I received a cool looking document last week, the copyright certificate of registration for the EHR Workflow Management Systems survey of features and functions.

A fan of open source and open minds, I license everything on this blog (and we everything on our product website) under the Creative Commons Attribution 3.0 License.

I essentially registered the copyright to give you (or anyone) the right to adapt and use the EHR workflow management survey criteria (with attribution, of course!).

So, please feel free to use or adapt and use the EHR Workflow Management Systems survey of features and function for any purpose whatsoever, knowing that you have the right to do so.

Have fun!

“#HIMSS10” was the hashtag used in tweets about this year’s HIMSS conference in Atlanta, March 1-4. Attendees searched Twitter for #HIMSS10 to follow a gigantic conversation. #HIMSS10, or more precisely the convergence it symbolizes to me, transformed my HIMSS conference experience.

I’ve been coming to HIMSS conferences for ten years. The added social media dimension improved my #HIMSS10 experience in three ways:

1. Blogging, Twitter, Facebook, LinkedIn, and so on, are all relatively new and interesting to me. HIMSS session content on these subjects was superb. In particular, Twitter 101 and the three Meet the Blogger sessions (delivered and moderated by Cesar Torres, respectively, and facilitated by Ward Seward, both of HIMSS) were high points. I’ve been blogging for a year and tweeting for a couple months, but I’m still a newbie, which is great, because learning (and sharing) is so much fun.
2. All the HIMSS sessions I attended (not just the social media sessions) were embedded in a dynamic, interactive, virtual matrix of back-channel chit-chat that entertained and provided valuable real-time annotations to what I observed at the podium. It was tonic that kept me awake (even after lunch or at the end of a long day) and provided a steady stream of valuable information (and links to valuable information) that I archived and, even now, as I write this post, consult.
3. Representing my blog (chuckwebster.com) and twitter account (@chuckwebster), I came to HIMSS with new motivation to absorb, connect, and take away as much as I could, so that I can turn around and think, write, and interact about that content as much as I can. I’m not a reporter. I don’t have press credentials, but I felt a little bit like one. Each time (which was rare) my attention began to lag, I’d mentally slap myself, so as to not miss anything important, so as to not misattribute or misquote someone, so as to maximize the number of juicy new ideas to combine with my own.

I have a new measure for HIMSS conference success: the number of new ideas I gain for future blog posts. By this measure #HIMSS10 hit it out of the ballpark. My ideas-for-future-posts.txt file just doubled. Of course, this number is only a coarse and indirect measure of something else, something more profound, involving learning, communication, and self-concept.

A short anecdote:

I wore a red carnation and tweeted this. A couple days later, while I’m walking the exhibit floor, I hear “Hey! You’re the guy with the carnation!” Well, yes I am. Do you follow me on Twitter? “No” Do you read my blog? (I stream tweets there) “No, I’ve just been reading all the tweets that contain #HIMSS10, and I remember one that said something like ‘I’m wearing a carnation, stop me if you see it,’ so I did.”

Splendiferous!

P.S. Follow me on Twitter at @chuckwebster

A while ago I proposed the following definition of clinical groupware:

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate a care team’s work.” (emphasis not in original)

I received a surprising number of suggestions (but: Post! Post!). All food for thought.

I do have a list of what I like and a list of what I think is possibly problematic about the definition. “plus the” and “tools” are on my second (possibly problematic) list.

I’m tempted to replace “plus the” with “using,” or reverse the order of the primary clauses and use “applied to.” However I’d like to pay respect to the Johnson-Lenzs’ pioneering definition of groupware. I definitely *want* someone from the larger groupware industry and academic community to *recognize” this relatively well know construction. Nonetheless, I did replace “+” with “plus” because, well, “+” is just not a word.

“Tools” was on the second list too, not so much because “tools” is vague (and even if it was vague, that’s not necessarily bad); it’s that it is too general (too high up the knowledge representation abstraction hierarchy, using artificial intelligence-speak, therefore violating the third requirement for a good definition). It might admit “examples” of clinical groupware that we don’t want to be counted as examples. A rock can be used to compel coordination. But it’s not nice.

“Communication technology” is very close to what I had in mind. It implies information processing too, I think. However, successful communication does not ensure successful coordination to achieve common goals. Diplomatic instances of this give rise to the euphemism “a frank and constructive exchange of views.”

I considered all the possible combinations of “information,” “processing,” “communication, “digital,” and “technology” but wasn’t happy with any of them. So I decided to leave it “tools” until I came up with better. I’d rather gradually tighten the definition to exclude false positive examples of clinical groupware than untighten to include false negative examples of clinical groupware.

I’m also looking for a level of abstraction slightly higher than computer code-based clinical groupware. Examples of codeless coordination technology include the electrical lights and signal systems used in medical offices to represent who is where–with what priority–in real-time. EncounterPRO’s Office View is a digital example of this kind of radar view, albeit with much more task status information and driven automatically by the workflow engine.

Some computers don’t rely on electrons at all (at least directly). They are physical machines that operate deterministically according to the laws of Newtonian physics (not the laws of a computer language). A problem to be computed is mapped to their physical state, the machines move to equilibrium or quiescence, and the solution is mapped back out. I used to build gadgets out of tinker toys and punch cards that would play Tic-Tac-Toe. It blows my mind to think of how different today’s world might be if Babbage had succeeded to build a computer based on gears and powered by steam.

Physical machines can also be used to communicate (and I’m not talking  tin cans and string here). I recall that Leonardo De Vinci designed a mechanical means to convey a pixel-image from one location to another. Black and white squares in a grid are flipped, drive cords running over pulleys, which flip corresponding squares in another room. I don’t know if he built it and I can’t find it on the Web (keep coming up with television shows about his inventions instead of his invention of the television–or maybe I have the wrong inventor).

If all this seems a bit far afield from clinical groupware, I’d stress that this definition needs to be “extensible.” It needs to be compatible with innovative approaches to coordinating patient care we haven’t even imagined yet.

Technology is about more than digital computers. Finding the right representation for a coordination problem can be most of the battle. Annotating that representation, or moving physical tokens around on it, can be a groupware solution. Many board games are based on this idea. I’d like the definition of clinical groupware to be compatible with any such fiendishly clever annotatable or mutable physical representation (such as the common grease board). Codeless clinical groupware prototypes may be part of a developmental process in which some step will be to digital format.

So far, the best phrase I’ve come up with to specialize “tools” and tighten up the definition is “coordination technology.” It captures what I think needs to be captured, and resonates nicely with current discussions about “care coordination.” 

So here is another candidate for a definition for clinical groupware (version 2.0):

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the coordination technology designed to support and facilitate a care team’s work.”

Just one problem though, it violates the fourth requirement for a good definition: Avoid obscurity. Coordination technology is not a commonplace and widely understood phrase. The interesting thing is that if I define coordination technology to be “tools designed to support and facilitate a (care) team’s work,” I end where I started.

So, for now at least, I think I’ll stick with my original definition for clinical groupware:

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate a care team’s work.”

P.S. Follow me on Twitter at @chuckwebster.

I predict:

Future extensible clinical groupware will coordinate delivery of EHR functionality to teams of users by combining modular components with executable process models whose usability (effectiveness, efficiency, and user satisfaction) will be systematically improved using business process management techniques.

Let’s break this long and complicated sentence into parts, understand them, and then understand the prediction as a whole.

1. Future extensible clinical groupware
2. will coordinate delivery of EHR functionality to teams of users
3. by combining modular components
4. with executable process models
5. whose usability (effectiveness, efficiency, and user satisfaction)
6. will be systematically improved
7. using business process management techniques.

I’ll cover these topics (though in a different order) and important relationships among them.

Usability: Effectiveness, Efficiency, and User Satisfaction

The International Organization for Standardization definition of usability is frequently invoked:

“[T]he extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use.” (my emphasis, ISO 9241)

Great definition…but it just seems so, well, “singleware-ish.” Clinical groupware needs a less abstract definition of usability that is more direct about groupware’s unique usability issues (see the sixth, seventh, eighth, ninth, and tenth quotes from my Clinical Groupware…Key Ideas post). How about: Clinical groupware usability is…

“The extent to which clinical groupware can be used by specified teams of users to coordinate activity and achieve specified collections of goals with overall effectiveness, efficiency and satisfaction in specified contexts of use.”

This definition of clinical groupware usability is consistent with the ISO definition, just more specialized in ways to make it practically relevant to clinical groupware usability. In either definition, notice the tuple: (specified users, specified goals, specified contexts). We will return to it in a later section.

That said, current discussions of EMR/EHR usability are shallow in two ways.

The first sense in which current discussions of usability are “shallow” I address in The Cognitive Science Behind Pediatric EMR Usability Checklists. Usability checklists are the tip of the cognitive science iceberg. The rest of the iceberg is “deep” usability. UI/UX (user interface/user experience) expert Steve Krug suggests (tweeted about here, how does one cite a tweet anyway?) taking an intro to cognitive science course. I agree.

But this post is about the second sense in which most usability discussion is shallow. I distinguish between shallow and deep EMR usability (inspired by an imperfect analogy to shallow versus deep models of medical reasoning). In fact, thinking about extensible EMRs using modular components requires thinking about deep usability. Consider the following quote about usability:

“Usability is often considered only important for developing user interfaces. But the user interface is only the surface of many interdependent components, each with their own features that make them more or less usable. As a result, the overall usability of a system is actually the aggregate of how well individual components that make up the system work together.” (my emphasis, Designing Healthcare Solutions with Microsoft BizTalk Server 2004)

Discussions about EMR user interfaces are about shallow usability (that is, about the surface or “skin” of an EMR). Deep usability is about the usability of individual components (seen and unseen) and how all those usabilities add up to total EMR system combined usability. In clinical groupware, deep usability spans time, space, content (multi-specialty), individual differences (potentially complementary, love the idea of team of experts versus expert team, especially the aviation and crew management connection, see my post Pediatric EMR Workflow System Usability–Roots in Aviation Human Factors), group dynamics, organizational structure, and culture in ways that prevent use of traditional usability assessment methods.

Executable Process Models

Modules and components will not be enough to achieve deep EMR usability, unless one of those modules is an executable process model. This executable process model will likely be a workflow engine executing workflow or process definitions (called “workplans” in the EncounterPRO Pediatric EMR Workflow System).

Otherwise we will just be stuck with another version of the traditional clickity-clickity-click-click-click, hunt-and-peck EHR that most physicians hate because they don’t want to be workflow engines–which is what I think most mean when they say they don’t want to be data entry clerks. Physicians (especially pediatricians, who run the lowest margin, highest volume businesses of any specialty) need the EHR workflow engine equivalent of a hyper-competent operating room nurse who automatically hands you the right data entry or order entry tool at the right time and place in the patient encounter.

In fact, that is the question: who or what is the workflow engine? If the answer is “who”, this is bad, because “who” is a person, a potentially expensive professional who should not be wasting their time doing what could be done more quickly, more consistently, and less expensively. If the answer is “what”, this is good, because “what” is a much less expensive inanimate object, the computer. If the computer can perform activities that don’t require a physician’s time and helps coordinate activities that do, then physicians will likely embrace clinical groupware and EMRs that include clinical groupware functionality.

Six years ago I attended the Health Summit held in Washington DC in 2004. I was the only representative from an EMR vendor serving small to medium size primary care clinics at the time (I checked the attendee list). Then Secretary Tommy Thomson, assembled assistant secretaries, and blue ribbon panelists laid out plans for a National Health Information Network. (Here’s an archived news report). Much discussion was devoted to the need to subsidize EMRs because of their effects of physician workflow and productivity. At the end of the conference folks lined up behind the aisle microphone to address the meeting. Finally, a white haired man, who identified himself as a solo family medicine physician, got the microphone:

“I don’t care if you give it to me free and then bribe me to use it, if it slows me down I won’t!”

Amen! (If anyone can point me to an archived transcript of the public comments I’d appreciate it.)

Business Process Management

Business Process Management is a “process optimization process.” On this blog I’ve written extensively about BPM in healthcare. Consistent with an extensible-EMR-via-modular-component approach, BPM functionality is also provided by a set of modules (called a BPM suite) that can be used with process-aware information systems to achieve four categories of benefits. Combining EMR/EHR with BPM technology contributes to well understood, consistently executed, adaptively resilient, and systematically improvable clinical and administrative workflow,

1. modeling and simulating all interaction patterns between physicians and other clinical and non-clinical staff, systems, and EMR components to create shared understanding about how to optimize care coordination processes and results; ( “well understood” )
2. coordinating and managing the handoff of patient care tasks across organizational boundaries; ( “consistently executed” )
3. providing real-time feedback to physicians and other care coordinators about care-in-progress to support patient care process adjustments; ( “adaptively resilient” )
4. monitoring care coordination outcomes to performance targets, and continuously refining and adjusting care coordination process flows and rules. ( “systematically improvable” )

These four categories of BPM contribution to healthcare roughly mirror my own 2005 five part list of contributions of workflow automation to EMR usability: naturalness, consistency, relevance, supportiveness, and flexibility. I didn’t know as much then about business process management as I do now, but I think my past self’s intuitions were spot on (thank you future self, you’re welcome past self).

Systematically comparing the 2005 column to the 2010 column would be a great post, especially since the five items on the left were motivated by usability concerns, not categories of BPM functionality. I’ll put a tickler in my ideas-for-future-posts.txt file.

Systematically Improved

However, I do want to address importance of flexible workflow to systematically improvable workflow.

• If workflow is not flexible, then it cannot be changed (without relying on a c# or Java programmer—no offense intended, since I am both myself).
• If workflow cannot be changed then it cannot be improved.
• If workflow cannot be improved then effectiveness, efficiency, and user satisfaction with workflow cannot increase.
• If effectiveness, efficiency, and user satisfaction cannot increase then higher levels of “deep” EMR usability can be achieved.
• Q.E.D.

Let’s address just one of these dimensions of deep EMR usability: EMR workflow efficiency. In 2005 I wrote about a BPM technique called process mining (called that by analogy to data mining):

“Workflow management systems generate tremendous amounts of time-stamped sequential data as a by-product of execution of process definitions by workflow engines. By analogy to data mining, analysis of such data (typically collected in log files) is called workflow or process mining [10]. Process mining can discover new and useful process definitions, compare process definitions to what users are really doing, and optimize existing process definitions—all of which can be used to improve ambulatory workflow.” ([10] reference: van der Aalst W and Weijters A. Process Mining: A Research Agenda. Computers in Industry 2004, 53(3):231-244.)

Process mining is an excellent example of BPM being a “process optimization process.” However, much of the best BPM academic and industrial research  has occurred and been presented across the pond (both the little one and the big one). (Similarly, the first published reference to “Clinical Groupware” appears in Clemensen, Larsen, and Bardram’s 2004 Developing Pervasive e-health for Moving Experts from Hospital to Home. Simon Larson’s kind response to my emailed questions indicates that what we call clinical groupware appears to be part of a larger set of European research and industry initiatives called “pervasive healthcare.” Sounds like a future post to me.) The United States is a remarkable generator of new information technologies, from the large high tech companies to the university spin-offs to inventors who start in a garage (as was literally so in the case of the EncounterPRO Pediatric EMR Workflow System). However, in this case the healthcare IT industry may have to look not just outside healthcare, but outside the US as well.

Coordinated Delivery of EHR Functionality to Teams of Users

I’ve dealt with this topic at length in three previous posts:

• Clinical Groupware: A Definition
• Clinical Groupware, Care Coordination, and EMR Workflow Systems: Key Ideas
• Ten Years Ago, Dallas HIMSS: Landmark Presentation on Modular Pediatric EMR Workflow Groupware

However, so this section can stand on its own (hyperlinks on printed hardcopy don’t work—yet) I’ll include a definition of clinical groupware:

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate the care team’s work.”

An earlier version of the prediction beginning (and ending) this post included the phrase “delivery of traditional EHR functionality.”

“Traditional EHR” is a popular term these days—to apply to your competitors at least (see my Mirror, Mirror, On the Wall, Which EMR is Least Traditional of All?). This section is not about traditional EHRs, but rather the functionality traditionally provided. I like the eight category list provided in 2003 in Key Capabilities of an Electronic Health Record System: Letter Report to the Institute of Medicine. Feel free to review. (Disclaimer: I helped EncounterPRO user Dr. Cooper write his 2003 HIMSS Davies Award winning application based on these eight categories.)

I removed “traditional” from my prediction about the future of clinical groupware because we will see new and decidedly untraditional EHR functionality delivered and coordinated by clinical groupware.

Modular Components

The best possible service this post can do is to define EMR extensibility, component, and module in ways that systematically relate them to each other and to deep EMR usability. However, it can be difficult to draft practical definitions, when it comes to information technology, without a reference implementation to ground meanings in practical real-world reality. If you’ve read *any* of my previous posts, I am sure you know what reference implementation I will use: EncounterPRO.

The EncounterPRO Pediatric EMR Workflow System (publicly presented at the Dallas HIMSS in 2000) pioneered not just workflow engine-driven clinical groupware for pediatrics and primary care, but a modular component-based workflow engine-driven clinical groupware for pediatric and primary care. This is not a coincidence. There are important connections among EMR workflow engines, modular EMR components, and deep EMR usability.

The EncounterPRO EHR Workflow Management System is the workflow management system used to generate a specialty-specific EMR workflow system (see Pediatric EMR Workflow Systems for further explanation). It is a platform for launching and managing EMR components just as an operating system is a platform for launching and managing user applications and software services. Both are “an agreement that the platform provider [gives] to the software developer that logic code will interpret consistently.”
(http://en.wikipedia.org/wiki/Computing_platform)

EncounterPRO EMR Workflow Systems are extensible by virtue of being generated by the EncounterPRO EHR Workflow Management System. Extensibility “means the system is designed to include hooks and mechanisms for expanding/enhancing the system with new capabilities without having to make major changes to the system infrastructure.”
(http://en.wikipedia.org/wiki/Extensibility)

An EMR “software extension is a computer program designed to be incorporated into another piece of software in order to enhance, or extend, the functionalities of the latter. On its own, the program is not useful or functional.” 
(http://en.wikipedia.org/wiki/Computing_platform)

EncounterPRO software extensions are components. Generically, a component “is any smaller, self-contained part of a larger entity.” However, I like even better (due to its early medical informatics context) Berkowicz, Barnett, and Chueh’s definition:

“A component is an encapsulated functional element that can be used as a building block in application construction. Components can be reused if the format of the data upon which they operate is fully specified, and if a consistent environment for application.” (1998, Component Architecture For Web Based EMR Applications).

EncounterPRO has half a dozen frequently used components (data display and order entry screens) and many specialized one-of components, about twenty in all. As long as a component adheres to EncounterPRO’s platform API (application programming interface), it can be incorporated into a process definition and executed. It doesn’t matter who created the component, EncounterPRO Healthcare Resources or a third-party source. Super users can add installed components to EncounterPRO process definitions without being .NET programmers.

Components need configuration to behave usefully. You may already be familiar with application configuration files (XML and otherwise). A configuration object is a collection of declarative data that determines component and platform behavior in response to particular environmental inputs (from users and other sources). Our configuration objects, stored as fields in tables, can be exported and imported to share customized EncounterPRO content.

Finally, EncounterPRO modules are collections of related components, and configuration data that determine component behavior to accomplish specific sets of logically related goals useful to specific classes of users (such as pediatricians, allergists, and obstetricians) in response to specific environmental inputs. “Module” is based on analogy to circuit boards on which are assembled electrical components such as resistors, diodes, and transistors (as I used to etch my own boards, I’m glad to find that hobbyists still do).

