EHR/EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow

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EHRs/EMRs have long been lauded for their potential contributions to legibility, decision support, and clinical research. They hold great promise for reducing medical error. However, until recently, EMR usability obstacles have not been sufficiently addressed. Typical EMR systems are not easy to use. Many physicians run small businesses. Anything that slows them down usually reduces their revenue. As a business proposition, EMRs must become not just comprehensive and accurate, but usable and fast. Lack of workflow management AKA business process management (BPM) capability is a major reason for many EMRs being difficult to use.


Usability is “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use.” However, in the case of EMR workflow systems, usability must be construed not only relative to single users, but also with respect to the entire team of patients, physicians, and clinical staff 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 EMR usability: naturalness, consistency, relevance, supportiveness, and flexibility. Workflow management concepts provide a useful bridge from usability concepts applied to single users to usability applied to users in teams. Each concept, realized correctly, contributes to shorter cycle time (encounter length) and increased throughput (patient volume).

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 EMR users in multiple roles. A patient visit to a medical practice office involves multiple interactions among patients, nurses, technicians, and physicians. Task analysis must therefore span all of these users and roles. Creation of a patient encounter process definition is an example of this kind of task analysis, and results in a machine executable (by the BPM 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 EMR 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 EMR user roles (related sets of activities, 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 application 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 EMR  workflow system represents and updates task status and responsibility in real time, this data can drive a display that gives all EMR 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 preferences.This obviously relates back to each of the previous usability principles. Unnatural, inconsistent, irrelevant, 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 EMR users may require different BPM process definitions, or shared process definitions that can be parameterized to behave differently in different user task-contexts.

The ideal EHR/EMR should make the simple easy and fast, and the complex possible and practical. Then the majority/minority rule applies. A majority of the time processing is 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!

(This post is based on material adapted from pages 12 and 13 of “EHR Workflow Management Systems in Ambulatory Care” from the published proceedings of 2005 HIMSS Dallas conference. I see that the PDFed PowerPoint is available on the HIMSS site here (as well as the technical paper).

P.S. 7/9/2009 While searching the Web for material on EHR/EMR, workflow, and usability I stumbled upon my own one page paper (for a poster) for the 2004 MedInfo conference in San Francisco. Archived here, for heaven knows what reason!

The following has got to be just about the most concise description possible of the relationship among these important usability principles and EMR workflow, which I suppose is what happens when you condense a five page paper down to a single page (including title and references!):

“EHR workflow management systems are more usable than EHRs without workflow management capability. Consider these usability principles: naturalness, consistency, relevance, supportiveness, and flexibility. EHR WfMSs more naturally match the task structure of a physician’s office through execution of workflow definitions. They more consistently reinforce user expectations. Over time this leads to highly automated and interleaved team behavior. On a screen-by-screen basis, users encounter more relevant data and order entry options. An EHR WfMS tracks pending tasks–which patients are waiting where, how long, for what, and who is responsible–and this data can be used to support a continually updated shared mental model among users. Finally, to the degree to which an EHR WfMS is not natural, consistent, relevant, and supportive, the underlying flexibility of the WfMS can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.”

Webster C. Workflow Management and Electronic Health Record Systems, Fieschi, M et al (eds.), Amsterdam: IOS Press, 2004, p 1904.

How I Became Interested In EHR Workflow Management Systems

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After a previous post on pediatric EMR workflow systems, I drew the following diagram to represent the relationship among medical specialty-specific workflow, EMR/EHRs, and workflow technology.


I was reminded of the original symbol of the Department of Health Management Systems (renamed from Health Information Sciences in 1995) at Duquesne University in Pittsburgh. In 1993 Sean McLinden, MD (Chair), Kathy Begler, MPM, RHIA (Assistant Chair), and I began the challenging but enjoyable task of founding a new academic department based on the interdisciplinary combination of medical, business, and computer knowledge and competence.


