The Health IT Standards Committee Health IT Implementation/Usability Hearing (agenda) was held today (July 23rd, 2013) in Washington DC. There’s lot of material posted online pertaining to the hearing, PowerPoints, position papers, questions and answers, etc. As I always do, when it comes to EHR and Health IT usability, I search through everything to find all references to “workflow,” to understand the contexts in which it is used and its intended meanings. My reactions are at the end of this post.
The following are slides or quotes from the three most relevant links.
EHR Vendor User Centered Design, Rollin (Terry) Fairbanks, MD, MS, Raj Ratwani, PhD
[CW: I added that magnifying glass.]
Testimony from Art Swanson, Director of User Experience at Allscripts Healthcare Solutions
“Other than patient safety, from the vendor perspective, the largest issues in usability revolve around two key concerns: Configuration/Personalization and workflow….
to design and evaluate the usability of a product or service, one needs to understand the users, the workflow, and the context of use. Because these elements are so dynamic in the healthcare domain, it poses significant challenges to design for optimal usability….
the complexity of addressing usability issues in a highly customized environment with numerous user profiles, workflows and configuration options is significant….
Additionally, Allscripts offers optimization services where clinical consultants will work with clients to optimize their process, workflows, and product configuration to ensure successful outcomes. As an example, we suggest “certified clinical workflows” in our Enterprise EHR product that clearly define the optimal clinical workflows for common tasks in the product….
layers of prescriptive regulatory compliance are in fact hampering our ability to adapt to the changing landscape….
the software development industry wants the goals and the measures but not to be told how to do it. We can determine the How if you tell us the What….”
Testimony of the American Medical Association
“The requirements in the Meaningful Use (MU) program stipulate a myriad of measures and objectives that physicians must fully meet in order to receive incentives and avoid reimbursement penalties. EHRs are predominantly engineered to capture MU data and often require additional steps outside the physicians’ workflow – shifting focus away from patient care….
regardless of their specialty, patient population, geography, or practice size, with limited exceptions, physicians are required to collect the same exact data on each and every patient even if a measure is not relevant to the patient’s visit, service, or is rarely used for clinical practice.
Stage 3 MU requirements should align measures in a way that does not require physicians to perform additional actions either due to limiting factors or that are outside their patient mix.”
My Reaction From, From a Process-Aware, Process-Centric, BPM, Open Workflow Platform Perspective
First of all, let me congratulate all involved, who brought up or even focused on workflow at this hearing. It is, I believe, the single most important obstacle, and opportunity, to greatly improving healthcare quality while reducing its costs.
My only quibble (and it is a big, maybe even enormous, quibble) is virtually all current discussion of workflow, including today’s, occurs outside the context of knowledge of, and experience with, modern workflow technology. I’ve over 200 blog posts on this blog, EHR Workflow Management Systems, and well over 20,000 tweets on my Twitter account at on exactly these topics. So, I (to use the cliche phrase) know of what I speak.
Let’s start with the first slide. Well Developed User-Centered Design involves detailed workflow analysis and safety data. See my blog post User-Centered EHR Design Considered Harmful (Try Process-Centered Instead) for my critique. Mind you, at the end of that blog post I do admit that some User-Centered Design practices are beginning to focus on workflows, but the problem is, they don’t occur in the occur in the context of highly-instrumented (relevant to patient safety data) highly-malleable workflows (most current EHRs are workflow oblivious). Just think if these sophisticated efforts to understand and improve EHR and health IT workflow were applied to EHRs based on workflow management systems, business process management suites, and sibling dynamic/adaptive case management software. I believe this will, in fact, happen. Eventually!
The next material comes from a well-known EHR vendor. Again, it’s accurate as far as it goes. Configuration and personalization of workflow is the key. Healthcare is indeed a challenge, due to a combination of structured and unstructured workflows (note, I’m talking about workflow, not data, though there is a connection). It is equally true that well-intended meaningful use regulations hamper workflow innovation, both at the level of improving current workflows, and adopting the healthcare workflow tech I advocate. However, I must disagree with the last sentence in the quote: “the software development industry wants the goals and the measures but not to be told how to do it. We can determine the How if you tell us the What….”
I don’t think so. The What needs to come from users and the market. See my blog post, Efficient and Moral Market-driven EMR and EHR Usability Innovation
Finally, the AMA states (my paraphrase) that Meaningful Use has reduced physician productivity. So true. And in the face of already runaway healthcare costs. Reduced productivity means that physicians can see fewer patients at the same level of care quality, or can only see more patients while suffering reductions in level of care quality.
As I wrote in my blog post, Fixing Our Health IT Mess: Are Business Models or Technology Models to Blame? there is no way out of software development’s “Iron Triangle” of Scope versus Resources versus Schedule, except to move to clinical systems implemented on truly open workflow platforms. In other words, regardless of the eventually scope of Meaningful Use negotiated among constituencies and stockholders, achieving its long-term goals requires the same kind of process-aware, workflow-aware information systems already much in favor and use outside of healthcare.
