Clinical Workflow Impediments

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While Electronic Health Record (EHR) systems in hospitals have been applauded for improving information transfer and for providing ready access to data to multiple providers, they have also been blamed for increased administrative tasks and for contributing to physician burnout.

But what has been their impact on the clinical workflow of healthcare professionals? Specifically, they wanted to know the primary impediments that were causing EHR systems to produce suboptimal workflows and mismatches.

To answer that question, researchers in the Netherlands studied the workflow habits of physician and nurses at one large university hospital and approached the topic from a lean management perspective. That is, they looked at those actions that added value and those elements that did not, with the goal of providing a detailed list of those actions that could be eliminated.

They took a qualitative approach to their study by making direct observations of the work activities of nine physicians and four nurses. Using a small audiovisual camera, they recorded 70 hours of involvement with the EHR.

What did they find?

They found 241 clinical worfklow impediments that they classified as “waste” and put all of them in 8 broad categories: transportation, inventory, motion, waiting, overproduction, overprocessing, defects, and skills and talent.


Transportation waste concerned unnecessary movement of information from one location to another. For example, researchers said the best example is users having to re-enter data between multiple incompatible computer systems and the EHR. As one nurse put it: It is of critical importance that we have access to a patient’s lab results from the first possible moment they were entered. The current EHR only contains lab results dating back to a maximum of five years. Maintaining multiple systems is therefore an unfortunate time-consuming necessity.


Inventory waste primarily concerns with information that still had to be entered by physicians into the EHR after conducting outpatient consultation sessions. As a result of physicians being unable to both treat their patients next to entering the required information into the EHR within the allotted time available per patient, significant backlogs accumulated over time.


Motion waste typically concerns any human movement that was unnecessary for the successful completion of the action. Examples include excessive toggling between tabs or scrolling up and down when looking for information, or having to click multiple times to accomplish a simple task when a simple click would have sufficed. This type of waste was identified most frequently by the researchers.


Waiting “waste” concerns doing nothing or working slowly while waiting for a previous step in the process to complete. Researchers said this could be waiting for data input from a colleague, slow application times, or the system unintendedly halting workflows due to design flaws.


Overproduction waste primarily manifested itself as physicians reluctantly preparing patient visits long before patients would arrive. As one physician put it: Because the EHR interface is so cluttered, I have to spend significant time looking and finding my way around. This has led to longer patient consultation sessions. My colleagues and I now tend to prepare consultations in the system in the evening before they come to see us.


Overprocessing waste concerns adding more value to a product than the customer actually requires. Examples include users entering more patient-related information than needed by fellow healthcare providers taking over patient care, or performing redundant checks enforced by the EHR. Both results in the additional time spent being wasted. For example, one physician told researchers: The predefined EHR template shown on my screen simply contains too many unnecessary data entry fields. Out of all 100 fields shown, only a couple are probably relevant to me. For instances, I am not going to ask a female patient of 9-years-old whether she has a history of using intoxicating drugs or smoking.


Defect waste occurs when products or services deviate from customer requirements or specifications. Researchers noted that these defects can cause situations critical to patient safety. One physician put it this way: A while ago, and this occurred multiple times with the same patient record, is that the lab results show were mixed up with another patient…We have to be on guard at all times and always need to check whether the correct patient name is indeed displayed next to the lab results.

Skills and Talent

Researchers say this type of waste concerns any wasteful activities conducted as a consequence of not fully utilizing or even misusing staff skills and talent. For example, the majority of interviewees argued that insufficient training caused them to either not be fully knowledgeable or how the EHR works, or not how to work most efficiently. The training sessions we had to attend—they did not make sense at all.

Cascading Effect of Clinical Workflow Impediments

The researchers also noted that certain types of wasteful activities could have a cascading effect on other activities. For example, when preparing cancelled patient consultations sessions (overproduction), clinicians would re-enter information from static non copy-pastable text documents into their prepared documentation (transportation). They would also spend excessive time searching at multiple locations in the EHR for the information they needed (motion) and experience technical problems such as the system halting (defects).

The researchers concluded by saying that no standard approach exists with regard to tackling the identified manifestations of waste. However, one prioritization could involve (1) eliminating waste that has a potentially negative effect on patient and staff safety and (2) eliminating waste that has a potentially negative effect on the quality (effectiveness) of clinician-EHR interaction and subsequent care delivered. Finally, they suggest eliminating waste that has a cascading negative effect on workflow.

Blijleven V, Koelemeijer K, Jaspers M. Identifying and eliminating inefficiencies in information system usage: A lean perspective. Int J Med Inform. 2017 Nov;107:40-47. doi: 10.1016/j.ijmedinf.2017.08.005. Epub 2017 Aug 24.