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Patient Care Clinical Workflow
- 1. Configuring Electronic Health Records PatientCare Clinical Workflow; Multiple Perspectives of Patient Care This material (Comp 11 Unit 2) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 2. Patient Care ClinicalWorkflow; Multiple Perspectives of Patient Care Learning Objectives - 1 • Enter a progress note as a Physician in a VistA simulation EHR environment. (Lab Exercise 1) • Enter nursing notes and implement physician orders as a Registered Nurse in a VistA simulation EHR environment. (Lab Exercise 2) 2
- 3. Patient Care ClinicalWorkflow; Multiple Perspectives of Patient Care Learning Objectives - 2 • Understand the importance of clinical workflows in the functioning of EHRs. (Lecture, Lab Exercises 1 and 2) 3
- 4. What is AWorkflow And Why Are They Useful? • Sequence of events • Series of tasks that produce an outcome • Establish a procedure or process • Delineate flow of activities • Improve efficiency of work activities – Optimize system efficiency – Improve patient care – Enhance patient safety – Recoup measurable cost savings 4
- 5. Workflows In TheClinical Environment • Typically clinicians do not think of the workflow as they are taking care of patients • Clinical workflows are often complex • Clinical workflows are dependent on the setting, on the clinician as well as the patient 5
- 6. Examples Of ClinicalWorkflows • Clinical workflows may be very different in different settings – In a doctor’s office: o Patient greeted at front desk and registered o Taken to exam room by MA o Seen by physician – In an ED: o Patient may have little time to register if very ill, usually greeted at front desk and triaged o Taken back into ED room and rapidly assessed by RN o Seen by physician 6
- 7. How Does theEHR Affect Clinical Workflows? • EHR affects information gathering and processing • EHR changes the way clinicians obtain information of past history • CPOE influences clinical decision making • CDS such as reminders, clinical guidelines and “hard stops” change workflows • Imaging visualization workflows are altered by the EHR PACS versus film 7
- 8. Conceptual Versus Actual Workflow 3.1Figure: (Cheng et al., 2003) 8
- 9. Analyzing Workflows -1 • Implementing EHR requires analysis and modification of workflows • Transition from current state to future state • Observation of workflows allows modifications during EHR implementation 9
- 10. Analyzing Workflows -2 • One method for analyzing workflows: – What are the tasks? – Who is performing them? – How are the tasks performed? – What is the sequence of events? – What are the critical steps? – What is the priority of the workflow and processes within the workflow? 10
- 11. Patient Care ClinicalWorkflow; Multiple Perspectives of Patient Care Summary - 1 • Defined workflows • Examined the importance of clinical workflows in health care systems • Looked at how electronic health records modify these workflows 11
- 12. Patient Care ClinicalWorkflow; Multiple Perspectives of Patient Care Summary - 2 • Looked at multiple examples of clinical workflows from different perspectives • Studied the differences between conceptualized and actual workflows • Underscored the importance of observational studies and workflow analysis. 12
- 13. Patient Care ClinicalWorkflow; Multiple Perspectives of Patient Care References - 1 References Aarts J, Ash J, Berg M. Extending the understanding of computerized physician order entry: implications for professional collaboration, workflow and quality of care. Int J Med Inform. 2007 Jun;76 Suppl 1:S4-13. Epub 2006 Jun 23. Damiani G, Pinnarelli L, Colosimo SC, Almiento R, Sicuro L, Galasso R, Sommella L, Ricciardi W. The effectiveness of computerized clinical guidelines in the process of care: a systematic review. BMC Health Serv Res. 2010 Jan 4;10:2. Review. Gooch P, Roudasri A. Computerization of workflows, guidelines, and care pathways: a review of implementation challenges for process-oriented health information systems J Am Med Inform Assoc 2011;18:738-748 Niazkhani Z, Pirnejad H, Berg M, Aarts J.Review Paper: The Impact of Computerized Provider Order Entry Systems on Inpatient Clinical Workflow: A Literature Review. J Am Med Inform Assoc 2009;16:539-549 Wetterneck TB, Lapin JA, Krueger DJ, Holman GTBeasley JW, Karsh B-T. Development of a primary care physician task list to evaluate clinic visit workflow BMJQS 2012;21:47-53 13
- 14. Patient Care ClinicalWorkflow; Multiple Perspectives of Patient Care References - 2 References Zheng K, Haftel HL, Hirschl RB, O"Reilly M, Hanauer DA. Quantifying the impact of health IT implementations on clinical workflow: a new methodological perspective J Am Med Inform Assoc 2010;17:454-461 Tables, Charts and Figures 3.1 Figure: Cheng CH, Goldstein MK, Geller E, Levitt RE. The Effects of CPOE on ICU workflow: an observational study. AMIA Annu Symp Proc. 2003:150-4. 14
- 15. Configuring Electronic HealthRecords Patient Care Clinical Workflow; Multiple Perspectives of Patient Care This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. 15
Editor's Notes
- #2 Welcome to Configuring Electronic Health Records: Patient Care Clinical Workflow; Multiple Perspectives of Patient Care. The component, Configuring Electronic Health Records, provides a practical experience with a laboratory component (utilizing the VistA for Education program) that will address approaches to assessing, selecting, and configuring electronic health records (EHRs) to meet the specific needs of customers and end-users.
