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Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran’s Health Administration



Svetlana Z. Lowry, Emily S. Patterson, Mala Ramaiah, Michael C. Gibbons, David Brick, Robert Calco, Greg Matton, Anne Miller, Ellen Makar, Jorge Ferrer


The National Institute of Standards and Technology (NIST) presented targeted recommendations from human factors workflow methods that could be used in ambulatory (outpatient) care settings to improve the fit of the Electronic Health Record (EHR) with workflow. We describe twelve of these recommendations for improving workflow before the physician encounter, during the physician encounter, at the end of the physician encounter, and during progress note documentation. Next, we describe how the recommendations were implemented in a software prototype, which was developed for a Veteran’s Health Administration VAi2 innovation project and interfaces with the VA’s electronic health record. The prototype implemented default preliminary order sets to support making medication ordering more efficient during the physician encounter; shared documentation sessions and medication lists with interdisciplinary team members to support transferring initiated tasks to another to complete; and exit summary narratives with business rules that defined the size of the summary in order to support having a one-page patient summary of the visit handed to the patient at the completion of the physician encounter. Our approach represents a fundamental paradigm shift in the way EHR support can be implemented to move from a billing-centered perspective to a more user-centered, and ultimately patient-centered, perspective.
Generating Evidence & Methods to improve patient outcomes


Lowry, S. , Patterson, E. , Ramaiah, M. , C., M. , Brick, D. , Calco, R. , Matton, G. , Miller, A. , Makar, E. and Ferrer, J. (2015), Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran’s Health Administration, Generating Evidence & Methods to improve patient outcomes, [online], (Accessed June 15, 2024)


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Created August 3, 2015, Updated November 10, 2018