Visualization of Process Flows in Hospital Information Systems

Transcription

1 From the Research Group Assessment of Health Information Systems Visualization of Process Flows in Hospital Information Systems Master thesis to obtain the degree of Master of Science in Health Informatics at the University for Health Informatics and Technology Tyrol submitted by of Victoria, Canada Innsbruck, 2003 Private Universität für Medizinische Informatik und Technik Tirol University for Health Informatics and Technology Tyrol

2 Minder of thesis and examiner: Co-Examiner: Ass. Prof. Dr. Elske Ammenwerth a Univ. Prof. Dr. Reinhold Haux a a University for Health Informatics and Technology Tyrol Accepted by the examination committee on from

3 Executive Summary With processes in the healthcare setting being as complex as they are today, it is important that they be properly managed. The management of processes comprises planning, directing and monitoring and one newly evolving technique for the monitoring of processes is through visualization techniques such as alerts and reminders. This thesis describes how processes in the healthcare setting can be represented and structured so that different visualization techniques can be applied in different ways. Visualization techniques are broken down into two axis, that is, by type and by location. Visualization techniques by type are described as active alerts and passive reminders. By location they are broken down by where they can be received in the clinical environment, that is in space, on the person and on the computer interface. This representation of processes requires the breakdown of processes into different views, these being what tasks have been completed longer ago, what tasks have recently been completed, what tasks are currently being completed, what tasks are outstanding and what tasks need to be completed in the future. In this thesis, alerts and reminders are applied to each of the five mentioned process views in order to find the best type of visualization technique for each process view. In order to test the newly derived concepts, they are applied on hand of the discharge management process at the Innsbruck University Medical Center. Through a physician interview, the analysis and modeling of the discharge management process and through understanding the current implementation environment, two concrete implementation suggestions, one being the Test Summary Report and the other being the Pending Discharge Report are made and described in detail. The steps for an actual implementation are also laid out. The thesis ends with a discussion of the findings made and a look at what the next steps will be in this area of research in the future. Future steps will include the more practical application of alerts and reminders in the clinical setting to test their usability.

4 Expression of Thanks Thanks go to all those who were involved with this master thesis. A special thanks goes to Ass. -Prof. Dr. Elske Ammenwerth for minding this thesis, and especially for all of her continuous contributions, support and suggestions with regard to this thesis. Thank you also to Univ. Prof. Dr. Reinhold Haux for his support. Thanks also go to Dr. Wolf Stühlinger, Dr. Georg Lechleitner and Gabriele Polanezky for initiating this thesis, and Sabine Sobhani for her contributions in the cooperation with the Technical University of Berlin. Additionally, special thanks go to Dr. Immanuel Wilhelmy, and Mag. Gerhard Umshaus for their support in the implementation phase of this thesis. Thanks also go to Dr. Armin Muigg for his cooperation and support in obtaining physician feedback. Finally, a special thanks goes to my friends and family who were of great support throughout the duration of this thesis.

5 Table of Contents 1 INTRODUCTION TOPIC AND MOTIVATION Hospital Information Systems Complexity of Processes in healthcare Management of processes in healthcare Monitoring of processes in healthcare Visualization to monitor processes in healthcare PROBLEMS GOALS QUESTIONS ENVIRONMENT STRUCTURE BASIC PRINCIPLES INTRODUCTION BASIC TERMS REPRESENTATION OF PROCESSES Introduction Modeling techniques Summary VISUALIZATION Introduction Visualization as a monitoring technique Visualization with alerts and reminders Summary ALERTS AND REMINDERS Introduction Demands and effects of alerts and reminders Shannon s communication model Types of Alerts and Reminders Passive Reminders Active Alerts Location of Alerts and Reminders Alerts and Reminders Received in Space Alerts and Reminders Received on the Person Alerts and Reminders Received on the Computer Interface CONCLUSION ALERTS AND REMINDERS TO SUPPORT CLINICAL PROCESS FLOWS: NEW CONCEPTS INTRODUCTION BREAKDOWN OF PROCESS FLOWS Process View 1: Tasks which have been completed longer ago Process View 2: Tasks which have recently been completed Process View 3: Tasks which are currently being executed Process View 4: Tasks which are outstanding Process View 5: Tasks which will have to be completed in the future APPLICATION OF COMMUNICATION THEORY AND ALERTS AND REMINDERS TO SUPPORT PROCESS VIEWS Process View 1: Tasks which have been completed longer ago Process View 2: Tasks which have recently been completed Process View 3: Tasks which are currently being executed Process View 4: Tasks which are outstanding Process View 5: Tasks which will have to be completed in the future CONCLUSION APPLICATION OF ALERTS AND REMINDERS TO MONITOR THE DISCHARGE MANAGEMENT PROCESS...63 Page 5

6 4.1 INTRODUCTION ANALYSIS OF REQUIREMENTS FOR ALERTS AND REMINDERS: PHYSICIAN INTERVIEW Introduction Physician Interview Structure Physician Interview Results What hinders a clinician in their everyday work? What helps a clinician in their everyday work? Concrete examples Summary DISCHARGE MANAGEMENT : ANALYSIS AND MODELING Introduction Business Process Diagram Discharge Management Ordering of final tests Results reporting Discharge report writing Summary IMPLEMENTATION ENVIRONMENT : CERNER MILLENNIUM AND DISCERN EXPERT Introduction Cerner Millennium Discern Expert Summary RECOMMENDATIONS FOR IMPLEMENTATION Introduction Recommendation Suggestion 1: Test Summary Report Recommendation Suggestion 2: Pending Discharge Report Summary IMPLEMENTATION Introduction Comparison of Implementation Suggestions (TILAK and Master Thesis) Additional Suggestions Summary CONCLUSION DISCUSSION OF FINDINGS AND CONCLUSION ANSWERS TO THE QUESTIONS DISCUSSION FUTURE STEPS APPENDIX APPENDIX A RULE BASED TEMPLATE APPENDIX B PHYSICIAN QUESTIONNAIRE REFERENCES CURRICULUM VITAE Page 6

7 1 Introduction University for Health Informatics and Technology Tyrol 1.1 Topic and Motivation Hospital Information Systems A hospital information system is defined as a subsystem of a hospital which comprises all information processing as well as the associated human or technical actors in their respective information processing roles (Haux, Winter, 2002). Hospital information systems comprise work process flows, which in turn are also comprised of a variety of tasks, which are in turn interrelated and need to be optimized (Prijatelj, 1999). The interrelation of these complex tasks related to processes in hospital information systems can be supported through workflow techniques. Workflow entails the integration of multiple tasks and different applications into a single processing stream (Hastedt-Marckwardt, 1999) Complexity of Processes in healthcare As mentioned above, workflow is needed in order to support complex tasks in the healthcare environment, especially because process flows in many areas of healthcare have shown to increase in complexity over the past decades. Two of the major changes in the clinical environment include the ever increasing specialization of specific areas in medicine, and the fact that patients are continuously increasing in age and therefore are becoming ill in ways which were non-existent in the past (Haux, Winter, 2002). Increased specialization and changes in demographics result in more recent methods of patient care requiring a higher level of communication between physicians, nurses, and other clinicians. Communication and coordination with regard to medical processes takes place on a daily basis. This becomes complex when taking into account that the diagnostic and treatment process of a patient usually involves various organizationally more or less separate units (Dadam, Reichert, 1997). The increase in specialization also results in the increase in mobility of patients (Leiner, Gaus, 2001), which makes this communication an even more daunting task. Page 7

8 The two situations leading to an increase in complexity above in particular result in the work of physicians, nurses and other caretakers being burdened by numerous organizational and medical tasks. New types of diagnosis, therapies and more complex illnesses (Leiner, Gaus, 2001) prove to require greater coordination of complex tasks, thereby in turn also leading to more complex processes. This complexity in processes requires the aid of techniques such as workflow Management of processes in healthcare With processes in the healthcare setting being as complex as they are today, it is important that they be properly managed. The management of processes comprises planning, directing and monitoring. Planning is done before a process is carried out, directing during the execution of a process, and monitoring during the entire evolution of the process, from beginning to end. It is important to realize that there are many advantages that can be gained from a well managed process, including reduced hospital costs due to reduced patient lengths of stay, increased rates of success of patient treatment due to greater coordination of activities amongst clinicians, and greater levels of clinician and patient satisfaction through the proper coordination and relaying of information regarding activities and outcomes. On the flip side, it is to be emphasized that poorly managed process can have negative effects. One of the major causes that lead to poorly managed processes is the hectic of the clinical environment. There are several consequences that emerge as a result of this hectic, and of poorly managed processes in general. In particular, there are many problems that show up directly at the patient point of care. Tasks are often forgotten, or relationships between tasks not recognized. Poorly managed processes also result in physicians, nurses and other clinicians making diagnostic and therapeutic mistakes ((Reichert, 2000), (Dadam, Reichert, 1997)). Reichert (Reichert, Dadam, 2000) mentions numerous other unwanted effects that result from poorly managed processes including: Page 8

9 patients have to wait because resources like physicians, rooms, or technical equipment are not available, medical procedures may become impossible to perform if information is missing, preparations have been omitted, or if a preceding procedure has been postponed, cancelled, or requires latency time. Subsequent appointments may therefore also have to be changed which results in increases in time efforts, if results are missing but urgently needed, tests or procedures may have to be performed repeatedly, patient stays in hospitals may increase, costs of patient treatment increase, invasiveness of patient treatment may increase, and missing information may lead to late or wrong decisions being made. As described above, the outcomes of poorly managed processes are often not acceptable. The problems that are encountered as a result of these mismanaged processes could perhaps be elevated, such that clinicians can work in an environment where they aren t so much concerned with managing their work, rather, where they are concerned with treating their patients Monitoring of processes in healthcare As previously mentioned, processes in the healthcare environment need to be planned, directed, and monitored. Although each of these subtasks are important in management, monitoring seems to be insufficiently supported. Techniques for the proper monitoring of processes in healthcare haven t been developed as far as techniques for planning and directing. Project management techniques have been integrated into healthcare related projects in the past and have been found to be useful to plan and direct projects effectively. Monitoring techniques are still behind in their development phase. This is why monitoring is currently of such importance. The monitoring of processes includes monitoring current tasks, monitoring what current tasks resulted from, monitoring what outcomes current tasks will have, monitoring decision making, and monitoring the updating of processes. Each of these monitoring steps is related to each of the others. Page 9

10 The monitoring of all of these tasks in the healthcare environment is often labor intensive. Physicians often need to manually coordinate the tasks needed in relation to their patients. In this process, the physician must not forget all of the dependencies that may exist between tasks, and who must be informed of these dependencies. Physicians and nurses are confronted with an overwhelming amount of activities every day, which they need to fit together and put into relation to the problems of individual patients (Dadam, Reichert, 1997). A certain degree of visualization techniques would aid in monitoring processes. Complex decisions, however, are being made every day, often without the aid of specialized visualization techniques (Falkman, 2000). The clinical setting hasn t provided healthcare professionals with the concepts and techniques necessary to support the monitoring of complex processes. Poor process transparency has been a major culprit in making it difficult to develop these techniques and the whole idea of process transparency is currently lacking in many areas of the clinical environment. If processes became more transparent, techniques for visualization could be used to realize the needed monitoring of processes and therefore reduce the consequences of poorly managed processes in the healthcare environment Visualization to monitor processes in healthcare As mentioned above, there is a great need in hospital information systems to find techniques that can be used to support the monitoring of processes in hospital information systems. This is where visualization techniques come into play. The compulsion to visualize processes has been emphasized as a sequel to the immense increase in medical information and knowledge during the last decades (Falkman, 2000). Visualization is needed to keep processes in focus, and help support information and knowledge logistics. Information and knowledge logistics typically applies to data. However, the same rational can be applied to processes in general. Providing the right information and knowledge (about processes) to the right people, in the right form (such as through various visualization techniques), at the right point in time (such that processes can still benefit), in the right location (where clinicians can use the information to support their tasks), in a form which is comprehensible (Haux, Lagemann, 1998) could greatly enhance the flows of processes. Page 10

11 Some prerequisites for visualization include analyzing current medical, care taking and administrative process flows and relationships between them and current applications. Weaknesses need to be found, and then the processes optimized ((Dadam, Reichert, 1997), (Reichert, 2000), (Knorr, Calzo, 1999)). Only then can concepts for the implementation of visualization techniques be defined. Concepts for the visualization of process flows need to be explored in greater detail so that the benefits realized in other industries (such as the automobile industry) can also be realized in healthcare. However, before the techniques employed in other industries can be applied in healthcare, hospital information systems must be prepared and built such that they can support these visualization techniques. A hindrance in the way of currently applying visualization techniques to monitor process flows is that clinical information processing is still currently based on data and functions, not on processes. Data based information processing doesn t support processes well because events or tasks often occur as single entities, not in relation to each other. These relationships between tasks are needed in order to properly visualize a process. In the past years however, there has been growing interest to support entire hospital functions through process oriented hospital information systems (Reichert, 2000). This seems to be a step in the right direction. In the clinical setting, processes of different complexity and duration can be identified and tasks often need to be performed in a certain order, sometimes with a given minimum or maximum time distance between them (Dadam, Reichert, 1997). By identifying and breaking down these tasks, visualization techniques can be introduced. Visualization techniques could alert a physician or other healthcare professional of tasks that need to occur in order for a process to occur smoothly. These techniques should be simple, meaningful, and purposeful. There is however currently still only very little known about visualization techniques in healthcare. It still needs to be derived what sort of impact visualization techniques can have in the clinical setting (Krall and Sittig, 2001), and whether techniques of visualization can even be applied in a meaningful fashion at all. Page 11

12 Physicians, nurses and other clinicians could benefit from techniques implemented to improve the visualization of data in the decision-making and learning processes (Falkman, 2000). Clinicians currently spend a great amount of time carrying out, working on, and searching for their specific tasks in processes (Reichert, 2000). Visualizing processes could release clinicians from these organizationally driven tasks, and increase the amount of time they have for caring for patients. With less attention needed in the area of processes, more attention could be paid to patient care. 1.2 Problems Concepts and techniques needed for the visualization of processes currently don t exist. Due to this, it needs to be explored which concepts and techniques could be purposely implemented to visualize processes in such a way that physicians and other health care professionals can reap benefits from the introduction of this new form of support. Processes need to be monitored such that clinicians receive all of the information and knowledge that they need for patient care through proper information and knowledge logistics. Exploring the implementation of new concepts is important, as these concepts need to support clinicians in such a way that they promote, not hinder, daily processes. It is important that these concepts be tested in a clinical environment in order to determine their use and practicality. P1. There are uncertainties regarding which concepts and techniques exist for the visualization of standardized process flows. P2. It is unclear which of these concepts and techniques for the visualization of standardized process flows are of use and applicable in hospital information systems. P3. It is unclear whether and how these concepts and techniques for the visualization of standardized process flows can be implemented. Page 12

13 1.3 Goals University for Health Informatics and Technology Tyrol The goal of this master thesis is to explore which concepts and techniques for the visualization of process flows exist. These concepts and techniques need to be put in relation and applied to processes in the health care environment in a concrete example in order to explore their use and meaningfulness in this particular setting. This example will take place at the Innsbruck University Medical Center. G1. The goal is to analyze which general concepts and techniques exist for the visualization of standardized process flows. G2. The goal is to ana lyze which concepts and techniques are meaningful for the visualization of standardized process flows in hospital information systems. G3. The goal is to analyze and empirically examine which concepts and techniques for the visualization of standardized process flows can be implemented in the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center. 1.4 Questions Q1. Which general concepts and techniques exist for the visualization of standardized process flows? Q1.1 How can processes adequately be represented to visualize standardized process flows? Q1.2 How can alerts and reminders be used to visualize process flows? Q1.3 What types of alerts and reminders exist and where can they be located to apply them appropriately in a hospital information system? Q2. Which concepts and techniques for the visualization of standardized process flows found in Q1 are suitable for implementation in a hospital information system? Page 13

14 Q2.1 How can process flows in hospital information systems be broken down? Q2.2 How can alerts and reminders be applied to process flows? Q3. Which concepts and techniques for the visualization of standardized process flows found in Q2 are meaningful to be implemented in the discharge management process of the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center? Q3.1 What requirements exist for the implementation of alerts and reminders in the discharge management process of the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center? Q3.2 How can various parts of the discharge management process of the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center be modeled? Q3.3 What implementation environments exist to implement alerting and reminding techniques in the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center? Q3.4 What implementation suggestions can and will be implemented in the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center? Page 14

15 1.5 Environment University for Health Informatics and Technology Tyrol The Tyrolean Provincial Hospitals (TILAK, 2002) have been working towards defining standardized process flows at the Innsbruck University Medical Center for a longer period of time. In the future, the TILAK would like to introduce standardized and visualized process flows so that recognizable use and process improvements can be realized. At the present, two parallel projects that deal with the standardization and visualization of process flows are being carried out at the TILAK. The first project encompasses a system analysis and strength and weakness analysis of discharge management on two hospital wards. A definition as well as the introduction of the new process (based on previous work in Austria) should be defined based on these analyses (anticipated to be paper-based). The second project encompasses supporting the introduction of standard processes through the visualization of process flows in the hospital information system. This master thesis occupies itself with the second project. First, it needs to be found out which concepts and techniques exist for the visualization of standardized process flows. Following this, these concepts and techniques will be put in relation to the hospital information system environment, and then concretely applied on hand of the discharge management process at the Innsbruck University Medical Center. Discharge management is a very extensive and important part of patient care. Many activities need to be clarified and carried out in a timely fashion so that patients, physicians, nurses, and other clinicians are all adequately prepared for a patient s discharge. Some of these activities include carrying out tests, receiving the results from these tests, filling out forms and writing reports, completing all appropriate patient rounds, contacting other healthcare professionals within and outside of the providing institution, carrying out specific medical procedures or preparing for transfers to other institutions, all within an appropriate amount of time. Discharge management was chosen as a suitable process because it can be analyzed well and is of moderate complexity. Page 15

