Thursday, September 28, 2006

Automated Workflow Environments and EMR

Well, we work in the next era of software development, not only designing applications, but also developing systems that communicate with each other, thus participating in a workflow.

Automating this workflow through the seamless integration of these apps is a task that challenges many of the industries that we work in.

Automated Workflow Environments are those systems where multiple systems contribute, collaborate and communicate to enable a network of these apps to actually solve complex problems very efficiently, with no human interaction. You can call them Digital Ecosystems.

You can construct workflow nets to describe the complex problems that these systems efficiently solve. Workflow nets, a subclass of Petri nets, are known as attractive models for analyzing complex business processes. Because of their good theoretical foundation, Petri nets have been used successfully to model and analyze processes from many domains, like for example, software and business processes. A Petri net is a directed graph with two kinds of nodes - places and transitions - where arcs connect 'a place' to 'a transition' or a transition to a place. Each place can contain zero, one or more tokens. The state of a Petri net is determined by the distribution of tokens over places. A transition can fire if each of its inputs contains tokens. If the transition fires, i.e. it executes, it takes one token from each input place and puts it on each output place.

In a hospital environment, for example, the patient journeys and processes involved, show a complex and dynamic behavior that is difficult to control. The workflow net which models such a complex process provides a good insight into it, and due to its formal representation, offers techniques for improved control.

Workflows are case oriented; each activity executes because of the case. In a hospital domain, a case corresponds with a patient symptom and an activity corresponds with a medical activity. The process definition of a workflow assumes that a partial order or sequence exists between activities, which establish which activities have to be executed in what order. Referring to the Petri net formalism, workflow activities are modeled as transitions and the causal dependencies between activities are modeled as places and arcs. The routing in a workflow assumes four kind of routing constructs: sequential, parallel, conditional and iterative routing. These constructs basically define the route taken by 'tokens' in this workflow.

Well, enough theory, how does this apply?

Think of this in practical terms using the example of an EMR* or CPR* System or HIS* System:
• A patient arrives at a hospital/clinic for a consultation or particular set of exams or procedures.
• The patient is registered using key demographics, if new to the hospital. A visit or encounter record is created in the Patient Chart (EMR) - with vitals, allergies, current meds and insurance details.
• The physician examines the patient and orders labs, diagnostic exams or prescription medications for the patient possibly using a handheld CPOE*
• The patient is scheduled for the radiliogy exams using the RIS - radiology info system; samples and specimens are sent to the LIS - laboratory info system or HIS (hospital info system)
• The RIS or CIS or LIS or HIS sends notifications to the Radiology and/or Cardiology and/or Lab or other Departments in the hospital through HL7 messages for the various workflows.
• The various systems in these departments will then send HL7 or DICOM or proprietary messages to get the devices or modalities, updated with the patient data (observations, restrictions, prior history, etc.)
• The patient is then taken around by the nurses to the required modalities in the exam/lab areas to perform the required activities. There may be lab reflex orders created to complete the lab procedures.
• The patient finishes the hospital activities while the diagnosis and study continues in the background with the care teams; these entire datasets are coalesced and stored in rich structured reports or multimedia formats in the various repositories - resulting in a summary patient encounter/visit record in the Electronic Patient Record in the EMR database along with possible follow up future visits and prescriptions.
• There could also be other workflows triggered - pharmacy, billing [based on CPT codes], etc.
• The above is just the scenario for an OUTPATIENT or Walk-in; there are other workflows for INPATIENT - ED/ICU/other patients.

The key problems in this 'Automated Workflow Environment' are:

• Accurate Patient Identification and Portability to ensure that the Patient Identity in the EMR is unique across multiple systems/departments/clinics and maybe hospitals. The Patient Identity key is also essential to Integrating Patient healthcare across clinics, hospitals, regions (RHIO) and states.
• Support for Barcode/RFID on Patient Wrist Bands, Prescriptions/Medications, Billing (using MRN, Account Number [and Visit/Encounter Number] and Order Number), etc to enable automation and quick and secure processing.
• Excellent interfacing with all primary ADT, Orders, Results, Charges, Supply Chain Management, Medication dispensing systems, Provider database systems, Registries, Financial software and IT Management and Transaction Tracking systems
• Quick Patient data retrieval and support for parallel transactions
Audits and Logs for tracking access to this system
• Support for PACS, Emergency care, Chronic care (ICU / PACU), Long Term care, Periodic visits, point of care charting, meds administration, vital signs data acquisition, alarm notification, surveillance for patient monitors, smart IV pumps, ventilators and other care areas - treatment by specialists in off-site clinics, Tele-Health, refills at Pharmacies, etc.
• Support for Care Plans, Order sets and Templates, results' tracking and related transactions.
• Quick vital sign results and diagnostic imaging/reporting with role based access to appropriate patient data.
• Effective display of specialty content - diagnostic/research images and structured "rich" multimedia reports.
Secure and efficient access to this data from the internet (home, affiliate clinics, other facilities)
Removal of paper documentation and effective transcription through support for digital scanning of old documents and accurate linking to the patient charts.
SSO-Single Sign On, Well defined Security roles, integrated Provisioning and Ease of use for the various stakeholders - here, the patient, the RN, physician, specialist, IT support, vendor maintenance, etc.
Seamless integration with current workflows with easy extensibility and support for updates to hospital procedures/processes/equipment/regulations.
Modular deployment of new systems and processes with a long term roadmap and strategies to prevent costly upgrades or vendor changes or technology limitations.
HIPAA, HL7, JCAHO/JCI and Legal compliance - an entire set of guidelines - privacy, security being the chief ones. HL7 compliance implies easy integration with other hospital/clinic systems. A hospital with HIMSS Stage 7 certification implies portable digital data end to end, with reduced paperwork and a seemless patient experience, without cumbersome physical documentation, with support for convenient online appointments, online patient results, online provider access,  online prescription refills, regulatory compliance, reduced error, etc.
• Efficient standardized communication between the different systems either via "standard" HL7 or DICOM or CCOW or proprietary.
• Seemless support for integration with a High speed Fiber network system for high resolution image processing systems such as MRI, X-Ray, CT, etc.
• A high speed independent network for real time patient monitoring systems and devices
• Guaranteed timely Data storage and recovery with at least 99.9999% visible uptime
• Original Patient data available for at least 7 years and compliance with FDA/regulatory rules.
Disaster recovery compliance and responsive resilient performance under peak conditions. Redundancy and Disaster Recovery implies that the system is easily recoverable without significant operational disruptions. Monitoring historic downtime trends and reviewing of downtime strategies apart from periodic verification of hot and cold recovery in off peak hours would ensure confident stress free adoption by the patient care teams.  
• Optimized, on demand and elastic data storage ensuring low hardware costs
Plug 'n' Play of new systems and medical devices into the network, wireless interference-free communication among the vital signs devices and servers, etc.
Location tracking of patients, providers and devices (RFID based) within the hospital
Centralized viewing of the entire set of relevant patient data - either by a patient or his/her physician
Correction of erroneous data and merging of Patient records.
• support for restructuring existing hospital workflows and processes so that this entire automated workflow environment works with a definite ROI and within a definite time period!
• Integration with billing, insurance and other financial systems related to the care charges.
• Integration with Business Intelligence systems for statistical comparisons, quality indicators, patient feedback, efficiency tracking, fraud prevention, epidemic prevention, anonymized research and reasonable prediction of outcomes. 
• Support for De-Identification or Anonymization for research studies.
Future proof and support for new technologies like Clinical Decision Support (CDSS) - again, a long term roadmap is essential.
Multi-lingual user interface and international data exchange possibilities
ROI: How does a hospital get timely returns on this IT investment?
  1. Minimization of errors - medication or surgical - and the associated risks
  2. Electronic trail of patient case history available to patient, insurance and physicians
  3. Reduced documentation and improvement in overall efficiency and throughput
  4. Patient Referrals from satellite clinics who can use the EMR's external web links to document on patients - thus providing a continuous electronic report
  5. Possible pay-per-use by external clinics/pharmacies - to use EMR charting/e-refill facilities
  6. Remote specialist consultation
  7. Efficient Charges, Billing and quicker settlements
  8. Better Clinical Decision Support - due to an electronic database of past treatments
  9. In the long term, targetted efficiency and essential innovation provides for better preventive care implying cheaper insurance and optimized treatment ensuring  fewer bills and reduced claim denials, thus leading to volume income, increased patient satisfaction with referrals to friends and relatives, providing long term sustainability in fiercly competitive environments and reducing state expenditure while improving care quality in socialist healthcare regions.
  10. Better compliance of standards and policies - HIPAA, JCI, privacy requirements, security 
  11. Reduced workload due to Process Improvement across departments - ED, Obstetrics/Gynecology, Oncology/Radiology, Orthopedic, Cardiovascular, Pediatrics, Internal Medicine, Urology, General Surgery, Ophthalmology, General/family practice, Dermatology, Psychiatry
  12. Improved Healthcare with Proactive/Preventive Patient Care due to CDSS.
  13. Efficient usage of Providers, Hospital Beds and Outpatient Devices/Resources through Predictive Planning using real time data and historic visit information - leading to improved outcomes for multiple patients receiving predictable and quality care in paperless and advanced medical centers. 
  14. Quality of Patient Care: A silent factor of a hospital's revenue is quality of patient care. One of the chief drivers of quality of patient care is the quality of information provided efficiently to the Physicians though which they can make those critical decisions.
  15. Performance Metrics or KPI's: Any hospital system needs efficient SMART goals that are periodically evaluated and improved upon:
    • Operational: Average Length of Stay/Volume Metrics, Time to service, Hospital Incidents/Infections, Patient Satisfaction, Physician performance, Patient readmission rate, Inpatient mortality rate, Operating Margin/Financial Metrics, Bed Occupancy Rate/Revenue Leakage Metrics/No-shows, Asset Utilization Rates/Inventory Turns, Service Requests
    • Server: CPU/RAM utilization report, (avg. time of disc transfer, I/Os per disc, Disc queues per spindle, average login time, average report display times, number of simultaneous users, Availability, Network Latency
    • Vendors: Service Requests, Incidents, SLA Response times
  16. Improved Emergency care through real time hospital preparedness, apart from reduced ambulance travel time
  17. Reduced Claims Denials: A hospital system that is well integrated and optimized for improved patient care, outcomes and experiences all the way from supplies procurement through optimal utilization, and with accurate documentation implying accurate fulfillment and accurate patient diagnosis and treatment processes (with the possible usage of Artificial Intelligence to feedback past/historical experience data into front end systems) finally leads to reduction in Claims Denials.
  18. Standards compliance: Innovative future-safe solutions need to be standards compliant since these standards are regularly reviewed by expert committees, vendors and regulators.
  19. Improved Community Health: Corporate Social Responsibility for regions implies better governance through reduced epidemics and better public health, mainly achievable through central health data repositories that receive realtime anonymized patient data from the various regional hospitals' EMR systems; the centralized health system in turn can provide alerts that prevent and restrict outbreaks in realtime apart from providing regional best practices and medication alerts to these subscribers.
  20. Customization and Adoption:  Technology or Innovation can only be as good as the customization involved for a seamless provider-patient experience. Too many clicks or screens can and will convert the clinical documentation task into painful detective work. The Digital Transformation of Healthcare when done right, has already proven invaluable (Epidemic detection and reduction, Standardized quality of care for common ailments, Knowledge base of Expert techniques, Well documented case histories, Anonymized Research for future improvements and life saving techniques, Medicare fraud prevention, Prevention of Insurance headaches and paperwork, Global digital access for patients to their prescriptions-records-scans-physicians, telemedicine, etc.). Over a reasonable time/effort, the healthcare system EMR would be customized to provide the best provider-patient interaction experience, similar to the pre-digital era. Experienced EMR implementation teams need to advise the best in class technology available for the requirements and demographics/economics involved.    
Now, the big picture becomes clear.

