Usable EHR Workflow Is Natural, Consistent, Relevant, Supportive and Flexible

This is my third of five guest blog posts covering Health IT and EHR Workflow.

Workflow technology has a reputation, fortunately out of date, for trying to get rid of humans all together. Early on it was used for Straight-Through-Processing in which human stockbrokers were bypassed so stock trades happened in seconds instead of days. Business Process Management (BPM) can still do this. It can automate the logic and workflow that’d normally require a human to download something, check on a value and based on that value do something else useful, such as putting an item in a To-Do list. By automating low-level routine workflows, humans are freed to do more useful things that even workflow automation can’t automate.

But much of healthcare workflow requires human intervention. It is here that modern workflow technology really shines, by becoming an intelligent assistant proactively cooperating with human users to make their jobs easier. A decade ago, at MedInfo04 in San Francisco, I listed the five workflow usability principles that beg for workflow tech at the point-of-care.

Consider these major dimensions of workflow usability: naturalness, consistency, relevance, supportiveness, and flexibility. Workflow management concepts provide a useful bridge from usability concepts applied to single users to usability applied to users in teams. Each concept, realized correctly, contributes to shorter cycle time (encounter length) and increased throughput (patient volume).

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 EHR 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 EHR 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 EHR 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 EHR 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. Plus, different EHR users may require different BPM process definitions, or shared process definitions that can be parameterized to behave differently in different user task-contexts.

The ideal EHR/EMR should make the simple easy and fast, and the complex possible and practical. Then ,the majority/minority rule applies. A majority of the time processing is simple, easy, and fast (generating the greatest output for the least input, thereby greatly increasing productivity). In the remaining minority of the time, the productivity increase may be less, but at least there are no showstoppers.

So, to summarize my five principles of workflow usability…

Workflow tech can more naturally match the task structure of a physician’s office through execution of workflow definitions. It can more consistently reinforce user expectations. Over time this leads to highly automated and interleaved team behavior. On a screen-by-screen basis, users encounter more relevant data and order entry options. Workflow tech can track pending tasks–which patients are waiting where, how long, for what, and who is responsible–and this data can be used to support a continually updated shared mental model among users. Finally, to the degree to which an EHR or health IT system is not natural, consistent, relevant, and supportive, the underlying flexibility of the workflow engine and process definitions can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.

Tomorrow I’ll discuss workflow technology and patient safety.

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!


  • Works for me. . .

    Naturalness is easy to achieve when “the map is the app”. A good UI is one that has a split screen with a calendar on one side and a to-do list on the other.

    Consistency & Flexibility – these work hand in hand – users either follow the best practice (orchestration) or they don’t follow it (but arrive at the same result because of the presence of governance).

    Relevance comes from parking context/situation forms at process steps – since data flows along pathways, all that is needed at any step is to post data essential for performance and provide data entry points for data that needs to be picked up at each step.

    Supportiveness comes from local rule sets at step forms, an ability to consult the Hx, and pre/post conditions coming into steps and leaving steps.

  • Thank you KW! (Karl or Walter?)

    This is what I mean when I frequently say these five principles of workflow usability just beg for workflow tech. A workflow professional, such as you, can immediately offer specific examples of how workflow tech (into which I lump workflow management systems, business process management, and dynamic or adaptive case management) supports all five principles.

    The only things I’d add to your excellent list is to elaborate Naturalness and Flexibility.

    I used to run a yearly three-hour tutorial on workflow tech for the old TEPR EMR conference. All my slides and speaker notes are online.

    Here’s a list of short definitions for “natural” culled from many places:


    “in conformity with nature”
    “functioning in a normal way”
    “expected and accepted”
    “having all the qualifications necessary for success”
    “suite by nature for a centain purpose or function”
    “in accordance with human nature”
    “ordinary and logical”
    “as one would expect”
    “freedom from constraint”

    “Naturalness” is one of the hardest to define usability qualities. It involves conformance, or fit, of a tool to the human, whether it is a glove, favorite shoe, smartphone or EHR. Cognitive science approaches to naturalness range from affordances (handles on coffee cups) to similarity between problems (such as creating accounting statements) and representations (spreadsheets). That discussion quickly becomes arcane. The best judge, of whether an EHR’s workflow feels natural, is how it feels to you. At each step of charting a patient, for example, the next thing you need to do should be obvious to you. Of the five workflow usability principles naturalness is perhaps the most subjective. It may also be the most important.”

