A White Paper About EMR Workflow, Usability, and Productivity in Pediatric and Primary Care

Short Link: http://j.mp/6vd4Zp

This letter to the New York Time’s editor about the adoption of traditional EMR systems in primary care sums up the problem:

“A high-volume, low-margin business like primary care medicine simply cannot support the costs. These include both the very high dollar cost of buying and maintaining a system and the huge drop in productivity that initially accompanies implementation.”

However, EHR workflow management systems, EMR workflow systems, and business process management technologies are ideal for high-volume, low-margin businesses such as ambulatory pediatric, family medicine, and obstetrics and gynecology practices. They can be more quickly and inexpensively deployed than traditional EMRs and they dramatically increase, not decrease, productivity.

My 2003 white paper “Electronic Medical Record Workflow Management: The Workflow of Workflow,” which includes results from a survey of primary care practices documenting a workflow automation-induced productivity surge, has garnered a lot of web traffic over the years. With all of the published news articles and conversations on the Web about productivity and usability and workflow being major obstacles to EMR adoption, I decided to update that 2003 white paper by adding a companion titled “Pediatric and Primary Care EMR Business Process Management” . Everything in the original “Workflow of Workflow” paper is still true and even more relevant today. However the HIT industry have evolved a lot in the past six years. Portions of this twelve page white paper are unavoidably somewhat technical in places, so this post is a shorter and less technical summary of its major points.

There is also the recent related post, “The Cognitive Psychology of Pediatric EMR Usability and Workflow,” about human perceptual and decision making information processing constraints that motivate use of EMR workflow systems.

I’ll start with the abstract, quote or summarize the most interesting material, throw in a few screen shots, and voila: the Reader’s Digest version of “Pediatric and Primary Care EMR Business Process Management: A Look Back, a Look Under the Hood, and a Look Forward.”

Pediatric and Primary Care EMR Business Process Management:
A Look Back, a Look Under the Hood, and a Look Forward

Abstract. We describe an ambulatory electronic health record (EHR) workflow management system (WfMS)—employed to create a high-usability pediatric electronic medical record (EMR) workflow system—that is currently in use by 4000 users at 300 medical offices and has been deployed since 1995. WfMS features and functionality include a workflow engine, workflow process definition editor, and a universally viewable annotated worklist that represents patient location and task status in real time. Clinical data flow into and out of the EncounterPRO Pediatric EMR Workflow System via the EncounterPRO Health Information Exchange (EPHIE, HIE) automatically and inexpensively due to coordinated workflow management across EMR and HIE subsystems. Business process management (BPM) add-on modules address the three most important dimensions of ambulatory EMR value: clinical performance, patient satisfaction, and practice profitability. Written physician comments about the resulting electronic medical record (EMR) workflow systems (two pediatric and one obstetrics, gynecology and family medicine) from three award winning case studies support the importance of workflow or process-aware EMRs to successful EMR deployment.

We distinguish between EHR workflow management systems (WfMSs) and EMR workflow systems. Just as a database management system is used to create and manage a database system, a EHR Workflow Management System is used to create and manage a EMR Workflow System (and the Family Medicine EMR Workflow System and Obstetrics and Gynecology EMR Workflow System, and so on).

When business process management (BPM) functionality is used to systematically optimize EMR workflow processes with respect to clinical performance, patient satisfaction, and practice productivity, we will speak generally about EHR business process management. However, during day-to-day EMR operation, users do not interact directly with either EHR WfMS or EHR BPM functionality (which are chiefly intended for use by EMR workflow system designers). When pediatric or other primary care EMR workflow system users access, rely upon, or benefit from BPM system functionality, we refer to that as EMR business process management (hence the title of this white paper).

EMR workflow systems are more usable than EMRs without workflow management capability. Consider these usability principles: naturalness, consistency, relevance, supportiveness, and flexibility.

  • EMR workflow systems more naturally match the task structure of a specialist’s office through execution of specialty-specific workflow process definitions.
  • These definitions consistently reinforce user expectations. Over time this leads to fast and effective interleaved team behavior.
  • On a screen-by-screen basis, users encounter more relevant data and order entry options.
  • An EMR workflow system tracks pending tasks in real time—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 EMR workflow system is not natural, consistent, relevant, and supportive, the flexibility of the underlying EHR workflow management system can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.

