PresentationPDF Available

Characterizing Surgical Clinic & Patient Communication Workflows to Guide mHealth Implementation

Authors:

Abstract and Figures

This presentation gives a definition of workflow within a clinical setting, presents two case studies regarding the importance of workflow analysis, and provides an overview of workflow analysis tools and methods to facilitate HIT implementations. My research team’s surgical site infection mobile health app, mPOWEr, is used as an example to illustrate how these tools and methods were used during a pilot implementation of mPOWEr in the Center for Reconstructive Surgery at UW Medicine.
No caption available
… 
No caption available
… 
No caption available
… 
No caption available
… 
No caption available
… 
Content may be subject to copyright.
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
process rates
rates
emergency care
21
Refs: 12, 13
Outcome measure examples
Type of measure Example
health outcomes
or illness rates
of SSIs
outcomes
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
1. AHRQ. "What is workflow?". Retrieved 1/22/16, from https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhatIsWorkflow.ppt.
2. AHRQ. "Why Care About Workflow." Retrieved 1/22/15, from
https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/WhyCareAboutWorkflow.ppt.
3. Han, Y., et al. (2005). "Unexpected Increased Mortality After Implementation of a Commercially Sold Computerized Physician Order Entry
System." Pediatrics.
4. Del Beccaro, M., et al. (2006). "Computerized Provider Order Entry Implementation: No Association With Increased Mortality Rates in an
Intensive Care Unit." American Academy of Pediatrics. Retrieved 1/22/16, from
http://pediatrics.aappublications.org/content/pediatrics/118/1/290.full.pdf.
5. (2015). "mPOWEr - mobile Post-Operative Wound Evaluator." Retrieved 1/15/16, from http://mpowercare.org/.
6. (2015). "About mPOWEr - mPOWEr." Retrieved 1/15/16, from http://mpowercare.org/about/.
7. Jarvis, W. R. Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, cost, and prevention. Infection control
and hospital epidemiology: the official journal of the Society of Hospital Epidemiologists of America 17(8): 5527 (1996).
42
References
8. Kazaure , H. S., Roman, SA, . a & Sosa JA, J. a. Association of postdischarge complications with reoperation and mortality in general surgery.
Archives of surgery 2012 (Chicago, Ill.: 1960) 147(11):10007.
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.
15. White, S. "Introduction to BPMN." Retrieved 1/30/16, from
https://www.ibm.com/developerworks/community/files/basic/anonymous/api/library/7624eb5a-089a-41bf-9b71-
b3c33739e18d/document/e908d328-7b50-40e3-8107-70af4e6bb48f/media.
44
ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
In response to the landmark 1999 report by the Institute of Medicine and safety initiatives promoted by the Leapfrog Group, our institution implemented a commercially sold computerized physician order entry (CPOE) system in an effort to reduce medical errors and mortality. We sought to test the hypothesis that CPOE implementation results in reduced mortality among children who are transported for specialized care. Demographic, clinical, and mortality data were collected of all children who were admitted via interfacility transport to our regional, academic, tertiary-care level children's hospital during an 18-month period. A commercially sold CPOE program that operated within the framework of a general, medical-surgical clinical application platform was rapidly implemented hospital-wide over 6 days during this period. Retrospective analyses of pre-CPOE and post-CPOE implementation time periods (13 months before and 5 months after CPOE implementation) were subsequently performed. Among 1942 children who were referred and admitted for specialized care during the study period, 75 died, accounting for an overall mortality rate of 3.86%. Univariate analysis revealed that mortality rate significantly increased from 2.80% (39 of 1394) before CPOE implementation to 6.57% (36 of 548) after CPOE implementation. Multivariate analysis revealed that CPOE remained independently associated with increased odds of mortality (odds ratio: 3.28; 95% confidence interval: 1.94-5.55) after adjustment for other mortality covariables. We have observed an unexpected increase in mortality coincident with CPOE implementation. Although CPOE technology holds great promise as a tool to reduce human error during health care delivery, our unanticipated finding suggests that when implementing CPOE systems, institutions should continue to evaluate mortality effects, in addition to medication error rates, for children who are dependent on time-sensitive therapies.
Article
Full-text available
Our goal was to determine if there were any changes in risk-adjusted mortality after the implementation of a computerized provider order entry system in our PICU. Study was undertaken in a tertiary care PICU with 20 beds and 1100 annual admissions. Demographic, admission source, primary diagnosis, crude mortality, and Pediatric Risk of Mortality III risk-adjusted mortality were abstracted retrospectively on all admissions from the PICUEs database for the period October 1, 2002, to December 31, 2004. This time period reflects the 13 months before and 13 months after computerized provider order entry implementation. Pediatric Risk of Mortality III mortality risk adjustment was used to determine standardized mortality ratios. During the study period, 2533 patients were admitted to the PICU, of which 284 were transported from another facility. The 13-month preimplementation mortality rate was 4.22%, and the 13-month postimplementation mortality rate was 3.46%, representing a nonsignificant reduction in the risk of mortality in the postimplementation period. The standardized mortality ratio was 0.98 vs 0.77, respectively, and the mortality rate for the transported patients was 9.6% vs 6.29%. This yields a nonsignificant mortality risk reduction in the postimplementation period. The standardized mortality ratio was 1.10 preimplementation versus 0.70 postimplementation. Analysis of the 13-month preimplementation versus 5-month postimplementation periods showed a non-statistically significant trend in reduction of mortality for all PICU patients and for transported patients. Implementation of a computerized provider order entry system, even in the early months after implementation, was not associated with an increase in mortality. Our experience suggests that careful design, build, implementation, and support can mitigate the risk of implementing new technology even in an ICU setting.
