NISTIR 7988

Integrating Electronic Health Records 

into Clinical Workflow: An 

Application of Human Factors 

Modeling Methods to Ambulatory 

Care

Sventlana Z. Lowry

Mala Ramaiah

Emily S. Patterson

David Brick

Ayse P. Gurses

Ant Ozok

Debora Simmons

Michael C. Gibbons

http://dx.doi.org/10.6028/NIST.IR.7988
NISTIR 7988

Integrating Electronic Health Records into Clinical 

Workflow: An Application of Human Factors Modeling 

Methods to Ambulatory Care

Svetlana Z. Lowry

Mala Ramaiah

Information Access Division

Information Technology Laboratory

Emily S. Patterson

Ohio State University

Columbus, OH

David Brick

NYU Langone Medical Center

New York, NY

Ayse P. Gurses

Johns Hopkins University School of Medicine

Baltimore, MD

Ant Ozok

University of Maryland, Baltimore County

Baltimore, MD

Debora Simmons 

St. Luke’s Health System

Houston, TX

Michael C. Gibbons

Johns Hopkins University

Baltimore, MD

http://dx.doi.org/10.6028/NIST.IR.7988

March 2014

U.S. Department of Commerce 

Penny Pritzker, Secretary

National Institute of Standards and Technology 

Patrick D. Gallagher, Under Secretary of Commerce for Standards and Technology and Director
ii

Acknowledgments

The authors gratefully acknowledge the intellectual contributions from the following reviewers: 

 Michael A. Wittie, M.P.H., DHHS/Office of the National Coordinator for Health IT, Office of the 

Chief Medical Officer, Office of Clinical Informatics

 Joseph Bormel, M.D., M.P.H., Medical Officer, Office of the Chief Medical Officer, Office of the 

National Coordinator for Health IT, U.S. Dept. of Health & Human Services (DHHS)

 Mary Frances Theofanos, Computer Scientist, Information Access Division, National Institute of 

Standards and Technology

 Brian Stanton, Cognitive Scientist, Information Access Division, National Institute of Standards 

and Technology

 Kristen K. Greene, Ph.D., Information Access Division, National Institute of Standards and 

Technology

 Eswaran Subrahmanian, Ph.D., Software and Systems Division, National Institute of Standards 

and Technology

 Michael L. Hodgkins, M.D., M.P.H., Chief Medical Information Officer, American Medical 

Association

 Steven E. Waldren, M.D., M.S., Sr. Strategist for Health Care IT, Center for Health IT

American Academy of Family Physicians

 Jason M. Mitchell, M.D., Medical Director, Clinical Informatics American Academy of Family 

Physicians

 Paul Latkany, M.D., Assistant Director of Informatics and Information Management, DoD/VA 

Vision Center of Excellence 

 Jeanie Scott, CPHIMS, Director, Informatics Patient Safety, VHA Office of Informatics and 

Analytics/Health Informatics

 Emily C. Webber, M.D., Riley Hospital for Children at Indiana University Health

 Korrie J. Mapp, CPE, Organic Ergonomics, LLC

 Emilie M. Roth, Ph.D., Principal Scientist, Roth Cognitive Engineering

 Kevin Jones, M.Sc., Assistant Director, Business Systems, Information Technology, The Ohio 

State University Medical Center

 Michael Kordek, M.D., M.B.I., Family Medicine Staff Physician, Geisinger Medical Group

 Nicholas Gibson, Implementation Consultant, Itentive Healthcare Solutions

 Gary Gartner, M.D., M.S., User Experience Clinician, Allscripts Healthcare Solutions, Inc.,

 Thomas H. Elmquist, M.D., New York Cardiovascular Associates

 Leigh Burchell, Vice President, Policy and Government Affairs, AllScripts, and 

 HIMSS Electronic Health Record Association
iii

DISCLAIMER

Certain commercial entities, equipment, or material may be identified in this document in 

order to describe a concept adequately. Such identification is not intended to imply 

recommendation or endorsement by the National Institute of Standards and Technology, nor 

is it intended to imply that these entities, materials, or equipment are necessarily the best 

available for the purpose.
iv

Table of Contents

Acknowledgments ..................................................................................................................... ii

Table of Contents .................................................................................................................... iv

Executive Summary ..................................................................................................................v

1 Introduction: Clinical Workflow Challenges with EHRs .................................. 1

2 Background of Workflow Modeling for EHRs....................................................... 4

3 Application of Human Factors Workflow Modeling Tools ............................... 6

4 Targeted Recommendations for EHR Developers and Ambulatory Care 

Centers for Improving Workflow ..................................................................................... 34

5 Conclusion ........................................................................................................................ 36

6 References ......................................................................................................................... 37
v

Executive Summary

Adoption of Electronic Health Record (EHR) systems in hospitals and outpatient clinics is accelerating. 

EHRs can support and revolutionize the way information is used to provide high-quality and safe patient 

care. At the same time, however, issues with workflow integration have contributed to slow rates of EHR 

adoption in some settings, including ambulatory outpatient care. Workflow is a set of tasks, grouped 

chronologically into processes, and the set of people or resources needed for those tasks that are necessary 

to accomplish a given goal. Workflow analysis is an integral part of the early stages of the User-Centered 

Design (UCD) process. UCD is an approach to designing systems and employs both formative and 

summative methods in order to achieve systematic discovery of useful functions grounded in an 

understanding of the work domain. 

In response to workflow integration challenges with EHRs, clinicians often develop workarounds to 

complete clinical tasks in ways other than were intended by system designers. A frequent workaround, for 

example, is copying and pasting text from a previous progress note for a patient to serve as a draft for the 

current progress note. In this report, two human factors workflow modeling tools, process mapping and 

goal-means decomposition, were used to collect, visualize, and document insights and the end-user needs 

to improve EHR workflow for clinicians in outpatient care settings. The findings identified clinical 

activities that require more relevant and flexible workflows in EHR designs to support end users’ needs. 

Based on the insights generated during collegial discussions with physician Subject Matter Experts 

(SMEs) and three interdisciplinary team meetings with clinical and human factors experts, we created 

process map visualizations and a goal-means decomposition diagram. 

The insights identified a wide range of opportunities to improve workflow through enhanced functionality 

with the EHR. Some of the opportunities included:

• At-a-glance overview displays to enable physicians to adapt patient schedules to smooth out 

predicted workload and better meet work-life balance objectives

• Support for remembering tasks to accomplish during a subsequent patient visit

• Redacting and summarizing laboratory results

• Drafting predicted orders a day before a patient visit to reduce the time to complete the orders 

during the visit

• Supporting moving from initial working diagnoses to formal diagnoses

• Supporting dropping or delaying tasks under high workload conditions

• Supporting different views of a progress note based upon role

• Distinguishing new documentation in a progress note from copied information from a different 

progress note

• Supporting communication with specialist physicians about referrals and consultations

• Tracking scheduled consults and review of laboratory results

Targeted recommendations for EHR developers and ambulatory (outpatient) care centers to improve 

workflow integration with EHRs are proposed to increase efficiency, allow for better eye contact between 

the physician and patient, improve physician’s information workflow, and reduce alert fatigue. These 

recommendations cover scenarios such as supporting tasks accomplished over multiple interactions with 

an EHR by multiple users, for example, a nurse practitioner drafting medication orders that are verified 

and completed by a physician.
vi

These recommendations provide a first step in moving from a billing-centered perspective (i.e., focusing 

on ensuring maximum and timely reimbursement) to a clinician-centered perspective where the EHR 

design supports clinical cognitive work, such as moving from an initial working diagnosis to a formal 

diagnosis for a complex patient. These recommendations point the way towards a “patient visit 

management system,” which incorporates broader notions of supporting workload management, and 

supporting the flexible flow of patients and tasks.
1

1 Introduction: Clinical Workflow Challenges with EHRs

Adoption of Electronic Health Record (EHR) systems in hospitals and outpatient clinics is accelerating.1

EHRs can support and revolutionize the way information is stored, accessed, shared, and analyzed for 

patients, patient cohorts, and organizations, creating a foundation for potentially dramatic improvements 

in quality of care, patient safety, public health monitoring, and research.2,3,4,5,6,7,8,9,10,11,12 At the same time, 

however, use errors from design flaws and poor usability with EHRs can negatively affect patient safety.13

Further, issues with workflow associated with EHR implementation, including inefficient clinical 

documentation, have contributed to slow rates of EHR adoption in some areas, such as ambulatory care 

settings14 and pediatric care15 and shown increased documentation time with major changes to the nature 

of documentation in ophthalmic care.16 Also, a recent survey study indicates that nearly 60% of 

ambulatory care providers report being dissatisfied with their EHR due to usability and workflow 

concerns.17

The purpose of this report is to demonstrate how applying human factors modeling methods can improve 

EHR workflow integration into the clinical workflow. Although there are multiple users for electronic 

health records, for the purposes of this project, the scope was primarily limited to physicians in an 

ambulatory (outpatient) care setting.

In healthcare settings implementing EHRs, an emerging consensus is that many of the critical risks for the 

care of patients associated with the use of the EHR are related not just to the system’s user interfaces, but 

also to the usefulness of the system’s functionality and workflow.18 Therefore, for the purposes of this 

document, we use a unified framework for defining EHR usability: “how useful, usable, and satisfying a 

system is for the intended users to accomplish goals in the work domain by performing certain sequences 

of tasks.”19

For systems used in high-risk environments, where mistakes can result in fatalities, ensuring system 

usability is a particularly important objective. Usability has traditionally been defined as “the extent to 

which a product can be used by specified users to achieve specified goals with effectiveness, efficiency 

and satisfaction in a specified context of use.”20 In order to achieve usability in such systems, it is critical 

to design for usability using best practices from User-Centered Design (UCD). UCD is an approach to 

designing systems; the approach is informed by scientific knowledge of how people think, act, and 

coordinate to accomplish their goals.21 UCD practices employ both formative (for informal suggestions) 

and summative (for formal validation) practices in order to achieve systematic discovery of useful 

functions grounded in an understanding of the work domain. 

