EHR difficulty? Solution may lie within work flow


In this article, Robert A. Dowling, MD, discusses practical aspects of a work flow analysis in your office, including its relationship with health information technology and some helpful resources and tools.

Robert A. Dowling, MD
Dr. Dowling

Urologists are accustomed to measuring “flow” in the office, but most of us have not applied the notion to measuring work flow. Effective work flow, as I will explain in this article, is important and beneficial to your practice for a number of reasons, yet it can be challenging. I will discuss practical aspects of a work flow analysis in your office, including its relationship with health information technology (IT) and some helpful resources and tools.

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Why is work flow important? According to a paper prepared for the Agency for Healthcare Research and Quality (AHRQ), “Health IT systems sometimes do not achieve their full potential due to a lack of integration of the health IT into clinical work flow in a way that supports the work flow among organizations (eg, between a clinic and community pharmacy), within a clinic, and within a visit. For health IT to be effective, it needs to be integrated into the multiple levels of work flow that exist in ambulatory health care delivery.” (

For example, you may be struggling with adoption of your EHR because your work flow does not align with that of the EHR system design. Perhaps your practice management system cannot accommodate information from your superbill. In some cases, the design of the HIT system may be suboptimal.

In many cases, though, your existing work flow may need examination and/or reengineering. In addition, many work flows in the office may be separate from IT systems altogether.

Defining work flow

What is work flow? According to the AHRQ, work flow is defined as “the sequence of physical and mental tasks performed by various people within and between work environments. It can occur at several levels (one person, between people, across organizations) and can occur sequentially or simultaneously. For example, the work flow of ordering a medication includes communication between the provider and the patient, the provider’s thought process, the physical action by the provider of writing a paper prescription or entering an electronic prescription into an electronic health record and transmitting the order electronically or having the patient take the prescription to the pharmacy to have the prescription filled.” ( The concept has its origin in Scientific Management Theory, or Taylorism, and had early application in auto manufacturing, according to Wikipedia (

Today, it is a mature science applied to many disciplines, including health care. Common work flows in a urology office might include “new prescription,” “phone messages,” “patient intake,” “new patient registration,” “equipment reprocessing,” “room turnover,” “benefits verification,” and more. A work flow is a process made of parts, and work flow analysis is an examination of the sequence of those smaller parts. It could involve patients, employees, objects, tasks, or any combination of these parts.


Next: Motivations for analyzing work flow in the urology practice


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Why might you need to perform a work flow analysis? The Institute of Medicine and others have called for work flow analysis to improve health care efficiency, safety, and quality in our country ( Other motivations in a urology practice might include reducing costs, managing medicolegal risk, enhancing your reputation with your patients and referring physicians, and patient/employee/physician satisfaction. Perhaps you have long known you have legacy processes at work in your practice that were not ideal but never really knew how to go about trying to improve them. It can start with a simple assessment of what you are currently doing (observing, interviewing, surveying, measuring) to look for opportunities. The main context for performing a work flow analysis is as part of a planned work flow reengineering process.

Many online resources available

How do you start? An excellent resource and toolkit can be found on the AHRQ website at Assembled here are over 100 tools ranging from simple checklists and flow chart templates to comprehensive EHR evaluation tools. For example, a work flow assessment checklist is available that includes most of the patient care activities that occur in a physician’s office ( This could easily be adapted to your office and serve as a framework for other analyses.

Bottom line: If you haven’t yet adopted health information technology in your practice, consider using these tools before your implementation. If you are one of the many struggling to use your systems after implementation, a checkup of your work flows may be in order and may help realign people and standardize processes in your organization. In any case, thinking about work flows will help orient your practice to the complexity of health care today and offer a do-it-yourself approach to dealing with that complexity.UT

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