Litmus Test for Detecting Frozen EHR Workflow

Short Link: http://j.mp/79mGR7

If a first year medical student says that a patient has a temperature, his or her attending may say something like “Of course your patient has a temperature, all patients have a temperature! Is their temperature normal or abnormal? Elevated or subnormal? What, exactly, is the patient’s temperature?

In the same sense, all software including EHRs, have workflow. The question is whether the workflow is good or bad and whether you have the means to adapt it to your purposes. EHRs whose workflow cannot easily be modified by a non-programmer have what might be called “frozen” workflow.

frozen_workflow1

Most EHR applications require the user to navigate between screens to enter data. An EHR workflow management system can be configured to drive common input screens in any order that makes sense. This is most commonly based on the visit reason. In other words, an EHR workflow management system can deliver customized workflow around a practice’s current workflow process for gathering data. For example, a practice may currently use a paper based workflow system that they like. This not only involves what data they gather, but when and who collects the data during the workflow. An EHR workflow management system can be configured, through use of its process definition editor, to precisely match this pre-existing workflow.

Some EHRs do increasingly deliver some workflow capability; that is, they can contribute to an increase in productivity by doing for the user what they would otherwise need to do themselves (navigate to the next screen, inform the next person what they need to do, trigger an external application such as a digital ECG, and so on). However, these EHRs rely on “frozen” process definitions. Their workflow cannot be easily changed to adapt to circumstances not foreseen by the programmer. Programmers are not clinicians, or even more important, not intimately familiar with each and every minute step of dealing with a patient in medical practice. Only users can claim this degree of familiar knowledge. This means that users cannot easily change what EHR screens occur in what order, who gets passed the task baton when, or what external application to fire up automatically.

Only a full-fledged EHR workflow management system provides additional user interfaces that allow users, not programmers, to bend EHR workflow behavior to their specific and evolving needs. For example, a user should be able to easily instruct the EHR to insert a new data gathering step between vitals and chief complaint, or to easily add the automatic playing of a preventative care video at the optimal point of a well visit.

Apply the following litmus test designed to detect frozen workflow:

The simplest test of whether an EHR is built on a workflow management system is to ask for a live demonstration of the following:

  1. Ask to see an encounter from beginning to end. Focus on the sequence of screens.
  2. Ask to see the process definition that controls the sequence of screens just observed.
  3. Ask to see a small edit in the process definition using the EHR process definition editor, such as the deletion or reordering of several steps.
  4. Ask to see the same encounter again, while focusing on whether or not the changes in the process definition have indeed resulted in the appropriate changes in screen sequence.
  5. If the screen sequence changes in just the way that would be expected if an EHR workflow engine is consulting the just edited process definition, then you are likely looking at an EHR workflow management system.

If an EHR cannot demonstrate steps (1-5), then the EHR lacks the capabilities of a workflow management system. It does have workflow (because all software applications have workflow). It may even have workflow that is good for a particular task and context. However its workflow is frozen.

This entry was posted in EHR Workflow. Bookmark the permalink. Post a comment or leave a trackback: Trackback URL.

7 Comments

  1. Posted August 1, 2009 at 11:58 pm | Permalink

    Implementing an EHR/EMR solution that works with “your” workflow is critical for a successful adoption. Most failures occur during the first year because the workflow and how the EHR will change it is not properly analyzed prior to selection and implementation. I am in the process of demoing Every EMR/EHR program out there starting with all programs that are CCHIT certified. I have already demoed about 12 and seen about 30 in operation, I should be finished by the end of Obama’s third term at my current pace.

    I would love to collaborate on topics or issues for our two sites. Can we exchange links to mutually benefit our readers.

    Best,
    Andrew Eriksen

  2. chuckwebster
    Posted August 2, 2009 at 8:06 am | Permalink

    Andrew,

    If the secret to living a long time is to set yourself a very difficult task, I think you’ll be around for quite a while.

    I’d be delighted to collaborate on topics of common interest.

    I’d also love to hear from you to what degree you observe workflow management system functionality in the EMR systems you review. Here’s a draft of a survey you are welcome to use.

    I’ve added you to my blogroll.

    Cheers

    –Chuck

  3. Posted August 2, 2009 at 11:09 pm | Permalink

    Chuck,

    Thanks for the encouragement…..I am not sure that I know what I am getting myself into.

    This work flow management assessment would be a great addition to our current evaluation methodology.

    Will the completed survey be emailed to you and where would the name of the program go?

    Thanks for the add, I added a link on my site as well.

    Andrew

  4. chuckwebster
    Posted August 3, 2009 at 12:41 pm | Permalink

    Thank you Andrew (I’m starting to see traffic arriving from freeemrsolution.com, hope you see likewise).

