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«2 Workflow in Physician Practices Ten Questions to Consider Concerning Practice Workflow 1. How would you identity and define the distinct tasks ...»

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Workflow in Physician Practices

Ten Questions to Consider Concerning

Practice Workflow

1. How would you identity and define the distinct tasks of your practice?

2. What specific people perform these tasks?

3. Does your practice have formal policies on how processes are

carried out?

4. What are the communication and information patterns in your


5. How would you rate communication in your practice?

6. Does your practice have a person in charge of resource management?

7. Have you attempted to reengineer your practice?

8. How many staff members need access to the same documentation at the same time?

9. Does your practice measure productivity per physician?

10. How does work flow from one staff member to the next?

Health care can be considered the most precise industry. No where or at no time can an error occur. To help ensure this, workflow technologies are becoming very critical in the physician practice. Workflow is a very interesting concept as it provides physicians and staff with a new way of looking at how processes and procedures are completed. So aside from itself being a process, it can also be thought of as a new way of thinking about how business is done.

2. Workflow in Physician Practices 23 Workflow in the Primary Care Physician’s Office: A Study of Five Practices Jeffrey D. Cooper, James D. Copenhaver, and Carolyn J. Copenhaver Workflow in business systems is not uncommon; for ten years it has been an important technology.1 Many restaurants, for example, especially those serving fast food, use workflow systems to route order information, often coupled to touch screens for rapid data entry. Workflow is no less important in the physician’s office; in fact, the flow of information in the healthcare setting is more critical than it is in most other industries. Yet despite the conclusion of many researchers and analysts that workflow systems at the point of care will deliver reduced costs, improve productivity, and more effectively manage the sea of documents flooding the average physician’s office, workflow automation in the physician’s office is rare.

Defining Workflow Workflow, a term that originated in the mid-eighties, has many definitions.

For this study, we define workflow as a computer-assisted (or automated) organizational process. An organizational process is a collection of activities related to a specific commitment, adding value to a product or service of the organization.2 Workflow is often used synonymously with reengineering, but workflow automation and business process reengineering are not the same thing. Workflow automation is a software technology that provides a means of automating a business process. Reengineering is the act of analyzing the business processes of a company or practice and changing them with the goal of improvement. Thus, business organizations can automate business processes using workflow software without reengineering them. Likewise, businesses can reengineer business processes without workow automation.

Workflow is also not the same as workflow automation.3 Any application that can route a document so that it flows (like e-mail) from one user to another can claim to be workflow. True workflow automation includes an array of essential features that go far beyond the simple routing of documents and depends on two critical factors, (1) automating manual process 24 Utilizing Technology to Arrange a Physician Visit steps and (2) distributing information to the workgroup, in this case, to the physician and his or her staff.

An automated workflow system has the following characteristics:

• Tasks These are activities that must be completed to achieve a business goal. The CPR (computer-based patient record) and workflow system in this study are task-based.

• People Tasks are performed in a specific order by specific people (i.e., nurses, physicians) based on business roles.

• Roles Roles are defined independent of the people or the processes that fill them; for example, the CPR defines a nurse’s role as different from a physician’s role in the physician’s office.

• Processes Processes are the sequences of steps to be performed based on business conditions. Workflow automation may mirror existing processes or call for redesigning processes to eliminate redundancies and bottlenecks and to account for simultaneity. Since redesigning processes involves an examination of why people do what they do and often requires changing the way people do their work, it may foster fear, uncertainty, politics, and resistance to change.

• Practices Practices are what actually happen in organizations. Only by capturing the practices is it possible to truly automate businesses.

• Policies Policies are formal written statements of how certain processes are handled. In most physician practices, policies are unwritten and must be remembered by the person assigned to the task.

Objectives of This Study This study describes the results of data collected from physicians of five independent ambulatory care practices that have installed a computerbased patient record (CPR) and workflow system from a Marietta, Georgia, vendor. The objectives of the study were to evaluate time savings, quality of care, office productivity and user acceptance of a CPR integrated with a clinical workflow system. The five participating practices vary in size from solo practitioners to six providers at two sites. Practices C, D, and E were well established and using traditional paper records before implementation of the CPR. Practices A and B are start-ups and opened their doors using the CPR. All five practices are completely paperless except for printed prescriptions and paper generated by external sources such as referring physicians, insurance companies, and laboratories. Most of these external source documents are scanned directly into the CPR and can be very rapidly retrieved.

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TABLE 2.1.

Patient volume pre- and postinstallation of a CPR and workflow system Practice No. of patients at time of installation No. of patients as of April 1, 1999

–  –  –

years (beta site) after installation of the CPR and workflow system (Table 2.1). The postinstallation surveys were completed by 10 physicians and physician extenders, 10 clinical personnel, and 6 nonclinical workers in the five practices. The 26 respondents were asked to rate each question in a series on a scale of 1 to 5 with 1 the lowest and 5 the highest. The questions asked for user perceptions of three general categories of CPR utility: time saving, quality of patient care, and office productivity. The survey consisted of questions including one question about workflow. In addition, a key person at each site was asked to fill out a questionnaire allowing free text concerning office productivity and profitability. In practices D and E, the key people were office managers; in offices A, B, and C a physician responded to this questionnaire. All respondents remained anonymous. The small number of sites and users beg caution in the interpretation of the results, although preliminary observation of 15 other sites in operation less than six months point to similar results.

