Automate Your EMR Cow Paths *and* Reengineer Them Too!

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Last Wednesday I attended a conference on “The Economic Stimulus Package and Healthcare Technology: How Will the Stimulus Money Flow and How Can You Prepare?” at Georgia State University. (Details at the end of this post.) There were over 300 attendees. Many of the people that I met were new to healthcare, but drawn to it by news of the pending federal stimulus monies for HIT. I agreed with and greatly appreciated *almost* everything that I heard.

My only quibble was the shared sentiment (expressed at the conference and frequently elsewhere) that getting physicians to change their workflow is one of the biggest barriers to EHR adoption.


Michael Hammer’s 1990 “Reengineering Work: Don’t Automate, Obliterate” Harvard Business Review article popularized the analogy that automating existing processes is akin to paving a meandering cow path instead of what should be done, which is to create a road that proceeds straight from point A to point B.  When successful, the results can be substantial increases in effectiveness and efficiency. However, business process reengineering failure rates have been reported to be 50 to 70 percent (or higher, given natural human reluctance to admit or publicize failure). User resistance is often blamed. Similar levels of failure have been reported for EMRs (this 2006 study is representative). The basic problem is that implementing *most* EHRs is an act of reengineering, and reengineering is a high risk endeavor.

A good way to explain this success rate is through use of the classic Thesis-Antithesis-Synthesis method of using a contradiction to motivate conceptual innovation:

  1. Thesis: ”Instead of embedding outdated processes in silicon and software, we should obliterate them and start over.” (Hammer, 1990)
  2. Antithesis: There are many, many reasons people resist change, and not all of them are bad.
  3. Synthesis: Automate the cow paths (so as to minimize the psychological shock of automating previously manual processes) and then systematically but gradually straighten and widen these paths until a straight and wide digital superhighway is attained.

How is it possible to “systematically but gradually” improve automated workflows? First implement workflow management system process definitions that fit the way workflow is already being accomplished. Second let users get used to the new technology. And third, only then gradually change the process definitions that determine EHR behavior at a rate that is no faster than can be tolerated. The workflow management system foundation, with its workflow engine that executes easily changed process definitions provides the means to accomplish process changes that do not require rewriting and recompiling software code. The business process management layer provides the means to systematically optimize process effectiveness, efficiency, and flexibility. (More on EMR BPM in this previous post.)

To summarize my main point:

Using EHRs that are easily molded to existing physician workflows, which can then be systematically improved while respecting normal human tolerance for change, is the key to EHR adoption.

Here is a bit more info about the excellent conference that provoked this post:

“The Economic Stimulus Package and Healthcare Technology:
How Will the Stimulus Money Flow and How Can You Prepare?”

Technology Association of Georgia,
Georgia Health Information Exchange, and
Georgia Chapter of the
Health Information and Management Systems Society

May 14, 2009,
Georgia State University
Atlanta, Georgia

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One Comment

  1. Posted May 18, 2009 at 11:23 am | Permalink

    I just want to echo the comments made by Dr. Webster regarding our approach to helping practices transition from paper to electronic medical records. We have found that the key is setting specific goals for the implementation. Our first goal is to get the practice seeing as many patients using EncounterPRO as they were seeing using paper medical records. We are very pleased to report that we are achieving that goal by the time our Practice Skills Instructors have finished the implementation process with the practice. One of the highest costs of transitioning from paper to EMRs is the cost of the decrease in practice productivity due to the steep learning curve. The slope of the learning curve is increased if the practice is learning new workflows as well as the screens of the software. We have found that tailoring the workflows to make things comfortable for the practice not only eases the stress levels of practice personnel, it facilitates getting back to pre-implementation levels of productivity much more quickly. This emphasis on pragmatic learning in the early stages of the practice’s transition to EMR’s reduces the psychic cost of the transition and the economic impact of lower practice productivity.

    The study of optimizing practice productivity by fine tuning workflows is entirely appropriate, but best undertaken after the practice has become comfortable with the EMR and its operations. Workflow management has to be flexible and provide the practice the ability to continually adapt the software to the changing requirements of the practice to fulfill its real potential.

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