National guidelines have been released to improve usability and patient safety by conducting summative 

usability tests of EHR software as a part of implementation.22 An acknowledged limitation of this 

approach is that it is difficult to identify workflow challenges arising from local implementation decisions 

and from the variation in the distribution of work across types of users. The Agency for Healthcare 

Research and Quality (AHRQ) report titled “Incorporating Health Information Technology into 

Workflow Redesign”

23 concluded that workflow analysis was needed in order to ensure successful health 

IT implementation. Additionally, in some cases, components that are created to meet the needs of 

particular types of users (such as physician order entry, nursing and pharmacy order processing, and 

nursing medication administration documentation) may not interact well with each other.24

Workflow has emerged as an issue for EHR adoption, productivity,25 and professional satisfaction for 

physicians.26 Issues with non-optimized workflow include making patient care more fragmented, 

introducing new risks to patient safety, and requiring more effort in coordination of care.22,23 For 

organizations that are interested in increasing the patient’s role in shared decision making and tailoring 
2

care to patient characteristics based upon recent evidence, EHRs provide little support and make it 

difficult for the team members other than physicians to support performing relevant tasks such as entering 

data from interviewing a patient into a draft of a progress note.27 Designing for healthcare is confronted 

by high variability and nonlinear nature of work.24,25 For example, workflow challenges that have been 

identified in the literature review include: 

 having to log in to multiple systems separately,26

 extensive manipulation of keyboards to enter information,27

 the number of clicks involved in medication ordering processes,28,29,30 

 difficulty in processing orders that are not standard,30,31

 difficulties in switching between different paths and screens to enter and retrieve information,29

 problematic data presentations such as patient medication profile design,31

 clutter of order and note screens,26

 difficulty seeing patient names on the screen,

32 and 

 missing free text entry and other word processing functionalities.29,30

In response to workflow integration challenges with EHRs, clinicians often develop workarounds to 

complete clinical tasks in ways other than were intended by EHR system designers.33,34 Workarounds are 

defined as actions that do not follow explicit rules, assumptions, workflow regulations, or intentions of 

system designers.35 The primary reasons for workarounds are improving efficiency, triggering memory, 

and increasing situational awareness, while additional reasons include knowledge/skill/ease of use, task 

complexity, and trust issues.33 Workarounds can be positive improvements or can be suboptimal. A 

frequent workaround, for example, is copying and pasting text from a previous progress note for a patient 

to serve as a draft for the current progress note. In one study, 25% of patient charts had text copied from 

prior clinical examinations, which can lead to confusion, medical error, and medico-legal harm.28

It is important to understand the potential impact of workarounds on patient safety. Designing systems 

that are poorly integrated into workflow may promote workarounds that bypass safety features. For 

example, poor coordination between bar coding and the medication administration record has been shown 

to prompt nurses to work around the documentation of medication administration.29 In addition, EHR 

documentation may not allow for the variety of patient care that is routine in healthcare – making the 

EHR a barrier to capturing important clinical documentation. While the challenge of meeting workflow 

expectations is considerable, the implications for patient safety are becoming more apparent in the 

literature.30 Modeling methods are needed to allow EHR software to accommodate the complexity of 

clinical environment workflows. Applying these methods will avoid contributing to patient safety issues31

directly through design flaws as well as indirectly through unsafe workarounds. In addition, there will be 

more opportunity to provide high-quality care when inefficiencies in documentation and other tasks not 

directly related to real-time care are reduced.

From a human factors perspective, the unit of analysis for a workflow applies to the entire work system. 

The work system is composed of the five main elements from the Systems Engineering Initiative for 

Patient Safety (SEIPS)36 framework (Figure 1): 1) people (individuals and teams), 2) physical 

environment, 3) tools and technologies, 4) tasks, and 5) organizational characteristics. The SEIPS 

framework combines three important aspects for modeling and improving workflow of an EHR: a 

systems approach, human factors engineering, and safety engineering. The framework indicates that 

changes made in the work system can have direct and indirect impacts on workflow and corresponding 

outcomes. 
3

Figure 1. The SEIPS framework for work system elements

From our literature review, workflow, workaround, and work system are defined as follows:

Workflow: A set of tasks, grouped chronologically into processes, and the set of people or resources 

needed for those tasks that are necessary to accomplish a given goal.32

Workaround: Actions that do not follow explicit rules, assumptions, workflow regulations, or intentions 

of system designers.34,35

Work system: The five main elements from the Systems Engineering Initiative for Patient Safety 

(SEIPS)36 model are used to define the work system (Figure 1): 1) people (individuals and teams), 2) 

physical environment, 3) tools and technologies, 4) tasks, and 5) organizational characteristics. 

This report focuses on ambulatory (outpatient) care settings. A staffing arrangement in ambulatory care 

can range from one doctor and a medical / front desk assistant to multiple staff members that may include 

intake registered nurse (s) and physician (s), who in some cases are supported by a nurse practitioner or 

physician assistant to provide care and a medical assistant to help with office tasks and paperwork. Most 

EHRs are designed and used in both ambulatory care and hospital settings, where there are significant 

variations in staffing and workflow. Workflows that are well documented in one area of care are not 

necessarily relevant to other areas. For example, a blood pressure reading and documentation for a simple 

consultation in a clinic and the associated workflow is very different from the continuous monitoring and 

documentation in a clinic when chemotherapy is being administered. 

Physical 

Environment

Lighting, noise, 

workspace design

Organization

Policies/procedures, 

culture, purchasing 

decisions

Tools/technologies

EHR, checklists, 

white board

Tasks

Ordering a series of 

lab tests and following 

up on the results

People (Clinicians, patients, 

family members)

Education, skills, preferences, 

habits, assumptions

PROCESSES

Care processes

Other processes

OUTCOMES

Clinical 

outcomes

LOS

Readmission

Patients/families

Satisfaction

Providers

Satisfaction

Burnout

WORK SYSTEM
4

2 Background of Workflow Modeling for EHRs 

There is immense literature on workflow modeling in general, including agent-based modeling and other 

“humans-not-in-the-loop” modeling. In our review, we focused on approaches to analyzing and depicting 

workflow from a human factors perspective. Human factors is defined as “the scientific discipline 

concerned with the understanding of interactions among humans and other elements of a system, and the 

profession that applies theory, principles, data, and other methods to design in order to optimize human 

well-being and overall system performance.”33 Human factors modeling methods are based primarily 

upon extraction of process flow and insights about challenges and variation from Subject Matter Experts 

(SMEs) during collegial discussions. Our review is not intended to be comprehensive, but does highlight 

the range of types of workflow models available for use. The application of the human factors workflow 

modeling tools in Table 1 may vary based on the context in scope (individual clinician, team, and patientcentered), unit of analysis (support for deviations in temporal ordering, level of incorporation of 

variability, complexity), and feasibility (time, effort).

Decisions on selecting the optimal human factors workflow modeling tool should be informed by 

multiple factors. Such factors include, but are not limited to, the type of environment where a system will 

be used; resources that are available for development, testing, and maintenance; and expertise required to 

properly apply the selected workflow modeling tool. Most importantly, the purpose of the system should 

determine how it should be modeled. More safety-critical systems require higher-fidelity modeling and a 

greater level of subsequent validation/evaluation/testing. Tool selection should maximize benefits, 

tangible and intangible, for the system and its users.

In the examples provided in this document, we show how the methods process mapping and goal-means 

decomposition can be applied for identifying the EHR workflow integration into the clinical workflow 

which can inform better design. 
5

Table 1. Human Factors Workflow Modeling Tools for EHRs

Tool Description

Artifact review33,34 Examination of cognitive artifacts used by users in order to identify tasks, strategies, and information 

and coordination needs.

Cognitive 

walkthrough34,35

A step-by-step process of having the user or team of users talk about their thinking and action-taking 

process while performing specific predefined tasks. It can be done while the user is performing or after 

they completed performing the task. A think-aloud protocol is often employed, where the user talks 

about their thinking process while they perform the tasks. 

Contextual inquiry 

and observation36,37

Unobtrusive observation of users performing relevant tasks supported by information technology in 

their natural working environments. This method is typically used early in the design process of EHR 

components and conceptualizing possible workflows.

Decision ladder37,38 Analysis of work tasks to determine cognitive strategies and processes used in a complex work domain. 

Insights represented as decision ladder representations with cognitive states (ovals) and cognitive 

processes (arrows). Shortcuts employed by domain experts to increase efficiency of decision making 

are annotated on the representation.

Design audits38,39 A design audit determines if a product's user interface adheres or departs from established design 

practices and standards. Typically a report is produced which lists human factors deficiencies and 

recommended solutions in order of priority.

Envisioned world 

technique40

Representatives from user groups do table-top or higher-fidelity simulations of how common and 

challenging tasks would be conducted in the context of using a technology in an envisioned scenario 

which has not yet been experienced.

Expert 

reviews/design 

critiques41

Evaluation of the system by experts with knowledge of human factors, usability heuristics, and 

common workflow challenges in order to ascertain design strengths and weaknesses as well as to 

recommend improvement opportunities. A structured walkthrough of typical tasks emphasizing the 

consistency of task flow across tasks and screens can be especially beneficial for identifying workflow 

issues due to multiple and complex processes.

Goal-directed task 

analysis42

Identification of situation awareness requirements to complete a task from multiple methods, including 

structured interviews, observations of operators performing their tasks, or analysis of documentation on 

users’ tasks.

Goal-means 

decomposition43

Means (how) for achieving (goals) are displayed visually in a concept map, which are derived from 

functional analysis.

Hierarchical task 

analysis44

A structured description of tasks that provides an understanding of the tasks users need to perform to 

achieve certain goals by interacting with software. Tasks are broken down into multiple levels of 

subtasks.

Participatory 

design45

Involves making the primary and secondary users of the workflow active participants in the design, 

conception, and evaluation of the workflow and its components. 

Process mapping46 Flowchart typical process flows with a sequence of process steps and frequently occurring branches as 

yes/no decision boxes.

Simulated 

environments47

Actual use settings or simulated environments with carefully designed scenarios can be observed to 

identify workflow issues with representatives from multiple user groups.

Stakeholder 

identification48

Identify and characterize objectives and tasks and their relationship to software requirements for 

effective workflow support.

Cognitive task/work 

analysis49,50

Identify tasks performed by primary and secondary users. Analyze which tasks are challenging, 

including due to goal conflicts, coordination across roles, and heavy reliance upon overloaded cognitive 

resources (memory, attention).

Workload 

assessment51

Focusing on determining user workload for different tasks in the workflow, with the ultimate goal of 

reducing workload (physical and mental) without compromising the work quality.
6

3 Application of Human Factors Workflow Modeling Tools 

Process mapping and goal-means decomposition were selected to demonstrate that the application of 

human factors workflow modeling tools can improve EHR workflow integration into the clinical 

workflow. Based on the insights generated during collegial discussions with physicians, Subject Matter 

Experts (SMEs), and three interdisciplinary team meetings with clinical and human factors experts, we 

created process map visualizations and a goal-means decomposition diagram. 

