Electronic Health Records (EHRs), Workflow Management Systems (WfMSs), Pediatric EMR Workflow Systems (WfSs), Clinical Groupware, Business Process Management (BPM), Adaptive Case Management (ACM), Human Factors, Cognitive Science, Learning, Education, and Kickbiking
At this spring’s HIMSS conference in Atlanta I went to the Meet the Bloggers sessions March 1-3 (see below for their blogs and Twitter handles). The panelists were informative, funny, and sometimes profound (in a change-the-world sort of way). I recently reviewed my notes and circled the most interesting (to me) comments.
I’ve not attributed individual comments to specific bloggers. These are my scribbled paraphrases, not direct quotes, and I don’t wish to misquote or misattribute. However, taken as a whole they display an intriguing variety of motivations, observations, and insight.
For example, after listening to the Meet the Bloggers panelists, I gained insight into not just why they blog (and tweet), but also why I do. After reviewing this list, perhaps you will too.
From the HIMSS 2010 Meet the Bloggers panelists:
My blog is the oldest!
I initially posted to force myself to research the HIT industry; now I post to connect.
I started my blog 4 1/2 years ago, my posting became less frequent, then Obama implemented a stimulus bill for my blog.
I wanted to have my voice heard. I’m a contrarian and I think others are interested in contrarian viewpoints.
My blog used to drive my twitter traffic. Now my tweets drive my blog traffic.
Twitter is a powerful tool if you follow the right people.
How has your blog evolved? I’m busier so I write shorter posts.
I find myself frequently referring back to something I said on my blog years ago.
We publish each new post at 6PM on a Wednesday.
I’m running out of things to say!
Thoughtful posts take a lot of time!
The best writers are the best readers. I get my ideas from reading and I’m not worried about running out.
A post is a result. If you haven’t done the work, you don’t have something to say.
What about experimentation? I think a lot about being edgy
Tell a story!
I engage in what I call blog sparring, I write a disagreeing post and link it to the original.
I’m grouchy and opinionated in public on order to advertize my side business.
Print is dead.
Initially my blog generated date money.
I used to email a long answer to a complex question to one person and I realized that was very inefficient.
I have to moderate comments because, believe it or not, there are humans who go around posting comments about Levitra.
The intersection of technology, medicine, and the future can generate a lot of material for blog posts plus the opportunity to meet the most interesting people.
Bloggers have a mission.
Do bloggers need to be controversial? My most popular post was not controversial at all. It addressed a common problem.
Is blogging (and tweeting) a creative, artistic act? Blogging helps me develop the other side (the right side) of my brain; I outline, add color and connections.
It’s a creative conversation; ideas coalesce; things fit together.
Content plus editing plus personality fills out a blog, builds trust.
When do you include personal details about yourself? When I can aid rational discussion with personal experience.
You can change things through what you write in your blog.
My blog is my personal brand.
My Twitter account is a memory device.
My blog is about getting different communities that should connect to do so.
Backlinks from blogs are becoming more powerful than from other sources.
Aggregating content is a creative process: what is most urgent this week?
I leave stuff out of my blog on purpose so my posts don’t turn into tomes and so others can post fill in the gaps through comments.
It takes at least 1000 visitors to get one comment.
I adapted the following list from here (added a missing panelist and some Twitter accounts).
I recently attended the Process.gov conference, specifically to attend a track about Adaptive Case Management. Before I tell you about adaptive case management and its relevance to clinical groupware and pediatric workflow, here’s some background and why I went.
“[There is a spectrum] between well-structured and ill-structured cooperative problem solving, and the kinds of groupware needed to facilitate computer-supported cooperative work in healthcare. Both kinds of cooperative problem solving require clinical groupware. EMR workflow systems fare especially well on well-structured care coordination problems. The EncounterPRO Pediatric EMR handles both ends of the spectrum well: a workflow engine to handle routine group workflows and the Office View to handle non-routine group workflows.” (Clinical Groupware, Care Coordination, and EMR Workflow Systems: Key Ideas)
Over the last decade workflow management systems (the source of this blog’s name) evolved and became business process management (BPM; I’ll keep the blog name, for now). During the same time, the EMR/EHR industry evolved more slowly, mostly adding features and functionality atop patient clinical data models. The user enters data, navigates to screens, and reviews data and enters orders (and many other people benefit from this effort). The user is, in effect, a workflow engine who pushes and pulls the traditional EMR through a patient encounter.
