Workflow Analysis: C A L I FOR N I A EHR Deployment Techniques H EALTH C ARE F OU NDATION Introduction ◾◾ California Rural Indian Health Board This investigation of workflow analysis and its (CRIHB) uses in the implementation of electronic health 3. Multi-site Expansion. Support for multi-site records (EHRs) is the fourth in a series of tactically clinics to expand adoption of their existing oriented issue briefs to come out of the California EHR product and implementation services to Networks for EHR Adoption (CNEA) initiative. Issue Brief at least three additional clinic sites. Grantees: The CNEA program was begun in 2006 to speed adoption and lower the overall cost of EHRs in ◾◾ Golden Valley Health Centers (GVHC) California community clinics and health centers ◾◾ Shasta Community Health Center (SCHC) (CCHC).1 In August 2008, eight grantees 4. Hospital-based Regional Extension. Grants representing four models of EHR deployment awarded to local hospitals to extend their were funded to advance the adoption of EHRs existing EHR product and implementation in the safety net and to share their experiences. services to CCHCs in a region or service area. Through this collaboration, an array of services has Grantees: been provided to support the adoption of EHR and other applications. The CNEA models and ◾◾ San Mateo Medical Center (SMMC) grantees include: ◾◾ The Children’s Clinic, Serving Children and Their Families (TCC), Long Beach, CA 1. National Network. Build or leverage existing EHR networks, often national in scope, to For additional information about the CNEA provide for individual or groups of clinics in initiative and collaborative models of adoption, California. Grantees: please see “Making a Connection: Clinics ◾◾ Open Door Community Health Center Collaborate on EHR Deployment” from the (ODCHC) in partnership with Our California HealthCare Foundation at Community Health Information Network www.chcf.org. (OCHIN) Overview ◾◾ Voxent (formerly Next Generation Health Organizations embarking on the process of Network) selecting and implementing an EHR system are 2. Clinic Consortia. Work with California clinic often advised that documenting or analyzing consortia to expand their existing EHR product workflow must be their first task. This admonition and implementation services to at least three of amounts to a barrier for the many organizations their members. Grantees: that have little practical experience with ◾◾ Redwood Community Health Coalition documenting or analyzing workflow. Encountering (RCHC) jargon-filled phrases such as “technology-enabled business process redesign” further mystifies the endeavor. J anuary 2011 To help clinics move effectively toward their goals in gathered from the analysis and rearranges, eliminates, or EHR adoption, this issue brief explores the stages of restructures tasks to make the process more efficient (i.e., workflow analysis, process mapping, and process redesign. less time-consuming, fewer hand-offs, clear accountability, It uses examples from the CNEA grantees to illustrate the and protocol- or rules-based). Process redesign also takes value of these tasks and how to approach them. into account the introduction of factors such as new hires, new programs and, most importantly, new technology EHR implementation is a complex and disruptive process. systems like EHRs. Workflow analysis can organize that process and engender staff buy-in, which is necessary to be successful. Process Tools, Techniques, and Tips for mapping provides a visual representation of current Analyzing Workflow processes that allows clinics to evaluate how well they There are many ways to approach conducting a workflow are working, where the bottlenecks lie, where variations analysis, but key success factors should be considered: occur between clinical sites and/or staff, and where tasks 1. Bring together a multidisciplinary team. Few clinical can fall through the cracks. Process redesign completes processes start and end in the same department. If the improvement cycle by devising ways to reorganize a given process crosses functional boundaries, it is processes, making them more efficient now and in the vital that a multidisciplinary group documents the future when the EHR is introduced. process. The perspective of all involved is essential for getting an accurate picture of the end-to-end flow of The CNEA grantees’ experiences bear out the wisdom information and for reaping important by-products of analyzing workflow before, during, and after of workflow analysis: improved communication, implementing an EHR. Collectively, workflow analysis, appreciation for everyone’s role in the process, and an process mapping, and process redesign can help clinics understanding of the value of compromise in creating save money, create greater staff satisfaction, smooth the opportunities for improvement. transition to the EHR, improve patients’ experience, and provide the roadmap for achieving clinical transformation 2. Make sure the process analysis—written narrative through health IT. or a process map—includes, at a minimum, a review by staff actually doing the work. Managers What Is Workflow? may not be aware of the level of variation in process Workflow refers to the interaction of processes (made that has evolved over time, or the “on the fly” steps up of tasks) through which a clinic or hospital provides involved under various circumstances. What’s more, health care to patients. Patient registration is an example the review may provide an opportunity to see how of a process, as is a medication refill. Confirming a tasks and responsibilities have evolved in ways that are patient’s insurance or checking that a prescription is not foreseen or reflected in job descriptions. current are examples of tasks within these processes. 