This approach was purposefully selected in order to illustrate human factors approaches to identify issues 

and opportunities with workflow that could potentially be addressed by EHR developers independent of 

implementation decisions at the local level, or by ambulatory care clinics independent of the particular 

EHR which is implemented.

In order to apply and exemplify these techniques, the human factors experts held the discussions with 

several physicians with experience in ambulatory care settings. The SMEs were presented with a 

description of the topics for discussion; the description explained that the purpose of the discussion was to 

utilize their subject matter expertise in order to better understand the workflow for a typical return patient 

grouped by the periods “before the visit,” “during the visit,” and “after the visit.” 

SMEs then discussed with interactive guidance from the investigator, a verbal walkthrough of a typical 

return visit and were asked to reflect upon and highlight challenging areas with the workflow that related 

to interactions with their EHR. 

These physician SMEs had experience with different EHRs, represented different areas of specialty and 

primary care, and had a diverse perspective on the ideal level of integration of EHRs into routine and 

exceptional workflows. They included both males and females and an age range from approximately 30 

years to 50 years old. A series of three focused interdisciplinary team meetings were held with human 

factors, informatics, and physician experts to generate the workflow models and accompanying insights 

for improving workflow. Notes during the discussions were taken by the human factors experts, and were 

shared within 24 hours following the discussion with the SMEs who had the opportunity to correct and 

augment the clinical information. Minor corrections were provided following two of the discussions, such 

as correcting the spelling of the blood condition eosinophilia (originally typed in the notes as 

eocenophillia). The notes across the discussions were compiled around related events or topics. Emerging 

insights were discussed among the authors of this report during scheduled meetings and as email 

discussions. Insights were supported, confirmed, and in some cases reframed by published studies in the 

literature and by related public posts to establish converging evidence. 

The process model and goal-means decomposition were iteratively generated and revised over a series of 

meetings. The representations were constructed with a commercial flowchart program. All of the SMEs 

were provided the opportunity to review and make corrections to the final draft of the document. The 

draft included all of the workflow diagrams constructed from their input and the interdisciplinary team 

meetings, which represents a high-level depiction of the primary steps in the actual workflow using an

EHR for an uncomplicated return patient. Four of the most important steps from the perspective of a 

physician provider are depicted in additional detail: ordering labs, ordering images, ordering medications, 

and ordering consults.

Figure 2 is a generalized portrayal of workflow, and thus may vary when customized for different work 

settings. Choices about what staff perform what roles will modify workflow, and individual clinician 

preferences will influence what steps are performed in what order and by what personnel, thus the step 
7

sequence and order may vary. Even for a particular clinic at an ambulatory care center, it is anticipated 

that workflow will vary based on whether the physician is ahead of or behind schedule. Nevertheless, a 

process map is a useful representation in that it identifies prerequisites for certain steps, distinguishes 

steps which are required for regulatory/certification purposes from other activities, and identifies the 

primary typical bottleneck, which is the “during the visit” portion of the process map. Workflow 

variations which reduce bottlenecks are anticipated to speed EHR adoption and increase efficiency of use, 

and thus improve efficiency, usability, and safety due to reductions of unsafe workarounds and 

opportunity costs from less time for patient care provision during the visit.

Steps in the workflow are visualized as an overview at a high level of detail in Figure 2 for EHR 

interactions related to a patient visit with a physician as primary care provider for an established patient 

who is returning for a routine visit. These steps are grouped by the following “buckets”:

1. Before the patient visit (approximately 1 to 3 days ahead)

2. During the patient visit

3. Physician encounter

4. Discharge

5. Documentation

Next, we have grouped insights from our discussions with SMEs into the five categories. We have chosen 

to represent the insights in the words of the SMEs to the extent possible, and the focus is on a physician 

interacting with an EHR without support by a physician extender or case manager related to a patient 

visit. We have annotated where particular steps are required for compliance purposes (for the Meaningful 

Use (MU) requirements, for Medicare billing, for accreditation by The Joint Commission). 

For example, “verify medications and allergies” is a required step where most EHRs require physicians to 

click “verify” after viewing a medication list and an allergy list. SMEs viewed this as a required activity 

that is done without much thought (just to navigate to another screen/task). On the other hand, physicians 

need to verify thoroughly that medications which they order, particularly if dosages are changing or they 

are high-risk, have correct dosages. This step will generally occur before explaining to the patient what 

they need to do. This process (i.e., “verify”) could be better supported with the EHR, particularly if the 

information is provided at the appropriate time in the workflow and does not require actions to document 

that the activity occurred. In other cases, the intent of the requisite compliance steps is accomplished best 

according to the SMEs at different times or by different users to support clinical workflow without 

interruptions. 
8

Balance the 

workload

Clinical overview 

and review new 

findings and labs

Patient 

Checkin, Vital 

Signs and 

Chief 

Complaint

Get History, 

Signs and 

Symptoms, 

review 

Review of 

Systems, 

make 

Presumptive 

Diagnosis

Initiate intent to 

order medications, 

procedures, labs, 

consults

Verify medications 

and allergies

Discharge

Patient education

Document and send 

consult/followup 

letter to relevant 

provider

Document relevant 

history, physical, 

assessment, plan

Documentation to 

support billing

Documentation for 

others (legal, 

research, compliance, MU)

Does patient have 

significant complexity or 

updates?

Yes

N o

Does patient need 

education?

Yes

Does patient need a 

summary?

N o

N o Is referral 

needed?

Yes

N o Review new findings

Explicit Orders: Medications, procedures, 

labs, imaging, consults/

referral

Does patient need a 

clinical procedure?

N o

Yes Clinical Procedure

Before Patient Visit

Warm up 

and 

remember 

pertinent 

information

Form initial 

treatment plan

Examine 

patient, 

physical

Yes Give patient 

summary

Physician and/or 

others tells/reviews 

patient initial 

assessment, plan, 

and “to do” 

activities, motivates 

following plan

After Visit

Pick ICD/CPT codes, verify insurance, 

investigate requirement for public 

reporting

Is more 

information 

needed?

N o

Yes

Review chart/

research guidelines, 

sideline consult

Collect Medicatio

n 

Reconcilia

tion data 

and 

Review of 

Systems 

data

Verify dosage for some medications

Document 

medications 

reconciled

Review prior history 

and physical

Figure 2. Overview process map for EHR use related to returning patient visit in ambulatory care
9

A. Before the patient visit

In Figure 3, there is an example of the process steps related to activities occurring with the EHR before 

the visit. These are:

 Balance workload,

 Clinical overview and review new findings and labs, and

 Review prior history and physical. 

There was high variability in whether and how physicians used information from the EHR in order to 

schedule patients in a way that would allow adequate time for challenging or new patients, meet quality of 

work-life needs (i.e., not have one or two isolated visits scheduled during a single day), or coordinate with 

other physicians in their practice (i.e., help out a colleague by adding a patient). All the SMEs emphasized 

that only about 10% to 25% percent of the patients required extensive review of historical information, 

reviewing new findings and laboratories prior to the in-person visit with the patient, or searching for 

guidance about a treatment plan in the scientific literature. Several of the SMEs reviewed the prior history 

and physical exam findings for every patient, either the night before, the morning before, immediately 

prior to seeing the patients, or at the beginning of the in-person interaction with the patient.

Balance workload

Clinical overview 

and review new 

findings and labs

Review prior history 

and physical

Does patient have 

significant complexity or 

updates?

Yes

N o

Before Patient Visit

Figure 3. Process map for activities conducted before a returning patient visit with the EHR

During the discussions with the SMEs, several suggested the addition of new features or increased 

flexibility for the workflow to better meet their needs. Opportunities for providing support via the EHR 

for cognitively challenging tasks suggested by the SMEs are:

3.A.1 Scheduling support with at-a-glance overviews of patients for the day: Up to several days 

prior to the visit, having the ability to get a “gist” of the overall workload for a day can be 

supported by knowing “at a glance” by viewing an overview of scheduled patients whether 

patients are routine as compared to new or particularly challenging patients (e.g., complex 

medical case, noncompliant patient). Of course, this kind of a display would depend upon 

accurate characterization of the patients when the information is entered. One SME described that 

looking at the size of a paper chart was a cue to how complex or challenging the patient was, 
10

which is not typically displayed at the top-level view in EHRs with document icons which do not 

vary based upon length, and that looking at the last note, hospital admission notes, and operation 

notes prior to seeing the patient was easily accomplished in this situation by opening and flipping 

through a paper chart. The timeliness of patient care can be improved by adding unscheduled 

patients that day, ideally by an assistant or nurse rather than the physician. For patients who need 

procedures or labs done urgently, the patients could be scheduled earlier rather than a typical 

practice of adding them at the end of the day. For example, a critically ill patient could be 

prioritized to be included in the schedule as soon as they arrive. As another example, a patient 

with acute knee pain could be scheduled at 1 p.m. in order to allow a same-day test, initiate 

treatment, and wait for a phone call to come in from a specialist before the end of the day. 

Alternatively, patients who are not scheduled who want same-day appointments can be delayed 

until the next day or later if a day is particularly busy or challenging. Infection control can be 

increased by shifting around the order of patients to avoid having an immune-compromised 

patient in the waiting room at the same time as a patient with chicken pox. New patients or 

particularly complex patients can be scheduled on days with lighter schedules or in the afternoon. 

Patients who have a history of being late or no-shows can be scheduled at the end of the day to 

avoid waiting and then rushing. Particularly light schedules can be optimized by moving patients 

to other days or into a tighter block to reduce waiting between patients.

3.A.2 Supporting remembering what to do during the patient visit: All of the SMEs described a 

need to better support remembering what to do during a patient visit, similar to having a post-it 

note on the top of a paper chart file folder for a patient or underlining, circling, or highlighting 

important information on a paper chart. The time when a decision is made to remember to do 

something during the visit could occur anytime immediately following the prior visit until the 

night before or the morning of the actual visit. Examples of the type of information to be 

remembered ranged widely, including updating patients about clinical information, such as 

significant findings from a consultant, a change to a treatment plan, a lab result, needing a 

vaccination, or preventive action done during the visit like, for example, a foot exam for a 

diabetic. Some wanted to remember particular areas to focus on during the physical exam, such as 

the left side. 

Another descriptive example was a patient who was challenging to diagnose at the prior visit. 

