Ramaiah M, Subrahmanian E, Sriram RD, et al. "Workflow and electronic health records in small medical practices."

Ramaiah M, Subrahmanian E, Sriram RD, et al. Workflow and electronic health records in small medical practices. Perspect Health Inf Manag 2012;9:1d.
This paper analyzes the workflow and implementation of electronic health record (EHR) systems across different functions in small physician offices. We characterize the differences in the offices based on the levels of computerization in terms of workflow, sources of time delay, and barriers to using EHR systems to support the entire workflow. The study was based on a combination of questionnaires, interviews, in situ observations, and data collection efforts. This study was not intended to be a full-scale time-and-motion study with precise measurements but was intended to provide an overview of the potential sources of delays while performing office tasks. The study follows an interpretive model of case studies rather than a large-sample statistical survey of practices. To identify time-consuming tasks, workflow maps were created based on the aggregated data from the offices. The results from the study show that specialty physicians are more favorable toward adopting EHR systems than primary care physicians are. The barriers to adoption of EHR systems by primary care physicians can be attributed to the complex workflows that exist in primary care physician offices, leading to nonstandardized workflow structures and practices. Also, primary care physicians would benefit more from EHR systems if the systems could interact with external entities.

To develop a deeper insight into understanding the workflow, the operational mode used in completing a task, the effect of context (primary care vs. specialty offices), and the interactions with external entities that are part of the workflow.

Tools Used
Type Clinic
Primary care and specialty care
Small and/or medium
Other Information
The study was done at 13 small-practice physician offices in the Baltimore and New York areas.
Type of Health IT
Electronic health records (EHR)
Type of Health IT Functions
Primary care offices did not have EHRs. Specialty care offices have varying degrees of EHRs implemented. All specialty care offices had scheduling software with varying degrees of automation of tasks (e.g., recording vitals, history, documenting the consultation, issuing certificates, and requesting labs). In all specialty offices, the appointment scheduling and registration tasks were computerized. The other task that was mostly computerized is billing.
Context or other IT in place
It must be noted that some of the offices have not yet implemented EHRs at all, some have implemented EHRs only to carry out certain tasks, and some have completely implemented EHRs efficiently.
Workflow-Related Findings
Variations between primary care and specialty care offices in terms of workflow: primary care offices encounter higher patient variety with not a lot of in-house services for sample collection, x-rays and other services. Variations in tasks and task flow in specialty offices tend to be low compare to that found in primary care offices due to the prescreening by the primary care physician and the more standardized set of transactions.
Delay and time consumption is mostly due to lack of adequate computer-based interfaces with external entities. Additionally, the external entities may not have a proper information infrastructure themselves resulting in the need to use telephones, faxes and other manual means of getting information. Patient scheduling and follow-up of appointments, gathering prior patient histories, handling referrals, and conducting other external interactions that take place through faxes, mail, and sometimes email. These interactions necessitate the use of paper-based systems augmenting the EHR system, even when an EHR system is in use.
Study Design
Only postintervention (no control group)
Study Participants
13 small practice physician offices - 4 primary care, 9 - specialty providers consented to participate in this study.