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The Perfect EHR Workflow – Video EHR

Posted on May 12, 2016 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’ve been floating this idea out there for years (2006 to be exact), but I’d never put it together in one consolidated post that I could point to when talking about the concept. I call it the Video EHR and I think it could be the solution to many of our current EHR woes. I know that many of you will think it’s a bit far fetched and in some ways it is. However, I think we’re culturally and technically almost to the point where the video EHR is a feasible opportunity.

The concept is very simple. Put video cameras in each exam room and have those videos replace your EHR.

Technical Feasibility
Of course there are some massive technical challenges to make this a reality. However, the cost of everything related to this idea has come down in price significantly. The cost of HD video cameras negligible. The cost of video storage, extremely cheap and getting cheaper every day. The cost of bandwidth, cheaper and higher quality and so much potential to grow as more cities get fiber connectivity. If this was built on the internal network instead of the cloud, bandwidth is an easily solved issue.

When talking costs, it’s important to note that there would be increased costs over the current documentation solutions. No one is putting in high quality video cameras and audio equipment to record their visits today. Not to mention wiring the exam room so that it all works. So, this would be an added cost.

Otherwise, the technology is all available today. We can easily record, capture and process HD video and even synchronize it across multiple cameras, etc. None of this is technically a challenge. Voice recognition and NLP have progressed significantly so you could process the audio file and convert it into granular data elements that would be needed for billing, clinical decision support, advanced care, population health, etc. These would be compiled into a high quality presentation layer that would be useful for providers to consume data from past visits.

Facial recognition technology has also progressed to the point that we could use these videos to help address the patient identification and patient matching problems that plague healthcare today. We’d have to find the right balance between trusting the technology and human verification, but it would be much better and likely more convenient than what we have today.

Imagine the doctor walking into the exam room where the video cameras in the exam room have already identified the patient and it would identify the doctor as she walked in. Then, the patient’s medical record could be automatically pulled up on the doctor’s tablet and available to them as they’re ready to see the patient.

Plus, does the doctor even need a tablet at all? Could they instead use big digital signs on the walls which are voice controlled by a Siri or Alexa like AI solution. I can already hear, “Alexa, pull up John Lynn’s cholesterol lab results for the past year.” Next thing you know, a nice chart of my cholesterol appears on the big screen for both doctor and patient to see.

Feels pretty far fetched, but all of the technology I describe is already here. It just hasn’t been packaged in a way that makes sense for this application.

Pros
Ideal Workflow for Providers – I can think of no better workflow for a doctor or nurse. Assuming the tech works properly (and that’s a big assumption will discuss in the cons), the provider walks into the exam room and engages with the patient. Everything is documented automatically. Since it’s video, I mean literally everything would be documented automatically. The providers would just focus on engaging with the patient, learning about their health challenges, and addressing their issues.

Patient Experience – I’m pretty sure patients wouldn’t know what to do if their doctor or nurse was solely focused on them and wasn’t stuck with their head in a chart or in their screen. It would totally change patients’ relationship with their doctors.

Reduced Liability – Since you literally would have a multi angle video and audio recording of the visit, you’d have the proof you’d need to show that you had offered specific instructions or that you’d warned of certain side effects or any number of medical malpractice issues could be resolved by a quick look at the video from the visit. The truth will set you free, and you’d literally have the truth about what happened during the visit on video.

No Click Visit – This really is part of the “Ideal Workflow” section, but it’s worth pointing out all the things that providers do today to document in their EHR. The biggest complaint is the number of clicks a doctor has to do. In the video EHR world where everything is recorded and processed to document the visit you wouldn’t have any clicks.

Ergonomics – I’ve been meaning to write a series of posts on the health consequences doctors are experiencing thanks to EHR software. I know many who have reported major back trouble due to time spent hunched over their computer documenting in the EHR. You can imagine the risk of carpal tunnel and other hand and wrist issues that are bound to come up. All of this gets resolved if the doctor literally walks into the exam room and just sees the patient. Depending on how the Video EHR is implemented, the doctor might have to still spend time verifying the documentation or viewing past documentation. However, that could most likely be done on a simple tablet or even using a “Siri”-like voice implementation which is much better ergonomically.

Learning – In mental health this happens all the time. Practicum students are recording giving therapy and then a seasoned counselor advises them on how they did. No doubt we could see some of the same learning benefits in a medical practice. Sometimes that would be through peer review, but also just the mere fact of a doctor watching themselves on camera.

Cons
Privacy – The biggest fear with this idea is that most people think this is or could be a major privacy issue. They usually ask the question, “Will patients feel comfortable doing this?” On the privacy front, I agree that video is more personal than granular data elements. So, the video EHR would have to take extreme precautions to ensure the privacy and security of these videos. However, from an impact standpoint, it wouldn’t be that much different than granular health information being breached. Plus, it’s much harder to breach a massive video file being sent across the wire than a few granular text data elements. No doubt, privacy and security would be a challenge, but it’s a challenge today as well. I don’t think video would be that much more significant.

