Five Guest Blog Posts On EHR and HIT Workflow, Usability, Safety, Interoperability and Population Health

John Lynn is taking a well-deserved week off to attend a family function. He asked if I was interested in five EHR workflow guest blog posts, a blog post a day this week, on EMR and HIPAA. Of course I said: YES!

Here’s the outline for the week:

I blog and tweet a lot about healthcare workflow and workflow technology, but in this first post I’ll try to synthesize and simplify. In later posts I drive into the weeds. Here, I’ll define workflow, describe workflow technology, it’s relevance to healthcare and health IT, and try not to steal my own thunder from the rest of the week.

I’ve looked at literally hundreds of definitions of workflow, all the way from a “series of tasks” to definitions that’d sprawl across several presentation slides. The one I’ve settled on is this:

“Workflow is a series of tasks, consuming resources, achieving goals.”

Short enough to tweet, which is why I like it, but long enough to address two important concepts: resources (costs) and goals (benefits).

So what is workflow technology? Workflow technology uses models of work to automate processes and support human workflows. These models can be understood, edited, improved, and even created, by humans who are not, themselves, programmers. These models can be executed, monitored, and even systematically improved by computer programs, variously called workflow management systems, business process management suites, and, for ad hoc workflows, case management systems.

Workflow tech, like health IT itself, is a vast and varied continent. As an industry, worldwide, it’s probably less than a tenth size of health IT, but it’s also growing at two or three times the rate. And, as both industries grow, they increasingly overlap. Health IT increasingly represents workflows and executes them with workflow engines. Workflow tech vendors increasingly aim at healthcare to sell a wide variety of workflow solutions, from embeddable workflow engines to sprawling business process management suites. Workflow vendors strenuously compete and debate on finer points of philosophy about how best automate and support work. Many of these finer points are directly relevant to workflow problems plaguing healthcare and health IT.

Why is workflow tech important to health IT? Because it can do what is missing, but sorely needed, in traditional health IT, including electronic health records (EHRs). Most EHRs and health IT systems essentially hard-code workflow. By “hard code” I mean that any series of tasks is implicitly represented by Java and C# and MUMPS if-then and case statements. Changes to workflow require changes to underlying code. This requires programmers who understand Java and C# and MUMPS. Changes cause errors. I’m reminded of the old joke, how many programmers does it take to change a light bulb? Just one, but in the morning the stove and the toilet are broken. Traditional health IT relies on frozen representations of workflow that are opaque, fragile, and difficult to manage across information system and organizational boundaries.

Well, OK, I’ll steal my own thunder just a little bit. Process-aware tech, in comparison to hardcoded workflows, is an architectural paradigm shift for health IT. It has far reaching implications for interoperability, usability, safety, and population health.

BPM systems are ideal candidates to tie together disparate systems and technologies. Users experience more usable workflows because workflows are represented so humans can understand and change then. Process-aware information systems are safer for many reasons, but particularly because they can represent and compensate for the interruptions that cause so many medical errors. Finally, BPM platforms are the right platforms to tie together accountable care organization IT systems and to drive specific, appropriate, timely action to provider and patient point-of-care.

The rest of my blog posts in this weeklong series will elaborate on these themes. I’ll address why so many EHRs and health IT systems are so unusable, un-interoperable, and sometimes even dangerous. I’ll argue that modern workflow technology can help rescue healthcare and health IT from these problems.

About the author

Chuck Webster, MD @wareFLO

Chuck Webster, MD @wareFLO

Chuck Webster, MD, MSIE, MSIS has degrees in Accountancy, Industrial Engineering, Intelligent Systems, and Medicine (from the University of Chicago). He designed the first undergraduate program in medical informatics, was a software architect in a hospital MIS department, and also VP and CMIO for an EHR vendor for over a decade. Dr. Webster helped three healthcare organizations win the HIMSS Davies Award and is a judge for the annual Workflow Management Coalition Awards for Excellence in BPM and Workflow and Awards for Case Management. Chuck is a ceaseless evangelist for process-aware technologies in healthcare, including workflow management systems, Business Process Management, and dynamic and adaptive case management. Dr. Webster tweets from @wareFLO and maintains numerous websites, including EHR Workflow Management Systems (, Healthcare Business Process Management ( and the People and Organizations improving Healthcare with Health Information Technology ( Please join with Chuck to spread the message: Viva la workflow!


  • @Chuck.. Great start…

    Your definition succinctly covers the core elements of workflows.

    “Workflow is a series of tasks, consuming resources, achieving goals.”

    It tells us there is a natural sequencing (i.e series). It’s not likely there can be 10 best ways to do something.

    It tells us that resources will be consumed and, reading between the lines, we can imagine these are scarce resources, so tasks typically need to be prioritized.

    Finally, it tells us that there is no merit performing tasks (work) that do not contribute to the advancement of goals.

  • “Natural, Consistent, Relevant, Supportive and Flexible” is a little vague, but be a little more specific and we will code it for you.

