Modelling workflow processes for clinical

information systems:Impact on decision support and healthcare outcomes

2 November 2011

Phil 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.

Components of workflow

(WfMC 1999)

Business process modelling 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 - task sequencing

Quaglini (2000)

Modelling clinical workflow - temporal constraints

Shahar 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 plans

Goal-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)

Modelling clinical workflow and pathways: multiple views

(Chu 1998)

Decision support systems: systematic reviews of evidence for effectiveness

• 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)

Healthcare outcomes

Computerized clinical guidelines: systematic reviews of evidence for 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/

Thank you!

Questions?

Contact:

Philip.Gooch.1@city.ac.uk