Reality Workflow Tool  

Introduction

Of all of the EHR concepts, the notion of "Workflow Management" is the newest and perhaps one of the more confusing. The topic itself is not new, there is much research on this topic, but little of it exists in terminology that is familiar to the medical market space. That makes it challenging for physicians to jump in and pick up the discussion. James Reitsema, one of the consultants we have listed - speaks about workflow at several of the conference we participate in. We have also written about workflow recently in our Industry Alert newsletter.

Why Is Workflow Important?

Workflow is important because the degree to which the user themselves can define and adjust the actual workflow that the computer EHR provides, is directly related to the degree of workflow enhancement that the EHR is likely to achieve when installed. It is "better" for and EHR to allow the user to adjust the systems workflow than to require an EHR vendor programmer to change it. This can be reflected in lower maintenance fees but mostly it allows the practice to quickly change and optimize its electronic workflow to match the manual workflow that the practice is fitting the EHR into. Obviously, if the EHR depends upon a vendor's programmer to make program adjustments, it will take longer than if the EHR was built on a workflow "engine" that allows the user to make the same changes, without any programming.

Adjusting Workflow Is More Than Simply Creating/Changing Templates

As we have surveyed EHR vendors and tried to develop questions that draw out the ability of one EHR versus another in the area of workflow, we have found that some vendors see "workflow" as allowing the physician user to create their own templates (of pick lists, for example) and to assert such templates to their EHR, so they can be recalled and used, shared with other practices, contributed to a template library, etc. Yet this is not true workflow management. Rather, the workflow management we are talking about goes beyond template creation and selection, to the issue of how templates or other workflow elements are selected and sequenced by their system and which ones are presented to which (types of) users, in which sequence to optimize the sequence of tasks that must be accomplished the specific encounter workflow required for each DIFFERENT type of patient seen in your practice. Workflow is therefore 3-dimensional in a sense, relating three sets of information - {practice users} with {encounter types} and the {workflow tasks} that must be accomplished to complete the encounter.

Perhaps an analogy is helpful. Thing of workflow as a group of blocks in a bucket (of all possible tasks your practice does). For any ONE TYPE of patient, there is a certain set of blocks required to be searched for and pulled out of the bucket, and then assembled in a specific order to build that specific workflow. Like building anything, certain practitioners are more suitable than other to perform a workflow task. A doctor can take the patient blood pressure, but a nurse may be a more suitable employee to do this particular task on a routine basis. So for each workflow element to be accomplished, there is a primary type of person that routinely performs the work, and perhaps a backup or secondary person who could perform it, if the primary person is not available for some reason.

Building Your Electronic Practice Workflow

Now multiply this build process for ALL TYPES of patient encounters seen in your practice, and for all types of SPECIALTIES operating in your practice, if you have a multi-specialty practice. For each encounter type there is one optimal workflow in which the exact tasks are done in sequence by the most appropriate workers with a minimal amount of wasted time. When that happens you have an efficient workflow. In an EHR system (with a workflow engine as its foundation), the system has the notion of this process and provides tools for the user to adjust and manage it. For example, the sequence of tasks required for a NEW ADMIT workflow to your practice might include: Task 1 - Patient Reception (done by Receptionist), Task 2 - Completion of Patient's medical history (done by Patient), Task 3 - Initial Interview of Patient and Review of Patient History (done by Clinical Specialist, or Office Nurse, or whomever in your specific practice), then Task 4 and so on, until all tasks have been completed.

An EHR built on a Workflow Management Engine foundation will have a screen where the user assembles the encounter types (1st element) with the specific tasks that make up the encounter workflow (2nd element) with the specific medical providers that do each task (3rd element). It will also have tools to display that workflow to each of the individuals responsible for completing a task in real-time as the task is running (the patient is being seen) and track (and alert the individual workers and the practice "workflow manager") to delays that are creeping into the workflow (such as the patient being in the exam room for 10 minutes waiting to see the nurse who hasn't dropped in yet). Such an Workflow Management Enabled EHR has both the tools to DEFINE workflow and the tools to TRACK workflow as it is actually happening, and so enable the users to interact with the workflow the EHR is tracking and modeling.

