Ebola, EHRs, and Evidence-Based Workflow: We Need Open and Transparent Healthcare Workflows

Thomas Eric Duncan, the Ebola patient released from Texas Health Presbyterian Hospital, died this morning at 7:51 a.m. The hospital first blamed a flaw in EHR workflow, but then retracted that claim the next day. Social media has been fractious. Basically, whether you like EHRs, as currently designed and implemented (”See, I told you so!”), or dislike EHRs, as currently designed and implemented (”Statement retracted, no flaw, case closed.”), predicted most reactions.

Unfortunately, I fear, we well never know for sure, the answer to the question, “”What did the EHR users know and when did they know it?” Barring some enforced Epic EHR contractual gag clause, accounts will be forthcoming. But, given the variety of strong biases many stockholders bring to the subject of EHRs and EHR workflow (and I am one of them), it seems unlikely that all will be satisfied. There are too plausible reasons why hospitals, EHR vendors, nurses, and physicians might be reluctant to potentially admit culpability.

We need an evidence-based workflow account of the complete who-what-why-where-when-and-hows sequence of EHR-mediated user activity that may, or may not, have contributed to Mr. Duncan’s release. The problem is, even if a blue-ribbon panel of experts, akin to the Rogers Commission that investigated the Challenger explosion, takes up the matter, current EHRs, of which Epic is emblematic, don’t represent workflow in a way that allows us to make the necessary inferences to explain what when wrong and who or what is to blame.

What do I mean by “represent workflow”? What I mean is, just as current EHRs represent data about patients and drugs and procedures and such, EHRs need to explicitly represent sequences of tasks (data gathering, order entering), the resources consumed (time, money, user attention), and, most important of all, the goals the tasks are intended to together accomplish. Why is representing goals so important? Because goals go to intent. Why was the nurse or physician trying to do when they clicked that button or spoke that command?

What I have just described — the explicit representation of tasks, resources, and goals — is how workflow management system work. True workflow systems, sometimes also known as business process management or dynamic and adaptive case management systems, execute or consult models of work and workflow to automatically do for users what would normally require users to do for themselves. Since these models are easier for clinical users to understand than computer code (Java, C#, Mumps, etc.) it’s easier for users to tell analysts how to design their preferred workflows. Sometimes precocious users even start tweaking workflows themselves. It makes them happier, to make workflow fit their work than make their work fit programmers workflow.

But here’s the important thing, EHR workflow systems leave a detailed, time-stamped trail of who-what-why-where-when-and-how users interacted with the EHR workflow systems. Right now, this kind of data is either absent, locked up in opaque event logs, or misleading, even if one were to be able to extract it. The very best event logs are generated by workflow management and business process management systems.

Even more important than open source and open data, is open and transparent workflow. I call this kind of EHR workflow “figureoutable” and “buildonable.” Mere mortals, who are not programmers, can figure it out and leverage it in ways that the original programmers might not have specifically imagined. These mere mortals include investigators trying to piece together what went wrong.

I’ve written several other blog posts about how process-aware EHR and public health IT systems might have operated to prevent Mr. Duncan’s release (see below). But even if even they will have failed us, they’d at least leave a trail of time-stamped workflow context from which to reconstruct past workflow and improve future workflow. So they won’t fail us the next time.

We, as a nation of patients, providers, payers, policy wonks, and politicians need more evidence-based workflow data, to create more effective, efficient, and safer workflows. We need the kind of open and transparent workflow that will only result from what academics call process-aware information systems.

If you’d like a well-received short course on workflow technology in healthcare, I can’t do any better than suggest my own five-part series:

BPM-based Population Health Management & Care Coordination: Workflow, Usability, Safety & Interoperability Perspectives


Posted in EHR Workflow | Leave a comment

Dear Mom, “Healthcare IT workflow & Business Process Management expert Chuck Webster”, Love Chuck

This blog post is a selfishly self-indulgent and self-promoting. But then, this *is* my personal website at ChuckWebster dot com. So if I can’t stick a selfishly self-indulgent and self-promoting blog post here, where can I stick it? (Don’t answer.)

jean

Actually, there is a serious point. It’s in the PS. This post is just a place to archive some links and tweets, so I can send it to my Mom (Hi, Mom!).

Dear Mom,

I know that I’ve gone on-and-on for decades about workflow in healthcare and workflow technology and business process management and process-aware information systems. You’ve always nodded sympathetically. I’d just like to let you know that I’m finally starting to make progress in educating healthcare and health IT about this stuff! I’ve been quoted in national on-line health IT trade publications! Twice! I’ve included quotes of me essentially quoting myself, plus what are called “tweets”. Tweets are kind of a cross between email, blog posts, and test messages…. I know you know I tweet a lot. These are examples of tweets that I “tweeted out” or that mention me.

