This lecture defines key terms related to workflow analysis and process redesign. It describes the role of a healthcare workflow specialist and their skills in process analysis and redesign. It reviews the importance of workflow improvement and health IT adoption for patient safety and quality of care. The lecture also describes the Centers for Medicare and Medicaid Services' meaningful use program and incentives for adopting certified electronic health record technology.
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data contained in a telecare database regarding the number of a clinic. The ultimate purpose of this study was to
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The Case Study of an Early Warning Models for the Telecare Patients in TaiwanIJERA Editor
To propose a practical early warning analysis model for the telecare patients, this study applied data mining
technology as a basis to investigate the classification of patient groups by disease severity and incidence using
data contained in a telecare database regarding the number of a clinic. The ultimate purpose of this study was to
provide a new direction for telecare system planning and developing strategies.
The subject of this case study was a private clinic which is providing telecare system to patients in Taiwan, and
we used three data mining techniques including discriminant analysis, logistic regression and artificial neural
network to construct an early warning analysis model based on several factors such as: Demographic variables,
pathological signals, health management index, diagnosis and treatment records, emergency notification signal.
According the results, the telecare system can build stronger physician-patient relationship in advance through
previously paying attention to patients’ physiological conditions, reminding them to do self-management, even
taking them to the hospital for observation. A comparison of discriminative rates showed that the artificial neural
network model had the highest overall correct classification rate, 85.52%, and thus is a tool worthy of
recommendation
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We have spent a lot of time this semester talking about various as.docxmelbruce90096
We have spent a lot of time this semester talking about various aspects of the health care industry -- cost, access, utilization, strategy. Another important aspect that needs to be balanced with all these other concerns is QUALITY!
What does QUALITY mean in health care?
How do you go about defining quality in health care? Is there just one measure of quality, or more?!
Find one outside article that addresses health care quality. Tell us about the article and how they define quality.
Be sure to post your citations
Alicia AliendreCOLLAPSE
Top of Form
Parent Post
In the health care industry quality of care means everyone participating in ways to improve health care such as health care professionals, patients and their families, researchers, payers, planners and educators. These changes lead to better outcomes in health, a better system performance in care, as well as better professional development.
When you describe quality, it’s the process for making strategic choices in health systems for quality assurance in health care and decision making. Although there are many outcomes to improve quality of care, the main concern is accomplishing a goal that will be beneficial for the future.
Good quality means providing patients with appropriate services in a technically competent manner, with good communication, shared decision making, and cultural sensitivity. In practical terms, poor quality can mean too much care (e.g., providing unnecessary tests, medications, and procedures, with associated risks and side effects), too little care (e.g., not providing an indicated diagnostic test or a lifesaving surgical procedure), or the wrong care (e.g., prescribing medicines that should not be given together, using poor surgical technique).
Quality can be evaluated based on structure, process, and outcomes (Donabedian 1980). Structural quality evaluates health system characteristics, process quality assesses interactions between clinicians and patients, and outcomes offer evidence about changes in patients' health status. All three dimensions can provide valuable information for measuring quality, but the published quality-of-care literature reveals that there is more experience with measuring processes of care.
Marie Savino
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* Safety- health care does not cause harm
* Effective- health care service is based on scientific and medical knowledge and is right for the.
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Application: Evaluation Project Part 1: Evaluation Plan Focus
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Because of the great differences between HIT systems and different goals of an evaluation, there is no one-size-fits-all evaluation plan. Different technologies require different evaluation methods. Consequently, in this part of your Evaluation Project, you will conduct research on how system implementations similar to the one you select have been previously evaluated. After exploring similar system implementations, you will select one research goal and viewpoint to use in the evaluation.
