Workflow Assessment

A thorough workflow analysis of the office should be performed. It will first help reveal structural changes that will need to occur within the office environment to facilitate the use of electronic devices to record information. Potential placement of workstations can be determined during the assessment, keeping in mind that the physical presence of paper charts will diminish after the new system is in place. Bottlenecks can be identified in the current process and care can be taken to avoid them in the redesigned workflow. This example workflow assessment was conducted in a small, one physician practice. While the previous process was functional and there was a good flow within the office, the process needed to be redesigned in order to accommodate an EHR. Carter <ref>Carter JH. Electronic Health Records, Second Edition. 2nd ed. American College of Physicians; 2008. [1]</ref> has designed a workflow analysis template that has been adapted to outline the processes that require changing. Carter's method is designed for larger ambulatory care clinics, but the general principles apply to small practices.

Identify task elements

• Paper chart: Patient record in current workflow
• Fee cards: Located in a filing cabinet, they contain the following information:
  • Encounter dates
  • Prior billing codes
  • Insurance information
• Weekly planner book: Yearly planner with physician schedule written in by office assistant, photocopied for reference each day.
• Charge slips: Documents sent to the billing company containing coding and billing information for visits.
• Faxes:
  • Health information exchange
  • Prescription refill requests
  • Diagnostic reports
  • Business documents
  • Spam
• Reminder letters: Generated at time of visit, these are held in a box for mailing at the appropriate time.

The patient insurance information is located redundantly in three locations: taped in the patient chart, on the fee card, and on the billing slip. The planner book contains the phone number of the patient, as does the chart.

This workflow may vary in various practices, but the task elements will be similar in paper based offices.

Identify task processes

• Patient reminders: Telephone call is made the day before.
• Scheduling: Appointments are documented in the planner book with phone number.
• Pre-visit: Charts are pulled and stacked. The fee card and blank billing slip are clipped to the chart.
• Patient arrival: The patient checks in at the desk and then is called to the exam room. The chart is retrieved from the stack of charts pulled for the day.
• Exam: The clinical notes are written on a variety of preprinted forms. The billing slip is filled out by the physician.
• Patient checkout: The chart is handed back to the front office with the billing slip and fee card. The patient is checked out and given any materials necessary. The billing slip is double checked. If tests are ordered, the chart is put on another stack to await the results or filed away if the visit needs no immediate followup.
• Results and prescription refills: The chart is pulled and the item for review is placed on the chart. As time permits, these are reviewed.

Conversion from paper records to EHR software is not a direct transition of records from paper to the computer. Rather, it introduces a whole new organization of the data in the practice. While the task objects in the paper workflow can be correlated to some of the data structure elements in the EHR, the processes will change.

Step One: Context Review
Area	Questions	Answers	Comments
Job description	What are the supervisory structures?	The office assistant works as an employee of the practice under the supervision of the physician-owner. The office assistant is given much autonomy, and can work independently. The physician can maintain front desk operation in case of absence. IT support is provided on contract.	Appropriate access controls will need to be set in the EHR to reflect duties and authorization to provide clinical care and maintenance of the system.
Quality reporting	What are the reporting requirements?	The ability to report quality measures is required to meet Meaningful Use.	OpenEMR has built in capabilities to do quality reporting.
Budgeting	Will resource requirements change?	The staffing in this small practice consists of two people with some operational functions outsourced (billing, IT, accounting.) There will be a greater need for IT support. Billing may become more streamlined with the ability to compile electronic reports for the billing company. During and after the implementation, it is expected that workload will increase for a time. While OpenEMR is available for no charge, there will be equipment and support costs. E-prescribing and coding data tables will have fees.	A part time clerical person may be needed to work during the transition to help with scanning and extra front office duties while implementation is ongoing.

