Why care about workflow when planning, implementing, and using health IT?

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Why care about workflow when planning,
implementing, and using health IT?
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Answer 1 To avoid pain and suffering

• Many clinics have implemented health IT only to
  find that they did not anticipate how much health
  IT can change clinical and administrative
  workflows.
• The unanticipated changes cause considerable pain
  during and after implementation for the clinic
  staff because suddenly the way things have to get
  done becomes very different.

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Answer 1 (continued)

• The pain and suffering caused by workflow
  problems is not just emotional. There can be
  significant disruption in
• Patient care
• Billing
• Communication
• So if you dont pay attention to workflow when
  implementing health IT, your patients, your
  staff, and your finances all may suffer.

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Some experiences

• Electronic Health Records Just around the
  Corner? Or over the Cliff?
• We recently implemented a full-featured
  electronic health record in our independent,
  4-internist, community-based practice of general
  internal medicine.
• We encountered various challenges, some
  unexpected, in moving from paper to computer. Its
  financial impact is not clearly positive work
  flows were substantially disrupted and the
  quality of the office environment initially
  deteriorated greatly for staff, physicians, and
  patients.
• That said, none of us would go back to paper
  health records, and all of us find that the
  technology helps us to better meet patient
  expectations, expedites many tedious work
  processes (such as prescription writing and
  creation of chart notes), and creates new ways in
  which we can improve the health of our patients.
  
• Baron et al. (2005). Annals of Internal Medicine,
  143 (3), pp.222-226

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Some more experiences

• How the Electronic Health Record Did not Measure
  Up to the Demands of Our Medical Home Practice
• One of our primary reasons for using an
  electronic health record initially was to receive
  lab results electronically. That way, we would be
  able to use clinical data to track treatment
  outcomes, target interventions to our needier
  patients, and facilitate our own quality
  improvement. Instead, we continue to receive lab
  data on paper documents that we scan and store as
  portable document format, or PDF, files, which
  means that we cannot trend them, search them, or
  use them as data elements.
• Fernandopulle Patel (2010). Health Affairs 29
  (4), pp. 622-628.

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Answer 2 It will assist in vendor selection

• By studying your workflows before choosing a
  vendor, you can
• Identify efficient and productive workflows that
  you would like to keep and inefficient ones that
  you would like to change.
• Determine how your workflows are likely to change
  after implementing the technology.
• With that information, you can ask each potential
  vendor about how their technology will affect
  different workflows.
• This way, you can select the vendor that best
  fits your practice.

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Some experiences

• Electronic Health Records Just around the
  corner? Or over the cliff?
• To support our electronic health records system,
  we needed to change the practice management
  system that was in place for scheduling and
  billing. To minimize the impact on
  physicianpatient interaction, we opted for an
  encrypted wireless network with Tablet personal
  computers (Hewlett Packard, Palo Alto,
  California), which we purchased from a different
  vendor.
• None of the physicians was especially
  computer-literate. The total quoted cost of our
  system, including hardware, software, training,
  and 1 year of support, was approximately
  140,000, which is within the range that other
  investigators have reported on a
  cost-per-physician basis.
• Baron et al. (2005). Annals of Internal Medicine,
  143 (3), pp.222-226

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Some more experiences

• Electronic Health Records Just around the
  corner? Or over the cliff?
• Our experience has been that complex software
  systems, like complex paper systems, come with a
  set of liabilities. Unlike the known liabilities
  of a paper charting system, whose origins and
  solutions lie within the control of a practice,
  the problems posed by the electronic health
  record were beyond our control.
• Resolving software glitches and errors required
  coordination with and cooperation of IT staff and
  software vendors outside the practice. These
  parties often had conflicting interests, leaving
  us with day-to-day work-flow problems that were
  difficult if not impossible to resolve.
• In the end, this amounted to a high unexpected
  cost of electronic health record implementation.
• Fernandopulle Patel (2010). Health Affairs 29
  (4), pp. 622-628.

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Assisting in Vendor Selection Example

• You might ask two different vendors what is the
  workflow for notifying physicians that lab test
  results are available?
• Vendor 1 says they are notified in their e-mail
  inbox that results are available.
• Vendor 2 says they are notified when they log
  into the electronic health record.

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Example (continued)

• If you have studied your workflow, you will know
  whether physicians regularly access e-mail or
  will have time to log into the EHR during the
  day.
• If your physicians regularly rely on e-mail, then
  vendor 1s system may work well for you.
• If your physicians document during or immediately
  after visits, then vendor 2s system may work
  best for you.

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Answer 3 To better prepare and train staff

• Every time you make a change to your practice,
  especially when implementing health IT, your
  clinical and practice management workflow will
  change.
• These changes may affect some staff members more
  than others.
• You need to train staff for the changes that will
  affect them.

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Preparing and Training Example

• Currently, physicians dictate notes during or
  after a visit.
• What will happen after you implement an EHR?
• If physicians still dictate the note
• Who will put the note into the EHR?
• When?
• Where will it be stored?
• In what form will it be stored?
• The answers to these questions
• indicate how much workflow will change.
• help you identify which staff members will have
  their workflows change and what training they
  will need.

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Answer 4 To plan ahead

• Although technology implementation may seem like
  a simple change, it is likely to be much more
  complex and challenging than you anticipate.
• By identifying how workflows will change, you can
  make better decisions.

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Planning Ahead Example

• Your clinic gives laptops to physicians so that
  they can access the EHR.
• Workflow analysis reveals that clinic scheduling
  provides physicians with time to review each
  patients chart just before seeing the patient.
• You like this workflow and want to keep it.

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Example (continued)

• Before the EHR, a staff person provided each
  physician with the paper chart for the next
  patient.
• But, the EHR system you selected only allows one
  person to be logged into a patient chart at a
  time.
• So, physicians cant review charts before seeing
  the patient because a RN or MA is logged in while
  rooming the patient.

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Example (continued)

• Because you purchased this EHR without realizing
  the impact on workflow, you are stuck having to
  choose between
• No physician access to patient records just
  before seeing a patient
• Delaying the physician entering the exam room for
  a few minutes so that there is time to review the
  chart after the patient is roomed
• Having the RN or MA record their notes on paper
  when they room the patient so that the physician
  can prepare.
• None of these are efficient workflows

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Wont the vendor analyze my workflow and tell me
what is best?

• Not really.
• Some vendors may analyze parts of your workflow.
• Some vendors may tell you what workflows you will
  need to have to accommodate their product.
• But the workflows required to accommodate a
  vendors product may not be good for your staff
  and your patients.

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Wont the vendor analyze my workflow and tell me
what is best (cont.)?

• No vendor will study all of your workflows.
• Vendors will not know what workflows are best for
  you. Only you can decide that.
• Before talking with a vendor, you need to be
  prepared to
• Tell them about your current workflows.
• Describe what you want your workflows to be like
  in the future.

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Conclusion

• Only by understanding the details of your
  workflows, you can
• Have more informed discussions with a vendor.
• Make good decisions for your clinic.
• Optimize your patient care and protect your
  clinic financially.

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References

• Baron RJ, Fabens EL, Schiffman M, Wolf E.
  Electronic Health Records Just around the
  corner? Or over the cliff? Annals of Internal
  Medicine 2005 (143)3 222-226.
• Fernandopulle R, Patel N. How the Electronic
  Health Record did not measure up to the demands
  of our medical home practice. Health Affairs
  2010 29(4) 622-628.