OK, my healthcare process improvement folks, I gave you a hard time a few weeks ago about always feeling you are different and I heard your responses. Now, let’s get down to business.
Healthcare Rosetta Stone
I want to build a common process framework for healthcare, but, I need guidance from both the healthcare folks out there, as well as my BPM and process framework geeks. We need to come up with a usable framework that will allow any healthcare organization, staff person, or systems to talk to each other in a meaningful way, much the way the Rosetta Stone allowed translation between multiple languages for the first time. The issue in developing this process framework is complex, but not unlike what we’ve seen in other industries (Healthcare, you are that different). The shared benefit of doing this is enormous.
Translating
The goal is to build out a process category called something like “Deliver Patient Services,” and ultimately develop meaningful, common process groups, processes, and activities within that category. Easy enough, we are a process shop and can spit out a framework with our eyes closed. In order to make this a meaningful framework, though, it has to allow any healthcare organization a guide to assembling their individual value stream and translate that to any other organization, individual, or system.
For example, one organization might assemble their process groups, processes, and activities based on disease, such as oncology, pediatrics, or cardiology. Yet another may assemble these based on access points, such as emergency department, clinics, or day surgery. And, yet another may categorize these based on the type (or age group) of the patient, such as newborns, adolescents, or adult care.
90/10 rule
I’ve also heard and read of organization using protocols to track and measure the outcomes of patient services. Many healthcare organizations report that nearly 90% of the actual services delivered (activities) fall under a small proportion (i.e., 10%) of the protocols they manage. That sounds like an area ripe for a framework. If you can identify that amount of the work under that focused of a set of categories, then you are getting close to a common language.
My internal framework guru tells me the key, right now, is to just get started. So, that is what we are doing. We’ll start with asking as many healthcare professionals what they actually do. The activities are the key. We’ll categorize those into processes, groups, and categories using the groupings that naturally evolve. The result won’t be the ideal process framework for any single healthcare organization, but it will be a starting point for every healthcare organization out there.
That is my Mission and I can’t wait to see what we come up with. Stay tuned and tell me what you think through your comments and emails.
Solve for Interesting
Seth Godin Blog
Jeremiah Owyang
IT Redux
HBR Blog
Clay Shirky Blog
SocialMedia Today
Chris Dixon
Brian Solis
Radar O'Reilly
Chris Brogan
The TIBCO Blog
Venture Beat
Engadget
Wired
Lifehacker
Mashable
The Verge
ARS Technica
GigaOM
All Things D
TechCrunch
Successful Workplace 
Might be useful…
From the IHE Wiki:
“Cross Enterprise Document Workflow (XDW) coordinates human and applications mediated workflows across multiple organizations.
Summary
The Cross-Enterprise Document Workflow (XDW) profile enables participants in a multi-organizational environment to manage and track the tasks related to patient-centric workflows as the systems hosting workflow management applications coordinate their activities for the health professionals and patients they support.
XDW builds upon the sharing of health documents provided by other IHE profiles such as XDS, adding the means to associate documents conveying clinical facts to a patient-specific workflow. XDW provides a common interoperability infrastructure upon which a wide range of specific workflow definitions may be supported. It is designed to support the complexity of health services delivery with flexibility to adapt as workflows evolve.
Benefits
XDW provides a common, workflow-independent interoperability infrastructure that:
provides a platform upon which a wide range of specific workflows can be defined with minimal specification and application implementation efforts on the workflow definition (e.g., Medical Referrals Workflow, Prescriptions Workflow, Home Care Workflow);
benefits many clinical and non-clinical domains by avoiding different competing approaches to workflow management;
increases the consistency of workflow interoperability, and enables the development of interoperable workflow management applications where workflow-specific customization is minimized;
facilitates the integration of multi-organizational workflows with the variety of existing workflow management systems used within the participating organizations;
offers the necessary flexibility to support a large variety of different healthcare workflows by not being overly constrained.”
http://ehr.bz/x9
Dr. Webster,
Thanks for the information on XDW. It looks to be a great reference on how organizations can structure the sharing of information on patients and their care. I hope to be able to dig deeper into the actual activities that would be contained underneath a system like this.
For example, the graphic that is used on the wiki refers to a lab report. I want to develop a list of all the other activities beyond laboratory activities, such as surgical or clinical visits.