16 1.6 Structure University for Health Informatics and Technology Tyrol The master thesis will contain both basic principles in the area of techniques and concepts needed for the visualization of process, as well as newly derived theories and concepts concretely applied to hospital information systems. The thesis will also concretely employ these newly derived theories and concepts in an example. The structure of the thesis will be as follows: 1. Introduction The introduction comprises a detailed project plan, including the topic and motivation, problems, goals, questions, boundaries, schedule, as well as this structural outline of the master thesis. 2. Basic Principles The basic principles section mainly focuses on finding information in the literature regarding visualization, and concepts and techniques which could be implemented for the visualization of process flows. 3. Alerts and Reminders to Support Process Flows: New Concepts The new concepts section comprises a detailed examination of how the techniques and concepts found in the basic principles section can be applied in a hospital information system. 4. Application of Alerts and Reminders to Monitor the Discharge Management Process The example of discharge management is used to concretely apply the theories and new concepts on hand of a real life example. This section describes this application. Page 16

17 5. Discussion of Findings and Conclusion This section focuses on describing the outcomes and conclusions with regard to each of the above sections. Page 17

18 2. Basic Principles 2.1 Introduction In the clinical setting, it is becoming more and more difficult for physicians, nurses, and other clinicians to keep track of patient s processes. This is in part due to the sometimes overwhelming amount of data and information which clinicians are being faced with nowadays. This overload sheds light on the need for a way to provide clinicians with techniques that better allow them to visualize the important data and information that is necessary for them to make their care taking decisions, and to work through their patient care processes. There are various techniques already available that could be used to support clinicians in their practice. However, they must be used in proper combination to make the best use of them. For instance, modeling techniques can be applied to electronic patient records in order to represent processes, which in turn could then be used to define areas where visualization techniques could be applied to support these processes. In this basic principles section, first of all, some basic terms will be introduced and defined in order to help guide the reader through various terminology in this thesis. Following this, the ideas mentioned above will be described in greater detail. More specifically, ideas regarding the representation of processes on hand of various process modeling techniques and concepts of visualization including some visualization techniques such as alerts and reminders will be described on hand of various examples. 2.2 Basic Terms Throughout this thesis there are various terms which may be new to the reader. This is why it is important to define these such that the meaning of each term is conveyed properly. These terms and their descriptions can be seen in the following list: Page 18

19 Information System (IS) An information system is that part of an enterprise which processes and stores data, information and knowledge. It can be described as the socio-technical subsystem of an enterprise which comprises all information processing as well as the associated human or technical actors in their respective information processing roles (Haux, Winter, 2002). Hospital Information System (HIS) The socio-technical subsystem of a hospital, which comprises all information processing as well as the associated human or technical actors in their respective information processing roles (Haux, Winter, 2002). Electronic Patient Record (EPR) A patient record encompasses all data and documents that are produced and deal with the medical care of a patient in an organization. An electronic patient record is then a patient record which is stored on a computer (Leiner, Gaus, 2001). Process A process is a series of repetitive tasks with a definable start and end, and is well-defined in terms of input, transformation and output of values for entities, relationships and attributes (Holland and Janzen, 2002). Clinical Process A process which takes place in the clinical environment. Task A task is a basic unit of work (Oxford, 2002). When many tasks are combined, an entire process can be formed. Alert A tool promoting a user to consider information in making a decision or performing an action. An alert suggests urgency and perhaps exigency (Krall, 2002). Reminder A tool promoting a user to consider information in making a Page 19

20 decision or performing an action. A reminder is a form of a memory aid and connotes less threat than an alert (Krall, 2002). Visualization Visualization is the power or process of forming a mental picture or vision of something not actually present to the sight (Oxford, 2002). From the process oriented aspect, it seeks to find meaning in unexplored data and to summarize large amounts of data into smaller and more clear representations (ATKOSoft, 1997), which can be meaningfully used by humans to recognize patterns in processes. Visualization can be used in order to communicate, explore, analyze, understand and learn from data (Falkman, 2000). From a human aspect, visualization can be seen as a type of memory aid (Krall, 2002). 2.3 Representation of Processes Introduction The clinical environment is seen as an environment consisting of many diverse processes. A process is a series of repetitive actions with a definable start and end, and is well-defined in terms of input, transformation and output of values for entities, relationships and attributes (Holland and Janzen, 2002). In the clinical setting, processes can often be supported by information systems. Hospital information systems, and more specifically electronic patient records, for example, serve as a basis for providing clinicians with the data and information that they need to carry out their everyday processes related to patient care. Hospital information systems, and once again more specifically electronic patient records, however, can only facilitate the visualization of processes in the clinical environment if they are structured appropriately. With proper structuring, it is meant that data and information should be chronological, time dependent, correct, useful, etc.. The proper structuring of the electronic patient record opens the door to many Page 20

21 possible techniques to enhance the conveyance of this data and information. For example, various techniques can be applied to model these processes, allowing the recognition of areas where visualization techniques could meaningfully be applied. The next section describes various ways in which a process can be represented, with a focus on some of the positive and negative aspects of each technique Modeling techniques There are various methods available to represent, or model, processes in the clinical setting. Most of these methods are of graphical nature. Methods include such models as business process diagrams, time-based diagrams and procedure modeling (Haux, Lagemann, 1998). Each technique is unique in its own way, and the positive and negative aspects of each technique will be discussed in the following paragraphs. One type of process modeling technique is the business process diagram. This technique provides a method for modeling a sequence of events while taking into account things which must be executed (Haux, Lagemann, 1998). This modeling technique is good because it displays process activities, their dependencies, their order and states of objects. It also provides the possibility to illustrate who carries out which process activities. It also allows for the illustration of reiterations in processes. A downfall of this process modeling technique is that it is sometimes hard to follow when a large process has been modeled. A second downfall may be that dependencies between activities may not be obvious or clear in all cases, which makes it hard to model them. There are various meta-models available to model a business process. Some examples of meta-models include event-driven process chains, UML activity diagrams and Petri nets. An example of a business process diagram, using the UML modeling technique can be seen in Figure 1. Page 21

22 23. Divide into portions on Bands 1 and Diet Kitchen cooks special meals 25. Band 1: Put items on tray 26. Band 2: Put items on tray 27. Transport service brings meals to wards 28. Distribution of meals Figure 1: Example of a part of a business process diagram showing a sequence of events and the dependencies between them. Another type of process modeling technique is the time-based diagram. A time-based diagram models the dependencies between process activities through displaying how much time is allowed to execute each activity. Some positive aspects of this modeling technique are that it is clear which activities are part of a process and how they are related (through time). A downfall, however is that this modeling technique does not illustrate who is responsible for which activity. It also doesn t allow for the modeling of reiteration in processes. An example of this type of modeling technique can be seen in Figure 2. Page 22

23 Figure 2: An example of a time-based model showing dependencies between activities through time A third type of modeling technique to be described here is procedure modeling. Procedure modeling is a way to structurally represent processing activities which describe which activities must be executed in a particular setting (Haux, Lagemann, 1998). This type of modeling technique has a few positive aspects, mainly being that it is a simple technique, it is easy to understand and it has the ability to reduce complexity in processes. It s ability to reduce complexity in processes however may perhaps also be a downfall of this technique, as a lot of important information may be missing in the model. Another downfall is that there is no specification of which individual is responsible for what, and there is also no way to see how different parts of the process are dependent on each other, or where a process may reiterate. That is, it is basically a listing of activities which take place in a process, but it isn t a tool which can represent an actual flow of a process. An example of procedure modeling can be seen in Figure 3. Page 23

24 Clinical Documentation Nursing Documentation Nursing Anamnesis Nursing Planning Nursing Protocol Physician Documentation Nursing Report Figure 3: An example of a procedure model, showing activities which must be carried out in a particular setting Summary In summary, it is clear that there are various techniques which can be used to model processes. Each of them in themselves are valuable and unique, and it must be decided, based on what the outcomes or effects of modeling should be, which is the best one for a particular situation. The three techniques described above, that is, business process diagrams, time-based diagrams, and procedure modeling, all have their advantages and disadvantages. Once a process has appropriately been modeled, various visualization techniques can be defined and applied. These visualization techniques will be described in greater detail in the following section. Page 24

25 2.4 Visualization Introduction University for Health Informatics and Technology Tyrol Visualization can be many things. From the point of view of the human aspect, generally speaking, visualization can be simply seen as a type of memory aid (Krall, 2002). More specifically, visualization is the power or process of forming a mental picture or vision of something not actually present to sight (Oxford, 2002). This can help give humans insight to and maintain focus with regard to complex phenomena (for example, complex processes) (ATKOSoft, 1997). The ability to maintain greater focus of phenomena provides humans with a greater opportunity to monitor processes in their surroundings and, for example, to decrease undesirable variations in practice (Krall, 2002). When visualization is seen from the process oriented aspect, it seeks to find meaning in unexplored data and to summarize large amounts of data into smaller and more clear representations (ATKOSoft, 1997), which can meaningfully be used by humans to recognize patterns in processes. Visualization can be used in order to communicate, explore, analyze, understand and learn from data (Falkman, 2000). Visualization can also be described as a monitoring technique. That is, it can provide people with the opportunity to better understand and interpret the world around them (Krall, 2002). Various factors come into play in this interpretation, including personal, cognitive aspects as well as process related aspects. Both play a major role in visualization. These two components are closely interrelated and both frequently appear in the healthcare setting. For example, hospital information systems receive a significant amount of data and information required for patient care through automated interfaces (such as to labs, bedside instruments, dictation systems, decision support systems, healthcare professional workstations, etc.) (Gardner, Kuperman, 1999). An even larger amount of data is entered manually into hospital information systems by physicians, nurses, and other clinicians. These data and information are needed and are part of processes, which are in turn carried out by humans who cognitively have Page 25

26 the ability to recognize patterns in these processes. Without the proper structuring and delivery of this information however, clinicians may often be faced with information overload. Benefits could be realized if data and information were presented in a way which would allow humans to better recognize those patterns an thus better understand and interpret processes (Gardner, Kuperman, 1999), (Holzinger, 2001). This support would also allow increased efficiency in the monitoring of tasks and processes. This presentation of data and information in a meaningful manner is often referred to as visualization. Summarizing, visualization entails many components, including human and process oriented components. It is clear that monitoring through visualization could bring many benefits in the healthcare environment where humans are constantly making decisions based on processes. However, visualization must be implemented in such a way that it helps, not hinders, humans in their decision making processes Visualization as a monitoring technique Visualization can be implemented to aid in the planning and execution of tasks. However, emphasis should be put on the ability of visualization to aid in the monitoring of all tasks from the start to the end of a process (Reichert, 2000). As mentioned in the last section, visualization must be carried out in a way such that it helps, not hinders, humans (Krall, 2002). Generally speaking, visualization most efficiently supports monitoring tasks when it presents and allows data and/or information to be realized in one view. With this it is meant that the receiver of the visualized data or information should be able to process this newly displayed phenomena all at once, not step by step (Holzinger, 2001). As mentioned in the motivation to this thesis, the monitoring of processing includes the need to monitor current tasks, monitoring what current tasks resulted from, monitoring what outcomes current tasks will have, monitoring decision making, and Page 26

27 monitoring the updating of processes (see Table 1). Various visualization techniques can be used to support various of these activities including, more specifically, what tasks have been completed, which tasks are still outstanding, and which tasks will still have to be completed in the future (see Table 2). A visualization technique should also give the user an idea of where his or her tasks or activities fit into an overall process (Reichert, 2000). What needs to be monitored? Current tasks What current tasks resulted from What outcomes current tasks will have Decision making Updating of processes Table 1: Listing of what needs to be monitored in a process in the clinical setting. Breakdown of monitoring tasks to be visualized Tasks which have been completed longer ago Tasks which have recently been completed Tasks which are currently being executed Tasks which are outstanding Tasks which are to be completed in the future Table 2: Listing of monitoring tasks which can be visualized through various techniques in the clinical setting. Visualization should provide a user with enough information to realize activities, but not with too much information. An information overflow such as through redundant visualization can often result in negative effects such as users becoming frustrated (Krall, 2002) and losing the general overview of their tasks. A user may not only assess visualization based on how much information it portrays, but also on subject domain, relevance to the particular circumstance, and context of the user s current task and focus of attention (Krall, 2002). It is evident that there are many ways that visualization can aid humans, but there are also many sensitive areas where visualization may go astray. Such areas include the variety of goals of visualization Page 27

28 that may exist, the type or dimensionality of data which is to be represented, and the dimensionality of the visualization technique which is to be used (Zorman, Stiglic, 1997). With increasing complexity of data and information to be visualized, there is also an increasing emphasis on visualizing it in a suitable manner. In summary, the emphasis on enhancing and improving visualization techniques and ensuring that they are implemented properly leads to the need to further develop techniques for the visualization of data and information in the decision making process in the healthcare environment (Falkman, 2000). The monitoring tasks which can effectively be visualized in the healthcare environment include which tasks have been completed longer ago, which tasks have recently been completed, which tasks are currently being executed, which tasks are outstanding and which tasks need to be completed in the future Visualization with alerts and reminders As mentioned above, there is a need for the development of techniques to support the monitoring of processes in the healthcare environment. Processes can be monitored through a variety of different visualization techniques. These techniques include anything which could help clarify and guide clinicians through processes in the clinical setting. For example, this may include anything from flow diagrams, to pictograms, to regular meetings with co-workers. Another example of a visualization technique is the use of alerts and reminders. This thesis focuses on this type of visualization technique, as it has been found to be successful not only in the clinical environment, but also in various other environments (for example, the automobile industry and in finance). Alerts and reminders are techniques which can be used interchangeably. A reminder is an example of a technique which can be used to aid in memory and displays very little threat (Oxford, 2002), (Krall, 2002). An alert can be seen as a notification (InvestorWords, 2002) in a stronger sense. Alerts often have a higher degree of urgency than reminders. Both alerts and reminders prompt a user to consider information in making a decision or performing an action (Krall, 2002). Because of Page 28

29 their interchangeability, alerts and reminders can be seen on a continuum as shown in Figure 4. Visualization technique Reminders Low Alerts High Urgency Figure 4: The continuum of reminders and alerts from low to high urgency. Alerts and reminders have also been implemented successfully in select cases in the healthcare industry (Bales, Austin, 1996, Hunt, Haynes, 1998, Shea, DuMouchel, 1996) (Rind, Safran, 1994) (Bradshaw, Gardner, 1988) (Raschke, Gollihare, 1998)), where there are a plethora of factors which come into play which may make the proper use of these visualization techniques less simple Summary Summarizing, alerts and reminders are both examples of techniques for visualization, but it must be remembered that they must be designed in such a way that they help, not hinder, the workflow of their user. The following section will describe the demands and effects of alerts and reminders, will describe how communication theory ties in with the use of alerts and reminds and will outline various types of alerting and reminding techniques with specific examples of each type. It will also outline the pros and cons of each visualization technique, with a focus on the healthcare setting. 2.5 Alerts and Reminders Introduction There are many different types of alerts and reminders that could, perhaps successfully, be implemented in a healthcare setting in order to help monitor processes more effectively through visualization. Each of these techniques must be Page 29

30 examined first though in order to determine their use in a clinical setting (Rind, Safran, 1994) (Raschke, Gollihare, 1998). A special emphasis must also first be laid on the demands and effects that alerts and reminders have in the clinical setting, as well as how these alerts and reminders can best be communicated. Techniques for alerting and reminding can be broken down into various categories. Some authors choose to break them down into their type, that is, whether they are active or passive (Krall, 2002). To add another dimension, for the purpose of this thesis, the breakdown of techniques is based on not only whether the alert or reminder is passive or active, but also the location of where the alerts and reminders are received by a clinician Demands and effects of alerts and reminders Alerts and reminders must be implemented such that they help, not hinder, clinicians in their everyday work. In order to implement them properly, various criteria and circumstances need to be evaluated. Users of systems which currently exploit the advantages of alerts and reminders have mentioned that more alerts often make a system more useful, but less easy to use (Krall, 2002). A fine line must be drawn between system usefulness and system use. One must not be compromised by the other. There is also a fine line between how alerts and reminders are presented and how users perceive them. The presentation of alerts is critical in determining their success. A major challenge in visualization is to present alerts and reminders to the appropriate individual, at the right point in time, along with an appropriate amount of information needed to complete the certain task (Gardner, Kuperman, 1999), (Dadam, Reichert, 1997), (Reichert, 2000). Initially determining who to alert or remind and what specific technique should be used is problematic (Gardner, Kuperman, 1999). Other factors also come into play, including the reallocation of tasks if the originally alerted or reminded person for some reason isn t able to carry them out (Reichert, 2000). Page 30

31 Alerts and reminders should be designed to be actionable, supportive of clinical practice and compatible with desired workflow (Krall, 2002, Warren, 1999). In principle, an alert or a reminder is an interruption in a user s workflow which in itself contradicts the fact that visualization techniques should not disturb workflow. This is why alerts and reminders need to be designed such that they are minimally disturbing and in end effect help a user in their process. There are a variety of different ways to display various degrees of alerts and reminders. The content of an alert or reminder is critical, but other characteristics such as size, color, shape, auditory cueing and other design elements may greatly influence a user s perception of the use of this type of visualization technique (Holzinger, 2001, Krall, 2002). A means to actually carrying out the steps that the visualization technique is displaying a user with is also crucial. An alert or reminder is practically useless if the user cannot understand the alert or reminder or has no means of continuing with a process. The individual user s perception of an alert or reminder is therefore key in determining it s success. Users in some situations may feel annoyed by alerts or reminders when they come at inappropriate times, when alerts and reminders appear with too high a frequency, or when they display data or information which has already been processed (Krall, 2002). In these cases, users may tend to avoid alerts and reminders altogether (Krall and Sittig, 2001) (Rind, Safran, 1994), leading to them becoming useless. This may also have the effect that alerts and reminders become less useful for other users of the same system, as these alerts and reminders are often interrelated and require the consistency of use for processes to be optimally supported. Another major problem with regard to alerts and reminders is that if they are not implemented properly, as mentioned above, users may begin to feel criticized (Krall, 2002). Users don t want to have the feeling that the alerting and reminder system sees them as being unable to remember their own tasks. It is clear that there are many aspects that must be taken into account when considering the implementation of alerts and reminders in the clinical setting. As in many situations, costs must be weighed against the benefits in order to attain a best Page 31

