Integrating Electronic Health Records into Clinical 

Workflow: An Application of Human Factors 

Modeling Methods to Obstetrics and Gynecology

and Ophthalmology

Svetlana Z. Lowry

Mala Ramaiah

Emily S. Patterson

Paul Latkany

David Brick

Michael C. Gibbons

This publication is available free of charge from:

http://dx.doi.org/10.6028/NIST.IR.8042

NISTIR 8042
Integrating Electronic Health Records into Clinical 

Workflow: An Application of Human Factors 

Modeling Methods to Obstetrics and Gynecology

and Ophthalmology

Svetlana Z. Lowry

Mala Ramaiah

Information Access Division

Information Technology Laboratory

Emily S. Patterson

Ohio State University

Columbus, OH

Paul Latkany

New York Eye and Ear Infirmary

New York, NY

David Brick

NYU Langone Medical Center 

New York, NY

Michael C. Gibbons

Johns Hopkins University

Baltimore, MD

This publication is available free of charge from:

http://dx.doi.org/10.6028/NIST.IR.8042

February 2015

U.S. Department of Commerce 

Penny Pritzker, Secretary

National Institute of Standards and Technology 

Willie May, Acting Under Secretary of Commerce for Standards and Technology and Acting Director 

NISTIR 8042
Acknowledgments

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

 Catalin Buhimschi, MD, Professor, Department of Obstetrics & Gynecology, Ohio State 

University

 Michael L. Hodgkins, MD, MPH, Chief Medical Information Officer, American Medical 

Association

 Madhavi Kurli, MD, Advanced Retina and Eye Cancer Center

 Ramu Muniraju, MD, MRCO, MSc, Consultant Ophthalmic Surgeon with special interest in 

Medical Retina, Ashford and St. Peter's Hospitals, NHS Foundation Trust and Clinical Lead 

Surrey National Diabetic Eye Screening Programme

 A. Gwendolyn Noble, MD, PhD, Department of Ophthalmology, Ann and Robert H. Lurie 

Children’s Hospital of Chicago, Northwestern University and Department of Ophthalmology and 

Visual Sciences, The University of Chicago

 Jess A. Pawlak, MS PMP CISA CHPS, Lumetra Healthcare Solutions

 Jayashree Ramu, MBBS, Clinical Research Fellow, Moorsfield Eye Hospital, NHS Foundation 

Trust

 Kara Rood, MD, Maternal Fetal Medicine Fellow, Obstetrics and Gynecology, Wexner Medical 

Center, The Ohio State University

 Bennett Spetalnick, MD, Obstetrics and Gynecology, Vanderbilt University

 Alex Vu, BS, Systems Developer for Clinical Applications, College of Optometry, Ohio State 

University Medical Center

 Dan Yin, MD, Ophthalmologist, Washington Eye Consultants
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........................................................................................................................... 3

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

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

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

2 Application of Human Factors Workflow Modeling Tool.................................................... 4

3 Process Maps and Workflow Redesign Opportunities for Ob-Gyn...................................... 6

4 Process Maps and Workflow Redesign Opportunities for Ophthalmology........................ 19

5 Targeted Recommendations for EHR Developers for Improving Workflow in Obstetrics 

and Gynecology and Ophthalmology .......................................................................................... 36

6 Conclusion ............................................................................................................................ 39

7 References............................................................................................................................. 40
v

Executive Summary

Adoption of Electronic Health Record (EHR) systems in all care settings 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 specialty care settings. Workflow analysis is an integral part of the early stages of the UserCentered 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 this report, a human factors workflow modeling tool, process mapping, was used to visualize and 

document insights and the end-user needs to improve EHR workflow for clinicians in two specialty 

outpatient care settings: 1) Obstetrics and Gynecology (Ob-Gyn) and 2) Ophthalmology. The findings 

identified clinical activities that required better coordination with specialized technicians (Ob-Gyn 

assistants and Ophthalmology technicians), better integration with specialized software and devices (fetal 

strips and a software for Ob-Gyn and OCT machines for Ophthalmology), unique data fields (number of 

drops and which eye in Ophthalmology), and 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 two interdisciplinary team meetings with clinical and human factors 

experts, we created process map visualizations and identified opportunities for innovation.

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

with the EHR for both specialty care areas. Although the specific examples and relative importance for 

the opportunities differed for the two specialties, there was remarkable similarity in the opportunities 

which were identified. The opportunities that were both found for both specialties’ EHR functionality

included:

• Before the patient visit, supporting:

o Reducing the risk of missing a target window of opportunity to provide optimal care 

actions due to scheduling issues

o Distinguishing between patients with a very high likelihood of getting a particular 

treatment from patients who are less likely to get the treatment

o Alerting physicians to information about patients that informs how to conduct a patient 

visit

o Integrating medication information from pharmacies, hospitals and current insurance 

formularies into the EHR

o Verifying that insurance requirements are met during the scheduling process

o Flexible real-time assignments of different staff to tasks across multiple patients 

simultaneously

o Usable access to patient data from diverse hardware platforms, including mobile devices

• During the patient visit, supporting:

o Displaying summary information in a format which matches how specialist physicians 

were trained to recognize patterns

o Reminding the physician of planned tasks to accomplish during a patient visit

o Integration of personal health record data, patient portal information, and patient entered 

information

o Cosigning of ancillary support notes and findings

o Integration of previously entered patient data into the current visit

o Multiple simultaneous patient evaluations

o Hands-free interaction with the EHR during procedures
vi

o Integrating information from specialized devices, software, data repositories

o Grouping conceptually related items with different formats (e.g., CIF, image, scanned 

image, fax, PDF, searchable text, structured data), particularly redundant data

o Locating original images on image acquisition devices when viewing electronically 

stored images

o Viewing annotations about data quality at the top level screen view

o Graphing of viewing formatted data (tables) over time to identify patterns and trends,

including extracting data from devices and standardized files

o Providing a draft order set to modify during the visit which is tailored to diagnostic and 

demographic information

o Verifying that recently changed insurance and regulatory requirements are met when 

ordering and interpreting diagnostic tests 

o Providing quick access to short summary syntheses of findings from recent research

o Selecting correct administrative diagnostic and procedural codes (ICD, CPT) for the visit 

documentation

o Selecting patient’s current insurance plan’s pharmaceutical formulary

o Providing medical necessity documentation for procedures, medications, transportation, 

convalescence, or work restriction

o Meeting informed consent requirements with procedure specific details

o A holistic approach to the goal of optimizing patient compliance to scheduled follow-ups 

and needed medical regimen

o Integrating surgical notes into the EHR

o Identifying, retrieving and displaying prior similar specialty prior notes

o Comparing images over time within the EHR

o Having orders include unique data fields for the specialty area

o Drawing templates with annotations, icons, and auto-generated text

o Sub-specialty-specific classification of patients based upon examination findings

• At the conclusion of the visit, supporting: 

o Informing patients about whether medications need to be obtained immediately following 

the visit 

o Informing patients about what to watch for and who to contact if particular events happen

o Optional redaction of particularly sensitive patient information from after-visit 

summaries

o Optimizing patient compliance

• For documentation, supporting:

o Correcting auto-generated information which is inaccurate

o Viewing of all information that will be saved in the EHR before being saved

o Draft documentation and encounter forms which are tailored to diagnostic information

o Reducing log-ins and sign-offs for multiple software packages and devices used to 

accomplish related functions

o Annotating documentation by patients and caregivers in a progress note

o Advanced features for image management, including extraction of quantitative data and 

images without being dependent on interfaces with other applications

o Having additional protections on personal health information

Targeted recommendations for EHR developers and Ob-Gyn and Ophthalmology centers to improve 

workflow integration with EHRs are proposed to improve quality of care, improve patient safety, and 

reduce medical-legal exposure. 

These recommendations provide a first step in understanding what the unique needs of two diverse 

specialty care areas are in order to better support workflow in general outpatient care settings. Some of 
vii

the recommendations relate directly to improving patient safety, including ensuring that patients receive 

treatments within evidence-based time intervals, providing integrated access to data from specialized 

devices in an efficient and usable manner, having orders include unique data fields for the specialty area

such as drops in the right or left eye, and having visual representations of data match specialty-specific 

norms, such as having the right eye be defined from the perspective of the patient. Recommendations 

include better support for non-clinical aspects of workflow for these specialties, such as scheduling 

patients for treatments at recommended time intervals and documentation of specialty-specific 

information, in order to facilitate high quality provider-patient interaction during a visit.
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 Barriers to adoption of health information exchange in small to 

medium sized family medicine practices include workflow.17 A facilitator to adoption of health 

information exchange in a recent study in primary care settings was found to be use-by-proxy strategies 

whereby medical scribes, clerks, case managers, and assistants retrieve data and relay the information to 

the physician during the point of care.18 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.19 Similarly, a recent mixed-methods study found that poor EHR usability, time-consuming data 

entry, and degradation of clinician documentation were among the prominent sources of professional 

dissatisfaction for physicians.20

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

EHR workflow integration into the clinical workflow for specialty care areas. 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 who provide care in two different specialty areas 1) 

Obstetrics and Gynecology and 2) Ophthalmology. Obstetrics and Gynecology is a diversified specialty 

concerned with the delivery of medical and surgical care to women. Per the Association of American 

Medical Colleges, this field combines two specialties: Obstetrics, which focuses on the care of women 

before, during, and after childbirth; and Gynecology, which involves the diagnosis and treatment of 

disorders of the female reproductive system, breasts, and associated disorders. Ophthalmology deals with 

the structure, function, diagnosis, and treatment of the eye and the visual system. Similarly, per the 

Association of American Medical Colleges, this includes problems affecting the eye and its component 

structures, the eyelids, the orbit, and the visual pathwaysIn this report, we will first consider challenges 

with the workflow for a returning patient in an outpatient clninic in Obstetrics and Gynecology, second in 

Ophthalmology, and finally make targeted recommendations to improve workflow in both specialties. 

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.21 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.”

22

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.”23 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.24 UCD practices employ both formative (for informal suggestions) 
2

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.

25 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”

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

IT implementation.

Workflow has emerged as an issue for EHR adoption, productivity,

27 and professional satisfaction for 

physicians.28 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 

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.29 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,28-30 

 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.34,35 Workarounds are 

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

system designers.36The 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.34 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. Benefits of copying and pasting a previous note include 

efficiency and prompting for the review of updates to previous findings. Suboptimal impacts of copying 

and pasting can include perpetuating inaccurate or outdated information or failing to take out 

documentation of activities which were not done during the visit resulting in inaccurate billing, as well as 

the potential of pasting information into the wrong patient’s chart when multiple charts are open at one 

time. In one study, 25% of patient charts had text copied from prior clinical examinations, which if pasted 

without needed corrections can lead to confusion, medical error, and medico-legal harm.30

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

that are poorly integrated into workflow may make it difficult for clinicians to be aware of critically 

important information when making diagnoses and creating treatment plans, thus leading to suboptimal 

care or delayed care. In addition, design that is not optimized for a specialty care area’s workflow may 

inadvertently promote workarounds that bypass safety features. For example, poor coordination between 
3

bar coding and the medication administration record has been shown to prompt nurses to work around the 

documentation of medication administration.31 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.32 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 issues33 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.

