Digitized Medicine

Today, while wearing my hat as the Board Chairman of the North Texas Regional Extension Center, I am writing a message primarily to my colleagues who practice medicine across North Texas.   I am sharing this message through my blog, however,  because others may be interested to see and hear what is happening at the grassroots level of local and regional health IT initiatives:

 

  
 February 2, 2011

To my physician colleagues across North Texas,

On behalf of the volunteer physician board members of the North Texas Regional Extension Center (NTREC), I am writing to inform you that registration for the federal electronic health record (EHR) incentive program has begun and that the money is already flowing.   In January, for example, two Oklahoma physicians at the Gastorf Family Clinic of Durant, OK, received $21,250 each for having implemented a certified EHR.   If you are considering making the jump to an EHR, or if you already use one, you may become eligible for EHR incentives up to $44,000 under Medicare or $63,750 under Medicaid by meeting “meaningful use” requirements.

NTREC receives federal grant funds for providing on-site technical consulting to enrolled physicians who are selecting, implementing or using an EHR.   This federal subsidy allows NTREC to charge primary care physicians only $300 for consulting services valued at $5,000.  

NTREC is focused on helping you:

• Select and implement a certified EHR (or upgrade your current EHR to a certified version),
• Optimize your practice workflow,
• Achieve meaningful use,
• Qualify for EHR incentives, and
• Obtain CME credit hours along the way

I am happy to report that NTREC services were successfully launched four months ago.   Since then, 289 physicians have enrolled for services and another 370 physicians have enrollment contracts in progress.   Our goal is to provide services to more than 1,500 physicians in North Texas by the end of 2011.   Our operational plans will enable us to scale physician services to even higher levels if needed to meet physician demand.  

The federal EHR incentive program and these discounted NTREC consulting services are unprecedented and genuine.   Please call NTREC to enroll and set an appointment for on-site consulting at (469) 648-5140 or by visiting  www.ntrec.org.   The NTREC’s dedicated team of experts will be considerate of your valuable time and show you how they can help you identify and meet your unique needs.

If you have questions, please don’t hesitate to contact me.

 

Sincerely,

 Matt Murray, M.D.

Brown Lupton Health Center

Texas Christian University

 

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Use of certified electronic health record (EHR) technology is a core requirement for physicians and hospitals to become “meaningful users” and to be eligible for payments under the Medicare or Medicaid EHR incentive programs.    Operationally, CMS requires providers who apply for these payments to submit the "CMS EHR ID" that their certified EHR technology is assigned.   Physicians and hospitals will benefit from an awareness of several issues revolving around EHR certification and on this CMS EHR ID, especially when "goin' to the CHPL" as noted below.

Awareness Issue #1:  The Office of the National Coordinator for Health Information Technology (ONC) in 2010 established a temporary certification program for EHR products.    A permanent certification program, which builds upon the current temporary program, is expected to be ready to launch by the end of 2011.   This program uses ONC-Authorized Testing and Certification Bodies to test and certify EHR products.   The list of certified EHRs is updated as new products are certified and posted on the Certified HIT Product List (CHPL) website.    CHPL is maintained by ONC and is the sole, designated authoritative list of currently certified EHR products.  

Awareness Issue #2:    ONC certification is different from that provided by the Certification Commission for Health Information Technology (CCHIT).    CCHIT certification is based on more comprehensive criteria.    CCHIT certification continues to be an important resource for those who are in the process of selecting an EMR because of this more comprehensive testing.    ONC certification testing, on the other hand, is specifically based on the CMS Meaningful Use criteria. 

Awareness Issue #3:   EHR products are tested and certified by ONC as either a Complete EHR or a Modular EHR.   A Complete EHR product is defined as an EHR product that meets all of the certification criteria for meaningful use.  A Modular EHR product is defined as an EHR product that meets at least one but not all meaningful use criteria.

Awareness Issue #4:   When a physician or hospital apply for their incentive payment they are asked to submit to CMS the "CMS EHR ID" that is assigned to their EHR product(s).  The CHPL website is the only place where this ID number can be found.  

Awareness Issue #5:    When looking for this CMS EHR ID number, it is helpful to know that this is not the same number ONC provides the EHR vendors when they are certified.    This is because some providers may decide to use a modular approach and combine Modular EHR products from different vendors in order to achieve meaningful use (i.e. a basic EMR without e-prescribing from one vendor and an e-prescribing module from another).  

