The Multi-Dimensional Organization - Part 2

In my preceding article, I discussed five primary dimensions of The Multi-Dimensional Organization (MDO).  In my July, 2011, article, “Rethinking Business in a Changing World,” I outlined new fundamentals that affect the way executives should think about their enterprise in this changing world. In the present article, I will discuss how an MDO perspective more effectively addresses these fundamentals. 

The five dimensions of the MDO:

·         Product capability services are the capabilities that are involved in the delivery of a product or service. 

·         Lines of business are responsible for management of products or services from concept through customer support. 

·         Primary support services provide capabilities that are not specific to the particular business or industry, but instead support business activities throughout the enterprise. 

·         Coalitions are collaborations that cross organizational boundaries and may engage participants from other parts of the enterprise or outside the organization. 

·         Enterprise leadership includes the executives and their supporting staff activities.

The new fundamentals:

·         Value creation

·         Sharable capabilities

·         Collaborations

·         Enterprise optimization

·         Risk abatement

·         Innovation

·         Regulatory compliance.

The impact of MDO on each of the fundamentals is discussed in the following sections.

Value creation.

The enterprise exists to produce value for customers and other stakeholders.  It’s no longer simply about profit.  Values include company reputation, product aesthetics and prestige, timeliness of delivery, quality of service after the sale and various product features.  And there are values that affect relationships with investors, suppliers and employees. 

Lines of business (LOB) should focus on values delivered in their products and services along with the capabilities they need to contribute those values.  Product capability organizations should focus on providing value to the lines of business they support with optimal utilization of resources. 

Support services should consider values for other stakeholders such as finance for investors, human resources for employees and procurement for suppliers.

Enterprise leaders must consider the values developed and acquired by the enterprise as a whole, considering relationships with customers, suppliers, other business partners, industry coalitions, and stockholders.  They must (1) provide an enterprise perspective on the creation of value to avoid sub-optimization, (2) evaluate the value contributions of LOBs and capability units in their respective roles and (3) determine the best way to invest limited resources to improve value delivery. 

In addition, enterprise leaders should understand the value of insights and market influence realized through participation in industry coalitions involving customers, competitors and others to gain insights and to influence the market.

Sharable capabilities.

The separation of product capability services from lines of business minimizes capability bias toward a particular line of business and enables more objective analysis and implementation of capability requirements, performance, and interfaces. 

Capabilities may be consolidated, or affiliated under a broader capability management to achieve economies of scale in technology or workload balancing.  Some capabilities may be outsourced to take advantage of greater economies of scale and enable the enterprise to focus on the core business.  Potential product implications of capability modifications can be evaluated in appropriate contexts, with an understanding of the impact on the enterprise as a whole, resulting in more objective investment and transformation priorities.  Consolidated capabilities improve agility by enabling existing capabilities to be engaged in new lines of business and by expediting changes that might otherwise require multiple, varied implementations.

Primary support services (e.g., finance and procurement) typically are implemented as shared capability services although they may operate through antiquated interfaces.  In some cases there are opportunities for consolidation or outsourcing to realize additional economies of scale. Recognition of these as a separate organizational dimension provides a better focus on their contributions and implementation of relevant policies and regulations.

Collaborations

A collaboration is any association of people and organizations work together to achieve a shared purpose.  Collaborations already exist as a recursive element in the traditional, management hierarchy. What is important is recognition that the operation of the enterprise occurs in a complex, collaborative network where many collaborations are cross-organizational coalitions that bring together people from different traditional organizations.  Many of these coalitions may not be formally identified, fostered and supported by enterprise management.    

For example, coalitions between representatives of LOBs, IT services and capability units are essential for developing and improving each capability to best meet the needs of its multiple users.  Coalitions are also essential for developing and implementing changes, such as product technology upgrades, affecting multiple capabilities.  These coalitions must be supported and the products of their efforts must become part of the enterprise business planning and transformation activities.

An MDO model legitimizes the roles of coalitions.  It highlights the need to know how people contribute to various coalitions and how they are contributing value to the enterprise. Formal recognition of the purpose, roles, responsibilities and participants in each coalition is the first step in providing leadership and managing the funding and motivation of such efforts.

Enterprise optimization                                                      

Enterprise optimization requires participation from all levels of an organization.  The different dimensions of an MDO bring different perspectives and empower individual organizations to optimize operations while broader optimizations are achieved through coalitions at the middle-management and enterprise levels. 

Each line of business has a responsibility for optimization of the delivery of their products or services. Each product capability provider has a responsibility to optimize the performance of their services, particularly the timeliness, cost and quality of their contributions to the internal customers they serve. Coalitions are essential to resolve cross-organizational problems and reconcile dependencies between organizations where there may be competing objectives. 

Enterprise leaders must achieve overall enterprise optimization considering different lines of business and business values.  Much of this may be accomplished through coalitions organized by corporate staffs for development of optimal strategies and business design, and for implementation of business transformations.  The contributions and cost of participants from outside the executive staff should be formalized and funded.

Enterprise optimization also may depend on synergy between different products or services or delivery of different products or services to the same customer.  For example, the use of the same windshield washer pump in multiple vehicle lines reduces design costs and part inventories, and customers who purchase a printer eventually will purchase many ink cartridges for that printer.  Individual lines of business must be motivated to realize these synergies.  Enterprise leaders must provide the mechanism by which this synergy is recognized and each line of business experiences reciprocity in some form for their contribution.

Risk abatement

Risk abatement must address potential single points of failure, vulnerabilities to attack, natural disasters and disruptive changes in technology and market conditions.  Redundancy must be balanced against efficiency and agility.

