Introduction

Wound care professionals should review clinical workflow regularly to provide effective and efficient wound care. If changes occur in your organization or the field, this review may prove vital in the face of growing patient numbers and high staff turnover.¹ Improving the efficiency and effectiveness of clinical workflows can improve both cost-effectiveness and employee satisfaction. Because of this dual purpose, quantitative and qualitative assessments should be considered when evaluating clinical workflows.

What Is Clinical Workflow?

Clinical workflow is the system of processes and features that support care delivery. It includes the structure of work as well as the steps and interactions that occur between staff and patients. Each member's clinical workflow within a multidisciplinary team will consist of different facets of care. For example, the clinical workflow for a wound care nurse might include the following:

• Chart review
• Wound assessment
• Communication with other disciplines
• Wound care delivery
• Caregiver education for carryover

Many processes can support workflow, including electronic health records (EHR), mobile computer stations or laptops, instant messaging between providers, and wound care timing alerts. With these technologies, wound care professionals can improve clinical workflow, which aids Clinical Decision Support (CDS) systems.

Clinical Decision Support Systems: Wound Care Workflow Essentials

First appearing in the 1970s, Clinical Decision Support (CDS) systems were meant to compare patient data to that within a computerized data source for targeted recommendations. Modern iterations of this software cost less and are not as time intensive as their predecessors.²Most CDS systems are meant to integrate with EHRs and similar technology and can typically be used on the following devices²:

• Desktop
• Tablet
• Smartphone
• Biometric monitoring
• Wearable health technology

There are diverse forms of CDS systems that vary from knowledge-based to non-knowledge-based. The former uses IF-THEN statements, while the latter may use artificial intelligence (AI), machine learning (ML), or even statistical pattern recognition.² In 2014 alone, approximately 41% of US hospitals that used an EHR also had a CDS system due to endorsement and incentives from government mandates. With approval from the United States and other countries like Canada, Australia, and others, CDS systems have modalities that help health care teams manage growing patient populations.²In terms of clinical workflow, this software may perform the following²:

• Remind clinicians to schedule testing or patient follow-up
• Identify cheaper medications or better insurance coverage options
• Aid in coding, patient triage, and other administrative tasks

As a system that has the potential to free up wound care professionals' time, CDS systems can be integrated into clinical workflow. Knowing when to assess and address a workflow is vital to adequately use this software.

When Should Clinical Workflows be Assessed and Addressed?

A workflow assessment should be one of the first steps in implementing a process improvement initiative, such as implementing a CDS system. Understanding how clinical work is currently done makes it possible to identify potential problems and inefficiencies. Not only that, but it ensures new initiatives refrain from interfering with the current workflows of clinicians or other professionals.⁴ This may include assessing the clinical workflows before developing and implementing a CDS system. In response to changes in clinical practice guidelines, new technology, or new evidence, changes in clinical workflows may be needed, especially in an ever-changing field like wound care.⁵ Therefore, clinical workflow needs to be reviewed regularly to remain effective and efficient. The frequency of review will vary by practice setting but should be considered at least annually and when a change in standards of care is implemented.⁴

Why Is It Important to Assess Clinical Workflow?

To understand the most frequent, most time-consuming, or error-prone decisions, it is necessary to understand the clinical workflow. Workflow assessment can help to identify potential problems and areas where improvements can be made to decrease unwarranted clinical variations.³ In many cases, small clinical workflow changes can greatly impact cost, quality, and patient satisfaction. For example, one study found that by making the results acknowledgment system for emergency room physicians electronic, the time it took to access results and initiate changes in care decreased significantly.⁷ This decrease in time can result in improved quality of care since the physicians can quickly intervene for critical values.

How Are Clinical Workflows Assessed?

There are several ways to assess clinical workflow. One common method is to use observations, interviews, or focus groups to understand the perspectives of the current workforce. These methods help wound care professionals understand the clinical workflow from the current staff’s perspective and identify potential problems or inefficiencies. However, these methods are at risk of bias due to the subjective nature of qualitative assessments.⁶More quantitative measures for assessment include the following⁶:

• Log file analysis
• Time-motion studies
• Computational ethnography

Computational ethnography is when assessors use data already collected by computerized processes to analyze workflows.⁶ While these methods may provide a more objective understanding of clinical workflows, they lack subjective input from clinicians that may help identify potential or current problems. The best clinical workflow assessments include a combination of qualitative and quantitative methods. This combination may help organizations and interdisciplinary teams best understand the objective clinical workflows and clinicians' subjective experiences and perspectives.

Conclusion

Clinical workflows determine the efficacy of wound care. Assessing these workflows may help improve efficiency and avoid inefficiencies when implementing a Clinical Decision Support (CDS) system. Workflows should be reviewed regularly. An assessment of clinical workflows should use qualitative and quantitative methods to understand best the objective clinical workflows and clinicians' subjective experiences.

References

1. Berner ES. Clinical Decision Support Systems: State of the Art. Agency for Healthcare Research and Quality. Published June 2009. Accessed October 19, 2022. https://digital.ahrq.gov/sites/default/files/docs/page/09-0069-EF_1.pdf.
2. Sutton RT, Pincock D, Baumgart DC et al. An overview of clinical decision support systems: benefits, risks, and strategies for success. npj Digit. Med. 2020;3(17). https://doi.org/10.1038/s41746-020-0221-y
3. Sutherland K, Levesque J‐F. Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework. J Eval Clin Pract. 2020;26:687–696. https://doi.org/10.1111/jep.13181.
4. Byrne C, Sherry D, Mercincavage L, Johnston D, Pan E, Schiff G. Advancing Clinical Decision Support: Key Lessons in Clinical Decision Support Implementation. National Coordinator for Health Information Technology. Published May 2015. Accessed October 19, 2022. https://www.healthit.gov/sites/default/files/acds-lessons-in-cds-implem….
5. Tanzini M, Westbrook J, Guidi S, Sunderland N, Prgomet M. Measuring Clinical Workflow to Improve Quality and Safety. In: Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, eds. Textbook of Patient Safety and Clinical Risk Management. Springer, Cham; 2021. Accessed October 19, 2022. https://doi.org/10.1007/978-3-030-59403-9_28.
6. Zheng K, Ratwani RM, Adler-Milstein J. Studying workflow and workarounds in electronic health record-supported work to improve health system performance. Ann Intern Med. 2020;172(11 Suppl):S116-S122. doi:10.7326/M19-0871
7. Georgiou A, McCaughey EJ, Tariq A, et al. What is the impact of an electronic test result acknowledgment system on Emergency Department physicians' work processes? A mixed-method pre-post observational study. Int J Med Inform. 2017;99:29–36. doi:10.1016/j.ijmedinf.2016.12.006