Awareness Issue #5:   As the website works today, the CMS EHR ID can only be found on the "Grocery Cart" page and only after the <Get CMS EHR ID> button is activated.    One first selects their EHR product(s), puts them in their "Grocery Cart" and then goes to their <Grocery Cart> page.    The button becomes available when one has either:

• selected a certified Complete EHR product

                                     or

• selected a set of certified Modular EHR products that meet all of the certification criteria      

It interesting and helpful that CHPL provides real-time feedback when selecting a set of Modular EHRs.  Once all of the criteria are met, the <Get CMS EHR ID> button becomes available.  

Awareness Issue #6:    Regarding the modular option, the CMS certification process does not include integrated testing of all the possible permutations of Modular EHR sets that can be selected.    So even though a set of Modular EHR products may produce a CMS EHR ID on the CHPL website, this does not mean that the selected set of products were tested as an integrated unit.   This does mean that the physician or hospital who is in the EHR selection process should not depend on the CMS EHR ID to determine whether the selected products can be interfaced or work together.     Due diligence will still be needed to ensure all of the selected Modular EHR products are compatible.   

In other words, if you're goin' to the CHPL and gonna' get an CMS EHR ID, it's best to know your EHR partners well before purchasing and implementing them!

Safe use of electronic medical records (EMRs) is enhanced when physicians focus their EMR implementation on quality of care improvements.  Effective communication among the staff about these key goals creates a positive environment that serves as a catalyst for successful use of the EMR.  In addition, large healthcare systems and small physician offices are both less likely to encounter patient safety issues when they align their health information technology (IT) strategies to quality of care goals.  

Case Study:  Several years ago the leadership of an Accountable Care Organization (ACO) formed between a local healthcare system and a multi-specialty physician group began working collaboratively on a common vision for patient safety excellence.  System-wide integration and use of medication reconciliation were top priorities.  The EMR used by the hospitals have an ambulatory component that meets all of the critical requirements determined by the physician board members.  If implemented, the ambulatory and hospital EMRs could be integrated and share the same master patient index, drug formulary, medication index, allergy index and set of clinical decision support rules.  However, the physician board, influenced by several leading opinion-makers who favored an alternative EMR, convinced ACO leaders to allow the physicians to purchase their own ambulatory EMR and use system resources to purchase and develop a data repository that could send/receive (bi-directionally) and store data between multiple sources.  The vendors involved promised they could provide the infrastructure and tools necessary to capture and manipulate the data.  Two years later a patient suffers a severe anaphylactic reaction after receiving an antibiotic injection in one of the physician offices.  An investigation reveals that although the EMR had properly displayed the allergy, the antibiotic order had not triggered an allergy alert.  Further research reveals multiple ways for an allergy to be entered into their customized, bi-directional medication reconciliation tool that would successfully display the allergy in the ambulatory EMR, but not trigger an alert during the ordering process.  Their conclusion is that the use of different EMRs with multiple drug formularies, multiple medication and allergy indices and different clinical decision support rules is more complex than anticipated.  They suspended use of the medication reconciliation tool until they could determine whether they could more effectively execute their current strategy.

Key Points:  Effective organizational characteristics and a focus on quality of care are important catalysts for safe EMR use.

Cultivating a culture of safety, promoting transparent communications and alignment of strategic planning with prioritized goals to improve quality of care are examples of organizational characteristics that facilitate safe EMR use.  In this case the organization did well creating a shared vision with common goals/priorities regarding quality of care.   However, organizational alignment fell apart when the unbalanced interests from one part of the organization created the perceived need for an alternative strategy.   Although the new strategic plan was plausible, the organization did not have the resources or organizational discipline to effectively execute plans that were considerably more complex.   It will be paramount for ACOs to effectively manage such issues in the future.  Similarly, even the small, individual physician practice is more likely to be successful with an EMR implementation when they develop a strategy to improve quality of care through the implementation of an EMR.  

Physicians would prefer that an EMR computer screen emulate a tri-fold flow sheet that inspires a "gestalt feel" for the whole clinical situation.   Instead, data split among multiple screens with the need for numerous mouse clicks and excessive scrolling in order to see all the information tends to frustrate clinicians.  The frustration comes as a result of the fragmentation of our thought processes and patterns which have developed over time.    In addition, "user interface" issues can become a patient safety risk.  The following case study provides an example of such an issue.   

