Sunday, May 3, 2015

#Informatics : Why can't I just pre-check this order?

Hi all - Sorry it's been a few months since my last post. No excuse other than lazy blogging. Oh, and developing an Informatics platform in the middle of Meaningful Use, ICD-10, and new regulatory focus on interoperability and configuration - It's can keep you very busy!

For this post, I wanted to try to address a few common questions, that many lonely Informatics people of the world sometimes hear, and sometimes struggle to answer : "Why can't I just ____________?", as in :
  1. "Why can't I just pre-check this order?"
  2. "Why can't I just make this order set?"
  3. "Why can't I just approve this policy?"
  4. "Why can't I just do what I used to do BEFORE?"
There is an answer to these vexing questions. It's called workflow. And if you're not clear about workflow is, you won't know how it quietly impacts us all.


Searching the web, I found a few competing definitions of the term "workflow" : 
  1. From Wikipedia's entry on Workflow : "an orchestrated and repeatable pattern of business activity enabled by the systematic organization of resources into processes that transform materials, provide services, or process information"
  2. From : "Workflow is the series of activities that are necessary to complete a task.
  3. From the very talented #workflow expert, Charles Webster, MD : "Workflow is a series of tasks, consuming resources, achieving goals." 
  4. Or from Google : "the sequence of industrial, administrative, or other processes through which a piece of work passes from initiation to completion."

Interestingly, Google also reports that the term "workflow" has suddenly become quite popular in writing :

From my perspective, workflow is what you do, how you do it, and when you do it. It's the [ WHO ] will [ WHAT ], in order, that drives the basic processes of your organization. Workflow is your recipe for success. If you're a chef, workflow is your winning recipe, perfectly executed. If you're a hospital, it's your clinical policies, perfectly executed. Workflow does not answer every detail about diagnosing pneumonia, but it outlines the mission-critical steps you need to identify/register your patient, listen to your patient, diagnose their disease, treat their disease, document their treatment, and finally bill effectively.

However you define it, organizations with good workflows generally succeed by delivering a high-quality product, predictably, at a good price. Organizations with bad or confusing workflows will struggle to do that. So it's vitally important to have good workflows to support your goals.


When discussing/documenting workflows, it's very common for people to use Visio or other software to create swim-lane diagrams or other algorithms or flowcharts. In experienced hands, they can be vital in documenting current and future-state workflows, but they can require some degree of training and time to create and interpret them correctly.

So I'm proud to share that I recently had the opportunity to collaborate with my outstanding informatics colleague Jessica Gould! Together we did some archetypal analysis and redesign, and developed this handy workflow documentation template that's fairly easy to teach and learn quickly :

[ WHO ] will [ WHAT ] [ how ] [ when ] [ where ] [ why ]

… where :
  • WHO ] will [ WHAT ] are the mandatory pieces of every workflow line.
  • how ] [ when ] [ where ] [ why ] are the optional descriptors of every workflow line.
So just as a teaching example, you can use this template to convert your favorite food recipe into a workflow/procedure - e.g. from the web page, this recipe for Quick Macaroni and Cheese :
  1. Cook two cups of macaroni until al-dente
  2. Make a roux by melting butter in pan and adding flour
  3. Stir constantly and cook until it is the color of caramel candy
  4. Slowly and carefully add milk while stirring
  5. Add cheese and seasonings when milk starts to steam, until melted and well-combined
  6. Pour over cooked macaroni and noodles
If we feed this recipe into our template, we get something that looks like this : 
  1. [ WHO ] will cook two cups of macaroni [ until al-dente
  2. WHO ] will make a roux [ by melting butter in pan and adding flour
  3. WHO ] will stir constantly and cook [ until it is the color of caramel candy ]
  4. WHO ] will slowly and carefully add milk while stirring
  5. WHO ] will add cheese and seasonings [ when milk starts to steam, until melted and well-combined ]
  6. WHO ] will pour [ over cooked macaroni and noodles ]
Now this incomplete workflow leaves us with a lot of questions, about who exactly should be doing these steps? 


To help fill out this workflow, we can expand the template just slightly : 

From : 
[WHO] will [WHAT] [how] [when] [where] [why

To : 
[WHO] will [WHAT] [how] [when] [where] [why] [time] [materialcost] [laborcost] [TOTALCOST] 

… and this now lets you play several "What-if?" scenarios, to help work out the most cost-effective way to execute your workflow. For example, if we ask a doctor to make this macaroni and cheese, if we assume a salary of $80/hr, then executing this workflow will take 23 minutes and cost you $33.17. (That's an expensive plate of macaroni and cheese!) (Click on the picture below to expand.)

By looking at the workflow designed with this template, you can quickly rearrange steps, reassign roles, and develop lean, cost-effective workflows that ultimately support your organizational goals. I believe that teaching this template to your staff can help them to easily write, analyze, and better develop your common workflows and procedures.


The reason is because your workflows support your organizational goals. And what supports the workflows? The people and tools in your organization. By that I mean all of your talent, and all of the tools they use to do their jobs : Your policies, procedures, guidelines, orders, order sets, clinical pathways, protocols, Alerts/MLMs (Medical Logic Modules), Documentation, Reports/Dashboards, Patient Education, Staff Education, Budgets, Job Descriptions/Contracts, Glossaries, Wikis, and Org Charts.

So often when a well-trained, seasoned Informaticist is assigned to a project, they might first ask :
  1. What is the goal of the project?
  2. What workflow(s) is/are needed to achieve the goal?
  3. What tools will we need to effectively support the needed workflow(s)?
Visually, this looks something like this :

… where the documents support the workflows that support the goals. And so depending on the workflow change, or desired new workflow, you have to mentally go through each one of those tools and ask : Do we need to create/modify/delete this tool to effectively support the desired workflow?
  • Some smaller change projects might be accomplished through developing only one of those tools.
  • Other larger change projects might require the development of many tools.
So when someone asks me, "Why can't I just pre-check the order in this this order set?", I will typically ask myself : 
  1. What is the organizational goal?
  2. What desired workflow does this order set support?
  3. What other tools are working together to support this desired workflow?
And if pre-checking the box will mean changes to other tools, then I might tell them something that sounds like this : "I know that pre-checking the order seems like a simple issue, but to make sure it continues to harmoniously support the workflow and organizational goals, we may have to update the staff education, patient education, and pharmacy budget too. Let's look at these and how they work together before we make the change."

Workflows also teach us that we are all, in fact, interconnected - both clinical and administrative staff. Each side depends on the other for success. 


This workflow issue existed in the paper world, but there was one crucial difference - There was more wiggle room. EMRs generally increase workflow accountability through two means : 
  • They make large amounts of data easily available for analysis - Reports that used to take months of chart review now takes seconds. It's easier to find poorly-supported workflows.
  • They enforce stricter documentation standards that were harder to enforce on paper - The legal-grade authentication of most EMRs prevents scenarios where one-person-filled-out-the-form-and-another-signed-it, just to satisfy a confusing workflow.
So I generally tell people that after their enterprise EMR goes live, they may experience a demand for workflow analysis and redesign to a degree and standard they were unused to in the paper world. I suspect it's this demand for high-grade, well-supported workflows that is driving the demand for trained, qualified, and experienced clinical Informaticists - And I'm proud to be one of them!

As always, this blog is for educational purposes only. I welcome discussion and feedback! How do you explain to end-users why it's sometimes-not-that-simple? All comments below are welcome!