Do you know of any inventories of these activities might reside? I didn’t see anything on the IHE wiki that might help.
You’re right. XDW is a workflow framework and you are concerned with workflow content. Content is interpreted within a framework (explicit or not) so sorting through existing healthcare workflow frameworks seemed relevant.
Aside from ephemera, such as process maps on butcher paper and white boards, I personally don’t know of any such inventories. If you flush any out of hiding with your post I’ll be delighted. I suspect the most accurate (evidence-based, as they put it in medicine these days) inventories currently reside, or will be generated from, two sources: data models of existing EHRs and health information systems and process mining of EHR and health information system event logs. The former is problematic due to the proprietary nature of such data models (they are often guarded like intellectual crown jewels) but I am hopeful about the later.
If you are interested, I gave an introductory presentation on EHR process mining at the recent Healthcare Systems Process Improvement conference in Las Vegas. I address the ambulatory domain, but these techniques also work for hospital EHRs and related information systems.
Video: http://ehr.bz/xd
Paper: http://ehr.bz/xc
What we are speaking of is essentially a healthcare workflow ontology. There is some medical informatics research in this area, but no agreed upon standard of which I am aware. Again, I will be delighted to be proved wrong.
Rather than generate healthcare workflow ontologies top-down, I’d rather see them arise bottom-up from actual “cow paths” that EHR and health IT users tread. Process mining will be invaluable in this regard, as it can, and has, been applied to understanding cross-organizational workflow.
For more on the cow path metaphor:
http://ehr.bz/ln
By the way, I am beyond delighted to see #Healthcare and #BPM (to use their Twitter hashtags) begin to seriously interact in social media venues such as blogs and Twitter.
Chuck
http://twitter.com/EHRworkflow
Chuck,
I can’t thank you enough for this information. We are on the same page with how this process framework should grow. It should start with the activities, then allow natural (and logical) categorizations to develop.
I really like the concept you put forth of starting to mine health information system event logs. If the tactical events are being captured, starting to aggregate those would be a great wealth of information and guidance.
I’ll keep you updated on our progress as we try to continue to push #bpm and #healthcare closer and closer together.
In case you aren’t familiar with our process classification frameworks, take a look at them on our website. We have a cross-industry version, as well as some industry-specific versions. I’m looking to add a meaningful healthcare version to that list, soon.
http://www.apqc.org/process-classification-framework
Ron
Ron,
I am glad to see APQC tackling a process classification framework for healthcare. I have referred many times in the past to your other frameworks which have been very helpful.
Here are a couple of suggestions. In my opinion, any healthcare framework, to be truly effective, must include Home Care. Providing healthcare in the patient’s home is increasingly important and must be integrated into the “big picture”.
You also may be interested in the article “Applying BPM for Improved Patient Care” http://www.processexcellencenetwork.com/business-process-management-bpm/articles. The call here is to “marry people, process, and technology”, also key to recognize in a successful framework.
Good luck with this effort. I believe the time is ripe and will be following with great interest.
Great point, Maryann. I talked about this in a recent blog entitled “Go home, Healthcare”. From being proactive to keeping customers away from facilities where falls and infections can occur, home monitoring and telehealth are beng pursued by most major hospital chains. Next week, I meet with a major DME (Durable Medical Equipment) service that is looking to be ‘clinically relevant’ by adding these capabilities to its services. Any framework lacking this component will be missing a very important part of the future of healthcare.
Chris,
I had read “Go home, Healthcare”. It is a great article – well done.
I was a founding member of an employee resource group concerned with helping employees and their families meet the challenges of disability and serious illness. We quickly learned that each of us is in some way touched by these things, or is but one or two degrees separated from someone who is.
That said, those of us working to improve the quality facet of healthcare must always remember the human side of the equation. The phrase “home healthcare” sounds very clinical. What we are talking about is a parent caring for their child, a spouse tending to the needs of the love of their life, a child trying to help their parents navigate their final journey, a friend reaching out to a friend in need.
If we keep these good people in mind and try to make things easier for them, we will be successful in achieving quality in healthcare.
Good comments, Mary Ann. Thanks.
Maryann,
Thanks for your reply and great point on the home care component. We’ll make sure we have that included in this framwork, for sure. Care delivered in the home and the roll the patient plays in their care are key themes that emerging from the recent feedback.