32 fit scenario. Other factors that come into play include weighing system use with system usefulness, deciding on how alerts and reminders are to be presented and how the user perceives them, and the logistics of alerting and reminding. The following section also describes communication, on hand of Shannon s communication model, as an important part of alerting and reminding in the clinical setting Shannon s communication model Before alerts and reminders can effectively be applied to support process views in the clinical setting, effective communication techniques must be taken into account. Each alerting and reminding technique has its own advantages and disadvantages, which will be discussed in following sections. However, knowing the advantages and disadvantages of each single technique is not enough to decide on which technique for visualization would work the best in a particular setting or situation. Certain theories of communication must also be taken into account. Perhaps the most well known communication model is that of Claude Shannon, who in 1948, devised a model of a communication system that is especially distinctive for its generality (Wyner, 1997). Because of this generality, it can also be applied in the case of the communication of information to clinicians through alerts and reminders. Figure 5 displays Shannon s communication model. Page 32

33 University for Health Informatics and Technology Tyrol Figure 5: Claude Shannon s communication model displaying how a message is transmitted through a certain communication medium, how it is affected by noise, and how and where it is received (Tschudin, 2000). In this model, it can be seen that there are quite a few important factors that come into play during communication. These factors are: the information source, the transmitter, sources of noise, the receiver, and the destination. In Shannon s model, the message which is communicated is also referred to as a signal. This model is especially appropriate in the case of alerts and reminders because they also pass through such a communication flow in order to be transmitted from the origin to the receiver. In the case of alerts and reminders, as to be described in greater detail below, the origin is often the hospital information system, and the receiver is the clinician. Not only the origin and the receiver though play an important role in alerting and reminding. Each other part of Shannon s model is also important and plays a key role when transmitting alerts and reminders. The information source is a very important part of the model. Without this, communication can t take place because there would be no message to be transmitted. In the case of alerts and reminders, the information source is most frequently the hospital information system. Data and information in the hospital information system must be kept such that alerts and reminders can be defined and Page 33

34 transmitted appropriately. That is, the data must be appropriately structured and correct. The transmitter, as displayed in Shannon s model, in the case of alerts and reminders, would be the actual alerting and reminding technique. That is, it would be the active or passive alert on the person, in space, or on the computer interface. The correct type of transmitter of the message must be chosen in order to be effective for the particular task at hand. Noise, in the case of Shannon s model could be anything hindering the transmission of a message. There are many sources of noise in the transmission of alerts and reminders in the clinical setting. Sources of noise will be described in greater detail in future sections of this master thesis. Examples include that an alert or reminder received in space could be interfered with by noise in the clinical surroundings (e.g. other pagers, telephones, verbal communication between professionals and patients, etc.). An alert or reminder received on the person may be affected by noise such as poor hearing and an alert or reminder received on the computer interface could be affected by noise such as poor interface design. All of these noise factors must also be taken into account when defining which type of alert or reminder to implement in a particular situation. In the case of alerts and reminders in the clinical setting, the receiver and the destination, as modeled by Shannon, come hand in hand. The receiver is the person who the message is intended for, and the destination is the location where the receiver acknowledges the message. These two factors are very important in that they decide whether or not the person who the alert or reminder is intended for receives his or her message in a form which is appropriate for that situation. It is clear that there are many factors that come into play when implementing alerts and reminders in the clinical setting. Each of these must be taken into account and thoroughly thought through in order to arrive at the best possible solution in each particular clinical situation. Tying in concepts related to Shannon s communication theory is important when defining which alerting and reminding techniques are Page 34

35 appropriate for particular situations. Taking into account such things as the information source, the transmitter, noise, the receiver and the destination with regard to each alert and reminder is of great importance. Each alerting and reminding technique must be analyzed to arrive at its best fit in the case of each process view which will be discussed in greater detail later on. As previously mentioned, alerts and reminders can be broken down in various ways, such as by location and type of alert or reminder. With location of an alert or a reminder it is meant, where the alert or reminder is received by an individual. For the purpose of this thesis, location has been broken down into three subcategories: on the person, on the computer interface and in space. An example of an alert or reminder which can be received on the person can be a message on a pager. An example on the computer interface may be a flashing light on the monitor indicating that a task is incomplete. An example in space may be a flashing light in a nursing station. With regard to the type of alert or reminder, it is meant whether the alert is passive or active. Reminders are often passive, and alerts are often active. The following sections will describe each type of alert and reminder in detail. First, passive and active alerts will be described with a focus on their distinctive uses. This will be followed by a description of the different locations where an alert or reminder can be received. The positive and negative aspects of each location will be included in this description, and examples of design aspects of each type will be given. A special focus will be put on how users cognitively receive and perceive the different types of alerts and reminders Types of Alerts and Reminders Passive Reminders Passive in itself refers to inactively working or operating, and not exerting force or influence upon something (Oxford, 2002). A reminder is passive and can more easily be ignored (doesn t necessarily have to be acted upon), is displayed and available in the background (Krall and Sittig, 2001), and is generally minimally invasive and urgent. Page 35

36 Reminders, in the clinical setting, are mainly used to inform clinicians of tasks which are fairly routine, discrete and things that are somewhat easy to remember (Krall and Sittig, 2001, Rind, Safran, 1994). They are often used as more of a reminder than for an alert because they are less sensitive to the reaction of the clinician. They therefore often provide only a minimum amount of information to the receiver (Krall, 2002). Passive reminders such as s waiting in an inbox (see Figure 6) can often be postponed because they often don t have a necessary critical response time. Figure 6: A passive reminder such as an waiting in an inbox can easily be postponed, ignored, or forgotten about altogether. A major difficulty associated with passive reminders is the decision of when to implement them, if at all. Routine tasks, for example, may be perceived differently by different clinicians. For example, a gynecologist may perceive a yearly pap test as being something that he or she doesn t need reminding of. However, another physician may need the reminder to inform his or her patient of the necessity for this test (Krall and Sittig, 2001). It is important to note that the overuse of passive reminders (as well as active alerts) may hinder a clinician s work. System designers are often eager to implement a plethora of alerting and reminding techniques with the intention to support clinicians Page 36

37 in their decision making processes. Even if a clinician isn t forced to directly act upon a certain reminder, too many can be time consuming and therefore disturb workflow, leading users of these techniques to often tend to override these visualization techniques (Holzinger, 2001, Prijatelj, 1999, Raschke, Gollihare, 1998, Rind, Safran, 1994) Active Alerts Active in itself refers to something existing in action, working, being highly effective, and having practical operation or results (Oxford, 2002). An alert is active and is fairly intrusive to the receiver. It often demands more immediate attention than a passive reminder (Krall and Sittig, 2001). That is, an active alert often forces the receiver of the alert to act upon it immediately. In many cases, the alerted task is urgent and must be carried out before the previous or next task can be carried out. Before going into further detail, it is important to note that there is no actual fine line between passive reminders and active alerts. Some may say that a certain visualization technique is passive, while others may say it is active. Basically, passive reminders and active alerts both exist in a continuum. Active alerts in the clinical setting are more often used as an alerting technique, not a reminding technique, since they often force the receiver of the alert to respond immediately (Krall, 2002). Active alerts are most often used in situations where a task is less easily remembered on one s own or if the task isn t routine (Krall and Sittig, 2001). Most importantly, however, is that active alerts are used when a task is seen as critical, and that negative effects can result if the task isn t carried out within a given amount of time. An active alert should provide a user with enough information (more than a passive reminder) to carry out the alerted task, and should encourage (or force) the receiver of the alert to react immediately (Krall and Sittig, 2001). An active alert disrupts a user s thought process more than a passive reminder would (Krall, 2002), thereby interrupting workflow. This interruption in workflow isn t necessarily a hindrance to the clinician if the interruption comes at the appropriate time. However, if the alert, such as an annoying pop-up window as seen in Figure 7 Page 37

38 comes at a time where the clinician isn t able to respond to it, or it is presented with too little information to respond to it, it is perceived as having a negative effect on workflow (Krall, 2002). Figure 7: A pop-up window such as the one seen above can be a hindrance to workflow if a clinician doesn t have enough information to complete the requested task. In the case above, a user could not continue with the task if they didn t have the appropriate business information. It was mentioned in the previous section on passive reminders that they should be used within bounds. This is also important, or even more important in the case of active alerts. Active alerts should be carefully implemented for many reasons, one of the main ones being that they can be quite disturbing of workflow The overuse of alerting techniques can also demand too much attention from the user, leading them to override, what often can be, critical alerts (Holzinger, 2001, Prijatelj, 1999, Rind, Safran, 1994) Location of Alerts and Reminders Alerts and Reminders Received in Space An alert or a reminder which is received in space is one which is received by a clinician independent of any sort of contact with communication media. This means that the clinician can receive the alert or reminder while in the clinical environment at places such as at the patient s bedside while doing rounds or in his or her personal working office, for example. Page 38

39 There are various concrete examples of alerts and reminders that can effectively be received in space. Of course, each has their own strengths and weaknesses which can be derived out of the following descriptions. These include, for example, lights in the clinical environment, blinking or rotating lights in the clinical environment (Bradshaw, Gardner, 1988), facsimiles, phone calls, personnel addressing devices (loudspeakers), and direct person to person communication. Some illustrations of these examples can be seen in Figure 8. Facsimile: Telephone: Loud Speaker: Blinking light (in nursing station): (FX-Software, 2002) (FX-Software, 2002) (Interactive- Blueroo, 2002) (Star, 2002) Figure 8: Examples of alerts and reminders which could be received in space. Receiving an alert or a reminder in space has a few benefits. The first noticeable benefit is that the receiver of the alert or reminder is fully mobile, and not bound to a device where an alert or reminder could be conveyed. Another benefit which results from this is that the workflow of the receiver of the alert or reminder isn t greatly interrupted. There are also some consequences of receiving an alert or reminder in space. For example, the person who is to receive an alert or reminder, for example, has no direct contact with the origin of the alert or reminder. This means that there is no way to ensure that the receiver actually acknowledges the receival and acceptance of the alert or reminder. There is therefore no guarantee that the receiver will respond, and more importantly, there is no way to enforce or force the receiver to respond, even if they did acknowledge the acceptance of the alert or reminder. More importantly, there may be very little or no way to tell who the alert or reminder is even meant for. Page 39

40 Because of the problems associated with the recognition of alerts and reminders in space, it is important that they be designed properly. One design aspect which has proven to improve the recognition of such messages is the employment of various senses (ATKOSoft, 1997, Holzinger, 2001). By activating a combination of senses, such as sight and sound, for example, the receiver becomes more aware of the alert or reminder. Sight is especially effective in combination with movement (Krall and Sittig, 2001). Seeing something moving or rotating increases awareness. Sounds are also important, especially their different forms (Holzinger breaks it down into noise, tones, sound effects, music and speech (Holzinger, 2001)). Different types and combinations of sounds can optimize information transfer and increase motivation to respond to the sound. These two (sight and sound) in combination can have a great impact on the receiver of a reminder or an alert Alerts and Reminders Received on the Person An alert or a reminder which is received on the person is one which is received by a clinician in combination with direct contact with communication media, but independent of having to be at a certain location to receive an alert or reminder. A clinician can therefore receive an alert or reminder anywhere in the clinical environment, given that the communication media through which the alert or reminder is conveyed is on the person. As with an alert or reminder which is received in space, one which is received on the person can also be received at places such as at the patient s bedside or in the clinician s personal working office. There are also various concrete examples of alerts and reminders that can effectively be received on the person. Once again, each of these has its own strengths and weaknesses which can be derived out of the following descriptions, positive and negative aspects and design aspects. Some techniques for alerting and reminding on the person include pagers (alphanumeric) (Gardner, Kuperman, 1999), palmtops / palm-pilots, cellular phones and laptops (mainly referring to smaller mobile laptops). Some illustrations of these examples can be seen in Figure 9. Page 40

41 Pager: Palm Pilot: Cell Phone: (HMC, 2002) (CNN.com, 2002) (Alcatel, 2002) Figure 9: Examples of alerts and reminders which could be received on the person. Alerts and reminders which are received on the person have some similar advantages to those received in space. For example, although the receiver of the alert or reminder is bound to the communication device conveying the message, he or she is still mobile. This means that there is a minimum distraction to workflow. Workflow is only distracted when the actual alert or reminder is conveyed and the receiver must react upon it. As compared to receiving an alert or reminder on the computer interface (to be described in the next section), when an individual receives one on the person, he or she has no choice of when they receive the alert or reminder. A difference as compared to alerts and reminders received in space is that ones received on the person are more bound to reach the actual receiver who the message is meant for. That is, with direct contact with the communication media, the receiver is closer to the origin of the alert or reminder. This means that there is an increased chance that the receiver will acknowledge and act upon the alert or reminder. There are also various downfalls that come at the expense of conveying alerts and reminders on the person. One of these downfalls is similar to one of those related to alerts and reminders conveyed in space. First of all, the receiver once again isn t forced to carry out an alerted or reminded task. He or she has the full ability to simply ignore a critical message or postpone it for later. Another downfall, not related to the conveyance in space, comes at the expense of the communication media. There are various media which can be used to convey alerts and reminders, some of which are Page 41

42 practical and small, others which may be large and clumsy. If the clinician is bound to this media, It is important that it doesn t get in the way of his or her everyday work. The problems of conveying alerts and reminders on the person are important to be overcome so that techniques for this type of alerting and reminding can be implemented optimally. Design aspects also play a key role here. As with the conveyance in space, the conveyance on the person can once again benefit from the employment of various senses (ATKOSoft, 1997, Holzinger, 2001). Once again, the activation of various senses such as, in this case, sound and touch (Krall and Sittig, 2001), the receiver once again becomes more aware of the alert or reminder. Hearing a noise, and, for example, feeling something vibrating both at the same time can help ensure that the receiver becomes aware of the alert or reminder which is trying to be conveyed. Design aspects of the actual communication media is also important. The media should be kept small (Gardner, Kuperman, 1999), perhaps small enough to fit in a pocket, so that it doesn t distract the workflow of the clinician. It should not require the main focus of the clinician Alerts and Reminders Received on the Computer Interface An alert or reminder which is received on the computer interface is the most frequently implemented type of alerting or reminder technique in the clinical environment (Krall, 2002). An alert or reminder which is received on the computer interface is one which can only be received by a clinician in direct contact with the communication media, while being bound to that communication media. These types of alerts and reminders are usually received at a healthcare professional workstation which can be situated, for example, in a nursing station or in the personal working office of a clinician. A clinician can therefore only receive an alert or reminder when he or she is situated at a computer workstation and is actively using this workstation. The user interface offers many alerting and reminding techniques which all have their positive and negative aspects. These can be attained from the forthcoming descriptions. Some examples (among many) of techniques include: a simple beep when a user presses an incorrect key (Holzinger, 2001), blocking a window until a certain task is complete (Krall, 2002), the use of pictograms and histograms (Krall Page 42

43 and Sittig, 2001), the use of various tabs on an interface (such as hidden tabs) (Krall, 2002), pop-up screens with messages with various options such as to carry out the task immediately or to postpone it, free text (static or dynamic) written on the interface (Bradshaw, Gardner, 1988), checklists, electronic mail, blinking lights, and status models such as traffic lights, thermometers, calculators (Krall, 2002), etc.. Some illustrations of these examples can be seen in Figure 10. Page 43

44 Traffic light: Thermometer: (Innsbruck- Universität, 2002) (Italia, 2002) Pop-up window: (Microsoft, 2002) Pictograms: (Eirich and Hauck, 2002) Figure 10: Examples of alerts and reminders which could be received on the computer interface. There are some advantages of receiving alerts and reminders on the computer interface. For example, when a clinician is logged into his or her workstation and receives an alert or reminder, it can be kept track of. That is, a log can be kept of which alerts and reminders the clinician was relayed. Receiving an alert or reminder directly at the workstation also has the effect that the attention of the clinician is already there and the message is most likely being conveyed to the correct recipient. Another advantage of this alerting and reminding technique is that computer software can be configured such that the clinician is required to act upon the alert or reminder (Krall, 2002). In other words, the software can be configured so that the clinician isn t able to carry on with their next task until the task which was alerted or reminded of is recognized or completed, whichever may apply. Another advantage is that the alert or reminder can be programmed into the electronic patient record of a patient in Page 44