One of the major challenges of risk abatement is identification of risks.  The 5 dimensions of an MDO provide a framework for this analysis.  Each of the capability service units can identify risks to the quality, cost and timeliness of their operations.  This is input to an impact analysis of the internal organizations they support. Each line of business can identify the impact of disruptions of the suppliers and capabilities they use and the potential consequences to their lines of business.

Similarly, support services, such as financial and information services, should identify risks such as investment risks and information security risks.

Coalitions should be part of the risk analysis.  Members of the coalitions should identify potential risks associated with disruptions of collaborative relationships or the interests they represent, both internal to the enterprise and with external stakeholders.

Corporate leadership and the executive staff, through coalitions, must drive risk identification and bring together the details of distributed risk analyses to identify common causes of risk and summarize potential consequences.  They must also analyze risks associated with the role of the enterprise in the ecosystem of customers, business partners, political entities and other stakeholders.  Managing these relationships is essential to sustained success of the business.  They must determine their level of risk tolerance and make appropriate investments in abatement measures considering costs and impact on different lines of business.

Innovation

Innovation is a critical aspect of competition in a rapidly changing world.  Executives cannot be the primary source of innovation, but must leverage the talents of employees and other stakeholders.  An MDO clarifies roles and responsibilities so that people throughout the organization can contribute innovation to the aspects of the business they know best.

Coalitions can bring together diverse expertise and points of view to think outside the box.  The scope of many solutions will be contained within organization units that can take initiative to identify and implement them.  Broader-scope effects or innovation from outside the affected organization must be recognized and escalated to the attention of leaders who can act on them for planning and investment activities where they can be given appropriate priority.  Contributions of individuals must be recognized and rewarded to sustain motivation.

Regulatory compliance.

Most businesses are now global either in their operations or in the delivery of their products or services.  This means an enterprise must comply with regulations of multiple political entities.  As with risk abatement, an MDO provides a framework for identification of regulated activities and implementation of compliance mechanisms. 

A corporate staff activity must track regulation changes around the world.  Relevant regulatory requirements must be identified, interpreted in the context of the business, and brought to the attention the organization units that may be affected.

Capability units must consider the regulations affecting their resources, materials and methods.  Lines of business must consider the regulations affecting their products and services—the design, the material content, and the risks to users where their products or services are delivered. Support services such as financial services, human resource management and information services must consider regulations such as financial accountability, employment practices and information security.

The implications of these regulation assessments should be reported to corporate leaders and their staff to determine the specific implications to the enterprise.  Some regulations may be subject to further interpretation, some may affect where operations are performed, and others may affect the choice of markets.  An MDO provides a framework for determining where and how compliance should be achieved.  Corporate leaders should periodically review the relevant regulations, and assess the mechanisms and accountability for compliance. 

Conclusion

While the new fundamentals are not entirely new concerns, attention to them has become increasingly important to the survival of today’s enterprise.  Most of the workforce is now knowledge workers who each have expertise and insights into their segment of the business.   While enterprise leaders have a critical role in reconciling and motivating different perspectives, they must utilize the abilities of people more directly engaged in the operation of the enterprise in order to be both efficient and agile.  An MDO provides a structure in which the fundamentals can be addressed by appropriate members the enterprise, and their expertise and insights can be fully utilized to address the challenges and opportunities.

The Multi-Dimensional Organization

Organization structures are changing.  Repetitive manual processes have been automated, so organizations are increasingly dominated by knowledge workers who resolve exceptions, and create, maintain and adapt business operations.  Global competition, increasingly rapid change, and pervasive computing and communications technology have made new ways of doing business a competitive necessity.   In particular, a virtual enterprise—multiple companies contributing to an end product or service—can successfully compete against the traditional, large, integrated company through exploiting greater economies of scale.

The successful enterprise, whether integrated or virtual, must develop a multi-dimensional organization (MDO) structure.  The conventional, two-dimensional, matrix organization divides the management of functional capabilities from the management of products or projects.  The new MDO is much more than people having two bosses with different perspectives.  An MDO has different groups of people dealing with different dimensions of the enterprise.

Two core concepts for organizing an MDO have been developed through work at the Object Management Group and are being incorporated in the VDML (Value Delivery Modeling Language) specification.  We call these core concepts collaboration and capability.

A collaboration is a group of participants, including people, organizations or machines, that participate in roles that contribute to a shared objective.  This core concept is the basis for modeling the structure of any organized human endeavor.  The virtual enterprise, referenced above, is a collaboration among participating companies.  A work group is a collaboration among people, a business process is a collaboration of participants in formally defined roles and relationships, and a management hierarchy is a recursive collaboration of people and organizations participating in their formal business roles.  Furthermore, a role in one collaboration, for example, a department manager role may be specified as a participant in another collaboration, for example, a member of a quality improvement task force.

A collaboration may be identified as having a capability.  A capability is the ability to perform a type of work by applying resources including, for example, people, materials, equipment, techniques and processes that work together to deliver the capability.  An organization of any size may be described as providing a capability.  A supplier may be viewed as having a capability to provide a particular type of component such as electric motors.  A department may be defined as having a general capability such as product engineering or manufacturing.  A work group that actually performs work may be defined as a capability unit having a specific capability such as damage assessment.  A capability may be offered as a service, so the collaboration that offers that service will be described here as a shared capability service unit.  See Value Chain Modeling, Part 1: Capability Analysis for more on capability services.