3. Don’t rely on the vendor for workflow analysis. Many EHR vendors will provide worksheets or other Process mapping, or flowcharting, involves diagramming tools for workflow analysis, but the questions on these all of the tasks required to carry out a process, and worksheets are primarily intended to inform higher- identifying the points at which one process intersects level vendor tasks (e.g., how many reference labs are with another. Process analysis, or workflow analysis, used, or what type of vital sign devices are used). addresses inefficiencies and bottlenecks revealed by the A greater level of specificity is required for process process mapping. Process redesign uses the information mapping and analysis. Clinic employees are the true 2  |  California HealthCare Foundation experts in the matter of overall workflow and the your site. We had a list of 150 current workflows before individual processes involved. we began defining our future workflows.” 4. Assign responsibility for the task by appointing The next step involves interviewing or discussing the a project manager, data steward, or other point workflow with the people involved in carrying out each person. This individual can keep the process moving process in order to write detailed descriptions. The forward and make sure that the workflow analysis description of a process should answer these questions: informs the EHR configuration and implementation process. They can also make sure that the workflow ◾◾ What is the process? (For example, registering a analysis and process maps are continually updated to patient or refilling a prescription.) reflect changes that occur over time. ◾◾ Are there important patient care processes that do not involve seeing a patient? (For example, dealing with Common Clinic Processes to Be Analyzed an abnormal lab result.) Often clinics have a difficult time knowing where to ◾◾ What are the tasks or steps involved? (For example, begin or which processes are most important to analyze. checking a patient’s insurance or confirming that a One approach is to take a high-level view of a patient’s prescription is up to date.) end-to-end interaction with the health center, from scheduling to keeping an appointment, checking in, ◾◾ What are the variations to these processes? Are there receiving service, checking out, and paying for the visit. acceptable reasons for process variations by clinic site? Variations in this process may occur depending on ◾◾ Who completes the process? Do several types of staff whether the individual is a new patient or a returning perform the same tasks? Is this a good example of one; an adult or child; a walk-in patient; and/or a person cross-training or is it a duplication of effort? with a specific type of insurance. Examining these end-to- end workflows reveals the more granular workflows and ◾◾ How long does it take? clinical processes they contain. Carlos Avina, quality ◾◾ Where are the bottlenecks where the process gets improvement/EHR implementation manager with interrupted or slowed? Has some staff member Community Health Clinic Ole, offered this list of process already found a way around such points? categories from which to start (see Table 1). ◾◾ Do some tasks need to be done more than once in a “It’s an amazing amount of work,” observed RCHC’s Dr. given process? (For example, must the same data be Robert Moore. “You have to analyze every workflow at entered at different points during patient check-in?) Table 1. Clinic Process Categories • Behavioral Health • Medical Records (MR) • Reception • Rooming Patients with Vitals • Billing Processes • Medications • Registration • Scheduling Protocols • Refills • Walk-in Clinic • Provider Working Hours • Case Management • Schedule 2 • Referral Processes • Appointment Types • Group Appointments • Phone Answering Processes • Incoming • Triage • Health Wellness Events • Outgoing • Post Visit • Immunizations • Reporting • Provider Processes • In-house Labs Workflow Analysis: EHR Deployment Techniques  |  3 ◾◾ Are there places where the process regularly stalls? diagram provides a visual snapshot of the flow, making (For example, in getting information from one staff it easier to “see” where efforts are duplicated and where member to another.) processes intersect and are dependent on each other (see Figure 1). It also adds a discipline to the task of A particularly important component of documenting improvement and allows for involvement of key players. processes for EHR implementation is the collection of all of the paper forms used by staff members. This Making a process map does not need to be a high-tech step is crucial because each of the tasks represented by endeavor. First, the mapping team should walk through a paper form will need to be provided for in the EHR. the process once or twice, taking notes as described above. In particular, the fee ticket, super bill, or encounter The most effective