I devised the symbol of the Department of Health Management Systems based on a Venn diagram that represented my own academic degrees:

Health = MD (University of Chicago)
Management = BS, Accountancy/Business (University of Illinois, Urbana-Champaign)
Information Systems = MSIS, Intelligent Systems/Artificial Intelligence (University of Pittsburgh)

There’s also an MSIE, Industrial Engineering (University of Illinois, Urbana-Champaign) in the mix, which was invaluable as a model for combining technical and management curriculum content while also focusing on particular domain or industry vertical (I concentrated on human factors and healthcare).


We presented the results of our curricular development at the 1995 International MEDINFO conference in Vancouver, Canada. (Webster, C, McLinden, S, & Begler, K. “Why Johnny Can’t Reengineer Health Care Processes with Information Technology”, In R. A. Greenes et al. (editors), MEDINFO’95 Proceedings, pp 1283-1287.): abstract and illustrations. (Our title was based on the famous 1986 book  “Why Johnny Can’t Read”. If I were to republish or update it, I’d likely change the title to the unisex and more politically correct “Why Johnnie Can’t Reengineer Health Care Processes with Information Technology.”)

Previous to Duquesne, I had worked as a programmer in the MIS department at Shadyside Hospital, where Dr. McLinden was CIO. We created the FELIX clinical information system. (Webster, C, Pople, A, Silva, R., Wang, X, and McLinden, S, A Tcl/Tk based graphical interface to medical and administrative information, Proc Annu Symp Comput Appl Med Care. 1994; 992).

“FELIX is a front-end application processor, with an open systems back-end, that provides a uniform and intuitive interface to clinical and administrative information. It consists of an information browser, three clinical applications, and three management applications. FELIX was developed in a community hospital environment, but has conceptual and technical roots in medical informatics and the Internet.”

Here’s an annotated visual cheatsheet for FELIX’s functionality (click to enlarge):


Note that while FELIX was not a clinical workflow management system per se, it did combine clinical and management functionality (in common with EHR workflow management systems).  While developing FELIX we covered the walls of a large conference room with flowcharts on butcher paper. I think that is when I began to investigate workflow management systems (with which I was familiar due to my industrial engineering degree) with an eye toward their application in healthcare. There is a bit more about FELIX here (including annotated screen shots). FELIX was a remarkable application for 1992, foreshadowing in many ways the Web-based medical information systems that would appear almost a decade later; notice that we used SGML, from which HTML was derived, and created our own graphical browser because the first Web browsers were not released until 1993 (Mosiac) and 1994 (Netscape).

In 1993, the first lecture I gave at Duquesne was about the great potential for use of workflow management systems at the point of care. This potential essentially derives from empowering non-programmer EMR users to modify EMR workflow without requiring direct involvement of a programmer. I took screenshots of workflow management systems that were in use in other industries and relabeled buttons and edited icons to make them appear like various clinical workflow management applications. I essentially storyboarded the use of an imaginary application that I would today call an EHR workflow management system.

Over five years the Department of Health Management Systems enrollment went from five to a hundred and thirty and every graduate got a job (folks transferred into the undergraduate program their junior year, and the masters was two years long). (While poking around in my digital archives for the “Why Johnny Can’t Reengineer Health Care Processes with Information Technology” and FELIX materials, I found my original online syllabi: amusingly retro but they standup remarkably well to the passage of fifteen years. Perhaps they are worth a future post.)

For the last ten years I’ve given presentations and published articles in proceedings and trade publications about workflow-enabled EMRs, EMR workflow systems, and EHR workflow management systems. My intent has been and continues to be to educate everyone who will listen, but especially the practicing physicians who will benefit most from this technology, about the potential for workflow management systems (now increasingly referred to as business process management systems) to improve EHR workflow and usability.

