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Changes in workflow for clinicians, health systems, and patients is an increasingly significant issue in the delivery of care. These changes impact quality, safety, and the effective use of technologies like electronic health records, and are intricately tied to the growing use of value-based payment systems in the public and private sector. 

Periods of change in healthcare, like the one we are in now, lead to new patterns in workflows, the creation of workarounds, and consequently, an acute sense of overwork for every constituency. 

"Workflow, Workarounds, and Overworked Health Systems: Innovations and Challenges for Quality, Safety, and Technology," ECRI Institute’s 24th Annual Conference, strengthened the emerging national dialog on practice efficiency and institutional culture and their effects on care.

The conference, planned and cosponsored by the nation's leading healthcare organizations, explored a range of issues that illustrate changes in the healthcare system and how they are being addressed.


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 Notes From Past Attendees

  • This was an exceptional conference on a complex and timely problem with a tremendous negative impact on our nation's health. ECRI did a terrific job of gathering key stakeholders with different perspectives.
    Karen Drexler, MD, National Mental Health Program Director, Addictive Disorders, Department of Veterans Affairs
  • This is the first time I have attended one of ECRI's conferences. I have been very impressed with the format, lots of opportunity for discussion. Excellent speakers who are leaders in the field.

     Anonymous, RN, MS, AOCN, Nurse Consultant


Tuesday, November 28, 2017 | 8:15 am to 6:10 pm
Wednesday, November 29, 2017 | 8:30 am to 12:40 pm

(Conference video recording)

Welcome, Acknowledgements, and Opening Remarks


Session 1: How Payment Impacts Workflow and Workarounds

This session examines the role of public and private payers as value payment initiatives take increasing hold in health systems, affecting what care is provided, the way care is delivered, and the effects this approach intends to make on quality, safety and cost. It examines initiatives that appear to be working and those that are not. Speakers are expected to address a wide range of issues including the impact on workflow and workarounds created by the rapid adoption of EHRs and accompanying meaningful use criteria; the use of clinical practice guidelines, clinical decision support, and quality measures. The influence of increasing attention to fraud and abuse investigations to incentivize adherence will also be considered. Growth in ACOs and other provider/insurer combinations in the private sector, as well as the public sector, will be examined for their impact.

Learning Objectives:

  • Examine the role of public and private payers in designing and implementing value-based payment initiatives in health systems
  • Explain how newer payer/provider delivery systems create new workflows and workarounds
  • Learn how the changing payment initiatives affect the ways that care is provided, with particular emphases on quality, safety, and cost


  • Moderator: Gail R. Wilensky, PhD, Senior Fellow, Project HOPE; Trustee, ECRI Institute
  • Kate Goodrich, MD, Director of the Center for Clinical Standards and Quality, and Chief Medical Officer, Centers for Medicare & Medicaid Services
  • William E. Golden, MD, MACP, Medical Director, Arkansas DHS Medicaid; Professor of Medicine and Public Health, University of Arkansas for Medical Sciences (Slides)
  • Samuel W. Ho, MD, Executive Vice President and Chief Medical Officer, UnitedHealthcare (Slides)

Session 2: Rate the Rater—The Purpose and Effectiveness of Quality Monitoring and Measurement-setting Organizations and their Influence on Standardization, Workflow, and Innovation

This session format will be a conversation led by Brent James examining the aims of quality assurance organizations, such as NQF, Leapfrog, and the Joint Commission. What is their purpose, how do they function in conjunction with the payer, provider and consumer communities, how are they structured, and how do we know they are working? It looks at case examples of measure selection when used for payment reward and punishment, motivation and recognition among caregivers, administrators, and consumers making choices among available providers.   It asks if we need fewer or more measures. It examines the interface among quality control, quality improvement, and quality design.

Learning Objectives:

  • Examine the influence of quality assurance organizations
  • Analyze the purpose and function of quality assurance organizations and how they work in conjunction with payer, provider, and consumer communities
  • Assess case examples of measure selection when used for purposes such as payment reward and punishment, as well as motivation and recognition among caregivers and administrators; learn how consumers use this information to make choices among available providers
  • Address whether there is a need for more or fewer measurements


Session 3: The Role and Influence of Electronic Health Records on Work Burden, Workflow, and Workarounds