Case Study:   A small practice had their EMR vendor develop a custom report called the Patient Summary that “pulls in” EMR data including lab and radiology results.  This report is useful while on-call because they can remotely access it from home over the Internet.   Over one weekend the on-call physician discovered that some of the lab results for one of his patients did not show up on the Patient Summary.    He checked several other patients and found another example of missing results.   He decided that this report was unreliable and that he would not use it until the issue was understood.  The EMR vendor was notified on Monday.   They quickly determined that the report was working normally and no data was missing.   They suspected the doctor forgot that this report displays a little <+> symbol at the bottom of the screen if there are additional lab results that will not fit in the space provided.   At that point the physician realized that he had used his new iPhone for the first time and that the small viewing display had made it very difficult to for him to see the small <+> symbol.

 

Key Points:

• Displaying medical data on a computer screen in a manner that meets the cognitive challenge at hand is difficult and can fragment a physician’s thought processes

 Since tri-fold computer screens are not a practical solution today, physicians need to involve themselves in the development of the EMR content screens that they will be using on a day-to-day basis.  For most EMR products these screens can be configured and used in various ways.  In this case the small display inherent to smart phones was inadequate when viewing the report.   But this is because it was not designed with the small viewing area and resolution of a smart phone in mind.  If presenting this data on a smart phone is a requirement for this physician, a new report will have to be developed in order to meet that new need.  

• “Think simple” when developing EMR screens that clinicians interact with

Complexity makes EMR use even more difficult and less safe.   Most EMRs allow modifications to some EMR screens that physicians interact with such as documentation templates, reports, orders and order sets.   Good advice to those who develop these screens is to “think simple”.   For example, if six gastroenterologists decide to each create their own list of 25 order sets to accommodate personal preferences, their EMR order set screen will display 150 order sets.   Creating a screen that displays 125 choices for physicians has a pre-determined fate.  They would be better served by collaborating on 25 evidence-based order sets to share.   The result will be less frustration, less variation from evidence-based medicine and less work when annually reviewing the content of order sets.

It is not uncommon to find physician groups who use the same version of the same electronic medical record (EMR) product but with significantly different degrees of satisfaction.  How can this be?  The following case study illustrates how successful EMR implementations leverage the capabilities of the EMR to streamline work flow and achieve specific goals.  This is the second of six case studies being used to describe the safe use of EMRs.

Work Flow and Communications Case Study:

A pediatric group in the final stages of selecting an EMR product sent their “physician champion” on site visits to two similar practices who had implemented identical versions of the same EMR.  At the first site visit the physicians are very pleased with the EMR and describe how clinical decision support tools help them achieve their goals.  For instance, during an 8 month-old Well Child visit the EMR defaults in a developmental history template that prompts age-appropriate questions.  With a single click on the order button an order set with routine orders for an 8 month-old Well Child visit displays.  The orders are completed in 30 seconds.  The pediatricians proudly tout the weight-based dosing option that calculates medication doses based on the patient’s current weight.

At the second site the physicians, parents and staff grumble about “going electronic” and complain about how long it takes to enter orders.  The visiting physician gains much insight while observing an 8 month-old Well Child visit.  The physicians rarely make eye contact with the parents as they struggle to find age-appropriate developmental screening questions from a long pick-list of questions they had built on a single developmental history template used for all patients.  They order each immunization, test and prescription separately.  Each test requires at least 5 clicks, three screens and a lot of scrolling.   They also manually calculate medication doses and type them onto the e-prescribing screen.   It takes several minutes to complete the orders.   When you ask why they don’t use the EMR’s weight-based dosing option, they reply that they discovered the weight-based dosing function is not safe to use.

Key Points:

• Successful EMR implementations leverage the capabilities of the EMR to streamline work flow and achieve specific goals

Most EMRs have at least some features that can be designed and configured to work in different ways, or not used at all, such as order sets, documentation templates, health care maintenance tools and other clinical decision support tools.  Understanding these capabilities and designing optimal ways to leverage them are critical for successful EMR implementations.  The first group knew their goals and designed the EMR to achieve them.  They were particularly adept at leveraging the EMR’s capabilities to streamline work flow.  The second group, on the other hand, is floundering with poor work flows and no apparent goals for the EMR other than “going electronic”.

