Author: Chandresh Shah

Someone recently wrote this on Twitter and it caught my attention. It caught my attention because everyone seems to be talking about Practice Workflow and how to optimize it. It is also being talked about in the context of EMR / EHR Software Systems. Yet majority of small practices struggle with the concept of Workflow precisely for this reason – it neither works nor flows as they expect it to. We may think it does, but it meanders, particularly for inefficient workflows. We know that a straight line should take a mile, but the inefficient meandering workflow may take 2 miles to get there. These workflows work eventually though and flow ultimately, because at the end of the day, somehow, things do seem to get done.

In a fantastic book edited by Ronda G. Hughes, Ph.D., published by NCBI (NIH) in 2008 titled – “Patient Safety and Quality“, there is a Chapter on Organizational Workflow and its Impact on Work Quality that I think everyone should read. I have extracted some important elements here.

Some Workflows are designed, while others evolve and happen organically over time. Most often, when workflow processes are looked at in isolation, they appear quite logical (and even efficient) in acting to accomplish the end goal. It is in the interaction among these processes that complexities arise. Some of these interactions hide conflicts in the priorities of different roles in an organization, for example, what the staff is accountable to versus the physician(s) and their schedule. Practices also adapt workflows to suit the evolving environment.

Over time, reflecting on workflows may show that some processes are no longer necessary, or can be updated and optimized.

Today, the need to think about workflow re-design is important due to several factors, including:

• Introduction of new technologies like EMR/EHR Software Systems
• New treatment methodologies
• Cost and efficiency pressures to improve patient flow
• Initiatives to ensure patient safety
• Implementation of changes to make the care team more patient-focused

Perhaps the most important reason that workflow is of pressing concern for today’s clinicians is the introduction of healthcare information technology (healthcare IT). While EMR software promises benefits, it can be disruptive to existing workflows in a practice.

EMR software systems assume a workflow structure in the way their screens and steps are organized. Practices that are thoughtful about workflow design are more likely to be successful in adapting to EMR Software Systems and being successful.

Do you think just by installing a good EMR you can accomplish this?  That will depend on the kind of workflow.

Poor Workflow

Practices rely on good information. Valuable information can be lost when poor workflows impede communication and coordination or increase interruptions.

A poorly functioning workflow includes:

• Unnecessary pauses and rework
• Delays
• Established ‘workarounds’
• Gaps where steps are often omitted.
• A process that participants feel is illogical.

Good Workflow

The design of good practice workflow is not simply about improving efficiency. Workflow processes are maps that direct the team (front office, clinicians, and back office) on how to accomplish a goal. A good workflow will help accomplish those goals in a timely manner, leading to care that is delivered more consistently, reliably, safely, and in compliance with standards of practice.

An excellent process can accommodate variations that inevitably arise in healthcare through interaction with other workflow processes, as well as factors such as workloads, staff schedules, and patient load.

Impedance and Hurdles in the Way of a Good Workflow

5 primary instances why EMR Software Systems can disrupt practice workflow:

1. Instead of using EMR Software implementation as an opportunity to re-design practice workflow, practice owners that just throw technology into the mix of an existing workflow are more likely to cause the process to become even more inefficient than before.
2. Treating EMR Software systems as a ‘necessary evil’ that has to be done. This thinking prevents proactive initiatives to re-design workflow.
3. Acquiring EMR Software as if it was a ‘commodity’ and Shopping solely on pricing, look-and-feel, etc.
4. Not involving the entire staff in decision-making.
5. Not being prepared to re-design your Workflow

Conclusion

In addition to looking for an EMR system that has the necessary features at a reasonable price, one should not compromise on practice workflow re-design. Most systems today have most of the features that a practice needs and industry competition has leveled the playing field where pricing differences are minimal.

Workflow re-design and optimization can be accomplished in two ways.

1. Find a Vendor / Re-seller that knows how to do this and has experience doing so.
2. Find a Consultant who can help.

Either way, EMR Software is anything but a Commodity.

I was visiting a Client in Los Angeles. He started up a new practice. He wanted to start with an EMR software that was a complete system to help him get started in the right way.
When we first talked last year, my first thought was that just like many others, he would want a system that can do everything without having to pay anything.

I was surprised when he emphasized that he had two objectives.

1. A system that was powerful enough to help him with clinical documentation and manage the business of a medical practice.
2. Someone who can be a ‘partner’ to help optimize the practice workflow and bring in efficiency.

What was missing here in the goals was – ‘how much’. He did not talk about pricing at all. Out of the four packages that were offered, he chose number 3 which had more value services, unlimited training, and immediate phone support when he needed it. He ended up paying a couple hundred dollars a month more than what he would have paid otherwise, but what he ended up getting was far more valuable.

During my time at this clinic last week, I found that he had been able to set up an extremely smooth workflow, and his staff was trained and happy. They knew that EMR Software was a tool that they needed to use optimally.

I did not see any of the standard negatives I see at other practices struggling with EMR Software implementation. I have seen some practices with the same software struggle. Part of the problem was that there were compromises made in the level of training they purchased.

