https://www.clinfowiki.org/wiki/api.php?action=feedcontributions&user=Lspiegel884&feedformat=atomClinfowiki - User contributions [en]2024-03-29T10:09:40ZUser contributionsMediaWiki 1.22.4https://www.clinfowiki.org/wiki/index.php/Clinical_workflow_analysisClinical workflow analysis2019-10-18T22:55:45Z<p>Lspiegel884: </p>
<hr />
<div><br />
== '''Clinical Workflow Analysis''' ==<br />
<br />
<br />
'''Introduction:'''<br />
The term workflow has been variably defined. The Agency for Healthcare Research and Quality (AHRQ), defines workflow as a sequence of cognitive and physical tasks listed chronologically that occur both within and between organizations that are required to accomplish specific work objectives. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously. When applied to the clinical setting the above definition generally holds true, with the work objective being a direct or indirect patient care function. For example, the workflow of ordering a medication includes communication between the provider and the patient, the provider's thought process, the physical action by the provider of writing a paper prescription or entering an electronic prescription into an electronic health record and transmitting the order electronically or having the patient take the prescription to the pharmacy to have the prescription filled. <br />
<br />
It is important to assess workflow because inefficiencies can negatively influence patient care and outcomes. Evaluating workflows can find deficiencies and areas that would benefit from improvements. In addition, when deciding to implement CDS, it is important to understand where in the workflow alerts should be used to most efficiently affect physicians. Research assessing health IT implementations demonstrates that delays in patient care, billing, and communication are likely to occur if workflow is not taken into account. This is generally due to the fact that clinical and practice management requirements are overlooked or oversimplified. As a form of ongoing process improvement, workflows should be continually assessed.<br />
<br />
<br />
'''Tools:'''<br />
A variety of tools are available to aid in the analysis of clinical workflows. The website of the Agency for Healthcare Research and Quality (AHRQ) contains one repository of tools useful in clinical workflow analysis (5). Some of the tools commonly used in clinical workflow analysis and redesign are:<br />
<br />
<br />
''1) Benchmarking'': The process of evaluating best practices of other organizations. This requires communicating with peers in similar organizations that are seen as successful in the objective being analyzed and determining whether these lessons can be applied to the workflow under consideration (6).<br />
<br />
<br />
''2) Check Sheet:'' A structured form for analyzing data about a specific work process or function (7). It is useful for documenting observational data about specific tasks in a workflow. Referenced is an example of a workflow assessment checklist provided by AHRQ (8).<br />
<br />
<br />
''3) Flowchart or Process Map:'' Flowcharts visually demonstrate specific steps in a work process arranged in sequential order. This allows understanding of the overall process and where improvement can be made (9). <br />
<br />
<br />
'''Steps in making a flowchart:'''<br />
<br />
1. DEFINE THE PROCESS that will be represented in the flowchart.<br />
<br />
2. DETERMINE ALL INDIVIDUALS, DEPARTMENTS, AND GROUPS INVOLVED in the process.<br />
<br />
3. BRAINSTORM THE STEPS in the process. The specific sequence is less important than determining all of the steps at this point (although thinking sequentially may help identify any missing steps).<br />
<br />
4. CONSTRUCT THE FLOWCHART GRAPHICALLY using rows or columns corresponding to the associated work units (e.g., provider, nursing). <br />
<br />
5. ARRANGE THE STEPS SEQUENTIALLY<br />
<br />
6. DRAW ARROWS between steps to show the process flow. <br />
<br />
7. REVIEW THE FLOWCHART and validate its accuracy with other individuals who are actually involved in the process.<br />
<br />
<br />
'''Advantages of flowcharts:'''<br />
<br />
• Demonstrates whether the flow of events makes sense and is smooth or if there is a lot of back-and-forth (numerous handoffs) between individuals<br />
<br />
• Highlights areas where decisions must be made<br />
<br />
• Shows which parts of a process are redundant or out of place<br />
<br />
• Identifies who completes each task in addition to what gets done<br />
<br />
• Shows areas that can be improved<br />
<br />
• Allows staff to clearly visualize their roles<br />
<br />
• Easy to learn and create<br />
<br />
<br />
'''Disadvantages:'''<br />
<br />
• Does not show value<br />
<br />
• Requires in-depth knowledge of the process<br />
<br />
<br />
'''Flowchart Example:'''<br />
<br />
• Medication reconciliation of original (A) and revised (B) workflows<br />
<br />
<br />
'''Example Flowchart:'''<br />
<br />
https://qualitysafety.bmj.com/content/qhc/20/4/372/F1.large.jpg<br />
<br />
<br />
'''Example of Clinical Workflow Analysis:'''<br />
<br />
An example of workflow analysis and redesign around implementation of an EHR is offered by ONC (11). This presentation discusses multiple clinical workflows in an outpatient medical practice and provides editable flowcharts for use as templates.<br />
<br />
<br />
== '''Workflow in the Emergency Department:''' ==<br />
<br />
<br />
'''Barriers to Efficiency:'''<br />
<br />
• Overcrowding<br />
<br />
• Increasing volumes<br />
<br />
• Boarding<br />
<br />
• Nurse/tech staffing<br />
<br />
• High acuity patients<br />
<br />
• Physician multitasking/interruptions<br />
<br />
<br />
'''Common ED Metrics:'''<br />
<br />
• Door to doctor time<br />
<br />
• Patient LOS<br />
<br />
• Time from admission order to transfer to inpatient ward<br />
<br />
• Door to room time<br />
<br />
• Time to lab draw/IV placement<br />
<br />
• Time from imaging order placed to completion <br />
<br />
• Physician patients per hour<br />
<br />
• Time from discharge order to patient leaving the ED<br />