This report focuses on two specialty care area ambulatory (outpatient) care settings. In both specialty care 

settings, there can be support staff for the physician with specialized knowledge and expertise beyond 

what is typical for non-specialty care settings. In Obstetrics and Gynecology care, an Ob-Gyn assistant 

obtains vital signs, collects urine and blood samples, prepares equipment, preps the patient, operates 

ultrasound machines, and relays medical information and instructions to patients. In Ophthalmology, 

Ophthalmic technicians work under the supervision of an Ophthalmologist to do clinical tasks such as 

measuring visual acuity, instilling ocular medications, obtaining historical information, and instructing 

the patient regarding medications, tests, and procedures. In all ambulatory care settings, there can be a 

range of staff. For example, there can be 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 annual gynecologic visit in a clinic and the associated workflow is very 

different from the continuous monitoring and documentation in a clinic when a pregnant patient with 

unstable blood pressure readings has recently experienced significant trauma.
4

2 Application of Human Factors Workflow Modeling Tool

Process mapping was selected to demonstrate that the application of human factors workflow modeling 

tools can improve EHR workflow integration into the clinical workflow for specialty care areas, even 

without considering workflow concerns related to implementation at a particular organization. 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. In a prior report, NISTIR 7988 “Integrating Electronic Health Records into Clinical 

Workflow: An Application of Human Factors Modeling Methods to Ambulatory Care”34, we provided a 

literature review of a wide range of potential human factors workflow modeling tools and guidance on 

how to select an appropriate tool to meet project objectives.

This approach was purposefully selected in order to illustrate a human factors approach 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 outpatient 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 the 

physicians with experience in the two specialty 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 the two areas of specialty care, 

and had a diverse perspective on the ideal level of integration of EHRs into routine and exceptional 

workflows. In Obstetrics and Gynecology, there were four physicians, including a senior physician with 

administrative experience, two senior physicians with informatics expertise, and a fellow physician who 

specialized in high-risk Obstetrics care. In Ophthalmology, there were two ophthalmologists, one of 

whom subspecialized in uveitis. 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. In one instance, a correction was provided following the 

discussion regarding the level of integration of fetal heart rate monitor data with the electronic health 

record. For both specialty care areas, we additionally verified the accuracy of the information with

informatics specialists who supported the specialty care areas during a one-hour one-on-one discussion 

with the human factors expert. 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 that were supported were further refined.

The process model was iteratively generated and revised over a series of meetings for Ophthalmology

with a physician and from notes from discussions with four physicians in Obstetrics and Gynecology. The 

representations were constructed with a commercial flowchart program. The maps are 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 
5

what steps are performed in what order and by what personnel, thus the step sequence and order may 

vary. Even for a particular clinic, it is anticipated that workflow will vary based on whether the physician 

is ahead of or behind the day’s schedule. Nevertheless, the process maps used in this project are a useful 

representation in that they identify prerequisites for certain steps, distinguish steps which are required for 

regulatory/certification purposes from other activities, and identify 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.

For both specialties, we have organized insights from our discussions with SMEs into five categories: 1) 

before the patient visit, 2) during the patient visit, 3) during the physician encounter, 4) discharge, and 5) 

documentation. We have chosen to focus on a physician interacting with an EHR with support by a 

technical specialist, but without support by a physician extender, case manager, or scribe. 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 for their specialties which they order, particularly if dosages are changing or 

they are high-risk, have correct dosages. 
6

3 Process Maps and Workflow Redesign Opportunities for ObGyn

Steps in the workflow are visualized in Figure 1 as an overview at a high level of the details in Ob-Gyn

for EHR interactions related to an established patient’s return visit with the specialist care provider in an 

outpatient setting. These steps are grouped as follows:

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

2. During the patient visit

3. Physician encounter

4. Discharge

5. Documentation
7

Adjust scheduling

Clinical overview 

and review new 

findings and labs

Patient 

Checkin, Vital 

Signs, and 

Purpose of 

Visit

Get History, 

Signs and 

Symptoms, 

review 

Review of 

Systems, 

associate 

the test 

results and 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

Privacy warnings

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 

and 

conduct 

needed 

inhouse 

tests

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 Review chart/

research guidelines, 

sideline consult

Collect Medicatio

n 

Reconcilia

tion data 

Preparatio

n 

informatio

n and 

Review of 

Systems 

data

Verify dosage for some medications

Document medications 

reconciled

Review prior history 

and physical

Decide on 

anticipated tests, 

procedures and 

preparation

Schedule any 

essential labwork 

prior to physician 

encounter

Prep 

patient

Review chart/

research guidelines, 

sideline consult

Figure 1. Overview process map for EHR use related to returning patient visit in Ob-Gyn

(Tip: Printing this page on a paper of size A3 or larger provides legibility to read the contents)
8

3.A. Before the patient visit

In Figure 2, there is an example of the process steps related to activities occurring with the EHR before 

the visit in Ob-Gyn. These are:

 Adjust scheduling in order to balance workload demands and take into account predictions and 

updates about how long types of patients will take and to meet the unexpected urgent needs of 

scheduled and unscheduled patients, 

 Clinical overview and review new findings and labs for patients with significant complexity and 

updates,

 Review prior history and physical for all patients, 

 Decide on anticipated tests, procedures, and preparation,

 Map the patient’s schedule with the technician’s schedule to decide what is possible and not 

possible to do at the visit.

Adjust scheduling

Clinical overview 

and review new 

findings and labs

Does patient have 

significant complexity or 

updates?

Yes

N o

Before Patient Visit

Review prior history 

and physical

Decide on 

anticipated tests, 

procedures and 

preparation

Schedule any 

essential labwork 

prior to physician 

encounter

Figure 2. Process map for activities conducted before a returning patient visit with the EHR in Ob-Gyn

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

flexibility for the workflow to better meet their needs. Many of these were decision support enhancements 

based upon information about the specific patient which would be available in the EHR. Opportunities for 

providing support during a typical return visit via the EHR for cognitively challenging tasks suggested by 

the SMEs are detailed below.

3.A.1. Reducing the risk of missing a target time interval to provide optimal care actions due to 

scheduling issues

In Ob-Gyn, there are time intervals to provide optimal care which are considered when adjusting 

scheduling. When patients are scheduled outside of that window, the care is less than optimal, and in 

some cases, there are patient safety concerns that arise. In obstetrics, visits and treatments are scheduled 

based upon the age of the fetus. For example, the first ultrasound imaging scan is performed before the 

end of the first trimester (i.e., less than 13 weeks). Having the scan before this time is important for 

accurately determining gestational age, which impacts the ability to accurately conduct serum screening 

for Down’s syndrome. Visualizations which highlight appointments that are past the recommended 

window or alerts about patients who have not yet been scheduled in the recommended timeframe for a 

recommended care action could reduce the risk of missing the target time interval. Similarly, patients who 
9

have reached stability can have increased flexibility in scheduling, including being deferred to longer 

intervals if a patient with more urgent needs has to be accommodated during scheduling.

3.A.2. Distinguishing between patients with a very high likelihood of getting a particular 

treatment from patients who are less likely to get the treatment

In Ob-Gyn, there are predictable patterns of care which can form the basis for visit checklists, order sets, 

encounter forms, and other documentation facilitation. In addition, there are indicators that could be taken 

advantage of relating to the certainty that plans will go as expected. In Gynecological care, the annual 

visit is likely to follow a predictable routine unless there are chronic problems such as hypertension, or 

diabetes, or past abnormal findings from PAP smears or endometrial biopsies. For patients with diagnoses 

specific to Ob-Gyn care, there are predicted treatment actions that are taken with a high certainty. 

Nevertheless, there are known exceptions to how these treatments are conducted, and alerting physicians 

in a prominent fashion to these factors would be highly useful. For example, in Obstetrics care, a patient 

may have had a lab result indicating protein in the urine on the last visit. When there is a “best practice” 

standard for care with consensus across providers, then templates could be built to support efficient use of 

standardized protocols.

3.A.3. Alerting physicians to information about patients that inform how to conduct a patient visit

In Ob-Gyn care, providers employed techniques to provide alerts when opening a patient’s chart that were 

helpful to tailoring the conduct of a patient visit. In most cases, these techniques were “positive 

workarounds” in that they used EHR functionality which was not designed for that purpose, and thus the 

use was less than optimal, if only because the other intended use was affected. Examples include using 

the problem list to identify patients who have already had the Tetanus-Diphtheria (TDAP) vaccination in 

a prior pregnancy or who lack the Rh antigen (e.g., is Rh-negative). Having this information incorporated 

into a tailored specialty care overview display would eliminate the need to have additional pop-up alerts 

or problem list items.

3.A.4. Integrating medication information from pharmacies, hospitals and insurance formularies

into the EHR

Obtaining accurate information about what medications a patient has been taking can be a challenging 

process for many reasons. Although there can be reasons for why the information might be incomplete or 

inaccurate, one of the more trusted sources of information is the pharmacy where a patient obtains the 

medication and the hospital where medications were administered during an inpatient stay. Insurance 

formularies and prescription drug benefits are important sources of information because this has the 

preferred list for what the patient has available and must pay to receive medications. Having this 

information integrated directly into the EHR would be beneficial when eliciting and verifying information 

about medications from patients and caregivers for both clinical and reimbursement purposes.

3.A.5. Verifying that insurance requirements are met during the scheduling process

In Ob-Gyn, some elements of the treatment plan can be determined based upon insurance requirements. 

When procedures or medications cost thousands of dollars, it is important to verify that insurance 

requirements are met during the scheduling process. Providing EHR functionality to ensure that these 

requirements are met during the scheduling process would be useful in order to allow the specialist 

physicians to focus more on the clinical aspects of the visit. In Gynecological care, some insurance 

companies have exclusions for coverage for birth control methods. For example, there is a non-surgical 

birth control outpatient procedure which costs thousands of dollars to perform.

3.A.6. Flexible real-time assignments of different staff to tasks across multiple patients 

simultaneously

There can be a high variability in terms of whether ancillary staff or specialist physicians do certain tasks, 

The flow of the day is improved when the assignment of tasks is flexible based upon bottlenecks that 
10

emerge during the day. Having the ability to flexibly allocate and re-allocate assignments would be

useful. Flexible allocation requires that the personnel assigned to meet requirements for reimbursement, 

accreditation, and for other entities are supported in the sequence of events (ordering in the chart can be 

required to be conducted before the procedure), documentation of interpretations in the correct portion of 

the chart by the appropriate person, and required sign-offs by primary care providers. Examples where 

specialized support staff can be assigned tasks include an ultrasound imaging (sonography) technique of 

the fetus.

3.A.7. Usable access to patient data from diverse hardware platforms, including mobile devices

Specialty care providers may work in a variety of clinical settings, even within a single day when time 

spent going from one setting to another can be used to prepare for patient visits. In different settings, there 

might be different platforms which are required to be used by the relevant organizations. In addition, 

requests for care may come outside of scheduled clinic hours, when mobile devices need to be used to 

respond to care requests. Therefore, usability of software needs to be achieved from diverse hardware 

platforms, including mobile devices and other platforms with limited screen size and no keyboard or 

touch screen interactions. Allowing efficient access from mobile devices would require meeting 

requirements for information security and information governance without excessive additional logins or 

other keyboard or screen interactions. 

3.B. During the patient visit

In Figure 3, the process steps related to activities occurring with the EHR during the returning patient visit 

in obstetrics care for a pregnant patient are shown. In obstetrics care, the pregnant patient is the 

“prototypical” case. Patients can also come for miscarriages, etc., but pregnancy is the most common 

example. The workflow varies for more complex patients. 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 during a typical return visit via the EHR for cognitively challenging 

tasks suggested by the SMEs are detailed below.

3.B.1. Displaying summary information in a format which matches how specialist physicians were 

trained to recognize patterns

In Ob-Gyn, specialist physicians had standardized specialized formats for viewing data within their fields. 

