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Characterizing Surgical Clinic &
Patient Communication Workflows to
Guide mHealth Implementation
Ross Lordon
PhD Student || Biomedical Health Informatics || School of Medicine || University of Washington
Outline
2
Start
Define
workflow
Importance
of workflow
analysis
Workflow
analysis tools
and methods
End
Workflow definition
Agency for Healthcare Research and Quality (AHRQ)
The flow of work through space and time, where work is
comprised of three components:
inputs are transformed into outputs
3
Ref: 1
Is workflow a just a series of sequential
steps in a process?
4
Ref: 1
No
5
Ref: 1
Components of workflow
Work Activities
Technologies People
Environments Organizations
6
Ref: 1
Outline
7
Start
Define
workflow
Importance
of workflow
analysis
Workflow
analysis tools
and methods
End
Why workflow analysis is important
Health information technology has the potential to
fundamentally change how clinical and administrative
workflows are performed
8
Ref: 2
Why workflow analysis is important
CPOE implementation at two children’s hospitals in early 2000’s
Hospital Pre-
Implementation
Mortality
Post-
Implementation
Mortality Change
Children’s Hospital
of Pittsburgh 2.8%
(13 months pre) 6.6%
(5 months post) + 3.8%
(significant)
9
Ref: 3
Children’s Hospital of Pittsburgh
10
Start
Hospital
contacted Supplies and
tests ordered
Patient
arrives and
receives care
End
Ref: 3
Children’s Hospital of Pittsburgh
11
Start
Patient arrives
at hospital
Supplies and
tests ordered
Patient
receives care
End
Registered
into EHR
Pharmacy fills
order
Ref: 3
Seattle Children’s Hospital
12
Hospital Pre-
Implementation
Mortality Post-Implementation
Mortality Change
Children’s Hospital of
Pittsburgh 2.8%
(13 months pre) 6.6%
(5 months post) + 3.8%
(significant)
Seattle Children’s
Hospital 9.6%
(13 months pre) 6.3%
(13 months post) - 3.3 %
(non
-
significant)
Refs: 3, 4
Seattle Children’s Hospital
• Visited Children’s Hospital of Pittsburgh
•Incorporated lessons learned
•Enlisted clinical leaders and super users
•Created common order sets
•Reinforced need for communication
•Tested and validated system prior to go live 13
Ref: 4
Outline
14
Start
Define
workflow
Importance
of workflow
analysis
Workflow
analysis tools
and methods
End
How do you evaluate workflows?
15
Example of workflow evaluation with mPOWEr
•Bridge the gap for SSI indication
communication
•500,000 cases annually
•Most SSIs occur between
discharge and follow up
appointment
•Gives context to remote clinical
care decision making
•Pilot implementation at UWMC 16
Refs: 5, 6, 7, 8
Common workflow evaluation tools and methods
•Usability testing
•Benchmarking
•Interviews
•Observations
•Flowcharting
•Checklists
17
Ref: 9
Usability testing
•How user friendly is the
intervention?
•User-based testing
•Expert heuristic evaluation
•Focus groups
•Post-use surveys
18
Refs: 10, 11
Benchmarking
The process of using metrics to determine how implementing HIT interventions
can have a positive or negative effect on workflows
Proximal
measures
Directly
measure how workflows have changed
Distal measures
Indicate workflows have changed
Outcome
measures
Imply work processes
changed but not how
19
Refs: 12, 13
Proximal measure examples
Metric Example
Efficiency
De
-duplication of work
Processing time
Duration
of phone consultations
Communication
Number of phone calls nurse receives daily
Added tasks/modified tasks
Data entry steps
increased or decreased
Information flow
How patient calls are
triaged
Usability of HIT Intervention
Perceived ease of use by staff
20
Refs: 12, 13
Distal measure examples
Metric Example
Patient health
process rates
CDS system recommends one test more
than another
Disease screening
rates
Adherence to guidelines or procedures
Patients asked to seek
emergency care
Patients advised their concerns are normal
21
Refs: 12, 13
Outcome measure examples
Type of measure Example
Patient
health outcomes
Disease
or illness rates
Patient condition improvement
Cost of care
Rate
of SSIs
Organizational
outcomes
Profitability
Quality measures
22
Refs: 12, 13
Interviews and observations
23
Ref: 14
Flowcharting (BPMN) overview
A formal notation used to visually depict stakeholders, work
processes, decision making, and information flows
24
Ref: 15
Flowcharting example
25
Patient
Care Team
Flowcharting example
26
Steps for effective flowcharting
27
Start
Map current
workflows
Generate
anticipated
workflows
Map post
implementation
workflows
End
Iterate for next
implementation
Mapping current workflows
28
Start
Observe and
interview Generate
draft flowchart Present to
stakeholders
End
Repeat until
accurate
Flowcharting example
29
Current workflow example
Nurse
30
Generating proposed workflows
31
Start
Envision how
intervention
will be used
Generate
draft flowchart Present to
stakeholders
End
Repeat until
accurate
Anticipated workflow example
Nurse
32
Mapping post implementation workflows
33
Start
Observe and
interview staff Generate
draft flowchart Present to
stakeholders
End
Iterate process
Post implementation workflow example
???
