Modifying clnic workflows final 0514
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Discussion of using workflows, technologies and architecture to adapt to the changing world of medicine. Presentation given at the Digital Health Innovation Summit in Philadelphia, PA on 5/14/2015
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Modifying clnic workflows final 0514
- 1. Using Technology to Modify Clinic Workflows Promoting Patient Engagement and Restoring Fun in Clinic Exam Rooms
- 2. More Accurately …. A story of failure How I’ve been totally unable to convince colleagues and health care systems to put more technology in primary care clinics ….
- 3. Or …the power of the second screen Photograph: Colin Anderson
- 4. Objectives and Goals Objectives Define and identify clinic workflows and designs Discuss variations that promote patient engagement Review technologies and techniques that can restore creativity and fun to the clinic experience Goal Show and outline current states Illustrate and map out variations that reduce work for everyone Demonstrate tools that add “spark” and help create “aha” moments in our exam rooms
- 5. “Form follows Function” “It is the pervading law of all things organic and inorganic, of all things physical and metaphysical, of all things human and all things superhuman, of all true manifestations of the head, of the heart, of the soul, that the life is recognizable in its expression, that form ever follows function. This is the law.” Louis Sullivan, “The Tall Office Building Artistically Considered” 1986
- 6. First, a personal story All of us are somewhere along a personal trip that defines who we are and helps understand where we are today. This will help you understand this presentation and help you evaluate the relevance of this session to your own situation.
- 11. Multiple modules in a Clinic
- 12. Expanded Design
- 13. Became Reality
- 14. Trouble in paradise Management outsourced to outside group No experience with novel clinic settings Continued traditional visits Form incompatible with function Very little interactivity with technology at the point of care Only minimal amount of patient engagement Has gradually changed over time but basic design of the “suite” remains
- 15. Observations Changing World Decreasing autonomy Increasing regulation Meaningful Use Issues Volume to Value migration Lifestyle diseases Population Health Increasing transparency Here to stay and growing EMR’s, EHR’s, PMR’s, PHR’s Imaging & Photography Patient satisfaction and engagement Patient originated information Telemedicine & virtual visits License expansion High cost of physical space
- 16. Change, change and more change Rapid adaption key to survival Industry responses Move transaction processing as close to customer as possible Decreasing costs Increasing value Changing who does what, where and how things are viewed Medically … allowing patients to participate in the process Medical inertia drags down required adaptation
- 17. What can be changed? Element Cost Workflow • Who does what • Who does where Low Technology • What’s in the room • Tools to help Medium Design • Architectural design • Bricks and mortar High
- 19. Secret fact: Computer is More for the patient than the physician
- 20. A closer look at workflow
- 21. Typical Office workflows 1 2 3 4 5 8 6 9 10 11 7 12 13 14 1 2 3 4 5 8 6 9 10 11 7 12 13 1 2 3 4 5 8 6 9 10 11 7 12 13 14 15 16 17 18 19 20 212223 24 26 27 28 29 30 31323334 1 2 3 4 5 6 78 8b 9 10 11 1112 131415 12
- 22. Technology Enabled Simplified Work Flows 1 2 3 4 5 6 7 7 8 8 9 10 11 12 13 14 1516 1 ‣ 5 9 ‣ 6 9 ‣ 7
- 23. Second attempt: Heartland Health Suburban ambulatory clinic Community hospital 60 clinics spread out over a 22 county area in NW Missouri and NE Kansas Engaged staff open to experiments
- 24. Existing Building: Architectural Layout Patterned after Greg Korneluk International Council for Quality Care No planning for information technology Brought in to take offices into a paperless environment Carved out “pilot” to allow for rapid expirimentation Provider’s Rooms Provider’s Rooms Provider’s Rooms Provider’s Rooms Provider’s Rooms Provider’s Rooms Functional Unit Functional Unit Functional Unit Functional Unit
- 25. Each provider had own workflow Exam Room In Dr’s Office Rooms Pt Takes Vitals Rooms Pt Review Meds, Allergies & Problems Documents HPI & ROS Rooms Pt Review Meds, Allergies & Problems Documents HPI & ROS Rooms Pt Review Meds, Allergies & Problems Documents HPI & ROS Prints Sheet for Physician Nurse Area Exam Room Physician Sees/Exams Using Paper Dictates Note Physician Sees/Exams Using Paper Physician Sees/Exams Uses Computer & Nurse Note Dictates Note In Dr’s Office Reviews and Signs Note Reviews and Signs Note Documents Note in Comptuer Documents Note in Computer Using Nursing Note Prints Sheet for Physician Traditional paper based with role stratification Traditional paper based with role expansion Collaborative, computer based with role expansion Collaborative, computer based, role expansion and at point- of-care Work Flows
- 26. Variable contributions and Trade Offs 0 1 2 3 4 5 6 7 8 9 10 Paper No Chart Same Tool 0 1 2 3 4 5 6 7 8 9 10 Paper Paper + Comp Comp + Dict Comp Nurses Time Documenting Physicians Time Documenting
- 27. Time spent in exam room