As to the point of whether patients would be comfortable with a video in the exam room, no doubt there would need to be a massive culture shift. Some may never reach the point that they’re comfortable with it. However, think about telemedicine. What are patients doing in telemedicine? They’re essentially having their patient visit on video, streamed across the internet and a lot of society is very comfortable with it. In fact, many (myself included) wish that telemedicine were more widely available. No doubt telemedicine would break down the barriers when it comes to the concept of a video EHR. I do acknowledge that a video EHR takes it to another level and they’re not equal. However, they are related and illustrate that people’s comfort in having their medical visits on video might not be as far fetched as it might seem on the surface.

Turns out that doctors will face the same culture shift challenge as patients and they might even be more reluctant than patients.

Trust – I believe this is currently the biggest challenge with the concept of a video EHR. Can providers trust that the video and audio will be captured? What happens if it fails to capture? What happens if the quality of the video or audio isn’t very good? What is the voice recognition or NLP isn’t accurate and something bad happens? How do we ensure that everything that happens in the visit is captured accurately?

Obviously there are a lot of challenges associated with ensuring the video EHR’s ability to capture and document the visit properly. If it doesn’t it will lose providers and patients’ trust and it will fail. However, it’s worth remembering that we don’t necessarily need it to be perfect. We just need it to be better than our current imperfect status quo. We also just need to design the video EHR to avoid making mistakes and warn about possible missing information so that it can be addressed properly. No doubt this would be a monumental challenge.

Requires New Techniques – A video EHR would definitely require modifications in how a provider sees a patient. For example, there may be times where a patient or the doctor need to be positioned a certain way to ensure the visit gets documented properly. You can already see one of the cameras being a portable camera that can be used for close up shots of rashes or other medical issues so that they’re documented properly.

No doubt providers would have to learn new techniques on what they say in the exam room to make sure that things are documented properly. Instead of just thinking something, they’ll have to ensure that they speak clinical orders, findings, diagnosis, etc. We could have a long discussion on the impact for good and bad of this type of transparency.

Double Edged Sword of Liability – While reduced liability is a pro, liability could also be a con for a video EHR. Having the video of a medical visit can set you free, but it can also be damning as well. If you practice improper medicine, you won’t have anywhere to hide. Plus, given our current legal environment, even well intentioned doctors could get caught in challenging situations if the technology doesn’t work quite right or the video is taken out of context.

Reality Check
I realize this is a massive vision with a lot of technical and cultural challenges that would need to be overcome. Although, when I first came up with the idea of a video EHR ~10 years ago, it was even more far fetched. Since then, so many things have come into place that make this idea seem much more reasonable.

That said, I’m realistic that a solution like this would likely start with some sort of half and half solution. The video would be captured, but the provider would need to verify and complete the documentation to ensure its accuracy. We couldn’t just trust the AI engine to capture everything and be 100% accurate.

I’m also interested in watching the evolution of remote scribes. In many ways, a remote scribe is a human doing the work of the video EHR AI engine. It’s an interesting middle ground which could illustrate the possibilities and also be a small way to make patients and providers more comfortable with cameras in the exam room.

I do think our current billing system and things like meaningful use (or now MACRA) are still a challenge for a video EHR. The documentation requirements for these programs are brutal and could make the video EHR workflow lose its luster. Could it be done to accommodate the current documentation requirements? Certainly, but it might take some of the polish off the solution.

There you have it. My concept for a video EHR. What do you think of the idea? I hope you tear it up in the comments.

Workflow Redesign Is Crucial to Adopting a New Health IT System – Breakaway Thinking

Posted on January 20, 2016 I Written By

The following is a guest blog post by Todd Stansfield, Instructional Writer from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield
Workflow analysis and redesign have long been touted as essential to health IT adoption. Most organizations recognize the importance of modifying current workflows to capitalize on efficiencies created by a new application and identify areas where the system must be customized to support existing workflows. Despite this recognition, there remains room for improvement. In fact, last month the Office of the National Coordinator (ONC) identified the impact of new IT systems on clinical workflows as one of the biggest barriers to interoperability (ouch).

A successful redesign includes both an analysis of current workflows and desired future workflows.

Key stakeholders – direct and indirect – should take part in analyzing existing workflows. An objective third party should also be present to ask the right questions and facilitate the discussion. This team can collaborate to model important workflows, ideally in visual form to stimulate thorough analysis. To ensure an efficient and productive meeting, you should model workflows that are the most common, result in productivity losses, have both upstream and downstream consequences and involve multiple parties. The National Learning Consortium recommends focusing only on what occurs 80 percent of the time.