• Automation of inefficient paper-based processes is a common risk to avoid

In the first office the physicians consider weight-based dosing to be a real time-saver and patient safety enhancement, but the second office considers it to be a patient safety risk.  It turns out that in the second office the nurse opens up and uses a single documentation template to enter documentation during the entire patient visit just like she did with paper records.  She keeps this template “open” because it takes too much time to submit part of the documentation, then re-open it to document more, then submit, re-open and so on.  So when the physicians used the weight-based dosing option, “today’s” weight would not display because the nurse had not yet submitted that data.  Thus, their poor work flow design and lack of synchronization not only slowed them down, but created a patient safety issue if the weight-based dosing option was used.  In the first office they avoided this by designing a “Vital Signs” template that the nurse used at check-in.  After the vital signs were entered into the template and “submitted” by the nurse the next logical documentation template conveniently popped-up to use. This group had used an IT consultant to help them redesign their work flow to take advantage of a paper-less environment.

• EMRs can interfere with physician-patient and physician-nurse communications

The lack of eye contact noted by patients in the second office is an example of how EMRs can impede communications in healthcare settings. It is prudent to be aware of the potential for such communication problems and to consider ways to avoid them.

I am using six case studies to illustrate that most EMR-related problems, even those involving hardware and software, can usually be traced back to some controllable factors.   The safe and meaningful use of EMRs is facilitated by leveraging these controllable factors to minimize these problems.  

This case study is the first of six cases used to illustrate aspects of EMR use that pose risks to patient safety.   The risks discussed in this case pertain to EMR hardware and software failures.  As with most EMR-related problems, the majority of patient safety issues associated with hardware/software failures can be traced back to controllable factors.  The safe and meaningful use of EMRs is facilitated by awareness of these risks and controllable factors.

Case Study:  At 0900 physicians in hospital-based ambulatory offices were suddenly unable to access their web-based EMR. The hospital’s IT Service Desk reported a wide outage of internet access due a “hardware failure” and the estimated time of repair was “unknown”.  The offices activated their paper-based downtime plans, but many patient safety issues were encountered.  For example, physicians were solely dependent on the patient’s recollection of allergies because they had no access to allergies recorded in the EMR.  A process was developed “on-the-fly” to use a laptop with mobile broadband connectivity to access the EMR, but before these were ready the original problem was resolved at 1130.  It was discovered that an IT employee installed a planned “Windows update” to the hospital’s networking hardware that morning with unexpected results.  After the problem was identified the update was “backed out” and the problem resolved.

Key Points:

• Hardware and software technology problems will occur, but most are preventable and can be minimized with proactive IT management

Access to secure and reliable patient data in an EMR is dependent on hardware and software that is properly sized, configured, managed and functioning.  Power outages, running out of data storage space, network outages, software conflicts, malicious intrusions and computer device failures are examples of technical problems that threaten safe use of EMRs.  Most technical problems, however, are preventable through proactive IT management.   For example, an old computer that burns out could have been prevented by proactively replacing old technology equipment at specified intervals.  Reputable IT experts know the “best practices” for proactive IT management (such as ITIL and COBIT).  In this case basic change management practices were not followed.  Physicians should make sure that their EMR hardware and software, whether physically located in their office or located elsewhere, are proactively managed by reputable IT experts.

• Physicians are responsible for developing “downtime plans” that describe how the office will safely care for patients when the EMR is unavailable

HIPAA requires patient data to be “backed up” and physicians need to be able to restore their EMR in the event of a complete hardware or software failure such as a flood, tornado or fire that destroys computer equipment and software.  “Disaster planning” addresses these needs and primarily requires the EMR vendor’s technical expertise and advice.  “Downtime plans”, on the other hand, primarily need the physician’s expertise to define what needs to happen in order to safely care for patients (what I call clinical continuity) and maintain business operations (commonly referred to as business continuity) when the EMR is unavailable.  Downtime planning should identify the critical patient data that is needed when the EMR is down and have written procedures on how that data will be accessed.  The plans should also describe procedures for the use of downtime paper forms for patient care tasks, medical record documentation and practice operation tasks (appointments, claims and billing) as well as what to do with them after the downtime.