In this article, I will discuss the dimensions of an MDO.  In Part 2, I will discuss how these dimensions complement the new fundamentals discussed in my July, 2011, blog, “Rethinking Business in a Changing World.”   

I define 5 primary dimensions of an MDO: (1) product capability services, (2) lines of business, (3) primary support services, (4) coalitions, and (5) enterprise leadership.  These dimensions are not new, but their roles and relationships have not been formally distinguished, understood and managed appropriately.  I will discuss each of these in the paragraphs that follow.

Product Capability Services

Product capability services manage the capabilities that are needed to deliver the products or services of the enterprise.  Traditionally, these capabilities were included within each line of business organization.  In an MDO, product capability services will be managed separately from line of business organizations so that they can be shared by multiple lines of business.  This is similar to the traditional matrix organization concept of separating management of a product or project from the management of teams used to do the work.  In an MDO, capabilities are offered by capability service units as sharable services that can be used by multiple lines of business.

Product capability services have a management hierarchy that is responsible for the operations of the service units and management of the resources they use.  The structure of the hierarchy may bring together capability service units that have similar skills, resources and methods to achieve economies of scale and consistency in management practices.  Other factors such as geographic locations of operations may also be a factor.  Product capabilities may include product development, as well as production operations, distribution and sales.

A product capability service unit contributes value directly to products or services.  Examples of broad product capabilities include product development, manufacturing operations, claims processing, patient care, network operations and product distribution.  These general capabilities are broken down to more specific capability service units with specific personnel, skills, tools and methods.  A product capability service unit will be engaged by one or more lines of business to contribute to the delivery of the associated product or service.  These capabilities will include core competencies and mission-critical operations. 

The use of shared services achieves economies of scale in the sharing of methods and resources, and greater agility to adapt to changes of requirements, technology and workload. The same capabilities may be engaged to form new lines of business. A capability services organization also may form secondary support services to consolidate support for multiple capability service units.  For example, a manufacturing capability organization may have support services for machine maintenance, materials handling and tool crib management.  These capabilities are not directly involved in the delivery of the enterprise product or service.

The workers in a capability service unit work for a capability manager; they do not work directly for the users of the capability.  The manager of a capability is responsible to his or her manager for the efficient and effective operation of the capability and utilization of resources, and he or she is responsible to the users of the capability for the cost, quality and timeliness with which the capability is applied for each user.

Lines of Business

A line of business (LOB) organization has responsibility for defining and managing a segment of the business that delivers a set of products or services based on product type, market segment, or both.  It is responsible for management of the products or services from concept through delivery. The LOB is concerned with market demand, product requirements, its position in the marketplace, its competitive advantages or disadvantages, and value delivery for its customer segment(s) as well as realization of value for the enterprise.

The LOB uses the services of product capability service units to perform the activities for development and production of its products or services.  The flow of deliverables and contributions of value can be described as a value stream—a collaboration of capabilities.  Interactions with the capability units are designed to minimize the coupling between each capability unit and the LOB so that each capability unit can be used by multiple LOBs.  The LOB represents an internal customer of product capability services, and it is concerned with the performance of the services it uses as they impact its customer and enterprise values.  A LOB may have a management hierarchy based on product or service groups for the product lifecycle. 

Primary Support Services

Primary support services provide capabilities that, generally, are not specific to the particular business or industry, but instead support business activities throughout the enterprise.  I distinguish these from the secondary support services (discussed earlier) that achieve economies of scale within broader capability organizations. The primary support services are (1) Finance and Accounting, (2) Procurement, (3) Human Resources, (4) Information Systems, and (5) Facilities Management.  All support services serve internal customers.  Primary support services may interact with enterprise activities at many different levels and in any branch of the organization.

As with a product capability service, a support service provides economies of scale, consistency and control for its aspect of the enterprise.  For example, finance and accounting ensures consistent application of accounting practices and reporting, and it controls the collection and disbursement of funds.  Information technology manages technical resources and ensures the integrity and security of information systems.  A primary support service also provides separation of responsibility for its aspect of the enterprise. 

The primary support service capabilities are not specific to the particular industry or enterprise but nevertheless serve the needs of the particular enterprise.  So a chart of accounts may be enterprise-specific, purchasing agents may specialize in particular categories of vendor products and services, and information systems application developers will translate enterprise-specific application requirements to computer programs. However, because they represent generic capabilities, many primary support services can be considered for outsourcing.

As with product capability services, the primary support services are concerned with the value they deliver to their internal customers and enterprise stakeholders along with the efficiency of their operations. Their management hierarchy will typically correspond to a taxonomy of their capabilities.

Coalitions

As discussed earlier, any organization can be viewed as a collaboration to achieve some shared purpose. Product capabilities, lines of business and primary support services generally have persistent management structures along with direct and persistent control over their employees and associated resources.  But operation of the business requires collaborations that cross organizational boundaries.  I call these coalitions. 

Coalitions bring together participants from different persistent organizations.  Coalitions may be temporary or long-term, but they focus on particular issues that require development of consensus or interdisciplinary insights and influence.  A participant in a coalition often represents the interests of their primary organization.    

Coalitions include committees, task forces, project teams, transformation initiatives, informal problem-solving and information exchange activities, interactions with customers and business partners, and professional communities.  As organizations have evolved and knowledge workers become an increasingly large segment of the work force, coalitions are consuming an increasingly significant portion of human resources.

Some coalitions already may be formally defined such as an executive committee or a project team, but many are formed informally based on business improvements, personal growth, sharing of expertise, ad hoc problem-solving or innovation.  Generally, participation in a coalition is not considered the primary responsibility of a participant.  

