Preventing Your EHR from Working Against You, Part I: EHR Workflow and Personal Work Habits

Every EHR is designed to work a certain way. The number of mouse clicks required to write a prescription; the number of screens viewed to order a lab; and the number of buttons pressed to generate a report all reflect the designers’ assumptions about how specific tasks are best accomplished.    The combination of clicks, screens, and buttons necessary to accomplish a task comprise a product’s workflow.   In all but the rarest cases, an EHR’s workflow is hard-coded and cannot be changed.   This means that in order to get any work done with an EHR you have to learn to do things its way.   Of course, the frustrations revealed by EHR users prove that this is often easier said than done. Training provides a straightforward way to learn how an EHR works. Unfortunately, training doesn’t necessarily help clinicians adapt their work habits to the EHR’s workflow.   When a clinician’s work habits clash with an EHR’s built-in workflow, unhappiness and decreased productivity are the usual result.

Work habits are highly personal. They are unconscious behaviors that develop over years of practice and training.  Few clinicians are aware of their work habits until something like an EHR insists on changing them.   Those who are switching from paper to an EHR are likely to have the most jarring experience.  However, even those switching from another EHR will experience some disquiet because their new EHR will not work exactly the same as their old one.

My introduction to the importance of personal work habits came nearly 16 years ago when I was trying to design a screen to display lab data. In an online group I asked a simple question: “Should lab data be displayed with dates trending downward, so that each row is a new date, or should they trend across the screen so that each column is a new date?”  Responses were about equally split between the two choices.  I was surprised by how passionately each group insisted that its choice was the correct one.    I doubt that anyone who responded had ever given much thought to display preferences, and only became aware of their preference when asked.

Knowledge of your personal work habits can be very helpful when selecting an EHR. Of course, if you are in a group with 200 doctors, your personal preferences are not likely to have much of an effect on the final product choice (unless you happen to be the CIO).   If you are in a smaller practice, however, awareness of your personal work habits might be the difference between choosing an EHR that you love and one that brings you to tears. The key to understanding your personal work habits is workflow analysis.

The AHRQ offers this definition of workflow (it is as good as any other): “Workflow is the sequence of physical and mental tasks performed by various people within and between work environments. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously.”  This definition correctly points out that workflows occur at multiple levels.  However, most available clinical workflow analyses concentrate predominantly on people-to-people workflows (I usually refer to these as group workflows).

Group Workflows
Group workflows involve processes in which things (information, people, materials, etc.) move from one person to another. For example, the patient intake process in most practices involves the following steps:  the patient interacts with the front desk staff, moves on to the medical assistant, and then sees the clinician.  This is a typical group workflow.    Analyses of group workflows are essential for both EHR selection and implementation.  Without them, identifying inefficiencies and redundancy is nearly impossible.  However, since their focus is on how work moves from one person to another, they are not very helpful in aiding individual clinicians determine how comfortable they will be interacting with an EHR.  For that, you need to look at your personal workflows.

Personal Workflow & EHR Evaluation
Recording a physical exam, writing a prescription and reviewing labs are typical workflow tasks that can be significantly altered by an EHR.  Analyzing your personal workflow begins with making a list of the tasks you perform most often.  After prioritizing your list, select a task and analyze it in more depth.  For example, you could look at the number of steps required, the time required, the materials that you need, etc.  Keep in mind that there is no right answer or one correct way to do this. You are simply trying to create a model of how you work.  So, how does all this help with selecting an EHR?  Once you feel pretty comfortable with your task list and the level of detail, you can use that to create a EHR test script.

Test Scripts
A test script is a set of step-by-step instructions for completing a task. Test scripts are valuable because they assure that you do the same task the same way each time. In addition, they help you to remain focused.  For example, if your EHR test script covers writing a prescription, it will have all the steps that you usually go through while writing a prescription. Since this is based on how you do things on paper, or with a different EHR,  it captures your expectations and workflow. When you are ready to select an EHR, you should use the test script to guide your interactions with each product.

When you are reviewing a product, a test script serves two functions:  1) it assures that you approach each EHR product in the same way–allowing for the closest you can get to an apples-to-apples comparison and 2) it assures that your personal work habits are taken into account. EHR test scripts are not foolproof, but they do provide a good feel for how a product works.

I hope this has been useful in helping you understand the value of personal workflow analysis in EHR selection. In the next post in this series, I will explain how to perform a personal workflow analysis for a specific task. See you then.


About four years ago, I began using the concept of personal workflows as a way of studying the factors that make clinicians uncomfortable when using EHRs.  This series of posts is inspired by “Preventing Your EMR from Working Against You—a Provider’s Guide to Workflow, a presentation that I did at the “Toward the Electronic Patient Record” conference (TEPR), May 20, 2008.  For those who would like more information on group workflow analysis, there are plenty of resources available. I suggest the following:

Electronic Health Records, Second Edition, Jerome H. Carter, (Chapters 16 and 23)
“Workflow Assessment for Health IT Toolkit,” Agency for Healthcare Quality and Research, 2010
“Workflow Analysis: EHR Deployment Techniques,” California Healthcare Foundation, 2011
Preventing Your EMR from Working Against You—a Provider’s Guide to Workflow,”  Jerome H Carter, TEPR, May 20, 2008.


Preventing Your EHR from Working Against You, Part II: Personal Workflow Analysis

Preventing Your EHR from Working Against You, Part III: Creating a Test Script





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