An Integrated Process for Co-Developing and Implementing Written and Computable Clinical Practice Guidelines.

The goal of this article is to describe an integrated parallel process for the co-development of written and computable clinical practice guidelines (CPGs) to accelerate adoption and increase the impact of guideline recommendations in clinical practice. From February 2018 through December 2021, interdisciplinary work groups were formed after an initial Kaizen event and using expert consensus and available literature, produced a 12-phase integrated process (IP). The IP includes activities, resources, and iterative feedback loops for developing, implementing, disseminating, communicating, and evaluating CPGs. The IP incorporates guideline standards and informatics practices and clarifies how informaticians, implementers, health communicators, evaluators, and clinicians can help guideline developers throughout the development and implementation cycle to effectively co-develop written and computable guidelines. More efficient processes are essential to create actionable CPGs, disseminate and communicate recommendations to clinical end users, and evaluate CPG performance. Pilot testing is underway to determine how this IP expedites the implementation of CPGs into clinical practice and improves guideline uptake and health outcomes.

An Evaluation Framework for a Novel Process to Codevelop Written and Computable Guidelines.

Clinical practice guidelines (CPGs) support individual and population health by translating new, evidence-based knowledge into recommendations for health practice. CPGs can be provided as computable, machine-readable guidelines that support the translation of recommendations into shareable, interoperable clinical decision support and other digital tools (eg, quality measures, case reports, care plans). Interdisciplinary collaboration among guideline developers and health information technology experts can facilitate the translation of written guidelines into computable ones. The benefits of interdisciplinary work include a focus on the needs of end-users who apply guidelines in practice through clinic decision support systems as part of the Centers for Disease Control and Prevention's (CDC's) Adapting Clinical Guidelines for the Digital Age (ACG) initiative, a group of interdisciplinary experts proposed a process to facilitate the codevelopment of written and computable CPGs, referred to as the "integrated process (IP)."1 This paper presents a framework for evaluating the IP based on a combination of vetted evaluation models and expert opinions. This framework combines 3 types of evaluations: process, product, and outcomes. These evaluations assess the value of interdisciplinary expert collaboration in carrying out the IP, the quality, usefulness, timeliness, and acceptance of the guideline, and the guideline's health impact, respectively. A case study is presented that illustrates application of the framework.

Multi-Method Study of Electronic Health Records Workflows.

EHRs transform work practices in ways that enhance or impede the quality of care. There is a need for in-depth analysis of EHR workflows, particularly in complex clinical environments. We investigated EHR-basedpre-operative workflows by combining findings from 18 interviews, 7 days of observations, and process mining of EHR interactions from 31 personnel caring for 375 patients at one tertiary referral center. We provided high-definition descriptions of workflows and personnel roles. One third (32.2%) of the time with each patient was spent interacting with the EHR and 4.2% using paper-based artifacts. We also mined personnel social networks validating observed personnel's EHR-interactions. When comparing workflows between two similar pre-operative settings at different hospitals, we found significant differences in physical organization, patient workflow, roles, use of EHR, social networks and time efficiency. This study informs Mayo Clinic's enterprise-wide conversion to a single EHR and will guide before and after workflow comparisons.

In Search of Vital Signs: A Comparative Study of EHR Documentation.

Vital sign documentation is an essential part of perioperative workflow. Health information technology can introduce complexity into all facets of documentation and burden clinicians with high cognitive load3-4. The Mayo Clinic enterprise is in the process of documenting current EHR-mediated workflow prior to a system-wide EHR conversion. We compared and evaluated three different vital sign documentation interfaces in pre-operative nursing assessments at three different Mayo Clinic sites. The interfaces differed in their modes of interaction, organization of patient information and cognitive support. Analyses revealed that accessing displays and the organization of interface elements are often unintuitive and inefficient, creating unnecessary complexities when interacting with the system. These differences surface through interface workflow models and interactive behavior measures for accessing, logging and reviewing patient information. Different designs differentially mediate task performance, which can ultimately mitigate errors for complex cognitive tasks, risking patient safety. Identifying barriers to interface usability and bottlenecks in EHR-mediated workflow can lead to system redesigns that minimize cognitive load while improving patient safety and efficiency.

Integrating Process Mining and Cognitive Analysis to Study EHR Workflow.

There are numerous methods to study workflow. However, few produce the kinds of in-depth analyses needed to understand EHR-mediated workflow. Here we investigated variations in clinicians' EHR workflow by integrating quantitative analysis of patterns of users' EHR-interactions with in-depth qualitative analysis of user performance. We characterized 6 clinicians' patterns of information-gathering using a sequential process-mining approach. The analysis revealed 519 different screen transition patterns performed across 1569 patient cases. No one pattern was followed for more than 10% of patient cases, the 15 most frequent patterns accounted for over half ofpatient cases (53%), and 27% of cases exhibited unique patterns. By triangulating quantitative and qualitative analyses, we found that participants' EHR-interactive behavior was associated with their routine processes, patient case complexity, and EHR default settings. The proposed approach has significant potential to inform resource allocation for observation and training. In-depth observations helped us to explain variation across users.

