Adaptive Case Management, Clinical Groupware, and Routine vs. Non-Routine Workflow in Medical Practice

Shot Link: http://j.mp/bNdXHu

I recently attended the Process.gov conference, specifically to attend a track about Adaptive Case Management. Before I tell you about adaptive case management and its relevance to clinical groupware and pediatric workflow, here’s some background and why I went.

Clinical groupware applications arrange along a spectrum from informal and ad-hoc groupware collaboration tools to formal process model-driven EMR workflow systems. When I researched the historical roots of clinical groupware in groupware and workflow systems I noted:

“[There is a 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.” (Clinical Groupware, Care Coordination, and EMR Workflow Systems: Key Ideas)

Over the last decade workflow management systems (the source of this blog’s name) evolved and became business process management (BPM; I’ll keep the blog name, for now). During the same time, the EMR/EHR industry evolved more slowly, mostly adding features and functionality atop patient clinical data models. The user enters data, navigates to screens, and reviews data and enters orders (and many other people benefit from this effort). The user is, in effect, a workflow engine who pushes and pulls the traditional EMR through a patient encounter.

ehr-wfms-bpm-collision1

Convergence of Concerns between
Clinical Groupware and Adaptive Case Management

This year’s Process.gov theme was “Adaptive Case Management,” a movement within the business process management community resembling, in some ways, the clinical groupware movement within the health information technology community. Both are innovative “outside-the-box” reactions to the traditional software and orthodoxy within each’s respective industry. I think both seek to return to the collaborative human-centric roots of groupware as it was originally envisioned. The big difference now, and potential advantage, is that we have an additional three decades of engineering and cognitive science ideas and technologies to realize this vision.

I went to Process.gov to try to capture some of the essence of adaptive case management ideas as they apply to creating a new generation of process-aware, but also human-centric, clinical groupware. As an emissary from the health information technology industry, my interest in combining ideas from clinical groupware and adaptive case management felt welcomed and reciprocated.

By the way, I used Twitter to record my Process.gov conference notes at @EMRGroupware (reserved for high-frequency, event-related, real-time note taking, to not flood @chuckwebster followers with minutia). If this post piques your interest, feel free to browse this archive.

What is Adaptive Case Management?

To answer this question I will have to pick and choose, because the answer was subject to spirited debate at Process.gov. So I will highlight what I think will be most accessible to the EMR, EHR, and clinical groupware overlapping communities.

I’m a fan of workflow engines, embedded in EMRs, executing process definitions to reduce the amount of work users have to do in order to use an EMR. These are the executable process models I’ve referred to in recent posts. However, I’m not a fan of making any EMR user, in any sense, subservient to predefined process models, because healthcare is chock-full of exceptions. Users have to be free to jump off the happy path, so to speak, and deal with the unexpected–to creatively improvise.

In 2004 I wrote (mentally replace “workflow management systems” with “business process management system or suite”):

“Evident throughout this article is a tension between straightforward, predictable, repetitive, high volume episodes of patient care versus more complex, less predictable, one-of-a-kind episodes, each of which is unique and therefore infrequent, but all of which taken together constitute a significant and important part of the ecology of health care. Traditional workflow management systems excel at what has been called ‘straight through processing’ (STP) in the banking and finance industries. For example, an order to sell shares in a publicly traded stock should ideally happen in a very short interval (that is, before the stock price changes materially). STP seeks to eliminate the human element that slows down stock trades, to only rely on humans for handling exceptional circumstances, and to reduce exceptional circumstances to an absolute minimum (if not altogether!). However, in health care exceptions happen all the time. Medical care is exception rich because abnormal states are, in effect, normally encountered occurrences.

Healthcare processes, and especially core patient-driven processes, are rife with exceptions—from the appointment no-show to the abnormal laboratory value to the undeniably unique history of present illness. And yet, these are in a way predictable and therefore categories and rules and workflows can be defined to facilitate execution of core clinical and administrative processes. Workflow management in health care, especially in and around the EHR, will be workflow with healthcare characteristics. While this may seem obvious, it also means that workflow management systems technology and concepts borrowed from other industries must necessarily be considerably adapted to become successful components of the next generation of electronic health records.” (EHR Workflow Management Systems: Essentials, History, Healthcare, 2004)

“Workflow with healthcare characteristics” was essentially a code phrase for the kind of ad-hoc, improvisational activities that I hoped to hear discussed in the Case Management track at Process.gov. And I did!