Few EHR Solutions Include Workflow Management Engine Foundations

Generally, only some of the newer EHR products embody the notion of full USER workflow management, those built from the ground up on workflow management engines. The rest typically support user template modification and retrieval, which is their notion of what user workflow management is all about. As the concept has emerged, they may have added on a practice workflow status monitor (one display that shows where everyone is and how long they have been waiting for what), but even this is generally not implemented in a way so that the information is being DELIVERED to the person tasked with each workflow element, or in a way that allows that person to easily call in reinforcements when the workflow schedule is delayed due to some unanticipated event in the practice.

A Workflow Analysis of Your Current Manual Process

The very first step in determining whether you are ready to computerize your clinical practice is to document what the workflow is for your specific practice, for every specialty in the practice and every provider who will be using the EHR system you are going to buy. This is the job of the Business Manager working with each of the other Physicians and their staff in the practice. Physician buy-in and support at this stage is critical and vital. Don't skip this step. You need it later to intelligently discuss what you want your EHR to do with your EHR vendor. If you don't explain to the EHR vendor what your practice workflow is, he won't know if his system is a good fit (although he will pretend it is) and more importantly, you won't have any good way of determining how good a fit it is easier. MSP makes a tool that can help you to document your practice workflow. While the MSP Reality Workflow Documenter™ is a simple tool, the database entries it creates are used by a second tool, our Reality EHR Selector™ to help you determine practice fit for a variety of EHR vendors. Registered users can access more data on workflow management from our site.

Show Me MY Workflow

Now you want to put the information about your practice to work and use it to help you evaluate any candidate EHR vendor you are considering.

The next time at a trade show, a vendor asks you, "Doctor, can I show you my system?" The answer is, "No, show my how you would automate my practice." And then pull out your practice workflow management diagram and ask it to customize his system to your exact workflow. After the blood returns to his face, and his legs cease wobbling, watch what he does. As you work through the items on your list, watch for the "vaporware" - the places which look like they are implemented, but actually have no content or capability behind them. Quietly note them. If you find a vendor who can actually do this for you, mark that one down on your short list of EHR vendors to talk to.

Be carefully about sales diversions. That's where the salesman starts down your list, find a convenient off ramp from your list back to his standard demo and you suddenly find yourself going along his demo path, not yours. You will learn less about his system is you allow such diversions. Keep him on track, showing you his specific workflow management tool and how it is changing the items on your list into the screen sequences to make it happen on his system. Once ONE customization is done, let him demo that customization to you and count the mouse clicks and number of screens that are displayed, and you will have a good idea of what actually using his EHR solution in your practice is going to look and feel like. Remember, his system needs to work in your practice, not in his booth at HIMSS or TEPR or AAFP or MGMA. It has to work with YOUR staff, not the EHR vendors highly experienced clinical specialists, who do these demos every day. If he can show you the screens required to customize his "standard" workflow (including the sequence of computer screens and templates required) to transform it into YOUR workflow, you are looking at an EHR that was built on a user workflow management engine enabled EHR. The process of customizing that system to exactly fit your current workflow is a key task to be negotiated if you acquire that EHR. The simpler and more intuitive it is, the better for you, because after the initial customization ("fitting" of his EHR to your specific workflow), the burden of continuing to fine tune it will either fall on you (or you will spend extra money to have someone else do it for you) or you will be stuck with automating the workflow you are currently doing (manually), which is almost never the ideal workflow you could be doing.

Where To Go From Here?

If you haven't thought alot about workflow to date and you are in the market for a new EHR, you need to begin pondering it. Make a list of all patient encounters. Make a list of all providers in your practice and the tasks they are qualified to perform. Make a list of each step that ONE type of patient must receive (the work items) and then WHO will best perform it. This will help you prepare for the installation step of actually customizing the sequence of EHR computer screens and items on each screen to automate the clinical aspects of your practice.

Here are some additional helpful resources for Registered users, at a nominal fee, that casts additional light on this process.

We also suggest you check out the JMJ Technologies (EncounterPro) website, as their system is built upon a user-accessible, workflow management engine and they have several good "white papers" on the subject. The 2005 EHR Vendor Survey, Andrew and Associates - available on this site is another excellent resources, as it tracks the level of workflow management achieved by over 45 different vendors.