WORKFLOW

Zen Clinicals: An Activity & Workflow based solution (2 of 4)



Part 2 of 4

Now that we have defined the various actors and the activities that they could be performing. It becomes to important to define the guidance as to how these activities will be delivered to their respective audiences. 

In the Zen Clinical System 

Zen Clinicals: An Activity & Workflow based solution (3 of 4)



Part 3 of 4

Sharing some of the UI screens that I had envisaged for the Zen Clinicals system. The core premise of the system is to be data driven and workflow driven and NOT BE a transactional system wherein a sequential set of activities or tasks are carried out.

Zen Clinicals ensures there are actionable insights that are presented to the right care providers at the right time. 

Welcome you to review the first two parts of this blog: 

Part 1: https://blog.hcitexpert.com/2015/12/zen-clinicals-1of3.html

Part 2: https://blog.hcitexpert.com/2018/07/zen-clinicals-patient-care-pathways-by-manish-sharma.html

Zen Clinicals: A Patient Care Pathways Solution (4 of 4)

A Clinical Care Pathways Workflow & Activity Orchestration

Overview

Clinical pathways are structured multidisciplinary care plans which address specific clinical scenarios and help to standardize and coordination of care.
The patient care pathways solutions have become an important clinical guidelines implementation tools in hospital settings. They have the ability to provide, not only a standardised care to the patients’ presenting same/ similar diagnosis, but also provide the ability to handle the variance from the defined care pathways for various specialties and diagnosis.
The care pathways also provides the ability to coordinate care of a patient across various user groups and user roles, like the group of nurses across shifts and across roles like doctors, nurses and administrative staff.
The Care Pathways aim to optimize the efficiency and quality of care
The care pathways solution that we propose to develop have the following features.

Clinical Data Repository

At the heart of our Patient Care Pathways solution is a clinical data repository that maintains a longitudinal patient care record. The Patient CDR is a data warehouse of the Patient’s clinical data that has been stored in the clinical data repository to enable data analysis across the patient episodes and visits.
The Clinical Data Repository provides the ability to organically analyse data from ‘similar’ patients across same or similar set of data points like diagnosis, test results and clinical studies.
The clinical data repository converts all the data captured in various connected systems to a analysable data point for the care pathways solution. The data captured in the external system
The clinical data repository is a the heart of the care pathways solution that contains information that has been stored in standardised format using the standard healthcare coding systems like ICD10, SNOMED CT, ICD10 PCS and others as applicable in the clinical scenario.
In-built into the Clinical Data Repository are latest big data analytics capabilities that are required to generate the statistical analysis of the adherence to the quality and efficincy of the Care Pathway.
The clinical data repository has the ability to generate, out of the box, all the analytical reports and predictive modelling required for todays’ clinicians to make the right decisions at the right time.
The Clinical Data Repository allows for the following features and functionalities that are relevant to the Care Pathways solution
  1. Allows for analysing historical outcomes from clinically similar patients, e.g. patients like me type of scenario matching
  2. Display the variance and outcomes for the patient specific pathway and across various patients

Care Pathways Designer

The Care Pathways designer is a visual tool that allows the user to define the workflow of activities based on a start condition. The Start Up condition for a Care Pathway could be a Code Red alarm for quarantine or it could be a set of questions that a care provider answers to based on the patient they are treating for, for instance, chest pain.
The Care pathways designer has at its core the following:
  1. Activities
  2. Activity Groups
  3. Users
  4. User Groups
  5. Workflow Designer
Care Pathways Designer Features:
  1. The care pathways designer is a tool that allows the care pathways design team to define the standardised care templates of activities that should be scheduled for a patient presenting a chief complaint or being treated for a chronic condition.
  2. The care pathways designer has a set of pre-defined activity categories. For example, Appointment Scheduling, Laboratory Orders, Radiology Orders, Pharmacy Orders and many more. Each of the activity categories are defined based on the corresponding activity that needs to be instantiated at the host system, such as an EHR or a HIMS Solution. The Patient Care Pathways solution allows the users to define these activity categories depending on the host system.
  3. The Care Pathways Designer tool allows the users to define the workflow for the care pathways. The tool allows the user to define rules and the activities (or activity groups) that will be instantiated depending on the condition of the rule.
  4. The Care Pathways designer tool also has the ability to define various outcomes and the activities that need to be performed to achieve those outcomes.

Rules Designer

The clinical pathways designer will have a rules designer that allows the users to select the various activities and activities groups to be the outcome and action targets for a clinical rule.
For instance, if the doctor selects a certain type of schedule H drugs to be ordered for a patient and the doctor does not have the authorization to order schedule H drugs, the order will be sent to the next level of authorization within the patient care team.
The rules can be included into the care pathways designer as workflow activities and decision criteria.

