www.usa.siemens.com/medical

Jonathan Emanuele and Laura Koetter,Siemens Medical Solutions USA, Inc., United States

WorkflowOpportunities andChallenges inHealthcare

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Workflow Opportunities andChallenges in Healthcareby Jonathan Emanuele and Laura Koetter,Siemens Medical Solutions USA, Inc., United States

Abstract

Workflow technology has expandedsubstantially into the healthcare industryover the last year. Hospitals are embracingthis technology as a means to improveoperational efficiency, achieve patientsafety goals, and positively influence thequality of care. This paper will explore theopportunities Business ProcessManagement (BPM) and workflowtechnology have to make a profound impacton patient care while examining thechallenges that are present in thehealthcare arena.

Introduction

Hospitals today face a constant challenge tofind ways to improve the quality of care,while at the same time reduce costs andincrease revenue. Concepts such as processoptimization, throughput, and efficiencyare gaining attention within the healthcarecommunity as a means to achieveoperational goals. Hospitals are increasinglyasked to tackle the problem of doing morewith less. For example, as the number ofpatient visits continues to rise, the numberof beds is not,1 and hospitals need to makebetter use of their assets. At the same time,the focus must remain on clinicalexcellence and quality of patient care.

Most emergency departments are at or overcapacity.2 The majority of hospitals losemoney when treating Medicare/Medicaidpatients: more than $25 billion in 2005.3

Staffing shortages exist across healthcarejob types, causing emergency departmentovercrowding, diversion of emergencypatients to other facilities, reduced numberof staffed beds to serve patients, delayeddischarge and increased length of stay forpatients, and decreased staff and patientsatisfaction.4

These challenges do not change the factthat patients deserve and demand safe andtop quality care. Patients put their trust inhospitals to treat them according to bestpractices, to ensure they receive theappropriate tests, medications, andinterventions for their conditions. Delayedcare delivery, unnecessary tests, medicationerrors, or preventable complications due toan omitted step in a plan of care increasesthe likelihood of poor patient outcomes.Workflow technology and BPM concepts,designed to help hospitals deliver the rightwork to the right people at the right time,are ideally positioned to serve the needs ofthe patient.

Other industries have used BPM concepts toautomate and improve processes withsuccess. Opportunities exist to bring BPM

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concepts to the healthcare industry;however there are significant challenges toaddress for successful utilization of theseconcepts. The healthcare industry has beenslow to adopt BPM practices and workflowtools. This is due, in part, to technologyconstraints. Only recently have we seen theincreased use of SOA-based healthcareinformation systems or electronic medicalrecords by which we can collect the datanecessary to leverage the possibilities ofbusiness process management. But evenwith growing data availability, there is aperception that healthcare is a much morecomplex environment than other industriesthat employ BPM, and that BPM is simplynot ready for that level of complexity.

For the healthcare industry to fully supportthe investment in BPM concepts andworkflow technology, the tools andtechnology must handle the complexconditions and challenges of a healthcareenvironment, from physical and financialresource constraints to utilizing technologyfor clinical decisions to variations in patientconditions and treatments. BPM in hospitalscan apply to administrative and operationalas well as clinical processes. Human liveswill be affected by these tools. There areopportunities for BPM to improve patientcare and operational processes andpotentially achieve significant financialsavings and ROI for the healthcare industry.In order for this to happen, BPM must takeinto account the unique challenges ofmanaging a care process for healthcareproviders and patients with workflowtechnology. Ideally, a fully optimizedhealthcare information system would allowpatients to receive the best care, in theleast amount of time, for the least cost, andwith increased profit margin for thehospital.

BPM is gaining traction in the healthcaresetting. As it continues to meet thechallenges and concerns of the industry,healthcare BPM as a movement will grow.Healthcare BPM is the vision for the futureof healthcare.