Read the following three scenarios, and select the one that is of most interest to you:
Scenario 1:
Your hospital is implementing a new unified acute and ambulatory Electronic Health Record (EHR) system through which patient care documentation will occur. Interdisciplinary assessment forms (including nursing), clinical decision support, and medical notes will be documented in this system. The implementation of the system is anticipated to improve the hospital’s performance in a multitude of areas. In particular, it is hoped that the use of the EHR system will reduce the rate of patient safety events, improve the quality of care, deter sentinel events, reduce patient readmissions, and impact spending. The implementation of the EHR system is also intended to fulfill the “Meaningful Use” requirements stipulated in the Health Information Technology for Economic and Clinical Health (HITECH) Act. As the hospital’s lead nurse informaticist, you have been tasked with planning the evaluation of the EHR implementation.
Scenario 2:
As the lead nurse informaticist in your hospital, you have been given the task of planning an evaluation for a soon-to-be launched computerized provider order entry (CPOE) system. The CPOE system is designed to replace conventional methods of placing medication, laboratory, admission, referral, and radiology orders. CPOE systems enable health care providers to electronically specify orders, rather than rely on paper prescriptions, telephone calls, and faxes. The intended goal of a CPOE system is to improve safety by ensuring that orders are easily comprehensible through the use of evidence-based order sets. In addition, the CPOE system has the potential for improving workflow by avoiding duplicate orders and reducing the steps between those who place medical orders and their recipients.
Scenario 3:
You are the lead nurse informaticist in a large urban hospital that has recently implemented a new .
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1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
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Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
1. Health Care Workflow Process
Improvement
Concepts of Workflow Process
Improvement
Lecture a
This material (Comp 10 Unit 1) was developed by Duke University, funded by the Department of Health and Human Services, Office of
the National Coordinator for Health Information Technology under Award Number IU24OC000024. This material was updated by
Normandale Community College, funded under Award Number 90WT0003.
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of
this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/
2. Learning Objectives
1. Describe the purpose for health care workflow
process improvement in the clinical setting
2. Describe the role of a health care workflow
specialist
3. Explain how health care workflow process
improvement and meaningful use are related
2
5. Process
Process: a series of actions or operations
“conducing” to an end
Procedure: The steps in a process and how
these steps are to be performed
5
(American Society for Quality (ASQ), 2011; Merriam-Webster, 2011)
6. Process Analysis
• Understanding process elements and the
relationships between them
• Identification of opportunities for
improvement
6
(Merriam-Webster, 2011)
8. Workflow
• “The flow of work”
• The way in which work progresses
through a process.
• In this component, the words workflow
and process will be used
interchangeably.
8
(Wikipedia, 2011; Concise Oxford English Dictionary, 2011)
9. What is Clinical Workflow?
• The way in which activities in the health
care setting are carried out, by whom, in
what order, etc.
• Some of the processes that make up
health care:
– Admitting a patient
– Submitting a claim
– Prescribing a medication
9
10. Example: Clinical Processes
Think about your last
visit to your provider. If
you could break the visit
up into clinical
processes, what would
they be?
(Everson, 2011)
10
11. Common Clinical Processes
You might have considered:
• Patient registration / intake / payment
• Waiting to be seen
• Information checking / gathering
• Checking vital signs
• Visit with the clinician
– Ordering tests
– Diagnosis
– Writing prescriptions
• Drawing blood
• Referral to another provider
• Billing
11
12. Data and Information Flow
The steps or path by which data are moved
through a work process or a system or some
combination of both, including the order of
steps, and operations performed on the data
(or information).
12
13. Health Care Workflow Specialist
Uses knowledge and understanding of
1. An organization’s objectives, structure and
procedures, and
2. Information technology
to improve an organization’s operations
13
14. Process Analysis Part of the Role
• Describe the Dance
• Overcome communications
problems in analysis
– Natural difficulty in describing procedure
– Inappropriateness of narrative text for
describing procedures
– Lack of common language between the
user and analyst
14
15. Process Analysis Skills
• Knowledge of data and data system
concepts
• Knowledge of clinical workflow concepts
• Able to communicate such concepts
• Able to identify problem areas
15
16. Process Redesign Role and Skills
• Role
– Choreographing a new dance between
humans, information, and computers
• Skills
– Ability to combine organizational knowledge
and technology to create a better way
16
17. Why is Health Care Workflow
Analysis and Redesign Important?