- 28. Exam Room Technology My own experience
- 29. Evolution of in-room technology
- 30. Enabling point of care interactivity
- 31. Second Screen Concept Primarily for the patient Doesn’t have to be a computer screen Smart Phone Attached device Procedure instrument screen Examples Dentist office Accountant Grocery Store
- 32. Current State
- 33. Web tools
- 34. Point of Care Diagnostic Devices Proscope HR Proscope Micro Earscope Firefly Dino-Lite Cellscope Camera(s) Spirometers
- 35. Design Revisited What’s out there now
- 36. Typical designs
- 37. Few designed with computer in mind
- 38. A good design
- 40. Summary
- 41. Change is Inevitable ….adaptation is the key to survival Workflows are the least expensive approach to change Internal policies and procedures (based on paper workflows) may be the hardest obstacle next to Reimbursement rule interpretations Exam room technology is the next least costly approach Computer(s) in room are for everyone in the room Use them to work in parallel Think outside the exam room Architecture is the most expensive Biggest enabler but requires 10-15 year foresight
Editor's Notes
- Presentation to discuss the relationship between work that we do and the design of the areas in which we physicians work.
- Another way to look at this presentation is a story about how hard it is to change the behavior.
- Yet another way to look at this presentation is to show the power of “the second” screen that enables a whole host of parallel functions
- Objectives are to define and identify current clinic work flows and the variations of those workflows and designs that promote patient engagement. We also want to cover techniques that can leverage existing technologies to restore creativity and fun to the clinic experience for both physicians and their patients..
- We’ve always been told that form follows function and for the most part this is true. The designs of our clinics are designed to facilitate the patient flow function. It’s important to realize that the architecture decisions last for decades and if the function changes during that time the form can’t be easily changed. Therefore it’s very important that some flexibility be built into any architectural design In order to avoid restriction of function.
- These ideas and this presentation are best told through a story since each of us are at any given moment a product of our environments. This story will also help you “the audience” evaluate the relevance of this presentation to your own situation.
- Over a decade ago I was working for Cerner, Corporation as one of several physician executives who helped clients implement their software. At that time Cerner was spending over $26M on health care and $1.25 of it on primary care in the Kansas City area. Cerner had the facilities and know-how to establish an on-site clinic to help associates avoid losing productive time traveling to and from offices and the usual interminable waiting for brief visits that occurred. The campus had already established a thriving Montessori pre-school on campus and an elaborate fitness facility to help associates support their families and their own health but no clinic. Cerner leaders noted and experienced personally huge variations in the nature, quality and types of primary care being provided as they visited the many primary care physicians in the area. This often lead to waste, duplication and a wide range of results that could be eliminated by building it’s own primary care clinic on campus.
- Focus groups were formed and a number of key high level goals were established. The important concepts were that we wanted to Leverage the connected campus maximize the human touch and contact with the providers Design the facilities around the patient, not the clinician (most associates were fed up with processes in place to benefit the clinician
- Then the associates were asked what type of experience they would want in their own clinic space. The following 8 features and characteristics kept coming up: Safe – the associates wanted a place that not only was physically safe but exuded a sense of safety for not only them but their young family members who would be using the facilities. This meant safety from HR and other pressures most were exposed to in a successful growing company. Private – means private. Not having to cross paths with other associates during the visit process. Quiet – most associates worked in large open areas that facilitated productivity and they wanted something in stark contrast where noise of all types was filtered out and they could focus on the interaction with the providers. Comfortable – this came up a lot. Most felt very uncomfortable in traditional office exam rooms and in many offices where they met with their physicians. Relaxed – the environment needed to support relaxation as a contrast from their work cubicles, areas and meeting rooms. Spacious – it was surprising how many of the associates commented on the small confines of most physician offices as well as many of their office cubicles and wanted something different, more like the open areas around the campus. Like home – since lifestyle is the foundation to good health the environment needed to be similar to what they experienced at home. Help support “magic moments” that could lead to needed lifestyle changes to optimize health.