Many coalitions are viewed as exceptions to the normal operation of the business.  People divert some of their time or effort to such activities, often without any accounting for the diversion of resources.  Participation in some coalitions may be supported by participants’ managers because they recognize the importance of the initiative to their areas of responsibility. However, there can be many coalitions that are informal and collectively can divert considerable effort from the function of the primary organizations.  This may cause some managers to discourage participation in coalitions as having a detrimental effect on the performance of their operations consequently resulting in sub-optimization.

The enterprise must recognize the importance of coalitions.  In the past, organization structures were published when necessary to communicate changes to the persistent organizational roles and reporting relationships. Coalitions  can come and go quickly, but such changes now can be recorded and communicated quickly with Internet and mobile technology, and these relationships have become increasingly important to recognize and understand.  In addition, incentives along with tracking of funding and value contributions are required to align these efforts with enterprise objectives. 

Participants in coalitions can bring together expertise and insights that are not otherwise available for management planning and decision-making. Coalitions must be recognized and managed as sources of important insights, solutions and innovations that must be escalated for appropriate attention by higher levels of management.  

Corporate leadership

Corporate executives and their staffs have responsibility for the overall direction and operation of the enterprise.  They have responsibility for governance, leadership, allocation of resources, and setting of policies and priorities from an overall enterprise perspective.  Further, they are responsible for changes to the business including adaptation to market changes, technology advances and new product/line-of-business opportunities.  They must maintain a business model that defines how the enterprise can be successful in bringing value to customers, suppliers and other stakeholders.  See Value Chain Modeling, Part 3: Value Propositions for more about value delivery.  They have a responsibility to ensure that the corporation is more than the sum of its parts through economies of scale, synergy between lines of business and corporate values and reputation.

Executives cannot do it all on their own, and they cannot simply track the financial numbers and delegate responsibility.  Too much delegation yields sub-optimization. Much of the work of executives involves resolving competing interests of different parts of the organization. Corporate leaders must be supported by staff activities for such things as research and development, strategic planning, market analysis, legal counsel, analytics, performance optimization, business design, regulatory compliance, security, risk management, and standards.  In addition, they must rely on participation of specialists from across the enterprise in coalitions with staff members for innovating, optimizing, problem-solving, governing and transforming the business.

The business strategy involves plans to influence or disrupt the market, and plans for changing the enterprise to gain market advantage and optimize enterprise value.  Plans must balance risk, agility and efficiency, while ensuring the integrity, regulatory compliance and security of the business.  Coalitions can provide the depth of knowledge of the business that is essential for timely and appropriate planning and decision-making by corporate leadership.

Executives must establish coalitions with other ecosystem participants to achieve mutual benefits.  The ecosystem involves customers, suppliers, economic and social factors, governments, various forms of disruptive events, and market trends as well as competitors.  See Value Chain Modeling, Part 4: Value Exchange for more about exchanges of value.  Vendor coalitions are important for timely receipt of quality products or services.  Government coalitions can improve the quality of regulations and the cost of compliance.  Customer coalitions can provide guidance for improving customer value of products and services. Coalitions that include competitors can develop standards and best practices that improve market opportunities as well as business operations.

Conclusion

Modern technology enables an MDO by eliminating time and distance barriers to communication between people and organizations.  The need to recognize multiple dimensions is heightened by the increased importance of knowledge workers in the optimal operation and continuous adaptation of the enterprise.

At the same time, the technology that has enabled MDO, also has enabled virtual enterprises.  A virtual enterprise is a collaboration of multiple, independent but participating companies.  Many of these companies operate as shared services to multiple enterprises.  These shared services can achieve economies of scale not available from traditional, internal capabilities of large corporations.  The services of these independent companies enable the rapid, low-risk, low-capitalization formation of a virtual enterprise thus eliminating barriers to entry into businesses otherwise dominated by large corporations.  New virtual enterprises can enter new markets very quickly, be highly efficient and scale easily as the business grows or declines.

A formalized, MDO and visible organization structure is essential for effective enterprise management and competition in the rapidly changing, global and highly competitive business environment.  The multiple dimensions clarify roles and responsibilities and legitimize coalitions to enable implementation of appropriate incentives and funding, and exploitation of employee talents and accomplishments.  Modern technology supports continuous update of the organization model, including coalitions, and the ability for employees to access this model for an understanding of active efforts, their own roles and relationships and opportunities for collaboration. 

The organization model of an enterprise should go beyond the immediate roles and relationships in order to provide a history of employee roles and relationships for accountability, recognition of achievements, and records of experience.  These are important for consideration in forming coalitions as well as developing and retaining people.

Full implementation of an MDO requires new processes to set priorities, manage organizational change and investments, coordinate related activities, provide incentives and exploit accomplishments and human potential.

Modernization of Patient Care Management

The current United States healthcare system is in transition from an era driven by paper records, human paper-handling and telephone calls, to an of era of electronic health records, people connected through mobile devices and the Internet, with moment-to-moment collaboration, communication and coordination.

In this article, I discuss a potential patient care system that exploits current computing and communications technology to transform healthcare delivery to a more integrated, responsive and efficient system.  I begin with related observations on the current state of the healthcare system, followed by a list of principles for an improved system, and finally I discuss modernization based on current information technology.  I conclude with references to current standards work that enables this transformation.

The Current System

Below, I focus on four fundamental problems with the current healthcare system: (1) care management is fragmented and inefficient, and (2) there is a failure of competition, (3) adoption of new medical technology is too slow, and (4) automation is preserving legacy systems.