In a nutshell, here are some things we did together:

1. Optimized Templates that would take care of 80-90% of patients within 90 seconds or less.
2. Front Desk optimized patient registration and scheduling process.
3. Empowering Patients to help with intake data to reduce their paperwork and staff’s time doing data entry.
4. Creating Notes such that billing is error-free with minimal rejection.
5. Setting up Management Reports to help practice owners and providers stay on top of Practice Finances by spending less than 5 minutes per week.

In short, if you like the EMR System you are looking at, make sure you get adequate training and services. EMR Software should be a tool to help re-engineer your Practice and optimize workflow.

In Economics, a commodity (Wikipedia) is a marketable item produced to satisfy wants or needs. Commoditization occurs as a goods or services market loses differentiation across its supply base, often by the diffusion of the intellectual capital necessary to acquire or produce it efficiently. So, has the EMR software market now effectively been commoditized?

The answer will depend on who you ask.

Let’s look at it from a Provider’s (Small Practice) perspective. It will also depend on why someone is considering EMR software. There are two classes of buyers:

1. Those who have used EMR software and want to switch because they are not happy.
2. Those who are considering EMR software for the first time.

Providers buying EMR software for the first time don’t see subtle differences in technology, value, and effectiveness. They don’t see the differences between vendors. ‘All EMRs are the same‘ – I’ve heard this phrase so many times it is not even funny. For this group, EMR software is a commodity.

On the other hand, Providers that want to switch because they are not happy. They know exactly what to look for, what works, what does not, and how to differentiate between vendors. They are looking for unique attributes that produce better value.

Even if the systems you evaluate seem to have similar ‘features’, each system handles workflow differently.

• Will a system help you create a better workflow for your practice and become more efficient?
• Will your vendor help you implement the system for efficiency? If vendors won’t, perhaps their re-sellers will.

There is unfortunately so much pricing pressure that vendors can’t afford to give lots of extra services. Vendors are going for ‘volumes’ of practices.

Re-sellers build their business on the Services Model. They want your business and they want that you will recommend them to your peers and colleagues. This is what creates a true win-win situation. Get into the spirit of ‘partnership’ with Re-seller.

What about pricing?

I know pricing can be an important factor. But step back for a minute – is it really that much of a factor? The difference between the system you want and the other EMR is perhaps $200 per month maximum. This is less than $10 a day. If a system makes you slog for 15 minutes more every day, you’ve just lost more than $10. In the bigger scheme of things, that $200 in higher fees will give you multiples back in return.

Bottom Line

Buy EMR software on value, not pricing. You should try to get more value, support, and services rather than negotiate pricing unless it is absolutely ridiculously priced.

In my informal survey of Successful EMR Software implementations, I have found 2 very important factors that make EMR Software implementation and Adoption successful.
I have used two words:

• EMR Implementation
• EMR Adoption

Let me distinguish between the two.

EMR Implementation is just about usage of the system. It implies that you are putting a layer on top of your practice workflow, trying to automate and speed up some of the tasks everyone does. It does not talk about improving practice and workflow efficiency. In other words, you are just doing things better. If your practice workflow is inefficient, with technology, you just make that inefficiency better.

EMR Adoption indicates that your practice uses and depends on the EMR system to help you become better and more efficient. It forces you to examine your processes and weed out inefficiencies.

What are the Two Secrets of Successful EMR Implementation?

1. Continuous Training
2. Focus on Adoption versus Implementation – Focus on Processes

Continuous Training

There must be a good plan for training with the right trainers. Sometimes training is done by IT people and that is ok, they know the application, and can show you what buttons to press, but they don’t always understand the practice workflow. It is always better to be trained by clinicians that know the system or by consultants that are experts in practice workflow. It is not important to learn every trick in the book, every intricate aspect of the EMR software to prepare for every possible workflow scenario.

Good training enforces, over time, simulations of workflows, ‘what-if’ situations.

Another important aspect of training is Continuous training and reinforcement training – not to different in philosophies from CME.

Too many practices and provides underestimate the importance of training. In the process, they over estimate their (and their staff’s) ability to learn the EMR system, however easy it may seem. Part of it is driven by the motivation to try to reduce costs.

Training is precisely the Wrong place to cut costs. It actually costs you more in the long run to cut training costs. I wrote an article in February 2013 about this.

EMR Software Adoption – Process ‘re-engineering’

After EMR software implementation, one mistake practices make is to assume that everything will stay the same day-to-day. You are investing in EMR technology to become better and more efficient. You should not just assume that by ‘implementing’ and ‘installing’ EMR Software, it is going to solve all your problems.

Again, distinguish between Implementation and Adoption. Strive to examine your workflows and how EMR software can help improve them – re-engineer them.

Conclusion

Once EMR Software is implemented and Adopted, it is a process of continuous improvement. It must be a sustained effort to stay on top with changes – staff turnover, software updates, regulatory updates (MU, ICD-10), etc. It takes continual effort to constantly strive for improvement to get results of increased efficiency.