This blog was instigated by my assessment that a number of trends are finally converging. Workflow management and business process management system technologies have matured and proven their use in a variety of other industries, and are poised to diffuse throughout healthcare. Issues of EMR usability and workflow have come to the fore: too many traditional (read non-workflow management system based) EMR implementations have failed; the rate of EMR adoption has been too slow, folks are beginning to figure out that the user isn’t the problem, it’s the technology. EMRs without sophisticated workflow automation foundations, tools, and infrastructure are not up to the job.

At the recent HIMSS conference in Chicago Dr. Armand Gonzalzles, a pediatrician who uses the EncounterPRO Pediatric EMR Workflow System, gave a great presentation about workflow management, EMRs, and primary care. Over three hundred attendees showed up early Sunday morning to hear his presentation (a larger attendance than I observed for any HIMSS presentation that was not a key note). However, even better than his presentation were the questions of the folks who lined up at the aisle microphone afterward (video interview with Dr. Gonzalzles about those questions here). What struck me was that they were not there to hear about EMRs (there were many other presentations at HIMSS on this subject), but rather they were there to hear about workflow management. They were there to hear about something new and different.

Most current EMRs, as they are currently constructed, are what Dr. Gonzalzles referred to as “hunt and peck” EMRs. The user must do a lot of “pecking” on buttons, tabs, menus, hot spots, and hyperlinks to figuratively drag an EMR through a patient encounter. In contrast, “anticipatory” EMRs (again, Dr. Gonzalzles’ excellently chosen word) anticipate what the user needs to do, and where they want to go next, because they can rely on a workflow engine to execute a custom defined process definition to pull the user (in a good way) through an encounter.

So, how did I get interested in EHR workflow management systems? I happened to get a bunch of (what at the time seemed) unrelated degrees (pre-med accountancy major?–come on!). And I was lucky enough to help design an innovative curriculum that practically reflected those degrees.

I feel like I now understand what  Søren Kierkegaard meant when he wrote, 

“Life can only be understood backward,
but it must be lived forward.”

Georgia’s Best EMR Used By Three of Top Ten Pediatricians

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Three of the top ten pediatricians listed in the July issue of Atlanta Magazine use the EncounterPRO Pediatric EMR (workflow system):

Dr. Byron Cotton of Kids & Teens Primary Healthcare of Atlanta

Dr. Prakash Desai of Cobb Pediatric Associates

Dr. Thomas Mahon of Snellville Pediatrics

Atlanta Magazine’s “Top Doctors” issue includes 165 physicians from 45 specialties. Castle Connolly, a New York based health research company, relied on a rigorous screening process to ask a randomly selected sample of local board-certified physicians who they would send their own children to for medical care.



Drs. Cotton, Mahon, and Desai’s impressive achievement prompted me to do some additional research into use of the EncounterPRO Pediatric EMR in Atlanta and Georgia.

I found this undated Clinical Information Technology Survey (archived here as well) conducted by the Georgia Chapter of the American Academy of Pediatrics. Of approximately 100 respondents, 28 used an EMR, of which 40% used the EncounterPRO Pediatric EMR. There were only three other EMRs used more than once, and they were used by only 10%, 7%, and 7% of the survey respondents respectively. Atlanta is a sophisticated medical and information technology market. Word of mouth as to which EMR to get is important, so I think this survey reflects extremely well on the EncounterPRO Pediatric EMR.

I am also reminded that several years ago M.D. News, a local magazine for physicians, conducted a survey of Georgia EMR companies and deemed the EncounterPRO EHR workflow management system the top EMR in Georgia. They subsequently did the excellent article “Wired! How Electronic Medical Records Have Transformed Duluth Pediatrician Jeffrey Cooper’s Practice”.


To do well in Georgia, whether you are a pediatrician or develop and market a pediatric EMR, is to do well in a state that does a lot of things rather well. We are both a beneficiary of, and contributor to, Atlanta and Georgia’s unique workforce, infrastructure, and business climate:

Best Managed State in the Southeast

No. 1 in U.S. for Workforce Training

Most Inexpensive U.S. City to Do Business

Second Fastest Growing City in America

Fastest–growing Port in the US (that’s sea, not internet, port!)

