What do processes have to do with EHR success?

As a parent I’ve learned there are two types of tasks–those my children won’t do the first time I ask them, and those they won’t do no matter how many times I ask them.  Here’s the segue.

Let’s agree for the moment that workflows can be parsed into two groups—Easily Repeatable Processes (ERPs) and Barely Repeatable Processes (BRPs). (I read about this concept online via Sigurd Rinde.)

An example of an ERP industry is manufacturing. Healthcare, in many respects, is a BRP industry. BRPs are characterized by collaborative events, exception handling, ad-hoc activities, extensive loss of information, little knowledge acquired and reused, and untrustworthy processes. They involve unplanned events, knowledge work, and creative work.

ERPs are the easy ones to map, model, and structure. They are perfect for large enterprise software vendors like Oracle and SAP whose products include offerings like ERP, SCM, PLM, SRM, CRM.

How can you tell what type of process you are trying to incorporate in your EHR? Here’s one way. If the person standing next to you at Starbucks could watch you work and accurately describe the process, it’s probably an ERP.

So, why discuss ERP and BRP in the same sentence with EHR? The reason is simple. The taxonomy of most, if not all EHR systems, is that they are designed to support an ERP business model. Healthcare providers are faced with the quintessential square peg in a round hole conundrum; trying to get BRPs into an ERP type system. Since much of the ROI in the EHR comes from being able to redesign the workflows, I think either the “R” will be sacrificed, or the “I” will be much higher than planned.

What do you think?


12 thoughts on “What do processes have to do with EHR success?

  1. If you’re using a holistic approach you need not artificially segment ERP and BRP, or for another example, process management and case management. The question is more if you are convinced your staff knows what they do (and hopefully they do in HC!) and empower them to demonstrate their skills or if you would rather control every step they do to complete a predefined procedure.


  2. I think many US hospitals have barely begun to address Administrative and Financial ERP processes, like managing invoices, remittances and basic accounting activities.

    The EHR’s of today seem to have been born from the basic ERP process of generating a bill. Perhaps if we categorized patient care activities into ERP and BRP, then just focus on the ERP we would be better off!

    IMHO the answers to bettering(?) healthcare lie in communications and assuring the right resources as available in a timely manner.


    • The introduction and suopprt for EMRs is based upon a RAND report, funded by the manufacturers of the EMR programs, which highlight transparency and cost savings. The studies have been shown to be flawed, with underlying cherry picking of positive reviews to please the study funders. Reviews coming out now show that the programs do not save money but in fact cost more in dollars and physician time. The programs are inflexible, require every box to be checked prior to moving on, are difficult to navigate and in fact are the very model of user unfriendly .There are at least 17 companies that lead in this industry. All have proprietary programs which absolutely do not speak to each other. So data from one hospital cannot be transmitted to another (a highly touted reason for these systems) as the companies are jealous and protective of their own software in the hopes that theirs alone may be adopted as the national standard. The whole system is a boondoggle and should at least be seriously evaluated by an independent and not monetarily involved body or perhaps it should all be scrapped.


  3. Paul,
    Your insight and comments are unfortunately right on.
    I have been in healthcare leadership positions (C level) in both the acute care and long term care sectors for nearly 40 years.
    I have seen hundreds of thousands of dollars even millions spent on EMRs in hopes of improving the effectiveness and efficiency of care delivery. The sad truth is if your day to day business (care) processes are dysfunctional… IT will only make them dysfunctional faster.
    From an operational performance stand point, when you pop the hood of EMRs you will discover that they in reality only account for 30% of the work that is performed on any given shift, day etc. In other words, 70% of the staff’s effort and work flow is never captured and therefore it’s never accounted for.
    Your point about healthcare being BRPs is extremely accurate.
    Why, I would suggest the following. Each nurse spends countless hours creating care plans (more often than not they are written for, judged by and surveyed by nurses). EMRs are over engineered with bloat ware to write care plans. Currently there are over 330 NOCs (nursing outcome classifications) and 542 NICs (nursing intervention classifications) subscribed to and incorporated into EMRs. Can you imagine trying to create a care plan?
    Worst yet as soon as the 1-2 hours are spent creating the plan, as soon as one enters SAVE the plan is obsolete.
    The reason is straight forward. While many EMRs generate “to-do” lists / work tracking printouts for Nurse Assistants, LPN and RNs, the fact these often paper based notes ( which are kept in what I like to call the “smock pocket file cabinet”) are primarily designed to account for the “planned or structured work” that is projected to be performed (30%). In reality the patient drives the need (35% i.e. the nurse call bell) and the staff generates the remaining 35% of the unscheduled and unplanned for work as they check in on their patients throughout the day
    At the end of the day there is no accounting of what is really taking place. As you are aware, if you can not measure you can’t manage. If you can’t memorialize actual business processes you can’t monetize them. There is no real time, operational performance business intelligence. The results are obvious, chaos.
    Unfortunately, most providers are being sold a bill of goods (EMRs) that are useless when it comes to their attempt to operate effectively and efficiently.


  4. The concept of BRP looks attractive, but I would like to belive it is from a customer/user point of view, not from an architect/developer point. What an architect/developer should do is to structurize complex problems, and breakdown complex solution into smaller, easy-to-control parts. And I also believe when people get to know more about a complex system, they will find out that no-linear workflow (or BRP) could also be built on a basic of well-collaborating linear workflow (or ERP).


      • Basically IT should address the needs of users instead those of developers because otherwise it might resemble a bureaucracy whose main intention is to justify its mere existence.
        If complex is not misunderstood and simplified here as complicated it must be clear that it cannot be reconciled with linearity because these two concepts are mutually exclusive. That said they can co-exist technically, though, and could even be beneficial in the circumstances.


  5. Hi Paul,
    Thank you for this nice blog, I agree with you introducing the BRP concept to be applied for Healthcare; and the addition of Tim O’Connor does really decribe why BRP is the right match of healthcare sector processes; the 70% of the nurse time is handling adhoc requests. However for these 70% adhoc processes, I think it could be segmented in tiny processes that can be repeated frequently in ERP model.
    In this case the model can be collaborative events and exception handling which triggers a tiny process to fulfill the job. As organization owner or manager I believe that all these activities should be documented to be able to support for right evaluations and performance measures.


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