1. Why care about workflow when planning, implementing, and using health IT?

2. Answer #1: To avoid pain and suffering Many clinics have implemented health IT only to find that they did not anticipate how much health IT can change clinical and administrative workflows. The unanticipated changes cause considerable pain during and after implementation for the clinic staff because suddenly the way things have to get done becomes very different.

3. Answer #1 (continued) The pain and suffering caused by workflow problems is not just emotional. There can be significant disruption in –Patient care –Billing –Communication So if you don’t pay attention to workflow when implementing health IT, your patients, your staff, and your finances all may suffer.

4. Some experiences… Electronic Health Records: Just around the Corner? Or over the Cliff? “We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients.” Baron et al. (2005). Annals of Internal Medicine, 143 (3), pp.222-226

5. Some more experiences How the Electronic Health Record Did not Measure Up to the Demands of Our Medical Home Practice “One of our primary reasons for using an electronic health record initially was to receive lab results electronically. That way, we would be able to use clinical data to track treatment outcomes, target interventions to our needier patients, and facilitate our own quality improvement…. Instead, we continue to receive lab data on paper documents that we scan and store as portable document format, or PDF, files, which means that we cannot trend them, search them, or use them as data elements.” Fernandopulle & Patel (2010). Health Affairs 29 (4), pp. 622-628.

6. Answer #2: It will assist in vendor selection By studying your workflows before choosing a vendor, you can –Identify efficient and productive workflows that you would like to keep and inefficient ones that you would like to change. –Determine how your workflows are likely to change after implementing the technology. With that information, you can ask each potential vendor about how their technology will affect different workflows. This way, you can select the vendor that best fits your practice.

7. Some experiences… Electronic Health Records: Just around the corner? Or over the cliff? “To support our electronic health records system, we needed to change the practice management system that was in place for scheduling and billing. To minimize the impact on physician–patient interaction, we opted for an encrypted wireless network with Tablet personal computers (Hewlett Packard, Palo Alto, California), which we purchased from a different vendor. None of the physicians was especially computer-literate. The total quoted cost of our system, including hardware, software, training, and 1 year of support, was approximately $140,000, which is within the range that other investigators have reported on a cost-per- physician basis”. Baron et al. (2005). Annals of Internal Medicine, 143 (3), pp.222-226

8. Some more experiences Electronic Health Records: Just around the corner? Or over the cliff? “Our experience has been that complex software systems, like complex paper systems, come with a set of liabilities. Unlike the known liabilities of a paper charting system, whose origins and solutions lie within the control of a practice, the problems posed by the electronic health record were beyond our control. Resolving software glitches and errors required coordination with and cooperation of IT staff and software vendors outside the practice. These parties often had conflicting interests, leaving us with day-to-day work-flow problems that were difficult if not impossible to resolve. In the end, this amounted to a high unexpected cost of electronic health record implementation”. Fernandopulle & Patel (2010). Health Affairs 29 (4), pp. 622-628.

9. Assisting in Vendor Selection: Example You might ask two different vendors “what is the workflow for notifying physicians that lab test results are available?” –Vendor 1 says “they are notified in their e-mail inbox that results are available.” –Vendor 2 says “they are notified when they log into the electronic health record.”

10. Example (continued) If you have studied your workflow, you will know whether physicians regularly access e-mail or will have time to log into the EHR during the day. –If your physicians regularly rely on e-mail, then vendor #1’s system may work well for you. –If your physicians document during or immediately after visits, then vendor #2’s system may work best for you.

11. Answer #3: To better prepare and train staff Every time you make a change to your practice, especially when implementing health IT, your clinical and practice management workflow will change. These changes may affect some staff members more than others. You need to train staff for the changes that will affect them.

12. Preparing and Training: Example Currently, physicians dictate notes during or after a visit. What will happen after you implement an EHR? If physicians still dictate the note –Who will put the note into the EHR? –When? –Where will it be stored? –In what form will it be stored? The answers to these questions –indicate how much workflow will change. –help you identify which staff members will have their workflows change and what training they will need.

13. Answer #4: To plan ahead Although technology implementation may seem like a simple change, it is likely to be much more complex and challenging than you anticipate. By identifying how workflows will change, you can make better decisions.

14. Planning Ahead: Example Your clinic gives laptops to physicians so that they can access the EHR. Workflow analysis reveals that clinic scheduling provides physicians with time to review each patient’s chart just before seeing the patient. You like this workflow and want to keep it.

15. Example (continued) Before the EHR, a staff person provided each physician with the paper chart for the next patient. But, the EHR system you selected only allows one person to be logged into a patient chart at a time. So, physicians can’t review charts before seeing the patient because a RN or MA is logged in while rooming the patient.

16. Example (continued) Because you purchased this EHR without realizing the impact on workflow, you are stuck having to choose between –No physician access to patient records just before seeing a patient –Delaying the physician entering the exam room for a few minutes so that there is time to review the chart after the patient is roomed –Having the RN or MA record their notes on paper when they room the patient so that the physician can prepare. None of these are efficient workflows

17. Won’t the vendor analyze my workflow and tell me what is best? Not really. Some vendors may analyze parts of your workflow. Some vendors may tell you what workflows you will need to have to accommodate their product. But the workflows required to accommodate a vendor’s product may not be good for your staff and your patients.

18. Won’t the vendor analyze my workflow and tell me what is best (cont.)? No vendor will study all of your workflows. Vendors will not know what workflows are best for you. Only you can decide that. Before talking with a vendor, you need to be prepared to –Tell them about your current workflows. –Describe what you want your workflows to be like in the future.

19. Conclusion Only by understanding the details of your workflows, you can: –Have more informed discussions with a vendor. –Make good decisions for your clinic. –Optimize your patient care and protect your clinic financially.

20. References Baron RJ, Fabens EL, Schiffman M, Wolf E. Electronic Health Records: Just around the corner? Or over the cliff? Annals of Internal Medicine 2005; (143)3: 222-226. Fernandopulle R, Patel N. How the Electronic Health Record did not measure up to the demands of our medical home practice. Health Affairs 2010; 29(4): 622-628.