45 general, where various clinicians could receive it, or it could be programmed such that it is only geared toward one clinician. Receiving an alert or reminder directly at the workstation, when programmed accordingly, has the effect that the message will most likely be conveyed to the correct recipient. An additional advantage of alerting and reminding on the computer interface is that more creative techniques can be employed. The user interface offers many ways of obtaining the attention of a user. Along with the advantages of alerting and reminding on the computer interface also come several disadvantages. One of the most important disadvantages is that the receiver of the message must actually be sitting at a workstation so that the alert or reminder can be conveyed. This almost presupposes that the receiver must know that there is an alert or reminder waiting for them in order to check for it. In many cases, clinicians don t spend the bulk of their time at a workstation. Along with this disadvantage comes the disadvantage of immobility. While the clinician is receiving his or her alert or reminder he or she is completely bound to and focussed on the workstation. Another disadvantage that can be experienced by clinicians is that, often being under time pressure, they may not be able to immediately respond to alerts and reminders because of a different outstanding task. If the alert or reminder demands that they carry out the task which was alerted or reminded of before they continue with any other work, it may result in a certain degree of frustration felt by clinicians. A final disadvantage which will be discussed here has to do with learning how to properly use new software (Bradshaw, Gardner, 1988). New software, such as alerting and reminding software, may require a lot of time on part of the clinicians so that they learn the new capabilities and functionality of the system. New icons, symbols, pathways, and workflow must be adjusted to before the system can be fully exploited (Holzinger, 2001). Because the use of the computer user interface to convey alerts and reminders is very sensitive, it is important that software be designed while considering aspects such as proper user interface design (Faulkner, 1998, Krall, 2002, Preece, Rogers, 1994) and the employment of various senses (ATKOSoft, 1997, Holzinger, 2001). Page 45

46 User interface design plays a major role in developing an alerting and reminding system that can effectively be used to transfer messages. Some, among many, of the aspects which must be kept in mind include the size and quantity of alerts and reminders as well their location on the computer screen (Holzinger, 2001). An alert or reminder in the middle of an interface will be noticed and adhered to more readily than one in the corner on the bottom of a screen (Krall, 2002). Color is also an important factor. Different colors have different impacts on users. For example, the color red is often associated with danger and threat (Holzinger, 2001), and in turn can also impose a threat on a clinician. The cognitive interpretation of colors, however, is different for everyone. 2-dimensional and 3-dimensional alerts and reminders also have different effects on clinicians. 3-dimensional alerts and reminders are often found to enhance information flow (Falkman, 2000). Within user interface design it must also be distinguished between the use of text and graphics for the conveyance of alerts and reminders. Text, for example, has the quality of being able to be precise in its message, but is often harder to cognitively recognize as compared to images because it involves more eye movement (Holzinger, 2001). Text fonts (Verdana and Tahoma are seen to be good choices (Holzinger, 2001)) as well as styles should be taken into consideration, as well as the length of the text. Dark text on a light background is also more appealing to the eye than light text on a dark background (Holzinger, 2001). Images should be detailed enough so that their meaning can be derived, but not so complicated that the receiver of the alert or reminder feels overwhelmed. As with alerts and reminders which are received in space or on the person, ones which are received on the computer interface should also exploit the employment of various senses, such as sight and sound. The combination of senses increases the chances that an alert or reminder will be properly recognized and acted upon. Page 46

47 2.6 Conclusion University for Health Informatics and Technology Tyrol This basic principles section went into some detail about the necessity to be able to model processes in the clinical setting in such a way that visualization techniques can appropriately be applied to aid clinicians in their everyday work. Some process modeling techniques were introduced in this section and their strengths and weaknesses were discussed. These techniques included the business process diagram, the time-based diagram and procedure modeling. It was found that each technique was unique and purposeful in different situations. Following this description of modeling techniques, visualization was described in detail. A general overview, and a breakdown of visualization techniques into alerts and reminders, with again further breakdowns into location (in space, on the person, on the computer interface) and types of alerts and reminders (active alerts versus passive reminders) was carried out. The descriptions in this basic principles section, which are mainly based on current research by a variety of authors from around the world, are the basis for the following new concepts section where the principles above will be used to find ways in which visualization techniques can appropriately be applied in the clinical setting. Page 47

48 3. Alerts and Reminders to Support Clinical Process Flows: New Concepts 3.1 Introduction In the last section, a review was conducted in order to discover techniques which could be used to visualize processes in the clinical environment. Alerts and reminders as visualization techniques were broken down into various categories and their strengths and weaknesses were defined. This new concepts section will comprise various parts. First of all, a breakdown of process flows will be carried out such that alerts and reminders can be applied to support each major part of a process. Following this, a detailed examination will be carried out regarding how the alerts and reminders found in the last section can meaningfully be applied to the various flow activities in a clinical setting. Effective communication will also be focused on in this section based on the theories outlined in the last section. 3.2 Breakdown of process flows Process flows in hospitals are quite complex and therefore need to be broken down to be monitored effectively through visualization techniques such as alerts and reminders. As mentioned in the previous section, the monitoring of processes includes the need to monitor current tasks, monitoring what current tasks resulted from, monitoring what outcomes current tasks will have, monitoring decision making, and monitoring the updating of processes. Alerts and reminders can be used to support some of these activities. More specifically, they can be used to monitor which tasks have been completed longer ago, which tasks have recently been completed, which tasks are currently being executed, which tasks are outstanding, and which tasks need to be completed in the future. Although each of these five process views, as can be seen in Figure 11, must interplay in order to allow processes to run smoothly, they are also quite different, and therefore also require a deeper analysis in order to discover which techniques could best be applied in each case to adequately support clinicians in their work. Page 48

49 tasks completed longer ago recently completed tasks tasks currently being executed outstanding tasks future tasks Current point in time Figure 11: A representation of the five process views with reference to the current point in time. The following paragraphs will describe each of these five process views in greater detail. A special emphasis will be put on describing their particular importance in an overall process, as well as the urgency with which information must be conveyed and how important the conveyed information is to a clinician at a particular point in time Process View 1: Tasks which have been completed longer ago Although some may be of the point of view that it isn t important for a clinician to know what tasks have been completed longer ago in the past, upon further investigation, it can be seen as an important part of a process to realize. What happened longer ago may give a clinician a better overview of were he or she stands in a current process and may also give a greater overview of the entire process overall. Although past tasks may not be of urgent use for current patient treatment and tasks, realizing what tasks occurred in the past may give insight into what current tasks resulted from. For example, blood test results from a year ago could be compared with more recent results to acquire about a patient s health status. Page 49

50 Figure 12 gives an overview of what all needs to be considered when visualizing data about which tasks have already been completed longer ago. This diagram takes into account the who, what, when and where of what happened longer ago. What previous tasks? Tests and results Surgical procedures Medication perscriptions etc... Who carried them out? Physicians Nurses Laboratory technicians Radiology specialists etc... Process begin <-- past future--> Process end When were they done? one year ago one month ago etc... Where were they done? On site Family physician office In a clinic etc... Current point in process Figure 12: Visualizing what has happened in the past taking into account the who, what, when and where with regard to what tasks have already been completed. As these tasks have already been completed longer ago, they may simply be interesting, informative or supportive of current patient care and are therefore minimally urgent Process View 2: Tasks which have recently been completed In contrast to the tasks which have been completed longer ago, tasks which have recently been completed are of greater importance to the current process. An important part of tasks which have recently been completed is the results of these tasks. For example, test results from various recent medical procedures are often needed in order to make decisions about the current and future care of a patient. Page 50

51 Figure 13 once again gives an overview of what all needs to be considered when visualizing data about the tasks which have recently been completed. This diagram takes into account the who, what, when and where of what happened in the recent past. What previous tasks? Tests and results Surgical procedures Physician round results Nursing round results Medication perscriptions etc... Who carried them out? Physicians Nurses Laboratory technicians Radiology specialists etc... Process begin <-- past future--> Process end When were they done? one week ago one day ago one hour ago one minute ago etc... Where were they done? On site Family physician office In a clinic etc... Current point in process Figure 13: Visualizing what has recently been completed taking into account the who, what, when and where with regard to what tasks have recently been completed. Those tasks which happened in the recent past are often of direct importance for the further treatment of a patient. This gives them a certain degree of urgency Process View 3: Tasks which are currently being executed Acknowledging which tasks are currently being executed is important in order to recognize that the tasks of a process are being completed in a timely fashion. It is also important so that clinicians can be prepared for the results of these tasks in order to plan further tasks. For example, if a clinician is aware that a patient is currently having a CT done, he or she can already prepare for the execution of the next task, such as the performance of an x-ray examination. Page 51

52 Figure 14 gives an overview of what all needs to be considered when visualizing data about which tasks are currently being executed. The diagram takes into account the who, what, when and where of what tasks are currently being executed. What current tasks? Tests Surgical procedures Physician rounds Nursing rounds Medication perscriptions etc... Who is carrying them out? Physicians Nurses Laboratory technicians Radiology specialists etc... Process begin <-- past future--> Process end When are they being done? now Where are they being done? On site Family physician office In a clinic etc... Current point in process Figure 14: Visualizing what has recently been completed taking into account the who, what, when and where with regard to what tasks have recently been completed. This process view is important in that realizing this information can help streamline all tasks in a process. This information is somewhat urgent, however not quite as urgent as the information needed in the next process view Process View 4: Tasks which are outstanding The recognition of tasks which are outstanding is extremely important and can be seen as the most important of the five process views. Realizing which tasks need to be carried out by which clinician, and in what amount of time is very important in order to guide through a current process. Recognizing which tasks are still outstanding also includes recognizing what and who current tasks resulted from Page 52

53 (combines with the process view: tasks which have recently been completed) and what outcomes will result through the completion of the current tasks (combines with the process view: which tasks will have to be completed in the future). Figure 15 gives an overview of what all needs to be considered when visualizing data about which tasks are still outstanding. This diagram takes into account the who, what, when and where of what tasks are still outstanding. What tasks are still outstanding? Tests Surgical procedures Physician rounds Nursing rounds Medication prescriptions etc... Who will carry them out? Physicians Nurses Laboratory technicians Radiology specialists etc... Process begin Process end When do they have to be complete? in one week in one day in one hour in one minute etc... Where will they be carried out? On site Family physician office In a clinic etc... Current point in process Figure 15: Visualizing what is currently going on in a process taking into account the who, what, when and where with regard to what tasks are still outstanding. This process view is the most complex of the five process views. Recognizing which tasks are still outstanding is urgent and entails a lot of information at once which a clinician must realize and process. Without the recognition of this information, processes can be delayed and therefore negative outcomes can appear. Page 53

54 3.2.5 Process View 5: Tasks which will have to be completed in the future Which tasks have to be completed in the future is also an important process view, as it gives a clinician an overview of what his or her process will look like and include in the future. It gives a clinician an overview of what tasks to expect in the future, and also gives the clinician the ability to prepare for these specific tasks ahead of time. As with the process view of which tasks have been completed, where one should not delve too far into the tasks of the past, this process view, which tasks will have to be completed in the future, should not delve too far into the future. A clinician should receive enough information on future tasks in order to prepare for them appropriately. However, too much information into tasks which are too far away can lead to information overload where the clinician can t appropriately place these tasks in his or her process. Figure 16 gives an overview of what all needs to be considered when visualizing data about which tasks will need to be completed in the future. This diagram takes into account the who, what, when and where of what will occur in a process. What tasks need to be completed in the future? Tests Surgical procedures Physician rounds Nursing rounds Medication perscriptions etc... Who will carry them out? Physicians Nurses Laboratory technicians Radiology specialists etc... Process begin <-- past future--> Process end When will they be done? six months one month one week Where were they done? On site Family physician office In a clinic etc... Current point in process Figure 16: Visualizing what is going to be needed to be done in the future in a process taking into account the who, what, when and where with regard to what tasks will become meaningful as time goes on. Page 54

55 Information on tasks which will occur in the future is semi-urgent. After all, these tasks of the future will continue to gain in importance and will soon become current or outstanding tasks. 3.3 Application of communication theory and alerts and reminders to support process views Through the application of alerts and reminders, each of the five process views mentioned above can be visualized such that a clinician can be aware of and informed about tasks which happened in the past, are currently taking place, and which will occur in the future. However, each of these tasks must be conveyed in the best respective way through the differing alerting and reminding techniques, in combination with communication theory as described previously. In these following sections, the characteristics of the process views will also be considered in combination with the characteristics of the various alerting and reminding techniques defined previously so that the two can be matched together. Special attention will be paid to the ideas behind communication theory which was also previously discussed. The goal of these sections is to define alerts and reminders that could appropriately be applied to each of the five separate process views Process View 1: Tasks which have been completed longer ago As previously mentioned, the need for a clinician to know which tasks in a process have been completed longer ago is minimally urgent. For example, a blood test from two or three months ago with an abnormal value on it may simply be needed as a reference, not to make critical decisions. Because information on tasks which occurred longer ago is minimally urgent, it would be appropriate to use passive reminders rather than active alerts as visualization techniques to inform a clinician. This is, however, only in the select cases where a visualization technique is at all necessary. Page 55

56 With regard to the location of where these reminders could best be received, the concepts of the previous sections on location need to be referred to. Based on the concepts described in the previous sections, in combination with the fact that tasks which occurred a longer time ago are minimally urgent, and that clinicians don t want to constantly be bothered with what happened a longer time ago, they would most likely only want this information upon request. Really, the only sensible place where this type of reminder could be located is on the computer interface, as clinicians spend a minimal amount of time at the computer. An example of a reminder to support this process view on the user interface could be a selection in the menu bar allowing a physician to view a list of all results of tests, for example, which were performed in the last month or year. Table 3 provides a summary of what type of visualization techniques should be used for this particular process view, where they would best be located, and a summary of examples which could be used in this case. Process View: Tasks which have been completed longer ago Alert or Reminder: passive reminders Location on the computer interface Examples: button or menu selection allowing a physician to print out results of all tests completed in the last month / year. Table 3: Summary of whether active alerts or passive reminders should be used and where they would best be located for the process view: Tasks which have been completed longer ago Process View 2: Tasks which have recently been completed The need for a clinician to know which tasks in a process have recently been completed has a certain degree of urgency. For example, results from a blood test carried out in the recent past are often needed quickly in order to make decisions about further patient treatment. Because information on recently completed tasks is somewhat urgent, it would be appropriate to use active alerts rather than passive Page 56

57 reminders as visualization techniques. Active alerts are invasive and often require the immediate attention of the receiver of the alert. Based on the previous concepts, a good example of an active alert to support this particular process view which could be located in space could be a flashing light in a nursing station informing a nurse that, for example, a laboratory result has been received which has abnormally high or low levels of results. An examples of an active alert which could be located on the person is a pager message being relayed to a physician informing him or her of the fact that complications have arisen due to a procedure which he or she just recently carried out. An example of an active alert which could be located on the computer interface, once again dealing with laboratory results, could be red flashing results on a report, once again indicating high or low test results. This last location, on the computer interface, however isn t as effective as the other locations, as clinicians often don t spend a great deal of time sitting at a workstation. In this case, the clinician practically already needs to know that there is an active alert waiting for them on the interface in order to respond to it. Table 4 provides a summary of whether active alerts or passive reminders should be used for this process view, where they would beset be located and a summary of examples which could be used in this case. Process View: Tasks which have recently been completed Alert or Reminder: Active alerts Location On the person, in space, on the computer interface Examples: a flashing light in a nursing station informing a nurse that, for example, a laboratory result has been received which has abnormally high or low levels a pager message being relayed to a physician informing him or her of the fact that complications have arisen due to a procedure which he or she just recently carried out. Table 4: Summary of whether active alerts or passive reminders should be used and where they would best be located for the process view: Tasks which have recently been completed. Page 57

58 3.3.3 Process View 3: Tasks which are currently being executed As already mentioned in the previous section, the information required in this process view of which tasks are currently being executed is somewhat urgent. This information is particularly important in order to streamline tasks in a process. These and the other previously defined characteristics of this process view help to define which alerting or reminding techniques could best be used in this sort of situation. In this situation, it would be fitting to use somewhat less invasive active alerts, such that to keep a clinician informed but not annoyed by tasks which are currently occurring. A good example of an active alert to support this process view which could be located in space is a personal addressing system announcement or a phone call informing a clinician that a patient is currently being operated on. An alert which could be received on the person could be a pager message informing a nurse that a patient s bandages are currently being removed and follow-up treatment will be needed shortly. On the user interface, a clinician could view a list of all tasks which are currently occurring. For this process view, it would be important for a clinician to have the option to specify whether or not he or she would like to be alerted in a particular situation. It is important to remember not to overload a clinician with unnecessary alerts and reminders. Table 5 provides a summary of the types and locations of the visualization techniques that could be used for this process view. Various examples are also provided. Process View: Alert or Reminder: Location Examples: Tasks which are currently being executed Active alerts On the person, in space, on the computer interface personal addressing system announcement or a phone call informing a clinician that a patient is currently being operated Page 58

59 on pager message informing a nurse that a patient s bandages are currently being removed and follow-up treatment will be needed list on the user interface displaying which tasks are currently occurring Table 5: Summary of whether active alerts or passive reminders should be used and where they would best be located for the process view: Tasks which are currently being executed Process View 4: Tasks which are outstanding As mentioned in the description of the process view of which tasks are still outstanding, the need for a clinician to know this information is very urgent. This type of data or information is definitely important for a clinician to carry on in a process. These characteristics of this process view help to define which alerting or reminding techniques could appropriately be applied in this sort of situation. Because data or information regarding tasks which are outstanding is highly critical, it would be fitting in this situation to use active alerts rather than passive reminders as visualization techniques to inform a clinician. In this case, the alerts should be even more invasive than in the previous process view. As previously described, active alerts are invasive, fairly disturbing of workflow and often require the immediate attention of a the individual who is being alerted. These characteristics of active alerts therefore make for a good fit in this particular process view. Based on the concepts defined in previous sections, a good example of an active alert to support this particular process view which could be located in space is a phone call on a certain ward informing them that a patient is ready for discharge, but that the discharge letter hasn t been signed by the attending physician yet. An example of an active alert which could be located on the person is a clinician s ringing cellular phone where communication leads to them realizing that patient X still needs to have a blood test done. An example of an active alert which could be Page 59