In other words, specialty-specific EMR workflow systems based on EHR workflow management system foundations are more usable than traditional EMRs that are not based on workflow management system foundations.

EHR Workflow Management System Functionality

 An EHR Workflow Management System includes a large number of optional data review and entry and order entry tasks. For example, Figure 1 shows the Chief Complaint screen.


Figure 1:Typical EMR Workflow System Screen
(Chief Complaint)

A subset of these tasks are selected to create a workflow process definition (sometimes called a workplan). In this example (Figure 2) the workplan is a pediatric workplan for “Standard Encounter Child Well Visit New Patient.” The Chief Complaint screen occurs as the third step in this workplan. A collection of specialty-specific workflow definitions configures a specialty-specific EMR Workflow System.


Figure 2: A Process Definition (”Workplan”) Controls
Presentation of Screens to Users

During workplan execution the Chief Complaint task time is automatically and continually updated in the office view (Figure 3). It can be seen as the pick item in the upper left. It has been languishing (in this demo situation) for 29 minutes. Touching the task bar brings up the Chief Complaint screen in order to complete it (back to Figure 1).


Figure 3:EMR Workflow System Office View

By automatically pushing specialty-specific task screens to the right users (on their To Do lists) and by indicating their status in real time on the office view where all staff can see them, tasks are accomplished quickly and the occasional ignored task is ignored only briefly. Workflow-oriented EMRs sometimes call this an Office View. Usability engineers refer to them as radar views, an airport control tower analogy.

EHR Business Process Management Functionality

Workflow or process-aware information systems—workflow management systems, business process management, monitoring, mining, and modeling systems—have great potential to address the central issues of healthcare reform: identification of best practices, coordination of care amongst providers and patients, and consistency across healthcare delivery processes. EMR users are increasingly asking for means to systematically improve the effectiveness and efficiency of a wide variety of EMR mediated processes. Goals include improved clinical outcomes, more satisfied patients, and increased practice profitability. Business process management ideas, techniques, systems and modules are relevant to all of these goals.

(The white paper also reviews the workflow management aspects of three HIMSS Davies winning applications for two pediatricians and one physician with a combined obstetrics, gynecology, and family medicine practice. If you’re not going to read the white paper, there is a previous self contained post about the award winning use of Pediatric; Obstetrics, Gynecology; and Family Medicine EMR Workflow Systems.)

Current developments in business process management are relevant to where EMRs and EHRs need to go, workflow-wise.  A number of trends are 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 productivity, usability, and workflow have come to the fore: too many traditional EMR implementations have failed due to problematic workflow and decreased productivity and EMR professionals are beginning to realize that the user isn’t the problem; it’s the usability of the technology (although we acknowledge the honest debate on this topic). And productivity, usability, and workflow are inextricably intertwined.

EMRs without sophisticated workflow automation foundations, tools, and infrastructure are not up to the job. Non-workflow-management-system-based EHRs are difficult to optimize in a business process management sense. Their workflows are highly constrained by the initial design decisions of their respective programmers. Their lack of easily changed workflow process definitions makes it difficult to systematically improve their workflows with respect to the wide variety of goals that motivate use of ambulatory EMRs.

The EHR Workflow Management Systems (and the workflow systems they create and manage, for pediatrics, family medicine, obstetrics and gynecology, etc.) are an example of a new class of process-aware ambulatory EHR/EMR software. This next step in the evolution of ambulatory EMRs is squarely at the intersection between two great software industries: electronic health record systems and workflow management/business process management systems. The hybrid EMR workflow systems that result will be more usable and more systematically optimizable than traditional EMRs with respect to user satisfaction, clinical performance, patient satisfaction, and practice profitability.

That’s the Reader’s Digest Condensed version. Whether you read it or not in the loo (as my British accented wife calls it, I hear that Reader’s Digest is popular there), well, I’m honored either way. (Maybe I’ll release it in Large Print Format too.)