Electronic health records, recently widely diffused, are new technology for most physicians and in most health systems. Like all new technologies, users need to adapt so that the new technology is an enabler of better and more efficient care. At present, EHRs are often seen by physicians and nurses as payment tools and inhibitors to care, disrupting familiar clinical patterns and practices. Complaints include slowing down care; the introduction of new types of errors – for instance through misuse of copy and paste functions, ergonomically challenging drop-down menus, or design barriers to obtaining the most relevant clinical information swiftly; alert fatigue; and multiple, nonstandard, and/or non-interoperable EHRs within and among institutions. Who is responsible for adapting EHRs to make them more useful? What are the interfaces between the developers of EHRs, the purchasers of the systems, and the users? Would the government or the private sector or a combination of these two drive positive change most effectively? Can a technology built for payment be effective in prioritizing workflow to enhance efficiency and ensure quality, or must EHRs for these latter purposes be designed from the get-go to be truly clinically effective?

Learning Objectives:

  • Examine electronic health records (EHRs) as a new technology for many physicians and health care systems that are intended to improve workflow but can sometimes stimulate workarounds
  • Explore whether EHRs could be designed differently and adapted to become better enablers of more efficient care
  • Explain the perception by some physicians and nurses that EHRs are primarily payment tools that can be inhibitors to care because they  disrupt familiar clinical patterns and practices and can result in slowing down care and introducing new types of errors


  • Moderator: Ronni P. Solomon, JD, Executive Vice President and General Counsel, ECRI Institute (Slides)
  • John Glaser, PhD, Senior Vice President, Population Health, Cerner Corporation
  • Patricia P. Sengstack, DNP, RN-BC, FAAN, Nursing Informatics Executive, Vanderbilt University Medical Center; Associate Professor, Vanderbilt University School of Nursing
  • Rollin "Terry" Fairbanks, MD, MS, FACEP, Founding Director, National Center for Human Factors in Healthcare; Assistant Vice President Ambulatory Quality and Safety, MedStar Health; Co-Director, MedStar Telehealth Innovation Center, MedStar Institute for Innovation; Associate Professor of Emergency Medicine, Georgetown University
  • Patrick J. Brennan, MD, Chief Medical Officer and Senior Vice President, University of Pennsylvania Health System

Session 4: When Workarounds are the Norm in Clinical Care

This session looks at issues in medical specialties where clinical practice guidelines and clinical pathways are commonly used to guide care. These include oncology and emergency medicine. While guidelines and clinical pathways can minimize unwarranted variations in care their implementation in EHRs also potentially creates obstacles to individualizing care due to rigid workflows or quality reporting requirements. The result can be the creation of workarounds to enable more flexible or efficient care delivery.  Do these workarounds lead to more efficient and better care as well as innovation, or are they symptoms of dysfunction and disarray? How do the workarounds also affect safety as well as work burden and costs? Is there an evidence-based literature on overwork, dehumanization or unrealistic expectations, and can the use of simulation exercises help bridge the gaps that arise between standardized care and on the ground exigencies of patient care?

Learning Objectives:

  • Recognize issues in medical specialties where clinical practice guidelines and clinical pathways are commonly used to guide care, such as oncology and emergency medicine, and how those guidelines and clinical pathways minimize unwarranted variations in care
  • Explore whether implementation of guidelines and clinical pathways in EHRs may sometimes create obstacles to individualizing care due to rigid workflows and quality reporting requirements
  • Examine whether simulation exercises can bridge gaps that arise between standardized care and exigencies of patient care


  • Moderator: Jeffrey C. Lerner, PhD, President and Chief Executive Officer, ECRI Institute
  • Richard L. Schilsky, MD, FACP, FASCO, FSCT, Senior Vice President and Chief Medical Officer, American Society of Clinical Oncology (ASCO)
  • Steven J. Stack, MD, Emergency Physician, Kentucky; Past President, American Medical Association
  • Ellen S. Deutsch, MD, MS, Medical Director, Pennsylvania Patient Safety Authority and ECRI Institute; Adjunct Associate Professor, University of Pennsylvania Perelman School of Medicine; and Senior Scientist, Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Pennsylvania (Slides)

Session 5: Standardization and Innovation in and Across Health Systems—What is Scalable?

This session looks at three parts of the larger “health system.” One is the role of MedPAC policy recommendations in facilitating large scale changes and the bi-direction where health systems influence policymakers. The second and third examine the ability to care for large diverse populations, as well as smaller ones with especially high needs and costs, in different geographical areas. Our case examples are Kaiser Permanente and the Camden Coalition, a Medicaid ACO. Speakers will discuss how they establish, manage, adapt, and grow care systems that address work burden, workflow, and innovation in this era of complex, dynamic change.