Doesn't the above set of requirements apply to any domain? This analysis need not be applicable only to a hospital domain, the same is true for a Biotech domain (where orders are received, data is processed, analyzed, and the processed data is presented or packaged). Similarly a Manufacturing Domain, Banking domain or Insurance Domain etc.

The need is for core engine software - based on EDI (Electronic Data Interchange) - that integrate and help in the Process Re-Engineering of these mini workflows securely and effectively and using common intersystem communication formats like X-12 or HL7 messages.

These Workflow Engines would be the hearts of the digital world!

*EMR - Electronic Medical Record
*CPR - Computerized Patient Record
*CDSS - Clinical Decision Support
*RHIO - Regional Health Information Organization
*CPOE - computerized physician order entry

Some of the information presented here is thanks to research papers and articles at:
*EMR Adoption Model
*Common Framework for health information networks
*Discovery of Workflow Models for Hospital Data
*Healthcare workflow
*CCOW-IHE Integration Profiles
*Hospital Network Management Best Practices
*12 Consumer Values for your wall

Healthcare Exchanges are the future:
   Imagine a scenario, wherein a patient can use his healthcare card to receive care in any hospital in his state, province or country.  Healthcare Information Exchanges (HIE) are data aggregating and messaging systems that provide population healthcare data, unified patient lookup, medication/procedure reviews, epidemic monitoring, anonymous patient research, cost savings through fraud prevention, optimal e-prescription systems, best care for current symptoms, clear billing comparisons, online regional provider appointments, insurance marketplaces, etc.; patients would also get to choose the best insurance provider from this health exchange using detailed statistics, patients could opt for cost effective and optimal treatment plans and patients would have true portability.    

