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Workflow analysis and modeling in medical IT projects

A.S. Ouvry1

Implementation of a medical IT system will always have an impact on the workflow in the hospital. The scale of the impact will depend on the scope and the complexity of the IT system itself. For example, implementation of a workstation for 3D image reconstruction will have an impact that will mainly affect the workflow within the radiology department itself. On the other hand, implementation of a hospital-wide PACS (Picture Archiving and Communication System) will have an impact not only on the workflow in the radiology department, but also on the workflow in the outpatient clinics, the wards, the emergency department, the intensive care units and the operating rooms. The greater the impact of an IT solution is likely to be, the more important it becomes to fully understand the existing workflow, and to create a consensus of opinion about the desired workflow among all those concerned.

Management Coalition (WfMC): `Workflow is the automation of a business process, in whole or in part, during which documents, information or work items are passed from one participant to another for action, according to a set of procedural rules' [2].

Figure 1. PROTOS (Pallas Athena, Apeldoorn, the Netherlands). Figure 1a. Workflow elements


The term `workflow' is a concept from Business Process Re-engineering (BPR), used to describe the processes involved in arriving at a given objective: `Workflow, according to those offering credible definitions, is any work process that must go through certain steps and be handled by more than one person on its way to completion. Workflow automation relieves people of some of these tasks. Inherent in workflow are concepts of teamwork, request and approval, routing and tracking of documents, filling out forms and doing things either in series or in parallel'. David Essex in `The Many Layers of Workflow Automation' [1]. `At the highest level, workflow is all those activities that combine the processes, the tools and the people all working toward a business objective'. Diane Hartingh, Senior Principal at American Management Systems (AMS), quoted by David Essex in `The Many Layers of Workflow Automation' [1] In the context of automation, `workflow' has a specific meaning, as defined by the Workflow In the radiology department, the processes are relatively well-defined activities, performed by various people or systems, at various locations, and at various times. These activities are supported, to an increasing extent, by computerized systems and appropriate software components.


Figure 1b. PROTOS symbols

The first step towards efficient workflow management is to identify and understand the

Partner, D&A Medical Group, Buren, the Netherlands.


August 2002


The first step towards efficient workflow management is to identify the various aspects.

various aspects of the workflow. Here, conceptual tools for analyzing and modeling workflow become important. These tools provide support for structured and comprehensive analysis of the workflow in all its aspects: processes, information, applications and organization. They provide a common framework for documenting knowledge of the processes, and for describing process bottlenecks, information flows, system integration, work organization, process improvement and process monitoring. Models of the workflow will provide a valuable aid to understanding the current situation, and for defining the desired future situation. The effects of re-designing the work processes and of introducing various IT solutions can then be examined in detail before the system is implemented. There are several tools for modeling and analysis on the market. The workflow models in this article have been made with PROTOS (Pallas Athena, Apeldoorn, the Netherlands) (Figure 1).

phase, the need for an IT solution and its scope are investigated in order to arrive at an investment decision. Then, detailed analysis of the requirements and definition of the system take place. The definition phase is usually split into an analysis and a design step. After the definition phase, the actual implementation of the system can start. The implementation phase comprises technical installation, system customization and configuration, and user training. Finally, the system becomes operational, and a cycle of maintenance and evolution begins. The value of workflow modeling and analysis in the different phases of a medical IT project is discussed below, taking implementation of a radiology PACS and an information management system in the cardiac echo lab as examples.

The concept phase: costs and benefits

Models will provide a valuable aid to understanding the current situation.

