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Process automation has become such a standard part of process improvement efforts at The Chester County Hospital, West Chester, Pa., that the list of desired automations is backlogged with many requests. Achieving this scale and scope of process improvement through workflow technology can teach us several important lessons.
The goal of applying IT to improve organizational performance will be advanced if the organization views its task as implementing, and then perpetually leveraging, application foundations. These foundations include an electronic health record, workflows, and rules engines and analytics) that in essence create an IT ecosystem. This foundation must be implemented. But the real implementation involves the ongoing use of the foundation to improve organizational performance. Implementation does not end the day after go-live.
You can't improve it if you can't measure it. One of the challenges for many organizations undertaking IT initiatives is their ability to quantitatively and qualitatively demonstrate the benefits achieved. Therefore, establishment of baseline measurement data is critical. The mapping of current state workflows and tracking the reduction in manual and non-value added activities post process optimization is necessary to ensure that desired gains are achieved.
Communication with team members should be supported by automated alert systems. Through integration of a workflow engine with existing paging systems or other electronic notification systems, members of the multidisciplinary care team can be actively noti¬fied of actions requiring their attention when they are not actively logged into the system or currently interacting with a patient. This differs from more passive solutions that may place an action on a worklist that re¬quires the practitioner to be in the system and at a specific screen to see the alert or notice for action.
It is also important to achieve a balance between optimizing processes and sending too many alerts to team members. The workflow engine can be used to track not only the state of the patient, but also the state of the messages being sent to the clinical staff. If staff members are receiving too many alerts, a workflow might consolidate messages or utilize an alternate communication method.
Lack of access to required data can impede success. Without available and updated information, it is virtually impossible to fully manage the state of a patient's care. Several data access problems may exist. Data may be incomplete, as when new healthcare information systems are implemented and historic data from older systems is not ported forward. Or, data may continue to exist in inaccessible paper formats. The level of automation and data available at a healthcare facility ultimately drives the prioritization of which processes are candidates for improvement with workflow technology.
Patient population data may not be perfect. In a clinical environment, a workflow engine often must identify the population of patients to whom the workflow applies. For example, a workflow that monitors compliance with Joint Commission/Centers for Medicare & Medicaid Services quality measures for acute myocardial infarction (AMI) must first identify patients with myocardial infarction. The workflow engine can be used to determine if a patient is a likely AMI patient, even if a diagnosis isn't entered into the system until the patient is discharged. We may instruct the workflow to check for elevated test results, often an indication of AMI. This identifies a patient, but there is still a margin of error-not all patients with elevated results have AMI and not all patients with AMI have elevated results. Therefore, the patient population data will be imperfect.
Technical feasibility opens automation questions. A balance must be determined between what a hospital is comfortable having the workflow engine do automatically, without user intervention, and which steps require human interaction. A workflow may seek clinician input at specific points in the workflow. Medication orders will always require human confirmation before activation. A dosage change must flag a pharmacist to review the request. While many functions are technically feasible, care and concern must be taken to evaluate how decisions might affect patient safety. At the end of the day, the hospital, not the workflow engine, remains responsible for patient care.
Workflows must offer the ability to deviate from the suggested action. The healthcare industry gives physicians the discretion to determine the care their patients need. This makes healthcare unique; it is unrealistic to force a single standard when developing clinical treatment processes. Even when evidence-based standards of care are encouraged, physicians have the opportunity to choose alternate treatment plans and every patient's condition, or combination of conditions, drive different clinical decisions. Therefore, if a medication is suggested for a patient, along with the option to place the order, the physician needs to be offered the options to order an alternate drug, decline placing the order, or find more information about the disease, drug, or guideline evidence. Clinical workflows require built-in flexibility to accommodate human discretion.
John Glaser, Ph.D., is CEO, Siemens Healthcare Health Services, Malvern, Pa., and a member of HFMA's Massachusetts-Rhode Island Chapter (firstname.lastname@example.org).
Ray Hess, MSA., is vice president, information management, The Chester County Hospital in West Chester, Pa. (email@example.com).
For more information see John Glaser's and Ray Hess's "Leveraging Healthcare IT to Improve Operational Performance," hfm February 2011
Publication Date: Tuesday, February 01, 2011