From Wiki (my contributions are strategically placed ellipses and emboldened bracketed annotations):

“[M]odules represent a separation of concerns [such as the concerns of pediatricians versus allergists versus obstetricians], and improve maintainability by enforcing logical boundaries between components….Modules are typically incorporated into the program through interfaces [EncounterPRO’s component APIs]. A module interface expresses the elements that are provided and required by the module. The elements defined in the interface are detectable by other modules. The implementation contains the working code that corresponds to the elements declared in the interface…One of the key aspects behind Modular Programming is the ability to separate concerns such that none or few modules depends upon other modules of the system. To have as few dependencies as possible is of utmost importance. Another key aspect is that when creating a Modular System, instead of creating a Monolithic application [traditional EHRs, in the views of many] where the smallest piece is the whole application itself, one creates several smaller Modules which, when composed together, will create the whole system….This makes Modularized Designed systems, if done right, far more reusable [by developers, and, increasingly, users too] than a traditional Monolithic design since all or many of these Modules may be reused in other projects. In addition it also makes breaking projects up into several smaller projects through divide and conquer easier….Modularized Programming is a loosely defined concept. With no official definition, it is the programming technique of composing loosely coupled modules, and forming them together into a complete system.” (http://en.wikipedia.org/wiki/Modular_programming)

While a definition of clinical groupware should not invoke software modules, components, and sharable content and behavior (proprietary and monolithic groupware and clinical groupware applications surely exist), they are nonetheless important aspects of progressive modern software architecture and development practice. They make it easier to create what needs to be created, clinical groupware or otherwise. Since clinical groupware should rely on the best software development architecture available, clinical groupware should indeed rely on modules and components and sharable content and behavior.

Future Extensible Clinical Groupware

Note the parallels between my descriptions of EMR usability and EMR extensibility.

EMR extensibility is the other side of the deep EMR usability coin. Deep EMR usability requires (1) combining the right components, collected into the right executable bundles (modules), achieving the right sets of logically related goals, for the right classes of expected users, in response to correctly predicted environmental inputs *and then* (2) application of a “process optimization process” to systematically improve overall usability dimensions of effectiveness, efficiency, and user satisfaction. The first step gets you in the ball park; the second step hits it out. The only practical means by which this will be achieved will be if modular EMR/EHR/clinical groupware systems also include within their very technological nature the ability to systematically change internal processes and workflows to better meet set objectives while working in typical environments.

For these and other reasons I predict:

Future extensible clinical groupware will coordinate delivery of EHR functionality to teams of users by combining modular components with executable process models whose usability (effectiveness, efficiency, and user satisfaction) will be systematically improved using business process management techniques.

P.S. Follow me on Twitter at @chuckwebster.

Here are the most recent 20 tweets from @EMRGroupware: Auxiliary account used by @chuckwebster for real-time, high-frequency, event-related Twittering (not wishing to flood timelines following @chuckwebster). Next use: HIMSS March 1-4, Atlanta. Feel free to follow and respond to me (temporarily at @EMRGroupware) on Twitter (my replies with links to your tweet should show up below), or comment directly to this post.

• Very sorry for delay (didn’t see and lost the context) “me too what?” RT @medicfurby @EMRGroupware hey, me too! >> 2010/03/05
• If you refer 2 Rule 1 of Professional Tweeting http://j.mp/cmYUqI close enough RT @theEHRGuy @EMRGroupware Do I meet that criteria? #HIMSS10 >> 2010/03/05
• That’s it! Back to DC #HIMSS10 confluence: modular (pediatric) #EMR/#EHR, creeping “BPMism”, social computing, HIT education, all connected! >> 2010/03/04
• Captain Sullenberger keynote: Aviation checklists (me: example of manual coordination technology http://j.mp/aYkgbg ) #HIMSS10 #EHR #EMR >> 2010/03/04
• Captain Sullenberger keynote: Crew Resource Management (CRM) (me: insights 4 coordination technology/clinical groupware?) #HIMSS10 #EHR #EMR >> 2010/03/04
• 1/2 hour 2 Captain Sullenberger keynote, mention aviation human factors/crew management systems? re #EMR #EHR http://j.mp/5lpJww #HIMSS10 >> 2010/03/04
• Blog Post: #HIMSS10 Best Ever: Due in Large Part to Social Media http://j.mp/9GEhUr >> 2010/03/04
• My wife on upcoming #HIMSS10 Captain Sullenberger keynote “& he retired yesterday! You are so lucky…Jealous” Retired » Blunt talk (I hope) >> 2010/03/04
• #HIMSS10 SIG: Pediatric Health Informatics & Technology (PHIT) http://j.mp/9xf9OM discussion of peds specific #EMR/#EHR modules, more later >> 2010/03/03
• 3rd “Meet the Bloggers” is starting: @Justin_Wilcox @TheEHRGuy @ed_dodds @johnsharp @tedeytan: 1st & 2nd MtBs both great, different #HIMSS10 >> 2010/03/03
• Intriguing 2 see BI (business intelligence) mentioned @ #HIMSS10, given link 2 BPM (business process management) http://j.mp/cJG9Bd #EMR#EHR >> 2010/03/03
• Attending: Using Analytics 2 Drive #EMR Value, Quality, & Meaningful Use #HIMSS10 #EHR http://j.mp/aYrYAl “MU” http://twitpic.com/16e2if >> 2010/03/03
• Attending: Using Analytics 2 Drive EMR Value, Quality, & Meaningful Use (Principe/Hafer) http://j.mp/aYrYAl “MU” http://twitpic.com/16e2if >> 2010/03/03
• Blumenthal Keynote: complete #EHR vs EHR modules allow innovation in architecture and flexibility in all respects #HIMSS10 #EMR #groupware >> 2010/03/03
• Waiting for #HIMSS10 keynote from David Blumenthal, MD, National Coordinator for Health Information Technology, Dept Health & Human Services >> 2010/03/03
• #HIMSS10 great conference so far, of course my measure is how many ideas 4 blog posts occur 2 me (as in: *strike* me like lightening bolts!) >> 2010/03/03
• No snow, but no degrees either (0°C) & wiiindy! Looks like no kickbiking to #HIMSS10 for me http://chuckwebster.com/kickbiking >> 2010/03/03
• #HIMSS10 Session Twitter 101: Professional tweets: A superb presentation by Cesar Torres, Manager, Web Content, HIMSS (attribute, Rule 6) >> 2010/03/02
• #HIMSS10 Session Twitter 101: Professional tweets: Rule 10: Be a leader (learn from others, share what you learn, excite!) >> 2010/03/02
• #HIMSS10 Session Twitter 101: Professional tweets: Rule 9: Did U screw up? (If so admit it If it gives U pause, pause! Delete isn’t untweet) >> 2010/03/02

For older tweets visit @EMRGroupware

A couple of days ago I drafted a definition for clinical groupware (Clinical Groupware: A Definition). There are things I like about it (with respect to the five requirements for a good definition) but it is by no means perfect (few definitions are). I needed to let my thinking on the subject incubate, the second step in the Wallas five step model of creativity: 1) preparation (which I’d already done to write  Clinical Groupware, Care Coordination, and EMR Workflow Systems: Key Ideas), 2) incubation, 3) intimation, 4) illumination, and 5) verification.

“Incubation is defined as a process of unconscious recombination of thought elements that were stimulated through conscious work at one point in time, resulting in novel ideas at some later point in time…The experience of leaving a problem for a period of time, then finding that the difficulty evaporates on returning to the problem, or even more striking, that the solution “comes out of the blue”, when thinking about something else, is widespread. Many guides to effective thinking and problem solving advise the reader to set problems aside for a time.” (http://en.wikipedia.org/wiki/Incubation_(psychology))

So I went to Atlanta’s Piedmont Park and enjoyed myself. As ideas occurred to me (intimation and illumination) I wrote them in a notebook. I would have tweeted them (@chuckwebster), but they were too fragmented and half-baked even for Twitter.

I’ll write a blog post based on all that cogitating. Your reaction to it will complete the last stage of the creative process: verification (for at least this cycle of revision of the clinical groupware definition). Stay tuned!

Until then, here are the pictures (and an introductory video).

Sorry Harper, you just don’t have enough hair to exhibit the dog halo effect.

Mediocre halo effect, but a magnificent shadow!

Good candidate, face stage left please. 

Thank you! We’ll let you know.

Hey! There’s a lion loose in the park. Doesn’t anyone notice?
(Exotic wild animals at large in Atlanta are becoming commonplace. )

 Now that’s what I’m talking about! Perfect 10!

I know how you feel Harper. I don’t want to leave either.

Thank you Graham Wallas, for making work so much fun.

Hey, someone’s been chewing on my notebook–Harper!

Last week I highlighted several dozen quotes about groupware, coordination, and workflow, and supplied commentary about their relevance to clinical groupware. This week I thought I’d take a stab at defining “clinical groupware” itself.

But first, what constitutes a good definition?

Southern Rose Buggy Tours
Beaufort, South Carolina
(From my recent vacation there)

While a graduate student in Intelligent Systems, I worked on lexicons for use by natural language processing systems. Lexicography is the science of creating dictionaries, which (I think obviously) includes the science of creating definitions. A good definition meets five requirements. I’ll use “horse” as an example.

A good definition:

1. Describes essential, not incidental, attributes of the thing or concept being defined. For example, while many horses are brown, “brown” is not part of the definition of a horse. Fast horses are more valuable than slow horses, but slow horses are horses nonetheless.
2. Avoids circularity. A horse cannot be defined simply as a member of the species equus.
3. Is not too specific or too general. The definition of a horse should be somewhere between that of a Shetland Pony and a mammal, true of everything that is a horse and falsely applied to everything that is not a horse.
4. Avoid obscurity. Use widely understood terms with clear meaning. A horse is a four-legged, solid-hooved, plant-eating domesticated mammal commonly ridden to perform work or obtain entertainment. (If you ask “Is a camel therefore a horse?” you’ve made my point. My definition is too general with respect to the third requirement on this list.)
5. A definition should be positive (what a thing or concept *is*) not negative (what a thing or concept is *not*), though sometimes this cannot be avoided (as is the case if blindness is defined to be the absence of vision). A horse is not a camel, but camels should not be invoked in the definition of a horse.

If you can think of exceptions to these requirements, I am not surprised. Creating dictionaries (and lexicons for natural language parsers) is exacting *and* frustrating. Word meanings subtly change from context to context. There are exceptions. I don’t think I ever created a perfect definition. But sometimes you can create a definition good enough for a specific purpose.

Speaking of which, my purpose is to craft a definition of clinical groupware.

I don’t have to start from scratch, since early CSCW (Computer-Supported Collaborative Work) researchers have already done some work for me. In 1982 Peter and Trudy Johnson-Lenz proposed this definition for groupware:

“GROUPWARE = intentional GROUP processes and procedures to achieve specific purposes + softWARE tools designed to support and facilitate the group’s work”

“Groupware” is a portmanteau word created by blending the morphemes  from “group” and “software.”

“Clinical” is an adjective modifying the “groupware” noun. “Clinical” means “pertaining to observation and treatment of patients,” so how about the following definition of clinical groupware?

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate the care team’s work.”

I think this definition of clinical groupware meets all five requirements for a good definition:

1. The definition describes essential, not incidental characteristics.
2. It doesn’t define “clinical groupware” circularly in terms of either “clinical” or “groupware” (which is why I did not use “software tools”).
3. The definition is not too general or too specific. For example, it avoids the undue specificity (in this non-pediatric context) of my use of the Johnson-Lenz definition of groupware to describe pediatric groupware in a previous post.
4. It uses terms commonplace within the community of its intended audience.
5. The definition is positive. For example, it does not define clinical groupware as being the opposite of traditional EMRs (whatever that would mean, since there are so many different ways to be the opposite of traditional EMRs).

This definition of clinical groupware is based on a well-reviewed definition of groupware. There are many varieties of clinical groupware, but I think the definition is flexible enough to apply to examples of clinical groupware (such as pediatric groupware) while being specific enough to be useful in discussion and communication. It focuses on what clinical groupware *is* and the goals it serves, not *how* it performs them. Being too prescriptive runs the risk of stifling innovation. I am a fan of workflow engines executing process definitions (called “workplans” in the EncounterPRO Pediatric EMR) and radar views supporting shared mental models, but there are other kinds of clinical groupware. I hope the definition can accommodate them as well.

Just in case you skipped to the last paragraph first (which I do sometimes to understand where an article is going before I decide to read it in entirety), here is my proposed definition for clinical groupware:

“Intentional care team processes and procedures pertaining to the observation and treatment of patients plus the tools designed to support and facilitate a care team’s work.”

As the phrase “clinical groupware” gains currency, 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

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.

References

1. Baecker, R. Part I: Introduction, Baecker, R. (Ed.) Readings in Groupware and Computer-Supported Cooperative Work: Assisting Human-Human Collaboration, Morgan Kaufmann, 1992.
2. Coleman, D. & Khanna, R., Groupware: Technology and Applications, Prentice Hall, 1995.
3. Ellis, C, Gibbs, S, & Rein, G, Groupware: Some Issues and Experiences, Communications of the ACM, Volume 34, No 1, January, 1991.
4. 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.
5. Frisse, M, Schnase, J, Metcalfe, E, Models of Patient Records, Vol 69, No 7, July 1994, Academic Medicine.
6. Grief, I. (Ed.) Computer-Supported Cooperative Work: A Book of Readings, Morgan Kaufmann, 1988.
7. Grudin, J. Groupware and Cooperative Work: Problems and Prospects, In Laural, B (Ed.), The Art of Human Computer Interface Design, Addison-Wesley, 1990.
8. 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.
9. Khoshafian, S. & and Buckiewicz, M., Introduction to Groupware, Workflow, and Workgroup Computing, Wiley, 1995.
10. 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.
11. 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.

Thank you to MedicExchange TV Industry News for mentioning my blog (on “EHR workflow management and business process management concepts, technologies, and products”) at about 4:30 into this week’s video segment.

I am always delighted to hear someone other than myself utter the words “EMR” or “EHR” and “workflow management” and “business process management” in the same sentence. It’s why this blog exists. It’s why I posted this video of an interview with a pediatrician speaking about EMR workflow management and business process management in his solo practice.

Thanks again to MedicExchange TV Industry News!

The DC Blizzard of 2010 (January 5-6, fourth most snow in DC weather history) is over except for the shoveling [CW: Ha! See P.S.S!]. Today, Sunday, is clear and cold. Yesterday the falling snow was so dense (up to 3 inches an hour) that sometimes it felt like I was walking through snow soup. Here are some of my favorite photos and videos…

Photos

This is my favorite. We’re looking west toward the Chinatown Friendship Arch. The green traffic lights add a touch of irony–there are no cars on the road, just people and dogs (though technically, there *are* cars on the road; dimly visible on the other side of the arch, are a number of stranded vehicles).

Transplants to DC from colder climes broke out their winter equipment.

I was not to be outdone: kickbikes for summer and kicksleds for winter.

One snowboard dudesss suggested that I get a Snow Jack tattoo. (Nope.)

Could I have a table outside, please?

Saturday evening: while I did not see the sun, I did see peripheral evidence of a lovely sunset. That’s the top of the Washington Monument to the left.

Videos

[See post to watch Flash video]Winter storms are time machines.

[See post to watch Flash video]7AM Chinatown Friendship Arch

[See post to watch Flash video]Wow! I didn’t DC had snow blowers!
(And no, I don’t know why WordPress centered three Flash videos but left justified the next three, despite my straight-forward HTML tags.)

[See post to watch Flash video]One, Two, Three, Four, Five!

[See post to watch Flash video]I’ll have a table outside please.

[See post to watch Flash video]All over except the shoveling.

P.S.

One day later…

See, we’re half way dug out already!

P.S.S. Four days later we get hit with another blizzard, officially making this the snowiest winter in DC history.

[See post to watch Flash video]They’re baaack!

Look familiar? While I did not ”get the shot”, for short periods the steeple was invisible.

 Reminds me of those statues on Easter Island!

 [See post to watch Flash video]In search of Starbucks

[See post to watch Flash video]A “Sunny” Blizzard

[See post to watch Flash video]Me, Standing on Ten Foot High Pile of Snow

(Text in blue is from the original HIMSS proceedings paper. My comments about that paper are in black.)

This post’s title does sound a bit like a press release issued ten years after the fact. I could have waited and published this on April 11th, 2010, because then will be ten years to the day since our presentation at the 2000 HIMSS conference, about an EMR workflow system for pediatric workgroups. However, with the HIMSS conference occurring here in Atlanta, March 1-4, I think more people will read this if I publish it now.

So…

*Almost* ten years ago, representatives from two pediatric practices (Cooper Pediatrics and McDonough Pediatrics, near Atlanta) and I presented Session 48 “The CPR in Eleven Paperless Physicians’ Offices: Performance, Processes, and Results” on April 11, 2000, at the Dallas HIMSS conference (CPR stood for Computerized Patient Record). Ten of the eleven practices were pediatric; one was family medicine. The proceedings paper is still on the HIMSS website (and archived here).

One forgets that in 2000 less than one percent of physician offices had comprehensive EMRs, let alone were paperless (except for scanning what came in from the world and what had to be printed back at it). However, that was not what made our presentation so remarkable. In three ways, it prefigured developments that are beginning to affect collective thinking of the HIT industry today:

• Workflow management systems (business process management today)
• Computer-supported collaborative work (groupware and workflow systems today)
• Componentized EMR architecture (software modules/plugins and service-oriented architecture today)

Session 48 (sounds a bit X-Files-ish) was really two presentations, because EMR workflow systems are two software applications (EMR plus workflow groupware: Tastes Great, Less Filling! Two great tastes that taste great together! It’s a dessert topping, and a floor wax! Sorry!). The 2000 title reflected only the EMR part of the presentation. In this post I resurrect material not explicitly referred to in the title: EMR workflow automation, workgroup coordination, and componentized modular EMR architecture.staff productivity.

EMR Workflow

From our proceedings paper (in blue, I’ve added bold emphases for purposes of this post):

Uncommon are instances of CPRs integrated with workflow systems that automate manual processes and distribute information within a workgroup.

A workflow system is a complex, dynamic assemblage of:

• Tasks—These are activities that must be completed in order to achieve a business goal. The CPR in this study has a task-based orientation.
• Actors—Tasks are performed in a specific order by specific actors (that is, receptionists, nurses, physicians) based on business roles.
• Roles—Roles are defined independent of the actors or the processes that fill that role. For example, the CPR defines a nurse’s role as different from a physician’s role in the ambulatory care office.
• Processes—Processes are the sequences of tasks to be performed based on business conditions. Workflow automation may mirror existing processes or call for redesigning processes to eliminate redundancies and bottlenecks, and to facilitate communication.

BUSINESS PROCESSES

Workflow Automation

The workflow-enabled CPR reduces the amount of time required to retrieve information, document care, order labs and procedures, and communicate among clinical and non-clinical staff by two important mechanisms: smart sequences and simultaneous communication. Smart sequences are based on who you are (physician, nurse), where you are (exam room, tech station), and “when” you are (that is, what has been accomplished, such as vital signs, and what remains to be done, such as physical exam), and drive the sequence of user interface screens. [CW: see discussion of simultaneous communication in upcoming section on clinical groupware.]

The CPR and workflow system allows instant communication within the office and simultaneous access of a medical record by various people in the office. When the healthcare provider orders a lab or procedure, the nurse is notified automatically and immediately. The physician need not bother with or waste productive time trying to locate a nurse or turning on a certain light. While the physician is still with the patient, the nurse can prepare for the procedure. In the case of vaccinations, the dosage, manufacturer, lot number, and the intended site of administration can be documented before even entering the exam room and while the physician is still charting the exam. The nurse can also enter the results of labs and the information will appear in the exam room for the physician, thus preventing interruptions.