A Sequential Data Analysis Approach to Electronic Health Record Workflow.

Failure to understand clinical workflow across electronic health record (EHR) tasks is a significant contributor to usability problems. In this paper, we employed sequential data analysis methods with the aim of characterizing patterns of 5 clinicians' information-gathering across 66 patients. Two analyses were conducted. The first one characterized the most common sequential patterns as reflected in the screen transitions. The second analysis was designed to mine and quantify the frequency of sequence occurrence. We observed 27 screen-transition patterns that were employed from 2 to 7 times. Documents/Images and Intake/Output screens were viewed for nearly all patients indicating the importance of these information sources. In some cases, they were viewed more than once which may show that users are following inefficient patterns in the information gathering process. New quantitative methods of analysis as applied to interaction data can yield critical insights in robust designs that better support clinical workflow.

Optimizing perioperative decision making: improved information for clinical workflow planning.

Perioperative care is complex and involves multiple interconnected subsystems. Delayed starts, prolonged cases and overtime are common. Surgical procedures account for 40-70% of hospital revenues and 30-40% of total costs. Most planning and scheduling in healthcare is done without modern planning tools, which have potential for improving access by assisting in operations planning support. We identified key planning scenarios of interest to perioperative leaders, in order to examine the feasibility of applying combinatorial optimization software solving some of those planning issues in the operative setting. Perioperative leaders desire a broad range of tools for planning and assessing alternate solutions. Our modeled solutions generated feasible solutions that varied as expected, based on resource and policy assumptions and found better utilization of scarce resources. Combinatorial optimization modeling can effectively evaluate alternatives to support key decisions for planning clinical workflow and improving care efficiency and satisfaction.

Medication and indication linkage: A practical therapy for the problem list?

BACKGROUND: Establishing a relationship between medications and diagnoses within a functioning electronic medical record system (EMR) has many valuable applications,such as improving the quality and utility of the problem list to support better decisions. METHODS: We evaluated over 1.6 million de-identified patient records from the Regenstrief Medical Record System (RMRS) with over 90 million diagnoses and 20 million medications. Using RxNorm, the VA National Drug File Reference Terminology, and SNOMED-CT (SCT)standard terminologies and mappings we evaluated the linkage for local concept terms for medications and problems (diagnoses & complaints). RESULTS: We were able to map 24,398 candidates as medication and indication pairs. The overall sensitivity and specificity for term pairs was 67.5% and 86% respectively and 39.5% and 97.4 when adjusted for term pair occurrence within single patient records. CONCLUSIONS: Medications can be mapped by machine to a disease/ disorder using established terminology standards.This mapping may inform many knowledge management and decision support features in an EMR.

The cost of adverse drug events in ambulatory care.

BACKGROUND: Many justifications for ePrescribing predict savings achieved by reducing the number of adverse drug events (ADEs) in the ambulatory setting however, there is little evidence from which to estimate the size of these savings. Estimating the cost of ADEs in the ambulatory setting would improve the reliability of these predictions. METHODS: We identified patients with potential ADEs in a primary care practice setting and characterized the patient's age along with charge and utilization indicators for 6 weeks pre- and post-event. We then used linear regression to determine charges attributable to an ADE. RESULTS: Charges were higher for patients following an ambulatory visit who were determined to have ADEs. This occurred in a linear fashion: 2 ADEs ($4,976); 1 ADE ($2,337); and no ADEs ($1,943). The charge attributable to a single ADE is $643 (2001 US dollars) or $926 (cost adjusted to 2006 US dollars). CONCLUSIONS: Patients with ADEs incur greater charges. The charges attributable to an ambulatory ADE are a significant cost to the health care delivery system on the order of $8 billion annually.

Towards an intelligent hospital environment: OR of the future.

Patients, providers, payers, and government demand more effective and efficient healthcare services, and the healthcare industry needs innovative ways to re-invent core processes. Business process reengineering (BPR) showed adopting new hospital information systems can leverage this transformation and workflow management technologies can automate process management. Our research indicates workflow technologies in healthcare require real time patient monitoring, detection of adverse events, and adaptive responses to breakdown in normal processes. Adaptive workflow systems are rarely implemented making current workflow implementations inappropriate for healthcare. The advent of evidence based medicine, guideline based practice, and better understanding of cognitive workflow combined with novel technologies including Radio Frequency Identification (RFID), mobile/wireless technologies, internet workflow, intelligent agents, and Service Oriented Architectures (SOA) opens up new and exciting ways of automating business processes. Total situational awareness of events, timing, and location of healthcare activities can generate self-organizing change in behaviors of humans and machines. A test bed of a novel approach towards continuous process management was designed for the new Weinburg Surgery Building at the University of Maryland Medical. Early results based on clinical process mapping and analysis of patient flow bottlenecks demonstrated 100% improvement in delivery of supplies and instruments at surgery start time. This work has been directly applied to the design of the DARPA Trauma Pod research program where robotic surgery will be performed on wounded soldiers on the battlefield.