1.      Fragmentation.  Healthcare providers tend to operate in silos, delivering their special capabilities.  An individual’s healthcare records are scattered among different providers.  The patient becomes the inefficient courier of records and medical information.  There is minimal coordination of care among specialists.  Tests are often duplicated, and risks of interactions may be overlooked.  Providers do not have incentives to share records with other providers.

2.      Competition.  Providers do not compete for patients based on service quality and price. Under capitation-based, managed care, patients choose providers from the payer’s network.  Providers are paid a fee for each covered patient, so they have incentives to minimize services and avoid patients with high service needs.  Under fee-for-service, providers are paid for performing services; more services generate higher income.  They receive the negotiated rates regardless of the quality of care.  Patients only see their deductibles, co-pays and denials of coverage, and they are not informed purchasers of healthcare services.  Unlike other markets, cost and quality have minimal impact on a patient’s treatment decisions or choice of provider.

3.      Technology transfer.  Transfer of new medical technology, including new services and procedures, from research to practice is hampered by many factors including FDA approval, denial of insurance coverage, provider business risk, resistance to change, and malpractice lawsuits.  The market does not reward rapid adoption of advanced medical technology. 

4.      Legacy systems.  Information technology has had a significant impact on medical testing and diagnosis, but, for the most part, it has not changed the way care is managed.  Automation of legacy systems solidifies conventional methods and may make the overall healthcare system more difficult to change.  While paper has been converted to electronic data and data is entered and viewed using electronic devices.  Patient records are more vulnerable to electronic intrusion, and the management of patient care remains unnecessarily fragmented, unresponsive, inconsistent and inefficient.

These problems require transformation of the healthcare system.  In this article I focus on one aspect—transformation of the way patient care is managed.

Key principles

Of course there are many principles for good healthcare.  The following principles are particularly relevant to patient care management. 

Market-Driven Improvements

For effective competition, provider pricing and quality improvements should be driven by market demand as expressed by patients.  Treatment decisions by patients should reflect consideration of cost as well as performance of providers.  Providers should be free to charge what they believe their services are worth, and consumers should be able to select a more expensive service that exceeds their coverage if they believe the value of the service to them merits the additional cost.  Demand from patients who are willing to accept the increased cost and potential risks of new technology should drive adoption of new technology as a competitive necessity.

Informed Consumers

Patients (consumers) should make informed decisions in their selection of care providers and treatment options.  Physicians are responsible for educating a patient about their treatment needs and options.  Costs and outcomes of procedures and medical conditions, including availability of advanced technology, should be published using standard categories and designations so they can be compared across providers.  A consumer should be able to consider providers and treatment alternatives along with the net out-of-pocket cost reflecting their insurance coverage.

Physician Leadership

Coordination of care requires medical expertise.  A primary care physician and his/her team should have responsibility for the overall health of a patient and coordination of care.  Primary care physicians must know when a patient should be referred to a specialist, must have an incentive to refer rather than treat, and must track and coordinate care.

Collaboration

The patient, the primary care physician and specialists, along with their respective teams, must collaborate to provide appropriate planning and treatment for the whole person.  Collaborative planning and follow-up should be life-long (at a level of intrusion determined by the patient) addressing not only acute and chronic care, but also health monitoring and preventive care.

Development of Best Practices

Generally, physicians develop their own best practices.  Professional groups must collaborate to define, share and continuously improve industry best practices.  This includes adoption of advanced technology and improvements to performance measures.  Acceptance of best practices should be supported by empirical data on performance and outcomes from controlled trials.  Performance measures and associated reimbursements must provide appropriate incentives for utilization and improvement of best practices.

Risk Management

Outcomes must be analyzed and rules must be formulated to define and manage risks.  Risk should be assessed based on patient circumstances and alternative technologies, while considering regulations, medication interactions, contraindications and conditions requiring immediate attention.  Risk data should be available for professionals and patients considering treatment options.

Medical Records

Patients and personnel of their authorized medical teams, as appropriate to their individual roles, must have timely access to the patient’s current medical records from all sources.  Even though individual providers go out of business, lifetime patient records must be available to support diagnosis and treatment as well as research. Reliable security methods must ensure privacy of patient medical records and enable the patient to restrict access by professionals based on need to know.  Providers must accept that patient records belong to the patient, and records must be available to support diagnosis and treatment by other providers.

You Get What You Pay For

Quality care requires extra effort to educate patients, collaborate with treatment teams, develop best practices and share medical records.  These efforts must be paid for or they won’t happen.

Application of Information Technology

Information technology is changing the way the world works.  The cost of computers, communications and data storage have become negligible.  Individuals can be always connected through mobile devices.   Computers can help improve timeliness, consistency, validation, guidance and retrieval of information, and they can alert professionals to emergent conditions and the availability of relevant information.  Computers can also relieve professionals of tedious, repetitive tasks, ensuring that they are performed in a timely and accurate manner. 

My previous article describes a vision of “The Knowledge Worker Cockpit.”  Healthcare professionals are knowledge workers.  That technology is a basis for the following characteristics of a future care management system.

Engagement of Services

Consistent data on provider rates and outcome statistics as well as availability of new technology should be publicly accessible, particularly in support of patient selection of a provider.  Web services should support comparison of out-of-pocket costs of different providers based on the coverage schedule of a patient’s payer.  As a result, providers will compete for patient business.  The patient should be able to proceed to schedule a doctor’s appointment and obtain preliminary tests based on symptoms, medical records and potentially a teleconference with a medical professional (see telehealth, below). 

