organization through process management coupled with advanced analytics. The goal of this technology solution is to support a culture of continual process.
Using Business Process Management and Business Intelligence to Improve Healthcare Extracted with permission from 2010 BPM and Workflow Handbook: Spotlight on Business Intelligence published by Future Strategies Inc., FL USA. Copyright 2010. www.FutStrat.com
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Using Business Process Management and Business Intelligence to Improve Healthcare Introduction The healthcare industry has seen an expanding focus on clinical outcomes as they are increasingly tied to reimbursement and meeting regulatory requirements. Hospitals must be able to improve and report on more clinical outcomes than ever before. These demands on healthcare organizations require leveraging technologies such as business process management (BPM) and business intelligence (BI) to help tackle these challenges.
Why Measuring Clinical Outcomes Is Essential Recent examples of regulatory requirements related to reporting of clinical outcomes include the American Recovery and Reinvestment Act (ARRA) of 2009 and Joint Commission/Centers for Medicare & Medicaid Services (CMS) core measures specifications. The ARRA legislation authorizes reimbursement incentives for eligible professionals and hospitals who successfully demonstrate that they are “meaningful users” of certified electronic health record (EHR) technology.1 The ARRA requirements include the submission of reports to CMS, and both Medicare and Medicaid will provide financial incentives for meeting the meaningful use definitions.2
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Hospitals have been required to report clinical outcomes even before ARRA. For example, the reporting of core measures is an effort by both the Joint Commission and CMS to provide a uniform set of quality standards for patient care. These guidelines outline evidence-based standards for the care of patients with a particular diagnosis such as acute myocardial infarction (AMI) or heart failure (HF). In addition to meeting reimbursement requirements, following the core measures guidelines should benefit the patient and hospital in terms of decreased mortality, improved patient health status and decreased length of hospital stay. The first version of the Specifications Manual for National Hospital Inpatient Quality Measures was published in 2005 for reporting of patient outcomes collected in that year. The most recent version of the specifications manual is 3.2, and will be used for reporting outcomes data collected for patients discharged between October 1, 2010 and March 3, 2011. These manuals provide explicit details regarding the data elements to be collected for a patient’s episode of care.3 The ultimate goal of collecting and reporting metrics is to learn from the data and improve patient care and outcomes. Reporting requirements developed by regulatory and reimbursement agencies are designed with the goal of guiding hospitals and care providers in interventions and practices that will result in improvements in the quality of care and better clinical outcomes. The adoption of evidence-based standards of care has potential for a positive impact on the quality of patient care, which may then be reflected in reporting as improved clinical outcomes.
eaningful Use. (2010, March 16). Retrieved April 12, 2010 from Health Information Technology website: http://healthit.hhs. M gov/portal/server.pt?open=512&objID=1325&parentname=CommunityPage&parentid=1&mode=2 Overview of ARRA Funding, EHR Certification, and Meaningful Use. (2010, March 15). Retrieved April 12, 2010 from HIS Office of Information Technology website: http://www.ihs.gov/recovery/documents/Overview%20of%20ARRA%20EHR%20Cert%20 Criteria%20and%20MU.pdf
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The Technology Business process management, or workflow technology, can be used in healthcare to coordinate communication, send reminders, and automate tasks for staff in various roles and across a period of time. These processes can result in improved patient care, more complete documentation, and better adherence to hospital protocols. Many healthcare information systems (HIS) send or receive messages to communicate information between systems. Traditional integration and interfaces, such as HL7 V3 Messaging Standard, have been successfully deployed for years.4 These standards are the basis for communicating and exchanging data between healthcare systems and networks. For example, when a patient is admitted, hospital admission/discharge/transfer (ADT) systems will send an HL7 ADT message with the A01 code outbound to other systems that may need to know about the new patient. The need developed within healthcare systems to provide more robust coordination, orchestration, and even automation of some processes. Taking a page from other industries, the next evolution in healthcare IT was to create a healthcare information system built on a service-oriented architecture through which a workflow engine could be coupled.
Figure 1: Traditional HIS
Healthcare Information System • Clinical Documentation • Orders • Results • ....
Interfaces
In this way, the healthcare IT landscape exposes core functionality through events/services that workflow technology can use to drive clinical processes. Following the HL7 A01 example, the workflow concept allows information systems to go beyond communicating information about the new patient by helping to make certain that the patient’s care is coordinated within and between all the systems and people involved in patient care. The combined workflow/healthcare system should be able to follow up to ensure that the admitted patient had a completed admission assessment documented in the clinical information system and has been evaluated and started on the appropriate care plans for patient problems, such as skin breakdown and fall risk.
Specification Manual for National Hospital Quality Measures. Retrieved April 12, 2010 from QualityNet website: http://www. qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=114166275609
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V3 Messages. Retrieved April 12, 2010 from Health Level Seven International website: http://www.hl7.org/implement/standards/ v3messages.cfm
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Implementing a workflow-enabled healthcare system is only one aspect of an automated solution. Equally as important is the ability to evaluate both clinical and process data in a meaningful way, which will enable the hospital to derive knowledge and insight into the effectiveness of its processes and where improvements may be needed. Historically, clinical data warehouses have been a valuable medical research tool. If you wanted to look for effective medications for a certain diagnosis in a certain population, having a well-populated warehouse is invaluable. Manually performing chart reviews for any more than a handful of patients is simply too labor intensive for large-scale research. These clinical data warehouses are typically limited to just the clinical data entered for the patient into their medical records. There is a huge amount of process data that is often not captured or integrated into the clinical data within the warehouse. For example, the clinical data often doesn’t show how many phone calls were needed, how many escalations were sent, or how much time passed. By combining the process data from the workflow engine and the clinical data from the healthcare information system, a more complete picture of the patient care practices can be developed.