To which I’d like to modestly add:

Home of the Best (and Only) Pediatric EMR Workflow System

HIMSS Davies Award Winning EMR Workflow Systems

[10/31: I’m giving a free webinar on Wednesday, Nov 5th! It’s about the same EHR workflow tech that won the HIMSS Davies Award three times in a row! See you there! Give me a shout out on Twitter just before! Cheers! –Chuck]

The first two physicians in solo practice who won the most prestigious award for use of an EMR are pediatricians. They won the HIMSS Davies Award in 2003 and 2004. They do not use a traditional pediatric EMR. Instead, they rely on a pediatric EMR workflow system (based on an EHR workflow management system). A third physician who specializes in family practice, obstetrics & gynecology in solo practice has also won the Davies Award (2005) for his use of an EMR workflow system that combines family practice, obstetrics & gynecology workflows. (While I’ll focus on the pediatric EMR workflow management system functionality here, I will also refer to the family practice, obstetrics & gynecology EMR workflow system as it relates to shared primary care concerns. I’ll focus a future post on the 2005 HIMSS Davies award application.)


Dr. Jeffrey Cooper, MD, FAAP, has used an EMR Workflow System at Cooper Pediatrics in Duluth, Georgia, since 1995. Dr. Armand Gonzalzles, MD, FAAP has used an EMR Workflow System at RiverPoint Pediatrics in Chicago, Illinois, since 1999. Dr. Cooper and Dr. Gonzalzles won the HIMSS Davies Award in 2003 and 2004 respectively.

Dr. Cooper and Dr. Gonzalzles both provide the following pediatric services: well child care; immunizations; hearing and vision screenings; sick visits, minor injury management; nebulized aerosol treatment; and school, preschool, disability, and family leave forms.

Dr. Cooper Pre/Post Results Summary

Dr. Cooper increased billings 400% and revenue 271%, which resulted in an increase in practice profit of 100%. Average charges per visit increased 171%. Before implementing a pediatric EMR workflow system Dr. Cooper saw six patients an hour. After implementing the pediatric EMR workflow system Dr. Cooper saw eight to ten patients an hour, even during the busy flu season. Previous to implementation Dr. Cooper’s practice had been closed to new patients. Several years after implementing the pediatric EMR workflow system Cooper Pediatrics total active patient count had more than doubled. Charting time decreased from four minutes to less than one minute (including prescription writing). Total patient check-in to check-out time decreased 42%. Both telephone call and drug refill turnaround time decreased 75%. Quality review scores increased from 90% to 97%. Immunization rate increased from 90% to 99%.

You can find Dr. Cooper’s original HIMSS Davies Award application here.

 Dr. Gonzalzles Pre/Post Result Summary

Revenue increased 77.5%. Profit increased 90.8%. Charges per visit increased almost 50%. Patient volume increased 200%. Immunization rates increased from 50% to 95%. Using link from pediatric EMR workflow system to already in place practice management system:  collections increased from 52% to 88%, denied claims went from 30% to zero, and insurance turnaround time decreased from 30 to 60 days to an average of 15 days. Charting time decreased by 72%. Telephone and drug refill turnaround times went from 24-28 hours to 15 minutes (or less). Quality review scores increased from 65% to 95%.

Dr. Gonzalzles’ original HIMSS Davies Award application can be found here.

In each winning HIMSS Davies Award application the physician author specifically mentions the importance of the EHR workflow management system foundation that makes their pediatric EMR workflow system possible.

