Automate Your EMR Cow Paths *and* Reengineer Them Too!

Short Link:

Last Wednesday I attended a conference on “The Economic Stimulus Package and Healthcare Technology: How Will the Stimulus Money Flow and How Can You Prepare?” at Georgia State University. (Details at the end of this post.) There were over 300 attendees. Many of the people that I met were new to healthcare, but drawn to it by news of the pending federal stimulus monies for HIT. I agreed with and greatly appreciated *almost* everything that I heard.

My only quibble was the shared sentiment (expressed at the conference and frequently elsewhere) that getting physicians to change their workflow is one of the biggest barriers to EHR adoption.


Michael Hammer’s 1990 “Reengineering Work: Don’t Automate, Obliterate” Harvard Business Review article popularized the analogy that automating existing processes is akin to paving a meandering cow path instead of what should be done, which is to create a road that proceeds straight from point A to point B.  When successful, the results can be substantial increases in effectiveness and efficiency. However, business process reengineering failure rates have been reported to be 50 to 70 percent (or higher, given natural human reluctance to admit or publicize failure). User resistance is often blamed. Similar levels of failure have been reported for EMRs (this 2006 study is representative). The basic problem is that implementing *most* EHRs is an act of reengineering, and reengineering is a high risk endeavor.

A good way to explain this success rate is through use of the classic Thesis-Antithesis-Synthesis method of using a contradiction to motivate conceptual innovation:

  1. Thesis: “Instead of embedding outdated processes in silicon and software, we should obliterate them and start over.” (Hammer, 1990)
  2. Antithesis: There are many, many reasons people resist change, and not all of them are bad.
  3. Synthesis: Automate the cow paths (so as to minimize the psychological shock of automating previously manual processes) and then systematically but gradually straighten and widen these paths until a straight and wide digital superhighway is attained.

How is it possible to “systematically but gradually” improve automated workflows? First implement workflow management system process definitions that fit the way workflow is already being accomplished. Second let users get used to the new technology. And third, only then gradually change the process definitions that determine EHR behavior at a rate that is no faster than can be tolerated. The workflow management system foundation, with its workflow engine that executes easily changed process definitions provides the means to accomplish process changes that do not require rewriting and recompiling software code. The business process management layer provides the means to systematically optimize process effectiveness, efficiency, and flexibility. (More on EMR BPM in this previous post.)

To summarize my main point:

Using EHRs that are easily molded to existing physician workflows, which can then be systematically improved while respecting normal human tolerance for change, is the key to EHR adoption.

Here is a bit more info about the excellent conference that provoked this post:

“The Economic Stimulus Package and Healthcare Technology:
How Will the Stimulus Money Flow and How Can You Prepare?”

Technology Association of Georgia,
Georgia Health Information Exchange, and
Georgia Chapter of the
Health Information and Management Systems Society

May 14, 2009,
Georgia State University
Atlanta, Georgia

Could You Do Me a Favor? “Electronic Medical Record Workflow Management: The Workflow of Workflow”

Short Link:

Could you do me a favor?

SERP stands for Search Engine Result Page. A white paper I wrote in 2003 about EMRs and workflow has consistently had a Google SERP rank = 1 for the search terms “EMR” and “workflow” (out of 177,000 total hits, when I most recently checked, see below).


Over the past decade I occasionally queried Google using the search terms “EMR” and “workflow” (and then also “EHR” and “workflow,” as “EHR” became increasingly popular, though “EMR” continues to outnumber “EHR” two or three to one). At first I was just interested in what was out there and wanted to make sure I read all the relevant material I could access. Periodically I’d repeat the search to make sure I caught any new material that appeared since last I searched.

[9/24/12 Update: The next link doesn’t work because the domain is gone. However, the link to a copy of the paper on my blog still works. However, not matter what you search for in Google, that working link is gone, gone, gone….]

After a while I started to find my own material. The 2003 white paper I wrote called “Electronic Medical Record Workflow Management: The Workflow of Workflow”drifted towards the top of the Google search engine results and eventually occupied the first position on the first page of links that Google presents in response to the query of “EMR” and “workflow”. (However, please note the P.S. below dated 6/11/2009, below!)

If you have read this far, you may be thinking: “What’s the favor?” and perhaps even “This guy is a bit obsessive!” In my own defense, I think that “EMR” and “workflow” are important search terms. First, I find much of the material on the Web that includes these terms to be potentially interesting. Second, if someone uses these terms and informs themselves about the subject, I think this is a good thing (the value of an informed public and all that). Third, if someone reads the “Workflow of Workflow” white paper, they may become interested in the EMR (now EHR) workflow management system that illustrates the ideas explained in the white paper.

Since a document’s SERP rank in Google is in large part determined by who links to it and resulting traffic, I guess I have only one thing left to say:

Could you do me a favor?

Please click on the following link: and then click on the link to the “Electronic Medical Record Workflow Management: The Workflow of Workflow” white paper (a PDF document) returned by Google’s Search Engine Result Page. (Better yet, also add a link to it from your web site please!)

Thank you!

P.S. (6/11/2009) Not willing to leave well enough alone, as an experiment I used a 301 permanent redirect to move the white paper from its old location to

and its search position dropped like a rock. Oh well! It was fun at the top of the Google search engine result position heap while it lasted. (Maybe it will crawl back up, or maybe it won’t. It will be interesting to observe.)

P.S. (6/21/2009) Cool! It worked. Never mind.

Video Interview Dr. Armand Gonzalzles: BPM and EMR Workflow Management in Primary Care

Short Link:

We caught up with Dr. Armand Gonzalzles, a Chicago-based pediatrician, after his recent presentation at HIMSS to conduct a short (eight minute) video interview, in order to explore some of the excellent questions from his audience.

Dr. Gonzalzles starts off with some general observations about EMRs, workflow management, and business process management, and the need for healthcare to catch up with other industries that are more advanced in their adoption of these technologies. He then addresses the following questions:

  • How did your patients react to use of an EMR?
  • Is it easy or hard to change your office workflows?
  • How long have you been using the an EHR workflow system and have you ever been tempted to change?
  • Is it difficult to keep the system up to date with respect to codes and drugs?
  • Have you integrated patient education into your workflow? Does it save you any time?
  • Could you share some general impressions about the impact of a BPM-style EMR workflow management system on your return on investment, patient satisfaction, and personal workload?

[flv: 320 240]
I am especially intrigued by Dr. Gonzalzles’ use of the phrase “business process management,” because BPM has so much to offer to the optimization of clinical outcomes, patient satisfaction, and practice profitability (particularly as EMR workflow management systems evolve into full-fledged EMR business process management systems).

P.S. (Update) I believe I was the first to present and write about an in-production EHR workflow management system, what might be called an EHR BPM system today, at the 2000 HIMSS conference in Dallas. I gave a similar presentation at the 1999 MS-HUG conference, though there was no published paper. There is, however, a blog post about the 2000 presentation, with links to the proceedings paper. From that blog post:

“In three ways, [the 2000 HIMSS presentation and paper] prefigured developments that are beginning to affect collective thinking of the HIT industry today:

  • Workflow management systems (business process management today)
  • Computer-supported collaborative work (groupware and workflow systems today)
  • Componentized EMR architecture (software modules/plugins and service-oriented architecture today)”