TRADITIONAL EMRS
VERSUS
EMR WORKFLOW SYSTEMS
We pioneered usable pediatric EMR workflow. Period.
In 1991 we wrote in the Journal of Medical Practice Management (reprinted here, page 11):
The combination of structured data entry, workflow automation, and screens designed for touch screen interaction optimally reduces inherent tradeoffs between information utility and system usability on one hand, and speed and accuracy of data entry on the other. Successful application of touch screen technology requires that only a few, but necessary, selectable items be presented to the user in each screen. Moreover, workflow, by reducing cognitive work of navigating a complex system, makes such structured data entry more usable.
In 2004 we wrote in the Proceedings of MedInfo in San Francisco (the top international medical informatics conference):
EHR workflow management systems are more usable than EHRs without workflow management capability. Consider these usability principles: naturalness, consistency, relevance, supportiveness, and flexibility. EHR WfMSs more naturally match the task structure of a physician’s office through execution of workflow definitions. They 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. An EHR WfMS tracks 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 WfMS is not natural, consistent, relevant, and supportive, the underlying flexibility of the WfMS can be used to mold workflow system behavior until it becomes natural, consistent, relevant, and supportive.
The EncounterPRO Pediatric EMR Workflow System is one of the first successful examples of clinical groupware. Its clinical groupware functionality "leads to highly automated and interleaved team behavior" and "support[s] a continually updated shared mental model among users."
And in 2005 we presented at, and expanded on this subject in the proceedings of, the HIMSS conference in Dallas (the following is adapted from that paper):
Usability is “the effectiveness, efficiency, and satisfaction with which specified users achieve specified goals in particular environments.” However, in the case of pediatric EMR workflow systems, usability must be construed not only relative to single users, but also with respect to the entire team of patients, pediatricians, and pediatric staff who work together for common goals. One might rephrase this definition of usability to become the effectiveness, efficiency, and satisfaction with which teams of users achieve collections of goals in complex social environments.
EncounterPRO Pediatric EMR Workflow System is "Clinical Groupware for Pediatric Practice." It is EncounterPRO's emphasis on the entire team, not just the individual user, that makes EncounterPRO different from traditional EMR "singleware": Our definition of EMR usability is indeed "the effectiveness, efficiency, and satisfaction with which teams of users achieve collections of goals in complex social environments." By the way, just because a traditional EMR gives users access to a shared database of patient data doesn't make them not "singleware." The shared database must contain for display real-time data about other relevant users, their goals, and task status in order of an EMR to quality as "clinical groupware."
Consider these major dimensions of pediatric EMR 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), increased throughput (patient volume), and a savings of time and resources that can be applied to seeing more patients, spending more time with each patient, and going home earlier.
THE PRINCIPLE OF NATURAL WORKFLOW
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 pediatric EMR users in multiple roles. A patient visit to a pediatric medical practice office involves multiple interactions among patients, nurses, technicians, and pediatricians. Task analysis must therefore span all of these users and roles. Creation of a pediatric process definition is an example of this kind of task analysis, and results in a machine executable (by the workflow engine) representation of task structure.
THE PRINCIPLE OF CONSISTENT WORKFLOW
Consistency is the degree to which an application reinforces and relies on user expectations. Process definitions enforce (and therefore reinforce) consistency of pediatric EMR user interactions with each other and with respect to task goals and context. Over time, team members rely on this consistency to achieve highly automated and interleaved behavior (an important effect of well-designed clinical groupware). Consistent repetition leads to increased speed and accuracy.
THE PRINCIPLE OF RELEVANT WORKFLOW
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 pediatric EMR user roles (related sets of activities, responsibilities, and skills) to select appropriate screens, screen contents, and interaction behavior.
THE PRINCIPLE OF SUPPORTIVE WORKFLOW
Supportiveness is the degree to which enough information is provided to a user to accomplish tasks. An EMR 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 (another important result of well-designed clinical groupware). For example, since a pediatric EMR workflow system represents and updates task status and responsibility in real time, this data can drive a display that gives all pediatric EMR users the big picture of who is waiting for what, for how long, and who is responsible.
THE PRINCIPLE OF FLEXIBLE WORKFLOW
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 pediatric EMR users may require different process definitions, or share process definitions that can be parameterized to behave differently in different user task-contexts.
