Tips and Tricks for Clinical Workflow Redesign

 Hi fellow CMIOs, CNIOs, and other Informatics friends,

Today I thought I'd share some materials I delivered in a talk back in 2023 for Dr. Judi Binderman, a really seasoned Clinical Informaticist and good friend of mine. I recently discovered these when going through some old slides. At the time, Dr. Binderman had asked me to speak briefly to her team at Community Medical Centers in Fresno, CA about some helpful tips and tricks of clinical workflow redesign : 

My talk was mostly related to workflow analysis, change management, documenting workflows, and workflow design. So I opened up first with a brief discussion about workflow analysis and change management : 

The first point that I usually emphasize for any new Clinical Informatics leaders is that work can be measured and estimated through a workflow gap analysis. The distance from the current state to the future state gives you a good estimate of the stakeholder(s) you will need to involve in a project, what they will need to learn and do (to achieve your future state), and so this gives you a good estimate of your project deliverables and project scope (for planning purposes) :

Once you have completed your gap analysis to get a sense of the current-state and future-state workflows, you can then review a list of common deliverables, to select what you will need to get your users from current to future state : 

Note that some of these deliverables (above) are inside of the Electronic Health Record (EHR), and other deliverables are outside of the EHR. You will want to identify all of the deliverables you anticipate needing/using, and then identify who you will need on your project team to help develop each deliverable.

Remember that workflow change management is a team sport - A common mistake is to think that you can make a change with 'only Doctors' or 'only Nurses'. Almost all clinical workflows depend on many stakeholders, from different enterprises, with a number of different roles. Understanding the different enterprises of your organization, and the different roles you may engage with, is helpful to make sure you've thought through all of the stakeholders you will need to make your project successful : 

Once you have a sense of the estimated stakeholders and deliverables, it's helpful to think through the steps you will need to develop your workflow. For teaching purposes, I usually shrink this down into ten (10) easy steps, that you can talk through with your development team : 

This discussion almost always brings up the debate (question?) about change / project management methodologies. Two common methodologies include : 

• Waterfall Methodology - Linear, step-by-step, good for plan-first approach, takes longer but especially well-suited for Healthcare or new high-risk scenarios where one build is all you can plan for.
• Agile (Software Development) Methodology - Iterative, emphasizes rapid feedback and adaptation, sometimes useful when clinical workflows are evolving or need user-centered design - but not ideal for Healthcare scenarios. Better built for speed and iterations.

Some people will argue that Waterfall can take too long, and they prefer the speed and flexibility of Agile. Personally, I'm not sure how well Agile fits into the many high-risk clinical workflows of Healthcare (since there is usually little room for error), and so I've condensed those ten (10) helpful steps in the slide above into this 'general-purpose change recipe' below :

Once you've gone through the exercise of writing out those ten steps, and developing your own change recipe - You can then import it into a spreadsheet, and add your common roles across the top to build out your own Responsibility Assignment (RACI) Matrix : 

This Responsibilty Assigment (RACI) Matrix can then walk you through the first step of your change management - Documentation of Request and Expectations ('Intake') - And help you to develop key questions that your requestor and their supervisor (e.g. Chief, Chair, or Director) can answer before you do further analysis.

Once you have their preliminary input and feedback, you (Clinical Informaticist) can then pursue the next steps of your journey - Analysis, scoping, prioritization, resource allocation, and project approvals - To help evaluate and develop the request, and make sure your Clinical and Administrative Leadership have the information they need to prioritize and approve the project : 

After your Administrative and Clinical Leadership understands :

• the project priority, estimated scope, estimated stakeholders, estimated deliverables, and necessary resources, 
• the estimated Total Cost of Ownership (TCO) and Return on Investment (ROI)

... they can effectively prioritize and approve the project, leading you to formal project initiation, project development, and the drafting, building, testing, approval, education, implementation, and support of your future-state workflows : 

So - What tips can I offer a new Clinical Informaticist for documenting workflows and workflow design?

My first tip is to closely examine the similarities between a 'Swimlane diagram' (Visio) and a Procedure : 

If we break down a a 'Swimlane diagram' (Visio), it basically answers the questions : 

Q : Who is doing what, and in what sequence (order)?

So with a small adaptation, we can revisit the traditional swimlane diagram as :

... which leads me to share a helpful discussion of what exactly a procedure is (adapted from Charles Webster, MD aka @wareflo, another brilliant Clinical Informatics mind I have had the fortune of learning from)

Procedure (n.) (synonym : workflow, recipe, process, algorithm) - An ordered series of tasks that uses people, time, and resources to achieve a desired goal or outcome.