<br />
• Number of patients who left without being seen<br />
<br />
<br />
'''Areas of Success in ED Workflows:'''<br />
<br />
'''1) Stroke''' <br />
<br />
• “Time is brain.” Decreasing time to thrombolytics and reperfusion therapies improve patient outcomes<br />
<br />
• EMS stroke activation to mobilize ED and neurology teams<br />
<br />
• Physical design and layouts of the ED can optimize stroke care: Resuscitation rooms close to CT scanners<br />
<br />
'''2) STEMI''' <br />
<br />
• Achieving door to balloon times under 90 minutes is important for STEMI outcomes<br />
<br />
• In the field STEMI activation and EKG transmission<br />
<br />
• Allowing ED physicians to activate cath labs have improved door to balloon times<br />
<br />
<br />
'''Ways to Improve Efficiency with ED Imaging:'''<br />
<br />
'''1) POCUS''' (point of care US)<br />
<br />
• Physicians using POCUS instead of formal US can decreased ED LOS<br />
<br />
• One specific study showed that POCUS as a screening tool for intussusception could reduce ED LOS and unnecessary referrals for US <br />
<br />
'''2) CT scans'''<br />
<br />
• Having a “CT expediter”: Their role is to check imaging protocol, check priority, check NPO status, preg test , renal function, IV placement, contrast allergies, isolation precautions, call for transport and CT availability. Decreased work up time by 35%, decreased LOS by 4%<br />
<br />
• Having radiologists prioritize ED reads<br />
<br />
<br />
'''Ideas for Improving Triage Workflow:'''<br />
<br />
'''1) Group triage'''<br />
<br />
• Physician and nurses going to new patients together <br />
<br />
• Can expedite treatment, initiation of orders, door to doctor time<br />
<br />
'''Physician triage'''<br />
<br />
• Physicians doing the initial triage evaluation instead of nurses<br />
<br />
• Diagnostic tests are entered earlier, expedites treatment, patient LOS is decreased<br />
<br />
<br />
'''Other Ideas for Improving ED Workflow:'''<br />
<br />
• Point of care lab testing<br />
<br />
• Mobile computers for efficient physician charting/order entry<br />
<br />
• Decreased ED referrals from clinic and increased direct admissions<br />
<br />
• Phlebotomists <br />
<br />
<br />
'''References:'''<br />
<br />
1) Unertl, K et al. J Am Med Inform Assoc. 2010 May-Jun;17(3):265-73<br />
<br />
2) Harrington L. Electronic health record workflow: why more work than flow? AACN Adv Crit Care. 2015 Jan-Mar;26(1):5-9.<br />
<br />
3) Bowens FM, Frye PA, Jones WA. Health information technology: integration of clinical workflow into meaningful use of electronic health records. Perspect Health Inf Manag. 2010 Oct 1;7:1d.<br />
<br />
4) Sheehan, B and Bakken, s. Approaches to workflow analysis in healthcare settings. Nurs Inform. 2012; 2012: 371<br />
<br />
5) https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit<br />
<br />
6) http://asq.org/learn-about-quality/benchmarking/overview/overview.html<br />
<br />
7) http://asq.org/learn-about-quality/data-collection-analysis-tools/overview/check-sheet.html<br />
<br />
8) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/Workflow_Assessment_Checklist.pdf<br />
<br />
9) http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html<br />
<br />
10) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/In-officePrescribing-PaperSystem.pdf<br />
<br />
11) https://www.healthit.gov/sites/default/files/tools/workflow_redesign_templates_v1.pptx<br />
<br />
12) Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign--Summary Report. (Prepared by the Center for Quality and Productivity Improvement, University of Wisconsin–Madison, under Contract No. HHSA 290-2008-10036C). AHRQ Publication No. 10-0098-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2010. <br />
<br />
13) White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimize medication reconciliation. BMJ Qual Saf Health Care. Epub 2011 Feb 11; doi: 10.1136/bmjqs.2010.047845<br />
<br />
14) Burström L, Engström ML, Castrén M, Wiklund T, Enlund M. Improved quality and efficiency after the introduction of physician-led team triage in an emergency department. Ups J Med Sci. 2016;121(1):38-44. doi:10.3109/03009734.2015.1100223.<br />
<br />
15) Gyftopoulos S, Jamin C, Wu TS, et al. The Use of an Emergency Department Expeditor to Improve Emergency Department CT Workflow: Initial Experiences. J Am Coll Radiol. 2019;16(3):327-332. doi:10.1016/j.jacr.2018.11.003.<br />
<br />
16) Huded C, Kravitz K, Menon V, et al. Impact of the Cms Algorithm for Door-To-Balloon Time Public Reporting on Door-To-Balloon Time Performance. J Am Coll Cardiol. 2018;71(11):A1161. doi:10.1016/s0735-1097(18)31702-9.<br />
<br />
17) Iannone P. Ameliorating the emergency department workflow by involving the observation unit: effects on crowding. Emerg Care J. 2015;11(1). doi:10.4081/ecj.2015.4957.<br />
<br />
18) Jauch EC, Holmstedt C, Nolte J. Techniques for improving efficiency in the emergency department for patients with acute ischemic stroke. Ann N Y Acad Sci. 2012;1268(1):57-62. doi:10.1111/j.1749-6632.2012.06663.x.<br />
<br />
19) Kim JH, Lee J-Y, Kwon JH, Cho H-R, Lee JS, Ryu J-M. Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care. 2017;00(00):1. doi:10.1097/pec.0000000000001283.<br />
<br />
20) Lee EK, Atallah HY, Wright MD, et al. Transforming hospital emergency department workflow and patient care. Interfaces (Providence). 2015;45(1):58-82. doi:10.1287/inte.2014.0788.<br />
<br />
21) Nguyen M, Louis C, Sahota PK, et al. 90 Improvement of Emergency Department Workflow and Their Effects on Patient Satisfaction. Ann Emerg Med. 2018;72(4):S39. doi:10.1016/j.annemergmed.2018.08.095.<br />
<br />
22) Nugus P, Braithwaite J. The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle? Soc Sci Med. 2010;70(4):511-517. doi:10.1016/j.socscimed.2009.11.001.<br />
<br />
23) Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program. Appl Clin Inform. 2018;9(2):248-260. doi:10.1055/s-0038-1641594.<br />
<br />
