Short Link: http://j.mp/9uGFwv
As the phrase “clinical groupware” gains currency [UPDATE: well, it gained and then lost that, but what it means is just as important today!], it’s worth considering the history of groupware in general, and workflow in particular, to understand the relationship between EMR workflow systems and clinical groupware. This relationship is at the technological heart of the care coordination problem.
Workflow systems are a form of groupware, and EMR workflow systems are a form of clinical groupware. Jonathan Grudin, in a 1994 Communications of the Association for Computing Machinery article (second most cited for “groupware” in Google Scholar) wrote:
“Desktop conferencing, videoconferencing, co-authoring features and applications, electronic mail and bulletin boards, meeting support systems, voice applications, workflow systems, and group calendars are key examples of groupware.” (Groupware and Social Dynamics: Eight Challenges for Developers, 1994, my emphasis)
Last week I described the landmark 2000 HIMSS presentation and proceedings paper about a workflow-based clinical groupware system installed in ten pediatric practices and one family medicine practice. In it I quoted from two early (1988 and 1992) collections of readings about groupware. I found so much relevant material that I collated, annotated, and published it (see below) so it can become part of a larger conversation about clinical groupware. I’ll refer to this material in future posts.
From My Bookshelf
|Year||Origins of Groupware||My Comments|
|"The term groupware was coined by Peter and Trudy Johnson-Lenz…as follows: “GROUPWARE= intentional GROUP processes and procedures to achieve specific purposes + softWARE tools designed to support and facilitate the group’s work”||I used this definition of groupware in my previous post Ten Years Ago, Dallas HIMSS: Landmark Presentation on Modular Pediatric EMR Workflow Groupware. "Groupware" was apparently coined even earlier, in 1978.|
|1988||"A new class of commercial software has been named “groupware.” It is software designed to take group work into account in an integral way. Groupware products...have in common that they put coordination technology into the hands of the group members, giving them access to the positive aspects of coordination—not just preventing collisions, but enabling collaboration. Groupware will be made commonplace, by the evolving understanding of what the key coordination technologies are, how they should appear to end-users, and what the software libraries are that embody this understanding."||Four posts about EMR workflow systems and care coordination:|
|1992||"Computer-supported cooperative work...is computer-assisted coordinated activity such as problem solving and communication carried out by a group of collaborating individuals. The multi-user software supporting CSCW systems is known as groupware"||"Computer-Supported Cooperative Work" and "CSCW" do not role off the tongue like "groupware." (4440 hits (2/2/10) in Google versus 63700 hits). Groupware is the software. CSCW is the combined system of software and people.|
|1988||"Groupware is distinguished from normal software by the basic assumption it makes: groupware makes the user aware that he is part of a group, while most other software seeks to hide and protect users from each other…Groupware…is software that accentuates the multiple user environment, coordinating and orchestrating things so that users can ‘see’ each other, yet do not conflict with each other"||EncounterPRO Pediatric EMR "users can ‘see’ each other" in the Office View ("radar view" to usability engineers)
Task colors correspond to users and roles.