Technology

BPM has many tools at its disposal forhandling the life-cycle of a businessprocess. Rules engines and workflowengines handle run-time execution, whilemodeling, simulation, and analytical toolsexist for offline optimizations. This sectionwill discuss the run-time applications thatcan be embedded into healthcareinformation systems.

Clinical Decision Support (CDS) is a well-established area in medical informatics.This field assists the clinician in makingmedical decisions, by providing access tothe data necessary to make an informedchoice. It is especially targeted atenhancing patient care and reducing errors.Typically, CDS systems involve a rulesengine, with the majority of these based onthe HL7 standard Arden syntax.5 Thesesystems function primarily by receivingtriggers from an electronic patient recordwhen data on a patient is entered, updated,or about to be updated. The rules enginethen gathers data from the database andperforms logic to respond with remindersor alert messages to the clinical staff. As anexample, during the physician order entryprocess, if the doctor is ordering a drug thathas potentially negative interactions withanother drug already listed as an activedrug the patient is taking, a rule can alertthe doctor to that interaction and suggestalternative drugs that would avoid thepotential problem. These rules are typicallyimmediate decisions or scheduled recurringdecisions. They are usually limited toclinical decision-making and do not takeinto account the notion of statemanagement and the need to adjustrecommendations over time as the processunfolds.

A workflow engine is a step beyond a rulesengine. Workflow engines specialize in theexecution of business processes, not justdecisions made at a discrete point in time.Workflow engines are beginning to beutilized in the healthcare industry, whichcan draw on the strong knowledge base inworkflow available from many otherindustries. The healthcare processes theseengines handle can deal with all aspects ofrunning a hospital, including clinical,

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financial, administrative, and operationalprocesses. These tools often make use ofgraphical flow-diagram interfaces, whichtry to make an executable workflow look asclose to a process diagram as possible.These tools can greatly assist in clinicaldecision-making by not only presentingclinicians with alerts and reminders, like arules engine, but also by handling theteamwork aspect of clinical decisions, thetime management and task allocationaspects of process delivery, state changes inpatient or operational conditions, andbehind-the-scenes automation of processsteps.

Workflow processes can be designed, built,modified, and maintained by a hospital.The workflows a hospital chooses toimplement are tailored to that hospital’sunique needs and problem areas. Hospitalscan let their process experts design theirworkflows, such as a team of physiciansand nurses working together to design aclinical workflow. All of this customizationcan be accomplished at the content level,without requiring custom code to bedeveloped or delivered by a hospital’s HISvendor. This allows for a large degree offlexibility, and sites may constantly updateand adapt their workflows well after theirinitial implementations. Additionally,workflows, or the ideas behind the

workflows, can be shared and exchangedbetween hospitals if desired.

According to Gartner, Inc., a keycomponent of the fourth generation of acomputer-based patient record is workflow.Gartner states that “workflow capability willbe an integral part of these [healthcareinformation] systems.”6 Workflow offerspotential to aide in clinical decisions,reduce medical errors, and even savehuman lives. Workflow technology makesthe vision of healthcare BPM possible.

Architecture

The following diagram represents anexample of the architecture of a workflowengine integrated with a healthcareinformation system (HIS). The integrationbetween the two is usually highlycustomized for optimal performance, butkey to the integration is a strong service-oriented architecture. The three maincomponents of a healthcare workflow are:the input of a process model, integrationwith the HIS system, and integration to anyadditional systems the hospital may have.

The process definition (Step 1) is providedby the healthcare provider organization orhospital. Process definitions can initially bedone on whiteboards, in tools like

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Microsoft® Visio, or in specialized modelingsoftware. In order for the model to beimportable, it must, at some point, beconverted to a language that the enginecan understand, such as XPDL. Theseprocess definitions define the process that ahospital wants to follow. They usually havea “happy-path” to ensure that what issupposed to happen is being done. Thesedefinitions also include what actions to takewhen the process deviates from the happy-path, such as notifying supervisors. Theprocesses are not performed as a one-timetransaction, like a rule in a rules engine.Rather, they span time, such as a patient’sentire visit or the length of a patient’s careat one facility.

