The following is a preview of a soon to be released article on Electronic Medical Records (EMRs) and business process. To receive a copy, contact me at: [email protected].
The move to electronic medical records (EMRs) is underway in the US. This critical component of health information systems is already yielding benefits for an inefficient system. However, without robust business process management (BPM) in place, EMRs will struggle to deliver on their potential. EMRs are lonely for business process.
Paving cowpaths
Capturing and managing records electronically has many benefits over paper-based systems, with or without Stimulus enticements. But what do we gain if we stop at making paper into digital records?
Moving to a digital system has a big impact on work activities. If an EMR is implemented without a very careful look at impact to work, inefficiency will be introduced alongside the disruption of learning new things. This can have a devastating effect on productivity and system acceptance.
Opening doors
Making things digital brings enormous opportunity IF all of that newly captured information is free to be used by more than one system, for analytics and dashboards, and for real-time decision making.
Beyond the obvious benefits, there is a need for new applications of technology to improve health outcomes. Reacting to dangerous situations like sepsis requires constant vigilance that isn’t so easy with multiple caregivers and departments interacting with patients. Technology, however, can be in a ‘constant query’ pattern that can see patterns emerge in the moment. EMRs are traditionally built to do this and are instead more focused on fee-for-service transactions.
The steady drumbeat
Beyond the immediate is the need for day in, day out management of organizational change. Healthcare is changing so rapidly that there are real risks of change fatigue and organizational burnout.
Training and retraining will be key to using EMRs efficiently as first rollouts and follow on releases need to be ‘swallowed’ by healthcare organizations. It is no longer reasonable to manage training as a separate set of information from business process when they can be one and the same.
The EMR won’t be a platform for continuously working to eliminate waste and improve operations. There needs to be a process layer above and distinct from the transactional EMR system where activity based costing, analysis, simulation and automation can occur. Why would you disconnect this work from process, change, training and EMR deployment? You don’t have to and you shouldn’t.
Lastly, there’s no reason for EMR implementations to be reinvention of the wheel in each healthcare organization. Frameworks are available through APQC and others. Just like process, change, training and system deployment, things like benchmarking and compliance need to be fully integrated to be easily managed.
If your EMR is lonely for business process, reach out to me for my article on the topic. I’d be happy to play matchmaker.
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Great post!
“without robust business process management (BPM) in place, EMRs will struggle to deliver on their potential”
Absolutely true. Posts such as yours help educate about the extraordinary potential for BPM and ACM (adaptive case management) in health information management.
“Technology, however, can be in a ‘constant query’ pattern that can see patterns emerge in the moment”
You may refer to complex-event processing and event-driven BPM.
An “event” is a change in state, such as a patient who gains weight and moves from obese to morbidly obese state categories. A complex patient event is a pattern of detected events amidst a patient event stream (such as moving from obese to morbidly obese combined with being diabetic). Complex event processing, implemented in conjunction with event-driven BPM, provides means to react to patient events in realtime. In process-aware information systems such as EMR / EHR workflow management (or business process management) systems, patient events can drive automated clinical workflows (such pushing action items to worklists) via workflow engines executing process definitions.
“The EMR won’t be a platform for continuously working to eliminate waste and improve operations. There needs to be a process layer above and distinct from the transactional EMR system where activity based costing, analysis, simulation and automation can occur”
Again, spot on.
One of the great promises of EHR workflow management systems, and healthcare BPM in general, is pairing activity-based costs (such as user cost-per-minute) with process definitions. Each step in a process definition is time-stamped when it’s available to be accomplished, when it starts to be accomplished, and when it actually is accomplished. Therefore the total cost for each patient encounter can be calculated. Combined with revenue per patient encounter from the practice management system, the profit for each encounter also can be calculated. In not-for-profit organizations this surplus revenue per encounter can be used to plan and expand services.
By comparing encounter profitability across similar medical practices and healthcare organizations, specific reasons for decreased productivity can be located: (1) a step is more expensive per minute than it should be (accomplished by less expensive resources at other practices), (2) a step takes longer to accomplish than it should (compared to other similar organizations), and (3) a step is executed more frequently than it should (compared to other healthcare entities). The win-win-win analytic result is to find too-expensive and too-long steps executed too-frequently and change workflow to increase productivity. Improving workflow usability can also contribute to greater patient safety.
If an EHR or HIT system does not incorporate a BPM-style workflow engine and process definitions, another BPM technology, process mining, can discover process models from EHR and HIT event logs. While current EHR and HIT system workflow is somewhat customizable (via data and order entry templates) lots more of the workflow is “frozen”. To edit, directly, declarative representations of workflow (think Visio), and then inject them directly back into the EHR, without reliance on expensive Java and C# programmers, is especially powerful used with processing mining. Therefore, as process mining gains popularity in healthcare, awareness for a host of BPM technologies, some of which you mention, will also gain mindshare.
I presented a paper on EHR BPM systems at MedInfo2010:
Clinical Intelligence, Complex Event Processing and Process Mining in Process-Aware EMR / EHR BPM Systems
http://chuckwebster.com/2011/07/clinical-intelligence/clinical-intelligence-complex-event-processing-process-mining-process-aware-emr-ehr-bpm-systems
Abstract
Systematic methods to improve the effectiveness and efficiency of electronic health record-mediated processes will be key to EHRs playing an important role in the positive transformation of healthcare. Business process management (BPM) systematically optimizes process effectiveness, efficiency, and flexibility. Therefore BPM offers relevant ideas and technologies. We provide a conceptual model based on EHR productivity and negative feedback control that links EHR and BPM domains, describe two EHR BPM prototype modules, and close with the argument that typical EHRs must become more process-aware if they are to take full advantage of BPM ideas and technology. A prediction: Future extensible clinical groupware will coordinate delivery of EHR functionality to teams of users by combining modular components with executable process models whose usability (effectiveness, efficiency, and user satisfaction) will be systematically improved using business process management techniques.
Charles,
Thanks for the feedback. I liked your point about Complex Event Processing. The two keys are being able to identify an event and determine the meaning (obese to morbidly obese). To have real value, then next step is to follow this with actions that solve the problem.
EMRs won’t do the process improvement. This is one of the lessons Michael Hammer pointed out years ago. If hospitals use the new system just to do things the old way, they are really missing out.
I, too, believe that there is a lot of opportunity to use ABC in healthcare to better understand costs.
I think one of the things that is going to come out of all this is the ability to compare performance across organizations. Frameworks like APQC’s Process Classification Frameworks will allow for common definitions of processes as well as granular performance metrics (and maybe even best practices based on leaders). This will be a quick way to improve healthcare performance on a system wide level rather than at the individual provider level.
I read that although many organizations experienced a drop in errors overall, at the beginning of moving to EMRs there was an increase in errors. Implementing the processes you’re talking about should help to fix that problem.