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  • 1. Clinical Workflow: The Foundation of EHR Implementation The role of the Clinical Informatics Assessment (CIA) process in EHR Implementation Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Presented by: Edward A Stern, RN [email_address]
  • 2.
    • Workflow Redesign and Clinical Transformation
    • Ed Stern, RN
    • Hospital workflow redesign initiatives often rely on project management methodologies without
    • considering the unique aspects of health care. Maintaining clinically relevant electronic
    • tools and content, and streamlining workflow to reflect core measures, regulatory mandates,
    • clinical practice guidelines, evidenced-based practice, and hospital strategic direction can pave
    • the way to a more successful result. A key component of this process is developing a methodology
    • to combine work redesign with clinical transformation. This presentation will present
    • concepts and strategies to assist health care informaticists with clinical redesign and clinical
    • transformation.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 3. Your Presenter
    • Edward Stern, RN (ed.stern@nothingbetter.com)
      • Consultant for NothingBetter Solutions, Healthcare Division
      • Member Board of Directors, CARING, an International Nurse Informatics Organization
      • Sr Informatics Project Lead, American College of Cardiology
      • A Nurse who still likes to “play” clinically in the ER and IR
    • Reese Gomez
      • SVP Dearborn Advisors
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 4.
    • Nonprofit Nursing Informatics (NI) organization dedicated to the educational advancement of the NI profession
    • More than 1400 members around the world with members in every state, and US territory
    • Most popular email list on NI
    • Educational conferences year round
      • This year, virtual education
    • “ The Best 20 bucks you’ll ever spend on your career”
    • Learn More: www.caringonline.org
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 5. Objectives
    • Define and Discuss “Clinical Workflow Assessment” process and it’s benefits
    • Define and document Original, Current and Future State workflows
    • Understand basic elements of a workflow chart
    • Explain and present to peers the fundamentals of assess, intervene and reassess model of workflow assessment
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 6. Public Perception?
    • “ The information systems at any McDonald's are more advanced, and more useful, than those in your doctor's office.”
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007 “ Record Time” – April ‘06
  • 7. Public Perception Workflow Forgotten
    • … and last summer, with his staff of three, he switched everything over to the new system. Patient information was entered on a screen instead of on a form attached to a clipboard; Saleh took notes and made orders using a sleek black tablet PC.
    • Within days, the office was in meltdown. Patients piled up in the waiting room, and Saleh all but lost control of his day-to-day work. Delays grew so bad, Saleh installed a TV to distract patients, and Cerner Corp., the company supplying his software, trundled in refreshments as a goodwill gesture. "I was running an hour-and-a-half or two-hours late," says Saleh. "That's the kiss of death for your practice. It was crazy.
    • A few months later, Saleh shows off his file rooms, filled floor to ceiling with paper charts. "No paper has been added to these since summer," he says proudly.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007 “ Record Time” – April ‘06
  • 8. “ It’s Workflows’ Fault”
    • Workflow is often a common “fault” area in the implementation of a technology.
    • The problem is that it is rarely ‘the’ workflow and more probably; that the wrong flow assessment, or not enough operations and systems workflows were considered.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 9. “ BFI” Implementation Study Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Complaints (“concerns”) Efficiency Time of implementation Go Live + X Days
  • 10. “ BFI” Down Time Study Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Complaints (“concerns”) Efficiency Time of Outage Outage Back Up
    • Anomaly Variables:
    • Why did “you” go down?
    • “ We have to back load all that data?”
  • 11. Change…
    • Let’s face it, the nursing industry is a “slow” change industry
      • Opportunity for the “Change Management Nurse”
    • “ Who moved my cheese” mentality – consider the changing paradigm of our non-clinical side of the industry.
        • “ Who Moved my Cheese” by: Spencer Johnson, M.D
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 12. Workflow Defined
            • From Wikipedia, the free encyclopedia
    • Workflow (WF) at its simplest is the movement of documents and/or tasks through a work process. More specifically, workflow is the operational aspect of a work procedure: how task are structured, who performs them, what their relative order is, how they are synchronized, how information flows to support the tasks and how tasks are being tracked. As the dimension of time is considered in Workflow, Workflow considers “throughput” as a distinct measure .
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 13. Clinical Assessment Defined
    • How would you define a Clinical Nursing Assessment?
      • Essentially an assessment looks at many different body systems from a nursing care approach
      • The unique focus of a nursing assessment is on the responses to actual or potential problems.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 14. What is Clinical Informatics Assessment ?
    • Simply stated, Clinical Informatics Assessment (CIA) is the process in which the clinical operation if broken down into fine step by step elements using an informatics work flow approach while remembering the clinical fundamentals
      • Think of it as a “pulse check” for the workflow process
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 15. More on Clinical Informatics Assessment
    • The focus is on clinical operations and how other business and systems elements interact with the clinical patient care environment
    • Systems Operations + Clinical/Business Operations = Potential Software Product and Project Effectiveness?
