Designing guideline-based workflow-enabled electronic health records

With the rising prevalence of chronic illness, there is a growing pressure to develop systems that engender evidence-based care. The potential for workflow support to coordinate services and improve communication in the context of chronic disease management is intuitively appealing, but is still a challenging (and hence rarely seen) accomplishment in practice. We examine the problem of achieving a close relationship of electronic health record (EHR) content to other components of a clinical information system (guidelines, decision support and workflow), with particular emphasis on integrating the EHR with workflow. We use the openEHR architecture, which allows extension of a core reference model via archetypes, to refine the detailed information recording options for specific points in the workflow and to represent the chain of instructions that is the workflow itself. We illustrate the use of openEHR for tracking the relationship of a series of clinical services or events to a guideline-based workflow via a case study of an early supported discharge (ESD) program for post-stroke rehabilitation. This case study shows the contribution guideline content and its derived workflow can have on problem specific EHR structure and demonstrates the potential for a constructive interaction of workflow support and the EHR. We conclude with a discussion of the practical boundary of applicability of workflow approaches versus decision support system approaches in supporting guideline-based care.