• “Mock downtime drills” are an effective way to determine whether an office is prepared for an EMR downtime

In this case the physicians deserve applause for developing written downtime plans.  However, if they had previously simulated a downtime, then they would have been prepared with back-up laptops ready and available.  Although mock drills in themselves create risks, they are much more controllable than the risks inherent to unplanned EMR downtimes.

In a previous blog the methods used to perform a work flow analysis in a physician's office as a part of the EMR selection process were described.  The  next steps are to:

 

Determine at a high level the future desired work flows (when an EMR will be used)

Prioritize this list of work flow desires

Develop a prioritized list of EMR functionalities needed to meet those  desires 

Compare EMR products based on these priorities

Document Future Desired Work Flows

An analysis of current work flow identifies bottlenecks in the physician's practice.  Changes in work flow may alleviate those bottlenecks.  Some of the identified changes may not be dependent on having an EMR and could be made immediately.  The other work flow changes that are dependent on using an EMR and will later become part of the EMR implementation.   

It is not readily apparent to many physicians how an EMR could improve work flow in their office.  There may also be unrealistic expectations about how an EMR could improve things.  Therefore, it is helpful to first gain knowledge about the "best uses" of ambulatory EMRs as experienced by other physicians before identifying desired future work flows.  To gain insights on the realistic and best uses of EMRs physicians may be wise to engage a knowledgeable IT consultant.  Alternatively, physicians may use other resources  to gain insights such as:

• DOQ-IT's Operational Redesign Workbook
• AHRQ Health IT Toolbox
• CCHIT
• Networking with colleagues
• Physician professional organizations

The knowledge gained on EMR "best uses" and the identified work flow  bottlenecks can now be analyzed together to determine at a high level what future work flows are desired for the practice. 

Prioritize this list of work flow desires

The physician practice may now discuss these desired work flow changes and prioritize them.  For the purposes of discussion let's suppose the practice has identified a top ten list of desired work flow changes that they want make when they implement an EMR.

Develop a prioritized list of EMR functionalities

The prioritized top ten list of desired work flow changes will naturally translate into a list of EMR functionalities that are top priority.  For instance, a practice that determines "refilling 80 prescriptions/day" is currently their top bottleneck, then the most important EMR functionality to compare among products is the usability of the EMR's e-prescribing feature.  A different practice may identify their top bottleneck to be getting patients through the check-in processes and determine that they want to reduce time patients spend filling out papers on clipboards by providing online registration forms and using a self-serve kiosk in the waiting room.  They also desire an EMR that can quickly register and check-in patients.  In that practice the most important EMR functionalities will be a robust patient portal, efficient integration with kiosks and the fewest number of necessary screens and "clicks" when registering or checking-in patients at the front desk.

Compare EMR products based on these priorities

EMRs have hundreds of functionalities.  It is not humanly possible to effectively compare hundreds of functionalities between different EMRs.  Comparing EMRs without focusing on specific needs easily leads to frustration and/or confusion.  Using the described list of prioritized EMR needs will improve the comparison process. 

Physicians might consider limiting their comparison to EMRs that have been certified by CCHIT (and soon to those certified for "Meaningful Use" as well).  One can be confident that a CCHIT-certified EMR has all of the functionalities that are described on the CCHIT website.  There are hundreds of such functionalities.   However, CCHIT does not necessarily quantify how well the EMR performs each function.  So, if a physician practice limits their comparison to CCHIT-certified EMRs, they can be assured the EMR can do those hundreds of things an EMR should be able to do and instead spend their time comparing how well the EMRs meet their own, identified "top ten" needs.  

Using an earlier example of an identified "top ten" EMR need, a comparison may find that EMR Product "A" allows prescription refills to be completed in 45 seconds using three screens and 17 clicks, while Product "B" refills prescriptions in 15 seconds (30 seconds faster) on one screen with 6 clicks.  Since the work flow analysis revealed that the practice has 80 refills/day, refilling prescriptions using Product "B"" would take 40 minutes less each day as compared to Product "B".  

In summary, it is helpful for a physician practice searching for an ambulatory EMR to perform a work flow analysis to identify the major bottlenecks in the office, gain insights on how EMRs can improve work flow, use this knowledge to develop a prioritized list of desired future work flows, identify the "top ten" things an EMR needs to do to meet those desires and then compare CCHIT-certified products based on this prioritized list of EMR needs.

