The High-Performance Medical Home and Primary Care EMR Workflow Systems: Key Ideas

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This is the first of several posts about the important role pediatric and primary care EMR workflow systems and business process management will play in achieving the high performance pediatric medical home model. A series of quotes sets the stage for further discussion in later posts. Here, I only editorialize a little bit, mostly through the material I choose to embolden.


By the way, you will notice that quotes 9 and 11 refer to workflow management systems (WfMSs) while quote 10 refers to business process management (BPM) suites. As WfMS vendors added additional products, which work in conjunction with workflow engines and process definitions to extend, monitor, and optimize automated processes, the “WfMS” industry became the “BPM” industry. You will also encounter the phrase “process aware” in the literature, though not in the particular quotes I have chosen to highlight here.

  1. “A medical home is defined as primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.” (, last retrieved 11/10/09)
  2. “The major question appears to be ‘Can we bend the cost curve?’ so we can afford to provide all people access to high quality healthcare in a medical home.” (David Tayloe, MD, 2008-2009 AAP President, Presidential Address, 10/17, 2009 AAP NCE):
    1. “We need changes to ensure that all private and public payers compensate general pediatricians and pediatric subspecialists per member per month fees on top of fee for service and based upon the complexity of our patient population to provide real medical homes for all patients.
    2. We need changes to make sure that families have community based care coordination, not 800 numbers. These are personnel in our communities to assist them in caring for their special needs children.
    3. We need changes to ensure all pediatricians utilize electronic health record systems that ensure that all patients have comprehensive, up to date, longitudinal health records, interoperability with other components of the larger system of care, and the efficient collection of data that facilitates quality improvement.
    4. We need changes to ensure that subspecialists develop care paths for children with chronic illness and then share those care paths with community pediatricians to ensure comprehensive, continuous, high quality, cost effective care.
    5. We need changes to ensure that subspecialists have the care coordination resources they need to provide medical home leadership for that subset of pediatric patients that require regular visits to pediatric subspecialists.
    6. And finally, we need changes to ensure that all children have 24/7 care in a medical home that is supervised by a qualified physician.”
  3. Antonelli, McAllister, & Popp, Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework, The Commonwealth Fund, 2009, last retrieved 11/10/09 ["coordination" occurs 256 times in this 26 page whitepaper, as well it should!]:
    1. “We conclude that integrated care coordination infrastructure is essential to create and sustain a high performance pediatric health care system
    2. “A functional information technology infrastructure can enable health care teams to reach their potential in supporting care coordination processes
    3. “Nearly all the expert informants describe the primary care ‘hub,’ health care home, or medical home as the logical and effective center for care coordination.”
    4. “Pediatric care coordination is a patient- and family-centered, assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of families. Care coordination addresses the interrelated medical, social, developmental, behavioral, educational, and financial needs in order to achieve optimum health and wellness outcomes”
    5. “An important component of care coordination is the creation of individualized care plans, informed by a comprehensive needs assessment and including a clear delineation of goals, roles, and responsibilities and expected outcomes.”
  4. Coordination is managing dependencies between activities.” (Malone & Crowston, The Interdisciplinary Study of Coordination, ACM Computing Surveys, 1994, last retrieved 11/10/09)
  5. “The simple capacity to connect and communicate data is insufficient. You need to connect, communicate, and coordinate. EMR workflow systems are all about coordination. Workflow engines execute process definitions in order to coordinate the accomplishment of tasks.”
  6. “Within pediatric subspecialties (such as allergy, endocrinology, neurology, gastroenterology, rheumatology, and pulmonary) creating and executing workflow process definitions for each different specialty, provide specialty-specific workflows against a common patient database. With respect to related primary care specialties (such as family medicine, general internal medicine, and obstetrics and gynecology) the same holds true. In both cases workflow process definitions span specialty or subspecialty boundaries to coordinate multi-disciplinary care.” (Pediatric and Primary Care EMR Business Process Management: A Look Back, a Look Under the Hood, and a Look Forward, 2009 whitepaper)
  7. “EMR workflow systems (WfSs) will need to coordinate execution of workflow processes among separate but interacting EMR WfSs. For example, when a general pediatric (GP) EMR workflow system (GP EMR WfS) forwards a clinical document to a pediatric subspecialist (PS) who is also using an EMR workflow system (PS EMR WfS), the GP EMR WfS eventually expects a referral report back from the PS EMR WfS. When the result arrives, it needs to be placed in the relevant section in the correct patient chart and the appropriate person needs to be notified (perhaps via an item in a To-Do list). If the expected document does not materialize within a designated interval, the GP EMR WfS needs to notify the PS EMR WfS that such a document is expected and that the document should be delivered or an explanation provided as to its non-delivery. The PS EMR WfS may react automatically or escalate to a human handler. If the PS EMR WfS does not respond, the GP EMR WfS may cancel its referral and also escalate to a human handler for follow up (find and fix a workflow problem, renegotiate or terminate an “e-Contract”). Interactions among pediatric EMR workflow systems, explicitly defined internal and cross-EMR workflows, hierarchies of automated and human handlers, and rules and schedules for escalation and expiration will be necessary to achieve seamless coordination among pediatric EMR workflow systems.” (adapted from EHR Workflow Management Systems in Ambulatory Care, 2005 HIMSS Proceedings published submission)
