Workflow Management and EHR Usability: 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

EHRs have long been lauded for their potential contributions to legibility, decision support, and clinical research. They hold especially great promise for reducing medical error. However, until recently, EHR usability obstacles have not been sufficiently addressed. Typical EHR systems are not easy to use. Many physicians are small businessmen and women. Anything that slows them down may also reduce their revenue. As a business proposition, EHRs must become not just comprehensive and accurate, but usable and fast. Lack of workflow management capability is a major reason for many EHRs being difficult to use.

Usability is “the effectiveness, efficiency, and satisfaction with which specified users achieve specified goals in particular environments.” [4] However, in the case of EHR workflow management systems, usability must be construed not only relative to single users, but also with respect to the entire team of users 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 EHR usability: naturalness, consistency, relevance, supportiveness, and flexibility [5]. Workflow management concepts provide a useful bridge from usability concepts usually applied to single users to usability applied to users in teams. (And, to pick up a thread that was introduced in the previous section, each dimension of usability can contribute in its own way to reductions in encounter length.)

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 users in multiple roles. For example, a visit to a cardiology office may involve multiple interactions among patient, nurses, technicians, and physicians. Task analysis must therefore span all of these users and roles. Creation of a process definition is an example of this kind of task analysis, and results in a machine executable (by the 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 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 user roles (related sets of ac- tivities, 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 applica- tion 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 workflow management system represents and updates task status and responsibility in real time, this data can drive a display that gives all 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 prefer- ences. This obviously relates back to each of the previous usability principles. Unnatural, inconsistent, irrele- vant, 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 users may require different proc- ess definitions, or shared process definitions that can be parameterized to behave differently in different user-task-contexts.

The ideal EHR (and EHR workflow management system) should make the simple easy and fast, and the com- plex possible and practical. Then the majority/minority rule applies. A majority of the time process instances are 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!


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! User-Centered, Human-Centered Process-Aware Health IT.

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