Workflow analysis and modeling in medical

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MEDICAMUNDI 46/2 August 2002 47
Management Coalition (WfMC):
‘Workflow is the automation of a business process, in
whole or in part, during which documents, information
or work items are passed from one participant to
another for action, according to a set of procedural
rules’ [2].
In the radiology department, the processes are
relatively well-defined activities, performed by
various people or systems, at various locations, and
at various times. These activities are supported, to
an increasing extent, by computerized systems and
appropriate software components. 
The first step towards efficient workflow
management is to identify and understand the
Implementation of a medical IT system will always
have an impact on the workflow in the hospital.
The scale of the impact will depend on the scope
and the complexity of the IT system itself. For
example, implementation of a workstation for 3D
image reconstruction will have an impact that will
mainly affect the workflow within the radiology
department itself. On the other hand,
implementation of a hospital-wide PACS (Picture
Archiving and Communication System) will have
an impact not only on the workflow in the
radiology department, but also on the workflow in
the outpatient clinics, the wards, the emergency
department, the intensive care units and the
operating rooms. The greater the impact of an IT
solution is likely to be, the more important it
becomes to fully understand the existing workflow,
and to create a consensus of opinion about the
desired workflow among all those concerned.
Workflow
The term ‘workflow’ is a concept from Business
Process Re-engineering (BPR), used to describe the
processes involved in arriving at a given objective:
‘Workflow, according to those offering credible
definitions, is any work process that must go through
certain steps and be handled by more than one person
on its way to completion. Workflow automation relieves
people of some of these tasks. Inherent in workflow are
concepts of teamwork, request and approval, routing
and tracking of documents, filling out forms and doing
things either in series or in parallel’. David Essex in
‘The Many Layers of Workflow Automation’ [1].
‘At the highest level, workflow is all those activities
that combine the processes, the tools and the people
all working toward a business objective’. Diane
Hartingh, Senior Principal at American Management
Systems (AMS), quoted by David Essex in ‘The
Many Layers of Workflow Automation’ [1]
In the context of automation, ‘workflow’ has a
specific meaning, as defined by the Workflow
Workflow analysis and modeling in medical
IT projects
A.S. Ouvry1
1Partner, D&A 
Medical Group, Buren,
the Netherlands.
Figure 1. 
PROTOS (Pallas
Athena, Apeldoorn, 
the Netherlands).
Figure 1a. 
Workflow elements
�
� 
Figure 1b. 
PROTOS symbols
48 MEDICAMUNDI 46/2 August 2002
phase, the need for an IT solution and its scope
are investigated in order to arrive at an investment
decision. Then, detailed analysis of the requirements
and definition of the system take place. The
definition phase is usually split into an analysis
and a design step. After the definition phase, the
actual implementation of the system can start. The
implementation phase comprises technical
installation, system customization and configuration,
and user training. Finally, the system becomes
operational, and a cycle of maintenance and
evolution begins.
The value of workflow modeling and analysis in
the different phases of a medical IT project is
discussed below, taking implementation of a
radiology PACS and an information management
system in the cardiac echo lab as examples. 
The concept phase: costs and benefits
The key purpose of the concept phase is to
examine the need for an IT solution, its intended
scope, and the consequences of its implementation.
In this phase, it is essential to arrive at a full
understanding of the probable cost, the benefits
and any potential drawbacks associated with the
implementation of the system. It is equally
important to understand the needs and the
expectations of the potential users of the system,
and of other important stakeholders.
It should be emphasized that implementation of
an IT system involves far more than simply pur-
chasing an item of equipment. The consequences
can be far-reaching, and an inappropriate decision
at this stage can lead to problems further down the
line, which may persist far into the future. It is not
only important to involve the end users and those
in related disciplines at this stage, but also to
consider the system within the wider context of
the whole enterprise. For example, a stand-alone
system that meets the needs of one department
may be difficult to interface with a projected
hospital-wide system in the not-too-distant future.
The concept phase should provide a realistic picture
of how the system will help the hospital to improve
its operational efficiency and effectiveness, and to
what extent financial benefits can be realized.
Workflow models (Figures 3, 4) are very useful in
visualizing and expressing the benefits that can be
achieved by implementation of a desired system.
various aspects of the workflow. Here, conceptual
tools for analyzing and modeling workflow become
important. These tools provide support for
structured and comprehensive analysis of the
workflow in all its aspects: processes, information,
applications and organization. They provide a
common framework for documenting knowledge
of the processes, and for describing process bottle-
necks, information flows, system integration, work
organization, process improvement and process
monitoring. 
