Healthcare Talent Transformation

EMR Blueprint: Steps 5, 6 & 7: Future State Workflow; Design, Build and Validate; User Testing

Andrea Morgan, AndreaKnowsEMR.com

Most providers will agree that they want to care for patients, document appropriately, bill confidently and have a smooth transition from paper to electronic medical records. Having a plan in mind, such as the one outlined here, will go along way toward meeting your objectives.

1. Practice overview
2. Role definition
3. Current state workflow defined
4. Validation
5. Future state workflow
6. Design, build, validate
7. User acceptance testing
8. Training
9. Build for production
10. Go-live support
11. Post go-live support can be provided by:
    ○ Phone
    ○ Email
    ○ Newsletter/tips and tricks
12. Refresher training
13. On-going needs for training:
    ○ Optimization
    ○ New hire training
    ○ Software updates

In an ongoing series, each of these steps will be discussed in turn. Let's take a look at Steps 5, 6 and 7, Future State Workflow; Design, Build and Validate; and User Acceptance Testing.

After determining the current practices it is necessary to map those to the functionality and/or limitations of the EMR that you’ll be implementing. This process is the documentation of future state workflows - how patient care will transpire and be documented after implementation. Once this work is complete, the system design can be started and built to the specifications outlined in the future state workflows. When this build has been completed, it is necessary to validate that tasks can be accomplished as designed. It is very important to complete this step as well as to have end users (not technical people) test to confirm.

Quick story to illustrate how one word, misunderstood and untested, can lead to tremendous challenges:
In a specialty practice, providers dictated their notes. They were assured that post-implementation, they would still be able to dictate. This made the providers happy. After go-live, providers dictated their notes as they always had, into portable tape recorders, and dropped the tapes off to be transcribed with the front desk assistant.

Providers grew very frustrated when, after a few days, their transcribed notes were not appearing in patients’ charts. After multiple help desk calls, visits from IT staff, some yelling and a few threats to unplug every machine here (that is a quote!)...still no resolution. The IT staff came to test the providers' computers and make sure that audio was working, sound files could be heard. Since they could, it was determined that it wasn’t an IT problem. Help desk ticket closed...those spoiled doctors...insert eyeroll here.

The problem? The IT understanding of dictation (speaking into a microphone attached to a PC so that a .wav file is created) and the providers understanding of dictation (speak into a separate recording device and have information transcribed) were very different. No one had validated the proposed workflow for dictation, agreed upon it and had it tested by those who would be using it. When IT tested it, it worked - for what they thought would happen. Providers were not given the opportunity to test, only placated and brushed aside.

It may sound obvious, but it is imperative to get users involved in the documentation of workflows and testing because they are the people who will be most impacted when misunderstandings arise. While it may be tempting to do whatever is necessary to make end users smile in the short term (or get them off your phone/out of your inbox) it is better for the organization in the long run to take the time to confirm and test the proposed workflows.

EMR Blueprint: Steps 3 & 4: Current State Workflow and Validation

Andrea Morgan, AndreaKnowsEMR.com

Most providers will agree that they want to care for patients, document appropriately, bill confidently and have a smooth transition from paper to electronic medical records. Having a plan in mind, such as the one outlined here, will go along way toward meeting your objectives.

1. Practice overview 
2. Role definition 
3. Current state workflow defined
4. Validation
5. Future state workflow
6. Design,build, validate
7. User acceptance testing
8. Training
9. Build for production
10. Go-live support
11. Post go-live support can be provided by:
    ○ Phone
    ○ Email
    ○ Newsletter/tips and tricks
12. Refresher training
13. On-going needs for training:
    ○ Optimization
    ○ New hire training
    ○ Software updates

In an ongoing series, each of these steps will be discussed in turn. Let's take a look at Steps 3 and 4, Current State Workflow Definition and Validation.

A suggestion: write down the basic workflow, each step for a typical office visit. Think about where time can be saved in the process as well as what may take longer during the learning phase of implementation.