Convergence of Concerns between
Clinical Groupware and Adaptive Case Management
This year’s Process.gov theme was “Adaptive Case Management,” a movement within the business process management community resembling, in some ways, the clinical groupware movement within the health information technology community. Both are innovative “outside-the-box” reactions to the traditional software and orthodoxy within each’s respective industry. I think both seek to return to the collaborative human-centric roots of groupware as it was originally envisioned. The big difference now, and potential advantage, is that we have an additional three decades of engineering and cognitive science ideas and technologies to realize this vision.
I went to Process.gov to try to capture some of the essence of adaptive case management ideas as they apply to creating a new generation of process-aware, but also human-centric, clinical groupware. As an emissary from the health information technology industry, my interest in combining ideas from clinical groupware and adaptive case management felt welcomed and reciprocated.
By the way, I used Twitter to record my Process.gov conference notes at @EMRGroupware (reserved for high-frequency, event-related, real-time note taking, to not flood @chuckwebster followers with minutia). If this post piques your interest, feel free to browse this archive.
What is Adaptive Case Management?
To answer this question I will have to pick and choose, because the answer was subject to spirited debate at Process.gov. So I will highlight what I think will be most accessible to the EMR, EHR, and clinical groupware overlapping communities.
I’m a fan of workflow engines, embedded in EMRs, executing process definitions to reduce the amount of work users have to do in order to use an EMR. These are the executable process models I’ve referred to in recent posts. However, I’m not a fan of making any EMR user, in any sense, subservient to predefined process models, because healthcare is chock-full of exceptions. Users have to be free to jump off the happy path, so to speak, and deal with the unexpected–to creatively improvise.
In 2004 I wrote (mentally replace “workflow management systems” with “business process management system or suite”):
“Evident throughout this article is a tension between straightforward, predictable, repetitive, high volume episodes of patient care versus more complex, less predictable, one-of-a-kind episodes, each of which is unique and therefore infrequent, but all of which taken together constitute a significant and important part of the ecology of health care. Traditional workflow management systems excel at what has been called ‘straight through processing’ (STP) in the banking and finance industries. For example, an order to sell shares in a publicly traded stock should ideally happen in a very short interval (that is, before the stock price changes materially). STP seeks to eliminate the human element that slows down stock trades, to only rely on humans for handling exceptional circumstances, and to reduce exceptional circumstances to an absolute minimum (if not altogether!). However, in health care exceptions happen all the time. Medical care is exception rich because abnormal states are, in effect, normally encountered occurrences.
Healthcare processes, and especially core patient-driven processes, are rife with exceptions—from the appointment no-show to the abnormal laboratory value to the undeniably unique history of present illness. And yet, these are in a way predictable and therefore categories and rules and workflows can be defined to facilitate execution of core clinical and administrative processes. Workflow management in health care, especially in and around the EHR, will be workflow with healthcare characteristics. While this may seem obvious, it also means that workflow management systems technology and concepts borrowed from other industries must necessarily be considerably adapted to become successful components of the next generation of electronic health records.” (EHR Workflow Management Systems: Essentials, History, Healthcare, 2004)
“Workflow with healthcare characteristics” was essentially a code phrase for the kind of ad-hoc, improvisational, human-centric (not process-centric) activities that I hoped to hear discussed in the Adaptive Case Management track at Process.gov. And I did!
A good way to explain the relevance of Adaptive Case Management ideas to clinical groupware is to go through a representative list of adaptive case management ideas and show how the EncounterPRO Pediatric EMR Workflow System implements each idea. The left-hand column of the table in the next section is adapted from the 14th and 15th slides in Jacob Ukelson’s excellent presentation, “What to do When Process Modeling Doesn’t Work” (slides posted here, based on a chapter by the same name in the timely new book Mastering the Unpredictable, put together by Keith Swenson and launched at Process.gov). The right-hand column maps each idea to a way in which the EncounterPRO Pediatric EMR Workflow System (AKA EncounterPRO Pediatric EMR BPM System, AKA EncounterPRO Pediatric EMR Adaptive Case Management System) implements the idea.
