August 13, 2019

The Patient Workflow: it's not just a form.

INTRO / SUMMARY
Watch this article as a video

As described, a PATIENT FILE may include both a PATIENT CHART (a relatively generalizable filing cabinet of patient information), and a PATIENT WORKFLOW (a highly flexible environment built for a particular need).

This post will look at the PATIENT WORKFLOW in more details.

1.   Why not call it a 'Form'?

The term form is used often throughout medicine to describe the standardized collection of information. Forms obviously can be paper-based, but digital. But in general parlance, they mean the same thing - standardized information collection.

Some physicians in American healthcare may not use forms regularly when recording information about a patient, as they often use free-text notes. However, many physicians use forms to help standardize the collection and reporting of their information. Also, throughout the world, non-physician care providers regularly use forms to collect patient medical information. Sometimes these forms contain free text fields, and other times they are discrete answer choices.

It is easy today for anyone to create a digital form using Survey Monkey or Google Forms. These products are widely available and have a simple 'drag-and-drop' environment.

Last year, I asked myself the question, "why can't we just use an off the shelf form builder, such as Survey Monkey, or Google Forms, or RedCap, or CommCare to collect patient data and call it an electronic medical record?".

The limitation of all the above systems is that although they are effective at collecting information, a medical workflow involves more than just collecting patient information.

This is why I used the term PATIENT WORKFLOW to highlight that I am referring to functionality within an EHR far more powerful than a form.

2.  What is a workflow?

A workflow can broadly be broken down into tasks that involve:

  1. Data Capture
  2. Data Display

Data Capture can be further broken down into

  1. Capture of patient information: e.g. clinical notes, physical exam findings, lab results
  2. Recording actions about a patient's care: e.g. book an appointment, order a medication, schedule a lab test.

In order to build an effective workflow builder within the EHR for a variety of care settings, we require components that can:

  1. Display information about a patient (eg. active medications, past lab results, active problem lists)
  2. Capture information about a patient (eg. discrete drop-down questions, free-text answers, pre-build questions, etc)
  3. Place actions about a patient's care (e.g. place medication orders, book appointments, etc)

Often multiple of the above functions are needed within the same component. For instance, a component of 'active medication list' needs to be able to

  1. Display information: e.g.the medication list
  2. Capture information: e.g. change a medication's status to stoped and record the date and reason why
  3. Place actions: e.g. to order a new medication

I haven't seen, yet, a workflow build that contains these types of components. And that is what we need to build.

EHRs require a workflow builder that taps into a giant toolbox that contains all the elements from within an EHR, but split up into discrete functional components that an organization can drag into the correct order they need for a dedicated workflow.

3.  Example of a Workflow & Form

We will look at the same ‘workflow’ but the first example builds this entire workflow into the EHR using a workflow builder, whereas the second example only able to customize in the EHR a form.


3a.  Example of a workflow

This hypothetical workflow is for an HIV outreach worker who is following up on patients who missed the prior day.

Every line in here is a self-contained component that could be 'drag-and-dropped' into the workflow builder.

1. Display missed appointment information

  1. Display / patient name, age, demographics,
  2. Display / HIV Program Summary Card
  3. Display / HIV Encounter History Panel
  4. Display / date of the missed appointment

2. Contact Patient

  1. Display / patient phone number
  2. Display /relative phone number
  3. Action / auto-dial patient

3. Document Phone Follow-Up

  1. Structured / number / “Number of call attempts”
  2. Structured / drop down / “Who does the phone belong to?”
  3. Structured / radial / “Was the patient contacted?”
  4. Unstructured / free text (long) / “Clinical Notes”

4. Next Steps

  1. Action / Book follow up appointment
  2. Action / Referral for in-field follow-up
  3. Action / Call back tomorrow

3b. Example as a ‘Form

If we consider the above workflow, but only have a standard form to use, all it could include:

1. Document Phone Follow-Up

  1. Structured / number / “Number of call attempts”
  2. Structured / drop down / “Who does the phone belong to?”
  3. Structured / radial / “Was the patient contacted?”
  4. Unstructured / free text (long) / “Clinical Notes”
  5. Unstructured / free text / “Plan of action”

The clinician would then have to flip through the PATIENT CHART, to obtain the other information they require to complete this standard workflow such as the patient’s backstory, and HIV care history. They would then have to click to the demographics section of the EHR to find the patient’s phone numbers and contact information. Dial this manually. Then return back to their form to document their phone call. Then move out of their form again, back into the general EHR to perform the actions such as booking follow up appointments and setting follow up reminders. This is a horrible ‘workflow’ experience.

Instead, as you can see, by being able to bring together all the modular pieces required for this workflow, it greatly increases the efficiency of the clinician, and also the ease with which they can operate the EHR.

No need to leave the WORKFLOW

A well-built WORKFLOW means that the user does not have to leave the WORKFLOW part of the application to open the PATIENT CHART.

This means they can see exactly the right information they need during the clinical encounter, optimizing their efficiency, and assisting in care.

In theory, this also means that each user is able to have a fully customized EHR experience, because their primary clinical tasks can be built as workflows.

For the many healthcare workers who’s job involves regular workflow tasks, this means they their EHR experience can be completely customized based on the type of work they do. This is a really cool way to think about the EHR.

Further posts will go into more details on how these workflow components should be bundled together with terminology services, logic, and pre-build options to make it easier and safe for those building workflows within an organization.

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