The KHIT Blog: Clinical workflow

Saturday, February 2, 2013

Clinical workflow

A couple of jpeg allusions.

Above, snarky bird's eye view jpeg analogy of my doctor's office at 8:03 a.m.

Or, how about the more traditional...

I have to give major props to Chuck Webster, MD, MSIE, MSIS, my Twitter pal** ("One-Man Trade Association for Electronic Health Records, Business Process Management and Natural Language Processing"), who took to a comment of mine, and made it into a blog post on his own blog.

I asked if I could repost his comment here as a blog post, the first time I have ever done such a thing (and I have over 200 blog posts about EHR workflow on this blog!). I’m working on my own blog post about the AHRQ study, but @bobbygvegas beat me to the punch. Good on you mate!

Dude, I Am Not Worthy.

But, thanks nonetheless Hugely so.

ChuckWebster.com

** Chuck and I go back in cyberspace to before our Twitter hookup. He was a co-founder of the EHR product "EncounterPRO," which my own Primary has used since 2004. My doc is also one of my REC clients. EncounterPRO was way late in the game getting certified. I'd frustratingly written my doc and his two partners off for 2012, but, to my extremely pleasant surprise, the vendor (Chuck was long gone) made it to Cert, and I helped them get to 2012 Attestation -- no thanks to their piddley MU "documentation" ( I got a free flu shot out of the deal late one Friday afternoon, though, after a long session).

Chuck and I will both be at HIMSS13 in NOLA. That will be something. I'm sure we'll hook up with Fred Trotter as well. Scary thought, that.

I am blessed. This Ole' Dawg has so much to continue learn.

apropos, see my July 8th, 2012 post (scroll down) for more visual ruminations on "workflow."

CHUCK REPLIES

Chuck left a comment, which I am moving up to the body of this post:

1 comment:

Chuck Webster MD MSIE MSIS @EHRworkflowFebruary 3, 2013 at 6:30 AM

That's a blast from the past! I wasn't a co-founder, but I worked with the EncounterPRO co-creators for over a decade. My Industrial Engineering/ Artificial Intelligence/ MD background met EHR workflow there. The original vendor website is gone but it was published under a Creative Commons copyright. Its pages on EHR usability and EHR workflow are archived here:

Usability
http://encounterpro.org/archive/pediatric-emr-usability.html

Workflow
http://encounterpro.org/archive/pediatric-emr-workflow.html

It was (and still is, glad to hear your PC uses it) light-years ahead of the EHR industry in its reliance on the kind of process-aware information systems technology I write about in my blog. That said, many of its ease-of-use-through-context-driven-workflow-features are making it into a variety of next generation health apps.

Re: #HIMSS13! Gladd to hear you'll be there. I hope I can get a HatCam video One-Minute Interview from you. May I add you to my HatCam goes to #HIMSS13! Twitter list?

https://twitter.com/EHRworkflow/hatcam-goes-to-himss13

A bit more on HIMSS HatCam One-Minute Interview videos…

http://chuckwebster.com/2012/03/social-media/hatcam-goes-to-himss12-video-interviews-fisheye-tours-bpm-process-mining

And thanks again for being my first guest post! (Maybe you'll be my second too!)

http://chuckwebster.com/2013/02/ehr-workflow/workflow-tactics-deployed-in-health-care-remain-stuck-about-10-15-years-behind-the-times

-- Chuck

to wit:

Proceedings: Healthcare Systems Process Improvement Conference,
Las Vegas, USA, Feb. 20, 2012.

Introduction

“There’s gold in them thar EHR processes!” (a paraphrase of “There’s gold in them thar hills!” popularly associated with the 1848 California gold rush, but origin debated). EHRs increasingly mediate patient care effectiveness, resource efficiency, and user happiness. EHR process mining is a new medical “imaging” technique, one which allows process diagnosticians to view workflow blockages, errant workflows, and unused resources. Process mining promises to do for healthcare workflow what Röntgen’s invention of X-rays and radiography in 1895 did for medicine proper.

