Section 2.7 Plan

Workflow and Process Redesign for EHR and HIE

Understand workflow and process redesign, as well as how to set expectations to achieve goals, initiate change management, and use process mapping as a means to manage the change brought about an introduction of electronic health records (EHR), health information exchange (HIE), or other health information technology (HIT).

Time needed: 40 – 80 hoursSuggested other tools: NA

IntroductionYou have most likely seen articles about unintended consequences of EHR or other HIT. Two key factors recognized in many of these articles are:

1. Workflow and process changes must be understood and managed. For example, one article described increased mortality at a children’s hospital that had implemented a commercial provider order entry system. Its deaths were largely due to overdoses of drugs as a result of inadequate calibration of dosing for pediatric services. Sadly, the hospital had not taken the steps initially to understand the differences between children’s needs and what is provided in a

commercial product that is normally used in an adult setting.

Workflow and process changes should be made to maximize the effectiveness of EHR and HIE. The changes must also point out the control points that must be present or should be added to the systems for optimal results.

2. Professional judgment must be applied when using any tool, including all forms of HIT. Computers can crunch data tirelessly and remind humans who may be forgetful in the rush of their everyday lives. The massive volume of data they are able to process at one time aids in decision making within the complex and sometimes confusing environment that is health care. However, they are not substitutes for the experience of trained workers.

Workflow and process changes should aid professionals, but are not substitutes for them.

Process Mapping as a Means to Manage ChangeProcess improvement experts suggest that the best way to help potential new users of information systems overcome resistance to change and appreciate their role is to demonstrate the efficiencies and safety of computer systems and to engage users in making their own changes. Building trust is especially important in the clinical community. Users must understand how and why certain processes are performed, be assured that the data are accurate, and that information surrounding the processes is evidence-based and comes from reliable sources.

When all individuals take a critical look at the processes they currently perform, bottlenecks, delays, duplication of effort, and other issues become clear—and powerful motivators for change. While some vendors may suggest that mapping current processes is not necessary because the product itself will introduce appropriate changes, experts counter that mapping current processes and workflows encourages process improvement initiatives to begin early and continue throughout the duration of the HIT project for several reasons:

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Starting to understand current processes and how they may be improved with HIT before an HIT product is selected can help users contribute ideas about what functions they would like to see in HIT, aiding the vendor selection process.

Correcting broken processes where possible in advance of HIT implementation helps keep these processes from being replicated in the HIT environment.

Having well-defined maps of current and corrected processes can enhance implementation activities. Opportunities for improvement will have been identified early and will not need further explanation. Implementers get a jump start in knowing what elements of current processes will be changed by the HIT and this can actually speed up implementation.

Initiating process improvement early helps prevent users from feeling as though they are being forced to accept someone else’s changes. During implementation, process changes should be fine-tuned and compromises should be made between what is desired and what is feasible or recommended by the vendor’s product.

Workflow and Process MappingProcess mapping is a fairly well-defined science, with a number of tools and techniques that can be deployed to understand current workflows and processes and identify opportunities for improvement. Process redesign is not a new concept for public health. The Public Health Informatics Institute has an extensive offering of resources on its Web site (see: www.phii.org), including those for process management (see: the PHII Collaborative Requirements Development Methodology [CRDM] at: http://www.phii.org/resources/view/6159/Collaborative%20Requirements%20Development%20Methodology%20%28CRDM%29%20Use%20Case%20Webinar).

Process mapping of clinical processes associated with use of EHR and HIE is difficult because the processes are performed mentally, clinicians rarely want to spend time mapping processes, and the people who do process mapping for clinicians can’t see their mental processes. The following steps are a good way to begin.

Mapping Current Workflow and ProcessesThe following steps should be used to map current workflow and processes before selection of EHR in order to initiate the change process, specify requirements for vendor selection, and appreciate key control points:

1. Identify processes to be mapped—those that will be impacted by the EHR or HIE being acquired.

2. Use mappers who actually perform the process; they know it best and they need to own the impending change.

3. Instruct participants about process mapping—why it is being done and how it is done.

4. Map current processes. Avoid jumping to proposing changes now (unless corrections can and will be made in the current environment). Mapping only what you think may be improvements can cause critical controls built into current processes to be overlooked.

5. Validate maps to ensure they reflect current processes, all variations, and all the information collected and processed (information payload).

6. Collect all forms and reports that are part of processes to be automated through HIT.

7. Collect baseline data or obtain benchmark data to define expectations for change and for use in benefits realization studies.

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Workflow and Process RedesignOnce current process maps are documented, the following steps should be used to map how you would like the workflows and processes to be performed with EHR and HIE.

