How to create EHR workflows that increase productivity

Workflows regulate your daily operations. They enable patient flow, ensure patient safety, and sustain the financial wellbeing of your practice. Any disruption to these workflows hampers your ability to practice medicine, and, consequently, generate revenue.

It has been well documented that implementing an electronic health record (EHR) system is unavoidably disruptive. From patient registration to billing and reimbursement, every step contained within each process could be altered during the EHR's installation.

That's why it's imperative that you conduct a thorough process analysis before implementing an EHR in your practice. It helps you understand your workflow and the inherent bottlenecks. It also gives you more information to evaluate the different systems available. Keep in mind, all EHR systems have built-in workflows that cannot be altered much. If you match your practice's processes as closely as possible to the EHR's workflow, it limits disruption.

DEFINING YOUR WORKFLOWS

From renewing a prescription to patient intake to sending orders to labs, processes facilitate your practice. Each process contains a series of steps performed by one or more staff members, and it all makes up the workflow. Analyzing your processes before EHR installation enables them to be streamlined or discarded if they're outdated or redundant.

Rosemarie Nelson, MS

"Primary care physicians, if they choose to do this on their own, are best served by physically walking through the entire process, from check-in through intake, through the exam room, and to check out, with their staff," says Rosemarie Nelson, MS, principal and health information and practice management consultant to the Medical Group Management Association. "That includes front desk, nursing, medical records, lab staff, and check-out, because no one person has the entire picture." Nelson also is an editorial consultant to Medical Economics.

When preparing for an EHR implementation, consider and plan workflows to cover three stages:

• The workflows in place before an EHR gets installed
• The workflows your practice creates so it can keep seeing patients during an EHR installation
• The workflows that result from refinements instituted after the EHR installation

Because many of an EHR's built-in workflows cannot be altered, medical staffs must train to use EHRs, rather than EHRs being built to accommodate a particular practice. EHR training, however, is not just about learning what's under the menus and what all the colored buttons do. It's also about learning to operate your practice in an entirely new way. Learning how the EHR works is only one aspect. The other is learning how to work with the EHR.

"An EHR is like a well-meaning assistant that tends to help you but insists on doing things its own way," says Jerome H. Carter, MD. "You'll have to re-adjust how you work." Carter is chief executive officer of Informatics Squared Inc. as well as the editor of the second edition of Electronic Health Records, published by the American College of Physicians.

"Knowing in advance that your practice will be disrupted gives you two choices," he says. "You can throw up your hands and say 'That's life,' or you can find an EHR that works as closely as possible to the way you already do things, which is doable."

Forcing your existing practice workflows to adapt to an EHR is disruptive. Data coming out of the Medical Economics EHR Best Practices Study clearly indicate that you can plan for this change and even minimize disruption by aligning your existing practice workflows with the built-in workflows in advance of installing the EHR.

Robert Rowley, MD

"The disruptive potential of an EHR to ordinary workflows in an office is largely a function of the design of the EHR," adds Robert Rowley, MD, a practicing family physician and healthcare information technology consultant. Rowley built an EHR for his own practice that eventually became the underlying technology for the Practice Fusion EHR.

"Some [EHRs]-especially the older systems designed years ago-are very unwieldy and slow down ordinary work processes," he says. "So choosing an easy one to work with is the first step."

Main Flow: Patient Seen in Office

So how do you select an EHR that fits your existing workflows? The best way, according to Carter, is to scrutinize and record the processes in your practice as completely as possible, regardless of how long it takes, before shopping for an EHR. This granular process analysis results in a roadmap you'll use when meeting with EHR vendors and demoing their products. (See the sample workflow)

"First, look at every major process you have,'" Carter says. "This helps you eliminate those that should not exist once the EHR is present." Determine:

• how many steps each process contains,

• what forms you use,

• what staff members are involved in each step,

• what information gets collected at each step, and

• what end result is expected of each step.

For example, a simple prescription renewal process might contain the following steps in a paper-based practice:

• A medical assistant (MA) takes the patient's request over the phone.

• The MA pulls the patient's chart and gives it to a clinician.

• The clinician examines the chart, okays the prescription, and notates the patient's record.

• The clinician then places the chart back where the MA will retrieve it.

• The MA phones in the medication order to pharmacy (alternately, the physician e-prescribes the medication).

• The MA puts the patient's chart back into records.

"If you take the time, you can figure out exactly how much work is being put into each process," Carter says. "Then, when someone is demonstrating an EHR, you can say to them, 'My MA is involved in the prescription renewal process. Show me how that process would work if the MA has to log in, leave me a message, and so forth.' Then, you can look at how that task gets accomplished with the EHR.

"Certainly you don't have to do that with every task," Carter adds. "But if you take the top 10-or if you go by the 80/20 rule (where 20% of the tasks traditionally use up 80% of a practice's time)-then you can identify the major tasks.

"It's not exactly science, but you can analyze different EHR systems based on processes and workflows that are actually happening in your practice. And using that information, figure out very quickly which EHR will work for you."

Carter also recommends that once you've completed the analysis of your processes, you create a test script containing those steps. Then use that script, which is a step-by-step description of a particular paper-based process, to vet EHR systems.

"If you do this," he says, "you'll have a much better idea of how EHRs compare not only to one another but also to how you already do things.

"That's why examining your workflow is the most important thing you can to do," Carter says. "You're essentially trying to find an EHR that will do the least amount of disruption as possible."

WHY SPECIFIC EHR WORKFLOWS?

The healthcare industry is shifting from paper-based to electronic communications and records. Medicare's meaningful use incentive program, and the emphasis on establishing working health information exchanges in the government's health reform legislation, means many common tasks must be handled differently.

"We used to hire medical records clerks to manually file outside correspondence into patients' paper charts," Rowley says. "Now, those needs have been replaced by people who scan the paper records into electronic files (usually PDFs), upload them into the EHR, and then tag them (assign the patient, give it a document type description, and put it in a doctor's e-bin for review). Same fundamental work, but now done electronically. Same number of personnel, but with re-purposed skills."

It's best to think like a businessperson when implementing practice-wide change, the experts say. This critical mindset is an essential key strategy that enables you to identify critical bottlenecks to your practice's workflow during the EHR implementation.

"By developing specific EHR workflows, practices can achieve operational improvements and efficiencies that enable them to see more patients-after getting through the learning curve and/or reducing operating costs," Nelson says.

Larger healthcare organizations can absorb or distribute EHR costs. Smaller practices, however, may feel the impact more directly. By aligning your processes with an EHR's built-in workflows in advance, you can forestall a severe revenue loss in your practice.

"If you're an academic medical center, you might be able to afford to waste millions of dollars on consultants and cost overruns. But a small business can't do that and, to me, that's essential," Carter says.

IMPROVING WORKFLOWS AFTER EHR INSTALLATION

Once you've settled on an electronic health record (EHR) system that disrupts your workflow the least, the next step is to examine workflows most affected by the EHR and establish a plan of action, according to Robert Rowley, MD, a practicing family physician and healthcare information technology consultant.

"It's always a work in progress," Rowley says.

Consultant Rosemarie Nelson, MS, agrees that once the multi-disciplinary team records the practice's processes and workflows and completes the necessary EHR training, its members should work together to compare and contrast ways to improve workflow. Physicians may wish to consider external assistance, but she advises caution.

"Outside experts can be a help here," Nelson says, "but usually not the vendor, because a vendor's experience centers around its system more than around medical practice operations. And practices' operations are not all created equally. Variances based on facility layout, staffing models, and patient demographics can dramatically change workflows." Leveraging staff knowledge is helpful because no one knows your processes better than them.

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