A Pediatric EHR Workflow System: 10 Questions For Barry Hayut, Xcite Health

Just in time for the American Academy of Pediatrics National Conference in San Diego, here is one of my increasingly infamous 10 question in-the-weeds interviews! This time about a remarkable pediatric EHR workflow system (also used by other primary care specialists). It used to be named EncounterPRO, under which name it won the first three ambulatory EHR HIMSS Davies Awards. This EHR workflow system is now called XciteEHR and my interview is with Barry Hayut, of Xcite Health. By the way, Xcite is hosting a free webinar, featuring me! I’ll talk about the difference between traditional EHRs and EHR workflow systems on November 5th at 12 Noon EST.

As a side note, this is a special interview for me because I was involved with the early design and implementation of this particular pediatric EHR workflow system. I expect many AAP attendees may remember EncounterPRO (originally developed by JMJ Technologies) and will find this interview of special interest. Creating and customizing EHR workflows for our customers, when I was EncounterPRO CMIO, really drove home the importance of true workflow technology at the point of care. Some of the older posts on this blog, EHR Workflow Management Systems, were about EncounterPRO.

  1. How did you end up in the pediatric EHR workflow system business?
  2. Could you discuss Meaningful Use 2 and why it’s important to be MU2 certified?
  3. Do you also sell a Practice Management system?
  4. What’s the difference between EHR workflow systems and mere EHR systems?
  5. Would you share your workflow, writer, editor, publicist analogy?
  6. What does a true EHR workflow system *do* for physicians?
  7. Would you show us the XciteEHR Office View and explain its functions?
  8. What physician specialty practice areas does the XciteEHR cover?
  9. How will you educate the world about true EHR workflow systems?
  10. Thoughts, Barry? About EHRs, workflow, and physician happiness?

By the way, Barry, congratulations on making the XciteEHR is a Complete MU2-certified EHR! You must be mighty proud of your certificate!

Starting Saturday, I’ll be updating and tweeting answers to the above questions on the AAP conference hashtag #AAP14. Stay tuned!

1. Barry, could you tell us a bit about how you ended up in the business of selling the award winning pediatric and primary care XciteEHR workflow system?

I was the CEO of a company that owned and managed multiple radiology outpatient centers. We experienced first-hand the needs of the physicians, office staff and patients for software that enhances productivity.

When we saw the EncounterPRO EHR’s superior workflow engine, Office View, and configurability, we decided to adapt it and integrate it with our Practice Management system and patient portal for seamless integration, productivity and ease of use.

2. In choosing an EHR for a physician practice, can you discuss Meaningful Use 2 and why it’s so important to be MU2 certified?

As you mentioned, XciteEHR is indeed Meaningful Use Stage 2 certified. Thank you.

Meaningful Use 2 is a set of very ambitious standards implemented by the Office of the National Coordinator for Health Information Technology, designed to create robust digital clinical records, track Meaningful Use metrics and Clinical Quality Measures, increase interoperability among various vendors, create uniform standards for reporting data to health agencies, and create standards for the secure communication of electronic health data to patients. Certification of an EHR is tied to incentive payments from the government to physicians with Medicare and Medicaid patients and eventually is expected to be the standard imposed by health insurance companies for all physicians.

3. Do you also sell a Practice Management system? (Scheduling, Billing, Accounts Receivable, etc.)

Yes, Xcite Health also has an integrated cloud-based Practice Management System with the EHR. It has scheduling, registration, billing, revenue cycle management, provider credentialing and vaccine inventory management. All of the billing codes such as CPT codes, ICD-9 codes, and in the near future, ICD-10 codes, flow seamlessly into the practice management system from the EHR so, as the physician finishes charting the patient encounter, the billing information is finished and sent to the payers, as well.

4. Talk to me about what it means to be an EHR workflow system, in contrast to a mere EHR system.

Let me first explain what we mean by workflow. As the leader in this area it is important that I explain how this ‘changes things forever’—for many physician practices!

If you feel that, as a physician, you are constantly giving instructions to your staff—and always following up to ensure things have been done—then XciteEHR is for you.