Detecting patterns and trends using these formats is central to diagnosis and treatment. For example, in 

prenatal care, the antepartum record has been standardized by the American Congress of Obstetricians 

and Gynecologists (ACOG), and has recommended that vendors reproduce this in electronic format.35 At 

this time, no vendor has yet been known to have done this formally, although some have the ability for 

providers to generate templates which could incorporate most of this information in a similar fashion as 

has been recommended. This format promotes the ability to see if a finding is new, such as protein in the 

urine, if there has been an unexpected change in fundal height, whether blood pressure is trending 

upward, etc. With the paper version, there was a standardized sense of “left and right” side of the chart 

and where to look for information and no need to “scroll” or otherwise manipulate the interface to quickly 

skim information. 
11

Adjust scheduling

Clinical overview 

and review new 

findings and labs

Patient 

Checkin, Vital 

Signs, and 

Purpose of 

Visit

___________

Regular 

scheduled 

pregnancy 

visit Miscarriage

Vaginal 

bleeding/

Contractions/

Pain

Post delivery 

or post miscarriage 

visit

Get History, 

Signs and 

Symptoms, 

review 

Review of 

Systems, 

associate 

the test 

results and make 

Presumptive 

Diagnosis

Initiate intent to 

order medications, 

procedures, labs, 

consults

Verify medications 

and allergies

Discharge

Patient 

education

________

In case of 

anomalies

Or abnormal 

presentation

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

Privacy warnings

Does patient need a 

clinical procedure?

N o

Yes

Clinical Procedure

_____________

Transvaginal U/S

Shots

Before Patient Visit

Warm up 

and 

remember 

pertinent 

information

_________

(Prework, 

Prenote)

Name

Age

Duration of 

pregnancy

How many 

time has 

been 

pregnant 

(gravidity)

Number of 

pregnancies 

with viable 

gestational 

age (parity)

Rh typing

Form initial 

treatment plan

Examine 

patient and 

conduct 

needed 

inhouse tests

_______

Abdominal 

girth

Fundal height

Presentation

Fetal 

movement

Fetal heart 

rate

Per vaginal 

exam

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

Collect Medicatio

n 

Reconcilia

tion data 

Preparatio

n 

informatio

n and 

Review of 

Systems 

data

Verify dosage for some medications

Document 

medications 

reconciled

Review prior history 

and physical

Decide on 

anticipated tests, 

procedures and 

preparation

Schedule any 

essential labwork 

prior to physician 

encounter

_____________

Non pregnancy 

related labs and U/S 

e.g., concerns with 

leg swelling

Prep 

patient

Review chart/

research guidelines, 

sideline consult

(Usually the Day Before)

Figure 3. Process map for activities conducted with the EHR during a returning patient pregnancy visit in Ob-Gyn

(Tip: Printing this page on a paper of size A3 or larger provides legibility to read the contents)
12

3.B.2. Reminding the physician of planned tasks to accomplish during a patient visit

It would be useful in Ob-Gyn to have the EHR support remembering tasks which are anticipated to occur 

during a visit based upon knowledge of the specialty care area, the type and timing of the visit, and 

ideally patient-specific factors. An example would be having an annual gynecological check-up visit 

template. This template could sequence planned activities, thereby serving like a reminder checklist, as 

well as generate draft order sets and draft documentation that is modified by the provider during the visit. 

With a paper-based system, for example, if you anticipated that a patient would need a PAP smear and 

associated lab orders, you could fill out the appropriate paper form the night before, as well as portions of 

an encounter form. In the event that a patient did have abnormal findings to discuss during a visit, having 

a reminder of the need to discuss these on a patient summary display would be valuable when reviewing 

the summary the night before, immediately prior to, and/or during a visit with a patient.

3.B.3. Integrating personal health record data, patient portal information, and patient entered 

information

As more patients take advantage of the opportunity to view, download, and enter information personally 

into personal health records, portals, kiosks, and phone-based applications, it would be useful to integrate 

this information directly into the relevant portion of the patient chart. Due to the variable health literacy of 

patients, particularly with respect to the specialty care area knowledge, this information should be 

displayed differently, such as a “comment” in a margin or upon roll-over of the relevant information 

along with information about who entered the comment and when. If the provider chooses to accept the 

change, the “accept change” paradigm might be employed for chart information that can be modified by 

the provider.

3.B.4. Co-signing of ancillary support notes and findings

In specialized care areas, there are often specialized ancillary support staff who do and document 

important care activities, but often are not able to sign their own notes. Supporting co-signing is an 

important feature for EHRs for this purpose. An Ob-Gyn assistant does and documents clinical tasks such 

as collecting vital signs, collecting urine and blood samples, preparing equipment, preparing the patient, 

operating ultrasound and X-ray machines, and relaying medical information and instructions to patients. 

3.B.5. Integrating previously entered data into the current visit

In specialized care areas, there are often unique data elements which are only typically accessible in notes 

sections of EHRs. Having the ability to see trends in these data would be useful in detecting clinical 

issues and monitoring change. In addition, there are some data that are important but do not change 

frequently, if at all. Having this information available without needing to enter it again would increase 

efficiency. Examples of information to integrate from previously entered data for Obstetrics care include 

fundal height, gestational age, last normal menstrual period. 

3.B.6. Multiple simultaneous patient evaluations

In specialized care areas, the unique knowledge provided by a physician with extensive knowledge in a 

subfield of medicine is typically accessed in an economical and efficient fashion by having multiple 

simultaneous patient evaluations occurring in parallel. Therefore, restricting physicians to having one 

patient chart open at a time might increase the chances of completing all planned activities and 

documentation without additional memory support. On the other hand, the risks of entering data on the 

wrong patient are higher when there are multiple patient charts open without additional safeguards such 

as having an interim state between “closed” and “open” for a chart such as “waiting for additional care”. 

For the specialty care areas, there is predictability of transitions in workflow by providers between 

patients requiring ongoing same day work, and knowledge about these transitions could be used to 

provide additional safeguards to reduce the risk of wrong patient errors. For example, times when the 

physician would likely leave the room to interact with another patient but then later return to finish a care 
13

episode during Gynecological care include prior to the physical examination while the patient is getting 

undressed, after the physical exam and before the physician discusses the findings and concludes the visit. 

3.B.7. Hands-free interaction with the EHR during procedures

During any outpatient care visit, there is often a physical examination when the provider would benefit by 

interacting “hands free” with the EHR. The benefit of having hands-free support is higher for some 

aspects of ophthalmological care. In particular, enabling voice-activated documentation of findings would 

be beneficial during the exam. This type of support is not easily provided with paper-based systems, 

where typically another person would document findings real-time during an examination which requires 

extensive use of the hands and a high memory requirement for detailed findings. Other specialty care 

areas with similar needs likely include physical therapy, occupational therapy, and dental care. Although 

rare, there are instances in Gynecological care where hands-free interaction would be helpful. In 

particular, a patient exam using a speculum for patients with abnormal pap smears can include detailed 

documentation requirements while the physician’s hands are busy and the patient is in medical stirrups, 

and in some organizations includes taking images that are included in the EHR. Interestingly, the use of 

medical scribes was reported to be more common in gynecological than obstetric care by one physician at 

one hospital. Hands-free interaction is particularly important when reduced physical interactions with 

keyboards and screens will reduce the chances of infection.

3.B.8. Integrating information from specialized devices, software, data repositories

In specialized care areas, there are frequently specialized devices, software, and data repositories which 

are currently poorly integrated with most EHRs. Some integration is particularly challenging due to the 

size of the files (movies, radiology images, pathology images), in which case integration of reports 

describing findings from those data would be helpful. Similarly, integrated applications which reduce the 

size of files by reducing the data, such as by only viewing a single image through a section of tissue, may 

not provide adequate support for high quality clinical care. Specifically, most EHRs currently available 

lack the ability to do at least one of the following for at least one of these areas:

1) Display and manipulate data in a structured format. Data can be analog or digital 

measurement, analog or digital output, or electronic of mechanical. Output from devices or 

software can be images, movies, discrete data, graphs, or reports. Output from humans could 

be interpretations of analog data, digital data, film, paper strips from cardiac or ventilation 

sensors, or faxes from specialists.

2) Have a dedicated data field for clinically important elements

3) Enable annotation of data in a data field

4) Include images or “strips” in the original format (e.g., CIF, DICOM, TIFF, JPG)

5) Support drawing in freehand format on images

6) Include or link to data in other formats (PDF, TIFF, other outputs)

7) Highlight/emphasize data to display at the top level screen view (highlight an allergy on an 

overview display)

8) Supporting graphing data to detect trends over time including quantitative associated image 

data

9) Supporting search of text in reports

10) Have the option to store the output from the acquisition device directly in the EMR without 

being dependent on an active link

11) Have the option to store the raw output directly in the EMR without being restricted to device 

report summaries

12) Have the option to use standardized clinical data acquisition device associated workflow such 

as the Integrated Health Enterprise

In Obstetrics care, fetal monitor strips display the fetal heart rate graphed over time, blood pressure 

readings are graphed over sequential visits, images from an ultrasound machine are viewed to aid 
14

diagnosis and treatment planning, as are images or movies (DICOM) from a fetal echocardiography 

machine.

3.B.9. Grouping conceptually related items with different formats (e.g., CIF, image, scanned 

image, fax, PDF, searchable text, structured data), particularly redundant data

For outpatient care settings which are not directly integrated into a large hospital system with a single 

organization for test results, it is typical to use multiple organizations to provide laboratory, radiology, 

and pathology results. In some cases, identical data could be integrated into the chart in multiple formats, 

such as from a fax which is scanned into the system and a PDF file. When there are updates to the 

findings, then this also needs to be collated. Without having conceptually related groupings, there is a risk 

of failing to find important information or important updates to information. Therefore, having all items 

related to a particular lab order in one unit would be extremely beneficial, particularly when some of the 

data are redundant, except for the formatting of the information.

3.B.10. Locating original images on image acquisition devices when viewing electronically stored 

images 

Images are centrally important in many aspects of healthcare. In some cases, it is critical to view images 

in their original format, such as chest x-rays, in order to identify clinically relevant phenomena. 

Supporting the ability to easily locate original images in a different format from electronically stored 

images would be extremely useful and increase the efficiency of workflow. Chest x-rays are important in 

any specialty. Specialty-specific images include fetal monitor strips displaying the fetal heart rate graphed 

over time, images from an ultrasound machine, and images or movies (DICOM) from a fetal 

echocardiography machine.

3.B.11. Graphing data over time to identify patterns and trends, including extracting data from 

devices 

A fundamental need when working with quantitative data is to visualize patterns and trends in data, which 

typically indicate a change in a clinical condition. Having the ability to view tables and graphs is centrally 

important to recognizing patterns. Ideally, this ability would include structured data extracted from 

devices such as DICOM images from a fetal echocardiography machine. In some cases, the graphing 

capability existed, but accessing it was not done because the judgment was that the process was too 

inefficient and that there was poor interface usability. Particularly important data to visualize in Obstetrics

are the fetal heart rate over time, fundal height, and cervical length in ultrasound images at subsequent 

visits. 

3.B.12. Providing medical history tailored to the specialty area

The specialist care providers prefer that a default view of patient history be one that is tailored to their 

specialty care area. Although this information is often theoretically available in a tailored view, reducing 

the number of “clicks” to have it automatically available would make it easier to use on a routine basis in 

an efficient manner. Particularly important information to have “at a glance” on one page for Obstetrics

care is patient age (particularly if the patient is over 35 years old, which is an “advanced maternal age”), 

how many times the patient has been pregnant, visit type, how many weeks pregnant the patient is, 

today’s weight, blood pressure and pulse, if a patient lacks the Rh antigen (e.g., is Rh-negative), labs or 

consult notes since the last visit, summary of lab data, fundal height data, vital sign data, problem lists 

specific to the specialty care area, and whether the patient had flu and TDAP vaccinations in prior 

pregnancies. 

3.B.13. Providing a draft order set that can be modified during the visit which is tailored to 

diagnostic information and other patient data 

There are many benefits to sending orders during the exam if it can be made efficient, including the 

opportunity to ask patients and caregivers information during the ordering process. Based upon the 
15

diagnostic information and other patient data, such as gestational age, the likely set of orders that will be 

made is highly predictable for most patients. Nevertheless, physicians need to ensure that there are not 

exceptions which require changing the orders. Therefore, having a draft order set provided would be 

beneficial. This type of functionality is particularly helpful when there are multiple options that look 

similar but where one is preferred. 

