This transcript is intended to provide webinar content in an alternate format to aid accessibility. We apologize for any inaudible or unclear content as a result of audio quality.

Workflow Redesign and EHRs

Presented by [Phil Deering and Pam Oach] (41-minute Webinar) [11-16-2010]

Angie LaFlamme:I’m going to give a brief overview of our REACH Program. REACH is a non-profit FederalHITRegionalExtensionCenter, dedicated to helping providers and clinics, small hospitals and other settings in Minnesota and North Dakota implement and effectively use their EHRs. Our mission is to assure that each of our REACH clients achieve meaningful use.

REACH is a program of the Key Health Alliance, a partnership of Stratis Health, the NationalWorldHealthResourceCenter and the College of St. Scholastica, which also collaborates with the North Dakota Healthcare Review and the University of North Dakota School of Medicine and HealthSciencesCenter for Rural Health.

I’m going to introduce our moderator this afternoon, Shirley Eichenwald-Maki. She’s an assistant professor in the Department of Healthcare Informatics and Information Management at the College of St. Scholastica in Duluth.

Shirley

Eichenwald-Maki:Thank you Angie. I’d like to introduce our two speakers for you this afternoon.

Pam Oachs, MA, RHIA is an assistant professor in the Department of Healthcare Informatics and Information Management at the College of St. Scholastica. Prior to working in academics, she worked at a large health system in various role including clinical quality improvement, Joint Commission accreditation, patient access, and information technology. Her interests focus on managing user involvement in health care technology including project management, change management and workflow analysis.

Presenting with Pam today is Phil Deering, who is a REACH regional coordinator and an HIT consultant for Minnesota and North Dakota. He is a hands-on consultant with expertise in project management, process documentation and redesign, software systems implementation, organizational change management, facilitation, and instructional design and training.

We’re pleased to have both of them presenting today on workflow redesign for EHRs and I believe Pam is going to be the initial presenter.

Pam Oachs:Thanks Shirley. Good afternoon. Today we’ll get started with the objectives for the webinar. As you’ve read those in our advertising material, we’re hoping you…

  • Learn the value of understanding current clinical workflows
  • Understand how workflow documentation can improve the success of an EHR implementation
  • Increase your awareness of practical workflow analysis tools
  • Receive suggestions on ways to involve clinical staff

Phil is going to get us started with our discussion.

Phil Deering:Hi. Thanks again it’s great to see many of you who we are currently working with in the attendee list, so hello to everyone who is a REACH client and for all of those of you who aren’t yet REACH clients, please feel free to check us out, we feel we have a lot to offer.

I thought we would start by talking about what’s so great about flowcharts and the underlying reason we use flow charting. That is that it gives us a visual representation of complicated things. When Pam and I started working on this I realized as with all of us in all of our lives we’re always waiting too long and we’re too busy, so I drew a flowchart where the first circle says get asked about doing a webinar on flow charting.

The flowchart directs us down to a box that says do you agree to do this? If I had said no I could go to the relax box that’s on the left, but I said yes and went to another decision point that says is this going to happen within a weekend? If it was no, then again you’d go to relax and not think about it. That brings us to yes with less than a week and we hit the panic box.

The underlying point there is that again flow charting is simple, we can do it with simple tools, you can draw it by hand but when you do it you can quickly start to get powerful lessons. The point here is that perhaps I could have re-engineered my process so I didn’t have to hit a panic box.

Enough kidding around,

Why are we having this in the REACH methodology and not only in REACH where we’re working with clinics to select and implement electronic health records, but really any other methodology that you’ll look at that would help people select and implement technology, especially electronic health records. There’s always an emphasis on process mapping.

Why is that true?

First, it’s a great way to begin engaging the organization in the concept of change. EHRs will force standardization. Within the constraints of an EHR every provider can’t do the things, they want to do it their own way so that over time, to be successful in an implementation there has to be one right way to do things. The EHR implement requires review of workflow and process mapping engages the entire organization or certainly begins with engaging a key team of people but then stretches out and engages the entire organization in a process of structured thinking.

