Our First EMR Workflow Engine

About a year ago, when our experience with our EMR approached the 5-year mark, I thought it was time we approached more advanced projects to automate our workflows.  In a practice like ours, which includes surgery, some of the most repetitive, time-consuming, labor-intensive workflows are those that prepare patients for the operating room.  Analysis of this workflow reveals there are 2 types of components:  very simple and very complex.  There is not much in the middle.

Complex steps, performed by an MD or nurse, include:

  1. Design of surgical procedure
  2. Location of procedure
  3. Choosing preoperative labs, imaging, consultations (i.e., cardiology)
  4. Interpreting results of the above testing
  5. Communication with the referring physician and preop consultants

Simple steps consist of generating the paperwork to reflect the medical decisions made in the complex steps:

  1. Chart notes documenting need for surgery and surgery design
  2. Initiate preop workflow with appropriate staff (i.e., surgery scheduling)
  3. Preoperative History and Physical
  4. Informed consent forms
  5. Preop and postop orders – implementation of above complex decisions
  6. Preop and postop patient instructions and other supporting information

With these thoughts in mind I began creating a set of body-site specific templates with the sole purpose of initiating and directing the above workflow steps from a single computer screen.  We have been using 2 of these templates for about 6 months; I would describe the results as a good first attempt.  This project is one of the few done by a physician that directly addresses workflow as well as documentation.

Three challenges make this process slow and laborious.

The first challenge is to automate the simple steps as fully as possible while leaving the complex steps in full control of the physician.  This is much more difficult than it sounds.  Too much automation will usurp control of clinical decision making from the physician; too little results in failure to fully leverage the EMR technology and may make the workflow more cumbersome than it was to start with.

The second challenge is making the templates user-friendly, which in this case means doctor-friendly.  That means getting rid of all the screen clutter and “white noise”, keeping only what is useful and necessary.  Many of the EMR’s built-in, “hard-wired” screens fail to do this well.

The third challenge is getting the code written correctly so the template interfaces properly with the EMR itself.  This includes trivial but maddening issues such as preventing duplicate actions from duplicate button clicks.  This also becomes frustrating when the template you are creating attempts to overcome shortcomings of the EMR itself.

Currently my conclusions are:

  1. The effort is worthwhile.  Although the workflow engine is far from perfect and far from finished, it is quite useful “in the trenches” taking care of patients in a busy clinic.  Every time I use the workflow engine I save $6.50, my estimate of what I would pay our staff to do the paperwork by hand.
  2. Some of the grunt work required to design and write a workflow engine is unavoidable.  An EMR that is flexible enough to write useful custom workflow engines must by definition require a high level of effort to customize.
  3. Software improvements are required in order to make workflow engine creation practical for most practices.  My IT experience is about as good as you will find among non-IT-professionals (35 years) but my skills are pushed to the limit making these templates.  That is unacceptable.  Notwithstanding conclusion #2, the situation can and must be improved.

About the author

Dr. Michael Koriwchak

Dr. Michael Koriwchak

Dr. Michael J. Koriwchak received his medical degree from Duke University School of Medicine in 1988. He completed both his Internship in General Surgery and Residency in Otolaryngology-Head and Neck Surgery at Vanderbilt University Medical Center. Dr. Koriwchak continued at Vanderbilt for a fellowship in Laryngology and Care of the Professional Voice. He is board certified by the American Board of Otolaryngology-Head and Neck Surgery.
After training Dr. Koriwchak moved to Atlanta in 1995 to become one of the original physicians in Ear, Nose and Throat of Georgia. He has built a thriving practice in Laryngology, Care of the Professional Voice, Thyroid/Parathyroid Surgery, Endoscopic Sinus Surgery and General Otolaryngology. A singer himself, many of his patients are people who depend on their voice for their careers, including some well-known entertainers. Dr. Koriwchak has also performed thousands of thyroid, parathyroid and head and neck cancer operations.
Dr. Koriwchak has been working with information technology since 1977. While an undergraduate at Bucknell University he taught a computer-programming course. In medical school he wrote his own software for his laboratory research. In the 1990’s he adapted generic forms software to create one the first electronic prescription applications. Soon afterward he wrote his own chart note templates using visual BASIC script. In 2003 he became the physician champion for ENT of Georgia’s EMR implementation project. This included not only design and implementation strategy but also writing code. In 2008 the EMR implementation earned the e-Technology award from the Medical Association of Georgia.
With 7 years EMR experience, 18 years in private medical practice and over 35 years of IT experience, Dr. Koriwchak seeks opportunities to merge the information technology and medical communities, bringing information technology to health care.

1 Comment

  • Dr Koriwchak,

    Have you thought about Doctor Order Sets as an integral part of your work flow analysis? I am a student at the University of Minnesota’s Institute for Health Informatics and we have been studying the integration of Order Sets into CPOE and an EMR. I just posted a data flow model that I created to extend 3 ONC use cases for Order Set Extension for Certified Physician Order Entry (CPOE). I invite you to review it on my LinkedIn home page at http://www.linkedin.com/in/jongaasedelen. Also if you know of any findings regarding improved outcomes due to Physicians using CPOE integrated with Doctor’s Order Sets I would appreciate hearing about them.

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