(Citation: Public domain images obtained from National Academy Press.
http://www.nap.edu/
Institute of Medicine, 2000, 2001; NRC, 2009)
• 98,000 or more people
die annually in the US
due to medical errors
• Lack of information and
care fragmentation called
out as leading
contributors
• Meaningful use of Health
IT will decrease this
number
17
18. Institute of Medicine (IOM)
6 Quality Areas for Health care
1. Safe
2. Effective
3. Efficient
4. Timely
5. Patient centered
6. Equitable
(Citation: Public domain image obtained from
National Academy Press, http://www.nap.edu/
Institute of Medicine, 2001)
18
19. EHR Incentive Program
• Using technology in meaningful way to improve quality
• “Meaningful Use” coined by the framers of the 2009
American Recovery & Reinvestment Act (ARRA)
• Addresses five national health policy priorities
• Improve quality, safety and efficiency and reduce health
disparities
• Engage patients and families
• Improve health care coordination
• Improve population and public health
• Ensure adequate privacy and security protections for personal
health information (PHI)
• Incentives and payment reductions (Penalties)
19
21. Meaningful Use Criteria
• Privacy and Security
• Data Capture and Sharing
• Data Standards
– ICD, SNOMED, RxNorm, LOINC
• Effective Clinical Workflows
• Computer-Based Order Entry
• E-Prescribing
• Clinical Decision Support
• Patient Health Information Exchange
21
22. Meaningful Use Requirements
Examples
• 1. “More than 30 percent of all unique patients with at
least one medication in their medication list seen by the
[eligible provider] EP have at least one medication order
entered using [Computer Physician Order Entry] CPOE.”
• 5. “The EP that transitions or refers their patient to
another setting of care or provider of care (1) uses
CEHRT to create a summary of care record; and (2)
electronically transmits such summary to a receiving
provider for more than 10 percent of transitions of care
and referrals.”
(Eligible Professional Meaningful Use Measures - Measures 1 and 5, 2016)
22
24. Meaningful Use
• Certified EHR Technology (CEHRT)
• CMS and ONC established standards
• Has the capacity to:
− Provide clinical decision support
− Support physician order entry
− Capture and query information relevant to health care quality
− Exchange electronic health information with, and integrate
such information from other sources
− Store data in a structured format
24
(CMS, 2016)
26. Concepts of Workflow Process
Improvement
Summary – Lecture a
• Defined key terms relevant to workflow analysis and
process redesign
• Described the practice workflow and information
management redesign specialist role and requisite skills
• Reviewed patient safety and health care quality reasons
why Health IT is a national priority
• Described the Centers for Medicare & Medicaid Services
(CMS) program to incentivize nation-wide adoption and
meaningful use of health IT
26
27. Concepts of Workflow Process
Improvement
References – 1 – Lecture a
References
Analysis. 2011. In Merriam-Webster.com. Retrieved December 21, 2011. from merriam-webster.com
Centers for Medicare and Medicaid Services. (2016). Certified EHR Technology. Retrieved from
cms.gov
Committee on Engaging the Computer Science Research Community in Health Care Informatics,
National Research Council. (2009). Computational Technology for Effective Health Care:
Immediate Steps and Strategic Directions. (W. Stead, & H. S. Lin, Eds.) Cambridge: National
Academies Press.
DeMarco, T. (1979). Structured Analysis and System Specification. New Jersey : Yourdon Press,
Prentice-Hall.
Demming, W. E. (1982). Out of Crises. Cambridge: MIT Press.
