Healthcare Business Process Management, Adaptive Case Management & Process-Aware EHR & Health IT Systems

"Adaptive Case Management" Style EHR Workflow Definition Editor

[The following workflow editor is "simpler" than the previous editor, with all those icons and arrows. However, is no less sophisticated. It's simply further away from structured workflow, and towards unstructured workflow. It's an example what's come to be called adaptive case management (sometimes called dynamic case management). Instead of representing clinical workflows in detail, it represents medical office ambulatory workflow at a general level (vitals, meds, ROS, exam, etc.) and emphasizes task state visibility (called "radar view" by usability engineers) to the care team). Users can easily jump off the happy path -- postponing, forwarding, escalating, cancelling, etc. -- but return to take-up previously interrupted tasks.]

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Now, I want to compare that classic workflow editor with a simpler workflow editor. In this scene … slide, it doesn’t look that simple but it will look simpler in a moment. If you can think of a health information system or in this case, an electronic health record, as a set of screens but also the little dotted lines, those are screen-less tasks. These screens allow users to review data from previous patient encounters, to enter more data that will be useful in making decisions at later points, as well as order entry screens in which assessments and diagnosis and treatments such as things that’ll send prescriptions off to the pharmacy. 

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Now, the screen-less tasks are also saving a lot of time and effort and money in user dissatisfaction. They’re automatically going to see if there are clinical labs and downloading them and then putting a list, an item in a work list. They’re printing educational materials at the printer that’s closest to the person who’s responsible for the patient. They’re creating automatic reminders based on schedules interacting with business rules or clinical decision rules so that obviously saves a lot of time and effort. 

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Where did it come from this workflow that I’m talking about? Well, we’re going to grab a bunch of those and we’re going to create a workflow. 

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Over on the left hand side, we have … it’s only eight steps, a typical encounter might be twenty steps but we will see what these are because we can look at the pick list that represents the workflow. 

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We  have “get patient,” so the nurse walks into the room, says, “I am bringing John Doe into room C,” and then the  next couple of screens pop up automatically. The nurse doesn’t have to go and navigate some complicated and clumsy menu hierarchy. 

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We’re going to collect some vital signs….

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…ask about allergies…

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…ask about medications…

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…We’re going to conduct a review assistance and that review assistance will be the right one based on whether it’s a child or an adult, whether that nurse likes … has a favorite review systems or it may be based on the physician that nurse works for and different specialists have different review systems. These systems can be very parameterized so that at each point of step and execution, they do the right thing.

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The examination step can be an entire other workflow definition, such as a screen to enter history of present illness, a screen for physical exam observations, then assessments and order entry for treatments. 

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…Finally, you get down to the billing steps … [note that we skipped the Evaluation and Management coding step: users are not cogs in workflow machines, they can cancel workflows, skip steps, postpone them, forward them to other members of the care team and so on]

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By the way, there’s something I call the litmus test for frozen workflow. After you see the demo of a system, say, “I’d like to see that demo again except I want you to make one change. I want you to bring up something that will allow you to edit the workflow.” It might look like that old-fashioned workflow editor with all the arrows and diagonal boxes or it might look like this or it might look like something else. 

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What I want you to do is go in there and change one thing, delete a step, change the order of a step and then I want you to go and do the demo again. If that system has an actual workflow engine that is consulting some kind of representation of workflow, it will do what you would expect it would do if it’s executing that recently edited model so in this case, it should skip the step of checking for allergies, asking the nurse ask the patient about allergies.

Third Example Workflow Editor (Non-Point-Of-Care Workflow Automation)

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Okay. Let’s look at a non-point of care workflow automation example.

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Here is a drag-and-drop hospital workflow definition editor and up here at the top is the beginning of the workflow, down at the bottom and at the end. It’s kind of like a cross between those two previous ones that we just looked at.

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…okay, we want to drag and drop. We want to create a step which is to go and get a signature from someone. …

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…Then when that happens, we want to forward it to a role or a group so anybody can look on this list of available tasks as kind of a pooling concept from computers and grab it and say, “Yes, quality assurance, everything has been done that I think should be done.” …

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…Even the manager gets to see it. We have two levels of quality assurance so everything goes through the manager…

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…Then finally, we see down here there’s like a little icon of a person and a arrow and going back to a question mark. We want to close the loop. We want to send back information to the person who ordered this workflow to say it was successfully accomplished…

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…This is just a skeleton of a workflow. We want to go in and customize these steps further. Let’s say we want to go to the manager’s step and we want to give them an option to add a little note so we’ve got the little pen symbol…

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…Now, suppose we want to make sure that every time that happens, an email gets sent to … maybe this is not the ultimate manager, maybe they’re filling in for someone or it needs to be copied to the other people who also have managing roles that are rotating through this department…

Workflow Engine Executes Workflow Definition (Non-Point-of-Care Example)

 

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Well, now, we have the executable process model. It’s a process model. It’s a process definition. It’s a workflow definition. I’m using these so you get familiar with the terminology, which can vary.

