How I Became Interested In EHR Workflow Management Systems

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After a previous post on pediatric EMR workflow systems, I drew the following diagram to represent the relationship among medical specialty-specific workflow, EMR/EHRs, and workflow technology.


I was reminded of the original symbol of the Department of Health Management Systems (renamed from Health Information Sciences in 1995) at Duquesne University in Pittsburgh. In 1993 Sean McLinden, MD (Chair), Kathy Begler, MPM, RHIA (Assistant Chair), and I began the challenging but enjoyable task of founding a new academic department based on the interdisciplinary combination of medical, business, and computer knowledge and competence.


I devised the symbol of the Department of Health Management Systems based on a Venn diagram that represented my own academic degrees:

Health = MD (University of Chicago)
Management = BS, Accountancy/Business (University of Illinois, Urbana-Champaign)
Information Systems = MSIS, Intelligent Systems/Artificial Intelligence (University of Pittsburgh)

There’s also an MSIE, Industrial Engineering (University of Illinois, Urbana-Champaign) in the mix, which was invaluable as a model for combining technical and management curriculum content while also focusing on particular domain or industry vertical (I concentrated on human factors and healthcare).


We presented the results of our curricular development at the 1995 International MEDINFO conference in Vancouver, Canada. (Webster, C, McLinden, S, & Begler, K. “Why Johnny Can’t Reengineer Health Care Processes with Information Technology”, In R. A. Greenes et al. (editors), MEDINFO’95 Proceedings, pp 1283-1287.): abstract and illustrations. (Our title was based on the famous 1986 book  ”Why Johnny Can’t Read”. If I were to republish or update it, I’d likely change the title to the unisex and more politically correct “Why Johnnie Can’t Reengineer Health Care Processes with Information Technology.”)

Previous to Duquesne, I had worked as a programmer in the MIS department at Shadyside Hospital, where Dr. McLinden was CIO. We created the FELIX clinical information system. (Webster, C, Pople, A, Silva, R., Wang, X, and McLinden, S, A Tcl/Tk based graphical interface to medical and administrative information, Proc Annu Symp Comput Appl Med Care. 1994; 992).

“FELIX is a front-end application processor, with an open systems back-end, that provides a uniform and intuitive interface to clinical and administrative information. It consists of an information browser, three clinical applications, and three management applications. FELIX was developed in a community hospital environment, but has conceptual and technical roots in medical informatics and the Internet.”

Here’s an annotated visual cheatsheet for FELIX’s functionality (click to enlarge):


Note that while FELIX was not a clinical workflow management system per se, it did combine clinical and management functionality (in common with EHR workflow management systems).  While developing FELIX we covered the walls of a large conference room with flowcharts on butcher paper. I think that is when I began to investigate workflow management systems (with which I was familiar due to my industrial engineering degree) with an eye toward their application in healthcare. There is a bit more about FELIX here (including annotated screen shots). FELIX was a remarkable application for 1992, foreshadowing in many ways the Web-based medical information systems that would appear almost a decade later; notice that we used SGML, from which HTML was derived, and created our own graphical browser because the first Web browsers were not released until 1993 (Mosiac) and 1994 (Netscape).

In 1993, the first lecture I gave at Duquesne was about the great potential for use of workflow management systems at the point of care. This potential essentially derives from empowering non-programmer EMR users to modify EMR workflow without requiring direct involvement of a programmer. I took screenshots of workflow management systems that were in use in other industries and relabeled buttons and edited icons to make them appear like various clinical workflow management applications. I essentially storyboarded the use of an imaginary application that I would today call an EHR workflow management system.

Over five years the Department of Health Management Systems enrollment went from five to a hundred and thirty and every graduate got a job (folks transferred into the undergraduate program their junior year, and the masters was two years long). (While poking around in my digital archives for the “Why Johnny Can’t Reengineer Health Care Processes with Information Technology” and FELIX materials, I found my original online syllabi: amusingly retro but they standup remarkably well to the passage of fifteen years. Perhaps they are worth a future post.)

For the last ten years I’ve given presentations and published articles in proceedings and trade publications about workflow-enabled EMRs, EMR workflow systems, and EHR workflow management systems. My intent has been and continues to be to educate everyone who will listen, but especially the practicing physicians who will benefit most from this technology, about the potential for workflow management systems (now increasingly referred to as business process management systems) to improve EHR workflow and usability.

This blog was instigated by my assessment that a number of trends are finally converging. Workflow management and business process management system technologies have matured and proven their use in a variety of other industries, and are poised to diffuse throughout healthcare. Issues of EMR usability and workflow have come to the fore: too many traditional (read non-workflow management system based) EMR implementations have failed; the rate of EMR adoption has been too slow, folks are beginning to figure out that the user isn’t the problem, it’s the technology. EMRs without sophisticated workflow automation foundations, tools, and infrastructure are not up to the job.

At the recent HIMSS conference in Chicago Dr. Armand Gonzalzles, a pediatrician who uses the EncounterPRO Pediatric EMR Workflow System, gave a great presentation about workflow management, EMRs, and primary care. Over three hundred attendees showed up early Sunday morning to hear his presentation (a larger attendance than I observed for any HIMSS presentation that was not a key note). However, even better than his presentation were the questions of the folks who lined up at the aisle microphone afterward (video interview with Dr. Gonzalzles about those questions here). What struck me was that they were not there to hear about EMRs (there were many other presentations at HIMSS on this subject), but rather they were there to hear about workflow management. They were there to hear about something new and different.

Most current EMRs, as they are currently constructed, are what Dr. Gonzalzles referred to as “hunt and peck” EMRs. The user must do a lot of “pecking” on buttons, tabs, menus, hot spots, and hyperlinks to figuratively drag an EMR through a patient encounter. In contrast, “anticipatory” EMRs (again, Dr. Gonzalzles’ excellently chosen word) anticipate what the user needs to do, and where they want to go next, because they can rely on a workflow engine to execute a custom defined process definition to pull the user (in a good way) through an encounter.

So, how did I get interested in EHR workflow management systems? I happened to get a bunch of (what at the time seemed) unrelated degrees (pre-med accountancy major?–come on!). And I was lucky enough to help design an innovative curriculum that practically reflected those degrees.

I feel like I now understand what  Søren Kierkegaard meant when he wrote, 

“Life can only be understood backward,
but it must be lived forward.”

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