We will keep you updated as we progress.
Thanks.
As it hasn’t been mentioned yet, there are a number of generic or semi-generic normative process models that might be adapted to the healthcare space. One that I toyed with translating to health delivery 4-5 years ago was VCOR (Value-Chain Operations Reference). The VCOR folks seemed mildly interested but the local hospital CIO’s I felt needed to be enlisted weren’t that supportive. Anyhow, rather than building a process framework from scratch, it might be worth a look-see to see if this could be a specialization of, say, VCOR. Another “oldie but goodie” dating back to the 70’s is BIAIT (and its derivatives).
As you likely know (given your employer), the SCOR model was translated into normative process models by TIBCO and made available to its users as process templates they could, in turn, specialize to their particular needs. Ontology is mentioned in the preceding comments. That, I think has been one of the major contributions of SCOR, along with standardized definitions of measurement that are now built in to ERP systems such as SAP. This, in turn, allows for the wide-spread collection and dissmenination of comparative performance data, sliced and diced by sector, region, etc.
Richard,
Thanks for your reply. We are very familiar with VCOR and SCOR in the supply chain/value chain space. We’ve mapped our process classification framework to both of these models, and we’d continue to do that for any new frameworks we develop. I am not as familiar with BIAIT, so I’ll look into that.
Also, in support of our Mission, APQC will figure out how to broadly disseminate the framework once it is created. That is why we are here!
Ron
As I Chief Medical Information Officer I have been central to what we call “workflow design” for close to 20 years, but after being industry standard BPM design over the last year or so I realize just how primitive medicine is in BPM maturity. In fairness, there are several reasons for this.
Medicine has always contained a larger proportion of analog to digital data compared with most other businesses. Also it is an industry aligned more as an individualized, apprenticeship model then a standardized, structured organization. These are explanations, not excuses and the paradigm needs to change. Having said that, this lack of standardization and evidence combined with the complexity creates a monumental challenge. Inpatient (Acute) care; Ambulatory care; Home care (professional or family); the Pharmaceutical industry; and the myriad of payment models and regulatory issues each add geometric complexity. Even the idea of a concept of “Deliver Patient Services” is inadequate when you include the patient’s own involvement in their health, which realistically is where 99.9% of the activities which could impact one’s health exist.
I agree with comment about a bottom up approach to healthcare redesign. The change management book “Switch” talks about finding “bright spots” in the organization and building on them. In the big picture, there is little truly EBM (Evidence based Medicine) in existence and with the cost of doing research combined with the barriers that privacy regulations impart, I see the gold standard of “randomized prospective trials” becoming extinct. Fortunately the evolution of Electronic Health Records in enabling the creation of structured health data with allow the statistical power of a huge sample size (“n”) to overcome the limitations of a retrospective study.
This is a journey without end, but each step provides the promise of improving the delivery of healthcare to the eventual improvement of “health,” now if we could just define it…but that is a rant for another time!
Dr. Landa,
I very much appreciate the information you shared with this response. Standardization definitely plays a role in the success of many industries, and I think there is a balance to find in healthcare that doesn’t boradly exist now. A standard framework can support this greatly.
The digital data you mention definitely gives quality measures to processes like never before, but if there’s nowhere to ‘hang’ that data in a common way, its interpretations is a big question mark. Also, data around specific processes without knowing the structure of end-to-end process is less useful. We can optimize a particular ‘thing’ by improving the numbers, but that may just move the logjam down the river a little bit.
Ron
I’m starting to see the framework in my head, and it looks like this:
1. Manage the healthcare enterprise (vision, strategy, direction)
2. Manage wellness and prevention (education, wellness checks, etc.)
3. Manage ambulatory care
4. Manage in-patient care (from emergency to corrective surgery)
5. Monitor healthcare (from blood sugar level to cardiac rhythm management)
6-12. Supporting activities (HR, Finance, IT, Facilities, etc.)
Thoughts?
Chris,
Those make logical sense to me as a first pass at high-level process categories, but I’d love to hear from some of the healthcare practitioners on this one.
This looks like a path towards categorizing activities (what practitioners actually do) that is agnostic on how they structure their organization (by disease/disorder, by population, etc.). There is some light organizational structure inferred, though (e.g., in-patient, ambulatory, etc.).
