A White Paper About EMR Workflow, Usability, and Productivity in Pediatric and Primary Care

Short Link: http://j.mp/6vd4Zp

This letter to the New York Time’s editor about the adoption of traditional EMR systems in primary care sums up the problem:

“A high-volume, low-margin business like primary care medicine simply cannot support the costs. These include both the very high dollar cost of buying and maintaining a system and the huge drop in productivity that initially accompanies implementation.”

However, EHR workflow management systems, EMR workflow systems, and business process management technologies are ideal for high-volume, low-margin businesses such as ambulatory pediatric, family medicine, and obstetrics and gynecology practices. They can be more quickly and inexpensively deployed than traditional EMRs and they dramatically increase, not decrease, productivity.

My 2003 white paper “Electronic Medical Record Workflow Management: The Workflow of Workflow,” which includes results from a survey of primary care practices documenting a workflow automation-induced productivity surge, has garnered a lot of web traffic over the years. With all of the published news articles and conversations on the Web about productivity and usability and workflow being major obstacles to EMR adoption, I decided to update that 2003 white paper by adding a companion titled “Pediatric and Primary Care EMR Business Process Management” . Everything in the original “Workflow of Workflow” paper is still true and even more relevant today. However the HIT industry have evolved a lot in the past six years. Portions of this twelve page white paper are unavoidably somewhat technical in places, so this post is a shorter and less technical summary of its major points.

There is also the recent related post, “The Cognitive Psychology of Pediatric EMR Usability and Workflow,” about human perceptual and decision making information processing constraints that motivate use of EMR workflow systems.

I’ll start with the abstract, quote or summarize the most interesting material, throw in a few screen shots, and voila: the Reader’s Digest version of “Pediatric and Primary Care EMR Business Process Management: A Look Back, a Look Under the Hood, and a Look Forward.”

Pediatric and Primary Care EMR Business Process Management:
A Look Back, a Look Under the Hood, and a Look Forward

Abstract. We describe an ambulatory electronic health record (EHR) workflow management system (WfMS)—employed to create a high-usability pediatric electronic medical record (EMR) workflow system—that is currently in use by 4000 users at 300 medical offices and has been deployed since 1995. WfMS features and functionality include a workflow engine, workflow process definition editor, and a universally viewable annotated worklist that represents patient location and task status in real time. Clinical data flow into and out of the EncounterPRO Pediatric EMR Workflow System via the EncounterPRO Health Information Exchange (EPHIE, HIE) automatically and inexpensively due to coordinated workflow management across EMR and HIE subsystems. Business process management (BPM) add-on modules address the three most important dimensions of ambulatory EMR value: clinical performance, patient satisfaction, and practice profitability. Written physician comments about the resulting electronic medical record (EMR) workflow systems (two pediatric and one obstetrics, gynecology and family medicine) from three award winning case studies support the importance of workflow or process-aware EMRs to successful EMR deployment.

We distinguish between EHR workflow management systems (WfMSs) and EMR workflow systems. Just as a database management system is used to create and manage a database system, a EHR Workflow Management System is used to create and manage a EMR Workflow System (and the Family Medicine EMR Workflow System and Obstetrics and Gynecology EMR Workflow System, and so on).

When business process management (BPM) functionality is used to systematically optimize EMR workflow processes with respect to clinical performance, patient satisfaction, and practice productivity, we will speak generally about EHR business process management. However, during day-to-day EMR operation, users do not interact directly with either EHR WfMS or EHR BPM functionality (which are chiefly intended for use by EMR workflow system designers). When pediatric or other primary care EMR workflow system users access, rely upon, or benefit from BPM system functionality, we refer to that as EMR business process management (hence the title of this white paper).

EMR workflow systems are more usable than EMRs without workflow management capability. Consider these usability principles: naturalness, consistency, relevance, supportiveness, and flexibility.