In order for these processes to be kicked offand for the state within the workflow to beupdated, it is important that the HIS systemnotify the workflow engine when majorevents happen (Step 2). A patient beingadmitted to the hospital, an order beingplaced, and an assessment being valued areall examples of events in the HIS that needto be pushed to the workflow engine. Atypical patient encounter workflow willstart on an admission, monitor updates tothe patient record throughout the stay, andterminate when the patient leaves thehospital.

There are many times the workflow processneeds to make a decision among multipleoptions in a process definition. The systemwill usually query the HIS to look upadditional information (Step 3). If there is aneed for complex queries or complexdecision logic, the workflow engine can calla rules engine (Step 4). For example,suppose an order to discharge the patientwas received and the engine needs todecide which tasks need to be completedbefore the patient is sent home. In order todo so, the engine will query the HIS andidentify pending orders, labs, dischargesummaries, and other steps that need to becompleted.

When incomplete activities are identified, itis necessary for the workflow engine topush a task to hospital staff (Step 5).Perhaps it is to remind a nurse to completean assessment that is overdue, or to notifyhousekeeping that a bed needs to be

cleaned. There are many modes ofcommunication that come into play here,including messages inside the HIS andmessages through external devices such aspagers, phones, and email. Whenorchestrating care, it is critical that theengine has access to hospital staff andclinicians, and can assign tasks to them andalert the next human in the escalationchain if a response is not documented inthe patient record.

The workflow engine is also capable ofperforming actions directly in the HISwithout human intervention, helping to getwork done (Step 6). These actions maymirror actions available to end users of theHIS, such as an order, saving anassessment, or adding a patient to a staffcensus. Automation of services withouthuman intervention is based upon hospitalagreement that some services do notrequire human input.

The final point to bear in mind whenapplying a workflow engine-enabled HIS isthat there may be other sources of data,other applications in the hospital, and newdevices that should be integrated in theprocess. The ability of the workflow engineto provide a rich set of programminginterfaces enables a hospital IT departmentto fully leverage the tool (Step 7). Forexample, a hospital may have a historicaldatabase of infectious disease data thatneeds to be queried when a patient arrives.The ability to interface with external datasources allows the workflow engine toleverage any electronic data or system thehospital may have.

Opportunities forHealthcare BPM

At any point in time, hospitals aremanaging several hundred processes acrossa myriad of departments and clinicians.Every patient passing through theemergency department or staying in a bedhas a unique and evolving plan of care,requiring treatment from multipleclinicians, departments and offsite facilities.Processes are in place to support care andkeep the hospital running. Patients must betransported, dietary trays delivered, blood

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drawn, vital signs monitored, resultsentered into information systems, bedscleaned, bills tracked, and so on. Thenumber of processes and patients in playfor any single member of the healthcareteam can be very significant.

The opportunities for BPM in healthcareabound. BPM and workflow technology canhave an impact by automating steps,integrating the team, pushing informationwhen and where it’s needed, managingcommunication points, and makingdecisions. Automating healthcare businessprocesses can positively impact the timeand resources necessary to provide patientcare. In an industry plagued by staffingshortages and high costs, better utilizationof human and physical resources enablesthe team to focus on patient care andresults in a better bottom line for thehospital. Workflows automate aspects ofthe healthcare delivery process to improvecompliance with policies and standards ofcare, eliminate communicationbreakdowns, and bring the interdisciplinaryteam in sync to deliver an integrated planof care.

A clinical care environment is hectic, multi-disciplinary and ever-changing. Treatmentplans must be reactive to unique patientconditions and physician decisions for care.Processes must be adaptive. Workflows canrespond quickly to changes in patientstatus, alerting clinicians of minor issuesbefore they become more serious andcostly conditions. Healthcare workflowsallow for variations in patient caredecisions, accommodating the needs of apeople-driven industry.

