What’s So Special about EHR Workflow Management Systems?

Short Link: http://j.mp/4Io0Ya

Someone contacted me with a challenge, “What’s so special about EHR workflow management systems and why can’t it be added to an existing EHR?”

Here is my answer:

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.

soap_box_speaking

By “cumbersome” I mean that most EHRs require expensive human users to do what should be done by less expensive combinations of software and hardware. Physicians don’t want to become data entry clerks; they just want to click once and as Star Trek’s Captain Picard says, “Make it so!”

By “inflexible” I mean there is no way for the user to easily improve task workflow in order to spend more time on value-added tasks directly benefiting patient and user. If an application requires a physician to click five times, four clicks of which are effortful and extraneous, there needs to be some sort of workflow or process editor to eliminate the four non-value added clicks that are wasting the physician’s time.

By “difficult to optimize with respect to process workflow”, I mean there is no way to systematically guide changes in EHR workflow so as to maximize patient satisfaction, clinical outcomes, and practice profitability goals. In contrast, processes driven by EHR workflow management systems can be analyzed through use of business process management (BPM) tools that suggestions ways to improve workflow processes. Workflow engines create workflow logs. These are step-by-step records of who clicked on what, when, where, and why. BPM tools can analyze these logs (through a technique called workflow or process mining) and suggest better workflows that will minimize non-value added tasks. This in turn frees human resources to be reallocated to value-added tasks that contribute to happier, healthier patients and greater take home income.

OK, fair enough, EHRs will need to incorporate WfMS technology. Why can’t EHR vendors just add workflow engines, process definitions, workflow logs, and process mining to existing EHRs? The word “workflow” has certainly been an EHR industry buzzword for the last five years. However, in the marketing din “workflow” has become almost meaningless. Yes, addition of messaging facilitates person-to-person coordination; interfaces make application-to-application coordination possible; and patient tracking is about coordinating the most important resource of all, patients. While these added capabilities can improve workflow, they aren’t workflow management. A workflow management system by definition requires a workflow engine that consults workflow or process definitions to drive tasks to people and applications. Tacking on messaging, interfaces, and tracking is a lot easier than picking up an EHR that does not rest on a workflow management system and then inserting beneath it a fully fledged workflow management system foundation, with its powerfully directive workflow engine, powerfully customizable process definitions, and powerfully analyzable workflow log.

Here is one way to think about “adding” a workflow management system to an existing EHR. When you look at a non-WfMS-based EHR you are looking at screens that are the result of a human programmer creating areas that will contain buttons and menus and so on, then placing these buttons and menus in these areas, and then connecting those buttons up with various functions and procedures that have also been created by a human programmer. This is why we need programmers in the first place; if it could be done more easily or less expensively we’d do it that way instead.

This is in fact what a workflow management system allows a non-programmer to do, to directly edit application workflow. Who creates the areas for the buttons, and then the buttons, and then connects the buttons with what happens when the buttons are pressed? The workflow management system does. You should now see why a workflow management system cannot simply be added to an existing computer application. The existing application was created by a human programmer. In order to add a workflow management system foundation you will have to replace the programmer with a workflow management system to regenerate the application. Therefore existing systems will need to be rewritten (by the very definition of how workflow management systems operate).

Several years ago we were giving a demo to a visiting physician who had happened to have taken some programming courses in college. During the demo the physician said, wait a minute, I thought you were going to demonstrate integration with my favorite patient questionnaire application. To which the user said, “Oops!” And then proceeded to pop up the process workflow definition editor within which he added the questionnaire task, set a couple of properties of that task, dismissed the editor, and then gave the demo again. This time the questionnaire screen popped up automatically at the intended step in the workflow. To which the visiting physician said, “I get it!” An EHR workflow management system is a development environment that lets non-programmers to create and edit their own EHR workflow systems. Exactly.

Adding a workflow management system to an existing EHR application would be like adding a foundation to a standing skyscraper or a hull to a floating ship. Many current EHRs will have to be rebuilt on top of workflow management systems foundations if they are to become the graceful, flexible and optimizable EHR systems that healthcare needs in the long run.