|1988||"All software will be groupware"||Most will be. All EMR software will include clinical groupware functionality.|
|Groupware Usability||Clinical Groupware Usability|
|1988||"The Human Factors in Computing community has a...challenge [to] find ways to test and evaluate technological impacts on groups. It’s difficult enough to get meaningful results that take into account differences in experience and individual differences of users to their reactions to user interfaces. But at least it’s possible to get volunteers to sit down with word processing systems and spreadsheet programs for relatively self-contained tasks. It is more difficult to “stage” a realistic group-work setting in a lab and have volunteers use the system in a way that provides meaningful data. Methodologies for testing individual user interfaces don’t apply as well to group support systems. As a result, CSCW is looking more to anthropology to find methodologies for studying groups at work in their natural settings."||We need new conceptual models to even think about clinical groupware usability. Previously I wrote:
Usability is “the effectiveness, efficiency, and satisfaction with which specified users achieve specified goals in particular environments. [ISO 9241]” However, in the case of pediatric EMR workflow systems, usability must be construed not only relative to single users, but also with respect to the entire team of patients, pediatricians, and pediatric staff who work together for common goals. One might rephrase this definition of usability to become the effectiveness, efficiency, and satisfaction with which teams of users achieve collections of goals in complex social environments". (Pediatric EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow)
|1991||"Until recently, most user interface research has focused on single-user systems. Groupware challenges researchers to broaden this perspective, to address the issues of human-user interaction with the context of multiuser or *group* interfaces. Since these interfaces are sensitive to such factors as group dynamics and organizational structure—factors not normally considered relevant to user interface design—it is vital that social scientists and end users play a role in the development of group interfaces."||"Similarities between a medical team and a football team are more than an amusing analogy. All teams are cognitive systems, and their study is called team cognition (with contributions from distributed cognition). Shared mental models, workspace awareness, radar views, and teams of experts versus expert teams are topics of team cognition that apply to all teams, including those in medicine and football." (Football Plays and EHR Workflow Congratulations Saints for their 2010 Super Bowl win!)|
|1990||"Evaluating groupware 'in the field' is remarkably complex because of the number of people to observe at each site, the wide variability of group composition, and the range of environmental factors that play roles in determining acceptance"||"It is the entire system of patients, parents, guardians, pediatricians, pediatric subspecialists, non-pediatric primary care physicians, physician assistants, nurses, staff, acute and subacute participants in all the workflows and processes of child health that needs to be optimized. [T]here is no guarantee that optimizing single user usability won’t in suboptimize higher level global system goals. So I prefer a definition of usability that emphasizes team, rather than individual, performance." (The Cognitive Science Behind Pediatric EMR Usability Checklists)|
|1990||"Five factors contributing to groupware failure…:
||Grudin provided five reasons why groupware fails in 1990 and expanded it to eight challenges in 1994. The list stands up well; here it is used in a 2008 Ph.D. thesis. "Groupware" was not just coined and discussed before the Web existed, but the difficulties of getting groupware right were understood in ways that still apply today. The same challenges that Grudin listed in 1990 and 1994 also apply to successful clinical groupware today.
Grudin’s Eight Challenges for (Clinical) Groupware Developers
(In Knowledge Management Systems and Customer Knowledge Use in Organizations, 2008, Ph.D. Thesis)
|1991||"Distributed Cognition takes as its unit of analysis a complex cognitive system: collections of individuals and artifacts that participate in the performance of a task. The external structures exchanged by agents of complex cognitive systems comprise its “mental” state and unlike individual cognition, where mental states are inaccessible, these states are observable and available for direct analysis."||Distributed clinical cognition requires distributed clinical information design. From my 2004 TEPR proceedings paper EHR Workflow Management Systems: Essentials, History, Healthcare (also see my post on interruptions): "Human-Centered Distributed Information Design...distinguishes four levels of distributed analysis: user, function, task, and representation, which correspond well to workflow management architectural distinctions."|
|"The Coordination Problem"||The Care Coordination Problem|
|1991||"The coordination problem is the 'integration and harmonious adjustment of individual work efforts toward the accomplishment of a larger goal'...Coordination systems address this problem in a variety of ways. Typically these systems allow individuals to view their actions, as well as the relevant actions of others, within the context of the overall goal. Systems may also trigger users’ actions by informing users of the states of their actions and their wait conditions, or by generating automatic reminders and alerts"||On the EncounterPRO Pediatric EMR Workflow System ("Clinical Groupware for Pediatric Practice") product website:
“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.” (EncounterPRO Pediatric EMR Workflow System care coordination vision)
|1990||"We define coordination theory as a body of principles about how activities can be coordinated, that is, about how actors can work together harmoniously...In coordination theory, the common problems have to do with coordination: How can overall goals be subdivided into activities? How can actions be assigned to groups or to individual actors. How can resources be allocated among different actors? How can information be shared among different actors to help achieve the overall goals?"