60 located on the computer interface is a pop-up window which appears when a nurse is trying to close a patient record, informing him or her of the fact that a transfer form needs to be filled out and signed before a patient can be discharged. Once again, in critical situations where information needs to be conveyed quickly and actively, conveying an active alert on the user interface may not be the best method. All of the visualization techniques mentioned above are quite threatening and in most cases must be responded to when they are received by the user. All of these techniques are somewhat disturbing of workflow, and would therefor be appropriate for visualizing this process view of what tasks are still outstanding. Table 6 provides a summary of whether active alerts or passive reminders should be used for this particular process view, where they should be located, and a summary of examples which could be used in this case. Process View: Tasks which are outstanding Alert or Reminder: Active alerts Location On the person, in space Examples: a phone call on a certain ward informing them that a patient is ready for discharge, but that the discharge letter hasn t been signed by the attending physician yet is a clinician s ringing cellular phone where communication leads to them realizing that patient X still needs to have a blood test done Table 6: Summary of whether active alerts or passive reminders should be used and where they would best be located for the process view: Which tasks are still outstanding? Process View 5: Tasks which will have to be completed in the future As mentioned in the description of the process view of which tasks will have to be completed in the future, the need for a clinician to know this information is semiurgent. After all, the tasks which have to be completed in the future will someday become current tasks. This is why this type of data or information is important for a Page 60

61 clinician to receive through visualization techniques. The characteristics of this process view help to define which alerting or reminding techniques could appropriately be applied in this sort of situation. Because data or information regarding tasks which will have to be completed in the future is only semi-urgent and semi-critical, it would be fitting in this situation to use passive reminders rather than active alerts. Based on previous concepts, a good example of a reminder to support this particular process view which could be located in space would be a facsimile sent to a certain ward informing them of the new admissions which will take place in the next week. An example of a reminder which could be located on the person is a beeper that requests that you call back a certain number, but not necessarily immediately. Information which may want to be conveyed in this case could be that the receiving physician will be needed during an operation the next day. An example of a reminder which could be located on the computer interface could be a list showing all of the names of the patients which are currently on the ward with their expected discharge dates. All of the visualization techniques mentioned above are semi-threatening where in some cases they need to be responded to right away and in others they don t. All of these techniques are lightly disturbing of workflow, and would therefore be appropriate for visualizing this process view of which tasks will have to be completed in the future. Table 7 provides a summary of whether active alerts or passive reminders should be used for this particular process view, where they should best be located and a summary of examples which could be used in this case. Page 61

62 Process View: Tasks which will have to be completed in the future Alert or Reminder: Passive reminders Location On the person, in space, on the user interface Examples: a facsimile sent to a certain ward informing them of the new admissions which will take place in the next week a beeper that requests that you call back a certain number, but not necessarily immediately. Information which may want to be conveyed in this case could be that the receiving physician will be needed during an operation the next day a list on the computer interface showing all of the names of the patients which are currently on the ward with their expected discharge dates Table 7: Summary of whether active alerts or passive reminders should be used and where they would best be located for the process view: Tasks which will have to be completed in the future. 3.4 Conclusion Process flows in hospitals are quite complex and therefore need to be broken down to be monitored effectively through visualization techniques such as alerts and reminders. Alerts and reminders can be used to support some of these activities. More specifically, they can be used to monitor which tasks have been completed, which tasks are still outstanding, and which tasks will still have to be completed in the future (Reichert, 2000). Following the breakdown of processes into their three main process views, and also following the breakdown of visualization techniques into their elementary components, it is possible to meaningfully apply certain alerting and reminding techniques to each process view. This section described this application in detail so that findings can be applied on hand of the real-life example of discharge management. This application will first be done in a paper-based manner, and then a practical application will follow. The results of these steps can be viewed in the next section. Page 62

63 4. Application of Alerts and Reminders to Monitor the Discharge Management Process 4.1 Introduction In the past two sections, basic principles and new concepts surrounding the visualization of process flows in hospital information systems were found. In particular, the specific alerting and reminding techniques based on type and location were discussed in connection with the three process views: which tasks have been completed, which tasks are still outstanding, and which tasks have to be completed in the future. This analysis lead to a better understanding of how alerts and reminders can best be implemented in the clinical environment. The theories which came out of these sections are implemented on hand of a real-life example in order to verify their practical use. A concrete example is analyzed and a sample implementation is carried out in this section. This implementation occurs in the process of discharge management on the neurological ward of the Innsbruck University Medical Center. Discharge management is a very extensive and important part of patient care. Many activities need to be clarified and carried out in a timely fashion so that patients, physicians, nurses, and other clinicians are all adequately prepared for a patient s discharge. Some of these activities include carrying out final tests, receiving the results from these tests, filling out forms and writing reports, completing all appropriate patient rounds, contacting other healthcare professionals within and outside of the providing institution, carrying out specific medical procedures or preparing for transfers to other institutions, all within an appropriate amount of time. Discharge management was chosen as a suitable process because it can be analyzed well and is of moderate complexity. In order to stay within the bounds of this master thesis, this application section will focus on the results of collaboration with a physician on the neurological ward of the Innsbruck University Medical Center. These results will compliment the analysis of Page 63

64 selected parts of the discharge management process which will be illustrated in greater detail through the aid of a business process diagram. Following this analysis, the Cerner Millennium computer supported application system of the Innsbruck University Medical Center and the Discern Expert System from Cerner (Cerner, 2002) will be described in order to show its abilities to implement alerts and reminders. Following this, recommendations for possible implementations and the actual implementation will be presented. Screen shots will be the main method used for illustrating how alerts and reminders can be and were implemented. 4.2 Analysis of Requirements for Alerts and Reminders: Physician Interview Introduction Even though various theories and concepts regarding the implementation of alerts and reminders have evolved through the previous sections of this master thesis, it is difficult and unwise to begin to implement these before having discussed them in greater detail with end users. End users can give great insight into how they view an information system, and especially how they view possible changes to this system. They can provide advice on how changes can benefit them the most, as well as the effects that less beneficial changes could have on them. In the case of this study, it was important to speak with a clinician who had quite a bit of experience working with the current hospital information system. Ideally, it would be better to speak with a larger representative sample of end users, however, due to the boundaries of this study this was not possible. It was decided to interview a physician on the neurological ward of the Innsbruck University Medical Center, as this is also one of the wards where the business process diagram was constructed. Through speaking with this physician, information regarding his views of alerts and reminders, as well as his suggestions of where alerts and reminders would be of most use for himself as well as other clinicians was sought. The results of this person to person interview are discussed in the next section. Page 64

65 4.2.2 Physician Interview Structure As mentioned above, the purpose of this interview with a physician on the neurological ward of the Innsbruck University Medical Center was to obtain better insight into how physicians view the use of alerts and reminders in the clinical setting, and especially where they feel they would be of greatest benefit to them. The interview took place in the Frauen-Kopf-Klinik (Women and Head Building) of the Innsbruck University Medical Center on the special neurological ward. The interview took place on Tuesday October 22, 2002 at 12:00 p.m. and took approximately 40 minutes. The interview partner was Dr. Armin Muigg, who was recommended for interview by the Information Technology Department of TILAK, as Dr. Muigg is quite familiar with the hospital information system as well as needs of fellow colleagues at the hospital. There were three main sections to the interview as follows: Section A: Opinions: Questions were asked regarding the general opinion with regard to the amount of data and information which is received by clinicians. Section B: Discharge Management Process: The discharge management process was discussed in some detail to come up with how it could perhaps be streamlined or improved upon. Section C: Processes and Alerts/Reminders: Questions were asked and discussed with regard to how alerts and reminders could meaningfully and purposely be implemented in the clinical environment. A special emphasis was put on where these alerts and reminders should appear, how they should appear, and the frequency of their appearance. Section D: Conclusion: This section was meant for the physician to be able to draw attention to other factors which he found important with regard to alerts and reminders. Page 65

66 The full interview questionnaire can be found in Appendix B Physician Interview Results As expected, the results of the physician interview added significantly to the theories and concepts previously developed for alerting and reminding in the clinical setting. The results were unexpected and new, which makes them even more valuable for this master thesis. The results can be broken down into three subcategories: what hinders a clinician in their everyday work, what helps them in their work and concrete examples. These three subcategories will be described in greater detail in each of the following subsections What hinders a clinician in their everyday work? Physicians and other clinicians receive a great amount of data and information every day. An important point which the physician in this interview made was that clinicians already deal with a great amount of useless information, that is, information that may be of interest for someone, but not everyone, or information which is redundant. The physician expressed that alerts and reminders, if they were to be useful, would have to be implemented very carefully in order to avoid bombarding clinicians with unwanted information. An important point which was made was that clinicians already receive a great deal of s and beeper messages all of the time, thereby making this a less useful mode of transmitting alerts or reminders. Another important point which was made was that alerts and reminders should also be implemented within reason and ration. Too many alerts and reminders would possibly negate their intended effect. That is, a clinician would most likely continually reduce the amount of attention they give to alerts and reminders if they become a common frequent occurrence What helps a clinician in their everyday work? When the physician in this interview was asked what would help him in his everyday work, the first thing that was mentioned was that alerts and reminders are needed which help, not hinder clinical work. He mentioned that he would appreciate a reduced amount of time at the personal computer, meaning that few mouse clicks Page 66

67 and good formatting of alerts and reminders would be a necessity. Another major factor which was raised was that the alerts and reminders should work without additional information having to be entered into the current hospital information system. An example which was mentioned was that medication contradiction alerting could be very helpful for a clinician, but it would mean that someone on the front line would have to first enter all patient medication information, which currently isn t being done as thoroughly as would be needed. Clear alerts and reminders on the user interface was also an important point which was raised by the physician. He mentioned that he wants to receive information on the topics which are of interest to him, and in a way which, with a quick glance, can be acknowledged and understood. Finally, perhaps the most important point mentioned in this interview was that, what the physician referred to as, self-driven alerting and reminding would be most beneficial at this point in time. He mentioned that a clinician should have the ability to bring forth an alert or reminder manually. That is, for example, to have the possibility on the user interface to print a list with required information needed for the physician to have a better overview of clinical activities or to remember tasks more easily. He also mentioned that the added functionality of these alerts and reminders being increasingly flexible by, for example, being able to enter date or time ranges for information would be of great benefit Concrete examples During this interview, various different concrete examples of how alerts and reminders could be implemented emerged. In specific, two of these examples were found to be suitable as suggestions for implementation in the discharge management process. These two examples will be described in greater detail here, as well as in the implementation section of this master thesis. Additionally, two further suggestions of how alerts and reminders could be implemented were quickly discussed, but were found to not fit well within the boundaries of this master thesis. These two further suggestions will simply be made note of, but not explored in any greater detail. Page 67

68 Example 1: Test Summary Report With a Test Summary Report, the physician thought that it would be important and useful to know who is currently a patient on the ward, which tests have been scheduled for each patient, which tests have been carried out, and whether or not results from these tests are available. He found that the best way to convey this type of reminder is to provide clinicians with the option on the user interface to view a list or send a list with this information to the printer. Example 2: Pending Discharge Report Discharge report writing is a major part of the everyday clinical process, and it is often difficult to keep track of which reports have been completed and which are still outstanding. In the interview, the physician mentioned that it would be helpful to gain a better overview over discharge reports. He made a similar recommendation as in example 1. He mentioned that a clinician should have the possibility on the user interface to view a list or send a list to the printer, specifying which discharge reports are still outstanding. He mentioned that additional useful functionality would be to provide the physician with the choice to give a number to specify for example, that he or she would only like to view the 10 or 20 longest outstanding discharge reports. Example 3: ICD Coding With regard to ICD coding, the physician mentioned that it would be useful to use alerts and reminders to warn users of plausibility errors in coding. Although this was a good suggestion, it will not be explored in greater detail here as it does not fit within the scope of this master thesis. That is, it has little to do with discharge management. Example 4: Allergy Controls With regard to allergy controls, the physician also mentioned that it would be a good idea to use alerts and reminders to warn clinicians of patient allergies, for example, when medication is being prescribed. On the one hand, this would not be a good Page 68

69 implementation suggestion at the time being as it would require additional data entry, and on the other hand, it also doesn t fit within the scope of this master thesis as it has less to do with discharge management Summary Summarizing, it was interesting and important to obtain the opinion of a clinician who is familiar with the current hospital information system. The ideas with regard to the implementation of alerts and reminders that arose through this interview were especially important as they, for a great part, would not have come to light had there not have been an interview. These ideas will be put to use in the following sections of this master thesis. More specifically, they will be the basis for the following discussion surrounding the business process of the discharge management process of the Innsbruck University Medical Center. The parts of the business process diagram which were chosen to be illustrated in greater detail fall back on the recommendations made by the physician. Also, the suggestions made by the physician will especially be used as a guide for implementation suggestions. 4.3 Discharge Management: Analysis and Modeling Introduction As mentioned in the basic principles section of this master thesis, process modeling techniques are needed in order to come to a better understanding of how a process works. Only following a thorough understanding of what a process entails, can decisions be made about how the process could be modified in a way that is beneficial to all people who are involved in the process. There are various process modeling techniques which could be used, some of which were described in the basic principles section. For the purpose of this project, the UML activity diagram was chosen as an adequate method to represent the business process of the discharge management process of the Innsbruck University Medical Center. This diagram, which will be described in greater detail in the following section, was constructed using the Unified Modeling Language (UML) by the Object Page 69

70 Management Group (OMG, 2002). The following section provides parts of the business process diagram of the discharge management process. Only the parts which are of interest for the implementation of alerts and reminders will be displayed and described in greater detail Business Process Diagram Discharge Management In this section, four sub-sections of the business process diagram of the discharge management process are illustrated and described in greater detail. These four subsections model final test ordering (1 diagram), results reporting (2 diagrams) and discharge report writing (1 diagram). In particular, emphasis is put on the areas where the alerts and reminders suggested in the physician interview could benefit the process. It is important to mention that the recommendations made for the improvement of the discharge management process are recommendations that could also benefit other processes at the Innsbruck University Medical Center. The parts of the discharge management process which are referred to in the recommendations are also parts of other processes which could possibly need optimization Ordering of final tests Test ordering is an important part of the discharge management process, as it requires a lot of coordination of various tasks, as well as the coordination of various personnel. Tests often need to be ordered in time so that they can also be carried out prior to the discharge of a patient. It is currently sometimes the case that patients are expected to be discharged, but they can t be discharged on time because certain tests weren t ordered on time, meaning that they haven t been carried out prior to the planned discharge date. The physician with whom collaboration occurred mentioned that it would be helpful to obtain a better overview over which tests have been ordered. The cutout section of the business process diagram of the discharge management process displayed in Figure 17 shows some of the questions that need to be asked during this ordering process, and the activities that need to be carried out to order tests. The red Page 70

71 explanation mark denotes current bottlenecks in the process and therefore areas which are of special interest for the implementation of alerts and reminders. This area shows where the implementation of alerts and reminders could possibly support clinicians in their work. Tests still need to be carried out 1Tests have been completed test has to be ordered by telephone test can be ordered over Cerner System Order test by phone Order test over Cerner System Documentation in the patient record Figure 17: A subsection of the business process diagram of the discharge management process of the Innsbruck University Medical Center which deals with... final test ordering. The explanation mark denotes the part of the process where alerts and reminders could possibly come. Denotes a part of the discharge management process where decisions must be reached whether or not tests still need to be carried out / ordered. A visualization mechanism could be implemented in this situation to provide a clinician with a quick overview of tests which have been ordered. Page 71

72 Results reporting Results reporting is also important in the discharge management process as results from tasks are often needed prior to the execution of following tasks, such as discharge report writing. Actually, two separate parts of the business process of the discharge management process deal with results. Both of these are illustrated in this section. Results reporting is also a task which is carried out through the coordination of various clinical activities, and through the coordination of various clinicians. In the physician interview, it was made clear by the interviewee that an overview of which results are complete and available to be viewed would simplify the work process of clinicians. As can be seen in the section of the business process diagram of the discharge management process in Figure 18, the path to find out which results are available is somewhat complex and could perhaps be simplified through the use of alerts or reminders. Figure 18 also displays the questions that need to be asked as well as the activities that currently take place in this part of the process. The red exclamation marks once again show the parts of the process where bottlenecks occur and the implementation of alerts or reminders could possibly be of benefit. Page 72

73 Start of the visit Physician looks in patient chart 1... Results aren't available Results are available Results aren't complete 2 Results are complete Make note in visit book Read and discuss results Further tests still need to be carried out 3 No further tests need to be carried out Further tests are ordered Figure 18: A subsection of the business process diagram of the discharge management process of the Innsbruck University Medical Center which deals with results reporting. The explanation marks denote the parts of the process where alerts and reminders could possibly come into play. Page 73

74 Denotes a part of the discharge management process where decisions must be reached whether results are available or not. A visualization mechanism could be implemented in this situation to provide a clinician with a quick overview of results which are available. Denotes a part of the discharge management process where decisions must be reached whether available results are complete or not. A visualization mechanism could be implemented in this situation to provide a clinician with a quick overview of results which are complete and which aren t. Denotes a part of the discharge management process where decisions must be reached whether or not further tests need to be carried out. A visualization mechanism could be implemented in this situation to provide a clinician with a quick overview of, for example, patients who are still in need of further tests. As mentioned above, there were two parts of the business process which dealt with results. Figure 19 displays the second part. It can also be seen in this figure that the path to find out which results are available is somewhat complex. There is often not a direct method to find out whether results are available or still pending. Clinicians often must look in various places to find this out. This second section of the business process also displays the questions that need to be asked as well as the activities that currently take place in this part of the process. The red exclamation marks again show the parts of the process where the implementation of alerts or reminders could possibly be of benefit. Page 74