What is workflow? Originating in the manufacturing arena, it has come to be an integral part of planning and managing implementations. Fundamentally, workflow delineates and defines the discrete steps involved in completing tasks.

Details may vary but the basic components of an office visit are the same: patient arrival, examination, billing. Many individual tasks are contained within each of those very broad categories. Very often tasks are completed out of habit and those are things that get overlooked and subsequently cause consternation upon implementation because the EMR is not aware of/programmed to take into account human habits. It can be, but only if those things are recognized and requested.  

For example, in placing lab orders for a diabetic patient, an endocrinologist may say to a nurse (or medical assistant), please order the usual tests for Mrs. Johnson. The nurse/MA knows that Mrs. Johnson is an established patient, has been seen several times in the practice. The doctor always orders Hemoglobin A1c, a lipid panel and fasting glucose for patients like Mrs. Johnson. This is called the current state workflow; the steps for this can be defined as follows:

1. Review labs for Mrs. Johnson
2. Fill out lab order form (specifying which tests are to be performed)
3. Sign order form (provider)
4. Give lab slip to Mrs. Johnson
5. In some offices, blood will be drawn and sent to the lab; in others, patient will need to go to a different location
6. Wait for lab results to be faxed to practice
7. File results in Mrs. Johnson’s chart

From one verbal request we’ve come up with seven distinct steps. Defining the current workflow in this manner should occur for each of the most common tasks in your practice. This is necessary so that the current practices can them be mapped to future practices that will be required once the electronic medical record is implemented. The more specific the current state workflows are, the more effective the future state workflows can be.

Validation is an integral part of this process because it helps to insure that the workflow as documented is what actually happens. As the saying goes, "two heads are better than one." It is helpful to have another set of eyes to confirm that the standard in the office is the same for all providers and that staff members understand what is meant when requests are made. It is amazing how people can hear the same words but have very different understanding.

In a specialty practice that I worked with, providers were told that after implementation they would be able to continue dictating progress notes. The providers understood this to mean that they could continue to speak into pocket recorders and have those recordings transcribed. The implementation team understood dictation to mean that providers would speak into a microphone attached to a computer. For weeks providers were frustrated because they kept asking why their dictations were not showing up in the patients charts, and the implementation team couldn't understand why they couldn’t find any .wav files. Same word, very different understanding. No validation of that workflow had taken place and the result was painful.

 

EMR Implementation Blueprint: Step 2: Role Definition

Andrea Morgan, AndreaKnowsEMR.com

Most providers will agree that they want to care for patients, document appropriately, bill confidently and have a smooth transition from paper to electronic medical records. Having a plan in mind, such as the one outlined here, will go along way toward meeting your objectives.

1. Practice overview
2. Role definition
3. Current state workflow defined
4. Validation
5. Future state workflow
6. Design,build, validate
7. User acceptance testing
8. Training
9. Build for production
10. Go-live support
11. Post go-live support can be provided by:
    ○ Phone
    ○ Email
    ○ Newsletter/tips and tricks
12. Refresher training
13. On-going needs for training:
    ○ Optimization
    ○ New hire training
    ○ Software updates

In an ongoing series, each of these steps will be discussed in turn. Let's take a look at Step 2, Role Definition.

Who’s on First? is a famous comedy skit, in which Abbott and Costello rather hilariously try to define roles on a baseball team. I think it’s a perfect illustration of how simple words can be misconstrued and how important it is to know who is going to do what.

In an EMR implementation, it is imperative that each role in the practice is taken into account and to have a clear understanding of who will be responsible for various tasks. Many times assumptions are made during the planning phase (rather than conversations had) that end up causing consternation as the EMR is being used.

It may seem to be a very basic step but I recommend making a list of each role in the practice and confirming how each will be expected to use the EMR. This will help lessen assumptions and increase understanding of how each staff member will be utilizing the system as workflows are defined. There are many unwritten rules in a medical practice and implementation of an EMR usually brings those into sharp relief.

In my sample list below, I’ve designated the Practice Manager as the person responsible for writing letters. That may or may not be true in your practice, but it is important to think about which role will be responsible for that function with the EMR, as well as whether that will be handled in the EMR at all.