Department of Health and Human Services; Centers for Medicare & Medicaid Services. (2010,
December 29). Medicare and Medicaid Programs- Electronic Health Record Incentive Program.
Retrieved from HHS.gov
Department of Health and Human Services; Centers for Medicare & Medicaid Services. (2010, July
28). Medicare and Medicaid Programs- Electronic Health Record Incentive Program. Retrieved
from HHS.gov
Eligible Professional Meaningful Use Core Measures Measure 1 of 15 -Stage 1. (2010, November 7).
Retrieved from CMS.gov
Eligible Professional Meaningful Use Core Measures Measure 3 of 15 -Stage 1. (2010, November 7).
Retrieved from CMS.gov 27
28. Concepts of Workflow Process
Improvement
References – 2 – Lecture a
References
Gall, J. (1978). Systematics : how systems work and especially how they fail . London: Wildwood
House Ltd.
Institute of Medicine. (2000). To Err is Human: Building a Safer Health System. (L. T. Kohn, J. M.
Corrigan, & M. S. Donaldson, Eds.) Washington: National Academies Press.
Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century
2001 . Washington: National Academies Press.
Miers, D. & White, S. A., & (2008). BPMN Modeling and Reference Guide. Lighthouse Pt: Future
Strategies, Inc.
Procedure. 2011. American Society for Quality Glossary. Retrieved from ASQ.org
Process. 2011. In American Society for Quality Glossary. Retrieved from ASQ.org
Process. 2011. In Merriam-Webster.com. Retrieved from Merriam-Webster Dictionary
Process Analysis. 2011. In Merriam-Webster.com. Retrieved from Merriam-Webster Dictionary
Process Improvement. 2011. In American Society for Quality Glossary. Retrieved from ASQ.org.
Process Re-engineering. 2011. In American Society for Quality Glossary. Retrieved from ASQ.org
Redesign. 2011. In Merriam-Webster.com . Retrieved from Merriam-Webster Dictionary
Workflow. In Wikipedia. Retrieved from Wikipedia.org
Workflow. 2011. In Concise Oxford English Dictionary. Retrieved from WordReference.com
28
29. Concepts of Workflow Process
Improvement
References – 3 – Lecture a
Images
Bart Everson, photographer. 2011. Doctor’s Office [Public Domain], Retrieved from: WikiMedia Commons
Centers for Medicare and Medicaid. 2016. Meaningful Use Incentives and Payments [Public Domain]. Retrieved from:
CMS.gov
Centers for Medicare and Medicaid. 2011. Meaningful Use Requirements [Public Domain]. Retrieved from: CMS.gov
National Academy Press. 2000. To Err is Human book cover. [Public Domain], Retrieved from: National Academy Press
National Academy Press. 2001. Crossing Quality Chasm book cover. [Public Domain]. Retrieved from: National
Academy Press
National Academy Press. 2009. Computational Technology for Effective Healthcare. [Public Domain]. Retrieved from:
National Academy Press
National Academy Press. 2001. Crossing Quality Chasm book cover. [Public Domain]. Retrieved from: National
Academy Press
Nesvacil, Alicia. 2016. Meaningful Use Stages. [Used with Permission]. Image courtesy of Alicia Nesvacil.
Charts, Tables, and Figures
1.1 Figure: Meaningful Use Criteria. [Public domain] Retrieved from CMS.gov
29
30. Concepts of Workflow Process
Improvement
Lecture a
This material was developed by Duke University,
funded by the Department of Health and Human
Services, Office of the National Coordinator for
Health Information Technology under Award
Number IU24OC000024. This material was
updated by Normandale Community College,
funded under Award Number 90WT0003.
30
Editor's Notes
Welcome to Health Care Workflow Process Improvement, Concepts of Workflow Process Improvement. This is Lecture a, Introduction to Health Care Workflows.
The objectives for Lecture a are to:
Describe the purpose for workflow analysis and redesign in the clinical setting,
Describe the role of a health care workflow specialist
Explain how health care workflow process improvement and meaningful use are related.
