Instructions
Review the Beacon Policy Brief. Also reread pgs. 149-150 and pg. 156 in your text that discuss before and after studies, benchmarking studies, and baseline data collection. Comparing all resources discuss your thoughts on building a foundation of electronic data to measure and drive improvement. Pay particular attention to the four challenges in the Beacon Policy Brief (pgs. 9-15), specifically Challenge 1: Improving data validity, and Challenge 4: Establishing a framework for community-wide measurement. Do you agree with these Challenges (#1, and #4) solutions? Engage your critical thinking would you have added or changed anything? Your paper should be a minimum of 1-2 pages.
Term Project Milestone 2
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Instructions
3rd Template Narrative due this week. Continue to work on the six Workflow redesign templates. After you have completed the third template share your thoughts on what you learned. Were there things that surprised you in the workflow? Should it have included more steps? Would this workflow have obstacles if deployed in diverse settings? Submit a paragraph discussing what your thoughts were as you completed the e-Prescribing Template. The paragraph should be a minimum of 250 words.
W3: Workflow Process Tools with 2 student reply 250 word each
This week we learned about tools that can be used to improve workflow processes. Compare the following listed tools, making sure to compare/contrast in your discussion the benefits and liabilities of each: (1) Swim-lane, (2) Systems flowchart, (3) Mind mapping, (4) Use Case. ( DUE WEDNESDAY)
Discussion Guidelines
Introduction to Workflow and Process Management in Health Care ?page 9
workforce, while lamenting that with only 40 percent of Americans obtaining a college degree, an
imminent shortage of knowledge workers in the United States is looming. Lesser (2011), however,
suggests that the knowledge worker who is skilled at gathering and synthesizing knowledge into
coherent and useful observations will become increasingly obsolete in the years ahead because
knowledge is becoming increasingly ubiquitous. In fact, today, the concept of knowledge
management has less to do with managing knowledge workers and more to do with compiling
knowledge and making it readily available. In health care, Alvai et al. (2010) define knowledge
management as the use of IT to enhance and facilitate evidence-based clinical decision making
suggesting, it is believed, that ? ? Knowledge management is the compilation of knowledge, which
can be performed by machine ? ? Knowledge workers apply knowledge, which still requires heuristic
thought and professional judgment by a human Lesser sees the knowledge worker being replaced
by the insight worker, who he describes as a person who is able to translate observations into
insights that can deliver impact. Perhaps it is not the terminology applied to these workers that is
important, but that they can effectively apply knowledge (whether internalized or through using
knowledge resources) in complex situations, often under extreme time pressures, and with a high
degree of uncertainty which is how Stead and Lin (2009) have characterized the current state of
health care. EHR vendors in their hold-harmless contract clauses often use the term professional
judgmen t in describing that EHR technology does not make clinical decisions and is not a substitute
for competent, properly trained, and knowledgeable staff to analyze the information presented by the
software. There is currently much debate about just how much trust can and should be put into
HIT and if one cannot trust the technology, why buy it? Alternatively, EHR or other HIT that is
viewed as a medical device would come under the Food and Drug Administration (FDA) regulatory
powers, a move they are strongly considering and one that has many concerned about the impact
that would have on product sales and innovation. Still, it must be acknowledged that understanding
knowledge workers within the context of workflow and process management for HIT is important
because knowledge is generally considered the product of data being processed into information
with human experience applied to that as illustrated in Figure 1.5. Some extend this continuum to
add wisdom the evaluation of whether the knowledge is of value (Ackoff 1989). Weinberger (2010)
even questions the oversimplification of the continuum in favor of a more complex knowledgegeneration process that is social, goal driven, contextual, and culturally bound. Appreciating what
knowledge workers do and how that impacts their use of IT has a direct impact on managing
workflows and processes in such an
Amatayakul, Margret. Process Improvement with Electronic Health Records : A Stepwise Approach
to Workflow and Process Management, Productivity Press, 2012. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/apus/detail.action?docID=5945148.
