EHR/EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow

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EHRs/EMRs have long been lauded for their potential contributions to legibility, decision support, and clinical research. They hold great promise for reducing medical error. However, until recently, EMR usability obstacles have not been sufficiently addressed. Typical EMR systems are not easy to use. Many physicians run small businesses. Anything that slows them down usually reduces their revenue. As a business proposition, EMRs must become not just comprehensive and accurate, but usable and fast. Lack of workflow management AKA business process management (BPM) capability is a major reason for many EMRs being difficult to use.


Usability is “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use.” However, in the case of EMR workflow systems, usability must be construed not only relative to single users, but also with respect to the entire team of patients, physicians, and clinical staff who work together for common goals. One might rephrase this definition of usability to become the effectiveness, efficiency, and satisfaction with which teams of users achieve collections of goals in complex social environments.

Consider these major dimensions of EMR usability: naturalness, consistency, relevance, supportiveness, and flexibility. Workflow management concepts provide a useful bridge from usability concepts applied to single users to usability applied to users in teams. Each concept, realized correctly, contributes to shorter cycle time (encounter length) and increased throughput (patient volume).

Naturalness is the degree to which an application’s behavior matches task structure.In the case of workflow management, multiple task structures stretch across multiple EMR users in multiple roles. A patient visit to a medical practice office involves multiple interactions among patients, nurses, technicians, and physicians. Task analysis must therefore span all of these users and roles. Creation of a patient encounter process definition is an example of this kind of task analysis, and results in a machine executable (by the BPM workflow engine) representation of task structure.

Consistency is the degree to which an application reinforces and relies on user expectations. Process definitions enforce (and therefore reinforce) consistency of EMR user interactions with each other with respect to task goals and context. Over time, team members rely on this consistency to achieve highly automated and interleaved behavior. Consistent repetition leads to increased speed and accuracy.

Relevance is the degree to which extraneous input and output, which may confuse a user, is eliminated. Too much information can be as bad as not enough. Here, process definitions rely on EMR user roles (related sets of activities, responsibilities, and skills) to select appropriate screens, screen contents, and interaction behavior.

Supportiveness is the degree to which enough information is provided to a user to accomplish tasks. An application can support users by contributing to the shared mental model of system state that allows users to coordinate their activities with respect to each other. For example, since a EMR  workflow system represents and updates task status and responsibility in real time, this data can drive a display that gives all EMR users the big picture of who is waiting for what, for how long, and who is responsible.

Flexibility is the degree to which an application can accommodate user requirements, competencies, and preferences.This obviously relates back to each of the previous usability principles. Unnatural, inconsistent, irrelevant, and unsupportive behaviors (from the perspective of a specific user, task, and context) need to be flexibly changed to become natural, consistent, relevant, and supportive. Plus, different EMR users may require different BPM process definitions, or shared process definitions that can be parameterized to behave differently in different user task-contexts.

The ideal EHR/EMR should make the simple easy and fast, and the complex possible and practical. Then the majority/minority rule applies. A majority of the time processing is simple, easy, and fast (generating the greatest output for the least input, thereby greatly increasing productivity). In the remaining minority of the time, the productivity increase may be less, but at least there are no show stoppers!

(This post is based on material adapted from pages 12 and 13 of “EHR Workflow Management Systems in Ambulatory Care” from the published proceedings of 2005 HIMSS Dallas conference. I see that the PDFed PowerPoint is available on the HIMSS site here (as well as the technical paper).

P.S. 7/9/2009 While searching the Web for material on EHR/EMR, workflow, and usability I stumbled upon my own one page paper (for a poster) for the 2004 MedInfo conference in San Francisco. Archived here, for heaven knows what reason!

The following has got to be just about the most concise description possible of the relationship among these important usability principles and EMR workflow, which I suppose is what happens when you condense a five page paper down to a single page (including title and references!):

“EHR workflow management systems are more usable than EHRs without workflow management capability. Consider these usability principles: naturalness, consistency, relevance, supportiveness, and flexibility. EHR WfMSs more naturally match the task structure of a physician’s office through execution of workflow definitions. They more consistently reinforce user expectations. Over time this leads to highly automated and interleaved team behavior. On a screen-by-screen basis, users encounter more relevant data and order entry options. An EHR WfMS tracks pending tasks–which patients are waiting where, how long, for what, and who is responsible–and this data can be used to support a continually updated shared mental model among users. Finally, to the degree to which an EHR WfMS is not natural, consistent, relevant, and supportive, the underlying flexibility of the WfMS can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.”

Webster C. Workflow Management and Electronic Health Record Systems, Fieschi, M et al (eds.), Amsterdam: IOS Press, 2004, p 1904.

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  1. Posted June 29, 2009 at 8:28 am | Permalink

    When considering workflow design, the concept of internal “transactions” can be useful. A patient’s visit to their doctor is a time in which different people in the practice collect different kinds of data regarding the patient’s condition and/or provide treatment(s) to the patient. As different people in the practice collect different kinds of data, a picture of the patient’s condition is being built. The accuracy and completeness of the picture is important to ensuring that the treatment prescribed or provided is appropriate. A well designed workflow ensures that the data gathered by each person in the practice is contributing to the painting of an accurate picture that facilitates good clinical decision making. The process of gathering data is facilitated by the naturalness and ease with which the system and the practice personnel interact.

    Because the “fit” of the EMR to the practice is a big part of the user experience, great care is needed when educating the practice and setting up the workflows for initial installation. While speed is one indicator of ease of implementation, if practice productivity is de-prioritized for speed of implementation, the result is a fast implementation that results in a less productive practice. That is spending hundreds of dollars less now to make thousands of dollars less later. The real test of the quality of an EMR implementation is, “How long does it take after implementation to get back to the level of encounters per day per doctor the practice enjoyed before the implementation?” The ability of an EMR to perform well against that standard is really a test of how natural, consistent, relevant, supportive and flexible the workflows presented by the EMR can be.

  2. chuckwebster
    Posted June 29, 2009 at 9:09 am | Permalink

    Thank you Frank!

    I sometimes fall into industrial engineering and human factors speak. You’ve restated the ideas in practical EMR implementation terms perfectly.

  3. Posted March 26, 2014 at 6:06 pm | Permalink

    Hi Chuck,
    We don’t consider it “falling” into the human factors, per your other comment. Maybe DIVING in. The Power2Practice EMR we created, specifically for the integrative medicine space ( balances the scales a little bit more. (Picture a continuous loop with “Physicians” above your two scales and “Patients” below.) We actually want to make sure the EMR is usable for the physician AND patient (with our Power2Patient portal, they fill out a 400 question health survey, track labs, and confirm appointments). And of course, we make sure the information is valuable coming and going both ways. Thanks for the always interesting on-topic info!

  4. chuckwebster
    Posted March 26, 2014 at 6:13 pm | Permalink

    I admire your enthusiasm! :)


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