- Initially the architects proposed a standard clinic layout that was slightly modified to enhance flow of the “patient” through the clinic but was really designed from the provider’s point of view. It was rejected and after a number of out-of-the-box interactive design sessions the following “module” was proposed for each provider. Key features included: A provider office where time could be spent in between patients or when they were not seeing patients. This office would be flanked on either side by exam suites consisting of consultation and examination areas separated by a movable divider. Most visits would take place in a consultation portion of the suite resembling a normal living room area. This would allow mothers to bring their children as a family unit to the clinic and let them play with toys while the provider interviewed them (if they were the patient) Would help alleviate tension, apprehension and fear that often accompanies a sterile exam room that interferes with child examinations. Each exam area would have it’s own bathroom/changing area that would have secure private pass thru slots for specimens if needed. The exam section would allow procedures and unfettered examinations with the exam table in the middle of the room. Large screen monitors on the walls would allow the patient to comfortably observe and participate in the exam or procedure if desired. The back entrance to each module would lead to radiology and other diagnostic areas as needed.
- The modules would then be combined into a clinic with as many modules as needed for the campus. We initially chose 3 modules based on anticipated volume for the World Headquarters campus.
- The central modules would then be surrounded by more advanced services, conference rooms for group visits and pharmacy and connected to the pre-existing fitness center.
- The result exceeded our imagination.
- Human Resources had come to a conclusion a firewall needed to be in place between the clinic operations and the “corporation” so we physicians and nurses who worked at Cerner and were involved in the design process were prohibited from practicing in this facility. The clinic was outsourced to another organization with some on-site clinic experience. Predictably none of the nurses and physicians they brought in understood what we were trying to achieve and set up a traditional pattern of patient interactions. They were lost in the spaces and were very uncomfortable using the embedded technology in front of the associate patients. Though the associates enjoyed the visits the providers complained how difficult it was to work in this environment. They complained they didn’t have a place to jot down notes in the consultation area, were horrified with the associate’s children playing with toys in these living room like areas, and also complained about having to get up and down out of the comfortable consultation chairs all day long. Additionally they felt the small “doctor’s office” between the rooms was too small and so most of them spent time in the rear of the building instead of in the exam suites as it was intended. At one point the design was questioned but over time small modifications were made to on-site clinics at other Cerner campuses but the basic suite approach was retained as the associates preferred these to traditional doctor’s offices in which they had been seen. Additionally changes were made so associates with clinical experience could actually be the ones practicing in the clinics.
- Back to reality. We live in a changing world and especially in healthcare. Through a variety of mechanisms individual physicians have gradually lost their autonomy. Skyrocketing costs and the attempts to reign them in have led to increasing regulation. Incentives as part of the Stimulus Act were accompanied by requirements for clinicians accepting up to $40K to implement EMRs actually use them in a meaningful way. Lately the fee-for-service reimbursement system that rewards volume is being threatened by a value-based reimbursement approach. Unfortunately these reimbursement mechanisms are plan-based as so individual providers have some patients in plans that reward volume while others in plans that are value-based. This leads to a schizophrenic environment. A large percentage of our patients are suffering from lifestyle diseases and we’re finding out there’s no “medicine” that will change lifestyles easily. Pressures are mounting to migrate from treating the next sick patient that walks in to proactively treating a population of assigned patients. Add to this more and more transparency is all but being forced, especially in those practices that have embraced patient portals and have “open notes” policies where the patients can see and review everything the physicians documents. We’re not going back. The new permanent fixtures are electronic systems, increasing use of non-invasive imaging and photography. Reimbursements are being pegged to patient satisfaction. There’s constant mounting pressure for distant providers to make virtual housecalls that have the potential to rob patients. Ancillary clinicians are fighting aggressively for licensure that would allow them to see and practice patients without physician supervision. And the rent keeps going up!
- What’s a person supposed to do to survive? Often I hear “can’t we just practice medicine?” Unfortunately we don’t live in a static world and medicine is probably one of the last industries to adapt in ways other industries have to this changing world. They have worked hard to push the work out as close to the customer/consumer as possible. This has lead to decreased overhead and added value for the consumer. They changed who does what and how things are viewed. If one would take a medical analogy they have allowed the patients to participate by managing their own information, ordering their own medications and choosing treatment options. But inertia is a very big beast and it’s direction is not easily changed.
- So what can be changed easily? First and foremost is who does what. Second, the technology enabling who does what. What’s very expensive to change is the brick and mortar of where things are done.