tools for charting the process may be a form is traditionally used to collect many kinds of whiteboard or large sheet of paper and some sticky notes. data beyond what is needed for billing. Notations on Each task in a process should be recorded on a note; then the encounter form often trigger the work of others in the notes are moved around until the current sequence performing or arranging for ancillary services to the of tasks is represented accurately. At this point, some patient. Understanding where and how these data will be organizations find it useful to use Microsoft Visio, Word, collected and communicated is an important part of the or PowerPoint to create process diagrams. These can help EHR-enabled workflow design. determine the level of detail at which the process analysis will be conducted. It should be possible to diagram an Process Mapping entire process on one page. The chart or diagram should Most clinics choose to develop process maps, or then be posted where the team and staff can review it over flowcharts, which can include all of the points described several days, adding thoughts and observations. When above. Turning a written description of a process into a the process map is finalized, it can be used as a “through Figure 1. Symbols in Process Mapping An oval shows the input A box or rectangle to start the process or the output shows a task or activity at the end of the process arrows show being performed direction of process flow There is only one arrow out of each activity box — if more A diamond shows yes a yes/no question or arrows are needed then you may need a decision diamond a decision no This shape is used to represent An oval shows the input a document or report to start the process or the output at the end of the process Source: Kathy Reims, M.D., adapted. 4  |  California HealthCare Foundation the lens of ” analysis, providing views from multiple a positive effect on productivity or efficiency, there is perspectives: technology, information flow, the patient resistance to the institutionalization of change because experience, and so on.2 of the thinking that “we’ve always done it this way.” For all of these reasons, widespread variation is often found It is important to remember that with process mapping across clinical sites within the same organization and (as with documenting processes) the creation of a map even between staff members doing the same tasks at the is not just a means of enabling EHR adoption. The same site. mapping process has value in itself. In order to create a visual representation of the tasks required to complete a Documenting back office, front office, health information given process, staff members from different parts of the management (medical records), and provider processes is a clinic or different disciplines must clearly communicate useful reality check, especially for managers who may not what they need from each other. This communication know how those tasks have evolved over time. In some helps build the mutual respect and understanding that cases, there are legitimate reasons for process variation and are indispensable to working together in the EHR different workflows. For example, GVHC has 28 medical implementation process. The goal of process mapping, locations across two counties that have slightly different however it is done, is to understand the current process reporting and public health surveillance requirements. as a prelude to improving it both before and after the Understanding these requirements and planning for them implementation of an EHR. A diagram presents the is an important part of EHR set-up and implementation. process in visual form, which can help to: By the time the multidisciplinary team has created a ◾◾ Reveal where the sequence of tasks is crucial; visual representation of the process, they have discovered ◾◾ Identify bottlenecks or interruptions; the waste and bottlenecks, and have often found ways to relieve them. Thus “workflow analysis” is not an ◾◾ Identify opportunities (often the same as bottlenecks); arcane skill, and does not require expertise beyond the ◾◾ Create solutions to relieve bottlenecks; collective experience of clinic staff. It simply takes time and input from everyone involved in carrying out the ◾◾ Re-analyze the new process; process. Further, making processes more efficient before ◾◾ Make efficiency improvements; and implementing them in an EHR saves a great deal of time and difficulty later. The analysis will also help set realistic ◾◾ Take advantage of the automation provided by expectations for what the technology can and cannot an EHR. do, and will get buy-in to the adoption process from all affected staff. Current State: “As Is” Workflows Although there may be a baseline understanding of how RCHC staff acknowledged that the main purpose of a particular process or task is completed in a clinic, over doing “as is” workflows is to give everyone the knowledge time staff members may develop workarounds, shortcuts, that what they do is part of a larger workflow, and will or other deviations from this baseline. When new staff need to be accounted for in the EHR-enabled clinic. This members come on board, their training often consists part of the implementation process creates opportunities of shadowing a fellow staff member and thus learning for engendering buy-in and is fundamental