24) Slain T, Rickard-Aasen S, Pringle J, et al. An Operational Analysis of Integrating Screening and Brief Intervention into the Normal Workflow of the Emergency Department Without Additional Resources. Ann Emerg Med. 2013;62(4):S101. doi:10.1016/j.annemergmed.2013.07.100.<br />
<br />
25) Strear C, Vissers R, Yoder E, Barnett H, Shanks T, Jones L. 30: Applying the Theory of Constraints to Emergency Department Workflow: Reducing Ambulance Diversion Through Basic Business Practice. Ann Emerg Med. 2010;56(3):S11. doi:10.1016/j.annemergmed.2010.06.059.<br />
<br />
26) Subash F, Dunn F, McNicholl B, Marlow J. Team triage improves emergency department efficiency. Emerg Med J. 2004;21(5):542-544. doi:10.1136/emj.2002.003665.<br />
<br />
27) Building one brown. HVP High Vol Print. 2005;23(2):34-37.<br />
<br />
28) Research Forum. Otolaryngol Head Neck Surg. 2000;123(2):P85-P144. doi:10.1016/S0194-5998(00)80031-5.<br />
<br />
29) https://www.healthcatalyst.com/success_stories/improve-appendectomy-care-outcomes-using-analytics-in-healthcare<br />
<br />
<br />
<br />
<br />
<br />
Contributions from <br />
[[User:Msoutzen|Msoutzen]] 07:57, 8 March 2012 (PST)<br />
Submitted by (M. Outzen, MS, OTR/L)<br />
[[Category:BMI512-WINTER-12]]<br />
Submitted by (Frank Longano).<br />
[[Category:BMI512-FALL-17]]<br />
<br />
Submitted by (Lindsey Spiegelman)<br />
[[Category:BMI512-FALL-19]]<br />
Combined these two sections into the: Clinical Workflow Analysis Page<br />
https://clinfowiki.org/wiki/index.php/Clinical_workflow_analysis<br />
https://clinfowiki.org/wiki/index.php?title=Methods_to_capture_workflow&action=edit&section=7<br />
Added first three sentences to paragraph #2<br />
Added in the section: Workflow in the Emergency Department<br />
References: 14-29</div>Lspiegel884https://www.clinfowiki.org/wiki/index.php/Clinical_workflow_analysisClinical workflow analysis2019-10-18T22:50:37Z<p>Lspiegel884: </p>
<hr />
<div><br />
== '''Clinical Workflow Analysis''' ==<br />
<br />
<br />
'''Introduction:'''<br />
The term workflow has been variably defined. The Agency for Healthcare Research and Quality (AHRQ), defines workflow as a sequence of cognitive and physical tasks listed chronologically that occur both within and between organizations that are required to accomplish specific work objectives. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously. When applied to the clinical setting the above definition generally holds true, with the work objective being a direct or indirect patient care function. For example, the workflow of ordering a medication includes communication between the provider and the patient, the provider's thought process, the physical action by the provider of writing a paper prescription or entering an electronic prescription into an electronic health record and transmitting the order electronically or having the patient take the prescription to the pharmacy to have the prescription filled. <br />
<br />
It is important to assess workflow because inefficiencies can negatively influence patient care and outcomes. Evaluating workflows can find deficiencies and areas that would benefit from improvements. In addition, when deciding to implement CDS, it is important to understand where in the workflow alerts should be used to most efficiently affect physicians. Research assessing health IT implementations demonstrates that delays in patient care, billing, and communication are likely to occur if workflow is not taken into account. This is generally due to the fact that clinical and practice management requirements are overlooked or oversimplified. As a form of ongoing process improvement, workflows should be continually assessed.<br />
<br />
<br />
'''Tools:'''<br />
A variety of tools are available to aid in the analysis of clinical workflows. The website of the Agency for Healthcare Research and Quality (AHRQ) contains one repository of tools useful in clinical workflow analysis (5). Some of the tools commonly used in clinical workflow analysis and redesign are:<br />
<br />
<br />
''1) Benchmarking'': The process of evaluating best practices of other organizations. This requires communicating with peers in similar organizations that are seen as successful in the objective being analyzed and determining whether these lessons can be applied to the workflow under consideration (6).<br />
<br />
<br />
''2) Check Sheet:'' A structured form for analyzing data about a specific work process or function (7). It is useful for documenting observational data about specific tasks in a workflow. Referenced is an example of a workflow assessment checklist provided by AHRQ (8).<br />
<br />
<br />
''3) Flowchart or Process Map:'' Flowcharts visually demonstrate specific steps in a work process arranged in sequential order. This allows understanding of the overall process and where improvement can be made (9). <br />
<br />
<br />
'''Steps in making a flowchart:'''<br />
<br />
1. DEFINE THE PROCESS that will be represented in the flowchart.<br />
<br />
2. DETERMINE ALL INDIVIDUALS, DEPARTMENTS, AND GROUPS INVOLVED in the process.<br />
<br />
3. BRAINSTORM THE STEPS in the process. The specific sequence is less important than determining all of the steps at this point (although thinking sequentially may help identify any missing steps).<br />
<br />
4. CONSTRUCT THE FLOWCHART GRAPHICALLY using rows or columns corresponding to the associated work units (e.g., provider, nursing). <br />
<br />
5. ARRANGE THE STEPS SEQUENTIALLY<br />
<br />
6. DRAW ARROWS between steps to show the process flow. <br />
<br />
7. REVIEW THE FLOWCHART and validate its accuracy with other individuals who are actually involved in the process.<br />
<br />
<br />
'''Advantages of flowcharts:'''<br />
<br />
• Demonstrates whether the flow of events makes sense and is smooth or if there is a lot of back-and-forth (numerous handoffs) between individuals<br />
<br />
• Highlights areas where decisions must be made<br />
<br />
• Shows which parts of a process are redundant or out of place<br />
<br />
• Identifies who completes each task in addition to what gets done<br />
<br />
• Shows areas that can be improved<br />
<br />
• Allows staff to clearly visualize their roles<br />