      • Consider how end-user usability plays into the product
      • The net result is a focus on assuring quality patient care while assuring efficient use of clinical informatics solutions.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 16. Factors to consider when building your CIA plan
    • It’s a Business Process but the Patient Comes First !
    • ROI is a relative factor in the business model, so consider hard and soft ROIs to prove your point
    • The depth of the process is relative to the complexity of the project
    • Marketing concepts apply too… Your patient is your client, the provider may be your client, and who else is your client…
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 17. When & How Can CIA Be Applied
    • Apply the concept any time clinical aspects need to be considered in a business model
    • Working very closely with the “IT side” of the process.
    • Be the link between the IT and business process
      • The clinical link, which is (or should be) the focus of all medical processes
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 18. Who benefits from CIA
    • The Patient!
      • Clinical needs are considered throughout the process
    • The Business
      • Business process and ROI is considered
    • The Clinical Realm
      • The needs for the clinical providers is recognized and built into the IT processes, as opposed to the clinical world having to “adapt” to the IT product.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 19. How do YOU boil water?
    • Exercise:
      • Using the 11x17 paper “define” the workflow for boiling water.
        • Goal: A cup of hot water
        • Please number each step you identify
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 20. How do YOU boil water?
    • Exercise:
      • Who thinks they “nailed” it?
      • Let’s review the results
        • Share your details with a person next to you.
        • Compare your results, how far apart are they?
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 21. Think Playwright
    • Writing a workflow is like writing a script.
    • You have:
      • A Plot
        • What needs to happen – Goal of the flow
      • Actors
        • Elements in the workflow; staff, equipment, policies etc..
      • Actions
        • What the actors are doing
      • Plot Twists
        • Decisions that are made
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 22. Test the Workflow
    • Reenactment
      • What’s out “plot” (Goal)
      • Select the cast while we walk through the workflow
        • Actors
        • Actions
        • Decisions
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 23. Assess, Intervene, Reassess
    • What we just did was “audit and review” a WF an Identified problems to correct.
      • Aka – Shadow assessment of a workflow
    • This is a common clinical nursing process…
    • We always
      • Assess the patient
      • Intervene if necessary
      • Reassess each intervention
    • It’s no different when building a workflow
      • Assess the current workflow you’ve documented
      • Intervene to correct problems
      • Reassess the workflow and see if it now matches your real process
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 24. How do YOU boil water?
      • Simple Answer
        • Fill Kettle with cold water
        • Turn on Kettle
        • Wait for water to boil
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 25. Boiling Water Workflow
    • What if we broke it down even more?
      • Simply adding water to the kettle can be more complex
        • Take Kettle to Sink
        • Turn on Cold Tap
        • Open Kettle
        • Move Kettle Under Tap
        • Wait for Kettle to Fill
        • Turn off Tap
        • Return Kettle to Work surface
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 26. Boiling Water Workflow
    • And… even more.
      • How do we turn on a faucet?
        • Grasp the tap mechanism
        • Turn mechanism clockwise
        • Wait until water pressure is high enough
        • Stop Turning mechanism
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 27. Boiling Water Workflow
    • Now bring it all together:
      • Fill Kettle with cold water
        • Take Kettle to Sink
          • Pick up kettle
            • Extend arm…(more)
          • Walk to sink
        • Turn on Cold Tap
          • Grasp the tap mechanism
          • Turn mechanism clockwise
          • Wait until water pressure is high enough
          • Stop Turning mechanism
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 28. Boiling Water Workflow
    • What are the exercise conclusions?
      • Don’t ask Ed to make you a cup of hot water
      • Workflows are everywhere
      • Workflows can be “considered complete” at almost any stage and any degree of complexity, it’s up to the clinical informatics person to assure that patient care and business needs are met
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 29. Workflow Complexity
    • Complexity varies based on the need of the audience
      • Here’s where some typical clinical “assessment” and critical thinking aspects come into play.
        • Who’s your audience?
        • What do they need to know?
        • What will they be doing with the information?
        • Where will this be used?
        • When will they need it defined?
        • When will it need to be updated?
        • Why do they need it documented and defined?
        • How does this play a role in the patient care and business processes?
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 30. “ Current State”
    • The exercise we just went through was a “current state” definition process
    • We defined the current operational state for a process… “boiling water to fill a cup”
    • The typical next step is “future state”
      • I disagree
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 31. What’s Original State
    • You’ll note that in the earlier “boiling water” exercise we didn’t consult any policy manual or printed instruction.
