Sometimes we consider workflow in the context of electronic health record (EHR) usability. We imagine workflow is a series of steps that are performed, usually in sequence, but sometimes with some variation in the sequence of steps. It's far more complicated. Holman et al [JAMIA 2015 Sep] recently published a report analyzing a large number of primary care physician workflows to conclude: 

PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a “dance” between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice.

Some workflows can be fairly simple. For instance, e-prescribing refills of a single medication (generic oral contraceptive) for a woman returning for her annual well woman exam. She has the same job, the same insurance plan, the same copay amounts, and the same medication. These details make this particular e-prescribing workflow simple. This can be done with fast, recognition-based, System 1 thinking which takes little cognitive effort. [Kahneman, Thinking, Fast and Slow].

Now by contrast, imagine an older patient with 8 different medications and as many chronic problems. Some of the medications are more expensive, because they're not available generically. Thus there are more opportunities for dug-drug and for drug-disease interactions. There may be opportunities for dual benefits from a new prescription that benefits more than one problem. If the insurance plan has changed since last year, then copays and coverage may be significantly different and thus require the attention of the physician and patient.  In some cases, prior authorizations may come into play. This process requires system 2 thinking, deliberative, slow and effortful, and requiring sustained attention. 

To appreciate the underlying complexity and mental effort, let's take a look at a simple e-prescribing workflow model, and then drill into the details.

e-Prescribing Workflow


Here's a diagram showing a simple e-prescribing workflow. The physician reviews the current medications and problems, takeing care of any renewals needed.  Some of the medications may need adjustment, such as a change in the number of daily tablets, switching to a new drug strength, or stopping the medication. New medicationss may be prescribed. Finally, the physician and patient have a conversation about what to expect from the new medication. Written materials may be provided by the physician, although pharmacies provide those written materials more commonly.

Medication Reconciliation

Medication reconciliation may be done at the review stage, during medication renewal, or later adjusting medications.

Medication reconciliation may be done at the review stage, during medication renewal, or later adjusting medications.

We haven't mentioned medication reconciliation (med rec) yet. It may be a part of some ambulatory encounters, particularly after transitions of care such as hospitalization or emergency department visits where medication lists have been changed. When should med rec be done? Can it be done more than once during the encounter? Does it need to be done for every encounter?  Medication reconciliation is a sidetrip in the e-prescribing workflow.

Renewing Medications

The timing of the next appointment determines which meds need to be renewed.

The timing of the next appointment determines which meds need to be renewed.

The decision to renew a particular medication depends on when the next anticipated visit would occur. Sometimes this is a matter of routine, such as every three or six months for someone with diabetes. That maybe once a year for somebody with high blood pressure. Fairly often, the interval is determined by newly identified clinical needs and negotiation between the patient and physician.  

Pharmacy Details

Hotter colors (red, orange) depict greater cognitive load.

Hotter colors (red, orange) depict greater cognitive load.

Sometimes it's simple. For an annual visit with no new medications and nothing changed, renewing all the medications may be as simple as a handful of clicks. However, if different prescriptions have different destinations (controlled substance prescriptions must be printed, some go to a mail order pharmacy for a 90 day supply, and others go to a local pharmacy for a 30 day supply), then it can get complicated. System 2 thinking again. 

Insurance constraints

Hotter colors (red, orange) depict greater cognitive load.

Hotter colors (red, orange) depict greater cognitive load.

Depending on the insurance formulary, some medications may have higher co-pays, and those copays can be unaffordable for many patients. Formulary visual cues at the point of care can lighten the physician's cognitive load somewhat. Nevertheless, it takes deliberate effort to find formulary alternatives that will be less expensive for the patient. The choice of an alternative medication is a collaborative process involving the patient.

Some medications (expensive, risky, or commonly overprescribed) require prior authorization by the insurance plan. This is a time-consuming process that will occur after the physician visit has been completed.

Workflow and subroutines

These subroutines are the deeper processes that are mentally effortful, variably performed,  even sometimes avoided (due to time constraints or a physician's saturated mental capacity). The system 2 thinking it requires carries a heavy congnitive load. Remember that health IT workflows can be quite variable and complex

AuthorJeff Belden

This is a faxed note from a physician’s office about someone you don’t know.

This is fairly typical of a modern EHR note “created” (or stillborn) by clicking on word choices from a list. The lists are designed with an eye toward being able to bill for the actual work done during the visit. The result is awful. Every doctor in the world would agree.

We can do better. We must try. Think of the reader caring for this patient later.


 This would have said the same thing:

He is here to follow-up on his SLE with renal disease, moderate proteinuria, hypertension, and hyperlipidemia.

A slightly more readable version (because it's a list) would be:

He is here to follow-up on his:

  • SLE with renal disease
  • moderate proteinuria
  • hypertension
  • hyperlipidemia

I think we physicians need to tell patients' stories, not just collect bullet points for billing. A well crafted, readable narrative will contain the data to justify the billing. If our typing skills are weak, we can learn voice recognition. 

AuthorJeff Belden

Sketching timelines

I first started thinking about graphical timelines when our team at University Missouri was working with our electronic health record vendor, Cerner, on a timeline for microbiology results (blood cultures and urine cultures). It was challenging to design timelines that were concise, intuitive, and effective.