If you feel that you are being asked to change the way you practice medicine to adapt to the strictures of your EHR software, then XciteEHR is for you.

Or, if you feel that you should not take a productivity hit when you implement an EHR and feel instead that your productivity should improve and finish charting as the exam is done, then the XciteEHR is for you

This is what truly sets us apart.

5. I love your workflow system / writer, editor, publicist analogy! Could you please share?

Our EHR workflows drive action, ensure consistency, and increase visibility by connecting your people with relevant tasks and information. It helps you rapidly transform your practice—with applications that connect the right people to the right information and the right work.

Other systems may claim to be “workflow systems.” However, a TRUE workflow system has 3 components—much like an author who needs three things to be successful. An author needs a writer—himself, an editor, and a publicist.

With a true workflow system:

  • YOU are the author, deciding how you practice medicine, and the XciteEHR was built to allow you to author the fine details of how workflow works in your office.
  • You need an editor to perfect and optimize the way you work and on-the-fly workflow editing tools allow your practice to fine-tune your office workflow.
  • And then you need a publicist – to PUBLICIZE this information to your whole staff—so they know ‘when and how’ to do their work – thereby meeting your expectations!

These three components: an engine, an editor, and a publicist, to provide visibility, are critical to having a blockbuster success when you implement an EHR.

XciteEHR is an easy-to-use tool built on top of a workflow engine that maximizes your success; it makes your team more efficient, your life easier, and your practice more profitable!

6. OK, that’s a true EHR workflow system *is*; what does a true EHR workflow system *do*?

Simultaneous processes take place as physicians and staff naturally and seamlessly interact with the program.

As an example, when physicians order vaccines from inside the exam room, the system simultaneously displays the tasks involved in completing the order on the office view screen prompting the appropriate staff members to respond wherever they may be.

While the physicians are finishing in the exam room, the nurses are already preparing to give vaccines. Not only that, the system is automatically queuing up the desired authorization forms and education materials as workplan steps. Before physicians walk out of the exam room, nurses can be ready to complete the necessary paperwork and administer the shots. Precious minutes are shaved off of the time that the exam room is occupied. Patients spend less time in the waiting room and less time in the exam room. The efficiencies yield happier patients and higher revenues.

There is no other system that has this sort of workflow. Because of this simultaneous processing, we are able to improve overall efficiency—and make the workday fly by—and end on time!

7. I know that the most visually striking feature of the XciteEHR is the Office View. Could you show us a screenshot (with de-identified data, of course!) and explain what we’re seeing—and its benefits?

The office view screen is what really sets us apart and is the heart of the office workflow.


The first thing you’ll notice on the office view screen is that it’s tailored to each individual office, with the exam rooms shown on the screen.

Also, each user or role is assigned a color for his or her task bars. For example, this doctor is assigned green and knows immediately that he/she has a patient waiting in room (4).

Each task is time-stamped in real time, so the user knows exactly how long the patient has been waiting for that particular task to be completed.

On the left taskbar, you’ll see that the patient has been waiting in the room for 9 minutes. And, on the right taskbar, it shows that the patient has been waiting on the physician to perform an exam for 3 minutes.

In reality, this prompts the physician to go and see the next patient, or to perform the next urgent task. The patient in room 8 is waiting on the nurse to give a vaccination. This is what I mean by simultaneous tasking—allowing for increased efficiency and a smoother work day and far, far greater coordination and patient satisfaction!

8. What physician practice areas does the XciteEHR cover?

We currently market to and are exceptional in the primary care areas of Pediatrics, Family Practice, Internal Medicine and Obstetrics/Gynecology. However, our workflow engine could be adapted to any medical specialty.

[CW: I'd like to interject here. The ability to customize workflow is critical for multi-specialty pediatric practices. See my Why Specialists Need Speciality-Specific EMRs That Understand More Than Their Specialty.]

9. I think it’s fantastic to see the kind of physician’s practice clinical workflow technology that the XciteEHR represents stepping into the health IT limelight, especially now that there’s health IT social media. How are you planning on educating the world about this type of award-winning EHR workflow technology?