    Successful HIE implementations have common threads of success:​
  •     They meet and balance many stakeholder needs​
  •     They are flexible and enable the continuous discovery of niche areas that further add significant value to their stakeholders and community​
  •     Their passionate leaders continually discover new sources of funding (both public and private) to remain financially viable, at least initially​

    The several Challenges and HIE Implementation Risks include:​
  •     Lack of interoperability standards in existing infrastructure and legacy vendors are sometimes slow to acceptance
  •     Lack of available and hospital facility IT resources, etc., lending to longer integration times and escalating costs​
  •     Competing priorities in the hospitals/departments during the HIE rollout can also slow down the implementation​
  •     Rapidly changing technology shifts may provide alternatives to the services that HIEs offer or plan to offer​
  •     Possible duplication and reimplementation of existing applications of the current ecosystem could indirectly increase scope​
  •     Slow Integration into existing workflows and slow adoption of the HIE post go live would be detrimental​
  •     Slow pace of HIE service adoption by clinical and health policy stakeholders​
  •     Rapidly escalating costs due to premium vendor costs​
  •     Fading local and federal government financial sponsorships​   

    The solutions include:​
  •     Prioritizing and appropriately phasing the HIE implementation. Timely and careful implementation of high value bundles of HIE services would help drive adoption and ensure sustainability​
  •     Understanding and responding to stakeholder/customer needs on an ongoing basis and offering products and services that solve their problems is a win-win​
  •     Achieving early value in HIE implementations builds trust driving open, transparent growth ​
  •     Leveraging lightweight and flexible technologies 
  •     Consistent implementation of interoperability standards is fundamental to achieving widespread HIE adoption​
  •     Identifying and reaching a critical mass of connected providers and hospitals/clinics/pharmacies is key
  •     Further, business intelligence and data analytics over the HIE would support actionable, effective clinical decision making, thus driving quality and cost improvement and transforming healthcare to pay-for-value​
The HIE implementation ROI can be measured through clinical outcomes, clinical process outcomes, financial savings, and user satisfaction apart from providing the government with valuable population health metrics including improvements in healthcare standards, epidemic and medication control, optimal healthcare delivery, etc. The typical metrics include: Utilization (exchange transactions); Participation (engagement of stakeholders); Clinical outcomes (quality indicators); Financial (cost avoidance and fraud prevention); and Users (active providers using system). Clinical process measures, including workflow, and measures of provider or patient satisfaction would indicate lower adoption of the HIE initially, since it would more typically be more frequently used during clinical reviews and policy planning apart from insurance markets/providers. Clinical outcomes, financial measures, measures of satisfaction, and clinical process measures should quickly ramp up to exhibit the highest reported usages in future.

What about the latest IT trends and their applications in healthcare?

We already know about Google Earth and Google Hybrid Maps and the advantages of Web 2.0
The next best thing is to search the best shopping deal or the best real estate by area and on a hybrid map - this recombinant web application reuse technique is called a mashup or heat map.
Mashups have applications in possibly everything from Healthcare to Manufacturing.
Omnimedix is developing and deploying a nationwide data mashup - Dossia, a secure, private, independent network for capturing medical information, providing universal access to this data along with an authentication system for delivery to patients and consumers.

Click on the below links to see the current 'best in class mash ups'
*After hours Emergency Doctors SMS After hours Emergency Doctors SMS system - Transcribes voicemail into text and sends SMS to doctors. A similar application can be used for Transcription Mashup (based on Interactive Voice Response - IVR): Amazon Mturk, StrikeIron Global SMS and Voice XML
* Calendar with Messages Listen to your calendar + leave messages too Mashup (based on IVR): 30 Boxes based on Voxeo , Google Calendar
* Housing/Climate/Jobs/Schools
* Visual Classifieds Browser - Search Apartments, visually
* - Real Estate/Home pricing
* - Rent comparison
* Weather maps
* - Free comparison shopping with your cell phone
* - 10 days weather forecast - worldwide map
* - Find matching music/movie based on "genre" in a visual way
* - Rent/Real Estate/Home pricing - linked to Craigslist
* - Google Maps + Travel Videos
* - Wheel of Zip Code based restaurants
* More sample links at this site (unofficial Google mashup tracker) includes some mentionable sites :
* latest news from India by map
* read news by the map - slightly slow
* view news from Internet TV by map -
* see a place in 360