<br />
• Easy to learn and create<br />
<br />
<br />
'''Disadvantages:'''<br />
<br />
• Does not show value<br />
<br />
• Requires in-depth knowledge of the process<br />
<br />
<br />
'''Flowchart Example:'''<br />
<br />
• Medication reconciliation of original (A) and revised (B) workflows<br />
<br />
<br />
'''Example Flowchart:'''<br />
<br />
https://qualitysafety.bmj.com/content/qhc/20/4/372/F1.large.jpg<br />
<br />
<br />
'''Example of Clinical Workflow Analysis:'''<br />
<br />
An example of workflow analysis and redesign around implementation of an EHR is offered by ONC (11). This presentation discusses multiple clinical workflows in an outpatient medical practice and provides editable flowcharts for use as templates.<br />
<br />
<br />
== '''Workflow in the Emergency Department:''' ==<br />
<br />
<br />
'''Barriers to Efficiency:'''<br />
<br />
• Overcrowding<br />
<br />
• Increasing volumes<br />
<br />
• Boarding<br />
<br />
• Nurse/tech staffing<br />
<br />
• High acuity patients<br />
<br />
• Physician multitasking/interruptions<br />
<br />
<br />
'''Common ED Metrics:'''<br />
<br />
• Door to doctor time<br />
<br />
• Patient LOS<br />
<br />
• Time from admission order to transfer to inpatient ward<br />
<br />
• Door to room time<br />
<br />
• Time to lab draw/IV placement<br />
<br />
• Time from imaging order placed to completion <br />
<br />
• Physician patients per hour<br />
<br />
• Time from discharge order to patient leaving the ED<br />
<br />
• Number of patients who left without being seen<br />
<br />
<br />
'''Areas of Success in ED Workflows:'''<br />
<br />
'''1) Stroke''' <br />
<br />
• “Time is brain.” Decreasing time to thrombolytics and reperfusion therapies improve patient outcomes<br />
<br />
• EMS stroke activation to mobilize ED and neurology teams<br />
<br />
• Physical design and layouts of the ED can optimize stroke care: Resuscitation rooms close to CT scanners<br />
<br />
'''2) STEMI''' <br />
<br />
• Achieving door to balloon times under 90 minutes is important for STEMI outcomes<br />
<br />
• In the field STEMI activation and EKG transmission<br />
<br />
• Allowing ED physicians to activate cath labs have improved door to balloon times<br />
<br />
<br />
'''Ways to Improve Efficiency with ED Imaging:'''<br />
<br />
'''1) POCUS''' (point of care US)<br />
<br />
• Physicians using POCUS instead of formal US can decreased ED LOS<br />
<br />
• One specific study showed that POCUS as a screening tool for intussusception could reduce ED LOS and unnecessary referrals for US <br />
<br />
'''2) CT scans'''<br />
<br />
• Having a “CT expediter”: Their role is to check imaging protocol, check priority, check NPO status, preg test , renal function, IV placement, contrast allergies, isolation precautions, call for transport and CT availability. Decreased work up time by 35%, decreased LOS by 4%<br />
<br />
• Having radiologists prioritize ED reads<br />
<br />
<br />
'''Ideas for Improving Triage Workflow:'''<br />
<br />
'''1) Group triage'''<br />
<br />
• Physician and nurses going to new patients together <br />
<br />
• Can expedite treatment, initiation of orders, door to doctor time<br />
<br />
'''Physician triage'''<br />
<br />
• Physicians doing the initial triage evaluation instead of nurses<br />
<br />
• Diagnostic tests are entered earlier, expedites treatment, patient LOS is decreased<br />
<br />
<br />
'''Other Ideas for Improving ED Workflow:'''<br />
<br />
• Point of care lab testing<br />
<br />
• Mobile computers for efficient physician charting/order entry<br />
<br />
• Decreased ED referrals from clinic and increased direct admissions<br />
<br />
• Phlebotomists <br />
<br />
<br />
'''References:'''<br />
<br />
1) Unertl, K et al. J Am Med Inform Assoc. 2010 May-Jun;17(3):265-73<br />
<br />
2) Harrington L. Electronic health record workflow: why more work than flow? AACN Adv Crit Care. 2015 Jan-Mar;26(1):5-9.<br />
<br />
3) Bowens FM, Frye PA, Jones WA. Health information technology: integration of clinical workflow into meaningful use of electronic health records. Perspect Health Inf Manag. 2010 Oct 1;7:1d.<br />
<br />
4) Sheehan, B and Bakken, s. Approaches to workflow analysis in healthcare settings. Nurs Inform. 2012; 2012: 371<br />
<br />
5) https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit<br />
<br />
6) http://asq.org/learn-about-quality/benchmarking/overview/overview.html<br />
<br />
7) http://asq.org/learn-about-quality/data-collection-analysis-tools/overview/check-sheet.html<br />
<br />
8) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/Workflow_Assessment_Checklist.pdf<br />
<br />
9) http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html<br />
<br />
10) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/In-officePrescribing-PaperSystem.pdf<br />
<br />
11) https://www.healthit.gov/sites/default/files/tools/workflow_redesign_templates_v1.pptx<br />
<br />
12) Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign--Summary Report. (Prepared by the Center for Quality and Productivity Improvement, University of Wisconsin–Madison, under Contract No. HHSA 290-2008-10036C). AHRQ Publication No. 10-0098-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2010. <br />
<br />
13) White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimize medication reconciliation. BMJ Qual Saf Health Care. Epub 2011 Feb 11; doi: 10.1136/bmjqs.2010.047845<br />
<br />
14) Burström L, Engström ML, Castrén M, Wiklund T, Enlund M. Improved quality and efficiency after the introduction of physician-led team triage in an emergency department. Ups J Med Sci. 2016;121(1):38-44. doi:10.3109/03009734.2015.1100223.<br />
<br />
15) Gyftopoulos S, Jamin C, Wu TS, et al. The Use of an Emergency Department Expeditor to Improve Emergency Department CT Workflow: Initial Experiences. J Am Coll Radiol. 2019;16(3):327-332. doi:10.1016/j.jacr.2018.11.003.<br />
<br />
16) Huded C, Kravitz K, Menon V, et al. Impact of the Cms Algorithm for Door-To-Balloon Time Public Reporting on Door-To-Balloon Time Performance. J Am Coll Cardiol. 2018;71(11):A1161. doi:10.1016/s0735-1097(18)31702-9.<br />
