FEATURE: WORKFLOW Workflow Viewpoints Analysis of Nursing Workflow Documentation in the Electronic Health Record Luann Whittenburg, RN, FNP here is increasing concern about EHR sys- KEYWords tems streamlining the nursing process. Workflow, electronic health record, nursing, concept analysis. T The perception is that the EHR has a pro- Abstract pensity to overlook the data and contribution of nursing care to patient healthcare outcomes. This This article amplifies the emphasis on organizational workflow reignited by the Institute of Medicine reports concern originates from the clear absence of an on healthcare quality. The analysis of nursing workflow is objective method in electronic health record sys- central to understanding the power of technology to modify tems to collect structured, coded nursing data to the fundamental constructs of nursing practice. The aim analyze the benefit of the nursing process: assess- is to understand the evolution of nursing workflow and the concept of workflow from the management and computer ment, diagnosis, outcome identification, planning, science perspectives used in electronic health records and implementation and evaluation. computerized provider order entry. The understanding of An examination of nursing workflow may provide an under- the workflow models within health information disciplines standing of the nurses’ workflow and contributions. This article may improve the model of nursing workflow underlying the reports on the background of the conceptual development for the implementation of electronic health record systems. The concept of nursing workflow as nurses carry out patient care in an article follows the Walker and Avant evolutionary method of acute care setting using the EHR. 19 concept analysis. NURSING THEORY IN HEALTHCARE TECHNOLOGY Nursing informatics is a relatively young specialty2,8 with preced- ing research focused on problem-driven studies such as electronic health record implementations; the professional organization of nursing informatics as a nursing specialty; and nursing terminol- ogy in preference to research on concept development about nurs- ing workflow in relation to technology. www.himss.org VOLUME 24 / NUMBER 3 n SUMMER 2010 n JHIM 71 Early health information systems represented a workflow per- condition of a right foot pressure ulcer or observance of a patient’s spective different from the traditional nursing workflow. Today, or family member’s response to teaching. health information systems are compelling new nursing com- In general, informaticians accept that information, when given petencies and innovative nursing workflow strategies to accom- meaning through interpretation, becomes knowledge. Manage- modate the protean electronic health record systems installed in ment and computer science colleagues focusing on the impact of many healthcare facilities. computers in their disciplines have been preparing students for If the objective of nursing informatics is to improve nursing successful working relationships with computerized information practice through the use of technology, then nursing workflow systems for decades.18 Management views computers as support- must be established to guide the conditions for technology trans- ing the accomplishment of management objectives and supports formation and provide the appropriate constraints. While the the trends in information processing that encourage decentraliz- term “workflow” is a universal concept applicable to multiple ing data—for example, iPhone applications and social networking disciplines, this article used the Walker & Avant19 concept devel- by employees. opment framework to guide the review of the litera- ture and identify the antecedents and consequences of nursing workflow along with empirical referents Early health information systems represented a and opportunities for further research. workflow perspective different from the BACKGROUND traditional nursing workflow. Today, health From any environment, at a basic level, a workflow information systems are compelling new represents a sequence of activities. At a practical level, workflow allows the assessment of activity in nursing competencies and innovative nursing context and the review of a sequence of work; such as all the nurse’s activities related to patient care workflow strategies to accommodate the on a given day on a given unit. At a greater level of protean electronic health record systems abstraction, workflow is a pattern of processes for information processing. installed in many healthcare facilities. In the early 1920s, F.W. Taylor and H. Gantt were intellectual leaders and pioneers of concept of workflow, with Gibbons and Smith7 report management results derive from the the Gantt Chart established as the iconic standard for the visual “workflow of the team,” while computer science defines workflow representation of workflow processes. Others participated in the as the scheduling of independent jobs on a computer and the set development of concepts involving information workflows includ- of relationships between all the activities in a project, from start ing M. Dewey of the Dewey Decimal System.20 to finish.6 However, the classic 1956 book on workflow was The Organiza- In this discipline, the common refrain is that data is less than tion Man by William H. Whyte. The 1920s to 1960s were the peak information; information is less than knowledge; and information periods of workflow formulation. By the 1980s, the concept of processing should be isolated from workflow. As derived from workflow was being dismissed by Abraham Maslow, who devel- past experience, the statements accurately reflect the data condi- oped the Hierarchy of Needs theory and gained wide acceptance tions in today’s healthcare information systems. in nursing schools as the key theory of the conceptualization of However, the purpose of collecting data, information and human needs.3 knowledge is to be able to make wise decisions (e.g., create wis- In the 1990s, the emphasis on organizational workflow was dom), and if data sources are flawed; meaning that if data is col- reignited by the Institute of Medicine reports on healthcare qual- lected in isolation from workflow, then one might reason that ity: To Err is Human11; Crossing the Quality Chasm.12 This period, management decisions based on a classic computer science model 1980-1990, experienced the emergence of Total Quality Manage- and interpretation of the established standard information work- ment and Six Sigma, and witnessed the evolution of Business flows will be flawed. Process Reengineering. The bright spot in the emphasis on qual- The net effect of an “isolated” workflow model must be sur- ity was that workflow again became the focus of management and mised to have transformed the data collection processes in health- researcher surveillance. care—and nursing in particular. Nursing data collection is more than discrete facts stored in a relational database. Nurses reply TRADITIONAL NURSING WORKFLOW on the data for patient care planning. Nurses transform the data The historical perspective of nursing workflow is as a clinical within electronic health systems by judgment into meaningful sequence of work focused on patient status, nursing interventions information. While the information by itself does not infer knowl- performed and the patient’s response. edge the cognitive and analytical ability of the nurse places EHR In the traditional view of nursing workflow, the nurse would data and information, in the context of the nursing workflow; and perform activities to detect changes in the patient’s condition. demonstrates that information processing for patient care deliv- Another example of traditional nursing workflow would be the ery should not be isolated from workflow for the confident deliv- work to observe a patient’s condition; e.g., no change in size or ery of healthcare quality. 72 JHIM n SUMMER 2010 n VOLUME 24 / NUMBER 3 www.himss.org METHODOLOGY context of an activity in a workflow instance.10 As mentioned, the methodology used in this analysis is the Walk- Documentation. Nursing data collected as discrete facts, er and Avant concept analysis method.19 The general findings of stored in a relational database, processed, and transformed into the literature are that workflow articles were typically associated meaningful information.17 with specific problems such as patient safety, medication admin- Practitioner orders. Practitioner instructions, written or oral, istration, specific nursing units or specific departments such as for the treatment of a patient’s medical care. the emergency department. A review of the computer science literature through the Applied ANTECEDENTS AND CONSEQUENCES Science and Technology Abstracts database, which has abstracts The antecedents and consequential occurrences for the concept of and periodicals from 1983 to present in engineering, aeronautics, nursing workflow are: chemistry, computer technology and applications, earth sciences, Antecedent occurrences: Patient need. energy and environment, mathematics, metallurgy and physics, Consequential occurrences: Application of the American identified 805 articles using the term “workflow” primarily relat- Nurses Association (ANA) Nursing Process, actor self-efficacy ed to information messaging schemas. and care delivery. Clarification of the concept was accomplished by analyzing the common use of the concept through the way in which the concept ASSUMPTIONS was expressed.16 The literature included articles over a