1. Identify potential problems in current workflows and processes and determine their root causes. Study the following areas:

□ Bottlenecks□ Sources of delay□ Rework due to errors□ Role ambiguity□ Unnecessary duplications□ Unnecessary steps□ Long cycle time□ Lack of adherence to standards□ Lack of information□ Lack of quality controls

The following tools may be helpful in identifying root causes of potential problems: □ Statistical charts (e.g., Radar, Pareto, Control)□ Relations diagrams□ Tree diagram□ Affinity diagram□ Force field analysis□ Cause and effect diagrams□ Physical layouts

2. Identify changes that may be able to resolve problems today.3. Educate about EHR and HIE and identify further changes that will be possible. 4. Document changes by creating a map showing proposed improvements. 5. Use new processes to create use case scenarios in order to identify functional specifications, and

later to build out the EHR and HIE applications to achieve improvements. 6. Test new workflows and processes. 7. Train all staff on new workflows and processes.8. Incorporate changes into policies and procedures.9. Collect current data about outcomes, evaluate against your goals, celebrate successes and correct

course where necessary. Conduct formal benefits realization as applicable.

Workflow and Process Mapping ToolsThere are several tools that may be used to document workflows and processes:

Systems flowcharts (most commonly used for documenting EHR processes and often recorded, at least initially, using only sticky notes on flip charts or a wall). Note: Some public health informaticists use entity relationship diagrams (ERDs) to conduct workflow and process analysis. While there are similarities between systems flowcharts and ERDs, systems flowcharts usually focus on process, while ERD focuses more on individual data elements.

Swim lane process chart (especially useful where there are multiple people or organizations involved in a process, such as for HIE)

Flow process chart (a more narrative approach that is often more comfortable for those new to HIT, although less supportive of documenting decision points or alternative flows)

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Systems FlowchartThe systems flowchart is the most popular tool used to map current and proposed workflows and processes. There are many symbols that can be used to illustrate special functions. However, most find the following basic symbols easy to understand and use (horizontal placement of a sticky note designates a process and the tilted view designates a decision point.) The flowchart on the right describes the “rules” for how to use the symbols.

Ovals designate boundaries: where the process begins and ends for each path through the workflow

Rectangles explain the process steps, including:

o Who (by credential)

o Does (action verb)

o What (with data)

Diamonds denote decision points:

o What choices? What alternatives?

o What information is needed to make the decision?

o Must have at least two branches, can have three. If more branches need, reference a separate decision table.

o Label all branches (yes/no, 1/2/3, < = >, etc.)

Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author

Example: Systems Flowchart for Medication Check-in Workflow with Opportunities for EHR

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Swim Lane Process ChartThe swim lane process chart is an excellent tool to depict a process that has many handoffs. It shows dependencies among the parties, making it ideal for illustrating the potential value of HIE.

In the example below, a physician handwrites a prescription, omitting the frequency. The pharmacy calls the physician to get the frequency. The prescription is filled and the patient takes the medication as instructed. The public health nurse, however, believes the patient is taking too much medication and reports this to the physician. The physician calls the patient regarding the corrected frequency but does not call the pharmacy, so this prescription, which permits a refill, remains in error. When the patient gets a refill, it is for the incorrect frequency. The use of e-prescribing (e-Rx) and HIE technology would support complete prescription writing at the point of care, most likely enabling the physician to order the appropriate frequency for the patient’s needs. The result is a significant improvement in patient safety, with fewer communication hassles.

Symbols used in the swim lane process chart may be the same as those used in a systems flowchart, or may simply be boxes as illustrated below. Typically, arrows are used to show handoffs between parties. It is assumed that the flow within a swim lane proceeds in the sequence designated, from left to right. Symbol placement (and color-coded blocks, if desired) can suggest timing of process steps.

Sample Swim Lane for Current Medication Check-in With Opportunities for HIE

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Flow Process Chart Template An example of a flow process chart is shown below. This is an older form of workflow and process mapping that is popular with end users. Users can list the steps they take to perform a process and track the time it takes to complete each step. If each step is performed on only one client, record, or other subject (such as documenting a visit), there is no need to record quantity. However, some tasks might be performed in a batch, such as loading all patients’ addresses to a GPS at the start of a day.

An analyst may then use the list to construct a flowchart and answer user questions that lead to proposed workflow and process improvements. There is also room for analyst notes.

Flow Process Chart

Process:

Present Proposed Analysis ()

Performed by:

Date:

Ope

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n

Tran

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Insp

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n

Dec

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n

Del

ay

Sto

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Tim

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Qua

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Why is it done this way? Notes Why is it done by this person? Why is it done at this time?

Why is it done at this location?Why is it done – is it necessary?

Details of present/proposed process:Notes ◊ D 1.

◊ D 2. ◊ D 3. ◊ D 4. ◊ D 5. ◊ D 6. ◊ D 7. ◊ D 8. ◊ D 9. ◊ D 10. ◊ D 11. ◊ D 12. ◊ D 13.

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◊ D 14. ◊ D 15. ◊ D 16. ◊ D 17. ◊ D 18. ◊ D 19. ◊ D 20. ◊ D 21. ◊ D 22. ◊ D 23. ◊ D 24. ◊ D 25.

Totals: Present Proposed

Summary: No. Time No. TimeOperations

Transportations Inspections

◊ DecisionsD Delays

StoragesTotals:

Copyright © 2014, Margret\A Consulting, LLC. Used with permission of author

An additional resource that provides a comprehensive discussion of workflow and process redesign for EHR and HIE is: “Process Improvement with Electronic Health Records: A Stepwise Approach to Workflow and Process Management”, M. Amatayakul, CRC Press, 2012.

Copyright © 2014 Stratis Health. Updated 03-10-14

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