Sunday, December 8, 2019

My Clinical Workflow Design Glossary

Hi fellow HealthIT and Clinical Informatics friends,

Sometimes people ask me about how I learned workflow design, and where I learned to quickly spot workflow problems.

After a few years of trial-and-error early in my career, and learning from a lot of other clinical informatics leaders in the field, I'm happy to share that good workflow design starts with this: Definitions.

Definitions are the lifeblood of any clinical informatics professional. They answer two very important questions : What is it called, and what does it do? When you define something, you are clarifying both its form and its function

So when I design (draft!) my own workflows, or workflows for other clinical staff - what are the things I define, and how do I define them? Adapted from my recent post and my 2015 post on The Informatics Domain and Workflow Management, I usually start off with the 24 most common tools found in modern Healthcare: 

A. Tools typically found OUTSIDE an EMR : 

  1. Plans (Project, Drafting, Building, Testing, Communication, Education, Go-Live, and Support/Monitoring)
  2. Policies/Procedures
  3. Guidelines
  4. Protocols
  5. Patient Consents
  6. Interfaces
  7. Staff / Patient Education Modules
  8. Committee Charters
  9. Org Charts
  10. Budgets
  11. Job Titles/Descriptions
  12. Staff Schedules
 B. Tools typically found INSIDE an EMR :
  1. Registration Information
  2. Clinical Documentation (Notes, Flowsheets, videos, audio, other media)
  3. Labs/Pathology
  4. Radiology/Images
  5. Orders
  6. Order Panels / Order Sets / Clinical Pathways
  7. Medical Logic Modules (MLMs)
  8. Clinical Decision Support (Best Practice Alerts (BPAs), Infobuttons, etc.)
  9. Security Groups / Profiles / Filters
  10. Reports/Dashboards
  11. Charges
  12. Patient Schedules
From here, we can break out a few terms, alphabetize them, and start to create a basic workflow design glossary :

[ DRAFT ] GLOSSARY - The DirkMD Workflow Design Glossary
(c) 2019 DirkMD
  1. Budget - A tool used to document and allocate future resources for a person, group, team, division, organization, or project
  2. Charge - Tools to create bills for services
  3. Clinical Decision Support (Best Practice Alerts (BPAs), Infobuttons, etc.) - Tools used to guide or force clinical staff into institutionally-defined best practices
  4. Clinical Documentation (Notes, Flowsheets, videos, audio, other media) - Documents used to record patient history, activities, status, and/or plans at a given date and time.
  5. Clinical Pathway - A collection of order sets used to standardize care for a defined condition or procedure.
  6. Charter (Committee/Team Charter) - Tools used to define the leadership, membership, mission, responsibilities, meeting frequency, measures of success, delegated authorities, quorum, and other information related to a team or committee
  7. Consent (Patient/caregiver consent) - Tools used to document patient/caregiver understanding of the risks/benefits of a procedure
  8. Dashboard - A collection of regularly- or continuously-updated reports used to routinely monitor a function or functions.
  9. Document - A tool used to record and transmit information 
  10. Education Module, Staff - Tools used to educate staff, using the institutionally-accepted language, about a topic or topics.
  11. Education Module, Patient/Caregiver - Tools used to educate patients or caregivers, in their language, about a topic or topics.
  12. Guideline - A tool used to educate staff about best practices to achieve a desired outcome
  13. Interface - A tool used to securely transmit information between systems
  14. Job Title/Description - Tools used to align a job role and responsibilities
  15. Labs/Pathology - Tools used to document results of a laboratory or pathology study
  16. Medical Logic Modules (MLMs) - Custom programming tools to electronically link two workflows
  17. Medical Record, Legal - The collection of clinical information related to a single patient that is routinely released to the patient, caregiver, and legal authorities upon request.
  18. Medical Record, Business (Comprehensive Record) - The total collection of clinical information related to a single patient, including the legal medical record, metadata, and other information.
  19. Order (aka 'prescription') - A tool used to document clear and well-defined instructions to deliver a defined type of patient care to a defined patient with a defined priority at a defined date/time with a defined duration in a defined manner, sometimes for a defined indication.
  20. Order Panel - A collection of orders with related functions which are used to standardize a common clinical function across a specialty or specialties, often with the intent of building into order set(s) (see below).
  21. Order Set - A collection of orders (and order panels) used to standardize and expedite the ordering process for a common, well-defined clinical scenario. 
  22. Org Charts - Tools used to define an organizational structure or reporting hierarchy.
  23. Patient Schedules - Tools used to define the planned date/time and duration of patient care. 
  24. Preference Lists ('Pick Lists') - Collections of commonly-used orders based on frequency of use, for a variety of purposes with no clearly-defined or designed scenario or function. 
  25. Plans (Project, Drafting, Building, Testing, Communication, Education, Go-Live, and Support/Monitoring) - Tools used to document and organize resources and activities needed for a future project or desired outcome
  26. Policies - A tool used to document and define an organizational standard 
  27. Procedures (aka 'Workflow', 'Recipe', or 'Algorithm') - A collection of ordered TASKS (see below) that uses people, time, and resources to achieve a defined goal.
  28. Protocols, Clinical - A tool used to automate and standardize a clinical process by documenting the delegation of order management responsibility to a registered and trained member of the patient care team.
  29. Protocols, Chemotherapy - A tool used to plan chemotherapy delivery and monitoring for a defined type of cancer.
  30. Radiology/Images - Tools used to display radiologic and other patient care still and video images and their interpretations. 
  31. Registration Information - Tools used to legally identify a patient, their address, their contact information, their payor information, and their emergency contacts.
  32. Reports - Tools used to display requested information related to a requested function or activity. 
  33. Staff Schedules - Tools used to define who is responsible for a patient care service at a defined date/time.
  34. Security Groups / Profiles / Filters - Tools used to allow or restrict access to a part (or parts) of the patient record
  35. TASK - The most granular unit of work, may be written as [WHO] will/may [WHAT] {how} {where} {when} {why}, where : 
  • [WHO] - Required field, describing who will perform the task 
  • will/may - Required field, use WILL for mandatory tasks, MAY for optional tasks
  • [WHAT] - Required field, describing the expected task{how} - Optional field, use only for clarity, describes how to perform the task
  • {where} - Optional field, use only for clarity, describes where to perform the task
  • {when} - Optional field, use only for clarity, describes when to perform the task 
  • {why} - Optional field, use only for clarity, describes why to perform the task
This is a pretty decent start, and while it's only a [DRAFT], it fortunately includes a number of terms that are not currently well-defined or published by any of the major regulatory or healthcare standards agencies.