Book
Research Methods in Human-Computer Interaction is a comprehensive guide to performing research and is essential reading for both quantitative and qualitative methods. Since the first edition was published in 2009, the book has been adopted for use at leading universities around the world, including Harvard University, Carnegie-Mellon University, the University of Washington, the University of Toronto, HiOA (Norway), KTH (Sweden), Tel Aviv University (Israel), and many others. Chapters cover a broad range of topics relevant to the collection and analysis of HCI data, going beyond experimental design and surveys, to cover ethnography, diaries, physiological measurements, case studies, crowdsourcing, and other essential elements in the well-informed HCI researcher's toolkit. Continual technological evolution has led to an explosion of new techniques and a need for this updated 2nd edition, to reflect the most recent research in the field and newer trends in research methodology. This Research Methods in HCI revision contains updates throughout, including more detail on statistical tests, coding qualitative data, and data collection via mobile devices and sensors. Other new material covers performing research with children, older adults, and people with cognitive impairments.
Article
Objectives To describe procedure-specific types, rates, and risk factors for postdischarge (PD) complications occurring within 30 days after 21 groups of inpatient general surgery procedures. Design Retrospective cohort study. Setting American College of Surgeons National Surgical Quality Improvement Program 2005 through 2010 Participant Use Data Files. Patients A total of 551 510 adult patients who underwent one of 21 groups of general surgery procedures in the inpatient setting. Main Outcome Measures Postdischarge complications, reoperation, and mortality. Results Of 551 510 patients (mean age, 54.6 years), 16.7% experienced a complication; 41.5% occurred PD. Of the PD complications, 75.0% occurred within 14 days PD. Proctectomy (14.5%), enteric fistula repair (12.6%), and pancreatic procedures (11.4%) had the highest PD complication rates. Breast, bariatric, and ventral hernia repair procedures had the highest proportions of complications that occurred PD (78.7%, 69.4%, and 62.0%, respectively). For all procedures, surgical site complications, infections, and thromboembolic events were the most common. Occurrence of an inpatient complication increased the likelihood of a PD complication (12.5% vs 6.2% without an inpatient complication; P < .001). Compared with patients without a PD complication, those with a PD complication had higher rates of reoperation (4.6% vs 17.9%, respectively; P < .001) and death (2.0% vs 6.9%, respectively; P < .001) within 30 days after surgery; those whose PD complication was preceded by an inpatient complication had the highest rates of reoperation (33.7%) and death (24.7%) (all P < .001). After adjustment, PD complications were associated with procedure type, American Society of Anesthesiologists class higher than 3, and steroid use. Conclusions The PD complication rates vary by procedure, are commonly surgical site related, and are associated with mortality. Fastidious, procedure-specific patient triage at discharge as well as expedited patient follow-up could improve PD outcomes.
Article
Accomplished authors, Preece, Rogers and Sharp, have written a key new textbook on this core subject area. Interaction Design deals with a broad scope of issues, topics and paradigms that has traditionally been the scope of Human-Computer Interaction (HCI) and Interaction Design (ID). The book covers psychological and social aspects of users, interaction styles, user requirements, design approaches, usability and evaluation, traditional and future interface paradigms and the role of theory in informing design. The topics will be grounded in the design process and the aim is to present relevant issues in an integrated and coherent way, rather than assembling a collection of chapters on individual HCI topics.KEY FEATURES: This truly integrated approach to HCI provides students with background information from psychology, sociology, anthropology, information systems and computer science provides principles and skills for designing any technology through the use of many interesting and state of the art examples. The author supported, highly interactive Web Site provides resources that allow students to collaborate on experiments, participate in design competitions, collaborate on design, find resources and communicate with others. The accompanying Web Site also features examples, step-by-step exercises and templates for questionnaires.
Article
Approximately 2 million nosocomial infections occur annually in the United States. These infections result in substantial morbidity, mortality, and cost. The excess duration of hospitalization secondary to nosocomial infections has been estimated to be 1 to 4 days for urinary tract infections, 7 to 8.2 days for surgical site infections, 7 to 21 days for bloodstream infections, and 6.8 to 30 days for pneumonia. The estimated mortalities associated with nosocomial bloodstream infections and pneumonia are 23.8% to 50% and 14.8% to 71% (overall), or 16.3% to 35% and 6.8% to 30% (attributable), respectively. The estimated average costs of these infections are 558to558 to 593 for each urinary tract infection, 2,734foreachsurgicalsiteinfection,2,734 for each surgical site infection, 3,061 to 40,000foreachbloodstreaminfection,and40,000 for each bloodstream infection, and 4,947 for each pneumonia. Even minimally effective infection control programs are cost-effective. In countries with prospective payment systems based on diagnosis-related groups, hospitals lose from 583to583 to 4,886 for each nosocomial infection. As administrators focus on cost containment, increased support should be given to infection control programs so that preventable nosocomial infections and their associated expenditures can be averted.
Incorporating Health Information Technology Into Workflow Redesign
  • P Carayon
  • B.-T Karsh
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.