Once you document current workflows, you can set your sights on the future. Workflow redesign meetings are the next step; you need them to build a roadmap of activities leading up to a go-live event and beyond – from building the application to engaging and educating end users. Individuals from the original workflow analysis sessions should be included, and they should be joined by representatives from your health IT vendor (who can define the system’s capabilities) and members of your leadership team (who can answer questions and provide support).

After the initial go-live, you need to periodically perform workflow analysis and continue adjusting the roadmap to address changes to the application and processes.

Why should you spend all the time and effort to analyze and redesign workflows? Three reasons:

  1. It makes your organization proactive in your upcoming implementation and road to adoption. You’ll anticipate and avoid problems that will otherwise become bigger headaches.
  2. It’s the perfect opportunity to request customizations to adapt your application to desired workflows.
  3. It gives your staff a chance to mentally and emotionally prepare for a change to their daily habits, increasing buy-in and decreasing resistance to the switch.

Thorough and disciplined workflow redesign is an important step to adopting a new health IT application, but of course it’s not the only one. You’ll still need leadership to engage end users in the project, education that teaches learners how to use the new application to perform their workflow, performance metrics to evaluate adoption, and continual reinforcement of adoption initiatives as the application and workflows change over time.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

Analytics Integration Back to EHR Can’t Disrupt the Workflow

Posted on November 3, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

One of the challenges we face with healthcare analytics is getting the right information to the right care provider at the right time. In many cases that means presenting the analytics information to the doctor or nurse in the EHR at the point of care. It’s hard enough to know which data to present to which person and at what point in the care process. However, EHR vendors have made this integration even more difficult since it’s not easy to interface the healthcare analytics insights into the EHR workflow. The integrations that I’ve seen are crude at best.

That’s absolutely where we need to go though. There are very few situations where you can disrupt the healthcare providers workflow and send them to another system. I love the second screen concept as much as the next, but that’s not reasonable for most organizations.

I did recently talk to a BI Manager from a hospital who talked about the way they’ve integrated some of their analytics into the EHR workflow of their doctors. What they were doing was basic at best, but did illustrate an important point of learning: inform, don’t interrupt.

The concept of informing the doctor and not interrupting the doctor is a good one. While there are likely a few cases where you’d want to interrupt the doctor, it’s more common that you want to inform the doctor of some insight on the patient as opposed to interrupting the workflow. Doctors love having the right information at their fingertips. Interrupting their workflow (especially when it was unnecessary) causes alert fatigue.

No doubt you have to be careful with how you inform the doctor as well. The insights you offer the doctor better be actionable and useful or they’ll become blind to that as well. That’s the challenge we face with healthcare analytics. How do we take the data and make it useful to the providers? The first step is going to be creating a pathway of communication from the analytics into the EHR. Everything else will evolve from that connection.

Healthcare IT Content The Way You Like It

Posted on November 12, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

As most of you know, I organized my first conference this year focused on Healthcare IT Marketing and PR (HITMC). I’m a few days away from officially announcing the HITMC 2015 event, so more information on that coming soon. One of my big takeaways from the HITMC 2014 event was that people want to consume the content the way they want to consume the content and that it’s powerful to repurpose the same content and display it in a different way.

Many of you have likely been reading Vishal Gandhi’s (@csvishal2222) Cost Effective Healthcare Workflow Series of blog posts that’s sponsored by ClinicSpectrum. I think it’s been a great series focused on many of the needs of practice managers and healthare clinics. However, Vishal and ClinicSpectrum decided to take the series to another level as they’ve repurposed the content in lots of different ways.

For example, they took a blog post on building accountability and consistency into your practice and created this slideshare presentation. They also created this video on the subject. I won’t be surprised to see an infographic on this soon too.

In another example, ClinicSpectrum took this EHR Workflow video interview I did with Vishal and turned it into a 3 part blog post: Part 1, Part 2, Part 3. I loved the approach since many people don’t want to sit down and watch a video which has a specific amount of time required to consume the video. However, they’ll happily read through a blog post on a subject that matters to them. While some do prefer the video format because you can hear the inflection in someone’s voice and the energy behind what they’re saying.

At Healthcare Scene, we’re doing everything we can to provide a wide variety of formats to people to allow them to consume the content we create the way they want to consume it. I’d love to hear what you think of all of these various forms of content. Which content format do you prefer? What could we do better? I look forward to hearing your thoughts on the subject.

Population Health Management and Business Process Management

Posted on June 13, 2014 I Written By

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and also VP and CMIO for an EHR vendor for over a decade. Dr. Webster helped three healthcare organizations win the HIMSS Davies Award and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO and maintains numerous websites, including EHR Workflow Management Systems (http://chuckwebster.com), Healthcare Business Process Management (http://HCBPM.com) and the People and Organizations improving Healthcare with Health Information Technology (http://EHRworkflow.com). Please join with Chuck to spread the message: Viva la workflow!