…workflow management system. This allows me to customize and streamline collaboration among providers and staff in ways that greatly improve practice efficiency. For example, while I am in the exam room with the patient, in addition to documenting, I am also directing and delegating. Staff members can prepare for procedures such as vaccines, aerosols, and injections before I even leave the room. We usually pass each other, me on the way out, they on the way in. I go immediately to the next patient, while they immediately perform their procedures. I don’t have to find them and I don’t have to tell them what to do. The EMR’s workflow management system takes care of that for me. (Dr. Jeffrey Cooper, MD, FAAP, Pediatrician)

The main advantage to EMR users of getting both a workflow system and a workflow management system—together—is that they can further customize the EMR workflow system to reflect their clinical needs, personal preferences, and business requirements. (Dr. Armand Gonzalzles, MD, FAAP, Pediatrician)

It is worth considering along side the above quotes the following quote from Dr. Harris’s 2005 winning HIMSS Davies Award application:

The EMR user interface is akin to the touch screen-oriented systems in restaurants: one screen at a time, with only the most relevant data displayed and options presented (although, of course, a user can always jump out of a particular screen sequence to accomplish an arbitrary task), and the sequences can be tweaked through the workflow management to make such occurrences infrequent…The workflow plans are tailored for each type of patient seen in the office (obstetrics, gynecologic, annual exams, family practice) assuring that key elements of the present illness, history and physical are addressed and documented. Work plans contain required laboratory tests for specific conditions, assuring that key tests are not forgotten. (Dr. Jeffrey Harris, MD, Family Practice, Obstetrics & Gynecology)

Dr. Harris’ original HIMSS Davies Award application can be found here.

All three HIMSS Davies Award applications speak eloquently for themselves, about dramatically increased “good” statistics (patient volume, active patients, revenue, profit, quality scores, and immunization rates) and just as dramatically decreased “bad” statistics (time to chart, wait time, check-in to check-out time, denied claims). All three winning applications explicitly attribute the success of their respective pediatric EMR and family practice, obstetrics & gynecology EMR workflow systems to the unique EHR workflow management system that serves as their foundation.

EMR Workflow Systems vs. EHR Workflow Management Systems

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I’ve added a new page to this website about “EMR Workflow Systems” (“EMR WfSs” to get it to fit on a WordPress navigational tab). By the way, there is an important conceptual (and practical) difference between an EHR Workflow Management System and an EMR Workflow System.

Just as workflow management systems are used to create and manage workflow systems–as discussed in Prof. van der Aalst’s book on workflow management systems–EHR workflow management systems are used to create and manage specialty-specific EMR workflow systems. This is similar, by analogy, to the way in which database management systems are used to create and manage database systems. Your baseball card collection database is a database system; it was a database management system, such as MS Access, that created and manages it.

“A workflow management system is a software package for the implementation of a workflow system. The term refers to a universally applicable system; in other words, a workflow management system is not customized to a specific business situation. By configuring such a system, it is turned into one which supports specific workflows. Unlike a workflow system, a workflow management system is a generic application.” (Page 357, Wil van der Aalst, Kees Max van Hee, Workflow Management: Models, Methods, and Systems, MIT Press, 2004.)

“A workflow system is one that supports the workflows in a specific business situation. Unlike a workflow management system, a workflow system usually consists of a workflow management system plus process and resource classification definitions, applications, a database system, and so on. We can compare the difference between a workflow management system and workflow system to that between a database management system and a database system.” (Page 357, Wil van der Aalst, Kees Max van Hee, Workflow Management: Models, Methods, and Systems, MIT Press, 2004.)

When you fill an EHR workflow management system with specialty-specific content (such as specialty-specific picklists of symptoms, physical findings, assessments, treatments and so on), add specialty-specific screens for (using pediatrics for example) immunization management, growth tracking, developmental checklists, rely on pediatric-specific functionality such as pediatric dosing and data norms, *and* create the necessary pediatric-specific workflow definitions (also known as process definitions), the result is a pediatric EMR workflow system. Different specialty-specific picklists, screens, other functionality, and workflow results in a different specialty-specific EMR workflow system.