The integration of healthcare information system data, workflow engine process data and reporting analytics is known as Healthcare Process Management (HPM) by Siemens Healthcare. This is the technology platform that supports an organization through process management coupled with advanced analytics. The goal of this technology solution is to support a culture of continual process improvement within healthcare.
An Approach To Measuring Clinical Outcomes The Metrics that Matter program, developed by Siemens Healthcare, uses integrated workflow and analytics designed with the goal of helping providers improve clinical outcomes and report complex information for use by hospital administration and clinical leaders. This program addresses key clinical processes related to falls, pressure ulcers, acute myocardial infarction, heart failure, pneumonia, and venous thromboembolism. Each process includes a workflow, an electronic clinical documentation form in the HIS, and an analytics report.
Figure 2: Workflow-Enabled HIS
Workflow Engine
Healthcare Information System Services (SOA)
Add Patient to Census Add Problem Create Worklist Item Place Order Send Email
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Figure 3: HPM-Enabled HIS
Workflow Engine
Healthcare Information System Services (SOA)
Analytics
The workflow template provides a standard workflow design that can be implemented by a hospital. The workflow can provide notifications such as the availability of critical results. In addition, the workflow can automate portions of the care process based on hospital policy, such as the placing of consult orders. The workflow supports nursing in achieving more complete and on-time clinical documentation in a format that can be used directly by the reporting system. The HIS clinical documentation form used along with the workflow may be a standard pre-existing form of documentation, such as a fall risk or skin assessment. The workflow can pull already charted information from these existing forms and populate a new form that is used specifically for recording information that will be reported by analytics. Examples include the specific documentation forms designed for the capture of data related to diagnoses such as acute myocardial infarction and heart failure forms.
An analytics report mines and evaluates retrospective data that is documented in one or more HIS forms. This report is used to trend clinical outcomes related to a specific metric, and can be used to compare performance to hospital benchmarks as well as national benchmarks. Reports can be scheduled for generation at predefined times or can be generated on demand by clinical and administrative personnel. The report specifications include details defining the patient population inclusion and exclusion criteria, including factors such as the time period, age, diagnosis, and other defined criteria specific to the metric being reported. One example of the Metrics that Matter program is related to heart failure core measures. A workflow is implemented that identifies potential heart failure patients based on data entered, including admitting diagnosis and starts monitoring for new data such as test results and clinical care orders related to this diagnosis. The workflow queries the HIS database at twenty-four hours after admission to retrieve certain
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information then automatically pre-populates the heart failure documentation form with this information, precluding a clinician from having to look the information up and value the appropriate fields on the form. One example is that the workflow checks to see if the patient is a smoker, and if so, has smoking cessation education been documented. The corresponding fields on the heart failure form are then populated by the workflow. All information populated on the form by the workflow is presented to clinicians for validation. Some data that must be included in core measures reporting is not available in the database as discrete data. An example is the HF-2 measure, which includes an evaluation of the left ventricular systolic (LVS) function. The information that must be reported for this measure is whether a heart failure patient has documentation in the hospital record that the LVS function was evaluated before arrival, during hospitalization, or is planned for after discharge. Since this documentation is often done by physicians on a paper progress note in the patient chart, it most likely will not be available in the electronic patient record as a discrete data element. In these cases, a clinician such as a nurse or case manager, or possibly a chart abstractor, will document the information in the electronic heart failure clinical documentation form. The combination of automated data retrieval by the workflow and manual documentation provides
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a complete and efficient manner for collecting the data elements in the EHR for use by business intelligence for reporting metrics data. A workflow is also used to promote quality care and possibly improve outcomes. After the initial population of the heart failure form, the workflow sends notification alerts to the nurse, case manager and abstracter informing them that the patient is identified as having heart failure. This notification is an alert in the healthcare information system that includes a link to launch the heart failure documentation form that has already been started by the workflow. The workflow sends other alerts also designed to improve outcomes, including reminders to provide smoking cessation education or discharge instructions if not documented. Finally, an analytics report is used to retrieve data on discharged patients with a diagnosis of heart failure. The report collects and analyzes data from the heart failure documentation form as well as other patient data in the electronic patient record and other information systems. It is expected that an integrated design process for workflow, documentation, and reporting can lead to both improved clinical outcomes as well as more efficient and effective reporting. Initial feedback related to this implementation approach is positive, and actual results are expected to be available in late 2010.
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Siemens Medical Solutions USA, Inc. 51 Valley Stream Parkway Malvern, PA 19355-1406 USA Phone: +1-888-826-9702 www.usa.siemens.com/healthcare
Siemens Medical Solutions USA, Inc. Health Services 51 Valley Stream Parkway Malvern, PA 19355-1406 USA Phone: +1-888-826-9702 www.usa.siemens.com/healthcare
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