EMR Selection Guide provides an outline of other topics on the selection process

 

EMR Implementation Guide provides an outline of topics on the implementation process

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For those who enjoy the ease and convenience of online shopping or use of self-pay kiosks for everyday activities like purchasing gasoline and groceries, it is hard to understand why medicine has remained so heavily paper-based.   On the other side, those who work closely with healthcare providers during and after technology projects recognize how complex and difficult it is.   Almost two thirds of technology projects fail as they run into problems such as unplanned costs, excessive delays, poor quality, expectations not being met and excessive numbers of unresolved issues.   When such “failures” are analyzed it is common to discover preventable causes such as poor planning, inadequate testing, poor work flow redesign, failure to identify and manage risks, poor communication, faulty implementation strategies, selection of the wrong technology products or the use of good technology in a way it was not designed to be used.   Although there are not simple recipes to follow that guarantee successful health IT implementations, there is a large body of knowledge regarding how best to manage technology projects in general.   A major resource for this knowledge is the Project Management Institute which promotes the science of project management throughout the world.   Although the details of project management are beyond the scope of blogging, there are eight knowledge areas that describe the principles of project management:

Procurement management	Obtain/purchase products and services, contract management, vendor management
Cost management	Budget and monitor costs
Project integration/communication	Objectives/goals, project plan, execution, monitoring status; managing changes; managing internal and external communications;  review/close project
Scope management	Establish scope of work needed, monitor and manage all processes and changes related to scope
Time management	Establish timeline based on work required, resource availability and scope; monitor and manage time constraints and schedule changes
Resource management	Who does what, when, where and how; establish project team; monitor and manage resource constraints and bottlenecks
Quality management	Test the application/product; follow project management principles
Risk management	Risk analysis, work flow analysis, risk mitigation planning, work flow redesign; change management

Understanding the basics of project management is more important for physicians than to understand the technology.  

Before selecting a technology product, these principles direct the physician to first identify the goals (or “objectives”) that are expected to be achieved by using the technology.   Defining the expected objectives allows the physician to then determine what the technology product specifically needs to do (the “requirements”) in order to achieve those goals.  This aligns technology purchases with the physician’s actual needs and expectations.  A common error is to select a technology product first and then figure out how to use it.   The risk with this faulty strategy is that, even if some value is gained, the physician’s actual goals and needs may remain unmet.  

The scope of a project is defined by what needs to be implemented in order to meet the identified goals and requirements.   A project plan and timeline can be created by determining how much work is required, within this defined scope, who is available to do that work (physicians, staff, temporary labor, vendor resources, consultants) and how much time those people have available to do project work.   Project management principles keep technology implementations “on track” by monitoring the scope and maintaining a balance between known work, known resource availability and established timelines.  It is easy for physicians or staff to become enamored with potentially valuable, but initially unplanned, uses of new technology during an implementation.  If these unplanned uses are piled onto the original scope of a project, then there is more work to do.   

The consequence of more work is the need for more people or time to complete the project.   Sometimes the additional work results in unbudgeted costs such as paying a consultant for additional hours to do the unplanned work.   Unplanned “scope creep” like this is a common malady that derails technology projects but can be avoided or contained by adherence to project management principles.  

And finally, an important aspect of project management is attentiveness to policies and procedures.   Policies and procedures that successfully manage risk within a paper-based work flow will become obsolete if technology creates a new electronic work flow.   A comparison of current work flow to future work flow along with a risk assessment during the project will identify needed changes to policies and procedures.

Search this site for other blogs on EMR Selections and EMR Implementations

 

 

Work flow analysis is valuable when selecting and implementing an ambulatory electronic medical record (EMR).   The results of this analysis will help the physician identify which EMR products are best suited to meet their expectations.   Physicians should have an understanding of the effort involved and prepare their practice for this important assessment.

Work flow analysis is hard work and takes a lot of time.  With time pressures on physicians to see patients and a payment system that rewards them more for higher numbers of patient visits than for higher quality of care, many physicians find it difficult to carve out enough time in their day for efforts like this.    As a result, work flow analysis is often not performed or is less than comprehensive during an ambulatory EMR selection and implementation.