  • EMR workflow systems more naturally match the task structure of a specialist’s office through execution of specialty-specific workflow process definitions.
  • These definitions consistently reinforce user expectations. Over time this leads to fast and effective interleaved team behavior.
  • On a screen-by-screen basis, users encounter more relevant data and order entry options.
  • An EMR workflow system tracks pending tasks in real time—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 EMR workflow system is not natural, consistent, relevant, and supportive, the flexibility of the underlying EHR workflow management system can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.

In other words, specialty-specific EMR workflow systems based on EHR workflow management system foundations are more usable than traditional EMRs that are not based on workflow management system foundations.

EHR Workflow Management System Functionality

 An EHR Workflow Management System includes a large number of optional data review and entry and order entry tasks. For example, Figure 1 shows the Chief Complaint screen.

chief_complaint1

Figure 1:Typical EMR Workflow System Screen
(Chief Complaint)

A subset of these tasks are selected to create a workflow process definition (sometimes called a workplan). In this example (Figure 2) the workplan is a pediatric workplan for “Standard Encounter Child Well Visit New Patient.” The Chief Complaint screen occurs as the third step in this workplan. A collection of specialty-specific workflow definitions configures a specialty-specific EMR Workflow System.

 workplan_standard_enccw_well_visit_new_pt

Figure 2: A Process Definition (“Workplan”) Controls
Presentation of Screens to Users

During workplan execution the Chief Complaint task time is automatically and continually updated in the office view (Figure 3). It can be seen as the pick item in the upper left. It has been languishing (in this demo situation) for 29 minutes. Touching the task bar brings up the Chief Complaint screen in order to complete it (back to Figure 1).

office-view

Figure 3:EMR Workflow System Office View

By automatically pushing specialty-specific task screens to the right users (on their To Do lists) and by indicating their status in real time on the office view where all staff can see them, tasks are accomplished quickly and the occasional ignored task is ignored only briefly. Workflow-oriented EMRs sometimes call this an Office View. Usability engineers refer to them as radar views, an airport control tower analogy.

EHR Business Process Management Functionality

Workflow or process-aware information systems—workflow management systems, business process management, monitoring, mining, and modeling systems—have great potential to address the central issues of healthcare reform: identification of best practices, coordination of care amongst providers and patients, and consistency across healthcare delivery processes. EMR users are increasingly asking for means to systematically improve the effectiveness and efficiency of a wide variety of EMR mediated processes. Goals include improved clinical outcomes, more satisfied patients, and increased practice profitability. Business process management ideas, techniques, systems and modules are relevant to all of these goals.

(The white paper also reviews the workflow management aspects of three HIMSS Davies winning applications for two pediatricians and one physician with a combined obstetrics, gynecology, and family medicine practice. If you’re not going to read the white paper, there is a previous self contained post about the award winning use of Pediatric; Obstetrics, Gynecology; and Family Medicine EMR Workflow Systems.)

Current developments in business process management are relevant to where EMRs and EHRs need to go, workflow-wise.  A number of trends are 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 productivity, usability, and workflow have come to the fore: too many traditional EMR implementations have failed due to problematic workflow and decreased productivity and EMR professionals are beginning to realize that the user isn’t the problem; it’s the usability of the technology (although we acknowledge the honest debate on this topic). And productivity, usability, and workflow are inextricably intertwined.

EMRs without sophisticated workflow automation foundations, tools, and infrastructure are not up to the job. Non-workflow-management-system-based EHRs are difficult to optimize in a business process management sense. Their workflows are highly constrained by the initial design decisions of their respective programmers. Their lack of easily changed workflow process definitions makes it difficult to systematically improve their workflows with respect to the wide variety of goals that motivate use of ambulatory EMRs.

The EHR Workflow Management Systems (and the workflow systems they create and manage, for pediatrics, family medicine, obstetrics and gynecology, etc.) are an example of a new class of process-aware ambulatory EHR/EMR software. This next step in the evolution of ambulatory EMRs is squarely at the intersection between two great software industries: electronic health record systems and workflow management/business process management systems. The hybrid EMR workflow systems that result will be more usable and more systematically optimizable than traditional EMRs with respect to user satisfaction, clinical performance, patient satisfaction, and practice profitability.

