Football Plays and Clinical Workflow

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A friend of mine is Dave Hubbard, the motivational speaker, an All-American collegiate athlete who played professional football in the 1970’s for Hank Stram of the New Orleans Saints and then the Denver Broncos. Dave is extremely familiar with healthcare both professionally (serial entrepreneur) and personally (broke his back jumping out of a perfectly good airplane!).


We’ve had a series of interesting conversations about, of all things, football plays and EHR workflow. We co-wrote the following post to see if we might enlist you in telling us if you think we’re on to something, or not.

–Chuck & Dave

Medical offices are like football teams: an offensive line moves a patient encounter forward while a defensive line seeks to create chaos and stop encounter progress. This analogy is more productive than you might think!

Medical office staff members interact in ways that are similar to a football team. For example, they have an offensive line whose responsibility it is to efficiently, effectively, and flexibly move an encounter from waiting room to checkout. There’s a quarterback who calls plays. Sometimes it’s the physician who directs staff to administer a vaccination or auditory test; sometimes the plays are called automatically based on the reason for the patient’s visit, such as “well child” versus “ear ache.”

Tasks are “passed” among team members, such as a nurse gathering vitals and checking medications and allergies before passing the assessment and treatment tasks to the physician. “Dropping the ball” results in inefficiency that slows the encounter and ineffectiveness that affects patient care and physician revenue.

The defensive line may be less obvious, but it consists of threats to the accomplishment of efficient, effective, flexible workflow. It is the offensive line’s responsibility to protect this workflow. For example, the phone nurse blocks defensive line interruptions that would otherwise distract the physician from maximizing use of the most important and constrained resource in the practice, his or her time. Anyone (or anything) who contributes to the hassle factor of practicing medicine is part of the defensive line.

Similarities between a medical team and a football team are more than an amusing analogy. All teams are cognitive systems, and their study is called team cognition (with contributions from distributed cognition). Shared mental models, workspace awareness, radar views, and teams of experts versus expert teams are topics of team cognition that apply to all teams, including those in medicine and football.

Using this football metaphor (and some ideas from cognitive science), we encourage you to think (and comment!) about office processes from the perspective that to win, the ways in which the plays are being run must be examined. Doing so will allow people to express what they are most proud of, but also to critically evaluate performance problems in a constructive way, one in which everyone is committed to success.

Questions to consider:

How is your medical practice similar to a football team?

What position does each employee play? Who is offense? Who is defense? Are there any special teams?

Who is the quarterback? The coach? Does everyone know their position?

What about the referee? The coach? The patient? The fans?

Who owns the team? Is there an owners’ association? A players’ association?

If your medical practice were a football team, what would be your version of the following: Holding? Tripping? Unsportsmanlike conduct? Unnecessary roughness? Running versus passing? Huddling? Incomplete pass? Field goal versus touchdown? Memorizing key plays? Time-out? Substitutions?

Suppose you could review game films with your staff. What are examples of plays you’ve run to achieve major yardage or touchdowns?

What are examples of plays where you’ve thrown for a loss, fumbled the ball, or suffered interceptions? Why did they occur and what can you do to keep them from happening again? How do you define victory?

Do different styles of medical practice lend themselves to different sports analogies? Soccer? Golf? Which do you suggest and why?

Litmus Test for Detecting Frozen EHR Workflow

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If a first year medical student says that a patient has a temperature, his or her attending may say something like “Of course your patient has a temperature, all patients have a temperature! Is their temperature normal or abnormal? Elevated or subnormal? What, exactly, is the patient’s temperature?

In the same sense, all software including EHRs, have workflow. The question is whether the workflow is good or bad and whether you have the means to adapt it to your purposes. EHRs whose workflow cannot easily be modified by a non-programmer have what might be called “frozen” workflow.


Most EHR applications require the user to navigate between screens to enter data. An EHR workflow management system can be configured to drive common input screens in any order that makes sense. This is most commonly based on the visit reason. In other words, an EHR workflow management system can deliver customized workflow around a practice’s current workflow process for gathering data. For example, a practice may currently use a paper based workflow system that they like. This not only involves what data they gather, but when and who collects the data during the workflow. An EHR workflow management system can be configured, through use of its process definition editor, to precisely match this pre-existing workflow.