Healthcare BPM ProcessOpportunities: Clinical,Operational, Financial, andAdministrative

Where are the process opportunities inhealthcare? As it has in other industries,BPM can improve operational, financial, andadministrative processes. But unique tohealthcare, BPM can also be implementedto improve clinical processes. In fact, ashospitals adopt workflow engines, theprocesses prioritized at the top of the listare most often clinical care improvementinitiatives.

Clinical processes focus on patient care.Processes may address patient safety goals,such as reducing patient falls or preventingpressure ulcers. National directives, such asThe Joint Commission’s annual NationalPatient Safety Goals,7 provide guidelines topotential patient safety initiatives. Keepingpatients safe reduces the risk of patientsuffering and more expensive treatments.

Improved patient care may stem fromfollowing evidence-based standards of care.Standards of care are treatment guidelinesfor patients with certain diagnoses.Guidelines are ever-changing and areupdated whenever new information on agiven treatment comes to light. Managingstandards of care with healthcare BPMallows for quick changes to processes andreduces the need to reeducate the teamafter each change — team members canrely on the workflow engine to manageguideline recommendations.

Clinical process improvements can bedesigned to respond to trends inhealthcare. For instance, MRSA (Methicillin-resistant Staphylococcus Aureus), a type ofbacteria resistant to certain antibiotics, ison the rise in healthcare settings. MRSAinfections accounted for two percent of thetotal number of staph infections in 1974and 63% in 2004.8 MRSA patients are morelikely to die, have longer hospital stays, andhave higher treatment costs.9 Implementingprocess improvements to help preventinfection and to identify and treat patientswho have been infected can help improvepatient safety and reduce costs.

Clinical processes are about providing thebest care for patients to decrease theirdistress and improve their health. Workflowmakes better care possible.

Operational process opportunities work toimprove efficiencies, reduce costs, andimprove patient throughput resulting in theability to treat more patients at reducedcost. Workflows can help to enhancecommunication channels, eliminateunnecessary phone calls, and allowclinicians to focus their time on directpatient care. Patient throughput is a majoroperational process that impacts ahospital’s bottom line. Efficiently managing

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the process of getting a patient into andout of a bed results in more patientsreceiving timely care and fewer patientsdiverted to other facilities.

Financial process improvementopportunities are critical. With tightmargins and underpayment for servicesrendered, hospitals must maintain strictcontrol of finances to be able to continueproviding care to the community. Aradiology appointment missed may meanan extra day in the hospital while theappointment is rescheduled — a day thatMedicare doesn’t cover. A dietary traydelivered to a discharged patient is waste.The longer a patient’s length of stay, thegreater the cost of care. There are ampleopportunities to use BPM to improvereturns.

Administrative process opportunitiesimprove documentation compliance.Administrative processes focus ondocumentation and assessment completion,signing of charts, processing of consentforms, etc. Incomplete documentation hasa direct impact on patient care; if thedocumentation is not done, the informationis not available for clinical decision-making.Lack of documentation may also impact thebottom line. Insurers will not reimburse forcare that may have been delivered, but wasnot documented.

Application of Healthcare BPM:JCAHO/CMS Acute MyocardialInfarction National HospitalQuality Measure

The Joint Commission and Centers forMedicare & Medicaid Services (JCAHO/CMS)put out quality measure guidelines for thetreatment of Acute Myocardial Infarction(AMI).10 These guidelines outline evidence-based measures of care suggested for thetreatment of patients with AMI. Followingstandards of care contributes to improvedhealth outcomes for patients presentingwith this condition.

While evidence-based guidelines are anaccepted industry standard, the actualadoption of guidelines by clinicians isdifficult to achieve. It takes an average offive years for guidelines to be adopted into

routine practice.11 As an example,JCAHO/CMS quality measures recommendpatients diagnosed with AMI receive a betablocker within 24 hours of arrival at thehospital. Approximately 50% of eligiblepatients do not receive beta blockers afteran acute myocardial infarction.12

The costs of non-compliance withJCAHO/CMS AMI quality measures includeincreased mortality, increased patienthealth issues, more expensive treatments,future readmissions, and extended lengthsof stay.