Anyway, thank you for your support, and for allowing me to explore whatever I wanted to explore while I was growing up.

Love Chuck

Bad EHR Workflow Played Role in Ebola Patient’s Release

“The real issue, to paraphrase healthcare IT workflow and business process management expert Chuck Webster, is a lack of process awareness. Today’s EHR systems – from Epic or any other vendor – can’t accept information from public health organizations at the point of care. If they could, that Texas Health physician would have seen that Duncan recently returned from Liberia, combined that knowledge with the symptoms Duncan presented and kept him in the hospital instead of sending him home. Building such process-aware systems will require ‘evolutions in workflow,’ Webster says.”

Hold on: Can we really blame Ebola in the US on an EHR?

““Process-aware systems have some sort model of work or workflow that is executable or at least mechanically consultable. Why do I say this? Because we, as a nation, need to be able to automatically, or at least semi-automatically push candidate workflows from public health organizations down to EHRs at the point-of-care,” Charles Webster, MD, wrote in a blog post. “And to do so in a way that supports, but does not disrupt, evolutions in workflow necessary to, say, flag someone who just came back from Liberia. The only way to do this is to actually model workflow. And to transmit these models of workflow via APIs….

Webster, in fact, suggested in an email exchange with Medical Practice Insider that the desired future state of EHRs should include getting the right patient data in front of the right person.

‘The context is essentially, what, who, where, when, why, and how (why I call it the journalistic model of usability). Of course, it’s a sort of back and forth dance, with the user initiating some workflows and the workflow engine initiating others,” Webster explained. “Much of the usability, safety, efficiency, and even interoperability of structured workflow-based EHRs and health IT systems requires the right platform (the workflow engine, graphical editor, workflow model combo) AND the proper programming of the workflow model by people who truly know the different clinical context and desirable workflows for each of those contexts.’”

My blog post Ebola, APIs & Workflow: We Need A More Process-Aware Health IT Ecosystem was even mentioned on Politico! (The online version of that free paper you see around when you visit me here in Washington DC.)

clicking

I’ve also appended a bunch of tweets after the following postscripts.

P.S. I’ve already weighed in about what role “workflow” may or may not have played in the unfortunate release of a patient infected with Ebola. You can review those blog posts here.

P.S.S. Careful with your comments. My Mom is reading this.

Posted in social-media | Leave a comment

If I Could Change One Thing About EHRs That Might Have Prevented Release Of The Dallas Ebola Patient

If I could change one thing about EHRs in general, it would be for them to be implemented on true workflow platforms, instead of the currently used structured document platforms. True EHR workflow systems have a workflow engine that does things for users automatically, saving them time and effort. Further, and possibly relevant to the Ebola vs. EHR case in Dallas, workflows can be created and customized by physicians, who know their workflows best. For example, a workflow definition could have been created that would have been triggered when the nurse entered the information the patient had traveled from Liberia. This workflow definition would have been executed by the workflow engine to do almost anything, from putting a work item into the physician worklist, to escalating to a text message to be sent to a supervisor if the work item was not completed within some short duration. Finally, this work item could have been posted to a generally visible status board, so all the members of the staff could know it was there. Patient data and task visibility is a big problem in many current EHRs, and workflow technology has a solution to this invisibility. Looking ahead, if we can model and execute clinical workflows, then we can transmit and monitor them as well. Eventually, public health entities will transmit candidate workflows to EHRs, to have useful effects at the point of care, but without the workflow disruption physicians find so troublesome. So, during the next Ebola-like crisis, public health departments will be able to broadcast actionable workflow to prevent the kind of mistake we may have witnessed in Dallas.

Posted in EHR Workflow | 2 Comments

HIMSS Amends Blog Post On Role Health IT Played In Discharge Of Ebola Patient

Boy did health IT social media buzz today regarding the possible role of health IT in the recent unfortunate release of a patient infected with the Ebola virus. I certainly weighed in, in my Ebola, APIs & Workflow: We Need A More Process-Aware Health IT Ecosystem. But I was small potatoes. Major papers reported a “flaw” in EHR workflow was being blamed.

And I tweeted the following, shown in the morning CNN news shows.

As the major trade and professional association representing health information management and technology, it was to be expected that HIMSS should weigh in as well. But what was interesting was they weighed in twice, deleting and replacing their first blog post with a second edited version. Here’s a comparison of the first version (left column) to the second version (right column). Differences are in blue.

The post was probably just accidentally published before intended. I’ve done that before. Most of the changes are just rewordings of the same basic ideas. But some of the changes are more interesting. First of all there’s the change in title.

First title:

IT Did Its Job in Dallas – But What About the Human Factor?