Learning Objectives:

  • Describe how health systems, including integrated ones, scale care for large populations in diverse geographical areas
  • Illustrate how health systems adapt to address work burden, workflow, and innovation in an era of consolidation into larger entities
  • Examine how policy development takes account of recommendations to change practice through adjustments in payment


Session 6: Rethinking Care for Everyone Case Studies—Standardization and Individuality for Underserved Populations

There are several definitions of “underserved.” Frequently, and legitimately, this refers to lack of access, cost of care, lower than average literacy, and many other social determinants of health among patients. In this session, we will explore issues for clinicians surrounding workflow, workarounds and the burdens of practice redesign in primary care in rural areas. We also delve into the special case of people suffering from substance use disorders and mental health issues. Standardization can be an enabler or an inhibitor to better care for these populations, and so can regulations like 42 CFR Part 2.

Learning Objectives:

  • Explore workflow and workaround issues surrounding primary care in rural areas
  • Explore the appropriateness of expanding the definition of “underserved” to encompass clinical conditions, as well as more customary categories, such as  income, minority status, lack of access, cost of care, literacy levels, cultural sensitivity by clinicians, and other social determinants to health
  • Examine the tradeoffs in designing regulations like 42 CFR Part 2 that lead to workarounds in the interface between maintaining privacy and providing care for patients with substance use disorders and mental health issues


  • Moderator: Joel Kupersmith, MD, Director, Center for Veterans Initiatives; Professor of Medicine, Georgetown University
  • Richard J. Roberts, MD, JD, Practicing Family Physician; Professor of Family Medicine, University of Wisconsin
  • David Wennberg, MD, MPH, Chief Science Officer, Quartet Health
  • Kimberly A. Johnson, PhD, Director, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA)

Day 2 

Opening Remarks

Session 7: VA Healthcare—A Case Study in Transforming to a High Performing Network (Slides)

This session is structured as a conversation. The military has always been associated with standardization as an efficient way to achieve ends, especially in complex situations, like warfare. In the US, active service members convert to becoming veterans, and in the process to using a different healthcare system. The health systems, as well as the individuals receiving care, must adjust. Standardization can lead to efficient workflow, but also to increased work burden and resulting workarounds if the system is too rigid. The Veterans Health Administration has had to address and lead on this issue. Its task and its opportunity to do this is increasingly complex and necessary especially as the Veterans Choice program expands and the interfaces with the civilian healthcare system more often. This can affect administrative processes, EHR interoperability related issues, and unique or at least more common care needs of the populations served, which for example, may have experienced physical and mental trauma. Expectations for a smooth running, high quality, system are especially high for this much watched health system – the largest in the nation. How senior clinicians and executives address the growing work burden as the population of veterans ages and as care for younger combat veterans becomes more complex is a challenge in its own right, but it is heightened in the era where innovation and cost effectiveness expectations are demanded.

Learning Objectives:

  • Identify how the military's historic reliance on standardization as an efficient way to achieve ends, especially in complex situations such as warfare, is adapted to care for veterans, especially those with complex conditions resulting from physical and mental trauma
  • Examine whether and how standardization can lead to inefficient workflow with increased work burden and workarounds if the system is too rigid and how the Veterans Health Administration has taken a lead on this issue as the largest health system in the nation
  • Recognize how workflows are impacted by interfaces in the Veterans Choice program which expands the need for coordination between the VA and civilian healthcare system


  • Moderator/Speaker: Stephan D. Fihn, MD, MPH, FACP, FAHA, Director, Clinical System Development and Evaluation (CSDE), U.S. Department of Veterans Affairs, Veterans Health Administration
  • Austin Frakt, PhD, Regular contributor to New York Times’ The Upshot; Creator of the Incidental Economist; Director, Partnered Evidence-based Policy Resource Center, Boston VA Healthcare System; Associate Professor, Department of Health Law, Policy and Management, Boston University School of Public Health
  • Neil C. Evans, MD, Chief Officer, Office of Connected Care, U.S. Department of Veterans Affairs, Veterans Health Administration
  • Clinton L. Greenstone, MD, Deputy Executive Director, Clinical Integration, VHA Office of Community Care, U.S. Department of Veterans Affairs; Clinical Assistant Professor of Medicine, University of Michigan Medical School

Session 8: CEO Panel—Adapting to Change and Driving Innovation

CEOs of major health systems must balance an extraordinary range of administrative, clinical, and financial issues and people if they are to manage increasing work burdens. These include the demands for quality measurement under value-based care payment and public demand for safety; routine and nonstandard clinical needs; an expanding range of services, including prevention and care at home, to populations in their service areas; the influx and adoption of new technologies including EHRs and the clinical technologies linked to EHRs, and telehealth. Some use special units to develop novel approaches, such as innovation centers that include constructing approaches drawing on behavioral economics. The CEOs will speak briefly about their systems and engage in conversation with the audience.

