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Foundation Members:
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CHIME Presents:
The CIO’s Guide to Implementing EHRs in the HITECH Era
CHIME Member Comments on
Chapter 10: EHR Implementation is the Perfect Time to Improve Workflows, Processes
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Question posed to members:
To achieve maximum efficiencies from a new application, it’s crucial for healthcare organizations to improve
workflows and redesign inefficient processes. From a CIO perspective, what are some ways you’ve used to encourage
this step in the process? What does an organization need to do to take a fresh look at “the way we’ve always done things”?
Comments:
“I learned awhile ago in order to be effective and implement change it is important to follow these ten rules. (These rules pertain to implementing an EMR). I can elaborate on each rule if needed.
• Rule 1: Effective Governance is Critical – develop a quick and decisive decision making process at all levels
• Rule 2: Leadership Counts – get clinical and business leaders involved and have them send a consistent message
• Rule 3: The EHR Implementation Needs To Be Clinically and Business Driven – not seen as an “IS Project
• Rule 4: The Clinical And Business Transformation Process Needs To Be Codified Before System Configuration Begins – the alternative is a poorly conceived system or major cost overruns
• Rule 5: Don’t Try To Do Everything At Once – set the right expectations
• Rule 6: The Process Does Not End With The Implementation – an evolutionary approach of processes and functionality and continuous improvement is needed
• Rule 7: Define What Constitutes Success Before Go-live, Or It Will Be Defined For You – even if goals are evolutionary and met in stages
• Rule 8: EHR Vendor Implementation Staff Know The Software, But Are Not Experts On Hospitals and Physician Practices – they’ll help configure any process you ask for (good or bad)
• Rule 9: It Is Challenging To Find Employees Who Have All The Skills That Are Needed – make sure to build in time to allow for extra training and growth
• Rule 10: Superior Training Leads To Superior Go-lives – start the training process early and train to workflows, not how to “push buttons””
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“Require written policies and procedures BEFORE training begins. Training is 90% new workflow and 10% technical navigation.
• Add specific workflow redesign tasks with owners on work plan
• Create a comprehensive communications plan so that all stakeholders are involved in new design
• Require department director sign-off in advance of “Go/No-Go” discussions.
• Verify adequate staff 24 hour live coverage for at least two weeks in order to address new workflow, this support cannot be provided by the vendor or IT staff.”
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“We conduct detailed pre and post process analysis with employees who perform day to day functions in all impacted areas as well as managers and administration where appropriate. We use LEAN methodologies including A3 Problem solving techniques and frequently why we do something and question its currently applicability.”
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“Using modeling and simulation programs... providing a visual representation= of the existing and proposed workflow. (Sometimes we've been able to utilize local university students to assist with this process).”
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“We have involved forward thinking physicians, nurses and other clinical staff to imagine how things could be better. These folks are coming up with several ideas of how patient care can be improved with technology. We have also contacted other facilities to discuss how they have done things differently to provide better customer service.”
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“1. Proactive - Map out the current state process upfront and then develop the new future state process. Spend as much time in training the process as w you do training on the applications.
2. Reactive - Put the application out there and let the users get used to it. Once they see the value, they naturally will change their processes' to become more efficient.
#2 is not the preferred methodology but sometimes it works out that way. Also, one must audit the process and application periodically to continue usage and improvement.”
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“This has always been our #1 objective during any application implementation and is included in the project charter. The challenge is and always will be change management. It’s very difficult for some to turn loose of the “way we’ve always done it” and look at the process from a new perspective. There are several tools in practice today (i.e. LEAN, Six Sigma, CQI, etc.) that can be but into motion that will assist in identifying the “correct” things to target.”
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“To improve inefficient processes first you need to identify what is really not working. When you are changing from a legacy application to a new Clinical system some of the inefficiencies are apparent. For instance, we found out that there were 3 different ways that end users were billing from the hospital. One was on paper, another in the legacy system and the third directly into the billing system. When this was brought to light we made an organization decision to have everyone bill directly into our new system. This process created efficiency in the departments in owning and monitoring their billing.
An important step to change the workflow process and improve the inefficient processes is for the end users to be trained on the application. At our facility, we have IT staff that are clinical plus we have had end users who have gone out for training on their Epic Applications. Health Information Management, Nursing Educators, Physician Champions, Pharmacists, OR Leaders and Educators, ED Physicians and Nurses, Ambulatory Administrative Directors and Physicians were some of the roles that were trained on the applications, as well as the IT Clinical Information Systems staff. This collaborative effort has allowed the organization to assess current processes prior to the implementation and have the end users determine best practice. We also had what is called “stop light session” that shows clinical staff that were not trained on the system what the new workflow would be. They then validated if it would work for them. This step allowed for the Clinicians who were trained to see how it can be done and champion the decisions on what is being changed for greater efficiencies.”
