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(NISTIR 7988) Integrating Electronic Health Records into Clinical Workflow: An Application of Human Factors Modeling Methods to Ambulatory Care



Svetlana Z. Lowry, Mala Ramaiah, Emily S. Patterson, David Brick, Ayse P. Gurses, Ant Ozok, Debora Simmons, Michael C. Gibbons


This report recommendations provide a first step in moving from a billing-centered perspective (i.e., focusing on ensuring maximum and timely reimbursement) to a clinician-centered perspective where the EHR design supports clinical cognitive work, such as moving from an initial working diagnosis to a formal diagnosis for a complex patient. These recommendations point the way towards a 'patient visit management system,' which incorporates broader notions of supporting workload management, and supporting the flexible flow of patients and tasks. Adoption of Electronic Health Record (EHR) systems in hospitals and outpatient clinics is accelerating. EHRs can support and revolutionize the way information is stored, accessed, shared, and analyzed. At the same time, however, issues with workflow integration have contributed to slow rates of EHR adoption in some settings, including ambulatory outpatient care. In response to workflow integration challenges with EHRs, clinicians develop workarounds to complete clinical tasks in ways other than intended by EHR system designers. A common workaround includes copying and pasting text from previous progress notes. In this report, human factors methods were used to collect, visualize and document insights to improve EHR workflow for physicians through additional software functionalities and increased flexibility during implementation. Process map visualizations and a goal-means decomposition diagram were generated based on the insights generated during collegial discussions with physician Subject Matter Experts (SMEs) and interdisciplinary team meetings. Targeted recommendations for EHR developers and ambulatory care centers to improve workflow integration with EHRs are proposed. These recommendations cover scenarios such as supporting tasks accomplished over multiple interactions with an EHR by multiple people, such as a nurse practitioner drafting medication orders that are verified and completed by a physician
NIST Interagency/Internal Report (NISTIR) - 7988
Report Number


Electronic Health Record (EHR), User-Centered Design (UCD), Workflow, Workaround, Human Factors Workflow Modeling Tools, Process Map, Goal-Means Decomposition


Lowry, S. , Ramaiah, M. , Patterson, E. , Brick, D. , Gurses, A. , Ozok, A. , Simmons, D. and C., M. (2014), (NISTIR 7988) Integrating Electronic Health Records into Clinical Workflow: An Application of Human Factors Modeling Methods to Ambulatory Care, NIST Interagency/Internal Report (NISTIR), National Institute of Standards and Technology, Gaithersburg, MD, [online], (Accessed April 24, 2024)
Created March 11, 2014, Updated November 10, 2018