Role	Sample of Responsibilities
Provider (MD, DO, NP, PA)	Progress notes, prescriptions, letters
RN	Injections, nursing notes
Medical Assistant	Rooming patient, taking history
Front Desk/Receptionist	Verifying insurance, scheduling appointments
Practice Manager	Patient relations, letters
Lab Tech	Fulfilling lab orders
Billing/Coding Specialist	Verifying proper charges
Per diem help	As specified based on role
Therapist	Progress notes, letters
Nutritionist	Notes, Patient instructions

 

That brings us to workflow…Step 3 of The Blueprint: Current State Workflow Defined which will be here in a few weeks.

 

In the meantime, enjoy Abbott & Costello - Check out the video or read the transcript.

 

Health Wonk Review: More Than Birth Control Edition

Healthcare-related news topped the headlines this week. Take a peek at the latest edition of Health Wonk Review hosted by Healthcare Economist.

Andrea Morgan is included in this week's HWR.  Read her article on the first step of implementing EMRs:  The Blueprint for the Evolving Physician.

A Blueprint for the Evolving Physician

Andrea Morgan, AndreaKnowsEMR.com

As clinical environments become more imbued with technology, there is a constant need to evolve and grow. Changing capabilities and opportunities, the availability of information and the necessity to incorporate components in medical decision making that might not have been around 10 years ago necessitates the evolution of providers.

Most providers will agree that they want to care for patients, document appropriately, bill confidently and have a smooth transition from paper to electronic medical records. Having a plan in mind, such as the one outlined here, will go along way toward meeting the objectives listed above.

1. Practice overview
2. Role definition
3. Current state workflow defined
4. Validation
5. Future state workflow
6. Design,build, validate
7. User acceptance testing
8. Training
9. Build for production
10. Go-live support
11. Post go-live support can be provided by:
    ○ Phone
    ○ Email
    ○ Newsletter/tips and tricks
12. Refresher training
13. On-going needs for training:
    ○ Optimization
    ○ New hire training
    ○ Software updates

In an ongoing series, each of these steps will be discussed in turn. Let's take a look at Step 1, The Practice Overview.

Begin at the beginning - so obvious yet so often overlooked. With so much discussion about meaningful use, the stimulus incentive, reduced reimbursements – many providers want to focus on the end and how quickly they can get there. Taking some time to plan and WRITE down the process by which you will implement whatever EMR system you choose will save so much frustration and time later. Start with the end in mind and get answers to some fundamental questions. What do you hope to accomplish? What does a day in the life of your practice look like once the EMR is fully functional? If you don’t have a good reference point from which to start, go visit other practices that have already implemented. Ask your vendor for referrals then CONTACT those people.

Honestly assess which members of your staff may be less technologically inclined than others. The ability to use a smartphone or post videos to YouTube does not equal documenting in a patient's chart. It may be necessary to re-train or reduce staff. Very often roles change post-implementation because some tasks that were performed by staff now must be done by physicians. This can cause frustration so be mindful of it.

A few examples of tasks and roles that often change after an electronic medical record implementation:

• Letters to patients or referring providers – are these done by office staff or provider? Should they include the progress note? 
• Refills - done by provider  or nurse? is there a refill line? are refill protocols documented?
• Documenting patient history - is this done by the nurse/MA during rooming? how much time does that add to rooming process? Will you do chart abstraction? can patient update this info himself? 
• Documenting phone calls to/from patients - how will information be communicated between office staff and providers? how many tries before creating documentation? Is phone call protocol documented?

Taking a look at the tasks and roles and identifying who does what will go a long way in getting your implementation started right. The practice overview is an integral part of the blueprint for a successful implementation.

Andrea Morgan is the founder and President of AndreaKnowsEMR.com As an EpicCare Ambulatory Certified technical trainer and consultant with over 15 years of pharmaceutical and EMR training experience, her areas of expertise include project management, curriculum development, and instructor led training as well as providing support to multiple medical specialities before, during and after EMR implementations.