    Re: The EHR Workflow Management System Survey.

    I changed initial “General Comments” to “General Comments and/or Software Name”

    Also added a required field for an email address at the bottom of the survey so that I can forward the results in delimited format back to you.

    Just click the “Send Email” button at the bottom of the survey.

    I’m applying the Creative Commons Attribution 3.0 License to everything in my blog. So you are free to reuse or adapt my material as long as you follow the instructions at Creative Commons Attribution 3.0 License.

    I added the following to my sidebar to make it easier.

    © 2009 Charles Webster, MD, MSIE, MSIS

    Please attribute Charles Webster, MD, MSIE, MSIS as the creator of this work.

    Please indicate the title of the Work: EHR Workflow Management Systems

    Please include this URL for the Work: chuckwebster.com

    Thank you!

    Additional Instruction

    So you are free to use and adapt the workflow survey as long as you include my name, the title, and a URL back to this site (it’s sort of like open source software, except it’s about ideas and words and images, not executable code).

    Let me know if you have any questions about the survey (or anything on the blog for that matter, which is sort of what the blog is for anyway, right?) or if I can be helpful with regards to any of the EMR workflow related aspects of your quest. I am truly quite interested!

    Cheers

    –Chuck

  5. Posted August 14, 2009 at 3:17 pm | Permalink

    I understand. I return from vacation next week and look forward to getting started. I will let you know if I have any questions.

    I just completed a test eval but when I hit the send button it actually gave me a 404 error. I wanted to see the format of the test results.

    Also, have you thought about developing a scoring system based on possible answers. I have been trying to develop something as a comprehensive EMR rating but maybe the answer is in developing separate surveys that rate each component of the EMR system.

    Let me know if you received the test survey.

    Best,
    Andrew

  6. chuckwebster
    Posted August 14, 2009 at 5:34 pm | Permalink

    You’re right. I get the same error and no survey results show up at my end.

    I think I broke it when I added a form for requesting product info/demo.

    Sorry, will fix it–after our new product website launches next week.

    Right now, when it works, I get something in my email like what I appended to the end of this comment (but there is a comma delimited option that I’ve not explored yet).

    Frankly, unless you really intend to conduct a full-fledged EMR/EHR WfMS/BPM survey, for your purposes the entire list of questions would be overkill (as in, if you go into the same amount of detail for every other area of EMR functionality you’ll end up with thousands of questions). I’d just use whichever make sense to you. For example, the litmus test mentioned in the blog post might be just right. Ask to see the natural task flow of an encounter, ask to see some user editable representation of the task flow (in EncounterPRO it looks like a picklist of steps, in other WfMSs it often looks like a Visio-style decision tree), ask for a change in the task flow (usually the easiest request to comply with is to delete a step), and finally ask to see the task flow of the encounter again. If the task flow changes in just the way that would be predicted if a workflow engine were executing a newly changed process definition, then there is likely a workflow engine under the hood. If they can’t show you a process defition, then there is nothing to customize and execute. Their workflow/taskflow/careflow is hard coded, or “frozen.”

    Once I fix the form you are welcome to use it. It’s got a simple setup syntax and I probably fat fingered it when I was testing the product info/demo request form. But I *really* intended the survey as form of search engine bait to connect with other folks such as yourself who are interested in EMR workflow automation. In its present form it’s not a very efficient way to manage survey data.

    I would like to see the results of any survey you do that includes questions about EMR workflow and business process management, preferably in a public venue such as your blog. Since I work for an EHR WfMS vendor it’s a bit awkward for me to go around asking EHR vendors for demos of their products. I would be perceived as having an axe to grind, and maybe I do. Me putting that survey on my blog is part of a bit of a campaign to get folks to make the connection between EMRs/EHRs on one hand and these very cool and useful set of ideas about, and technologies for, automating and optimizing workflow.

    Enjoy your vacation!

    –Chuck

    ———- Forwarded message ———-
    From: Anonymous
    Date: Mon, Mar 23, 2009 at 2:16 PM
    Subject: EHR Workflow Management Systems Criteria Survey
    To: chuckwebstermd@gmail.com

    General Comments:

    1. Does the EHR implement, embed, or rely on a workflow management
    system?: Yes

    Comment:

    2. Does it rely on its own proprietary workflow engine?:

    Comment:

    3. Does it rely on a third party workflow engine or workflow
    management system?:

    If yes, which one?:

    Comment:

    4. Can screen sequence be determined by a user editable process
    definition?:

    Comment:

    Comment:

    5. Can process definitions be executed based on reason for patient
    visit?:

    Comment:

    6. Can different process definitions be defined for different
    specialties?:

    Comment:

    7. Can different clinics on a common database use different process
    definitions?:

    Comment:

    8. Can different roles (nurse, physician) trigger different process
    definitions?:

    Comment:

    9. Are different process definitions supplied for different
    specialties?:

    Comment:

    Comment:

    10. Can “screenless” activities be added to process definitions
    so they will be automatically executed?:

    Comment:

    11.Can process definitions have execution priorities?:

    Comment:

    12. Can process definition be scheduled for recurring execution?:

    Comment:

    13. Can concurrently executing process definitions consolidate common
    steps?:

    Comment:

    14. Can process definition authors designate certain steps as being
    optional or required?:

    Comment:

    15. Can process definitions behave differently in different clinical
    circumstances (patient age, sex, race, etc)?:

    Comment:

    16. Can process definitions be owned by roles and users?:

    Comment:

    17. Can other users in the same or different role assume ownership
    during process definition execution?:

    Comment:

    18. Are process definitions stored in a database separate from
    application programming code?:

    Comment:

    19. Can a process definition be triggered by an external application
    (eg. scheduler based on visit reason)?:

    Comment:

    20. Can a process definition be triggered by a user?:

    Comment:

    21. Can process definitions assign work items directly into both
    role-based and user-based work lists?:

    Comment:

    22. Can process definition work items have deadlines?:

    Comment:

    23. Can a work item deadline trigger an alert?:

    Comment:

    24. Can deadlines intentionally be allowed to expire?:

    Comment:

    25. Can process definitions trigger other process definitions?:

    Comment:

    26. Over what duration can process definitions span?:

    Comment:

    27. Can process definitions and their work items enforce role and
    user permissions?:

    Comment:

    28. Is there a “radar view” to allow all users to monitor process
    definition progress?:

    Comment:

    Comment:

    29. Is the work item status display coded (with colors or other cues)
    according to work item ownership by role or by user?:

    Comment:

    30. Can a user view and complete work items that have been assigned
    to another user or role?:

    Comment:

    31. Can reminders be automatically generated for overdue work items?:

    Comment:

    32. Can a user delegate a work item (move it between worklists) to be
    accomplished by another user or role at a later time?:

    Comment:

    33. Can one user or role create a reminder for the same user or role
    to accomplish a work item at a later time?:

    Comment:

    34. Are pending work items for one user (their worklist) or role
    visible to other users at the same time?:

    Comment:

    35. Can screen navigation be driven by process definition execution?:

    Comment:

    36. Is work item execution time logged for later analysis?:

    Comment:

    37. Is work item execution beginning time logged for later analysis?:

    Comment:

    38. Is work item execution end time logged for later analysis?:

    Comment:

    39. Is the user accomplishing an activity logged?:

    Comment:

    40. In what form is work item execution logged?:

    Comment:

    41. Can permission to perform a task be granted to a role but revoked
    for a user?:

    Comment:

    42. Can permission be revoked by role but granted to an individual
    user in that role?:

    Comment:

    43. Are these permissions visible in the work item status display?:

    Comment:

    44. Can abnormal data values trigger process definition execution?:

    Comment:

    45. If system logs process activity,, specifically what is logged?:

    Other:

    Comment:

    46. What are activity completion conditions?:

    Other:

    Comment: test

  7. chuckwebster
    Posted August 23, 2009 at 5:17 pm | Permalink

    Fixed. Thanks
    –Chuck

4 Trackbacks

  1. [...] A good start six years ago, however they actually barely scratch the descriptive surface of a fully functional EHR WfMS. (Although, if one had to prioritize, criteria 8, 9, and 11 are arguably the most important and the basis for my Litmus Test for Detecting Frozen EHR Workflow post.) [...]

  2. [...] Many EHRs are cumbersome, inflexible, and difficult to optimize with respect to their process workflow. Implemented correctly, an EHR workflow management system is graceful, flexible, and optimizable. If you understand the reasons for these advantages you will also understand why other kinds of EHRs cannot easily fix their problems. By the way, this is not to say that EHRs have not added important task management capabilities in recent years. However, this task management is typically based on “frozen” workflow. [...]

  3. By Pediatric EMR Workflow Systems on June 7, 2009 at 7:01 pm

    [...] (that is, universal) characteristics of EHR workflow management systems (for example and for example) while touching on EHR business process management as well. However, while EMR customizers [...]

  4. [...] While more and more traditional pediatric EMRs are adding task management, this is relatively frozen workflow. Without a workflow engine and associated process definitions (called “workplans” in [...]

Post a Comment

Your email is never published nor shared. Required fields are marked *

*
*

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>

You can add images to your comment by clicking here.