<br />
17) Iannone P. Ameliorating the emergency department workflow by involving the observation unit: effects on crowding. Emerg Care J. 2015;11(1). doi:10.4081/ecj.2015.4957.<br />
<br />
18) Jauch EC, Holmstedt C, Nolte J. Techniques for improving efficiency in the emergency department for patients with acute ischemic stroke. Ann N Y Acad Sci. 2012;1268(1):57-62. doi:10.1111/j.1749-6632.2012.06663.x.<br />
<br />
19) Kim JH, Lee J-Y, Kwon JH, Cho H-R, Lee JS, Ryu J-M. Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care. 2017;00(00):1. doi:10.1097/pec.0000000000001283.<br />
<br />
20) Lee EK, Atallah HY, Wright MD, et al. Transforming hospital emergency department workflow and patient care. Interfaces (Providence). 2015;45(1):58-82. doi:10.1287/inte.2014.0788.<br />
<br />
21) Nguyen M, Louis C, Sahota PK, et al. 90 Improvement of Emergency Department Workflow and Their Effects on Patient Satisfaction. Ann Emerg Med. 2018;72(4):S39. doi:10.1016/j.annemergmed.2018.08.095.<br />
<br />
22) Nugus P, Braithwaite J. The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle? Soc Sci Med. 2010;70(4):511-517. doi:10.1016/j.socscimed.2009.11.001.<br />
<br />
23) Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program. Appl Clin Inform. 2018;9(2):248-260. doi:10.1055/s-0038-1641594.<br />
<br />
24) Slain T, Rickard-Aasen S, Pringle J, et al. An Operational Analysis of Integrating Screening and Brief Intervention into the Normal Workflow of the Emergency Department Without Additional Resources. Ann Emerg Med. 2013;62(4):S101. doi:10.1016/j.annemergmed.2013.07.100.<br />
<br />
25) Strear C, Vissers R, Yoder E, Barnett H, Shanks T, Jones L. 30: Applying the Theory of Constraints to Emergency Department Workflow: Reducing Ambulance Diversion Through Basic Business Practice. Ann Emerg Med. 2010;56(3):S11. doi:10.1016/j.annemergmed.2010.06.059.<br />
<br />
26) Subash F, Dunn F, McNicholl B, Marlow J. Team triage improves emergency department efficiency. Emerg Med J. 2004;21(5):542-544. doi:10.1136/emj.2002.003665.<br />
<br />
27) Building one brown. HVP High Vol Print. 2005;23(2):34-37.<br />
<br />
28) Research Forum. Otolaryngol Head Neck Surg. 2000;123(2):P85-P144. doi:10.1016/S0194-5998(00)80031-5.<br />
<br />
29) https://www.healthcatalyst.com/success_stories/improve-appendectomy-care-outcomes-using-analytics-in-healthcare<br />
<br />
<br />
<br />
<br />
<br />
Contributions from <br />
[[User:Msoutzen|Msoutzen]] 07:57, 8 March 2012 (PST)<br />
Submitted by (M. Outzen, MS, OTR/L)<br />
[[Category:BMI512-WINTER-12]]<br />
Submitted by (Frank Longano).<br />
[[Category:BMI512-FALL-17]]<br />
<br />
Submitted by (Lindsey Spiegelman)<br />
[[Category:BMI512-FALL-19]]<br />
Combined these two sections into the: Clinical Workflow Analysis Page<br />
https://clinfowiki.org/wiki/index.php/Clinical_workflow_analysis<br />
https://clinfowiki.org/wiki/index.php?title=Methods_to_capture_workflow&action=edit&section=7<br />
Added first three sentences to paragraph #2<br />
Added in the section: Workflow in the Emergency Department<br />
References: 14-28</div>Lspiegel884https://www.clinfowiki.org/wiki/index.php/Clinical_workflow_analysisClinical workflow analysis2019-10-18T22:42:54Z<p>Lspiegel884: </p>
<hr />
<div><br />
== '''Clinical Workflow Analysis''' ==<br />
<br />
<br />
'''Introduction:'''<br />
The term workflow has been variably defined. The Agency for Healthcare Research and Quality (AHRQ), defines workflow as a sequence of cognitive and physical tasks listed chronologically that occur both within and between organizations that are required to accomplish specific work objectives. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously. When applied to the clinical setting the above definition generally holds true, with the work objective being a direct or indirect patient care function. For example, the workflow of ordering a medication includes communication between the provider and the patient, the provider's thought process, the physical action by the provider of writing a paper prescription or entering an electronic prescription into an electronic health record and transmitting the order electronically or having the patient take the prescription to the pharmacy to have the prescription filled. <br />
<br />
It is important to assess workflow because inefficiencies can negatively influence patient care and outcomes. Evaluating workflows can find deficiencies and areas that would benefit from improvements. In addition, when deciding to implement CDS, it is important to understand where in the workflow alerts should be used to most efficiently affect physicians. Research assessing health IT implementations demonstrates that delays in patient care, billing, and communication are likely to occur if workflow is not taken into account. This is generally due to the fact that clinical and practice management requirements are overlooked or oversimplified. As a form of ongoing process improvement, workflows should be continually assessed.<br />
<br />
'''Tools:'''<br />
A variety of tools are available to aid in the analysis of clinical workflows. The website of the Agency for Healthcare Research and Quality (AHRQ) contains one repository of tools useful in clinical workflow analysis (5). Some of the tools commonly used in clinical workflow analysis and redesign are:<br />
<br />
''1) Benchmarking'': The process of evaluating best practices of other organizations. This requires communicating with peers in similar organizations that are seen as successful in the objective being analyzed and determining whether these lessons can be applied to the workflow under consideration (6).<br />
<br />
''2) Check Sheet:'' A structured form for analyzing data about a specific work process or function (7). It is useful for documenting observational data about specific tasks in a workflow. Referenced is an example of a workflow assessment checklist provided by AHRQ (8).<br />
<br />