I’ve reread the postings on this blog – it’s often good to “go back to the beginning”. It is an excellent discussion. As you can see from my posts, I tend to focus on people; in this case, the people who are the receivers of healthcare, or those navigating the waters of healthcare on behalf of a loved one. My own healthcare network is currently rolling out a “new, state-of-the-art patient portal” as part of their new “state-of-the art integrated electronic health record system.” Oh goody! I get to experience the process from the patient’s viewpoint. (BTW, this experience includes 3 weeks with no patient portal at all!)
Anyway, now I’m thinking about this healthcare PCF from that perspective and asking whether the processes that we will ask the patients to perform are adequately represented therein. I see the term “customer” as a reference to the Healthcare Enterprise (thank you, Dr. Webster for the link to the IHE Wiki). How then do we reference the patient? Are they the “consumer”? The “end-user”? Who are they in all of this?
And how do we address their needs? What are the processes for educating them on the use the new interface, explaining the importance of their participation – talk about “change management”! How do we provide the answer to their inevitable question “What’s in it for me?” After all, isn’t this ultimately about them and their health?
Or is it?
Maryanne,
Great points, for sure. Thanks for the re-read.
A patient-centered approach is a must. I think if you read some of Chris Taylor’s other posts on this blog, you’ll see his references to Social BPM. In today’s social world, healthcare organizations will no longer be able to ignore the patient. Especially with Government payments being held back and paid only if an organization offers a solid patient experience. You would hope the organization will have an understanding of what their patients value from them, and include that in their BPM efforts. The patient will have many more ways of telling them in the future, and the great organizations will listen (and many already are listening.
I can tell you this is another way healthcare can learn from other industries. Their are numerous examples where consumer-based organizations are VERY customer-focused and adjust their processes regularly based on customer input.
I can tell you that while we develop the healthcare process classification framework, we will work at keeping patient front and center. And we’d love to have you included in the process to keep us honest.
-Ron
Thank you Mary Ann, for your “Thank you”!
Business process management ideas and software can accommodate both patient-centric and physician-centric emphases. The patient role is a “role”, just as the physician’s role is too. According to the Workflow Management Coalition’s “The Workflow Reference Model” a role is “a collection of participants based on a set of attributes, qualifications and/or skills.”
http://www.wfmc.org/standards/docs/TC-1011_term_glossary_v3.pdf
So, what are a patient’s (or customer’s or client’s or whatever is consistent with political, marketing, or ideological orientation) attributes, qualifications or skills? When a process-aware health information system is designed, encompassing patient activities, the patient’s role needs to be defined as part of that design. More abstractly, the patient is a resource, just as other users are resources, necessary to accomplish a business process (or clinical process, health process, or just “process”, again terminology varies according to agenda).
Just as physicians, nurses, technicians, transcriptionists, billers, and other staff have worklists in which workitems appear (placed there by a workflow engine executing a process definition, or placed there in an ad-hoc fashion by a human user), patients could and should have worklists of workitems too (perhaps appearing in smartphones). Of course, patients (and physicians and nurses and others too) may ignore these items, in which case these items can be programmed to automatically escalate. Some of these items also may be accomplished automatically or semi-automatically via home or mobile devices on, connected to, near, or ambiently present near, the patient.
Current structured-document, as opposed to structured-workflow, EHRs don’t have the necessary process-centered data models necessary to represent patient and provider roles and to automatically, semi-automatically, or manually (but with real-time activity monitoring and visibility plus subsequent opportunity for design-time improvement) execute, or “enact”, healthcare processes. This is a large part of the reason that I believe that health IT needs to move from debate about patient-centered versus physician-centered design (“Who is the real user?”) to a more encompassing view (including explicit and executable representations) of the processes within which users (including patients) are embedded.
Lisp (Allegro STORE) and XSLT + HealthShare HIE is a very viable platform on which to do “database publishing” of experience- & evidence-based patient education, instruction and self care advice.
Lisp (Allegro STORE) and XSLT + HealthShare HIE is a very viable platform for doing “Clinical Prevention” where “Clinical Prevention” can be defined as evidence-based attention to significant factors involving the onset, progression, recovery and complication of (from) Disease. This would ideally be directly interfaced with the acute and chronic care needs correlated with the patient and family’s goals of care.