Phases of an IT project

The various phases of an IT project are shown in Figure 2. An IT project starts as a concept at a high level within the organization. In the concept

The key purpose of the concept phase is to examine the need for an IT solution, its intended scope, and the consequences of its implementation. In this phase, it is essential to arrive at a full understanding of the probable cost, the benefits and any potential drawbacks associated with the implementation of the system. It is equally important to understand the needs and the expectations of the potential users of the system, and of other important stakeholders. It should be emphasized that implementation of an IT system involves far more than simply purchasing an item of equipment. The consequences can be far-reaching, and an inappropriate decision at this stage can lead to problems further down the line, which may persist far into the future. It is not only important to involve the end users and those in related disciplines at this stage, but also to consider the system within the wider context of the whole enterprise. For example, a stand-alone system that meets the needs of one department may be difficult to interface with a projected hospital-wide system in the not-too-distant future. The concept phase should provide a realistic picture of how the system will help the hospital to improve its operational efficiency and effectiveness, and to what extent financial benefits can be realized. Workflow models (Figures 3, 4) are very useful in visualizing and expressing the benefits that can be achieved by implementation of a desired system.

Figure 2 Phases of an IT project.

The phases of an IT project are: concept, definition and implementation.



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Figure 3. Workflow in a typical video-based echo lab.

Figure 4. Workflow in a digital echo lab (Duke University Medical Center)

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Figure 5. Conventional workflow in a radiology department (University Hospital Aachen, Germany)

The concept phase usually ends with a decision on the investment by the hospital management. The following example examines the motivation for a digital information management system in a cardiac echo lab. Figure 3 shows the workflow in a typical video-based echo lab. Activities that will be automated in a digital workflow, and will therefore disappear, are shown in red. Calculating the costs associated with these activities in terms of staff (Full Time Equivalent or FTE) needed and materials used provides essential input for the financial costbenefit analysis. Figure 4 shows the workflow in a digital echo lab (Duke University Medical Center) after implementation of the EnConcert echocardiography information management system (Philips Medical Systems) [4]. The activities and sub-processes supported by the EnConcert system are shown in

green. Comparison of the analogue and the digital workflow shows that, in addition to the financial benefits, significant operational improvements are achieved by streamlining the process of study interpretation and distribution of results: · Shorter report throughput times · Easy access to patient studies · Faster reading of patient exams. In addition to the financial return-on-investment analysis, the workflow analysis gives a good picture of the potential operational benefits that can be achieved and the process changes that are necessary in order to fully realize these benefits.

The definition phase: analysis and design

The definition phase usually starts with an analysis of the current situation.

The definition phase of an IT project usually starts with an analysis of the current situation: technical infrastructure, procedure and data



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Figure 6. Workflow models of current and desired situation for filmbased and digital radiography.

volume, and work places. At this stage, a detailed workflow analysis of the clinical and supportive processes involved is very helpful in order to arrive at a complete and comprehensive statement of system requirements: · Functional requirements for each process step · System configuration and customization for integration in the hospital workflow (e.g. standardized reporting, user authorization) · Requirements for integration with existing IT systems.

Analysis: current situation

Figure 5 shows the current workflow situation in a radiology department (University Hospital, Aachen). The colors indicate the activities and sub-processes that are already supported by computer systems: · Radiology scheduling application (yellow) · Radiology information system (green) · Radiology reporting system (blue). The PACS that will be implemented in this department will have to interface with these systems. On a more detailed level the workflow model contains information on the number of workplaces, the organization of the reporting and authorization process and work procedures for each sub-process.

Design: desired situation

The definition phase comprises analysis of the current situation and design for the new situation.

The workflow model of the current situation outlines the activities and sub-processes, the information used and created, work organization and work distribution, as well as the applications currently being used.

Once the desired way of working has been defined, the work processes are re-designed, and the

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Figure 7. Workflow for a CT exam (University Hospital Aachen, Germany).

Figure 7a. Workflow for the examination.