Second title:

Health IT Is Only a Portion of the Solution – Addressing Human Factors Are Key

And the following, from the first post:

“We are all paying very close attention to the situation and the role health IT may have played in determining the proper Ebola diagnosis. As we understand the circumstances, the separation of nursing and physician notes in the electronic record may have contributed to a lack of cross-team knowledge sharing. Communication in a busy emergency room, and between clinicians in any patient care setting, is vital to providing quality care. And health IT is only one solution. As we understand the circumstances to-date, the separation of nursing and physician notes in the patient’s record may have contributed to a lack of cross-team knowledge sharing. This presents an opportunity to explore the role health IT can, or should, play in determining a clinical diagnosis….The IT system at Texas Health Dallas did the job it was designed to do. Can it be improved? Absolutely, and it appears that they are working on that.”

Was replaced by this, in the second post:

“As we understand the circumstances to-date, the separation of nursing and physician notes in the patient’s record may have contributed to a lack of cross-team knowledge sharing. This presents an opportunity to explore the role health IT can, or should, play in determining a clinical diagnosis….First and foremost, communication is vital to providing quality patient care – whether in a busy emergency room or in a doctor’s office. Clinicians must be able to share information with each other across clinical disciplines and with their patients. Health IT is only one solution to the goal of cross-team knowledge sharing.”

The rest of the changes were, as I said, minor. But feel free to examine them as well.

So. What do you think?


Posted in EHR Workflow | 4 Comments

Ebola, APIs & Workflow: We Need A More Process-Aware Health IT Ecosystem

Reviews are in!

I was all set to write a blog post about today’s #HITsm API (Application Programming Interface) questions. (See below if link is out of date.) I’ve “consumed” APIs (written code to call them). I’m even creating a crude API for a little Internet-Of-Things project I call @MrRIMP.

  • Topic 1: Modified from @KBDeSalvo: What will the #healthIT ecosystem be like in 2024? What role can APIs play?
  • Topic 2: Pay now or pay later: How much consistency should EHR APIs have? via @GrahameGrieve #HITsm
  • Topic 3: Via @UsabilityPeople: What is needed for APIs to be more “usable?”
  • Topic 4: Modified from @Greg_meyer93: Are APIs the solution? Are they simply ‘enablers?’
  • Topic 5: Raised by @VinceKuraitis: Public API. Describe & discuss the benefits.

But then….

…blamed on EHR workflow…

Well, IT hit the fan this morning (at least on Twitter). The failure to immediately quarantine an Ebola patient upon presentation to a Texas emergency department is being blamed on EHR workflow.

Now, whether or not it’s the EHR fault, I don’t know. I’m looking forward to some sort of forensic workflow post mortem…. But lots of people cc’d me on tweeted links to the story, because, presumably, I tweet a lot about EHR and health IT workflow and workflow tech. Since workflow can be between people, between people and machines, or between machines, workflow problems aren’t automatically EHR problems. But discussion will be fascinating to watch play out.

No, what I really want to do here so pivot from Ebolagate to how a more process-aware health IT system could better respond to similar public health emerging emergencies. Back in 2008 I gave the following presentation at the HIMSS conference in Florida. You can watch it here for 18 bucks. My presentation was, essentially, about APIs and workflow between public health entities and EHRs.

This is a framework I developed to compare connecting an EHR to a public health IT system:

  • Project Management
  • Standard Data Format
  • Simplicity of Dataflow
  • Maturity of Transport Infrastructure
  • System Stage (such as Production vs Testing)
  • Data Format

I think it’s still a pretty good way to compare health IT interface and integration projects. Perhaps at some future date I’ll update the rest of my slides to reflect today’s concerns and technologies.

But for now I want to get this blog post up before today’s #HITsm chat on APIs (Application Programming Interfaces).

The basic problem confronted by public health professionals and users of EHRs in emergency departments boils down to the degree to which the systems they use are “process-aware.” Process-aware systems have some sort model of work or workflow that is executable or at least mechanically consultable. Why do I say this? Because we, as a nation, need to be able to automatically, or at least semi-automatically push candidate workflows from public health organizations down to EHRs at the point-of-care. And to do so in a way that supports, but does not disrupt, evolutions in workflow necessary to, say, flag someone who just came back from Liberia. The only way to do this is to actually model workflow. And to transmit these models of workflow via APIs.

P.S. I’ve got over 50,000 tweets about healthcare workflow (including cat videos) at @wareFLO, and about a third of million words across this several blogs.

Please interact with me on Twitter at @wareFLO, leave comments on any of my blogs, and contact me to help accelerate change. While I believe it is only a matter of time before current workflow-oblivious health IT system are replaced by truly process-aware health IT systems, we may be in a race. A race to implement these systems, at the front lines of healthcare, before the next, more virulent Ebola-like threat looms.


Posted in healthcare-BPM | Leave a comment