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Someone contacted me with a challenge, “What’s so special about EHR workflow management systems and why can’t it be added to an existing EHR?”
Here is my answer:
Many EHRs are cumbersome, inflexible, and difficult to optimize with respect to their process workflow. Implemented correctly, an EHR workflow management system is graceful, flexible, and optimizable. If you understand the reasons for these advantages you will also understand why other kinds of EHRs cannot easily fix their problems. By the way, this is not to say that EHRs have not added important task management capabilities in recent years. However, this task management is typically based on “frozen” workflow.
By “cumbersome” I mean that most EHRs require expensive human users to do what should be done by less expensive combinations of software and hardware. Physicians don’t want to become data entry clerks; they just want to click once and as Star Trek’s Captain Picard says, “Make it so!”
By “inflexible” I mean there is no way for the user to easily improve task workflow in order to spend more time on value-added tasks directly benefiting patient and user. If an application requires a physician to click five times, four clicks of which are effortful and extraneous, there needs to be some sort of workflow or process editor to eliminate the four non-value added clicks that are wasting the physician’s time.
By “difficult to optimize with respect to process workflow”, I mean there is no way to systematically guide changes in EHR workflow so as to maximize patient satisfaction, clinical outcomes, and practice profitability goals. In contrast, processes driven by EHR workflow management systems can be analyzed through use of business process management (BPM) tools that suggestions ways to improve workflow processes. Workflow engines create workflow logs. These are step-by-step records of who clicked on what, when, where, and why. BPM tools can analyze these logs (through a technique called workflow or process mining) and suggest better workflows that will minimize non-value added tasks. This in turn frees human resources to be reallocated to value-added tasks that contribute to happier, healthier patients and greater take home income.
OK, fair enough, EHRs will need to incorporate WfMS technology. Why can’t EHR vendors just add workflow engines, process definitions, workflow logs, and process mining to existing EHRs? The word “workflow” has certainly been an EHR industry buzzword for the last five years. However, in the marketing din “workflow” has become almost meaningless. Yes, addition of messaging facilitates person-to-person coordination; interfaces make application-to-application coordination possible; and patient tracking is about coordinating the most important resource of all, patients. While these added capabilities can improve workflow, they aren’t workflow management. A workflow management system by definition requires a workflow engine that consults workflow or process definitions to drive tasks to people and applications. Tacking on messaging, interfaces, and tracking is a lot easier than picking up an EHR that does not rest on a workflow management system and then inserting beneath it a fully fledged workflow management system foundation, with its powerfully directive workflow engine, powerfully customizable process definitions, and powerfully analyzable workflow log.
Here is one way to think about “adding” a workflow management system to an existing EHR. When you look at a non-WfMS-based EHR you are looking at screens that are the result of a human programmer creating areas that will contain buttons and menus and so on, then placing these buttons and menus in these areas, and then connecting those buttons up with various functions and procedures that have also been created by a human programmer. This is why we need programmers in the first place; if it could be done more easily or less expensively we’d do it that way instead.
This is in fact what a workflow management system allows a non-programmer to do, to directly edit application workflow. Who creates the areas for the buttons, and then the buttons, and then connects the buttons with what happens when the buttons are pressed? The workflow management system does. You should now see why a workflow management system cannot simply be added to an existing computer application. The existing application was created by a human programmer. In order to add a workflow management system foundation you will have to replace the programmer with a workflow management system to regenerate the application. Therefore existing systems will need to be rewritten (by the very definition of how workflow management systems operate).
Several years ago we were giving a demo to a visiting physician who had happened to have taken some programming courses in college. During the demo the physician said, wait a minute, I thought you were going to demonstrate integration with my favorite patient questionnaire application. To which the user said, “Oops!” And then proceeded to pop up the process workflow definition editor within which he added the questionnaire task, set a couple of properties of that task, dismissed the editor, and then gave the demo again. This time the questionnaire screen popped up automatically at the intended step in the workflow. To which the visiting physician said, “I get it!” An EHR workflow management system is a development environment that lets non-programmers to create and edit their own EHR workflow systems. Exactly.
Adding a workflow management system to an existing EHR application would be like adding a foundation to a standing skyscraper or a hull to a floating ship. Many current EHRs will have to be rebuilt on top of workflow management systems foundations if they are to become the graceful, flexible and optimizable EHR systems that healthcare needs in the long run.
I have (somewhere) a copy of a several hundred page user manual for a typical document management system-oriented EHR. It has a hundred pages of chapters about workflow. These chapters tell an human user what to click, in what order, and in what circumstances in order to perform a variety of tasks. If you look at chapters about workflow for an EHR workflow management system, you will see that they are about editing EHR workflows so that these tasks happen automatically after a user just clicks the button and “fires and forgets.”
EHR workflow management systems are built on a foundation that can “Make it so!” This is the EHR workflow management system unique selling proposition *and* its barrier to entry for EHRs that are not workflow management systems.