to change the deviations, which then become institutionalized. management. “It’s not just the doctors that will be However, even in cases where a shortcut can lead to impacted,” notes Nancy Oswald, RCHC’s CEO, “it’s Workflow Analysis: EHR Deployment Techniques  |  5 the whole team: front desk, medical assistants (MA), were written, looking for a computer. We then gave them providers, billing, finance, and leaders.” The Children’s laptops, which proved to be too clumsy to carry around, Clinic also used the workflow analysis process to their until we finally put computers in the exam room.” Insight advantage. They began it six months before their intended about hardware placement and sufficiency is one of the EHR go-live by constituting a workgroup composed of important lessons to be learned through future state staff from all clinical sites. Their goal was to standardize workflow analysis. processes across sites, and they worked collaboratively to design processes that worked for large and small sites alike. Matching the Template to the Reality Understanding workflow can have a big influence on how the EHR is configured and on its ease of use. For Future State: “To Be” Workflows example, as Voxent (formerly NGHN) developed its Tanya Parker, director of implementations for Voxent standardized clinical documentation templates, the pilot (formerly NGHN), said, “The end result of the workflow clinics played a large role in providing input. analysis is a vision for how the clinic will operate once the Their workflow involved rooming the patient, taking EMR is implemented, as well as specific and executable vitals, interviewing the patient, and then performing plans to support that vision.” After the current “as is” an ultrasound and documenting those results. The templates reflected this flow, with the ultrasound workflows are documented, mapped, and analyzed, the documentation placed on the third tab. next step is to envision how those processes will change When the templates were provided to the organization’s with the introduction of an EHR system. Because it can affiliates, it was discovered that some workflows were be difficult to imagine the future state without adequate different than the pilot clinics’. For example, one clinic training in the EHR, Parker recommends completing performed the ultrasound first, before the patient this training before tackling the “to be” workflows. This interview and vitals. The EHR interface was clumsy for ensures that staff members have some concrete ideas this clinic, requiring extra “clicks” as they navigated the template to document results. about what EHRs can do to automate and simplify processes. This problem also necessitated more training at clinics where the established process flow didn’t match the documentation sequence presented in the EHR Future state workflows reflect how technology can template. automate processes and make them more efficient. The workflows need to take into account seemingly mundane details such as where documentation occurs (e.g., exam room, nurses station, hallway) and the specific forms Several CNEA grantees found the future state workflow used to record data (in most cases, the encounter form or documents to be a vital part of their training materials. other preprinted charge ticket). The information is used GVHC imbeds standards and policies in their workflow to determine how these functions and communication documentation. For example, encounters are closed triggers will occur within the EHR. within 72 hours of the visit, and the EHR training is used to enforce not only how to use the system but “One thing we didn’t do well before implementation what the organizational performance expectations are. was look at our patient flow and workflow,” said Dean GVHC found it beneficial to document the current Germano, CEO at SCHC. “We knew we had made a responsibilities of staff members involved in carrying mistake when we saw our nurses walking down the hall out a particular process or task, and then determine how with a piece of paper on which the patient’s vital signs those responsibilities may change in the future to identify 6  |  California HealthCare Foundation where gaps in skills exist or where individualized training off of the fax and pulls the patient chart. Then she clips is needed. In some cases, new processes and tasks have the request to the chart and puts the whole thing in the required that the job descriptions be updated to reflect medical assistant’s tray. The MA may have to call the the changes in responsibilities introduced by the EHR patient or the pharmacy before giving the chart to the workflows. doctor. The doctor reviews the chart and the request and either creates a new prescription or not. Either way An Example: The Medication Refill Process the doctor has to document the decision, and then give Before and After EHR the chart back to the MA. The MA then either contacts In the following example of one clinic’s process for the patient (if there is not a new prescription) or the renewing a prescription, it is clear that many staff pharmacy (if there is), and she documents what she did. members are involved. “Refill requests come in from Then the records clerk puts the charts back.” 3 Figure 2 the pharmacy by fax. Our records clerk gets the requests shows the same process, converted into a diagram. Figure 