How the EncounterPRO Pediatric EMR Workflow System Implements Business Process Management *and* Adaptive Case Management
EncounterPRO’s Workplan Editor (analogous to business process management’s process definition editor) and
EncounterPRO’s Office View (analogous to adaptive case management’s case folder).
The manner in which EncounterPRO implements each of the following additional adaptive case management ideas can also be directly or indirectly illustrated by a relevant screenshot. However, this post is already too long, so I’ll publish those screenshots in a future post.
(The following table really gets into the weeds, so to speak. If you’d rather skip the table and remain on the fairway click here. Or, just read the bold stuff.)
Adaptive Case Management Concepts and Comparison with Business Process Management
Examples of How EncounterPRO Implements Adaptive Case Management and BPM
Every process has an owner
EncounterPRO's equivalent to BPM's process definitions are called workplans. All the tasks in an executing workplan have the same process ID. A user (such as the patient's physician) or role (such as nurse) owns an entire process. A non-owner can chose to accomplish a task that is part of a process owned by another user or role, however EncounterPRO will ask if they wish to assume ownership and track this.
Every process instance has a
goal,
a deadline, and
a defined work product.
Defines what to do, not how to do it.
The goal of a workplan is usually the reason for the pediatric visit, such as well child, sick visit, or vaccinations.
For some tasks, such as vaccinations and preventive health guidelines, EncounterPRO uses rules to determine when and if tasks due or over due. Routine tasks such as collecting vitals (screenshot) and checking allergies (screenshot) show up in EncounterPRO's Office View "rooms" (functional equivalent of case folders) along with task status (including the number of minutes the task has been waiting for completion)
EncounterPRO's defined work product is the set of tasks making up a workplan.
EncounterPRO workplans tell EncounterPRO screens and screenless activities (such as automatically printing patient educational material at the most convenient printer) what to do; they don't tell EncounterPRO users what to do.
Provides visibility within the context of the execution of the process instance
Shows work done by each user
Shows hand-offs between each user
EncounterPRO's Office View shows, in real-time, the location and status (such as how long the task has been waiting) of all tasks posted by workplans or by users.
The state of single process (that is, an executing workplan) can be viewed in which all accomplished tasks are "checked off' (visually highlighted).
Manages and controls through
Tracking (visible activity, Hawthorne Effect)
deadlines,
and goals (dictates what, not how)
This item recapitulates previous points about visibility, tracking, deadlines, and goals (what/not how), but focuses on importance to management and control. If you can't see what your pediatric care team is doing in real-time, then you can't manage your pediatric care team in real-time. The Hawthorne Effect refers to a well know psychological experiment that shows that people who know their work activity is being observed achieve higher levels of performance. Pediatricians often comment that since each member of the care team knows that what they are doing (and not doing) is visible to everyone else on the care team, minute-by-minute, in the Office View (EncounterPRO's multi-room "Case Folder"), everyone is on their toes.
Many processes are a mix of routine and unpredictable processes
Combined management of routine and non-routine workflows is where EncounterPRO truly excels. Much of general pediatric practice is routine and therefore amenable to automation via EncounterPRO's workflow engine executing workplans for well and sick child visits, vaccinations, and so on. One pediatrician who uses EncounterPRO famously exclaims that if he can't chart an otitis media visit in 30 seconds, that something is wrong (as is, tell someone to reboot the server!). On the other hand, pediatric practice has its share of exceptions and emergencies, which conspire to disrupt routine, and therefore automatable, workflows. This is where EncounterPRO's version of adaptive case management's case folder comes in to play. A pediatrician can step away from a task in a routine workflow to deal with an interruption or minor emergency but know that they (or someone) will eventually spot the next unaccomplished task of the workplan in EncounterPRO's Office View. For more details about how EncounterPRO makes this possible see Interruptions, Usability, and Pediatric and Primary Care EMR Workflow.