In an earlier study of changes in office patient volume and staffing levels, volume was observed to grow at five times the rate of growth in staff. Since patient volume correlates positively with revenue, and staffing level correlates positively with expense, there is good evidence that the workflow-enabled CPR increased profitability by allowing medical practices to see more patients with a less than corresponding increase in human labor.

According to the IOM, the greatest motivation for practitioners to use CPR’s would be evidence that CPRs can help to improve the quality of patient care and to reduce administrative burdens. This study yields preliminary evidence that a computer-based patient record combined with a workflow management system can yield a paperless office within two weeks or less after installation and that paperless offices indeed can produce immediate improvements in time savings, profitability, and

Clinical Groupware

I’ll address the relationship between clinical groupware and EMR workflow systems in future posts, but for now refer to the following descriptions of groupware:

“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’ (1982)” (Baecker, Readings in Groupware and Computer-Supported Cooperative Work: Assisting Human-Human Collaboration, Ronald M. Baecker (Editor), 882 pages, Morgan Kaufmann, 1992.)

And

“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.” (Lynch, Snyder, and Vogel, 1990, quoted in in Readings in Groupware and Computer-Supported Cooperative Work: Assisting Human-Human Collaboration, Ronald M. Baecker (Editor), 882 pages, Morgan Kaufmann, 1992.)

From our proceedings paper:

Simultaneous communication is based on posting tasks to be done in a central location (a CPR screen that provides an office “big picture”), which allows everyone to know what needs to be done and act accordingly.

And

At the heart of the workflow system is the “big picture” screen that tracks patients throughout the visit. From this screen, configured to the office specifications of each site, everyone can see where each patient is, which provider the patient is waiting for, what service the patient is waiting for, and finally, how many minutes the patient has been waiting. And the observer can easily take charge of a pending task simply by touching its representation on the “big picture” screen.

[click slide to animate] 

From PowerPoint slide notes:

“A workflow-enabled CPR should show everyone the runways and holding patterns of patients as they wait for service. On the left of each room is the name of a patient. On the right are tasks (vital signs, examination…) waiting to be done. Colors correspond to who is responsible for a patient or task. At number indicates the minutes the patient has been waiting.  Touching a patient or task color bar displays the appropriate screen for accomplishing the task.“

EncounterPRO’s big picture Office View is called a “radar view” by usability engineers, for obvious reasons.

Component Architecture

Just as I started the previous section on clinical groupware with a quote, I’ll do so again. Speaking of groupware….

“Ideally these coordination tools should be implemented as reusable software modules that may not stand alone, but can be used by developers as components of other domain-specific products.” (p. 8, Greif, Computer-Supported Cooperative Work: A Book of Readings, Irene Greif (Editor), 793 pages, Morgan Kaufmann, 1988.

The best way to present our own comments on the importance of modular and extensible EMR component architecture is to highlight two slides along with their slide handout notes (still available on the HIMSS website and archived here). They refer to Microsoft’s COM objects, not today’s Web services, .NET components, plugins, and so on, so I’ve supplied an updated translation. These slides are also animated, so be sure to click on them.

(I admire the WordPress plugin system that allows me to extend my blog to publish these Flash videos based on ten-year-old PowerPoint slides. The average WordPress blog has five plugins. This one has fifteen. Works great. It’s similar to the point I’m making about extensible EMRs–ironic!)

Two slides from our presentation (animated):

From PowerPoint slide notes:

“Allow developers to customize the workflow-enabled CPR, since one size does not fit all. Here Microsoft’s Component Object Model (COM) is critical, since it allows a developer or VAR to add their own screens as options for selection by the workflow engine.”

Updated translation:

“Allow users and developers to customize EMR workflow groupware systems, since one size does not fit all. Here Microsoft’s .NET, Web services, plugins, and other modular means to extend EMR functionality are critical, since they allow a user, developer or reseller to add their own screens and functionality as options for selection by the workflow engine.”

From PowerPoint slide notes:

“This slide is for the programmers in the audience (please explain it to the non-programmers). Decide to work with a workflow-enabled CPR that relies on a COM architecture possessing a set of publicly accessible APIs, so you can assemble a best-of-breed component solution and customize to your users or market.”

Updated translation:

“This slide is for the programmers in the audience (please explain it to the non-programmers). Decide to work with an EMR workflow groupware system that relies on a modern modular architecture possessing a set of publicly accessible APIs (application programming interfaces, check out the WordPress plugin API), so you can assemble a component solution customized to your users and market.”

After our 2000 presentation we continued to emphasize the relationship between clinical group workflow requirements and modular componentized EMR platforms:

“Workflow management systems are usually highly componentized, in that the workflow engine does not need to know much about the applications that it executes (just the prerequisite circumstances for execution and what context information to supply). This componentization provides a route … to introduce new EHR functions or ways of accomplishing them (such as a new decision support module or data display) into work-a-day … settings.” (“EHR Workflow Management Systems: Essentials, History, Healthcare”, TEPR Conference Proceedings, 2004, Fort Lauderdale)

The EncounterPRO Pediatric EMR Workflow System did not start out as single function system, as many other EMRs did. It wasn’t a prescribing system or a vaccine tracking system or a practice management system (OK, that’s usually two functions: scheduling plus billing). EncounterPRO was and is a workflow system and workflow systems coordinate work. EncounterPRO coordinates system-to-system, system-to-user, user-to-system, and user-to-user interactions. To do so, EncounterPRO coordinates modules, components, users, and roles to manage an ambulatory patient encounter for a team of physicians and clinical staff. EncounterPRO’s workflow engine and process definitions on one hand, and componentized modular architecture on the other, are two sides of the same EMR workflow groupware coin.

Conclusion

OK, (just in case you skipped directly to this conclusion) lets deconstruct this post’s subtitle, ”Modular Pediatric EMR Workflow Groupware”:

• “Modular”–A module is “a self-contained component (unit or item) that is used in combination with other components.” EncounterPRO’s modular components are its optional screens and screenless activities that can be combined into a network of task interdependencies. This network is automatically executed by a workflow engine. Third-party components and functionality can be added into this mix. Task statuses is displayed and updated in a group-facing display called the Office View.
• “Pediatric”–The EncounterPRO Pediatric EMR Workflow System was the first Windows-based EMR for pediatrics. Two pediatricians won the HIMSS Davies Award for their use of EncounterPRO. Seventy percent of EncounterPRO users are pediatricians. Three out of ten of Georgia’s top ten pediatricians (EMR users plus non-EMR users) use EncounterPRO.
• “EMR”–Did I mention that EncounterPRO is not *just* a workflow-oriented groupware system, but an EMR too?
• “Workflow“–”The automation of a business process, in whole or part, during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules.” In the EncounterPRO EHR Workflow Management System (used to create specialty-specific EMR workflow systems), these procedural rules are called “workplans,” although they are more generally called “workflow definitions” or “process definitions” in the workflow management/business process management industry.
• “Groupware”–”Intentional GROUP processes and procedures to achieve specific purposes + softWARE tools designed to support and facilitate the group’s work.” The original Johnson-Lenz definition is a good one.
  • “GROUP” = pediatric staff.
  • “specific purposes” = pediatric care.
  • “intentional…processes” = workflows of multiple tasks intentionally triggered to achieve pediatric goals.
  • “intentional…procedures” = multiple steps for each workflow task intentionally accomplished to achieve pediatric goals.
  • “softWARE tools” = pediatric EMR workflow groupware.
  • “designed to support…the group’s work” = a “radar view” supports a shared mental model, updated in real time, of task status among pediatric staff. EncounterPRO’s Office View “accentuates the multiple user environment, coordinating and orchestrating things so that users can ‘see’ each other, yet do not conflict with each other.” (Lynch, Snyder, and Vogel, 1990, quoted in in Readings in Groupware and Computer-Supported Cooperative Work: Assisting Human-Human Collaboration, Ronald M. Baecker (Editor), 882 pages, Morgan Kaufmann, 1992.)
  • “designed to…facilitate the group’s work” = visual representations of task status are “hot”; selecting a task brings up screen to accomplish it; tasks appear without need for user attention due to automatically executed workflow definitions; users trigger optional workflows that cause more tasks to appear on user and role worklists and in the Office View.

Terminology has evolved: workflow management systems, business process management, computer-supported cooperative work, clinical groupware, components, modules, plugins, CPRs, EMRs, and EHRs. The technologies manifesting these ideas have evolved greatly (for example, the Web did not yet exist when “groupware” was first coined, defined, and discussed). But the ideas themselves have been around for decades (well, “pediatric EMR” a decade and a half). I’d like to think our presentation and paper “The CPR in Eleven Paperless Physicians’ Offices: Performance, Processes, and Results” on April 11, 2000, at the Dallas HIMSS conference is a bit of a landmark.

However, I am hardly a disinterested observer. So you be the judge.

I “data mined” my Twitter “thought stream” this weekend and reminded myself of an interesting question on the Six Sigma & Process Improvement website.

Question:

“In the Healthcare environment, are there institutions using BPM software platforms in conjunction with ERP (fiscal) and EHR (medical) platforms?”

(BPM stands for Business Process Management, a frequent topic on this blog and EncounterPRO Pediatric EMR Workflow System website.)

Since no one answered it, I nominated myself.

You can see my posted response at:

http://www.sixsigmaiq.com/Question.cfm?externalID=1647 (Short Link: http://j.mp/6b3AlQ )

But below is a more readably formatted version.

My answer:

What a great question! EMR/EHRs, workflow systems, BPM, and financial applications are converging and we (patients, physicians, solution developers) should all be glad they are finally doing so.

Process-aware technologies such as workflow management systems and business process management suites have matured and proven their worth in various industries. They will diffuse throughout healthcare. At the same time, traditional (that is, non-process-aware) electronic medical/health records (EMR/EHR) are coming under increased critical scrutiny. Many EHR implementations fail, estimates range from 30 to 70 percent. Government efforts to increase EHRs adoption by physicians paradoxically have had the opposite effect. A big part of the problem is that physicians realize that traditional EHR workflow is one-size-fits-all, and therefore does not fit them. In response, a growing number of EHR professionals are beginning to realize that physicians are not the problem; it is lack of usable and flexible EHR workflow.

EMR/EHR productivity, usability, and workflow issues are effectively blocking adoption of a technology, which if it were to be adopted, would greatly improve (1) our knowledge of what works and what doesn’t (clinical outcomes research), (2) coordination of care between clinicians and clinicians and between clinicians and patients (interoperability), (3) real-time monitoring of patient care (alerts, reminders, compliance with care plans), and (4) means to systematically improve medical care effectiveness, efficiency, and patient and physician satisfaction.

EMR/EHR productivity, usability, and workflow issues are inextricably intertwined, a Gordian knot of interdependencies. Process-aware technologies such as workflow engines, process definitions, and business process management techniques are promising ways to manage these interdependencies.

Non-process-aware EHRs are difficult to optimize in a business process management sense. Their workflows and processes are too highly constrained by design and implementation decisions made by traditional programmers using third generation computer languages. A physician should not have to rely on a C# or Java programmer to tweak his or her workflow. Lack of easily changeable workflow/process definitions at points of care, and points between, makes systematic improving clinical workflow difficult, slow, and expensive.

EMR/EHRs built on workflow management system/business process management suite foundations are the next logical evolutionary step of EHR technology. They are essentially a new class of clinical information systems, existing at the intersection between two great software industries: electronic medical/health record systems and process-aware workflow management systems/business process management systems. The hybrid EMR workflow systems that will result will be more usable and more systematically optimizable than traditional EMRs with respect to user and patient satisfaction, clinical performance, and hospital and medical practice financial viability.

That’s the vision, at least. The reality is that I am aware of one well-known EHR workflow management system/business process management suite on the hospital side and one such system on the ambulatory, medical office side. I am also aware of a number of document imaging/scanning workflow systems used by healthcare payers and in non-clinical hospital departments; however I don’t “track” them. Without structured syntax and semantics of patient-specific data, the following important activities will not be possible: clinical outcomes research, institution-to-institution coordination of care, real-time patient care activity monitoring, and the process mining that will be necessary to improve the these activities.

Fortunately, I am seeing an uptick in interest by healthcare organizations and health information technology vendors in process-ware/workflow management system/business process management approaches to problems that traditional EMRs have failed to solve. This interest is evinced in trade publication articles about the potential for BPM in healthcare, press releases about new initiatives to use a BPM system in a healthcare venue, blog posts and comments (see below), occasional job announcements, and excellent questions such as yours.

For example, the following is a randomly picked blog comment (not my blog or comment, see http://j.mp/5R9N3s, written by someone familiar WfM/BPM but directed toward the physician blog author):

“Most existing EMR systems are a combination of data collection and storage (the facts) and the workflows associated with these facts (e.g. the follow-ups, ticklers. Etc.) The facts can be standardized but the workflows vary from practice to practice and physician to physician….Most existing EMRs handle workflow as if every physician/practice were identical…There is a whole separate class of software products with names like workflow management or business process management which is focused on how facts flow between people and what happens when flows are interrupted…Once you’ve seen a general workflow system in action you never want to go back.”

You also mentioned integration of fiscal applications into the EMR/EHR BPM mix. As great a picture as I have painted, the picture that results when you add financial data is even more extraordinary. I used to work in a hospital MIS department (wow! when I think about that potential!). However for the last decade I’ve worked in the primary care industry, specifically in pediatric and primary care. So in my following comments about combining clinical cost and clinical workflow data I will stick to what I know. However, I think you can extrapolate to other specialties and institutional venues.

One of the great promises of EHR workflow management systems in general, and pediatric and primary care EMR workflow systems in particular, is the pairing of activity-based costs with process definitions. Since each step in a pediatric process definition is time stamped as to when it is available to be accomplished, when it starts to be accomplished, and when it is actually accomplished and who (cost per minute) and where (rent per minute) is the resource used during each task, the total cost of each pediatric encounter can be calculated. With the revenue per pediatric encounter that is available from the practice management system (a fiscal application), the profit per each encounter can be calculated.

By comparing encounter profitability across pediatric practices, specific reasons for decreased profitability can be located: (1) a step is more expensive per minute than it should be (that is, it is accomplished by less expensive resources at other pediatric practices), (2) a step takes longer to accomplish than it should (compared to other practices), and (3) a step is executed more frequently than it should (compared to other practices). The win-win-win analytic result is to find those too expensive and too long steps being executed too often and change the workflow to increase encounter profitability.

That’s just one example of the power of combining EHRs, BPM, and cost data.

So, to answer your question: “In the healthcare environment, are their institutions using BPM software platforms in conjunction with ERP (fiscal) and EHR (medical platforms)?”:

There are a couple of mature existence proofs that EMR/EHR workflow systems/BPM platforms work well and have excellent potential. A metaphorical light bulb is turning on over the collective heads of the healthcare IT industry. And there are excellent questions like yours. Thank you for asking it!

P.S. I couldn’t figure out how to insert URLs into the Six Sigma website answer text box. However, I recently added links to more material about BPM in healthcare at http://chuckwebster.com/ehr-workflow-ehrs-wfmss

Are you a pediatrician coming to the Health Information and Systems Society Conference this March 1-4, 2010, in Atlanta, Georgia? You should know something:

You are coming to our town!

Can You Find the Peach?
(Click to zoom in)

As I wrote this June in “Georgia’s Best EMR Used By Three of Top Ten Pediatricians”, thirty percent of Georgia’s top ten pediatricians (EMR users plus non-users) use the EncounterPRO Pediatric EMR Workflow System. A Georgia Chapter of the American Academy of Pediatrics survey indicates forty percent of pediatricians in the State of Georgia who use an EMR use EncounterPRO.

We have a particularly high concentration of pediatricians in the Atlanta metro area who use EncounterPRO. My own back-of-the-envelope calculation, based on estimates of how many pediatricians live and work in the Atlanta metro region and how many pediatricians use a comprehensive EMR, plus our own customer statistics, leads me to believe that more than half of the pediatricians who use a comprehensive EMR in Atlanta use the EncounterPRO Pediatric EMR Workflow System.

If you are coming to Atlanta for HIMSS we would love to give you a live demo and/or arrange your visit to a pediatric practice in Atlanta using the EncounterPRO Pediatric EMR. Just use the form at the link below and we will pick you up at your conference hotel or the Georgia World Congress Center, transport you to our headquarters and/or a pediatric practice, and deliver you back to your hotel or conference venue.

And, if you can find the peach in the zoomable panoramic Atlanta skyline, we’ll enter you into a drawing for a crisp brand new C note (AKA one hundred semolians).

100 Peach Bucks

Provide contact information to visit EncounterPRO, get a face-to-face demo, and/or visit a pediatric practice using the EncounterPRO Pediatric EMR Workflow System.

P.S. Even if you are not coming to Atlanta anytime soon, we’d still love to give you a demo of a pediatric EMR that is the opposite of the traditional clickity-clickity-click-click-click, hunt-and-peck, point-and-click EMR (pediatric or otherwise).

Gosh! (Fake humility intended.)

I was having writer’s block problem. It’s not that I don’t have enough ideas, but rather that I have too many. They jostle and shout “Me!” “Me!” “Me!” and sometimes I don’t have a good way to prioritize. (Maybe I need something like the EncounterPRO Pediatric EMR Workflow System’s big picture “radar view”—AKA Office View—which helps prioritize pending tasks.)

Then this came in over the transom. Last year my white paper on “EMR Workflow, Usability, and Productivity in Pediatric and Primary Care” was the most downloaded article on Healthcare Technology Online.
 
Since old news is no news (this was announced on December 22nd, but I was on beach holiday and did not notice, was I too busy tweeting?  Perhaps I should have been following @HCTechnology on Twitter?) my decision about what to write about was effectively made.  However, folks wouldn’t have been paying attention back then anyway. Now that folks are reattaching the Web to their brains, maybe it’s for the best.

The article on Healthcare Technology Online republished my blog post “A White Paper About EMR Workflow, Usability, and Productivity in Pediatric and Primary Care” about the longer (and more technical) white paper “Pediatric and Primary Care EMR Business Process Management: A Look Back, a Look Under the Hood, and a Look Forward.” That white paper was in turn an update to my 2003 white paper “Electronic Medical Record Workflow Management: The Workflow of Workflow” By the way, please see instructions at “Could You Do Me a Favor? “Electronic Medical Record Workflow Management: The Workflow of Workflow” so I can keep that at the top of Google for the search terms “EMR” plus “workflow” (http://www.google.com/search?q=emr+workflow )

Thank You!

First and foremost I’d like to thank all the little people who made this possible—the children whose pediatricians use our product, the High-Usability EncounterPRO Pediatric EMR Workflow System.

Second, thank you Ken Congdon, chief editor at Healthcare Technology Online, for republishing the white paper at just the moment that a giant light bulb turned on over the collective heads of the healthcare information technology industry.

But most of all I’d like to thank family physician Geoffrey Wittig, M.D. He wrote the letter to the editor at the New York Times, about the impact of traditional EMRs on the high-volume, low-margin business of primary care, which caused me to update the original EMR workflow white paper.

“A high-volume, low-margin business like primary care medicine simply cannot support the costs. These include both the very high dollar cost of buying and maintaining a system and the huge drop in productivity that initially accompanies implementation.”

May your common sense rule the day.

P.S. “Me!”, “Me!”, “Me!”