Now, if you accept the definition above as true, then you can create a simple template for writing a task, the most basic building block of a procedure (synonym : workflow, recipe, process, algorithm) : 

Task = [ WHO ] will/may [ WHAT ] { how } { when } { where } { why } 

where : 

• [ WHO ] = Role of the person that will perform the task
• will/may = Use "WILL" for required tasks, "MAY" for optional tasks
• [ WHAT ] = Brief description of the task
• { how } = Optional modifier, use only when needed to clarify how the task is performed
• { when } = Optional modifier, use only when needed to clarify when the task is performed (for timing/duration)
• { where } = Optional modifier, use only when needed to clarify where the task is performed
• { why } = Optional modifier, use only when needed to clarify why the task is formed

You can then include this in your own 'workflow glossary', where you define and organize your favorite high-grade (policy-grade) terminology related to workflow design : 

... but you can also use it to start writing out procedures for all sorts of things. My favorite teaching example is to take a poorly-written process (in this case, a poorly-developed process for baking and delivering cupcakes) :  

... and turn this into a well-developed process that identifies not only the necessary steps and deliverables of the workflow, but also the necessary stakeholders and their Directors/Chiefs : 

So that's a very helpful skill for the new Clinical Informaticist - Learning how to write an effective procedure. Procedures create clarity and helps you develop solutions. And this also means that your policy manual will be an excellent source of common clinical workflows, their stakeholders, and their deliverables : 

Plus, once you understand how to write a task and a procedure, you can then easily estimate the cost of the procedure by assigning either : 

• Cost = Labor + Materials
• Cost = (Salary * Time) + Materials

... to each step : 

Just for fun, you can use this trick to estimate the cost of a box of macaroni and cheese, if different clinical roles made it : 

... and so, by writing out a procedure and assigning an estimated cost to each step -  you can see the different estimated costs for an MD, an RN, a LPN, and a MA making mac and cheese :

Understanding this (and the regulatory scope-of-practice questions that naturally arise from this level of analysis) can not only help you estimate costs, but also save money, and help your clinicians to work at the top of their license - See the estimated cost of this workflow below, with an RN giving a cupcake to the patient : 

... versus the estimated cost of the workflow if an LPN gives the cupcake to the patient : 

And so, to summarize : 

And some helpful final thoughts : 

And one more final thought (wisdom once passed to me by another experienced Clinical Informaticist, early in my career) : If you're ever lost, start to untangle your workflows by writing a good procedure. 

I hope this has been a helpful journey into how to document, analyze, and develop your own clinical workflows. If you have any questions, please feel free to leave them in the feedback/comment section below! (And special thank you to both Dr. Judi Binderman and Dr. Charles Webster for their contributions to this post!)

REMEMBER : This blog is for education and discussion purposes only - Your mileage may vary. Have any other helpful tricks for quickly untangling or developing clinical workflows? Feel free to leave them in the comments section below! 

Where's the Clinical Informaticist?

Hello fellow CMIOs, CNIOs, and other Applied Clinical Informatics friends,

This month I'd share some cool discoveries I've made with some friends recently, in a helpful blog post about finding the Clinical Informaticist(s) in your organization, and/or identifying the need for them.

One of the common challenges of Applied Clinical Informatics is that Informaticists can sometimes be hard to find. Typically due to a number Human Resources (HR) and other industry issues, they can sometimes be hidden behind : 

• FALSE NEGATIVES - E.g. People who actually do Clinical Informatics work, but aren't necessarily titled "Clinical Informaticist" in their job title, or aren't recognized as doing Clinical Informatics work at all.
• FALSE POSITIVES - E.g. People who are called "Clinical Informaticist", when they don't necessary do the work that might commonly fall under the domain of the Clinical Informaticist (or they only do a specialty branch on the larger 'tree' of Applied Clinical Informatics - See below.)