Collaboration

Collaboration is an important and often overlooked element of good patient care management.  A primary care physician should collaborate with specialists, and each physician should collaborate with his or her team.  Some collaborations may engage international experts in teleconferences.  Information technology can support collaboration through communication of messages as well as scheduling and support of meetings and teleconferencing.  This may be obvious in a hospital setting, but it should continue in community care and through transitions between community and hospital care.

Telehealth

Telehealth supports some aspects of healthcare remotely, using electronic devices and communications.  This includes devices for monitoring vital signs and other symptoms as well as support for collaboration between patient and professionals.  Patients, particularly in remote areas, may resolve some health problems without the necessity of travelling to an office, clinic or hospital.  For others with chronic conditions, it provides monitoring of symptoms that might otherwise require hospitalization.  The data collected by electronic sensors or patient inputs can be sent directly to a care management system for monitoring and initiation of alerts to professionals if important changes occur in the condition of the patient.

Treatment Planning and Coordination

The care management system will be highly interactive and support collaboration on treatment planning and decision-making.  Pre-defined planning elements will include guidance and constraints, links to defined services (e.g., lab tests) and frequently occurring patterns of activities applicable to particular situations or medical conditions, including best practices.  Individuals doing treatment planning may capture frequently used tasks and patterns of activities in their personal libraries to expedite their planning efforts.  Treatment plans can be developed and changed as the patient’s circumstances evolve.

Timely Response

Automated plan management will provide personal schedules along with follow-up actions on events such as alerts on over-due activities, reports of relevant information, and completion of pre-requisite activities. Critical changes in the condition of a patient can trigger alerts or corrective action to ensure that appropriate action is taken in a timely fashion.  Appropriate professionals or their alternates can be notified immediately regarding key events via mobile devices.

Electronic Health Record

There has been much attention to the development of electronic health records (EHR).  The primary care physician, the specialists and their teams must all have access to a consistent, shared EHR (not necessarily stored in one location).  A patient HER should provide access to all current medical information and should be retained, under patient control, for a lifetime medical history. The system will apply standards for the form of various types of records or transformation of records from different sources to a consistent form.  It also will support timely communication of updates.  Records must be accessible to authorized personnel only to the extent authorized by the patient.  Authorization and withdrawal of authorization must extend to all sites where a patient’s records may be accessed or replicated.

Audit Trail

The care management system will generate an electronic audit trail of activities performed, events that occurred, decisions made, and the associated circumstances as defined by the EHR.  The system should provide the ability to reconstruct a case snapshot that reflects the state of the case at a particular point in time as the context for events, activities and decisions.  An audit trail will also track individual accesses to medical records for privacy assurance.  Records on services to individual patients will provide the basis for reimbursement for services, including services delivered through remote monitoring, teleconferences or other means that do not require a physical meeting of the physician and patient.   

Analysis                                                                                                       

Computer-based analysis of treatment histories will provide insights on treatments, health trends, causes of medical conditions, and best practices.  The care management system will provide data on actual practices and outcomes to support identification and improvement of best practices and analysis of risks.  Applications will support analysis of outcomes, costs and timeliness of procedures as well as identification of factors related to variances in treatment, outcomes and total costs of treatment for specific medical conditions. 

Guidance

Interactive guidance can provide support for use of best practices and can both encourage and support consideration of new technology.  Guidance can be provided in terms of task requirements, planning and decision-making alternatives, risk and cost factors and contingency plans for emergent conditions.   Guidance may be triggered by the initiation of certain activities, or it may be determined by automated reasoning triggered by events and based on the patient’s EHR.  A more sophisticated system may “learn” case circumstances when certain activities or patterns are often initiated and suggest them to physicians. The system may also inform the physician of current trends or epidemics that may be relevant to the patient’s condition.

Constraints

Constraints can be specified for the planning or initiation of tasks, task completion criteria, authorizations as well as actions that may be affected by regulations, interactions or contraindications.  Constraints can help prevent mistakes or oversights and enforce policies and procedures.

Conclusion

The automation of patient care management is typically envisioned within a hospital setting where solutions can be implemented and governed by a single administration.  However, patients don’t spend their lives in a hospital; for most people a hospital stay is a brief episode in their lives.  Advances in information technology will support automation that integrates hospital care, community care, remote care, continued health monitoring and preventive measures.

The facilities discussed above are based on technology described in my previous blog post on “The Knowledge Worker Cockpit.”  The goal is to provide access to “power tools” for knowledge workers, such as doctors, nurses, medical technicians and others, including patients, who must participate in health care and make decisions about services based on their personal insights, experience and expertise in order to do the job right.

Development of standards is a key challenge.  The healthcare system consists of many independent providers and payers with scattered patient records and diverse computer systems.  The activities of multiple providers must be integrated and coordinated through shared supporting technology, and the records (or interfaces to them) must be consistent for sharing and electronic processing through compliance with an Electronic Healthcare Record (EHR) standard.

The Object Management Group (OMG) is developing a specification for case management modeling (Case Management Model and Notation) that supports the modeling of specific types of cases (including patient care management).  A case-type model will provide case record specifications and planning elements that make it easy and flexible  to plan and manage individual patient care in collaboration with others, to streamline care management and to improve the quality and timeliness of outcomes.  

The OMG Healthcare task force is working on additional standards in cooperation with the HL7 standards organization.  Public recognition of the value of these standards, along with demand for their implementation, is a key factor in transforming the US healthcare system.

