Leading health IT specialists at the Mayo Clinic, the Pentagon and elsewhere are touting a process to standardize tasks in electronic health records. They hope to bring the same kind of consistent quality in other data-heavy industries like manufacturing and banking — and avoid problems like those seen in the troubled rollout of the Pentagon’s new EHR system.
This spring, a group of health industry and technical experts released a field guide to sharing clinical activities through use of Business Process Model and Notation and related methods for reducing clinical steps to simple computerized orders. Many other industries use BPMN to standardize and optimize everything from assembly lines to money routing.
The group intends the field guide to create common language for expressing these health care processes so they can be understood consistently and accurately.
Currently, most health care systems use pictures of flow charts to describe how work gets done. Such charts, stored in loose-leaf binders or on hard drives, are difficult to access and don’t describe the steps in sufficient detail. Clinicians in a large health system might have thousands of ways to do a procedure. Some methods are efficient, while others are not and could be harmful.
The BPMN technology is “a few years away from being mainstream” in health care, said Ken Rubin, director of standards and interoperability for the Veterans Health Administration Office of Knowledge Based Systems, but there’s a crying need for it. “Putting ourselves as an industry in a position of being able to rapidly share and distribute good clinical practices across institutions could be a game-changer,” he said.
The work involves “transforming tacit information into explicit knowledge,” Col. Jacob Aaronson, an IT leader in the Pentagon’s Defense Health Agency, said at a recent conference sponsored by the Object Management Group. This knowledge lets the EHR help clinicians do their jobs more efficiently.
The field guide focuses on implementing parts of common clinical processes that an EHR can help standardize. Putting these processes in the business notation enables the EHR to walk clinicians and patients through their tasks according to standard protocols based on best evidence. BPMN also allows flexibility for clinicians to adapt to changing patient needs, said Jonathan Nebeker, deputy chief medical informatics officer at the VHA.
A specialty consult might offer a good target for BPMN to improve efficiency, he said. Specialists may require that certain tests be done before they see the patient in person, while the insurer may require a pre-approval. A model in BPMN can describe everything that computers and people need to do; the computer can see when tests aren’t done on time and remind the patient or the clinician to get with the program, literally, or move the tasks to someone else.
A big advantage of BPMN is that it is standard, so pathways encoded to it can be deployed by vendors or providers in many different computer systems, speeding the generation and sharing of best practices, Nebeker said.
As chief medical information officer for the military’s EHR transition team in 2014, Aaronson said, he attempted to standardize the Defense Health Agency’s business processes in preparation for moving from a homegrown to a commercial EHR. Application of the modeling process involves defining the clinical steps, creating the computer modules, training staff and then optimizing the EHR to support the system.
Through a combined process of mapping those “process steps” to either individuals involved in care practices, or computer modules that carry out those steps (such as laboratory orders) on behalf of a caregiver, common processes can be tailored to fit in clinics or hospitals of varying sizes and staffing.
“This was a really good idea, but we didn’t do it,” Aaronson said.
That may have contributed to the chaotic launch of the Cerner EHR at four military bases last year, during which clinicians complained of illogical workflows, wasted time and painstaking workarounds. “We were seeing problems of not having an understanding of the transitions from ambulatory to in-patient care; problems with understanding the end-to-end business,” he said.
Creating the standardized business processes requires specialists to spend a healthy amount of time figuring out what these processes consist of, then programming them individually into a workflow. Aaronson was unable to get the health agency to loan the specialists to his team, he said.
Some Department of Veterans Affairs officials also see the process as an important way to make health care more efficient. Several of them were working on it in the VHA.
“The way health care is done now, if you were to take a car factory, you’d come in the door, the lights are off, you carry the parts to this guy and he does a weld, then waits in line for the window guy, then runs into someone and gets lost. It’s the way we made cars before Henry Ford came along,” said Shane McNamee, a former VA official who is now with startup mdlogix. “There’s no reliability in the system.”
Cerner Corp. is developing some examples of the standard — for instance, modular versions of pediatric asthma treatment regimens — and incorporating them into its HealtheIntent population health management system, said Chief Medical Informatics Officer Marc Overhage.
“We have computerized decision support, but the idea of Business Modeling Processes and sister standards is to start to say, ‘Let’s take this to a higher level and make sure the health care processes are happening in a reliable, reproducible fashion,’” he said.
EHR vendor Epic also has shown some interest in the technology, as have major health care systems like Duke, Intermountain and the Mayo Clinic. The idea is to foster consistent health care across big institutions, said the VA’s Rubin.
The VA could use the standard pathways to promote best practices throughout the VA and share them with facilities in the private sector, where veterans get much of their care, he said. “If pathways are precise, repeatable and well-documented, it’s a big win for health care,” he said.