75 Results are still pending 1 Results aren't pending Physician looks in visit book Physician looks in results file Physician looks in HIS Results are available 5 Results aren't available... Results can be ordered over HIS Results are requested over HIS Results can't be ordered over HIS Physician phones for results Figure 19: A subsection of the business process diagram of the discharge management process of the Innsbruck University Medical Center which deals with results reporting. The explanation marks denote the parts of the process where alerts and reminders could possibly come into play. Denotes a part of the discharge management process where decisions must be reached whether results are pending or not. A visualization mechanism could be implemented in this situation to provide a clinician with a quick overview of results which are still pending and which are complete. Denotes an activity in the discharge management process where a clinician Page 75

76 (physician in this case) must actively look for results in the visit book. A visualization technique could be used in this situation to inform the clinician of where the result can be found. This way the clinician wouldn t have to look in various different places to find it. Denotes an activity in the discharge management process where a clinician (physician in this case) must actively look for results in the results file. A visualization technique could be used in this situation to inform the clinician of where the result can be found. This way the clinician wouldn t have to look in various different places to find it. Denotes an activity in the discharge management process where a clinician (physician in this case) must actively look for results in the hospital information system. A visualization technique could be used in this situation to inform the clinician of where the result can be found. This way the clinician wouldn t have to look in various different places to find it. Denotes a part of the discharge management process where decisions must be reached whether results are available or not, following the manual search for the answer in the visit book, the results book or the hospital information system. This step could also be eliminated through the implementation of visualization techniques in an earlier part of the process. Page 76

77 Discharge report writing Discharge report writing plays an especially important part in the discharge management process as it is one of the last steps that is carried out before a patient is discharged. A discharge report is typically to be completed prior to the discharge of a patient. However, discharge reports are often outstanding and need to be completed at a later point in time. Discharge report writing is also a task which is carried out through the coordination of various clinical activities, and through the coordination of various clinicians. The physician, in the interview, mentioned that a good overview over which discharge reports still need to be completed could be very helpful. It is clear that this information could be lost when there are many discharge reports that need to be completed not only for the current patients, but also for those which left the hospital longer ago. As can be seen in the section of the business process diagram of the discharge management process in Figure 20, the path for the correction and completion of discharge reports isn t linear as it can reiterate. This brings a certain degree of complexity into this part of the business process. Once again, alerts and reminders could perhaps alleviate a certain amount of this complexity by giving clinicians a better overview over the state of discharge reports. As in the other parts of the discharge management business process diagram, Figure 20 also displays the questions that need to be asked as well as the activities that currently take place in this part of the process. The red exclamation marks once again show the parts of the process where the implementation of alerts or reminders could possibly be of benefit. Page 77

78 Discharge report is written 1 Discharge report is read for corrections Corrections are needed 2 Corrections aren't needed Discharge report is sent to the head physician online Corrections are needed 3 Corrections aren't needed Corrections are made to discharge report Figure 20: A subsection of the business process diagram of the discharge management process of the Innsbruck University Medical Center which deals with discharge report writing. The explanation marks denote the parts of the process where alerts and reminders could possibly come into play. Page 78

79 Denotes a part of the discharge management process where the activity of writing the discharge report is carried out. In this case, visualization techniques could be implemented in order for the clinician to find out whether the discharge report has already been started, whether it is in the correction cycle or if it possibly has already been completed. Denotes a part of the discharge management process where decisions must be reached whether corrections to the discharge report need to be made or not. Again, visualization techniques could be implemented to provide clinicians with a better overview of the state in which the discharge report is currently in. Denotes a part of the discharge management process where decisions must be reached whether corrections to the discharge report need to be made or not. In this case, the decision is made by a different clinician than in the previous case. Again, visualization techniques could be implemented to provide this other clinician with a better overview of the state in which the discharge report is currently in Summary As mentioned previously, it is very important to fully understand a certain business process before changes can be made to this process. In the case of this master thesis, the discharge management process of the Innsbruck University Medical center was modeled such that points in this process could be found where alerts and reminders could possibly be implemented. The analysis of this discharge management process, especially the four subsections modeled above brought light to some important things. First of all, an important finding that can be derived from these diagrams is that the implementation of alerts or reminders would appropriately fit into the existing process. Concrete locations in the process were found. Additionally, it is important to Page 79

80 realize that the weaknesses in the process described by the physician in the interview could also be seen in this process. The suggestions which came to light in the physician interview, combined with the business process diagrams illustrated in this section will be used in combination with the specifications of the alerts and reminders module and hospital information system described in the next section to come up with several concrete implementation suggestions later on in this master thesis. 4.4 Implementation Environment: Cerner Millennium and Discern Expert Introduction It is important, when implementing new functionality into an already existing system, to do so in a way which is of least hindrance and most practicality for system designers, implementers, and end users. Following discussions with various information technology experts of TILAK, the Discern Expert System from Cerner (Cerner, 2002) was chosen as an appropriate tool of implementing alerts and reminders into the existing Cerner Millennium computer supported application system. The following sections will give a description of these two systems Cerner Millennium Cerner Millennium is a computer supported application system which is currently being used by the Innsbruck University Medical Center. Cerner Millennium offers various functionality, including the functionality of the PowerChart module which is of most importance for this master thesis and for implementing alerts and reminders in general. The PowerChart module provides functionality surrounding the electronic patient record. Some of the functionality provided by PowerChart includes integrating clinical information from multiple locations throughout the continuum of care, giving clinicians instant access to longitudinal patient information, including lab results, radiology reports, emergency room records, etc., displaying data in the electronic patient record to best meet the needs of caregivers, improving compliance with care and regulatory standards, assisting caregivers in making more informed clinical decisions Page 80

81 by having a completed patient history and results at their fingertips, enabling clinicians to review data, enter orders, document care all in a graphical user interface and reducing medication errors and adverse drug events (Cerner, 2002) Discern Expert (The following information is taken from the Discern Expert Cerner Millennium Support Guide-Product Introduction (Cerner, 2002)) Discern Expert functions outside of, but in conjunction with, Cerner Millennium applications to provide the user a means to add a level of decision support to currently occurring transactions. System activity from Cerner Millennium applications can be used to trigger or evoke a Discern Expert module to start an evaluation. Discern Expert is an event-driven, rule-based product. It can be successfully employed by health professionals to perform cost containment, quality assurance, resource utilization, interdepartmental communication, and risk management. It provides the ability to perform both asynchronous and synchronous processing. With asynchronous processing, the task is performed in the background without interaction from the user. Synchronous processing allows the interaction between the user and the system to occur in real time, with the user required to respond to the system s request in order to proceed to the next screen. Discern Expert s main activity is to monitor events of interest within the client s licensed Cerner products and take action(s) depending upon user-defined criteria. A small sample of events that can invoke Discern Expert includes admissions, transfers, discharges, orders, and results. Events can be captured either before or after they are processed. Discern Expert also can trigger on events that occur in non- Cerner systems that are interfaced to Cerner s systems via a foreign system interface. Discern Expert provides the ability to act prospectively when these events occur, either before or after they are processed, potentially preventing complications or the performance of unnecessary tasks. Discern Expert users create rules with IF-THEN logic that allows users to apply their own criteria to a set of events and then take actions compatible with their goals. Page 81

82 For example: IF: An order is received AND the patient s white blood cell count is too high THEN: Send an message to the treating physician. Discern Expert employs an advanced, graphical user interface-based editor that allows for the easy creation of syntactically correct rules. Examples of actions the system can take include sending terminal and printer messages, sending electronic mail messages, calculating results, creating new and add-on orders, canceling orders, generating reports, performing or verifying results, and generating order or result comments. These actions can be prepared for implementation by using a rules based template. An example of this template can be viewed in Appendix A Summary First upon learning the capabilities of the Discern Expert system and the current Cerner Millennium computer supported application system (more specifically PowerChart) is it possible to make recommendations for the implementation of alerts and reminders. Otherwise these suggestions would be of little or no use for implementers and therefore also of no use for end users. The information which was obtained through learning these two systems (rather, one system and one smaller sub-component) will be used in combination in the following section on recommendations for implementation. 4.5 Recommendations for Implementation Introduction When deriving new concepts and theories, it is important not only to make them work on paper, but also to try them out in real life. The concepts and theories in this master thesis have been developed such that they can be applied in a variety of settings. However, to stay within the scope of this project, they will be implemented on hand of the discharge management process of the Innsbruck University Medical Page 82

83 Center. This section describes two implementation suggestions in greater detail. These suggestions will then be implemented in the next section. These recommendations are mainly based on the theories and concepts derived in previous sections, as well as on the information and ideas obtained through the physician interview and the information gained through modeling and understanding the discharge management process. A special emphasis has also been put on taking into account the capabilities of the Discern Expert system for the implementation of alerts and reminders described above. The two concrete recommendations are a Test Summary Report and a Pending Discharge Report. These two recommendations will be described below. Within each recommendation, descriptions regarding which part of the process (tasks which were completed longer ago, tasks which were recently completed, which tasks are currently being completed, which tasks are outstanding, and which tasks will have to be completed in the future) the recommended alert or reminder affects will be referred to. Also, a description of which type of visualization technique (active alerts or passive reminders) should be implemented will be given along with the location of where the alert or reminder should be found (on the person, in space or on the computer interface). A suggestion for the layout of these visualization techniques will also be made. Screen shots from the current hospital information system will also be included to provide the reader with a better understanding of how the implementation could look. Finally, a rules based template from the Discern Expert module will be constructed for each implementation suggestion. This template, along with the layout suggestions will be used for the actual implementation. Page 83

84 4.5.2 Recommendation Suggestion 1: Test Summary Report Description A Test Summary Report is a list that can be viewed or is sent directly to the printer, that is, it is displayed to be viewed or printed by the printer, when a clinician specifies so on the user interface, thereby requesting this list. The Test Summary Report provides a clinician with the following information: The title of the list (Test Summary Report) the date and time, the requesting physician, the requesting ward, the names of the patients who are currently on the ward, which tests have been scheduled for each patient, which tests have been carried out for each patient, and whether or not results from the completed tests are available. It is important to emphasize that this list should only be printed or brought up to be viewed upon request of the individual clinician, not automatically. Need There are various reasons why this list is needed. First of all, physicians are currently experiencing difficulties with the current ward information list which is available to them in the current system which displays part of this information. The physician which was interviewed mentioned that the current list is too slow and there is too much unnecessary information displayed, making it hard to extract needed information. Physicians also want to be able to obtain information other scheduling of tests and test results, so that they can better streamline and plan their work processes. This information is currently not easily and readily available to them. Page 84

85 Finally, some basic information on this list such as the names of the patients who are currently on the ward would be helpful, for example at the beginning of a shift or prior to rounds, to help clinicians gain a better overview of the patients. Process view The Test Summary Report occurs across two process views. These two views are which tasks have recently been completed and which tasks are outstanding. The parts of this visualization technique which fall under the first process view of which tasks have recently been completed is, in some sense, which patients are currently on the ward, the scheduling of tests, the execution of tests and the results reporting of completed tests. The parts of this visualization technique which fall under the second process view of which tasks are outstanding are the not yet completed tests which are scheduled for the patients and the not yet reported results for tests which have been executed. Active alerts or passive reminders Both active alerts and passive reminders could be implemented in this situation as two process views are touched upon. Both process views, which tasks have recently been completed and which tasks are outstanding, would typically employ active alerts. However, based on the requests extracted from the physician interview, classifying this Test Summary Report as an active alert would not be of particular use here because to obtain the Test Summary Report, the clinician must already actively request this list. This makes this list more of a passive reminder. After all, when a list is printed at a printer, it is not seen as an active alert because the clinician still has the chance to ignore it. Location To decide on the location of where the Test Summary Report should be received by a clinician it is important to fall back on the theories defined in the previous sections. It wouldn t be sensible for a clinician to receive a Test Summary Report on the person, especially when taking into account the wishes of the interviewed physician. Page 85

86 Technically it would be difficult to transmit a list directly to the person. It would be most sensible for a Test Summary Report to be received in space (when it is sent to the printer) or received on the computer interface (when the clinician chooses to just view the list, not print it). The following provides a summary of the information on which process view this visualization technique falls under, whether active alerts or passive reminders should be used and the location of where this visualization mechanism should be transmitted to. Process View: Tasks which have been completed Tasks which are outstanding Type: Passive reminder Location: In space On the computer interface Layout Proper layout and design of the Test Summary Report is essential so that users accept the list and use it to aid them in their everyday work. Through collaboration with the physician in the physician interview, the following example of Test Summary Report list was constructed: Page 86

87 Test Summary Report Requesting Physician: Dr. X Requesting ward: X Date: DD.MM.YYYY Time: HH.MM Patient Name (Surname, Name) Scheduled test Test completed? Results available? Doe, Jane XXX No No Goodall, Susan XXX Yes Yes XXX Yes No XXX No No Smith, John XXX Yes No XXX No No Thompson, Allan XXX No No XXX Yes No XXX Yes Yes XXX Yes No Innsbruck University Medical Center Page 1 of 1

88 The Test Summary Report should be sorted alphabetically by patient surname, and then by test. All tests belonging to a patient should be listed one after the other. There are various possibilities for the layout of the user interface, that is, how this reminder could be invoked. The first suggestion is one where there is a button directly visible on the user interface which the user presses, in order to bring up a screen which provides the user with an option of which reminder he or she would like to invoke. This user interface recommendation in the current Cerner Millennium computer supported application system can be seen in Figure 21.! Figure 21: Screen shot from the Cerner Millennium computer supported application system. A recommendation for how the Test Summary Report reminder could be invoked as a button directly on the user interface is illustrated. The button in the upper right hand corner with the exclamation mark would be the one that the clinician would press to bring up the window shown in Figure 22. Page 88

89 Figure 22: Screen shot of reminder window evoked by pressing the specified button on the hospital information system user interface. In this reminder window, the clinician can specify which reminder list he or she would like to print or view. Another layout possibility is the option to invoke the reminder in the existing menu bar. This recommendation could possibly be the more appealing one, as it would involve less clicks for the user. The list, for example, could be invoked under the menu Patientenliste (English patient list). Under this menu there could be an option reminders. Under this option there could be a sub-menu which supplies all of the reminders which the clinician could choose from. This user interface recommendation in the current Cerner Millennium computer supported application system can be seen in Figure 23. A suggestion of what the actual submenu system could look like is displayed in Figure 24. Page 89

90 Figure 23: Screen shot from the Cerner Millennium computer supported application system. A recommendation for where reminders could be invoked in the menu bar is illustrated.... Reminders? Test Summary Report... Pending Discharge Report Figure 24: Possible layout suggestion of how the Test Summary Report reminder could be evoked from the menu bar. By programming the command to evoke reminders in the menu bar space is saved on the user interface and less clicks are needed. On the other hand, they are also less visible. Page 90

91 Process Improvement The aim of suggesting the implementation of the Test Summary Report was to suggest a way in which to improve upon the current discharge management process flow. This Test Summary Report touches upon the final test ordering and result reporting business process sub-sections modeled in Figure 17, Figure 18 and Figure 19. In Figure 17, a Test Summary Report could provide a clinician with the information needed to answer the question of whether tests still need to be carried out or if they have already been completed. Therefore, the bottleneck at exclamation mark one could be eliminated. In Figure 18, the Test Summary Report could inform a clinician whether results from tests are available or not and also whether or not they are complete. Thereby, bottlenecks at exclamation marks one and two could be eliminated. However, the bottleneck at exclamation mark three cannot be eliminated through the use of this Test Summary Report. In Figure 19, the Test Summary Report could once again provide the clinician with information on whether results are available or not and thereby eliminate the bottlenecks at exclamation marks one and five. The current suggestion for the layout of the Test Summary Report could not eliminate the bottlenecks at exclamation marks two, three or four. However, they could be eliminated if the Test Summary Report provided the additional information on where results are located. Page 91

92 Rules based template University for Health Informatics and Technology Tyrol The following template (which can also be seen in full in Appendix A) is used for the programming of alerts and reminders in the Discern Expert module of the Cerner Millennium computer supported application system. Although a great part of the template must be completed by actual programmers and those who are more familiar with the internal workings of the Discern Expert module, the following is a start to the template, and perhaps one of the more important parts of it as it specifies what actions and reactions must occur in the alert or reminder. The sections of the template marked with XXX must be filled out later on during the implementation. MAINTENANCE SECTION Title: Test Summary Report File name: XXX Date: 1/15/2003 Duration: XXX Authors: XXX Version: XXX Institution: XXX Specialist: XXX Validation: XXX LIBRARY SECTION Purpose: Send list to the printer or displays list on user interface when Test Summary Report command on user interface is executed. Explanation: Keeping clinicians informed of which patients are on a ward and which tests have been scheduled and completed and which results are available is key for everyday clinical activity. Key words: ward clinicians patients tests results Citations: XXX KNOWLEDGE Page 92

93 Priority of Module: XXX EVOKE SECTION XXX LOGIC SECTION The triggering event is the execution of the user interface command requesting the Test Summary Report. ACTION SECTION Send TEST SUMMARY REPORT to PRINTER Or Display TEST SUMMARY REPORT on user interface Recommendation Suggestion 2: Pending Discharge Report Description The Pending Discharge Report is a list that is displayed to be viewed or sent directly to the printer, that is, it is brought up to be viewed or printed by the printer, when a clinician executes the appropriate command on the user interface, thereby requesting this list. The Pending Discharge Report provides a clinician with the following information: The title of the list (Pending Discharge Report) the date and time, the requesting physician, the requesting ward, user specified parameters (see further description below), the names of the patients where discharge reports are still outstanding, and when these patients were discharged. Once again, this list should only be displayed to be viewed or printed upon request of the individual clinician, not automatically. Also, the user interface command should provide the capability for the clinician to supply a number. That is, if the clinician Page 93