While some have tried to tackle these HR challenges, concrete job descriptions are hard to find since there is such a wide variation of practice, in the general 'tree of Informatics' - which spans a number of disciplines related to both data storage ('data in') and data retrieval ('data out') functions : 

If your search for a Clinical Informaticist turns up negative, you will probably need to establish the need to hire one (or more) to help with your clinical workflow analysis and development. Historically, there have been two common approaches to doing this in #Healthcare - the 'Clinical Choir' approach, and the 'Executive/Financial' Approach: 

Each of these historic approaches come with some pros and cons : 

1. The 'Clinical Choir' Approach - Where the Clinical Staff recognizes the need for workflow updates and redesign, and collectively asks for Applied Clinical Informatics resources. PROS : Support from clinical end-users can be very helpful to support the allocation of FTE(s) for Clinical Informatics. CONS : Difficult to execute. Most clinical end-users aren't familiar with the potential role of Applied Clinical Informatics in their day-to-day workflows, so it's not easy to get them to ask for it by name. 
2. The Executive / Financial Approach - Where the Executive / Finance teams recognize the need for improved Return on Investment (ROI) and overall improved stewardship of technology investments, and so they collectively ask for Applied Clinical Informatics resources. PROS : Support from Executives and Finance officers can also be helpful to support the allocation of FTE(s) for Clinical informatics. CONS : Most ROI from workflow design and improvement falls under the category of 'soft ROI' which could easily be attributed to other departments, or it falls into the category of cost reduction rather than revenue improvements. (Both will help your organization, but one is easier-to-identify.) So putting a hard number to ROI or cost reduction that stands up to scrutiny will require some real pre-planning before you execute your improvement projects.

So for today, I'd like to share a new approach that I recently discovered, when I worked with some of my trusted Project management and Compliance colleagues (Jim McGennis and Elle Box) to combine my 10-step change management recipe with a Responsibility Assignment (RACI) Matrix :

First, a brief reminder that my recommended ten steps for clinical change management (originally published back in 2018) helps to create consistent outcomes through the thoughtful analysis, scoping, development, and planning of workflow changes (both big and small) :

After combining these ten change steps (above) with a Responsibility Assignment (RACI) Matrix (typically used by experienced Project Managers for assigning responsibility for various tasks), new discoveries were made and additional clarity was achieved. (Note : If you're new to Responsibility Assignment / RACI matrices, please see this Wikipedia article for a helpful introduction. And special thanks to PM guru Jim McGennis, for introducing me to this powerful tool.)

The basic premise of a RACI matrix is that you create a grid (spreadsheet) of roles versus steps, and then assign these four categories in each step : 

• (R)ESPONSIBLE (also recommender) - The one (or more) person(s) who are responsible to complete the task.
• (A)CCOUNTABLE (also approver or final approving authority) - Who is ultimately answerable for the correct and thorough completion of the deliverable or task, who also ensures the prerequisites of the task are met, and delegates the work to those responsible.
• (C)ONSULTED (sometimes consultant or counsel) - Those whose opinions are sought, typically subject matter experts (SMEs), and with whom there is two-way communication
• (I)NFORMED (sometimes informee) - Those who are kept up-to-date on progress, often only on completion of the task or deliverable, and with whom there is just one-way communication.

Putting my 2018 clinical change management recipe together with the RACI matrix has been remarkably helpful and enlightening. And with some help from Compliance colleages (thanks to Compliance guru Elle Box for her help reviewing and refining the descriptions), the first thing I began to notice was the number of roles that participate in one or more steps of change management : 

Roles that participate in one or more steps of clinical change management

 

Roles that participate in one or more steps of clinical change management

... as well as the details of exactly who is (R)esponsible, (A)ccountable, (C)onsulted, and (I)nformed at each step. (*Note : In the slide above, you'll notice that the Applied Clinical Informaticist already has a different set of roles and responsibilities than the Clinical IT Analysts. More to come on this shortly...)

When we look at the first phase of the change recipe (documentation of request and expectations, or intake) it's easy to see who has primary and secondary (R)esponsibility - Both the clinical end-user and the official requestor - their supervisor, director, chair, or chief - who needs to help support the request : 

First phase of change : Documentation of Request and Expectations ('Intake')

First phase of change : Documentation of Request and Expectations ('Intake')

As we move to the second phase of the change management recipe (Analysis, scoping, prioritization, resource allocation, and project approval), we can see that suddenly the Chief Information Officer picks up (A)ccountability, while the Applied Clinical Informaticist has primary (R)esponsibility for the literature search, sponsor identification, workflow gap analysis, workflow development, scoping of deliverables, and identification of stakeholders. Together with a number of (C)onsultants including Clinical IT Analysts, Medical Librarians, Compliance, Regulatory, and Finance, they will also help review regulations and estimate a Total Cost of Ownership (TCO) and Return-on-Investment (ROI), providing much more helpful information for Senior Executives who will need to prioritize and approve this project before it can be assigned. (*Note : By serving this important workflow analysis role, the Applied Clinical Informaticist will also become a subject matter expert (SME) for other experts who will be (R)esponsible for later steps in the change recipe.)

