Workflows are a big challenge in healthcare interoperability. Workflows exist everywhere, and in all forms. There are complex workflows, simple and straight-forward workflows, confusing workflows, cross-domain workflows, single-domain workflows, static workflows, dynamic workflows, defined workflows, and undefined workflows. Workflows are at the core of everything that happens in healthcare. We, as an industry are just beginning to understand how to go about defining workflows from an electronic perspective. For years IHE and other standards development organizations have been creating implementation guidance components that ultimately make up these larger workflows. These workflows derive from the various medical colleges that spend much time studying clinical workflows and producing guidance on implementation of these workflows in healthcare practices.
This blog post will not go into detail on all the different types and aspects of workflows mentioned above, however, it will introduce a couple of approaches that IHE has been using: static workflows and dynamic workflows.
Static workflows are those that are very well defined, and rarely, if ever, need to change from their original guidance. I admit that I am no expert in radiology, but I do know that the radiology domain profiles workflows that are fairly well understood and able to be controlled – at least to some degree. For example, a patient needs to have a certain imaging procedure performed, so they will first be registered in the system, an order will then be placed for the imaging procedure, the procedure will be scheduled and placed onto a DICOM Modality Worklist. The procedure is managed on the worklist according to the specifics involved (which are different for various imaging procedures). All in all, the process is fairly well understood. What happens outside the bounds of that particular procedure are of course variable, but the imaging procedure itself fits nicely into a well-defined workflow, and is finished within a single outpatient visit.
Dynamic workflows are much less predictable and must provide appropriate levels of adaptability in order to be successfully implemented. These workflows are those that are very open ended and dependent on many varying factors. Did the patient actually take their medication? Did the patient schedule that follow up appointment? It turns out that it is hard to ensure that patients follow their care plans prescribed by their providers. It is often times equally as hard for the patients themselves to follow their own care plans, amid busy schedules, with families to manage, work, etc. Sometimes tasks are forgotten or deemed to be less important than the task competing for their immediate attention. There is also a level of importance placed upon any given task in a patient’s care plan based on the amount of benefit that would be received from the task.
For example, a care provider may prescribe some sort of physical therapy, and if the patient completes the physical therapy then she will show signs of improvement (less pain, more mobility, etc). Maybe that is enough to satisfy the patient, but it would not satisfy her doctor. The patient decides to stop going to the physical therapy sessions because she thinks she is “better enough.” However, her condition worsens over the next few months, and she must schedule a follow up visit with her doctor to determine how to reengage with her physical therapy. The same scenario could be applied to many other situations, one common example being medication adherence for anemia.
Another aspect of primary care is dealing with patients that have comorbidities. Multiple chronic conditions can greatly complicate being able to effectively care for a patient. Combined with the fact that different people have different metabolic rates for medications that are not based on consistent factors – such as body weight, height, and vital signs – the doctor needs a system that is flexible and adaptable in order to do their job. This is one reason that adoption of EHRs has been so sluggish in the past few years. They tend to constrain care providers to a certain workflow that gets in the way of the doctor caring for their patient.
Workflows are addressed in IHE domains in various different ways depending on the clinical use cases being addressed. There are a handful of different underlying standards that are profiled, and in many cases those standards are profiled in slightly different ways for the varying clinical use cases present. Workflows exist everywhere, in every system – both healthcare specific and generic. What makes implementation guidance effective is a combination of factors, one of the key factors being how well the clinical workflow is understood by the specification author (or committee) and how well the underlying standard is matched to the clinical use case in a way that an implementer (i.e. health IT software vendor) can understand and write code to it, providing a useable product to the clinician.