Clinical Workflow Design for Health Information Systems

Chapter 10 of 11

Workflow design helps to analyze how organization works and implement new measures to increase productivity. Workflow design in the health sector is increasingly becoming recognized as a vital component to the successful integration of Electronic Health Record (EHR) technology in ambulatory care. The patterns of action clinicians apply to perform tasks and produce results describes clinical workflow.


Clinical workflow is the flow of work through time and space encompassing all activities, environments, technologies, people and organizations engaged in promoting and providing healthcare. Clinical workflow asks how processes are performed within a healthcare establishment, including both administrative and clinical work.

Workflow 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:


  • 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 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 problems during and after the implementation because of the sudden shift in operational activities. The change in the workflow also caused a significant disruption in patient care, communication and billing. Organizations must pay extra attention to new workflow when implementing health IT to minimize the effect of the change on patients, staff, and finances.

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 expert can also identify any inefficiency that need to be modified in the organization’s current workflow to implement health IT.

Better Prepare and Train the Staff

Adopting health IT will change the way workflow functions in clinical practice and organization management. Preparing and training the staff ahead of the implementation will help them adjust to the possible changes in the clinical workflow.

Plan Ahead

People may see health IT implementation as a simple change, it is actually very complex and challenging. To make good decisions, healthcare administrators must identify how the workflows will change because of the health IT implementation.


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. They 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, most hospital workers often use it interchangeably with clinical protocols and guidelines.

Criticisms of care pathways arose from the 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 EHR by using the clinical workflow design. However, there are growing concerns about 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.

In 1999, the Institute of Medicine revealed the patient information safety vulnerabilities of the US healthcare system. It recommended the need for widespread adoption of EHRs to improve healthcare quality. These include improvement in adherence to clinical care guidelines, 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.


Incorporating clinical workflow design in Health Information Systems has three major components:

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 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.

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.


Benchmarking Tools

Benchmarking is the process of evaluating best practices and other metrics used in other organizations and applying them to one’s organization. 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 and the degree of potential for such advancement.

There are four types of benchmarking in healthcare: internal, competitive, functional, and generic. Internal benchmarking functions within an organization and involves offices, departments, or divisions, within the same health facility. Competitive benchmarking is concerned with how partners do business in the same market and provide a direct comparison of products or services. Functional and generic benchmarking are performed at organizations which may have a specific similar function such as payroll or purchasing.

Ideally, benchmarking is a team process as the outcome has to do with changing current practices, with effects felt throughout the organization. The benchmarking team should have members with subject knowledge such as communications and computer skill, facilitation, and sponsorship of senior management. Benchmarking metrics can be categorized in four categories: productivity, quality, time, and cost.

Checklist Tools

A checklist is simply a form that many health information managers use to record data quickly and easily as well as identify the actions and requirements needed by the organization. Most 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.

High reliability organizations (HROs) that carry out hazardous and complex operations, such as aviation and aerospace industry, firefighting, military operations, nuclear power production, and engineering, use checklists as cognitive aids. These organizations have many years of experience with checklist development and implementation.

Flowchart Tools

Flowcharts are used to demonstrate the steps within a given process visually. 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 and are used to evidently display the flow of people, services and information in a hospital or any health facility. It can show the flow of services in a hospital, from the admission to discharge.

Flowcharts also list the service type that each division in the hospital must deliver for total satisfaction of patients. It shows the flow of services from one unit to the other, strongly indicating all processes to be carried out to achieve a common goal.

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.

Usability Evaluation Tools

Usability evaluation tools are used to determine the extent of user-friendliness of Health Information Systems. They compare systems prior to procurement, identify necessary improvements needed for a current system, obtain user feedback, and other design suggestions.


Usability evaluation is centered on how well users can learn about a product and as well use it to their betterment and emphasizes how satisfied users are with the overall process, learning about a product and using it. In Health Information Systems, usability is concerned with how useful the system is for users, taking into consideration the complexity or ease of getting acquainted with the system and how it benefits users.

Practitioners use several methods to obtain feedback from users about an existing Health Information System or plans related to a new Health Information System.


To help you to further understand usability evaluations, usability has to do with the quality of a user’s experience when interacting with products or systems, including websites, software, devices, or applications. Usability is directly concerned with the quality of users’ experience when interacting with Health Information Systems. It is a vital component of workflow design for Health Information Systems and captures effectiveness, efficiency and the overall satisfaction of the user. Usability comprises factors such as:

  • Intuitive design
  • Efficiency of use
  • Memorability
  • Error frequency and severity
  • Ease of learning
  • Subjective satisfaction
  • Usability and User-Centered Design

Usability is a key factor in designing a clinical workflow of Health Information Systems. The process of usability reveals relevant information about users’ experience when dealing with Health Information Systems; this helps determine the appropriate measures of the workflow. The key to developing a highly usable Health Information System is hinged on using UCD.

The UCD focuses on creating a system based on users’ needs. The process outlines all the phases in the design and development of a system with a focus on acquiring superb knowledge of who will use the system. Many UCD methodologies use the international standard but the UCD process does not state the specific methods for each phase.