 

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The workflow engine looks at it and says, “Okay. I need to send a to-do item to this person. When they click on it, it’s going to pull up this form. It might be in a tablet as they’re wandering around the hospital.

 

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Then, I want to forward the results of that into some pool where other people will grab it and do something with it.”

 

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It needs … ultimately, everything … the manager has to sign off on everything because in this place, they have two levels of quality assurance

 

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…and finally, we want whoever initiated this needs-to-know that it was done so we’re closing the loop….

 

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...and the workflow terminates.

 

 

 

 

 

True Workflow Automation Increases Productivity, Alternatives Don't

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All right. Now, I don’t have enough time. This is cat, dog, tree version of business process management but I did want to pull out an example number from a case study. There was a paper manual process for creating … generating the patient admissions packet in a hospital. It cost $2.40, it was estimated. Then, after the workflow was automated using a workflow engine and process definition and so forth, the cost per packet dropped to $0.45. This is on the border of increase in productivity of three or four hundred percent.

I’ve seen this before and what’s fascinating is, I’ve seen many manual paper processes automated that did not use workflow automation, did not use true workflow automation with the workflow engine doing all that work. Guess what? Those end up reducing productivity. People have to click a lot because if there is no workflow engine in the computer, the human has to do all that work and they got to click, click, click and they complain about that.

Other things … the other dimensions of increased productivity are things like if you greatly reduce the cycle time so if all the steps are not having to wait around for someone to pick up the baton and move it to the next person, flow is going to happen more quickly. When you get a shorter cycle time, you get higher throughput and for the given amount of resources, you’re going to be able to scale up or you’re going to achieve the same amount with reduced resources.

Next Steps: List High Value Workflows

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All right. If my enthusiasm, my animations [in the original slides] and this data has convinced you, “Maybe I ought to investigate this further,” this is my workflow of where to go. You might call it meta-meta workflow, the workflow of workflow of workflow. We’re learning right now. That’s what we’re doing right here.

Well, you kind of … this is called a split, by the way and it is a … both of these happen in parallel and you look at your environment and you say, “Well, what are the high value workflows? What are the things …” and we’ll … on the next slide, we’ll talk about what is a high value workflow an those workflows, the details about those workflows will inform you about a set of requirements so that you can compare workflow products or workflow platforms or vendors.

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Let’s look at workflow value. Workflow value is a function of a number of users. The more users that are use it, well, then the more valuable it’s going to be, more happy people, the greatest good for the greatest many. The more frequently the workflow is executed, the more valuable it will be. If it’s executed every fifteen minutes, it’s going to be a lot more valuable than if it’s executed every couple of weeks.

The financial value is important. Is there something writing a check at the end of the successful workflow?

Then finally, the difference between a better workflow and the current painful workflow, the current ineffective, inefficient and unhappy user workflow, the bigger that is, the more the workflow value is going to be.

My Next Speaking Engagement!

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BPM Solutions

Process Orchestration Engine (AKA workflow engine) to drive the progression of work in structured and unstructured processes or cases

Model-Driven Composition environment for designing processes and their supporting activities and process artifacts

Content Interaction Management supporting e progression of work, especially cases, based on changes in the content itself (documents, images and audio)

Human Interaction Management enables people to naturally interact with processes they're involved in

Connected Processes and Resources they control, such as people, systems, data, event streams, goals and key performance indicators (KPIs)

Continuous Analytics monitor activity progress, and analyze activities and changes in and around processes

On-Demand Analytics to provide decision support using predictive analytics and optimization

Business Rule Management systems guide and implement process agility and ensure compliance

Management and Administration monitor and adjust technical aspects of BPM platform

Process Component Registry/Repository for process component leverage and reuse

Cloud-Based Deployment of about features and functions across desktop platforms and mobile devices

Social Media Compatible external and/or similar internal activity streams integrated with workflows

*Adapted from Gartner

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