Following the visit, the physician had searched and discovered that in the Balkans in Bosnia, wild 

boars mixed with domestic pigs, resulting in resurgence in endemic trichinosis. During the next 

visit, he decided to ask the patient about their country of origin to see if this might be the 

diagnosis. The physician used a flag in an inbox program for months as a reminder since there 

was no available support in the EHR, and he did not routinely read the last note from a prior visit 

before patient visits. 

In addition, a few SMEs suggested supporting remembering information to support building and 

maintaining a relationship with patients with less direct clinical relevance, such as asking about 

“a fishing trip that was mentioned at the last visit,” mentioning “to say hello to a parent” that is 

also treated by the same physician, or emphasizing the importance of adhering to a particular 

aspect of a treatment plan for which the patient previously has deviated, such as cutting pills in 

half to save money. There was strong consensus that these reminders should not be permanently 
11

maintained in the formal record, as the purpose was to support short-term memory of what to do 

during the visit, which was already officially documented. Suggestions for how to meet this need 

included reminders that were displayed when a chart was opened, flags on labs, annotations to 

overviews of patients indicating a reminder that could be viewed upon roll-over, personal notes 

when a chart is opened, time-based reminders that come into an inbox, and annotations to prior or 

scheduled vaccinations. It is important to note that all these features should be “displayed on 

demand” by a user. 

3.A.3 Cognitive “warm-up” support: Immediately prior to entering the patient’s room with a paperbased chart, physicians typically have a summary sheet outside the door which could be 

reviewed. Information could include the patient’s full name and nickname (which several SMEs 

mentioned was critical for patient rapport – not just the last name), the patient’s vital signs taken 

during check-in, information brought in by the patient such as blood pressure data on a home 

monitoring device, information filled out by the patient in the waiting room on forms, the 

medication list, or other relevant information. Particularly when the computer was located in the 

patient room, this “warm-up” was not well-supported with the EHR. Some SMEs expressed a 

desire to have a mobile device which was always logged in to support this, one SME went to his 

personal office before every patient visit in order to log in to get this information although he felt 

that it was inefficient, and some SMEs still used paper printed from the EHR for this purpose.

Several SMEs used the computer extensively during the exam, and would be willing to look at 

this kind of summary “warm up” information after entering the room, and even, in some cases, 

sharing the screen with the patient so that they could view the information at the same time. 

SMEs suggested this information would be helpful for this purpose on a single display for each 

patient: full name, date of birth, current diagnosis, current medications, recent visit summary, 

problem list, allergy, past medical history, and new notifications. SMEs described the critical role 

of having patient narratives as free text, particularly for historical information, in order to capture 

subtle yet important distinctions about when events occurred and the level of certainty about the 

events.

B. During the patient visit

In Figure 4, the process steps related to activities occurring with the EHR during the visit are shown. 

These are:

 Check in patient, obtain vital signs and chief complaint from patient,

 “Warm up” and remember pertinent information,

 Collect medication reconciliation data and review of systems data,

 Get history, signs and symptoms, review of systems, make working or presumptive diagnosis,

 Examine patient, physical,

 Form initial treatment plan,

 Review chart/research guidelines, informal consult,

 Initiate intent to order medications, procedures, labs, consults,

 Verify medications and allergies,

 Pick diagnostic (ICD-9-CM, ICD-10-CM) and procedure (CPT) codes, verify insurance, 

investigate requirement for public reporting,

 Verify dosage for some medications,

 Explicit Orders: medications, procedures, labs, imaging, consults/referral,
12

 Clinical Procedure,

 Patient education,

 Give patient summary,

 Physician and/or others tells/reviews patient initial assessment, plan, and “to do” activities, 

motivates following plan,

 Document relevant history, physical, assessment, plan,

 Documentation to support billing,

 Document medications reconciled, and

 Documentation for others (legal, research, compliance, MU).

Several of the steps described are highly similar across the SMEs, presumably due to influences from 

regulatory aspects: what occurs during the check-in process, verifying medications and allergies prior to 

ordering medications, verifying Review of Systems data, assigning a diagnosis, patient education, and 

giving patient’s summary information. There was greater variability in terms of what elements of the 

workflow were shared across multiple roles. The SMEs described different approaches to doing tasks, 

shared across personnel such as a primary care or specialist physician, physician assistant, nurse 

practitioner, intake nurse, nurse educator, case manager, medical assistant (clerk), and even in some cases 

the patient or family member when paper forms were used. Variation was described in by typically:

 Collects the Review of Systems data for the appropriate body functions, 

 Enters the information into the EHR, 

 Determines the diagnostic (ICD-9-CM, ICD-10-CM) and procedure (CPT) codes, 

 Determines whether insurance covers particular activities, 

 Verifies the accuracy of relevant medication types and dosages, and 

 Makes changes to the schedule during the day.
13

Patient 

Checkin, Vital 

Signs and 

Chief 

Complaint

Get History, 

Signs and 

Symptoms, 

review 

Review of 

Systems, 

make 

Presumptive 

Diagnosis

Initiate intent to 

order medications, 

procedures, labs, 

consults

Verify medications 

and allergies

Discharge

Patient education

Document relevant 

history, physical, 

assessment, plan

Documentation to 

support billing

Documentation for 

others (legal, 

research, compliance, 

MU)

Does patient need 

education?

Yes

Does patient need a 

summary?

N o

N o Is referral 

needed?

Explicit Orders: 

Medications, procedures, 

labs, imaging, consults/

referral

Does patient need a 

clinical procedure?

N o

Yes Clinical Procedure

Warm up 

and 

remember 

pertinent 

information

Form initial 

treatment plan

Examine 

patient, 

physical

Yes Give patient 

summary

Physician and/or 

others tells/reviews 

patient initial 

assessment, plan, 

and “to do” 

activities, motivates 

following plan

Pick ICD/CPT codes, verify insurance, 

investigate requirement for public 

reporting

Is more 

information 

needed?

N o

Yes

Review chart/

research guidelines, 

sideline consult

Collect 

Medicatio

n 

Reconcilia

tion data 

and 

Review of 

Systems 

data

Verify dosage for some medications

Document 

medications 

reconciled

Figure 4. Process map for activities conducted during a returning patient visit with the EHR
14

During the discussions with the SMEs, several suggested the addition of new features or 

increased flexibility for the workflow to better meet their needs. Opportunities for providing 

support via the EHR for cognitively challenging tasks suggested by the SMEs are:

3.B.1 Managing patient flow

SMEs described that the natural affordance of paper charts in slots outside exam rooms as letting 

them know whether they can slow down or need to speed up visits based upon how long the 

queue is of patients waiting for them, and would like this functionality provided in the EHR. In 

some cases, this functionality exists, but users find it difficult to use without targeted training and 

support in implementing the feature. They stated that they would quickly interact with waiting 

patients to let them know they were running behind and to expect a delay in care when there were 

four or more patients waiting.

3.B.2 Identifying time-critical notifications

All of the SMEs described an “inbox” metaphor in their EHRs where time-critical information is 

grouped together with less time-critical information. Typically, none of the SMEs looked at their 

inbox after entering the room for the first patient visit until after the final patient visit was 

completed, unless possibly during a lunch break. SMEs mentioned that no one can see how full 

the inbox is when they send a message to it, unlike what occurs when a note is placed on a pile of 

existing requests at a desk or on an empty chair. With paper-based requests, it is fairly easy to 

determine the size of a stack, the messiness of the stack, whether or not the request has been 

moved from one place to another, indicating that it has been noticed, and which requests are most 

recent (or urgent if reordered at a later time) based upon what is on top. SMEs described four 

instances in the last month where information relevant to that day’s visit was viewed after the 

visit had been completed, including a patient who requested disability paperwork filled out which 

could have been done during that day’s visit along with addressing his chief complaint and 

performing health maintenance activities, but ended up requiring scheduling an additional 

appointment, and therefore an additional payment, a week later to accomplish it. Similar issues 

have been reported in the literature.

52 Although there were no obvious solutions, characteristics of desired solutions could be to: 1) 

abandon the inbox metaphor completely, 2) reduce information sent to the inbox (e.g., send 

notifications about updated labs to an area dedicated to showing lab information with highlighted 

new information for groups of patients), 3) segregate types of information channeled to the inbox 

(e.g., time-critical information for that day displayed separately from other information), and 4) 

eliminate/group/thread messages containing redundant information or updates about the 

information.

3.B.3 Redacting and summarizing laboratory results

Most SMEs reported great need for single summary page for every patient that would include 

recent lab tests in a summary format; in addition to the most recent lab results, it is important to 

include in the summary pertinent historical lab data relevant to the patient’s diagnosis.

Some of the users informally create their own, typically with handwritten notes added to a 

printout from the EHR. Physicians who specialized in geriatrics wanted certain conditions of the 

patient such as diabetes, hypertension, heart disease, smoking, emphysema, pulmonary disease, 

atrial fibrillation, cancer, drugs that require close monitoring like warfarin, pain medications like 
15

opiates, who they live with, and key issues. SMEs described that the medical assistants download 

recent results from a separate system and redact them for their physicians into the chart. The 

information is entered into a template for system assessments in order to support users’ quickly 

scanning the information, and will fit onto a single page where discharge instructions are printed 

describing the regimen, emergency instructions for the patient, special instructions, and subcategorized information within these areas. It would be helpful if the EHR would similarly redact 

information onto a summary display as well as support having identical formats from different 

companies, searching within and across documents, and adding free text commentary directly 

onto the summarized information. 

In addition, an important critically needed feature is one to support tracking lab results 

longitudinally across time, including grouping related labs and annotations. These results could 

be searched by date done, date accessed, whether they were abnormal, or by key phrases in the 

annotations or progress notes. 

3.B.4 Drafting predicted orders

Several physicians described that they would like the capability to initiate without fully 

committing yet to orders that would likely be decided upon and/or explicitly ordered during the 

visit. Examples include lab orders that are typically ordered on a routine basis for a diabetic 

patient, a colonoscopy which is indicated to be due, and a pneumonia vaccine which is assumed 

to be needed based upon the age of the patient. Several SMEs mentioned that there are often 

changes to predictions about what orders will be made based upon information obtained from the 

patient, such as providing a different date for the last colonoscopy than was documented in the 

EHR. Many physicians felt like they were on the verge of doing more orders (medications, labs, 

procedures, imaging) during the visit if the process could be made more efficient, and one 

approach to improving efficiency is to batch modify “draft orders” to change them to “actual 

orders” during a visit. It would also be important in the workflow to purposely delay ordering 

particular draft orders which require additional information, such as information from a 

radiologist about which imaging test is best to order, information about whether a procedure is 

covered by the patient’s insurance, or information about which pharmacy is used by the patient 

prior to ordering.