 

Speed and Efficiency versus Cost and Customization

Andrea Morgan, AndreaKnowsEMR.com

Most electronic medical records offer some ability to customize. Some providers take hours to learn about all the possibilities and design a system that replicates their current practices while others want to work with the software as configured by the vendor because that allows for a speedier implementation cycle. Of course there are advantages to each of these options.

The customization route allows providers to gain access to and familiarity with the selected system prior to implementation. That time is often used to examine existing workflows and determine how to best alter the system to reflect current practices. The ability to customize orders, letterhead, user interface and many other components can give providers a sense of comfort and confidence once the system is implemented since they have had some say in development.

Customization takes time. There is no way to avoid meetings, conference calls, analysis, interviews, emails and more meetings in order to get workflows clarified, software changed and tested, changed again and re-tested. Providers have to make the decision and commitment to spend time away from patient care to devote the necessary energy and attention to the process. The feelings of familiarity and comfort are garnered by spending time to get to the perfect balance of customization and cost effectiveness.

Skipping customization (or severely limiting it) has the benefit of speeding up the time between acquisition and implementation. The software can be installed on site with users trained and patients being seen within weeks rather than months. This approach gives users the opportunity to jump right in and begin seeing the increased efficiencies that electronic medical records can bring about. Patient information is readily available and can be utilized by staff to for medical decision making.

Lack of customization often brings about increased frustration however. The way medical practices work varies from office to office, speciality to specialty and in some cases, doctor to doctor within a practice. Using software that hasn’t been customized to address these differences requires that providers change the way they practice medicine. Processes that always seemed straightforward – placing a lab order or writing a letter – may have many more steps than they did previously. Taking the software “as is” means providers must learn to work DAW – dispense as written (in other words, to the software’s specifications as opposed to provider preference).

There are many changes inherent in the implementation of an EMR and even with customization there has to be the expectation that some adjustment and flexibility will be required for all involved. Getting guidance from others who have implemented electronic medical records can be helpful in deciding how much customization to pursue, and when. Spending on advice beforehand can save time, money and frustration during and after the implementation process.

Andrea Morgan is the founder and President of AndreaKnowsEMR.com As an EpicCare Ambulatory Certified technical trainer and consultant with over 15 years of pharmaceutical and EMR training experience, her areas of expertise include project management, curriculum development, and instructor led training as well as providing support to multiple medical specialities before, during and after EMR implementations.

Learn about the BUSINESS of Medicine

We are pleased to introduce our newest blogger, Andrea Morgan. Andrea is the founder and President of AndreaKnowsEMR.com  As an EpicCare Ambulatory Certified technical trainer and consultant with over 15 years of pharmaceutical and EMR training experience, her areas of expertise include project management, curriculum development, and instructor led training as well as providing support to multiple medical specialties before, during and after EMR implementations.

The implementation of an electronic medical records system impacts the providers fundamental ability to make money. We have to be cognizant of this as we make decisions that will impact that business. It isn’t enough to say that software is user-friendly or intuitive and that productivity will return to normal *eventually* when the real costs of losing productivity can be jobs and practice stability.

I’m not advocating learning about billing per se, but about all the things that impact a provider’s financials – staff costs, office space, insurance, licensing, pretzels in the break room – for the purpose of looking at the EMR as a tool to support the existing functions and have as little negative impact as possible.

I recently read a great book by Dr. Steven Hacker, The Medical Entrepreneur that goes into great detail about the business aspects of setting up a medical practice. This book provides excellent depth of knowledge for a topic that is often overlooked by consultants and even by providers.

When assessing EMR solutions, very often providers want to know the bottom line – how much will it cost, how long will it take, how frustrated will I be – and while those answers may be (relatively) easy to come up with, they may not encompass the business costs on a holistic (as opposed to strictly fiscal) level.

For consultants, I think this book will give excellent insight on how to best support the practice during the implementation process. Understanding how the business of medicine works can only improve the level of analysis, quality of solutions and empathy that you will be able to provide to client.