Healthcare BPM can contribute to themanagement of the Acute MyocardialInfarction care process. Utilizing a workflowengine and interacting with the inter-disciplinary care team, BPM can have animpact on patient health and outcomes.

A workflow engine can gather real-time andhistoric patient information – results,assessments, orders, problems, diagnoses –to identify AMI patients as soon as possible.Once identified, the workflow startsmonitoring for the measures of care. If ameasure of care, such as aspirinadministration within 24 hours of arrival, isnot fulfilled, the workflow engine notifiesthe appropriate roles in the care team tomake a decision. A suggestion is made toconsider placing an order. For othermeasures of care, suggestions mightinclude the request of a procedure orpatient education. In all cases, the clinicianhas an option to follow the suggestion ordocument a reason he/she chose analternative. The workflow engine continuesto listen to responses, escalating issues notaddressed or progressing to other steps inthe process as the patient receives care.Throughout the process, role-based usersinteract with the information systems,sending new information to the workflowengine, affecting process decisions.

In addition to patient identification andmonitoring of measures of care, theworkflow engine can be utilized to collectcompliance data for reporting to the JCAHOand CMS organizations. Data is collectedthroughout the patient visit, highlightingmissing information or incomplete care.This data can be utilized internally by a

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hospital for quality and processimprovement purposes, offering thehospital an opportunity to identify ways toimprove patient health and rates ofcompliance.13

Application of Healthcare BPM:Bed Management

One of the pressing problems in hospitals isachieving efficiency in the bed turnoverrate, or the ability for the hospital to getone patient out of the hospital bed and thenext person into that bed as quickly aspossible. In an average hospital, a singlebed is turned 53 times per year. In ahospital operating in the 75th percentile, abed is turned 61 times per year. Theincreased bed turnover equates to arevenue gain of more than $7 million.14 Thepieces in play include transportation,housekeeping, facility maintenance, and abed inventory system. The workflow engineallows a system to track, in real-time, whena patient exits his or her room upondischarge, to schedule all housekeepingand maintenance activities immediately, totrack when those staff members leave theroom, having completed their tasks, andmark the bed as available for a new patient.The state the workflow engine manages inthis case isn’t the state of the patient, butthe state of the bed. By tracking beds thatrequire cleaning, location of housekeepingpersonnel, time required to clean, andother statistics, you can more accuratelymanage the bed turnover in the hospital.

Challenges to Healthcare BPM

The opportunities for healthcare BPMabound and the potential benefits to thehealthcare industry are great. As with allBPM projects, however, healthcare BPM isnot without significant challenges. Somechallenges are similar across industries –access to data required, degree ofautomation, sending too many alerts andreminders. But healthcare has a very uniqueresponsibility – patient health. If aworkflow process dealing with a caraccident claim fails, the effects areundesirable, but do not affect a human life.If a healthcare process fails, it has the

potential to cause patient harm. It isimperative to address the challenges andneeds of healthcare BPM with great careand attention.

Lack of Access to Data Required

Healthcare workflows utilize data fromelectronic information systems to makedecisions. One of the greatest impedimentsto building workflow-based healthcareinformation systems is lack of access to allrelevant data. Without available andupdated information, it is virtuallyimpossible to fully manage the state of apatient’s care.

Several data access problems may exist.Data may be incomplete, as when newhealthcare information systems areimplemented and historic data from oldersystems is not ported forward. Or, data maycontinue to exist in inaccessible paperformats. There is wide variation in the levelof automation among hospitals. Theindustry is in favor of an electronic patientrecord, with real-time data entry andinteraction, but adoption varies widely.Some facilities still operate on a manualpaper-based system. Many others exist in amiddle ground, with some aspects of thecharting process entered electronically andother aspects still communicated on paper.