3.B.5 Transferring initiated tasks to another to complete

All SMEs believed that physicians were typically the bottleneck in the process flow in 

ambulatory care settings. All of them felt that there were aspects of how the EHRs were designed 

that increased the time spent during this bottleneck which had the potential for unintended 

consequences for patient care. For example, there could be a lower quality of care due to less time 

to spend interacting with the patient and lower reimbursement because visits were somewhat 

longer or fewer could be scheduled in a day. In several cases, examples of superior support for 

workflow with paper-based charts were described. Many of these examples had the common 

theme of transferring portions of tasks under the responsibility of physicians in order to make the 

overall process more efficient, such as:

 Preparing for visit: A medical assistant could pull together data dispersed throughout 

the chart in a summarized, systematic format for elements which are commonly needed 

based upon the disease. For example, diabetic patients could have their last few A1C 

readings, blood pressure readings, and weight summarized. The patient-specific goals 

that were provided at the last visit could be included, such as a diet and exercise plan or a 

target weight to achieve.
16

 Scheduling: A medical assistant or nurse could review and modify a schedule to add in 

unscheduled patients, avoid having an immune-compromised patient in the waiting room 

at the same time as a patient with an infectious disease, in response to information that a 

patient is running late in arriving to the appointment, or other factors.

 Review of systems data collection: Medical assistants, intake nurses, nurse practitioners, 

or physician assistants could collect and type in some Review of Systems data for the 

appropriate body functions collected from the patient or caregiver which are then 

reviewed by physicians for accuracy with the patient.

 Verifying medication reconciliation data: Medical assistants, intake nurses, nurse 

practitioners, physician assistants, or case managers could verify and reconcile lists of 

medications from various sources with the patient and caregiver, potentially also 

including filling the pill box and verifying that labels brought in on home medication 

bottles match the documented medications in the EHR.

 Screening questions/reminders: An intake nurse could ask patient screening questions 

and resolve and document clinical reminders for preventive care activities prior to or 

following a patient visit with the physician.

 Print vital signs: Intake nurses or medical assistants could print vital sign information 

and leave it outside the door of an exam room to make it easier for physicians to quickly 

read and interpret this information prior to walking into a room.

 Draft progress notes: Commensurate with their training and license, clinicians other 

than the physician could draft progress note assessments, conduct portions of a physical 

exam (e.g., a diabetic’s foot exam), and collect historical information from the patient.

 Draft orders: Resident physicians, nurse practitioners, physician assistants, case 

managers, nurses, or medical assistants could draft predicted orders for routine situations, 

which are then verified by a physician prior to becoming an explicit order.

 Patient summary/education: Case managers or nurses can provide patient summaries 

and education to patients that are initiated by a physician or known to be required by 

standard protocols.

 Billing codes: Scribes, medical assistants, or specialized information management 

personnel could assign diagnostic (ICD-9-CM, ICD-10-CM) and procedure (CPT) codes 

to a visit and prompt physicians to add sufficient documentation to justify 

reimbursement.

3.B.6 Supporting dropping or delaying tasks under high workload conditions

Based upon our discussions with SMEs, tasks are sometimes dropped or delayed when there is 

extreme time pressure due to high workload or one patient taking a longer time than scheduled. 

Therefore, it is suggested that the EHR be designed to be robust to dropping or delaying these 

tasks. Likely this will require “decoupling” tasks that have been merged to simplify the interface 

interaction, but create issues with workflow during deviations from a routine sequence. Tasks that 

were identified by our SMEs as on the potential cutting block during high workload conditions 

for some patients include:

 Deal with more than one issue,

 Screening/preventive,
17

 Conversation for rapport,

 Detailed physical exam,

 Blood pressure reading, 

 Review all new results, 

 Orders during visit,

 Patient paperwork,

 Ensure correct medication brand, pharmacy, or insurance coverage,

 Education,

 Set wellness goals,

 Verify patient knows what to do next,

 Clinical reminders/alerts, and

 Documentation.

3.B.I Physician encounter

The definition for clinical encounter from ASTM E1384-02a - Standard Guide for Content and 

Structure of the Electronic Health Record is: "(1) an instance of direct provider/practitioner to 

patient interaction, regardless of the setting, between a patient and a practitioner vested with 

primary responsibility for diagnosing, evaluating or treating the patient’s condition, or both, or 

providing social worker services. 

(2) A contact between a patient and a practitioner who has primary responsibility for assessing 

and treating the patient at a given contact, exercising independent judgment." 

In Figure 5, the process steps related to activities occurring with the EHR during a physician 

encounter are shown. These are:

 Get history, signs and symptoms, review of systems, make working or presumptive 

diagnosis,

 Examine patient, physical,

 Form initial treatment plan,

 Review chart/research guidelines, sideline consult,

 Initiate intent to order medications, procedures, labs, consults,

 Verify medications and allergies,

 Pick diagnostic (ICD-9-CM, ICD-10-CM) and procedure (CPT) codes, verify insurance, 

investigate requirement for public reporting,

 Verify dosage for some medications,

 Explicit Orders: Medications, procedures, labs, imaging, consults/referral,

 Clinical Procedure, and

 Document relevant history, physical, assessment, plan.
18

The steps described had striking similarity across the SMEs. Nevertheless, there appeared to be 

high variation in whether and how the EHR was used during this period, how extensive each of 

the activities typically were for each SME, different based upon the type of patient, how complex 

the patient was, context of how busy the day was, and other factors.

Get History, 

Signs and 

Symptoms, 

review 

Review of 

Systems, 

make 

Presumptive 

Diagnosis

Initiate intent to 

order medications, 

procedures, labs, 

consults

Verify medications 

and allergies

Document relevant 

history, physical, 

assessment, plan

Explicit Orders: 

Medications, procedures, 

labs, imaging, consults/

referral

Does patient need a 

clinical procedure?

Yes Clinical Procedure

Form initial 

treatment plan

Examine 

patient, 

physical

Pick ICD/CPT codes, verify insurance, 

investigate requirement for public 

reporting

Is more 

information 

needed?

N o

Yes

Review chart/

research guidelines, 

sideline consult Verify dosage for some medications

Figure 5. Process map for activities conducted during a physician encounter with the EHR

During the discussions with the SMEs, several suggested the addition of new features or 

increased flexibility for the workflow to better meet their needs. Opportunities for providing 

support via the EHR for cognitively challenging tasks suggested by the SMEs are:

a. Supporting established diagnosis-based workflow: Several SMEs mentioned that 

elements of the provider exam were predictable based upon established diagnostic 

information. One SME differentiated between diagnoses which were working diagnoses 

(not yet confirmed or a broader category than would be achieved later), established, and 

new problems. For established diagnoses, templates could be generated to guide 

information typed in by the medical assistants that would impact on where the physical 

assessment was focused. It is important to note that few patients have a single diagnosis; 

it is typical to have complex combinations of multiple diseases, and these patients 

account for the majority of healthcare expenditures.53 One SME emphasized that 

information generated by medical assistants would need to be distinguished from 

information generated by providers with more medical training (physicians, nurse 

practitioners, physician assistants).

b. Supporting moving from working diagnoses to formal diagnoses: Every SME 

expressed enormous frustration that most elements of their EHRs assumed that a 
19

diagnosis was already established at a detailed level. The consensus was that problem 

lists were not accurate based upon extensive workarounds, not having the information at 

the time it was required to be entered, or difficulties in modifying existing diagnoses once 

selected. For determining new diagnoses, the desired workflow was to start with less 

detailed working diagnoses based upon observable signs and symptoms, and then confirm 

or disconfirm possible diagnoses via a differential diagnosis process, and then 

progressively get more detailed in the diagnosis as more information was available. For 

example, a patient might start with a symptom of a cough at which time “cough” is the 

most appropriate description of the signs and symptoms focused on during a diagnostic 

process before a definitive diagnosis is known. The physician might then suspect that the 

patient has tuberculosis along with one or two other possible explanations for the cough. 

While labs are being ordered to confirm or disconfirm tuberculosis, the patient might be 

proactively treated as if he has tuberculosis in order to start treatment earlier, as well as to 

protect other patients and the public. At the end, a detailed ICD-9 diagnostic code may be 

selected after most or all of the evidence has been collected and analyzed. Any 

interaction with the EHR which was based upon a detailed ICD-9 code, such as writing a 

progress note, writing an order, and documentation to support billing, was frustrating in 

this situation. Workarounds (such as selecting a generic “unspecified” ICD-9 code or an 

alternative ICD-9 code which was unlikely) were reported in order to do the activities 

which were considered necessary to establish the accurate detailed diagnosis. Allowing 

“unknown” to be selected as a diagnosis in order to perform activities in the EHR would 

be ideal from a physician’s perspective. One paper suggests having the ability to label 

diagnoses with certainty information such as active or resolved and which department or 

clinician entered the diagnosis.54 It is important to update the diagnostic information in a 

timely fashion to meet reimbursement needs, document known information about 

diagnoses, report relevant quality metrics, and conduct research based upon cohorts of 

patients with the same diagnosis.

c. Supporting reviewing changes to medications: High variability was reported regarding 

the process for medication reconciliation. In some cases, there was a compliance mindset 

of “checking the box” with minimal effort to verify that medications were correct. In 

some cases, physicians believed that they were only responsible for verifying medications 

which they personally had ordered. In some cases, some described how others expended 

significant time and effort in reconciling medications, including going through each and 

every medication physically with bottles brought in by the patient and even going so far 

as to personally place pills in daily pill boxes for patients to ensure that they are correct. 

Because medication reconciliation is required by The Joint Commission, there was a step 

described in the process to meet that requirement. In addition, however, some SMEs 

described additional informal “double-checks” at various points during the provider 

exam. Generally, this verification step was not done with all medications, but only those 

medications which were new, problematic, changing, or particularly high-risk and related 

to the reason for the visit. Support for this verification step could be incorporated into the 

EHR by displaying medication lists and in particular highlighting changes to lists over 

time for types of medication and dosages of medication, including what changes will 
20

occur once drafted medication orders are explicitly executed. In order to support the 

detection of side effects, this information could be viewed against other data, such as 

weight or blood pressure.

