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EMR Workflow, Business Process Management, Adaptive Case Management, Clinical Groupware for Pediatric and Primary Care | Print |

The best and most authoritative explanation of workflow management systems ideas and technologies is Wil van der Aalst and Kees van Hee's Workflow Management: Models, Methods, and Systems (MIT Press, 2002). Over the past decade terminology and thinking about workflow have evolved. The workflow management systems industry became the business process management (BPM) industry. Recent exciting developments emphasize adaptive case management (ACM), dealing with predictably unpredictable workflows, which typify the hectic environments of pediatric and primary care medical practices. By combining BPM and ACM approaches process-aware clinical groupware can make routine workflows fast and easy while adapting, in real-time, to non-routine workflows. In doing so, process-aware clinical groupware greatly improves EMR usability and productivity.



You don't need to be a workflow expert to benefit from the EncounterPRO-OS Pediatric EMR Workflow System (just as you don't have to be an automotive engineer to drive a car). However, if you are so interested, here is a quick cheat sheet about workflow management, business process management, adaptive case management, and clinical groupware concepts and terminology.

The three most important workflow ideas that EncounterPRO-OS Pediatric Workflow System implements are:

  • A workflow engine saves you and your staff time and effort by executing process definitions.
  • Process definitions ("workplans" in EncounterPRO-OS) are customizable sequences of screens with large buttons that mirror sets of task steps. Different encounter types (well versus sick versus newborn versus vaccination), roles and users (physicians versus nurses, Dr. Smith versus Dr. Jones, orders (developmental testing versus education), and data (such as doing something automatically with a scanned in document).
  • A "radar view" (called Office View in EncounterPRO-OS) allows all staff members to see whose tasks for which patients have been waiting for how long and in what exam room (like a view from an airport control tower, except patients instead of planes). EncounterPRO-OS's Office View is an important (though not only) part of EncounterPRO-OS's clinical groupware functionality. It helps users to see what each other are doing (and not doing), moment by moment, to facilitate teamwork and care coordination.

The EncounterPRO-OS Pediatric EMR Workflow System is based on mature, robust technology (workflow managementgroupware, and business process management systems) that is prevalent in many other industries, but which has not yet become widespread in healthcare. If you'd like more information please visit the blog Electronic Health Record Workflow Management Systems.

EMR Workflow Systems 101

The combination of EHR and EMR workflow management, workflow systems, clinical groupware, business process management, and adaptive case management is such a BHAI (Big Hairy Audacious Idea) that it is sometimes difficult to separate the extraneous from the essential. As a consultant put it: "Cat, Dog, Tree!" To which we replied, what do you mean? To which she replied "Cat, Dog, Tree!" All very Zen... but we think we got it. What is the absolute minimum number of ideas that we can present that only go together in one way (a dog chasing a cat up the tree) and thereby illustrate the difference between a traditional "hunt-and-peck" EMR and the "anticipatory" EncounterPRO-OS Pediatric EMR Workflow System. This is what we came up with:

Cat, Dog, Tree!

The EncounterPRO-OS Pediatric EMR Workflow System includes a large number of optional data review and entry and order entry tasks. For example, Figure 1 shows the Chief Complaint screen.

Figure 1: Typical EncounterPRO-OS Pediatric Workflow System Screen(Chief Complaint)

A subset of these tasks is selected to create a workflow process definition, or “workplan” in EncounterPRO-OS speak. In this example (Figure 2) the workplan is a pediatric workplan for “Standard Encounter Child Well Visit New Patient.” The Chief Complaint screen occurs as the third step in this workplan. A collection of pediatric-specific workplans configures an EncounterPRO-OS Pediatric EMR Workflow System.

Figure 2: A Process Definition (”Workplan”) Controls
Presentation of Screens to Users

During workplan execution the Chief Complaint task time is automatically and continually updated in the Office View (Figure 3). It can be seen as the pick item in the upper left. It has been languishing (in this demo situation) for 29 minutes. Touching the task bar brings up the Chief Complaint screen in order to complete it (back to Figure 1).

Figure 3: EncounterPRO-OS Pediatric EMR Workflow System Office View

The EncounterPRO-OS Pediatric EMR Workflow System implements a form of what is increasingly called adaptive case management. Each room in the office view is equivalent to a case folder in a case management system. 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). 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’).

By automatically pushing the pediatric task screens to the right users (on their To-Do lists) and by indicating their status in real time on the office view where all staff can see them, tasks are accomplished quickly and the occasional ignored task is ignored only briefly. EMR workflow systems are clinical groupware. However, there are two kinds of clinical groupware. There is the workflow-engine variety (a traditional BPM engine pushes clinical tasks to users and tracks their status) and there is the keep-all-the-users-aware-of-the-status-of-all-relevant-clinical-tasks-all-the-time variety (adaptive case management using shared displays such as radar views). The EncounterPRO-OS Pediatric EMR combines both kinds of clinical groupware--to achieve levels of usability and productivity that traditional EMRs cannot. Because they are not clinical groupware.

Combined management of routine and non-routine workflows is where EncounterPRO-OS truly excels. Much of general pediatric practice is routine and therefore amenable to automation via EncounterPRO-OS's workflow engine executing workplans for well and sick child visits, vaccinations, and so on. One pediatrician who uses EncounterPRO-OS 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-OS'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-OS's Office View.

By the way, notice that these screenshot have been reduced to about 380 by 540 pixels, and they're still readable! That's because just a few big buttons on each screen (made possible by spreading the buttons across screens) is so much more easily and accurately "hit" in quick succession than traditional "hunt-and-peck" EMR user interfaces.

If we've whet your appetite (in keeping with the Cat, Dog, Tree metaphor) here's some more to chew on.

EMR Workflow System Glossary

Phrase Definition Medical Example
Work Item Task to perform Vitals signs awaiting performance during a patient encounter
Workflow Definition Description of a process detailed enough to drive
EMR behavior
Get the Patient, Take Vitals and a Chief Complaint, Review Allergies, Review Medications, Review of Systems, Examination Screen, Evaluation and Management, Billing Approval
Worklist List of tasks to perform A nurse's To-Do list
Case Particular application of a workflow management system A particular patient's encounter managed by a workflow management system
Process Order of tasks to be performed and resource
A Well Child pediatric visit
Resource Something that
accomplishes tasks(usually a user)
A physician, nurse, technician
Role Set of related skills accomplished by a resource The role of nurse or physician
Routing Types of routing include sequential, parallel, conditional, or iterative task execution Routing a recording to a transcriptionist and the report back to the physician
Task Unit of work carried out by a resource Obtain vital signs
Trigger An event that changes a work item into an activity Starting to accomplish the task of responding to a phone message by selecting a To-Do list item
Workflow A process and its cases, resources, and triggers The tasks and people involved in accomplishing a patient encounter
Workflow Definition Editor User application or interface for creating workflow definitions An ordered picklist representing Get the Patient, Take Vitals and a Chief Complaint, Review Allergies, Review Medications, Review of Systems, Examination Screen, Evaluation and Management, Billing Approval
Activity Performance of a task Performance of a task Obtain vital signs within a patient encounter


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