The level of automation and data availableat a hospital facility drives prioritization ofwhich processes are candidates forimprovement with workflow technology.The iterative nature of BPM allows forcontinuously changing workflows – startsimple and add to the workflow process asnew features are implemented at thehospital site.

Identifying Patient Populationswith a Workflow Engine

In a clinical environment, a workflowengine often must identify the populationof patients to whom the workflow applies.For example, a workflow that monitorscompliance with JCAHO/CMS AcuteMyocardial Infarction quality measuresmust first identify patients with myocardialinfarction. Information available to identifya patient with a specific condition is not

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always complete. The workflow engine canbe used to determine if a patient is a likelyAMI patient, even if a diagnosis isn’tentered into the system until the patient isdischarged. We may instruct the workflowto check for elevated test results, often anindication of AMI. This identifies a patient,but there is still a margin of error — not allpatients with elevated results have AMI andnot all patients with AMI have elevatedresults. Therefore, our patient populationdata is not perfect. Data available to make adecision may be limited, out of date, orpotentially inaccurate.

Workflows do not replace humaninteractions in planning and providing care.Processes must be built to include, notexclude, opportunities for humanintervention and feedback. In the case ofidentifying a patient population, such asAMI, the system can give clinicians theopportunity to inform the workflow thatthe patient is not an AMI patient andshould be excluded from the population. Inthe case of a suggested order that is notappropriate for the patient, clinicians musthave the opportunity to override thesuggestion. Humans and automatedprocess management working together arethe ideal solution.

Technical Feasibility OpensAutomation Questions

An integrated workflow engine opens thedoor to numerous technically feasiblepossibilities for process management. Theworkflow engine can be called upon toperform actions behind the scenes, such asautomatically updating the patient recordor automatically placing orders.

A balance must be determined betweenwhat a hospital is comfortable having theworkflow engine do automatically, withoutuser intervention, and which steps requirehuman interaction. A workflow may seekclinician input at specific points in theworkflow. Medication orders will alwaysrequire human confirmation beforeactivation. A dosage change must flag apharmacist to review the request. Whilemany functions are technically feasible,care and concern must be taken to evaluatehow decisions might affect patient safety.

At the end of the day, the hospital, not theworkflow engine, remains responsible forpatient care.

Physicians Choose DifferentTreatment Options

Physicians make different decisions whentreating patients with similar conditions.The healthcare industry gives physiciansthe discretion to determine the care theirpatients need. This makes healthcareunique; it is unrealistic to force a singlestandard when developing clinicaltreatment processes. Even when evidence-based standards of care are encouraged,physicians have the opportunity to choosealternate treatment plans and everypatient’s condition, or combination ofconditions, drive different clinical decisions.

Healthcare BPM must be flexible. While aworkflow may suggest best practicesaccording to hospital or national guidelines,workflows must offer the ability to deviatefrom the suggested action. If a medicationis suggested for a patient, along with theoption to place the order, the physicianneeds to be offered the options to order analternate drug, decline placing the order, orfind more information about the disease,drug, or guideline evidence. Clinicalworkflows require built-in flexibility toaccommodate human discretion.

Communicating with Team Members

Throughout a workflow process, it may benecessary to give information to or requestdecisions and actions from members of theteam. In a clinical environment, it isimperative that the team members receivethese messages in a timely manner. Howthe information is delivered is important. Ifthe only method for communicating withteam members is on a stationary computerscreen in an office or nurse station, thenthere is the potential that team memberswill not log in often enough to receive newinformation. Options must exist to supportcommunication via additional devices, suchas PDAs, pagers, and phones. These optionsbring their own issues, such as securityconcerns or limited reception in all areas ofthe facility. In workflow building, it is

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important to identify the appropriate devicefor communication for each team memberand time of day, sometimes utilizingmultiple communication methods.

