Visualization of Process Flows in Hospital Information Systems

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 www.umit.at

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

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.

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.

Table of Contents 1 INTRODUCTION... 7 1.1 TOPIC AND MOTIVATION...7 1.1.1 Hospital Information Systems...7 1.1.2 Complexity of Processes in healthcare...7 1.1.3 Management of processes in healthcare...8 1.1.4 Monitoring of processes in healthcare...9 1.1.5 Visualization to monitor processes in healthcare...10 1.2 PROBLEMS...12 1.3 GOALS...13 1.4 QUESTIONS...13 1.5 ENVIRONMENT...15 1.6 STRUCTURE...16 2. BASIC PRINCIPLES...18 2.1 INTRODUCTION...18 2.2 BASIC TERMS...18 2.3 REPRESENTATION OF PROCESSES...20 2.3.1 Introduction...20 2.3.2 Modeling techniques...21 2.3.3 Summary...24 2.4 VISUALIZATION...25 2.4.1 Introduction...25 2.4.2 Visualization as a monitoring technique...26 2.4.3 Visualization with alerts and reminders...28 2.4.4 Summary...29 2.5 ALERTS AND REMINDERS...29 2.5.1 Introduction...29 2.5.2 Demands and effects of alerts and reminders...30 2.5.3 Shannon s communication model...32 2.5.4 Types of Alerts and Reminders...35 2.5.4.1 Passive Reminders...35 2.5.4.2 Active Alerts...37 2.5.5 Location of Alerts and Reminders...38 2.5.5.1 Alerts and Reminders Received in Space...38 2.5.5.2 Alerts and Reminders Received on the Person...40 2.5.5.3 Alerts and Reminders Received on the Computer Interface...42 2.6 CONCLUSION...47 3. ALERTS AND REMINDERS TO SUPPORT CLINICAL PROCESS FLOWS: NEW CONCEPTS...48 3.1 INTRODUCTION...48 3.2 BREAKDOWN OF PROCESS FLOWS...48 3.2.1 Process View 1: Tasks which have been completed longer ago...49 3.2.2 Process View 2: Tasks which have recently been completed...50 3.2.3 Process View 3: Tasks which are currently being executed...51 3.2.4 Process View 4: Tasks which are outstanding...52 3.2.5 Process View 5: Tasks which will have to be completed in the future...54 3.3 APPLICATION OF COMMUNICATION THEORY AND ALERTS AND REMINDERS TO SUPPORT PROCESS VIEWS...55 3.3.1 Process View 1: Tasks which have been completed longer ago...55 3.3.2 Process View 2: Tasks which have recently been completed...56 3.3.3 Process View 3: Tasks which are currently being executed...58 3.3.4 Process View 4: Tasks which are outstanding...59 3.3.5 Process View 5: Tasks which will have to be completed in the future...60 3.4 CONCLUSION...62 4. APPLICATION OF ALERTS AND REMINDERS TO MONITOR THE DISCHARGE MANAGEMENT PROCESS...63 Page 5

4.1 INTRODUCTION...63 4.2 ANALYSIS OF REQUIREMENTS FOR ALERTS AND REMINDERS: PHYSICIAN INTERVIEW...64 4.2.1 Introduction...64 4.2.2 Physician Interview Structure...65 4.2.3 Physician Interview Results...66 4.2.3.1 What hinders a clinician in their everyday work?...66 4.2.3.2 What helps a clinician in their everyday work?...66 4.2.3.3 Concrete examples...67 4.2.4 Summary...69 4.3 DISCHARGE MANAGEMENT : ANALYSIS AND MODELING...69 4.3.1 Introduction...69 4.3.2 Business Process Diagram Discharge Management...70 4.3.2.1 Ordering of final tests...70 4.3.2.2 Results reporting...72 4.3.2.3 Discharge report writing...77 4.3.3 Summary...79 4.4 IMPLEMENTATION ENVIRONMENT : CERNER MILLENNIUM AND DISCERN EXPERT...80 4.4.1 Introduction...80 4.4.2 Cerner Millennium...80 4.4.3 Discern Expert...81 4.4.4 Summary...82 4.5 RECOMMENDATIONS FOR IMPLEMENTATION...82 4.5.1 Introduction...82 4.5.2 Recommendation Suggestion 1: Test Summary Report...84 4.5.3 Recommendation Suggestion 2: Pending Discharge Report...93 4.5.3 Summary... 100 4.6 IMPLEMENTATION... 100 4.6.1 Introduction... 100 4.6.2 Comparison of Implementation Suggestions (TILAK and Master Thesis)... 101 4.6.3 Additional Suggestions... 103 4.6.3 Summary... 105 4.7 CONCLUSION... 105 5. DISCUSSION OF FINDINGS AND CONCLUSION...108 5.1 ANSWERS TO THE QUESTIONS... 108 5.2 DISCUSSION... 113 5.3 FUTURE STEPS... 117 6. APPENDIX...118 6.1 APPENDIX A RULE BASED TEMPLATE... 118 6.2 APPENDIX B PHYSICIAN QUESTIONNAIRE... 120 7. REFERENCES...122 CURRICULUM VITAE...125 Page 6

1 Introduction University for Health Informatics and Technology Tyrol 1.1 Topic and Motivation 1.1.1 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). 1.1.2 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

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. 1.1.3 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

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. 1.1.4 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

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. 1.1.5 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

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

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

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

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

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

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

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

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

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

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 2.3.1 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

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. 2.3.2 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

23. Divide into portions on Bands 1 and 2 24. 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

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

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 2.3.3 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

2.4 Visualization 2.4.1 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

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. 2.4.2 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

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

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. 2.4.3 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

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. 2.4.4 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 2.5.1 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

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. 2.5.2 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

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