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Healthcare // Electronic Health Records
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Charles Webster
Charles Webster
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The Mismatch Between Healthcare Software, Healthcare People

The workflow built into healthcare software must make processes better and not worse.

Many physicians and other health IT users hate the software they feel forced to use. In particular, a growing sentiment is that some EHRs and health IT systems actually make healthcare workflow worse, not better. HIMSS has even pinpointed workflow as the single most acute usability pain point. Does healthcare IT have a workflow usability problem? And what can be done about it?

I just returned from two conferences. One was the annual meeting of hospital CIOs (CHIME 13). The other was about workflow technology (iBPMS Expo). That meeting was not healthcare-specific, but there was considerable agreement there that healthcare is one of the most promising verticals for the application of workflow technology.

[ Want to make smart use of mobile? Avoid these traps: When Smartphones Do Dumb Things.]

Many health IT systems violate most or all of the five principles of workflow usability for which I've been evangelizing since 2004 (at that year's MedInfo conference). If we address and fix these workflow flaws, users will like their systems a lot more than they do now.

Much health IT software workflow does not match healthcare task structure. The very definition of workflow is a series of tasks consuming resources and achieving goals. If health IT software workflow does not match the everyday workflows required to perform healthcare jobs effectively and efficiently, those tasks will be performed, if at all, in the only alternative way: ineffectively and inefficiently. Workflow technology has models that can be changed to match real-world workflow needs and preferences.

Much health IT software workflow is inconsistent, both within and across health IT systems. Similar information may require completely different workflows to access, depending on which vendor or even which programmer wrote a particular module. Workflow models can be changed to impose more consistency within and between health IT software applications.

Many health IT software applications overwhelm users with irrelevant data and data/order entry options. At each step in a workflow, only a small subset of the possible data or entry options is relevant, yet users face high-resolution screens thick with tiny checkboxes. Workflow technology uses knowledge of sequence within a workflow to filter out information and options irrelevant to performing a step. Doing so is even more critical as workers move to smaller and smaller mobile devices.

Much health IT software fails to support users' shared mental models of workflow. One of the very few benefits of paper-based workflow is that documents and forms can explicitly and visually represent workflow state. Whoever has the documents has the responsibility. Whatever remains to be filled out signals what remains to be done. Instead, workflow state is hidden in database tables and obscure screens. Workflow technology keeps track of workflow state, which can be displayed so all users are continually aware of what remains to be done.

Most important of all, many health IT software applications are not flexible. The workflows are hardcoded. If the software is unnatural, inconsistent, irrelevant, and unsupportive when installed, it cannot easily be changed to become natural, consistent, relevant, and supportive. Workflow technology relies on a variety of means for users to change workflow without having to be computer programmers themselves.

So I ask, as I have asked for many years (with increasingly positive reception, I'm glad to say): If healthcare workflow is a problem, and health IT inability to handle it is the problem, why aren't we using workflow technology?

Workflow technology, sometimes called business process management (BPM) or dynamic/adaptive case management, can better match healthcare workflow because it models tasks, workflows, goals, and resources. Some of this technology excels at repetitive workflows. Some excels at supporting more unpredictable workflows of medical knowledge workers.

Current EHRs and health IT systems model all sorts of things, especially patient medical states and therapies, but they don't usually model workflows. And they certainly don't execute or consult those models to help physicians and other users do their jobs. Instead, workflows are hardcoded as Java, C#, and MUMPS if-then and case statements. This workflow is invisible and immutable to the users, who best know their workflows and most need to create, edit, tweak, customize, and improve them.

Workflow technology is literally decades old. It's widely used in other industries such as manufacturing, finance, and banking. Many of the innovative SMAC technologies, social, mobile, analytics, and cloud applications, services, and platforms daily filling health IT trade journal and website headlines have under their hood the kind of workflow technology I'm writing about here. The academics call these systems process-aware information systems (PAISs). In some respects, SMAC is like an epidemiological vector, bringing into healthcare the antidote to the workflow-oblivious technology plaguing us.

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S Silverstein MD
S Silverstein MD,
User Rank: Apprentice
11/18/2013 | 9:49:55 AM
Complexities of medicine - Hiding in plain sight
As to the difficulties with any type of "workflow modeling' in clinical medicine, if you've not practiced medicine, i recommend the following short article (fulltext free):

Hiding in plain sight: what Koppel et al. tell us about healthcare IT, Nemeth & Cook, J. Biomedical Informatics 2005.

Key passage:


The core issue is to understand healthcare work and workers. On the surface, healthcare work
seems to flow smoothly. That is because the clinicians who provide healthcare service make it so. Just beneath the apparently smooth-running operations is a complex, poorly bounded, conflicted, highly variable, uncertain, and high-tempo work domain. The technical work that clinicians perform resolves these complex and conflicting elements into a productive work domain.

Occasional visitors to this setting see the smooth surface that clinicians have created and remain unaware of the conflicts that lie beneath it. The technical work that clinicians perform is hiding in plain sight. Those who know how to do research in this domain can see through the smooth surface and understand its complex and challenging reality. Occasional visitors cannot fathom this demanding work, much less create IT systems to support it.


In other words, the "workflow" of medicine is "constant, on-the-fly improvisation."  How do you build IT to accommodate that?

Not easily.  And probably not with business-computing (mercantile/management/manufacturing/) methodologies.
S Silverstein MD
S Silverstein MD,
User Rank: Apprentice
11/18/2013 | 9:39:20 AM
Re: Is this something hospitals can fix?
"Not worth keeping around" is an understatement.

6 feet under, to be specific.

Want to see an example of what hospitals try to do to protect their bad health IT investment?  [1]

How about Motions for Prior Restraint (unconstituional gag orders)?  See

[1] Definitions:

Good Health IT ("GHIT") provides a good user experience, enhances cognitive function, puts essential information as effortlessly as possible into the physician's hands, can be easily, substantively and cost-effectively customized to the needs of medical specialists and subspecialists, keeps eHealth information secure, protects patient privacy and facilitates better practice of medicine and better outcomes. 

Bad Health IT ("BHIT") is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation. 


S Silverstein MD
S Silverstein MD,
User Rank: Apprentice
11/18/2013 | 9:34:51 AM
Patient harm and death
The mismatch you point out as a factor in clinician dissatisfaction and decreased efficiency, also harms and kills people.

I should know - after 20 years in the field of Medical Informatics and 15 writing about the problems (, my mother died of a health IT-related mishap.  I am aware of infants ( and adults ( meeting similar fates.

The ECRI Institute did a study recently - 9 weeks/36 hospitals/volunteer data (i.e., a fraction of the true total)/171 health IT "mishaps" serious enough to cause harm/8 injuries/3 possible deaths.  (

I am just the reporter here.

The Milqutoast attitrudes about health IT that focus on the technology/users and not its true customers (sick patients) need to be ramped up a bit.
Michael Endler
Michael Endler,
User Rank: Author
11/15/2013 | 4:01:44 PM
Re: Is this something hospitals can fix?
I was wondering the same thing.

But either way, it sure sounds like a mess. With health care costs rising, I'm sure this sort of institutional inefficiency isn't helping matters. Workflow software that doesn't match a physician's actual workflow hardly sounds like it's worth keeping around.
David F. Carr
David F. Carr,
User Rank: Author
11/15/2013 | 11:31:46 AM
Is this something hospitals can fix?
Is this something the enterprise can really fix, as opposed to an issue the vendors really need to address?
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