That’s the Reader’s Digest Condensed version. Whether you read it or not in the loo (as my British accented wife calls it, I hear that Reader’s Digest is popular there), well, I’m honored either way. (Maybe I’ll release it in Large Print Format too.)

EMR Featuritis, Usability, and Workflow: A Video

Short Link: http://j.mp/5CRUr8

Today’s trend is to add more and more EMR features. At first only the most important features are created and special attention is paid to simple and elegant usability. However, each additional feature adds less and less value, until adding features actually reduces the total value of having a EMR in the first place.

featuritis_curve

This phenomenon of feature creep or “featuritis” is well known. It is:

“the proliferation of features in a product such as computer software…Extra features go beyond the basic function of the product and so can result in baroque over-complication rather than simple, elegant design.”

and

“adding feature upon feature until the simple things you used to do are no longer simple, and the whole thing feels overwhelming…

The solution to “featuritis” is to:

Give users what they actually want, not what they say they want. And whatever you do, don’t give them new features just because your competitors have them!”

The following short three minute video illustrates the point (timed transcript below if you’d prefer to skip the video). The actual charting of a simple straight forward pediatric encounter only takes 37 seconds, from start to end. One pediatrician I know famously says “If I can’t chart a routine otitis media encounter in under 30 seconds, I know something is wrong!” (As in, the server is slow today, tell someone to fix whatever needs to be fixed.)[flv:http://www.chuckwebster.com/video/pediatric-emr-37-sec-chart-encounter/EproPeds3min320x240.flv 320 240]

By the way, the comment that using a finger instead of a mouse takes only a third of the 37 observed seconds only initially seems implausible. There are 17 clicks. Can you tap your finger 17 times in 12 seconds? Certainly you can. Wait, you protest, what about tapping a finger in *different* places? Nope, can still be done in 12 seconds. Musicians do this sort of thing all the time. As noted in a previous post, the cognitive motor skills necessary for data entry in a pediatric EMR workflow system more resemble that of a piano player than a knowledge worker. (By the way, I’m planning on a future post that critiques EMR data and order entry from the point of view of psychological models of musical cognition, learning, and motor skill.)

piano_hands_keys

I’ve nothing against ten minute-plus on-line demos of every jot and tittle of what a pediatric EMR can do. Back in 2002 it took an act of congress to get an EMR demo (the basic issue was that folks resented having to register and provide lead information *before* they even got to see a demo and decide whether or not they wanted to provide their personal information). I believe that my “one click” demo of a pediatric EMR workflow system pioneered the self-running browser-hosted voice-narrated EMR demos that are now common (note the “Version 4.0.02 (10/23/2002”). (Send me a link if you know otherwise.)

What most pediatric EMRs miss is the common sense rule that the simple should be easy and the complex possible. But making the complex possible should not make the simple hard. That is the lesson of the need to avoid the downhill slope side of the EMR Featuritis Curve.

Whether for the search engine robots, for purposes of improved Web accessibility, or just for the speed readers who find videos an inefficient use of their time, here is the time-tagged, color-coded, word-for-word transcript of 37 seconds to chart a routine pediatric encounter.