[CW: See related quotes from The Interdisciplinary Study of Coordination and Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework (where "coordination" occurs 256 times)]
|"EMR BPM suites [Business Process Management/EMR workflow systems plus BPM modules] coordinate clinical tasks and synchronize clinical data across existing pediatric, pediatric subspecialty, and non-pediatric primary care EMRs. They also help coordinate clinical activities, streamlining clinical tasks, triggers, and timelines related to a care coordination process, and assuring they are completed as defined by a care coordination process model. An EHR BPM suite makes care coordination processes more efficient, agile, and visible by ensuring that every care coordination process step is explicitly defined, monitored over time, and optimized for maximum productivity." (Well Understood, Consistently Executed, Adaptively Resilient, and Systematically Improvable Pediatric and Primary Care EMR Workflow)|
|1990||"Narrow definition of coordination: the act of managing interdependencies between activities performed to achieve a goal"||The following quotes, from a treatise on coordination (next row, left), the other from a paper about workflow-based clinical groupware for pediatric practice (next row, right), show that EMR workflow systems are coordination systems.|
|1990||Numbers in brackets ([1-4]) map between equivalent concepts in the quote to the left (written in 1990 about solving the "coordination problem") and the quote on the right (written ten years later about workflow-based clinical groupware that solved the care coordination problem within ten pediatric practices).
"Components of coordination and associated coordination processes:
[CW: This quote is not specifically about care coordination. However, it surely applies to the care coordination problem. To the degree that workflow systems address the coordination problem, clinical groupware workflow systems address the care coordination problem.]
|"A workflow system is a complex, dynamic assemblage of:
Processes, as described in this quote, clearly are about managing interdependencies  (task performance based on conditions).
|Informal & Unstructured vs. Formal & Structured Coordination||Informal & Unstructured vs. Formal & Structured Care Coordination|
|1991||"Cooperative problems can be thought of as existing at some point on a spectrum ranging from unstructured problems at one end to prescriptive tasks at the other. Unstructured problems are those requiring creative input from a number of users which often cannot be detailed or described in advance...Prescriptive tasks, on the other hand, represent the routine procedural cooperative mechanisms used to solve problems which have existing group solutions. Prescriptive tasks respond well to detailed control of cooperation while unstructured problems require a significant degree of freedom to be exercised by the cooperative system."||I was privileged to audit classes taught by Herbert Simon, the Nobel prize-winning economist, cognitive scientist, and artificial intelligence researcher. (BTW, he graduated from my alma mater, the University of Chicago).
I came to cognitive science and medical informatics from Industrial Engineering (including operations research), which emphasized what Simon called "well structured" problems. He had written "Operations research has demonstrated its effectiveness in dealing with the kinds of management problems that we might call 'well structured,' but it has left pretty much untouched the remaining, 'ill structured,' problems."
|1995||"Groupware systems can be separated into two very broad categories:
||Clinical groupware applications also exist along a spectrum from ill-structured cooperative problem solving (requiring unpredictable group input) to well-structured cooperative problem solving (amenable to workflow engines executing process definitions). While EMR workflow systems are closer to the well-structured end of this spectrum, the EncounterPRO Pediatric EMR handles both routine and non-routine pediatric workflows well (see next comment below).|
|Workflow Systems are Groupware||EMR Workflow Systems are Clinical Groupware|
|1995||"Some people infer antithesis between the formal policy orientation of workflow and the informal collaborations of groupware....Although groupware is associated with systems that encourage and nurture information group interactions, there are groupware systems that encourage and enforce more formal interactions between team members: for example, shared calendars or scheduling systems.... workflow...is really just another type of groupware"||This perceived "antithesis" is due to lack of appreciation of the spectrum between well-structured and ill-structured cooperative problem solving and the kinds of groupware needed to facilitate computer-supported cooperative work in healthcare. Both kinds of cooperative problem solving require clinical groupware. EMR workflow systems fare especially well on well-structured care coordination problems. The EncounterPRO Pediatric EMR handles both ends of the spectrum well: a workflow engine to handle routine group workflows and the Office View to handle non-routine group workflows.|