34
What happened?
35
Unanticipated complications
•Competing demands with patient portal enrollment
•Time constraints
•Staff turnover during go-live
•Lack of formal buy-in with clinic staff
•Clinical champion in different clinic
•Research team enrolled patients
36
Results from pilot implementation
•61 patients approached during 6 week pilot implementation
•29 opted to enroll in mPOWEr
•19 had surgery
•18 completed at least one tracking session
•6 used mPOWEr more than three times
•2 patients contacted the clinic with concerns mentioning mPOWEr data
•Average training time of 12.2 minutes per patient
37
Discussion and lessons learned
•Checklist created to formalize implementation process and timeline
•Formal agreements drafted for future implementations
•Engage with a clinical champion embedded within the clinic
•Created videos to make patient training more efficient
•Workflow changes are inevitable
•Expect the unexpected
38
Conclusion
•Understanding workflows is critical prior to implementing an HIT intervention
•Any HIT intervention has the potential to fundamentally change workflows
•Many tools are available to facilitate HIT implementations
•Start with a small pilot implementation prior to large go-live events
•Use lessons learned to iterate implementation process
•Have contingency plans for when (not if) the unexpected happens
39
Acknowledgements
This work was supported in part by the
National Institutes of Health, National
Library of Medicine (NLM) Biomedical and
Health Informatics Training Program at the
University of Washington (Grant Nr.
T15LM007442). The content is solely the
responsibility of the authors and does not
necessarily represent the official views of
the National Institutes of Health.
Questions
www.mpowercare.org || @mpowercare
Ross Lordon || PhD Student || Biomedical Health Informatics || rlordon@uw.edu || @mr_lordon
References
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42
References
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Archives of surgery 2012 (Chicago, Ill.: 1960) 147(11):1000–7.
9. AHRQ. "All Workflow Tools | AHRQ National Resource Center." Retrieved 1/12/16, from https://healthit.ahrq.gov/health-it-tools-and-
resources/workflow-assessment-health-it-toolkit/all-workflow-tools.
10. Jonathan Lazar, Jinjuan Heidi Feng, and Harry Hochheiser (2010) Chapter 10 (Usability Testing) from Research Methods in Human-Computer
Interaction. Wiley.
11. Preece, Jennifer; Rogers, Yvone; and Sharp, Helen. “Chapter 13: Asking users and experts.” Interaction Design: Beyond Human-Computer
Interaction. New York: J. Wiley & Sons, 2002.
12. Carayon, P. and B.-T. Karsh (2010). "Incorporating Health Information Technology Into Workflow Redesign ". Retrieved 1/30/16, from
https://healthit.ahrq.gov/sites/default/files/docs/citation/workflowsummaryreport.pdf.
13. AHRQ. "Benchmarking | AHRQ National Resource Center." Retrieved 1/15/16, from https://healthit.ahrq.gov/health-it-tools-and-
resources/workflow-assessment-health-it-toolkit/all-workflow-tools/benchmarking.
43
References
14. AHRQ. "Interview | AHRQ National Resource Center." Retrieved 1/16/15, from https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-
assessment-health-it-toolkit/all-workflow-tools/interview.
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https://www.ibm.com/developerworks/community/files/basic/anonymous/api/library/7624eb5a-089a-41bf-9b71-
b3c33739e18d/document/e908d328-7b50-40e3-8107-70af4e6bb48f/media.
44