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You will notice something new at the beginning of each post to this blog and on the EncounterPRO Pediatric EMR Workflow System website: “Short Link:” followed by a short and somewhat cryptic URL (http://j.mp/4ogmwT). If you click on it (try it!) you simply end back where you started, on this same page.

What’s the point? Short URLs, or short links, are used in SMS messages and Twitter tweets, which are a maximum of 140 characters long. At eighteen characters, the short link leaves 122 for the trenchant, piquant, pithy, and necessarily concise tweets about what you are doing or thinking.

Why am I doing this? In fact I’ve avoided Twitter for the same reasons I initially avoided blogging. The phrases “self-indulgent,” “banal,” and “navel-gazing” came to mind. For example, the following study found that 40.55% of tweets are “pointless babble.”

Then last February I registered http://twitter.com/chuckwebster (so my Twitter handle is @chuckwebster). While Twitter was new (to me, it’s been around since 2006) if it turned out to be important I wanted to be *the* @chuckwebster of out estimated 613 Charles Websters in the US to have that account, not @chuckwwebster or @chuckwebster5.

A use for Twitter that immediately made sense to me was real-time microblogging of a live event for folks who cannot attend. So I sent 40 tweets in 60 minutes at Dr. Gonzalzle’s presentation “Workflow Management EMR Systems and the Primary Care Physician” at the HIMSS conference in Chicago last April. Fun to do once but exhausting (lots of typos too), and I don’t attend enough such events to merit further investigation (or so I thought at the time).

Your Personal Twitter Timeline as a Thought Stream

I continued to read about business uses for Twitter. Then I had lunch with someone very knowledgeable about Web who used to agree with me about the apparent pointlessness of Twitter, but who now has 240 “followers.”

Dave: I’ve got 240 followers on Twitter.

You’ve got 240 followers on Twitter?!

Dave: That’s what I said.

What do you tweet about?

Dave: Thought of the day, interesting quotes, links to interesting articles, that sort of thing.

That’s nice, but why bother?

Dave: It’s fun, some interesting people follow my tweets and I follow them too. And folks are clicking through to my other Web sites.

Oh! (Hmmm…web traffic…maybe I was a bit hasty!)

Thought of the day…thought stream…Twitter recently changed the question above its tweet submission box from “What are you doing?” to “What’s happening?”, encompassing more interesting material than “Having breakfast.”

Then I read about research (“Study Reveals Two Types of Twitter Users” and “Is it Really About Me? Message Content in Social Awareness Streams”) that divided Twitter users as Meformers versus Informers, “two different types of ‘content camps’: a majority of users focus on the ’self’, while a smaller set of users are driven more by sharing information.” That second set of users sound a lot like me (or at least how I like to think of myself).

Coincidently, at the same time I read about Twitter Informers, I stumbled across a list of WordPress plugins that help coordinate Twitter and WordPress. I realized that I could use my tweets to generate content on this blog (scroll down to the bottom of the right-hand margin on this blog). Since each new tweet causes the oldest tweet to disappear, I’ve “archived” a set of tweets to the end of this post so I can refer to them below.

During my recent holiday vacation I wasn’t going to have access to my laptop at the beach. I faced writing two posts and scheduling them to be published automatically on vacation. I will tell you the truth. That felt like work. And I write this blog because it is fun. Was there a way for me to conveniently submit material to this blog from my smartphone? It would give me something to do while soaking in the rays.

I then began to think about my Twitter account as a convenient mobile extension to this blog. The fact that it would *only* allow me to submit 140 characters at a time was almost a relief (I do go overboard). It was almost an enforced “stop working so hard.” Just have fun exploring something new and if what I post is self-indulgent, so what, it will just be lost in the noise and eventually disappear in a massive haystack of other inconsequential tweets.

Then the snow storm hit DC just before my wife was about to fly down to Key West and the best real-time news (compared to cable and even the Web) I could get about DC travel conditions was Twitter. I tracked the key words “DC”, “DCA” (Reagan National Airport), and “snow” plus the hash tag “#snowpocalypse”. Here was a source of real-time news alerts that was really useful.

Huh. I was impressed.

In the meantime, sitting at the beach, I’m reading about different Twitter applications, culture, and uses. Eventually I began to think of my own tweets as resembling the email reminders I already send myself.

Using just the email subject line, I often send myself emails with subject lines starting with “remind think about…”, “remind what is connection between X and Y?”, “remind blog post idea: …” and “remind cell photo pretty sunset at piedmont park” (with attached image). Sometimes I include a Web URL in the email body. When I get back to my office or laptop I sort my emails in outlook and go back and data mine this “thought stream” (wasn’t I thinking about X a few months ago, ha! here’s the link I was looking for).

While an email subject line can hold more than 140 characters, it is similar to a tweet: telegraphic, no formatting, targeted audience. So I decided to conduct an experiment. For the next two weeks, over the recent holidays, I resolved to not touch my laptop. I’d just use my smartphone to access the Web and update this blog. I would post once or twice a day, and while I’d try to be an Informer, I’d give into a Meformer urge once in a while, just so I could understand that inclination.

It was fun. I “meformed” a bit more than I intended: vacation photos, a bit of doggerel when bored, an obscure reference to Michael Keaton’s character in the Night Shift. Hey, I was on vacation. But I also found some interesting content on the Web that I wished to remind myself to explore and possibly post about later (and didn’t mind if anyone else eavesdropped).

If I go back over my recent tweets they appear to fall into one or more three categories:

• Informer-style Branded Content: Comments, quotes, and links related to the EncounterPRO EMR Workflow System product line (pediatrics, family medicine, obstetrics & gynecology, usability, workflow) that will likely continue. (13 tweets: green bullets)
• Informer-style Unbranded Content: Such as material related to Twitter itself. It’s the new thing that I am currently learning about, thinking about, and excited to share. This content will likely wax and then wane, to be replaced about whatever intrigues me next. (7 tweets: blue bullets)
• Meformer-style Content: Of most interest mostly to me, a relative or a friend. (3 tweets: red bullets)

Plus a more recent short video tweet that spans all three categories: Branded Informer (mention of EncounterPRO), Unbranded Informer (look, I can tweet a video!), and plain ‘ol Meformer (”It’s cold here in Atlanta!”).

URL Shortening Services

Oh. So why am I putting URL short links my blog pages and those of our product website? So I can tweet them. So you can too. For example, coincident with publishing this blog post I tweeted “Blog post: Twitter Holiday: Sun, Sand, Surf, Smartphones, Short URLS, Social Media, and Pediatric EMR Workflow Systems http://j.mp/4ogmwT” More and more people surf the Web on their cell phones and communicate using Twitter. If you want to tweet one of my blog posts or our product pages, just copy and paste the Short Link into your tweet.

On the other hand, you could go to the trouble of creating your own short links at one of the many free URL shortening services. Why did I choose j.mp? If you look back over my tweets (below) you may notice that I tried different URL shortening services: http://bit.ly (favored by Twitter), http://multiurl.com (enables tweeting more than one URL, each with a description), and http://j.mp (two characters shorter than bit.ly, but also belongs to bit.ly). I chose j.mp because it results in an exceptionally short URL (18 characters) and because it belongs to bit.ly, a Twitter partner and therefore not likely to go away soon.

Conclusion

That’s how and why I started twittering. Is Twitter the greatest thing since sliced bread? I don’t know. I recently read that national and international use of Twitter from the desktop Web browsers is flat lining, but that smartphone access continues to grow. This is consistent with my experience; I didn’t see the point of Twitter until I realized what I could conveniently use it to do things from my smartphone.

Right now, Twitter is a way for me to interact with my blog in both real time (the direct feed) and to publicly, but informally, archive ideas for future posts. Sort of miniature trailers for potential longer attractions to come. Therefore many of my future tweets will be about the same subjects I address here in the blog: pediatric and primary care workflow systems, their usability, and the extraordinary potential for applying business process management techniques to improving healthcare processes.

Since I’ll be attending HIMSS here in Atlanta March 1-4, maybe I’ll try to live blog that from my smartphone. I can bump my live feed of tweets to the top of this blog’s right-hand column (replacing the photo of  our kickbikes) so it will be hard to ignore. Check back then (even if you aren’t a regular reader).

Also, (surprise!) sometimes I just don’t know when to stop writing. Since brevity is the soul of wit, maybe Twitter can teach me to be (t)wittier. I just don’t know. But I am interested in finding out.

If you are interested in finding out too, or interested in some of the same subjects as I am (pediatric EMRs, workflow, usability, cognitive science, kickbiking, and, for the moment, Twitter), and you have a Twitter account, I hope you’ll follow me (I’ll likely follow you right back). If you don’t have a twitter account, head over to www.twitter.com get one: free!

Tweet you later!

@chuckwebster

Archive of Recent Tweets as of Date of this Post, Color-coded by Category (Green •: Branded “Informer,” Blue •: Unbranded “Informer,” and Red •: “Meformer”)

(from newer to older…)

Wishing I was in Key West……tweeting from the beach…

·         End Key West Twitter Holiday Is my wife wearing a cruise ship for a hat? http://www.twitpic.com/wcxn4 Will I continue to tweet? Que Sera Sera! 4 days ago

·         Test: Shortest URL shortener? Which links work? http://en.wikipedia.org/wiki/URL_shortening http://j.mp/8XKXlo http://www.j.mp/8XKXlo j.mp/8XKXlo 5 days ago

·         Wanna no y I have a Twitter acct? To tweet things. See, I got ideas coming at me all day. I couldn’t fight’em off if I wanted Happy New Year 6 days ago

·         Blog post idea: recent article care coordination gap » EMR workflow systems = EMR care coordination systems http://j.mp/5n0E1d Pediatric EHR 1 week ago

·         MSFT”use [workflow] model to interpret behavior [and to] reason…how to optimize the business process” http://j.mp/6ntnVa Pediatric EMR EHR 1 week ago

·         MSFT”which individuals are contributing work to which business process…to understand costs and workloads” Pediatric EMR http://j.mp/6ntnVa 1 week ago

·         http://twitpic.com/vc8nv Mobile Office: subject usable EMR workflow, locale beach, 1999 technology PALM VII–readable in direct sunlight! 1 week ago

·         MSFT”Workflow models can be used to gain insight into the flow of work through an organization” Pediatric EMR http://www.multiurl.com/l/0Oi 1 week ago

·         Microsoft “Benefits that a workflow model can bring are insight, monitoring, and optimization.” Pediatric EMR http://www.multiurl.com/l/0Oi 1 week ago

·         There once was a tweet, a bit of a cheat, that did not obsess, or even address, the author’s central conceit http://bit.ly/6dkU7o Merry XMas 1 week ago

·         Cycle time from 80 to 30 minutes, improved bottom line and patient satisfaction http://bit.ly/8NeKZn quote EncounterPRO pediatric EMR user?? 2 weeks ago

·         Watch http://ehrworkflow.com for new EMR / EHR workflow and usability pediatric, subspecialty, family medicine, OB/gyn. content…developing 2 weeks ago

·         Read about pediatric EMR workflow systems at http://chuckwebster.com/pediatric-emr-workflow 2 weeks ago

·         Groupware versus Workflow http://bit.ly/8nzRQd need both clinical groupware http://bit.ly/57uxWG and pediatric EMR WfSs http://bit.ly/6DeFlE 2 weeks ago

·         “Products designed to…reflect…work patterns of physicians…reduce EHR implementation difficulties” http://bit.ly/8WoBp2 arg 4 EMR WfSs! 2 weeks ago

·         http://twitpic.com/u7qfw - Arrived in Key West. Here’s the view out the window. (Grin!) 2 weeks ago

·         Merry Christmas and Happy New Year from Key West! http://bit.ly/602CpE Check out my “Twelve Days of EMR Beta Testing” http://bit.ly/83b6Uv 2 weeks ago

·         Idea: Complex Event Processing http://bit.ly/8YltPT and Pediatric EMR Workflow Systems, user-defined events trigger automated workflows 2 weeks ago

·         I’ll try to be more of a Twitter Informer than Meformer. Read about social awareness streams at http://www.bit.ly/PUcvD and http://www.bit.ly/3JEtPb 2 weeks ago

·         …worked like a charm! 2 weeks ago

·         Going on vacation, want to post ruminations from the beach, installed Twitter Tools for Wordpress, let’s post a test tweet to my blog… 2 weeks ago

·         Audience member caught up with me, is your system enterprise ready, what do you mean? Handle multiple specialty workflows, absolutely! 2009-04-05

·         That’s it for ed sessions today. Nw to find a coffee house, get online, and do some work. Thnks fr following my twitter updates this morning 2009-04-05

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Bill Blazejowski (Michael Keaton’s character in Night Shift)

“Wanna know why I carry this tape recorder? To tape things. See, I’m an idea man Chuck. I got ideas coming at me all day…I couldn’t even fight them off if I wanted. Wait a second…hold the phone. Hold the phone!

[Speaking into the phone]

Idea to eliminate garbage. Editable paper. You eat it, it’s gone. You eat it, it’s outta here. No more garbage.”

1. Early groupware/computer-supported cooperative work relevant to clinical pediatric EMR/EHR workflow & usability http://www.twitpic.com/xddkk about 23 hours ago
2. Current ski conditions for Key West, Florida (I kid you not, check out this screen shot) http://www.twitpic.com/x5jw9 8:11 PM Jan 7th 
3. http://j.mp/7mTLDm Testing new short-linked pediatric-specific High-Usability EncounterPRO EMR Workflow System website, does this link work? 7:47 PM Jan 7th 
4. http://twitvid.com/B97D2 - Video News Flash! Atlanta Chill: Waterfall by EncounterPRO Pediatric EMR Workflow System headqtrs freezes solid! 7:06 AM Jan 7th 
5. “Medical practices are a home-grown industry, really a cottage industry, so every single one is different.” http://j.mp/7Xluox Arg 4 EMR WfS 8:39 AM Jan 5th 
6. Natural EMR EHR workflow “fits” tasks w/o work arounds, is normal, logical, expected, st8 4ward, “intuitable” based on prior user experience 8:42 AM Jan 4th 
7. RT @AMFitnessCoach “Tru njoyment comes from activity of the mind & exercise of the body; the 2 are united.” Chess Boxing! http://j.mp/8h1c1A 7:44 AM Jan 4th 
8. Tape recorder! Idea 4 blog post: Sun, Sand, Surf, Cellphones, Short URLs, Social MEdia & Pediatric EMR Workflow Systems www.chuckwebster.com 10:35 AM Jan 3rd 

My parents live on a farm in Illinois (center upper right). That’s the Mississippi River in the lower left and a backwater lake (center) where I fished from my eight-foot flat boat (it’s still in there in the weeds. Imagine three boys and a big ~1950 Johnson outboard motor on such a tiny vehicle. We moved very slowly.). In the winter the lake would freeze and we’d skate, sled, and snowmobile. It was a lot of fun!

Nowadays I spend most of my time in DC or Atlanta. DC can be fun in the winter too.

But my folks now spend their winters in an RV by the ocean in Key West. This is their view! Wow. One of my aunts knitted or darned (or whatever!) that red, gray, and white “throw.” Comfort food for the soul.

 Each morning we have breakfast..

…pick up the mail at the post office, which is strangely popular with the famous Key West chickens…

 ”Keep track of every little thing with the
EncounterPRO Pediatric EMR Workflow System”

…and go to the beach…

 …while Dad reads the Key West Citizen.

Eventually we head to Mallory Square to watch the sunset.

That’s our holiday tradition. I hope you enjoy yours as much!

Again, Merry Christmas and Happy New Year.

–Chuck

PS I sang a parody of the Twelve Days of Christmas at this year’s Christmas party called

“The Twelve Days of EMR Beta Testing”

Sung (obviously) to the tune of Twelve Days of Christmas, it ended this way:

• On the twelfth day of beta testing
• Epro sent to me
• Twelve users using
• Eleven printers printing
• Ten doctors leaping
• Nine patients dancing
• Eight bills a billing
• Seven screens appearing ( “in quick succession matching pediatric workflow” [muttered quickly under the breath])
• Six nurses disbursing
• Fiiiiive neeeetwooooork piiiiiings! (loudly and obnoxiously drawn out)
• Four calling users
• Three touch pens
• Two bugs rid of
• And a paper record in the debris (groan!)

I was inspired by “12 Days of Christmas Song: A Music Geek Carol!” The fifth line (in reverse order) is sublime.

Originally titled “Traditional EMRs are Problematic, but Let’s Not Throw the Baby Out with the Bath Water,” then “Have Your Cake and Eat it Too: Structured EMR Data AND High Productivity,” I eventually decided that “Mirror, Mirror, On the Wall, Which EMR is Least Traditional of All?” was most clickable. (William Safire said something like “Avoid cliché’s like the plague”, but while I admired his column in the New York Times I took his advice with grain of salt).

The “traditional” EMR is taking it on the chin lately.

I’ve thrown a few punches myself…

 http://www.google.com/search?q=%22traditional+EMR%22+site%3Achuckwebster.com

…but I’m not the only one. Check it out yourself…

http://www.google.com/search?hl=en&q=%22traditional+EMR%22

Or take my word for it. I grabbed quotes from the first three pages Google returned and summarized them below by way of paraphrase. I changed vendor and product names to protect the….(innocent? guilty?). Of course, by the time you click the list will have evolved and lengthened (and this post will be on it, how is that for self-reference?).

1. Our EMR implements in much less time than a traditional EMR
2. Our EMR costs much less than an a traditional EMR
3. Our EMR makes physicians more money than traditional EMRs
4. Our EMR requires less change to existing workflows than traditional EMRs
5. Our EMR has fewer security vulnerabilities than traditional EMRs
6. Our EMR helps physicians see more patients than traditional EMRs
7. Our EMR has the 20% of traditional EMR features, 80% of their value, and 200% of their usability
8. Studies have refuted the claims of traditional EMR vendors
9. 30-70 percent of traditional EMR implementations fail
10. Traditional EMRs cause physicians to see fewer patients than pre-EMR implementation
11. Traditional EMRs cause physicians lose revenue relative to pre-EMR implementation
12. Traditional EMRs do not eventually return to pre-EMR implementation productivity levels
13. Traditional EMRs require pointing and clicking that wastes physician time
14. Traditional EMRs distract physicians from focusing on their patients
15. Traditional EMRs implement features mandated by bureaucrats, not physician needs
16. Traditional EMR features are so cumbersome that some are often not even ever used
17. Traditional EMRs are sold by salespeople know their software does not help physicians (harsh!)
18. Traditional EMRs create documents full of cookie-cutter language in which relevant information is hard to find
19. Web-based EMRs are the alternative to traditional EMRs
20. Document imaging-based EMRs are the alternative to traditional EMRs
21. Advertising-supported EMRs are the alternative to traditional EMRs
22. Less-is-more EMRs are the alternative to traditional EMRs
23. Speech recognition-based EMRs are the alternative to traditional EMRs
24. Natural language processing-based EMRs are the alternative to traditional EMRs
25. EMRs that visualize patient data in a different way are the alternative to traditional EMRs
26. Open source EMRs are the alternative to traditional EMRs
27. Mind-controlled EMRs are the alternative to traditional EMRs (just kidding, but cool video)

Pile-On!

If you believe EMR marketing departments these days, most EMRs are not traditional at all, perhaps an example of the Lake Wobegon Effect (where “all the children are above average”). As my mom used to say, “What in the world is going on here?” (“Nothing Mom!”) What is it about traditional EMRs that have made them so radioactive even traditional EMR vendors are beginning to attack them?

