Workflow Tactics Deployed in Health Care Remain Stuck About 10-15 Years Behind the Times

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Some of the best writing and insights on the web are comments. They get buried, below the fold, in web-speak borrowed from the newspaper world. For example, @bobbygvegas‘s comment, about EHR workflow, on 6 Ways AHRQ Will Study EHRs, Workflow, struck a chord with me. (I wonder if Bobby being musically inclined has anything to do with this?). I’ve written similar laments. So I asked if I could repost his comment here as a blog post, the first time I have ever done such a thing (and I have over 200 blog posts about EHR workflow on this blog!). I’m working on my own blog post about the AHRQ study, but @bobbygvegas beat me to the punch. Good on you mate!

@bobbygvegas‘s comment appears, in full, immediately after the Twitter exchange leading to this momentous first. It’s a well-written, slightly feisty (I like!), call to healthcare to catch up with the rest of the world in its thinking about workflow. Since it is, essentially, an editorial (with which I very much agree), I include some slides from a PowerPoint that @bobbygvegas mentions: “Workflow Demystified” (“Prepared by HealthInsight as part of our work as the Regional Extension Center for Nevada and Utah, under grant #90RC0033/01 from the Office of the National Coordinator, Department of Health and Human Services. 9SOW-UT-2010-00-112”). The diagrams do not correspond exactly to @bobbygvegas‘s editorial paragraphs. But I include them to encourage you to download and study the entire slide set.

And then…

…and then to …

So, here, posted with permission, is @bobbygvegas‘s complete comment.

[The following is reposted, with permission of its author @bobbygvegas from]

“4. Extract clinical data in logs and audit trails that have been time-stamped from the EHR to reconstruct clinical workflow related to the health IT system. This information validates and supplements the data recorded by human observers.”


Better late than never, one supposes. I’ve been arguing this for years. An EHR audit log is essentially an information workflow record that should be mined to analyze routine tasks times-to-completion and variability. Analysis can also reveal the “pain points,” i.e., iterative, recurrent “flow” barriers. You then couple these data with data taken regarding concomitant physical tasks to flesh out a more useful picture for systematic improvement activities.


The very word ‘workflow’ has become a cliche. Rolls readily off the tongue with little thought given to what it entails. A more apt analogy might be a traffic copter shot of the jerky stop-&-go freeway traffic of rush hour. In most clinics, it’s nearly ALWAYS rush hour.

I joked in one jpeg I did for my blog that this was my Primary’s office at 8:03 a.m.


See also (freely distributable)

A decade ago I was working in risk management in a relatively small private issuer credit card bank. I had free run of most of the internal network. I got to looking at our in-house developed collections call center system (~1,000 collectors working the phones every day), and knew the source language and data tables architecture, so I started importing the data into SAS and mining them.

I was able to rather quickly show management that their staffing deployment and call volumes were egregiously misaligned. We were typically spending $1,000 to collect $50 (or less). It was a lava flow of waste.

On the basis of these rather simple call log analytics we were able to save the bank about $5 million a year in Collections Ops cost, dragging the VP of Collections kicking and screaming all the way (his annual bonus was tied in part to his budget, which was the largest in the company).


“Workflow” tactics deployed in health care remain stuck about 10-15 years behind the times, as they don’t drill down into time consumed and error rates. Mining the audit logs might be of great utility here — though the datetime() stamps are gonna need to be more granular than just down to the second. SQL now supports time capture down to the microsecond, though tenths or hundreds would likely suffice.


Another barrier here in general might be “once you’ve seen one audit log data dictionary, you’ve seen one audit log data dictionary.” Recall that we have at this point nearly 1,800 “complete Certified EHR systems.”

Let’s hope this AHRQ study will move us usefully ahead.

PS (my, Chuck Webster’s, PS). I often use Google to search for new material about EHRs and workflow (or, egotistically, to see where my content ranks). Sometimes I’ll see a quote from a comment and get excited. Something new! Someone new! But when I click on it, it’s just me. It’s an example of jamais vu. Something that should seem old and familiar momentarily seems new and unfamiliar. @bobbygvegas‘s comment had the opposite effect on me. It was classic deja vu. Something that I could not have seen before, because @bobbygvegas just wrote it, seemed like something I’d written and misplaced, only to be rediscovered. I hope others will feel, similar to me, that @bobbygvegas speaks the truth. I hope he speaks for a growing number of health IT professionals and EHR users with increasingly sophisticated understanding of workflow and its relevance to managing healthcare’s spaghetti processes.

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