Changing Workflow Must Serve Patients and Practices

EHRs and WorkflowEHRs and Workflow

William A. Hyman
Professor Emeritus, Biomedical Engineering
Texas A&M University,
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A common complaint about EHRs is that their use is not in accordance with existing clinical workflow and that they are therefore disruptive, distracting and inefficient. Such a complaint is part of usability in that we might assume that the complained of EHRs are capable of receiving, storing and presenting all of the necessary information, but that they do not do so in an actually helpful manner. Moreover idiosyncrasies, from the perspective of the user, can lead to a variety of errors. Part of such complaints is that the developers of the EHR didn’t understand clinical workflow, didn’t bother to find out, or didn’t bother to incorporate what they did know.

With this background it was interesting to hear Dr. Mostashari, National Coordinator for Health IT, US Department of Health And Human Services, say in a recent presentation that the above workflow analysis issue has it backwards. Speaking on a Health Affairs webinar , Dr. Mostashari’s perspective was that workflow has to be redesigned to meet the capabilities of EHRs. His analogy in this regard was that when electric power was first introduced into industry its use mimicked the way of using the power source it was replacing, e.g. typically a drive belt and multiple pulley system that distributed power from the single source to each machine. It was only later that individual electric motors were provided for each machine, thereby redesigning the machines to meet the new means of power. Whether or not this is a worthy analogy can certainly be debated.

However if one is willing to try to stretch this analogy to EHRs it seems reasonable to demand that the EHRs be well designed in the first place, i.e. it does not make sense to have to adopt to any and all EHRs no matter how ill conceived they are. In addition, any change in workflow must serve the patients and the practice, not just the demands of the EHR. In this regard we need to seriously record and compile patient outcomes and misadventures, and then not assume that bad results are a learning curve issue.  While there is no doubt a learning curve with any new system, the more important question is at what level does the learning plateau, and how complication free and stable is the new norm. In addition, the issue of what happens during the learning period is usually skipped over. In this regard I am reminded of the issue of deploying so called safety syringes which are meant to reduce accidental needlesticks. Because of the demands associated with manipulating many such devices, OSHA acknowledged that needlesticks might go up initially after a “safety” syringe was introduced and the users figure out how to actually use them. This is the ultimate in on-the-job training in that the workers are being put at risk while they learn how to be safe. From the patient’s perspective, unless one is truly devoted to education, a reasonable response to the risks that occur during the learning period is get back to me after you have learned.

Moreover, if it were true that an EHR was well designed and that adopting workflow to it would indeed be beneficial (beyond earning Meaningful Use incentive payments) then who is that should be defining the necessary workflow modifications? Is it that the EHR vendors should be saying “here is the product, now figure out to best use it”, or should the vendor be providing guidance on how to best utilize the features it provided? The instructional requirements for medical devices might be helpful in this regard, They include that the “labeling bears information for use including, indications, effects, routes, methods, and frequency and duration of administration, and any relevant hazards, contraindications, side effects, and precautions under which the device can safely be used”.

Perhaps over time, and either by research or by happenstance, what Dr. Mostashari hypothesized is correct. People will adopt to the demands of their EHRs and it may be all for the good. But the smog belching, CO2 generating power plants that provided the power for all of those electric motors has at least some people nostalgic for a nice water wheel.