EHR Productivity Survey Discussion: Process-Aware HIT

The following preamble and table of contents is for surfers who randomly land here and may benefit from a bit of orientation. Skip to the content!

In 2003 and 2004, I wrote a series of white papers about workflow-centric, instead of data-centric, EHRs. It’s taken 13 years, but much of what I wrote is finally becoming true. This is one of a sequence of blog posts adapted from those white papers and (republished) during HIMSS16. Terminology has evolved, but the ideas are as relevant now, if not more so, as then. (Take me to the beginning of this series of blog posts!)

  1. EHR Workflow Management Systems: Essentials, History, Healthcare (Written In 2004!)
  2. The Critical Difference Between Workflow Management Versus Mere Workflow: Process-Aware HIT
  3. The Critical Importance of Executable Model Of EHR Workflow: Process-Aware HIT
  4. Different Versus Same Person Versus Time EHR Workflow: Process-Aware HIT
  5. Multi-Specialty, Multi-Site, Multi-Encounter Workflow Management: Process-Aware HIT
  6. A Survey of EHR Workflow Management Productivity: Process-Aware HIT
  7. EHR Productivity Survey Discussion: Process-Aware HIT
  8. Workflow Management and EHR Usability: Process-Aware HIT
  9. User-Centered, Human-Centered Process-Aware Health IT
  10. Process-Aware Workflow Management Systems With Healthcare Characteristics: Process-Aware HIT
  11. The Future of EHR Workflow Management Systems: Process-Aware HIT
  12. Interruptions and Exceptions in IT Enabled Healthcare Workflows: Process-Aware HIT
  13. Clinical and Administrative Healthcare Workflow Patterns: Process-Aware HIT
  14. Process Mining Time-Stamped Health IT Data: Process-Aware HIT
  15. Capacity Management Implications of Healthcare Workflow Technology: Process-Aware HIT
  16. The Roots of Task-Workflow Pragmatic Interoperability: Process-Aware HIT
  17. Who Or What Is The Workflow Engine: That Is The Question: Process-Aware HIT
  18. References for EHR Workflow Management Systems: Process-Aware HIT
  19. Glossary of EHR Workflow Management Systems Terminology: Process-Aware HIT

Why did visit volume increase? The most likely reason is that encounter length decreased, freeing up resources to see more patients. Consider this hypothetical and simplified example. If average encounter length is 30 min- utes, then resources such as waiting and exam rooms, as well as staff are tied up during this time. However, if encounter length is reduced to 15 minutes, then resources are freed up that can be used to see another patient. Shorter visits incline toward greater visit volume.

However, the real question is “Why did the encounter length decrease?” Three reasons: decreased non-value- added EHR activities, increased parallelism among value-added EHR activities, and better coordination among EHR activities.

Value-added activities are typically those that someone will pay for. To use a manufacturing example, an auto- mobile buyer may willingly pay for a leather interior but will be loath to pay for fixing a defect that shouldn’t be there in the first place. Encounter length is determined by a combination of value-added and non-value-added EHR activities. EHR value-added activities include entering data that may be used in a future decision or making a decision that affects the welfare of the patient. Non-value-added activities include navigation from screen to screen and searching for the next person to handover the next activity in the encounter. If these non-value-added activities, and the time required to accomplish them, can be eliminated, encounter length can be reduced.

Process definitions can be used by the workflow engine to accomplish exactly this. Instead of users having to proceed through multiple clicks to search for the next data or order entry screen, the workflow can be controlled by the process definition and the user merely needs to click ‘Next’, ‘Next’, ‘Next’…. (Of course, a user always has the option of jumping out of an executing definition to manually access a different screen than the one pre- sented. Over time, with process definition refinement, this usually happens less and less.) Similarly, instead of user having to find the next user to hand off the next activity, the workflow engine can do this instead, perhaps by forwarding items into a user’s To-Do list or onto a generally available status screen of pending tasks.

Reduction of non-value-added activities can go only so far in reducing encounter length. Once the non-value- added activities are eliminated, there are still value-added activities, and these cannot be eliminated without re- ducing the overall value to the patient. However, many value-added activities can be accomplished at least par- tially in parallel. While it is true that the patient can only be one place at one time, and this imposes a certain requirement for the serial accomplishment of activities that require interaction with the patient, there are preparatory portions of these activities that can indeed be accomplished in parallel—if only the people needed to accomplish them can be informed of the need at the earliest possible moment during the encounter.

Printing and assembly of educational materials to be delivered to the patient or setting up trays of materials necessary for obtaining a specimen or administering a vaccination can be accomplished before the physician even leaves the exam room. While the physician is seeing the patient, orders can be entered and forwarded into To- Do lists or onto real-time task status screens and staff can accomplish these preparatory steps. When the physician walks out of the room, procedure trays are ready and staff members are waiting at the door to do whatever they need to do with the patient.

Now that so much is happening so quickly and at the same time, a coordination problem potentially arises, but workflow management systems have a solution for that as well. The real-time task tracking capabilities of workflow management comes into play.

The workflow engine, in executing process definitions, keeps track of what activity is waiting, how long, where and for whom. This information can be fed not only into To-Do lists, but also onto a status screen available to all EHR users. For example, in Figure 4 we can see an office status screen. We can see rooms, tech station, nurse station, exam room one and so on. In room one is Jessica Dalwart waiting for vital signs and several other tasks. Each task pending completion is tagged with a continually updated number representing the total number of minutes that have elapsed since that task was posted to the office view. These can be used to prioritize tasks when many are competing for attention. Patients are color coded according to physician; tasks are color coded according to who or what role is responsible for completing the task. So, at a glance, a nurse can see all pending nursing tasks or a physician can see all his or her patients.

The office view supports all the users in building a shared mental model of everything that needs to be done on moment-by-moment basis. In this particular case, the status screen is “hot” in that a user can select a task (such as vitals) and the EHR will take that user directly to the relevant EHR screen for accomplishing that task. When the task is completed, the workflow engine removes the task from the status screen (or the To-Do list, if that was the means by which the task was selected and accomplished).

This survey’s results do not mean that EHR workflow management systems are sufficient in and of themselves for generating such dramatic productivity improvements. Investment in a workflow management system has its largest positive effect when work teams already strive to share information, distribute decision making, and im- prove processes. (An EHR workflow management system gives them the tools to accomplish what they have already been trying to do.) Thus, successful workflow management is highly dependent on social factors (as are many other information technology initiatives).

Much of what I wrote about in this 2003-2004 series of white papers is indeed coming into existence today. The basic idea of building workflow-centric health IT systems is indeed gaining steam. Many of my tweets during HIMSS16 are about companies embedding workflow engines in their products. In addition, we are seeing a surge of Business Process Management technology in healthcare and health IT. Terminology varies. Sometime they are called Healthcare or Care Management Systems. What they have in common is a “process-awareness” that has been mostly missing to day in recent medical informatics and health IT history. This new layer of cloud-based workflow engines addresses thorny issues of EHR and health IT usability, productivity, safety, and interoperability. Indeed, since my 7000-word, 5-part series, Achieving Task and Workflow Interoperability in Healthcare , was published in 2015, I’ve seen considerable progress. Also see my recent 10,000 word, 5-part series on Pragmatic Interoperability published on HL7Standards immediately before HIMSS16.

It is still useful to look back at my 2003 and 2004 series on EHR workflow management systems for seminal ideas that are only now being realized in products and driving results. In many instances, I have written considerably more material on various subtopics.

Take me to the next blog post in this series! Workflow Management and EHR Usability: Process-Aware HIT.

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