Models of the workflow will provide a valuable aid
to understanding the current situation, and for
defining the desired future situation. The effects of
re-designing the work processes and of introducing
various IT solutions can then be examined in detail
before the system is implemented. There are several
tools for modeling and analysis on the market. The
workflow models in this article have been made
with PROTOS (Pallas Athena, Apeldoorn, 
the Netherlands) (Figure 1).
Phases of an IT project
The various phases of an IT project are shown in
Figure 2. An IT project starts as a concept at a
high level within the organization. In the concept
�
Figure 2 
Phases of an IT project.
The first step 
towards efficient 
workflow 
management is 
to identify the 
various aspects.
Models will 
provide a 
valuable aid to
understanding
the current 
situation.
The phases of an
IT project are:
concept, 
definition and
implementation.
MEDICAMUNDI 46/2 August 2002 49
� Figure 3. 
Workflow in a typical video-based echo lab.
� Figure 4. 
Workflow in a digital echo lab (Duke University Medical Center)
50 MEDICAMUNDI 46/2 August 2002
green. Comparison of the analogue and the digital
workflow shows that, in addition to the financial
benefits, significant operational improvements are
achieved by streamlining the process of study
interpretation and distribution of results:
• Shorter report throughput times
• Easy access to patient studies
• Faster reading of patient exams.
In addition to the financial return-on-investment
analysis, the workflow analysis gives a good picture
of the potential operational benefits that can be
achieved and the process changes that are necessary
in order to fully realize these benefits.
The definition phase: analysis and design
The definition phase of an IT project usually
starts with an analysis of the current situation:
technical infrastructure, procedure and data
The concept phase usually ends with a decision on
the investment by the hospital management.
The following example examines the motivation
for a digital information management system ina
cardiac echo lab. Figure 3 shows the workflow in a
typical video-based echo lab. Activities that will be
automated in a digital workflow, and will therefore
disappear, are shown in red. Calculating the costs
associated with these activities in terms of staff
(Full Time Equivalent or FTE) needed and materials
used provides essential input for the financial cost-
benefit analysis.
Figure 4 shows the workflow in a digital echo lab
(Duke University Medical Center) after
implementation of the EnConcert echocardiography
information management system (Philips Medical
Systems) [4]. The activities and sub-processes
supported by the EnConcert system are shown in
�
Figure 5. 
Conventional work-
flow in a radiology
department 
(University Hospital
Aachen, Germany)
The definition
phase usually
starts with an
analysis of the
current 
situation.
MEDICAMUNDI 46/2 August 2002 51
Figure 5 shows the current workflow situation in a
radiology department (University Hospital,
Aachen). The colors indicate the activities and
sub-processes that are already supported by
computer systems:
• Radiology scheduling application (yellow)
• Radiology information system (green)
• Radiology reporting system (blue).
The PACS that will be implemented in this depart-
ment will have to interface with these systems. On a
more detailed level the workflow model contains
information on the number of workplaces, the
organization of the reporting and authorization
process and work procedures for each sub-process.
Design: desired situation 
Once the desired way of working has been defined,
the work processes are re-designed, and the
volume, and work places. At this stage, a detailed
workflow analysis of the clinical and supportive
processes involved is very helpful in order to arrive
at a complete and comprehensive statement of
system requirements:
• Functional requirements for each process step
• System configuration and customization for 
integration in the hospital workflow (e.g. 
standardized reporting, user authorization)
• Requirements for integration with existing 
IT systems.
Analysis: current situation
The workflow model of the current situation
outlines the activities and sub-processes, the
information used and created, work organization
and work distribution, as well as the applications
currently being used. 
� 
Figure 6. 
Workflow models of
current and desired
situation for film-
based and digital 
radiography.
The definition
phase comprises
analysis of the
current situation
and design for 
the new situation.
52 MEDICAMUNDI 46/2 August 2002
implementation of the IT system, and what
additional activities are required. Experience in
projects has shown that the use of workflow models
helps to involve the personnel in the discussion
about the new work processes, and in transferring
know-how about the impact of the IT system on
the workflow to different levels in the organization.
The various aspects of workflow management in
radiology have been dealt with in depth by 
T. Wendler and C. Loef in a previous issue of
Medicamundi [3].
corresponding IT solution is specified (Table 1).
These aspects are interrelated and, although they
require different skills, they should be dealt with
simultaneously. The design phase results in a
blueprint for the system to be implemented and a
workflow model for the new work processes
(Figure 6).
