Why care about workflow

when planning, implementing,

and using health IT?
 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.
 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.
 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

 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.

 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.
 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

 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.

 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.”
 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.
 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.
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.
 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.
 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.

 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.
 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
 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.
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.
 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.
 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.