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


  1. Posted July 27, 2009 at 9:59 am | Permalink

    The quote from the letter to the New York Times accurately summarizes what I believe to be a problem in perceptions. The author of the letter is exactly right; any high volume, low profit business can not afford anything that is difficult to adopt and limits productivity. Doctors practicing primary care medicine are working in what business people would refer to as a “fixed selling price environment”. Practices negotiate with insurance companies annually to determine the amount of reimbursement they will receive for the services they provide to the insurance company’s policy holders. The price the insurance company will pay the practice for a patient encounter with specific services included remains “fixed” for the term of the contract. The formula for determining profit is: selling price minus cost of goods sold equals profit. If the selling price is fixed, the only way to effect profit is to change the cost of goods sold.
    In the practice of primary care medicine the cost of treating a patient is mainly defined by the time the practice spends working with the patient. There are two components to the cost of treating the patient: the cost of the practice’s physical plant and the cost of the practice’s personnel. Both of these costs increase as the amount of time involved in treating the patient increases.
    Understanding this set of basic business principles as they apply to the practice of primary care medicine and EMR’s leads to the conclucion that what primary care physicians need is a EMR that can help them manage their costs to optimize profitability.
    While physicians have an understandable economic incentive to reduce the amount of time they spend with the patient, they have an equally understandable emotional incentive to provide great pateint care. The emotional incentive is clearly the stronger of the two as is provable by doctor’s widely reported lack of business acumen.
    The natural counter balancing force to the economic incentive is patient satisfaction. If the doctor spends too little time with patients, the patients will believe they are not being treated well and move to a physician where they believe they are being treated better. The net effect is a loss in practice productivity due to fewer patients being treated.
    The role of the EMR is to provide the practice with accurate data regarding: the reimbursement they will receive for the services they render, the costs they incurred for the rendering of the services, the degree to which the services rendered met with clinically accepted standards for the treatment of the diagnosis recorded and the degree to which the patient was satisfied with the services rendered.
    Given all of the above, the process of treating a patient has to result in a profitable transaction for the practice that provides the patient with services that are appropriate for the condition with which the patient is presenting, and that the patient finds to be satisfying.
    It is a time honored business truth to say, “You can’t manage what you can’t measure.” The EMR has to help physicians measure all of the pramaters listed above so they can manage their workflows to make sure the desired results are achieved.
    The ability to manage workflows based on measuring the effects of the workflows in use is crucial to the on-going success of the practice. Workflows shold not be static. They have to be changeable to adapt to the results they are achieving.
    I opened by saying that I thought the quote from the letter in the New York Times showed a problem with perceptions. The problems to which I was referring are the perception that a workflow system is the same thing as a workflow management system and that EMR’s cannot help in the running of a high volume, low profit business. Both are invalid perceptions.
    As a business person without anywhere near the academic credentials of my esteemed collegue Dr. Webster, I tend to believe more strongly in business case histories than in academic treatices. I certainly mean no disrespect to academicians. I believe they work in a rarified atmosphere in which they try to eliminate variables to reach pure conclusions. While I very much appreciate the effort, the uncontrolled variables with which business people must deal are the details in which the devil lies. It is wonderful to find a situation in which the academicians theories and real world experience support each other. The use of Workflow Management Systems is theoritically a wonderful solution to the business problems presented by a high volume, low profit business like the practice of primary care medicine. The case histories recognized by HIMSS and the quotes from doctors using a workflow management system in their practice, when taken in combination with the academic theories show that what the academics thought would be true actually is true in the real world. This is truely a beautiful thing.

  2. chuckwebster
    Posted July 28, 2009 at 8:37 am | Permalink

    No offense taken! However, I don’t think this is an issue of technology diffusion from university to industry, but rather from abroad to the US. For example, none of the first seven International Conferences on Business Process Management have occurred in the US. All were held in Europe (Eindhoven, The Netherlands; Potsdam, Germany; Nancy, France; Vienna, Austria; Milan, Italy; Ulm, Germany) except for 2007 (Brisbane, Australia). If anything, I think it is the academic types who are playing an important role in making this progress abroad known to a small but growing US audience.

One Trackback

  1. [...] Electronic Health Record Workflow Management Systems Electronic Health Records (EHRs), Workflow Management Systems (WfMSs), Pediatric EMR Workflow Systems (WfSs), Business Process Management (BPM), Human Factors, and Kickbiking Skip to content Welcome!ContentsPediatric EMR WfSsEHR WfMSsGalleryKickbikingPresentationsSurveyContact Me « A White Paper About EMR Workflow, Usability, and Productivity in Pediatric and Primary Care [...]

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.