Tom DeMarco, an early pioneer and thought leader in process analysis, said in his 1979 book, Structured Analysis and System Specification, that “Procedure, like dance, resists description” (Demarco, 1979). One of the workforce roles described by the Office of the National coordinator for Health IT (ONC), is the Health Care Workflow Analysis and Redesign Specialist. Using this analogy, individuals in process analysis and redesign jobs are experts at both “describing the dance,” and at “choreographing a better one.”
Before we start, and in a way, as an introduction, we will cover the following definitions:
Process,
Process Analysis,
Process Redesign,
Workflow,
Workflow Analysis, and
Data and Information Flow.
Merriam-Webster (2011) defines process as a series of actions or operations conducing to an end. Similarly, the American Society for Quality (ASQ) (2011) defines Process as “a set of interrelated work activities characterized by a set of specific inputs and value added tasks that make up a procedure for a set of specific outputs.”
Still another authoritative source, the Business Process Modeling Notation (BPMN™) standard (Miers and White, 2008) defines a process as, “what an organization does – it’s work – in order to accomplish a specific purpose or objective.” And goes on to say that most processes have input, consume resources, and produce output.
The word Procedure is related to process. The American Society for Quality (ASQ 2011) defines a Procedure as: “The steps in a process and how these steps are to be performed for the process to fulfill a customer’s requirements; usually documented.” Processes can be described at different levels of detail – High level, i.e., not much detail, or a very granular level, i.e., a lot of detail. I think of the latter as a procedure.
Important characteristics of processes for our work are that processes have 1) steps, also called activities, actions, operations, or tasks, 2) the steps have sequence or order, 3) processes have inputs and outputs, and that 4) processes happen over and over, i.e., are ongoing. For example, appointment scheduling is a common process in health care facilities.
Merriam-Webster (2011) provides several definitions for the word analysis. The one most relevant for our work here is: “an examination of a complex, its elements, and their relations or a statement of.”
So, a Process Analysis is an examination of a process to understand its elements such as the inputs, the process steps, the outputs; and the relationships between them, including things like:
the order of steps,
what things can be done in parallel versus sequentially,
who or what performs the steps,
maybe where they are performed, and
what information is needed or generated.
Because the goal of our “analysis” is to ultimately improve a process, we also look for things like gaps, lack of conformity with best practice such as meaningful use of health IT and health care quality improvement, delays, redundancy, rework, and lack of efficiency. For us, the combination of 1) understanding process elements and the relationships between them and 2) identification of opportunities for improvement comprise Process Analysis.
Merriam-Webster (2011) defines redesign as: “to revise in appearance, function, or content.”
Process Redesign, then, is the revision in appearance, function, or content of a process. The reason why we analyze a process is to improve it. The improvement is achieved through Process Redesign. A significant amount of process redesign in health care today involves the introduction of electronic health records (EHR). A report published by the Institute of Medicine (2001), Crossing the Quality Chasm, offers six key areas in which health care in general can be improved, and ultimately these six areas, discussed in detail later, are our goal. For now, we will think of “better” as “safer, more efficient, more convenient, less errors, and more cost effective.”
In quality improvement, process redesign, also called process re-engineering, sometimes has the connotation of, drastic and major changes expected to result in breakthrough improvements. The American Society for Quality (2011) defines Process Re-engineering as: “A strategy directed toward major rethinking and restructuring of a process; often referred to as the “clean sheet of paper” approach.”
This is in contrast to Process Improvement, which sometimes takes on the connotation of more incremental change, is defined more specifically by the American Society for Quality (2011) as: “the application of the plan-do-check-act cycle to processes to produce positive improvement and better meet the needs and expectations of customers.” We will cover more about both of these different approaches in the unit on Process Redesign.
