Section 4.5 Implement
Workflow and Process Improvement
with EHR and HIE
Understand key workflow and process considerations while implementing an electronic health record
(EHR), health information exchange (HIE), or other health information technology (HIT).
Time needed: 40 - 80 hours
Suggested other tools: Section 2.6 Workflow and Process Redesign for EHR and HIE
Introduction
As the implementation process begins to unfold, addressing workflow and process changes becomes
critical. This tool highlights important elements to consider while implementing EHR, HIE, and other
HIT.
How to Use
1. Review Section 2.6 Workflow and Process Redesign for EHR and HIE, which describes how to
map current workflows and processes, as well as spot problems and determine their root causes.
Retrieve the workflow and process maps you developed during this stage of planning.
2. Prepare to change your workflows and processes consistent with your goals for acquiring the
HIT. As you do so, be aware of the following:
a. While most vendors today recognize the importance of attending to workflow and process
changes, most do not have the staff resources to make it a cost-effective part of their
implementations. Though this is unfortunate, it forces the health care organization to address
workflow changes which it knows best. This also contributes to a thorough understanding of
the HIT function and creates ownership of the change.
b. There are no “silver bullets” in improving workflows. Many organizations seek “best practice
workflows” to adopt. While there is a growing body of literature on the importance of
incorporating workflow redesign into HIT and there are clinical practice guidelines, most
experts agree that work is needed in this area and that analyzing and improving workflows
locally is an essential element of change management. The following are some examples of
generic resources and specific tools:
i.
Incorporating Health Information Technology into Workflow Redesign,
AHRQ Publication No. 10-0098-EF (October 2010) available at:
http://healthit.ahrq.gov/sites/default/files/docs/citation/workflowsummaryreport.pdf
ii. AHRQ National Guideline Clearinghouse, http://www.guideline.gov/
iii. Improving Transitions of Care in LTPAC: An Update from the Theme 2 Challenge
Grant Awardees, March 21, 2013. Office of the National Coordinator (ONC) for
Health Information Technology:
Section 4 Implement—Workflow and Process Improvement with EHR and HIE - 1
http://www.healthit.gov/sites/default/files/challengegrantslessonslearnedltpac_paper.
pdf
c. Your vendor may or may not support workflow and process improvement, but regardless you
must build this task and its associated time and resource requirements into your project plan.
The change imposed by EHR and HIE is great for new users. They must understand how and
why the changes are needed and be reassured that the changes will support their ability to
deliver the best possible quality care. Trust in the process is essential. Engaging users in
understanding current workflows and processes and learning how the system will improve
them will go a long way toward achieving better adoption. Consider using the tool below to
highlight key changes brought about by EHR and HIE and their rationale:
Example of Summary of Key Workflow and Process Improvements
Task
Current
Process
Improved
Process
Technology
Rationale
1. Registration
Manual entry via
phone or faxed
document
2. Compilation of
assessment
data
Standalone data
entry system
Portal for referring
provider to be
guided in submitting
all data
Integrated with all
other components
-Portal
-EHR
-Admin/Billing
System
-EHR
-Admin/Billing
System
3. Review of
Medication List
-Fax from
referring provider
-Client query
during visit
-Pull updates from
health information
exchange service
Participate in
state’s HIO
-More complete
and accurate
-Available to all
users
-Autopopulates
data to reduce
data entry burden
-Alerts for timely
completion
-Obtain current list
of currently
prescribed
medications with
complete sig
d. Workflow and process change is not the same as customization of EHR. Even though some
minor tweaking may be needed once a product is implemented, desired workflow and process
improvements should be reflected in the technology acquired. These workflow changes
should reflect your goals for adopting EHR. Do not lose sight of these goals. If, however, you
find that the technology is driving workflow changes that are truly problematic, you may find
it necessary to customize the product.
