Workflow: A Crucial Component of EHRs

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1RedesigningWorkflow: A CrucialComponent of EHRs
Phil Deering
Paul Kleeberg
Joe Wivoda
Regional Coordinator
Clinical Director
HIT Consultant
REACH
REACH
National Rural
Health Resource Center
What It’s All About2Is ThatWhatIt’s AllAbout?
Put YourRight Foot In
Put YourRight FootOut
Please Stand Put YourRight Foot InAnd Shake itAll AboutDo the HokeyPokey andTurn YourselfAroundWhat It’s Really All About Inefficiency – When Hospital implementsEHR Hospital installs computers in each room MDs don’t enter orders Nurses return to nursing station to enter the orders That’s where they used to write up paper orders Safety – With New EHR MDs order meds on paper Nurses enter orders in EHR Because paper is still in play, some drugs getadministered without the record being updated 3Objectives Learn the value of understanding currentclinical workflows Understand how workflow documentationcan improve patient safety, quality of careand clinical efficiency Learn how to get started with workflowdocumentation Review some workflows for actual examplesof improvement4Why Map Processes? Excellent early step to engage the organization inthe idea of change EHR will force standardization EHR implementation requires a review of workflow Process mapping engages structured thinking Potential for process improvement Almost always “aha moments” Captures key controls, processes, important waysyou are unique EHR bring benefits only when People and Processintegrate with technology — process mappingmakes this connection.5Process Maps & the EHR Process maps illustrate nature of the activitiesand the sequence & flow of the work Process maps are a visual representation ofcomplex activities Process mapping begins the changemanagement process by engaging users Process maps help identify problems andworkarounds in the current system Process maps can form the basis foridentifying functional requirements in theEHR6How to Map Processes With a reason Way too much work to complete without a clear purpose Understand current state to enable proper EHRimplementation Ensure EHR-enforced process don’t affect quality, safety, orefficiency General process improvement, safety, or other With a team of experts – those who do the work Dynamically – in a way that can be updated With or without flow charting tools With a sense of engagement or excitement7Using Shapes8Process:WhoDoesWhatTerminator:Start andFinishDecision:Questionwith 2choicesYesNo• Generally run top to bottom, left toright• Each step needs to say clearly:• Who – Subject• Does – Verb• What – Object• Decision diamonds represent keychoices or decisions.• Label routes• Yes or No most frequentExercise9 9ScenarioAfter two incidents of responding to tearful calls from their 9-year oldchild, a parent decides to document the process of making sure the childleaves the house with her lunch.Situation:•Monday, Wednesday and Friday: The parent makes a regular baglunch for the child.•Tuesdays: The child takes $3.50 to buy school lunch – the parentleaves early that morning and doesn’t have time to make a lunch.•Thursday: In addition to lunch, the child takes an extra snack (granolabars, fruit, etc) because she stays late for soccer practice.•The parent will make the lunch, (or money, or lunch and extra snack)put it on the counter. The child will put the lunch in her backpack andleave.Please get a post-it pad and write out the steps of this process. Take 5 minutes to think andarrange, then we will discuss as a group.Flowcharting• Assemble team• Give folks stickynotes and bold pens• Start with beginningand end of the process1011• Use a square pad fordecision diamonds• Don’t start drawinglines12• Add steps as youthink of them• When steps arecomplete review forimprovements –What jumps out?13• Because you usedsticky notes, it’seasy to change• Note improvementswith star or othercolor• Continue to review–look harder, ask“Why do we dothat” and “Do we allagree this is theright way?”14• When completedraw the lines• Move into anelectronic format• Digital camera is agreat tool – phoneswork in a pinch• CAUTION:Photos or paperdon’t lendthemselves toupdatesTo What Level: Process Map vs.Work Instruction Common hang up – how much detail? Remember the purpose: Feeding the design of an EHR Standardization Improvement Distinguish between flow charts and workinstructions Flows are higher level – Who / Does / What Work instructions are the details15In Home First AppointmentProvider goesTo client homeproviderGives Frontdesk completedpaperworkProviderperformsDiagnosticAssessment
IntakePaperwork,PrivacyFormscompleted
Front deskverifiesInsurancebeforehandIf info availableYesNoProviderInforms them theyMust rescheduleWith parent/guardianFront deskverifiesInsurance
Client andparent/guardiancompletesSDQ
ProviderCompletesCASII
Providerenter SDQInto onlinedatabase andprint outfor chartIs parent/guardianAvailable to signpaperworkNotes:• Provider completes CASII is a process flow step• Steps to fill out CASII would be work instructionsand would not appear on a flow chart• Note use of Who / Does / What• Note all sorts of opportunities for improvementLet’s Talk About Some RealExamples1718CPOE Before the EHR19Some Possible Issues…20CPOE After the EHR21Some New Issues…22A Clinic Process: Lab Orders – Pre-EHR23Opportunities for Improvement24Clinic Lab Orders – Post EHR25EHR is in, But Our Work May Not Be Done…A Bit More Theory26Power of Swim Lanes27Provider – Nurse, NP or MD CMASwim lanesshow who doeswhatSwim lanesshow HandoffsMoving from Design toImplementation Redesign is the easy part of changingworkflows When you know Who / Does / What you canbegin to plan the change management effort Publicize the new design Clear roles and tasks will ignite discussion andraise change management issues Training plan emerges from Who / Does /What Training should be role 28 -based and process-focused 28Process Mapping Tools Start with paper and sticky notes Move to an electronic format Visio is great but expensive Other products like FlowBreeze less expensive PowerPoint has all the shapes Excel works well http://www.breezetree.com/articles/how-to-flow-chart-in-excel.htm Worst case, write out without symbols usingIf statements instead of diamonds29Conclusion The power of process mapping lies in the visualrepresentation of complicated concepts Process mapping is a vital step in preparing forEHR implementation Process mapping has inherent benefits beyond theEHR Engaging people who do the work is essential tosuccess Understanding and communicating Who / Does/What empowers the change management effort30Bonus Slide — What to Map Common process list:1. Pre-Visit– Appointment scheduling– Diagnostic studies scheduling– Insurance verification– Chart preparation3. Patient intake– Documentation of vitals, HPI, etc.– Check on health maintenance– Patient preparation4. Review chart– Review results (incl. images)– Review past encounter data– Review other provider & patient-supplied data5. Clinical documentation– Validate history data– Record physical exam– Document encounter notes6. Care planning– Develop care plan consistent with guidelines317. Medication management– Order medications– Manage refills: local pharmacy, mail order– Manage samples– Reconcile medications across continuum ofcare8. Ordering– Diagnostic studies– Surgery– Referrals– Admissions– Nursing services9. E&M coding10. Charge capture11. Patient instruction– Education– Summary of visit12. Check out

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