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Modelling workflow processes for clinicalinformation systems:Impact on decision support and healthcare outcomes2 November 2011Phil GoochCentre for Health InformaticsSchool of InformaticsCity University LondonUK
Aims of this seminar• Define and describe the relationships between clinical workflows, guidelines, pathways and decision support• Compare and contrast the evidence base for the effectiveness of systems that implement these components• Summarise the findings of a recent review of how these components can be integrated as process-oriented systems and what challenges need to be overcome
Workflow“The automation of a business process ... during which documents, information or tasks are passed from one participant to another for action, according to a set of procedural rules” (WfMC 1999)• A workflow (Wf) process definition (PD) identifies the various activities, rules and associated control data.• A Wf enactment engine interprets the PD and schedules Wf activities• A workflow management system (WfMS) stores Wf PDs, creates, executes and manages Wf instances and controls their interaction with Wf participants and applications.
Business processmodelling of workflow(Benson 2005)
Clinical workflow“The flow of care-related tasks [for] the management of a patient trajectory: the allocation of multiple tasks of a provider or of co-working providers in the processes of care and the way they collaborate” (Niazkhani et al 2009)• Patient care as a structured, collaborative process• Co-ordination of work - scheduling, synchronisation, roles, resource allocation, temporal constraints• Information flow – integrating guidelines with info in the medical record• Monitoring – dynamic task changes in the light of new information
Modelling clinical workflow - temporal constraintsShahar et al (1998)
Clinical decision support systems (CDSS)Aim to provide diagnostic and treatment recommendations and advice at the point of care, i.e. information tailored for the specific patient under consideration by the clinician during a consultation• Often implemented as part of computerized physician order entry system (CPOE)• Active - provide automated advice in the form of alerts, commentary and recommendations in response to events occurring within the application while the user works• Passive - manually invoke or consult the system first before receiving decision support (e.g. ‘Infobuttons’)
Clinical guidelines“Systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” (Field & Lohr 1990)• Contain recommendations for best practice based on systematic reviews of clinical evidence, consensus statements and expert opinion.• Goal is to reduce variation in medical care by promoting the most effective treatments, and to provide a means of quality control in clinical practice via audit
Care plansGoal-directed treatment plans, specific to a patient’s needs, which are signed and time-stamped (Fox et al. 2006)• Should include best practice treatment from clinical guidelines.• But must be specific to the given patient, and include a temporal dimension (‘by [date], patient X will receive [treatment], will be able to perform [goal]’)
Clinical pathways“Structured multidisciplinary care plans ... for a specific clinical problem ...implementing local protocols based on clinical guidelines” (Campbell et al 1998)• Describe tasks to be carried out together the timing, task sequence and role that completes each task.• Should form a single, multidisciplinary record that becomes part of the patient’s overall clinical record.• Task timing, sequencing, and role-based task enactment are all features of workflow systems.
Modelling clinical workflow and pathways: activity on node• Clinical pathways arose from the application of project management techniques to the management of clinical processes (Zander 1988)• activity-on-node network consisting of nodes, representing project activities, and arcs, representing the precedence relationship between activities.• Duration (and usually role) assigned to each node. - Earliest start time (EST), Earliest finish time (EFT) - Latest start time (LST), latest finish time (LFT) (Hillier & Lieberman 2010)
Modelling clinical workflow and pathways: multiple levels(Dang 2008)
Modelling clinical workflow and pathways: multiple views(Chu 1998)
Decision support systems: systematic reviews of evidence foreffectiveness• Clinical practice (reduction in errors, quality of documentation, patient outcomes) is improved by active rather than passive CDSS - CDSS success factors include: recommendations actionable via a computer, availability at the point of care, and integrated with clinical workflow (Kawamoto et al. 2005)• Guideline adherence is improved by CDSS that use a knowledge base derived from clinical guidelines (Garg et al 2005)• Little evidence of effect on patient outcomes, but positive impact on practitioner performance (Jaspers 2011)
Computerized clinical guidelines: systematic reviews of evidencefor effectiveness• Two systematic reviews: Shiffman (1999) and Damiani (2010)• Improved documentation and guideline adherence (Shiffman) but no meta- analysis as systems were too heterogeneous in terms of outcome measures and study types• Improved the ‘process of care’ (Damiani) - somewhat vague, post-hoc binary intervention variable based on the conclusion of each study• Neither review distinguished between systems that simply present guideline- based recommendations on a computer - i.e. for individual clinical decisions - from systems that model and support longitudinal, longer-term clinical processes
Clinical pathways: systematic reviews of evidence for effectiveness• Clinical pathways are associated with reduced in-hospital complications, improved documentation but do not increase length of stay or hospital costs.• However, the clinical pathway development and implementation process is poorly reported, so the key factors critical to success cannot be determined (Rotter et al 2010).• Stroke patients on a clinical pathway may have lower QoL and satisfaction scores (Kwan 2003)
Process-oriented health information systems• ‘Computer-aided healthcare workflows’: integration of guidelines and protocols with a health information system (HIS) (Song et al 2006)• ‘Process-oriented health information systems’: formally models guidelines, workflows, or clinical pathways and provides support for clinical decisions that extend over time
Implementing process-oriented health information systems
Findings• Modelling clinical workflow does not guarantee clinical workflow integration or point-of-care use• ‘Idealised’ workflow needs to adapt to actual workflow for a given patient• Workflow integration to provide point-of-care support tends to involve: • use of an integrated device for data collection, display and decision support (e.g. mobile) • use of electronic encounter forms that mirror paper-based forms • augmented use of paper for data input and/or output
Findings• Web technologies are being used to integrate guidelines, workflows, pathways and clinical decision support• Use of formal models, shared knowledge resources and ontologies• Decomposition of clinical processes into discrete workflow steps is often at odds with the collaborative nature of clinical work.• Challenge is to provide adaptive workflow that allows dynamic modification of tasks, roles, and activity sequencing in response to changing conditions• Evidence-base for process-oriented systems is in its infancy - perhaps because it is a potential enabler of intervention, rather than an intervention itself
Going further …• JAMIA paper: http://jamia.bmj.com/content/18/6/738.full• Recent conference workshops: • http://www.uni-ulm.de/in/prohealth-11.html • http://aimedicine.info/aime11/AIME_11_Keynote_Manfred.pdf• Process mining: http://processmining.org/