WORKFLOW-2007

Objections to Flight vs Digital

• I am not a flyer

• It weighs to much• I can crash and burn• I could never learn

those controls• It will get in the way of

my walking

• I am not a computer type person

• It costs to much• I can crash and burn• I could never type

• It will get in the way of my patients

Process

• Not all will be happy-10-15% love island and will not move

• It will be painful at times• We are all in this together• -Basic computer skills-typing

– 15 dollars for typing program

• Failure and non-participation is not optional• We have clear goals and excellent technical

support

Biggest Obstacle to Speed and adapting digital methods

It Requires a Paradigm

shift

4 FACTORSTHE JEDI INCIRCLE

ACCESS FOR PATIENTSINCLUDES SATISFACTIONSENSE OF BEING CARED

DECREASED COSTS

IMPROVED QUALTITY OF CARE

HAPPIER PROVIDERS

WE NEED TO KNOW THE ENEMY

Anytime you see paper, it is a sign of inefficiency

PAPER

• MANUAL LABOR-$$$$$

• AUTOMATED LABOR

• PRIMARY CARE LOW MARGIN

• DO WE HAVE A MARGIN FOR OUR MISSION?

Time

Cost

Paper

Cost of Doing Nothing

Compliments Dan Russler, McKesson

Time

Cost

Paper

EMR

Cost of Parallel Systems – Paper and EMR

Compliments Dan Russler, McKesson

Do you feel like a peasant?

“We are at the mercy of Chevera…

Government,

Insurance companies,

Regulators,

Politicians,

EMR

Does this sound like the doctor’s lounge?

Going to the Mountains

Magnificent 7 Basic Concepts of Workflow

The Magnificent 7

1. Computers don’t improve anything

2. Productivity is how you use the computer

3. Deep change hurts - Kakushin

4. Continuous improvement helps - Kaizen

5. Workflow is hard work - Keep at it

6. Empower the Patient – Ease the burden

7. Finish it – Enjoy it

Concept 1 - Computers don’t improve anything

• Understand the Productivity Paradox

• Automation may not fix bottle necks

• Your EMR is not the gold mine -YOU are

y

If you have a mess and computerize it

You end up with a computerized

mess

Concept 2 Productivity is how the

computer is used

it is thesame all over

Viewers

• Paper in an electronic environment

• Chart can be in several places

• Productivity none• Minimal Interaction

Basic Users

• Interaction is limited

• Dictation is used• Ordering• Past medication• No large

productivity gains

Strivers

• Use Templates to enter information

• Early in program first 1-2 years

• More efficient • Replacing

transcription but spending time on machine

Arrivers

• A lot of time invested and now not needed

• Extremely good at their systems

• Reaping productivity gains

System Changers

• Maximum Productivity

• Incorporate add-ons and workflow changes

• Bend it to their will

Concept 3 -

Workflow change depends ondeep change -

Kakushin革新

Kakushin

A Deep Change

revolutionary change or radical improvement

Everything will be different

Think in the Future

Mechanical Swiss Watch

Kakushin = 革新 which means innovation

You make a large investment in a new direction Some people revolutionary

change

Efficiency

Transition

Luxury Auto

• Mercedes Benz Quality investment value sturdy

• BMW Style, handling, functional

• Audi Style, space, affordable

• Volvo Safe, Reliable, Quality

• Jaguar Attractive

• Toyota cheap dependable

Bottom Line

• Status and Prestige

• High Quality

• Resale Value

• Performance

• Safety

Build the Car but different

• Great handling but a pleasant ride

• Fast and smooth but a low fuel consumption

• Super quiet but light

• Elegant styling but aerodynamic

• Warm but functional

• Great Stability and yet low friction

First Year

• Sold 2.7 times more Lexus the Mercedes Benz the leader

EMR

• Improve Quality but decrease costs

• Improve Documentation but have more time with patients

• Improve access for patients but leave for home at 5

• Increase R and D but improve margins

Kaizen

改善

Concept 4-Continuous improvement

Kaizen

• Incremental continuous quality improvement

• You get a little better each day

• Limited by technology

• Significant Limitation

The Toyota Way-

Measure Everything

Patientarrives in

Preop

Arrivedon time?

StartIV

Spike &hang

antibiotic

Circulatorgive Abx.

on the wayto OR

PatientcompletesAnesthesia

Questionnaire

Physician'spreprinted order

for antibiotic

Surgeon givestelephone orverbal order

Hand writtenon

chart

Nurse notes order

Four Routes for Preoperative Antibiotic Orders

Antibiotic to patient

before incision

PhoneOrder to

Pharmacy

Nurse tellsPharmacists:

pt name, allergy,M#, ordering MD

Labelgenerated

Techlabelsbag &

fillsorder

R.Phcertifies

order

Antibiotictubed to

PAAMain

Pharmacy

SatellitePharmacy

YES

NPO?