Some EHRs do increasingly deliver some workflow capability; that is, they can contribute to an increase in productivity by doing for the user what they would otherwise need to do themselves (navigate to the next screen, inform the next person what they need to do, trigger an external application such as a digital ECG, and so on). However, these EHRs rely on “frozen” process definitions. Their workflow cannot be easily changed to adapt to circumstances not foreseen by the programmer. Programmers are not clinicians, or even more important, not intimately familiar with each and every minute step of dealing with a patient in medical practice. Only users can claim this degree of familiar knowledge. This means that users cannot easily change what EHR screens occur in what order, who gets passed the task baton when, or what external application to fire up automatically.

Only a full-fledged EHR workflow management system provides additional user interfaces that allow users, not programmers, to bend EHR workflow behavior to their specific and evolving needs. For example, a user should be able to easily instruct the EHR to insert a new data gathering step between vitals and chief complaint, or to easily add the automatic playing of a preventative care video at the optimal point of a well visit.

Apply the following litmus test designed to detect frozen workflow:

The simplest test of whether an EHR is built on a workflow management system is to ask for a live demonstration of the following:

  1. Ask to see an encounter from beginning to end. Focus on the sequence of screens.
  2. Ask to see the process definition that controls the sequence of screens just observed.
  3. Ask to see a small edit in the process definition using the EHR process definition editor, such as the deletion or reordering of several steps.
  4. Ask to see the same encounter again, while focusing on whether or not the changes in the process definition have indeed resulted in the appropriate changes in screen sequence.
  5. If the screen sequence changes in just the way that would be expected if an EHR workflow engine is consulting the just edited process definition, then you are likely looking at an EHR workflow management system.

If an EHR cannot demonstrate steps (1-5), then the EHR lacks the capabilities of a workflow management system. It does have workflow (because all software applications have workflow). It may even have workflow that is good for a particular task and context. However its workflow is frozen.

The Next Five Years: The EHR Network Effect

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Last week I gave an invited presentation to the Columbia chapter of the South Carolina Health Managers Association on EHR topics. Having never been to Columbia, or tasted the famous South Carolina yellow barbecue sauce, I went (as they say) with relish.

My presentation was “The Next Five Years:The EHR Network Effect” and I thought I’d summarize it here. (What it has to do with EHR Workflow Management Systems will become apparent towards the end.)


A network effect occurs when adding products or service increases the value of existing network products or services. The classical example is (a) one telephone is not worth anything, (b) two telephones connected to each other are perhaps worth a little bit, (c) but millions of networked phones are worth a whole lot.

There is much current discussion about health information exchanges (HIEs) and sustainable business models. To the degree that an HIE facilitates the creation of a network of EHRs a network effect may be to increase the value of each individual EHR. The more valuable a network of EHRs is, the more whoever benefits from that value will pay to sustain the HIE. Over the next five years (to pick an arbitrary planning horizon) exploiting the network effect will likely be key to creating financially sustainable HIEs.

The rest of my presentation consisted of examples of existing and potential EHR network effects. An obvious example is an EHR user relying on data from another EHR to provide patient care. If we expand our scope to the network effect of adding health information systems to a network, then there is the (again, obvious) value of EHR messaging: incoming lab results, refill requests, decision support, etc.; outgoing E-Prescriptions, disease and vaccine registry data, payment for outgoing quality data, etc.

However, the three network effect examples I focused on were:

1. Biosurveillance

Adding EHRs to a network of EHRs that participate in a biosurveillance program increases the ability to accurately red flag potential bio-terror events and this increased accuracy causes an increase in value that accrues to each member of the EHR network.

2. Population Management

Adding EHRs to a network of EHRs that participate in a population management program increases the quality of inferences about population health state which, when fed back to individual EHRs to affect patient care, increases the value of each participating EHR.

3. Process Benchmarking

EHRs generate considerable process data that is not part of the official patient record. This data includes who did what to whom, where, when, how and often even why. Much of this data is gathered for privacy and security audit trail purposes. Some, depending on the EHR, is actually a byproduct of internal task management mechanisms.

Chose an output metric or weighted combination of metrics; compare your EHR productivity to the average and the best productivity of other EHRs on a process benchmarking network of EHRs; now drill down and explain the differences between your productivity and that of other EHR installations. Use these explanations to change your processes and improve your productivity.

Of all of these EHR network effects, I believe that process benchmarking may potentially be the most compelling value proposition for a majority of medical practices. Of course, everything looks like a nail when you have a hammer, and this blog is titled “Electronic Health Record Workflow Management Systems…”

More on process benchmarking in a later post.