Time
0:00 Let’s chart a patient!
0:03 The set up is that the nurse has already seen the patient, brought him back to the examination room, taken a chief complaint, taken vital signs, and has completed her job
0:16 I’m finishing up with the patient in exam room four, I look at my office view screen, and I notice that Tommy Smith in room one has been waiting the longest to be seen by me, that’s how I know who to go see next
0:30 I open the chart and I notice that Tommy has a sore throat and his temperature is 102 and that his strep is positive
0:39 It’s time to go see the patient
0:41 I open the door, introduce myself and start examining the patient while taking a bit more history from the mother
0:50 After examining the patient I formulate a diagnosis and treatment
0:57 Now it’s time to chart the patient
1:01 So let’s look at our watches (everyone with a second hand) let’s go ahead and start…
1:07 …NOW…
1:08 I open the chart
1:13 Chart my physical exam, my pharyngitis exam
1:19 Chose my diagnosis of strep pharyngitis
1:25 Make my treatment duracef and follow up in 3 days
1:31 Write my prescription
1:33 Edit my follow up if necessary
1:37 Have created a beautiful chart
1:42 Check my billing
1:44 And I’m finished
1:45 (Audience: Exclamations, 37 seconds! Wow!)
1:50 As you can see I did this with a mouse in 37 seconds
1:56 In reality, with a finger or a stylus you can do this in about a third the time
2:03 I know this because when I’ve looked at timed studies of our current physicians’ charting at pediatrics or family practice, the average chart for a sick visit is 28 seconds.
2:20 Not bad!
2:22 A well visit is actually around 55 seconds, there’s more to chart! Make’s sense.)
2:30 Our physicians can chart quickly, they can chart accurately, and more efficiently. The end result is that patients move through your practice much faster, creating the opportunity to see more patients, spending more time with individual patients, or going home early
2:58 Thank you!

P.S. Less is more.

The Cognitive Psychology of EHR/EMR Usability and Workflow

Short Link: http://j.mp/7fbVl1

Which targets are easier to hit quickly, accurately, and repeatedly? Small checkboxes or large buttons?

fitts-law-checkboxes-vs-large-buttons1

If this was an interactive Flash demo, I’d give you some instructions about what to click in what order and then present back to you some speed and error statistics. Since it is not a Flash demo–yet–at the end of this post, I provide a link to a more sophisticated online demo of Fitts’s Law that does exactly that.

For one year as a graduate student in Industrial Engineering, I worked as a programmer at the Coordinated Science Laboratory at the University of Illinois in Champaign-Urbana on an aviation human factors project studying pilot error. (Workflow related, perhaps worth a post. The other year I worked on a computer simulation of patient workflow through the student health center. Also workflow related and perhaps worth a post.) Professors Bill Rouse and Christopher Wickens (Aviation Research Lab) and their graduate students met regularly to present and discuss their research. There is where I first encountered two psychological laws that are highly relevant to high-productivity heads-down data input and order entry, which means they are highly relevant to pediatric EMR workflow systems.

Fitts’s Law: “The time required to rapidly move to a target area is a function of the distance to and the size of the target.” (Wiki article on Fitts’s Law. Paul Fitts was an Air Force psychologist.)

Hick’s Law: “The more choices you have to choose from, the longer it takes for you to make a decision.” (There’s a Wiki article, but this one on a Taekwondo site is a lot more fun. At one time or another who hasn’t wanted to “strike or break with a fist” some badly designed piece of software?)

In human factors speak, an EHR button or checkbox or tab is a “target.” Why do toys and senior-friendly products have just a few large buttons? Because these large targets are easier to “acquire” (press, click, touch, etc.) quickly and accurately than smaller ones.

big-button

Applied to EHR/EMR user interfaces, Fitts’s and Hick’s laws translate into “lots of small buttons all over the place are incredibly time consuming, frustrating, and error prone.” This is why the EMR workflow systems have just a few large consistently placed buttons on each screen.

How, might you ask, can EMR workflow system present *enough* buttons to a physician so that they can enter all the data and orders that they need? Funny you should ask…instead of just a few big screens containing many small buttons and checkboxes and so on, we spread larger buttons (and no checkboxes, not a one) across many screens. How, might you ask, are you expected to navigate to the right screen at the right time in order to click on the right button? Again, funny you should ask…for each specific situation (well child visit, sick child visit, vaccination, etc.) we present the right screens in the right sequence back to you in a way that mirrors the natural order of the tasks you need to accomplish. That is what a workflow management system does (among many other valuable services). It is intrinsic to its nature. It does the scut work of navigating to the next screen for you.

