Workflow & Redesign for EHR Implementation

Objectives:

  • Learn the keys to successfully redesigning the workflow in your practice
  • Learn how to analyze and enhance patient flow in your practice
  • Learn how the flow of information affects your overall workflow

Electronic Health Record Implementation Means Redesign & Workflow Changes

Every day you and your staff see patients, write prescriptions, send bills, review labs and X-rays, and perform a host of other jobs. All of this is accomplished by the physician and the staff using workflows that have been adopted over time. Workflows are the various ways the office accomplishes its myriad tasks during the day. The paper chart, to a certain degree, has mandated a certain workflow in the family physician office.

Family physician office workflow of the 21st century will be radically different. The change will come about both because of the electronic health record and the aims of the Future of Family Medicine project. The electronic health record, implemented properly, will automate information flow in the family physician office. The Future of Family medicine project envisions patient centered care in redesigned offices, using advanced information technology with an emphasis on efficiency, quality and safety.

Since the paper chart has mandated a certain workflow, it twould be a mistake to assume that a functional electronic health record will adapt to your current workflow. The current workflow based on paper charts is cumbersome and inefficient. An electronic health record and a complete information technology solution for your office will enable a more logical, efficient workflow.

Family physician office workflow can broadly be broken down into two categories:

  1. The flow of patients entering the office and getting their needs met within the office environment
  2. The flow of patient information within the office environment, whether the patient is physically present or not. This information includes clinical, social and billing information.

Keys to Success

The right technology is only half the secret to successfully implementiong an EHR. Other factors having to do with how your office functions are critical as you redesign what you do from top to bottom. The concepts make it much easier to implement effective health information technology:

  1. Patient focus: Addressing your patients' needs with the correct care in an effection manner is the central focus of the office. Information technology acts as a tremendous facilitator if it is implemented and used with patient focus in mind.
  2. Teamwork philosophy: Transitioning and working with an electronic health record requires close teamwork. Nurses and medical assistants must work in close coordination in order to get patient care accomplished real-time. Empower your staff to do significantly more than usually occurs in a paper-based office. This, in turn, allows continual improvement and new ideas.
  3. Cross training: Significantly more staff, including physicians, need to cross-train in order to be familiar with other job functions. In large offices, it is sometimes useful to break up the staff into smaller, more functional patient care units This will also require cross training.
  4. Job rotation: A new computerized office environment rewards non-traditional thinking about job descriptions. The thinking should transition from "everyone has a job to do" to "what tasks are necessary, performed by whom, to achieve efficient workflow with minimal waste." Some examples are as follows:
  • The physician, instead of delegating prescription calls in to the pharmacy, is now able to complete the task himself quicker than delegating the task because of electronic mail or digital faxing. Some of these tasks that the physician can now do faster than delegating them is counterintuitive to the conventional wisdom that a physician should only be doing tasks that are generating revenue.
  • The medical assistant or nurse is now able to capture more of the patient history by using guidelines and prompting.
  • The front office staff, medical assistant and nurse are now able to refill prescriptions and answer questions because of previous guidelines set up by the physicians and office staff.
  • The patient not only has more autonomy with regard to medical decisions, but is now put to work entering his or her history to be reviewed at the time of the office visit.

Enhancing Patient Flow

The electronic health record acts as a catalyst for office workflow. Demographic and clinical information is available throughout the office and can be accessed real-time by a range of different staff. This enables and actually mandates a completely new way of working.

Office Layout and Patient Scheduling

Although it is often not possible to reconfigure your office, there are certain office layouts that may be more conducive to enhanced patient flow and efficient workflow.

  1. Consider not even having a personal office. Many family physicians have a workspace adjacent to the examining rooms. This allows for more awareness of what is going on in the office and examination rooms and allows for "visual control". By observing patient flow and certain cues when a patient is in the room, the family physician is much more aware of patient flow and is able to keep up more efficiently with the work being done. This creates a system used in manufacturing called a "pull system," whereby work is pulled into the next available area. This tends to minimize patients in the waiting room and maximize the useful work in the examination room. The examination room has patients occupying it with the physician doing useful work a significantly larger percentage of the time.
  2. Consider kiosks with computers in your waiting room or other spaces where patients can provide an interactive history. In this way, information about the patient's problems and history is available to the physician at the time of patient contact. This allows more time to be spent accomplishing useful work with the patient.
  3. Think about how you can fax and print prescriptions, patient information, and patient education from the examining room. Information technology allows more things to be accomplished with the patient in the examination room. This includes prescriptions faxed or printed, patient information and education and possibly even billing. Thus there is less that needs to be done either before or after the encounter. Some family physicians have been able to minimize or even eliminate their waiting room in this way.
  4. Consider open access scheduling. This means any patient that desires is able to be seen the same day. Taking care of patients' problems promptly and efficiently encourages good office workflow and reduces the waste of redundant work (patients calling back if their needs are not met etc.).

Using some of the above strategies, you should find that the cycle time or amount of time a patient spends in your office is decreased. Time is saved in the waiting room and by eliminating other wasted steps that do not help you or the patient. What you should find is the time spent with the patient doing useful work is the same or greater than with the paper world.

Enhancing Information Flow

The principal goal when implementing a health information technology solution in the office is to transition from a "batch and queue" system to a system that exhibits continuous flow. Most paper-based physician office systems have piles of charts in various places (batches of charts) waiting for something to be done with them (in-line or queue). Computerization should make this older system disappear to be replaced by a continuous flow system where information is available everywhere in the office simultaneously, can be viewed anywhere in the office simultaneously and can be acted on immediately anywhere in the office.

This continuous flow is made possible by a number of technological features as well as a new philosophy of working:

  1. A robust electronic messaging system within the office and for practices with more than one location is essential. Couple this with computerized faxing and, if feasible, patient access to the physician via email, and it is now possible to tackle everyday tasks expeditiously and completely. Because patients know that they can get their needs met with minimal effort and trouble, they are less likely to call for trivial matters. Meeting patients' needs in this way has a profound effect. It significantly reduces office workload and decreases frustration and anxiety in your office. Both physicians and staff then find they have added time to effectively treat patients during the office visit and also improve the current system.
  2. A robust system for receiving and sending electronic documents from anywhere in the office environment (as well as possibly at home) can save tremendous amounts of time as well. This involves e-mail and electronic fax capabilities throughout the office. Consultations, radiology reports and other documents will be received by fax modem and will no longer converted into paper form. The documents are electronically reviewed and signed if necessary and routed to the appropriate chart.