EMR vendors with a-, un-, non- or anti-traditional EMRs (not sure of the correct prefix here) invoke and attack a “traditional” EMR straw man with some or all the following characteristics. A traditional EMR has structured template-driven forms with complicated, inflexible, time-consuming, distracting (from the patient) drop-down menus, check boxes, radio buttons that require massive change to physician workflow. Traditional EMRs have so many features, mandated by so many bureaucrats, that access to the right feature at the right time is effectively impossible, because it is buried. Generated patient notes and letters contain repetitive superfluous cookie-cutter language in which relevant information is hard to find and therefore often ignored.

I think that’s the heart of the traditional EMR stereotype. I refer to them as traditional, hunt-and-peck, clickity-clickity-click-click-click EMRs. We put it forcefully this way on the EncounterPRO website:

WHY TRADITIONAL EMRS ARE INADEQUATE AND A FUNDAMENTALLY NEW DESIGN IS REQUIRED

Traditional “Hunt and Peck” EMRs are not usable for high-productivity data and order entry, nor can they be flexibly adapted to anticipate individual user requirements and preferences. These EMRs are not designed on the process-aware clinical groupware foundations that are required for systematic optimization of clinical performance, workflow efficiency, and user and patient satisfaction.

There is an alternative.

The new generation of EMRs that is capable of being meaningfully used to meet these requirements will be built on workflow engines executing process definitions. These EMRs anticipate user workflow.

The EncounterPRO Pediatric EMR Workflow System, built on the EncounterPRO EHR Workflow Management System, is an example of this new class of highly usable, productive, and optimizable EMRs.

However, some traditional EMR critics go too far and advocate getting rid of the extraordinarily valuable structured data. I’ve been criticizing “traditional” EMRs for years, publically since September 15, 1999, to be exact. I know the culprit–its flaws and its virtues–and structured data is not the problem.

Generating useful structured data requires the imposition of precise structure and meaning on collected data. Such data are easier to aggregate (important for clinical research such as outcome studies), easier to transport (in the sense of transferring specific data between applications), and more appropriate for driving the automated performance of patient-specific tasks such as alerts and workflows. We published our own solution to the need for both structured data and high productivity in 2001, when we wrote:

“In our opinion, the combination of structured data entry, workflow automation, and screens designed for touch screen [today including stylus] interaction optimally reduces inherent tradeoffs between information utility and system usability on one hand, and speed and accuracy of data entry on the other. Successful application of touch screen technology requires that only a few, but necessary, selectable items be presented to the user in each screen. Moreover, workflow, by reducing cognitive work of navigating a complex system, makes such structured data entry more usable.” (also discussed in “The Cognitive Psychology of Pediatric EMR Usability and Workflow” )

Let’s go through the list of criticisms of “traditional” EMRs one by one.

1. Our EMR implements in much less time than a traditional EMR
   • You’ll be “Live in Five” (back to pre-EMR implementation patients-per-day in five days) with the EncounterPRO Rollout & G0-Live SYSTEM
2. Our EMR costs much less than an a traditional EMR
   • Our total cost of ownership is substantially less than traditional EMRs because the largest single expense to owning an EMR is the time it takes for you to learn and use it.
3. Our EMR makes physicians more money than traditional EMRs
   • Pediatricians using the EncounterPRO Pediatric EMR Workflow System can more than double patient volume, billings, and revenue.
4. Our EMR requires less change to existing workflows than traditional EMRs
   • “Using EHRs that are easily molded to existing physician workflows, which can then be systematically improved while respecting normal human tolerance for change, is the key to EHR adoption” (quote from  “Automate Your EMR Cow Paths *and* Reengineer Them Too!” )
5. Our EMR has fewer security vulnerabilities than traditional EMRs
   • Workflow management systems have an additional layer of security due to role-based task execution permissions and detailed workflow audit trails. Workflow management systems represent individual tasks at a higher degree of granularity than non-workflow management systems. Workflow engines execute process definitions that contain these tasks. The workflow engine consults a role-based permission system to decide whether or not a user has the right to initiate or complete each task. As a result, a workflow management system can enforce controls over what can and can’t be done before hand, and provide a more detailed audit trail afterwards.
6. Our EMR helps physicians see more patients than traditional EMRs
   • See response to claim 3
7. Our EMR has the 20% of traditional EMR features, 80% of their value, and 200% of their usability
   • See post and this page that address “EMR Featuritis”
8. Studies have refuted the claims of traditional EMR vendors
   • Three primary care physicians–two pediatricians and one obstetrics/gynecology and family medicine physician–submitted detailed documentation, hosted site visits, and won the first three HIMSS Davies Awards for ambulatory care excellence.
9. 30-70 percent of traditional EMR implementations fail
   • “The basic problem is that implementing *most* EHRs is an act of reengineering, and reengineering is a high risk endeavor.” (Source) Implementing the EncounterPRO Pediatric EMR Workflow System is not an act of reengineering, resulting in a virtual 100% rate of successful implementation.
10. Traditional EMRs cause physicians to see fewer patients than pre-EMR implementation
    • See 3
11. Traditional EMRs cause physicians lose revenue relative to pre-EMR implementation
    • See 3
12. Traditional EMRs do not eventually return to pre-EMR implementation productivity levels
    • See 3
13. Traditional EMRs require pointing and clicking that wastes physician time
    • Done right, pointing-and-clicking is much faster than all the alternatives (except perhaps mental telepathy, but that technology hasn’t been perfected yet). See “The Cognitive Psychology of Pediatric EMR Usability and Workflow” for explanation.
14. Traditional EMRs distract physicians from focusing on their patients
    • “One Georgia pediatrician, a winner of the HIMSS Davies Ambulatory Care Award of Excellence for his use of the EncounterPRO EHR, shows his attentiveness using one hand to steady an energetic child and the other hand to enter data and orders out of the corner of his eye, facilitated by large colorful buttons. A workflow engine pushes screens in preprogrammed sequences so he is not distracted by screen-to-screen navigation. His focus remains uninterrupted and attentive to the concerned parent.” (Article: “What Makes a Great Pediatric EHR?”)
    • “A Chicago pediatrician, who also won the HIMSS Davies Ambulatory Care Award using the EncounterPRO EHR, notes that its customizable workflow has made his office so much more efficient that he can see more patients and spend more time with each patient. Efficiency allows more time to be available to parents and patients.”  (Article: “What Makes a Great Pediatric EHR?”)
15. Traditional EMRs implement features mandated by bureaucrats, not physician needs
    • Short anecdote: I presented to an audience of health professionals almost all of whom worked for various government agencies. An animated question-and-answer period ensued. Many of the questions where “Have you thought of…?”, “Why don’t you add…?” To which I answered “Yes”, “Yes”, and “Yes” and “Our sales people aren’t being asked for it,” and  ”It hasn’t lost us any sales.” There was a moment of befuddled silence, and finally someone from the audience commented “That’s a really stupid reason for not doing something!”
16. Traditional EMR features are so cumbersome that some are often not even ever used
    • “Since 1994 we’ve been adding pediatric-specific features to the first Windows-based pediatric EMR (and workflow system), however EncounterPRO’s completely customizable workflows “anticipate” what you need and where you want to go, unlike “hunt-and-peck” EMRs that force you to click your way through cluttered screens and lengthy picklists. Our philosophy is to optimize, not maximize, pediatric EMR features. With EncounterPRO you can have your features and use them too.” (Usability)
17. Traditional EMRs are sold by salespeople know their software does not help physicians (harsh!) 
    • Our sales folk sleep very well at night! I do too. I believe EMR workflow systems will be transformational at healthcare industry, organizational, professional and personal levels.
18. Traditional EMRs create documents full of cookie-cutter language in which relevant information is hard to find
    • I took two courses on natural language generation in graduate school and even presented a paper at a workshop on the topic. Automating the writing of fluent, appropriate, and natural language is difficult. However, getting rid of structured medical data and databases is akin to throwing the baby out with the bath water. The issues are complicated, interesting, and reflect well on EMR workflow systems. Look for a future post.
19. Web-based EMRs are the alternative to traditional EMRs
    • Many workflow management systems and business process management suites are web-based. It’s only a matter of time before EMR workflow systems are delivered in this manner too.
20. Document imaging-based EMRs are the alternative to traditional EMRs
    • Ironically, many of the first commercial workflow systems (such as FileNet’s WorkFlo system back in the 80s) were document scanning/imaging solutions. Why ironic? I am arguing that EMR Workflow Systems are the next step in EMR/EHR evolution (see my recent white paper on this topic), but workflow systems (and the underlying workflow management systems that create and manage them) are decades old. Healthcare is that far behind other industries in adopting workflow technology.
21. Advertising-supported EMRs are the alternative to traditional EMRs
    • This is an alternative business model, not EMR model. And in the immortal words of the solo family medicine physician, “I don’t care if you give it to me free and then bribe me to use it, if it slows me down I won’t!”
22. Less-is-more EMRs are the alternative to traditional EMRs
    • See 7
23. Speech recognition-based EMRs are the alternative to traditional EMRs
    • I worked on a speech recognition project in graduate school (writing natural language syntax grammars for the Pilot’s Associate project) so I know a bit about the topic. The Holy Grail is large-vocabulary, speaker-independent, continuous speech recognition. I’m a fan. But it is not an “alternative” to structured data EMRs, any more than scanning/imaging is.
24. Natural language processing-based EMRs are the alternative to traditional EMRs
    • However words get digitized, whether through speech recognition or optical character recognition (or physician fingers), they need to be combined into phrases and sentences and meaning derived. There’s been some interesting work in this area. But it’s not ready to replace structured data entry.
25. EMRs that visualize patient data in a different way are the alternative to traditional EMRs
    • New ways to view data result in more decisions to make about which view is appropriate at each workflow step. However, the way in which data is presented at a particular step can be determined automatically by the workflow engine. New ways to view data increase the need for EMR workflow automation, not diminish it.
    • EMR workflow systems also generate a lot of new workflow-related data that will need to be visualized. Increasingly, as patients begin to interact with EMR workflow systems via Web portals, their activities (infotherapy, supplying information, documenting compliance) will become part of the EMR record proper, and therefore need to be visualized too.
    • Both are examples of a complimentary relationship between new ways to look at patient data and the larger EMR system within which this data is viewed.
26. Open source EMRs are the alternative to traditional EMRs
    • There are some excellent open source workflow management systems out there. I’d like to see some pressed into service within health care. In fact, if you’ve read any of my posts about how to solve the pediatric medical home care coordination problem, the more EMR workflow systems the better!
27. Mind-controlled EMRs are the alternative to traditional EMRs (just kidding, but cool video)
    • I look forward to mind-controlled EMR workflow systems! I suspect that even in the “mind’s eye” Fitts and Hicks Laws will hold true.

The central issue is whether we can have EMRs with high productivity data entry *and* that can produce structured data.

Productivity is the quality and quantify of output divided by cost of input needed to cause the output. The value of data is what you can do with it and you can do many more valuable things with structured, than unstructured, data. The most important input costs are the time and effort of the physician user to master and use an EMR. Reducing these costs is requires improving EMR usability. Improving EMR usability requires improving workflow. The most effective and efficient way to improve EMR workflow is with an EMR workflow system.

EMR workflow systems are compatible with, and can strategically combine all of, the “alternatives” offered by critics of traditional EMRs. In the main, these alternatives are input modalities, delivery platforms, or business models, all of which are needed. But none of them directly addresses the contradictory need for both structured data and high productivity (except perhaps for natural language processing, which is not yet a sufficiently mature technology).

In the long run, it’s not whether you speak into it or write on it, whether you get if for free or have to pay for it (as long as it’s worth it), or whether the code executes in front of you, down the hall, or across the country. It’s whether EMR effectiveness, efficiency, and usability can be systematically improved to achieve well understood, consistently executed, adaptively resilient workflow. Doing so will require both structured data and high productivity. The best, most obvious, most comprehensive, most mature means to achieve these goals are business process management techniques applied to process-aware EMR workflow systems.

“Mirror, mirror on the wall, which EMR is least traditional of all?”

“The EncounterPRO EMR Workflow System is least traditional of all.”

Many thanks to the Technology Association of Georgia for publishing one of my white papers on EHR Workflow Management Systems.

TAG has many excellent resources on their web site, and I had them in mind when I recently wrote:

“Atlanta is a sophisticated medical and information technology market….To do well in Georgia, whether you are a pediatrician or develop and market a pediatric EMR, is to do well in a state that does a lot of things rather well. We are both a beneficiary of, and contributor to, Atlanta and Georgia’s unique workforce, infrastructure, and business climate:

Best Managed State in the Southeast

No. 1 in U.S. for Workforce Training

Most Inexpensive U.S. City to Do Business

Second Fastest Growing City in America

Fastest–growing Port in the US (that’s sea, not internet, port!)

To which I’d like to modestly add:

Home of the Best (and Only) Pediatric EMR Workflow System”

Most of our product website focuses on EMRs for pediatrics and related primary care specialties. This blog is more opinionated and predictive about where I think healthcare is going (application of business process management to process-aware EMRs). The white paper states the more general (not pediatric-specific) case for EMR/EHR workflow management systems while maintaining focus on more immediate benefits.

Below is the beginning and end of the white paper. If you want to fill in the gap (”…”) you can download the complete document here.

Electronic Health Record Workflow Management Systems:
The Next Step in EHR Evolution

Nov 1, 2009

Charles Webster, MD, MSIE, MSIS
Chief Medical Informatics Officer
EncounterPRO Healthcare Resources, Inc.
Atlanta, Georgia

Implementing an Efficient Electronic Health Record

Electronic Health Records (EHRs) are becoming more than just electronic patient documentation systems; they are evolving into tools that assist physicians in managing the patient care tasks they perform for major types of patients they see. These systems allow providers to analyze, manage and optimize the work that has to be performed, as well as to direct and to delegate it to others. EHRs based on a Workflow Management System (WfMS) accomplish this by offering a way for the user to customize workflow to practice specialty, to local clinical and administrative processes and to user preferences. If an EHR can be instructed to do tasks in a customized sequence - automatically - based on who the patient is, why they came to the office, what care needs to be provided, when and where care needs to be provided, and how it best fits the office staffing, the EHR is not just a patient documentation system, it is an EHR Workflow Management System.

Workflow Management versus Mere Workflow

Most EHRs have basic task management functionality, yet very few are built upon a user-controllable WfMS “engine.” “Workflow systems” and “Workflow Management Systems” are frequently confused and poorly differentiated, yet there is an important distinction. This distinction is particularly important to know if a physician is planning to automate his or her office and is in the market for an EHR. A Workflow Management System is a software application that stores and executes workflow (or process) definitions to create and manage workflow processes by facilitating interactions among users and applications. Users usually interact with workflow systems, not the WfMSs used to implement them. It is the underlying WfMS that allows a workflow system to be flexibly tailored to local processes and user preferences, and to be easily monitored and maintained by the user, not the computer software vendor. The less a user is dependent upon their EHR software vendor, the faster changes can be made and the less maintenance cost there will be.

…

Conclusion

The earliest EHR systems were developed primarily to automate patient charting functions. If an EHR cannot chart patient data, then it scarcely seems to qualify as an EHR at all. Next, additional functions and capabilities were added in a drive to eliminate paper (except for that which must be scanned in from the outside world or printed in order to communicate). However, even when the paperless office is achieved, this does not mean that the paperless office is efficient. The availability of WfMS-based EHRs brings us to that next step in the evolution of the EHR development, in which we have not only gotten rid of paper but inefficiencies as well. EHR WfMSs have already begun to impact the EHR market. Each of the first three Health Information Management and Systems Society’s Davies Awards (2003, 2004 and 2005) included physicians who relied on a WfMS-based EHR (the EncounterPRO EHR) to achieve remarkable improvements in volume, billing, cost, and convenience – for themselves and their patients.

When looking at an EHR, one may wonder whether or not it is an EHR WfMS; simply ask this question: Who or what is the workflow engine? If the answer is “who”, this is bad, because “who” is a person; a potentially expensive professional who should not be wasting their time pursuing non-value-added EHR activities. If the answer is “what”, this is good, because “what” is a much less expensive inanimate object; the computer. If the computer can accomplish non-value-added activities and help coordinate value-added activities, then workflow is likely being automated by a true Electronic Health Record Workflow Management System.

This post is fourth in a series about EMR workflow systems and the high performance medical home model. The first post presented 12 key quotes. The second post introduced coordinated workflows among pediatric, subspecialty, and other primary care practices. The third stressed creation of well understood, consistently executed, adaptively resilient, and systematically improvable workflow within and between practices. This post discusses how to select a future proof pediatric EMR.

I took a short virtual tour of just a few websites of pediatricians who use the High-Usability EncounterPRO Pediatric EMR Workflow System. I read their staff bios and mission statements. Guess what? Many pediatricians practice with subspecialists in such areas as cardiology, neurology, gastroenterology, endocrinology, nephrology, allergy/immunology, emergency medicine, and developmental-behavioral pediatrics (and that was just a sampling from about 15 percent of our customers). Many pediatricians also practice with other primary care physicians in family medicine, general internal medicine, and obstetrics & gynecology. Some pediatricians are double (or even triple) board certified.

Communication of Shared Meaning across Specialty Boundaries

If you are a pediatrician, reflect on how much you know about the other medical specialties that you call on when you refer a patient. Throughout your career, starting in medical school, you’ve been exposed to much more than pediatric medicine and you use this knowledge to better coordinate your patients’ care. Consider how you communicate with a physician from another different specialty. Each of you share a common foundation of basic medical knowledge, plus you both understand enough about the other specialty in order to communicate. You use words to mean the same thing.

Soon your EMR will need to be like you, and know enough about other specialties in order to coordinate care with other EMRs. They need to mean the same things.

Meaning is shared between two systems (human or computer) when the following occurs:

1. An external real world entity (drug, diagnosis) is referred to by an internal concept
2. The internal concept is encoded as symbol (word, number, ICD-9 code)
3. The symbol is transmitted across a channel (air, paper, TCP/IP, string)
4. The symbol is decoded to an internal concept
5. The internal concept refers to the same external real world entity (drug, diagnosis)

Two systems that can do this are “semantically interoperable.”

Of course, it is more complicated than I make it seem. For example, meaning is usually composed smaller bits of meaning (AKA “words’” as in my “Chuck likes workflow”  sentence diagram). However, my simplified portrayal is sufficient for the main point I will make below.

General-purpose versus Specialty-specific EMRs

You may be aware of a recurring debate about so-called general-purpose EMRs versus specialty-specific EMRs. Applied to pediatrics it goes like this: general-purpose EMRs were designed for adult medicine and lack pediatric-specific functionality (screens, picklists, and workflow). As a result they cannot do what a pediatrician needs quickly and easily. Homegrown pediatric-specific EMRs on the other hand started with pediatric-specific functionality, carry out stereotypic pediatric workflows, and don’t try to be anything besides a pediatric EMR.

Sounds like a slam-dunk for the pediatric-specific EMR, right? The problem with this debate is that only makes sense for traditional EMRs that lack customizable workflow. An EMR workflow system can support multiple specialties (including general adult medicine) working off the same patient database and make is seem to each specialist (or generalist) as if they are using their own specialty-specific EMR. That was the point of quotes 6 and 8 in the post that kicked off this series on the relevance of EMR workflow systems to the medical home.

Think about the implications for coordinating workflow between pediatricians, subspecialists, and other primary care physicians to achieve the high performance medical home. Some multi-specialty practices already market themselves this way:

“When your family physician or your child’s pediatrician determines you or your child should see a specialist that usually means a trip down the hall. Don’t worry about carting your records. Our modern electronic medical record system makes sure you have the best care from each specialist under the watchful eye of your personal physician. And when your child grows up, transition is seamless to a family medicine physician who will also coordinate the best care possible”

These practices are taking advantage of a multi-specialty capable EMR to implement a version of the medical home, by taking advantage of the default “semantic interoperability” gained from sharing the same EMR database.