The Workflow topic on Wikipedia (2011) defines workflow as: “A workflow consists of a sequence of (connected) steps.” Another online resource defines workflow as, “the sequence of processes through which a piece of work passes from initiation to completion (Concise Oxford English Dictionary, 2011).”
In everyday use, the terms workflow and process are used interchangeably. Workflow is often more specifically thought of as the flow or path of the work steps, i.e., the way in which work progresses, including things like order of steps and selection between alternative steps. Like a process, a workflow has inputs and outputs, i.e., resources (mass, energy, information) and the people or things that perform the steps or activity that comprise the work are considered. In this component, the words workflow and process will be used interchangeably.
Now that we have defined workflow and processes in general, we can talk more specifically about health care. Clinical Workflow is way in which activities in the health care setting are carried out, by whom, in what order, etc. Examples of clinical workflows include:
Admitting a patient
Submitting a claim
Prescribing a medication
Think about your last visit to your provider. If you could break the visit up into clinical processes, what would they be?
You might have considered:
Patient registration / intake / payment
Waiting to be seen
Information checking / gathering
Checking vital signs
Visit with the clinician
Ordering tests
Diagnosis
Writing prescriptions
Drawing blood
Referral to another provider
Billing
Or something like them. They are all sets of activities that accomplish a particular goal (a sub-goal) of a patient visit. For example, checking vital signs measures and records necessary data for patient care. Information checking such as medication reconciliation, i.e., comparing the medications that the patient is currently taking to those that are listed in the patients chart, is necessary for quality of care and patient safety. Each of these processes accomplishes a part of a patient visit; each would be considered a process or a workflow.
One person’s data flow may be another person’s information flow … Like process and workflow, the words data and information have specific definitions that are used in certain fields, and are often interchanged on other fields and in everyday use.
Early work done in the 1960’s and 70’s uses the term “data flow,” more people today tend to use “information flow”, for the distinction see (the diaphoric definition of data -DDD and the general definition of information - GDI).
For this component, and because most of the literature that you will see uses the two words interchangeably, in this component, we will too.
When we use the terms data flow and information flow, we mean the steps or path that the data takes through a work process or a system or some combination of both, including the order of steps, and operations performed on the data (or information).
A health care workflow specialist uses knowledge and understanding of two key things 1) an organization’s objectives, structure and procedures, and 2) information technology for the purpose of improving how the organization operates and achieves its goals.
Tom DeMarco, introduced earlier as a pioneer and thought leader in process analysis, likens process analysis to describing a dance. He adds further insight to the process analysis part of the role by emphasizing the intensive communication requirement, and by describing the following three key communications challenges that process analysts face:
The first is the Natural difficulty in describing any process or procedure.
The second is the inappropriateness of narrative text for describing procedures, and
finally there is a lack of common language between the user and analyst.
Health Care Workflow Specialists require very strong written, visual/graphic, and verbal communication skills to overcome these challenges. Successful Health Care Workflow Specialists are strong listeners, and are able to identify when others are uncomfortable or having difficulty or not in agreement and are able to constructively work through difficult situations.
DeMarco further outlines process analysis skills helpful to overcome the challenges inherent in Process Analysis. These are:
Knowledge of data and data system concepts,
Knowledge of clinical workflow concepts, and the
Ability to communicate these concepts.
We added the ability to identify problem areas.
If Process Analysis is describing the dance, Redesign is choreographing or planning a new dance. For us, the dance is the interaction between humans, information and computers in the clinical setting. The key skill a Process Redesign Specialist needs is the ability to combine, analyze and synthesize the organizational knowledge, including knowledge of clinical workflow and technology to create a “better way.”
John Gall in his 1970’s book Systemantics said, “systems run best when designed to run down hill.” The goal of process re-design is to find the “down hill” design, i.e., the design that takes the least amount of input energy to get the desired output. The “down hill” design is the one that will have the least errors, the highest quality, the happiest staff, and the lowest cost.