page 10 ? Process Improvement with Electronic Health Records Data Production Information
Knowledge Re?nement Action Social Context Use Figure 1.5 Data information knowledge
generation. (From Copyright © MargretA Consulting, LLC. With permission.) environment. A key
difference lies in the fact that in generating and applying knowledge, there are few visual clues
present that make the workflows and processes apparent. In a manual worker environment, every
step in a process and the sequence of those steps can be seen. Where the paper chart on a door in
a clinic was an indicator that the room contained a patient, the paper chart no longer exists. Printed
and color-coded forms served similar purposes. The challenge now is to understand the world where
knowledge workers or insight workers look into the black box that is the vast resources of the
computer and process that knowledge in their own black box that is the equally mysterious brain.
Consider the following Case Study 1.2. Case Study 1.2: Diagnosis Drug Selection A physician
(endocrinologist) who had used an EHR for several months was desirous of using it better. He was
not sure what that meant, but he was convinced that he was not using it to its full potential. As a
result, he sought a consultant skilled in workflow and process management to observe him as he
performed his work with his patients. The first patient visit observed was an immediate challenge.
The patient had come for one of her regular three-month diabetes check-ups, but also complained of
having a urinary tract infection that was getting worse, despite that her primary care physician had
given her a prescription a few days prior. As the primary care physician was now on vacation, she
asked her endocrinologist for help. The endocrinologist was highly sympathetic, and stated he would
give her a different prescription. He called up the womans universal medication list on his EHR and
identified with her which drug she was taking for the infection.
Amatayakul, Margret. Process Improvement with Electronic Health Records : A Stepwise Approach
to Workflow and Process Management, Productivity Press, 2012. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/apus/detail.action?docID=5945148.
Introduction to Workflow and Process Management in Health Care ?page 11
The consultant could not see what the endocrinologist was thinking next, but could see him move
his mouse to a link to the Internet from his EHR, then pull away from the link. He next picked up a
paperback Physician Desk Reference and flipped through it not stopping on any given page.
Finally, he opened his e-prescribing screen and selected a drug. The screen showed a green light
that the drug was on formulary for the patients pharmacy benefits, and no alert appeared that the
drug was contraindicated. The endocrinologist asked the patient if she still wanted to go to the retail
pharmacy identified in the system, and upon her positive response struck a key invoking the
prescription transaction to be sent to the designated pharmacy. He told the patient to be sure to see
her primary care physician if the new drug did not solve the problem or seek emergency care in the
event of any significant reaction. After the patient left and the endocrinologist and consultant
debriefed, the endocrinologist acknowledged that, not being a urologist and so not knowing other
choices of suitable drugs for this patient, he was frustrated by the fact that he could not use the EHR
to perform a search for a better choice of drug given her diagnosis and symptoms. He stated that he
considered calling a colleague, but decided he had neither the time nor the inclination to expose his
lack of knowledge in front of his patient, so he simply entered a drug he knew from his medical
school days that was in the same class of drugs as the one she was taking and hoped that the
system would alert him to any serious issues. While fortunately in follow-up with the endocrinologist
the patient did get better on his choice of drug, it was observed that at that time there was no EHR
that had the type of clinical decision support he was seeking. His only other alternative was to review
a list of drugs by class in his Physician Desk Reference or automated drug knowledge base, reading
about each drug in turn to make a potentially more informed decision. While in Case Study 1.2 the
potential for redesigning the process was not positive, it illustrates both the difficulty in seeing the
process and the need for a better product that would make knowledge easier to extract and use. (As
an aside, studies have repeatedly shown that clinicians have significant informational needs that are
not met in their practices, with estimates that one clinical question arises per patient visit, and as
many as 70 percent of these questions go unanswered (Ketchell et al. 2005; Ely et al. 2007).)