94 enters the number 10, he or she is requesting the 10 longest pending discharge reports. Need There is a current need for this Pending Discharge Report because the writing of discharge reports often gets delayed and clinicians can easily loose an overview of which reports have been completed and which still need to be written. Discharge reports themselves are of importance because they are often needed to continue patient treatment in another location by various other clinicians. However, currently, as mentioned by the physician who was interviewed, the writing of these reports isn t of great priority. This could perhaps be due to the fact that there is little information available to clinicians about the status of individual reports. Another reason why this Pending Discharge Report could be of benefit to clinicians is because it could also provide an overview of the discharge dates of patients who s discharge reports are still not completed. This could help clinicians prioritize the writing of these reports. That is, the discharge reports from patients discharged longer ago could be written before those from patients recently discharged. Process view Some may feel that this Pending Discharge Report may once again fall under two process views. That is, which tasks are still outstanding and which tasks will have to be completed in the future. However, it was derived from the physician interview that this task of completing discharge reports is not high on the list of tasks that need to be completed every day at the hospital. Other tasks are often of greater urgency. This is why this task of completing discharge reports often gets delayed. This leads to the Pending Discharge Report being more of a task which fits into the process view of which tasks will have to be completed in the future. Active alerts or passive reminders Tasks which will have to be completed in the future demand passive reminders as opposed to active alerts. The use of the Pending Discharge Report as a passive Page 94

95 reminder is fitting in this situation, as once again, the clinician must already actively request this list. Location As with the Test Summary Report, the Pending Discharge Report reminder should either be transmitted to the clinician in space (when it is sent to the printer) or on the computer interface (when the clinician chooses to just view the list, not print it). Transmitting this list directly to the person would once again not be sensible because of technical limitations. Also, the interviewed physician also made clear that he would like to see this list on the computer interface or printed out. The following provides a summary of the information on which process view this visualization technique falls under, whether active alerts or passive reminders should be used and the location of where this visualization mechanism should occur. Process View: Tasks which will have to be completed in the future Type: Passive reminder Location: In space On the computer interface Layout The proper layout and design of the Pending Discharge Report is also essential so that users accept the list and use it to aid them in their everyday work. Once again, through collaboration with the physician in the physician interview, the following example of a Pending Discharge Report was constructed: Page 95

96 Pending Discharge Report Requesting Physician: Dr. X Requesting ward: X Date: DD.MM.YYYY Time: HH.MM Pending discharge reports for all discharged patients / XXX longest pending discharge reports. Patient Name (Surname, Name) Doe, Jane Goodall, Susan Smith, John Thompson, Allan Discharge date XXX XXX XXX XXX Innsbruck University Medical Center Page 1 of 1

97 The Pending Discharge Report should be sorted chronologically by discharge date so that a clinician, on a quick glance, can see which discharge reports have been pending the longest. There are, as with the Test Summary Report, various possibilities for the layout of the user interface, that is, how this reminder could be invoked. The first suggestion is similar as before where there is a button directly visible on the user interface which the user presses, in order to bring up a screen which provides the user with an option of which reminder he or she would like to invoke. Please refer to Figure 21 for the user interface recommendation in the current Cerner Millennium computer supported application system. The button in the upper right hand corner with the exclamation mark would once again be the one that the clinician would press to bring up the window shown in Figure 22. In this reminder window, the clinician can specify which reminder list he or she would like to print or view. In the case of the Pending Discharge Report, the user also has the option to specify a number so that only the oldest pending discharge reports are displayed. If the box is left blank, the list should display all missing discharge reports. Another layout possibility is the option to invoke the reminder in the existing menu bar. This recommendation could possibly be the more appealing one, as it would once again involve less clicks for the user. The list, for example, could be invoked under the menu Patientenliste (English patient list). Under this menu there could be an option reminders. Under this option there could be a sub-menu which supplies all of the reminders which the clinician could choose from. This user interface recommendation in the current Cerner Millennium computer supported application system can be seen in Figure 23. A suggestion of what the actual submenu system could look like is displayed in Figure 25. Page 97

98 ... Reminders? Test Summary Report... Pending Discharge Report? List all pending... List 10 longest pending... List 20 longest pending Figure 25: Possible layout suggestion of how the Pending Discharge Report reminder could be evoked from the menu bar. In the case of the Pending Discharge Report, the user has the additional option in the sub-menu to choose whether he or she would like to list all pending discharge reports or just the 10 or 20 longest pending discharge reports. By programming the command to evoke reminders in the menu bar space is saved on the user interface and once again, less clicks are needed to evoke the reminder. On the other hand, they are also less visible. Process Improvement As with the Test Summary Report, the aim of suggesting the implementation of the Pending Discharge Report was to suggest a way in which to improve upon the current discharge management process flow. This Pending Discharge Report touches upon the discharge report writing business process sub-sections modeled in Figure 20. In Figure 20, the Pending Discharge Report could provide a clinician with information on whether or not a discharge report has been written. This wouldn t necessarily eliminate the bottleneck at exclamation mark one, however the process could be streamlined there because a clinician could decide on which discharge reports need to be completed with greatest urgency. The bottlenecks at exclamation marks two and three however couldn t be eliminated or reduced with the current layout of the Pending Discharge Report, as it does not provide information on the particular stages in which discharge reports are currently in. It only provides information on whether or not they are complete. Page 98

99 Rules based template As in the previous rules based template defined for the Test Summary Report, the following template is defined for the Pending Discharge Report. MAINTENANCE SECTION Title: Pending Discharge Report File name: XXX Date: 1/15/2003 Duration: XXX Authors: XXX Version: XXX Institution: XXX Specialist: XXX Validation: XXX LIBRARY SECTION Purpose: Send list to the printer or display list to be viewed when Pending Discharge Report command on the user interface is executed. Explanation: Keeping clinicians informed of which discharge reports are still pending following the discharge of patients is key for everyday clinical activity. Key words: ward clinicians patients discharge reports Citations: XXX KNOWLEDGE Priority of Module: XXX EVOKE SECTION XXX LOGIC SECTION Page 99

100 The triggering event is the execution of the user interface command requesting the Pending Discharge Report. ACTION SECTION Send PENDING DISCHARGE REPORT to PRINTER Or Display PENDING DISCHARGE REPORT on user interface Summary This section outlined two suggestions for implementation to support the discharge management process of the Innsbruck University Medical Center. The first suggestion was a Test Summary Report which, when requested by clinicians, provides an overview of what patients are currently on a ward, which tests have been ordered for these patients, which tests have been completed, and whether or not results from these tests are available. The second implementation suggestion is a Pending Discharge Report which provides clinicians, when requested, an overview of which discharge reports are still pending for patients which have already been discharged. The clinician has the possibility to enter a date range such that, for example, the list only shows pending discharge reports for patients who were discharged over ten, 15, etc. days ago. Both of these implementation recommendations were described with regard to the theories and concepts defined in previous sections, that is, with regard to process views, passive reminders and active alerts. Rules based templates were also defined for each of the two implementation suggestions such that they could more easily be implemented in the Discern Expert module of the current Cerner Millennium computer supported application system. 4.6 Implementation Introduction The implementation of new concepts and ideas into an existing system is something which must be done with caution and in collaboration with various people including hospital information technology personnel, programmers, end users, etc. Only when Page 100

101 all of these groups decide to work together can a successful implementation take place. In the case of this master thesis, the implementation suggestions defined in the previous section were presented to information technology personnel of the TILAK in order to determine whether the two suggestions would first of all be practical and second of all to see if they were even programmable. Discussions lead to the following two outcomes: The Test Summary Report was seen as a good suggestion, however at the time being, the programming of this implementation suggestion would be far too complex for the current capabilities of the system. It was determined that the interface is missing between ordered tests and whether the results from these tests are available. It was decided that the benefits versus the costs of implementation currently could not be justified. The Pending Discharge Report was also theoretically seen as a good idea. In fact, a similar report, however with more information, was recently introduced and shown to clinicians on the Neurological ward by information technology personnel of the TILAK. The list which has already been introduced will be shown and described in greater detail in the following section in order to show similarities and differences in the two implementation suggestions Comparison of Implementation Suggestions (TILAK and Master Thesis) The screen shot shown in Figure 26 is an intermediate solution which has been suggested by information technology personnel of the TILAK. It is important to mention that this solution is still currently being revised and improved upon. This list currently shows all documents which have been written for a patient (for each case). A blank denotes that a document is missing. Of course some information in this list Page 101

102 such as patient name and ward has been blended out due to reasons of confidentiality. Figure 26: Screen shot of the implementation suggestion made by information technology personnel at the TILAK. This table shows that information on missing discharge reports (Arztbrief) is also shown (blank means missing). The following list provides translations of some key words in this list in order to clarify content: German English Aufnahmestatus <--> Admission status Page 102

103 Bestätigung <--> Confirmation EEG <--> Electroencephalogram Sono <--> Sonogram Stationärer Arztbrief <--> Discharge letter Aufnahmedatum <--> Admission date Entlassungsdatum <--> Discharge date When this list is compared with the Pending Discharge Report suggested in this master thesis, it is clear that the information displayed with regard to discharge reports in the Pending Discharge Report is also contained in the list suggested by the TILAK. Something that comes to mind when viewing this list from the TILAK is that for the list suggested in this master thesis, the clinician had the option to enter a number to specify that he or she only wants to see the longest outstanding discharge reports. At first glance it would seem that the list suggested by the TILAK doesn t have this same functionality. However, the information technology personnel who are currently further designing this list mentioned that there is also an option to be able to sort the list in various ways. It is interesting to see that similar implementation suggestions have evolved independent of each other. This may be a clear sign that this type of information is urgently needed by clinicians and that it is time to implement such a list Additional Suggestions It is clear that implementation suggestions aren t always implemented or are implemented in a different way than is expected or defined. However, even if a suggestion isn t implemented (such as the Test Summary Report suggested in previous sections), many other important ideas, concepts and suggestions arise through critical discussions with, for example, information technology personnel. Due to time constraints, further ideas which have evolved through discussions and conversations throughout this master thesis couldn t be explored in greater detail. Page 103

104 However, these ideas shouldn t be lost as they may still have great impacts on the future of hospital information systems. Through discussions with mainly information technology personnel, the following ideas for alerting and reminding in the clinical setting arose which could still be looked into in the future: A discharge checklist: A discharge checklist could be a list where a clinician could check which tasks still need to be completed prior to the discharge of a patient. For example, this list would contain things such as whether a discharge report has been written, whether an operation report has been written, whether the future care of a patient has been prepared for, whether necessary further appointments have been made for a patient prior to discharge, etc. Operation report alert / reminder: An operation report alert would be one which alerts a clinician of the fact that an operation has occurred, but that the operation report still hasn t been written. Operation reports are expected to be completed within a certain amount of time following an operation. Therefore, such an alert could be triggered when an operation report is still pending, for example, 2 hours following the completion of an operation. Care level alert / reminder: Care level alerts or reminders are ones which would provide a clinician with information on which care level a patient is at prior to discharge. For example, if a patient is at care level 3, additional tasks should have to be performed prior to discharge to ensure that the patient still receives adequate care following their discharge. The clinician should be alerted or reminded of these tasks. Length of stay alert / reminder: With length of stay alert or reminder it is meant that clinicians should perhaps be alerted or reminded of the fact that a certain patient has been hospitalized for a longer amount of time than is usual. The clinician should then perhaps explore in greater detail the reasons behind this longer length of stay. Organizational alerts and reminders: A suggestion was made that it may also be meaningful to implement alerts and reminders not only in the clinical part of Page 104

105 patient care, but also in the organizational or administrative aspect of patient care. All of the suggestions mentioned above are ones which could currently be of interest for clinicians as well as administrators and are ones which could be implemented in the current hospital information system. The further exploration of these ideas would possibly prove to be useful and interesting Summary In this section, the outcomes of discussions with information technology personnel of the TILAK regarding the previously defined implementation suggestions were illustrated. It was found that one of the two suggestions (the Test Summary Report) made in this thesis currently can t be implemented mainly to current insufficiencies in interfaces between various data. The other of the two suggestions (the Pending Discharge Report) was found to currently already be in the process of being implemented by the TILAK. This implementation section was therefore mainly used to compare the implementation suggestion of the Pending Discharge Report with that of the similar list created by the TILAK. It was interesting to find that similar implementation suggestions arose independent of each other. Following this comparison, an important section with additional suggestions was also included so that interesting ideas which arose throughout this master thesis aren t lost. 4.7 Conclusion The application of the concepts defined in previous sections of this master thesis was extremely important in order to determine their usefulness and to see if they could positively be implemented in a real life setting. The theories and concepts of this thesis were applied on hand of the discharge management process of the Innsbruck University Medical Center. Various steps were gone through in order to come up with appropriate implementation suggestions. Page 105

106 A physician interview was one of the first major steps toward coming up with implementation suggestions. Dr. Armin Muigg of the Neurological Ward of the Innsbruck University Medical Center was interviewed in order to arrive at what would help him in his and his colleagues work and what would hinder them. Two concrete implementation suggestions arose through this interview, one being Test Summary Report and the other being the Pending Discharge Report. These two suggestions were defined in greater detail. Once these suggestions which arose through the physician interview were defined in greater detail, the business process diagram of the discharge management process at the Innsbruck University Medical Center was examined to see where these suggestions could have impacts on the overall process. Parts of the process mainly dealing with test ordering, results reporting and discharge report writing were examined in greater detail. Following the physician interview and the detailed examination of the discharge management business process diagram, a part of this master thesis was devoted to describing the Cerner Millennium computer based application system and the Discern Expert module in a bit of detail. The Discern Expert module is used to program alerts and reminders into the Cerner Millennium system. Perhaps the most interesting part of this application section is the actual concrete implementation suggestions. The Test Summary Report and the Pending Discharge Report suggested in the physician interview were defined in great detail in this section. The concepts and ideas defined in previous sections of this thesis were referred to. In particular, theories with regard to process views, types of visualization techniques and location of visualization techniques were referred to. Suggested layouts of the two implementation suggestions were also illustrated. What occurred with regard to the actual implementation of the two suggestions was described lastly. In summary, it turned out that the Test Summary Report could not be implemented due to current insufficiencies in interfaces between certain data. The second implementation suggestion, the Pending Discharge Report, was found to Page 106

107 currently be in the process of being implemented by the TILAK. Therefore, a comparison was made between the suggestion made by the TILAK and the suggestion made in this master thesis. Following this, ideas for future implementation suggestions were also documented and described. Through this application section, it was interesting to apply newly derived theories and concepts in a new setting. The suggestions for implementation made in this section are just a start to the application of alerts and reminders in the clinical setting. Hopefully these ideas will help interest grow in this area in the future. Page 107

108 5. Discussion of Findings and Conclusion Ideas surrounding the visualization of process flows in the clinical setting are found to be sparsely developed. This is why this master thesis is devoted to the derivation of these visualization techniques, more concretely, alerts and reminders, with regard to their application in the clinical setting. The three main sections of this master thesis: derivation of basic principles, the explanation of new concepts with regard to supporting process flows in the clinical setting and the application of these new concepts on hand of a concrete example attempt to fill this knowledge gap. 5.1 Answers to the Questions The findings and conclusions with regard to this master thesis can best be described with regard to the questions which were initially asked in the planning phase of this master thesis. The first major question was: Q1. Which general concepts and techniques exist for the visualization of standardized process flows? In the basic principles section of this thesis, a literature search was carried out in order to arrive at what currently exists in the area of visualization. Various sources of information were found and merged together in order to arrive at a comprehensive view of the current state of visualization. This question was broken further broken down into three sub-questions: Q1.1 How can processes adequately be presented to visualize standardized process flows? In this basic principles section, a discussion surrounding the idea that in order to even begin to implement visualization techniques into a certain process, the process first and foremost needs to be understood and evaluated. This can be reached by appropriately modeling the process using a modeling technique such as the UML modeling technique. Page 108

109 Q1.2 How can alerts and reminders be used to visualize process flows? Visualization was introduced as a monitoring technique to aid in the planning and execution of tasks. It was found that there are many tasks that often need to be monitored in a process including current tasks, what current tasks resulted from, what outcomes current tasks will have, decision making and the updating of processes. However, following further analysis, five major tasks were found which can adequately be monitored through visualization techniques in the clinical setting. These are: tasks which have been completed long ago, tasks which have recently been completed, tasks which are currently being completed, tasks which are outstanding and tasks which need to be completed in the future. Each of these five tasks can usually be found in a process. Q1.3 What types of alerts and reminders exist and where can they be located to apply them appropriately in a hospital information system? Once a process has appropriately been modeled and it has been derived in which parts of the process visualization techniques could be implemented, it was found that visualization techniques need to be broken down and evaluated in order to arrive at a best fit for each applied visualization technique in each part of a process. Visualization techniques were broken down by type (active alerts versus passive reminders) and by location of where they can be received (in space, on the person or on the computer interface). Various visual examples of each type of visualization technique were given in order to provide the reader with a better understanding of what was meant by each type. Some information on communication theory was also described in this section in order to provide some ideas on how visualization techniques can best be communicated. The next major question which was asked was the following: Q2. Which concepts and techniques for the visualization of standardized process flows found in Q1 are suitable for implementation in a hospital information system? Page 109

