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Unique features of healthcare processesMalcolm Pradhan The goals of modelling business processes are to improve the efficiency of the organisation, lower costs, reduce inventory, improve product delivery time, and to promote innovation. In general, business process and workflow modelling in business focuses on the following three areas: The automation of documents and forms through approval processes; supporting the collaboration between employees; improving communication within an organisation. In addition to these areas of focus, the manufacturing industry models customer demand, development, production, and ordering. In health we try to improve efficiency but also to improve safety of healthcare delivery; it iis possible to achieve both through the thoughtful process reengineering. So why can't we transfer directly lessons from business and manufacturing into health? This paper presents some broad observations about the nature of the health system that make it a challenging domain in which to model and change business processes. GovernanceOne of the unique characteristics of the healthcare system is the hierarchical nature of the medical and nursing staff, and the clear delineation of responsibilities [1] . This deficit of real teamwork in healthcare means that healthcare processes in hospitals that consider the totality of patient care are rarely planned, but have evolved without overall clinical governance. In general, a single doctor or unit is responsible for the outcome of a patient (the primary doctor), however during the care process numerous requests are made to other areas of the hospital to provide specific services, such as laboratory tests, pathology tests, radiology, and specialty consultations (service units). Usually, the service units do not play a role in the care of the patient beyond the specific request from the primary doctor. For example, if a patient is sent for a chest x-ray before day surgery and the radiologist detects a tumour, the responsibility of the radiologist is to report the x-ray result and send the report back to the doctor in charge of the patient; often in the same manner as all the normal results. Although an individual radiologist may ring the doctor in charge of the patient to explain an unusual result, this action is not usually required as part of the business process and therefore cannot be relied upon. Complex High Bandwidth CommunicationWe will use the term channel to describe the method by which information travels in the healthcare system. In most hospitals the most common channels are paper forms, and conversations [2] . An increasing number of institutions are improving their level of computerisation, however the adoption for clinical data has been slow. A very common problem in healthcare is that very few channels of communication are used for all information, irrespective of the urgency or impact of the information. In our chest x-ray example, the finding of a tumour on a routine pre-operative test without a history of lung masses on the request form should inform the radiology department that a diagnosis of cancer is now highly significant in the care of the patient. In most cases, however, the report is not sent via an 'urgent' channel in which the timely receipt of the information by the referring doctor is acknowledged. If such an urgent channel existed, any delays in reading the report after a pre-determined time, say 1 day, should automatically trigger a reminder to the primary doctor via page or mobile phone. In the situation where urgent channels already exist, they tend to be based on the referring unit, such as the emergency department, rather than based on the clinical utility of the information. Because institutions rarely prioritise information delivery and acknowledgement of receipt, patients bear the unnecessary risk of clinically significant results being lost in the background of normal results that have lower clinical importance. From a risk management perspective, the value of information of a test result depends on the ability of that information to change the current decision, and the magnitude of the consequences if the information is ignored; healthcare processes do not support directly the special treatment of high value information. Changing practiceIt is much easier to model healthcare processes than it is to change them. Compliance to new workflows and business practices is a major stumbling block in the implementation of clinical information systems and best-practice guidelines [3, 4] . It is worth noting that the current state of the patient not only determines the importance of information, like test results, but it also determines the likelihood of staff compliance to new processes. In the case of our pre-operative patient, if the screening anaesthetist excluded the patient from surgery while awaiting a test result from radiology it is more likely that the test result will be checked; the referring doctor is now waiting on the result before she can inform the surgeon, the patient, and the operating theatre. If, however, the patient was allowed to remain on the operating list unless the new test results was significantly abnormal, then the test is more likely to go unchecked because so many tests are ordered with little clinical utility [5, 6] . In this example the patient would be waiting a test to 'rule-in' the surgery rather than 'rule-out', and therefore there is more motivation by stakeholders to check the result. Stakeholder analysis is a critical step in business process reengineering, and aligning stakeholder's values to the desired result is critical to the implementation of risk mitigation techniques. It is often easier to change the drivers and organisational structure to support a particular practice, than it is to change an individual at a time [7] . Computer information systems are widely used in healthcare today for returning laboratory results, and for administration purposes. Computerisation provides a convenient and potentially effective point of intervention to provide automation and support for healthcare processes. One of the main reasons for modelling healthcare processes is to target points in the workflow for intervention. Computerisation has demonstrated significant benefits for physician order entry [8, 9, 10] , both for patients due to reduced adverse drug reactions, and for institutions through reduced length of stay. Beyond physician order entry, the opportunities for interventions, particularly in an inpatient setting, become harder for two reasons. The first is that current clinical information systems do not capture key clinical detail using controlled terminology that can be used by decision support systems to automate workflow and reduce error. The second factor relates to the challenge of integrating information technology into the current workflow processes of clinicians in a way that ensures high compliance - it is much harder to integrate computers into ward rounds than it is for outpatient clinics where doctors work from a desk. Clinical contextHospital information systems often only collect information for administration purposes, such as the patient's name, age, marital status and address. For workflow process purposes the clinical detail of the patient is required to determine the complexity of the case and the subsequent potential risks. The clinical context of a process is the variable complexity of each patient, such as comorbidities, concurrent medications and psychosocial factors that can make outcomes difficult to predict. The variability between patients means that the same process may have different outcomes and there may be a need for various strategies to improve the health outcomes for each patient. This clinical information that is lacking from hospital information systems is vital for accurate workflow process modelling and analysis. Collection of this information would allow for automation of risk assessment. The lack of clinical details in the information systems also limits the interpretation that service units, such as laboratories, radiology or specialist consults, can apply to the results they generate. These service units depend on the clinical detail to be provided on request forms, where it is often neglected. This lack of information makes it difficult for the service units to place a value of information on the test result, and there is a consequent lack of alerting systems for abnormal results that will change clinical decision making. Where clinical detail is available on the hospital information system, it is often difficult to capture it due to a lack of controlled terminology. References
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