Challenges and Needs for Workflow and Process Management for Knowledge Workers
Understanding knowledge workers and the knowledge-management challenges they face is
important not only to appreciate how difficult it is to understand and redesign their workflows and
processes because they cannot be seen, but also to
Amatayakul, Margret. Process Improvement with Electronic Health Records : A Stepwise Approach
to Workflow and Process Management, Productivity Press, 2012. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/apus/detail.action?docID=5945148.
Page 12 ? Process Improvement with Electronic Health Records
appreciate what workflow and process challenges they face and how the characteristics of
knowledge workers may impact their ability to adopt new workflows and processes even when they
are right for them. Clearly, from the two case studies described already, workflows and processes
performed by clinicians as they acquire data, process it into information, and apply their experience
to generate and apply knowledge are largely performed mentally. It should also be clear that little
things mean a lot. Consider the following Case Study 1.3 summarized from The Health Care Blog
(Pullen 2010). Case Study 1.3: Sequencing of Data in an EHR Ed Pullen, MD, observes on The
Health Care Blog that EHRs have a bad reputation among many physicians for generating progress
notes that are so verbose and filled with standard phrases that they are nearly useless to other
physicians, and even to the physician who produced the note in the first place. He observes that
EHRs are very good, and possibly too good, at creating documentation to assure payment and
reportedly good at standing up to legal scrutiny because they are generally more complete and
follow standards of practice. However, he notes that EHRs have been engineered to intentionally
create a SOAP note familiar to physicians from years of use of paper charts. As a result, S
ubjective and O bjective information are described first, then A ssessment and P lan. However, most
consultants or physicians who want to refresh their memory of the patient generally want a quick
understanding of the patients condition and treatment, not the details of how the diagnosis and
treatment plan was determined. Dr. Pullen suggests that having to scroll down to see the end of
notes, which tend to be longer in the EHR, is time-consuming and may be missed if a reader is
unwilling or forgets to scroll down. He suggests that the EHR be designed to obviously capture the
information in the existing sequence, but to display it in reverse order, as APSO. He concludes his
post with, We need to modify our work processes to make our technology work for us, not try to use
the technology to electronically reproduce previous workflows. Responses to the post described in
the above Case Study 1.3 were positive, with one commenter reporting on an anonymous survey of
pediatricians who acknowledged making at least one diagnostic error a month, and just under half
stating that at least once a year an error was made that harmed patients. When asked to identify the
reasons for the diagnostic process errors, about half cited a lack of information in the patients
medical history or failure to review the medical chart. While obviously both can be attributed to
human error, the workflows and processes associated with EHR should make documenting in and
reviewing of the chart easier. The Institute of Medicine in its first patient record study report (Dick
and Steen 1991) described the notion that EHRs encompass a broader view of the record than
today, moving from the notion of a location for keeping track
Amatayakul, Margret. Process Improvement with Electronic Health Records : A Stepwise Approach
to Workflow and Process Management, Productivity Press, 2012. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/apus/detail.action?docID=5945148.
Introduction to Workflow and Process Management in Health Care ?page 13
of patient care events to a resource with much enhanced utility. It is such enhanced utility that must
be designed into products and adopted into workflows and processes. Unfortunately, part of the
issue with adoption of EHRs is that clinicians are only now just beginning to understand the potential
for what enhanced utility can be afforded by an EHR. Knowledge workers often display certain traits,
or characteristics, that may preclude them from taking advantage of such enhanced utility.
Knowledge workers ? ? Are able to work on many projects at the same time ? ? Learn in a creative,
inquiry-driven, and self-controlled manner ? ? Are able to multiply the results of their efforts through
soft factors such as emotional intelligence and trust Need to be empowered to make the most of
their deepest skills Make decisions autonomously, where traditional command-and-control
paradigms are not effective for them to contribute to achievement of organizational interests ? ? ? ?