|1995||"Workflow is one of the hottest areas in groupware today...Workflow is often explained with the analogy of the factory floor. In America, manufacturing made great strides in productivity during the late ‘80s and early ‘90s, mostly due to automation. Now, visionaries want to take the automated processes of the factory floor and apply them to the office."||This was written in 1995, which shows how far behind the healthcare industry is in adopting groupware and workflow systems. Patients aren't widgets and pediatric offices aren't factory lines. However, many of the same industrial engineering techniques that helped increase manufacturing productivity can also be applied to pediatric and primary care. To "bend the cost curve" healthcare needs to make similar "great strides in productivity" (Though, to be fair and balanced, please read the late great William Safire on bending the cost curve).|
|1995||"In groupware technologies, workflow systems constitute some of the most powerful environments that enable collaborative computations to automate workflow processes"||Adapted to healthcare: In clinical groupware technologies, EMR workflow systems constitute some of the most powerful environments that enable collaborative computations to automate clinical workflow processes.|
It is fitting to close this litany of groupware, coordination, and workflow quotes and comments with one more wrinkle, what Frisse, Schnase, and Metcalfe call “The Problem of Language: The efforts to integrate information from disparate sources into a single, unified, computer-based patient record are challenged more by the enormous range of human expression than by technology” (Models of Patient Records,1994). Using the phrase “medical groupware,” not “clinical groupware”, they eloquently describe the importance of medical “conversation” to clinical groupware (see my earlier posts on syntactic, semantic, pragmatic, and “conversational” EMR interoperability):
Models for Patient Records
“When performance is defined as the result of collective efforts rather than as the result of the actions of an individual, software systems supporting these activities may be labeled under the popular rubric groupware….Although it is tempting to think of these activities as “transactions” it is equally valid to consider them “conversations” related to the solution of specific tasks….Using conversations as a central metaphor for handling patients’ records reflects workflow in a clinical setting….the introduction of groupware designed to facilitate conversations will allow for the acknowledgement and representation of the centrality of human conversation rather than force individuals to reconstruct these conversations through examination of data tables and unstructured patient records….medical groupware helps us redefine where our information systems are going and reflect on their origins and true purpose….it should be remembered that the system is nothing more or less than the community of individuals who collectively care for one another.” [CW: my emphasis]
Some workflow systems literally model, execute, and monitor speech acts (proposals, counter-proposals, promises, excuses, and so on). If we are to move from “conversation” as an interesting metaphor, to practical ways to coordinate the “community of individuals who collectively care for one another,” we will need both the informal and spontaneous clinical groupware, and the more formal and prescriptive clinical groupware known as EMR workflow systems. Their strategic combination is at the technological heart of the care coordination opportunity.
- Baecker, R. Part I: Introduction, Baecker, R. (Ed.) Readings in Groupware and Computer-Supported Cooperative Work: Assisting Human-Human Collaboration, Morgan Kaufmann, 1992.
- Coleman, D. & Khanna, R., Groupware: Technology and Applications, Prentice Hall, 1995.
- Ellis, C, Gibbs, S, & Rein, G, Groupware: Some Issues and Experiences, Communications of the ACM, Volume 34, No 1, January, 1991.
- Flor, N, & Hutchens, E. Analyzing Distributed Cognition in Software Teams: A Case Study of Team Programming During Perfective Software Maintenance, In Joenemann-Belliveau, T, Moher, T. & Robertson, S. (Eds.) Empirical Studies of Programmers, Fourth Workshop, Ablex, 1991.
- Frisse, M, Schnase, J, Metcalfe, E, Models of Patient Records, Vol 69, No 7, July 1994, Academic Medicine.
- Grief, I. (Ed.) Computer-Supported Cooperative Work: A Book of Readings, Morgan Kaufmann, 1988.
- Grudin, J. Groupware and Cooperative Work: Problems and Prospects, In Laural, B (Ed.), The Art of Human Computer Interface Design, Addison-Wesley, 1990.
- Johnson-Lenz, P. & Johnson-Lenz, T. Groupware: The Process and Impacts of Design Choices. In Kerr, E. & Hiltz, S. (Eds.), Computer-Mediated Communication Systems: Status and Evaluation, Academic Press, 1982.
- Khoshafian, S. & and Buckiewicz, M., Introduction to Groupware, Workflow, and Workgroup Computing, Wiley, 1995.
- Malone, T. & Crowston, K, What is Coordination Theory and How Can It Help Design Cooperative Work Systems, In Halasz, F. (Ed.) CSCW 90: Proceedings of the Conference on Computer-Supported Cooperative Work, Los Angeles, Oct 7-10, 1990, ACM.
- Rodden, T. & Blair, G. CSCW and Distributed Systems: The Problem of Control, Bannen, L., Robinson, M, & Schmidt, K, (Eds.) Proceedings of the Second European Conference on Computer-Supported Cooperative Work, Sept 25-27, 1991, Amsterdam.