This is my fifth and final of five guest blog posts covering Health IT and EHR Workflow.

Way back in 2009 I penned a research paper with a long and complicated title that could also have been, simply, Population Health Management and Business Process Management. In 2010 I presented it at MedInfo10 in Cape Town, Africa. Check out my travelogue!

Since then, some of what I wrote has become reality, and much of the rest is on the way. Before I dive into the weeds, let me set the stage. The Affordable Care Act added tens of millions of new patients to an already creaky and dysfunctional healthcare and health IT system. Accountable Care Organizations were conceived as virtual enterprises to be paid to manage the clinical outcome and costs of care of specific populations of individuals. Population Health Management has become the dominant conceptual framework for proceeding.

I looked at a bunch of definitions of population health management and created the following as a synthesis: “Proactive management of clinical and financial risks of a defined patient group to improve clinical outcomes and reduce cost via targeted, coordinated engagement of providers and patients across all care settings.”

You can see obvious places in this definition to apply trendy SMAC tech — social, mobile, analytics, and cloud — social, patient settings; mobile, provider and patient settings; analytics, cost and outcomes; cloud, across settings. But here I want to focus on the “targeted, coordinated.” Increasingly, it is self-developed and vendor-supplied care coordination platforms that target and coordinate, filling a gap between EHRs and day-to-day provider and patient workflows.

The best technology on which, from which, to create care coordination platforms is workflow technology, AKA business process management and adaptive/dynamic case management software. In fact, when I drill down on most sophisticated, scalable population health management and care coordination solutions, I usually find a combination of a couple things. Either the health IT organization or vendor is, in essence, reinventing the workflow tech wheel, or they embed or build on third-party BPM technology.

Let me direct you to my section Patient Class Event Hierarchy Intermediates Patient Event Stream and Automated Workflow in that MedInfo10 paper. First of all you have to target the right patients for intervention. Increasingly, ideas from Complex Event Processing are used to quickly and appropriately react to patient events. A Patient Class Event Hierarchy is a decision tree mediating between low-level events (patient state changes) and higher-level concepts clinical concepts such as “on-protocol,” “compliant”, “measured”, and “controlled.”

Examples include patients who aren’t on protocol but should be, aren’t being measured but should be, or whose clinical values are not controlled. Execution of appropriate automatic policy-based workflows (in effect, intervention plans) moves patients from off-protocol to on-protocol, non-compliance to compliance, unmeasured to measured, and from uncontrolled to controlled state categories.

Population health management and care coordination products and services may use different categories, terminology, etc. But they all tend to focus on sensing and reacting to untoward changes in patient state. But simply detecting these changes is insufficient. These systems need to cause actions. And these actions need to be monitored, managed, and improved, all of which are classic sterling qualities of business process management software systems and suites.

I’m reminded of several tweets about Accountable Care Organization IT systems I display during presentations. One summarizes an article about ACOs. The other paraphrases an ACO expert speaking at a conference. The former says ACOs must tie together many disparate IT systems. The later says ACOs boil down to lists: actionable lists of items delivered to the right person at the right time. If you put these requirements together with system-wide care pathways delivered safely and conveniently to the point of care, you get my three previous blog posts on interoperability, usability, and safety.

I’ll close here with my seven advantages of BPM-based care coordination technology. It…

  • More granularly distinguishes workflow steps
  • Captures more meaningful time-stamped task data
  • More actively influences point-of-care workflow
  • Helps model and understand workflow
  • Better coordinates patient care task handoffs
  • Monitors patient care task execution in real-time
  • Systematically improves workflow effectiveness & efficiency

Distinguishing among workflow steps is important to collecting data about which steps provide value to providers and patients, as well as time-stamps necessary to estimate true costs. Further, since these steps are executed, or at least monitored, at the point-of-care, there’s more opportunity to facilitate and influence at the point-of-care. Modeling workflow contributes to understanding workflow, in my view an intrinsically valuable state of affairs. These workflow models can represent and compensate for interruptions to necessary care task handoffs. During workflow execution, “enactment” in BPM parlance, workflow state is made transparently visible. Finally, workflow data “exhaust” (particularly times-stamped evidence-based process maps) can be used to systematically find bottlenecks and plug care gaps.

In light of the fit between complex event processing detecting changes in patient state, and BPM’s automated, managed workflow at the point-of-care, I see no alternative to what I predicted in 2010. Regardless of whether it’s rebranded as care or healthcare process management, business process management is the most mature, practical, and scalable way to create the care coordination and population health management IT systems required by Accountable Care Organizations and the Affordable Care Act. A bit dramatically, I’d even say business process management’s royal road to healthcare runs through care coordination.