Wait it minute, you say. You could stipulate that EncounterPRO is an an ideal vehicle for implementing a high performance pediatric medical home *if* everyone uses the same EncounterPRO database. However you are a solo pediatrician. Why should you care?

I wish I could say “Simple!…” but I can’t. Some answers deserve to be complicated, and this is one of them.

(That said, click here to skip the complicated stuff anyway and get to my point.)

Of Data Models and Medical Ontologies

Reconsider steps 1-5 to transmission of shared meaning and achieving semantic interoperability. In step 2 a concept refers to a real world entity and is encoded as a symbol. In step 4 a concept refers back to the real world entity. If either source or target EMR lacks the right concept, meaning is not successfully shared. Where do these EMR “concepts” come from?

They come from each EMR’s conceptual data model, which is:

“…a map of concepts and their relationships. This describes the semantics of an organization and represents a series of assertions about its nature. Specifically, it describes the things of significance to an organization (entity classes), about which it is inclined to collect information, and characteristics of (attributes) and associations between pairs of those things of significance (relationships).”

Let’s see if I can make use of my word substitution technique to make the above quote more relevant:

…a map of pediatric, subspecialty, and primary care concepts and their relationships. This describes pediatric or primary care practice clinical knowledge and operational workflow. Specifically, it describes the things of significance to an organization (patients, body parts, diseases, treatments, specialties etc.) , about which it is inclined to collect information, and characteristics of (such as size, weight, duration, etc.) and associations between pairs of those things of significance (such as has-assessment(Tom Smith, asthma), is-prescribed (Tom Smith, Albuterol), is-specialty(Dr. Jones, pediatric neurology), common-assessment(epilepsy, pediatric neurology)).

Data models are closely related to ontologies, increasingly proposed to provide semantic interoperability between EMRs.

“An ontology defines a set of representational primitives with which to model a domain of knowledge or discourse.  The representational primitives are typically classes (or sets), attributes (or properties), and relationships (or relations among class members)….The key role of ontologies with respect to database systems is to specify a data modeling representation at a level of abstraction above specific database designs (logical or physical), so that data can be exported, translated, queried, and unified across independently developed systems and services.” (Tom Gruber, Ontology, Encyclopedia of Database Systems, Ling Liu and M. Tamer Özsu, Eds., Springer-Verlag, 2008, retrieved 12/2/09)

(Ah yes…takes me back to my Knowledge Representation course in Intelligent Systems at Pitt.)

I could substitute in words from the pediatric and primary care domain as I did before, but you get the idea. A medical ontology or data model is the set of things, stuff, objects, entities, individuals, etc. (for examples, patients, body parts, diseases, treatments, specialties etc.) about which a community of medical agents can think and communicate. These entities have properties (such as size, weight, duration, etc.) and relationships (has-assessment, is-prescribed, is-specialty, common-assessment, and so on). And an EMR can only do things and communicate about them consistent with its domain model.

Again I simplify, as was the case when I described the five steps to successful transmission of shared meaning. It’s still sufficient to make my main point (which is…).

What’s my point? Intelligent systems (you, or increasingly, EMRs) cannot communicate about concepts they cannot represent. First used in a pediatric office (1995), today most EncounterPRO users are pediatricians. However, EncounterPRO is also used by pediatric subspecialists and other primary care physicians. Its data model was designed from the get-go to be used by multiple related specialties, even if it is best known as a pediatric-specific EMR. Its screens, picklists, and workflows serve the same complimentary specialties that will need to coordinate their activities to achieve the high performance pediatric and primacy care medical home.

“I am a solo pediatrician, why should I care about multi-specialty EMRs?”

To future proof your practice.

• You may eventually add a pediatric subspecialty or other primary care specialty to your list of board certifications—EncounterPRO’s specialty-specific automated workflows will switch specialties when you do.
• Your practice may add a subspecialist or non-pediatric primary care partner—specialty-specific workflows will allow you and your partners to “Have It Your Way” while not stepping on each other’s toes.
• Or you may need to communicate and coordinate with other general-purpose or specialty-specific EMRs as part of a high performance virtual medical home.

If you think any of these events may happen in your future, please consider getting a pediatric EMR that can do more than pediatrics.

The key insight I hope to impart in this series of posts that started with 12 quotes is this: Well understood, consistently executed, adaptively resilient, and systematically improvable workflow *between* health care organizations is not possible without well understood, consistently executed, adaptively resilient, and systematically improvable workflow *within* health care organizations. Each post tries to achieve this goal in a different way.

This Week I Play With Words

My plan was to start with authoritative statements from both the primary care and workflow automation domains, and then systematically describe how the ideas they represent fit together. One way to do this is to take a quote from one domain, insert, delete, and substitute some words from the other domain, and see if the quote still makes sense (if this sounds a little flakey, hang in there). For example, “BPM suites coordinate tasks and synchronize data across existing systems,” becomes “EMR BPM suites coordinate clinical tasks and synchronize clinical data across existing systems,” and the phrase “work-in-progress” becomes “care-in-progress,” and so on.

You get the idea. Here’s quote 12 from the BPM domain:

1. Papazoglou and 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.”

Here’s the BPM quote applied to the pediatric and primary care coordination domain:

1. Webster, adapted from Papazoglou and Ribbers:  
   1. EMR BPM suites 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.
   2. A true pediatric EHR BPM suite enables pediatricians and staff to:
      1. Model and simulate all interaction patterns between physicians and other clinical and non-clinical staff, systems, and information sources to create shared understanding about how to optimize care coordination processes and results. [CW: “well understood"]
      2. Coordinate and manage the handoff of patient care tasks across organizational boundaries. [CW: "consistently executed"]
      3. Provide real-time feedback to pediatricians and care coordinators about care-in-progress to support patient care process adjustments. [CW: "adaptively resilient"]
      4. Monitor care coordination outcomes to performance targets, and continuously refine and adjust care coordination process flows and rules. [CW: "systematically improvable"]

Sounds good! I’d consider such a product if I wanted to build a high-performance pediatric and primary care medical home system. Actually, I do. And you should too.

Several comments:

First, I emphasized “care coordination” rather than simply “patient care” or “healthcare” because I wanted to stress the relevance of workflow and BPM technology to the care coordination aspect of the pediatric health system as described in quote 3.

Second, I emboldened four bracketed phrases of my own contrivance (“well understood,” “consistently executed,” “adaptively resilient,” and “systematically improvable”) because they provide a useful checklist, so to speak, for comparison of traditional EMRs to process-aware EMRs (“process awareness” being a prerequisite for applying BPM to EMR processes).

And third, a caveat—EMR BPM doesn’t exist yet. You can’t simply buy a BPM suite and use it for EMR BPM. Right now the closest you can get to EMR BPM is an EMR workflow system. However EMR workflow systems have the process-aware foundations required for full-blown EMR BPM, that is, well understood, consistently executed, adaptively resilient, and systematically improvable EMR-mediated care processes.

Let’s Try It Again

Recall the topics of pragmatic interoperability and conversations between EMRs in a previous post? Quote 7, adapted from the original, described a conversation between the EMRs representing a community pediatrician and a pediatric subspecialist. Let’s further adapt it to a diagram of an “e-contract” (quotes 10 and 11) between two workflow management systems (circa 2000, though I was not aware of it at the time).

Adapted from Figure 1 in Grefen, Aberer, Hoffner & Ludwig,
CrossFlow: Cross Organizational Workflow
Management inDynamic Virtual Enterprises, 2000.
(http://lsirpeople.epfl.ch/aberer/PAPERS/CSSE%20′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)

Here’s quote 7 after I’ve inserted “Invoke,” “Monitor,” “Control,” and “Get Result” at the places in text that correspond to the arrows in the diagram:

“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 (“Invoke”) 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 (“Result”), 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 (“Monitor”), 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 (“Control”) 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.”

The quote above is a “conversation” between two EMRs, one acting for a pediatrician, the other acting for a pediatric subspecialist. Similar sorts of diagrams are possible for a subspecialty-based medical home for pediatric patients that require regular visits to pediatric subspecialists, or for transfer of a patient’s records from a pediatric to an adult medical home. One of the advantages of workflow automation is that process definitions can change without resorting to rewrite of the programming code that makes EMRs possible. It should be up to pediatric, subspecialist, family medicine, obstetrics & gynecology, and other primary care stakeholders, to negotiate cross-practice EMR workflows and e-contracts consistent with their clinical and business objectives. They should not need to take into account the fragile, ambiguous, unscalable, frozen workflows of traditional EMRs (that is, EMRs lacking workflow management system foundations and BPM functionality).

When presenting a new concept (to my intended audience, I certainly didn’t invent the ideas, just this specific example of their application), it can be helpful to present the same basic idea in several different ways. The following is another diagram of a process shared across organizations.

This figure  is adapted from the introduction to the 2001 dissertation, The Contracting Agent: concepts and architecture of a generic software component for electronic business based on outsourcing of work. (Andries van Dijk. - Eindhoven : Technische Universiteit Eindhoven). Workflow Engine A kicks off workflow A1 through A5, but between A3 and A4 outsources steps B1 through B3 via Web services.

Rob Allen’s Workflow: An Introduction also covers communicating workflow engines at a basic level (pages 10-24) and is a useful overview of workflow in general.

I can’t resist my little word substitution game again. Dr. van Dijk also notes:

“An influential approach to the modelling of communicating information systems is called the language / action perspective (LAP). The basis for LAP was a growing awareness that linguistic theories are relevant for the design of communicating information systems. A cornerstone of the LAP approach is the linguistic theory of speech acts developed by Searle in 1969.”

You would surely agree that an EMR is an “information system,” and that “interoperating” is an instance of “communicating,” so replace “communicating information systems” with “interoperating EMRs” and you get:

“An influential approach to the modelling of communicating information systems is called the language / action perspective (LAP). The basis for LAP was a growing awareness that linguistic theories are relevant for the design of interoperating EMRs. A cornerstone of the LAP approach is the linguistic theory of speech acts developed by Searle in 1969.”

I previously mentioned relevance of linguistic theory to EMR interoperability–I rest that case.

An Obvious Question

 An obvious question occurs. If there is such a great “fit” between what EMRs need and what workflow systems and business process management do, why hasn’t it happened yet? I myself have been puzzled by this. I think there is an element of NIHism (Not Invented Here-ism). The United States is a remarkable generator of new information technologies, from the large high tech companies to the university spin-offs to inventors who start in a garage (as was literally so in EncounterPRO’s case). Much workflow research took place, and many commercial BPM products created, outside the US (as I noted previously).

However, EMR workflow management systems are not prevalent in Europe either (the Soarian system, initially developed in Germany, being the sole exception of which I am aware). So I have another theory, which I will hold for a later post.

Nonetheless, workflow management systems and business process management technology is diffusing into the healthcare industry at an increasing rate. Some day most pediatric and primary care (and other general-purpose and specialty-specific) EMRs will be EMR workflow systems, although by then I expect the phrase “workflow system” to disappear. It will be the non-workflow system EMRs that will require qualification, much as we use “analog watch” or “silent movie” today (so-called retronyms) to distinguish them from their modern descendants.

Last week I posted 12 quotes, three from pediatrics and primary care sources, five from computing sources, and four from me or the High-Usability EncounterPRO Pediatric EMR Workflow System website. What was my purpose?

My purpose was and is (as usual) to raise the profile of workflow management systems and business process management with respect to the important goals of increasing the effectiveness and efficiency of, and participant satisfaction with, healthcare processes. So far, my posts have alternated among praising WfMS and BPM technology, arguing that EMR systems need to rely on process-aware foundations, and asserting that traditional EMRs lack this critical prerequisite for systematic improvement of effectiveness, efficiency, and satisfaction. I chose these 12 quotes about key concepts to make a point: The central problem we face in improving healthcare and “bending the cost curve” is the need for better coordination.

So far, the most comprehensive vision of care coordination is the medical home model (quote 1). So far, the most comprehensive technology for coordinating complex interdependent activities is workflow management systems and business process management. I wanted to start with authoritative statements (quotes 1-12) from both domains and then systematically describe how the ideas they represent fit together. I hope to convince you (if not in this post, then perhaps in a future post) that the high-performance medical home requires coordination infrastructure that is not, and in fact cannot, be provided by traditional EMRs. However, EMR workflow systems are prime candidates for providing important portions of this infrastructure.

May I regress? When I was a graduate student in Intelligent Systems I took courses in linguistics, including phonetics, morphology, syntax, semantics, pragmatics and discourse analysis (plus computational linguistics and natural language processing and generation). These courses were about communication between humans–and between humans and computers. It turns out that syntax, semantics, and pragmatics (and possibly discourse analysis as well) are also relevant to communication between computers, including EMRs.

Much is made of the need for EMRs to interoperate with each other and other information systems (as well it should). Current efforts focus on syntactic and semantic interoperability. Syntactic interoperability is the ability of one EMR to parse (in the high school English sentence diagram sense) the structure of a clinical message received from another EMR (if you are a programmer think: counting HL7’s  “|”s and “^”s, AKA “pipes” and “hats”). Semantic interoperability is the ability for that message to mean the same thing to the target EMR as it does to the source EMR (think controlled vocabularies such as RxNorm, LOINC, and SNOMED).

Plug-and-play syntactic and semantic interoperability is currently the holy grail of EMR interoperability. We hear less about the next level up: pragmatic interoperability. As soon as, and to the degree that, we achieve syntactic and semantic interoperability among general pediatric, pediatric subspecialty, and other primary care EMRs, issues of pragmatic interoperability will begin to dominate. And they will manifest themselves as issues about coordination among EMR workflows.

Here are succinct descriptions of semantic versus pragmatic interoperability:

“Semantic interoperability is concerned with ensuring that a symbol has the same meaning for all systems that use this symbol in their languages. Symbols are real world entities indirectly (i.e., through the concept they represent). Therefore, the semantic interoperability problems are caused either by different abstraction of the same real-world entities or by different representations of the same concepts….”

“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. Pragmatic interoperability problems arise when there are differences in the meaning of data in the exchanged messages (e.g., semantic problems) or there are differences in the interaction protocols of the systems that exchange these messages.” (p 44, Pokraev, Model-driven semantic integration of service-oriented applications. PhD thesis, Univ. of Twente, 2009)

I’ll return to issues of semantic interoperability between pediatric EMRs and between pediatric and non-pediatric primary care EMRs in a future post. But in this post, I’ll focus on pragmatic interoperability as it relates to the high-performance medical home model.

Pragmatic interoperability is not possible without semantic and syntactic interoperability, and semantic interoperability is not possible without syntactic interoperability. Makes sense; you and I (and EMRs, intelligent systems all–eventually) have to parse what we hear (download, import, etc.) before we understand it, and we need to understand what we parse before it can have its intended effect, which is often to cause us to act in coordination with the source of the message.

(If a “conversation” ensues, we’re getting into theories of discourse analysis. I do think that EMRs eventually will indeed “converse” among themselves, engaging in the equivalent of “coherent sequences of sentences, propositions, speech acts or turns-at-talk”. In fact, one of the first theories of workflow relied on speech acts (see this early tutorial on ”Coordination-based Workflow” [emphasis not in original]) and one of the first workflow management systems relied on this theory. The conversational metaphor is already being exploited within the SOA (service-oriented architecture) community and eventually will surely diffuse into discussions about EMR-to-EMR and EMR-to-non-EMR interoperability. Of course, individual “sentences” will most likely be based on an artificial language, perhaps a future version of HL7, not natural human language.)

OK, back to the high-performance pediatric medical home. It won’t be possible without coordinated pragmatic interaction among pediatric, pediatric subspecialist, and non-pediatric primary care EMRs. Note that I did not say interaction among pediatricians, pediatric subspecialists, and primary care physicians. Yes, the pediatric and primary care medical concept is possible without EMRs. It just won’t be high performance, that’s all. Without automated communication between EMRs the high-performance part of the pediatric medical home simply won’t be possible. Humans, including pediatricians (and their staff), are slow (no offense!), inconsistent (no offense!), and expensive (no offense!), compared to automatically communicating information systems.

EMRs in general, and most pediatric EMRs in particular (whether they are general purpose EMRs adapted to pediatrics or home-grown specialty-specific EMRs), have the same problems that motivated the best known process-aware information system—BizTalk Server.

“With the integration and communication infrastructures complete our applications can now ’speak’ to other applications over the Internet, but we don’t have a good mechanism for telling them when and how to say it. We have no way of representing the process. Today the ‘process’ is spread throughout the implementation code of every participant involved in the process. This mechanism for representing the process of business interactions is fragile, prone to ambiguities, does not cross organizational boundaries well, and does not scale. The larger the process gets and the more participants that are involved, the more static the process is and the harder it is to propagate changes and new players into the process” (BizTalk Orchestration - a new technology for orchestrating business interactions, Microsoft Research, 2000, quoted in Andrade et al, Coordination for Orchestration, Arbab and Talcott, Coordination Models and Languages, 2002, my emphasis)

By the way (just so you don’t get the wrong idea), simply adding a BizTalk adaptor to a traditional EMR won’t turn it into a process-aware EMR workflow system. That’s not my point. My point is—use of traditional EMRs to implement the care coordination infrastructure required by the medical home model will result in fragile, ambiguous, unscalable, frozen cross-organizational workflows, the opposite of a “high-performance” medical home. Even Microsoft agrees with me (although it would be more pragmatically accurate to say I agree with Microsoft).

More, much more, later…

• Politician: It’s the coordination, stupid!
• Real Estate Agent: Coordination, coordination, coordination!
• Chuck Webster: Coordination is what EMR workflow systems do.

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.” (www.aap.org/healthtopics/medicalhome.cfm, 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.” (EncounterPRO Pediatric EMR Workflow System vision)
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, http://lsirpeople.epfl.ch/aberer/PAPERS/CSSE%20′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.

This Saturday I spent a pleasant day with my wife in New York’s Central Park watching the leaves, dogs, and people compete for attention. The dogs won.

My mind wandered to an offhand remark I made several weeks ago about “form following function” accounting for the appearance of the High-Usability EncounterPRO Pediatric EMR Workflow System. I know that some dogs are bred for show and others are bred for performance. Might there be an analogy between dog breeds and EMRs? (Yeah, I know, bit of a stretch, “wandered” might be an understatement.)

I found the following at Canine Diversity FAQ on dogdimension.org:

What is meant by “form follows function”?

When we say “form follows function” in a dog breeding context we mean that the most efficient physique for a particular breed purpose will, over time, be produced simply by mating dogs that successfully fulfill that purpose, with no need for breeders to hold theories about the relative lengths and angular relationships of bones of the skeleton, or to breed according with such theories. The most successful examples of dogs able to fulfill their purpose will automatically be the ones that are best adapted physically to that purpose.

Novice breeders sometimes fall into the fallacy of believing that in order to breed a good working dog, it is necessary to practice canine engineering, attempting to construct a physical machine according to a plan or blueprint laid out in the breed standard. This amounts to an inversion of “form follows function” into “function should follow form.” In practice, the most critical factors in working dog performance are usually mental, behavioral, and metabolic; the dog must have a mentality, behavioral traits, and energy metabolism adapted to breed purpose. These things are far more important than theories of “conformation,” many of which are often far removed from the form that is actually most efficient for a given purpose.

Many EMRs conform to stereotypes and checklists. In contrast, I’d categorize EncounterPRO as a “good working dog.”