We want to teach physicians to demand true workflow management technology from their EHR vendor. There is no excuse for lost productivity when a medical practice adopts an EHR. With true workflow management technology, a practice should see an increase in productivity in the first three to six months of use, not a decrease. Physicians do not know what to demand because they do not understand the efficiencies that a true workflow system can deliver to them.

We are going to conduct a series of webinars and marketing campaigns to educate physicians about how to make the EHR system to work for them and NOT how the physicians and their staff must conform to the EHR system.

10. Last thoughts, Barrry?

Unfortunately the term workflow has been too commoditized. It seems that if you can string together a serious of computerized actions you can call it workflow.

In many of the other systems, the physicians are choosing from menus, templates and options to figure out next steps. Each practice role player is on his/her own with their tasks, as if everybody is on their own island.

Since getting involved in this field way back in the late 90’s, I have looked at every EHR out there. What is now the XciteEHR, looks and works completely differently from every other type of EHR on the market.

In the XciteEHR once configured by the physician the way she/he likes to practice medicine, the workflow engine will present the right task screens, based on the action taken by the physician, to all relevant practice role players simultaneously and can be viewed and tracked on the Office View screen.

The XciteEHR is built on a strong history and experience of having been in the market for over 20 years—but its features currently surpass every other EHR on the market today—exponentially surpassing all others in one area. Happiness.

I believe that true EHR workflow, customizable to specialty and user needs and preferences, is the single most important key to dramatically increasing physician happiness (yes, happiness) to use an EHR.

[CW: Excellent, Barry! Thank you for working to improve healthcare workflow with information technology! In fact, I even have a special badge I give to the folks in the white hats, the cavalry, as it were, rushing to the aid of physicians ensnared in workflow-oblivious IT systems! See below...]

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Ebola, EHRs, and Evidence-Based Workflow: We Need Open and Transparent Healthcare Workflows

Thomas Eric Duncan, the Ebola patient released from Texas Health Presbyterian Hospital, died this morning at 7:51 a.m. The hospital first blamed a flaw in EHR workflow, but then retracted that claim the next day. Social media has been fractious. Basically, whether you like EHRs, as currently designed and implemented (”See, I told you so!”), or dislike EHRs, as currently designed and implemented (”Statement retracted, no flaw, case closed.”), predicted most reactions.

Unfortunately, I fear, we well never know for sure, the answer to the question, “”What did the EHR users know and when did they know it?” Barring some enforced Epic EHR contractual gag clause, accounts will be forthcoming. But, given the variety of strong biases many stockholders bring to the subject of EHRs and EHR workflow (and I am one of them), it seems unlikely that all will be satisfied. There are too plausible reasons why hospitals, EHR vendors, nurses, and physicians might be reluctant to potentially admit culpability.

We need an evidence-based workflow account of the complete who-what-why-where-when-and-hows sequence of EHR-mediated user activity that may, or may not, have contributed to Mr. Duncan’s release. The problem is, even if a blue-ribbon panel of experts, akin to the Rogers Commission that investigated the Challenger explosion, takes up the matter, current EHRs, of which Epic is emblematic, don’t represent workflow in a way that allows us to make the necessary inferences to explain what when wrong and who or what is to blame.

What do I mean by “represent workflow”? What I mean is, just as current EHRs represent data about patients and drugs and procedures and such, EHRs need to explicitly represent sequences of tasks (data gathering, order entering), the resources consumed (time, money, user attention), and, most important of all, the goals the tasks are intended to together accomplish. Why is representing goals so important? Because goals go to intent. Why was the nurse or physician trying to do when they clicked that button or spoke that command?

What I have just described — the explicit representation of tasks, resources, and goals — is how workflow management system work. True workflow systems, sometimes also known as business process management or dynamic and adaptive case management systems, execute or consult models of work and workflow to automatically do for users what would normally require users to do for themselves. Since these models are easier for clinical users to understand than computer code (Java, C#, Mumps, etc.) it’s easier for users to tell analysts how to design their preferred workflows. Sometimes precocious users even start tweaking workflows themselves. It makes them happier, to make workflow fit their work than make their work fit programmers workflow.