The workflow model shows the clinical workflow for the new situation.

corresponding IT solution is specified (Table 1). These aspects are interrelated and, although they require different skills, they should be dealt with simultaneously. The design phase results in a blueprint for the system to be implemented and a workflow model for the new work processes (Figure 6). At the highest level, the workflow model shows the clinical workflow for the new situation: it shows which (supporting) activities are automated, which sub-processes and activities will be affected by the

implementation of the IT system, and what additional activities are required. Experience in projects has shown that the use of workflow models helps to involve the personnel in the discussion about the new work processes, and in transferring know-how about the impact of the IT system on the workflow to different levels in the organization. The various aspects of workflow management in radiology have been dealt with in depth by T. Wendler and C. Loef in a previous issue of Medicamundi [3].



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Figure 7b. Detailed workflow for the reporting sub-process.

On a more detailed technical level, the workflow model shows the required interaction between the new system and the existing systems, needed in order to achieve the desired clinical workflow. Hence, the workflow model for the new situation can serve as an input tool for designing optimal clinical work processes, as well as for the design of the required system workflow. Figure 7a and 7b

1. Process re-design · Digital workflow for each of the modalities · Scanning request forms and other documents · Routing film folders during the hybrid period (mixed film/digital environment) · Digital reporting and digital signature · Electronic distribution of results 2. Application configuration · User rights · Work lists · Release of information to referring physicians 3. System configuration · Amount of memory · Archiving strategy and technology · Number and type of workstations · Peripherals for printing and scanning · Interfaces with existing systems

Figure 8. PROTOS symbols used in the workflow models.

Table 1. Implementation of PACS: activities in the design phase.

shows the clinical and supporting system workflows for a CT examination study after implementation of PACS (University Hospital Aachen). Figure 7a shows the workflow for the examination itself, while Figure 7b shows the detailed workflow for the reporting sub-process. Human activities are indicated by a blue dot and system activities by a black dot.

The model shows the interaction between new and existing systems.

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Workflow models are a useful tool for understanding the impact of an IT solution.

The radiology reporting application was developed at University Hospital Aachen. EasyLink and EasyWeb are products from the Philips PACS portfolio.

Implementation phase: procedures and training


Workflow analysis and modeling play an important role in medical IT projects. Implementation of an IT system requires an understanding of the processes involved and, depending on the scope and complexity of the system, will involve a certain amount of process re-design. Workflow models are a useful tool for understanding the impact of an IT solution on the clinical work processes, defining the expectations and requirements for an IT solution, and managing the change process associated with the implementation of an IT system. They can play an important role in: · Demonstrating the need for an IT solution by showing the workflow benefits of the proposed solution · Managing the change process by providing support for the systematic analysis of the current workflow and the design of the desired workflow · Ensuring consistency in implementation by providing useful training material and processrelated work instructions.


In the implementation phase, the workflow models that were created during the design phase are further refined with more precise information on the new work procedures and fallback scenarios. This information is compiled in a comprehensive process-oriented procedure handbook, which can also be made available on-line. For example, PROTOS can generate the handbook in htmlformat for publication on the hospital's intranet. In combination with an on-line system manual, this provides a complete process-oriented user reference manual. The PROTOS symbols used in the workflow models are shown in Figure 1. Experience to date indicates that the workflow models, in combination with the work procedures and user instructions, form a practical tool for training new users.

Maintenance and evolution

Workflow analysis and modeling play an important role in medical IT projects.

The workflow model produced during the design and implementation phases serves as a guideline for maintenance of the system, and for extensions and improvements to meet emerging needs (Figure 8). In particular, it can be used to analyze the impact of any proposed system changes.


[1] Essex D. The Many Layers of Workflow Automation. Healthcare Informatics, June 2000: 128-135. [2] Workflow Management Coalition.

We thank Prof. Dr. B.B. Wein from the University Hospital in Aachen, Germany, and Mr. D.B. Adams, Rdcs from Duke University Medical Center, North Carolina for their contribution in the development of the workflow models presented in this article.

[3] Wendler T, Loef C. Workflow Management ­ Integration Technology for Efficient Radiology. Medicamundi 2001; 45,4: 41-48. [4] Adams DB. The Digital Echo Lab. Agilent Technologies Publication, 2000.



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