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Sunday, September 23, 2018

Who is responsible for clinical workflow?

RACI Chart 02
Dirk Stanley asked the above question via Facebook. My initial response focused on the keyword "responsible". In normal conversation, this often means "who has the authority", rather than "who does the work", which are often different.

I applied these concepts from RACI matrices in my initial response. If we look at one area-- medication management, physicians still retain accountability; but responsibility, consulting, and informing relationships have been added to this workflow in many ways over many decades, centuries and millennia.

At first physicians did it all: prescribe, compound, and dispense. Assistants took over some responsibilities for the work, eventually evolving into specialties of their own (nurses and MAs).  Compounding and dispensing further evolved into its own specialty apothecaries and pharmacists taking on some of the responsibilities. This resulted in both the expansion and contracting of the drug supply. More preparations would be available but physicians would also be limited by those available in their suppliers formulary. Introduction of these actors into the workflow required the physician to inform others of the order.

The number of preparations grew beyond the ability of human recall requiring accountable authorities to compile references describing benefits, indications for and against, possible reactions, etc; which physicians would consult. I recall as a child browsing my own physicians copy of the PDR -- being fascinated by the details. This information is now electronically available in physician workflows via clinical decision support providers.

Compounding & preparation led into further specialization, introducing manufacturing and subsequent regulatory accountability, including requirements for manufacturers to inform reference suppliers about what they make.

Full Accountability for what can be given to a patient at this stage is no longer under direct physician control.

Health insurance (and PBMs) changed the nature of payment, farther complicating the matters and convoluting drug markets well beyond the ability of almost anyone to understand. The influence of drug prices on treatment efficacy is easily acknowledged. But most physicians lack sufficient information to be accountable for the impact of drug pricing on efficacy and treatment selection. PBMs are making this information available to physicians and their staff. EDI vendors are facilitates this flow of information.

Physicians, pharmacists and payers variously accept different RACI roles to ensure their patients are taking / filling / purchasing their medications. In some ways this has evolved into a shared accountability. I routinely receive inquiries from all of the above, my own responsibility to acquire, purchase, and-take my medications has evolved into simple approval for shipping it to my home.

Attempts to improve availability of drug treatment to special populations (i.e.Medicaid) via discount programs such as 340B add to physician responsibilities. They must inform others of their medication choices for their patients.

Recently, information about prevalence of opioid related deaths and adverse events have introduced yet another stakeholder into the workflow. State regulatory agencies are informed of patient drug use, and want to share Prescription information with physicians accountable for ordering medications.

My own responsibilities as a software architect require me to integrate the needs of all these stakeholders into a seamless workflow. One could further explore this process. I've surely missed some important detail somewhere.

And yet, after all this, the simple question in the title remains ... answered and yet not answered at the same time.

     -- Keith

P.S. This question often comes up in a much different fashion, and one I hear way too often: "Who is to blame for the problems of automated clinical workflow in EHR systems?"

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