YES

YESNO

PAA nurse writesABX on MAR

PAANurseMixes

Antibiotic

Anesthesiagives atstart ofcase

MD writes antibiotic onAnes record

YES

Time to preppatientbeforecase?

NO

NO

Nurse picksup antibioticfrom tubes

Revieworders for

preopmeds

Anesthesia verbalorders

Four Antibiotic Sources

Pharmacy Pyxis OR Drug BoxAnesthesia

Tray

Recordsadministrationcomputerized

OR case record

Inputs orderinto computer

NO

YES

MedicationAllergy?

PAA nursereviewspatientallergy

NO

SelectalternateantibioticYES

Medicationallergy Select

alternateantibiotic

YES

NO

Anesreviewspatientallergy

Medicationallergy

Selectalternateantibiotic

YES

NO

Contact Surgeon

Delaycase

YES

NO

Cancelcase

Process map patient care

Time- from Drucker’s The Effective Executive

The Supply of Time is totally inelastic. No matter how highthe demand, the supply will never go up. There is no price for

it and no marginal utility curve for it. Moreover, timeis totally perishable and can not be stored. Yesterday’s time is

gone forever and will never come back. Time is, therefore, is always in short supply. Time is totally irreplaceable…

There is no substitute forTIME

The Toyota Way

Look for what is valuable to the customer (patient)……..

NOT what you may value

Waste

• Not safe 50000-100000 deaths due to errors

• 42% respondents experience poor or inefficient care

• 45% recommended care not given (not insurance related)

• ¾ of US population wants change

• 47 million uninsured

Workflow to find waste

• Overproduction

• Waiting

• Unnecessary transport

• Over processing or incorrect processing

• “Seeing someone who you should not-hospital rounds

• Patient Staff

• Movement back and forth

• Prescription in pt with allergy

Workflow to find waste

• Excess inventory

• Unnecessary movement

• Defects

• Unused employee creativity

• Prescription refills

• Clickitis

• Pt left without needed shot

• I am the boss

Patient Perspective

Start Done

PatientArrives

ChecksIn andWaits

Room

Nurse

Wait Doctorsees

GetsTests Gets

Rx

WaitsForRx

WaitsFor tests

DoesPlan

Workflow Digital and Not Digital

Concept 5 Workflow Workflow Workflow

You can not go Back-Lower the ODDS

Let’s Lower the OddsLet’s Go to the Office….

First Step – Patient comes to Clinic

Patient Value to See You

Decides to comePhone Call 9 pmGive InformationRememberGet in Car Go to Office

68 minutes 68 minutes for 6 minute for 6 minute office visitoffice visit

Did they need to come?

To pay a billPick up something

Physician View of Patient (who did not need to see me)

• Low margin revenue– Exchange of data– Rechecks– Patient who does not need to be there– Could someone else do it?

• Non-visit care tomorrow (e-Visits)

• Work smarter – not harder

Patient comes to a receptionist

Think about your office

Waste?

• Efficient

• Paper there Did we need it? How did it get there?

• Looked in computer Phoned

WASTEWASTE

Patient Enters the Clinic

VALUE

WASTE

Pt coming toOffice

PatientRegistering

Lobby Waiting

• 19/20 were waiting one filling form

VALUE

WASTE

Pt coming toOffice

PatientRegistering Patient in lobby

Vital Signs

Vital Signs

WASTE

Accurate?

Paper?

Time to Log in?

VALUE

BP/Pulse/Weight

60 seconds

VALUE

WASTE

Pt coming toOffice

PatientRegistering Patient in lobby

VS

Vital Signs pulse BP

• ..\Movies 2006\MVI_2995.AVI

Patient waits for doctor

Pt coming toOffice

PatientRegistering Patient in lobby

VS Waiting forDoctor

Doctor needs to know you are ready

NOW THE DOCTOR ARRIVES

Doctor does the writingDoctor does the data entry

MD Documenting – IS IT WASTE OR IS IT VALUE

Hand Writing

30 words per minute

Typing 60 words per minute

Dictating 180 words per minute

Editing 7200 words per minute

  

