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Monday, June 30, 2014

Back to the health IT tech stuff: NISTIR 7988

Executive Summary
Adoption of Electronic Health Record (EHR) systems in hospitals and outpatient clinics is accelerating. EHRs can support and revolutionize the way information is used to provide high-quality and safe patient care. At the same time, however, issues with workflow integration have contributed to slow rates of EHR adoption in some settings, including ambulatory outpatient care. Workflow is a set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal. Workflow analysis is an integral part of the early stages of the User-Centered Design (UCD) process. UCD is an approach to designing systems and employs both formative and summative methods in order to achieve systematic discovery of useful functions grounded in an understanding of the work domain.

In response to workflow integration challenges with EHRs, clinicians often develop workarounds to complete clinical tasks in ways other than were intended by system designers. A frequent workaround, for example, is copying and pasting text from a previous progress note for a patient to serve as a draft for the current progress note. In this report, two human factors workflow modeling tools, process mapping and goal-means decomposition, were used to collect, visualize, and document insights and the end-user needs to improve EHR workflow for clinicians in outpatient care settings. The findings identified clinical activities that require more relevant and flexible workflows in EHR designs to support end users’ needs. Based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created process map visualizations and a goal-means decomposition diagram...
39 pages. Well worth your time. Link to the full document here (pdf).

Figure 1. The SEIPS framework for work system elements

From our literature review, workflow, workaround, and work system are defined as follows:

  • Workflow: A set of tasks, grouped chronologically into processes, and the set of people or resources needed for those tasks that are necessary to accomplish a given goal.
  • Workaround: Actions that do not follow explicit rules, assumptions, workflow regulations, or intentions of system designers.
  • Work system: The five main elements from the Systems Engineering Initiative for Patient Safety (SEIPS) model are used to define the work system (Figure 1): 1) people (individuals and teams), 2) physical environment, 3) tools and technologies, 4) tasks, and 5) organizational characteristics.
 Below, one of my graphical takes on workflow.

Click to enlarge it it's difficult to read. Interesting, "the Systems Engineering Initiative for Patient Safety." Recall one on my earlier posts regarding "Systems Engineering." The "SEIPS model" publication is firewalled, so I've not yet been able to find it and read it without paying (cheapskate), but I bet it's safe to say it contains zilch about the cultural "workforce engagement" impediment that I've been discussing of late. You instead get stuff like this:
There is immense literature on workflow modeling in general, including agent-based modeling and other “humans-not-in-the-loop” modeling. In our review, we focused on approaches to analyzing and depicting workflow from a human factors perspective. Human factors is defined as “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimize human well-being and overall system performance.” Human factors modeling methods are based primarily upon extraction of process flow and insights about challenges and variation from Subject Matter Experts (SMEs) during collegial discussions...
"...the understanding of interactions among humans..."

To include psychosocial workplace toxicity? 'eh? Do we not need to understand that factor?

Another of my workflow graphics.

Again, click to enlarge it it's difficult to read.

My graphics are better. :)

OK, I've just read all of it. Very good elucidation of the problems bedeviling EHR use in clinical workflow. Again, worth your (and my) time.
In response to workflow integration challenges with ambulatory physicians using EHRs, we have employed standard human factors methods in order to identify insights for EHR developers and ambulatory care centers. The methods illustrated in this document are process maps and goal-means decomposition diagrams informed by goal-oriented individual collegial discussions with physician Subject Matter Experts to walk through the typical workflow of a returning patient in an ambulatory care setting. We have identified a wide variety of potential opportunities to improve workflow with EHRs from a physician perspective. We anticipate that improving workflow might require an expansion in focus from the historical goal of supporting reimbursement to also improving quality of patient care as well as the quality of work-life for physicians. In order to increase the ease of implementing our insights, we provide a set of targeted recommendations.
Yeah. Blah, blah, blah. All necessary and good, but, nothing really new here. And, nothing whatsoever on the implicit, fundamental (albeit overlooked) "cultural/interpersonal" aspects of "Human Factors."

Another of my Photoshops.

Clinical practice is an irreducibly "high cognitive burden" enterprise requiring accurate and effective ongoing n-way communication between all participants. High performance teams have to be healthy -- in every sense of the word.

Re-read my little recent trilogy:


In which my friend Dr. Leslie calls me out. And, my response:


More to come...

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