User & User Group based Task Lists

The system will have a user specific task list that will inform the user on the various activities that a user (nurse, doctor, admissions and billing users) needs to perform vis-a-vis a patient. The Task list will help the user to complete the tasks that have been generated based on the various active care pathways for the various patients.
The system also has the ability to share the generated tasks between a group of care providers. This allows for the nurses taking care of the patients across the various shifts to review the tasks that have been completed or not completed during an earlier shift.

Care Pathway Dashboard

The system will have a comprehensive Care Pathway Dashboard. The dashboard will display the following:
  1. The Care Pathway adherence Index displays the variance or conformance of a care pathway when applied to multiple patients.
  2. The Care Pathway patient adherence Index, this displays the effectiveness of a care plan when applied to a specific patient.
In both the above scenarios, the care plan adherence Index will display the deviations, the variances and adherence levels to the defined care plan. It will also list out the activities that were done in addition or in variance of a defined care plan.
In addition to the variance and conformance metrics the Care Pathway Dashboards will display to the users the following:
  1. The Patient Specific Care Pathway Activity Scheduler: Displays the day by day list of all the activities that have been defined (scheduled) in a care plan. It also has the ability to showcase the activities by a shift.
  2. Care Pathway timeline: Displays the care plan timeline and recorded variance and non-conformance detection
  3. Outcomes Recording: The Care Pathway solution also allows the users to record the outcomes for each of the planned activities and the Outcomes defined for the Care Pathway.

Care Pathway Push Notifications & Alerts Center

The Care Pathway Push Notifications and Alerts center is an important part of our solution. The Care Pathway push notification system identifies the most important and high priority tasks that need to be performed for each of the patients. The users are alerted about these high priority tasks on their associated mobile devices.
The Care Pathway Push Notifications have been designed to be non-obstrusive and presented in a way the user has configured these to be delivered to them. This is done to ensure there is no alert-fatigue generated based on our notifications and alerts center.
In addition to the Push Notification for tasks to be performed on a high priority, the Care Pathways solution also has the ability to provide alerts of outstanding or upcoming, completed or activities in variance of the defined Care Pathway to relevant team members.
Each alert and push notification will be configured with a level of priority (that can be assigned to the alert type or determined by the system) and depending on the Level of Priority of that alert and notification, the system will present the alert to the user.

Additional Resources & Standards Definitions:

  1. The care pathway models in the tool are based on the following industry standards:
    1. OMG Case Management Model and Notation (CMMN), and
    2. HL7 GELLO and
    3. vMR

Care Pathway Examples:

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Workflow, Usability, Safety & #Interoperability Perspectives by Dr.Charles Webster, @wareflo – Part5 #AMIA2016

Population Health Management and Business Process Management: Part – 5
“Workflow is a series of tasks, consuming resources, achieving goals.”

This article has been re-published with the authors permission. The article was first published by Dr. Charles Webster on his blog here

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


Additional Blog Posts by the Author
  1. Five Guest Blog Posts On EHR & HIT Workflow, Usability, Safety, Interoperability and Population Health
  2. Interoperable Health IT and Business Process Management: The Spider In The Web
  3. Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible
  4. Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!
  5. Population Health Management and Business Process Management
Author

[tab]
[content title=”About Dr. Charles Webster”]

Dr. Charles Webster

HIMSS14, HIMSS15, and HIMSS16 Social Media Ambassador! If you’ve got a healthcare workflow story, I want to tell it, blog it, tweet it, interview you, etc. Dr. Webster is a ceaseless evangelist for process-aware technologies in healthcare, including Workflow Management Systems, Business Process Management, and dynamic and adaptive case management.

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Workflow, Usability, Safety & #Interoperability Perspectives by Dr.Charles Webster, @wareflo – Part4 #AMIA2016

Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions! : Part – 4
“Workflow is a series of tasks, consuming resources, achieving goals.”

This article has been re-published with the authors permission. The article was first published by Dr. Charles Webster on his blog here

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.

Additional Blog Posts by the Author
  1. Five Guest Blog Posts On EHR & HIT Workflow, Usability, Safety, Interoperability and Population Health
  2. Interoperable Health IT and Business Process Management: The Spider In The Web
  3. Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible
  4. Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!
  5. Population Health Management and Business Process Management
Author

[tab]
[content title=”About Dr. Charles Webster”]

Dr. Charles Webster

HIMSS14, HIMSS15, and HIMSS16 Social Media Ambassador! If you’ve got a healthcare workflow story, I want to tell it, blog it, tweet it, interview you, etc. Dr. Webster is a ceaseless evangelist for process-aware technologies in healthcare, including Workflow Management Systems, Business Process Management, and dynamic and adaptive case management.