3.B.14. Verifying that recently changed insurance and regulatory requirements are met when 

ordering and interpreting diagnostic tests 

When procedures or medications cost thousands of dollars, it is important to verify that insurance 

requirements are met during the ordering process. Providing EHR functionality to ensure that these 

requirements are met during the ordering process would be useful if the functionality has the ability to 

update the information on a frequent basis.

3.B.15. Providing quick access to short summary syntheses of findings from recent research

In all care areas, there is always a need to take advantage of recent research to provide high quality care. 

Providing links to published studies might be helpful, but unlikely to be used in the context of a timeconstrained visit. Having quick access to a short excellent summary that synthesizes a number of findings 

would be beneficial.

3.B.16. Selecting correct administrative codes (ICD, CPT) for the visit documentation

Every provider’s note on every patient is required to support an accurate selection of a diagnostic code 

from the International Classified of Diseases (ICD) and procedure code from the Current Procedural 

Terminology (CPT) code set in order to receive reimbursement for care. Providing support to ensure this 

requirement is met would likely create a greater opportunity for clinicians to focus more on the clinical 

aspects of interacting with a patient. It would be extremely useful to support transitions between code sets 

such as ICD-9 to ICD-10. For example, the ICD-9 code for Macular Degeneration Not Otherwise 

Specified is 362.50. With ICD-10, the same disease is coded as H35.30.

3.B.17. Selecting patient’s current insurance plan’s pharmaceutical formulary

During the ordering process, medication orders need to be restricted to the patient’s current insurance 

plan’s most recent pharmaceutical formulary in order to meet insurance requirements and determine the 

cost of the medication when potentially expensive. Providing support for this requirement would allow 

providers to focus more on clinical aspects of the ordering process. By integrating the details of the 

patient’s pharmacy benefits, the provider and patient through shared decision making can decide on 

which medication option to choose. If a subsequent determination by the insurance is required, the 

delayed decision should be placed in a queue that can subsequently be completed to optimize compliance, 

efficiency, and outcome.

3.B.18. Meeting medical necessity documentation for procedures, medications, transportation, 

convalescence, or work restriction 

Providers are in some cases required to provide documentation to meet legal requirements for 

documentation. Examples include documentation for procedures, medications, transportation, 

convalescence, or work or driving restrictions. Providing support would reduce the complexity of 

ensuring that requirements are met efficiently and accurately and help optimize outcomes and 

compliance.

3.B.19. Meeting informed consent requirements with procedure specific details

Providers are required to obtain informed consent from patients for medical procedures. Having the 

ability for patients and caregivers to obtain this information prior to the visit would improve the ability for 

them to make an informed decision and to have an efficient visit and help optimize outcomes and 

compliance.
16

3.B.20. A holistic approach to the goal of optimizing patient compliance to scheduled follow-ups 

and needed medical regimen

Providing high quality care to patients is increasingly being defined to include applying evidence-based 

strategies to improve patient compliance to a treatment plan. Data in the electronic health record can help 

to inform a “learning health system” about what approaches to achieving patient compliance are best 

suited to patient cohorts based on an individual patient’s historical compliance as well as generalized 

ethnic and other compliance information such as family caregivers’ preferences.

3.B.21. Integrating surgical notes into the EHR

Surgical minor procedures in a clinic setting as well as more involved procedures in an ambulatory 

surgery center or a hospital need to be directly integrated into the patient’s medical record in order to 

provide appropriate follow-up care.

3.C. Discharge

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

flexibility for the workflow to better meet their needs during the period at the conclusion of the visit 

(discharge). Opportunities for providing support during a typical return visit via the EHR for cognitively 

challenging tasks suggested by the SMEs are detailed below.

3.C.1. Informing patients about whether medications need to be obtained immediately following 

the visit 

For some care situations, obtaining medications needs to be done immediately following the visit rather 

than the typical situation of within a day or two following the visit. Taking advantage of knowledge of the 

diagnosis and medication to highlight this need for patients would be useful. Supporting informing 

patients of this information, such as by integration into a printout received at the conclusion of the 

session, would be valuable.

3.C.2. Informing patients what to watch for and who to contact if particular events happen

After the visit, patients will occasionally need to contact a healthcare provider in the event that something 

unexpected or undesirable occurs. Including this information in a printout handed to the patient would be 

valuable.

3.C.3. Optional redaction of particularly sensitive patient information from after-visit summaries

In all care settings, patient information has the potential to be highly sensitive, including mental health 

diagnoses, infectious diseases, obesity or drug use, genetic information, and information which could 

impact a professional or personal reputation. Nevertheless, Ob-Gyn care frequently has documentation 

which is highly sensitive for the majority of patients, or which is potentially problematic when shared 

with caregivers, family members, or friends. Examples include history of pregnancies, abortions, 

miscarriages, infertility, sexually transmitted diseases, drug and alcohol use, spousal abuse during 

pregnancy, results of mandatory drug testing, identities of donors for sperm and eggs, and evidence that 

the parent is not the genetic father of a child. In situations where patients wish to explicitly redact 

particular information from After Visit Summaries or other paperwork that is routinely printed or 

disseminated in the presence of caregivers, it would be extremely helpful to be able to support this option. 

Given that providing this summary is a requirement for Medicare reimbursement, having an option to 

print a redacted After Visit Summary at the completion of the visit would be particularly helpful. A 

related issue is that patients may not wish to give personally identifiable information associated with their 

patient data. It would be extremely useful for the EHR to permit anonymization of patient data per 

patient’s wishes.
17

3.C.4. Supporting optimization of patient compliance

Patients may need to be on a certain medication regimen or have certain procedures or tests performed. 

There should be queue management including automated contacting of the patient when there is no 

evidence that medications have been filled or tests have been performed. If critical care steps haven’t 

occurred, as evidenced by lack of receipt of pharmacy evidence that a medication for a particular patient 

was dispensed, or from imaging centers that a particular imaging test has not been performed, the lack of 

compliance can be escalated as warranted to automatically contact the patient and subsequently involve 

support staff or provider. The queue should be alterable to not overwhelm the user with queue fatigue 

and should be alterable to specific patient’s needs, reliability of receipt of external data, and provider 

workflow.

3.D. Documentation

Documentation of a visit is not conducted in any particular step in the workflow. Some specialists begin 

documentation prior to the visit and make all orders and complete all documentation with the patient. 

Some complete documentation in-between patients or during breaks. Some complete documentation the 

night after a visit was completed. Documentation elements include:

 Relevant history, physical, assessment, and plan;

 Detailed descriptions to 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.

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 during a 

typical return visit via the EHR for cognitively challenging tasks suggested by the SMEs are detailed 

below.

3.D.1. Correcting auto-generated information which is inaccurate

All of the healthcare providers had experiences with inaccurate information which was auto-generated 

from devices or software packages for a variety of reasons. Unsurprising sources of inaccuracies included 

sensor failures, missing data, “wrong patient” data, and situations where nurses are aware of a need to 

update a problem list but are not authorized to do (e.g., the nurse can order antibiotics based upon a 

urinalysis result based upon a physician order, but is not allowed to add UTI to the problem list). Not 

having the ability to correct inaccurate information is potentially dangerous when providing care. 

Workarounds such as creating an addendum to a note stating that a patient has an inaccurate diagnosis 

listed are likely not effective, and certainly are suboptimal. The auto-generated notes can sometimes only 

be viewed when a legal discovery request occurs sometimes providing surprising auto-generated 

information that is incorrect. Viewing all entered and auto-generated data associated with a patient visit 

should occur prior to having the data enter the medical record.

3.D.2. Drafting documentation and encounter forms which are tailored to diagnostic information

In Gynecological care, there are predictable patterns of care which can form the basis for draft encounter 

forms and other documentation facilitation. In addition, in Ob-Gyn, there are indicators that could be 

taken advantage of relating to the certainty that plans will go as expected. For example, the annual visit is 

likely to follow a predictable routine unless there are chronic problems such as hypertension, or diabetes, 

or past abnormal findings from PAP smears or endometrial biopsies.
18

3.D.3. Reducing logins and sign-offs for multiple software packages and devices used to 

accomplish related functions

In specialty care, niche software and devices are frequently employed that are not used or available in 

inclusive EHRs. Having support for a single login process, reducing challenge questions and other 

keystrokes during logins, and reducing additional logins following automatic sign-offs would be 

beneficial. There are some unique elements to these needs for Obstetrics care. The additional login and 

sign-off requirements were estimated by one Ob-Gyn physician to add 1.5 hours to an 8 hour day when 

the visits were scheduled for 15 minutes each. One obstetrician reported that a staff member opened four 

EHRs on each computer in each exam room with the patient’s information pulled up simultaneously 

before he entered the room to enable a more efficient visit and to avoid “wrong patient” errors. Another 

obstetrician reported having to copy and paste information from an ultrasound software package into the 

EHR or else no longer have access to it one or two weeks later when the patient returned for a follow-up 

visit. In addition, there were separate passwords for the EHR, one other software, and the fetal strips 

monitoring software, some of which required challenge questions in addition to a login process. The 

access times to the other software could theoretically be inspected during a lawsuit to determine if a note 

was documented before the information was accessed, which could add the need for additional logins if a 

task took long enough to create an automated sign-out. For example, in order to have a compliant 

sequence for a non-stress test, the physician would access the software and check the tracing. Then the 

findings would be documented in a note in the EHR, including the specific issues, and then the chart 

needs to be signed off on within 48 hours. In order to accomplish this goal, HIPAA privacy and security 

rules need to be followed in order to protect Personal Health Information (PHI) data and mitigate the risks 

of identity theft.

3.D.4. Annotating documentation by patients and caregivers in a progress note

More patients are expected in the future to take advantage of the so-called ‘blue button’ opportunity to 

view their progress note documentation. The demand will likely increase to correct misinformation or 

otherwise annotate the note. Because the patient is not a healthcare professional at the organization, it is 

likely inappropriate to use the workflow for corrections to the health record from professionals. 

Therefore, this information should be displayed in a different fashion, such as a “comment” in a margin or 

upon roll-over of the relevant information along with information about who entered the comment and 

when. One provider stated that having physicians engage in discussions about aspects of the chart, 

including requests from patients to explain portions of a note to them, would be an undesirable outcome 

due to the additional workload burden. Therefore, the design would likely need to minimize the frequency 

of “back and forth” communications between physicians and patients about annotations and progress note 

information.

3.D.5. Having additional protections on personal health information

Although current examples of issues with personal health information being disseminated beyond the 

wishes of patients and caregivers were not commonly observed, several of the providers expressed 

concerns about the potential for this to occur and described individual anecdotes as “proof of concept” 

that issues could arise. Data repositories are being generated with access being provided to non-traditional 

users, such as schools in order to verify immunizations. In general, it is anticipated that a subset of 

patients will feel strongly about the desire to protect a particular data element from use in population 

health research or other population-based initiatives (e.g., marketing studies). Providing electronic 

support for “opting in or out”, similar to options for organ donation programs, would be an interesting 

area for consideration in the next generation of EHRs. Possible areas might include “Do Not Resuscitate” 

advance directives or not allowing blood transfusions for religious reasons (e.g., Jehovah’s witness 

patients). Accomplishing this objective will likely require negotiations between stakeholder groups with 

differing, and potentially conflicting, perspectives in this relatively uncharted territory.
19

4 Process Maps and Workflow Redesign Opportunities for 

Ophthalmology

Steps in the workflow are visualized in Figure 4 as an overview at a high level of detail for 

Ophthalmology for EHR interactions related to an established patient’s return visit with the specialist care 

provider in an outpatient setting. These steps are similarly grouped as:

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

2. During the patient visit

3. Physician encounter

4. Discharge

5. Documentation
20

Adjust scheduling

Clinical overview 

and review new 

findings and labs

Patient 

Checkin, Vital 

Signs, 

Generic 

Ophthalmic 

Tests and 

Purpose of 

Visit

Get History, 

Signs and 

Symptoms, 

review 

Review of 

Systems, 

associate 

the test 

results and 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, 

tests, consults/referral

Does patient need a 

clinical procedure?