ACM can be used for “in-situ” process discovery (Design-by-Doing, not Doing-by-Design)
EncounterPRO, in contrast to most BPM systems that represent workflows using decision tree-like diagrams, represents its workflows as checklists of potentially optional tasks. EncounterPRO's workplans are bit like traditional BPM process definitions in that they can indeed be executed by EncounterPRO's workflow engine. However, unlike traditional BPM systems, users are free to cancel, postpone, or refer tasks to other users. In this EncounterPRO's workplans resemble adaptive case management templates. You can think of a template as similar to checklist (popular in aviation and becoming more popular in medicine). The EncounterPRO Pediatric EMR Workflow System comes with a set of standard workplan templates for sick, well, and vaccination visits, for both the nurse and pediatrician roles. However, users are free to deviate from them at will. Users also can provide information that are necessarily unknown when the workplans were originally devised. For example, when a user gets to the e-prescribing step for the first time for a patient, they can ask which pharmacy is most convenient and select the pharmacy from a pick list. When the workplan executes again for the same patient it will automatically use the previously specified default pharmacy, eliminating redundant clicks and conversation. "Design-by-Doing", rather than "Doing-by-Design", allows users participate in design of their own workflows, without being computer programmers or process modeling analysts.
ACM extends process management to new use cases
A use case is high-level description, or scenario, of typical interactions between users and an information system. Use cases are often used as a first step in gathering user requirements and as input to creating the process models that drive business process management system behavior. New use cases therefore do not have models to drive system behavior. Adaptive case management systems do not require elaborate predefined process models to manage cases, therefore they are ideal for environments in which there is a great deal of variation across cases. EncounterPRO uses workplans (a hybrid between BPM's process definitions and ACM's templated checklists) to drive routine workflows (saving pediatricians clicks and from wondering whether everything that needs to get done will in fact be accomplished). However, in EncounterPRO, every user action, no matter how ad-hoc or simple, is also executed by EncounterPRO's workflow engine. Users are free to order tasks that are not on any workplan, and tasks are still executed, made visible, tracked, and disposition logged, along with all the other tasks that do happen to be part of any executed workplan. In this way EncounterPRO allows users to deal with use cases for which there are no predefined workplans, but still provide the kinds of process-aware support of user activities essential for a well-run pediatric office.
Operational process warehouse and process system of record
EMRs, EHRs, and clinical groupware will eventually be required to submit detailed patient safety reports. The most flexible, detailed, and timely reports will require what might be called a "process warehouse." A process warehouse is an archive of time-tagged data about pediatric and primary care processes that can be used to answer questions about those processes. EncounterPRO, by virtue of its workflow engine logging all task activity (modeled and ad-hoc) generates a tremendous amount of time-tagged data about who did what to who, when, how, and why. This data can be used to reconstruct your actual processes through a form of data mining (called process mining or automated process discovery). Traditional EMRs/EHRs, in contrast to process-aware clinical groupware (modeled or ad-hoc), do not distinguish between tasks at the same fine degree of granularity as process-aware clinical groupware. Traditional EMRs often have high resolution screens with a multitude of simultaneous data review and entry and order entry options. Multiple user events, spanning multiple tasks, are often committed together to the underlying database, conflating together logically separate workflow steps. In contrast, workflow engine-driven clinical groupware typically presents just the data review and entry and order entry options on each screen that are relevant to single step in a task workflow sequence. For example, a nurse checking allergies and then current medications are two different tasks that should be distinct and acquire different time stamps.
Non-process aware EMRs/EHRs also do not capture all the potential meaningful timestamps for those events that they do log. They may log when data and orders are committed to a database but they do not typically log when tasks are first available to be accomplished, when they begin, when they complete, and other relevant timed-stamped events such as cancellation, postponement, or forwarding (the ad-hoc activities). Much of this missing temporal information is invaluable for understanding why a user did what he or she did in terms of available options and active goals. Ability to reconstruct this context will be crucial for reporting on, and improving the safety of, clinical groupware-mediated care team processes.
EncounterPRO’s Office View is a Set of “Case Folders” Where Each Room is a “Case Folder”
The single most salient aspect of the user interface of a case management system is the case folder. It holds all the pending tasks for a case, details about their status, and means for users to take over and complete a task.