So with this glossary above, what advice do I give people trying to build workflows?
  1. Start with documenting your procedures (workflows), using the template outlined in the above definition of TASK. (You can also use flowcharting/swimlane diagrams, but I find this method to be faster, easier to train, and less prone to error.) Both your current-state and future-state workflows will be key to understanding what kind of tools, time, people, and resources you will need to get from Point A to Point B.
  2. Determine which tool(s), both inside and outside the EMR you will need to support your future-state procedure (workflow). Most clinical workflows depend on a combination of tools, from both inside the EMR and outside the EMR. You can almost take the above glossary, and circle the tool(s) you will need to get from Point A to Point B, to create a list of project deliverables.
  3. Draft those tools. Review your current-state workflows with your end-users, and use them to build your future-state workflows. Get their input as you draft your new tools, both inside and outside the EMR. 
  4. Build those tools. Once your end-users approve the drafted tools, you can bring them to IT, policy writers, finance, and other administrative users to build the final tools you will need to support your new future-state workflow.
  5. Test those tools. There are four types of testing you'll want to consider. If they are inside the EMR, they may need more testing than those outside the EMR, but generally they include : Unit testing (to make sure each design piece functions as expected), Integrated Testing (to make sure the pieces work together as expected), Regression Testing (to make sure the pieces work together as expected with other pre-existing tools in the setting they are expected to function in), and End-User Acceptance Testing (to make sure the end-users can use the tools to perform the expected tasks). 
  6. Communicate and Educate (Train) those tools. Let your clinical and administrative users know about the clinical (inside EMR) and administrative (outside EMR) tools you will need to support your new workflow(s), and show them how to use them in anticipation of your defined go-live date.
  7. Deliver / Implement those tools. Deliver both the clinical (inside EMR) tools and administrative (outside EMR) tools at the expected implementation (go-live) date.
  8. Support and monitor those tools. Make sure you have a plan for how to support end-users, and monitor the effectiveness and their ability to use your new tools, both inside the EMR and outside the EMR, to support the desired workflow(s). 
I hope this helps demystify the workflow design process, which is tightly interwoven with the definitions for both clinical and administrative tools, and baked into your project (and change) management strategies. 

Remember this page is for educational discussion only! Do not use any of the above definitions or procedures for professional purposes, without the approval of your clinical informatics, legal, operational, and senior leadership.

Have any other definitions or workflow design principles you'd like to share, or other comments/feedback? Please leave your thoughts in the comments box below!

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