$$$$$$$$$$$$

$$$$$$$$$$

$$$$$$$$

$$

$$$$$$$$$$$$$$$$$$$$$$$$

Options for Data Entry to EMR

1. Handwriting recognition

2. Typing

3. Dictation

4. Voice recognition

5. Templates

6. Patient entered data with editing

1. Doctor using Handwriting Recognition

Slow, but seems great until have more than 6 words or misrecognition occurs

VitalsCheck-in

21 15 12 = $32Doctor for Data EntryHandwriting or Handwriting Recognition

PhysicianDocumentation

EMR and 15 Minute Office Visit Doctor Handwriting

Checkout

EscortPhysician Exam

NursingDocumentation

Escort

4

Graphic derived from Dan Russler, MD, McKesson,

Making Money

Wasting Money

Money Spent

Doctor Does the Data Entry

0

24

68

10

121416

1820

Initial Install 3 Mo 1 Yr

Paper

EMR

Productivity Drop with EMR

Kaiser Northwest, Portland, OR

Time of Office Visit

Revenue Drop after EHR

-7.00%

-5.00%

-3.00%

-1.00%

1.00%

3.00%

5.00%

7.00%

RVU % decrease

1st quarter

2nd quarter

3rd quarter

4th quarter

Total

Carilion Health Care – Carilion Health Care – Roanoke, VARoanoke, VA

Where did they put the Computers?

13

VitalsCheck-in

21 4 12 = $42

Using the Doctor for Data Entry

EMR and the 15 Minute OVDoctor Typing

Checkout

EscortPhysician Exam

NursingDocumentation

Escort

2

Making Money

Wasting Money

Money Spent

8

We could have nursing do this

What would that look like?

Data Entry into a Field-Prevention

PREVENTION REVIEWThis review was done when the adult was 55 years old on Thursday, October 14, 2004.

We have discussed the following topics which are important for all people in your age group:cholesterols every five years (see past medical history for your value),

smoking habits (can be found in past medical history), alcohol use, abstinence, and being in a car with a driver who has been drinking,

recreational drugs, aspirin should be taken daily , sexual practices, Prostate check yearly:last exam 2004 and offered counseling.

The following should be done yearly:height, weight, and blood pressure: done this year

Injury prevention is as follows: seatbelts: yesSmoke detectors: yes

Bicycle and motorcycle helmet does not bikeGuns and violence: no gun in home

Other risk factors reviewed: passive smoke: not at riskExposure to tuberculosis: yes-(you are at risk and need a TUBERCULIN TEST YEARLY)

Sunscreens: no-(you should WEAR SUNSCREENS 15 OR ABOVE)Radiation to neck no

Have a family history of colon cancer, familial polyposis: noColonoscopy or alternative examination recommended after age 50 colonoscopy 2004

Risk for back problems: not at riskBrushing teeth and dental care: yes

Exposure to loud noises: not exposedYou are at risk for diabetes: no risk

Your risk for cancer is related to these relatives: none. You have had a divorce in your family or separation, felt sad or are grieving: no

You are angry or are frequently angry: YESYour shots are up to date: yes and can be found in past medical history. We recommend all families know CPR.

REVIEW OF SYSTEMS:

VitalsCheck-in

21 14 12 = $42

Using the Doctor for Data Entry

PhysicianDictating

The EMR and the 12 Minute Office VisitNurse for Documentation

Checkout

EscortPhysician Exam

NursingDocumentation

Escort

VitalsCheck-in

21 112 = $32

PhysicianDocumentation

Checkout

EscortPhysician Exam

NursingDocumentation

Escort

12

Nurse for Data Entry18% ReductionLabor Cost

3

2

We can dictate

3

VitalsCheck-in

21 14 12 = $38

Doctor for Data EntryDictation

PhysicianDictation

EMR and the 15 Minute Office VisitDoctor Dictating

Checkout

EscortPhysician Exam

Nursing Documentation

Escort

2

Staff management of dictation

1

Inability to answer problemsPoor referral managementInsurance rejection issues

4

10

2

? Decreased patient safety & satisfaction

Making Money

Wasting Money

Money Spent

3

Transcription cost

• Physician

• Nurse

• Patient

21 16 12 = $4210

Cost Comparison of EHR Data-Entry Workflows

21 112 12 = $374

Where is the WASTE? Where is the VALUE?

21 13 12 = $294

What are we doing in the exam room?

WASTE vs VALUE

1. History

2. Physical Exam

3. Plan

4. Write Prescriptions

Who is the owner of a person’s health?

Who is the customer?

Instructions

• 40% lost in minute

• 80% lost in 30 minutes

• Incorrectly remembered

» J Royal Soc Med 2003 96:219-222

Information

71% of time patients are given nothing following their visit

68% of patients of Mayo Internists did not report what physician thought was a problem

54% a major problem

Concept 6 - Empower the Patient

You are at the office

• A partner’s patient who has hypertension comes to see you because in the last ten days she has noted that her blood pressure is elevated from its baseline.

