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

Short Link: http://j.mp/7ZpM37

I attended the 2009 American Academy of Pediatrics National Conference and Exhibition in Washington, DC. Here are some impressions and observations.

(I used to write long trip reports and email them to coworkers and friends. And then follow up: Did you read it? What do you think? More than one person diagnosed me as a frustrated blogger, which I steadfastly denied until earlier this year.)

Presidential Address by Dr David Tayloe (EncounterPRO User Since 1999)

Dr. David Tayloe, AAP’s 2008-2009 president, opened the conference by addressing healthcare reform and information technology. His summary of the strategic relationships among reform, EHRs, pediatric, and primary care was clear and compelling. He described a vision of each pediatric practice becoming their patients’ medical home, cited his own experience at Goldsboro Pediatrics in North Carolina, and pointed out that adult medicine has a lot to learn from pediatrics regarding progress in this area.


A Slide From Dr. Tayloe’s AAP Presidential Address

And yes, Goldsboro Pediatrics has been using the EncounterPRO Pediatric EMR Workflow System since 1999.

Pediatric Documentation Challenge on Saturday, October 17th, 2009

Dr. Joseph Schneider moderated (wonderfully) the onstage demonstration of a complex pediatric scenario by eight EMR vendors, including theEncounterPRO Pediatric EMR Workflow System. He warned the audience the scenario was extra-complicated and not to expect anyone to complete the scenario in the allotted time. During introductory remarks he instructed the audience to pay special attention to interoperability and quality reporting on one hand, and workflow and ease of use on the other (and thank you, Dr. Schneider, for the public shout out to me about my decade long educational campaign for EMR workflow automation and usability).

I stayed for the entire series of demonstrations with what was initially about an audience of one hundred. Dr. Roy, using the EncounterPRO Pediatric EMR Workflow System, was one of only two demonstrators who completed the pediatric scenario (I corroborated this assessment with several other diehards who also made it through the almost four hour session). Comparing seven traditional hunt-and-peck EMRs to an anticipatory EMR workflow system triggered considerable ideation on my part about EMR workflow, which I’ve “demoted” to a “Closing Thoughts” section below.

EncounterPRO Booth Traffic

We had steady booth traffic, from new folks interested in individualized demos and providing contact information for follow up investigation, and from existing customers (it’s always great to see a familiar face!)


Here’s Brett Cleary(sales manager) and Kris Griffith (product manager) demoing and answering questions, and me, looking for a kickbiking partner.

Kickbiking DC’s Downtown Public Sculpture

As soon as the weather cleared up Sunday afternoon Dr. Roy and I took a three-hour tour of public art in downtown DC.

  • Modern Head by Roy Lichtenstein
  • The bronze reliefs at the Navy Memorial
  • And the sculpture gardens at the National and Hirshhorn art galleries


Dr. Roy Explaining Comparison of Femoral and Radial Pulses
as Depicted in the Navy Medicine Bronze Relief


Calder’s Red Horse in the National Art Gallery Sculpture Garden

Along our kickbikejourney we came up with:

The Top Ten Similarities between EMR Workflow Systems and Kickbikes

I’ve a web page about kickbikes on this blog. I’ve been meaning to post a paean to kickbiking; however there is a direct feed from this blog to a page on our product site. A headline there, about kickbikes, might seem a bit out of place. So, while walking up hills or waiting for traffic signals, we brainstormed the Top Ten Similarities between EMR Workflow Systems and kickbikes. Here’s the first draft. Some of these need some explanation. Watch for a longer post (in some future slow news week) with the same name as this subsection.

  1. Easy
  2. Unusual Appearance
  3. Fun
  4. Good for You
  5. Fast
  6. European Roots
  7. Child Friendly
  8. Extra Stable
  9. Endorsed by Me
  10. Designed by Physicians

(“Workflow” and “Kickbike” both have eight letters. Coincidence?)

Closing Thoughts about Apples, Oranges, and Peaches and A Decade of Market Education

As I watched the seven EMR apples and one EMR orange (or peach if you will, since we’re based in Atlanta), I was struck once again how similar traditional EMRsare to each other: large screens crammed with data and droves of data entry and order entry options. The user is the workflow engine, clicking on a succession of menus, tabs, buttons, checkboxes, textboxes, scroll bars, radio buttons not just to enter data and orders, but to get to the right tab, screen, dialog box, or popup. I’m a relatively trained observer since I’ve been participating in these events since the early days of TEPR’s documentation challenges—and *I* havetrouble remembering who is who. Other than location, color, finish, gradient, and minor aspects of widget shape (buttons with oval versus sharp corners, flat borders versus 3D bevels, etc.) all seven EMRs looked and worked more similarly than differently.

Traditional EMRs Rest on Structured Document Management Foundations

Traditional EMRs rest on database foundations that represent declarative knowledge about medicine and patients. Seems like a good foundation, right? But wrong from a workflow usability and process optimization point of view. Traditional EHRs are essentially structured document management systems (using relational databases to store structured data entered into document-like user interfaces and generate document-like reports) onto which are being grafted limited (and limiting, see discussion of “frozen” EMR workflow) degrees of task management. Traditional EHRs have lots of small targets on each screen that compete with each other for attention, plus the need for overt user direction to navigate from screen to screen. The smaller and more numerous EMR “targets” are, the more Fitts and Hicks Laws work against the user, resulting in slow, errorful data and order entry.

I recall a TEPR documentation challenge years ago that relied on what looked like at least a 12 foot wide 10 foot high projection screen. At one point the moderator actually had to walk over to the screen, crouch down, and don reading glasses to read a check box label. That’s small!

I did in fact notice at the AAP pediatric documentation challenge that, under time pressure and distraction (often from someone at the user’s elbow who was really trying to help), there were numerous times when the wrong check box or radio button was selected and then unselected. Human factor folks call these unintended user behaviors “slips” to distinguish them from intentional behavior called “mistakes.”

By the way, when I was a graduate student in Industrial Engineering at Illinois, I wrote a FORTRAN program that analyzed a stream of data from a PDP-11 that monitored a cockpit simulator (a Link Trainer, a *real* cockpit simulator, not a simulated simulator). The program flagged potential pilot errors (buttons they pushed, control surfaces they manipulated) during simulated emergencies. Then a human judge would try to figure out whether the errors were slips or mistakes. Of course, it’s been a few decades, so I could be mistaken.

Anticipatory EMR Workflow Systems Rely on Workflow Management Foundations

In contrast, EMR workflow systems rest on database foundations that represent procedural knowledge about medical workflows and processes, into which medical and patient knowledge and data are added and integrated. In which kind of EMR do you think workflows and processes are more easily understood, optimized, and monitored? Which kind of EMR will result in shortest patient wait times and encounter length? Highest task throughput and patient volume? The answer is the reason why productivity numbers are so good in the three HIMSS Davies Award-winning applications submitted by the two pediatricians, and one ob/gyn-family medicine physician, who use an EMR Workflow System.

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.


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 years AAP one of my booth mates said “Shoot, you just missed him! This fellow was walked by, saw our sign [“EncounterPRO Pediatric EMR Workflow System”], 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!

EMR systems will need to become EMR workflow, and EMR business process, management systems, if they are to achieve the meaningful use that will be necessary to participate in the positive transformation of the US healthcare system. I do see progress. The “planets” (that is, federal initiatives, educated consumers, compelling case studies, and thought leadership) are aligning. It should start getting very interesting, right…about…now.

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