But here’s the important thing, EHR workflow systems leave a detailed, time-stamped trail of who-what-why-where-when-and-how users interacted with the EHR workflow systems. Right now, this kind of data is either absent, locked up in opaque event logs, or misleading, even if one were to be able to extract it. The very best event logs are generated by workflow management and business process management systems.

Even more important than open source and open data, is open and transparent workflow. I call this kind of EHR workflow “figureoutable” and “buildonable.” Mere mortals, who are not programmers, can figure it out and leverage it in ways that the original programmers might not have specifically imagined. These mere mortals include investigators trying to piece together what went wrong.

I’ve written several other blog posts about how process-aware EHR and public health IT systems might have operated to prevent Mr. Duncan’s release (see below). But even if even they will have failed us, they’d at least leave a trail of time-stamped workflow context from which to reconstruct past workflow and improve future workflow. So they won’t fail us the next time.

We, as a nation of patients, providers, payers, policy wonks, and politicians need more evidence-based workflow data, to create more effective, efficient, and safer workflows. We need the kind of open and transparent workflow that will only result from what academics call process-aware information systems.

If you’d like a well-received short course on workflow technology in healthcare, I can’t do any better than suggest my own five-part series:

BPM-based Population Health Management & Care Coordination: Workflow, Usability, Safety & Interoperability Perspectives

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Dear Mom, “Healthcare IT workflow & Business Process Management expert Chuck Webster”, Love Chuck

This blog post is a selfishly self-indulgent and self-promoting. But then, this *is* my personal website at ChuckWebster dot com. So if I can’t stick a selfishly self-indulgent and self-promoting blog post here, where can I stick it? (Don’t answer.)


Actually, there is a serious point. It’s in the PS. This post is just a place to archive some links and tweets, so I can send it to my Mom (Hi, Mom!).

Dear Mom,

I know that I’ve gone on-and-on for decades about workflow in healthcare and workflow technology and business process management and process-aware information systems. You’ve always nodded sympathetically. I’d just like to let you know that I’m finally starting to make progress in educating healthcare and health IT about this stuff! I’ve been quoted in national on-line health IT trade publications! Twice! I’ve included quotes of me essentially quoting myself, plus what are called “tweets”. Tweets are kind of a cross between email, blog posts, and test messages…. I know you know I tweet a lot. These are examples of tweets that I “tweeted out” or that mention me.

Anyway, thank you for your support, and for allowing me to explore whatever I wanted to explore while I was growing up.

Love Chuck

Bad EHR Workflow Played Role in Ebola Patient’s Release

“The real issue, to paraphrase healthcare IT workflow and business process management expert Chuck Webster, is a lack of process awareness. Today’s EHR systems – from Epic or any other vendor – can’t accept information from public health organizations at the point of care. If they could, that Texas Health physician would have seen that Duncan recently returned from Liberia, combined that knowledge with the symptoms Duncan presented and kept him in the hospital instead of sending him home. Building such process-aware systems will require ‘evolutions in workflow,’ Webster says.”

Hold on: Can we really blame Ebola in the US on an EHR?

““Process-aware systems have some sort model of work or workflow that is executable or at least mechanically consultable. Why do I say this? Because we, as a nation, need to be able to automatically, or at least semi-automatically push candidate workflows from public health organizations down to EHRs at the point-of-care,” Charles Webster, MD, wrote in a blog post. “And to do so in a way that supports, but does not disrupt, evolutions in workflow necessary to, say, flag someone who just came back from Liberia. The only way to do this is to actually model workflow. And to transmit these models of workflow via APIs….

Webster, in fact, suggested in an email exchange with Medical Practice Insider that the desired future state of EHRs should include getting the right patient data in front of the right person.

‘The context is essentially, what, who, where, when, why, and how (why I call it the journalistic model of usability). Of course, it’s a sort of back and forth dance, with the user initiating some workflows and the workflow engine initiating others,” Webster explained. “Much of the usability, safety, efficiency, and even interoperability of structured workflow-based EHRs and health IT systems requires the right platform (the workflow engine, graphical editor, workflow model combo) AND the proper programming of the workflow model by people who truly know the different clinical context and desirable workflows for each of those contexts.’”