I have (somewhere) a copy of a several hundred page user manual for a typical document management system-oriented EHR. It has a hundred pages of chapters about workflow. These chapters tell an human user what to click, in what order, and in what circumstances in order to perform a variety of tasks. If you look at chapters about workflow for an EHR workflow management system, you will see that they are about editing EHR workflows so that these tasks happen automatically after a user just clicks the button and “fires and forgets.”

EHR workflow management systems are built on a foundation that can “Make it so!” This is the EHR workflow management system unique selling proposition *and* its barrier to entry for EHRs that are not workflow management systems.

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4 Comments

  1. Jill Hogan
    Posted December 11, 2011 at 9:19 pm | Permalink

    I have deployed EHR systems for the past 7 years and I tell you what…You are correct on all accords…EHRs are messy and are taking millions of dollars to implement, customize and manage. I did work in the pharmacy industry where we did utilize BPM workflow / amazing!! Most of the older EMR’s on the market cannot adapt, most are having to come out with new solutions, some of the vendors that came out a little later and employed this technology were smart and will have a great marketplace in the future.

  2. chuckwebster
    Posted January 26, 2012 at 5:09 pm | Permalink

    Jill,

    Many apologies for the delay in approving your comment, which is so spot on! (I usually respond to emails that are automatically generated when new comments await moderation, something failed this time, maybe *I* need BPM!)

    I agree that older EMRs that were not based on workflow engines, process definitions, and graphical editors will have to play catchup, if they can. That said, a few of these older EMRs do have this wonderful combo, either custom built or based on third-party business process management systems. I especially excited by the myriad of BPM functionalities this opens up. Moving to a process-aware (executable declarative process model) foundation makes so much possible that addresses the heart of current EMR dysfunctionality, from process mining-enhanced business intelligence to cross-organizational workflows to greater usability though user-centered workflow design. I am convinced that EMR or EHR BPM (whatever you call it, HPM for Healthcare Process Management or CPM–oops, that’s taken–for Clinical Process Management) is about to explode upon the Health IT scene.

    Delighted by your comment. It’s another hopeful datapoint in a trend toward more process-aware, BPM-style EMR/EHR workflow systems.

    I wrote the following all of three years ago!

    From: 2009 AAP NCE EncounterPRO Pediatric EMR Trip Report: Demos, Kickbikes, and Workflow

    http://chuckwebster.com/2009/10/ehr-workflow/2009-aap-nce-encounterpro-pediatric-emr-trip-report-demos-workflow

    Understanding of EMR Workflow and Business Process Management in Healthcare is Gradually Increasing

    Picture a graph that depicts progress toward higher and higher levels of market understanding of, and appreciation for, workflow management systems, EMR workflow systems, and business process management. By “workflow” and “workflow management” I don’t mean the meaningless ad copy that is thrown around and sprinkled on most EMR brochures and vendor websites. By “workflow management” I mean the same thing as what professionals and academics and workflow and business process management system vendors mean in the workflow and business process management system industry.

    1999 to 2009 TEPR-HIMSS-MedInfo-AAP EMR/EHR WfMS/BPMS Progress Graph

    The X axis for that graph is now 10 years long. Data points are based on an unscientific series of impressions and vignettes: questions I received from an audience, a presentation I attended, a conversation in our exhibit booth. I began to see material on the web besides my own around 2004, plus have an occasional encouraging conversation. But it wasn’t until recently that I began to get the impression of a large uptick surrounding recent discussions of certification, usability, and meaningful use.

    At the 2004 Fort Lauderdale TEPR show a physician watched a demo of EncounterPRO, asked a couple of questions about the customizability of the screen sequences, and exclaimed “This is a workflow management system, isn’t it?” 2004 was the first of three years that I gave a three hour TEPR tutorial about workflow management systems in healthcare, so I assumed that he had just sat through that session, but he hadn’t. Before becoming a physician he had simply worked in one of the many industries in which workflow management systems are more prevalent. He’d seen them before and so could recognize one when he saw one again.

