Understanding and Addressing Clinical Workflow to Facilitate Implementation

Being a relative newcomer to implementation science, I am still learning about this field’s many contributions to the development of methods for promoting widespread adoption and integration of evidence-based practices, interventions, and policies. My specific interest is in applying knowledge from implementation science to improve the delivery of cancer care. I had a chance to do so in one of my first activities as Associate Director for NCI’s Healthcare Delivery Research Program. As part of the Cancer Moonshot, I contributed to the issuance of a funding opportunity announcement that called for a strategic research investment, based on implementation science, to accelerate the clinical adoption of integrated systems that gather and monitor patient-reported symptoms and provide decision support and care using evidence-based guidelines. This announcement has resulted in the creation of a research network known as IMPACT (Improving the Management of symPtoms during And following Cancer Treatment) that will be deploying integrated symptom monitoring and management systems in a variety of oncology settings, identifying barriers and facilitators of system adoption, and evaluating the impact of these systems in relieving symptoms, improving cancer treatment delivery, and promoting optimal healthcare utilization. More information about IMPACT can be found at https://impactconsortium.org .

As part of NCI’s involvement in this cooperative agreement, I have come to appreciate the many challenges investigators face when they attempt to introduce changes to existing clinical routines. In the case of IMPACT, these changes include how patients report their symptoms, how clinicians receive these symptom reports, how clinicians act upon the symptom reports, and what care or assistance patients receive to relieve their symptoms. A key challenge in introducing these and similar changes into busy outpatient oncology settings is addressing their impact on existing clinical workflows. The nature and extent of changes to existing workflows associated with an intervention may be critical factors in determining whether implementation is successful. This recognition has motivated me to learn more about ways to analyze clinical workflow as well as ways to incorporate information on clinical workflow into intervention design and delivery. The topic of clinical workflow appears to have received limited attention, to date, in the implementation science literature despite general recognition of its importance.  For those interested in an introduction to clinical workflow analysis and a summary of research in the field, I recommend the chapter and the systematic review listed at end of this blog post.

Workflow refers to the procedural aspects of a work system, and workflow analysis refers to understanding the unfolding of work activities over time. In addition to activities, other elements of workflow to consider are the actors and the information and resources they have or should have available to perform a clinical task or achieve a clinical objective. Workflows in healthcare are often more complex than those in other industries owing to the broad range of patient issues (e.g., comorbid conditions) and systems issues (e.g., interactions with electronic health records) that can affect even seemingly routine tasks. A common strategy in analyzing existing workflow in clinical practice settings is to conduct interviews or focus groups with the clinicians and relevant others in which they describe the various steps associated with an aspect of care. This source of information, combined with reviews of clinic policies and procedures, often ends up describing how clinical care should be delivered which may differ from how care is routinely delivered. Accordingly, it may be useful to also conduct naturalistic observations to capture the ways in which the everyday clinical workflow may differ from the “ideal” type.

Once these data are collected, a summary that represents a model of the workflow can be prepared in written or graphical form. Given the frequent need to model activities among multiple actors that unfold over time, the creation of flow charts or process maps that visualize the workflow is a common practice. The use of an existing graphical modeling language, such as the Business Process Model and Notation (which can be accessed through Microsoft Visio®), offers the ability to depict workflows in a standardized manner that can be compared across different practice settings and research projects. The level of detail and primary focus of the flow chart should be driven by its potential use. An analogy can be made to cartography, in that maps also differ in what they highlight and, in their scale, depending on their intended use.

With the existing workflow modeled, it is now possible to identify the type and number of workflows changes the new intervention may require. One strategy for doing so is to conceptualize the intervention in terms of its clinical workflow. A useful tool for this purpose is the clinical workflow plan worksheet originally developed by the AIMS Center at the University of Washington for implementing collaborative care interventions. This worksheet requires those completing it to break down each collaborative care task in terms of who, how, when, and where it will be performed. Part of this work may include identifying changes to the electronic health record or its portals that are required to introduce the intervention. Using this information, a revised clinical workflow that incorporates the proposed intervention can be constructed. In many instances, this new workflow would then be shared with clinicians and others at the participating practice(s) for feedback that may suggest additional revisions to the workflow. Use of this type of iterative process has the potential to identify and address many concerns about an intervention on the part of clinicians and staff prior to initial deployment in the practice setting.

In summary, investigators seeking to implement an intervention in a clinical practice setting should consider conducting a systematic analysis to identify the ways in which their intervention will alter existing workflows. This task can be accomplished using existing workflow analysis tools that discretely categorize the changes being proposed. Sharing this information with those working in the practice setting is likely to provide useful feedback that may contribute to more successful implementation.

Please share your comments or other information on this topic with me at paul.jacobsen@nih.gov or tweet me: @pbjacobsen

Recommended Readings

Ozkaynak M, Unertl KM, Johnson SA, Brixey JJ, Haque SN. (2016). Clinical workflow analysis, process redesign, and quality improvement. In: Finnell J, Dixon, B, eds. Clinical Informatics Study Guide. New York: Springer, Cham; 2016:135-161. doi:10.1007/978-3-319-22753-5_7 .

Unertl KM, Novak LL, Johnson KB, Lorenzi NM. Traversing the many paths of workflow research: Developing a conceptual framework of workflow terminology through a systematic literature review. J Am Med Inform Assoc. 2010;17(3):265-273. doi:10.1136/jamia.2010.004333 .