    • We all know that the way something was “originally intended” to work as been modified by those doing the task. Sometimes that modification is dramatic.
    • Original State: is going back to the “stone age” of process
      • The way it was originally intended to be done
        • e.g. Boiling water with fire!
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 32. Original State Integration Decisions
    • Review the original policy manual
    • Determine how far from the documented current state the original state is.
    • Decide if there is a need to change the “current state” or change the “original state” (e.g. update the policy)
      • If the policy needs to be updated, you might as well wait until after the “future state” is defined
    • Decide if there is a need to integrate the two
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 33. Problem, Action and Response
    • Another nursing clinical action plays a role in assessing Current and Original State: Identify the Problem, Document the Required Action and Response
      • Does the miss match of “original” and “current state” cause a problem for operations today and/or in your future?
      • What action do you need to take now, if any?
      • What will staff and management response be?
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 34. Documentation Process
    • Outline format
    • Powerpoint
    • Pen and Paper
    • Visio
      • Simply stated… learn Visio or hire the talent.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 35. Flow Chart 101
    • While we can’t teach you Visio, you should at least be able to read a flow sheet now
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 36. Flow Chart 101 Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 37. Flow Chart 101
    • Process
      • Defines various processes in the workflow
    • Document
      • Typically a reference to a document
        • e.g. Policy Manual
      • Sometimes used to refer to the process of documentation
    • Decision
      • Yes, No, type “routes” to tak
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 38. Flow Chart 101
    • Manual Operation
      • A process such as filling out a paper form of the state, or some other process outside the automation
    • Terminator
      • Beginning or end of the flow
    • Annotation… is what is is.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 39. Flow Chart 101
    • Connect the dots!
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 40. Cross Functional Flowsheet Copyright 2007 Available online at www.nothingbetter.com/tepr2007
    • Primary Actors for one WF:
    • ED Providers
    • ED Staff
    • ED Nurse
    • Admitting
    • Bed Management
    • Receiving
    • In Patient, & Surgical Services
    • “ other”
  • 41. Example of a Simple Workflow in Visio Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Send the Patient Home
  • 42. Same “Plot” but an Integrated Workflow Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Send the Patient Home
  • 43. Previously Separate Variable Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Discharge to In-Patient
  • 44. Commonly Defined “Workflows”
    • Workflow can mean different things to lots of different people.
    • It’s critical that your operational plans include the role and definition of “workflow” from the very beginning
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 45. Defining Workflow by Category in Your Organization
    • Functional Systems Workflows
      • How the software system will function in the work process
        • “ Click here, then enter this, and drag that”
    • Business Operational Workflows
      • How the business (patient care and operations business) model operates and physically gets executed
        • “ Go down the hall, make a left, pick up the form, and complete”
    • Integrated Workflows
      • Integrated Department
      • Integrated Software modules
      • Integrated systems and operations workflows as one.
    • Touch Points
      • Where Operational and Systems “bump” into one another
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 46. Example of Integrated Workflow
    • Order for CBC
      • Order placed in System by MD
      • RN acknowledges order in system and notes it is a “nurse draw”
      • Print lab specimen label
      • Obtain blood collection supplies
      • Draw Blood using hospital procedure 554.123
      • Affix completed labels
      • Tube to Lab using hospital procedure 554.124
      • Indicate in system blood drawn and to lab
      • Wait for results in system
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 47. Example of Integrated Workflow
    • Order for CBC
      • Order placed in System by MD
      • RN acknowledges order in system and notes it is a “nurse draw”
      • Print lab specimen label
      • Obtain blood collection supplies
      • Draw Blood using hospital procedure 554.123
      • Affix completed labels
      • Tube to Lab using hospital procedure 554.124
      • Indicate in system blood drawn and to lab
      • Wait for results in system
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007 TP OP SYS TP OP OP OP OP SYS TP OP
  • 48. “ Commercially Prepared Workflow Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Compliments of Eclipsys
  • 49. Eclipsys Transforms the Workflow Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Compliments of Eclipsys
  • 50. Modernize Your Workflow
    • Exercise:
      • Let’s modernize your workflow for boiling water. We’re applying a “new” technology to the process.
    • How do you: “Boil Water in an Ion Oven?”
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 51. Boil Water in an Ion Oven?
    • Exercise:
      • Who thinks they “nailed” it?
      • Let’s act it out and see how we did.
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 52. Boil Water in an Ion Oven?
    • What did we learn?
    • Lesson: Know the product you’re defining the process for.
      • With an EHR, that means see it, learn it, then apply it
    • All other rules you’ve learned apply
      • e.g. – test it and re-assess it
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007 What’s an Ion Oven and how does it work?