- #3 The objectives for this unit, Patient Care Clinical Workflow; Multiple Perspectives of Patient Care, are to: Enter a progress note as a Physician in a VistA simulation EHR environment. Enter nursing notes and implement physician orders as a Registered Nurse in a VistA simulation EHR environment.
- #4 Understand the importance of clinical workflows in the functioning of EHRs.
- #5 This lecture will define clinical workflows, provide examples, and discuss how implementing the electronic health record affects these workflows. It will also discuss a method to conceptualize workflows, and analyze them. A workflow may be defined as a sequence of events that occur during the delivery of health care. It's a series of tasks, that when performed leads to an outcome. For example, let us consider an example of a workflow in the kitchen, where the preparation of food requires performing a series of tasks that leads to the final product, which is the prepared food item. To prepare a simple item such as a peanut butter sandwich, the ingredients first need to be identified and collected - in this case bread and peanut butter - then a utensil must be found to extract the peanut butter from its jar and spread it on the bread, and then finally assemble the sandwich. These steps define a process, in this case the production of a peanut butter sandwich, and establish a procedure for generating this outcome, here the process of collecting the ingredients and assembly of the final product. This process of delineation of the flow of activities into a specific sequence can be described as a workflow. Once the concept of workflow is defined, it can then be examined to look for inefficiencies in the work activity being analyzed. In the case of the peanut butter sandwich, if a spoon had been used to extract peanut butter from the jar, and a knife used to spread the ingredient while assembling the sandwich, we might have come to the conclusion when analyzing the workflow that a single utensil would have been sufficient, increasing the efficiency of the process, and resulting in some measurable savings of time or resources or money. This redesigned workflow, with one less utensil to clean, would save time, dishwater detergent, water, electricity, and money over the long term. While this is an extremely simplistic example to define the concept of a workflow, the principle is the same in the clinical environment. While taking care of patients, clinicians also perform a sequence of events and engage in tasks that produce a specific outcome, such as defining the diagnosis or implementing the management plan for the patient. A similar procedure can be established for clinical events, though clinical workflows, will undoubtedly be more complex than making a peanut butter sandwich. By delineating workflows and analyzing the flow of activities, system efficiencies can be optimized, patient care can be improved, resulting in measurable savings.
- #6 When clinicians provide patient care services, they typically are centered on the needs of the patient, implying that they may not be adhering to a specific workflow. In fact, clinicians may not be able to articulate the exact processes of the workflow, especially since clinical workflows often tend to be complex and sophisticated. Clinicians may engage in multitasking, suggesting that multiple workflows may be in progress at the same time. Additionally, workflows in the clinical environment are usually dependent on the setting, on the clinician who is performing the task, as well as on the patient. For example, the workflow for obtaining a history and performing an examination may be different in the intensive care unit (ICU) as compared to a similar process in a nursing home. The workflow of the same history and physical may be different when performed by an endocrinologist as compared to the workflow of an ophthalmologist. Workflows may differ based on the ability of the patient to provide answers to questions asked by the clinician, and cooperate with the clinician during the physical examination. For example, an extremely sick patient in the ICU may not be able to provide a history, which changes the workflow for the clinician. At the same time that the clinician is performing the history and physical workflow and documenting elements of both in the patient’s electronic health record (EHR), another workflow, such as retrieving the patient’s historical data through the EHR may also be occurring. This is an example of two different workflows that are occurring in parallel, but which combine in the overall process of patient care and may even be synergistic with respect to the outcome that is desired. In this example, a delay or bottleneck in one workflow might affect the other; if the clinician is unable to find pertinent historical data in the EHR, it may be difficult to ask the patient the relevant questions for appropriate diagnosis, the anticipated outcome of this process. There can be a great deal of complexity in clinical workflows.