The other terrific thing about doing process mapping is that it gives us an opportunity to implement process improvements long before we have completely implemented the EHR. Because again, when people have the ability to visualize processes, aha moments or low hanging fruit, things that can be quickly improved tend to pop out.

The success of EHR comes from not just implementing technology but from changing the way people work and the way the business process is implemented at the clinic, we realize the importance of using process mapping.

Pam and I are going to pass the ball back and forth so Pam is going to take a minute and talk about the next few slides.

Pam Oach:Process maps specifically illustrate the nature of the activities and the sequence of work.

As Phil said, process maps are a visual representation of complex activities. It’s what they are, who does themand when are they done? Process mapping really begins the change management process by engaging users. Process maps can’t be created without engaging the users, those who do the work and can realistically demonstrate the workflow, that can identify problems and work around opportunities for improvement.

Process maps can be used to identify the unique functional requirements for an EHR in one’s facility because you’re able to document what’s really going on in your workflow.

Again, the focus here is on the process rather than the EHR technology. The thing to remember about process is that it’s often hidden by a focus on specialties and departments, particular functions, and a process should cross those functional boundaries so that you aren’t working with too narrow of a scope. You need to remain customer focused. Who is the customer? Who’s at the end of the process that you need to work for?

For example, how many times does a patient ask for the same information? We often have that complaint from our customers. Oftentimes if a patient is seeing numerous providers, after they see the first provider and then go to the second and they are again telling the same story. Your workflow can help you identify where those redundancies are and where different departments could work better together.

The definition of a process is the complete set of activities that cross functional boundaries to accomplish a task. If you have an event the tasks that go along with the process and then what are the results?

Phil Deering:When you’re beginning a process mapping initiative one of the first things you want to do is what we call in consultant language, frame the process. Basically, you need to understand what the boundaries are of the process that you’re going to be documenting. Where does it begin? Where does it end? How deep into that process are you going to go?

When you identify the boundaries that helps you identify who the people are that you would be talking to. So, if you’re doing a clinical process and you want to concentrate on what’s happening inside the examining room then you may not need people from finance or administration on that team. On the other hand, if you’re talking about the process of getting the patient in the door and getting them roomed, then you probably need to have a broader set of people involved in that process.

So by framing the process we mean, figuring out what you’re going to document and then who the team of people will be that will help you do that. There is a lot of discussion in the workflow analysis about how much time we spend on the current as-is process as opposed to the to-be process. One thing we know for sure is if you’re going to undergo a major change, like the change that will occur when you implement an electronic health record, it’s essential to have enough documentation in place so that when you implement the new technology that no important steps in your process are left out.

That’s a general answer but in the end if you think in a way that process maps are the checklist to make sure that you’ve covered all the things you need to cover in your electronic health records, that’s the level you want to go to.

Finally, once you have a visual representation of the existing process it becomes relatively easy to begin moving the boxes around and develop the new to-be process.

Pam Oach:We have a couple practical examples to provide you. One is a one-page process frame and of course once you start adding information that will expand to more than one page; however, it does exactly what Phil mentioned. It sets the boundaries for the process so that you can identify what the process is you’re looking at, what the trigger event is that starts that process and then the milestones which then bring you to the result.

For instance, if you’re looking at the process of a patient coming in to be seen in the clinic, the trigger event may be the patient checking in. The result may be the patient checking out and being treated. Then what’s happened within that is that the patient is roomed, has vital signs taken and are seen by the provider, etc.

So identifying the process can be done in some overview milestone steps. Also, in this example you’re able to identify who the stakeholders and customers are. Remember customers can be internal as well as external, so your customers obviously are the patient, but also there may be other care providers you’re working with in this process who are also customers within. People like the lab technicians, physicians, registration staff, who are the stakeholders in this process and who are involved.

Mechanisms can be documented as far as, are you using technology currently?

Is there a check-in process through your software?

Is it a manual telephone call?

What are the mechanisms that you’re using?

Also a case for action and assessment… it’s good to identify why you want to look at this process. What will the benefits be if you move forward and look to streamline this process? That then goes along with your vision. What do you want it to look like? What’s your goal in analyzing this process, looking at the workflow and improving it?