A medication timeline will be far more helpful to me as a family physician, since I often struggle to understand a patient's medication history over the preceding years. it is difficult to find out when the medication was started or stopped, when it was was changed, and whether a medication had been tried in the past.

Fail early, fail often

I made a number of failed pencil sketches that I've shown here that were ineffective at handling the cognitive challenge.

In the sketches, I explored using the height of the graph to display the dose, but none of the ideas really worked, mostly because they did not scale when the dose range could vary 16-fold or more. The dose of lisinopril can range from 2.5 mg to 80 mg daily, for instance.

Inspired by flight search

Then one day I was inspired by the beautiful and elegant visual design used by the flight search engine, Hipmunk. I immediately imagined an intuitive way to display a medication timeline.

In the process of making this online book, Inspired EHRs: Designing for Clinicians available freely online at, our design team had internal arguments about whether to make the timelines different hues of color, or whether to vary the line width of the bars. I think we made the right decision ultimately. By sticking with grayscale, we can then temporarily paint certain line categories different colors to give them visual meaning. For instance, all the hypertension drugs could be colored orange temporarily, to help the user see when the hypertension drug changes occurred.

Take the medication timeline for a spin 

You'll find it here. See if it's intuitive you, or if there are some ways it could be improved. Let us know if you have feedback at If you're aware of any EHR that is using a medication timeline, let us know at

AuthorJeff Belden

Inspired EHRs: Designing for Clinicians (formerly EHR Usability Style Guide) is a generously illustrated, interactive e-book for health IT developers, whether EHR / PHR / healthcare app software vendors, EHR client organization implementation teams, EHR consultants, or usability professionals. We made this book to be clinically relevant, inspirational, and illustrative, but not prescriptive. Freely available on the web at, it's available as a PDF version as well. 

Medication Timeline. Traveling back in time to see past medication use at a glance.

Written in an accessible, science journalist style, the book was developed in a series of workshops with the support and encouragement of our colleagues of the Electronic Health Record Association (EHRA) Clinician Experience Workgroup. This book was made possible thanks to the generous support of the SHARP-C Project of the Office of the National Coordinator of Health IT and the California HealthCare Foundation. The team, based at the University of Missouri-Columbia in partnership with Involution Studios Boston included colleagues from the University of Maryland Human-Computer Interaction Lab and The University of Texas Health Sciences Center-Houston.
We hope to produce a series of similar interactive e-books on related health IT topics. 

The content of this book and the code of its prototypes is made available under the Apache 2.0 open source license. This license agreement allows anyone to freely use the code and ideas presented in this book, subject to the conditions listed at

To provide feedback on the book, email us at
To discuss future books, email me at


Jeff Belden MD 
Project Leader for Inspired EHRs: Designing for Clinicians at
Twitter: @inspiredEHRs, @jeffbelden, @toomanyclicks

AuthorJeff Belden

I haven't posted here much lately. I've been leading a team writing an EHR Usability Style Guide with the community of EHR vendors as the target audience. I might call it "EHR Style Guide: Killer Design - Safe at Any Speed".

If you are attending HIMSS Annual Conference in Orlando this week, I'd be glad to tell you more about it. I'll be presenting to a meeting of EHRA stakeholders Tuesday AM at 1000 in Room West 106 (reservations required for that one), hosted by the EHRA Clinician Experience Workgroup. This group has been very supportive of our effort, including some of its members attending our 2-3 day design workshops at their own expense.

If you can't make that meeting, I'll be attending most other Usability Community meetings during the week (here's that schedule) and I'd love to show you a quick tour then. I'll also be at the HIMSS pre conference workshop "Understanding Usability in Organizational Strategy" on Sunday.

Here's a glimpse at some content from the book.

Medication Timeline

It's hell to figure out the historical course of a patient's medications. It's even worse when the patient is taking 20+ medications that have been started, stopped, and adjusted during transitions of care from home to hospital to extended care and back. 

We have a cure.

A graphical medication timeline is visually intuitive, a breeze to learn, and packs a lot into a  small space. Here's a screenshot of our working prototype.


There are a few simple rules that you need to know. Black is the maximum dose (for that med for that particular diagnosis – see the illustration below), gray is less, lighter is lower. If you've played with stock market timelines, you'll know how to drive this one.


I've shown timeline sketches to physicians who can look at the timeline and recreate a plausible clinical scenario from the timeline graph alone. This kind of data visualization can markedly reduce cognitive load (mental effort), making it easier to spot trends and see the interrelationships between different medication courses. It should be safer as well. I think it's fun!

When will the EHR Usability Style Guide be available?

I'll give a sneak preview to anyone this week. The final product will be available on July 1, 2014 on the Apple iBookstore and on the web. I'll tell you how to get it as the release day approaches. I'll tell you more about our team and the sponsors later. These illustrations were done by Jennifer Patel at Involution Studios in Boston, our design firm. You can follow me an Twitter at @jeffbelden or @toomanyclicks. I'll tweet when I post here again.

Abbreviations: HIMSS (Health Information Management Systems Society); EHRA (Electronic Health Records Association)

AuthorJeff Belden