and Work Flow Processing, What’s the Diff?
Today many health facilities are aggressively pursuing new EMR and CPOE systems to
extend their already installed core HIS systems. The new federal ARRA program is
promoting adoption of these new systems in an effort to reduce healthcare costs. ARRA
will reward or penalize facilities that do not achieve “meaningful use” of new systems. In
fact, just recently the Obama administration was able to get hospital trade associations to
agree to cut health care payments by some $200 billion over the next decade, thereby
implying that they will be able to cut costs by at least that amount. With $200 Billion as the
savings goal more than a new EMR or CPOE will be needed. Health organizations will have
to find ways to do more with less labor and capital resources. HIS, CPOE and EMR alone
will not, and cannot, achieve this goal.
What will be needed is in depth work flow and process reengineering systems and tools
to support these efforts. Some health providers who are aggressively pursuing new EMRs
and CPOEs believe the vendor systems they plan to purchase will include all the
capabilities necessary to address work flow, moreover some vendors just started to
market their systems on that basis. What many providers do not understand is the day and
night difference between an HIS/CPOE/EMR and a system designed to document, analyze,
and proactively support work flow improvements.
The National Academy of Sciences, Institute of Medicine, in January 2009 issued a new
report entitled; Computational Technology for Effective Health Care: Immediate Steps and
Strategic Directions, in it they stated:
“The tasks and workflow of health care.
Health care decisions often require reasoning under high degrees of uncertainty about the
patient’ s medical state and the effectiveness of past and future treatments for the particular
patient. In addition, medical workflows are often complex and non-transparent and are
characterized by many interruptions, inadequately defined roles and responsibilities,
poorly kept and managed schedules, and little documentation of steps, expectations,
“Current implementations of health care IT.
Many health care institutions do spend considerable money on IT, but the IT is often
implemented in systems in a monolithic fashion that makes even small changes
hard to introduce. Furthermore, IT applications appear designed largely to automate
tasks or business processes. They are often designed in ways that simply mimic existing
paper-based forms and provide little support for the cognitive tasks of clinicians or the
workflow of the people who must actually use the system”.
From the IOM point of view “meaningful use” goes beyond CPOE and EMR. They want
information processing to take on more proactive work flow tasks.
Now let’s look at some of the differences.
Information Processing with HIS/EMR/CPOE
These systems, many in use today go back twenty years or more, are designed to support
data transactions. They are focused on data elements, capturing them, transmitting them,
storing them, and reporting on them. The classic orders and results system in your HIS is a
good example. Clearly administrative systems do this extremely well. They are good at
aggregating data, doing historical analyses, and generating passive reports.
What the CPOE and EMR add to the HIS system is a more sophisticated front-end and a
back-end. When you look at the CPOE what you really have is a very good tool for source
data capturing designed to speed communication by eliminating human re-keying, related
errors and the delays that are inevitable in paper systems.
On the other end we have the EMR which is a giant data repository designed to store
everything historical about the patient. It can rapidly retrieve a patient medical history, but
even the images that are stored in the EMR are static data with little meaning until
interpreted by humans.
Both the CPOE and the EMR are primarily reactive systems. When we find proactive
elements in the CPOE they tend to be limited to very specific activities and rarely are
cross functional or transcend department lines. For example drug to drug interaction is
proactive, but clearly limited in focus. They are rich in validity checks such as; incomplete
order, order requires secondary consult, etc. Within these systems if work flow is
addressed they rarely go beyond the next clinical step, for example, a requested
procedure will require prep work up. And when we consider non-clinical patient related
tasks the CPOE and the EMR are totally lacking.
As further stated in the previously mentioned NAS IOM report:
“The health care IT systems of today tend to squeeze all cognitive support for the
clinician through the lens of health care transactions and the related raw data, without
an underlying representation of a conceptual model for the patient showing how data fit
together and which are important or unimportant”.
Therefore, if we want to reduce operational and clinical costs by $200 billion, we need to
look seriously at all patient related processes and work flows, both clinical and non-
Work Flow and Process Improvement Systems
Systems and tools designed around process improvement and work flow simplification are
focused on addressing the following critical questions:
1. What is the next critical task that needs to be completed?
2. Who is responsible for the task?
3. What resources are needed to complete it?
4. When does it need to be completed by?
5. What is the current status of the task?
6. If it’s running late, what impact will it have on other tasks, and what
are our alternatives?
As you can see these questions are proactive and transcend both clinical and non-clinical
activities. For example in order to discharge a patient at a targeted time, say 11am, we
need to make sure the usual ancillary tests are completed and related results are
available to the physician doing rounds. In addition, and more often overlooked, are many
non-medical services that must be completed at an appropriate time or the discharge
target time will be missed. Operational services such as transportation, patient education,
referral requests and service approvals (Rehab, Hospice, Nursing Home, etc.), finance,
social services, nutrition consults, and others cannot be ignored.
There are many other patient centric examples such as chronic disease management,
enterprise access, case management, and sometimes just routine daily care management
where a patient needs to be seen by multiple ancillary and other care givers and work
flow coordination is critical.
A single work flow failure causing a delay of service (such as a re-scheduled surgery
resulting from an antibiotic medication not administered, because the patient was delayed
in radiology) can result in unhappy physicians and patient dissatisfaction, both of which
will eventually negatively impact revenues. Not at all a desired result when you already
have told the feds you would voluntarily cut out $200 billion of payments.
Systems designed for work flow improvement and enhanced patient processes do need
and use data from an EMR and HIS and apply at least the following tools:
• Workflow documentation tools
• Work flow analysis and simplification tools
• Data extraction / integration tools
• Process re-engineering tools
• Intelligent forms
• Document imaging, storage and retrieval
• Simulation / modeling optimization tools
• Work Portals
Commercial industry has applied these concepts and tools for decades. They are integral
elements in operational improvement programs as Six Sigma and LEAN. Healthcare has
seriously lagged behind in this effort. Maybe it’s because we have tried to adopt the
classic HIS tools, when we should have been applying more work flow systems tools.
ARRA has mandated that we must achieve ‘meaningful use’ of our systems. In summary,
work flow systems focus on the future (what should be happening now and next) while the
EMR tells us what happened yesterday. Which is more meaningful?
Both will be needed if we are to cut our operating budgets by $200 billion.
The Kelzon Group
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