N o

Yes Clinical Procedure

Before Patient Visit

Warm up 

and 

remember 

pertinent 

information

Develop initial 

treatment plan

Examine 

patient 

and the 

eye

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 

for required procedures, investigate 

requirement for public reporting

Are generic 

Ophthalmic 

tests done?

N o

Yes

Review chart/

research guidelines, 

sideline consult

Collect Medicatio

n 

Reconcilia

tion data 

Preparatio

n 

informatio

n and 

Review of 

Systems 

data

Verify dosage for some medications

Document medications 

reconciled

Review prior history 

and physical

Decide on 

anticipated tests, 

procedures and 

preparation

Map the patients’ 

schedule with the 

technician’s 

schedule to decide 

what is possible and 

what is not possible 

at the visit

Schedule test

Perform test

Information sources (Medical 

devices, lab results, etc.)

Figure 4. Overview process map for EHR use related to returning patient visit in Ophthalmology

(Tip: Printing this page on a paper of size A3 or larger provides legibility to read the contents)
21

4.A. Before the patient visit

In Figure 5, the process steps related to activities occurring with the EHR before the visit are displayed. 

These are:

 Adjust scheduling in order to balance workload demands and take into account predictions and 

updates about how long types of patients will take and meet the unexpected urgent needs of 

scheduled and unscheduled patients, 

 Clinical overview and review new findings and labs for patients with significant complexity and 

updates,

 Review prior history and physical for all patients, 

 Decide on anticipated tests, procedures, and preparation, and

 Map the patient’s schedule with the technician’s schedule to decide what is possible and not 

possible to do at the visit.

Adjust scheduling

Clinical overview 

and review new 

findings and labs

Does patient have 

significant complexity or 

updates?

Yes

N o

Before Patient Visit

Review prior history 

and physical

Decide on 

anticipated tests, 

procedures and 

preparation

Map the patients’ 

schedule with the 

technician’s 

schedule to decide 

what is possible and 

what is not possible 

at the visit

Figure 5. Process map for activities conducted before a returning patient visit with the EHR for 

Ophthalmology

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

flexibility for the workflow to better meet their needs. Many of these were decision support enhancements 

based upon information about the specific patient which would be available in the EHR. Opportunities for 

providing support during a typical return visit via the EHR for cognitively challenging tasks suggested by 

the SMEs are detailed below.

4.A.1. Reducing the risk of missing a target time interval to provide optimal care actions due to 

scheduling issues

In Ophthalmology, there are time intervals to provide optimal care. When patients are scheduled outside 

of that window, the care is less than optimal, and in some cases, there are patient safety concerns that 

arise. For example, an intravitreal injection of a medication is typically given to treat macular 

degeneration during recommended time intervals, on a recurring basis. It is not standard practice to 

provide this injection too soon after the last injection. If the time interval between injections is more than 

the suggested interval after the prior injection, the eye disease may get worse, leading to a possibly 

irreversible loss of visual acuity. Patients who are at particularly high risk for failures to appropriately

schedule a visit include patients who have dementia, memory loss, multiple medical problems, live in 
22

more than one location (such as a college student or retiree with a winter and summer home), or have a 

history of missing scheduled appointments or failing to schedule appointments. Optimal compliance and 

persistence with a particular treatment regimen will lead to optimal outcomes. The EHR could use the 

patient’s diagnosis, last visit, and recommended time interval for the next step in the care plan, and 

likelihood of missing an appointment to provide decision support for the scheduler or physician. 

Additionally, the EHR could communicate directly with the patient, such as by contacting the patient by 

email to remind him or her to schedule a care action within a particular time window, and escalating the 

communications when the anticipated visit is not scheduled as expected. Visualizations which highlight 

appointments that are past the recommended window or alerts about patients who have not yet been 

scheduled in the recommended timeframe for a recommended care action could reduce the risk of missing 

the target time interval. Similarly, patients who have reached stability can have increased flexibility in 

scheduling, including being deferred to longer intervals if a patient with more urgent needs has to be 

accommodated during scheduling. For example, a patient with Age-related Macular Degeneration (AMD) 

typically requires monthly monitoring during a return visit. If a patient has not received an injection in the 

last six visits, then this interval can be extended to 8 weeks to 12 weeks. 

4.A.2. Distinguishing between patients with a very high likelihood of getting a particular 

treatment from patients who are less likely to get the treatment

In Ophthalmology, there are predictable patterns of care which can form the basis for visit checklists, 

order sets, encounter forms, and other documentation facilitation. In addition, there are indicators that 

could be taken advantage of relating to the certainty that plans will go as expected. For example, annual 

eye screenings follow a predictable routine unless there are chronic problems such as glaucoma, or 

diabetes, or past abnormal findings from eye examinations. For patients with diagnoses specific to the 

field, there are predicted treatment actions that are taken with a high certainty. Nevertheless, there are 

known exceptions to how these treatments are conducted, and alerting physicians in a prominent fashion 

to these factors would be highly useful. For example, stroke specialist may have written explicit 

instructions not to give an intravitreal injection to a patient with macular degeneration for a period of time 

after a stroke.

4.A.3. Alerting physicians to information about patients that informs how to conduct a patient 

visit

In Opthalmology, providers employed techniques to provide alerts when opening a patient’s chart that 

were helpful to tailoring the conduct of a patient visit. In most cases, these techniques were “positive 

workarounds” in that they used EHR functionality which was not designed for that purpose, and thus the 

use was less than optimal, if only because the other intended use was affected. Examples include

identifying patients with special needs, such as prisoners, autistic patients, patients requiring interpreters, 

and patients who are only willing to receive care from one particular provider. Having this information 

incorporated into a tailored specialty care overview display for multiple patients scheduled for that day 

would eliminate the need to use “workaround” pop-up alerts or problem list items.

4.A.4. Integrating medication information from pharmacies, hospitals and insurance formularies

into the EHR

Obtaining accurate information about what medications a patient has been taking can be a challenging 

process for many reasons. Although there can be reasons for why the information might be incomplete or 

inaccurate, one of the more trusted sources of information is the pharmacy where a patient obtains the 

medication and the hospital where medications were administered during an inpatient stay. Insurance 

formularies and prescription drug benefits are important sources of information because this has the 

preferred list for what the patient has available and must pay to receive medications. Having this 

information integrated directly into the EHR would be beneficial when eliciting and verifying information 

about medications from patients and caregivers for both clinical and reimbursement purposes.
23

4.A.5. Verifying that insurance requirements are met during the scheduling process

In Ophthalmology, some elements of the treatment plan can be determined based upon insurance 

requirements. When procedures or medications cost thousands of dollars, it is important to verify that 

insurance requirements are met during the scheduling process. Providing EHR functionality to ensure that 

these requirements are met during the scheduling process would be useful in order to allow the specialist 

physicians to focus more on the clinical aspects of the visit. For example, an intravitreal injection for 

macular degeneration costs thousands of dollars for the medication, and thus the ability for insurance to 

pay for it needs to be incorporated into the scheduling process. In addition, there can be restrictions on 

when actions are performed in order to obtain reimbursement. For example, Medicare limits the number 

of tests that can be done in a single visit, such as not reimbursing when a visual field test and an optic

nerve scan are conducted on the same day.

4.A.6. Flexible real-time assignments of different staff to tasks across multiple patients 

simultaneously

There can be a high variability in terms of whether ancillary staff or specialist physicians do certain tasks.

The flow of the day is improved when the assignment of tasks is flexible based upon bottlenecks that 

emerge during the day. Having the ability to flexibly allocate and re-allocate assignments would be 

useful. Flexible allocation requires that the personnel assigned to meet requirements for reimbursement, 

accreditation, and for other entities are supported in the sequence of events (e.g., ordering in the chart can 

be required to be conducted before the procedure), documentation of interpretations in the correct portion 

of the chart by the appropriate person, and required sign-offs by primary care providers. Examples where 

specialized support staff can be assigned tasks in vision care include an optical coherence tomography 

(OCT) imaging technique of the eye.

4.A.7. Usable access to patient data from diverse hardware platforms, including mobile devices

Specialty care providers may work in a variety of clinical settings, even within a single day when time 

spent going from one setting to another can be used to prepare for patient visits. In different settings, there 

might be different platforms which are required to be used by the relevant organizations. In addition, 

requests for care may come outside of scheduled clinic hours, when mobile devices need to be used to 

respond to care requests. Therefore, usability of software needs to be achieved from diverse hardware 

platforms, including mobile devices and other platforms with limited screen size and no keyboard or 

touch screen interactions. 

4.B. During the patient visit

In Figure 6, the process steps related to activities occurring with the EHR during the visit are shown. 

These are:

 Check in patient, obtain vital signs or eye vital signs like visual acuity and intraocular pressure

(per eye) 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, do eye examination (i.e., physical examination)

 Form initial treatment plan,

 Review chart/research guidelines, informal consult,

 Initiate intent to order medications, labs, procedures, imaging procedures, 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,
24

 Verify laterality (right eye or left eye) for eye procedures,

 Explicit orders for medications, procedures, labs, imaging, consults/referral,

 Do 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,

 Correct documentation to support billing including signing scribe entered information,

 Correct document medications reconciled, and

 Correct documentation for others, e.g., legal, research, compliance, Meaningful Use.

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, Ophthalmology technician, 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 when the provider:

 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.
25

Adjust Scheduling

Clinical 

overview and 

review new 

findings and 

labs

Patient Checkin, 

Vital Signs, Generic Ophthalmic Tests 

and Purpose of 

Visit

Get History, 

Signs and 

Symptoms, 

review Review 

of Systems, 

associate the 

test results and make 

Presumptive Diagnosis

Any 

catastrophic 

change?

Coumadin use

Any cerebral 

stroke?

Initiate intent to order medications, procedures, 

labs, consults

Informed consent

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 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?

N o Review new findings

Explicit Orders: Medications, 

procedures, tests, consults/referral

Does patient need a clinical 

procedure?

N o

Yes Clinical Procedure

Before Patient Visit

A Day Before

Warm up and 

remember 

pertinent 

information

Injection day or 

not How many 

injections done 

earlier

Last injection 

particulars

Condition of 

each eye

Visual acuity 

stable or worse 

in each eye OCT – compare 

thickness over 

time

Fluorescein test 

needed or not 

Develop initial treatment 

plan Discussion and injection or 

no injection

Examine 

patient and 

the eye

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 for 

procedures, investigate requirement for public 

reporting

Are generic Ophthalmic tests 

done?

N o

Yes

Review chart/research 

guidelines, sideline consult

Collect Medication 

Reconciliation 

data 

Preparation 

information 

and Review of 

Systems data

Verify dosage for some medications

Document medications 

reconciled

Review prior history 

and management 

information

Vision dropped or 

intraocular pressure 

high

Decide on 

anticipated tests, 

procedures, 

referral 

Check the drug 

inventory

Patient 

preparation

Likelihood to get 

the treatment

Map the patients’ schedule with the technician’s 

schedule to decide what is 

possible and what is not 

possible at the visit

Time per procedure

Injection day or Laser day

Insurance Compliance of 

tests

Schedule test

Perform test

Is other 

specialist 

consultation 

necessary?

N o

Yes

Is it 

necessary 

before the 

visit?

Yes

N o

Referral

Specialist 

consultati

o n

Is the patient 

regular on 

treatment?

N o

Reinforce 

appointme

nt 

notificatio

n

Yes

Information sources 

(Diagnostic Devices, 

Lab results, etc.)