Enough deep thoughts—here are the photos.

“Right side! That’s my good side. Must remember to lick to the right!”

“I know what my best side is!”

“While he sleeps, I watch.”

“You think I’m cute?…”

“…I AM ‘WHITE FANG’!”

“How do I feel about my owner today? Does she deserve the ball?
What’s in it for me? I’m teetering on a knife edge here folks…”

“Paparazzi! Pleh! Can’t they leave us alone?!”

[See post to watch Flash video]

“White Fang: The Movie”
(small dog! best viewed in full screen
mode, black square lower right)

 Next week, back to more serious stuff. Thanks for indulging me!

Checklist: “A list used to ensure that no tasks are omitted, no important aspects are forgotten, and all key functions are checked”

Advantages of usability checklists include:

• “practical”
• “visible to clients and evaluators in terms of purpose”
• “quick to administer”
• “relatively comprehensive”
• “flexible and undemanding in analysis”

I like checklists, especially for pilots and kickbikers. In my previous post “An Untraditional Website for an Untraditional Pediatric EMR” I listed my ten top favorite age-related Web accessibility guidelines (similar to, though not exactly, a checklist). However, my perspective on EMR usability checklists, as someone who’s taken a few courses in human factors and cognitive science–is a bit skeptical. But, I’m even skeptical about my skepticism, so at least I’m willing to be convinced otherwise.

To understand my concerns you need to realize the degree to which usability engineering is applied cognitive science.

Cognitive Science is the Iceberg

Why do I bring up cognitive science? Because EMR usability checklists are just the tip of a cognitive-science-applied-to-EMRs iceberg. If all you know or care about is the part of the iceberg that is visible and above the water, well, you don’t understand the complete picture.

Let’s start with the part of the iceberg that’s beneath the waterline. On my shelf, from one of my courses, is the first edition of Cognitive Science: An Introduction. Published by MIT Press in 1987, its introductory description of cognitive science holds up well.

One of the most important intellectual developments of the past few decades has been the birth of an exciting new interdisciplinary field called cognitive science. Researchers in psychology, linguistics, computer science, philosophy, and neuroscience realized that they were asking many of the same questions about the nature of the human mind and that they had developed complementary and potentially synergistic methods of investigation. The word cognitive refers to perceiving and knowing. Thus, cognitive science is the science of mind. Cognitive scientists seek to understand perceiving, thinking, remembering, understanding language, learning, and other mental phenomena. Their research is remarkably diverse, ranging from observing children, through programming computers to do complex problems, to analyzing the nature of meaning.

Since the above description was written, anthropology has been admitted to the fold. While I haven’t taken any actual courses in it, I’ve followed anthropology’s contributions to cognitive science and medical informatics, including theories of distributed and team cognition. An aside: My interest in anthropology began when I read Spradley’s Participant Observation, published just before I started medical school. My intention was to keep a set of field notes about my experiences. Swamped, I shelved the project. However, it turned out that one of my anatomy lab mates was studying me!  Segal, Daniel. 1988. “A Patient So Dead: American Medical Students and Their Cadavers.” Anthropological Quarterly 61:17-25. It happened again during my Intelligent Systems degree at Pitt. My interest remains piqued.

By the way, in a previous post I distinguished between traditional EMRs, based on declarative representations of medical knowledge and patient data, and EMR workflow systems in which procedural knowledge about workflows and processes is represented. The declarative/procedural distinction is a classic topic in cognitive science.

Usability is the Tip of the Iceberg

The most frequently cited definition of usability is from the International Organization for Standardization:

The effectiveness, efficiency, and satisfaction with which specified users can achieve specified goals in a particular environment.

In a three hour tutorial I used to give at TEPR (2004-2006), called EHR Workflow Management Systems: The Key to Usability, I would critique definitions of usability from “User friendly” to the ISO 9241 definition.

(One of these days I’m going to update and publish those slides. Stay tuned. $300 value–I believe that was what about what TEPR charged about a hundred folks to attend.)

I tweaked the ISO definition (am I in trouble?)  to emphasize the relevance of EMR usability to the collaborative performance of teams of users.

The tweak–from

• users-to-users,
• goal-to-goals, and
• environment-to-environments

–is due to my engineering background. 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. Even if pediatric EMR usability checklists work, with respect to a single user, goal, and environment, there 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.

As soon as one begins to think about usability in terms of cognition distributed across teams of humans embedded in a EMR workflow matrix, what I call the “three multis” come to the fore:

• multi-encounter,
• multi-site, and
• multi-specialty.

The three multis–spanning time, space, and specialty–are relevant to the pediatric medical home model, in a systems engineering sort of way. I mentioned the three multis in my 2003 white paper, “EMR Workflow Management: The Workflow of Workflow” (page 6), but I’ll more systematically highlight their relevance to the goals of the medical home model in a future post.

Why Am I Skeptical?

As I do appear to like usability, the topic, why am I skeptical about the use of checklists to measure EMR usability?

1. Most checklists I have examined are not based on sophisticated notions of EMR workflow management. There is a deep and profound connection between workflow and usability (previous post: “Pediatric EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow“). Since most EMRs are not workflow systems, the checklists I have seen don’t do this connection justice.
2. If usability is relative to a specified user (such as pediatrician) and goal (managing a pediatric patient) in a particular environment (a real pediatric practice), how can someone–who is not the specified user (usability expert, not pediatrician), does not have the same specified goal (measuring usability, not managing a pediatric patient), and does not operate in the user’s particular environment (simulated, not real)–accurately estimate usability? There are ways around this, such as participant observation and other techniques to study cognition in the wild. But they do not lend themselves to checklists.
3. Folks underestimate the long-term strategic cost of discouraging new, different, innovative, and improved EMR user interfaces, when they argue that current EMR user interfaces should be standardized to maximize positive transfer of learning between them. Recall the resistance from some DOS users to adopting the graphical operating systems from Apple and Microsoft? (By the way, the Xerox Star 8010 Dandelion, the first graphical user interface I used, predated the Apple Lisa by two years and Windows 1.0 by four years: Video 1. Video 2. Look familiar?). Usability checklists developed for DOS applications would have retarded, not encouraged, long-term OS UI usability. Let’s not make that mistake with EMRs.

Apply cognitive science to improve the human-computer interface; you get usability engineering. Apply usability engineering to improve the physician-EMR interface; you get EMR usability checklists (among other things). These checklists are the distilled residue of a tremendous amount of theoretical and experimental investigation. To adopt any of these checklists without understanding the cognitive science behind the usability, or the systems engineering behind the engineering, is to mistake the tip of the iceberg for what keeps it afloat.

Come to think about it, I’m not skeptical about EMR usability checklists, just their unskeptical use.

OK. That was me playing devil’s advocate.

So, convince me otherwise.

P.S. Here’s my weekend kickbike checklist (copied directly from my phone):

Edit
5:48 AM, April 1, 2007  
 
Kickbike checklist
Binocs
Tea/water
Sun glasses
Metrocards
Food/dessrt
Books
Music/head phones
Chairs
Forks
Plastic bags
Paper towels
Toolkit
Nuts (for squirrels)
Check air
Towel
Bug spray
Camera
Extra shirts (if summer)
Sunday paper
Allen wrench for stems black tape on it
Silver multitool thingy
Two ball end wrench for lever on allen wrench
Air pump

Folks ask why our pediatric EMR looks so different from traditional EMRs. I’m also asked why our product website looks so different from other EMR product websites. There is a connection.

The following Dilbert comic strip (circa 1999) was taped to my door for years (and must be around somewhere, because I would not have knowingly tossed it).

I’ll get back to the strip later.

The High-Usability EncounterPRO Pediatric EMR Workflow System is designed to be used in the fast-paced, dynamic, and distracting environment of a pediatric office. Its large buttons, and ability of compensate for less than perfect environmental conditions, are based on the same design principles that make senior-friendly products senior-friendly and pilot-friendly cockpits pilot-friendly. The basic idea is “senior-friendly is everyone-friendly is pediatrician-friendly.” 

My Top Ten Age-related Web Accessibility Guidelines

1. Large buttons (”actual” EncounterPRO buttons) and underlined hyperlinks (retro!)
2. No menus, shallow hierarchy
3. Large san-serif font, extra space between lines
4. Black on white and lots white space (most important material in foveal vision)
5. Frequent emphasized headlines (chunked for skimming)
6. Important phrases highlighted (again, for skimming)
7. Glossary for technical terms
8. Text-relevant illustrations (no generic clip art or photos, multimodal depth of processing issue)
9. Omnipresent sitemap (such as a comprehensive navbar or fat footer)
10. Redundant and intrapage navigation, backward and forward links (retro!)

You may disagree with some of these guidelines (and accessibility researchers often disagree among themselves). They’re just the ones that have made the most sense to me over the years. By the way, senior-friendly and child-friendly usability guidelines have a lot in common, but I’m going to reserve that material for a  future post.

Feel free to do your own research and weigh in.

www.google.com/search?q=web+accessibility+age+OR+senior+OR+older

Traditional EMR product websites do not typically follow these kinds of guidelines. Many websites are (allusion to comic strip ahead) some combination of Flash and html, or, even if there is no Flash present, they look “webbish” in that way: small form factor crammed with small font text, lots of menus, and generic medical illustrations (mostly happy medical professionals). And no fat footers or backward and forward links.

If you design for usability based on age-related accessibility guidelines, interestingly, the result is a bit retro. This is both understandable and not bad. After all, the DrudgeReport is, by some accounts, the best designed site on the web *and* looks like it’s caught in a mid-nineties time warp. One shouldn’t be surprised, since design principles should be timeless. They are a consequence of the structure and function, and therefore limitations, of our human body and cognitive systems. Part of the problem is that “webbishness” trumps good old-fashioned usability and accessibility.

Some of the following are a bit whimsical, but all contain at least a grain of truth:

My Top Ten Reasons for Designing A Senior-Friendly Pediatric EMR Website

1. Show that we know and care about accessibility. The EncounterPRO EMR benefits from guilt by association with website.
2. Maximize length of time on website by making it easy on the eyes and obvious to navigate.
3. Appeal to older pediatricians. Supposedly, older physicians are slower to adopt EMRs. Andrew Erikson posted this comment about traditional EMRs prompting physicians to retire. (Might the teensie-weensie little eye-straining checkboxes and radio buttons be part of the problem?) We think that EncounterPRO is ideal for the semi-retired pediatrician who just wants a part-time practice.
4. Seniors are the fastest growing web user demographic.
5. Both sets of my, and my wife’s, parents are alive and clicking, and I’d like them to appreciate this work of great usefulness and beauty.
6. I am the most frequent visitor to our website and *I* appreciate less eye strain, easy to recognize hyperlinks, and large targets to click.
7. To make a point by being symbolically different and memorably distinctive.
8. Generate interesting material for a blog post; after all, *you’re* reading this, right?
9. More and more children have senior caretakers. Pediatric practices sometimes link to the website of their EMR vendor (example, lower right) to show they are using the latest technology to help their patients.
10. Seniors like to print websites. I do too. The pages print well.

The Unbearable Sameness of EMR Brochureware Websites

Most EMR product websites look and feel alike for three reasons.

1. They are based on templates.
2. They are “designed” by management.
3. They are about similar products.

By “based on templates” I do not refer to templates used by EMRs, but rather to the content-free templates into which is stuffed information about the EMR product. The vendor may have downloaded an inexpensive template from an online store such as templatemonster.com or relied on a web marketing company. If a marketing firm is engaged, to keep costs down they usually have their own inventory of templates from which they select and mock up a few designs, and go with whichever the EMR vendor prefers. It used to be that you could tell a Frontpage website from a mile away. Now what’s obvious is the whole generic corporate sameness and lack of personality that characterizes most EMR brochureware websites.

By “designed by management” I mean that most EMR websites are designed to please upper level EMR vendor management (a la Dilbert’s Pointy-Haired Boss: “The website needs to be more webbish. But not too webbish.”). The folks who have the fire in their belly, who know and love their EMR, do not typically design the websites that ought to convey this knowledge and love. The result is a distance between the slick professional marketing orientation of the website and the immediate raw authentic experience and dreams of EMR users and designers.

By “similar products” I mean that most traditional EMRs are the clickity-clickity-click-click-click structured document management systems to which I referred in last week’s post.

Applying similar website templates to similar EMR products to please similar people yields similar outcomes. That’s why the EncounterPRO Pediatric EMR Workflow System website doesn’t look like other EMR websites. You can’t tell a book by its cover, but sometimes you can tell an EMR by its website.

Dont Confuse a Pretty Website with a Useful Website, or a Pretty EMR with a Usable One

Most managers, and many of the website designers who cater to them, mistake pretty websites for useful websites. Useful websites are found by the right people to deliver the right information to improve their lives.

Imagine what encounterpro.com looks like to a search engine. Notice that the images are absent but the words remain. Search engines can’t see (yet); they can only read (oops! spoke too soon). Content is king, as the saying goes, and, for the most part, content = words. And not just any words in any order will do. As Flash and as webbish and as social and as interactive as the web has become, in most cases the majority of the value of a website to its visitor is thoughtful, knowledgeable, and compelling prose. About a subject that is important to the reader. That helps them improve their lives.

Honestly, if ten years from now most successful EMRs are EMR workflow systems, but the EncounterPRO Pediatric EMR Workflow System isn’t one of them, we will still have made an important contribution to healthcare.  This is what I meant in an earlier post by “Sell an idea, not a product.” That said, the best, and most certain, way to long-term success for our pediatrician customers and for us, is to challenge, educate, and change an industry.

I attended the 2009 American Academy of Pediatrics National Conference and Exhibition in Washington, DC. Here are some impressions and observations.

(I used to write long trip reports and email them to coworkers and friends. And then follow up: Did you read it? What do you think? More than one person diagnosed me as a frustrated blogger, which I steadfastly denied until earlier this year.)

Presidential Address by Dr David Tayloe (EncounterPRO User Since 1999)

Dr. David Tayloe, AAP’s 2008-2009 president, opened the conference by addressing healthcare reform and information technology. His summary of the strategic relationships among reform, EHRs, pediatric, and primary care was clear and compelling. He described a vision of each pediatric practice becoming their patients’ medical home, cited his own experience at Goldsboro Pediatrics in North Carolina, and pointed out that adult medicine has a lot to learn from pediatrics regarding progress in this area.

A Slide From Dr. Tayloe’s AAP Presidential Address

And yes, Goldsboro Pediatrics has been using the EncounterPRO Pediatric EMR Workflow System since 1999.

Pediatric Documentation Challenge on Saturday, October 17th, 2009

Dr. Joseph Schneider moderated (wonderfully) the onstage demonstration of a complex pediatric scenario by eight EMR vendors, including theEncounterPRO Pediatric EMR Workflow System. He warned the audience the scenario was extra-complicated and not to expect anyone to complete the scenario in the allotted time. During introductory remarks he instructed the audience to pay special attention to interoperability and quality reporting on one hand, and workflow and ease of use on the other (and thank you, Dr. Schneider, for the public shout out to me about my decade long educational campaign for EMR workflow automation and usability).

I stayed for the entire series of demonstrations with what was initially about an audience of one hundred. Dr. Roy, using the EncounterPRO Pediatric EMR Workflow System, was one of only two demonstrators who completed the pediatric scenario (I corroborated this assessment with several other diehards who also made it through the almost four hour session). Comparing seven traditional hunt-and-peck EMRs to an anticipatory EMR workflow system triggered considerable ideation on my part about EMR workflow, which I’ve “demoted” to a “Closing Thoughts” section below.

EncounterPRO Booth Traffic

We had steady booth traffic, from new folks interested in individualized demos and providing contact information for follow up investigation, and from existing customers (it’s always great to see a familiar face!)

Here’s Brett Cleary(sales manager) and Kris Griffith (product manager) demoing and answering questions, and me, looking for a kickbiking partner.

Kickbiking DC’s Downtown Public Sculpture

As soon as the weather cleared up Sunday afternoon Dr. Roy and I took a three-hour tour of public art in downtown DC.

• Modern Head by Roy Lichtenstein
• The bronze reliefs at the Navy Memorial
• And the sculpture gardens at the National and Hirshhorn art galleries

Dr. Roy Explaining Comparison of Femoral and Radial Pulses
as Depicted in the Navy Medicine Bronze Relief

Calder’s Red Horse in the National Art Gallery Sculpture Garden

Along our kickbikejourney we came up with:

The Top Ten Similarities between EncounterPRO and Kickbikes

I’ve a web page about kickbikes on this blog. I’ve been meaning to post a paean to kickbiking; however there is a direct feed from this blog to a page on our product site. A headline there, about kickbikes, might seem a bit out of place. So, while walking up hills or waiting for traffic signals, we brainstormed the Top Ten Similarities between EMR Workflow Systems and kickbikes. Here’s the first draft. Some of these need some explanation. Watch for a longer post (in some future slow news week) with the same name as this subsection.

1. Easy
2. Unusual Appearance
3. Fun
4. Good for You
5. Fast
6. European Roots
7. Child Friendly
8. Extra Stable
9. Endorsed by Me
10. Designed by Physicians

(“Workflow” and “Kickbike” both have eight letters. Coincidence?)

Closing Thoughts about Apples, Oranges, and Peaches and A Decade of Market Education

As I watched the seven EMR apples and one EMR orange (or peach if you will, since we’re based in Atlanta), I was struck once again how similar traditional EMRsare to each other: large screens crammed with data and droves of data entry and order entry options. The user is the workflow engine, clicking on a succession of menus, tabs, buttons, checkboxes, textboxes, scroll bars, radio buttons not just to enter data and orders, but to get to the right tab, screen, dialog box, or popup. I’m a relatively trained observer since I’ve been participating in these events since the early days of TEPR’s documentation challenges—and *I* havetrouble remembering who is who. Other than location, color, finish, gradient, and minor aspects of widget shape (buttons with oval versus sharp corners, flat borders versus 3D bevels, etc.) all seven EMRs looked and worked more similarly than differently.

Traditional EMRs Rest on Structured Document Management Foundations

Traditional EMRs rest on database foundations that represent declarative knowledge about medicine and patients. Seems like a good foundation, right? But wrong from a workflow usability and process optimization point of view. Traditional EHRs are essentially structured document management systems (using relational databases to store structured data entered into document-like user interfaces and generate document-like reports) onto which are being grafted limited (and limiting, see discussion of “frozen” EMR workflow) degrees of task management. Traditional EHRs have lots of small targets on each screen that compete with each other for attention, plus the need for overt user direction to navigate from screen to screen. The smaller and more numerous EMR “targets” are, the more Fitts and Hicks Laws work against the user, resulting in slow, errorful data and order entry.

I recall a TEPR documentation challenge years ago that relied on what looked like at least a 12 foot wide 10 foot high projection screen. At one point the moderator actually had to walk over to the screen, crouch down, and don reading glasses to read a check box label. That’s small!

I did in fact notice at the AAP pediatric documentation challenge that, under time pressure and distraction (often from someone at the user’s elbow who was really trying to help), there were numerous times when the wrong check box or radio button was selected and then unselected. Human factor folks call these unintended user behaviors “slips” to distinguish them from intentional behavior called “mistakes.”

By the way, when I was a graduate student in Industrial Engineering at Illinois, I wrote a FORTRAN program that analyzed a stream of data from a PDP-11 that monitored a cockpit simulator (a Link Trainer, a *real* cockpit simulator, not a simulated simulator). The program flagged potential pilot errors (buttons they pushed, control surfaces they manipulated) during simulated emergencies. Then a human judge would try to figure out whether the errors were slips or mistakes. Of course, it’s been a few decades, so I could be mistaken.