Step Two: Identifying processes that will be redesigned.
Challenges and opportunities	Possible instances
Process creates a bottleneck in patient flow	Currently, charts are accessible by only one person at a time. With the EHR, different parts of the record can be accessed by both staff members.
Process creates a significant delay in patient care.	Currently, stacks of charts are isolated for physician review after receiving results. With the EHR and fax server, physical charts no longer need to be matched to reports and moved around. Physical retrieval of charts is no longer an issue. Less paper will be wasted.
Staff may be under-utilized or inefficiently used	Front office can multitask and perform some tasks while the patient is seen because the patient record is always available in the EHR for viewing. Insurance verification and preparation for patient exit can be done with access to full patient record while the patient is in the examination room.
Opportunity to increase revenue	Insurance billing information can potentially be electronically provided to tot he billing company, possibly improving the quality of insurance company billing information. Reimbursement may improve.
Process is perceived as having no value to the patient	If the use of the EHR in time enhances productivity, more time will be available for direct patient contact. After-visit summaries and patient educational materials will be more readily available. Clinical information will be available for after hours phone calls from patients, potentially minimizing emergency room visits. Patient records are immediately accessible from the keyboard during patient phone calls, preventing delays on the phone.

Step Three: Consideration of Information Flow, Process Controls, and Assessments
Area	Factor	Example process	Proposed process
Information flow	When is the information first known?	Demographic and insurance information is solicited from the patient in person or over the phone. Results generally come in by fax or mail. This information comes through the front office.	Paperwork can be emailed, faxed, or mailed to the patient and brought in for the visit and scanned. A fax server can be used, and results can be transferred into the EHR electronically. This can be done by anyone in the office.
	Who knows of the data, that it exists, and where?	The patient knows demographic and insurance information. The patient is aware of outside procedures and hospital visits. This information is relayed to the front office.	An optional patient portal can be used for entry of this information by the patient. Secure communication can also take place.
	What are the pertinent codes for the information?	The coding is done either by looking up previous visits in the paper charts or by memory of common codes. Books and online tools are available for lookup.	Previous codes are available at a glance in the EHR. A dictionary of codes can be imported into the EHR for quick selection.
Process controls	Follow-up	At the time of the visit, follow-up reminders are generated and placed in envelopes for future mailing on schedule.	The EHR can track follow-up schedules and help generate the appropriate mailing lists.
	Communication	Verbal communication in this small office is used.	This will most likely not change, but the EHR provides a messaging system that can be used if the other person is not available to talk.
Assessments	How are the patients scheduled and triaged based on acuity?	The experience based judgment of the office staff is used to schedule acutely ill patients quickly. Clinical expertise is provided by the physician.	This process will not change. Extra information can be placed in the EHR prior to the visit.

Step Four: Outlining the New Process and Changes Needed
Person	Action	Documentation	Change
Physician	Clinical visit	The encounter will be documented in the EHR.	Forms and flow will change from the paper method.
	Coding and Billing	The appropriate codes will be entered into the EHR.	The pink slips no longer need to be filled out by hand. They can be generated with a report or electronically communicated to MBA. The white cards will no longer be needed to look up prior visit codes and insurance.
	Results processing	The scans or faxes can be placed in the EHR for review and the review can be electronically documented.	Physical gathering of the information will no longer be necessary.
Office assistant	Patient reminders	The entire record can be reviewed when calling, so calls can be completed with more information on the reason for visit. Documentation of the call can be made.	The phone number and visit reason no longer need to be written in the planner book.
	Scheduling	The appointments are put on the OpenEMR calendar	This replaces the planner book in the workflow.
	Building and setting up charts	No action needed	There will be no need to build blank charts, nor will return patients need to have their charts pulled for the day's appointments.

Discussion:

These processes do not necessarily need to happen all at one time. Further analysis will determine the order of workflow changes to minimize disruption to office operations. The main processes that will change are the scheduling, clinical charting, and billing paperwork. Training for each step is essential for a smooth and efficient transition.

Reference

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