Visit Documentation

Document and send 

consult/followup letter to 

relevant provider Yes

Figure 6. Process map for activities conducted with the EHR during a returning patient with Age-related Macular Degeneration in 

Ophthalmology
26

Age-related macular degeneration was purposely picked as an example due to its relatively low 

complexity, which facilitated making a fairly simple process map. The return visit for this type of disease 

could be characterized as following a pre-planned procedure for treatment where you are mainly checking 

to see if there are any exceptions to the common situation where you would need to modify the plan. The 

sequence is almost robotic in getting an image, reviewing it, possibly getting an OCT image, and then 

providing an eye injection. In comparison, a return visit for a uveitis patient is a much more complex 

process. With uveitis, there is an ongoing search, often for years, to explain symptoms and a definitive 

explanation may never be found. Therefore, the step of “Get history, signs and symptoms, review of 

systems, make working or presumptive diagnosis” is a primary focus and highly cognitive challenging. It 

is critical to employ subtle co-construction of meaning between the physician and the patient where the 

patient initially describes symptoms and changes in symptoms, the physician does targeted queries that 

are based upon a deep knowledge of the subject domain. There are “rules of thumb” about common 

queries such as redness, pain, light sensitivity, and change in vision, but there are frequent deviations 

from what might be implemented using a “checklist” approach. Similarly, the step of “Form initial 

treatment plan” has many more possibilities than with macular degeneration. In addition to having a 

larger set of possible treatments, there is a greater need to educate the patient on when to seek medical 

help for particular symptoms. In some cases, there are catastrophic risks with irreversible vision loss that 

require patients to advocate for care when certain symptoms occur, even if there is no scheduled or 

planned visit with the specialist.

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 during a 

typical return visit via the EHR for cognitively challenging tasks suggested by the SMEs in 

Ophthalmology care are:

4.B.1. Displaying summary information in a format which matches how specialist physicians were 

trained to recognize patterns

Specialist physicians have standardized specialized formats for viewing data within their fields. Detecting 

patterns and trends using these formats is central to diagnosis and treatment. In Ophthalmology , there is 

specialized iconography and abbreviations that are used to document the examination findings which is 

not commonly used in EHR systems. Also, the equivalent of systemic vital signs such as visual acuity 

and intraocular pressure are frequently not optimally aggregated or displayed across multiple visits.

Additionally, it is standard to refer to right eye (oculus dexter – OD) first and the left eye (oculus sinister -

OS) second. The laterality is from the perspective of the patient, not from the perspective of someone 

looking at the patient. With software upgrades for some EHRs, the display of “left eye” and “right eye” 

has inadvertently been changed to the perspective of a provider viewing a patient, causing confusion and 

can be dangerous for patients because clinical personnel have been trained to the patient-centric standard.

4.B.2. Reminding the physician of planned tasks to accomplish during a patient visit

It would be useful to have the EHR support remembering tasks which are anticipated to occur during a 

visit based upon knowledge of the specialty care area, the type and timing of the visit, and ideally patientspecific factors. For example, there are some diagnoses, such as macular degeneration, that require highly 

standardized care for the vast majority of patients. Taking advantage of knowing what actions are 

expected in the design of supporting displays or templates would be useful. Highlighting patients for 

whom the routine approach would be altered is also extremely valuable, such as a patient who has 

experienced a recent stroke and thus should not receive an intravitreal injection during the visit. Also, 

reminders regarding obtaining same-day images prior to the provider’s examination is important for clinic 

workflow. In more complex and varied care such as for patients with uveitis, aggregating important 

historical events such as prior and current medications; and, these patients should have laboratory analysis 

reminders within specific time intervals (if not being co-managed with other physicians). Also, 
27

facilitating what elements of the work-up and treatment had been performed in relation to uveitis activity 

to reduce cognitive workload will help achieve optimal outcomes.

4.B.3. Integrating personal health record data, patient portal information, and patient entered 

information

As more patients take advantage of the opportunity to view, download, and enter information personally 

into personal health records, portals, kiosks, and phone-based applications, it would be useful to integrate 

this information directly into the relevant portion of the patient chart. Due to the variable health literacy of 

patients, particularly with respect to the specialty care area knowledge, this information should be 

displayed differently, such as a “comment” in a margin or upon roll-over of the relevant information 

along with information about who entered the comment and when. If the provider chooses to accept the 

change, the “accept change” paradigm might be employed for chart information that can be modified by 

the provider.

4.B.4. Co-signing of ancillary support notes and findings

In specialized care areas, there are often specialized ancillary support staff who do and document 

important care activities, but often are not able to sign their own notes. Supporting co-signing is an 

important feature for EHRs for this purpose. An Ophthalmic technician performs and documents clinical 

tasks such as measuring visual acuity, instilling ocular medications, obtaining historical information, and 

helping instruct the patient regarding medications, tests, and procedures

4.B.5. Integrating previously entered data into the current visit

In specialized care areas, there are often unique data elements which are only typically accessible in notes 

sections of EHRs. Having the ability to see trends in these data would be useful in detecting clinical 

issues and monitoring change. In addition, there are some data that are important but do not change 

frequently, if at all. Having this information available without needing to enter it again would increase 

efficiency. Examples of information to integrate from previously entered data for Ophthalmology include: 

per eye visual acuity, visual acuity with both eyes and with or without correction, intraocular pressure, 

cup to disk ratio, and corneal topography. 

4.B.6. Multiple simultaneous patient evaluations

In specialized care areas, the unique knowledge provided by a physician with extensive knowledge in a 

subfield of medicine is typically accessed in an economical and efficient fashion by having multiple 

simultaneous patient evaluations occurring in parallel. Therefore, restricting physicians to having one 

patient chart open at a time might increase the chances of completing all planned activities and 

documentation without additional memory support. On the other hand, the risks of entering data on the 

wrong patient are higher when there are multiple patient charts open without additional safeguards such 

as having an interim state between “closed” and “open” for a chart such as “waiting for additional care”. 

For the specialty care areas, there is predictability of transitions in workflow by providers between 

patients requiring ongoing same day work, and knowledge about these transitions could be used to 

provide additional safeguards to reduce the risk of wrong patient errors. For example, times when the 

physician would likely leave the room to interact with another patient but then later return to finish a care 

episode include after a patient has received eye drops which require time to achieve efficacy prior to an 

examination.

4.B.7. Hands-free interaction with the EHR during procedures

During any outpatient care visit, there is often a physical examination when the provider would benefit by 

interacting “hands free” with the EHR. The benefit of having hands-free support is higher for some 

aspects of Ophthalmological care. In particular, enabling voice-activated documentation of findings 

would be beneficial during the examination. This type of support is not easily provided with paper-based 

systems, where typically another person would document findings real-time during an examination which
28

requires extensive use of the hands and a high memory requirement for detailed findings. Other specialty 

care areas with similar needs likely include physical therapy, occupational therapy, and dental care. There 

are some extensive eye examinations when there are many findings to remember to document while using 

both hands. During motility examination of eye movements multiple prisms may need to be held by the 

examiner. In addition, a peripheral retinal examination requires a condensing lens in one hand and a 

scleral depressor in the opposite hand. Interacting with the EHR during these examinations is extremely 

difficult, and secondary in priority to the use of other specialized eye equipment. Hands-free interaction is 

particularly important when reduced physical interactions with keyboards and screens will reduce the 

chances of infection.

4.B.8. Integrating information from specialized devices, software, data repositories

In specialized care areas, there are frequently specialized devices, software, and data repositories which 

are currently poorly integrated with most EHRs. Some integration is particularly challenging due to the 

size of the files (movies, radiology images, pathology images), in which case integration of reports 

describing findings from those data would be helpful. Similarly, integrated applications which reduce the 

size of files by reducing the data, such as by only viewing a single image through a section of tissue, may 

not provide adequate support for high quality clinical care. Because images and reports from an Ocular 

Coherence Tomography (OCT) device or raw data from visual field devices need to be easily accessible 

for the correct patient during the visit, typically the Ophthalmologist will currently have multiple 

windows from networked devices like the OCT device of the Fundus cameras open along with the EHR 

while seeing the patient. Specifically, EHRs currently available lack the ability to do at least one of the 

following for at least one of these areas:

 Display and manipulate data in a structured format. Data can be analog or digital 

measurement, analog or digital output, or electronic or mechanical. Output from devices or 

software can be images, movies, discrete data, graphs, or reports. Output from humans could 

be interpretations of analog data, digital data, film, paper strips from cardiac or ventilation 

sensors, or faxes from specialists.

 Have a dedicated data field for clinically important elements

 Enable annotation of data in a data field

 Include images or “strips” in the original format (e.g., CIF, DICOM, TIFF, JPG)

 Support drawing in freehand format on images

 Include or link to data in other formats (PDF, TIFF, other outputs)

 Highlight/emphasize data to display at the top level screen view (highlight an allergy on an 

overview display)

 Supporting graphing or putting data into a table or other structured format to detect trends 

over time including quantitative associated image data

 Supporting search of text in reports

 Have the option to store the output from the acquisition device directly in the EMR without 

being dependent on an active link

 Have the option to store the raw output directly in the EMR without being restricted to device 

report summaries

 Have the option to use standardized clinical data acquisition device associated workflow such 

as the Integrated Health Enterprise

4.B.9. Grouping conceptually related items with different formats (e.g., CIF, image, scanned 

image, fax, PDF, searchable text, structured data), particularly redundant data

For outpatient care settings which are not directly integrated into a large hospital system with a single 

organization for test results, it is typical to use multiple organizations to provide laboratory, radiology, 

and pathology results. In some cases, identical data could be integrated into the chart in multiple formats, 
29

such as from a fax which is scanned into the system and a PDF file. When there are updates to the 

findings, then this also needs to be collated. Without having conceptually related groupings, there is a risk 

of failing to find important information or important updates to information. Therefore, having all items 

related to a particular lab order in one unit would be extremely beneficial, particularly when some of the 

data are redundant except for the formatting of the information. An example would be to support 

grouping the relevant set of information for a patient with retinal vein occlusion to enable a physician to 

investigate the findings efficiently.

4.B.10. Locating original images on image acquisition devices when viewing electronically stored 

images 

Images are centrally important in many aspects of healthcare. In some cases, it is critical to view images 

in their original format, such as chest x-rays, in order to identify clinically relevant phenomena. 

Supporting the ability to easily locate original images in a different format from electronically stored 

images would be extremely useful and increase the efficiency of workflow. Chest x-rays are important in 

any specialty. Specialty-specific images include images and reports from an Ocular Coherence 

Tomography (OCT) device, fluorescein angiograms, corneal topography, visual fields and autorefractor 

output.

4.B.11. Graphing of viewing formatted data (tables) over time to identify patterns and trends,

including extracting data from devices

A fundamental need when working with quantitative data is to visualize patterns and trends in data, which 

typically indicate a change in a clinical condition. Having the ability to view tables and graphs is centrally 

important to recognizing patterns. Ideally, this ability would include structured data extracted from 

devices such as DICOM images from a fetal echocardiography machine and images from an Ocular 

Coherence Tomography (OCT) device. In some cases, the graphing capability existed, but accessing it 

was not done because the judgment was that the process was too inefficient and that there was poor 

interface usability. Particularly important data to visualize are intraocular pressure over time to determine 

how it interacts with medication changes, retinal nerve fiber layer changes over time, and retinal thickness 

measurements from an OCT device.

4.B.12. Providing medical history tailored to the specialty area

The specialist care providers would prefer that a default view of patient history be one that is tailored to 

their specialty care area. Although this information is often theoretically available in a tailored view, 

reducing the number of “clicks” to have it automatically available would make it easier to use on a routine 

basis in an efficient manner. Particularly important information to have “at a glance” on one page are the 

equivalent of “vital signs” for Ophthalmology, such as: intraocular pressure, visual acuity, and visual field 

output separated and grouped per eye.