One physician who uses the an EMR workflow system dismisses non-workflow automated pediatric EMRs as “hunt-and-peck” EMRs, because users have to hunt and peck (click) in order to figuratively drag the EMR through a patient encounter. He calls his EMR workflow system an “anticipatory EMR” because, like a good OR nurse,  it anticipates what you want to do next and hands you the right data input or order entry tool to accomplish it quickly and without error.

Another pediatrician who uses an EMR Workflow System was a pre-med music major. It is rather uncanny to watch him “play” his EMR. Picklists are large wide buttons reminiscent of piano keys (rotated 90 degrees). He sort of turns his hand so that one finger strikes one key on one screen while another finger strikes another key on the next screen and so forth in quick succession. Data and order entry in a pediatric EMR workflow system relies on cognitive and motor skills more similar to that of a musician than a knowledge worker.

I’ve been at this for a long time. In 1991 I wrote the following comment about EMR usability and workflow (originally published in the Journal of Medical Practice Management, but reprinted here, page 11). In light of slow EMR adoption rates that are due in large part to slow EMR data input and order entry, the comment is even more relevant today:

The choice of touch screen technology and large icons deserves some comment. A major motivation for using a structured data entry approach is not just to obtain structured data but also to increase the speed of data entry. Fitts’s Law [5] is a mathematical model of time to hit a target. It basically says that larger targets are easier, and faster, to hit. Fitts’s Law seems obvious, but it is often ignored when designing electronic patient record screens because the larger the average icon, button, scrollbar, etc., the fewer such objects can be placed on a single screen. A natural inclination is to display as much information as possible; EPR screens are thus often crowded with hard-to-hit targets, slowing the user rates of data entry and increasing associated error rates.

Fitts’s Law, in conjunction with constrained screen “real estate,” suggests use of a few, large user-selectable targets. Displaying fewer rather than many selectable items tends to increase the number of navigational steps, unless some approach is used–such as a workflow system–that automatically and intelligently presents only the right structured data entry screens.

In our opinion, the combination of structured data entry, workflow automation, and screens designed for touch screen interaction optimally reduces inherent tradeoffs between information utility and system usability on one hand, and speed and accuracy of data entry on the other. Successful application of touch screen technology requires that only a few, but necessary, selectable items be presented to the user in each screen. Moreover, workflow, by reducing cognitive work of navigating a complex system, makes such structured data entry more usable.

I couldn’t have put it better myself. (I do know that quoting oneself is pretty darn self indulgent, but, hey, this is a blog.)

By the way, here is that really cool interactive flash demo of Fitts’s Law that I referred to earlier (and a screen shot from that demo).

fitts-law

I’m thinking about doing something similar in Flash with respect to simulated data input and order entry using a simplified EMR user interface. There would be two versions: (1) A single screen with a hundred small buttons in a ten-by-ten grid, and (2) a succession of ten screens with ten large buttons apiece.  Similar to the interactive demo of Fitts’s Law, buttons would flash and the user would try to click the indicated button as quickly as possible (“cued target acquisition” in human factors parlance). After clicking ten buttons the total time and error rates would be displayed. (Dear medical informatics student, this sounds like a fun project, send me a link when you are done and I’ll post it.)

With apologies to the human factors community:

There once was a pilot named Fitts:
“Large targets are more easily hit.”
    His words became law:
    “Small is a flaw!”
And target for my doggerel wit.

(Doesn’t sound too bad if you slightly deemphasize the “s” in “Fitts”.)

P.S. There is more about EMR usability and workflow in a previous post: “Pediatric EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow.”

