4 Workflow and Process Improvement with EHR and HIE

Introduction

As the implementation process begins to unfold, addressing workflow and process changes becomes critical. This tool highlights important elements to consider while implementing EHR, HIE, and other HIT.

How to Use

1.Review 2.7 Workflow and Process Redesign for EHR and HIE, which describes how to map current workflows and processes, as well as spot problems and determine their root causes. Retrieve the workflow and process maps you developed during this stage of planning.

2.Prepare to change your workflows and processes consistent with your goals for acquiring the HIT. As you do so, be aware of the following:

While most vendors today recognize the importance of attending to workflow and process changes, most still do not have the staff resources to make it a cost-effective part of their implementations. Though this is unfortunate, it forces the health care organization to address workflow changes that it knows best. This also contributes to a thorough understanding of the HIT function and creates ownership of the change.
There are no “silver bullets” in improving workflows. Many organizations seek “best practice workflows” to adopt. While there is a growing body of literature on the importance of incorporating workflow redesign into HIT and there are clinical practice guidelines, most experts agree that work is needed in this area and that analyzing and improving workflows locally is an essential element of change management. The following are some examples of generic resources and specific tools:
Incorporating Health Information Technology Into Workflow Redesign, AHRQ Publication No. 10-0098-EF (October 2010) available at
Public Health Informatics Institute Resources,
AHRQ National Guideline Clearinghouse,
Improving Transitions of Care in LTPAC: An Update from the Theme 2 Challenge Grant Awardees, March 21, 2013. Office of the National Coordinator (ONC) for Health Information Technology: (This may be applicable to LPH because of similar functions for the public health nurses and home health nurses.)

Your vendor may or may not support workflow and process improvement, but regardless you should build this task and its associated time and resource requirements into your project plan. The change imposed by EHR and HIE is great for new users. They must understand how and why the changes are needed and be reassured that the changes will support their ability to deliver the best quality care. Trust in the process is essential. Engaging users in understanding current workflows and processes and learning how the system will improve them will go a long way toward achieving better adoption. Consider using the tool below to highlight key changes brought about by EHR and HIE, and their rationale:

Example of Summary of Key Workflow and Process Improvements

Task / Current Process / Improved Process / Technology / Rationale

Registration

/ Manual entry via phone or faxed document / Portal for referring provider to be guided in submitting all data / -Portal
-EHR
-Admin/Billing System / -More complete and accurate
-Available to all users

Compilation of intake data

/ Standalone data entry system / Integrated with all other components
Portal for referring provider, client’s PCMH to obtain patient status information / -EHR
-Admin/Billing System / -Auto populates data to reduce data entry burden
-Alerts for timely completion
-Care coordination

Review of Medication List

/ -Fax from referring provider
-Client interview during visit / -Pull updates from health information exchange service / Participate in state’s HIO / -Obtain current list of currently prescribed medications with complete sig
-Comply with transitions of care requirements

Workflow and process change is not the same as customization of EHR. Even though some minor tweaking may be needed once a product is implemented, desired workflow and process improvements should be reflected in the technology acquired. These workflow changes should reflect your goals for adopting EHR. Do not lose sight of these goals. If, however, you find that the technology is driving workflow changes that are truly problematic, you may find it necessary to customize the product.

Case study: An LPH department recently acquired an EHR and has distributed personal digital assistants (PDAs) to nurses to use to document visit notes. During the first month, several nurses expressed concerns that note taking was extending visit times. They began to lobby for extra time at the end of each day to document notes. A review of the notes suggested that nurses were entering more information in “comment” fields and not entering structured data into the drop-down menus on the templates (or in some cases were doing both—resulting in occasional inconsistencies between structured data and narrative comments). Retraining was instituted, but there was little improvement. It was then realized that nurses did not appreciate the full effect of this change in workflow. They did not trust that the data entered via the templates was sufficient to describe their work. Once this was addressed by illustrating how the data were subsequently populating other system components and resulted in more complete data gathering, the nurses became more comfortable in completing only the templates and their productivity improved. They knew they could enter comments on special situations, but did not need to do so for every routine entry. They also appreciated not needing to go back after the visit was completed to correct or complete data entry. The system immediately alerted them to missing data, and if data were not available at the time of the visit, the alerts remained in the system for easy identification and completion later.

Most EHR systems are built to adjust to user preferences, to some degree. Templates may need to be changed to reflect special data requirements, users should be able to change their dashboards to accommodate personal preferences, etc. The software should have tools that allow either the user or a facility systems administrator to make necessary changes. However, most products are not customizable at the software level, at least unless the vendor makes the change. This is important because customizing an EHR can be a double-edged sword, with the potential to customize it back to old ways—resulting in problems achieving goals and patient safety risks. Engaging users in mapping current and improved workflows and processes helps them engage in the change process.
Any change in an EHR must also assure that necessary control points that impact care embedded in current workflows and processes are retained. Numerous articles have been published about the potential for unintended consequences of HIT. In large measure, these consequences have come about because workflows and processes were not studied thoroughly and changed appropriately so that current controls were included or enhanced. As you plan your implementation and any customization, review the Guide to Reducing Unintended Consequences of Electronic Health Records offered by the Agency for Healthcare Research and Quality available at:
Change imposed by an EHR or HIE must recognize the importance of professional judgment. EHRs and HIE are tools; a hammer in the hands of a novice will create a mess, but in the hands of a skilled craftsman can create a thing of beauty. Health care professionals must understand that the systems being implemented are only tools—and administrators need to appreciate this as well.

For example, a nurse may receive data through an HIE process and start to act on it, only to suspect that it is not for the specific client under care at the time. There must be a way to validate person identity to ensure that person matching in the HIE was correctly performed. Too many of these concerns will lead to discontinued use. In order to correct such issues, mapping the new workflow and process should help pinpoint problem areas. For example, the HIE may find that its source data are not standardized, making person matching difficult. It may need to require that all participants standardize on a specific set of demographic data.

Whether or not the vendor provides assistance with workflow changes or not, it may still request that workflow and process maps be supplied in order for it to prepare modifications that will make for a smoother go-live. The vendor may request that workflow and process maps be documented in a preferred format. Most vendors will accept either a systems flow chart format or a simple list, perhaps recorded on a spreadsheet. Some organizations wonder why they need to map improved processes before selecting a vendor, because the maps may need to be redrawn to accommodate functionality that the vendor provides. Requirements analysis cannot be performed without a solid understanding of current workflows and processes and the desired improvements. In addition, automating broken processes is risky. To the extent that you can, improve processes—or at least recognize improvement opportunities—prior to automation.

3.As you develop your improved workflows and processes with a specific vendor product, document them in a new version of the workflow and process maps. This is time well spent because these maps can be used in system testing, training, policy and procedure development, and referred to years later when system upgrades arrive.

Section 4 Implement—Workflow and Process Improvement with EHR and HIE - 1