Jerome Carter, MD, November 9, 2015

The importance of clinical workflow is now widely-acknowledged, especially as it pertains to software usability and implementation.  However, this acknowledgment only scratches the surface of the fundamental role of clinical processes as they pertain to software design, care delivery, or even clinical outcomes.  All clinical care consists of processes, and in-depth analysis of those processes can offer valuable insight into a range of problems.   

Clinical decision support addresses the challenges of providing information at specific points within a clinical process. Patient safety and errors are indicators of what goes wrong during processes.  Clinical outcomes are the outputs of clinical processes.    Care coordination is a matter of properly aligning and synchronizing clinical processes.  Results  management is, in essence, about closing the loop for ordering processes.  Clinical care consists of processes, and these processes can be described mathematically, modeled graphically, and executed computationally. Successful application of information technology to clinical care has to begin with processes because the key assumption when implementing clinical software is that it will in some way make processes more efficient, effective, efficacious or productive. 

Improving clinical processes, whether with software or otherwise, requires that one have the ability to analyze them in sufficient depth to determine the current state (i.e., what’s wrong) and project the future state (i.e., how things will be different—better or worse).  Processes consist of a series of steps (control and flow), information movements (production and use), resource utilization, and interactions (human-human, human-machine).    Properly understanding a process requires specific information about each of these aspects.  Unfortunately, such specific information is rarely available (or even sought) before attempting to alter or implement a clinical process.   

Clinical pathways and practice guidelines are well-known examples of attempts at managing clinical processes, and each can be limited by the lack of specific information.  Practice guidelines are not one-size-fits-all—every patient is unique.  “Unique” is merely another way of saying a patient’s information is different.   Genetics makes one different, as do current medications, co-morbid conditions, education level, or income.  When it comes to research on clinical care and clinical processes, information is rarely captured at the required level of detail.    

Although it is possible to describe processes in detail mathematically, such approaches are rarely seen in the informatics literature.  The same holds true for software implementation, and often, clinical software design as well.  Every workflow issue can be traced back to problems in one or more of the four aspects of clinical processes.  Steps may be incorrect or in the wrong sequence. The information required for a step may be missing or incorrect. Needed resources may be  unavailable or work is sent to the wrong person or device. Uncovering the specific cause of an errant process requires a level of detail beyond the capabilities of flowcharts or simple swim lane diagrams. Models must be richer and the analysis methods used to collect process-related data must be more exacting in order to understand and address real-world clinical care challenges.   The required tools exist, but for the most part, they are unknown in healthcare.  By acting as an educational resource and gathering place, Clinical Workflow Center aims to foster interactions between professional communities while demonstrating new approaches to clinical workflow analysis and modeling. 

Clinical Workflow Center 2.0
Business process management (BPM) and related technologies are the most significant additions to Clinical Workflow Center (CWC).   BPM suites are application development environments. They represent mature technology that can be used to convert workflow models into real applications.  Thus, it is possible to model a process and then directly support it with custom software. Even better, there are robust open source BPM tools that are suitable for clinical applications! With the addition of BPM information, CWC articles will fall into three main categories: Workflow in Practice, Professional Skills, and BPM/Workflow Technology.

Workflow in Practice
Problems and solutions are the focus here.   Typical topics might include the role of workflow analysis and modeling in software selection/implementation, decision support, care coordination, practice optimization, care quality, etc.  

Professional Skills
Given the above discussion, workflow analysis and modeling are important professional skills. Unfortunately, few resources are available that teach clinical workflow analysis and modeling methods beyond basic flowcharting techniques.  None address the four aspects of clinical processes in sufficient detail to create robust workflow models.  Articles in this category will discuss everything from graph theory and the mathematical properties of workflows to techniques for gathering workflow information in workplace settings and specific modeling tools/tips. 

BPM/Workflow Technology
As noted above, BPM suites can be used to build workflow applications. Accordingly, articles in this category will discuss BPM suites and modeling tips in terms of application development and implementation. 

Articles in all categories may be any of the following types: tutorials, product reviews, case studies, technology overviews, literature reviews, technical reports, research reports, or opinion pieces.  Anyone may submit articles for publication. 

In order to foster communication and interaction, a forum is provided. Registration (username, email) is required to participate in the forum.  An event calendar is also available to promote workflow-related conferences, seminars, classes, and similar experiences. 

Brief product announcements will also be published.  Product announcements will remain on CWC for four weeks. 

“Library” has replaced “Resources” as the title grouping of pages that provide listings of books, articles, reports, and other reference materials. In addition, the number of topic pages will be expanded from two to four.

Information on submitting content of any kind to CWC can be found here (or click on “Contribute” under the “About” menu item).

EHR Science has many workflow-related posts that were written between 2011 and 2014. A few of them will be updated/expanded (mainly to illustrate new methods and/or tools) and republished on CWC.  Future workflow-related posts will appear exclusively (or nearly so) on CWC. 

Clinical Workflow Center began in October 2014 as an effort to upgrade the EHR Science discussion forum.  However, in the process of doing that upgrade, it became clear that workflow issues were at the heart of many clinical care issues, and thus deserved a more formal treatment (also the upgrade trashed the site).  In all, the entire metamorphosis has taken slightly more than a year due to feature creep and trying to decide what exactly CWC’s  mission should be.  The outcome of those deliberations is before you: a place where one can discover, share, learn, and discuss everything clinical workflow… Hope you agree. 

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