THE IDEAL PEDIATRIC EMR (WORKFLOW SYSTEM)
The ideal pediatric 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 show stoppers!
Artwork Courtesy of A Child's Night Out
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| TESTIMONIALS |
"Waiting times have been dramatically reduced every step of the way—not just the waiting room time. Parents are happier because going to the doctor no longer takes two hours out of their already overcrowded schedule. I can see more kids per hour with an actual increase in preventive services like screenings and vaccines—thus improving healthcare and increasing revenue at the same time." Jeffrey D. Cooper MD Pediatrician EncounterPRO User Since 1995 (and HIMSS Davies Award Winner)
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"It has allowed our physicians to increase the number of patients they see in a day...And it has given the physicians that were already high-volume the opportunity to spend a little more time with their patients and be more personable." Dee McGee, Pediatric Practice Manager EncounterPRO User Since 1995
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"It's really helped my lifestyle. I'm working three and a half days a week, I used to work seven days a week. So it's really made life much easier, and the staff love it!" Armand Gonzalzles MD Pediatrician EncounterPRO User Since 1999 (and HIMSS Davies Award Winner)
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"The payroll savings and increase in collections repaid our total investment in 18 months." Allen R. Carter Jr., Business Manager, Family Medicine EncounterPRO User Since 2000
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"We have seen incredible results as to the increase in patient volume we can handle." Patricia Hernandez, Clinic Administrator, OB/GYN Practice EncounterPRO User Since 2000
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"At a time when physicians are being squeezed by cost constraints of record proportions while trying to continue to provide quality care, it is absolutely imperative that you look for a system that delivers security, cost efficiencies, and unparalleled quality of care in a new way—EncounterPro is that system." John Ivan Sutter MD Pediatrician EncounterPRO User Since 2000
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"One Monday in the winter we had only two of our five doctors in the office. Then my partner was stuck at the hospital and I was left by myself. At the end of a long day I had seen 79 patients! I wasn’t even frazzled." Karen Kamachi MD Pediatrician, EncounterPRO User Since 2000
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"My office went live 2 days ago and it's unbelievable! For the first time in my nearly 15 years in pediatric practice I left my office with all my charts and notations completed for the day...Thank you so much for giving me a life again!" Angela D. Hunt MD Pediatrician EncounterPRO User Since 2001
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"When I selected EncounterPRO, the biggest motivating factor was the concept of having an office screen that displays the necessary patient activities. This is similar to the ER board that many of us are familiar with that lists where each patient is and what procedure needs to be done next. In a procedure-oriented practice like ophthalmology, the efficiency from this tool is tremendous. The idea of telling staff what to do silently without disruption took me over the top. Features like this can eliminate the need for signaling lights or flags on exam room doors. The final big feature is workflow. Essentially, the program automatically sequences through your documentation depending upon the type of exam you have chosen." Phelgar Washington MD Ophthalmology EncounterPRO User Since 2001
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"We have seen a dramatic impact in lower cost, higher quality and increased speed of healthcare services. Parent satisfaction has dramatically increased as a result of the improved quality and timesavings of our healthcare services." Charles Gregg Pediatric Office Manager EncounterPRO User Since 2002
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"EncounterPRO has reduced the amount of time it takes to produce medical records. The system promotes more teamwork and greater staff efficiency." Linda Hall Office Coordinator Pediatrics EncounterPRO User Since 2002
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"The EMR user interface is akin to the touch screen-oriented systems in restaurants: one screen at a time, with only the most relevant data displayed and options presented (although, of course, a user can always jump out of a particular screen sequence to accomplish an arbitrary task), and the sequences can be tweaked through the workflow management to make such occurrences infrequent...The workflow plans are tailored for each type of patient seen in the office (obstetrics, gynecologic, annual exams, family practice) assuring that key elements of the present illness, history and physical are addressed and documented. Work plans contain required laboratory tests for specific conditions, assuring that key tests are not forgotten." Jeffrey Harris MD Obstetrics Gynecology and Family Practice EncounterPRO User Since 2003 (and HIMSS Davies Award Winner)
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"Benefits I have noticed personally included: decreased turnaround time for telephone messages, decreased turnaround time for prescription refills, decreased turnaround time for referrals, improved efficiency of office procedures such as immunizations and tests, decreased time spent at the end of the day returning phone calls, writing refills, and completing charts." William Long MD Pediatrician EncounterPRO User Since 2004
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