Clinical Workflow Design for Health Information Systems

Chapter 9 of 11



Clinical workflow is the flow of work through time and space encompassing all activities, environments, technologies, people and organizations engaged in promoting and providing health care. It aims to answer the questions who, what, when, where and how things are performed within a healthcare establishment, including both administrative and clinical work.

Workflow is not exactly a sequence of steps. Instead, it is a sequence of mental and physical tasks performed by various people within and between clinical environments. The clinical workflow can occur at different and multiple levels that work simultaneously or sequentially to achieve a common goal.

There are four types of clinical workflow designs [1]:


  • The workflow between a primary care physician and an emergency department physician in sharing patient health information
  • The workflow between a community pharmacy and a primary care physician


  • the workflow between a doctor, nurse or patient
  • The workflow of healthcare information in electronic or paper formats among people at a clinical practice


  • The workflow performed during a patient visit


  • The workflow within the mind

Clinical workflow is simple yet complex. What seems like an uncomplicated “physician’s order” involves complex mental and physical steps that are being carried out by several people who are working in harmony in different locations within a healthcare organization.


Avoid pain and suffering

Most clinics that adopted health IT found that they did not anticipate the change in the clinical and administrative workflows that might occur due to health IT implementation. These unanticipated changes caused pain among many healthcare staff during and after the implementation because of the sudden change in the way things had to be done. The change in the workflow brought about by the implementation of health IT also caused a significant disruption in patient care, communication and billing within the healthcare institution. Organizations must pay extra attention to the new workflow when implementing health IT in order to minimize the effect of change on patients, staff and finances [2].

Assist in vendor selection

Before choosing a vendor, the health information management expert should study the organization’s current workflow to identify the most efficient and productive workflows that the organization should keep.  The health information management expert can also identify any inefficiencies that need to be modified in the organization’s current workflow in order to implement health IT [2].  

To better prepare and train the staff

Adopting the health IT will change the way workflow functions in the clinical practice and organization management. These changes may affect many staff and other workers. Preparing and training the staff ahead of the implementation will help them adjust to the possible changes in clinical workflow [2].

To plan ahead

Although many people think that the health IT implementation is a simple change, it is actually very complex and challenging. To make good decisions, healthcare administrators must identify how the workflows will change as a result of the health IT implementation [2].  


Care pathways (the predecessor of the clinical workflow design) are structured multidisciplinary care plans that elaborate the important steps in patient care by identifying specific clinical problems and offering structured means to develop and implement local protocols based on clinical guidelines.

Care pathways were first introduced to the nursing practice in the 1980s to improve the clinical practice and the quality of patient care. Despite its long history, the concept of care pathways remains unclear. In fact, most hospital workers often use it interchangeably with clinical protocols and guidelines [3].

Criticisms of care pathways arose from the various limitations that are brought about by the paper-based care pathway documents. Many nurses found it difficult to tailor the paper-based pathway documents to the needs of different patients. With the advent of computerization, many experts believed that the healthcare organization could overcome the care pathways’ limitations by allowing the integration of the guideline-based decision support and the electronic health record by using the clinical workflow design. However, there are growing concerns of the clinical guideline research communities. Examples of such growing concerns include the lack of consistent standards, the existence of different models and the duplication of effort. These concerns contributed to the diminishing confidence of healthcare organizations in the care pathways [3].

In 1999, the Institute of Medicine revealed the patient information safety vulnerabilities of the United States’ health care system and recommended the need for widespread adoption of electronic health records to improve health care quality [4].

Electronic health record use is yet to be widely implemented in the United States. However, the available data regarding its impact on clinical practices are still conflicted. Nevertheless, experts believe using clinical-decision-support-embedded electronic health records poses several benefits: Adherence to clinical care guidelines can improve, overall clinical documentation legibility and completeness can be achieved and the length of patients’ in-hospital stay can become shorter compared to the expected outcome using traditional paper-based medical records [4].


Incorporating clinical workflow design in health information systems has three major components, namely [5]:

Process definition

Process definition is the representation of a business process that supports automated enactment or manipulation by a system that manages workflow. It consists of a network of activities, the information about the individual activities and the criteria that indicate the start and the end of the process associated with health information technology applications and data. Process definition may contain both manual and automated workflow activities and references to sub-processes.

Process Instance

Process instance is the representation of a single enactment of a process. The workflow management system creates, manages and terminates the process instance. Every process instance signifies one enactment of the process that uses its own data, represents a unit of work that passes through a workflow management system and exhibits its internal state by representing its own progress towards completion with respect to its own constituent activities.


A worklist is a list of work items used by a given workflow participant. It forms part of the interface working between a worklist handler, the process (often through a query mechanism) that requests work items from a workflow engine to create a list and a workflow engine. Some workflow management systems require the placement of the work items into the worklist for the subsequent accessing, processing and implementing by the worklist handler.