• Meds Lisinopril 20 mg daily

• BP 152/93

What did we learn?

• We can not judge quality of care by reviewing a chart!

• Inputs are important

• Computerized history provided more information that was critical to this case, and was valuable to the clinician

Vendors

• The literature has been around for forty years

• Without an EMR not all that practical

• Names are in the handout-None are here except one

Instant Medical History (IMH)

• Software program you buy 50 dollars a month from Primetime Practice

• 75000 questions• Install into a computer• Tool on e-mail/internet for patients to use-

Medfusion AAFPs portal• 45 EMRs have as the interface to patient-This is

hugewww.medicalhistory.com

How does it work?

Patient Doing History

OUTPUT IS GIVEN TO YOU

• Given to you on paper• Given to you in

electronic form like into Word

• Directly into an EMR

ADVANTAGES

Collects more data then a clinician and organizes it into a readable form

Patient is better organizedPatients can do this

Patient collects information that the clinician misses

• 40% of time provided useful information not typically elicited

• Essential Questions missed

• Pilot’s Checklist

How dangerous is health care?

Number of encounters per death

Dea

ths

per

yea

r

REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

Mountain Climbing

Bungee Jumping

Driving

Manufacturing

Chartered Flights

ScheduledAirlines

European Railroads

Nuclear Power

Note: both dimensions are logarithmic scales

10 10,000 100,000 1,000,000 10,000,000

10

100

1,000

10,000

Health Care

Socially Sensitive

Highly Adaptable

SARS

Documentation

• Most Clinicians do E4 work 55904

• Most Clinicians Code E3 work 55903

• Most Clinicians document E2 work.55902

Others

• Patient controls interview-length of time

• Doctor only deals with positives

• Research

• Multimedia

• High patient acceptance

• Scales

Scales

• Zung Depression• Rahe Stress Scale• Urology Scales• Wast• Conners• Anxiety• Pain impairment• Patient Education Needs

Tough Diagnosis

8

20.1

2012345678

Min

utes

Traditional

S

O

A

P

E

Time of a Routine Office Visit

Subj.Subj. Obj.Obj.

PlanPlan

Pat EdPat Ed

3 2 0.13

2012345678

Min

utes

Software

S

O

A

P

E

Future Time of a Routine Office Visit

Subj.Subj. PlanPlan

Pt. EdPt. EdObj.Obj.

Complete PhysicalComplete Physical

35

7

0.1

58 7

0.1

1517

0

5

10

15

20

25

30

35

Minutes

OLD NEW

S

O

A

P

E

SubjSubj

ObjObjPlanPlan

SubjSubjObjObj

PlanPlan

Extra TimeExtra Time

Jane DoeChief Complaint Sore throat

VS stableSore throat 3 days duration

Lets look at history

80/20 Rule

20% of your questions get you 80% of the content

Negatives are time intensive

Analogy Mining for Diamonds!

Mining-Topsoil sand it is easyOpen ended questions

Listening 2 minutes

What are the results of All this labor

It is like MiningYes/No questioning-tailings

You can use a machine toDo the hard time consumingWork

You are in controlYou will trust the work doneCheck out a few things

A Clinic Story They see it and own it

• History was done on 5-page paper form, then translated into EMR

• Patients often forgot to bring form

• Office staff could see pt. on same or next day basis

• “Insurance problems” was common barrier to early-OB care

A Clinic Story

Call for Visit

Come in Today or Tomorrow for Intake

Intake VisitIMH

Rx Vitamins

Insurance Forms

Video

Prenatal Labs drawn in office

MD Visit – 1-2 wks laterHistory reviewed

Exam

Plan/Discussion

Call for Visit

Wait 1-2 Weeks

Send History Form in Mail

Initial New OB VisitInsurance Forms

Video

MD Visit

History reviewed (or re-collected if pt. forgot questionnaire)

Exam

Prenatal Labs ordered, pt. sent to lab

Rx Vitamins

Plan/Discussion

PLAN: Change workflow, add IMH

A Clinic Story

RESULTS in FPC

PRE:

NO Show rate: 40%

MD Time: 1 hr/pt

Indicators: missing

POST:

11%

45 min/ pt

all met

You have the Subjective Portion

• Answers to a series of yes and no questions

• Minor alterations• Documentation has improved• Quality has improved-

– Pilot check list– More complete inventory– ATMs and electronic tickets

• Computer has had structured data entry

Impression and Plan

• Using the Internet for plan if you do not have a template

Concept 7 – Finish IT, Enjoy IT

Go home at 5PM with work done!

Go get em

References

• Bush Roger W Reducing Waste in US Health Care Systems JAMA 2007 297 871-874.