When pushing action requests and alerts toteam members, care must be taken to avoidoverloading the person with too manymessages. If a doctor is being paged everytime a lab result posts, he or she willquickly start to ignore the pages entirely. Itis important to consider the number ofinteractions that may be requested of asingle person across workflows. A balancebetween optimizing processes and sendingtoo many alerts to team members shouldbe considered. The workflow engine can beused to track not only the state of thepatient, but also the state of the messagesbeing sent to the clinical staff. If staffmembers are receiving too many alerts, aworkflow might consolidate messages orutilize an alternate communication method.

Conclusion

Healthcare is a complex environment withopportunities for BPM and workflowtechnology to improve patient care andoperational efficiencies. Healthcare BPMfaces technical, clinical, and culturalchallenges. Despite these challenges, BPMis powerful and possible in healthcare. Thispaper has demonstrated that workflow canbe applied in healthcare environments.Healthcare BPM is a movement and visionfor the future of healthcare.

The architecture presented in this paperdescribes at a high level the Soarian®product of Siemens Medical Solutions USA,Inc. and the workflow opportunities andexamples discussed are processes currentlyimplemented or in development, using theSoarian® HIS, at hospitals around the globe.

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1 The Advisory Board Co. (2007, January 17). Leveraging IT to Optimize HospitalThroughput: An Improved Approach to Managing Capacity. Presented at MarylandHIMSS conference.

2 American Hospital Association. (April 2006). The State of America’s Hospitals – Takingthe Pulse: Findings from the 2006 AHA Survey of Hospital Leaders. Retrieved Jan 18,2007, from http://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2006.html

3 American Hospital Association. (Oct 2006). Underpayment by Medicare and MedicaidFact Sheet. Retrieved Jan 18, 2007, from:http://www.aha.org/aha/content/2006/pdf/underpaymentfs2006.pdf

4 American Hospital Association. (April 2006). The State of America’s Hospitals – Takingthe Pulse: Findings from the 2006 AHA Survey of Hospital Leaders. Retrieved Jan 18,2007, from: http://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2006.html

5 The Arden Syntax for Medical Logic Systems. (updated July 21, 2006). Retrieved January29, 2007, from: http://cslxinfmtcs.csmc.edu/hl7/arden/

6 IMIA Yearbook 2003. (Feb 2003). Leveraging IT to Improve Patient Safety. Pg. 8.Retrieved January 23, 2007, from:http://www.himss.org/content/files/whitepapers/PatientSafetyWhitePaper122602.pdf

7 The Joint Commission. (2007). National Patient Safety Goals. Retrieved January 18,2007, from: http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

8 Centers for Disease Control and Prevention. (updated Oct 6, 2006). MRSA in HealthcareSettings. Retrieved Dec 11, 2006, from:http://www.cdc.gov/ncidod/dhqp/ar_MRSA_spotlight_2006.html

9 Pennsylvania Health Care Cost Containment Council. (August 2006). MRSA inPennsylvania Hospitals. PHC4 Research Brief, 10, 1–4.

10 Centers for Medicare & Medicaid Services (CMS) and the Joint Commission onAccreditation of Healthcare Organizations (JCAHO). (June 2006). The SpecificationsManual for National Hospital Quality Measures, Version 2.0. Retrieved July 2006, from:http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htm

11 Lomas J, Sisk JE, Stocking B. (1993). From evidence to practice in the United States, theUnited Kingdom, and Canada. Milbank Q, 71, 405–410.

12 Bradford WD, Chen J, Krumholz HM. (1999). Under-utilisation of beta-blockers afteracute myocardial infarction. Pharmacoeconomic implications. Pharmacoeconomics,15, 257–268.

13 Portions of the subject matter disclosed herein are the subject of pending patentapplications.

14 The Advisory Board Co. (2007, January 17). Leveraging IT to Optimize HospitalThroughput: An Improved Approach to Managing Capacity. Presented at MarylandHIMSS conference.

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