HITC Workflow Webinar 4.24.12

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

The Health Information Technology Community

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


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 Processesworkflow: 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 ProcessesPeople &

CommitmentPeople &

Commitment

ProcessProcess

TechnologyTechnology

BusinessBusinessGoals

&Metrics


Major Healthcare Processes

Clinical Business



Clinical BusinessTime 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 BusinessTime 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

Registration/Check-in

Schedule

Clinical encounter

Patient education

Billing

Patient Check-out


Conducting a workflow evaluationAgency 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


Create and Submit Lab Order

Get Acknowledgement

Order OK?Electronic Signature

Receive ResultsNeed More

Labs?Enter Into EHR Inform Patient

YesNo

NoYes


•Order Sets•Order Protocols•Lab System (LIMS) Interface

•Lab System (LIMS) Interface

•Clinical Decision Support•Order Protocols

•Electronic Signature




•Patient Communication

•Physician•Nurse•Lab


•Physician•Nurse

•Physician •Physician•Nurse•Lab

•Physician •Physician•Nurse•Admin Staff

•Physician•Nurse•Patient

•Diagnosis•Possible labs

•Lab acknowledgement

•Original Lab Order•Lab Ack.•Diagnosis

•Physician ID •Original Lab Order•Lab Results•Diagnosis

•Original Lab Order•Lab Results•Diagnosis

•Lab Results•Diagnosis

•Patient Info•Lab Results•Diagnosis

•Faster•Less Error Prone

•Faster•More available


•Safer•Faster

•Faster•Greater availability



•Faster•Greater availability•Improved Communication

Data Needed

Who is involved?

EHR Functionality

Benefit

Workflow



Get Acknowledgement




YesNo

NoYes


























•Safer•Faster





Data Needed

Who is involved?

EHR Functionality

Benefit

Workflow



Get Acknowledgement




YesNo

NoYes


























•Safer•Faster





Data Needed

Who is involved?

EHR Functionality

Benefit

Workflow



Get Acknowledgement




YesNo

NoYes


























•Safer•Faster





Data Needed

Who is involved?

EHR Functionality

Benefit

Workflow



Get Acknowledgement




YesNo

NoYes


























•Safer•Faster





Data Needed

Who is involved?

EHR Functionality

Benefit

Workflow


Doctor Office Visit Process StepsArea Task

Check in Make appointmentCheck in Check in with receptionistCheck in Look up patient informationCheck in Update formCheck in Verify insuranceCheck in Co-Pay Intake You waitIntake Nurse comes and gets youIntake Takes you to exam roomIntake Takes VitalsIntake Enters into health record - electronic or paper chartIntake Gets symptomsIntake Exam processIntake Nurse LeavesIntake Wait againExam Doctor looks at recordExam Review symptoms, vitals, etc. (SOAP)Exam Do tests and/or do orders (lab, radiology, etc.)Exam Get results via fax, electronically, phone or otherExam & Checkout Review resultsExam & Checkout DiagnosticsExam & Checkout Treatment planCheckout Inform PatientCheckout 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


MedicationRefill 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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Questions?