Authors should avoid quoting themselves, but I cannot help but note that in 2005 I wrote about EHR workflow systems:

“Process Mining[:] Workflow management systems generate tremendous amounts of time- stamped sequential data as a byproduct of execution of process definitions by workflow engines. By analogy to data mining, analysis of such data (typically collected in log files) is called workflow or process mining [1]. Process mining can discover new and useful process definitions, compare process definitions to what users are really doing, and optimize existing process definitions—all of which can be used to improve ambulatory workflow.” [2]

oday, EHR process mining can discover, monitor and improve evidence-based processes (not assumed processes) by extracting knowledge from event logs available in (or “generatable” from) today's EHRs. Process mining can answer three types of questions [3] for an EHR-using hospital or clinic: What is happening inside processes (Discovery)? It can compare what is happening with what should be happening (Conformance: especially relevant to medical error and patient safety). It can suggest ways to improve healthcare process effectiveness, efficiency, and user and patient satisfaction (Enhancement)...

This man writes some important stuff. Read the entire paper (pdf).

LET A THOUSAND WORKFLOW ALLUSIONS BLOOM

1. Coupling.

2. Damping.

3. Sequential and parallel tasks.

4. Sequential and Parallel tasks.

5. Serial tasks; handoffs.

6. Procedure.

7. Within a defined process: improvisation.
A photo I shot in Dec 2008 of my friend the eminent
jazz bassist Blaise Sison at the Bellagio.

8. Outpatient visit door-to-door functional overview.
I tried to depict the relative consumption of time, a factor missing from the usual "flow diagram."

I will riff at length on all of this shortly.

OK, 2ND HALF SUPERBOWL POWER OUTAGE

So, let me expound on my workflow analogies while the 49'ers lick their wounds and try to use the downtime to re-group.

[1] and [2], Coupling and Damping.

I know a fair amount about audio physics and sound production, having owned and operated an audio recording studio. Permit me to ramble just a bit.

Audio fidelity is -- beyond architectural/ambient audio considerations -- a function of tight coupling and heavy damping. Why are the magnets in hifi/stereo speakers so large and heavy? To clamp down completely on extraneous voltage/sound signals, so that only intended sound reproduction voltage/data get through to push the speakers via which to generate sound. It takes tight damping, coupled with high power (watts at 120 VAC) to faithfully reproduce the spectrum of sound we want and expect. This is why cheap speakers sound like crap.

This goes to accuracy and precision. Replication of outcomes is a function of predictable and quantifiable I/O -- and the application of sufficient energy.

[3] and [4], sequential and parallel tasks.

In any organized group/team activity there are rules and roles. The rules govern the permissible. The roles map to both the expected within the rules and the potential.

[5], related to [3] and [4], "handoffs." The analogy, both with respect to sports activities and business process "teams," should be obvious. You hand things off to others on your staffs/team members routinely.

[6] a music chart is a "procedure." It tells you "what" and "when," -- and by whom, if it's a conductor's "score."

[7] "Improvisation" space, latitude for constructive self-expression ("judgment") within a procedure and within the rules/roles.

___

Well, I've had only mixed success using my sports and music analogies in health care clinics. If you care neither about sports nor music, these allusions may well not resonate. But, health care operations are quite unlike the typically tightly coupled sequential and parallel processes that characterize manufacturing. Health care ops are spaces where high variability is the norm -- amid chronic work overload much of the time.

Continuing the riff, in both sports and music (think team sports and, in particular, rock/jazz ensemble music here), there are rules, roles, and openings for improv. Effective sports team players are "court/field aware," as are improvisational ensemble musicians. You are alert to and act upon circumstances providing opportunities for ad hoc "improvement"/expression. You train to be able to handle "contingency" effectively and to support your fellow team members or players across the span of activity. One happy result is that the quality of play is frequently "more than the sum of its parts."

___

But, candidly, that's "playflow." This is "workflow." A lot of reaction I get? "You guys and your ivory-tower theories. All I wanna do is come to work every morning and go home at 5. This is not a Div I basketball team or jazz band."

Yeah. And, your job is less important.