Second phase of change : Analysis, scoping, prioritization, resource allocation, and project approval

Second phase of change : Analysis, scoping, prioritization, resource allocation, and project approval

When we arrive in the third (Project Planning) phase, now the Executive Sponsor has picked up (A)ccountability, while the Project Manager has primary (R)esponsibility for working with the Applied Clinical Informaticist, Clinical IT Analyst, and others to plan the necessary parts of the project, including Gantt charts, RACI Matrices, and/or other formal project plans :

Third phase of change : Project Planning and RACI Matrix / Gantt Chart Development

 

Third phase of change : Project Planning and RACI Matrix / Gantt Chart Development

Assuming all of the above phases have been completed, this now brings us to the fourth phase of change - The drafting of workflows, for which the Applied Clinical Informaticist has primary (R)esponsibility, typically in conjunction with the Clinical IT Analyst, Compliance, and the End-users. 

Fourth phase of change : Drafting of Workflows

Fourth phase of change : Drafting of Workflows

While some organizations may not yet have implemented blueprints in their development process, this step can be very helpful because :

• Blueprints help to create understanding, align clinical stakeholders, let you conduct tabletop workflow discussions and reviews, and obtain preliminary approvals before the Clinical IT Analysts begin their build (in the next step).
• Once approved, and with a few small changes, blueprints can also become your downtime forms, in case your electronic system is ever down for planned maintenance or other unplanned reasons.

This now brings us to the fifth and sixth phases of change, the building of deliverables and testing of workflows, where the Clinical IT Analyst now has primary (R)esponsibility to build and test the deliverables, typically in conjunction with the Applied Clinical Informaticist and the End User (for end-user acceptance testing).

Fifth and sixth phases of change : Building of deliverables and testing of workflows

 

Fifth and sixth phases of change : Building of deliverables and testing of workflows

For the seventh phase of change (Final workflow approval), the Applied Clinical Informaticist now assumes primary (R)esponsibility and works to secure the necessary final approvals in conjunction with Senior Leadership and a number of other stakeholders. (*Note that the Executive Sponsor still has (A)ccountability for this step.)

Seventh phase of change : Final Workflow Approvals

 

Seventh phase of change : Final Workflow Approvals

 

Finally, for the eighth phase (Communication and Education/Training), ninth phase (Implementation/Publication), and tenth phase (monitoring and support) of change, the Clinical IT trainers, Clinical Education / Training team, Communications Team, and End-Users now all share (R)esponsibility, and typically do their steps in conjunction with the Applied Clinical Informaticist and the Clinical IT Analysts.

Eighth, ninth, and tenth phases of change : Communication, Education, Implementation, Monitoring, and Support

 

Eighth, ninth, and tenth phases of change : Communication, Education, Implementation, Monitoring, and Support

IN CONCLUSION : 

What does this exercise (combining change management recipe with a RACI responsibility assignment matrix) teach us? Five helpful take-home points : 

1. Clinical change management is a team sport that requires the participation of a large number of stakeholders to work together in a clear, highly-detailed, highly-coordinated fashion, where different roles will be (A)ccountable for some steps, have primary (R)esponsibility in some steps, serve as a (C)onsultant in other steps, and need to be (I)nformed of other steps.
2. The roles of the Applied Clinical Informaticist and Clinical IT Analyst are separate and distinct roles that often work together, but serve in distinct and unique capacities, and thus should have separate and distinct job titles and descriptions.
3. Before projects are approved, the Applied Clinical Informaticist has primary (R)esponsibility for the analysis, scoping, prioritization, and resource allocation, typically in conjunction with (C)onsulting expertise from the Clinical IT Analyst, End-users, Compliance, Regulatory, Finance, Executive Sponsor(s), and Senior Leadership.
4. The Applied Clinical Informaticist also has primary (R)esponsibility for the drafting of workflows (blueprints of deliverables), typically in conjunction with (C)onsulting expertise from the Clinical IT Analysts, Compliance, and End-Users. These blueprints will help to create understanding and alignment, and later serve as downtime forms in the event of a planned or unplanned downtime. 
5. The Clinical IT Analyst often provides (C)onsulting expertise during earlier analysis and scoping phases of the change, but then assumes primary (R)esponsibility for the building and testing of electronic deliverables, before providing additional (C)onsulting expertise during the implementation phase of the change. 