    Note that we will assist non-profits and “failed” projects at no charge or reduced rates depending on the scope of issues.

  • The often missed part of this whole process is to first map out the current processes…whether you are using an EHR or not.

    Most private practices have reinvented the wheel, and maybe don’t have the most efficient processes, but they work just fine and they are comfortable with them.

    Once an EHR is acquired, the practice sees the EHR vendor has created their own processes, so the practice either changes their processes or goes the customization route.

    A lack of desire to change usually steers this route to customization. Once again, mapping out processes become a necessity.

    There’s all sorts of tech to help map out processes, but really, what a private practice needs to do is map it out on index cards and lay it all out so they can see how smooth or convoluted things are.

  • Hi John,

    Thank you for your comment.

    Do you see any limitations in current abilities to customize EHR workflow?

    How might EHR and health IT software be changed, to make it easier for users to customize software to local requirements, preferences, traditions, idiosyncrasies, etc?

    That’s where I’m heading in my next four blog posts (again, thank you John Lynn, for this opportunity).


  • There are multiple limitations including:
    1) Programming
    2) Organizing
    3) Completion of project

    Programming: no matter how simple a piece of software is made to be, there will generally need to be a person who is specially training to accomplish the programming

    Organizing: until a practice understands the importance of organizing and mapping work flows, it will never get done.

    Completion of project: How many websites are started by practices that never get completed? Everyone at a practice is busy, there generally isn’t time for yet another project…such as EHR customization.

    All of these items scream for a specialist or consultant to see this type of project through to the end.

    Guess who is terrible for this? The EHR vendor (if you care to know why, ask and I’ll tell you tomorrow).

    Think about it…using the website analogy: it doesn’t get much easier than WordPress to built a website. Yet, so many offices don’t have someone that can do this. Maybe someone has a cousin who can help, but without any sort of organization to the process, it either looks completely amateur and/or never gets finished.

  • My overall life has been dedicated to workflow. One of the coolest applications I dealt with was from a Company called Optika, which had a neat workflow design tool that integrated programming and steps to come up with a great flexible solution.

    To me workflow in the practice has been optimized over decades around the seeing of patients (Ambulatory Setting). This optimum workflow is achieved and then comes the main problem, EHR software. See the issue is the software is the exact opposite of good workflow, much of it is unusable, and talk about disruptive, have your internet go down and see how well your workflow is going with 40 patients in the lobby and 8 doctors screaming. The issue in workflow is that the software is being designed by developers and often hard coded (alluded to above) and very burdensome to change or use.

    To me the issue is the EHR software itself needs to have a much needed change, but in reality with all the new requirements by the Government, really EHR use is anti-workflow at it’s core.

    That is not all products, but so many are just copies of another. That being said, the 4GL tools are needed, like Oracles BPM (Business Process Management) tools. Oracle purchased Optika Workflow tools, but a few others obviously exists. For Workflow to be successful in practices BPM type tools will need to be invoked to allow end users control over workflow design changes/requirements for this industry to evolve.

    That being said, in the meantime there is a great opportunity for consultants to sell workflow for leading software applications in the EHR space (vertical) that can fit a square peg in a round whole at least to the point that the practice can benefit from what they are required to purchase and use.

  • Chuck,

    Specifically to answer your question:
    Do you see any limitations in current abilities to customize EHR workflow?

    As stated in post above, now flexibility by technology or consultant to do anything without being in this stiff box the EHR vendor has built. As also noted, technology is often so complex it requires to much time to use.

  • @ AXEO MED – I’m with you, but before you can program, you have to map out the processes. This is what drives people crazy. In the real world, you can swerve and change and have holes in processes, but still make it happen.

    Computers require logic. Holes aren’t allowed. The specificity required to program a simple process (work flow) generally sends folks into a coma.

    @ Brendon – like any small business, medical practices have reinvented the wheel many times. One of the draws of a franchise is they have mapped out all the processes for you ahead of time.
    Very few medical offices have efficient work flows.
    They have flows that work for them, and the people who’ve been with them for years, but they are generally not efficient, but good enough.
    I’ve felt, but not proven, that most of the processes that come “stock” with an EHR are optimal in a perfect world. They generally would be good processes if an office was willing to completely change how they function.
    Either way

  • […] If you have time, the series is definitely worth reading.  Here is the link to the first post, Five Guest Blog Posts On EHR & HIT Workflow, Usability, Safety, Interoperability and Population … […]

  • As a patient Identity processor with seven hospitals and many clinics now coming on board. I have seen time after time the same issues. How can we have a place when we combine multiple rows and uncombine them to let other health care professionals know what has been done with the record.
    This would help stop tickets being opened because the details would already be in the application.
    What makes this difficult is when a Patient ID or MRN is being used at multiple facilities for multiple patients.
    If we had this tool it would help stop the confusion of this issue.
    Maybe something someone could consider!
    It would also be helpful for fruad cases.

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