    Another example: at this year’s AAP one of my booth mates said “Shoot, you just missed him! This fellow was walked by, saw our sign, stopped dead in his tracks, and exclaimed ‘Workflow System! I’ve seen lots in other industries, but I’ve never seen a workflow system in health care!” He was an ER physician not shopping for an EMR, but I thought you should know.” Shoot! I missed him! Add a data point to my 1999 to 2009 TEPR-HIMSS-MedInfo-AAP WfMS/BPMS Progress Graph!

  3. Jill Hogan
    Posted February 21, 2012 at 2:44 am | Permalink

    Chuck,

    I wish I could be there in Vegas to see your presentation. I was just there this past January with my husband at a Starkey hearing conference. I’m not an audiologist; however I could understand most everything that was presented. The most important take away was how we could leverage innovation to make the world a better place.

    Personally I feel many Doctors and healthcare institutions are taken advantage of by larger EMR giants. I recall joining many EMR projects where the systems that were purchased required extreme configuration, consulting services and additional ongoing maintenance costs that were not fully realized by the healthcare entity. Looking back, this bamboozlement by the healthcare vendors became very clear as I began working for startup EMR companies. There missions were to make EMR easy to use, implement, maintain and reasonable priced. As I was introduced more and more to BPM workflow systems and overall user design theories in the pharmaceutical industry I became to realize this will begin to bleed into EMR and truly explode to the next level.

    This true workflow integration is only the first step as you know. I met a gentleman on a plane about ten years ago who told me after we began chatting he was working on biometric regulation and monitoring clothing for the government. This sort of smart technology should be applied as a basic medical intervention where possible in our current health institutions. Below is a summary of what items healthcare organizations should be doing to innovate the delivery of healthcare.

    1. Innovation mission, Innovation departments, innovation programs rolled out to the entire workforce and patient / employee feedback loops that are integrated into this overall process
    2. Robust System Architecture & Interoperability among clinical / billing / HMS
    3. Work Flow / BPM / rules engines algorithms
    4. User Centered Designed Principles being employed by UCD experts
    5. Speed to change and improve current / future software / processes using Agile methodologies
    6. Smart Device / Alert integration into system design
    a. A user should never have to perform data entry into a system that could be harnessed to capture this information. This smart monitoring should be able to process all data to provide logical timely alerts based on patient specific disease. i.e. O2 stats and amt of O2 being admin over time would be collected real time and analyzed with other patient factors occurring, admin of meds, etc and would alert based on patient specific changes
    7. Use artificial intelligence to ensure system is learning treatment outcomes specific to patient, patient groups, within hospital and among other institutions, and research. (Living and breathing body of knowledge to be presented to users when appropriate) – Establish process for real time integration of data and outcomes.
    8. Human User Interface Improvements
    a. Ergonomics of healthcare – holograms, better visual data dashboards and data presentation – no pushing around carts
    b. Voice recognition – Suri for healthcare providers – Use for documentation / reporting / charting to elicit discrete data. How many nurses write down what they are going to document on paper and stick it in their pocket? Isn’t voice technology there!
    c. Integration of OCR technologies in translating traditionally scanned paper progress notes test results, immunization records, etc
    9. Improved physical layouts for buildings to facilitate collaboration and workflows
    10. Migration towards hosted, dedicated cloud IT infrastructure outsourcing that can reduce capital expenses, ease to do business, security, and ability to grow and stay current with technology

    11. Patient mobile healthcare delivery, lifestyle changes, behavior modifications, and support groups

    12. Telemedicine Programs - bringing healthcare to everyone (home health / rural limitations)

    I would love to find all those innovators (vendors /devices mngf/lab/pharmacy) and have them bring these items to a small scale healthcare facility to launch such new technologies / methods and ideas. Does such a place exist?

    Jill:)

  4. chuckwebster
    Posted March 21, 2012 at 10:39 am | Permalink

    Fantastic comment! (especially about BPM plus EMRs)

    Frankly, it’s triggered so many ideas and reactions that I’m going to have to ruminate a bit before I organize and summarize them.

    And, no I do not know of such a place. Anyone else?

    Thank you very much!

    –Chuck

One Trackback

  1. By Pediatric EMR Workflow Systems on June 7, 2009 at 6:59 pm

    [...] about the general (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 [...]

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