110 In order to arrive at which of the concepts and techniques derived in the basic principles section could best be applied in the clinical environment and how, it was first important to explore and describe the clinical environment and its processes, and more specifically a hospital information system, in greater detail. Two sub-questions arose out of Q2 which are answered below. Q.2.1 How can process flows in hospital information systems be broken down? Perhaps the most important result of this analysis was the breakdown of clinical processes into five process flows. These mirror the five tasks defined to be monitored through visualization techniques in the basic principles section. Process view one was tasks which have been completed long ago, process view two was tasks which have recently been completed, process view three was which tasks are currently being executed, process view four was which tasks are outstanding and process view five was tasks which will have to be completed in the future. Each of these process views were described with regard to their importance in an overall process, the urgency with which information regarding each process view should be relayed to clinicians and how important information conveyed with regard to each process view is to a clinician at a particular point in time. Examples were also given for each process view so that the reader would once again obtain a better understanding of the breakdown of processes in the clinical setting. Q2.2 How can alerts and reminders be applied to process flows? Following the previous analysis, the ideas of communication theory and the breakdown of alerts and reminders discussed in the basic principles section were combined with the breakdown of clinical processes into the five process views in order to find matching characteristics and find appropriate ways to apply alerts and reminders as visualization techniques in the clinical setting. Appropriate matches were found for each process flow. More specifically, details regarding what type of visualization technique should be applied to each process view (active alerts versus passive reminders) and the location of where the alert or reminder could best be Page 110

111 received (in space, on the person or on the computer interface) were emphasized with concrete examples out of the clinical environment. The last major question which was asked in this thesis was: Q3. Which concepts and techniques for the visualization of standardized process flows found in Q2 are meaningful to be implemented in the discharge management process of the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center? The application of the new theories and concepts defined in the master thesis on hand of the real life example of the discharge management process at the Innsbruck University Medical Center proved to be a very interesting and important task. This application brought light to additional interesting aspects of alerting and reminding in the clinical setting which weren t previously brought to awareness. This last major question was broken down into four sub-questions which are answered below. Q3.1 What requirements exist for the implementation of alerts and reminders in the discharge management process of the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center? It is appropriate and wise to involve all parties who are involved with and benefit (or perhaps will see a negative effect) from the implementation of new ideas into existing processes, work flows, systems, etc. This is why this application section began with a physician interview. A physician on the neurological ward of the Innsbruck University Medical Center was asked to give his opinions surrounding what he thought about alerting and reminding. He gave his opinions with regard to what could possibly help him and his colleagues in their work, what would hinder them, and he gave a few concrete examples of alerting and reminding techniques that could benefit him in his work. Two examples (a Test Summary Report and a Pending Discharge Report) were then explored in greater detail. Page 111

112 Q3.2 How can various parts of the discharge management process of the Cerner- Millennium computer supported application system at the Innsbruck University Medical Center be modeled? A business process diagram of the explored discharge management process was analyzed to see where these two implementation suggestions could impact the process and how. It was found that these two suggestions mainly impacted areas of the process dealing with test ordering, results reporting and discharge report writing. Q3.3 What implementation environments exist to implement alerting and reminding techniques in the Cerner-Millennium computer supported application system at the Innsbruck University Medical Center? Once the impact of these two implementation suggestions was explored, the Discern Expert module (used to implement alerts and reminders into the Cerner Millennium computer supported application system) and the Cerner Millennium computer supported application system were briefly illustrated in order to give a bit of background information on how alerts and reminders are implemented. Q3.4 What implementation suggestions can and will be implemented in the Cerner- Millennium computer supported application system at the Innsbruck University Medical Center? Following these descriptions, the actual recommendations for implementation were described in detail. The Test Summary Report and the Pending Discharge Report were both elaborated on with regard to what information they are to convey to a clinician, which process view they fit into in the clinical setting, whether they can be defined as active alerts or passive reminders and whether thy could best be relayed to a clinician on the person, in space or on the computer interface. It turned out that both recommendations were to be relayed in space and/or on the user interface. Therefore, user interface design was also discussed. Following these discussions, rules based templates (needed to specify programming instructions in the Discern Expert module) were filled in for both recommendations. Page 112

113 Following the detailed descriptions of both implementation suggestions, the actual implementation followed. Through interesting discussions with information technology personnel from the TILAK, it was discovered that there are currently limitations in data interfaces, making it very difficult to implement a Test Summary Report, the way it was described, at this point in time. It was also discovered that an implementation similar to the Pending Discharge Report is currently already being defined at the TILAK. Due to this, the implementation section mainly focuses on a comparison of the Pending Discharge Report and the TILAK suggestion. Also, additional implementation suggestions which came about through information technology personnel which could perhaps be explored in greater detail in the future are illustrated. 5.2 Discussion Throughout this master thesis, various different steps were followed and techniques were used in order to arrive at the end product. Each step along the way, it was discovered that some steps were more meaningful than others, and that often problems arose which could perhaps be avoided in the future. If some things were done in other ways, different results could have arisen. Each major result of this master thesis is discussed in detail in this section. A special emphasis is put on how results may have been different if steps had been carried out differently. Perhaps two of the most significant ideas which arose from this thesis were the definition of visualization techniques on two axis (by type and location) and the breakdown of processes into five process flows. On the type axis, active alerts and passive reminders were chosen to be explored in greater detail. There are many other types of visualization techniques which could perhaps be explored in the clinical environment, but alerts and reminders were chosen because it was found that previous attempts have already been made in the clinical environment and others to make use of these techniques. Even though these attempts have already been made, the use of alerts and reminders in hospitals was a fairly new topic which still needed exploring. Page 113

114 A problem which arose through the breakdown of visualization techniques by type was that active alerts and passive reminders were found to exist on a continuum. However, for the sake of applying these techniques, they needed to be broken down more concretely. That is, they needed to be defined as though they didn t exist on this continuum. At certain points in was difficult to concretely apply either a definite alert or a definite reminder in a certain situation. The breakdown of alerts and reminders into where they could be received in the clinical environment was also an important result. Three locations were decided upon: in space, on the person and on the computer interface. This breakdown proved to be fitting in the clinical environment, especially because it also fit with the business processes and technology currently being employed in this setting. This breakdown also seemed to cover all logical possibilities of locations in the clinical environment. Another section of this thesis which was found to be very helpful was the one describing communication. Many different models of communication were looked at when trying to find one appropriate for the conveyance of alerts and reminders in the clinical setting. However, in the end, the well know Shannon s communication model was chosen. This model helped describe the effects of the communication of information throughout the clinical environment especially with regard to where problems could occur during this communication. Without the description of communication, it would have been difficult to try to apply visualization techniques to different parts of clinical processes. There would have been a gap and little evidence that the alerts and reminders suggested in following sections would be of use. The breakdown of processes into five process flows was an interesting and iterative tasks which developed over time. Initially, three process views were defined. These were: which tasks have been completed, which tasks are still outstanding, and which tasks will have to be completed in the future. Work was continued on the thesis following the determination of these process views, and as time went on it was found that these three views did not cover all parts of a process which can take place in the clinical environment. These three process views were partially also found to be too Page 114

115 broad. For example, the process view of which tasks have to be completed did not decipher between tasks which occurred a longer time ago and those which occurred recently. As the thesis progressed it was difficult to apply alerts and reminders to this process view because it encompassed everything that happened in the past, recent and longer ago. Another process view which was forgotten altogether was the one of which tasks are currently occurring. At first it seemed that it would not be appropriate to apply visualization techniques such as alerts and reminders to this type of process view, but once again, as time went on, it was clear that they could also be beneficial in this situation. In the end, five new process views were defined. These were: tasks which happened longer ago, tasks which have recently been completed, tasks which are currently being completed, tasks which are outstanding and tasks which are to be completed in the future. The application of alerts and reminders to support the five defined process views was done with information from all sections. It was found that all of the information which was gathered and principles which were explained helped find good fits for alerts and reminders to each of the process views. This however was only possible after all of the process views were defined properly. Difficulties were encountered when alerts and reminders were applied to the originally defined three process views. Upon reviewing these and expanding them to five it was found though that better fits between alerts and reminders and process views were found. The final section, application of alerts and reminders to monitor the discharge management process, was a critical one in order to display the effectiveness of using alerts and reminders in the clinical setting. The discharge management process was chosen for the application and it was found that this process was very appropriate as it was somewhat complex, had reoccurring tasks and had bottlenecks and many places for improvement. This process was moderately difficult to model, sometimes creating a challenge when trying to come up with ideas on how the process could be monitored through visualization techniques. Another process which could perhaps have been explored in the clinical environment is the admission process, as it also has a certain degree of complexity and there are Page 115

116 also tasks which reoccur just as in the discharge management process. The fact that the ideas of this thesis were only applied in one process limit the results quite a bit. A physician interview was very important in this thesis in order to arrive at what clinicians view as important when implementing alerts and reminders. In this case, only one physician was interviewed which isn t ideal. In the ideal situation it would be beneficial to obtain many different opinions from various types of clinicians as the suggestions made by one physician may not be representative of all clinicians. It was found that the ideas gathered throughout this interview lead in a direction which was beneficial to this thesis, but which wasn t expected. As already mentioned, if a similar project were to be done again it would be a good idea to leave more time to interview more clinicians in order to obtain a broader view of what they would find beneficial. Even without several interviews, concrete implementation suggestions and ideas arose. Two implementation suggestions which arose in the implementation section were a Test Summary Report and a Pending Discharge Report. It was found that the Test Summary Report would be of great use for clinicians, however, the current limitations of the Cerner-Millennium system don t allow a feasible implementation. The Pending Discharge Report was also seen as a useful implementation suggestion which was actually already being suggested for implementation by the TILAK. Therefore, another independent implementation would not be pursued. Perhaps to better implementation suggestions, it would be wise to collaborate more closely with IT staff. The close collaboration with clinicians is also very important, but collaborating with actual implementers and programmers would have been a good idea in order to know ahead of time what is currently being implemented or worked on and what can and cannot be done. This closer collaboration could also perhaps increase the chance that a project such as this one becomes more practically oriented. At this point only the theoretical material of this thesis can be explored, making the outcome very limited. Page 116

117 Overall, it was found that there were roadblocks along the way during this thesis which were important to overcome before further progress could be made. Various things mentioned above could be done differently in order to perhaps arrive at different results. However, it was found that the results which arose were suitable for the allotted time. 5.3 Future Steps The ideas, concepts and theories which have evolved throughout this master thesis build a basis for further research in the area of visualization in the clinical setting. It would be ideal if interest in this area would continue to grow so that the benefits of alerts and reminders can increasingly be seen in the clinical setting in the future. The TILAK is currently continuing work on their version of the Pending Discharge Report. The results and acceptance of this report will be key to the understanding of whether or not alerts and reminders can continue to find their place in the clinical environment. In the future, it would also be ideal to be able to implement some of the other suggestions made in this thesis to test their usability. Following this, it would also be recommended to try to apply alerts and reminders on hand of other processes in the clinical environment. Also in the future, as systems expand and interfaces between them grow, and as computers continue to find their common place in the clinical environment, it will be easier to implement alerts and reminders. It must however still be made sure that this implementation of alerts and reminders would help, not hinder clinicians in their work. Page 117

118 6. Appendix University for Health Informatics and Technology Tyrol 6.1 Appendix A Rule Based Template MAINTENANCE SECTION TITLE: FILE NAME: DATE: DURATION: AUTHORS: VERSION: INSTITUTION: SPECIALIST: VALIDATION: XXX XXX XXX XXX XXX XXX XXX XXX XXX LIBRARY SECTION PURPOSE: Send message to XXX s InBox and print a message to XXX when a positive blood culture has been resulted. EXPLANATION: Notifying XXX and XXX of a positive blood culture is standard operating procedure. KEY WORDS: blood culture clinical event positive infection control asynchronous CITATIONS: PRIORITY of Module: XXX Evoke on CLINICAL_EVENT where, EKS_CE_NORMALCY_E KNOWLEDGE EVOKE SECTION E1 the triggering request for event set name of C Blood and a event class of Microbiology with a result status *Any Result Status is Postive Page 118

119 LOGIC SECTION EKS_CE_NORMALCY_INCOMING_L L1 the triggering request for event set name of C Blood and a event class of Microbiology with a result status *Any Result Status is Postive ACTION SECTION EKS_INBOX_A A1 Send a Phone Msg related to Refer to L1 to the In-Box of Attending Physician with Positive Blood Culture and A positive Blood Culture was resulted with High. AND EKS_MESSENGER_A A2 Send message with subject Positive Blood Culture and message A positive Blood Culture was resulted with a High priority. Page 119

120 6.2 Appendix B Physician Questionnaire Master Thesis - Visualization of Process Flows in Hospital Information Systems Physician Questionnaire The following questionnaire is meant to be used as a basic framework for a person to person interview with a physician on the neurological ward of the Innsbruck University Medical Center. The questions are geared towards deciphering which alerting and reminding techniques would be useful (and where they would be most useful) from a clinical (physician) point of view. Date of interview: Interview start time: Interview end time: Interviewer: Interviewee: Location: Remarks: Section A: Opinions 1. Do you feel that there is an overload in data and information that you need to process every day? 2. Do you find this data and information is currently difficult to manage? Page 120

121 Section B: Processes and Alerts/Reminders (Explain what an alert / reminder is / types of alerts and reminders / where they can be received) 3. Where do you think alerts and reminders could best be implemented into your daily work process? (e.g. to bring awareness to unusual results, to bring awareness of an incomplete discharge report) 4. What type of alerting or reminding would you find most appropriate for these situations? That is, how would you like to receive this alert or reminder? (e.g. as an message, as a frozen screen on the user interface, as a bold or colored number on a report) Section C: Conclusion 5. Is there anything else you would like to bring to my awareness with regard to the implementation of alerts and reminders in the current hospital information system? Page 121

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123 von Informationssystemkomponenten am Beispiel von Krankenhausinformationssystemen. 1 ed. Stuttgart: B.G. Teubner Stuttgart; Haux R, Winter A, Ammenwerth E, Brigl B. Strategic Information Management in Hospitals. An Introduction to Hospital Information Systems. 1 ed. New York: Springer; HMC. Target Call Center. August 21, 2002, electronic source: Holland B, Janzen J. Guidelines for process modeling. August 22, 2002, electronic source: Holzinger A. Basiswissen Multimedia. Würzburg: Vogel; Hunt D, Haynes B, Hanna S, Smith K. Effects of computer-based decision support systems on physician performance and patient outcomes. A systematic review. JAMA 1998;280: pp Innsbruck-Universität. Elektronische Zeitschriften Bibliothek. August 21, 2002, electronic source: Interactive-Blueroo. Canada Adopts. August 21, 2002, electronic source: InvestorWords. The biggest, best investing glossary on the web. August 7, 2002, electronic source: Italia C. Friends of Ciao Italia. August 21, 2002, electronic source: friendsofciaoitalia.html. Knorr K, Calzo P, Röhrig S, Teufel S. Prozessmodellierung im Krankenhaus. In: Electronic Business Engineering / 4th International Conference on Industrial Informatics; 1999; Heidelberg: Physica Verlag; p Krall M. Clinicians' Assessment of Outpatient Electronic Medical Record Alert and Reminder Usability and Usefulness Requirements: a Qualitative Study [Master]. Oregon: Oregon Health and Science University; Krall M, Sittig D. Objective assessment of usefulness and appropriate presentation mode of alerts and reminders in the outpatient setting. In: Proceedings of the Annual Symposium of the American Medical Informatics Association; 2001; Portland: Hanley & Balfus, Inc. Medical Publishers; p Leiner F, Gaus W, Haux R, Knaup-Gregori P. Medizinische Dokumentation. Lehrbuch und Leitfaden für die Praxis. 3 ed. Stuttgart: Schattauer; Microsoft. Error Messages. August 21, 2002, electronic source: Page 123

124 OMG. Object Management Group. October 11, 2002, electronic source: Oxford. Oxford English Dictionary. 2002, electronic source: Preece J, Rogers Y, Sharp H, Benyon D, Holland S, Carey T. Human-Computer Interaction. 1 ed. Essex: Addison-Wesley; Prijatelj. Success factors of hospital information system implementation: what must go right? Stud Health Technol Inform 1999;68: pp Raschke R, Gollihare B, Wunderlich T, Guidry J, Leibowitz A, Peirce J, Lemelson L, et al. A Computer Alert System to Prevent Injury From Adverse Drug Events - Development and Evaluation in a Community Teaching Hospital. JAMA 1998;280(15): pp Reichert M. Prozessmanagement im Krankenhaus - Nutzen, Anforderungen und Visionen. Das Krankenhaus 2000;92(11): pp Reichert M, Dadam P, Mangold R, Kreienberg R. Computer support of workflow in the hospital: concepts, technology and application. Zentralbl Gynakol 2000;122(1): pp Rind D, Safran C, Phillips R, Wang Q, Calkins D, Delbanco T, Bleich H, et al. Effect of Computer-Based Alerts on the Treatment and Outcomes of Hospitalized Patients. Arch Intern Med 1994;154: pp Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive systems for preventive care in the ambulatory setting. JAMIA 1996;3: pp Star. Star Headlight and Lantern Company of Canada Ltd. August 21, 2002, electronic source: TILAK. Tiroler Landeskrankenanstalten GmbH. October 11, 2002, electronic source: Warren J. Introduction to Minitrack: Information Overload on the Physician's Desktop. In: 32nd Hawaii International Conference on System Sciences; 1999; Hawaii; Wyner A. The significance of Shannon's Work. Aug 16, 2002, electronic source: Zorman M, Stiglic M, Kokol P, Malcic I. The limitations of decision trees and automatic learning in real world medical decision making. J Med Syst 1997;21(6): pp Page 124

125 Curriculum Vitae Marital Status: not married Birthdate: , Victoria, BC, Canada Bachelors degree in Health Information Science at the University of Victoria, British Columbia, Canada (Degree: B.Sc. in Health Information Science) Work-term semester at the Kootenay Boundary Community Health Services Society, Nelson, British Columbia, Canada Work-term semester at the Vancouver/Richmond Health Board, Vancouver, British Columbia, Canada. May 2000 International work-term semester at the Institute for Biometry and Medical Informatics, Greifswald, Germany Masters degree in Medical Informatics at UMIT present Research assistant at the University for Health Informatics and Technology (UMIT), Tyrol, Austria. I hereby declare to have completed this work independently and to have used no aids other than those mentioned. Page 125