The single most salient aspect of the user interface of the EncounterPRO Pediatric EMR Workflow System is the Office View (click previous screenshot to see animation). Each room in the office view is equivalent to a case folder in a case management system. In the Office View animation, patients and tasks appear (automatically due to workplan execution or optionally due to ad-hoc user initiated activity) and disappear (started and completed by users). In contrast to the animation, in which activity systematically proceeds from upper-left to lower right, in a real-world pediatric office tasks appear and disappear less systematically–to the eye. Each of the colorful little bricks indicates who, what, why, when, and where details that are continually updated over time. And each of these colorful little bricks is also a big fat target that, when clicked or tapped, brings up the screen necessary to accomplish the task (making it disappear from the “case folder,” that is, “room’).
Pediatrician Dr. Armand Gonzalzles MD
on Leveraging Business Process Management
in his Busy Chicago Pediatric Practice
You may think that business process management and adaptive case management are the sole preserve of large organizations with sophisticated IT staffs. However, listen to this eight minute interview with a solo pediatrician who uses workflow management and business process management to run his busy pediatric practice. If you are interested, this post describes the context in which the interview took place.
Eventually, all EMRs in high-volume, low-margin specialties like pediatrics, family medicine, and obstetrics/gynecology, will require process-aware clinical groupware that makes the routine fast and easy (through reliance on executable process models) but also makes the non-routine “ownable,” trackable, visible, accomplishable, and subject to deadline and escalation. There simply won’t be any other way to inject mission-critical clinical information systems into these fast-paced, chaotic environments, than to use ideas from business process management and adaptive case management, adapted to “workflow with healthcare characteristics” of course!
P.S. While we’re on the subject of successfully completing scheduled tasks, I’m reminded of a short anecdote. Around 1995 my wife opened an international hotel in Russia (four years after the dissolution of the USSR). She bought a book about Russian toasts and etiquette. With her background in quality control and continuous improvement, and mine in industrial engineering, we were quite taken with one toast in particular, “To the success of the scheduled tasks!” It sounded so, well, Soviet. One of the graduate students in the Health Management Systems program at Duquesne University had emigrated from Russia. He blanched when I jokingly offered the toast. “Where did you hear that?” It turns to apparently be the official toast of the Young Communists, which he’d been forced to join, the sort of thing that he left Russia to avoid.
So, with respect to this blog’s tasks, to encourage a conversation between the worlds of EMRs/EHRs/clinical groupware and workflow management systems/business process management/adaptive case management: “To the success of the scheduled tasks!”
Process.gov has four topic areas: State and Local, Defense and Intel, Civilian and Health, as well as Integration and Deployment. I’m looking for innovative current and future potential uses for business process management in healthcare.
Here are the most recent 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: Process.gov: The BPM in Government Event, April 14-15, 2010, Reston, VA. 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. If you see “No public Twitter messages” below, Twitter is busy! Try again in a bit.
Dear “Folks who followed me during process.gov” My main twitter acct is @chuckwebster, where I tweet about #EHR#EMR#BPM & #usability Thx! >>2010/04/16
Well, that’s a wrap of #BPM vs #ACM, 200 tweets in two days, now to write a blog post summarizing relevance to #EMR#EHR clinical #groupware>>2010/04/15
Key is use changing process definition at run time by skipping a step (once or always) or supplying value or makeing default for aways) >>2010/04/15
Give users tools to accomplish ad-hoc work, adapt on the go #process.gov >>2010/04/15
Communication and mentoring are key, incorporate rules to enforce task order or state changes process.gov >>2010/04/15
Provide only tools user needs, notes, discussion, dashboards, reports, give users control over user experience-personalization >>2010/04/15
case folder is the coordinating object, needs to be open and flexible, move things around, add things on the fly, >>2010/04/15
Challenge #1: Predicting and predefining how knowledge work happens #process.gov >>2010/04/15
Presentation: Adapting to Case Management, Tom Shepherd, Global360, Case360 product #process.gov >>2010/04/15
There are BPM/ACM products that can shift back and forth between routine and knowledge work modes (me: key in EMR workflow system!) >>2010/04/15
