#EHRbacklash Isn’t About Electronic Health Records; It’s About Kludgy, Standalone, Workflow-Oblivious #EHR Applications

Update 2/19/13:

I love this tweet!

It concatenates three themes I’ve addressed over-and-over in this blog of 200+ posts and my Twitter account of 15,000+ tweets: EHR usability, interoperability, and workflow.

On the surface, these concerns may seem unrelated. But there are deep and profound connections among them. Lets start with the most interesting two words in this tweet: “workflow oblivious”.

What’s the Connection to Process-Awareness?

If “workflow-oblivious” is the devil, what is its opposite? It is “process-aware”, which I write and tweet about frequently. Workflow and process are approximate synonyms. (Yes, I am aware of potential different nuances in meaning. Make a comment and I’ll explore them together with you!). And “oblivious” and “aware” do seem diametrically opposite and antithetical.

So, I argue, condemning EHRs because they are workflow-oblivious is very close to, if not the same thing as, praising the alternative, EHRs that are process-aware.

What is process-aware? Check out My Rejected Presentation Proposal: Process-Aware Information Systems Come to Healthcare. It means software than can reason about workflow and act to make it make it fast, easy, and better. Bits-and-pieces include workflow engines, process definitions, and graphical editors to allow non-programmers, sometimes actual users, to create and edit their own workflows.

What’s the Connection to Usability?

Check out my five principles of usable EHR workflow:

  • 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. (From 2009’s EHR/EMR Usability: Natural, Consistent, Relevant, Supportive, Flexible Workflow but presented in EHR Workflow Management Systems in Ambulatory Care in the published proceedings of 2005 HIMSS Dallas conference.)

What’s the Connection to Interoperability?

There is an important level of interoperability above syntax and semantics. It could be called workflow interoperability, or pragmatic interoperability (like syntax and semantics, pragmatics is a subdiscipline within linguistics).

The essential point is this. You cannot have great workflow between healthcare organizations without great workflow within healthcare organizations. I know the temptation to divide and conquer. EHRs have lousy workflow, so lets make up for it with great communication connections between healthcare organizations. Sorry, won’t work. Large virtual enterprises are made up of smaller virtual or non-virtual enterprises. If these smaller entities, hospitals, clinics, etc., have lousy workflows between inputs and outputs, then whatever we create out of their combination won’t be much, if any, better. I’m reminded of my statics and dynamics classes during the year I spent in undergraduate Civil Engineering: you can’t build a superior bridge out of inferior materials. You can’t build superior workflows out of inferior workflows.

So, in closing, let me simply repeat the tweet that made me write this blog post.


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