Oh, the yellow barbecue sauce at the Palmetto Pig near the Devine Street Bridge was…divine (and the hush puppies were the best I’ve ever had).


EncounterPRO User to Present At HIMSS

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Congratulations to Dr. Armand Gonzalzles of Riverpoint Pediatrics in Chicago (an EncounterPRO EHR user since 2000) for his upcoming presentation at the 2009 Health Information Management Systems Society Conference in Chicago.


Dr. Gonzalzles’ presentation “Workflow Management EMR Systems and the Primary Care Physician,” (Sunday, April 5, 9:45 AM – 10:45 AM in Room S403b at the McCormick Place Convention Center) will review how his Riverpoint Pediatrics practice in Chicago achieved practice transformation with workflow improvements with EHR adoption. Dr. Gonzales will review the steps required to change practice and physician workflows within the practice when adopting an EHR.

Attendees will learn to describe how a physician workflow changes are enhanced with EHR usage, explain the importance of workflow analysis when adopting an EHR for your practice, identify how to spend more quality time with patients instead of documenting the visit, and discuss how to improve overall practice administration.

Recently I had the pleasure of serving on an expert panel with Dr. Gonzalzles advising the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) on “Assessing the Economics of EMR Adoption and Successful Implementation in Physician Small Practice Settings.”  Here is the final report (some very interesting observations about workflow management that I intend to highlight in a later post).

Dr. Gonzalzles is a past winner of the 2004 HIMSS Ambulatory Care Davies Award of Excellence (his winning application here).

 Congratulations again, Dr. Gonzalzles!


Welcome! (EHR + WfMS = EHR WfMS)

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Who Am I?

Charles (Chuck) Webster, MD, MSIE, MSIS

Why Am I Blogging?

I am blogging and tweeting, at @EHRworkflow [CW: now @wareflo], to connect with professionals and researchers interested in electronic medical records and electronic health records on one hand, and workflow management systems and business process management on the other. More specifically, I am blogging and tweeting to connect professionals and researchers interested in electronic medical records, electronic health records on one hand, workflow management systems and business process management. I’ll also likely blog and tweet about aspects of clinical natural language processing that support this integration and synthesis.

What Will I Be Blogging About?

I will be blogging about Electronic Health Record Workflow Management System (EHR WfMS) and Business Process Management (BPM) concepts, technologies and products.


I coined the term EMR Workflow Management System (now EHR Workflow Management System or EHR WfMS) sometime in 2002 in conversation and email. However, my first article on the concept was the earlier “Structured Data Entry in a Workflow-enabled Electronic Patient Record” which appeared in The Journal of Medical Practice Management, Volume 17, Number 3, Pages 157-161, 2001 and was reprinted (page 11) in the Medical Records Institute’s Health IT Advisory Report, Volume 3, Number 6, July 2002 (pages 11-15). As of the date of this post it has eight citations that Goggle Scholar knows of; OK, two were by me, but I am pleased that (a) someone noticed and (b) they cited their source.

My first public use of the phrase Electronic Medical Record Workflow Management System was the 2003 white paper “Electronic Medical Record Workflow Management: The Workflow of Workflow”, which appeared on the then JMJ Technologies website. In 2003 I wrote the workflow management criteria used in the EHR workflow management system survey used by Andrew and Associates and published in Advance for Health Information Executives as well as contributed the core EHR WfMS concepts discussed there. I subsequently tweaked the survey criteria in 2004 and 2005 for those surveys and as well as contributed additional conceptual material to follow on articles). Since then I’ve continued to develop these ideas and present them at a variety of regional, national, and international conferences as well as publish in conference proceedings, trade journals, and on the Web. “EHR Workflow Management Systems: Essentials, History, Healthcare” (TEPR Conference, May 19, 2004, Fort Lauderdale), “EHR Workflow Management Systems in Ambulatory Care” (HIMSS, February 14, 2005, Dallas), and this EHR Scope Fall 2007 article “What Makes a Great Pediatric EHR?” are representative.

In particular I hope to stimulate discussion between EHR, WfMS, and BPM professionals.

Blogs, even technical ones like this, need to lighten up occasionally, so I’ll post occasionally about kickbiking and other personal interests or add a vacation photo to my gallery.

When Will I Post?


Where will I post?

Here (

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