Case study: A home health agency recently acquired an EHR and has distributed personal digital
assistants (PDAs) to nurses to use to document visit notes. During the first month, several nurses
expressed concern that note taking was extending visit times. They began lobbying for extra time at
the end of each day to document notes. A review of the notes suggested that nurses were entering
more information in “comment” fields and not entering structured data into the drop-down menus on
the templates (or in some cases were doing both—resulting in occasional inconsistencies between
structured data and narrative comments). Retraining was instituted, but there was little improvement.
It was then realized that nurses did not appreciate the full effect of this change in workflow. They did
not trust that the data entered via the templates was sufficient to describe their work. Once this was
addressed by illustrating how the data subsequently populated other system components and resulted
in more complete data gathering, the nurses became more comfortable in completing only the
templates and their productivity improved. They knew they could enter comments on special
situations, but did not need to do so for every routine entry. They also appreciated not needing to go
back after the visit was completed to correct or complete notes. The system immediately alerted them
Section 4 Implement—Workflow and Process Improvement with EHR and HIE - 2
to missing data, and if data were not available at the time of the visit, the alerts remained in the
system for easy identification and completion later.
d. Most EHR systems are built to adjust to user preferences, to some degree. Templates may
need to be changed to reflect special data requirements; users should be able to change their
dashboards to accommodate personal preferences, etc. The software should have tools that
allow the user or a facility systems administrator to make necessary changes. However, most
products are not customizable at the software level, at least unless the vendor making the
change. This is important because customizing an EHR can be a double-edged sword, with
the potential to customize it back to old ways—resulting in problems achieving goals and
patient safety risks. Engaging users in mapping current and improved workflows and
processes helps them engage in the change process.
e. Any change in an EHR must also assure that necessary control points that impact care
embedded in current workflows and processes are retained. Numerous articles have been
published about the potential for unintended consequences of HIT. In large measure, these
consequences have come about because workflows and processes were not studied
thoroughly and changed appropriately so that current controls were included or enhanced. As
you plan your implementation and any customization, review the Guide to Reducing
Unintended Consequences of Electronic Health Records offered by the Agency for
Healthcare Research and Quality available at: http://www.healthit.gov/unintendedconsequences/.
f. Change imposed by an EHR or HIE must recognize the importance of professional judgment.
EHRs and HIE are tools; a hammer in the hands of a novice will create a mess, but in the
hands of a skilled craftsman can create a thing of beauty. Health care professionals must
understand that the systems being implemented are only tools—and administrators need to
appreciate this.
For example, a nurse may receive data through an HIE process and start to act on it, only to suspect
that it is not for the specific client under care at the time. There must be a way to validate person
identity to ensure that person matching in the HIE was correctly performed. Too many of these
concerns will lead to discontinued use. In order to correct such issues, mapping the new workflow
and process should help pinpoint problem areas. For example, the HIE may find that its source data
are not standardized, making person matching difficult. It may need to require that all participants are
standardized on a specific set of demographic data.
Section 4 Implement—Workflow and Process Improvement with EHR and HIE - 3
g. Whether or not the vendor provides assistance with workflow changes, it may still request
that workflow and process maps be supplied in order to prepare modifications that will make
for a smoother go-live. The vendor may request that workflow and process maps be
documented in a preferred format. Most vendors will accept either a systems flow chart
format or a simple list, perhaps recorded on a spreadsheet. Some organizations wonder why
they need to map improved processes before selecting a vendor, because the maps may need
to be redrawn to accommodate functionality that the vendor provides. Requirements analysis
cannot be performed without a solid understanding of current workflows and processes and
the desired improvements. In addition, automating broken processes is risky. To the extent
that you can, improve processes—or at least recognize improvement opportunities—prior to
automation.
3. As you develop your improved workflows and processes with a specific vendor product,
document them in a new version of the workflow and process maps. This is time well spent
because these maps can be used in system testing, training, policy and procedure development,
and referred to years later when system upgrades arrive.
Copyright © 2013
Section 4 Implement—Workflow and Process Improvement with EHR and HIE - 4
Updated 11-20-13