A Survey of EHR Workflow Management Productivity: Process-Aware HIT

The following preamble and table of contents is for surfers who randomly land here and may benefit from a bit of orientation. Skip to the content!

In 2003 and 2004, I wrote a series of white papers about workflow-centric, instead of data-centric, EHRs. It’s taken 13 years, but much of what I wrote is finally becoming true. This is one of a sequence of blog posts adapted from those white papers and (republished) during HIMSS16. Terminology has evolved, but the ideas are as relevant now, if not more so, as then. (Take me to the beginning of this series of blog posts!)

  1. EHR Workflow Management Systems: Essentials, History, Healthcare (Written In 2004!)
  2. The Critical Difference Between Workflow Management Versus Mere Workflow: Process-Aware HIT
  3. The Critical Importance of Executable Model Of EHR Workflow: Process-Aware HIT
  4. Different Versus Same Person Versus Time EHR Workflow: Process-Aware HIT
  5. Multi-Specialty, Multi-Site, Multi-Encounter Workflow Management: Process-Aware HIT
  6. A Survey of EHR Workflow Management Productivity: Process-Aware HIT
  7. EHR Productivity Survey Discussion: Process-Aware HIT
  8. Workflow Management and EHR Usability: Process-Aware HIT
  9. User-Centered, Human-Centered Process-Aware Health IT
  10. Process-Aware Workflow Management Systems With Healthcare Characteristics: Process-Aware HIT
  11. The Future of EHR Workflow Management Systems: Process-Aware HIT
  12. Interruptions and Exceptions in IT Enabled Healthcare Workflows: Process-Aware HIT
  13. Clinical and Administrative Healthcare Workflow Patterns: Process-Aware HIT
  14. Process Mining Time-Stamped Health IT Data: Process-Aware HIT
  15. Capacity Management Implications of Healthcare Workflow Technology: Process-Aware HIT
  16. The Roots of Task-Workflow Pragmatic Interoperability: Process-Aware HIT
  17. Who Or What Is The Workflow Engine: That Is The Question: Process-Aware HIT
  18. References for EHR Workflow Management Systems: Process-Aware HIT
  19. Glossary of EHR Workflow Management Systems Terminology: Process-Aware HIT

In a survey of 200 practices using an EHR workflow management system, thirty-six responded. Of these, twenty practices had pre-existing operations, so they could compare their before and after experiences. The average practice had been on an EHR WfMS for 2.7 years, had 3.76 physicians, and 17.5 total staff. Their specialties were pediatrics (55%), family medicine and internal medicine (35%), obstetrics/gynecology (5%) and multi- specialty (5%).

The survey was a self-assessment survey which covered the categories of usability, revenue, expenses, time and quality.


Practices achieved competency in five weeks. Of the practices 85% had achieved a paperless office (except for printing paper destined for the outside world or scanning incoming documents). These offices took an average of eleven weeks to achieve this paperless state. Notably, 100% of physicians used the EHR.

Revenue (and related figures)

Visits per day increased 13.5%. Exam rooms increased 34%. Charges per visit increased $17. Billing increased 30%. Denied claims decreased 61%. And revenue increased 24%.

Expenses (and related figures)

Total staff decreased from 17.5 to 16.7 fulltime equivalents. The staff to physician ratio decreased 12%. (Which is good because physicians generate revenue while staff generate expenses.) Transcription costs decreased 67%. And (in conjunction with the previously described increase in revenue) the estimated pay back period for EHR software and hardware was fifteen months.

Time and Quality

Time and quality have a very interesting relationship. Before the quality management movement, most people assumed that one must increase the amount of time spent on a product or service in order to increase its quality. (This is not necessarily true.) More to the point, patients see timeliness and convenience as an important element of the quality of care. If they do not have to wait or the encounter is shorter and allows them to get back to work on time, this is perceived as increased quality. These practices estimated a 13.5 minute decrease in patient wait, a six minute decrease in charting time, and a 16 minute decrease in overall encounter length. The amount of time to return a phone call to answer a question or to refill a prescription decreased by two hours and 45 minutes and four hours, respectively. Finally, in spite of a higher volume of shorter visits, immunizations increased by 25% (in pediatric practices) and quality review scores increased by 17%.

Much of what I wrote about in this 2003-2004 series of white papers is indeed coming into existence today. The basic idea of building workflow-centric health IT systems is indeed gaining steam. Many of my tweets during HIMSS16 are about companies embedding workflow engines in their products. In addition, we are seeing a surge of Business Process Management technology in healthcare and health IT. Terminology varies. Sometime they are called Healthcare or Care Management Systems. What they have in common is a “process-awareness” that has been mostly missing to day in recent medical informatics and health IT history. This new layer of cloud-based workflow engines addresses thorny issues of EHR and health IT usability, productivity, safety, and interoperability. Indeed, since my 7000-word, 5-part series, Achieving Task and Workflow Interoperability in Healthcare , was published in 2015, I’ve seen considerable progress. Also see my recent 10,000 word, 5-part series on Pragmatic Interoperability published on HL7Standards immediately before HIMSS16.

It is still useful to look back at my 2003 and 2004 series on EHR workflow management systems for seminal ideas that are only now being realized in products and driving results. In many instances, I have written considerably more material on various subtopics.

Take me to the next blog post in this series! EHR Productivity Survey Discussion: Process-Aware Health IT.

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