Physicians essentially have two options to obtain a work flow analysis:

1. Hire a consultant
2. Perform the work flow analysis themselves

Hiring an IT consultant who is experienced with work flow analysis at the beginning of the EMR selection process is a more expensive option but will likely result in a more comprehensive analysis.  The consultant will interview key physicians and staff, create work flow descriptions and maps, analyze the results, review them with the practice and develop recommendations.  The physicians and staff will spend time with the consultant during this process, but most of the time and effort necessary for the documentation and assessment will be done by the consultant.

Alternatively, physicians may decide to perform work flow analysis on their own.  If so, there are a variety of methods and tools available to assist the effort.  These include:

1. AHRQ’s Health IT Tool Box website
2. DOQ-IT Operational Redesign Workbook
3. PITO Physician Information Technology Office Needs Assessment

These tools will guide the physician through the documentation of current work flows, an analysis of them and then considerations of redesigned future work flows.  The initial tedious steps to document current work flows are to:

1. Collect all paper forms used in practice
2. Select a workflow guide to facilitate analysis (i.e. one of the three listed above)
3. Identify major processes to map out (key processes vs. all processes)
4. Gather information on each process by interviewing people involved in each process
5. Write detailed descriptions of each process
6. Create detailed work flow maps (at least for the major processes)

Collecting paper forms will help identify specific paper-based processes that are unique to the practice.  The purposes of paper-based processes are important to understand and account for when future work flows are redesigned.  If the new technology tools and work flows do not account for the purpose of a paper-based work flow, and that purpose remains pertinent, then a work-around will need to be discussed and designed.  The goal should be to convert all paper processes to electronic ones, but the limits of technology or the costs involved will limit the ability to fully achieve this.

A work flow analysis guide will help the practice identify other key work flow processes that are generally known to be important for physician practices to assess when selecting and implementing an EMR.  As shown in the snapshot below of part of the DOQ-IT Workbook, these guides will lead the practice through questions to ask about each process:

After interviews with people involved in the process are completed, a description for each process is documented and then used to synthesize current work flow maps. A work flow map serves as a visual representation of the described workflow.  As described in a previous blog, these maps are useful when analyzing current work flow and redesigning them into future work flows.  My next blog will describe how the results of work flow analysis will facilitate the selection of an EMR that meets the needs of the physician office.

 

Work flow analysis and future work flow redesign are often cited as key factors of successful implementations of ambulatory electronic medical records (EMRs) in physician practices.  This is the first in a series of blogs to discuss the value of performing workflow analysis before selecting an ambulatory EMR.

It is unfortunate that work flow analysis, if performed at all, is typically not done until an EMR has been selected and the implementation initiated.  Although physicians intuitively understand the value of good workflows in the office, how workflow analysis helps the physician choose an EMR is not so obvious. 

Workflow analysis can provide the physician practice insights on what to look for in their new EMR product if done early in the selection process.  To get the most out of a work flow analysis it is best to start with a clear purpose in mind.   Some important reasons for initiating work flow analysis before selecting an EMR are to:

• Identify current office inefficiencies
• Initiate critical thinking about desired future work flows
• Develop a prioritized list of desired future workflows (what are the most important ways an EMR is expected to help the practice?)
• Develop a prioritized list of the most important EMR functionalities that are needed in order to realize these desired future work flows
• Set realistic expectations on how the EMR is expected to help achieve goals and attain better workflows 

When a work flow analysis is completed the physician practice should expect to see: 

• Detailed descriptions of current office work flow
• Detailed work flow maps of key office processes
• An analysis that identifies current inefficiencies, bottlenecks and opportunities for improvements
• A high-level outline of desired future workflow redesigns (how the office will work when a EMR is operational)
• A list of changes that could be made now...even before selecting an EMR

A workflow analysis will initially result in written descriptions of the key processes that the physician practice thrives on each day.  These written descriptions are then synthesized into a workflow map that may look something like this:

 

This current workflow map can be used by the practice to design better workflows.  Using the current workflow example from above, the draft development of a future workflow map might initially look something like this:

Developing workflow descriptions and critically thinking about desired future workflows will help identify what an EMR needs to be able to do well for the practice.  Knowing what the EMR needs to do well will help the practice identify and prioritize needed EMR functionalities.  This knowledge will simplify the comparison of EMR products as discussed in the next several blogs.