2. Medication Refill Process — Before EHR MR clerk pulls MA retrieves Is the Chart and slip information/ Refill request patient chart, chart, faxed no are placed in request received by fax clips refill med request MA basket complete? request to chart and reviews yes Provider Is a new MA gives chart MA calls yes Provider documents the prescription to provider with patient and/or reviews chart prescription renewal authorized? request and pharmacy to and request in the chart complete info clarify request no Chart is returned Provider documents to MA tray reason for declining request MA contracts pharmacy to refill Chart is returned prescription to MA tray Chart is returned MA contacts patient to MR and explains reason for denial MR clerk files chart Source: Dawn Weathersby, M.S.N., R.N., adapted. Workflow Analysis: EHR Deployment Techniques  |  7 In a busy clinic that handles dozens of refill requests per Continuous Process Improvement day, the diagram reveals several points of potential delay: Clarifying and improving work processes makes EHR adoption go more smoothly. In turn, EHR ◾◾ Where the records clerk needs to pull the patient’s implementation further improves work processes. chart, clip the fax to the chart, and provide that This “conversation” between the EHR and workflow information to the MA; can also facilitate productive conversations among staff ◾◾ Where the MA needs to contact the pharmacy for members. Often this communication results in more clarification and provide the request and the patient efficient processes and workflows, and gives teams a information to the provider; greater ability to weather the disruption that EHR implementation can bring. ◾◾ Where the provider needs to find and review the relevant information in the patient chart; Choosing not to document and analyze workflows ◾◾ Where the provider needs to create a new prescription before EHR implementation is choosing to do it later. order and document it; and Documenting workflows early in the process provides the opportunity to change inefficiencies even before EHR ◾◾ Where the MA needs to contact the pharmacy or implementation. Putting off workflow documentation patient again, once the provider has renewed or and analysis simply postpones the cost and increases the declined to renew the prescription. In the medication refill process diagrammed above, Figure 3. Medication Refill Process — After EHR several of the delay points could be addressed with the capabilities of an EHR. For example, all of the steps Rx refill request involving pulling charts and physically moving them received and around can be eliminated, as can separate steps for routed to inbox documentation. The EHR makes all of the patient’s information available immediately, and can be customized Provider reviews to save new prescriptions to the patient’s record. Clinical inbox, clicks on messaging or tasking eliminates routing paper forms and patient chart to notices. In the following diagram, the refill request from review information the pharmacy is received in the EHR, where the provider can review it and take appropriate action. The MA can then contact either the patient or the pharmacy directly Renew yes Send eRx to pharmacy if necessary, and send the completed prescription to be medication? through EHR refilled. (See Figure 3.) In several CNEA clinics, this process has been further refined to have RNs, working no Refill request complete according to clinical protocols and standing orders, Note to EHR, send accomplishing a large portion of the incoming refill message to MA requests thereby freeing providers of this task. through EHR clinical MA calls patient and messaging explains Rx declination Source: Dawn Weathersby, M.S.N., R.N., adapted. 8  |  California HealthCare Foundation chances of a chaotic go-live that lasts several months an EHR. “We have too much invested in this to not have or longer. Moreover, clinics that postponed workflow it used properly,” noted the deputy director of GVHC. analysis took longer to return to previous levels of productivity than those that performed the analysis earlier Why Workflow Analysis Is Worth the Time in the process.4 SMMC found that of their 17 ambulatory Health care workflows tend to be quite complicated clinics, those that participated in a clinic redesign because they are carried out by a variety of staff members, collaborative in 2004 (pre-EHR) were significantly better departments, and care partners. Documenting these prepared for EHR implementation. Essentially, the EHR processes can lead to a detailed understanding of how implementation became an extension of the redesign different tasks interact and depend on each other. process and the clinics understood their workflow very Often multiple processes need to be coordinated, with well. As RCHC staff put it, “The time dedicated to time-sensitive information handed off to different developing workflows is better spent before go-live than departments and provided to patients. after. The time spent before is a proactive investment; after go-live, the effort is reactive, and can negatively Analyzing workflow provides other benefits. It creates impact implementation.” better communication among managers, providers, and staff; it engenders respect for the part that each process plays in patient care; and it can provide a framework for the coordination