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“Active and early involvement from the affected departments. Simple tools, not really complex workflow management tools. The willingness to say “good enough” rather than to aim for absolute perfection. Encouraging positive attitude from all involved and coaching or asking for individuals to avoid negativity.”
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“As part of all upgrades or implementations we make it a standard operational effort to review workflow and processes. It seems to better accepted since a team is doing the review and includes changes during the upgrade or implementation.”
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“The approach depends on the situation and organizational support provided. With a new or invigorated leader in the business area the normal vendor led implementation approach can be very successful for a departmental system. Sometimes “as is” and “to be” workflows are needed to inform improved processes. At other times a full third party consulting engagement is necessary to unfreeze an organization. I all events we clearly define a charter with goals and targets and metrics. A sponsors committee meets regularly during the project to review progress and remove barriers towards achieving the goals.
In physician offices we use a LEAN approach with “as is” and “to be” workflows.”
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“In the past 20 months I’ve served in an Interim CIO role where we did a couple of things:
Started up a Revenue Cycle Management group whose mission was to create, monitor and review KPI’s that were major PFS and other financial related indicators. The RCM group not only looked at PFS but also all ancillary and clinical areas that had some impact on the RCM bottom line. By bringing these folks to the table, it was a very high learning curve of cross departmental dependency of information helping the account to be much cleaner and required less manual intervention.
I was asked to facilitate a cross functional departmental review of patient throughput over several months. This process began identifying and creating action plans to minimize lag times and information constraints that would decrease patient time in the ED and transfers to the IP side. By bringing the right people to the table and creating ownership opportunities to achieve successful incremental improvements, the team began to understand and improve bottlenecks.”
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“ We have had our key users meet weekly to re-design workflows with the new system in mind. It is always a challenge to get existing users of existing systems to think outside traditional workflow boundaries, but we have had some success in getting them to think outside those lines. Additionally, we had Elsevier in for a couple of days to meet with our clinicians and to make recommendations about workflow changes that would be necessary to take advantage of evidenced based practice content. They were able to identify a number of workflow "philosophies" that probably needed to change to take full advantage of our new integrated clinical system currently being installed and to more fully reflect evidence based best practices. We are just starting to digest their suggestions.”
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“We are fortunate to have a team of lean/six sigma experts within our organization. Over the past two years we have worked very hard to develop an integrated implementation methodology that intertwines "process innovation" (process improvement) activities with information system activities. With significant endorsement and support from our CEO and Vice Presidents we do not implemented new IT solutions without process innovation activities occurring.”
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“We have used the Lean Sigma tools such as Change Acceleration and Workouts successfully. Even more important to the success is the executive sponsorship of such change initiatives to ensure that they are not viewed as IT projects.”
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“Setting up calls and discussions with other hospitals that have gone through the process.”
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“One of the things I've done is discuss the need for process and job re-engineering with the vendor and I emphasize the need for these two items. The vendor then, is required to offer an acceptable solution as part of the implementation plan on how to analyze and re-engineer processes and job descriptions.”
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“1. Set the tone early on and make process improvement a guiding principle for how you approach the project
2. Consider using trained "industrial engineer" types to map current & future workflows and identify no/low value adding steps., assign someone to ask "why" 5 times to ensure you truly get past the "it's always been that way"
3. Don't go nuts with process improvement, "the perfect is the enemy of the good" and people can only take so much change at once.
4. Prioritize: Focus on the processes where there a clear benefits to be had, and leave others to be tackled post live, once there is a better understanding of what living in an electronic future means/looks/feels like”
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“The implementation team is challenged with identifying workflow/process improvement over the course of the project. Typically, that includes an assessment, by the primary users, of what is working well, and what is not. We will consider these responses, vendor recommendations on best practice and any efficiency steps we can identify. Occasionally, there is “evidence” regarding a process, and we will present that with options. Always, it is a team decision regarding the ultimate process designed and implemented.”
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“My facility is fairly open to looking at the process. I encourage looking at the full utilization of a new application/system. We also research what other facilities have done and implemented. This allows us to “learn from other’s mistakes” and allows us to have a better understanding of what direction to take with the new application.”
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“I can’t say that I entirely agree with this statement. The organization has to first understand their current workflow and the reason it is that way. The workflow may be just fine. In this scenario to then introduce a new application, it should not require process redesign but rather serve as a baseline/benchmark for what at a minimum the new application must support. With all new application implementations the process is to validate the current workflow, i.e. create a baseline, then understand the new options (if any) presented via the new application. So as an organization, you need to have knowledgeable people of their business/department along with peer contacts in other organizations. A shortage of this talent typically indicates the need to supplement resources with consultants so that all options are considered and the stakeholders, i.e. decision makers, can make the improvements that match the needs/strategy of the organization.”