BPM: process drives data collection and sends it on, ACM data drives processes (to collect new data which in turn drives processes) >>2010/04/15
BPM: predict/define process, implement automated process, ROI from scaling up and repeating / Adaptive case management needed for one-offs >>2010/04/15
It is the success of BPM in automating routine work that results in more and more knowledge work left over…(in healthcare??) >>2010/04/15
Henry Ford, invented assemply line, Frederick Taylor applied mass production techniques to routine office work (scientific management)… >>2010/04/15
Comment audience: iPad will require combination of technology to support both structured and unstructed work processes #process.gov >>2010/04/15
“case management” the phrase comes from social work, legal system, and (ironically!) healthcare #process.gov >>2010/04/15
Mixture of routine work (defined procedures) and knowledge work (open ended and undefined) >>2010/04/15
Knowledge worker = people who “figure out” what they need to do (search and rescue example) #process.gov >>2010/04/15
Presentation: Supporting Knowledge Work & Unpredictable Processes, Keith Swenson, Fujitsu #process.gov >>2010/04/15
Pucher: ACM moves process analysis phase from pre-execution in2 process execution, give infrastructure, learn about processes & improve them >>2010/04/15
I can’t leave the iPad alone, literally or figuratively (how many EMR users can say *that* about their EMR?). Last week I explored the relationship between EMR/EHR/clinical groupware contextual usability and process awareness. This week I consider the following apparent contradiction:
“The iPad is not a laptop. It’s not nearly as good for creating stuff. On the other hand, it’s infinitely more convenient for consuming it — books, music, video, photos, Web, e-mail and so on. For most people, manipulating these digital materials directly by touching them is a completely new experience — and a deeply satisfying one.” (Looking at the iPad From Two Angles, David Pogue)
However another article reports that of all industries healthcare is most agog at the iPad’s form factor and usability.
“So while the rest of the world texts, tweets, and generally fawns over the thing, that’s muted compared with the reception the iPad is getting in the health care universe…This isn’t just hot-new-toy fever sweeping the mediverse, though: If the iPad becomes as ubiquitous in medical facilities as the iPod is everywhere else, it could usher in literally billions in savings.” (An Apple a Day: Will the iPad revolutionize health care?, Martha White)
The apparent contradiction? Physicians need to create content at the point of care, not just consume it. They will resist hauling around multiple devices. While the iPad has a virtual keyboard and an optional keyboard accessory, and there’s Dragon Dictation, clicking (or in this case, tapping) to perform routine data entry is not likely to go away.
“I have read reports from ‘excellent’ EHR systems…which contain disastrous errors created by a 0.5 mm slip of the mouse pointer and a click. This is what happens when two opposite diagnoses differ by one consonant and are adjacent in the pull-down list. We are trying to treat the patient but we are really doctoring the EHR.”
“Even most template driven EMR software would not be fun on an iPad. Checking a check box with touch can be painful if the check box is too small, no?”
The answer is obvious. There’s even a psychological law.
Fitts’s Law: “The time required to rapidly move to a target area is a function of the distance to and the size of the target.” (Wiki article on Fitts’s Law)
For user interface design, Hick’s Law complements Fitts’s Law:
Hick’s Law: “The more choices you have to choose from, the longer it takes for you to make a decision.” (Wiki article on Hick’s Law–you’ll have to copy and paste “http://en.wikipedia.org/wiki/Hick’s_law” into your browser, WordPress doesn’t handle apostrophe’s in links well)
“Acquiring” (human factors speak for click or tap) one small “target” amidst many “competing” targets is slower, more effortful, and error prone than a large target among just a few alternatives.
How, might you ask, can EMRs, EHRs, or clinical groupware present *enough* buttons to their physician users so they can enter all the data and orders that they need? Instead of just a few big screens containing many small buttons and checkboxes and so on, spread larger buttons (and no checkboxes, not a one) across many screens.
How, might you ask, are you expected to navigate to the right screen at the right time to click on the right button? For each specific context (well child visit, sick child visit, vaccination, etc.) present the right screens in the right sequence to the user in a way that mirrors the natural order of the tasks the user needs to accomplish. That was my major point in last week’s post Contextual Usability, My Apple iPad, and Process-Aware Clinical Groupware for Pediatric Practice.
