John Glaser
Ray Hess

Using technology to automate clinical workflows enables hospitals to enhance quality of care, increase throughput, reduce costs, and optimize the patient experience.

At  a Glance 

The use of technology to automate clinical workflows at The Chester County Hospital in West Chester, Pa., has resulted in the following benefits:  

  • An 82 percent reduction in hospital-acquired MRSA infections  
  • A significant reduction in catheter-associated urinary tract infections  
  • Enhanced documentation of pre-existing pressure ulcers (The Centers for Medicare & Medicaid Services classifies pressure ulcers that develop during a hospital stay as "never events.")  

Today's healthcare providers face constant pressure to improve the quality, safety, and efficiency of care while reducing costs and increasing revenue. Many incentives encourage providers to improve performance (such as financial incentives to demonstrate meaningful use of electronic health records [EHR] technology)-and increasingly, the healthcare community is being asked to do more with less. These pressures extend to all aspects of the organization, from clinical operations to revenue cycle and administrative processes.

Investments in process optimization, throughput, and workflow efficiency technologies offer a way for providers to meet operational goals against the backdrop of an ever-more daunting strategic agenda.

A Framework for More Intelligent Processes

Although healthcare providers have traditionally lagged behind other industries in their use of sophisticated process optimization tools due to the myriad complexities of the processes needing to be automated, the use of business process management, or workflow technology has become something of a niche in the healthcare IT industry.

Workflow technology is the backbone of process automation, effectively building a safety net around patient care processes or core support/administrative processes. In considering the degree of process automation that may exist within a provider setting, the hierarchy progresses from simple rules and alerts that most information systems are capable of providing to the full automation of a process, driven by a sophisticated workflow engine, capable of taking work off of a team member's shoulders.

Workflow engines specialize in the execution of a business process, not just decisions made at a discrete point in time. The technology can greatly assist in clinical decision making not only by presenting clinicians with alerts and reminders, but also by directing the teamwork aspect of clinical decisions, the time management and task allocation aspects of process delivery, responses to changes in patient or operational conditions, and behind-the-scenes automation of process steps. Consider the following levels of process automation.

Rules and clinical decision support system alerts. The most basic alerting process triggers a notification that something must be done or considered (e.g., alerting a physician of a drug-drug interaction). A common concern at this level is alert fatigue, where an overload of prompts can simply become noise and are in turn avoided.

Rules with intelligence. This next level moves beyond the simple alerting process that most healthcare IT systems are capable of; this next level builds in intelligence to drive actions and help with process flow (e.g., rules that may also include timers, escalations, and links to a form needing completion). This is the first step in process automation.

Basic automation/work reduction. At this stage, tasks such as the completion of forms, clinical notes, orders, and handoffs move from manual processes to automated processes, thus removing work from various team members and ensuring required process steps are fulfilled.

"GPS [global positioning system] level." At this level, the technology guides users through multiple aspects of a care process. For example, the entire protocol for managing a congestive heart failure patient can be triggered through a workflow.

GPS-plus level. This level goes beyond just guiding caregivers and represents full automation of part of a process. It is at this stage that human intervention can be completely eliminated in some process steps or handoffs.

"Autopilot" level. This is the gold standard for business process management, representing full automation, in which a complete function or process can be totally handled by the workflow system. For example, a hospital's bed-cleaning process can be fully automated in that the system not only tells various support team members what to do, but also tracks and reports what's happening with the process in real time.

Impact of Intelligence  

In every process improvement project, an explicit process is identified with the goal of managing it as efficiently and effectively as possible. Through the use of a workflow engine, automation allows for a much higher degree of reproducibility, decreased variation in the execution of each process step, decreases in missed or delayed steps, fewer errors, more timely completion of the process, decreased staff workload, and ultimately, improved outcomes.

For example, the bed turnaround process at a typical hospital may include up to 20 steps, with 15 handoffs of information. With every handoff comes the potential for failure or delay, creating an environment where variance-in processes and, therefore, in outcomes-can thrive. Of course, process automation through IT can help; however, it's just one piece of the puzzle. What's needed is a way to connect all the steps in the process and track them in terms of timing and sequence. This connecting and tracking of process steps is the differentiating feature of a workflow management system, which gives providers the ability to examine and improve the process of care.

The use of workflow technology to automate processes-especially those related to the Centers for Medicare & Medicaid Services (CMS) core measures and Joint Commission requirements-has delivered compelling results for several providers. Of particular importance to health systems across the nation is the avoidance of CMS "never events," a set of hospital-acquired conditions the agency has deemed to be preventable, and thus, not reimbursable. Following are some specific examples of the clinical and business gain that can result from the application of intelligence to key processes via the use of a workflow engine at The Chester County Hospital.

Foley Catheter Workflow

With an eye toward preventing the occurrence of CMS never events, The Chester County Hospital (CCH), a 220-bed community hospital in West Chester, Pa., implemented a Foley catheter workflow in October 2008. The workflow is activated when a clinician identifies and documents that a patient has a Foley catheter, then notifies caregivers when to replace or remove the catheter based on the amount of time (48 hours) the hospital has allocated to complete that action. The catheter-associated urinary tract infection (CAUTI) rate for the 12 months before the solution was fully deployed was 5.61 infections per 1,000 catheter days. This rate dropped by more than 50 percent-to 2.74 infections per 1,000 catheter days-in the 12 months following full training and deployment.