What's on the wish list ? Well, a worldwide mashup for real estate, shopping, education, healthcare will do just fine. Read on to try out YOUR sample...
OpenKapow: The online mashup builder community that lets you easily make mashups. Use their visual scripting environment to create intelligent software Robots that can make mashups from any site with or without an API.
In the words of Dion HinchCliffe, "Mashups are still new and simple, just like PCs were 20 years ago. The tools are barely there, but the potential is truly vast as hundreds of APIs are added to the public Web to build out of".
Don also covers the architecture and types of Mashups here with an update on recombinant web apps

Keep up to date on web2.0 at

Will Silverlight and simplified vector based graphics and workflow based - xml language - XAML be the replacement for Flash and JavaFX?

Well, the technology is promising and many multimedia content web application providers including News channels have signed up for Microsoft SilverLight "WPF/E" due to the light weight browser based viewer streaming "DVD" quality video based on the patented VC-1 video codec.

Microsoft® Silverlight™ Streaming by Windows Live™ is a companion service for Silverlight that makes it easier for developers and designers to deliver and scale rich interactive media apps (RIAs) as part of their Silverlight applications. The service offers web designers and developers a free and convenient solution for hosting and streaming cross-platform, cross-browser media experiences and rich interactive applications that run on Windows™ XP+ and Mac OS 10.4+. There is a Silverlight for LINUX too (Moonlight-Mono)

The new way to develop your AJAX RIA "multimedia web application" is - design the UI with an Artist in MS Expression Blend or Adobe Illustrator and mashup with your old RSS, LINQ, JSON, XML-based Web services, REST and WCF Services to deliver a richer scalable web application.


Charles Vaz said...

In response to a blog article about Australian Health Information Technology, I have a few comments.
I feel the adoption of EMR and HL7 at a regional level is a must for every country in this age.
Information Technology is so far ahead in many spheres in Medical Technology but its strange that most departments in a hospital still use paper.
I have a nice article on EMR on my Blog discussing the need for EMR implementation and the ROI (Return on Investment).
I would appreciate your comments but I sincerely feel that waiting for HL7 version 3 is not recommended since a delay in getting healthcare improved and integrated will only lead to increased costs of implementation and a bigger learning curve for the stakeholders.
Also, with OMG and Service based Architectures the communicating departments in the hospital need not worry whether the communication under the hood is HL7 2.3 or HL7 3 or HL7 2.4 - since there will always be a myriad of products in a hospital - due to legacy reasons.
Lastly, thanks for your articles.


Cuckoo said...

Nice interesting article. :)

Thanks for dropping by at my blog. Have replied you there. Hope to see you more often.

And by translation, you meant Altavista ? I have put it on my Travel blog.

Charles Vaz said...

A nice article at Dr. Scott Shreeve's Blog - "A New Dimension: Introducing the XHR" sums up my article nicely.

Good addition to the vocabulary.
In fact this is what my blog article at was trying to hint at.

XHR - "Mashup" - What's in a name? The truth lies is in the perfect implementation of an EMR that gives a Web 2.0 type experience to the Patient, Physician, Consultant and the Insurance Company.

Thanks for an innovative article that gave me a concluding thought to my article.

Keep writing,
Best Regards,

Charles Vaz said...

Heath Data Management has a nice complementary article on 21st century EHR initiatives for:

* Embedding decision support capabilities, including appropriate alerts, into EHRs.

* Using clinical data to support research aimed at improving the quality of care and preparing for pay-for-performance.

* Looking for ways to increase connectivity so that hospitals and clinics can readily share life-saving clinical information.

* Supporting the growth of EHRs at clinics by coordinating these projects through hospitals.

* Phasing in personal health records that include data entered by patients.

* Adding new components to EHRs designed to make the data more complete. These include a broad range of test results, from diagnostic images to electrocardiogram strips. The military is even taking the step of adding dental records to its EHR.

* Providing easier access to EHRs at the point of care through wireless networks.

Thanks to a nice article at their site, I have reproduced their words above.