Transition to the CPR At each of the practices, physicians were trained for four hours on the CPR.

The clinical and nonclinical staffs required less than four hours of training.

All but one of the physicians reported that after one to two week’s time they felt “proficient” using the CPR and workflow system. None of the offices experienced any significant downtime after they went on line or reported any significant losses of office productivity during implementation and training.

Description of the CPR The CPR and workflow system used by the healthcare providers in this study is a client-server application that utilizes a monitor in every exam room. It operates on a Windows NT and SQL Server platform. The application focuses on structured data entry that permits queries, quality assessments, collections of specific data (Open and Closed Assessments, Drug History, Family History, etc.), and research. The CPR has been specifically designed for easy clinical data entry using touch screens, for browsing and skimming, and for the aggregation of data according to the preferences of 26 Utilizing Technology to Arrange a Physician Visit each office. The screens are uncluttered and feature large icons. The CPR also supports free text data entry via either keyboard or dictation. By using dynamic “short lists,” each physician can chart a typical encounter in 30 seconds or less, far less than the 2 minutes it typically takes a doctor to complete a paper chart. The workflow automation is supported by a Navigational Interface as opposed to the more common Multiple-Document Interface (MDI) of most CPRs. At the heart of the workflow system is the Office Screen, which tracks a patient throughout the visit. From this screen, observers are able to see where each patient is, which provider the patient is waiting for, what service the patient is waiting for, and finally, how many minutes the patient has been waiting.

Consistent with true workflow automation, information, beginning with patient check-in, flows from screen to screen in a cumulative and valueadded process until patient checkout. Members of the workgroup add value by adding more information or by making judgments based on the information provided to them by the application.4 This information is available in real time to multiple users throughout the process. Also consistent with true workflow automation, in every practice involved in this case study— and all other practices served by this vendor—there is 100% physician compliance. This is critical, since health care in the physician’s office is a collaborative process.

Automation of Office Processes To automate office processes, the processes first must be identified. A CPR can automate four core processes of a physician’s office: (1) information retrieval, (2) care documentation, (3) orders, and (4) communications.5 Information retrieval refers to the medical history that the physician needs in order to make informed clinical decisions. Care documentation relates both to delivery of care and capture of charges. Order selection refers to prescriptions, lab tests, immunizations, and so on. Communication refers to messaging between physician and patients, physician and staff, and physician and colleagues.

In addition, there are subsets to these core processes. (For an example of the automation versus the manual process of a prescription refill requested by phone, see Table 2.2.) The workflow must be configurable to accommodate the processes and subsets of processes of each office, as these vary in type and sequence based on specialty and physician preference. For example, an orthopedic surgeon may want X rays of the patient before each examination; other physicians would not need X rays. An obstetrician may want to know the blood pressure and urine protein level of every patient, while to a dermatologist these measures would be of little or no importance.

The processes most commonly identified in a typical primary care office would include patient check-in, medical record retrieval, triage (determinWorkflow in Physician Practices 27 TABLE 2.2. Step-by-step comparison of prescription refill process after telephone encounter

–  –  –

ing chief complaint and checking vital signs), documentation of the patient history, review of systems, physical examination, lab orders, procedure orders, assessment, treatment plan, checkout, and finally, storage of the medical record. Following is a broad and simplified composite description of the workflow processes in the five primary care practices examined in this study.

Check-In and Record Retrieval In a nonautomated physician’s office, the paper chart itself is a medium for workflow. While some offices wait for the patient to arrive before pulling the medical record from the storage cabinet, more efficient practices already have the paper chart waiting at the reception area. Even though this system improves the movement of the patient through the office and reduces patient waiting times, it requires many man hours of preparation either early in the morning or at the end of the day for the next day’s schedule. In the paperless office with workflow, check-in can be accomplished by simply clicking on the patient’s name on the appointment 28 Utilizing Technology to Arrange a Physician Visit schedule. Not only is the medical record automatically called up, a log is made of the patient’s arrival and arrival time, and the triage nurse is notied that a patient is waiting. The seamless flow of information allows the front office staff and the triage nurse to work together to maximize their productivity.

Triage The triage nurse’s duties vary between offices but typically consist of eliciting the chief complaint and the history of the present illness, measuring the pertinent vital signs, and choosing a patient priority level. These functions should remain unchanged in the automated office; however, documentation of common conditions can be made much quicker by using a “pick list,” or template of frequent complaints. Research shows that use of default templates both improves efficiency and increases compliance with practice-defined guidelines.6 As stated earlier, in the five practices under study touch screens are used to facilitate rapid data entry. The triage nurse using automatic workflow has another advantage over a paper-burdened counterpart: he or she can tell which examination rooms are empty and of those which ones are prepared for the next patient. This simple function of the CPR saves the nurse from manually walking to the room to see if it is ready before assigning a patient to the room. Frequently in nonautomated offices, a color-coded light system is used for this task, and while it may be functional, the light system requires constant human intervention to keep it up-to-the-minute accurate.

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