A Knowledge Worker Cockpit

In my last two blogs, I noted the shift of the work force from production workers to knowledge workers.  Most routine work has been automated.  The work that now dominates is to resolve problems and exceptions, and to implement changes that address new opportunities or requirements.  In the future, improving the efficiency and effectiveness of knowledge workers will be key to achieving competitive advantage both through improving the delivery of greater value at competitive prices, and through the ability to quickly adapt to changing business needs.  Current technology—e.g., the Internet, mobile communications, hand-held computers—have enabled more powerful support for knowledge workers.  I believe a knowledge worker can become much more effective with controls at his/her fingertips to access information and supporting services along with interactive supports for planning, decision-making, communication, collaboration and coordination—a knowledge-worker cockpit.

The following are a few examples of knowledge work that are representative of much of the work of running and managing an enterprise.

·         Customer support

·         Process improvement

·         Professional services

·         Product development

·         Product introduction

·         Business transformation

·         Application development

·         Facility construction

·         Process improvement

·         Marketing campaign

·         Claim resolution

·         Audit

The diversity of these forms of knowledge work illustrates the potentially broad scope of application of technology to support knowledge work.

Knowledge work is not predictable.  Each situation may require a variation in the necessary tasks and decisions, but it is also necessary to plan the work for timely, coordinated action.  I believe knowledge work is most often work that requires collaboration, and that participants are often involved in multiple collaborations at the same time, with different teams.

In the Object Management Group (OMG) we are currently working on a specification proposal for modeling a case management environment that we (the submitters) call Case Management Model and Notation (CMMN).  This specification defines a language for modeling a type of case to support planning, decision-making, collaboration and coordination on individual cases. 

The following are definitions of terms used for a number of key concepts in CMMN.  These terms are incorporated in the discussion of knowledge worker cockpit functions later in this blog.

Case. A situation to be managed or resolved that may involve multiple participants and occur over an extended period of time.  In different contexts, this may be called an “initiative,” a “pursuit,” a “project,” a “campaign,” etc.

Case file.  Records or references to data relevant to a specific case that represent the history and current state of the case.

Task.  A unit of work or a delegation to an independent application, service, process or case.  A task may be performed by one or more participants, or it may be automated.  A complex task may encapsulate multiple, related tasks.

Fragment.  A reusable pattern of related tasks that occur together.  A fragment may be adapted for a particular case plan.

Event.  Specification of a change of state or occurrence in time that triggers an alert or action.

Gateway. A decision activity that may be manual or automated where subsequent actions must be determined based on current circumstances.

Plan.  Tasks, fragments, events, other elements and dependencies between them that represent the current plan for a particular case.  The plan may be revised and extended as the particular case evolves.

Role.  A specification of the involvement of a participant in the case.  Multiple tasks may reference the same role indicating that they are to be performed by the same participant.

Pallet.  A collection of the elements that are available for planning in a particular case. Such elements may be dragged and dropped into a case plan.

Lifecycle.  The phases of a case that reflect progress and determine the nature of work required during different periods in the life of a case.

A case type model will contain specifications for the case file, commonly occurring tasks, process fragments, alerts for delayed actions, decisions with suggested alternatives, events that are triggered by changes in the case file, rules that validate inputs and control when tasks can be enabled, tasks that engage multiple participants in a collaboration, and so on. 

The case type model will facilitate planning and incorporates best practices by defining templates of the above concepts for a particular type of case. This will be a significant step toward providing a knowledge worker cockpit that puts information, connections and controls at the fingertips of the knowledge worker and assists him or her in keeping track of multiple responsibilities and collaborative relationships.

In earlier blogs I have discussed case management automation as a technology to support the work of knowledge workers, but my focus has been on modeling.  In this blog I approach the issue from a different perspective—exploring ways that information technology could improve the efficiency and effectiveness of knowledge workers in both their individual and collaborative efforts. This is broader in scope than the proposed CMMN specification.  In particular, this discussion includes features that would be part of an interactive case management system, not just the modeling of a case type as defined by CMMN.

I have organized features of a knowledge worker cockpit under seven general categories that are discussed in the sections that follow.  These are features to be experienced by knowledge workers when they are doing their knowledge work.

Planning and decision-making support

Knowledge work involves planning and decision-making to organize what will be done, when and by whom.

·         Interactive planning and display options.  Planning of activities for a case requires an interactive facility for structuring a plan with display options that provide different ways of looking at the plan.

·         Filtered pallet.  There may be a number of different types of elements that may be incorporated in a plan.  A filtered pallet will offer the elements that are valid both in that context, such as the current lifecycle state, and for the person doing the planning.

·         Best practice patterns.  Relevant patterns of activities that represent best practices are provided as tasks and fragments in the pallet to make it easy to apply best practices.  Historical data can be analyzed to identify new or evolving patterns.

·         Guidance on alternatives.  When planning is required or a gateway is encountered, a list of alternatives that are based on the particular situation can be offered for consideration.

·         Contingency plans.  Contingency plans can be included in a plan to be put into immediate effect if the associated circumstances occur.

·         Estimates of cost and duration. Computations can be performed on plan fragments or proposed plan alternatives to compute estimated costs and durations.

·         Risk factors.  Risk factors for tasks or fragments can be obtained from reference information and potentially can be adjusted for particular circumstances or for consideration of alternatives.

·         Priority scheduling. Planned activities can be automatically scheduled based on duration estimates and resource availability so that priority activities may preempt lower priority activities.

Support for collaboration with others

Knowledge work typically involves collaboration with others to determine a course of action and coordinate the delivery of results.

·         Meeting scheduling and notices. Meetings can be scheduled based in appropriate participants, their availability and priority of issues.