- What impresses me is the effort that clinicians, healthcare architects and administrators expend to ignore the computer which is the foundational element for just about everything we do in our world today. "Elephant in the room" or "Elephant in the living room" is an English metaphorical idiom for an obvious truth that is either being ignored or going unaddressed. The idiomatic expression also applies to an obvious problem or risk no one wants to discuss.[2]
- …when at the same time when used properly patients like the computer. If you doubt this ask yourself, “Would you feel comfortable if the bank teller, grocery store clerk or your stock broker with scribble down your desires and then go to a separate room to execute them?” Survey: Do Patients Really Care if You Use Your EHR in the Exam Room? April 25, 2014 by Melissa McCormack Profitable Practice Most Patients Don’t Mind Electronic Note-Taking During Exams We asked patients three separate questions: whether it would bother them for their doctor to type on a desktop computer, on a laptop computer and on a tablet during an office exam. The overwhelming response to all three questions was, “No.” Patient Attitudes Toward Physician Use of Tablet Computers in the Exam Room Scott M. Strayer, MD, MPH; Matthew W. Semler, MD; Marit L. Kington, MS; Kawai O. Tanabe, MP (Fam Med 2010;42(9):643-7.) Background and Objectives: Previous research has examined patients’ attitudes toward use of exam room computers by physicians. Our objective was to determine patient attitudes toward physicians’ exam room use of new tablet computers. Methods: A random sample of 96 patients was interviewed immediately following a visit to a physician at an outpatient family medicine clinic at a large academic medical center in central Virginia. We excluded visits to first-year residents. Patients were asked about their attitudes toward technology use in the exam room using a previously validated 16-item structured questionnaire on patient attitudes toward technology use in the exam room. Results: The response rate was 97%. Survey results showed mostly positive patient perceptions of the tablets regardless of age, gender, race, ethnicity, and income. There were differences in attitudes toward privacy (by race and education), use of tablets by the physician (by education and age), depersonal- ization of the office visit (by race), and speed of medical files overview (by age). Conclusions: The use of tablet computers by physicians in the examining room is perceived positively by most patients. Conclusions The success of redesigning primary care and correctly implementing HIT over the next several years will rely on rigorous evaluation of new systems, software, and devices. Also, cost-effectiveness data and implementation strategies should be studied as these new systems are designed and deployed. Particular attention should be paid to minorities, disadvantaged patients (including low education), and older patients to ensure that the benefits of HIT do not create additional health disparities in our health care system.
- Now let’s look specifically at work flows.
- These workflows represent steps in the paper world and how they’ve changed with the digitalization of the process. Note any changes? Probably not. Key point? While we’re living in a different world we just haven’t bothered to change our function one iota. We’re still behaving and doing things as if they are still on paper. Workflow Redesign Templates Provided By: The National Learning Consortium (NLC) Developed By: Health Information Technology Research Center (HITRC) Practice and Workflow Redesign Community of Practice
- What would/should the same processes look like if we [medicine] behaved like any other company? Turns out the workflow above is doable today without any changes in technology. And this is where my own story continues ….
- Second Act. One of Cerner’s (and coincidentally one of my) clients happened to open up a new clinic and I was consulted to help that clinic go “paperless.” Timing was just right and I elected to leave Cerner and actually go work for this client as a front-line primary care physician and lead the move away from paper.
- Unlike the opportunity at Cerner, the clinic was already built using a layout expoused by the International Council for Quality Care (http://icqc.org). Key elements: Pod or modular design Each provider was given 3 exam rooms and 1 procedure room On-stage, off-stage areas. Or more precisely a separation of patient and provider traffic. One entrance for patients, another for providers Supplies and support staff centralized one door away from every exam room
- I was the 4th provider in this clinic and at the outset we identified 4 distinct ways each of us preferred to work. There was one physician who was technology averse, preferred to work in a complete paper environment. Accepted printouts that he’d use to dictate notes in his office but otherwise did everything by memory as he didn’t want “anything between him and his paitents.’ Another provider used the computer but used printouts of the information nurses had entered on which he add his own observations and then retired to his office in between paitents to dictate notes. A third provider would actually review patient information on the computer in the exam room but completed her work on the computer in the office. And then there was me … I did everything on the computer in the exam room with the patient.
- We examined several approaches and timed who was involved in documentation. We time studied the amount of time nurses spent in handling all of the work around their documentation. First in an environment where the physician was paper-based, the nurses did a lot of the documentation in their own nursing forms on the computer. The physician was using the paper chart so a significant portion of the nurses time was spent managing the chart cabinet where all of the patient charts were located. The nurses working with physicians who didn’t use or require the paper chart eliminated almost 40% of their time per visit. When we changed the work flow where the nurses were actually using the same documentation tool the physicians used we further cut down the amount of nursing time involved in a patient’s visit. Taking the same approach we examined the physician’s time spent documenting In the paper world a significant amount of time was spent paging through the chart to locate needed past information that contributed to the time spent in the documentation process. The computer sped this up somewhat but still managing the paper chart was a problem. If the paper chart was not pulled at all but the physician used the computer for past information and then dictated the physician actually spent the least amount of time in the documentation process. On the other hand if the physician did all of the work … he spent the most time when compared to all of the other approaches.