A professor at the University of Arkansas, Dr. Elizabeth Pierce, told a story in one of her information quality classes about Penn State that is a great example of designing systems that run down hill. At Penn State Campus, the foot paths made by students did not last very long. Whenever the University built a new building or expanded, instead of fencing off new landscaping, they left it open and waited for students to make paths between the buildings. The architects and landscaping staff waited to see where the paths were worn. These were usually the shortest distances between the most important places on campus, and the places where walkways were most needed. Once they were spotted, the foot paths would be replaced by a paved walkway to make the new route a permanent part of the campus map and with good lighting so they were safe. Or if the foot paths were considered unsafe or undesirable, the campus planners would find some type of barrier to discourage further use of the foot path. Less wise institutions are not able to see the signs of a process trying to “run down hill” and fence off areas as soon as new construction is complete. People still make paths, but they are muddy and messy and lack safe lighting.
A similar example in intensive care units is the importance for people on a ventilator to have the head of their bed at a 30o – 45o angel. One creative and early team in health care quality improvement used red tape to mark the bed so that it was easy for the staff to see whether or not the bed angle was correct. This was much easier than other methods like a question on a check list, “is the height of the head at least 30 degrees?” A clever person redesigned the process to “run down hill”.
Why do we need to improve the workflows and processes currently used in the health care organization? Why are we using health information technology in the clinical setting at all?
A 2000 Institute of Medicine (2000) report estimated that 98,000 or more people die annually in the US due to medical errors. This is more than die from motor vehicle accidents, breast cancer or AIDS, and more than die from Alzheimer's, diabetes or pneumonia.
The 2001 report, Crossing the Quality Chasm, specifically listed five imperatives for increasing quality of health care in the United States. This list included
Reengineered care processes,
Effective use of information technologies,
Knowledge and skills management,
Development of effective teams, and
Coordination of care across patient conditions, services, and sites of care over time (Institute of Medicine, 2001).
Most of these involve or depend on Health IT. Workflow Process Improvement is at the heart of increasing the quality of health care. As the great thought leader of quality, Edwards Deming stated, “You can only elevate individual performance by elevating that of the entire system” thus, this effort is focused on the entire health care system. (Demming, 1982)
Crossing the Quality Chasm provided six aims and simple rules for redesign of health care. They are:
Care should be safe, as safe for patients in their health care facilities as in their homes.
The science and evidence behind health care should be applied and served as the standard in the delivery of care.
Care and service should be cost effective and waste should be removed from the system.
Patients should experience no waits or delays in receiving service.
The system of care should revolve around the patient, respect patient preferences, and put the patient in control.
Unequal treatment should be a fact of the past; disparities in care should be eradicated. (Institute of Medicine, 2001)
Importantly, increasing the quality of care is our goal. Implementing technology is a way to achieve this goal.
Under the American Recovery and Reinvestment Act or ARRA, the Health Information Technology for Economic and Clinical Health (HITECH) Act established a program offering incentives to help providers implement standardized technology. The purpose of these incentives is to encourage the greater health care community to implement EHRs, thus paving a path to improving quality. In order to receive the incentives, the expectation is that the providers meet a set of criteria by adopting certified technology and use the technology in meaningful ways. “Meaningful Use” of EHRs is used to collectively describe those criteria.
This coordinated adoption of EHRs across health care providers address the five established national health policy priorities.
Improve quality, safety and efficiency and reduce health disparities,
Engage patients and families,
Improve health care coordination,
Improve population and public health, and
Ensure adequate privacy and security protections for personal health information (PHI).
Eligible providers and hospitals can qualify for incentives during the first stages of Meaningful Use, but as the program continues, there will be Medicare payment reductions imposed for providers who do not meet the criteria.
The incentives are a fixed dollar amount for the initial years while the penalties for not meeting the requirements are in the form of a several percentage point decrease in the reimbursement payments from the Center for Medicaid and Medicare (CMS). The grid outlined in this slide indicates the incentives per year that an eligible provider can receive when starting the program in 2011, 2012, 2013 or 2014.