This was my fifth and final blog post in this series on healthcare and workflow technology solicited by John Lynn for this week that he’s on vacation. Here was the outline:

If you missed one of my previous posts, I hope you’ll still check it out. Finally, thank you John, for allowing to me temporarily share your bully pulpit.


Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!

Posted on June 12, 2014 I Written By

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and also VP and CMIO for an EHR vendor for over a decade. Dr. Webster helped three healthcare organizations win the HIMSS Davies Award and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO and maintains numerous websites, including EHR Workflow Management Systems (http://chuckwebster.com), Healthcare Business Process Management (http://HCBPM.com) and the People and Organizations improving Healthcare with Health Information Technology (http://EHRworkflow.com). Please join with Chuck to spread the message: Viva la workflow!

This is my fourth of five guest blog posts covering Health IT and EHR Workflow.

When you took a drivers education class, do you remember the importance of mental “awareness” to traffic safety? Continually monitor your environment, your car, and yourself. As in traffic flow, healthcare is full of work flow, and awareness of workflow is the key to patient safety.

First of all, the very act of creating a model of work to be done forces designers and users to very carefully think about and work through workflow “happy paths” and what to do when they’re fallen off. A happy path is a sequence of events that’s intended to happen, and, if all goes well, actually does happen most of the time. Departures from the Happy Path are called “exceptions” in computer programming parlance. Exceptions are “thrown”, “caught”, and “handled.” At the level of computer programming, an exception may occur when data is requested from a network resource, but the network is down. At the level of workflow, an exception might be a patient no-show, an abnormal lab value, or suddenly being called away by an emergency or higher priority circumstance.

Developing a model of work, variously called workflow/process definition or work plan forces workflow designers and workflow users to communicate at a level of abstraction that is much more natural and productive than either computer code or screen mockups.

Once a workflow model is created, it can be automatically analyzed for completeness and consistency. Similar to how a compiler can detect problems in code before it’s released, problems in workflow can be prevented. This sort of formal analysis is in its infancy, and is perhaps most advanced in healthcare in the design of medical devices.

When workflow engines execute models of work, work is performed. If this work would have otherwise necessarily been accomplished by humans, user workload is reduced. Recent research estimates a 7 percent increase in patient mortality for every additional patient increase in nurse workload. Decreasing workload should reduce patient mortality by a similar amount.

Another area of workflow technology that can increase patient safety is process mining. Process mining is similar, by analogy, to data mining, but the patterns it extracts from time stamped data are workflow models. These “process maps” are evidence-based representations of what really happens during use of an EHR or health IT system. Process maps can be quite different, and more eye opening, than process maps generated by asking participants questions about their workflows. Process maps can show what happens that shouldn’t, what doesn’t happen than should, and time-delays due to workflow bottlenecks. They are ideal tools to understand what happened during analysis of what may have caused a possibly system-precipitated medical error.

Yet another area of particular relevance of workflow tech to patient safety is the fascinating relationship between clinical pathways, guidelines, etc. and workflow and process definitions executed by workflow tech’s workflow engines. Clinical decision support, bringing the best, evidence-based medical knowledge to the point-of-care, must be seamless with clinical workflow. Otherwise, alert fatigue greatly reduces realization of the potential.

There’s considerable research into how to leverage and combine representations of clinical knowledge with clinical workflow. However, you really need a workflow system to take advantage of this intricate relationship. Hardcoded, workflow-oblivious systems? There’s no way to tweak alerts to workflow context: the who, what, why, when, where, and how of what the clinical is doing. Clinical decision support will not achieve wide spread success and acceptance until it can be intelligently customized and managed, during real-time clinical workflow execution. This, again, requires workflow tech at the point-of-care.

I’ve saved workflow tech’s most important contribution to patient safety until last: Interruptions.

An interruption–is there anything more dreaded than, just when you are beginning to experience optimal mental flow, a higher priority task interrupts your concentration. This is ironic, since so much of work-a-day ambulatory medicine is essentially interrupt-driven (to borrow from computer terminology). Unexpected higher priority tasks and emergencies *should* interrupt lower priority scheduled tasks. Though at the end of the day, ideally, you’ve accomplished all your tasks.

In one research study, over 50% of all healthcare errors were due to slips and lapses, such as not executing an intended action. In other words, good clinical intentions derailed by interruptions.

Workflow management systems provide environmental cues to remind clinical staff to resume interrupted tasks. They represent “stacks” of tasks so the entire care team works together to make sure that interrupted tasks are eventually and appropriately resumed. Workflow management technology can bring to clinical care many of the innovations we admire in the aviation domain, including well-defined steps, checklists, and workflow tools.

Stay tuned for my fifth, and final, guest blog post, in which I tackle Population Health Management with Business Process Management.


Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible

Posted on June 11, 2014 I Written By

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and also VP and CMIO for an EHR vendor for over a decade. Dr. Webster helped three healthcare organizations win the HIMSS Davies Award and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO and maintains numerous websites, including EHR Workflow Management Systems (http://chuckwebster.com), Healthcare Business Process Management (http://HCBPM.com) and the People and Organizations improving Healthcare with Health Information Technology (http://EHRworkflow.com). Please join with Chuck to spread the message: Viva la workflow!

This is my third of five guest blog posts covering Health IT and EHR Workflow.

Workflow technology has a reputation, fortunately out of date, for trying to get rid of humans all together. Early on it was used for Straight-Through-Processing in which human stockbrokers were bypassed so stock trades happened in seconds instead of days. Business Process Management (BPM) can still do this. It can automate the logic and workflow that’d normally require a human to download something, check on a value and based on that value do something else useful, such as putting an item in a To-Do list. By automating low-level routine workflows, humans are freed to do more useful things that even workflow automation can’t automate.

But much of healthcare workflow requires human intervention. It is here that modern workflow technology really shines, by becoming an intelligent assistant proactively cooperating with human users to make their jobs easier. A decade ago, at MedInfo04 in San Francisco, I listed the five workflow usability principles that beg for workflow tech at the point-of-care.

Consider these major dimensions of workflow usability: naturalness, consistency, relevance, supportiveness, and flexibility. Workflow management concepts provide a useful bridge from usability concepts applied to single users to usability applied to users in teams. Each concept, realized correctly, contributes to shorter cycle time (encounter length) and increased throughput (patient volume).

Naturalness is the degree to which an application’s behavior matches task structure. In the case of workflow management, multiple task structures stretch across multiple EHR users in multiple roles. A patient visit to a medical practice office involves multiple interactions among patients, nurses, technicians, and physicians. Task analysis must therefore span all of these users and roles. Creation of a patient encounter process definition is an example of this kind of task analysis, and results in a machine executable (by the BPM workflow engine) representation of task structure.

Consistency is the degree to which an application reinforces and relies on user expectations. Process definitions enforce (and therefore reinforce) consistency of EHR user interactions with each other with respect to task goals and context. Over time, team members rely on this consistency to achieve highly automated and interleaved behavior. Consistent repetition leads to increased speed and accuracy.

Relevance is the degree to which extraneous input and output, which may confuse a user, is eliminated. Too much information can be as bad as not enough. Here, process definitions rely on EHR user roles (related sets of activities, responsibilities, and skills) to select appropriate screens, screen contents, and interaction behavior.

Supportiveness is the degree to which enough information is provided to a user to accomplish tasks. An application can support users by contributing to the shared mental model of system state that allows users to coordinate their activities with respect to each other. For example, since a EMR  workflow system represents and updates task status and responsibility in real time, this data can drive a display that gives all EHR users the big picture of who is waiting for what, for how long, and who is responsible.

Flexibility is the degree to which an application can accommodate user requirements, competencies, and preferences. This obviously relates back to each of the previous usability principles. Unnatural, inconsistent, irrelevant, and unsupportive behaviors (from the perspective of a specific user, task, and context) need to be flexibly changed to become natural, consistent, relevant, and supportive. Plus, different EHR users may require different BPM process definitions, or shared process definitions that can be parameterized to behave differently in different user task-contexts.

The ideal EHR/EMR should make the simple easy and fast, and the complex possible and practical. Then ,the majority/minority rule applies. A majority of the time processing is simple, easy, and fast (generating the greatest output for the least input, thereby greatly increasing productivity). In the remaining minority of the time, the productivity increase may be less, but at least there are no showstoppers.

So, to summarize my five principles of workflow usability…

Workflow tech can more naturally match the task structure of a physician’s office through execution of workflow definitions. It can more consistently reinforce user expectations. Over time this leads to highly automated and interleaved team behavior. On a screen-by-screen basis, users encounter more relevant data and order entry options. Workflow tech can track pending tasks–which patients are waiting where, how long, for what, and who is responsible–and this data can be used to support a continually updated shared mental model among users. Finally, to the degree to which an EHR or health IT system is not natural, consistent, relevant, and supportive, the underlying flexibility of the workflow engine and process definitions can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.

Tomorrow I’ll discuss workflow technology and patient safety.


Interoperable Health IT and Business Process Management: The Spider In The Web

Posted on June 10, 2014 I Written By

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and also VP and CMIO for an EHR vendor for over a decade. Dr. Webster helped three healthcare organizations win the HIMSS Davies Award and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO and maintains numerous websites, including EHR Workflow Management Systems (http://chuckwebster.com), Healthcare Business Process Management (http://HCBPM.com) and the People and Organizations improving Healthcare with Health Information Technology (http://EHRworkflow.com). Please join with Chuck to spread the message: Viva la workflow!