Then of course also important are the metrics or measures. How will you measure this process and whether or not you’re improving or not? The measures are important.

Next you’ll find another example, a different template per se, but the same types of content where you identify the process, you have identified the benefits, what the metrics are, how you will measure those and then what are your goals? What’s your vision? Again, another template and tool you can use to help identify that process and why you want to move forward, as well as what your goals are in analyzing that workflow.

Phil Deering:I believe that this presentation will be made available to all of you and certainly I know at the end we leave behind some email contacts so if people want these specific little tools that you’re seeing embedded in the slides, know that we can provide those.

Mapping as-is process – we touched on this a bit but again this is always a sense of tension, especially when people know that the future is going to change quite a bit. It’s like, why should we spend all this effort mapping the current process? Let’s talk about that.

First of all, one of the ways to think about process mapping is like unpeeling an onion or going layer by layer and since the notion of processes is often complicated and hidden to people, people know they do a job, but they rarely think of the fact that they are a part of a business process. By describing your business visually and providing these various levels and Pam will show you examples, basically you’ll begin to get a sense of the things that you do in the clinic and make boxes that represent them.

Use an 80/20 rule of sufficient detail.

This is one of those things that makes sense in general, but how you really know what the 80 and 20 is. Certainly, when you get to the level of work instruction, you know you don’t want to go any deeper than that. Work instruction are things where the detail of the instruction doesn’t fit well within the sort of three or four words that you can fit in a process flow box.

We want to capture about 80% of the activity we do and we want to capture it in simple descriptions. Again, we talked about the notion of low hanging fruit. I think we don’t have to dwell on that and I want to encourage you, in that if you begin to illustrate what you do you will see methods and places for improvement. Certainly they may be around redundancies, around people not working at the top of their license or around actual important things that are being skipped that you need to capture.

You can’t do this with outsiders you need to do it with the people who do the work.

Pam Oach:The to-be process really is a follow up after you’ve identified your current as-is process. The new to-be process is a combination of what is currently and then also the design of technology that you’ll be implementing. It helps you to identify functional benefits, how we can improve as well as functional constraints. Even though we may want to do this process in this way, what are the constraints in doing that?

Doing the workflow between the current and the new to-be process can help you identify that and in doing that forms the basis for change management and training. So, when you have the diagrams of your current processes, which you can’t do without the involvement of the people doing them, you also need their involvement to improve the process. How can it be done better? Both of those workflows can help set the stage for staff understanding that there needs to be change and what that change will be.

It allows for the workflows to be distributed widely and discussed throughout the staff doing them.

Let’s look over a few examples of how this would look. The first slide shows the same process, once in the current form as it’s being done and then on the right hand side, how it could be done in a to-be or future process. The difference is basically using voice recognition for clinical documentation versus dictating, using digital dictation or where you need to have more information going manually to your transcriptionist.

You can see the flow showing maybe 5-7 steps on the current as-is process involving the radiologist who’s dictating his interpretations, a clerk who’s picking up packets of information needed for transcription, the transcriptionist getting those packets and transcribing the records, and then returning the completed reports, and again the clerk bringing those back to radiology.

The difference then as you look to improve, what you’re looking for are areas where maybe you can cut down on steps and eliminate variations and that sort of thing. The one diagram shows dictating films using voice recognition which is all electronic. The transcriptionist can retrieve that, dictate a report from the system, validate the content and the radiologist can then sign off.

This is an example because of course everyone’s process will be different, but when you look at workflows hopefully you can find those areas that can simplify a process.

Some process mapping tools and what they’re meant to do is to give you tools that can show varying levels of detail. The tool selection may depend on the nature of the process being mapped. The tools can be paper based as Phil mentioned earlier, they can be hand drawn. It can be automated, web based, etc. There are many tools that allow flow charting and diagram building that can be used.

The key is to choose the tool that works best for your organization. Maybe your organization is familiar with using flow charting. Maybe they used slim line diagrams, whatever the case is the tool isn’t as important as understanding the process. The key to workflow analysis is using whatever tools work best for your organization so the processes can be mapped out and understood.