Orders represent the currency of healthcare; up to 80% of healthcare costs are in the orders. The order results process is the ideal workflow point to streamline both the medical and business tasks associated with healthcare. This article addresses the use of an automation system to simplify the process, which would lower transaction costs while improving service.
is the Chairman and Founder and
is the CEO and President of MedOrder, Inc., Seattle, WA.
is also a General Partner with Mi3 Venture Capital and a member
of the Editorial Board of this journal.
The Order Loop is defined as the pathway linking the referring
physician to a center for patient transaction (eg, radiology,
laboratory, pharmacy, etc.) and the return of patient information
(eg, reports, images) to the referring physician. The Order-Loop
defines healthcare delivery with 4 billion orders per year. (The
term "Order Loop" has been filed as a registered trademark by
MedOrder, Inc., Seattle, WA. The term as trademarked is a
description or concept tied to MedOrder's medical software and
Every medical process is an order-result (Order-Loop
). The medical record is a collection of Order-Loops such as
laboratory, radiology, visits notes, prescriptions, consultations,
and surgery reports. Automation of the Order-Loop produces a
horizontal integration across vertical systems, transforming
healthcare, just as Enterprise Resource Planning and Materials
Resource Planning solutions have transformed manufacturing. These
processes have allowed companies to innovate new successful
Healthcare industry trends of falling connectivity costs and
increasing e-commerce capabilities, such as "Web Services," will
facilitate the adoption of workflow automation in healthcare. The
Order-Loop is expected to play a key role in this exciting change
Orders represent the currency of healthcare. Up to 80% of
healthcare costs are in the orders. The order-results process is
therefore the key healthcare delivery process, requiring automation
in order to lower transaction costs while improving service. The
present situation in healthcare can be characterized as an
explosion in medical information and regulations. This is
increasing costs and worker stress, which leads to widespread
institution financial stress. The healthcare system is in a
The Internet promise to improve healthcare (e-health) is widely
accepted, yet remains unfulfilled. The Internet is a necessary tool
but is insufficient by itself to transform the industry. Web
automation of broken processes is not transforming. Transformation
requires a visionary approach to bridge existing structural
What are the existing barriers?
* Healthcare delivery is a distributed, mostly manual process,
transcending multiple boundaries among patients, physicians,
institutions, and payers.
* 25% of all healthcare costs are consumed in the existing
paper-fax-phone communication process. At least 30% of orders
contain errors or major deficiencies. Information transmission,
management, and retrieval is inefficient and error prone.
* Rising regulatory burdens of coding, compliance, and
documentation are overwhelming healthcare workers.
* Existing software solutions are inward (vertical)
business-focused versus outward (distributed) medical-communication
* Existing manual workflow processes poorly bridge the vertical
islands of medical automation.
* Multiple information retrievals are required to reconstruct a
"medical" picture from transactions.
* A Unified Medical Portal Interface to medical information is
required to simplify retrieval and information representation.
This article will address a graphical user interface (the
Anatomic Navigator, MedOrder, Inc.) that targets the need for a
unified medical portal interface. Medical thinking, training, and
treatments are organized around physiology and anatomy. For
example, medical specialists follow this pattern: cardiologist,
urologist, neurologist, pulmonary, endocrine, etc. Existing systems
categorize information by business categories (radiology,
laboratory, pharmacy, hospital), rather than medical categories
(gastrointestinal, heart, urinary, endocrine). The Anatomic
Navigator facilitates navigation and display by medical as well as
traditional business categories. This results in efficient,
"organized," medically meaningful information access.
To insure that the Anatomic Navigator effectively meets the
needs of the customer, a strategic thinking tool known as the HIGH
5 will be described.
Strategic thinking tools
Thinking and planning are activities that we perform every day.
The sequence in which we complete our thinking and planning steps
is an important factor in achieving maximum effectiveness. Ideally,
we should devote an adequate amount of time to thinking about all
sides of a particular problem before progressing too far with
planning or implementing a solution. Many of us learn this lesson
the hard way. We sometimes forge ahead with elaborately developed
plans, without thinking enough about what we ultimately hope to
achieve with our plans. We then have to go back to the beginning to
rethink our options, before resuming the planning and
Strategic thinking tools (or frameworks) can be used to aid in
the process of strategic thinking. One of the most attractive
attributes of strategic thinking tools is that radiologists with
various levels of business education and experience can use them.
The tools are easy enough to be understood and applied by
radiologists who have not had any formal business training.
The broad acceptance of these tools comes from the fact that
they are easy to learn and highly effective. Essentially, this is
because the tools communicate at a fundamental level between
people. For example, in a regional healthcare community, where
people possess diverse backgrounds, these tools enable the players
to cross boundaries and relate effectively at a common, fundamental
A specific tool known as the HIGH 5 will be used to discuss the
Anatomic Navigator approach to the Order Loop. The HIGH 5 is a tool
or framework for thinking about the needs of the customer. The
framework of the HIGH 5 is simply a set of five factors (which
requires a selection process similar to that of the 8020 rule --
80% of the impact can be found in 20% of the factors). In a
well-run organization or department, the HIGH 5 is the guiding
focus for all personnel. In this manner, the organization never
loses the focus of the customer.