This is my second of five guest blog posts covering Health IT and EHR Workflow.

If you pay any attention at all to interoperability discussion in healthcare and health IT, I’m sure you’ve heard of syntactic vs. semantic interoperability. Syntax and semantics are ideas from linguistics. Syntax is the structure of a message. Semantics is its meaning. Think HL7’s pipes and hats (the characters “|” and “^” used as separators) vs. codes referring to drugs and lab results (the stuff between pipes and hats). What you hardly every hear about is pragmatic interoperability, sometimes called workflow interoperability. We need not just syntactic and semantic interop, but pragmatic workflow interop too. In fact, interoperability based on workflow technology can strategically compensate for deficiencies in syntactic and semantic interoperability. By workflow technology, I mean Business Process Management (BPM).

Why do I highlight BPM’s relevance to health information interoperability? Take a look at this quote from Business Process Management: A Comprehensive Survey:

“WFM/BPM systems are often the “spider in the web” connecting different technologies. For example, the BPM system invokes applications to execute particular tasks, stores process-related information in a database, and integrates different legacy and web-based systems…. Business processes need to be executed in a partly uncontrollable environment where people and organizations may deviate and software components and communication infrastructures may malfunction. Therefore, the BPM system needs to be able to deal with failures and missing data.”

“Partly uncontrollable environment where people and organizations may deviate and software components and communication infrastructures may malfunction”? Sound familiar? That’s right. It should sound a lot like health IT.

What’s the solution? A “spider in the web” connecting different technologies… invoking applications to execute particular tasks, storing process-related information in a database, and integrates different legacy and web-based systems. Dealing with failures and missing data. Yes, healthcare needs a spider in the complicated web of complicate information systems that is today’s health information management infrastructure. Business process management is that spider in a technological web.

Let me show you now how BPM makes pragmatic interoperability possible.

I’ll start with another quote:

“Pragmatic interoperability (PI) is the compatibility between the intended versus the actual effect of message exchange.”

That’s a surprisingly simple definition for what you may have feared would be a tediously arcane topic. Pragmatic interoperability is simply whether the message you send achieves the goal you intended. That’s why it’s “pragmatic” interoperability. Linguistics pragmatics is the study of how we use language to achieve goals.

“Pragmatic interoperability is concerned with ensuring that the exchanged messages cause their intended effect. Often, the intended effect is achieved by sending and receiving multiple messages in specific order, defined in an interaction protocol.”

So, how does workflow technology tie into pragmatic interoperability? The key phrases linking workflow and pragmatics are “intended effect” and “specific order”.

A sequence of actions and messages — send a request to a specialist, track request status, ask about request status, receive result and do the right thing with it — that’s the “specific order” of conversation required to ensure the “intended effect” (the result). Interactions among EHR workflow systems, explicitly defined internal and cross-EHR workflows, hierarchies of automated and human handlers, and rules and schedules for escalation and expiration are necessary to achieve seamless coordination among EHR workflow systems. In other words, we need workflow management system technology to enable self-repairing conversations among EHR and other health IT systems. This is pragmatic interoperability. By the way, some early workflow systems were explicitly based on speech act theory, an area of pragmatics.

That’s my call to use workflow technology, especially Business Process Management, to help solve our healthcare information interoperability problems. Syntactic and semantic interoperability aren’t enough. Cool looking “marketectures” dissecting healthcare interoperability issues aren’t enough. Even APIs (Application Programming Interfaces) aren’t enough. Something has to combine all this stuff, in a scalable and flexible ways (by which I mean, not “hardcoded”) into usable workflows.

Which brings me to usability, tomorrow’s guest blog post topic.

Tune in!


Five Guest Blog Posts On EHR and HIT Workflow, Usability, Safety, Interoperability and Population Health

Posted on June 9, 2014 I Written By

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and also VP and CMIO for an EHR vendor for over a decade. Dr. Webster helped three healthcare organizations win the HIMSS Davies Award and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO and maintains numerous websites, including EHR Workflow Management Systems (http://chuckwebster.com), Healthcare Business Process Management (http://HCBPM.com) and the People and Organizations improving Healthcare with Health Information Technology (http://EHRworkflow.com). Please join with Chuck to spread the message: Viva la workflow!

John Lynn is taking a well-deserved week off to attend a family function. He asked if I was interested in five EHR workflow guest blog posts, a blog post a day this week, on EMR and HIPAA. Of course I said: YES!

Here’s the outline for the week:

I blog and tweet a lot about healthcare workflow and workflow technology, but in this first post I’ll try to synthesize and simplify. In later posts I drive into the weeds. Here, I’ll define workflow, describe workflow technology, it’s relevance to healthcare and health IT, and try not to steal my own thunder from the rest of the week.