Learning Objectives:

  • Assess how CEOs of major health systems balance an extraordinary range of administrative, clinical, financial, and human issues to manage increasing complex work burdens
  • Compare an array of complex demands in standardizing health system services that include quality measurement under value-based care payment; public demand for safety; routine and nonstandard clinical needs; out-of-hospital care; the influx and adoption of new technologies, including EHRs and the clinical technologies linked to EHRs; and telehealth
  • Discuss how some CEOs employ special units to create novel approaches to standardization, such as innovation centers that draw on behavioral economics


Capstone Session: What Patients and the Public Want—Safe, Affordable, Personalized Care

This session draws on some of the key constituencies that seek to understand workflows and workarounds and to balance innovation and the standardization that comes with accountability as health systems become larger, more integrated and data-driven. Patients want predictability and protections, but also access to affordable, safe, personalized care.  Our discussants will provide patient-centered perspectives from the health services research community, insights from successful efforts to drive transformative change, and political perspectives aimed at seeking to find the balance that serves the public best while taking account of multiple constituencies' needs and demands. Our discussants will do more than just synthesize learnings from the previous conference sessions—they will explore a range of actions needed to support the various actors in the health care system.

Learning Objectives:

  • Recognize the political perspectives among key constituencies aimed at seeking innovation and standardization to balance needs and demands among multiple constituencies
  • Gain insights from efforts to drive transformative change aimed at making care safer, more affordable, and appropriately personalized
  • Evaluate patient-centered perspectives from the health services research community on workflow, workarounds, and work burdens


  • Moderator: Janet Marchibroda, MBA, Director, Health Innovation Initiative and Executive Director, CEO Council on Health and Innovation, Bipartisan Policy Center (BPC)
  • Joe V. Selby, MD, MPH, Executive Director, Patient-Centered Outcomes Research Institute (PCORI) (Slides)
  • A. Thomas McLellan, PhD, Chairman of the Board of Directors and Co-Founder, Treatment Research Institute; Senior Scientific Editor, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, 2016 (Slides)
  • Amy Bassano, MA, Acting Deputy Administrator for Innovation and Quality and Acting Director, Center for Medicare and Medicaid Innovation (CMMI), Centers for Medicare and Medicaid Services

Closing Remarks

Our thanks to the following organizations who helped to plan and cosponsor this free public service conference.


AcademyHealth, Bipartisan Policy Center, Department of Veterans Affairs, Georgetown University, Kaiser Permanente, Leonard Davis Institute of Health Economics at the University of Pennsylvania, University of Pennsylvania Health System

Conference Venue

Georgetown University
Lohrfink Auditorium in Hariri Building
3800 Reservoir Road, NW
Washington, DC 20057


This page includes important information about continuing education credits, articles, and resources related to workflow, workarounds, and overworked health systems.

​Continuing Education

  • CME Accreditation Statement: This live activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME). ECRI Institute is accredited by the ACCME to provide continuing medical education for physicians.
  • AMA Credit Designation Statement: ECRI Institute designates this live activity for a maximum of 11.00 AMA PRA Category 1 Credit(s) TM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.
  • This activity has been approved for a total of 13 California State Nursing contact hours by the provider, Debora Simmons, who is approved by the California Board of Registered Nursing, Provider Number CEP 13677. (9.0 for Day 1 and 4.0 for Day 2)
  • This program has been approved by the Supreme Court of Pennsylvania’s Continuing Legal Education Board for up to a total of 11.5 substantive credits.
  • Certified Public Health (CPH) credits are awarded for attendance in the Workflow, Workarounds, and Overworked Health Systems:  Innovations and Challenges for Quality, Safety, and Technology conference, located in Washington, DC on November 28-29, 2017. Attendees may allot 1 credit per 1 hour of participation, up to 7.5 credits for Day 1 and 3.5 credits for Day 2 for a maximum of 11 credits over the two-day conference.

For questions regarding education credits, please contact or call (610) 825-6000, ext. 5439.

Conference Resources