Workflow Management and EHR Usability: Process-Aware HIT

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EHRs have long been lauded for their potential contributions to legibility, decision support, and clinical research. They hold especially great promise for reducing medical error. However, until recently, EHR usability obstacles have not been sufficiently addressed. Typical EHR systems are not easy to use. Many physicians are small businessmen and women. Anything that slows them down may also reduce their revenue. As a business proposition, EHRs must become not just comprehensive and accurate, but usable and fast. Lack of workflow management capability is a major reason for many EHRs being difficult to use.

Usability is “the effectiveness, efficiency, and satisfaction with which specified users achieve specified goals in particular environments.” [4] However, in the case of EHR workflow management systems, usability must be construed not only relative to single users, but also with respect to the entire team of users 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 EHR usability: naturalness, consistency, relevance, supportiveness, and flexibility [5]. Workflow management concepts provide a useful bridge from usability concepts usually applied to single users to usability applied to users in teams. (And, to pick up a thread that was introduced in the previous section, each dimension of usability can contribute in its own way to reductions in encounter length.)

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 users in multiple roles. For example, a visit to a cardiology office may involve multiple interactions among patient, nurses, technicians, and physicians. Task analysis must therefore span all of these users and roles. Creation of a process definition is an example of this kind of task analysis, and results in a machine executable (by the 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 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 user roles (related sets of ac- tivities, 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 applica- tion 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 workflow management system represents and updates task status and responsibility in real time, this data can drive a display that gives all 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 prefer- ences. This obviously relates back to each of the previous usability principles. Unnatural, inconsistent, irrele- vant, 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 users may require different proc- ess definitions, or shared process definitions that can be parameterized to behave differently in different user-task-contexts.

The ideal EHR (and EHR workflow management system) should make the simple easy and fast, and the com- plex possible and practical. Then the majority/minority rule applies. A majority of the time process instances are 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!


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Take me to the next blog post in this series! User-Centered, Human-Centered Process-Aware Health IT.

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