Students of physicians, and many physicians themselves, agree with many, if not all, of these
characteristics. Physicians routinely go from the diabetic patient with a urinary tract infection if only
to another diabetic patient but this one with cancer. They have mastered much knowledge, but do so
on their own terms. Never put them in a classroom with other physicians to learn how to use the
EHR, as each will feel that he or she is the only one who does not know how to use a computer, will
be extremely embarrassed, and essentially shut down their learning process until they can apply
their intuition to learn on their own. It is often said that other than their knowledge, physicians only
assets in caring for patients are time and trust; take either of those away and they will perform well
below their potential. Both CDOs and patients have put physicians on a pedestal because of their
skills; yet because physicians fear failure (and the threat of a malpractice lawsuit) perhaps more than
anything else, they often appear to be ultra-conservative, plodding, and resistant to change. Atler
(2005) as well as Matson and Prusak (2010) describe the need to better manage knowledge workers
(in all industries) because they are the key source of growth and opportunity. Atler notes, however,
that because they dont like to be told what to do, they enjoy more autonomy than other workers,
[and] much of their work is invisible and hard to measure, they are left alone without the process
improvement that other workers benefit from. This reinforces the notion that knowledge management
is not managing knowledge workers, but supplying knowledge that knowledge workers can tap into
to better perform their work but that they often get no help to use and that they resist when such
help is made available to them. The result then is very much about the law of supply and demand . If
clinicians do not demand such functionality and usability, there is no incentive for
Amatayakul, Margret. Process Improvement with Electronic Health Records : A Stepwise Approach
to Workflow and Process Management, Productivity Press, 2012. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/apus/detail.action?docID=5945148.
page 14 ? Process Improvement with Electronic Health Records
vendors to supply it. Interestingly, while a corollary may seem to be if clinicians do not know what to
demand, there will surely be no supply, this is not quite the case. In many cases, as clinicians start
to adopt EHR, they envision much greater functional capabilities than the system can supply
sometimes leading to product improvement; but unfortunately more often, it seems, disappointment
and what are considered failed implementations with no feedback to vendors. This discussion may
suggest that physicians are the only knowledge workers in health care, and that is certainly not true.
However, it does seem that others who could and should be characterized as knowledge workers in
health care often operate in the shadows of physicians and thus do not display and sometimes do
not operate as knowledge workers. Conrad and Sherrod (2011) urge nurse managers to develop
knowledge worker skills related to data gathering, analysis, and identifying clinical trends and
patterns
As unit leaders, nurse managers need to equip themselves with skills to harness the
power of electronic data systems and rapidly translate patient findings and information into
knowledge that informs and produces quality patient-care outcomes. More advanced forms of BPM,
and ideally workflow and process management for HIT, incorporate human interaction management
so that many people and systems interact in structured, ad-hoc, and sometimes completely dynamic
ways to complete one to many transactions (Vom Brocke and Rosemann 2010). In describing
Ochsner Health Systems EHR implementation, Belmont (Guerra 2011) observes that they adopted
the mantra that integration will trump preferences. He observes that while this did not mean the
vendors way was the only way, it did mean that when someone said, I want to do it my way, this
was a signal to sit down and say, Can you live with the integrated version of this? Key Points ? ?
The economic and clinical health of America depends on health reform, aided by health information
technology . The U.S. healthcare system is in need of a clinical transformation that focuses on using
electronic health records in the right way . ? ? To optimize use of hardware and software that may
aid in creating an effective and efficient healthcare system, management of workflow and process
performed by people who are knowledge workers and within the context of an integrated policy
structure is vital. ? ? Knowledge management and business process management alone are
insufficient to meet emerging knowledge worker needs. Integration is needed at every level, from
system interoperability to sharing health information across the continuum of care and engaging all
stakeholders in the value proposition.
Amatayakul, Margret. Process Improvement with Electronic Health Records : A Stepwise Approach
to Workflow and Process Management, Productivity Press, 2012. ProQuest Ebook Central,
http://ebookcentral.proquest.com/lib/apus/detail.action?docID=5945148.
Introduction to Workflow and Process Management in Health Care ? page 15
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http://www.mckinseyquarterly.com/ Boosting_the_productivity_of_knowledge_workers_2671
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