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“The implementation of the EMR in a hospital setting should not be about implementing new software tools and technology. Hospitals must use this opportunity to redesign their model of care and optimize workflows, and support those activities with the technology tools. We preceded each phase of our EMR implementation with a deep look at our practices and workflows. For example, for nursing and allied health online clinical documentation, we brought in a firm that specializes in redesigning the model of care for these clinicians. We spent a lot of time analyzing and defining scope of practice for each clinician (i.e. respiratory, social, PT), developing unit-based councils to promote communications and coordinated processes between them, taking a hard look at the manual documentation they were currently producing and current workflows, and bringing in relationship-based nursing concepts to the new design. After that was completed, we implemented an interdisciplinary documentation tool to support the new way they were now practicing in a collaborative fashion. This may work differently in each hospital but it’s essential that clinical transformation is the goal and the technology is used to support it.
Often, external consultants are needed in order to obtain best practices and a fresh, objective look at current practices and policies.”
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“Once you have recognized you need an application or a “better” way, the first thing I want to do is examine the processes we have today. Determine what are keepers and what has to go. I like to ask the question: In a perfect world, how should this work? All great ideas but hard to execute. My experience tells me workflow design is either like a root canal, or it is a game. I try to keep the team focused on the end objective, and to walk backwards from there to the current state. The future state is nirvana, and the future state is reality today. I use an analogy from my father: It is hard to know where to go until you recognize where you have been. Put another way, not everything from the past or current is great, so what should it be. The real issue here is to pick people who can see broadly, and can sell dreams and ideas.”
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“The operational area must sponsor the new technology and workflow. Use of organization "change agents" is key, the should be part of a process redesign team that is trained in LEAN, DMAIC, etc.”
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“This is very difficult. Even though we emphasized this from the beginning, it is very hard for end-users to redesign their processes until they know and understand the new system. And they generally don't have a very good idea what it entails until after go live. You will find that people will continually fall back on their current workflows, and many people don't know anything else. The only way I've found to break through this is to engage an outside business consultant who understands best practices and can implement those changes in the department. Sometimes we do that BEFORE we go live with the system, because many times it is not system dependent.”
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“As part of the Design Phase of any system, you need to document the current work flow, then document what steps will be eliminated as a result of the newly implemented application. Once the system is implemented, those same documents should be used to audit, to ensure that unnecessary steps have been eliminated in the work flow process. This is a "standard" that my staff follows.”
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“The first thing we did was to frame the implementation as a clinical transformation project, and not an I.T. project...we next decided on what our goals and objectives were, with a focus on measurable goals and objectives....with the measurable goals and objectives in mind, we developed methods to measure our current state, mapping the current process producing the current metrics....then we began to drive consensus towards a new process design by seeing what steps/processes of the current process could go-away with the HER implementation, plus we looked for best practice from other facilities by conducting site visits to see how their workflows were designed, and how they moved to those processes ,ie...over time, or gradually, whether by design, or discovery as they learned more about the system implemented. A key to all this was involving representatives from the various stakeholder groups, so that any anticipated change was organic, ie...embraced from within the dept/unit, as opposed to be mandated from outside of the dept...while this step takes more time, we felt it created a sense of ownership within the stakeholders, and created within them a vested interest to see the change through, and work with I.T. as a partner in the implementation.”
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“At our organization, we collaborate w/the Engineering dept. at our local university. They have students that have learned lean technology, process improvement methodology, how to do time studies, statistics, etc. that need and want experience. We have the areas that need to be revamped (I will not automate a cow path). The students come in and work in one dept. for either their senior design project, masters or PHD project. It is a win-win all around as they have experience that we do not have as well as they have limited health care experience and spend a fair amount of time following staff and then asking why. Usually when they are done mapping our current process we can all look at it and realize that there is a better way and then they help us w/the better way.”
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“Promoted and "sold" the concept of Clinical Transformation. Introduced it in the IS Strategic Plan, have since set up site visits to organizations that have been successful in process redesign. Currently working on an approach to adopting and implementing process redesign into all IS projects.”
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“Fortunately for me, the organization took a step, many months ago, toward process centered management and encouraged every department to look at various workflows and evaluate them for both efficiency and effectiveness. At the start of every IS related project, I encourage the team to review how things are done and make improvements prior to the implementation. This may include workflow diagrams, flow charts, use case analysis, or process diagrams, data collection, FMEA, etc.”
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