A good way to explain the relevance of Adaptive Case Management ideas to clinical groupware is to go through a representative list of adaptive case management ideas and show how the EncounterPRO Pediatric EMR Workflow System implements each idea. The left-hand column of the table in the next section is adapted from the 14th and 15th slides in Jacob Ukelson’s excellent presentation, “What to do When Process Modeling Doesn’t Work” (slides posted here, based on a chapter by the same name in the timely new book Mastering the Unpredictable, put together by Keith Swenson and launched at Process.gov). The right-hand column maps each idea to a way in which the EncounterPRO Pediatric EMR Workflow System (AKA EncounterPRO Pediatric EMR BPM System, AKA EncounterPRO Pediatric EMR Adaptive Case Management System) implements the idea.

How the EncounterPRO Pediatric EMR Workflow System Implements Business Process Management *and* Adaptive Case Management

In this representative sequence of EncounterPRO screenshots are two screens that directly illustrate EncounterPRO’s hybrid combination of business process management and adaptive case management.

  • EncounterPRO’s Workplan Editor (analogous to business process management’s process definition editor) and
  • EncounterPRO’s Office View (analogous to adaptive case management’s case folder).

The manner in which EncounterPRO implements each of the following additional adaptive case management ideas can also be directly or indirectly illustrated by a relevant screenshot. However, this post is already too long, so I’ll publish those screenshots in a future post.

(The following table really gets into the weeds, so to speak. If you’d rather skip the table and remain on the fairway click here. Or, just read the bold stuff.)

Adaptive Case Management Concepts and Comparison with Business Process Management Examples of How EncounterPRO Implements Adaptive Case Management and BPM
Every process has an owner EncounterPRO's equivalent to BPM's process definitions are called workplans. All the tasks in an executing workplan have the same process ID. A user (such as the patient's physician) or role (such as nurse) owns an entire process. A non-owner can chose to accomplish a task that is part of a process owned by another user or role, however EncounterPRO will ask if they wish to assume ownership and track this.
Every process instance has a
  • goal,
  • a deadline, and
  • a defined work product.
  • Defines what to do, not how to do it.
The goal of a workplan is usually the reason for the pediatric visit, such as well child, sick visit, or vaccinations.

For some tasks, such as vaccinations and preventive health guidelines, EncounterPRO uses rules to determine when and if tasks due or over due. Routine tasks such as collecting vitals (screenshot) and checking allergies (screenshot) show up in EncounterPRO's Office View "rooms" (functional equivalent of case folders) along with task status (including the number of minutes the task has been waiting for completion)

EncounterPRO's defined work product is the set of tasks making up a workplan.

EncounterPRO workplans tell EncounterPRO screens and screenless activities (such as automatically printing patient educational material at the most convenient printer) what to do; they don't tell EncounterPRO users what to do.

Provides visibility within the context of the execution of the process instance
  • Shows work done by each user
  • Shows hand-offs between each user
EncounterPRO's Office View shows, in real-time, the location and status (such as how long the task has been waiting) of all tasks posted by workplans or by users.

The state of single process (that is, an executing workplan) can be viewed in which all accomplished tasks are "checked off' (visually highlighted).