I know there's a lot to unpack here, but I hope this review helps to demystify the process, and helps you look at your own change recipe and the roles that are (A)ccountable for,  (R)esponsible for, (C)onsulting on, and (I)nformed of each step. I also hope it helps to dispel the misunderstandings and confusion about the roles of the Applied Clinical Informaticist and the Clinical IT Analyst, two important roles that often work together but each of which require their own skill sets, job titles, job descriptions, and support.

Remember, the above is all a [ DRAFT ] and this blog is for educational and discussion purposes only - Your mileage may vary! Have any feedback or experiences you would like to share? Please feel free to leave comments in the comment section below!

What can Cardiac Myocytes teach us about Teamwork and Workflow?

Hi fellow CMIOs, CNIOs, and other #HealthIT and Applied Clinical #Informatics friends,

Today's post is short, but one that I think most clinical friends will understand and appreciate. For conceptual teaching purposes only, I'm going to ask the question : 

"Q : What can Cardiac Myocytes teach us 

about Teamwork and Workflow Design?"

Here's my theory : Clinicians may actually have an advantage here. If you've ever studied the human heart - it's anatomy, it's functions, its biology, and its electrophysiology - You already know a lot about teamwork, workflow design, clinical operations, and essentially how to get things done. 

After all, cardiac myocytes and humans (clinical leaders and team members) both work towards a common goal. We both can function as individual units, but we function even better together as a well-organized, well-synchronized team : 

[ DRAFT ] TABLE - A tongue-in-cheek but honest comparison of Myocytes with Humans (Clinicians)

Let's face it, healthcare is a team sport. So when I'm working with other clinical leaders, especially new ones - For support, I often remind them of the importance of the infrastructure and tools that, especially as clinicians, we sometimes take for granted - Good : 

• Regulations (both Federal and State)
• Governance (e.g. Committee structures)
• Leadership
• Direction
• Management
• Communication
• Bylaws
• Policies/Procedures
• Training / Onboarding
• Continuing Education
• Offboarding
• Teamwork

After all, when growing a plant - it's not just the seeds you need to worry about, it's also the soil. So without enough of this 'supporting soil' (the tools above) in place, it becomes very easy to run into problems growing the seeds - And so for end-users, managers, directors, leaders, and executives alike, this can sometimes result in loss of efficiency, frustration, disorganized workflows, problems not getting solved in a timely basis, etc.

Typically, these tools don't get enough attention from new clinical leaders, because until they are in a leadership position - their focus has largely been on 'clinical things' like working with patients, diagnosing and treating diseases, performing operations and procedures, etc. While those are all the reasons we are in healthcare, it's still important to understand the many 'non-clinical' tools that make those things happen. (In truth, those tools are just as clinical as penicillin - But due to time constraints, they usually don't teach much about them in medical schools.)

What I find especially interesting is that, as a physician who during my career has treated cardiac tachyarrhythmias at the bedside (using beta-blockers, calcium-channel blockers, adenosine, cardioversion, etc.) - There are often similar analogous ways to treat these same 'human tachyarrhythmia' problems on project teams : 

So when I have the opportunity to teach a new clinical leader about how to solve problems and function in teams, I simply remind them that modern human biology has evolved over thousands of years to solve these same sorts of problems that we experience in healthcare today - And so sometimes, looking inward with a microscope is just as helpful as looking outward with a telescope. 

Finally, one of my clinical informatics colleagues and good friend Stefanie Shimko-Lin, BSN RN CD-L CD-PIC FHIMSS once shared this cardiac analogy with me : "Collateral circulation is a workaround, that happens when the desired workflow doesn't work. If you make it easy to do the right thing, people will do it."

These analogies may all seem a bit peculiar and tongue-and-cheek, but if you're a clinical leader - I hope this blog post helps to spark helpful discussion and learning with your own clinical leadership and project teams, so that you can better solve the workflow and operational issues you might encounter in your daily clinical routines.

Remember, this blog is for educational and discussion purposes only - Your mileage may vary! Have any other helpful analogies or advice for new clinical leaders? Feel free to share them in the comments section below!

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 www.dirkstanley.com

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!