''3) Flowchart or Process Map:'' Flowcharts visually demonstrate specific steps in a work process arranged in sequential order. This allows understanding of the overall process and where improvement can be made (9). <br />
<br />
<br />
'''Steps in making a flowchart:'''<br />
<br />
1. DEFINE THE PROCESS that will be represented in the flowchart.<br />
<br />
2. DETERMINE ALL INDIVIDUALS, DEPARTMENTS, AND GROUPS INVOLVED in the process.<br />
<br />
3. BRAINSTORM THE STEPS in the process. The specific sequence is less important than determining all of the steps at this point (although thinking sequentially may help identify any missing steps).<br />
<br />
4. CONSTRUCT THE FLOWCHART GRAPHICALLY using rows or columns corresponding to the associated work units (e.g., provider, nursing). <br />
<br />
5. ARRANGE THE STEPS SEQUENTIALLY<br />
<br />
6. DRAW ARROWS between steps to show the process flow. <br />
<br />
7. REVIEW THE FLOWCHART and validate its accuracy with other individuals who are actually involved in the process.<br />
<br />
'''Advantages of flowcharts:'''<br />
<br />
• Demonstrates whether the flow of events makes sense and is smooth or if there is a lot of back-and-forth (numerous handoffs) between individuals<br />
<br />
• Highlights areas where decisions must be made<br />
<br />
• Shows which parts of a process are redundant or out of place<br />
<br />
• Identifies who completes each task in addition to what gets done<br />
<br />
• Shows areas that can be improved<br />
<br />
• Allows staff to clearly visualize their roles<br />
<br />
• Easy to learn and create<br />
<br />
<br />
'''Disadvantages:'''<br />
<br />
• Does not show value<br />
<br />
• Requires in-depth knowledge of the process<br />
<br />
<br />
'''Flowchart Example:'''<br />
<br />
• Medication reconciliation of original (A) and revised (B) workflows<br />
<br />
<br />
'''Example Flowchart:'''<br />
<br />
https://qualitysafety.bmj.com/content/qhc/20/4/372/F1.large.jpg<br />
<br />
'''Example of Clinical Workflow Analysis:'''<br />
<br />
An example of workflow analysis and redesign around implementation of an EHR is offered by ONC (11). This presentation discusses multiple clinical workflows in an outpatient medical practice and provides editable flowcharts for use as templates.<br />
<br />
<br />
== '''Workflow in the Emergency Department:''' ==<br />
<br />
<br />
''Barriers to Efficiency:''<br />
<br />
• Overcrowding<br />
<br />
• Increasing volumes<br />
<br />
• Boarding<br />
<br />
• Nurse/tech staffing<br />
<br />
• High acuity patients<br />
<br />
• Physician multitasking/interruptions<br />
<br />
''<br />
Common ED Metrics:''<br />
<br />
• Door to doctor time<br />
<br />
• Patient LOS<br />
<br />
• Time from admission order to transfer to inpatient ward<br />
<br />
• Door to room time<br />
<br />
• Time to lab draw/IV placement<br />
<br />
• Time from imaging order placed to completion <br />
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• Physician patients per hour<br />
<br />
• Time from discharge order to patient leaving the ED<br />
<br />
• Number of patients who left without being seen<br />
<br />
<br />
'''Areas of Success in ED workflows:'''<br />
<br />
'''1) Stroke''' <br />
<br />
• “Time is brain” Decreasing time to thrombolytics and reperfusion therapies improve patient outcomes<br />
<br />
• EMS stroke activation to mobilize ED and neurology teams<br />
<br />
• Physical design and layouts of the ED can optimize stroke care: Resuscitation rooms close to CT scanners<br />
<br />
'''2) STEMI''' <br />
<br />
• Achieving door to balloon times under 90 minutes is important for STEMI outcomes<br />
<br />
• In the field STEMI activation and EKG transmission<br />
<br />
• Allowing ED physicians to activate cath labs have improved door to balloon times<br />
<br />
<br />
'''Ways to Improve Efficiency with ED Imaging:'''<br />
<br />
'''1) POCUS''' <br />
<br />
• Physicians using POCUS instead of formal US can decreased ED LOS<br />
<br />
• One specific study showed that POCUS as a screening tool for intussusception could reduce ED LOS and unnecessary referrals for US <br />
CT scans<br />
<br />
• Having a “CT expediter”: Their role is to check imaging protocol, check priority, check NPO status, preg test , renal function, IV placement, contrast allergies, isolation precautions, call for transport and CT availability. Decreased work up time by 35%, decreased LOS by 4%<br />
<br />
• Having radiologists prioritize ED reads<br />
<br />
'''Ideas for Improving Triage Workflow:'''<br />
<br />
'''1) Group triage'''<br />
<br />
• Physician and nurses going to new patients together <br />
<br />
• Can expedite treatment, initiation of orders, door to doctor time<br />
<br />
'''Physician triage'''<br />
<br />
• Physicians doing the initial triage evaluation instead of nurses<br />
<br />
• Diagnostic tests are entered earlier, expedites treatment, patient LOS is decreased<br />
<br />
'''Other Ideas for Improving ED Workflow:'''<br />
<br />
• Point of care lab testing<br />
<br />
• Mobile computers for efficient physician charting/order entry<br />
<br />
• Decreased ED referrals from clinic and increased direct admissions<br />
<br />
• Phlebotomists <br />
<br />
<br />
'''References:'''<br />
<br />
<br />
1) Unertl, K et al. J Am Med Inform Assoc. 2010 May-Jun;17(3):265-73<br />
<br />
2) Harrington L. Electronic health record workflow: why more work than flow? AACN Adv Crit Care. 2015 Jan-Mar;26(1):5-9.<br />
<br />
3) Bowens FM, Frye PA, Jones WA. Health information technology: integration of clinical workflow into meaningful use of electronic health records. Perspect Health Inf Manag. 2010 Oct 1;7:1d.<br />
<br />
4) Sheehan, B and Bakken, s. Approaches to workflow analysis in healthcare settings. Nurs Inform. 2012; 2012: 371<br />
<br />
5) https://healthit.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit<br />
<br />
6) http://asq.org/learn-about-quality/benchmarking/overview/overview.html<br />
<br />
7) http://asq.org/learn-about-quality/data-collection-analysis-tools/overview/check-sheet.html<br />
<br />
8) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/Workflow_Assessment_Checklist.pdf<br />
<br />
9) http://asq.org/learn-about-quality/process-analysis-tools/overview/flowchart.html<br />
<br />
10) https://healthit.ahrq.gov/sites/default/files/docs/workflowtoolkit/In-officePrescribing-PaperSystem.pdf<br />
<br />
11) https://www.healthit.gov/sites/default/files/tools/workflow_redesign_templates_v1.pptx<br />
<br />
12) Carayon P, Karsh B-T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign--Summary Report. (Prepared by the Center for Quality and Productivity Improvement, University of Wisconsin–Madison, under Contract No. HHSA 290-2008-10036C). AHRQ Publication No. 10-0098-EF. Rockville, MD: Agency for Healthcare Research and Quality. October 2010. <br />
<br />
13) White CM, Schoettker PJ, Conway PH, et al. Utilising improvement science methods to optimize medication reconciliation. BMJ Qual Saf Health Care. Epub 2011 Feb 11; doi: 10.1136/bmjqs.2010.047845<br />
<br />
14) Burström L, Engström ML, Castrén M, Wiklund T, Enlund M. Improved quality and efficiency after the introduction of physician-led team triage in an emergency department. Ups J Med Sci. 2016;121(1):38-44. doi:10.3109/03009734.2015.1100223.<br />
<br />
15) Gyftopoulos S, Jamin C, Wu TS, et al. The Use of an Emergency Department Expeditor to Improve Emergency Department CT Workflow: Initial Experiences. J Am Coll Radiol. 2019;16(3):327-332. doi:10.1016/j.jacr.2018.11.003.<br />
<br />
16) Huded C, Kravitz K, Menon V, et al. Impact of the Cms Algorithm for Door-To-Balloon Time Public Reporting on Door-To-Balloon Time Performance. J Am Coll Cardiol. 2018;71(11):A1161. doi:10.1016/s0735-1097(18)31702-9.<br />
<br />
17) Iannone P. Ameliorating the emergency department workflow by involving the observation unit: effects on crowding. Emerg Care J. 2015;11(1). doi:10.4081/ecj.2015.4957.<br />
<br />
18) Jauch EC, Holmstedt C, Nolte J. Techniques for improving efficiency in the emergency department for patients with acute ischemic stroke. Ann N Y Acad Sci. 2012;1268(1):57-62. doi:10.1111/j.1749-6632.2012.06663.x.<br />
<br />
19) Kim JH, Lee J-Y, Kwon JH, Cho H-R, Lee JS, Ryu J-M. Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care. 2017;00(00):1. doi:10.1097/pec.0000000000001283.<br />
<br />
20) Lee EK, Atallah HY, Wright MD, et al. Transforming hospital emergency department workflow and patient care. Interfaces (Providence). 2015;45(1):58-82. doi:10.1287/inte.2014.0788.<br />
<br />
21) Nguyen M, Louis C, Sahota PK, et al. 90 Improvement of Emergency Department Workflow and Their Effects on Patient Satisfaction. Ann Emerg Med. 2018;72(4):S39. doi:10.1016/j.annemergmed.2018.08.095.<br />
<br />
22) Nugus P, Braithwaite J. The dynamic interaction of quality and efficiency in the emergency department: Squaring the circle? Soc Sci Med. 2010;70(4):511-517. doi:10.1016/j.socscimed.2009.11.001.<br />
<br />
23) Ozkaynak M, Wu DTY, Hannah K, Dayan PS, Mistry RD. Examining Workflow in a Pediatric Emergency Department to Develop a Clinical Decision Support for an Antimicrobial Stewardship Program. Appl Clin Inform. 2018;9(2):248-260. doi:10.1055/s-0038-1641594.<br />
<br />
24) Slain T, Rickard-Aasen S, Pringle J, et al. An Operational Analysis of Integrating Screening and Brief Intervention into the Normal Workflow of the Emergency Department Without Additional Resources. Ann Emerg Med. 2013;62(4):S101. doi:10.1016/j.annemergmed.2013.07.100.<br />
<br />
25) Strear C, Vissers R, Yoder E, Barnett H, Shanks T, Jones L. 30: Applying the Theory of Constraints to Emergency Department Workflow: Reducing Ambulance Diversion Through Basic Business Practice. Ann Emerg Med. 2010;56(3):S11. doi:10.1016/j.annemergmed.2010.06.059.<br />
<br />
26) Subash F, Dunn F, McNicholl B, Marlow J. Team triage improves emergency department efficiency. Emerg Med J. 2004;21(5):542-544. doi:10.1136/emj.2002.003665.<br />
<br />
27) Building one brown. HVP High Vol Print. 2005;23(2):34-37.<br />
<br />
28) Research Forum. Otolaryngol Head Neck Surg. 2000;123(2):P85-P144. doi:10.1016/S0194-5998(00)80031-5.<br />
<br />
29) https://www.healthcatalyst.com/success_stories/improve-appendectomy-care-outcomes-using-analytics-in-healthcare<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
<br />
Contributions from <br />
[[User:Msoutzen|Msoutzen]] 07:57, 8 March 2012 (PST)<br />
Submitted by (M. Outzen, MS, OTR/L)<br />
[[Category:BMI512-WINTER-12]]<br />
Submitted by Frank Longano.<br />
[[Category:BMI512-FALL-17]]<br />
<br />
Submitted by (Lindsey Spiegelman)<br />
[[Category:BMI512-FALL-19]]<br />
<br />
Combined these two sections into the: Clinical Workflow Analysis Page<br />
https://clinfowiki.org/wiki/index.php/Clinical_workflow_analysis<br />
https://clinfowiki.org/wiki/index.php?title=Methods_to_capture_workflow&action=edit&section=7Added first three sentences to paragraph #2<br />
Added in the section: Workflow in the Emergency Department<br />
References: 14-28</div>Lspiegel884https://www.clinfowiki.org/wiki/index.php/Methods_to_capture_workflowMethods to capture workflow2019-10-18T22:25:39Z<p>Lspiegel884: /* Workflow Analysis */</p>
<hr />
<div>In the process of implementing any new systems in the hospital, it is imperative to do '''workflow studies''' to determine the “as-is” (current state) and the “to-be” (future state) work processes of the healthcare providers.<br />
<br />
== Introduction ==<br />
<br />
Two methods commonly used by project teams to '''capture the workflows''' are the time-motion study and the work sampling study. Additional methods include qualitative questionnaires and quantitative measures to track movement. Since neither of these methods can provide a complete illustration on their own, using a combination of approaches can provide the most comprehensive information for workflow assessment.[5,6]<br />
<br />
== Time motion study ==<br />
<br />