A Conversation About EMRs, Workflow, Usability, and Productivity

Short Link: http://j.mp/6vyEuD

Frank Martin posted a comment to one of my earlier posts that triggered the following conversation. I am “promoting” this conversation to a full fledged weekly post because I think its content deserves it. (And maybe just a little because this is a holiday weekend.)

conversation

Frank: We here at EncounterPRO have become very comfortable with the term “Workflow Management”, but I am not sure that everyone in our market is familiar with the term and its meaning in the context of the practice of medicine. At its most basic, Workflow Management is “organizing the way things get done inside a process to insure all of the goals set for that process are accomplished”.

Chuck: That is a good common sense explanation of the benefit of workflow management. However, the technical means by which this benefit is accomplished is very different between traditional EMRs and EMR workflow systems. Traditional EMRs are structured document management systems. While more and more traditional EMRs are adding task management, this is relatively frozen workflow. Without a workflow engine and associated process definitions (called “workplans” in EncounterPRO), the workflow management benefit cannot be generated as automatically or flexibly.

Frank: Seeing a patient is a pretty complicated process with several sophisticated goals. The first goal is gathering all of the clinical data appropriate to the patient’s condition in a way that paints a complete and accurate picture of that condition. This picture is used to facilitate clinical decision making and problem solving. The second goal is creating a profitable transaction for the practice. The third goal is creating a satisfying experience for children and families. I have not attempted to prioritize these goals, but rather simply list them in no particular order. There may be other goals that people would like to accomplish, but I think these are the big three.

Chuck: The tension that occurs when trying to optimize all three goals, when they sometimes conflict, is what I was trying to capture in this (admittedly enigmatic) diagram. For example, short term profit might be increased by reducing staff, but at the expense of decreased patient satisfaction as their wait times go up. One of the wonderful qualities of workflow management systems is that they can ameliorate these tradeoffs. With a EMR workflow system, fewer staff can see more patients *and* patient wait times can decrease.

Frank: Painting an accurate picture of the patient’s condition requires that all of the people in the practice know exactly what information they have to gather. The role of the EMR workflow system is to present the screens in such a way that none of the required data is missed. Different people collect different kinds of data at different times during the encounter so the system has to present the right screen to the right person at the right time.

Chuck: The usability principles of natural, consistent, and relevant workflow apply here.

Frank: Creating a profitable transaction for the medical practice is really all about the control of time. Each person in the practice has a different rate of pay. This rate of pay can be broken down into minute by minute intervals. Physicians have the highest rate of pay and other people in the practice have lower rates of pay. The practice has a cost of providing the exam rooms. The amount of floor space taken up by clinical exam rooms can be calculated and then divided by the number of minutes these rooms are available for patient use. This can give the practice a personnel cost and a physical plant cost for the exam, if the EMR is capable of measuring the time each person from the practice spends interacting with the patient and the time the patient spends in the facilities provided by the practice. The cost of providing the services of the encounter subtracted from the revenue received for the encounter will equal the profit created by that encounter.

Chuck: One of the great promises of EHR workflow management systems or healthcare BPM in general, and specialty-specific EMR workflow systems in particular, is the pairing of activity-based costs with process definitions. Since each step in a process definition is time stamped as to when it is available to be accomplished, when it starts to be accomplished, and when it is actually accomplished and who (cost per minute) and where (rent per minute) is the resource used during each task, the total cost of each patient encounter can be calculated. In conjunction with the revenue per patient encounter that is available from the practice management system, the profit per each encounter can be calculated.

By comparing encounter profitability across similar medical practices, specific reasons for decreased profitability can be located: (1) a step is more expensive per minute than it should be (that is, it is accomplished by less expensive resources at other practices), (2) a step takes longer to accomplish than it should (compared to other practices), and (3) a step is executed more frequently than it should (compared to other practices). The win-win-win analytic result is to find those too expensive and too long steps that are being executed too frequently and change the workflow so as to increase encounter profitability.

Frank: Creating an encounter that satisfies the patient is another complex phenomenon. There are many factors that could go into this equation: the total amount of time from check in to check out, the procedures preformed, the personnel seen, the diagnosis made, the plan of treatment recommended, the amount of time the patient spent unattended. This is a partial list of the things inside an encounter that might positively or negatively affect the patient’s satisfaction with that encounter.