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[content title=”Latest Articles”]

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Workflow, Usability, Safety & #Interoperability Perspectives by Dr.Charles Webster, @wareflo – Part3 #AMIA2016

Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible : Part – 3
“Workflow is a series of tasks, consuming resources, achieving goals.”

This article has been re-published with the authors permission. The article was first published by Dr. Charles Webster on his blog here

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.

In the next blog post in the series, I’ll discuss workflow technology and patient safety.

Additional Blog Posts by the Author
  1. Five Guest Blog Posts On EHR & HIT Workflow, Usability, Safety, Interoperability and Population Health
  2. Interoperable Health IT and Business Process Management: The Spider In The Web
  3. Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible
  4. Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!
  5. Population Health Management and Business Process Management
Author

[tab]
[content title=”About Dr. Charles Webster”]

Dr. Charles Webster

HIMSS14, HIMSS15, and HIMSS16 Social Media Ambassador! If you’ve got a healthcare workflow story, I want to tell it, blog it, tweet it, interview you, etc. Dr. Webster is a ceaseless evangelist for process-aware technologies in healthcare, including Workflow Management Systems, Business Process Management, and dynamic and adaptive case management.

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[content title=”Latest Articles”]

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Workflow, Usability, Safety & #Interoperability Perspectives by Dr.Charles Webster, @wareflo – Part2 #AMIA2016

Interoperable Health IT and Business Process Management: The Spider In The Web: Part – 2
“Workflow is a series of tasks, consuming resources, achieving goals.”

This article has been re-published with the authors permission. The article was first published by Dr. Charles Webster on his blog here

Just in time for the 2016 AMIA Symposium, I’m delighted that Manish Sharma, the force behind @HCITExperts, is republishing my five-part series on workflow technology in healthcare. Thank you Manish!

Dr. Charles Webster

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! 

Additional Blog Posts by the Author
  1. Five Guest Blog Posts On EHR & HIT Workflow, Usability, Safety, Interoperability and Population Health
  2. Interoperable Health IT and Business Process Management: The Spider In The Web
  3. Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible
  4. Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!
  5. Population Health Management and Business Process Management
Author

[tab]
[content title=”About Dr. Charles Webster”]

Dr. Charles Webster

HIMSS14, HIMSS15, and HIMSS16 Social Media Ambassador! If you’ve got a healthcare workflow story, I want to tell it, blog it, tweet it, interview you, etc. Dr. Webster is a ceaseless evangelist for process-aware technologies in healthcare, including Workflow Management Systems, Business Process Management, and dynamic and adaptive case management.

[/content]
[content title=”Latest Articles”]

[/content] [/tab]

Workflow, Usability, Safety & #Interoperability Perspectives by Dr.Charles Webster, @wareflo – Part1 #AMIA2016

BPM-based Population Health Management & Care Coordination: Part – 1

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

This article has been re-published with the authors permission. The article was first published by Dr. Charles Webster on his blog here

Just in time for the 2016 AMIA Symposium, I’m delighted that Manish Sharma, the force behind @HCITExperts, is republishing my five-part series on workflow technology in healthcare. Thank you Manish!

– by Dr. Charles Webster

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, its 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).
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.
Additional Blog Posts by the Author
  1. Five Guest Blog Posts On EHR & HIT Workflow, Usability, Safety, Interoperability and Population Health
  2. Interoperable Health IT and Business Process Management: The Spider In The Web
  3. Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible
  4. Patient Safety And Process-Aware Information Systems: Interruptions, Interruptions, Interruptions!
  5. Population Health Management and Business Process Management
Author

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Dr. Charles Webster

HIMSS14, HIMSS15, and HIMSS16 Social Media Ambassador! If you’ve got a healthcare workflow story, I want to tell it, blog it, tweet it, interview you, etc. Dr. Webster is a ceaseless evangelist for process-aware technologies in healthcare, including Workflow Management Systems, Business Process Management, and dynamic and adaptive case management.

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@IFTTT you could in Healthcare by @msharmas


Was reading this article published in a leading newspaper sometime back,

Naturally, I tried thinking of usecases to apply the technology in a Healthcare setting. 

About IFTTT
IFTTT works with a series of simple recipes using channels.  

IFTTT stands for IF this then that

Channels are “connected” apps, like Gmail, Google Calendar, Google Contacts, Twitter and many others supported by IFTTT. You can download IFTTT for android or iOS and start connecting channels to your account.  