- #7 Clinical workflows can be different in different settings, and different clinicians within the same setting can have entirely different workflows. The following example will examine clinical workflow in a practice environment that uses an EHR. In a doctor’s office in an outpatient setting, a patient is usually greeted at the front desk by a registrar who performs a series of tasks necessary to enter patient data into the system. After ascertaining identifying particulars, such as name and birth date, the registrar may check the patient's appointment against the office practice management system, and ensure that demographic and patient insurance data is up-to-date. Patient may be required to sign forms, and will usually flag the EHR to let the clinical team, including the medical assistant, nurse, and physician know that the patient has arrived. This series of tasks comprises the clinical workflow for the registrar. The questions that the registrar asks the patient are usually pursuant to scanning the electronic health record and determining what data fields need to be entered into the system. Next, the patient may be taken into the examination room by the medical assistant, who has been alerted to the patient's presence by a task performed by the registrar as part of their workflow. The medical assistant then performs a series of tasks that are quite different from that of the registrar. This may include obtaining a chief complaint from the patient and will usually involve taking vitals, checking for allergies, medications, and then updating the EHR with relevant information. The medical assistant will then, as part of that workflow, flag the chart to let the physician know that the patient is ready. Subsequently, the patient may be seen by a physician, who will perform another series of tasks which form the physician’s workflow process. The physician may have already scanned the electronic health record, and may have reviewed relevant information such as the chief complaint, the vitals, and any prior communications that the patient may have had with the practice. This preparatory phase is usually a part of the physician’s workflow in the outpatient setting. The physician will then ask a series of questions based on the patient history, and may examine the patient, decide to offer a treatment, or perform additional tests. At this stage the physician may also decide to refer the patient to another clinician, or may recommend ancillary treatment such as physical therapy. The physician will also usually arrange for follow-up with the patient, either as a subsequent office visit, or even over the telephone, or by e-mail. This represents a workflow for the physician, and it is variable, depending on the physician’s course of action after obtaining the history and performing the examination. Another variable course of action is that the physician may decide to document the encounter while in the room with the patient, or subsequently after the visit, or at the end of the day. The physician’s workflow may also be modified by other factors, for example, if time is limited, documentation may be deferred to the end of the day. A physician’s workflow is very different and much more complex than a medical assistant’s workflow, even though both of them have had contact with the same patient for the same clinical issue in the same setting. Workflows may be substantially different in a different setting. For example, instead of going in to the doctor's office, a patient might have felt very ill, and chosen to go to the emergency room. In that case, the registration process might take a very short period of time, since it is imperative that sick patients are seen in the emergency room as soon as possible. In the emergency department (ED), a patient who is very ill may be initially processed at the front desk then quickly taken back into an ED room and assessed by another clinician such as the nurse, a nurse practitioner, or in significantly ill patients, directly by the physician. The role of the ED front desk is to triage the patient, and determine if the patient has a significant or critical illness, in order to expedite their treatment. The nurse who assesses the patient in the emergency department room has a different clinical workflow than the medical assistant who might assess a patient in the outpatient setting. The nurse’s assessment is usually much more comprehensive than that of the medical assistant, and may involve initiating treatments aggressively in consultation with the physician. The ED physician’s workflow, while superficially similar to the outpatient counterpart, is also substantially different. While the ED physician usually obtains a history and performs an examination, they may also order urgent laboratory or radiology tests which usually have a very rapid turnaround time as compared to the outpatient setting. These tests need to be reviewed quickly and integrated into the decision-making process, and the ED physician needs to incorporate this task into the workflow or risk missing vital information. Unlike the outpatient physician, by the end of the encounter, the ED physician also has to decide whether to admit the patient into the hospital, or discharge him from the emergency department. If the ED physician considers admitting the patient as part of the clinical workflow, then the case will have to be discussed with the hospital physician who will be taking over responsibility for the patient. So even though both ED and outpatient physicians are involved in patient care, there are different workflows that each follow.