Tools and Techniques

Benchmarking tools

Benchmarking is the process of evaluating best practices and other metrics used in other organizations and applying them to one’s own organization. The tools that are used to implement benchmarking are called benchmarking tools. Health information professionals use benchmarking tools to find more options for a potential solution and bring in new ideas from other organizations. Benchmarking tools also determine specific areas of improvement within the organization and the degree of potential for such improvement [7].

Checklist tools

A checklist is simply a form that many health information managers use to quickly and easily record data as well as identify the actions and requirements needed by the organization. Most health information managers and other health IT professionals find that using a checklist helps to extract data in a useful manner and effectively register occurrences of events, tasks, incidents and problems within the organization’s health information system [7].

Flowchart tools

Flowcharts are used to visually demonstrate the steps within a given process. Most health IT professionals use flowchart tools to find one or more sources of problems within a health information system and identify the potential areas that need improvement. Flowchart tools are also used to pinpoint the groups, personnel and departments responsible for a given process or task [7].

Interview tools

Interview tools are used when asking questions about sensitive issues. Health information experts use them to gain insight about the issues that are significant to the users of the system and to collect new ideas, feedback or suggestions needed to improve the health information system within an organization. At the beginning of the project, interview tools are important to determine the needs of the users; at the end of the project, these tools are needed to clarify findings [7].

Usability evaluation tools

Usability evaluation tools are used to determine the extent of user-friendliness of a health information system. They are used to compare systems prior to procurement, identify necessary improvements needed for a current system, obtain user feedback and other design suggestions during the design phase of a system and determine how the system affects workflow [7].

Best Practices

Best practices for creating a clinical workflow design for a health information system outline six basic steps [8]:

Step 1: Determine what processes need assessment

Before creating a health information system, it is important to determine which processes within the organization need assessment. Experts recommend building a core team that will be responsible for making decisions. The team should include a physician; patient care associate; administrative staff involved in coding, billing and payment; clinical manager and someone who has analyzed the organization’s workflow in the past.

Step 2: Create a preliminary flowchart

A flowchart is essential to determine the steps and activities involved in the process. It also identifies where the process starts and ends. After creating the flowchart, the health information manager can decide who else is needed to be involved in the analysis team.

Step 3: Add more details to the flowchart

With the help of the analysis team, add details to the high-level flowchart. For each of the process steps and decision points, identify:

  • The purpose of the step
  • The technology needed for the step
  • The person or group responsible to carry out the step
  • The kind of supervision needed for the step
  • The environmental factors that might affect the step
  • Other people who might influence the execution of the step
  • Other information needed to execute the step

Step 4: Determine the persons, groups or departments that need to be interviewed or observed

  • Decide who among the team will do the interview and observation
  • Identify all the individuals involved in each step or process
  • Observe and interview the medical record staff if the planned system involves the patient chart
  • Study the staff responsible for entering the insurance form, clinicians involved in coding, coders and billing staff if the planned system involves the payment process

Step 5: Do the observations and interviews

  • Use the flowchart as the “best guess” of core team
  • Determine the details needed for the interview and observation of the people involved in the process
  • Identify when the process may vary and under what circumstances each could vary
  • Record the details of what is happening
  • List the questions that are usually asked
  • Record the data that are entered and where they are entered
  • Know and list the role of the person who records the data

The health information expert should learn the details of the process he or she is studying, ask the people who contribute to the process and how they are affected by the process. He or she can then use the notes gathered from the interviews and observation to update and modify the steps and processes listed on the initial flowchart.


To successfully implement information technology in the health care setting, health IT managers and developers must examine how the organizational dynamics, such as change in management procedures and leadership, may affect the successful integration of electronic health record technology with the clinical workflow. They must analyze and rethink internal organizational elements that may greatly influence electronic health record implementation and success [9].

The widespread adoption of electronic health record technology across all settings of the health care sector is likely to occur in the near future. All clinicians will use EHR systems as their central tool for their practice. However, even with the existence of incentive programs, the road to EHR adoption remains slow, as IT experts together with clinicians continue to move toward the successful integration of EHR meaningful use into the clinical workflow design. By implementing the HITECH Act, clinicians’ work environment is slowly changing. The integration of health IT in the healthcare practice is inevitable. Clinicians, with the help of health IT experts, must overcome the issues and disruptions in their practice with a better clinical workflow and embrace the potential long-term benefits of using EHRs to improve the quality of their healthcare delivery [9].


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  4. Henriksen, K., Battles, J. B., Keyes, M. A., Grady, M. L., Campbell, E. M., Li, H., … & Guise, J. M. (2008). The impact of health information technology on work process and patient care in labor and delivery.
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  6. Table of Contents. (n.d.). Retrieved September 17, 2015, from
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  8. How do I evaluate workflow? (n.d.). Retrieved September 21, 2015, from
  9. Bowens, F. M., Frye, P. A., & Jones, W. A. (2010). Health Information Technology: Integration of Clinical Workflow into Meaningful Use of Electronic Health Records. Perspectives in Health Information Management / AHIMA, American Health Information Management Association, 7(Fall), 1d.