I’ve looked at literally hundreds of definitions of workflow, all the way from a “series of tasks” to definitions that’d sprawl across several presentation slides. The one I’ve settled on is this:

“Workflow is a series of tasks, consuming resources, achieving goals.”

Short enough to tweet, which is why I like it, but long enough to address two important concepts: resources (costs) and goals (benefits).

So what is workflow technology? Workflow technology uses models of work to automate processes and support human workflows. These models can be understood, edited, improved, and even created, by humans who are not, themselves, programmers. These models can be executed, monitored, and even systematically improved by computer programs, variously called workflow management systems, business process management suites, and, for ad hoc workflows, case management systems.

Workflow tech, like health IT itself, is a vast and varied continent. As an industry, worldwide, it’s probably less than a tenth size of health IT, but it’s also growing at two or three times the rate. And, as both industries grow, they increasingly overlap. Health IT increasingly represents workflows and executes them with workflow engines. Workflow tech vendors increasingly aim at healthcare to sell a wide variety of workflow solutions, from embeddable workflow engines to sprawling business process management suites. Workflow vendors strenuously compete and debate on finer points of philosophy about how best automate and support work. Many of these finer points are directly relevant to workflow problems plaguing healthcare and health IT.

Why is workflow tech important to health IT? Because it can do what is missing, but sorely needed, in traditional health IT, including electronic health records (EHRs). Most EHRs and health IT systems essentially hard-code workflow. By “hard code” I mean that any series of tasks is implicitly represented by Java and C# and MUMPS if-then and case statements. Changes to workflow require changes to underlying code. This requires programmers who understand Java and C# and MUMPS. Changes cause errors. I’m reminded of the old joke, how many programmers does it take to change a light bulb? Just one, but in the morning the stove and the toilet are broken. Traditional health IT relies on frozen representations of workflow that are opaque, fragile, and difficult to manage across information system and organizational boundaries.

Well, OK, I’ll steal my own thunder just a little bit. Process-aware tech, in comparison to hardcoded workflows, is an architectural paradigm shift for health IT. It has far reaching implications for interoperability, usability, safety, and population health.

BPM systems are ideal candidates to tie together disparate systems and technologies. Users experience more usable workflows because workflows are represented so humans can understand and change then. Process-aware information systems are safer for many reasons, but particularly because they can represent and compensate for the interruptions that cause so many medical errors. Finally, BPM platforms are the right platforms to tie together accountable care organization IT systems and to drive specific, appropriate, timely action to provider and patient point-of-care.

The rest of my blog posts in this weeklong series will elaborate on these themes. I’ll address why so many EHRs and health IT systems are so unusable, un-interoperable, and sometimes even dangerous. I’ll argue that modern workflow technology can help rescue healthcare and health IT from these problems.


Next Week’s Topic – EHR Workflow

Posted on June 6, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Next week, it’s going to be a little different around here. Next week, I’m going to be spending the week at Zions National Park as part of a family reunion. We did this a couple years back and unless things have changed, I’ll be stuck completely off the grid with no wifi or even cell coverage (Although, I may slip into town one day to check my email). Should be quite the experience.

I’ve actually done this a few times before and you probably didn’t know it. I just schedule the posts to appear and no one even realized I was gone. In fact, when I’ve done it in the past, I’ve had some of my highest traffic days on the blog. Don’t ask me how that works.

Next week, I decided to do something a little bit different. When I first started blogging, I remember a blogger “turning over the keys” to his blog to another blogger for the week. I always thought that was a kind of cool idea. Usually the person who “drives” the blog for the week enjoys it, the readers get another perspective, and the blog keeps humming while I’m wrestling 4 children and 12 cousins in the wilderness.

That’s indeed what I’ve done. Next week, I’m passing the keys to the EMR and HIPAA blog over to Chuck Webster, MD. Most people know him better as @wareFLO. He’s also well known for his famous HIMSS hat cam which has now been transitioned to Google Glass. However, Chuck is most well known for his interest in love passion adoration addiction to EHR and Health IT workflow. See his blog for example.

If you say EHR, he thinks workflow. If you say HIE, he thinks workflow. If you say population health, he thinks workflow. If you say meaningful use, he thinks workflow. If you say revenue cycle management, he thinks workflow. If you say donuts, he thinks workflow (This seems appropriate on National Donut day).

Needless to say, next week Chuck is going to be taking you through a series of blog posts covering EHR and Healthcare IT workflow. I’ve seen the preview and there are some real valuable nuggets that he’ll share. I particularly like the posts he’s planning for later in the week.

How’s that for a preview? Of course, if you hate EHR workflow, then I’ll be back with my regularly scheduled programming the week after. I look forward to hearing what you all think about Chuck’s posts. If you like the idea, maybe we’ll do it again in the future. Either way, I hope you’ll welcome Chuck next week and give him the same honest feedback, support, critiques, and suggestions in the comments that you give me.