MONDAY MORNING ERRATUM

Interesting. Where would you put that? "Social Hx"? Drop down menus for number and types of firearms and ammo inventories?

Gun violence is a public health issue. And the NRA has been disturbingly influential in public health policy. Since the 1990s, it has suppressed research in gun violence by targeting the sources of funding. In 1996, pro-gun members of Congress tried to eliminate the CDC’s National Center for Injury Prevention and Control. They failed in getting rid of the center, but the House of Representatives cut $2.6 million from the CDC’s budget—the exact amount the agency had spent on firearm injury research the previous year. And they added restrictive language on any appropriation to the CDC: “none of the funds available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control.” In 2011, Congress extended the restriction to include all Department of Health and Human Services agencies, including the National Institutes of Health, the nation’s leading medical research agency.

Astoundingly, the NRA was also responsible for a provision in the Affordable Care Act. Into this landmark health care law, NRA-backed legislators quietly inserted “Protection of Second Amendment Gun Rights.” [emphasis mine] This section bans doctors, health care programs, and insurers from “collection of any information relating to the presence or storage of a lawfully possessed firearm or ammunition in the residence or on the property of an individual.” This provision stifles research in gun violence, and it is so vaguely worded it could be interpreted to prohibit doctors from asking patients about guns. This provision was so alarming to the AAP and other child-advocacy groups that they wrote a letter to the Department of Health and Human Services “vehemently” rejecting this provision in the ACA and urging the department to “craft policy” to “limit the harmful impact of this section of the Act.”

Yep. There it is.

Section 2716(c) et seq

‘‘(c) PROTECTION OF SECOND AMENDMENT GUN RIGHTS.—

‘‘(1) WELLNESS AND PREVENTION PROGRAMS.—A wellness and health promotion activity implemented under subsection (a)(1)(D) may not require the disclosure or collection of any information relating to—

‘‘(A) the presence or storage of a lawfully-possessed firearm or ammunition in the residence or on the property of an individual; or

‘‘(B) the lawful use, possession, or storage of a firearm or ammunition by an individual.

‘‘(2) LIMITATION ON DATA COLLECTION.—None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used for the collection of any information relating to—

‘‘(A) the lawful ownership or possession of a firearm or ammunition;

‘‘(B) the lawful use of a firearm or ammunition; or

‘‘(C) the lawful storage of a firearm or ammunition.

‘‘(3) LIMITATION ON DATABASES OR DATA BANKS.—None of the authorities provided to the Secretary under the Patient Protection and Affordable Care Act or an amendment made by that Act shall be construed to authorize or may be used to maintain records of individual ownership or possession of a firearm or ammunition.

‘‘(4) LIMITATION ON DETERMINATION OF PREMIUM RATES OR ELIGIBILITY FOR HEALTH INSURANCE.—A premium rate may not be increased, health insurance coverage may not be denied, and a discount, rebate, or reward offered for participation in a wellness program may not be reduced or withheld under any health benefit plan issued pursuant to or in accordance with the Patient Protection and Affordable Care Act or an amendment made by that Act on the basis of, or on reliance upon—

‘‘(A) the lawful ownership or possession of a firearm or ammunition; or

‘‘(B) the lawful use or storage of a firearm or ammunition.

‘‘(5) LIMITATION ON DATA COLLECTION REQUIREMENTS FOR INDIVIDUALS.—No individual shall be required to disclose any information under any data collection activity authorized under the Patient Protection and Affordable Care Act or an amendment made by that Act relating to—

‘‘(A) the lawful ownership or possession of a firearm or ammunition; or ‘‘(B) the lawful use, possession, or storage of a firearm or ammunition.’’.

Pages 766-767 in the PPACA (pdf).

___

More to come...

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Brave New Health

Commonwell Health Alliance

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist
___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?
A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD
___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel
___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD
___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."

- Dr. Jan Gurley
___

"'Solutions' exist only in mathematics."

- Karen Martin
___

"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

- Adrian Gropper, MD
___

"Economist, rope, tree: some assembly required."

- Source unknown

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICY
I cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.

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Saturday, February 2, 2013

Clinical workflow

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