If completion of a step is not documented in the system, the workflow technology will escalate the issue to the appropriate members of the clinical team as defined by the organization. In essence, it constantly listens and prompts next steps based on the information gathered-whether the information consists of a new result or a missing piece of clinical documentation.

Pressure Wounds Workflow

The workflow for CCH's pressure wounds present-on-admission process is another good example of how the technology helps improve the coordination of patient care. The end goal is to document pre-existing pressure ulcers. Although this is first documented by the nurse during the initial patient assessment, it must also be documented by the physician, which is not always easy. The workflow extracts the information from the nursing assessment and, if a pressure wound was documented, notifies the physician with a documentation reminder. It's a one-click action for the physician to place a note in the medical record.

The wound care workflow not only helps CCH comply with CMS requirements, but also has a positive financial impact, since CMS classifies pressure wounds that develop during the patient's hospital stay as never events. It's efficient for the physician, it allows clinicians to meet their compliance requirements, and Chester County avoids any financial consequences that could result from failure to document pre-existing ulcers.

Infection Control Workflows

Decreasing hospital-acquired infections is a major patient safety concern and the focus of CMS and other regulatory agencies. Methicillin-Resistant Staphylococcus Aureus (MRSA) is one organism that has received considerable attention over the past several years, thus becoming a key focal point of CCH's infection control efforts.

CCH's review of its data showed a high dependence on manual processes that allowed an estimated 25 percent of MRSA-positive patients to go unrecognized at the time of bed placement. Developing a way to automatically identify and alert staff to these patients was a critical initiative for the hospital. Fortunately, support for automation already existed, since many of the key data elements for automation already existed within the hospital's information system or were electronically discoverable. For example, the results for all hospital-performed lab tests resided in the clinical repository. Admission assessment data from nursing were stored electronically, and all new lab results were in HL7 transactions that could be scanned for relevant information as they came into the system.

With the proper logic created via the workflow engine, the IT system was able to identify every patient who had a history of MRSA or a new positive MRSA culture. The system was also programmed to listen for negative MRSA screens that would allow a patient to come out of isolation. If a history existed, the system created a text-to-speech message that alerted the nursing bed manager/supervisor to the condition. Bed managers must acknowledge the call via the telephone keypad or the system will call back. Additionally, the patient's physician, staff nurse, and the infection control department are notified via system alerts or e-mail. The notification includes the source of previous infections and the need for a MRSA screen if the patient is a history-only patient. The system then listens for screen results to determine whether the patient should stay in isolation. In every instance, the information is pushed immediately to the appropriate person so that isolation status can be optimized.

Pennsylvania Act 52, which requires proactive MRSA screens for patients identified as "high risk," went into law in 2007. As a result, the workflow was modified to evaluate all non-MRSA patients for high-risk status and to alert clinical staff to obtain a screening test when needed. The system automatically maintains and updates the infection control database with the patient's latest information. For example, it alerts laundry staff via a printed report of exact floor census, including isolation patients, so that the proper number of isolation gowns is available on each floor. It also alerts housekeeping that the room held an isolation patient and needs an "isolation clean" upon transfer or discharge. The process was further extended to request the proper supplies from central supply, monitor that the correct isolation flags are set in the system, set the flags when appropriate, and create nursing notes for the clinical staff. This reduces documentation time and ensures accurate and complete notes.

Use of the MRSA workflow, in conjunction with expanded screening criteria and conventional measures, such as vigilant attention to hand hygiene, led to a significant reduction in MRSA infections (approximately 82 percent) while increasing total awareness of other contagious infection workflows. From 2005 through 2009, the number of patients identified with MRSA nearly doubled (341 to 606), while the number of infections that were hospital-acquired dropped from a rate of 0.58 to 0.18.

An unintended benefit of the MRSA workflow was the positive affect it had on other infection control efforts, such as vancomycin-resistant enterococci (VRE) and C. difficile, for which similar workflows were added later. Although these rates were already starting to trend downward, the hospital continues to experience declines in infection rates as a result of this initiative.

Unlocking the Value of Healthcare IT

In the examples noted above, the implementation of internal process improvements supported by workflow technology that builds intelligence into key process steps drove measureable improvements in the quality of patient care. In fact, as an early adopter of an integrated workflow system since 2003, CCH now has more than 75 clinical and support processes automated.

Health care is the most complex, knowledge-driven industry in the world and represents one of the most important economic challenges of our time. IT can transform health care, but only if it facilitates
sustained process optimization within a framework of extraordinary complexity and variability.

Today's health systems need a strategy that enables them to improve the productivity of their resources, increase throughput across the organization, and optimize processes to enhance the patient experience. In short, they need a strategy that addresses the process of care-a strategy that drives intelligent processes. Workflow technology offers the potential to unlock the true value of healthcare IT.

John Glaser, PhD,is CEO, Siemens Healthcare Health Services, Malvern, Pa., and a member of HFMA's Massachusetts-Rhode Island Chapter (

Ray Hess is vice president, information management, The Chester County Hospital, West Chester, Pa. ( 


Publication Date: Tuesday, February 01, 2011

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