My blog post Ebola, APIs & Workflow: We Need A More Process-Aware Health IT Ecosystem was even mentioned on Politico! (The online version of that free paper you see around when you visit me here in Washington DC.)


I’ve also appended a bunch of tweets after the following postscripts.

P.S. I’ve already weighed in about what role “workflow” may or may not have played in the unfortunate release of a patient infected with Ebola. You can review those blog posts here.

P.S.S. Careful with your comments. My Mom is reading this.

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If I Could Change One Thing About EHRs That Might Have Prevented Release Of The Dallas Ebola Patient

If I could change one thing about EHRs in general, it would be for them to be implemented on true workflow platforms, instead of the currently used structured document platforms. True EHR workflow systems have a workflow engine that does things for users automatically, saving them time and effort. Further, and possibly relevant to the Ebola vs. EHR case in Dallas, workflows can be created and customized by physicians, who know their workflows best. For example, a workflow definition could have been created that would have been triggered when the nurse entered the information the patient had traveled from Liberia. This workflow definition would have been executed by the workflow engine to do almost anything, from putting a work item into the physician worklist, to escalating to a text message to be sent to a supervisor if the work item was not completed within some short duration. Finally, this work item could have been posted to a generally visible status board, so all the members of the staff could know it was there. Patient data and task visibility is a big problem in many current EHRs, and workflow technology has a solution to this invisibility. Looking ahead, if we can model and execute clinical workflows, then we can transmit and monitor them as well. Eventually, public health entities will transmit candidate workflows to EHRs, to have useful effects at the point of care, but without the workflow disruption physicians find so troublesome. So, during the next Ebola-like crisis, public health departments will be able to broadcast actionable workflow to prevent the kind of mistake we may have witnessed in Dallas.

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HIMSS Amends Blog Post On Role Health IT Played In Discharge Of Ebola Patient

Boy did health IT social media buzz today regarding the possible role of health IT in the recent unfortunate release of a patient infected with the Ebola virus. I certainly weighed in, in my Ebola, APIs & Workflow: We Need A More Process-Aware Health IT Ecosystem. But I was small potatoes. Major papers reported a “flaw” in EHR workflow was being blamed.

And I tweeted the following, shown in the morning CNN news shows.

As the major trade and professional association representing health information management and technology, it was to be expected that HIMSS should weigh in as well. But what was interesting was they weighed in twice, deleting and replacing their first blog post with a second edited version. Here’s a comparison of the first version (left column) to the second version (right column). Differences are in blue.

The post was probably just accidentally published before intended. I’ve done that before. Most of the changes are just rewordings of the same basic ideas. But some of the changes are more interesting. First of all there’s the change in title.

First title:

IT Did Its Job in Dallas – But What About the Human Factor?

Second title:

Health IT Is Only a Portion of the Solution – Addressing Human Factors Are Key

And the following, from the first post:

“We are all paying very close attention to the situation and the role health IT may have played in determining the proper Ebola diagnosis. As we understand the circumstances, the separation of nursing and physician notes in the electronic record may have contributed to a lack of cross-team knowledge sharing. Communication in a busy emergency room, and between clinicians in any patient care setting, is vital to providing quality care. And health IT is only one solution. As we understand the circumstances to-date, the separation of nursing and physician notes in the patient’s record may have contributed to a lack of cross-team knowledge sharing. This presents an opportunity to explore the role health IT can, or should, play in determining a clinical diagnosis….The IT system at Texas Health Dallas did the job it was designed to do. Can it be improved? Absolutely, and it appears that they are working on that.”

Was replaced by this, in the second post:

“As we understand the circumstances to-date, the separation of nursing and physician notes in the patient’s record may have contributed to a lack of cross-team knowledge sharing. This presents an opportunity to explore the role health IT can, or should, play in determining a clinical diagnosis….First and foremost, communication is vital to providing quality patient care – whether in a busy emergency room or in a doctor’s office. Clinicians must be able to share information with each other across clinical disciplines and with their patients. Health IT is only one solution to the goal of cross-team knowledge sharing.”

The rest of the changes were, as I said, minor. But feel free to examine them as well.

So. What do you think?

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