Manages and controls through
  • Tracking (visible activity, Hawthorne Effect)
  • deadlines,
  • and goals (dictates what, not how)
This item recapitulates previous points about visibility, tracking, deadlines, and goals (what/not how), but focuses on importance to management and control. If you can't see what your pediatric care team is doing in real-time, then you can't manage your pediatric care team in real-time. The Hawthorne Effect refers to a well know psychological experiment that shows that people who know their work activity is being observed achieve higher levels of performance. Pediatricians often comment that since each member of the care team knows that what they are doing (and not doing) is visible to everyone else on the care team, minute-by-minute, in the Office View (EncounterPRO's multi-room "Case Folder"), everyone is on their toes.
Many processes are a mix of routine and unpredictable processes Combined management of routine and non-routine workflows is where EncounterPRO truly excels. Much of general pediatric practice is routine and therefore amenable to automation via EncounterPRO's workflow engine executing workplans for well and sick child visits, vaccinations, and so on. One pediatrician who uses EncounterPRO famously exclaims that if he can't chart an otitis media visit in 30 seconds, that something is wrong (as is, tell someone to reboot the server!). On the other hand, pediatric practice has its share of exceptions and emergencies, which conspire to disrupt routine, and therefore automatable, workflows. This is where EncounterPRO's version of adaptive case management's case folder comes in to play. A pediatrician can step away from a task in a routine workflow to deal with an interruption or minor emergency but know that they (or someone) will eventually spot the next unaccomplished task of the workplan in EncounterPRO's Office View. For more details about how EncounterPRO makes this possible see Interruptions, Usability, and Pediatric and Primary Care EMR Workflow.
ACM can be used for “in-situ” process discovery (Design-by-Doing, not Doing-by-Design) EncounterPRO, in contrast to most BPM systems that represent workflows using decision tree-like diagrams, represents its workflows as checklists of potentially optional tasks. EncounterPRO's workplans are bit like traditional BPM process definitions in that they can indeed be executed by EncounterPRO's workflow engine. However, unlike traditional BPM systems, users are free to cancel, postpone, or refer tasks to other users. In this EncounterPRO's workplans resemble adaptive case management templates. You can think of a template as similar to checklist (popular in aviation and becoming more popular in medicine). The EncounterPRO Pediatric EMR Workflow System comes with a set of standard workplan templates for sick, well, and vaccination visits, for both the nurse and pediatrician roles. However, users are free to deviate from them at will. Users also can provide information that are necessarily unknown when the workplans were originally devised. For example, when a user gets to the e-prescribing step for the first time for a patient, they can ask which pharmacy is most convenient and select the pharmacy from a pick list. When the workplan executes again for the same patient it will automatically use the previously specified default pharmacy, eliminating redundant clicks and conversation. "Design-by-Doing", rather than "Doing-by-Design", allows users participate in design of their own workflows, without being computer programmers or process modeling analysts.
ACM extends process management to new use cases A use case is high-level description, or scenario, of typical interactions between users and an information system. Use cases are often used as a first step in gathering user requirements and as input to creating the process models that drive business process management system behavior. New use cases therefore do not have models to drive system behavior. Adaptive case management systems do not require elaborate predefined process models to manage cases, therefore they are ideal for environments in which there is a great deal of variation across cases.

EncounterPRO uses workplans (a hybrid between BPM's process definitions and ACM's templated checklists) to drive routine workflows (saving pediatricians clicks and from wondering whether everything that needs to get done will in fact be accomplished). However, in EncounterPRO, every user action, no matter how ad-hoc or simple, is also executed by EncounterPRO's workflow engine. Users are free to order tasks that are not on any workplan, and tasks are still executed, made visible, tracked, and disposition logged, along with all the other tasks that do happen to be part of any executed workplan. In this way EncounterPRO allows users to deal with use cases for which there are no predefined workplans, but still provide the kinds of process-aware support of user activities essential for a well-run pediatric office.
Operational process warehouse and process system of record EMRs, EHRs, and clinical groupware will eventually be required to submit detailed patient safety reports. The most flexible, detailed, and timely reports will require what might be called a "process warehouse." A process warehouse is an archive of time-tagged data about pediatric and primary care processes that can be used to answer questions about those processes. EncounterPRO, by virtue of its workflow engine logging all task activity (modeled and ad-hoc) generates a tremendous amount of time-tagged data about who did what to who, when, how, and why. This data can be used to reconstruct your actual processes through a form of data mining (called process mining or automated process discovery). Traditional EMRs/EHRs, in contrast to process-aware clinical groupware (modeled or ad-hoc), do not distinguish between tasks at the same fine degree of granularity as process-aware clinical groupware. Traditional EMRs often have high resolution screens with a multitude of simultaneous data review and entry and order entry options. Multiple user events, spanning multiple tasks, are often committed together to the underlying database, conflating together logically separate workflow steps. In contrast, workflow engine-driven clinical groupware typically presents just the data review and entry and order entry options on each screen that are relevant to single step in a task workflow sequence. For example, a nurse checking allergies and then current medications are two different tasks that should be distinct and acquire different time stamps.