3.B.II Discharge

In Figure 6, the process steps related to activities occurring with the EHR during discharge are 

shown. These are 

 Explicit Orders: Medications, procedures, labs, imaging, consult/referral,

 Clinical Procedure,

 Give patient summary, and

 Physician and/or others tells/reviews patient initial assessment, plan, and “to do” 

activities, motivates following plan.

Discharge

Patient education Does patient need 

education?

Yes

Does patient need a 

summary?

N o

N o

Explicit Orders: Medications, 

procedures, labs, imaging, 

consults/referral

Does patient need a 

clinical procedure?

Yes Clinical Procedure

Yes Give patient 

summary

Physician and/or 

others tells/reviews 

patient initial 

assessment, plan, and 

“to do” activities, 

motivates following 

plan

N o

Figure 6. Process map for activities conducted during discharge with the EHR
21

We have further provided diagrams for the workflow of explicit orders in labs, imaging, 

medication, consult in figures 6a, 6b, 6c, and 6d respectively.

Order lab/s

 Comments to lab

 Call lab doctor or 

director

Physician reviews chart –

history, physical

Makes working diagnosis

Pick a specific lab or 

company

Get exact procedure code 

for lab (ICD-9/10 or 

Diagnosis Code)

 Insurance 

verification

 Compliance

Plan labs based on 

working diagnosis

Patient goes to lab

 Alert physician if 

prelim results or 

final results do not 

come into EHR by 

certain time

 Stat labs ordered 

needs to be on top 

of the pile

Final results

 File the results

 Act on the results

 Alert physician that 

more labs are 

coming or that final 

results are not 

entered Consider new labs/

orders/education

Link final results with 

prelim results/new orders 

and versions of the final 

result (fax, pdf, direct 

push)

Prelim results

Explicit Orders: Labs

Figure 6a: Workflow of Explicit Orders: Labs
22

Order imaging

 Comments to lab

 Call lab doctor or 

director

Physician reviews chart –

history, physical

Makes working diagnosis

Pick a specific lab or 

company

Get exact procedure code 

for imaging (ICD-9/10 or 

Diagnosis Code)

 Insurance 

verification

 Compliance

Plan imaging based on 

working diagnosis

Patient goes to lab

 Alert physician if 

prelim results or 

final results do not 

come into EHR by 

certain time

 Stat imaging 

ordered needs to be 

on top of the pile

Final results

 File the results

 Act on the results

 Alert physician that 

more labs are 

coming or that final 

results are not 

entered Consider new labs/

orders/education

Link final results with 

prelim results/new orders 

and versions of the final 

result (fax, pdf, direct 

push)

Prelim results

Explicit Orders: Imaging

Figure 6b: Workflow of Explicit Orders: Imaging
23

Order medication

 Comments to 

pharmacy

 Call pharmacy

Physician reviews chart –

history, physical

Makes working diagnosis

Pick a specific pharmacy

Get exact procedure code 

for medication (ICD-9/10 

or Diagnosis Code)

 Insurance 

verification

 Compliance

Plan medicaiton based on 

working diagnosis

Patient goes to pharmacy

 Alert physician if 

patient got the 

medication 

 Stat medication 

ordered needs to be 

on top of the pile

 Discuss medications with 

patient

 Plan course of action: repeat 

monitoring, labs, etc.

Explicit Orders: Medication

Figure 6c: Workflow of Explicit Orders: Medication
24

Order consult

 Comments to 

physician/hospital

 Call physician/

hospital

Physician reviews chart –

history, physical

Makes working diagnosis

Pick a specific physician or 

hospital

Get exact procedure code 

for consult (ICD-9/10 or 

Diagnosis Code)

 Insurance 

verification

 Compliance

Plan consult based on 

working diagnosis

Patient goes to physician’s 

office/hospital

 Alert physician if 

patient never got 

the consult

 Stat consults 

ordered needs to be 

on top of the pile

Final results

 File the results

 Act on the results

 Alert physician that 

more labs are 

coming or that final 

results are not 

entered Consider new labs/

orders/education

Link final results with 

prelim results/new orders 

and versions of the final 

result (fax, pdf, direct 

push)

Prelim results

Explicit Orders: Consult

Figure 6d: Workflow of Explicit Orders: Consult

During the discussions with the SMEs, several suggested the addition of new features or 

increased flexibility for the workflow to better meet their needs. Opportunities for providing 

support via the EHR for cognitively challenging tasks suggested by the SMEs are:

a. One-page patient summary: Several SMEs described that the required After-Visit 

Summaries for compliance purposes were too long, generally about ten pages. In 

addition, elements included in the after-visit summary handed to patients could be 

inappropriate. For example, infants are not likely to need to attend a tobacco cessation 

program, yet reminders like this are sometimes required to be included in a printed 

summary in order to be compliant with requirements from accrediting organizations. In 

addition, required terms can be confusing to patients who had diagnoses explained to 

them more in “lay terms” and then handed information with clinical terms. For example, 

a patient might have been told that “A young and healthy kidney has 80 mL -100 mL of 

cleaning capacity, yours is now 42 mL, and dialysis will be required at 15, normally by 

age 60.” Then on the after-visit summary, this information is documented as “ICD-9-CM 
25

585.3 Chronic Kidney Disease Stage III (moderate),” which they might have a difficult 

time realizing is the same as what was explained to them. Although there was some 

variation in what SMEs described they needed specifically, generally all of them agreed 

that a one-page summary with the required information attached would be an 

improvement. Suggestions for what information to include in a one-page summary are: 1) 

what is required to do today, 2) what was ordered, 3) what medications are new or 

changed, including what has been stopped and what to continue taking at home, 4) 

information about when the next appointment is, 5) testing/referrals between now and the 

next appointment, and 6) instructions, including what to bring to the next appointment.

b. Supporting handing off patient education: Patient education can be initiated by the 

physician and then handed off to others, such as the intake nurse, case manager, 

physician assistant, or nurse practitioner. In some cases, there are specialized roles, such 

as a diabetic nurse educator, for specific educational purposes. Current means of 

supporting this handoff such as clinical reminders that are required for all diabetic 

patients are not fully effective at capturing patient-specific information on what to focus 

on. Some paper-based mechanisms are still usefully employed, such as handing education 

packets of brochures on particular topics with handwritten notes at the top for the person 

who accepts the handoff. Supporting this process with less reliance on the patient and 

paper-based mechanisms via the EHR would be useful. Understanding what motivates 

the patient to invest energy into improving health is a particularly important aspect of 

patient education, and supporting physicians sharing this information, such as wanting to 

be able to spend time with grandchildren without being intubated due to overexertion, 

would be helpful in making education more patient-centered.

3.B.III Documentation

In Figure 7, the process steps related to activities occurring with the EHR during documentation 

are shown. These activities document:

 Relevant history, physical, assessment, plan,

 Support billing,

 That medications were appropriately reconciled,

 Requirements that must be met for others, such as legal, research, compliance, and 

Meaningful Use requirements, and

 Consult requests or a follow-up letter after a consult to relevant providers.
26

Document and send 

consult/followup 

letter to relevant 

provider

Document relevant 

history, physical, 

assessment, plan

Documentation to 

support billing

Documentation for 

others (legal, research, 

compliance, MU)

Is referral 

needed?

Yes

N o

Document 

medications 

reconciled

Figure 7. Process map for activities conducted during documentation with the EHR

During the discussions with the SMEs, several suggested the addition of new features or 

increased flexibility for the workflow to better meet their needs. Opportunities for providing 

support via the EHR for cognitively challenging tasks suggested by the SMEs are:

a. Reducing time spent on documentation of provided care

All of the SMEs reported immense frustration with reduced productivity (fewer patients 

scheduled in a day) or reduced personal time due to an increased time to document care. One of 

the SMEs changed organizations in the hopes of having more time with patients and less doing 

documentation from a combination of organizational expectations for how many patients to see a 

day as well as the EHR that was used. Some physicians had made the decision to work solely in 
27

hospital settings and no longer in ambulatory care in order to avoid the increased documentation 

burden when the EHR was installed. There was consensus that a positive feature of the EHR was 

an increased ability to document progress notes from home or other locations. The risks of failing 

to return a patient’s chart in a timely fashion if brought home to document care were considered 

too great with a paper-based system, and therefore most of the SMEs chose to stay in the office 

to conduct documentation for patients seen that day for an hour or more. With the introduction of 

the EHR, all of the SMEs reported an ability to leave the office earlier but an increase in time 

spent doing documentation from home at night. 

Few of the SMEs did any documentation in the EHR during the visit, primarily because the 

perception was that interacting with the human-computer interface reduced the ability to 

effectively communicate with the patient. Communicating with the patient was considered critical 

for eliciting and interpreting historical information from the patient, understanding concerns for 

diagnosis, understanding barriers to implementing a proposed treatment plan, building and 

maintaining a rapport, and motivating adherence to a treatment plan. Communication that was 

done with the physician’s back to the patient or with the physician’s eye gaze averted to the 

computer was judged to be sub-optimal for these purposes. Another SME explained that “If while 

creating the note things occur to me that I want to find out I can do that, if I had to finish the note, 

say goodbye, and move on, then there would be less flexibility about thinking and looking into 

the problems.” One physician described that he does all of his documentation after the visit, but 

that he wished that he could do it during the visit. The benefits of doing documentation real-time 

with the patient would include avoiding to ask them something that is needed for an order, having 

the opportunity to review the documentation with the patient in order to detect and correct 

mistakes in interpretation, wanting to show patients lab results and imaging studies on the 

computer, having a more efficient documentation process that relies less on memory which is 

impacted by seeing other patients prior to documentation, and having a faster and more efficient 

process. 

Suggestions to increase the acceptability of doing some or all documentation during the patient 

visit were having a continuous login or otherwise increase the efficiency of the login process, 

being able to share the screen with a patient to show lab results or other results together, being 

able to position the body towards the patient by having a mobile device, being able to benefit 

real-time from decision support which impacted the steps which the patient had to do next, and 

being able to provide the patient with a printed summary of what was documented during the visit 

to remind them of what to do next and how to do it. Making the process of reviewing results more 

efficient and having the ability to lower the required health literacy level needed to interpret the 

results were opportunities identified by several SMEs. For example, having results clearly marked 

as regular as opposed to abnormal, displaying reference ranges, and using less clinical terms such 

as “blood sugar” would help when sharing the screen with patients without medical training. 

Finally, eliminating or greatly reducing requirements to interact real-time with the EHR for 

longer-term goals such as entering detailed data to justify that a procedure is necessary for 

reimbursement would increase the willingness to begin a progress note during the visit. 