of different processes. All of this shared “Before they can be trained on the knowledge can help clinics save time and money, create greater staff satisfaction, and provide a better patient EHR product, clinics need to be trained experience. on the opportunities for redesign.” In addition to making the best use of technology, — Nancy Oswald CEO, RCHC redesigning processes as a group also makes the implementation of the EHR go more smoothly. All staff members come to the technology with a better understanding of how their tasks feed into the larger Even after implementation, workflows need to be audited clinic workflow, and a greater appreciation for the tasks of and tweaked in a continuous improvement cycle. Ten others. EHR implementation can become an opportunity months after the implementation of their EHR system, to re-train staff toward more efficient work processes. TCC realized that they needed to “go back to the basics” and reexamine their workflows. They found that the EHR systems consist of a set of highly flexible and process maps and workflow assumptions developed configurable data input tools that can be sequenced during the implementation no longer fit their needs. Staff in ways that best suit the staff members who will be had developed their own workarounds or verbal changes inputting data or retrieving patient information. The to the flow that had not been put on paper. Some CNEA process of EHR implementation is largely about tailoring grantees had to stop the EHR implementation process to the system to these preferences and workflows. If there catch up with the documentation of new workflows and are four different preferences about how to accomplish decisions that were being made rapidly and on the fly. the same task, the EHR becomes difficult to set up and Continuous assessment of workflow and clinic processes, nearly impossible to support. As the chief medical officer therefore, is a necessary part of maximizing the benefits of at SMMC pointed out, “Whenever you do one of these Workflow Analysis: EHR Deployment Techniques  |  9 implementations, you expose your faults.” Despite the processes, technology upgrades, and the discovery of many benefits promised for the future, approaching a efficiencies. workflow analysis can seem like an act of faith. It is easy to see at the beginning that it will require work and Therefore it is important to build system audits into that some unpleasant realities will have to be faced. The the culture of the organization, so that ideal and actual obstacles and problems that no one has wanted to deal workflows are constantly re-aligned. As one CNEA with will be revealed quite clearly. grantee observed, “Technology must support the workflow. That’s absolutely critical to success.” It can be hard to believe, then, that conducting a workflow analysis will be worth the pain. Nevertheless, the experiences of the CNEA grantees suggest that workflow analysis is not only necessary for EHR Author S.A. Kushinka, M.B.A., Full Circle Projects, Inc. implementation, but also a positive experience overall. Aside from enabling EHR implementation, process maps About the F o u n d at i o n created during the workflow analysis will continue to be The California HealthCare Foundation works as a catalyst to useful for: fulfill the promise of better health care for all Californians. ◾◾ Training new hires; We support ideas and innovations that improve quality, increase efficiency, and lower the costs of care. For more ◾◾ Training for newly revised EHR processes, for information, visit us online at www.chcf.org. example at a mock clinic session; Endnotes ◾◾ “Institutionalizing” best practices and organizational 1. The Blue Shield of California Foundation, the California standards; and HealthCare Foundation (CHCF), and the Community ◾◾ Embedding clinical protocols in a process. Clinics Initiative (CCI), a joint project of Tides and The California Endowment, are funding this project. Conclusion 2. Adapted from Kathy Reims, M.D., presentation to grantees This issue brief attempts to demystify the process of of the Building Clinic Capacity for Quality initiative, workflow analysis and highlight the benefits that can August 3, 2010. She is chief medical officer of CSI accrue at all stages of EHR implementation. The benefits Solutions, LLC. include greater staff readiness for EHR implementation, 3. This written description and the diagrams which better coordination between processes, and improved follow it are based on examples in: Dawn Weathersby, adherence to operational and clinical protocols. All of M.S.N., R.N., Quality Improvement Advisor, DOQ-IT. these result in enhanced satisfaction for staff and patients. “Understanding Workflow: Part 1.” Doctor’s Office Quality-Information Technology. Posted on the AHRQ Workflow analysis itself is not a high-tech undertaking. Web site (www.healthit.ahrq.gov). Rather it is a process that relies on human interaction, in 4. California HealthCare Foundation, “For the Record: EHR which respectful attention is paid to each person’s work, Adoption in the Safety Net” (www.chcf.org). and avenues for communication across work functions are broadened and developed. Its usefulness is grounded in the assumption that workflows are not static. They evolve over time in response to changing tasks, new care 10  |  California HealthCare Foundation