Non-process aware EMRs/EHRs also do not capture all the potential meaningful timestamps for those events that they do log. They may log when data and orders are committed to a database but they do not typically log when tasks are first available to be accomplished, when they begin, when they complete, and other relevant timed-stamped events such as cancellation, postponement, or forwarding (the ad-hoc activities). Much of this missing temporal information is invaluable for understanding why a user did what he or she did in terms of available options and active goals. Ability to reconstruct this context will be crucial for reporting on, and improving the safety of, clinical groupware-mediated care team processes.

I frequently blog about EncounterPRO’s workflow engine and workplans/process definitions, and how they can make routine pediatric patient encounters simple and easy (“Pick a post, any post!”). Much of ambulatory pediatrics is sufficiently routine (“If I can’t chart a routine otitis media encounter in under 30 seconds, I know something is wrong!”) that EncounterPRO’s executable process model can do much of work for the user that the user would otherwise have to do for themselves to operate a traditional pediatric EMR. However, even in a high-volume, low-margin businesses like primary and pediatric care, the non-routine does happen. In fact, I wrote an entire (and longish) post about interruption theory and how EncounterPRO compensates for the “routine” non-routine interruptions that threaten completing all the necessary hand-offs and tasks of pediatric care.

EncounterPRO’s Office View is the key.

EncounterPRO’s Office View is a Set of “Case Folders” Where Each Room is a “Case Folder”

The single most salient aspect of the user interface of a case management system is the case folder. It holds all the pending tasks for a case, details about their status, and means for users to take over and complete a task.

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EncounterPRO’s Office View Leverages
Case Folder = Exam Room Metaphor
(From Ten Years Ago, Dallas HIMSS: Landmark Presentation
on Modular Pediatric EMR Workflow Groupware
)

The single most salient aspect of the user interface of the EncounterPRO Pediatric EMR Workflow System is the Office View (click previous screenshot to see animation). Each room in the office view is equivalent to a case folder in a case management system. In the Office View animation, patients and tasks appear (automatically due to workplan execution or optionally due to ad-hoc user initiated activity) and disappear (started and completed by users). In contrast to the animation, in which activity systematically proceeds from upper-left to lower right, in a real-world pediatric office tasks appear and disappear less systematically–to the eye. Each of the colorful little bricks indicates who, what, why, when, and where details that are continually updated over time. And each of these colorful little bricks is also a big fat target that, when clicked or tapped, brings up the screen necessary to accomplish the task (making it disappear from the “case folder,” that is, “room’).

Pediatrician Dr. Armand Gonzalzles MD
on Leveraging Business Process Management
in his Busy Chicago Pediatric Practice

You may think that business process management and adaptive case management are the sole preserve of large organizations with sophisticated IT staffs. However, listen to this eight minute interview with a solo pediatrician who uses workflow management and business process management to run his busy pediatric practice. If you are interested, this post describes the context in which the interview took place.

Eventually, all EMRs in high-volume, low-margin specialties like pediatrics, family medicine, and obstetrics/gynecology, will require process-aware clinical groupware that makes the routine fast and easy (through reliance on executable process models) but also makes the non-routine “ownable,” trackable, visible, accomplishable, and subject to deadline and escalation. There simply won’t be any other way to inject mission-critical clinical information systems into these fast-paced, chaotic environments, than to use ideas from business process management and adaptive case management, adapted to “workflow with healthcare characteristics” of course!

P.S. While we’re on the subject of successfully completing scheduled tasks, I’m reminded of a short anecdote. Around 1995 my wife opened an international hotel in Russia (four years after the dissolution of the USSR). She bought a book about Russian toasts and etiquette. With her background in quality control and continuous improvement, and mine in industrial engineering, we were quite taken with one toast in particular, “To the success of the scheduled tasks!” It sounded so, well, Soviet. One of the graduate students in the Health Management Systems program at Duquesne University had emigrated from Russia. He blanched when I jokingly offered the toast. “Where did you hear that?” It turns to apparently be the official toast of the Young Communists, which he’d been forced to join, the sort of thing that he left Russia to avoid.

So, with respect to this blog’s tasks, to encourage a conversation between the worlds of EMRs/EHRs/clinical groupware and workflow management systems/business process management/adaptive case management: “To the success of the scheduled tasks!”

(Sorry about that, Gregory!)

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