Requirements to enter data as structured text were viewed as one of the top contributors to an 

increase in the time spent documenting progress notes. Several physicians felt strongly that there 

were too many “clicks” required to enter information, both because of poor usability of the 

interface as well as too much emphasis on categorizing information into structured elements. In 

comparison with a paper-based system, clicking through an interface to document information 

and categorizing information into structured elements are primarily new tasks which largely did 

not exist in the previous systems. In situations where there were paper forms where selections 

were made, there were fewer options for structured data. For example, there might be 3 options 
28

on a paper form but 300 options in an EHR for categorizing information. In some cases, with 

paper-based systems, other personnel would provide additional data when categorizing 

documentation on paperwork into billing codes or other structured data, but this work was 

invisible to physicians.

There was large variation in the preferences and experiences of the SMEs with strategies to make 

documentation more efficient. One SME reported that all of her progress notes were created using 

templates, and felt that was a good strategy when there were clear expectations about what 

information should be recorded in what order. She felt that this aided efficiency and 

standardization across providers in her small practice. Other SMEs reported that templates 

encouraged “garbage in garbage out,” documentation which was less reliable than with paperbased systems, particularly for the information documented by intake nurses and medical 

assistants using templates. Another SME described frustration with a template that placed a large 

amount of auto-generated text in the note when clicking “denies to all” to meet billing and legal 

requirements, creating a longer note than is used when “only the positive findings” were desired 

to be documented for clinical needs. He described that it was difficult to understand information 

generated in this way when the note has “cough denied, temperature denied” etc. In one situation, 

he was not able to locate in the note the information which he considered critical for diagnosis 

that the patient was not urinating every night, even though he looked explicitly for it.

Several of the SMEs had attempted and then abandoned strategies to increase the efficiency of 

documentation. One SME reported that copying and pasting and “smart text” where typing 

commands generate auto-text had a “vigilance problem.” The issue was that it would be too easy 

to put the wrong or outdated information in or in the wrong place and not detect it, and then 

someone later, including himself, could act on it not realizing that it was incorrect. One physician 

described an attempt to use automated speech recognition for dictation for a patient with scleritis, 

which is inflammation of the white of the eye. He stopped using the software when what was 

documented in the note was “squirrel actress.” Another SME described that colleagues relied 

upon medical assistants to draft the note and then completed it, but they did not like that approach 

because it was too tempting to rely upon what was typed without reviewing it, and he felt the 

medical knowledge level was not high enough for this task. One SME described a reluctance to 

use any scribe, including a medical student, because the risk would be too high of 

misunderstanding and thus not correctly documenting the historical information, diagnosis, and 

treatment plan. This was particularly problematic if the physician had information from prior 

visits which contributed to these elements which were not discussed in detail during the visit.

b. Supporting different views of a progress note based upon role

One potential design opportunity would be to change the view of the progress note based upon a 

particular role. For example, the progress note for a primary care physician would have a 

different view from a specialist such as a urologist physician, who might not need to see all of the 

information displayed to the primary care physician. Similarly, the view of the note for primary 

care providers could differ from the view of a billing and coding specialist. When multiple views 

are provided, it is recommended that physicians be able to view the note from the perspective of 

other roles on demand in order to ensure that they are meeting the needs of others with their 

documentation. All SMEs described frustration with requirements to enter information into 

progress notes which match the types of codes which were applied to the notes in order to have 

sufficient justification to receive reimbursement for services. Although all of the SMEs 

acknowledged the central importance of receiving reimbursement in order to function as a 

business, this information was often not important for clinical needs. 
29

Similarly, all of the SMEs described that progress notes are accessed for a wide variety of 

purposes, including documenting clinical needs for themselves for the next time they see the 

patient, documenting information for colleagues who may treat the patient in the same role, 

documenting information for team members who treat the patient in different roles (e.g., case 

manager, intake nurse), and documenting information for research and quality improvement 

purposes.

c. Distinguishing new documentation from copied information

A well-known and frequent workaround with all EHRs is to copy and paste information. There 

are three known variations: 1) to copy from one progress note from a prior visit for the current 

visit which serves as a first draft that is then revised to increase the efficiency of documentation, 

increase coverage, and reduce the likelihood of having contradictory information across notes; 2) 

to copy information into a temporary repository, such as Notepad, in order to view it in parallel 

with another tab, system, or time period in order to remember information; or 3) to copy 

information from one patient with a similar diagnosis to another, in order to have a working draft 

which is then revised to increase the efficiency of documentation and provide a template of what 

to include. A concern with this type of workaround is that billing should be done only for 

procedures that were done in that visit, and therefore it is important for coding and billing 

personnel to distinguish between old (copied) and new (typed) information. With one system, this 

need was met by copied text having a light gray background and that newly typed text in the 

progress note turned clear. Another solution is to have a template for notes which includes a 

section for “Historical Information.”

d. Supporting communication with specialist physicians about referrals and 

consultations

SMEs raised what they considered to be a critically important patient safety issue resulting from 

changes in documentation practices associated with changes from paper-based referrals to EHRbased referrals to specialist physicians. The pattern is to have much sparser to non-existent 

documentation or communication following a consultation by a specialist physician.

The SMEs created a fictional scenario in order to illustrate this issue. 

With a paper-based system, the following would be typical of documentation by a specialist 

physician regarding a decision of whether to undergo a surgical procedure to replace a heart 

valve: "Bob Smith is a 17 year old who developed rheumatic fever 6 months ago. Please see his 

last note for a full description of his initial course of rheumatic fever. He was treated with 

antibiotics at that time, and remains on prophylactic antibiotics. His mitral valve was significantly 

damaged during the episode. He has severe mitral regurgitation due to significant damage to the 

anterior leaflet of the mitral valve. The mitral regurgitation vena contracta was 1 cm thru the 

anterior leaflet of the mitral valve. There is significant left atrial and left ventricular dilation. 

There is both systolic and diastolic left ventricular dilation. His shortening fraction is, however, 

normal. In addition, Bob has been complaining of shortness of breath with mild activity. He has 

no congestive heart failure on exam. His electrocardiogram shows left atrial and left ventricular 

enlargement but no strain patterns.” This case was presented at a surgical conference, and there 

was unanimous agreement that this patient should undergo an attempted repair or replacement of 

this valve. We reviewed this data with Dr. Jones, from pediatric cardiothoracic surgery who 

agreed the patients risk/benefit ratio favors surgical repair of this valve.
30

Following the implementation of an EHR at both the primary care physician’s and the specialty 

physician’s organizations, the following might be received from the specialist physician after 

seeing the patient via the EHR:

"1. Acute rheumatic endocarditis – 391.1 (Primary)

 2. Rheumatic mitral insufficiency – 394.1, Moderate”

The SME’s interpretation of how this situation occurs is that workflow for billing is prioritized 

over the workflow for informing the referring physician about the conclusion reached by the 

specialist physician. In other words, because billing required ICD-9 codes but a free-text narrative 

is not, sometimes the narratives are not written before the consult cycle is completed. 

When the workflow support of an EHR supports timely billing, such as by automatically closing, 

locking, and signing an encounter based upon actions taken by a medical assistant, this situation 

is more likely to occur. When there is support for a free text narrative within the EHR, sometimes 

there is little support for formatting, spell checking, controlling page breaks or paragraph 

locations, or other layout elements. In some cases, the free text narrative information is not 

printed on the first page, but on subsequent pages and therefore can easily be missed by the 

receiving physician.

The SME described that this information would be uninformative as to whether the patient 

needed the surgical procedure ordered because the diagnoses were already known prior to the 

visit with the specialist. In this situation, the specialist physician would need to be contacted 

directly in order to better understand the assessment, or alternatively, the patient would accept the 

patient’s or caregiver’s interpretation of what was explained to them by the specialist during their 

visit with him or her.

The SMEs went on to describe workarounds employed to better support this process. With most 

EHRs, specialists can create a letter in a Word document and attach it electronically to the autogenerated text (the ICD-9 codes) and then someone in the primary care office would scan the 

word document into the EHR. In this case, the text could not be searched and often the scanned 

document would be placed in a place separate from other information received from specialists.

e. Supporting real-time documentation

The SMEs described three potential models relating to documentation during the actual patient 

visit:

1) No documentation during the visit. In this situation, the physician would review portions 

of the chart before seeing the patient, and do orders and documentation after the visit. In 

some cases, printed information would be taken into the room and handwritten notations 

would be made on the printout during the visit.

2) Draft documentation during the visit. In this situation, the physician would typically 

review new results with patient, do any simple orders during the visit, do consult requests 

that did not require extensive documentation, and create an initial draft of a note, 

typically employing a personal shorthand to increase efficiency and which would be 

replaced with a longer format after the visit.
31

3) Full integration of documentation during the visit. Only one SME used this approach. In 

this situation, he reviewed the last progress note immediately after greeting the patient 

(without showing this to the patient), entered data from the history real-time and from the 

physical immediately following the exam, did all orders and consult requests, finalized 

documentation which was done throughout the visit, signed the note, and then explained 

to the patient what steps to do next.

Several of the SMEs mentioned that they would like to pre-populate notes prior to the visit and 

enter information in abbreviated format into notes during the visit in order to aid writing the note 

at a later time. In addition, several SMEs mentioned that a mobile device or tablet would be 

preferable during the visit to improve patient-provider communication. It is possible that 

alternative functionality could be developed which avoids hard stops, alerts, verification steps, 

structured documentation, menu-driven interfaces, and typing to support real-time documentation 

in an efficient format. In this situation, “smart swipes” (as opposed to smart text) would not be 

used to auto-generate longer text, but instead to predict common interactions or things to 

remember to do later and to aid memory of what occurred at a later time when a progress note is 

modified and expanded. One SME mentioned that, rather than feeling uncomfortable dictating in 

front of the patient, it was actually preferred so that the patient could correct misinterpretations. 

Therefore, dictation that is partial and played back later could be incorporated into this workflow. 