The iPad and similar devices may indeed transform digital medicine. If they do, one important reason will likely be that it forces EMR, EHR, and clinical groupware developers to get rid of those cramped rows of itty-bitty little checkboxes and endlessly scrolling lists of skinny pick list items. To do so requires clinical groupware to ask and answer the right question at the right time and act appropriately, to hand to the user the right data or order entry screen with all, but only, the right data or options. I don’t see any other way for clinical groupware to do this than to rely on some form of user-programmable executable process model.
Apple started selling iPads today. I bought one. I published this post from it.
There’s an important relationship between
iPad-like form factors, task-at-a-time workflow, and contextual usability in mobile settings on one hand and
process-aware clinical groupware for pediatric practice (AKA pediatric EMR workflow systems) on the other hand.
I’ll use as a springboard Todd Biske’s Context Aware Computing and the iPad (please read the original!) in which he writes (though I’ve replaced “meeting room” with “exam room”, “meeting” with “patient encounter”, and “subject of the meeting” with “type of patient encounter”):
“Now, we have the potential for device with a larger form factor that can present a touch-based interface, completely tailored to the task at hand…Imagine going into an [exam] room where your iPad is able to determine your [exam] room…where it knows what [patient encounter] you’re in and who else is in the room…it knows the [type of patient encounter], and can now present you with a purpose-driven interface for that particular [patient encounter]…How many times have you been in a [patient encounter] only to wind up wasting time navigating around through your files…trying to find the right information. What if you had an app that organized it all and through context awareness, presented what you needed?…As we have more use of BPM [business process management] and Workflow technologies, it is certainly possible that context awareness through location, time, presence of others, and more can allow more appropriate and efficient interfaces for task display and execution, in addition to providing context back into the system to aid in continuous improvement.” (my emphasis)
Compare Todd Biske’s account of contextual awareness with a quote from my own 2005 HIMSS proceedings paper about EHR workflow management systems. EHR workflow management systems use specialty-specific process definitions to create specialty-specific clinical groupware, such as pediatric EMR workflow systems. Pediatric EMR workflow systems combine pediatric-specific screen and screenless components into modules and perform (“enact” in workflow automation terminology) pediatric workflows for pediatricians, staff, and patients:
“The process definition saves the user from having to navigate manually through a thicket of menus, tabs, or popup lists; the EHR presents the correct screen given the context of the user’s tasks. If an EHR can be instructed (that is, customized) in what to do—automatically—based on who, what, why, when, where, and how, the EHR is not just a patient documentation system, it is an EHR workflow management system….Process definitions are used by the workflow engine in a similar way to rules being used by an expert system. The workflow engine reasons about who, what, why, when, where, and how in order to save the user work. Who is the user? (Dr. Jones or Dr. Smith?) What is their role in the office? (Physician, nurse, technician?) Why is the patient here? (Well child? Chronic disease management?) When is ‘now’, relative to what has been accomplished and what remains? Where is the user? (Exam room? Tech station?) How does this specialty accomplish its tasks? Each step in the process definition corresponds to a specialized data presentation, acquisition, or transformation task. The process definition describes the event that triggers the presentation of the screen as well as a context that informs its content and behavior. For example, the Review of Systems screen allows the nurse to do just that, review the patient’s systems. It is triggered by the completion of the preceding screen (or by the nurse logging into the EHR in the exam room in the presence of the patient after all the preceding tasks in the process definition have been accomplished).” (my emphasis)
Todd Biske writes about business meetings and I pediatric ambulatory encounters, but we address the same thing: contextual usability. In conversation (though this is the first time I’ve blogged about it) I often refer to what I call my journalism theory of usability. Journalism is all about context. To achieve contextual usability clinical groupware needs to ask itself the same questions journalists ask themselves to write compelling and useful news reports—who, what, why, when, where, and how? Automated answers to these questions drive context-aware automatic behaviors, such as offering the right screen at the right time and place or accomplishing useful tasks in the background without need for human intervention.