To hospitals, small and large practices and health care facilities this means millions of dollars. The MU incentives considerably offset the cost of obtaining and implementing Health IT.
Some of the Meaningful use criteria include (CMS, 2016):
Privacy and Security,
Data Capture and Sharing,
Data Standards, such as
ICD, SNOMED, RxForm, LOINC,
Effective Clinical Workflows,
Computer-based Order Entry,
Electronic Prescribing,
Clinical Decision Support,
Patient Health Information Exchange
For providers to meet or successfully claim that they are using Health IT meaningfully, they must achieve the requirements stated in the meaningful use rule. We can use the following two examples of what providers are being measured against.
The first example is the requirement that “More than 30 percent of all unique patients with at least one medication in their medication list seen by the eligible provider have at least one medication order entered using CPOE” (Eligible Professional Meaningful Use Core Measures Measure 1, 2016).
Another example is “The EP that transitions or refers their patient to another setting of care or provider of care (1) uses CEHRT to create a summary of care record; and (2) electronically transmits such summary to a receiving provider for more than 10 percent of transitions of care and referrals” (Eligible Professional Meaningful Use Core Measures Measure 5, 2016). The full criteria is available on the CMS website.
Meaningful Use (MU) has evolved since the beginning of the program. Originally the criteria outlined both a core set and a choice within the menu set of objectives for eligible professionals, eligible hospitals and CAHs. For 2016, eligible professionals must meet ten objectives and eligible hospital and critical access hospitals must meet nine objectives.
Each year, meaningful use objectives expand on their previous version focusing on the aims and priorities of the Nationality Quality Strategy. Initial focus during Stage 1 was electronic capture and sharing data. Stage 2 criteria encouraged the use of health IT for continuous quality improvement at the point of care and the exchange of information in a structured format.
For 2015 and beyond, the focus continues with data capture and structured format, while adding an additional focus of improving outcomes using Health IT.
One of the fundamental requirements of meaningful use, in addition to meeting the measures, is to use certified technology. CMS and the Office of the National Coordinator for Health Information Technology (ONC) have established standards and other criteria for certified technology that providers must use in order to qualify for this incentive program.
CEHRT (pronounced ‘sert’) has the capacity to:
provide clinical decision support
support physician order entry
capture and query information relevant to health care quality and
exchange electronic health information with, and integrate such information from, other sources
store data in a structured format. Structured data allows patient information to be easily retrieved and transferred, and it allows the provider to use the EHR in ways that can aid patient care.
Certified EHR technology gives assurance to purchasers and other users that an EHR system or module offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria.
Certification also helps providers and patients be confident that the electronic health IT products and systems they use are secure, can maintain data confidentiality, and can work with other systems to share information.
Source: https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/certification.html
Meaningful Use began in 2011 requiring providers to meet Stage 1 objectives. In subsequent years, additional stages of Meaningful Use were implemented, again, paving the path to improved quality outcomes.
In April 2016, CMS introduced additional proposal to expand on the goal for improving quality outcomes using CEHRT, while also focusing on payment reform. In the proposed rule, meaningful use is renamed, Advancing Care Information, and is one of four components that eligible providers would need to submit to meet the expanding requirements.
This concludes Lecture a of Concepts of Health Care Workflow and Process Analysis.
In this lecture, we:
Defined key terms, including Process, Process Analysis, Process Redesign, Workflow, Workflow Analysis, and Data & Information Flow.
Described the practice workflow and information management redesign specialist role and skills. In addition, we worked an example where we described a patient visit in terms of clinic processes.
Discussed the patient safety and health care quality reasons why Health IT is a national priority and the Centers for Medicare & Medicaid.
Discussed the CMS program to incentivize nation-wide adoption and meaningful use of health IT.