Time motion study basically means the study of what a person is doing and how long it takes to do it. It involves the investigator to follow the subject and record the temporal aspects of events (e.g. tasks) under evaluation. This method is also known as the stop ]watch method and is currently considered as the gold standard in performing a workflow study. It gives detailed description of the workflow processes of the healthcare provider. However, it is tedious and labor intensive and hence is more costly as well. The investigator has to keep up and follow the subject studied for long periods of time as well as capture as accurate as possible the time it takes to perform the action.<br />
<br />
In an article by Zheng et al. [4], the authors used a time motion study to create a checklist called STAMP (Suggested Time and Motion Procedures). Through their observations they were able to make some determinations regarding the time and movement of their study group, but also encountered the issue that healthcare does contain many unpredictable actions and therefore certain actions could not be accurately analyzed.<br />
<br />
== Work sampling ==<br />
<br />
Work sampling on the other hand is counting how many times the action is done by the subject observed in a fixed time. For example, how many times the physician looks to the computer screen during a 10 minutes consultation. This method can be directly observed, or the person him/herself can keep a log of it. This workflow capturing method can be non-reliable, especially if the subject has to log in the data. Also this method may not be feasible if the person has to constantly travel from one place to another, as the investigator will then have to keep following up with him/her. However,work sampling does not introduce as much bias as time-motion studies, as the investigator does not shadow the subject as much. As data from work-sampling studies are usually extrapolated, a larger sample size is required to get better data representation.<br />
<br />
== Interviews and Surveys ==<br />
<br />
Interviewing and surveying vital players in a workplace system can also provide fundamental information useful to construct workflows. The subjects are either interviewed on a series of questions about their workflow or subjects are required to fill out surveys detailing their workflows.[5,6]<br />
<br />
Costa et al. [6] found that one engineering firm created a process for their user interface designers to collect information on the workflows of their clients. This method, the User Behavior and Analysis Modeling (UBAM) process, included inquiring their clients on the environment of the workplace, the user, the tasks performed, the data accessed, and the functions needed to support their tasks. In addition, three types of collection practices were observed among these designers. Fast designers used simple drawings that were only meaningful to the designers themselves. Formal designers used clear and organized displays of their work, which was understood by both the designers and their clients. Finally, beautiful designers used “…visually appealing…” [6] graphics to present workflows that were also comprehensible by both designers and clients.[6]<br />
<br />
However, there are limitations to this method. It only provides information from one point of view at any given time. Although this could be solved with more investigators collecting samples at one time, too many observers can lead to disruptions in the workflow.[6]<br />
<br />
== Automatic Movement Tracking ==<br />
<br />
Automatic movement tracking utilizes portable devices that are attached to their subjects. The subjects’ movement throughout their workday is monitored. By identifying and tagging certain work stations before the tracking process, an investigator can deduce the type of work being done at time intervals preset in the devices. This method is most similar to a time motion study, yet it allows for the investigator to monitor the time and movement of multiple subjects at one time. The also reduces the cost of having more investigators. The investigator is only limited by the number of devices, and the operability of these devices.[5]<br />
<br />
Once the information is compiled, it can be combined with the data collected using the other methods discussed above. This comprehensive approach can be used to create a 3-D or virtual model of the workflow. Regardless of what method is used, a detailed mapping of the workflow is needed to ensure success in the reaching the goals of the change in process.[5]<br />
<br />
== References ==<br />
<br />
# A comparison of time-and-motion and self-reporting methods of work measurement. Burke TA, McKee JR, Wilson HC, Donahue RM, Batenhorst AS, Pathak DS. J Nurs Adm. 2000 Mar;30(3):118-2<br />
# Modeling Clinical Trials Workflow in Community Practice Settings Sharib A. Khan, MBBS MA,1 Philip R.O. Payne, MPhil,1 Stephen B. Johnson, PhD,1 J. Thomas Bigger, MD,2 and Rita Kukafka, DrPH, MA1,3 AMIA Annu Symp Proc. 2006; 2006: 419–423.<br />
# A Comparison of Work-Sampling and Time-and-Motion Techniques for Studies in Health Services Research .Steven A. Finkler, James R. Knickman, Gerry Hendrickson, Mack Lipkin, Jr., and Warren G. Thompson.. Health Serv Res. 1993 December; 28(5): 577–597.<br />
# Using the time and motion method to study clinical work processes and workflow: methodological inconsistencies and a call for standardized research. Kai Zheng, Michael Guo, David Hanauer. J Am Med Inform Assoc. 2011 September; 18(5): 704–710. <br />
# Toward automated workflow analysis and visualization in clinical environments. Mithra Vankipuram, Kanav Kahol, Trevor Cohen, Vimla L. Patel. J Biomed Inform. 2011 Jun;44(3):442-440.<br />
# Fast, Formal, & Beautiful: Effectively Capture, Document, and Communicate User Workflow Information for Designing Complex Healthcare Software Systems. Jean M. R. Costa, Xianjun Sam Zheng, Roberto S. Silva Filho, Xiping Song. Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2012 Sep;56(1):526-530.<br />
<br />
<br />
Submitted by Jo Nie Sua<br />
<br />
[[Category:BMI512-FALL-09]]<br />
<br />
Reference 4:<br />
<br />
Submitted by Cody Schindeldecker<br />
<br />
[[Category:BMI512-FALL-12]]<br />
<br />
References 5 and 6: <br />
Submitted by Jessica S. Pierre<br />
<br />
[[Category:BMI512-SUMMER-13]]</div>Lspiegel884