Biske also refers to “providing context back into the system to aid in continuous improvement.” This is business process management’s (BPM) “process optimization process.” Process-aware clinical groupware is more systematically improvable using business process management techniques than EMR/EHR/clinical groupware without process models (which is most). From a recent post intended to be something of a manifesto:
“The only practical means by which [systematic improvement] 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.” (Usable Clinical Groupware Requires Modular Components and Business Process Management)
A workflow engine executing process definitions (an “executable process model”) makes it possible for clinical groupware to automatically present the right screen, data or order entry options, and presentation format at the right time and place in pediatric workflow to save pediatricians time and concern. The workflow engine automatically does the right thing at the right time and place because it consults a process model, that is, the set of process definitions that model pediatric workflow and processes for a particular pediatric office. The executable process model makes clinical groupware both context aware *and* flexibly so (that is, editable by users, without the special technical knowledge of a computer programmer).
If a pediatric task languishes beyond customizable parameters (such as duration), it automatically escalates to the attention of a care coordinator or physician. The “severity” of the escalation (such as passive visual cue versus pop-up alert that requires dismissal versus flashing red lights and a siren) and to whom (user versus supervisor versus emergency response team) are also part of the executable process model. Tasks are escalated in a manner that is contextually appropriate because the process model represents actionable knowledge about escalation context and is under control of clinical staff who understand this context.
P.S. A long quasi-personal note: The Apple iPad is programmed in Objective-C, which was developed by Brad Cox, a graduate (Ph.D. Mathematical Biology) of my alma mater, the University of Chicago. For C# programmers there’s MonoTouch, which still requires a Mac to deploy to the iPad. I encountered object-oriented languages such as SmallTalk (Objective-C combines features of the C and SmallTalk programming languages) while a graduate student in Industrial Engineering at the University of Illinois and then medical student at the University of Chicago (through an elective course in the Department of Mathematics). I was interested in simulating biological systems embedded in simulated social systems. Techniques for doing so have potential for simulating (and understanding) changes in patient clinical state within simulated (and understood) socio-technical systems for improving patient clinical state. Sounds theoretical, right? However, there are potential practical applications of this approach for systematically improving clinical outcomes, patient satisfaction, and practice productivity. The key is to take a complete systems engineering view of the pediatric medical home. As an industrial engineer, I was already familiar with the use of FORTRAN for discrete-event modeling and simulation of patient flow through medical offices, emergency rooms, and hospitals. One such project at the university health clinic paid my tuition and stipend for one year during graduate school. Object-oriented programming languages are a natural for simulating complex systems (the EncounterPRO Pediatric EMR Workflow System uses object-oriented technology to achieve its highly componentized and modular platform architecture). I later considered use of Objective-C for simulating patient flows in a medical office combined with a Markov model of evolution of patient clinical state (a now standard technique). Every interesting idea does seem connected to every other interesting idea, in a six-degrees of separation sort of way. Objective-C influenced design of the Java programming language for which I eventually certified as a programmer. I recently developed some simulations of pediatric patients flowing through pediatric clinics (based on actual, though deidentified, data using workflow/process mining techniques, I’ll blog about it soon). Wouldn’t it be cool to run it on the iPad? The point being to give a pediatrician or primary care physician a tool to understand and improve patient flow through their office. (Warning! flight of fantasy ahead!) And then climb in a time machine to go back and hand it to my past-self! Of course, I don’t remember anyone materializing in front of me with an iPad, so the time machine part probably won’t happen—fun to think about though! Regardless, the iPad’s form factor, task-at-a-time workflow, and contextual usability make it a great user interface for the process-aware clinical groupware I advocate, for busy pediatricians or any high-volume, low-margin ambulatory specialty. By the way, we also have Brad Cox and Objective-C to thank for paving the way to modular component-based clinical groupware.
Brad Cox of Stepstone largely defined the modern concept of a software component. He called them Software ICs and set out to create an infrastructure and market for these components by inventing the Objective-C programming language.
Bio: Chief Medical Informatics Officer,
EncounterPRO Healthcare Resources, Inc.,
Atlanta, Georgia.
About those initials (my mother used to say I was killing myself by degrees): BS, Accountancy, University of Illinois; MD, University of Chicago; MSIE, Industrial Engineering, University of Illinois; MSIS, Intelligent Systems, University of Pittsburgh.
(Those are kickbikes.)
TX! BTW 1st thing I did was catch up Ur tweets RT @ faisal_q WB RT @chuckwebster: Back from vacation, including from Twitter…much refreshed! 4 days ago
