A presentation summarizing findings of a workflow analysis done at a health clinic.

1. Workflow: Is it flowing?
A rapid workflow analysis of a community clinic
by Kari Johnson, Mike Blyth, Priyanna Mehta
© 2013, Mike Blyth. All rights reserved.

2. NextGen EHR Use
• Rooms could be better optimized for using
either a laptop or the in-room computer
• Most EHR charting is done outside the room
• MAs and providers generally seem to use EHR
efficiently
• Providers might save time by doing more
charting while in the room

3. NextGen Hiccups
• Citrix logs out regularly (roughly every 30 min)
o Annoyance! Requires that someone log back in to keep
outside connections going but this is often forgotten
o While Citrix is logged out, NextGen continues working
which allows user to resume where they left off
o When Citrix logs out, the window does not come to the
front of the screen so the user is unaware until they click
that window specifically

4. NextGen Hiccups
• Occasional lockups or prolonged pauses
• Frequent shorter pauses--can interrupt train of
thought. WiFi reconnect?
• Generating the visit doc takes 30-50 seconds and
is usually done 1-2 times

5. NextGen Hiccups
• Provider-specific “Quick Saves” appear to be
difficult to change once they are in place
o Frustrating as providers cannot easily make changes on
their own
• Users have to select printer each time (no
defaults or wrong defaults set)

6. NextGen EHR: Scanned Docs
● Scanned documents do not have titles, but are
listed as “Scanned Document 001” etc.
● Scanned documents open at a random zoom
factor rather than to “fit the screen,” 100%, or
other constant factor

7. NextGen EHR: Scanned Docs
● Process for entering abstracted data from docs
○ Provider gets paper (fax) doc
○ Opens patient record, creates encounter
○ Enters abstracted information from document
● Or
○ Provider highlights info on doc for HIM to enter

8. NextGen EHR: Scanned Docs
● Dr. A’s suggestion
○ HIM receives document, creates encounter in chart
○ Provider sees document, opens encounter and enters
abstracted data
○ This saves the provider the time of creating the
encounter

9. NextGen EHR: Scanned Docs
● Another possible workflow (observed at LCC)
○ Fax arrives, is sent to nurse (may triage to MA)
○ Nurse/MA creates encounter (abstracts data?)
○ Nurse/MA prints barcode header sheet and attaches to
fax document
○ Fax is sent to queue for batched scanning, each doc with
a header, so go directly into patient chart.

10. Waiting Room
● The temperature of the waiting room can easily
make waiting less pleasant
○ The waiting room tends to be uncomfortably cold
compared to other parts of the clinic
○ On particularly cold days, the windows appeared to be
contributing to the draftiness in the waiting room
○ Some patients brought blankets and laid them over their
legs while they waited

11. Waiting Room
• The reading materials in the waiting room were
a bit lacking
o The free books rack was often empty
o One patient expressed a desire for both books and
games for smaller children
o There were no reading materials for adults, such as
magazines

12. Waiting Room
• The TV is an underutilized resource
o The placement of the TV isn’t ideal; only half of the left
side of the clinic can actually see it
o The programming doesn’t seem to engage the patients
● A survey could identify what patients would be interested in
watching
o The lack of Spanish subtitles on the TV is a definite issue,
no matter what programming is on the TV

13. Wait Times -- Brainstorm
● Disconnect between arrival times and
appointment times
● For a patient waiting more than 15 minutes in
the exam room
○ MA can check in on patient briefly and let them know to
expect a provider soon
○ Let a patient know they have not been forgotten

14. Wait Times -- Brainstorm
● Allow patients to use the in-room computer?
● If patient portal becomes available, encourage
patients to access it while in the room?

15. Health Information Management
● Huge amounts of paper entering the clinic
○ Hard to control when faxes regularly come in and
automatically print (Example: 40 page hospital summary)
○ With a paper chart, incoming paper would go in the
chart. Now where does it go?
○ Not everything should be printed but there is not an
option to defer printing
○ eFax would be a possible solution

16. Health Information Management
• Long, multi-step process for incoming faxes
○ When faxes arrive, they are stamped with current date
and then verified in EPM to confirm that the person is a
clinic patient
○ If the person is a patient, then a note is placed in EPM
that documents the fax was received
○ If the person is not a patient, the fax is sent back to the
sender

17. Health Information Management
• Only two places with electronic access to
hospital records: St. D’s and C
o Not all hospitals are covered, so it can make finding a
patient’s history in the hospital difficult
o What about the iCare HIE? When is this used to access
shared databases?
• Distinguishing between priority and nonpriority
labs can be confusing at times

18. Health Information Management
• A pain point at the clinic is getting EHRs from
other facilities
o If a patient has relevant records from another site, such
as an ultrasound for St. D’s, the data needs to be
collected for a visit at the clinic
o However, obtaining a lot of information takes time
o In one instance, getting ultrasound results for a patient
took so long that another patient with a 2:00
appointment was still in the waiting room at 3:00

19. Health Information Management
• There are a few potential solutions to this issue:
o Since patients are asked about hospital visits when an
appointment is made, why not ask them if they had any
relevant clinic visits or lab work?
o Since NextGen is shared between several clinics, could an
agreement be made that would allow this clinic to get
their data directly?
● In a sense, this set-up would be like a small-scale
health information exchange (HIE) for all participants

20. Lab/Provider Approval Queue (PAQ)
• Some providers have concerns about the way
their lab results are transmitted
o Oftentimes, results can be delivered more than once,
which can lead to overlap and confusion
o Sometimes, lab results do not appear in the EHR in a
timely manner, which makes it difficult for a provider to
rely on their PAQ
o Results may also be sent to the wrong provider

21. Lab/Provider Approval Queue (PAQ)
• On the other side of this issue, the lab has their
own set of concerns
o If results don’t come through in a timely manner, the lab
has to call Quest to “push” the results
o If a lab result is attached to the wrong encounter by the
person who places the order, it will inevitably go to the
wrong provider
● This is a particularly big issue with ultrasounds, since
they are considered a separate encounter

22. Patient Cycle Times

23. Patient Cycle Times
Three methods used to observe patient flow:
• Follow individual patient through entire visit
o Most detailed from patient perspective
• Simultaneously observe MA, provider, and
patients through clinic session
o Integrated view of all that’s happening
• Use tracking slips to get basic time data
o More patients, but only minimal data

24. Patient Cycle Times -- Individual Pt

25. Patient Cycle Times -- Team

26. Patient Cycle Times -- Tracking Form
● Front desk fills in the arrival and
appointment times
● Observers enter time when MA
calls patient, and the provider
name
● MA or provider enters start and
finish time for provider in room
● Observers enter any lab time and
the check-out time

27. Patient Cycle Times -- Limitations
● Small sample size: 52 total including 24 using the tracking
sheets
● Not all time points are known for all records
● Limited, non-random selection of providers and services
○ For example, hard to compare a brief prenatal visit
including 1-hour glucose tolerance test with a
complex medical patient

28. Patient Cycle Times
• Data for visits with 17 providers, with 1 to 8 visits each
Service Patients observed
Women’s Health 24
Pediatrics 10
Adult Medicine 9
Adolescent Medicine 3
Safe Place 2

29. Patient Cycle Times
● The average (mean) total
cycle time measured for all
patients was 86 minutes from
arrival time (95% confidence
interval 74-99 minutes)
● The peak around 50 minutes
mainly represents women’s
health visits

30. Patient Cycle Times
Service Mean time (CI)
(minutes)
Median time
(minutes)
Adult 110 (94-125) 106
Peds 110 (84-136) 100
Women 69 (55-83) 55
These times are based on actual arrival times, not
the appointment time. Note that in some cases the
endpoint was discharge of patient from the room,
while in others it was arrival at the checkout window.

31. Patient Cycle Times (Appointment)
Service Mean time (CI)
(minutes)
Median time
(minutes)
Adult 78 (67-90) 84
Peds 79 (64-94) 80
Women 41 (23-59) 35
These cycle times are measured from the
appointment time given to the patient, i.e. 15
minutes prior to the listed provider appointment time.

32. Patient Arrival Times

33. Waiting Times: In Lobby
● Half of patients are called by the
MA within 14 minutes of the
appointment time given to the
patient, and within 26 minutes of
their actual arrival.
● One quarter of patients wait longer
than 25 minutes beyond their
stated appointment time, and 34
minutes beyond arrival.

34. Waiting Times: For Provider
● 75% of patients wait less
than 22 minutes after being
prepped, and half wait less
than 16 minutes
● MA’s could tell patients to
expect at least a 15 minute
wait
● MA’s could “drop in” after 15
minutes to let pt know they’re
not forgotten

35. Waiting Times: After Provider
● Most adult patients are
finished within 10 minutes of
the provider leaving
● Children do not leave as
quickly, likely because of
immunizations
● We don’t have enough data
do know how labs,
immunizations, and waiting
for the plan summary may
affect the wait

36. Service Times: MA Prep
● Half of patients are ready to
be seen by the provider
within 9 minutes of being
called by the MA

37. Service Times: Provider
● Out-of-room time is not shown
● Provider in-room time was greater
than 28 minutes for half of adult
patients, and greater than 38
minutes for 25%. Only 25% of adult
patients were seen for less than 17
minutes
● Fewer pediatric visits required more
than 30 minutes
● Short women’s visits are likely due to
the short visits in the particular clinics
observed (e.g. prenatal)

38. Thank you!
We enjoyed our time here, thank you for openly
welcoming us!
We hope the information we have gathered will
help the clinic and its patients.