- We also looked at time in the patient’s room (a big patient satisfier by the way). Completely paper driven workflows minimized the time in the exam room … but maximized the amount of time needed for that work to be available for others across the system. On the other hand those that did all of their work in the exam room spent more time with the patient but their work was immediately or almost immediately available to others.
- The techniques and keys to making the whole visit process fun and engaging the patients.
- We first were using standard issue notebook computers but found this unworkable as the exam rooms weren’t designed for this. There was no good place to place the notebooks, do the work in the room. We either had to stand with our backs to the patients or sit with them on our laps with the computer between us and the patients. We quickly learned that patients wanted and actually needed to see things on our screens. Tablets might be the solution but we found their screens too small for effective sharing … not to mention that we actually dropped a few of them with predictable results. We went to fixed, wireless computers using standard 19” screens (which we discovered actually worked well in portrait mode that minimized scrolling). Eventually we landed on the sweet spot of using touch screen all-in-one devices into which we were able to plug a wide range of USB devices to maximize the efficiency of a primary care physician office.
- Leverage input and inexpensive off-the-shelf devices. Don’t need a lot of specialty equipment. These AIO’s could actually be used to let the patient participate in the documentation without having to touch a keyboard, sign in-room procedural consents and use interactively with all of the imaging devices that patients enjoyed as much as physicians. Key point is that when the patient, physician and computer form a triangle … magic happens.
- But we also discovered the single 21-23” screen wasn’t enough. We needed more real estate!
- This is what our exam rooms have now become. The clinician can chose to mirror or extend the computer’s screen and pull the patient into the whole experience.
- What we also found was there were a host of other web-based tools and applications that could be used on either screen as needed to access all of the information right during the visit. I’ve personally found that Google Translate has worked magic and I’ve yet to see any patient whose original language wasn’t translatable. The beauty of the All-In-One devices is that they have built in microphones and great speakers so we were able to conduct an interview often without having to touch the keyboard, using it to cut-and-paste English translations as needed to include in the note. Another tool that is a huge time saver is Zygote Body (formerly Google Body). This is a web based Google Maps for the body. This allows the patient to point at and manipulate the screen, diving into organs if needed to explain their symptoms. When we (patient and clinician) locate the source of the complaint it can but captured and pasted into the note.
- An ever growing array of digital tools and devices can maximize the ability of the primary care clinician to make diagnoses that in the short term past required referral to specialists. In fact, it’s my opinion that all screenings should and can be done at the primary point of care and only those that fail screening should be referred to specialists. Specialists shouldn’t see any normals.
- Now lets look at office designs as they can either support or hinder the ability to exploit a patients and clinicians’ desire to live in the digital world.
- Most clinics are designed with minimal thought given to technology and mirror the jail-cell mentality that permeates a volume based world.
- There are some that are beginning to incorporate and recognize the elephant in the room … but they’re still jail cells. Holzer Clinics (Athens, OH) The Mayo Clinic in Scottsdale, Ariz., is redesigning some exam rooms so that physicians can work on electronic medical-records and not turn their backs on patients. Hematologist Ruben Mesa consults with a patient, Larry Jackson. MAYO CLINIC Alegant Lakeside Clinic, Omaha, NE
- One company that I’ve been very impressed with is MidMark Clinical Solutions. I’ve never used them but they understand ergonomics and present the best blend of what we originally designed at Cerner in a way that can pass the CFO’s pen. They recognize the on-stage/off-stage world, minimize traffic and incorporate technology at the point-of-care. http://www.midmarkclinicalsolutions.com/procedure-workflows/dermatology#sthash.NzpcJkdK.dpbs
- Some examples of their work for different types of clinics. These designs are flexible and support all of the digital work flows needed to improve the exam room experience for both the patients and physicians.
- In summary, chage is inevitable. Many things we don’t like are here to stay. Many of the barriers to changing who does what are found in internal documents, procedures and policies and need to be challenged as most are not absolute requirements. The computer in the exam room needs to be set up for the patient. Digital platforms allow parallel work processes and these need to be adopted in the medical world for survival. Architecture is the most expensive investments and have a tail that is longer than anticipated and need to be made with the future, not only the present, in mind.