- #8 The previous scenarios included the use of electronic health records as a part of clinician workflows. When organizations move from paper to electronic health records, there is a change in workflows. The electronic health record affects information gathering and processing. It changes the way that clinicians obtain information, especially remote clinical information and data related to past medical history. For example, if the physician admitting a patient into the hospital wanted access to information that had been collected during a hospital admission a few years ago, in a paper records workflow, the physician would have to go down to the medical records department, access the paper record, and find the appropriate data entry by reading through the paper records. With an electronic health record, the clinician does not have to leave the point of care in order to find information, and may use electronic searching tools in order to locate data. Computerized physician order entry influences clinical decision-making. The ability to choose appropriate order sets allows aggregation of individual orders, which changes clinical processes. For example, a patient who is admitted to the hospital with chest pain of a possible cardiac etiology requires specific laboratory tests to be performed over a period of time in order to determine if the patient has had a myocardial infarction or heart attack. With a paper chart, the physician might have to write these orders out individually, but with an electronic health record, pertinent orders related to this specific clinical condition, such as the laboratory tests, can be ordered using a single computerized physician order entry (CPOE) set. This is more efficient, enhances the standard of care, and fosters patient safety. The electronic health record allows clinical decision support tools such as reminders and clinical guidelines to be incorporated into clinical processes, streamlining workflows for physicians. EHRs can also introduce the concept of a hard stop to the workflow which can completely stop all processes until an inquiry in the process is resolved. Consider the example of a patient who has been admitted to the hospital with a diagnosis of pneumonia. The admitting physician orders an intravenous antibiotic drug using a CPOE. The EHR clinical decision support engine notes that the antibiotic drug that has been ordered is a member of the penicillin family, and that the patient has a known allergy to penicillin. This prompts the clinical decision support engine to show an alert, which is displayed as a window on the EHR interface screen. The order cannot be completed until the physician acknowledges the alert, and the antibiotic cannot be ordered until the alert is overridden by the physician. This is an example of a “hard stop”, where the entire workflow grinds to a halt until the physician resolves the issue. Workflows are also altered by the use of health IT in imaging. Before digital image records became prevalent in hospitals, if a patient had an imaging study such as an x-ray done, the physician treating the patient would have to go down to the radiology department and physically pick up the x-ray film in order to review it. Now, with the advent of a picture archiving and communication system, or PACS, and dissemination of images over a computer network, physicians can view images using a PACS workstation or on the same monitor as the EHR at the point of care. This has led to significant efficiencies of patient care associated with the timely retrieval of potentially significant imaging data. Of course, although one physician might enter orders into the EHR, other clinicians often collaborate in the decision-making process. There is often a profound impact on workflow beyond the provider entering the orders, and this must be considered when transitioning from a paper to an electronic health record.
- #9 During the planning and implementation of an electronic health record, it may be advantageous to conceptualize ideal clinical workflows. However, one issue that may arise is the fact that the actual workflow may be very different than the conceptual model. This figure is from Cheng’s observational study on the effects of CPOE on ICU workflow from the AMIA Annual Symposium Proceedings in 2003. At the top of the figure, the conceptualization of the CPOE workflow is quite linear. The physician writes an order, the pharmacist verifies the order, the unit clerk delivers the order, and the nurse administers the order. There is an advantage to this linear process as prescription and transcription errors are reduced in this model. However, the actual workflow that was observed in practice is different. At times, the nurse initiated the order by processing a verbal request from the physician. In this case the physician may not have placed the actual order right away, but the nurse may have administered the drug before the actual order was written. With paper records, nurses can check that an order was written by observing the physician writing it at the bedside, or by looking at the paper charts. With an electronic health record, physicians do not usually enter their orders at the bedside, and nurses need to converse with physicians to ensure that the order was entered in the CPOE, sometimes, which interrupts the physician’s workflow. As you can see, the actual observed workflow was not linear, but had multiple feedback loops which suggested inefficiencies in the system.
- #10 Implementing an electronic health record system effectively requires special attention towards the analysis of clinical workflows. This will allow an organization to make modifications to workflows and perhaps to the clinical information system in an effort to maintain a smooth and efficient process of patient care as the EHR is integrated into the patient care model. It would be appropriate to summarize that workflow analysis allows a smooth transition from the current state to the future state of EHR use.
- #11 One method for analyzing workflows is to ask a series of questions while observing clinical workflows. The observer will need to know something about the task that is being performed, paying close attention to the process itself, and how the people for performing these tasks conduct their work. It is important to pay close attention to the sequence of events and try to determine the critical steps in the process, since these are potential chokepoints that could affect other clinical workflows. When there are a number of clinical processes occurring simultaneously or in tandem, it is also important to understand which specific processes within the workflow require prioritization, and what level of priority each process in the workflow has in relationship to the system as a whole.
- #12 This concludes Patient Care Clinical Workflow; Multiple Perspectives of Patient Care. In summary, this lecture defined workflows, examined the importance of clinical workflows in health care systems, and looked at how electronic health records modify these workflows.
- #13 Multiple examples were provided of clinical workflows from different perspectives and the differences between conceptualized and actual workflows were examined. Observational studies and workflow analysis are integral to the effectiveness of workflow systems.
- #14 References slide. No audio.
- #15 References slide. No audio.
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