·         Specialized collaborations.  Information, queries and conversations can engage appropriate personnel based on their role assignments and collaboration topics.

·         Teleconferencing with shared display. Ad hoc teleconferencing with shared displays can be immediately available as appropriate to circumstances and availability of participants.

·         Access to experts.  Experts on relevant topics should be easily identified and engaged in ad hoc collaboration using appropriate modes of communication.

Monitoring

Connectivity of participants through various devices and locations enable them to provide timely updates and be kept aware of evolving circumstances.

·         Tracking and follow-up.  Participants should be connected so that the current state of the case is immediately available and can be monitored to identify delays, disruptive events and variations from the plan.

·         Progress reporting.  Problems, accomplishments and progress should be reported to concerned individuals according to their interests and authorization.

·         Event alerts.  Certain changes in the state of a case should be recognized and trigger actions or awareness for appropriate persons.

·         Scheduled alerts.  Failure to accomplish actions within a specified time period, or the need to initiate actions on a schedule or at a specified point in time, should be automatically triggered and brought to the attention of appropriate people.

Control

·         Validation of actions. Certain actions (e.g., prescribing a medication) can be validated against facts of the particular case.

·         Authorization.  Restricted actions or decisions can be automatically directed for approval.

·         Checklists.  Lists of potential actions or requirements can be adapted to a particular case to generate follow-up tasks and tracking.

·         Signatures.  Electronic signatures can provide assurance that a document was created or approved by the designated person and that the content has not been changed. An electronic signature can also include specific versions of documents the signer relied upon when endorsing the primary document.

·         Prerequisites.  Planned tasks can be deferred or enabled based on the state of the particular case. Prerequisites may determine activities that must be completed or data that must be available before a planned activity can become active.

·         Planning constraints. Availability of elements for planning can be restricted based on the authority of the planner, the facts of the case or the current lifecycle phase.

·         Application of policies and best practices.  Policies and best practices can be presented to participants when relevant, and can be expressed as rules that restrictor provide guidance for plans, decisions and actions.

Management of participation

·         Resource acquisition, assignments.  Resources and personnel can be acquired and assigned based on availability and priorities.

·         Shift-based teams.  In multi-shift operations, participants must be scheduled as active in their roles during their assigned shifts.

·         Assignment changes.  Alerts and pending actions must be redirected when an active participant is replaced.

·         Sub-teams.  On large projects, multiple teams will work on the same initiative with different plans requiring coordination and shared case information.

·         Participant availability.  Task assignments must reflect participant availability recognizing competing responsibilities and time allocations.

·         Separation of responsibilities.  Persons must not be assigned to roles where there may be a conflict of interest or loss of checks and balances.

Participant personal support

·         Personal viewpoints.  Individuals must be presented with personalized information about their involvement in multiple cases including their personal work list and schedule of tasks.

·         Schedule management. Individuals can modify their schedule to reflect personal preferences and constraints.

·         Priorities.  Participant assignments must have priorities with visibility of effects of delays.

·         Resource requirements.  Participant’s tasks must reflect supporting resource requirements, such as equipment or raw materials, with support for obtaining or scheduling required resources.

·         Progress notes.  Participant progress notes should be included with task records.

·         Record of conversations.  Participants should be able to retrieve threads of messages and meeting notes related to specific topics.

·         Data input requirements. Tasks must provide forms and instructions for entry of appropriate data.

·         Input edits.  Entered data should be validated for syntax, spelling and possible values (e.g., valid state names for a state field) as well as other measures to eliminate inadvertent errors.

·         Computations.  Where appropriate, tasks should include computations to provide supporting information.

·         Personal library.  A participant may capture task specifications fragments and other elements in a personal library to be re-used in the current or other cases.

Information access

·         Case file.  Data on the state of the case must be available and retrieved automatically when appropriate.

·         Reference collection.  A collection of reference information, relevant but not specific to the case, should be available through appropriate searches.  Reference information should be automatically retrieved when particularly relevant.

·         Support for conditional expressions.  Conditions of rules and constraints must be expressed in terms of appropriate case data to implement restrictions or trigger actions.

·         Searches and queries.  Participants must be able to easily find information that is relevant to particular circumstances for current analysis, planning and decision-making.

·         Analyses.  Participants must have access to analysis and modeling tools along with supporting data to properly analyze the current situation, identify historical patterns, and anticipate potential consequences of decisions.

·         Event-driven updates.  The case file should be automatically updated as external events are reported so it reflects the current situation as accurately as possible.

Summary

This list of functions represents a vision of future support for knowledge workers.  Many of these functions are performed in some way today, some with assistance of information technology. Those supported by information technology are seldom integrated to provide a seamless onnection of the knowledge worker to the case and other participants. 

Many of these functions are considered in the proposed CMMN specification for modeling case types.  A case management model will also provide a context for access to supporting functions such as related services, computations and identification of risks.  However, CMMN only addresses modeling of case types, so availability of many of these features will depend on the particular implementation of a case management system.  In addition, the full support of knowledge work will require supporting infrastructure, integration with related systems, and development of additional standards.  For example, development of electronic health record standards is a key requirement for automated patient care management.

In the long term, these functions should be provided in an integrated environment, a cockpit, that surrounds and links knowledge workers with appropriate information, collaboration support and controls as appropriate to the type of case and their particular responsibilities. 

For additional perspectives on case management and the nature of knowledge work, see Mastering the Unpredictable: How Adaptive Case Management Will Revolutionize the Way That Knowledge Workers Get Things Done, by Keith Swenson, et al.