So far I think I’ve done a good job of posting about the general (that is, universal) characteristics of EHR workflow management systems (for example, “What’s So Special about EHR Workflow Management Systems?” and “Litmus Test for Detecting Frozen EHR Workflow”) while touching on EHR business process management as well. However, while EMR customizers (“customizers”, not “customers”)  interact directly with an EHR workflow management system (three words!), physicians, physician assistants, nurses, technicians, and administrative staff typically do not. They interact directly with the EMR workflow system (two words!) that pops out when you turn the crank on the EHR workflow management system.

That’s the difference between an EMR (or EHR) workflow system and an EHR (or EMR) workflow management system.

Walking the Fine Line between Marketing and Education

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The title of this blog is “Electronic Health Record Workflow Management Systems” and I work for a company that develops and markets an EHR workflow management system [CW: true then, not now, insights still hold]. How much should you trust what I have to say about the subject?

Good question!

Last week I compared a bunch of identical apples to a juicy orange. I labeled the apples “EHRs” and the orange “An EHR WfMS”. I think my point was pretty obvious; most EHRs are as similar as apples but EHR workflow management systems are so different from EHRs that comparing the two is almost like comparing apples and oranges. I included the EncounterPRO logo above the orange because EncounterPRO is a good example of an EHR workflow management system.


I received two sorts of comments (although I wish folks would post them instead of calling or emailing them!): the professorial “Chuck, that looks like an advertisement.  Since you have an educational site, the commercial bias seems out of place and undermines your educational mission,” and the more partisan “Chuck, couldn’t you make those apples more sour and wormy looking?”

For years I’ve occasionally given a stock presentation with the title “Walking the Fine Line between Education and Marketing.” Its genesis was in the very first two presentations I gave at a trade conference. After the first presentation, the survey comments came back “Too commercial!” and “Infomercial!” I retooled and the comments came back “Excellent!” and “Very educational!” but also “Didn’t tell me where I could find a product with the described characteristics.” I began to wonder about the fine line between marketing and education.

1motivational_sequence3Above is one of the slides (based on Monroe’s much cited Motivation Sequence) from the resulting presentation. The column on the right is my application of Monroe’s motivational sequence to selling an idea, not a product.    

In the presentation I define a number of terms–selling, advertising, marketing, editorializing, informing, and educating–lying along a spectrum of benefit to the vendor versus benefit to the audience, and point out that there are many areas of overlap. In order to educate one has to persuade; in order to sell one has to educate, etc. The trick is to find a presentation that maximizes benefit for *both* the audience and a presenter.


This is a version of the disclosure slide that I recommend (although, of course, specific conference instructions and policies regarding disclosure take precedence). It accomplishes two very important goals. First, it of course alerts your audience to take what you have to say with a grain of salt. Second, if in fact they find your talk informative and persuasive, they sometimes take the next step and ask if you happen to know of a product that is a good example of what you are talking about. A classic win-win presentation.

4_savvy_audienceThe average adult American has seen more than a million ads. We are appropriately wary and skeptical about any and all information sent our way. We also understand there is unspoken quid pro quo. If someone respectfully provides valuable information, we usually extend to them the right to implicitly and discreetly ask for our consideration of their product. This is the essential principle behind the “White Paper.”

Back to that EncounterPRO logo:

First, a blog reader can easily hit the back button, whereas formal presentations to (relatively) captive audiences necessarily have different and stricter rules of speaker etiquette.

Second, health information technology conferences often stipulate that a company or product logo can appear no more than N times, which I interpret as permission to use a logo up to N times. So logos do indeed appear once in a while in education materials.

Finally, this is a blog. Blogs are (or are at least expected to be) more informal and authentic than stand-up trade industry presentations. I initially intended to display just the apples and the orange, but there was this inviting empty white space above the orange. Acting on impulse (an informal and authentic act) I inserted the EncounterPRO logo, with its randomly placed dots on the left representing chaotic workflow and its inline dots on the right representing orderly workflow.

To answer the question I asked at the beginning of this post. If I provide interesting and useful information about EHR workflow management systems, respect you and your intelligence, and disclose my self-interest; I suspect you can answer the question yourself.