At the highest level, the workflow model shows the
clinical workflow for the new situation: it shows
which (supporting) activities are automated, which
sub-processes and activities will be affected by the
Figure 7. 
Workflow for a CT
exam (University
Hospital Aachen,
Germany).
�
Figure 7a. 
Workflow for the
examination.
The workflow
model shows the
clinical workflow
for the new 
situation.
MEDICAMUNDI 46/2 August 2002 53
shows the clinical and supporting system workflows
for a CT examination study after implementation
of PACS (University Hospital Aachen). Figure 7a
shows the workflow for the examination itself, while
Figure 7b shows the detailed workflow for the report-
ing sub-process. Human activities are indicated by
a blue dot and system activities by a black dot. 
On a more detailed technical level, the workflow
model shows the required interaction between the
new system and the existing systems, needed in
order to achieve the desired clinical workflow.
Hence, the workflow model for the new situation
can serve as an input tool for designing optimal
clinical work processes, as well as for the design of
the required system workflow. Figure 7a and 7b 
1. Process re-design
• Digital workflow for each of the modalities
• Scanning request forms and other documents
• Routing film folders during the hybrid period
(mixed film/digital environment)
• Digital reporting and digital signature
• Electronic distribution of results
2. Application configuration
• User rights
• Work lists
• Release of information to referring physicians
3. System configuration
• Amount of memory
• Archiving strategy and technology
• Number and type of workstations
• Peripherals for printing and scanning
• Interfaces with existing systems
� 
Figure 7b. 
Detailed workflow
for the reporting
sub-process.
��
Table 1. 
Implementation of
PACS: activities in
the design phase.
� 
Figure 8. 
PROTOS symbols
used in the workflow
models. 
The model
shows the 
interaction 
between new
and existing 
systems.
54 MEDICAMUNDI 46/2 August 2002
Conclusion
Workflow analysis and modeling play an important
role in medical IT projects. Implementation of an
IT system requires an understanding of the
processes involved and, depending on the scope and
complexity of the system, will involve a certain
amount of process re-design.
Workflow models are a useful tool for under-
standing the impact of an IT solution on the
clinical work processes, defining the expectations
and requirements for an IT solution, and
managing the change process associated with the
implementation of an IT system. They can play an
important role in:
• Demonstrating the need for an IT solution by 
showing the workflow benefits of the proposed 
solution
• Managing the change process by providing 
support for the systematic analysis of the 
current workflow and the design of the desired 
workflow
• Ensuring consistency in implementation by 
providing useful training material and process-
related work instructions.
Acknowledgements
We thank Prof. Dr. B.B. Wein from the University
Hospital in Aachen, Germany, and Mr. D.B. Adams,
Rdcs from Duke University Medical Center, North
Carolina for their contribution in the development
of the workflow models presented in this article.
The radiology reporting application was developed
at University Hospital Aachen. EasyLink and
EasyWeb are products from the Philips PACS
portfolio.
Implementation phase: procedures and
training
In the implementation phase, the workflow models
that were created during the design phase are
further refined with more precise information on
the new work procedures and fallback scenarios.
This information is compiled in a comprehensive
process-oriented procedure handbook, which can
also be made available on-line. For example,
PROTOS can generate the handbook in html-
format for publication on the hospital’s intranet.
In combination with an on-line system manual,
this provides a complete process-oriented user
reference manual. 
The PROTOS symbols used in the workflow
models are shown in Figure 1.
Experience to date indicates that the workflow
models, in combination with the work procedures
and user instructions, form a practical tool for
training new users.
Maintenance and evolution
The workflow model produced duringthe design
and implementation phases serves as a guideline
for maintenance of the system, and for extensions
and improvements to meet emerging needs
(Figure 8). In particular, it can be used to analyze
the impact of any proposed system changes.
References
[1] Essex D. The Many Layers of Workflow Automation.
Healthcare Informatics, June 2000: 128-135.
[2] Workflow Management Coalition.
http://www.aiim.org/wfmc/.
[3] Wendler T, Loef C. Workflow Management – 
Integration Technology for Efficient Radiology.
Medicamundi 2001; 45,4: 41-48. 
[4] Adams DB. The Digital Echo Lab. Agilent 
Technologies Publication, 2000.
Workflow
models are a
useful tool for
understanding
the impact of
an IT solution.
Workflow 
analysis and
modeling play
an important
role in medical
IT projects.