The factors selected for the HIGH 5 should be based on a careful
analysis of customer needs. This can be accomplished via surveys,
interviews, focus groups, etc. It is important to periodically
reassess the factors to constantly ensure that the clinical needs
of the customer and the technical capabilities of the vendor are
synchronized. This process is referred to as the clinical/
technical tie. The Anatomic Navigator HIGH 5 will present the
clinical need. The Anatomic Navigator technology presents the
technical solution required to meet the clinical need.
The clinical need
Reduction of workflow-driven costs
is accomplished by reducing the number of steps, phone calls, and
paperforms in the order process, thereby reducing ordering and
results reporting costs. In addition, reduction of the downstream
cost of claims processing is accomplished by providing automated
coding at the point of order generation. The result is a reduction
in the order process cost from $15 to $25 per order to $7 to
is accomplished by providing access to guidelines, patient
preparation instructions, and contraindication notices
automatically, all of which reduce order-related errors. Errors in
the coding necessary for reimbursement are reduced from 25% to 30%
Improved information access is accomplished with the use of an
image-based browser that speeds up the medical ordering and results
reporting process. The browser provides intuitive point-and-click
access to critical clinical and administrative information. For
example, retrieval of radiology exam guidelines from the ACR is
reduced from 2 minutes per exam to <10 seconds.
Improved regulatory compliance
is accomplished through the automatic generation of the correct
ICD-9 codes, improving ICD-9 to CPT code matching, assuring
electronic signature of changed orders, and identifying and
creating appropriate ABNs automatically. In addition, a secure
message structure ensures compliance with the new HIPAA rules.
are accomplished by: flagging ABNs at the point-of-order, which
improves Medicare reimbursements; providing improved coding; and
being online at all times, thereby reducing the chance of missing
Benefits from using tools
There are a number of benefits of using strategic thinking
tools. In a given application of strategic thinking tools, some of
the benefits will be more significant than others. However, it is
important to review all of the benefits to make sure that the users
are getting the most utilization that they can for any given
application. The benefits described below are characterized in
terms of the HIGH 5 tool.
Developing a common framework for solving problems
The HIGH 5 provides a framework in the form of a selection of
the most critical factors required to serve the needs of the
customer. It has been found that five factors is often the right
Identifying a common language for addressing problems
The language consists of the HIGH 5 and the meaning behind the
selection process. This tool addresses a specific type of problem
where customer satisfaction is key to the solution. Whenever a
similar problem needs a solution, the team can revert back to the
HIGH 5 tool for implementing the solution.
Thinking with simultaneous focus and flexibility
Focus is derived by having a framework. However, in establishing
the content (eg, the details of the five factors), there is
flexibility for individual input as team consensus is
Stimulating creativity in problem resolution
The creative process is derived from having a team brainstorm
the content within the framework. The developmental process for
arriving at the final set of five factors is up to the creativity
of the team.
Communicating by asking the right questions to find the
The question raised by the HIGH 5 tool is: What are the needs of
the customer? After considering an array of possibilities, the
question focuses on how to combine and prioritize factors to
achieve the final five factors.
Promoting teamwork in problem solving
Teamwork is established as the process moves from individual
input to consensus of the final result. All of the benefits of
using tools are enhanced by the use of teams wherever possible.
Establishing team confidence in the problem solving
Confidence is achieved as the consensus process is carried out.
The utilization of a framework is essential to organize individual
inputs into a consensus.
Building a foundation for future problem solving
As situations change (eg, technology, clinical service, or
socioeconomic changes) an update of the HIGH 5 becomes appropriate.
The foundation established in creating the initial HIGH 5 makes
this an efficient and effective process.
Providing outlines for planning
Strategic thinking with the use of tools promotes "doing the
right things." Planning, the process of "doing things right"
follows. The establishment of the HIGH 5 represents "doing the
right things." The details of how each of the five factors is
carried out represents "doing things right."
Focus on customer satisfaction
A meaningful team activity should always focus on the customer.
The customer can be thought of as someone receiving a service or as
management receiving results. The development and execution of the
HIGH 5, as described above, fundamentally ensures that customer
satisfaction is brought to fruition.
The technical solution
The clinical problem is shown in Figure 1. The practice of
medicine is based on anatomy and physiology. This is the way in
which physicians are taught to think. This model of medicine is
consistent for all the disciplines that apply to medicine,
including diagnosis, treatment, examinations, education, training,
and specialization. Therefore, it follows that any parallel system
for orders and other areas of business transactions would follow
the same model of medicine. Unfortunately, this has not been so,
prior to Anatomic Navigation.
Instead, a healthcare information model that treats business
transactions as independent inputs is presently being used. Areas
of transactions treated in this manner include order codes,
laboratory information, billing, radiology information,
medications, etc. It is the disconnection created by conflicting
models (the medical model opposed to the healthcare information
model) that has resulted in the cost, error, access, compliance,
and revenue challenges outlined above.
Conversion of information between the two models is cumbersome,
costly and error prone. It is estimated that the information
transformation process consumes 20% to 30% of a physician's time.
The technical solution is shown in Figure 2.
The solution to the dilemma presented above is to use a single
model for both medicine- and business-related entries. With the use
of an Anatomic Navigator (driven by an anatomic information model)
medical intuitive views of information remove the disconnection
between the conflicting models described above. Medical intuitive
views of information can improve the order process by intuitively
constraining and simplifying the available codes to a given medical
problem. It is evident that a medical interface is needed to bridge
between the medical and business needs. The order results process
is the ideal workflow point to streamline both the medical and
business tasks associated with healthcare.