The Critical Importance of Executable Model Of EHR Workflow: 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

At the heart of an EHR workflow management system is the workflow or process definition, which is used by a workflow engine to drive EHR behavior. For example, in Figure 2, applying the Workflow Reference Model to an ambulatory context, we see on the left a process definition. In this case, the process definition drives the se- quence of screens presented to two members of the ambulatory team, to the nurse and then to the physician: (1) Get Patient, (2) Take Vital Signs and a Chief Complaint, (3) Review Allergies, (4) Review Medications, (5) Examination, (6) Assessments, (7) Orders, (8), Evaluation and Management code generation, and (9) Billing Approval.

On the right is a process instance, sometimes referred to as a case. This is the actual patient encounter. To use an analogy, if the list on the left is a recipe, then the list on the right is the actual cake!


Workflow management systems have workflow or process definition tools. These are graphical editors that al- low a non-programmer to define or modify EHR workflow, in effect, to program or debug EHR workflow be- havior. Figure 3 depicts one such tool. (By the way, this gives rise to a litmus test: if an EHR purports to be an EHR workflow management system, ask to see the process definition tool. While it may not look exactly like Figure 3, it should allow changes in a process definition used by the workflow engine to drive EHR behavior.) In this case, the process definition saves the user from having to navigate manually through a thicket of menus, tabs, or popup lists; the EHR presents the correct screen given the context of the user’s tasks.

Process definitions are used by the workflow engine in a similar way to rules being used by an expert system. The workflow engine reasons about who, what, why, when, where, and how in order to save the user work. Who is the user? (Dr. Jones or Dr. Smith?) What is their role in the office? (Physician, nurse, technician?) Why is the patient here? (Well child? Chronic disease management?) When is “now”, relative to what has been accomplished and what remains? Where is the user? (Exam room? Tech station?) How does this specialty accomplish its tasks?

Each step in the process definition corresponds to a specialized data presentation, acquisition, or transformation task. The process definition describes the event that triggers the presentation of the screen as well as a context that informs its content and behavior. For example, the Review of Systems screen allows the nurse to do just that, review the patient’s systems. It is triggered by the completion of the preceding screen (or by the nurse log- ging into the EHR in the exam room in the presence of the patient after all the preceding tasks in the process definition have been accomplished).

Note, however, that the process definition does not merely drive a sequence of screens with respect to a single user; rather, it drives a sequence of activities, some visible as screens, others not (printing, messaging, and so on) across a team of users occupying a variety of roles (nurse, tech, specialty provider). There are many such screenless tasks, such as printing patient materials, automatically inserting a work item into a worklist, or communication with other applications such as devices (ECG, vitals), intra-office programs (billing, patient inter- view), or communicating with the outside world (laboratory, e-prescribing).

Thus, EHR workflow management systems offer means to integrate applications with applications (such as communication from scheduling to patient charting and order entry and then on to billing, or between a medical device and the EHR), integrate applications with users (such as retrieving data from already existing systems), and integrate users with users (as in this example, in which the nurse’s tasks precede the physician’s tasks and information is forwarded from the nurse to the physician—in a more complex and realistic scenario, the physi- cian might delegate additional tasks to the nurse and monitor them.)

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.

For more on the incredible value of executable models of healthcare workflow, see my BPM-based Population Health Management & Care Coordination: Workflow, Usability, Safety & Interoperability Perspectives.

Take me to the next blog post in this series! Different Versus Same Person Versus Time EHR Workflow: Process-Aware HIT.

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