I showed you an excellent definition of experience, and also, there are definitions of engagement out there, that use words like activation, but as a systems engineer, as an industrial engineer, I look at it in terms of, experience is what the system does to the patient, and engagement is what the patient does back. When you’re building systems, you need to really, really, really simplify.

Now, we’re adding technology in there, and this technology is interacting with the staff in the healthcare system. If this technology helps them do their job, then they do a better job interacting with the patient. If this technology does a good job, and it does it in a way that frees them from a lot of work they had to do before, it frees up time and attention, that can be spent on creating wonderful experience, that’s the smiles.

At the same time this is happening, we have a consumerization process. A lot of the younger generation, they don’t want to talk to anybody on the phone, God forbid go someplace to deal with customer service, they just want to sit there in front of the TV and click on an app. What’s happening is these backend systems, the systems behind the smiles, are actually being exposed digitally to patients. This has interesting implications. It can free up they system, free up the staff, to deliver better service.

Basically, and again, this is like, I started at the thirty-thousand foot level, I zoomed in, and now I’m zooming back out. I believe that workflow, including messaging, is absolutely essential to creating an optimal set of relationships of data flows and work flows, between the patient and the system or staff, and technology.

Take me to the next post in this series: Re-Integrating Healthcare Data and Healthcare Workflow: Patient Experience.

Re-Integrating Healthcare Data and Healthcare Workflow: Patient Experience

Several decades ago, when I got my Master’s, one in Industrial Engineering, focusing on workflow, and the other in Medical Informatics, focusing on data, I have watched this process happen. There’s been a kind of a split, the data flow folks went one way, and the workflow folks went the other way. Many of the early hospital information systems were actually designed by managing engineers, managing engineers were industrial engineers.

What’s happened in the last couple of decades is, the medical informatics, health IT folks, who are focused on data, have built most of the systems that people interact with. While at the same time, the workflow folks have gone into total quality management, Six Sigma, Lean, process improvement, and that’s been a kind of unfortunate chasm, because obviously these problems really require both kinds of expertise.

I believe that workflow technology, what academics call process aware information systems, is the window of opportunity to knit back together the workflows and the data of healthcare. Structured messaging is an excellent example of a particular kind of workflow technology.

We’re really zooming out here. Something about that title, “Wellness Through Workflow”, sounds like a public health announcement. Wellness, the state of being in a good physical and mental health. Workflow, a series of steps, consuming resources, achieving a goal. Think about the relationship between workflow technology outside of healthcare. A lot of the apps that are making things very convenient. Google, now Siri, are using various kinds of workflow technology, supplemented by machine [inaudible 00:34:43]. Not only can we reunite data and workflow, using workflow technology, we can also we can reunite healthcare workflows and non-healthcare workflows.

At the top of the hour, I hope you’ll join. It tends to be kind of a free-for-all. Basically, even if you’re not into workflow and patient experience, but you’re interested in healthcare, health IT, we’d love you to join us. That’s at ehr.bz/blabworkflow. It’ll ask you to use your Twitter credentials to log in, and then, at the top of the hour, Jimmie Vanagon, a general internist, the guy who’s waving right there, is co-host. Love to hear what you think about what I’ve said, or just about anything else.

Thank you. That’s my Gmail address, ChuckWebsterMD, but the best to get ahold of me is on Twitter, , and everybody start using that #POWHIT hashtag, People and Organizations improving Workflow with Health Information Technology. Then, join our blab at the top of the hour, by the way Chrome, and I hear Firefox works, I always use Chrome. There is an iOS app, Chrome on Android, I hear, works. Thank you all for attending, and viva la workflow, onward workfloistas. Thank you.

Take me to the beginning of this series: Better Patient Experience Through Structured Messaging and Workflow Technology.