  8. “Consider the three “Multis” of workflow management. Ask: Do you have multi-specialty workflow management, in which different specialties and specialists can rely on different workflow definitions? Do you have multi-site workflow, where medical practice sites in different parts of town can share in workflow definitions? Do you have multi-encounter workflow, especially important for chronic disease management? (Electronic Medical Record Workflow Management: The Workflow of Workflow, 2003 whitepaper)
    1. Think of multi-specialty workflow in terms of analogy to rail mass transportation in a major city such as London or New York. Subway lines start in different places, end in different places, stop in different (but also similar) places along their way, but work together in a globally coherent system. Each specialty has its own collection of workflow definitions, whose constituent tasks may or may not be shared with each other (sort of like subway stops, to continue the analogy). Patients enter one workflow (subway line) but may switch to another workflow during the course of consultation between specialists. Specialty workflows start and stop in different places while sharing resources and working together in a globally coherent system.
    2. Consider multi-site workflow management. The same specialist may be at one medical practice location one day but at another the next. Can specialty workflow definitions be shared across sites, eliminating the need for creating separate, basically identical, workflow definitions for each site? Alternatively, can different sites create their own site specific workflow definitions? Can each site track its patients in its local office layout, but can a supervisor also easily see what is happening at another site? (“Hey! I’m calling from the Eastside office to ask why Mr. Smith has been waiting an hour for his vitals.”) Can workflow definitions span sites, so that a patient can be seen in one office but show up at another office for testing that is only available there?
    3. Multi-encounter workflow management includes the following: follow-ups, a step in one workflow definition triggers application of a future workflow definition (such as returning for a specialized test); referrals, in which a workflow definition triggers a future review of an intervening external consultation; and recurring activities such as screening tests and chronic disease management.”
  9. “In today’s businesses, the application of workflow management systems (WFMSs) is widespread. [CW: Not yet in healthcare! And this quote is 10 years old!] The use of WFMSs ensures a well-structured and standardized management of processes within organizations [Geor95]. Traditionally the emphasis of workflow management has been on homogeneous environments within the boundary of a single organization. In the context of close cooperation between companies, where companies combine their efforts and become virtual enterprises, processes crossing organizational boundaries have to be supported [Lud99a]. This implies extending the functionality of workflow support so that workflow management systems in different organizations can be linked to management integrated cross-organizational processes.” (Grefen, Aberer, Hoffner & Ludwig, CrossFlow: Cross Organizational Workflow Management in Dynamic Virtual Enterprises, 2000,′00.pdf
    [CW: you'll need to copy and paste the link into your browser and and then replace the single quote with a real one,  the one on your keyboard should work, WordPress does not appear to handle this character well], last retrieved 11/10/09)
  10. “An e-contract is the computerized facilitation or automation of a contract in a cross-organizational business process.” (Cheung, Chiu, and Till, A Three-Layer Framework for Cross-Organizational e-Contract Enactment, 2002, last retrieved 11/17/09; terminology is evolving, but the “contract” metaphor is a great way to introduce the general idea of explicitly modeled, automatable, and monitorable cross-organizational workflow)
  11. “As companies use automated workflow systems to control their processes, a way of linking workflow processes in different organizations is useful in turning the co-operating companies into a seamless operating virtual enterprises…contracts [are] a way to find suitable partners, connect WFMSs of different kinds, control outsourced workflow, and share an abstraction of the workflow specification between the partners” (Koetsier, Grefen, and Vonk, Contracts for Cross-Organizational Workflow Management, 2000,  last retrieved 11/11/09)
  12. Papazoglou, and P. M. A. Ribbers, “e-Business: Organizational and Technical Foundations”. J.Wiley & Sons, April 2006, quoted at S-Cube, last retrieved 11/10/09:
    1. “BPM suites coordinate tasks and synchronize data across existing systems. They also help coordinate human process activities, streamlining tasks, triggers, and time lines related to a business process, and assuring they are completed as defined by a process model. A BPM suite makes processes more efficient, compliant, agile, and visible by ensuring that every process step is explicitly defined, monitored over time, and optimized for maximum productivity.
    2. A true BPMS enables business users to:
      1. Model and simulate all interaction patterns between workers, systems and information sources to create shared understanding about how to optimize business processes and results.
      2. Coordinate and manage the handoff of work across boundaries.
      3. Provide real-time feedback to business managers about work-in-progress to support in-line business process adjustments.
      4. Monitor process outcomes to performance targets, and continuously refine and adjust process flows and rules.”

How would you put this material together? In future posts I’ll do my best to do so.

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