4.B.13. Providing a draft order set to modify during the visit which is tailored to diagnostic 

information and other patient data 

There are many benefits to sending orders during the visit if it can be made efficient, including the 

opportunity to ask patients and caregivers information during the ordering process. Based upon the 

diagnostic information and other patient data, the likely set of orders that will be made is highly 

predictable for most patients. Nevertheless, physicians need to ensure that there are not exceptions which 

require changing the orders. Therefore, having a draft order set provided would be beneficial. This type of 

functionality is particularly helpful when there are multiple options that look similar but where one is 

preferred. Examples include prescribing eyeglasses will be helped by knowing prior eyeglass 

prescriptions and previous refractions grouped per eye in a standardized format sphere, cylinder, prism, 

and for contact lenses knowing prior base curves, diameters, and powers. The eyeglass prescription 

determination will frequently occur early in the visit prior to fundus examination. For macular 
30

degeneration with a choroidal neovascular membrane where it is planned to continue treatment, it is 

highly predictable that patients will receive an intravitreal injection during the visit.

4.B.14. Orders including requiring unique data fields for the specialty area 

For specialty care areas, there can be unique data fields for orders. Examples include eye drop 

medications which need to specify which eye (right eye, left eye, or both eyes) and the number of drops 

(which frequently differ for one eye as compared to the other in certain diseases such as uveitis). For 

uveitis, there is often a long tapering regimen over weeks of less frequent administration of eye drops per 

day.

4.B.15. Verifying that recently changed insurance and regulatory requirements are met when 

ordering and interpreting diagnostic tests 

When procedures or medications cost thousands of dollars, it is important to verify that insurance 

requirements are met during the ordering process. Providing EHR functionality to ensure that these 

requirements are met during the ordering process would be useful if the functionality has the ability to 

update the information on a frequent basis. In Ophthalmology, the cost of medications, such as those 

available treatments for “wet” macular degeneration, are often the most expensive part of care. For both 

patient and provider, anything that specifies the accurate actual cost to the patient at the time of the visit 

will streamline care and result in improved outcomes. In addition less expensive but important diagnostic 

tests such as an optical coherence tomography (OCT) imaging technique of the eye is an important 

diagnostic tool with insurance and regulatory requirements that frequently change. Although ideally it 

often would be most convenient for patients to receive tests on the same day, insurance rules frequently 

require the outpatient to return on multiple days and may not pay for more than one test per day. It would 

help the provider and patient plan for needed treatment by clarifying these restrictions at the time of the

patient visit.

4.B.16. Providing quick access to short summary syntheses of findings from recent research

In all care areas, there is always a need to take advantage of recent research to provide high quality care. 

Providing links to published studies might be helpful, but unlikely to be used in the context of a timeconstrained visit. Having quick access to a short excellent summary that synthesizes a number of findings 

would be beneficial.

4.B.17. Selecting correct administrative codes (ICD, CPT) for the visit documentation

Every provider’s note on every patient is required to support an accurate selection of a diagnostic code 

from the International Classified of Diseases (ICD) and procedure code from the Current Procedural 

Terminology (CPT) code set in order to receive reimbursement for care. Providing support to ensure this 

requirement is met would likely create a greater opportunity for clinicians to focus more on the clinical 

aspects of interacting with a patient. It would be extremely useful to support transitions between code sets 

such as ICD-9 to ICD-10. For example, the ICD-9 code for spontaneous abortion is 634.00. With ICD-10, 

the code is O03.5.

4.B.18. Selecting patient’s current insurance plan’s pharmaceutical formulary

During the ordering process, medication orders need to be restricted to the patient’s current insurance 

plan’s most recent pharmaceutical formulary in order to meet insurance requirements. Providing support 

for this requirement would allow providers to focus more on clinical aspects of the ordering process. By 

integrating the details of the patient’s pharmacy benefits as well as the costs with and without insurance 

coverage, the provider and patient, through shared decision making, can decide on which medication 

option to choose. If a subsequent determination by the insurance is required, the delayed decision should 

be placed in a queue that can subsequently be completed to optimize compliance, efficiency, and 

outcome.
31

4.B.19. Meeting medical necessity documentation for procedures, medications, transportation, 

convalescence, or work restriction 

Providers are in some cases required to provide documentation to meet legal requirements for 

documentation. Examples include documentation for procedures, medications, transportation, 

convalescence, or work or driving restrictions. Providing support would reduce the complexity of 

ensuring that requirements are met efficiently and accurately and help optimize outcomes and 

compliance.

4.B.20. Meeting informed consent requirements with procedure specific details

Providers are required to obtain informed consent from patients for medical procedures. Having the 

ability for patients and caregivers to obtain this information prior to the visit would improve the ability for 

them to make an informed decision and to have an efficient visit and help optimize outcomes and 

compliance.

4.B.21. A holistic approach to the goal of optimizing patient compliance to scheduled follow-ups 

and needed medical regimen

Providing high quality care to patients is increasingly being defined to include applying evidence-based 

strategies to improve patient compliance to a treatment plan. Data in the electronic health record can help 

to inform a “learning health system” about what approaches to achieving patient compliance are best 

suited to patient cohorts based on an individual patient’s historical compliance as well as generalized

ethnic and other compliance information such as family caregivers’ preferences.

4.B.22. Integrating surgical notes into the EHR

Surgical minor procedures in a clinic setting as well as more involved procedures in an ambulatory 

surgery center or a hospital need to be directly integrated into the patient’s medical record in order to 

provide appropriate follow-up care.

4.B.23. Identifying, retrieving and displaying prior similar specialty prior notes

Providers should be able to easily identify and retrieve prior notes within their own specialty over time. 

This includes subspecialty specific queues. For instance, having any subspecialty notes buried in 

Ophthalmology, notes can be very laborious to retrieve if each note must be opened. In particular, having 

the ability to group notes by specific provider or provider type would be useful; examples of specialists in 

Ophthalmology include optometry, comprehensive Ophthalmology, pediatric Ophthalmology, 

vitreoretinal surgeon, glaucoma, cornea, and uveitis specialists. Notes would ideally be viewed separately 

as a past ocular history rather Bethan needing to be extracted from a complete past medical history.

4.B.24. Drawing templates with annotations, icons, and auto-generated text

There is a wide variety of needs in Ophthalmology regarding requiring drawing templates. In some 

settings, annotation over images would suffice, however in other settings and before images are taken,

drawings are frequently used and having icon to text generation including type of pathology and location 

would be helpful and efficient. Examples include color coding of lesions, such as having hard exudates be 

yellow, veins be blue, and arteries be red.

4.B.25. Comparing images over time within the EHR

In Ophthalmology, comparing images previously taken compared to the current visit is centrally 

important in detecting clinical findings. Graphing images retrieved from integrated devices might be more 

likely to fail than drawn directly from the EHR data repository. Examples include OCT images, visual 

field data, corneal topography, and axial length measurement.

4.B.26. Orders including requiring unique data fields for the specialty area 
32

In Ophthalmology, there can be unique data fields for orders. For example, eye drop medications need to 

specify which eye (right eye, left eye, or both eyes) and the number of drops (which frequently differ for 

one eye as compared to the other in certain diseases such as uveitis). For uveitis, there is often a long 

tapering regimen over weeks of less frequent administration of eye drops per day.

4.B.27. Supporting sub-specialty-specific classification of patients based upon examination findings

In Ophthalmology, patients are often classified at the sub-specialty level based upon findings from eye 

examination. These classifications could be supported by targeted software classification based upon 

easy-to-enter examination findings. For example, there could be tabs for subspecialty care clinics; 

examples include Age-related Macular Degeneration (AMD), diabetic retina, glaucoma, etc. For example, 

a diabetic retina clinic could have a list of retinal features which can be checked off as the patient is 

examined, and the software generates a classification based upon the selected lesions. If only 

Microaneysms are selected, the classification is mild Nonproliferative Diabetic Retinopathy (NPDR). If 

hard exudates are selected as well, then the classification is maculopathy. When certain lesions are 

selected, then additional prompts appear to look for additional indicators, such as new vessels in diabetic 

retinopathy. In general, using targeted displays with fewer “clicks” required to enter structured data by 

minimizing navigation across screens and reducing dialog boxes would be useful for all providers in all 

specialty care areas. On the other hand, flexibility is needed to navigate to other templates or areas of the 

EHR when new findings are identified.

4.C. Discharge

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

flexibility for the workflow to better meet their needs during the period at the conclusion of the visit 

(discharge). Opportunities for providing support during a typical return visit via the EHR for cognitively 

challenging tasks suggested by the SMEs are detailed below.

4.C.1. Informing patients about whether medications need to be obtained immediately following 

the visit 

For some care situations, obtaining medications needs to be done immediately following the visit rather 

than the typical situation of within a day or two following the visit. Taking advantage of knowledge of the 

diagnosis and medication to highlight this need for patients would be useful. 

Supporting informing patients of this information, such as by integration into a printout received at the 

conclusion of the session, would be valuable.

4.C.2. Informing patients what to watch for and who to contact if particular events happen

After the visit, patients will occasionally need to contact a healthcare provider in the event that something 

unexpected or undesirable occurs. An example is explaining the symptoms of retinal detachment for 

patients with posterior vitreous detachment. Supporting informing patients of this information, such as by 

integration into a printout received at the conclusion of the session, would be valuable.

4.C.3. Optional redaction of particularly sensitive patient information from after-visit summaries

In all care settings, patient information has the potential to be highly sensitive, including mental health 

diagnoses, infectious diseases, obesity or drug use, genetic information, and information which could 

impact a professional or personal reputation. Given that providing this summary is a requirement for 

Medicare reimbursement, having an option to print a redacted After Visit Summary at the completion of 

the visit would be helpful. A related issue is that patients may not wish to give personally identifiable 

information associated with their patient data. It would be extremely useful for the EHR to permit 

anonymization of patient data per patient’s wishes.
33

4.C.4. Supporting optimizing patient compliance

Patients may need to be on a certain medication regimen or have certain procedures or tests performed. 

There should be queue management including automated contacting of the patient when there is no 

evidence that medications have been filled or tests have been performed. If critical care steps haven’t 

occurred, as evidenced by lack of receipt of evidence from the pharmacy that a medication for a particular 

patient was dispensed or from imaging centers that a particular imaging test hasn’t been performed, the 

lack of compliance can be escalated as warranted to automatically contact the patient and subsequently 

involve support staff or provider. The queue should be alterable to not overwhelm the user with queue 

fatigue and should be alterable to specific patient’s needs, reliability of receipt of external data, and 

provider workflow.

D. Documentation

Documentation of a visit is not conducted in any particular step in the workflow. Some specialists begin 

documentation prior to the visit and make all orders and complete all documentation while with the 

patient. Some complete documentation in-between patients or during breaks. Some complete

documentation the night after a visit was completed. Documentation elements include:

 Relevant history, physical, assessment, plan;

 Detailed descriptions to 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.

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

flexibility for the workflow to better meet their needs. Additional opportunities were identified for useful 

features, including 1) automatic generation of clinic letters, 2) the capability to produce audits on patient 

outcomes or a summary of procedures and complications, and 3) retrospective analysis of patient data for 

research purposes (e.g., complications for patients getting cataract surgery). Opportunities for providing 

support during a typical return visit via the EHR for cognitively challenging tasks suggested by the SMEs 

are detailed below.

4.D.1. Correcting auto-generated information which is inaccurate

All of the healthcare providers had experiences with inaccurate information which was auto-generated 

from devices or software packages for a variety of reasons. Unsurprising sources of inaccuracies included 

sensor failures, missing data, and “wrong patient” data. Some of the sources of inaccuracies were 

unexpected, including poorly designed data tables where deleted records resulted in diagnoses/problems 

migrating from the deleted patient to the next patient in the data table, additions and customizations to 

data tables lost during software upgrade installations, inaccurate demographic data entered by clerks, data 

from test patients included in reports (e.g., address as 321 Blastoff Avenue), when software upgrades 

return previously addressed “bugs” such as incorrect placement of the right and left eye or cause data loss 

when permissions are incorrectly set for roles, dates defined as when data were entered rather than when 

an eye examination was conducted, lost data when using auto-build documentation features such as 

structured text and smart phrases, unusual uses of dropdown options for purposes other than intended by 

system designers (e.g., “Source radio/TV” as an option for a referring physician to track where patients 

had heard about the clinic), and interface interactions unexpectedly deleting data (e.g., double-clicking 

deletes image data without warning or the ability to recover). Not having the ability to correct inaccurate 

information is potentially dangerous when providing care. Workarounds such as creating an addendum to 

a note stating that a patient has an inaccurate diagnosis listed are likely not effective, and certainly are 

suboptimal. The auto-generated notes can sometimes only be viewed when a legal discovery request 

occurs sometimes providing surprising auto-generated information that is incorrect. Viewing all entered 
34

and auto-generated data associated with a patient visit should occur prior to having the data enter the 

medical record.