Anticipatory EMR Workflow Systems Rely on Workflow Management Foundations

In contrast, EMR workflow systems rest on database foundations that represent procedural knowledge about medical workflows and processes, into which medical and patient knowledge and data are added and integrated. In which kind of EMR do you think workflows and processes are more easily understood, optimized, and monitored? Which kind of EMR will result in shortest patient wait times and encounter length? Highest task throughput and patient volume? The answer is the reason why productivity numbers are so good in the three HIMSS Davies Award-winning applications submitted by the two pediatricians, and one ob/gyn-family medicine physician, who use the EncounterPRO EMR Workflow System.

Understanding of EMR Workflow and Business Process Management in Healthcare is Gradually Increasing

Picture a graph that depicts progress toward higher and higher levels of market understanding of, and appreciation for, workflow management systems, EMR workflow systems, and business process management. By “workflow” and “workflow management” I don’t mean the meaningless ad copy that is thrown around and sprinkled on most EMR brochures and vendor websites. By “workflow management” I mean the same thing as what professionals and academics and workflow and business process management system vendors mean in the workflow and business process management system industry.

The X axis for that graph is now 10 years long. Data points are based on an unscientific series of impressions and vignettes: questions I received from an audience, a presentation I attended, a conversation in our exhibit booth. I began to see material on the web besides my own around 2004, plus have an occasional encouraging conversation. But it wasn’t until recently that I began to get the impression of a large uptick surrounding recent discussions of certification, usability, and meaningful use.

At the 2004 Fort Lauderdale TEPR show a physician watched a demo of EncounterPRO, asked a couple of questions about the customizability of the screen sequences, and exclaimed “This is a workflow management system, isn’t it?” 2004 was the first of three years that I gave a three hour TEPR tutorial about workflow management systems in healthcare, so I assumed that he had just sat through that session, but he hadn’t. Before becoming a physician he had simply worked in one of the many industries in which workflow management systems are more prevalent. He’d seen them before and so could recognize one when he saw one again.

Another example: at this years AAP one of my booth mates said “Shoot, you just missed him! This fellow was walked by, saw our sign [“EncounterPRO Pediatric EMR Workflow System”], stopped dead in his tracks, and exclaimed ‘Workflow System! I’ve seen lots in other industries, but I’ve never seen a workflow system in health care!” He was an ER physician not shopping for an EMR, but I thought you should know.” Shoot! I missed him! Add a data point to my 1999 to 2009 TEPR-HIMSS-MedInfo-AAP WfMS/BPMS Progress Graph!

EMR systems will need to become EMR workflow, and EMR business process, management systems, if they are to achieve the meaningful use that will be necessary to participate in the positive transformation of the US healthcare system. I do see progress. The “planets” (that is, federal initiatives, educated consumers, compelling case studies, and thought leadership) are aligning. It should start getting very interesting, right…about…now.

From: mga CHILDRENSPedtrcsCtrEastMain [email address deleted]
Sent: Friday, October 16, 2009 1:06 PM
To: Frank Martin; Chuck Webster
Subject: Our Thoughts on EncounterPRO

Please contact me about my enthusiasm for our EncounterPRO System, and how we may continue to promote your outstanding improvement in our ability to give excellent pediatric care.  I wish to express that ….
 
We noted even at the The University of Michigan’s Mott Children’s Hospital, where medical informatics is a strategic priority, the EncounterPRO EMR, surpasses even the best system that we had ever previously seen.  The benefits, for both the academic and community pediatrician, are such that now I cannot imagine practice without the efficiency and quality this particular EMR brings to the pediatrician. 
 
GROWTH and DEVELOPMENT:  for pediatrics, the ability to plot and chart growth and development real-time, allows our parents to see and take-home a printing of their child’s growth chart and graph, weight, height, etc., in real-time that demonstrates the patient’s percentiles over time.  The milestones, as tedious as they are, are easily presented, for checking at the development visits, so that not a single one is missed, and all recorded at the same time as evaluation. 
 
SICK VISITS:  The templates WE have been able to easily developer and save, with ease even while I am seeing patients, provides a fast and simple way for our practice to give a consistent standard of care throughout the group, and even while teaching residents, we provide a systematic approach for every patient. 
 
DOCUMENTATION AND BILLING:  Having the ICD codes attached to every diagnosis, provides superb documentation, and assists us in ordering labs and studies, and most of all having appropriate ICD codes match with the CPT codes.  The EncounterPRO EMR dovetails with the Office Management Software, even third party providers, such that submitting a clean claim, the first and every time, is no longer a struggle.  We no longer need to have a full-time coder, EncounterPRO makes sure every diagnosis has the proper ICD code, and that these are appropriately linked with the CPT code, seamlessly presented to the Pediatrician while completing the chart. 
 
SAVES MONEY & GENERATES INCOME:  The software’s data base of ICD and CPT codes, linked to the medical terminology that Pediatrician’s naturally use, saves the expensive coding services that we have had to so long suffer in the past.  Now our billing and collections team can focus on the business, and not the medical terminology.  Further, EncounterPRO makes sure we are offered the relevant choices, as pediatricians, while we are charting.  Important charges and not accidently missed, such as ancillary procedures and even medical supplies that can be covered by payers, if only the Pediatrician remembers to code for the service.  This has increased our ability to truly code and bill for the services we were previously providing, but now are able to document appropriately.  We have noted not only savings but improved revenue. 
 
PATIENT SATISFACTION:  EncounterPRO keeps track of the time the patient waits, and the time each service provider, both support staff, and medical staff, for every patient.  Having these running clocks, visible on the screen while the patient is moving through the office template, keeps us all aware of where every patient is, what they are waiting for, what they need, and how long it is taking us to provide the service.  We have noted an immediate 50% reduction in wait times, just from the efficiency obtained when the data is easily visible to the whole team.  We now can boast, not apologies, about our cycle times.  Our patient love the printed prescriptions, that are easy for the pharmacists to read, and the time saved by pointing and clicking, instead of writing is more accurate and faster.  The new e-prescribing feature allows us to choose and reward those pharmacies who best serve our patients.  We have found that small locally-owed pharmacies are eager to serve our patients quickly and with a complimentry attitude toward our practice.  In short, the patient satisfaction from the EncounterPRO system is another value.
 
We are grateful for the EncounterPRO team, and how they have partnered with us for a more successful way to serve our patients.  Beyond the fees associated for the service and the product, we want to write a heart-felt thank you for an outstanding advance in our ability to serve our most important pediatric patients.

MICHAEL GEORGE ANDERSON, MD, MBA, ESQ, FAAP

President and Corporate General Counsel

CHILDREN’S PEDIATRICS CENTERS - EAST MAIN
391 East Main Street
Canton, Georgia 30114
http://ChildrensPediatrics.com
http://HappyHealthy.com

Dr. Roy Benaroch (Dr. Roy) will demonstrate the High-Usability EncounterPRO Pediatric Workflow System at the AAP Pediatric Documentation Challenge™ on Saturday, October 17, 2009 – 2:00-5:45pm, at the American Academy of Pediatrics National Conference & Exhibition in Washington, DC.

The AAP Pediatric Documentation Challenge™ is Session E1087 and will take place in the Technology Learning Center – Room 149 at the Washington Convention Center. Dr. Roy is tentatively scheduled for 3:03 PM, but arrive early to get a seat. Dr. Roy has demoed the EncounterPRO Pediatric EMR at previous AAP national conferences. EncounterPRO has demoed at all previous AAP Pediatric Documentation Challenges. Visit us at Booth 1543 in the exhibit hall.

From all the folks at EncounterPRO Healthcare Resources, thank you Dr. Roy!

AAP Pediatric Documentation Challenge™
Saturday, October 17, 2009 – 2:00-5:45pm
Washington Convention Center
Technology Learning Center – Room 149
Session E1087

3:03 pm The EncounterPRO EHR, Version 5
EncounterPRO Healthcare Resources, Inc
Demonstrator: Roy Benaroch, MD, FAAP

Dr. Roy was born and raised in Miami, Florida. There, he was an avid SCUBA diver and State Champion Pente player. During his years at Tulane University pursuing a degree in Biomedical Engineering, Dr. Roy performed in several musicals and rock and roll bands, playing keyboards, saxophone, bass guitar, and singing. He has lived in the Atlanta area since beginning medical school at Emory University in 1990. Dr. Roy completed residency through the Emory University Affiliated Hospitals in 1997, and then served as Chief Resident and Instructor in the Department of Pediatrics. He has continued his involvement on the Emory faculty as an Assistant Professor of Pediatrics. He was Board Certified in Pediatrics in 1997 and joined Pediatric Physicians, PC in 1998. Dr. Roy lives in Dunwoody, Georgia, with his wife and three children. In addition to his work as a pediatrician, Dr. Roy enjoys swimming, vegetable gardening, and writing. Dr. Roy has written two books for parents, Solving Health and Behavioral Problems from Birth to Preschool: A Parent’s Guide and A Guide to Getting the Best Healthcare for Your Child. His blog, The Pediatric Insider, features more of Dr. Roy’s essays on many parenting and health topics.

 A Guide to Getting the Best Health Care for Your Child

5.0 out of 5 stars Dr. Roy fan!, July 24, 2007

“Dr. Benaroch has been my children’s pediatrician for several years now, and I can’t say enough good about him. This is not one of those books written for a few bucks or fifteen minutes of fame. Dr. “Roy”, as all his patients lovingly call him, practices what he preaches. He is just as genuine, helpful, good-natured, and compassionate as a pediatrician can get… and is unarguably THE BEST! No wonder why many of my friends and acquaintances go to him for their child’s health care. I remember the huge amount of support he gave me, the mom, after the birth of my third child. I felt like I got therapy for me as well as a fantastic check-up for my baby. I’m thrilled to have his new book filled with useful and caring information. Can’t wait for his third book! Thank you Dr. Roy!!!”

 Solving Health and Behavioral Problems from
Birth through Preschool: A Parent’s Guide

5.0 out of 5 stars Great book!, January 19, 2008

“This book is full of great information for all those medical/behavior issues you are unsure about when you have a little one. We pull it out all the time when one of our children has a rash, earache or even as we tackled potty training! The book is humorous and easy to read! We have found our newest “baby gift” because it will be used for years to come, unlike a rattle or toy!”

Dr. Roy has contributed to numerous podcasts at Pediatrics for Parents:

Pediatrics for Parents Show 57 - …Dr. Roy Benaroch talks about the flu and the flu vaccine….

Pediatrics For Parents Show 55 - …Dr. Roy Benaroch answers question on MRSA and allergies….

Pediatrics for Parents Show 45 - …Dr. Roy Benaroch explains tears in babies….

Pediatrics for Parents Show 44 - …Dr. Roy Benaroch gives his thoughts on autism….

Pediatrics for Parents Show 43 - …Dr. Roy Benaroch explains pink eye and its treatment….

Pediatrics for Parents Show 42 - …Dr. Roy Benaroch explains the FDA’s ruling on children’s cough and cold medicines….

Pediatrics for Parents Show 41 - …Dr. Roy Benaroch gives his opinion on Jessica Seinfeld’s new book, Deceptively Delicious….

Pediatrics for Parents Show 38 - …Dr. Roy Benaroch discusses the latest in vaccine news….

Pediatrics for Parents Show 37 - …Dr. Roy Benaroch answers your questions….

Pediatrics for Parents Show 31 - …Dr. Roy Benaroch talks about when to call the doctors….

Pediatrics for Parents Show 30 - …Dr. Roy Benaroch answers your questions….

Pediatrics for Parents Show 28 - …Dr. Roy Benaroch talks about safe sites for health information….

Pediatrics for Parents Show 27 - …Dr. Roy Benarock describes ways to save on medication costs….

Again, thank you for all you do, Dr. Roy.

Whenever I need help thinking outside the box I call on Dave Hubbard. For example, a few months ago I was trying to think of a good analogy to workflow in a medical office and Dave and I ended up co-writing about similarities between football plays and medical workflow. It’s been a popular post, web traffic wise.

(By the way, Dave has a blog on fitness–here’s a post on fit kids.)

Recently I considered the value of a positive customer experience of implementing a pediatric EMR and the beneficial transformations that can be achieved. I drafted a blog post, but it was, frankly, a dry exposition about economics of EMRs as commodities, goods, services, experiences, versus opportunities for transformation. (Entirely what you would expect though, from a premed Accountancy major.)

Dave Hubbard and Parachute

To liven it up, I again called on Dave.

Inside the Box (Or You Can Just Skip to Out-of-the-Box Fun Part)

So, as I said, I was thinking about EMR cost, value, experience, and transformation, and then Frank Martin pointed me to The Experience Economy, in which Joseph Pine II and James Gilmore distinguish among five levels of customer value (see below).

Which of the following kinds of product value can a pediatric EMR deliver?

That of:

• Undifferentiated stuff (commodities: flour, gas)
• Tangible things (goods: vehicles, furniture)
• Activities executed for a customer (services: tax returns, dog walking, legal services)
• Time spent with a customer (memorable experiences: theater, tour guide)
• Demonstrated customer outcomes (transformations: personal trainer, psychiatrist, productivity improvement)

If EMRs are interchangeable (many practically are, though not yet from an interoperability point of view), they are commodities. Delivered as a complete system of software and hardware, an EMR resembles a tangible good. And some EMRs are delivered as a service over the Web, though many such services also eventually become commodities.

What about the value of experiences and transformations created during implementing, going live, and optimizing a pediatric EMR workflow system?

Recent EMR market trends highlight EMR experience, or usability, as a key product differentiator. Is a pediatric EMR easy, even fun, to use? (We think our unique pediatric EMR workflow system fits this description.)

Further, what about the ability of a pediatric EMR to transform? After all we make the strong assertion at the top of our home page that

“Adopting the EncounterPRO Pediatric EMR
Workflow System is a transformative practice,
professional, and personal experience.”

What the heck is that?

If I were to fall back on tried-and-true ways I’d start by…oh just read the fun stuff!

Going Live with a Pediatric EMR is as Easy as Jumping Out of an Airplane

“It was a beautiful summer day in northern California - 1982. I was about to embark on the adventure of a lifetime. Our instructor was an ex-Vietnam jumper and had thousands of jumps behind him. Jumping was his life. He had been teaching people how to jump for years, five days a week at this location. He had never had a mishap. It would take almost a full day of training for each of us to gain the knowledge and the confidence we would need to step out of that airplane…”

So began a new chapter in Dave Hubbard’s life. To give away the ending, Dave’s chute did not open, but he survived to tell his story. Since that moment, Dave has told and retold his story, applying it to a wide variety of subject matter across scores of industries, to inspire and motivate.

An All-American collegiate athlete who played professional football in the 1970’s for Hank Stram of the New Orleans Saints and then the Denver Broncos, Dave is familiar with healthcare professionally (serial entrepreneur) and personally (after all, he broke his back jumping out of a perfectly good airplane!). Combining an appreciation of team spirit and performance with an understanding of information technology, Dave has inspired thousands to better confront their fear and prepare for success.

Adopting a pediatric EMR is increasingly about the total EMR rollout and go-live experience rather than merely achieving specific EMR functional goals. (And skydiving is all about experience; after all, you’re already on the ground.) Pediatric EMR rollout and go-live experience includes two components: emotion and meaning. “We were afraid but also eager and curious; we confronted our fears, overcame all obstacles, and grew individually and as a team.” This process of working through emotion to meaning is the great intangible key to pediatric EMR rollout and go-live success.

Analogies between skydiving and adopting a pediatric EMR include:

Murphy’s Law applies to both. (”Anything that can go wrong will go wrong.”) Therefore imagine everything that can go wrong to prevent it; survive problems before they happen.

Preparing to go live with your pediatric EMR is like packing your chute. (And your implementation coordinator is like your jumpmaster!)

Dealing with anxiety about taking a step into the relative unknown (to you) is like making your first move out the airplane door. (“Feet out! Get out! Go!”) Your pediatric EMR vendor, like your pilot, will do everything possible to drop you on the target, but it’s up to you to steer and land. It’s a cooperative effort.

Surviving the inevitable ups and downs (and then ups) of implementing, training, and getting back to previous levels of productivity takes mental preparation that begins *before* you set in motion events for which there is no “Undo.”

Make Dave’s story your story…

“It was a beautiful summer day in my hometown - 2010. I was about to embark on the adventure of a lifetime. Our instructor was an ex-pediatric EMR user and had hundreds of EMR implementations behind her. Helping people make the jump to a pediatric EMR was her life. She had been teaching people how to use EHRs for years, five days a week all over the nation. She had never had a mishap. It would take almost a full day of training for each of us to gain the knowledge and the confidence we would need to use our new pediatric EMR to see our first patient…”

Epilogue

What’s our point?

The true value of a pediatric EMR (workflow system) is not in specific product features and services available, but rather, it is in the transformational experience that can happen to you and your pediatric practice.

And:

You’ll be in safe hands with our jumpmasters and instructors!

Our new website for the High-Usability EncounterPRO Pediatric EMR Workflow System is just a bit more than a month old and we are pleased.

Some Recent Web Statistics

Before we published our new content I checked our search engine result position on Google and we did not appear on any of the first 10 search engine result pages (that’s 10 pages times 10 links per page). Four weeks later, for the Google search terms “pediatric” + “emr”, EncounterPRO.com moved from heavens knows where to the first page returned by Google (as of the date of this post; nothing except my crossed fingers guarantees we’ll stay there).

http://www.google.com/search?q=pediatric+emr

By the way, at this very moment we’re also on the first result page returned by Bing

http://www.bing.com/search?q=pediatric+emr

and Yahoo.

http://search.yahoo.com/search?p=pediatric+emr

Again, given the perverse logic of the Web, where for every action there is an opposite and unintended consequence, who knows what the effect of me even writing about this topic  here will do, or undo.

Compared to the same four weeks in 2008 our traffic is up more than threefold (not counting this blog), and our leads are up almost fivefold. During what is usually a slow month (Pediatric EMR leads and sales are cyclic), we’ve had more leads during the last four weeks (28 days) than any previous month.

A Bigger and Better Website

In 1993 I storyboarded a future EMR workflow system. I borrowed some screenshots from an existing workflow management system and replaced icons and text labels with medical content. I painted a picture of a future work environment in which non-programmers familiar with office workflow create and customize their own their own high-usability EMRs. Later I chanced upon the EncounterPRO Pediatric EMR Workflow System, based on the EncounterPRO EHR Workflow Management System. Here was the EMR workflow system that I storyboarded years ago.

There are advantages and disadvantages to being so far ahead of the curve. One disadvantage is that while many people know what to expect from an EMR, they don’t know what to expect from an EMR workflow system. In fact, folks often ignore or discount “workflow system” and categorize EncounterPRO as a mere EMR. This is why I continually stress differences between traditional hunt-and-peck EMRs and anticipatory EMR workflow systems.

The basic problem is this: how to compress EncounterPRO’s unique selling proposition to a sound bite that gets past preconceived market notions and traditional EMR stereotypes. Marketing types have asked me to express in ten words or less what makes EncounterPRO different and better. I’ve replied that, unfortunately, it would take a textbook on human factors and workflow automation to first educate and then make that case.

The new 33,000 word product website (and this 60,000 word blog) *is* that textbook. However, it is a textbook that has been chopped up, illustrated, and cross-linked so as to create two mutually supporting websites. One, this blog, educates (but occasionally promotes); the other, the product site, promotes (and occasionally educates, but relies on this blog for in-depth educational exposition).

In effect, since Google (and Bing and Yahoo and other search engines) like words so much, I’ve turned a disadvantage into a disadvantage: