WORKFLOW2007

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WORKFLOW-2007
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Objections to Flight vs Digital

• I am not a flyer
• It weighs to much
• I can crash and burn
• I could never learn those controls
• It will get in the way of my walking

• I am not a computer type person
• It costs to much
• I can crash and burn
• I could never type
• It will get in the way of my patients

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Process

• Not all will be happy-10-15 love island and
  will not move
• It will be painful at times
• We are all in this together
• -Basic computer skills-typing
• 15 dollars for typing program
• Failure and non-participation is not optional
• We have clear goals and excellent technical
  support

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Biggest Obstacle to Speed and adapting digital
methods

• It Requires a Paradigm
• shift

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4 FACTORSTHE JEDI INCIRCLE
DECREASED COSTS
ACCESS FOR PATIENTS INCLUDES SATISFACTION SENSE
OF BEING CARED
HAPPIER PROVIDERS
IMPROVED QUALTITY OF CARE
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WE NEED TO KNOW THE ENEMY

• Anytime you see paper, it is a sign of
  inefficiency

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PAPER

• MANUAL LABOR-
• AUTOMATED LABOR
• PRIMARY CARE LOW MARGIN
• DO WE HAVE A MARGIN FOR OUR MISSION?

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Cost of Doing Nothing
Paper
Cost
Time
Compliments Dan Russler, McKesson
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Cost of Parallel Systems Paper and EMR
Paper
EMR
Cost
Time
Compliments Dan Russler, McKesson
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Do you feel like a peasant?

• We are at the mercy of Chevera
• Government,
• Insurance companies,
• Regulators,
• Politicians,
• EMR

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Does this sound like the doctors lounge?
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Go with the Magnificent 7
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Going to the Mountains
The Seven Steps to Better Workflow
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Magnificent 7 Basic Concepts of Workflow
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The Magnificent 7

• Computers dont improve anything
• Productivity is how you use the computer
• Deep change hurts - Kakushin
• Continuous improvement helps - Kaizen
• Workflow is hard work - Keep at it
• Empower the Patient Ease the burden
• Finish it Enjoy it

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Concept 1 - Computers dont improve anything

• Understand the Productivity Paradox
• Automation may not fix bottle necks
• Your EMR is not the gold mine -YOU are

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y
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If you have a mess and computerize it

• You end up with a computerizedmess

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Concept 2 Productivity is how the computer is
used it is thesame all over
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Viewers

• Paper in an electronic environment
• Chart can be in several places
• Productivity none
• Minimal Interaction

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Basic Users

• Interaction is limited
• Dictation is used
• Ordering
• Past medication
• No large productivity gains

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Strivers

• Use Templates to enter information
• Early in program first 1-2 years
• More efficient
• Replacing transcription but spending time on
  machine

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Arrivers

• A lot of time invested and now not needed
• Extremely good at their systems
• Reaping productivity gains

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System Changers

• Maximum Productivity
• Incorporate add-ons and workflow changes
• Bend it to their will

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Concept 3 -Workflow change depends ondeep
change -
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• Kakushin
• ??

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Kakushin

• A Deep Change
• revolutionary change or radical improvement
• Everything will be different
• Think in the Future

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Mechanical Swiss Watch
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Kakushin ?? which means innovation

• You make a large investment in a new direction
  Some people revolutionary change

Transition
Efficiency
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Luxury Auto

• Mercedes Benz Quality investment value sturdy
• BMW Style, handling, functional
• Audi Style, space, affordable
• Volvo Safe, Reliable, Quality
• Jaguar Attractive
• Toyota cheap dependable

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Bottom Line

• Status and Prestige
• High Quality
• Resale Value
• Performance
• Safety

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Build the Car but different

• Great handling but a pleasant ride
• Fast and smooth but a low fuel consumption
• Super quiet but light
• Elegant styling but aerodynamic
• Warm but functional
• Great Stability and yet low friction

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First Year

• Sold 2.7 times more Lexus the Mercedes Benz the
  leader

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EMR

• Improve Quality but decrease costs
• Improve Documentation but have more time with
  patients
• Improve access for patients but leave for home at
  5
• Increase R and D but improve margins

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Concept 4-Continuous improvement

• Kaizen
• ??

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Kaizen

• Incremental continuous quality improvement
• You get a little better each day
• Limited by technology
• Significant Limitation

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The Toyota Way-

• Measure Everything

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Process map patient care
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Time- from Druckers The Effective Executive
The Supply of Time is totally inelastic. No
matter how high the demand, the supply will never
go up. There is no price for it and no marginal
utility curve for it. Moreover, time is totally
perishable and can not be stored. Yesterdays
time is gone forever and will never come back.
Time is, therefore, is always in short supply.
Time is totally irreplaceable There is no
substitute for TIME
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The Toyota Way

• Look for what is valuable to the customer
  (patient).. NOT what you may value

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Waste

• Not safe 50000-100000 deaths due to errors
• 42 respondents experience poor or inefficient
  care
• 45 recommended care not given (not insurance
  related)
• ¾ of US population wants change
• 47 million uninsured

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Workflow to find waste

• Overproduction
• Waiting
• Unnecessary transport
• Over processing or incorrect processing

• Seeing someone who you should not-hospital
  rounds
• Patient Staff
• Movement back and forth
• Prescription in pt with allergy

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Workflow to find waste

• Excess inventory
• Unnecessary movement
• Defects
• Unused employee creativity

• Prescription refills
• Clickitis
• Pt left without needed shot
• I am the boss

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Patient Perspective
Waits For tests
Gets Tests
Checks In and Waits
Does Plan
Waits For Rx
Patient Arrives
Room
Doctor sees
Gets Rx
Wait
Nurse
Start
Done
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Workflow Digital and Not Digital
Concept 5 Workflow Workflow Workflow You can
not go Back-Lower the ODDS
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Lets Lower the OddsLets Go to the Office.
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First Step Patient comes to Clinic
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Patient Value to See You
Decides to come Phone Call 9 pm Give
Information Remember Get in Car Go to Office
68 minutes for 6 minute office visit
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Did they need to come?
To pay a bill Pick up something
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Physician View of Patient (who did not need to
see me)

• Low margin revenue
• Exchange of data
• Rechecks
• Patient who does not need to be there
• Could someone else do it?
• Non-visit care tomorrow (e-Visits)
• Work smarter not harder

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Patient comes to a receptionist

• Think about your office

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Waste?

• Efficient
• Paper there Did we need it? How did it get
  there?
• Looked in computer Phoned

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WASTE
Do you have lines in your office?
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Patient Enters the Clinic
Preparation
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VALUEWASTE
Pt coming to Office
Patient Registering
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Lobby Waiting

• 19/20 were waiting one filling form

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VALUEWASTE
Pt coming to Office
Patient Registering
Patient in lobby
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Vital Signs
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Vital Signs

• WASTE
• Accurate?
• Paper?
• Time to Log in?

• VALUE
• BP/Pulse/Weight
• 60 seconds

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VALUEWASTE
VS
Patient Registering
Pt coming to Office
Patient in lobby
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Vital Signs pulse BP

• ..\Movies 2006\MVI_2995.AVI

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Patient waits for doctor
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VS
Waiting for Doctor
Patient Registering
Pt coming to Office
Patient in lobby
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Doctor needs to know you are ready
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NOW THE DOCTOR ARRIVES
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Doctor does the writingDoctor does the data entry
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MD Documenting IS IT WASTE OR IS IT VALUE




   

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Options for Data Entry to EMR

• Handwriting recognition
• Typing
• Dictation
• Voice recognition
• Templates
• Patient entered data with editing

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Doctor using Handwriting Recognition
Slow, but seems great until have more than 6
words or misrecognition occurs
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EMR and 15 Minute Office Visit Doctor Handwriting
Checkout

Physician Documentation
Check-in
Vitals
Doctor for Data Entry Handwriting or
Handwriting Recognition
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1
1
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4
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Physician Exam
Escort
Escort
Nursing Documentation
Making Money
Wasting Money
Money Spent
Graphic derived from Dan Russler, MD, McKesson,
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Doctor Does the Data Entry
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Productivity Drop with EMR
Time of Office Visit
Kaiser Northwest, Portland, OR
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Revenue Drop after EHR
Carilion Health Care Roanoke, VA
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Where did they put the Computers?
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EMR and the 15 Minute OVDoctor Typing

Checkout
Check-in
Vitals
Using the Doctor for Data Entry
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2
1
42
3
4
2
8
12
Physician Exam
Escort
Escort
Nursing Documentation

Making Money
Wasting Money
Money Spent
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We could have nursing do this

• What would that look like?

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Data Entry into a Field-Prevention
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PREVENTION REVIEW This review was done when the
adult was 55 years old on Thursday, October 14,
2004. We have discussed the following topics
which are important for all people in your age
group cholesterols every five years (see past
medical history for your value), smoking habits
(can be found in past medical history), alcohol
use, abstinence, and being in a car with a
driver who has been drinking, recreational
drugs, aspirin should be taken daily , sexual
practices, Prostate check yearlylast exam 2004
and offered counseling. The following should be
done yearlyheight, weight, and blood pressure
done this year Injury prevention is as follows
seatbelts yes Smoke detectors yes Bicycle and
motorcycle helmet does not bike Guns and
violence no gun in home Other risk factors
reviewed passive smoke not at risk Exposure to
tuberculosis yes-(you are at risk and need a
TUBERCULIN TEST YEARLY) Sunscreens no-(you
should WEAR SUNSCREENS 15 OR ABOVE) Radiation to
neck no Have a family history of colon cancer,
familial polyposis no Colonoscopy or alternative
examination recommended after age 50 colonoscopy
2004 Risk for back problems not at
risk Brushing teeth and dental care yes Exposure
to loud noises not exposed You are at risk for
diabetes no risk Your risk for cancer is
related to these relatives none. You have had a
divorce in your family or separation, felt sad or
are grieving no You are angry or are frequently
angry YES Your shots are up to date yes and can
be found in past medical history. We recommend
all families know CPR. REVIEW OF SYSTEMS
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The EMR and the 12 Minute Office VisitNurse for
Documentation
Checkout

Physician Dictating
Check-in
Vitals
Using the Doctor for Data Entry
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1
1
42
4
3
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Escort
Physician Exam
Escort
Nursing Documentation
Nurse for Data Entry 18 Reduction Labor Cost
Physician Documentation
Checkout

Check-in
Nursing Documentation
Vitals
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1
1
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12
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Physician Exam
Escort
Escort
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We can dictate
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EMR and the 15 Minute Office VisitDoctor
Dictating
Checkout

Physician Dictation
Check-in
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Vitals
Doctor for Data Entry Dictation
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1
1
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2
2
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Escort
Escort
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Physician Exam
Nursing Documentation
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Decreased patient safety satisfaction
?
Transcription cost
Staff management of dictation

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Making Money
Inability to answer problems Poor referral
management Insurance rejection issues
Wasting Money
Money Spent
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Cost Comparison of EHR Data-Entry Workflows

• Physician
• Nurse
• Patient

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1
1
42
12
6
10
2
1
1
37
12
12
4
2
1
1
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12
3
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Where is the WASTE? Where is the VALUE?
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What are we doing in the exam room?

• WASTE vs VALUE
• History
• Physical Exam
• Plan
• Write Prescriptions

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Who is the owner of a persons health?

• Who is the customer?

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Instructions

• 40 lost in minute
• 80 lost in 30 minutes
• Incorrectly remembered
• J Royal Soc Med 2003 96219-222

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Information

• 71 of time patients are given nothing following
  their visit
• 68 of patients of Mayo Internists did not report
  what physician thought was a problem
• 54 a major problem

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Concept 6 - Empower the Patient
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Give the Patient a Copy of Their Note
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You are at the office

• A partners patient who has hypertension comes to
  see you because in the last ten days she has
  noted that her blood pressure is elevated from
  its baseline.
• Meds Lisinopril 20 mg daily
• BP 152/93

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What did we learn?

• We can not judge quality of care by reviewing a
  chart!
• Inputs are important
• Computerized history provided more information
  that was critical to this case, and was valuable
  to the clinician

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Vendors

• The literature has been around for forty years
• Without an EMR not all that practical
• Names are in the handout-None are here except one

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Instant Medical History (IMH)

• Software program you buy 50 dollars a month from
  Primetime Practice
• 75000 questions
• Install into a computer
• Tool on e-mail/internet for patients to
  use-Medfusion AAFPs portal
• 45 EMRs have as the interface to patient-This is
  huge
• www.medicalhistory.com

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How does it work?
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Patient Doing History
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How many of your patients can do this?
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OUTPUT IS GIVEN TO YOU

• Given to you on paper
• Given to you in electronic form like into Word
• Directly into an EMR

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ADVANTAGES

• Collects more data then a clinician and organizes
  it into a readable form

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Patient is better organizedPatients can do this
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Patient collects information that the clinician
misses

• 40 of time provided useful information not
  typically elicited
• Essential Questions missed
• Pilots Checklist

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How dangerous is health care?
Note both dimensions are logarithmic scales
REGULATED
DANGEROUS
ULTRA-SAFE
(gt1/1000)
(lt1/100K)
Driving
Scheduled
Deaths per year
Airlines
Chartered
Flights
European
Mountain
Railroads
Climbing
Nuclear
Manufacturing
Bungee
Power
Jumping
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Number of encounters per death
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Socially Sensitive
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Highly Adaptable

• SARS

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Documentation

• Most Clinicians do E4 work 55904
• Most Clinicians Code E3 work 55903
• Most Clinicians document E2 work.55902

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Others

• Patient controls interview-length of time
• Doctor only deals with positives
• Research
• Multimedia
• High patient acceptance
• Scales

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Scales

• Zung Depression
• Rahe Stress Scale
• Urology Scales
• Wast
• Conners
• Anxiety
• Pain impairment
• Patient Education Needs

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Tough Diagnosis
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Time of a Routine Office Visit
Plan
Subj.
Obj.
Pat Ed
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Future Time of a Routine Office Visit
Subj.
Plan
Obj.
Pt. Ed
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Complete Physical
Subj
Extra Time
Plan
Obj
Subj
Plan
Obj
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Jane Doe Chief Complaint Sore throat VS
stable Sore throat 3 days duration
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Lets look at history

• 80/20 Rule
• 20 of your questions get you 80 of the content
• Negatives are time intensive
• Analogy Mining for Diamonds!

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Mining-Topsoil sand it is easyOpen ended
questionsListening 2 minutes
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What are the results of All this labor
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It is like MiningYes/No questioning-tailings
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You can use a machine to Do the hard time
consuming Work
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You are in control You will trust the work
done Check out a few things
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A Clinic Story They see it and own it

• History was done on 5-page paper form, then
  translated into EMR
• Patients often forgot to bring form
• Office staff could see pt. on same or next day
  basis
• Insurance problems was common barrier to
  early-OB care

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A Clinic Story
PLAN Change workflow, add IMH
Call for Visit Come in Today or Tomorrow for
Intake Intake Visit IMH Rx Vitamins Insurance
Forms Video Prenatal Labs drawn in office MD
Visit 1-2 wks later History reviewed Exam Plan/D
iscussion
Call for Visit Wait 1-2 Weeks Send History Form
in Mail Initial New OB Visit Insurance
Forms Video MD Visit History reviewed (or
re-collected if pt. forgot questionnaire) Exam Pre
natal Labs ordered, pt. sent to lab Rx
Vitamins Plan/Discussion
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A Clinic Story

• RESULTS in FPC
• PRE
• NO Show rate 40
• MD Time 1 hr/pt
• Indicators missing

• POST
• 11
• 45 min/ pt
• all met

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You have the Subjective Portion

• Answers to a series of yes and no questions
• Minor alterations
• Documentation has improved
• Quality has improved-
• Pilot check list
• More complete inventory
• ATMs and electronic tickets
• Computer has had structured data entry

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Impression and Plan

• Using the Internet for plan if you do not have a
  template

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Concept 7 Finish IT, Enjoy IT

• Go home at 5PM with work done!

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Go get em
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References

• Bush Roger W Reducing Waste in US Health Care
  Systems JAMA 2007 297 871-874.

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