Userfocus, an independent consultancy that specializes in usability training and usability consultancy, stated that there are many principles behind UCD. Design is centered on in-depth knowledge of users, tasks, and environments. This is driven and refined by user-centered evaluation and addresses the whole user experience. Users are involved throughout the iterative design and development process. The UCD process includes:

  • Specifying the context of use: Involves the identification of the people who will make use of the system, what it will be used for, and under what conditions.
  • Specifying the requirements: Identifies business requirements or user goals that should be met for the system to be successful.
  • Producing the design solutions: Can be conducted at different stages; from building from a rough concept to a complete design.
  • Evaluating designs: Involves usability testing with the users of the system. Useful in obtaining information about users’ experience to help the new development make necessary improvement.

The UCD process has several variations and you can select a method to use based on your needs.


User Experience (UX) is about having an in-depth understanding of users, what they need, what they value, their abilities as well as their limitations. Moreover, UX considers the business goals and objectives of the project managing group.


Health IT Usability and UX is primarily concerned with how advances in the design and use of health IT systems can reduce EHR usability-related problems for clinicians. Implementing usability test results requires the collaboration of various stakeholders in the health sector. This includes Department of Health and Human Services (HHS) and other institutional stakeholders who can help to develop and disseminate best practices.

Enhancing the usability of health IT system is a major point for reducing clinical problems, through better alignment of the EHR with optimum workflow care delivery, clinical decision-making and other tasks. Health IT developers should diligently work with their clients and support users’ flexibility to ensure that products meet their satisfaction. They also need to be mindful of their duty to help users know when their decisions make health IT less effective or stray from established clinical rules. Since today’s Clinical Decision Support (CDS) tools tend to be difficult to use and can result in clinician exhaustion, adopting a vigorous framework for effective CDS, as the National Academy of Medicine recently outlined, might be impactful. Other health providers go through the similar challenges with their health IT systems. Clinicians, developers, and other stakeholders can work together to promote best practices that reduce the problems associated with these tasks in some areas. EHR developers can improve the way information is presented and displayed in order to minimize information overload.

Improvements of the user interface can enhance health IT system usability, efficiency, user experience, and end-user satisfaction in several ways. Health IT developers need to implement methods for basic clinical operations across EHRs and this will prevent clinicians from using different interface each time they switch between systems.

The health sector should consider options for development and adoption of healthcare-specific GUI design components. Components like flow sheet list generation as well as navigation components fit to the busy clinical environment that can support the clinician’s cognitive process and the clinical workflow. An improved design of the physical environment can help lessen EHR-related burden by making it effortless for clinicians to interact with health IT systems in ways that align with current workflows.

Although a lot has been put in place over the years to standardize the clinical content contained in health IT, discrepancies in major areas have continued to result in frustration and burden for clinicians. The major priorities for coordination across EHR systems are hinged on:

  • Standardization of medication information across EHR systems such as the consistent use of generic drug names and presenting medication instructions (dose and frequency)
  • Standardization of order entry content, so that order names, care activities, and order set components are presented consistently
  • Developing conventions for the display of results

Promoting better implementation decisions in the deployment of health IT systems to improve clinicians’ efficiency and satisfaction and lessen the burden, is a step in the right direction. Additionally, health IT developers and institutions that manage system deployment can enhance end-user engagement and training. This is to ensure that the product procured by an organization will meet the needs of its end-users and their desired workflows.

Developing technologies such as facial recognition tools can be explored deeply. Transparent and thoughtful planning around budgeting for health IT investments can ensure adequate resource availability for training and constant support. Comprehensive stakeholder strategies to improve interoperability will have great impact on usability and burden reduction.


Best practices for creating a clinical workflow design for a Health Information Systems outline six basic steps:

Step 1: Determine What Processes Need Assessment

Before creating a Health Information System, it is important to determine which processes 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 identifies where the process starts and ends.

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 for carrying out the step
  • The kind of supervision required for the step
  • The environmental factors that might affect the step
  • Other people who might influence the execution of the step
  • Additional 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.

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
  • 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. Use the notes gathered from the interviews and observation to update and modify the steps and processes listed in the initial flowchart.

Step 6: Usability Evaluation

Carrying out a usability evaluation helps to better understand how users can best interact and use the system. It reveals the satisfaction users get from the system and thus helps in creating an effective workflow design that meet users’ requirements.


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

The widespread adoption of EHR technology across all settings of the healthcare sector is likely to occur soon. All clinicians will use EHR systems as their central tool for their practice. 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. 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.


  1. Agency for Healthcare Research and Quality (AHRQ)(n.d.1). Workflow assessment for health IT toolkit. Retrieved from
  2. Ibid.
  3. Ibid.
  4. Ibid.
  5. Ibid.
  6. Gooch, P., & Roudsari, A. (2011). Computerization of workflows, guidelines, and care pathways: a review of implementation challenges for process-oriented health information systems. Journal of the American Medical Informatics Association: JAMIA, 18(6), 738–748. Retrieved from
  7. Ibid.
  8. 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. In: Henriksen. K., Battles, J.B., Keyes, M.A., et al., editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 4: Technology and Medication Safety). Rockville, MD: Agency for Healthcare Research and Quality (US); Retrieved from:
  9. Gooch, P. (2011). Modelling workflow processes for clinical information systems: Impact on decision support and healthcare outcomes. Retrieved from
  10. AHRQ (n.d.3). All Workflow Tools. Retrieved September 17, 2015, from
  11. Ibid.
  12. Ibid.
  13. Ibid.
  14. Ibid.
  15. Workflow Management Coalition (1996). Table of Contents. Retrieved from
  16. Op. Cit. AHRQ (n.d.1)
  17. 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.