HITC Workflow Webinar 4.24.12

The Health Information Technology Community

EHR Workflow: Easy, high-impact changes for
accelerating implementation success

©2012 The HIT Community, LLC. All Rights Reserved. 1

Michael Levinger
• President, CEO and Co-founder of The HIT
Community
• 30+ years of experience in the successful
use of mission-critical software including
EHRs and Health Information Technology
• On the faculty of Boston University teaching
a masters degree course on Electronic
Health Records
• Serves as the Health IT “Ask the Expert” for
Pri-Med
• Member of Massachusetts REC workgroup
on Health IT Workforce Development


Welcome!


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Agenda
• Overview of workflow Re-engineering
• Healthcare processes impacted by EHR
deployment
• Workflow re-engineering of healthcare
processes
• Critical Success Factors
• Questions & Answers


Polling Question
• Put in polling question from last time on where
attendees are in the EHR deployment process


Healthcare Clinical Processes
workflow: n., in an office or industrial organization, the
sequence of processes through which a piece of work
passes from initiation to completion - Oxford English Dictionary


Laundry Process

= Success!


Example:
Laundry Process
 What is what we’re
told we should do?
(Perceived As-Is)
 What do we really
do? (Real As-Is)
 What should we
do? (Should-Be)


Common Workflow Improvement Methodologies
• Total Quality Management (TQM)

• Business Process Re‐engineering (BPR)

• Plan‐Do‐Check‐Act (PDCA)

• Six Sigma

• LEAN Systems

• LEAN Six Sigma


Polling Question
• Have you ever done a structured business
process redesign?
– Yes
– Now


EHR & Healthcare Processes
People &
Commitment

Goals
Business & Process
Metrics

Technology


Major Healthcare Processes
Clinical Business


Clinical Business
Time management and scheduling
Reviewing diagnostic test results and
clinical documents
Diagnostic test ordering
Patient encounter documentation
Electronic prescribing
Electronic signature
Clinical decision support
Disease management
Data analysis and report generation
Patient education


Clinical Business
Time management and scheduling Registration/Check-in
Reviewing diagnostic test results and Schedule
clinical documents Clinical encounter
Diagnostic test ordering Patient education
Patient encounter documentation Billing
Electronic prescribing Patient Check-out
Electronic signature
Clinical decision support
Disease management
Data analysis and report generation
Patient education


Conducting a workflow evaluation
Agency for Healthcare Research and Quality identified 6 major
categories of impact on workflow
1. Reminders, alerts, and reports that, when provided, increased
efficiency and improved workflow.
2. Administrative and clinical workflow, and work/job design that have
positive and negative impacts on workflow and job content
3. Patient-provider consequences of the health IT system that affected
workflow
4. Interface design that affected job content and workflow
5. System integration that, in all cases, positively affected workflow
6. Planning activities and their impact on workflow

Carayon P, Karsh B‐T, Cartmill RS, et al. Incorporating Health Information Technology Into Workflow Redesign‐‐Summary Report. (Prepared by the Center for
Quality and Productivity Improvement, University of Wisconsin–Madison, under Contract No. HHSA 290‐2008‐10036C). AHRQ Publication No. 10‐0098‐EF.
Rockville, MD: Agency for Healthcare Research and Quality. October 2010


Question
What are key processes you feel you need to redesign as part of your
EHR Implementation?
- Patient Check-in
- Intake
- Exam
- Diagnosis
- Order Entry – Diagnostic or Treatment
- Prescribing
- Patient Check-out
- Insurance Claim
- Other


Easy Workflow Re-design Steps
1. Identify what is the workflow and its key process
steps?
2. What is key information needed at each process
step?
3. What people are involved for each process step?
4. What EHR functionality is used for each key process
step?
5. What are the benefits from changing/improving the
workflow?


Easy Workflow Re-design Steps
1. Identify what is the workflow and its key process
steps?
2. What is key information needed at each process
step?
3. What people are involved for each process step?
4. What EHR functionality is used for each key process
step?
5. What are the benefits from changing/improving the
workflow?

Diagnostic Test Ordering – Example BPR


Diagnostic Test Ordering –
Example BPR
Workflow
Yes
No

Create and Submit Get Yes Electronic Need More No
Order OK? Receive Results Enter Into EHR Inform Patient
Lab Order Acknowledgement Signature Labs?

Data Needed
•Diagnosis •Lab •Original Lab •Physician ID •Original Lab •Original Lab •Lab Results •Patient Info
•Possible labs acknowledge Order Order Order •Diagnosis •Lab Results
ment •Lab Ack. •Lab Results •Lab Results •Diagnosis
•Diagnosis •Diagnosis •Diagnosis

Who is involved?
•Physician •Physician •Physician •Physician •Physician •Physician •Physician •Physician
•Nurse •Nurse •Nurse •Nurse •Nurse •Nurse
•Lab •Lab •Lab •Admin Staff •Patient

EHR Functionality
•Order Sets •Lab System •Clinical Decision •Electronic •Lab System •Clinical •Lab System •Patient
•Order (LIMS) Support Signature (LIMS) Interface Decision (LIMS) Interface Communication
Protocols Interface •Order Protocols Support
•Lab System •Order
(LIMS) Protocols
Interface

Benefit
•Faster •Faster •Faster •Safer •Faster •Faster •Faster •Faster
•Less Error •More •Less Error Prone •Faster •Greater •Less Error •Greater •Greater
Prone available availability Prone availability availability
•Improved
Communication


Example BPR
Workflow
Yes
No


Data Needed

Who is involved?

EHR Functionality
(LIMS) Protocols
Interface

Benefit
•Improved
Communication


Doctor Office Visit Process Steps
Area Task
Check in Make appointment
Check in Check in with receptionist
Check in Look up patient information
Check in Update form
Check in Verify insurance
Check in Co-Pay
Intake You wait
Intake Nurse comes and gets you
Intake Takes you to exam room
Intake Takes Vitals
Intake Enters into health record - electronic or paper chart
Intake Gets symptoms
Intake Exam process
Intake Nurse Leaves
Intake Wait again
Exam Doctor looks at record
Exam Review symptoms, vitals, etc. (SOAP)
Exam Do tests and/or do orders (lab, radiology, etc.)
Exam Get results via fax, electronically, phone or other
Exam & Checkout Review results
Exam & Checkout Diagnostics
Exam & Checkout Treatment plan
Checkout Inform Patient
Checkout Follow up actions (schedule follow-up visit, referral, prescription, etc.)
Checkout Billing


Medication Refill Process

• Original Workflow
• 16 Process Steps
• Substantial staff
involvement
• Multiple Decision
Points

Source: California Healthcare Foundation Workflow Analysis:
EHR Deployment Techniques by S.A. Kushinka, M.B.A. , Full
Circle Projects. January 2011


Medication
Refill Process
• Post workflow
redesign
• Now 7 steps
• Substantially less
staff involvement

Source: California Healthcare Foundation Workflow Analysis:
EHR Deployment Techniques by S.A. Kushinka, M.B.A. , Full
Circle Projects. January 2011


Polling Question
What are some of the benefits that might come
from workflow re-design in healthcare?
• Reduced staff time
• Reduced out-of-pocket costs
• Faster
• Better clinical care
• Safer clinical care
• Better patient satisfaction
• Other

Workflow Redesign – Success Factors
• You need a team:
– Of staff doing the work
– Multidisciplinary
– Include everyone involved in the process
– Unemotional
– Unbiased
– Not “blaming”
• Focus on the “real” work flow – not the expected or
prescribed workflow
• Workflow redesign should be an integral part of EHR
implementation
• Get to the root cause of inefficiencies
• KISS

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Tools / Data / Expertise
• The expertise to succeed:
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How to create conversation, engage members, and collaborate to
achieve results
– Expertise in online knowledge, communication and collaboration tools
– Quantify results – healthcare performance measures and data analytics

Voice of the people - Our mission is to help all healthcare
providers through critical healthcare industry inflection points.


Questions?


HITC Workflow Webinar 4.24.12

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