  • 53. Modernize Your Workflow
    • Exercise - For Real:
    • Let’s say an “Ion Oven” is nothing more than a fancy name for a Microwave.
    • How do you: “Boil Water in a Microwave”?
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 54. Future State
    • What you just developed is the Future State
    • When defining your future you have flexibility within the parameters of the software application
    • You need to make sure you understand the potential and assess and test your theoretic ideas
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 55. Future State Design Principles
    • Support evidence-based care guidelines
    • Reduce duplication of effort and data
    • Enhance access to care information
    • Facilitate collaboration and communication among care providers
    • Support timely clinical decision support
    • Reduce variability of care
    • Drive measurable improvements in quality and safety
    • Support continuity of care across the continuum of services and settings
    • Support interdisciplinary care and model of collaborative practice
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Compliments of Dearborn Advisors
  • 56. Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Future State Design Process Compliments of Dearborn Advisors Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 Validation Final Review & Signoff Current State Confirmation Future State Discovery Exploration Consensus, Negotiation, & Decision Making
  • 57. Future State Design Sessions Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Workflow Redesign Management and Coordination Compliments of Dearborn Advisors Nursing Pharmacy Physicians Current State Confirmation Future State Integration & Signoff Future State Discovery Future State Validation Future State Consensus Facilitated Session Facilitated Session Facilitated Session Work Group Session Facilitated Session(s) Facilitated Session(s) Facilitated Session(s) Facilitated Session Facilitated Session Facilitated Session Facilitated Session Work Group Session Work Group Session
  • 58. Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Future State Process Vision Medication Management Compliments of Dearborn Advisors Ordering Clinicians
    • I have easy access to complete and accurate patient information
    • I have access to relevant medical knowledge for a specific disease
    • I am guided toward cost- effective treatment choices and safe ordering practices
    • I am alerted of potential adverse drug events
    • The system will be easy to use and enhance my workflow
    • I will be properly trained on the system and understand how to use it
    • I am confident that my orders will be executed as I intended
    Patients / Families
    • My child’s care is coordinated between multiple clinicians and facilities
    • My child’s care team has ready access to my medical history and what medications I am taking
    • Before doing anything to my child, the care team makes sure he/she is the right person and that what they are about to do was intended for my child
    • My child will receive care that is appropriate for him/her and medications that work the best him/her
    • I will be involved in my child’s decision making
    • My family will be educated about my child’s care
    Pharmacists
    • I know my role and accountabilities for updating and communicating patient- specific information
    • I know what other clinicians have viewed and how they have responded to alerts
    • I have decision support tools that identify patients who require closer monitoring
    • I can spend more time as a clinician and less time clarifying orders
    • I will be properly trained on the system and understand how to use it
    • I am confident that the medications I dispense are appropriate and will be given the right way
    Patient Care Team
    • I am reminded to complete assessments & administer medications based on established standards
    • I have ready access to patient-specific medication administration information
    • I will receive clear and concise orders that I can act upon
    • I know that patient medications will be available when I need them
    • Decision support tools alert me if there is an issue
    • I am confident that I am providing safe, high-quality patient care
  • 59. Med Mgmt Example Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Compliments of Dearborn Advisors
  • 60. Potential WF Team Structure Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Compliments of Dearborn Advisors
  • 61. Copyright 2007 Available online at www.nothingbetter.com/tepr2007
    • Future state workflow input
    • Changes in roles and responsibilities
    • Initial build outputs
    • Dictionaries and screen format
    • Technical requirements
    • Functional build of system
    • Reports
    • Configured screen flows
    • Rules and alerts
    • Deployment strategy
    • Revised policy and procedures
    CPOE Teams Clinical Design Team
    • Consensus on future state process workflows
    • Answers to key process questions
    • Agreement on process design decisions
    • Integration of processes between departments
    • Pre and post go-live outcome measures
    • Final screen design
    • Final screen flows
    • Final data sets/terminology
    • Final order sets
    • Final reports
    • Final policy and procedures
    Steering Group
    • Recommendations to senior management
    • Accept the final design
    • Budget issues & risk management
    Team Roles and Decisions Compliments of Dearborn Advisors
  • 62. Question: Why Do All This Future State Prep?
    • Why do you think this is important?
    Copyright 2007 Available online at www.nothingbetter.com/tepr2007
  • 63. Copyright 2007 Available online at www.nothingbetter.com/tepr2007 Current State Orders Workflow Compliments of Dearborn Advisors
  • 64. Copyright 2007 Available online at www.nothingbetter.com/tepr2007 The Answer: Future State Orders Workflow Compliments of Dearborn Advisors
  • 65. Questions and Exercises Remember a copy of this presentation is available online at www.nothingbetter.com/tepr2007 Copyright 2007 Available online at www.nothingbetter.com/tepr2007