Recipes
IFTTT allows you cook up your own recipes. Recipes are composed of this and that. Once you have connected the apps to your IFTTT account, you can start creating recipes. 

“this” in the recipe stands for a Trigger Condition or criteria, much like the IF condition you would create in an excel sheet, or in code.
“that” is the action that would be performed when the Trigger condition is met. Based on this condition being TRUE, IFTTT will execute that Trigger Action.
Lets take an example now, assume you are attending a conference and you would like to keep a list of tweets that you liked, and you want to retweet these out later or incorporate these in a blog. Given this scenario, you could do the following steps in IFTTT

  1. Download the App on your phone and create an account
  2. In the IFTTT app enable the Twitter & Google Drive “channels” by connecting to your Twitter and Google Drive credentials
  3. Once you have connected the channels, lets head over to Create a recipe
  4. Click Create recipe and it will ask you for a Trigger Channel, select Twitter
  5. Next, select the Trigger Conditions from the list of possible options provided by IFTTT based on the channel selected
  6. For our usecase we will select “New Liked Tweet by you” as the Trigger Condition
  7. Next we want IFTTT to save the “Liked” tweet in an excel file, for that we will select the trigger Action channel as Google Drive
  8. And we will select the Trigger Action as “Add row to spreadsheet”
  9. IFTTT will keep adding all the tweets you liked to the spreadsheet that you have selected

IFTTT you consider Healthcare Use cases 
OK, so we now have some understanding and agreement in terms how we are able to very simply, and with no coding, able to create a logic statement and get some work done. In fact you have just “Integrated” two apps and got them to “interoperate”

Lets now assume, IFTTT you could use in Healthcare use cases, What would you do?

What IFTTT offers is a set of features that allows for the end-user to create some of the rules based on their day-to-day circumstances. Lets say a nurse wanted the EHR system to Alert a doctor based on a certain specific parameter, but incorporating that logic would require a “code-change” to be done by the EHR vendor. The process is long-drawn to bring in such changes. 

Instead IFTTT the EHR system can incorporate the ability for the nurse to create her own recipe by providing Channels corresponding to various modules in the EHR system, and also provide the end users Trigger Actions  and Trigger Conditions (pre-defined by the EHR vendor).

Lets consider some of the usecases that can be enabled for an IFTTT type functionality in Healthcare

  • appointment reminders for doctors based on urgency of care
  • reminders to the nurse to change patient medication dosage based on doctors suggestion of lab results
  • pharmacy requisitions based on quantity on hand value defined
  • checking and validating medical actions for medical errors
  • patient discharge process alerts to all departments


IFTTT app allows for the end user to create her own “recipes” and “share” these within the community. And considering every patient’s treatment circumstances are different, clinical teams can setup trigger and action criteria that are active for a particular patient and can be continuously changed based on patient condition. Additionally, it also provides the end-user the ability to make enhancements to the system’s in-built logic by enabling customisation at the user end and instantaneously.

Once the patient gets discharged the clinical staff can have the ability to save all the tasks related to similar disease “patients like” scenario, to be templated for future
 

IFTTT you could Connect Healthcare Devices
Thinking a bit ahead to the future, one could control certain medical devices based on trigger based activities. So imagine, the nurse comes along with the doctor for the ward rounds and she is able to adjust the IV flow based on a doctor’s recommendations

IFTTT patients’ could

Patients too can be allowed to use IFTTT-like functionality by allowing them to create a folder in her google drive that contains all her electronic records emailed to her or her doctor

Patients can also setup reminders for their appointments since their hospital app enables the IFTTT-like functionality.
 
Patients can be sent alert notifications on their wearables or phones, about daily Medication reminders using IoT-based devices that dispense their medications

The power of IFTTT is in the simplicity and custom trigger and action criteria it provides it’s users

While writing the above article I recalled the time I was working in a Healthcare IT Product development company in Bangalore and we were looking to incorporate an Alerts & rules engine into our HIMS product. While defining the requirements for the solution, we had discussions with our end users in terms of how they would like the notifications from the system to be delivered. They all reported “Alert Fatigue” to be a factor in terms of how they went about using the system. They wanted to be able to control what alerts they saw and how they would like to view these alerts. 

An IFTTT-esque functionality incorporated within EHR systems will go long way in helping the end-users “customise” the solution based on their current requirements. They would be able to create focussed alerts based on their daily work. 

Afterall, the workflows in the hospital undergo a constant change and an EHR should be able to allow the end-users to incorporate customised workflow and rules

Author

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Manish Sharma

Founder HCITExpert.com, Digital Health Entrepreneur

Connect with me via any of my Social Media Channels

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