    With respect to flexible workflow, this is exactly what most EHRs and health IT systems lack, because they aren’t based on workflow platforms. Most are based on structured-document platforms instead of structured-workflow platforms. It is this “structure” that makes workflow tech flexible. Workflow, the order of tasks, consuming resources, achieving goals, is extracted out of third-generation computer languages such as Java, C#, and MUMPS, and represented declaratively in databases that, essentially, model work. These models of work can both be executed by various kinds of work engines and can be understood and modified by the people who know their workflow best: the users.

    Anyway, I much appreciate your excellent comment, proving a point that I think both of us want to prove: health IT needs workflow tech.



    PS Just a reminder! Tomorrow I tackle patient safety and workflow, and on Friday I tackle the big one: Population Health Management!

  • Agree that anyone trying to make a workflow “natural” for a group of users has their work cut out for them.

    Unless, of, course, you hand these users tools that allow them to build, manage and own their own processes.

    Once you do this, the steps along the processes become their steps, the forms they park at these steps become their forms, and the data fields on these forms are the ones they decide are needed to a) make decisions b) enrich the data stream.

    90% of the usual complaints simply disappear. Don’t like it? All you have to do is change it.

    Not much left to worry about except providing a decent UI and here, long before computers, we carried around agenda books that showed fixed time commitments on one side and floating time (to-do) tasks on the other. It worked then, no reason why an e-version of something like FiloFax will not work today.

    I constantly remind my clients that a UI such as this can handle any mix of structured (BPM) work and unstructured (ACM) work – the model is ultra simple and familiar.

    All of us come in every day, take note of our fixed time appointments and attend to to-do tasks in between fixed time appointments. We do this very day, all day long.

    I look forward to your next two posts.


    Karl Walter…

    I seem to respond to any of three names. Some people call me Karl, some Walter. My two German Shepherds both called me Woof. Any time I failed to be responsive they would bark.

    I think Max Pucher is the only person who calls me “Karl Walter”.

  • This is a fantastic elaboration of what it takes to make a great software application. I agree that the flexibility component is one of the core principles. From my experience, I can say that flexibility is probably the most important component. Personalities and past repetitions have shaped each user uniquely, and while we want to offer the “best” workflow, there is almost always a requirement for variance. For example, some physicians read an x-ray from head-to-toe, while others do the opposite. Both achieve excellent results, regardless of their approach. Providing flexibility in the workflow configuration at the user level is critically important. However, it is a juggling act to provide enough flexibility, but not so much that the rest of the staff functions one-off for each user they support.

    Providing solutions to physician-owned practices has been a rewarding experience. It has sculpted our organization and reiterated the significance of flexibility. Not to ignore the other critical principles, but I can say that our priority of flexibility has been a good model for us.

    I appreciate your details on the processes and principles, and look forward to your future posts.


    Steve Deaton

  • Thank you Steve.

    You are, of course, completely correct. Flexible workflow is the most important property of EHR and health IT software. It’s also the most difficult to provide to users without overwhelming them with options for changing their workflows. This is why I favor workflow technology. Its architecture is specifically designed to expose these options in ways that make sense to users, from flow charts to screen designers to easily tweakable checklists. BTW, I notice you’re with a medical imaging company. Medical imaging platforms were amongst the earliest adopters of the kind of workflow technology we’re praising here. In my opinion, it’s one of the more important channels for diffusion of process-aware information systems philosophy and technology into healthcare.

    Thank you for your comment and I’m sorry I was delayed in responding directly to you!


Click here to post a comment