4.D.2. Drafting documentation and encounter forms which are tailored to diagnostic information

In Ophthalmology, there are predictable patterns of care which can form the basis for draft encounter 

forms and other documentation facilitation. In addition, there are indicators that could be taken advantage 

of relating to the certainty that plans will go as expected. For example, annual eye screenings follow a 

predictable routine unless there are chronic problems such as, glaucoma, or diabetes, or past abnormal 

findings from eye examinations. There will also be the need to document in a different template because 

of new findings.

4.D.3. Reducing logins and sign-offs for multiple software packages and devices used to 

accomplish related functions

In specialty care, niche software and devices are frequently employed that are not used or available in 

inclusive EHRs. Having support for a single login process, reducing challenge questions and other 

keystrokes during logins, and reducing additional logins following automatic sign-offs would be 

beneficial. There are some unique elements to these needs for these areas in Ophthalmology, including 

signing into a different workstation required locating and signing off of another workstation with an 

active login. Being routinely required to sign off when leaving a patient room is undesirable and 

inefficient. Also, imaging software repositories ideally should be opened within one EMR to avoid errors 

or time inefficiencies associated with having to locate the correct patient within the associated 

applications. Ophthalmology providers in certain settings also describe the need to login and locate a 

specific patient in several separate applications simultaneously including laboratory, radiologic imaging, 

ocular imaging, outpatient scheduling, and surgical scheduling. In order to accomplish this goal, HIPAA 

privacy and security rules need to be followed in order to protect Personal Health Information (PHI) data 

and mitigate the risks of identity theft.

4.D.4. Annotating documentation by patients and caregivers in a progress note

More patients are expected in the future to take advantage of the so-called ‘blue button’ opportunity to 

view their progress note documentation. The demand will likely increase to correct misinformation or 

otherwise annotate the note. Because the patient is not a healthcare professional at the organization, it is 

likely inappropriate to use the workflow for corrections to the health record from professionals. 

Therefore, this information should be displayed in a different fashion, such as a “comment” in a margin or 

upon roll-over of the relevant information along with information about who entered the comment and 

when. One provider stated that having physicians engage in discussions about aspects of the chart, 

including requests from patients to explain portions of a note to them, would be an undesirable outcome 

due to the additional workload burden. Therefore, the design would likely need to restrict “back and 

forth” communications between physicians and patients about annotations and progress note information.

4.D.5. Having additional protections on personal health information

Although current examples of issues with personal health information being disseminated beyond the 

wishes of patients and caregivers were not commonly observed, several of the providers expressed 

concerns about the potential for this to occur and described individual anecdotes as “proof of concept” 

that issues could arise. Data repositories are being generated with access being provided to non-traditional 

users, such as schools in order to verify immunizations. In general, it is anticipated that a subset of 

patients will feel strongly about the desire to protect a particular data element from use in population 

health research or other population-based initiatives (e.g., marketing studies). Providing electronic 

support for “opting in or out” along the lines of organ donor programs would be an interesting area for 

consideration in the next generation of EHRs. Possible areas might include “Do Not Resuscitate” advance 

directives or not allowing blood transfusions for religious reasons (e.g., Jehovah’s witness patients).
35

Accomplishing this objective will likely require negotiations between stakeholder groups with differing, 

and potentially conflicting, perspectives in this relatively uncharted territory.

4.D.6. Advanced features for image management, including extraction of quantitative data and 

images without being dependent on interfaces with other applications

Advanced features and technological innovations in working with images would be beneficial for 

Ophthalmology. In particular, extracting quantitative data from images would be useful. There are third 

party niche applications providing support in this area, but the interfaces can be expensive or unreliable 

for integration.
36

5 Targeted Recommendations for EHR Developers for 

Improving Workflow in Obstetrics and Gynecology and 

Ophthalmology

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 specialty care outpatient centers for Obstetrics 

and Gynecology and for Ophthalmology. In specialty care areas where there are specialized support staff 

for clinical purposes, there can be fewer ancillary support that facilitate meeting documentation, billing, 

and legal requirement. Therefore, there is an opportunity for the EHR to optimize the provider’s goal of 

having the patient receive the needed care by helping the provider meet efficiently and accurately

complex documentation, insurance, and regulatory requirements. Finally, a distinguishing feature of 

specialty care areas is the diverse set of niche devices and software packages which need to integrate with 

the EHR for optimal workflow and to reduce the cognitive load for a physician wanting a summary “gist” 

of a patient immediately prior to a patient encounter. Therefore, the EHR needs to integrate and group 

data from diverse sources and in diverse formats. Following are targeted recommendations which distill 

the lessons learned from the insights detailed in Section 2.

For EHR developers interested in increasing EHR adoption in outpatient clinics primarily providing 

obstetrical care, we recommend the following to improve EHR-related workflow during the patient visit:

 Displaying summary information for an individual patient in the format recommended by the 

American College of Obstetrics and Gynecology-, which matches how specialist physicians were 

trained to recognize patterns for ante-partum care

 Supporting integrating information from specialized devices, software, data repositories

 Supporting graphing of viewing formatted data (tables) over time to identify patterns and trends 

including extracting data from devices

 Providing a draft order set to modify during the visit which is tailored to diagnostic information

and number of weeks pregnant

 Supporting optional redaction of particularly sensitive patient information from after-visit 

summaries

 Reducing logins and sign-offs for multiple software packages and devices used to accomplish

related functions

For EHR developers interested in increasing EHR adoption in outpatient clinics primarily providing 

Gynecology care, we recommend the following to improve EHR-related workflow during the patient 

visit:

 Distinguishing between patients with a very high likelihood of getting a particular treatment from 

patients who are less likely to get the treatment

 Alerting with the information about patients that informs how to conduct a patient visit

 Providing a draft order that can be modified during the visit which is tailored to diagnostic and 

demographic information

 Supporting hands-free interaction with the EHR during procedures

 Supporting optional redaction of particularly sensitive patient information from after-visit 

summaries

For EHR developers interested in increasing EHR adoption in outpatient clinics providing ophthalmology

care, we recommend supporting the following to improve EHR-related workflow during the patient visit:

 Orders for the specialty area, including requiring unique data fields 

 Verifying that insurance requirements are met during the scheduling process 
37

 Flexible real-time assignments of different staff to tasks across multiple patients simultaneously

Cosigning of ancillary support notes and findings

 Integrating information from specialized devices, software, data repositories

 Grouping conceptually related items with different formats (e.g., CIF, image, scanned image, fax, 

PDF, searchable text, structured data), particularly redundant data

 Annotations by patients and caregivers to documentation in a progress note

 Advanced features for image management, including extraction of quantitative data and images 

without being dependent on interfaces with other applications

 Additional protections on personal health information

 Distinguishing between patients with a very high likelihood of getting a particular treatment from 

patients who are less likely to get the treatment

For two specialty care areas, we identified similar “pain points” which could be considered in efforts 

targeted at other specialty care areas with unique requirements. These issues span many areas in the 

design and implementation of EHRs, including:

 Adding data fields required for specialty care areas, such as the number of drops and which eye 

for application for medications

 Following labeling conventions for specialty care areas, such as the definition of right and left 

eyes and standardized color coding for types of eye lesions

 Reducing navigation steps to access and update the relatively small subset of historical 

information, medications, and laboratory and procedure results needed for the specialist; this 

includes having quick access to a tailored summary, the tasks to be performed during the visits 

for testing and treatments, and what sign-offs are required for actions such as labs; not having to 

use multiple software packages with overlapping functionality in order to view diagnostic testing 

results would also reduce navigation costs

 Supporting patient scheduling to meet target windows for optimal care, identify patients who can 

be safely deferred, accommodate predictable needs for additional time, identify patients who have 

not yet scheduled critical visits, and incorporate constraints from insurance requirements for 

reimbursable tests in a particular visit

 Reducing the relative benefits of using workarounds compared to the intended design use of 

features which negatively impact the usability of the interface and accuracy of documented 

information; specifically, anticipating actions to make them done more efficiently during the visit 

to increase the ability to communicate with empathetic eye contact with the patient and reducing 

the time to document progress notes and adding information to displays and templates which are 

displayed in problem lists (but are not problems)

 Supporting voice activation for documentation during “hands-on” examinations with patients 

while holding specialized equipment, particularly when reduced physical interactions with 

keyboards and screens to reduce infection is important

 Integrating information from devices unique to the specialty care areas; of particular interest is 

increasing the efficiency of logins and signoffs, maintaining the quality of large imaging and 

video files when accessed via the EHR, and supporting documentation of the review of data from 

devices without requiring redundant or “out of sequence” documentation

 Integrating information from pharmacies directly into the EHR

 Supporting communications with patients, including reminders and suggestions for correcting or 

augmenting documented information; balancing additional burdens on the physician and 

providing access and the ability to correct and comment on information is important; for After 

Visit Summaries, allowing patients to redact sensitive data would be beneficial, particularly for 

Obstetrics care
38

 Considering opportunities for use of the EHR data across patient cohorts for research and quality 

improvement initiatives and for avoiding undesirable uses of the data such as for marketing 

purposes.

Overall, our recommendations provide a first step in applying a traditional human factors modeling 

technique to two diverse specialty care areas in order to suggest directions to pursue to further advance 

the widespread implementation of EHRs which are tailored to local specialty care needs. Our findings 

suggest that, even within these two areas, there is high variability within the specialty area based upon the 

type of patient condition, patient demographic variables, the health condition, the uniqueness of the 

treatment plan, the organizational support, the clinic staffing, and individual patient factors that influence 

the risk of missing appointments or failing to comply with treatment plans.

Some of the recommendations relate directly to improving patient safety as well as workflow. For 

example, patients are at risk of morbidity, and possibly mortality in some situations, if they do not receive 

treatments within evidence-based time intervals, such as providing integrated access to data from 

specialized devices in an efficient and usable manner, having orders include unique data fields for the 

specialty area such as drops in the right or left eye, and having visual representations of data match 

specialty-specific norms, such as having the right eye be defined from the perspective of the patient.

As electronic health records are conceptualized more uniquely in order to better fit the workflow patterns

of a particular niche, it will likely be more difficult to have an inflexible standardized approach to 

implementation, maintenance, and information sharing. Debates on the relative advantages and 

disadvantages of niche “best of breed” EHRs as compared to “one size fits all” EHR designs are not new. 

On the other hand, some of the opportunities identified for specialty care areas may be viewed as useful 

or meet a similar need in other areas where it has not been highlighted to be a priority need. In addition, it 

may be possible to have a standardized approach to the format, structure, and approaches to retrieving

data without having a standardized approach to workflow design and visualizations which support that 

workflow directly, and thus likely improve patient outcomes.
39

6 Conclusion

In response to workflow integration challenges with ambulatory physicians using EHRs, we have 

employed a standard human factors method in order to identify insights for EHR developers and 

ambulatory care providers in Obstetrics and Gynecology and in Ophthalmology. The method illustrated in 

this document is process maps 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. For two specialty care areas, we identified similar “pain points” which could be considered in 

efforts targeted at other specialty care areas with unique requirements, such as dental care, occupational 

therapy, and physical therapy. We have identified a wide variety of potential opportunities to improve 

workflow with EHRs from a physician perspective. In order to increase the ease of implementing our 

insights, we provide a set of targeted recommendations for EHR developers interested in better serving 

the unique needs of these users.
40

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