Chuck: You have expressed (in conversation) some very interesting ideas about associating each encounter with a simple measure of patient satisfaction (“On a scale of one to five, how would you rate this visit”) so as to benchmark, not just cost, but patient satisfaction as well. Since patient satisfaction predicts longer term profitability, it is a nice counter balance to purely cost driven workflow benchmarking.

Frank: A good workflow management system would help the practice by providing data that would give the practice insight into what could be changed in their workflow to optimize performance on each of these strategically important metrics.

Chuck: In other words, a good workflow management system is a business process management system. I discussed this in a post that critiqued the idea of “meaningful use” of EHRs.

Thank you Frank! I think this sort of public conversation about the relationship between pediatric workflow management and business process management systems (workflow engines, process definitions, benchmarking, and costing) on one hand and practice profitability and patient satisfaction is a very useful exercise.

Some Mid-Nineties Medical Informatics Course Outlines: Enjoy!

Short Link: http://j.mp/6vyEuD

Last week I wrote about how I became interested in EHR workflow management systems. While looking for some diagrams to illustrate relationships among medicine, business, and technology, I happened to browse some old medical informatics-related material and syllabi for courses that I taught at Duquesne University.

For example, here is a 1997 RealVideo of me talking about streaming video with respect to computer-based learning in an introductory medical informatics class. This video was optimized to run over a 28k modem (2 frames per second!). What a hoot and how far we have come!

[flv:http://wareflo.com/video/webster_duquesne_1997/chuck.flv 320 240]

1997 RealVideo optimized for 28k modem at 2 fps (painful!).

With respect to the syllabi, there is not much direct relevance to EHR workflow management systems to speak of (“workflow” the word appears nowhere, though there were some interesting student projects on the subject) however, I do think that they are almost quaintly entertaining. The two syllabi that actually have any graphics have a retro pre-Dreamweaver/pre-WordPress look, but they’re also prescient in terms of the future (our present) that they visualize.

Except for the JAVA programming course, the syllabi were first created for the 94-96 school years (but were last taught in 98-99). Warning to propeller heads: these were basic courses for undergraduates with no technical background. Also keep in mind that the first web browser had only been introduced in 1993, and then the first Netscape browser appeared in 1994. (And most of the links are broken due to ten years of link rot.)

Medical Informatics

“This course provides an introduction to medical informatics: its roots in computing and health science, its subdisciplines (such as medical imaging, document management, and decision support), and its interactions with other fields (particularly business and cognitive science). Topics include medical databases, networks, multimedia, artificial intelligence, communication standards, and signal processing. ”

Elements of Health Information Science

“This course provides an introduction to computer programming for individuals who will need to work with health care software developers. Alternating between learning new programming concepts and techniques, and application of those concepts and techniques to health care examples, students will learn to create simple medical software, such as dialogue screens for medical information systems, disease management applications, and automated patient surveys.”

Health Information Science

“This course is an introduction to World Wide Web technologies and their relationship to health care. While emphasis will be on the hands-on skills of molding text and images into coherent Web sites, and their uploading and maintenance, due attention will be given to special problems in health care and the Web, such as the quality of medical images, the importance of security, and the increasing role of the health care consumer in Web-based health information systems.”

World Wide Web Programming

“This course is an introduction to Java technology, hands-on and conceptual. You will write, modify, compile, and execute Java applications, applets, and servlets, while considering their relevance to a wide variety of technological, economic, and (yes) political issues. Since my interests are medical, many of my examples will be too.”

Keeping in mind the neophyte audience and that this period was in some ways the dawn of the Web with respect to healthcare applications of Web technology, the course outlines hold up rather well. The explicit and implicit predictions about future use of information technology in healthcare were spot on. If this blog is as accurate with respect to EHR workflow management and business process management technology over the next fifteen years, I’ll follow up with a “Told You So” post in 2024.