Theoretically aspects of the patient encounter could be audio-taped to support this process as 

well, such as when the provider explains the next steps to be taken by a patient near the end of the 

visit.

f. Tracking scheduled consults and review of laboratory results

Several of the SMEs commented that it would be helpful to have support for a small-group 

practice or larger organization as a whole to ensure that intended actions to be done by others do 

not inadvertently get dropped. A related category mentioned by several of the SMEs was having a 

reminder to verify that tasks done by others were performed as intended, such as a consultant 

scheduling an appointment with the patient, a patient scheduling a critical appointment, or the 

appropriate person viewing the results of a biopsy to determine whether tissue sample indicates 

cancer. In one organization, an SME explained that specialist physicians have their performance 

measured by how many requested patients are seen within a time window such as six weeks. In 

situations where a patient needed to have a test done first or it was unlikely that the patient could 

be scheduled within that time, a relatively common practice was to cancel the original 

appointment request and ask the primary care physician to order another one in order to meet the 

performance expectation. This practice increased the risk that patients would fail to have care 

from a specialized physician within a desired time period. Some form of “tracking” functionality 

could be created to review a block of patients within a certain period of time who have had 

consults requested to determine if they had been scheduled. This functionality would display 

when a referral order was executed, when an appointment was made with the patient (or when a 

cancellation occurred), when a patient was notified of the appointment, when the patient attended 

the consultation session, when an evaluation was documented, when an evaluation was 

communicated, and when an evaluation was viewed by a primary care provider. Similarly, 

patients who have had labs or other procedures ordered which generate findings that are 

contained within the EHR could track whether they had been viewed since the findings had 

arrived.
32

In summary, the following opportunities to improve workflow were identified based on the 

discussions with several physician SMEs in ambulatory care:

 Scheduling support with at-a-glance overviews of patients for the day,

 Supporting remembering what to do during the patient visit,

 Cognitive warm-up support,

 Managing flow,

 Identifying time-critical notifications,

 Redacting and summarizing laboratory results,

 Drafting predicted orders,

 Transferring initiated tasks to another to complete,

 Supporting established diagnosis-based workflow,

 Supporting moving from working diagnoses to formal diagnoses,

 Supporting reviewing changes to medications,

 One-page patient summary,

 Supporting handing off patient education,

 Supporting dropping or delaying tasks under high workload conditions,

 Reducing time spent on documentation of provided care,

 Supporting different views of a progress note based upon role,

 Distinguishing new documentation from copied information,

 Supporting communication with specialist physicians about referrals and consultations,

 Supporting real-time documentation, and

 Tracking scheduled consults and review of laboratory results.

C. Managing conflicting goals: goal-means decomposition diagram

Many of the opportunities to improve workflow might conflict with goals, particularly for other 

nonclinical stakeholders. This is partly due to the historical situation in which coding and billing 

specialists tended to be the primary users of the first EHRs. In order to resolve usability and 

workflow issues raised primarily by physicians who have begun using EHRs, it is our belief that 

there may need to be a reprioritization of top-level goals for EHR use. Figure 8 displays a goalmeans decomposition diagram, which is a human factors modeling method of displaying at lower 

levels in a visualization the means (how) for achieving higher-level goals.55 Generally there are 

two or three top-level goals which conflict, such as safety and production for a nuclear power 

plant which produces energy in a safe manner. Every level then is further deconstructed into the 

means for achieving the goal at a higher level. A goal-means decomposition is typically done in 

the context of a functional analysis for what functions will be viewed as useful by a particular 

group of users, mostly independently from the detailed mechanisms by which means are 

achieved. Note that there are many variations on visual representations of decompositions, as 

outlined in Table 1. This particular representation captures functions and the means for achieving 

them, and therefore is a ‘goal-means’ breakdown, as opposed to a hierarchical task analysis, 

which would depict tasks and subtasks in a ‘whole-part’ breakdown, similar to what would be 

done with a hierarchical organizational chart. 

In Figure 8, for physicians in ambulatory care using EHRs to provide care to patients, we have 

identified three top-level goals: 1) patient care, 2) billing/reimbursement, and 3) physician quality 
33

of work-life. From the physician’s perspective, patient care is a higher priority than compensation 

or physician quality of work-life in general when there are goal conflicts which cannot be 

resolved in a way which fully meets all goals. 

There is an interaction with the patient primarily with providing patient care and in the 

satisfaction for physicians from building and maintaining a positive relationship with the patient. 

Autonomy in clinical decision making, minimizing administrative burden, focusing on patient 

care and maintaining the quality of clinical care provider work-life are highly valued to clinicians. 

Workflows which adversely impact these values will result in, for example, a reduction in quality 

of work-life; and predictably will lead to increased clinician burnout, stress, and dissatisfaction 

with the work and with EHRs. Workflows that meet patient care needs and the needs of 

physicians to have a high quality of work-life might be viewed positively by end users and easily 

adopted, but may fail to meet the organization’s needs for supporting billing and thus may be 

eventually replaced with a system that meets those needs. In particular, requirements to document 

compliance measures in order to avoid penalties need to be supported by the EHR functionality. 

This visualization highlights the need to identify stakeholders in the design of the workflow, and 

our recommendation is to prioritize primary clinical users over secondary administrative and 

billing users explicitly when there are trade-offs during design.

Patient Care Physician Quality 

of Worklife Reimbursement

Problem 

List/Codes

Bill

Billing 

Document

ation

Good 

Relationshi

p with 

Patient

Schedule 

Patients

Assess/

Diagnose Plan Educate Patient

Document 

Clinical 

Impression

s

Efficient 

NonClinical 

Work

Autonomy 

of Decision 

Making

Support 

QI/

Research

Avoid 

Penalties

Document 

Complianc

e 

Measures

Minimize 

Administra

tive 

Burden

Figure 8. Goal-means decomposition diagram for EHR use by ambulatory physicians
34

4 Targeted Recommendations for EHR Developers and 

Ambulatory Care Centers for Improving Workflow

In order to make our insights easier to act upon, we have identified two groups which might 

benefit from what we have learned in this project: EHR developers and ambulatory care centers. 

Following are targeted recommendations which distill the lessons learned from the insights 

detailed in Section 3.

For EHR developers, we recommend the following to improve EHR-related workflow during the 

patient visit:

 Increase efficiency for these tasks:

 Reviewing results with the patient,

 Drafting pre-populated orders to be formally executed later, and

 Supporting drafting documentation with shorthand notations without a keyboard;

 Design for empathetic body positioning and eye contact with the patient while personally 

interacting with the EHR and while sharing information on the EHR screen with the 

patient and family members;

 Support dropping tasks and delaying completion of tasks to help with daily flow; and

 Verification of alarms and alerts and data entry without “hard stops.” 

For ambulatory care centers, we recommend the following to improve EHR-related workflow 

during the patient visit:

 Moderate organizational design flexibility (staffing, processes);

 Design room to support patient rapport and EHR access;

 Minimize redundant data entry from interoperability;

 Reduce clinic pace or increase flexibility of pace;

 Ensure functionality that supports continuity in the task performance in the case of 

interruption (which will allow one person starting and another completing tasks); and

 Relax requirements to enter detailed data for others (administrators, billing/coding, legal, 

accreditation) during fast-paced patient visits.

Overall, our recommendations provide a first step in moving from a billing-centered perspective 

on how to maintain accurate, comprehensive, and up-to-date information about a group of 

patients to a patient -centered perspective. This perspective more centrally revolves around the 

needs of primary care providers, including physicians, physician assistants, and nurse 

practitioners. These recommendations point the way towards a “patient visit management 

system,” which incorporates broader notions of supporting workload management, supporting 
35

flexible flow of patients and tasks, enabling accountable distributed work across members of the 

clinical team, and supporting dynamic tracking of steps in tasks that have longer time 

distributions. For example, the concept of “ordering a medication” involves concepts of 

anticipating potential orders, updating order expectations with input from patients regarding their 

priorities and new information, revising the details of orders in order to meet reimbursement and 

other requirements, and tracking the status of tasks done by others prior to a patient receiving the 

medication.

As electronic health records are conceptualized in order to better fit the workflow patterns in 

physician offices, the insights from our SMEs in several cases identified affordances which were 

available in a paper-based system but were not easily translated into the current generation of 

electronic health records. Their comments are not provided in order to suggest a return to paper, 

but rather to identify functionality to support with the electronic health record design as well as 

with choices made during the implementation of electronic health records. There are several ways 

in which paper-based documentation was more flexible in nature. One is that access to a piece of 

paper for entering, viewing, highlighting, updating, and annotating information was done by other 

means (primarily physical constraints) than by an electronic login with an associated defined 

organizational role. Another is that it was rather difficult to update and disseminate changes to 

paper forms, particularly to add requirements for additional documentation, but that this is much 

easier to do in an electronic environment. In particular, it is easier for administrative or other 

personnel to embed required documentation elements, create templates with required items to 

complete within a workflow, or enforce a structure upon entered information with an electronic 

format. Getting a "gist" of how complicated a patient or collection of patients are was possible 

naturally with paperwork that had more pages when it was longer as compared to electronic icons 

without this information and which are only available when requested to be viewed. Changing the 

sequencing of patients with paper was more naturally done than with electronic health records. 

Finally, workflow variations tend to be easier to accommodate with patients. 

Real-time adjustments by staff to variation in workflow is clearly important to provide a high 

quality of care, have efficient patient flow, meet reimbursement objectives, and allow a 

reasonable quality of work-life for staff. These are not just mechanical sequences of pre-identified 

tasks, but are contextual and have high variability across patients, providers, units, and 

organizations. There are variations in workflow at multiple levels, and workflow for individual 

patients combine to create a series of activities for a physician to complete. Workflow for 

physicians is integrated with the workflow of supporting members of a team. The workflow of the 

team is coordinated with consultations with specialists with clinical expertise. The workflow of 

the clinical personnel is integrated with the workflow of billing and legal personnel. Elements of 

documentation produced from the workflow can be analyzed for patterns that can be used for 

quality improvement and research purposes. In an electronic environment, new capabilities are 

available to allow new forms of interaction and communication, which subsequently changes the 

nature of the work itself, and thus the routine and exceptional workflows that need to be 

supported.
36

5 Conclusion

In response to workflow integration challenges with ambulatory physicians using EHRs, we have 

employed standard human factors methods in order to identify insights for EHR developers and 

ambulatory care centers. The methods illustrated in this document are process maps and goalmeans decomposition diagrams informed by goal-oriented individual collegial discussions with 

physician Subject Matter Experts to walk through the typical workflow of a returning patient in 

an ambulatory care setting. We have identified a wide variety of potential opportunities to 

improve workflow with EHRs from a physician perspective. We anticipate that improving 

workflow might require an expansion in focus from the historical goal of supporting 

reimbursement to also improving quality of patient care as well as the quality of work-life for 

physicians. In order to increase the ease of implementing our insights, we provide a set of 

targeted recommendations.
37

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