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You Might Be Thinking About the Clinical Workflow Incorrectly

Change in healthcare is not easy, but in today’s fast paced world, it’s necessary. Advances in medicine, new technology, ubiquitous regulations, and new reimbursement models are evolving quickly.  Making any change in healthcare, however, is complicated by the fact that the quality of healthcare services can impact the quality of life of those receiving them, and more times than not, healthcare processes involve a collaboration of internal and external people, software, and processes.  These processes, software, people, and information must be woven together in highly complex and elaborate ways so that they work together to ensure that patients receive optimal treatment. 

This is a discussion for anyone who is interested in making improvements to clinical workflows so that they work better internally for staff, patients and externally in collaboration with other healthcare professionals to ensure the best possible care is provided.

If Congress gave out a purple heart type of award that could be given to industries that face severe challenges and yet somehow manage to make things work in whatever challenging situation given to them, it would – or should – be given to healthcare year over year.  

Small, medium, and large sized medical organizations equally face similar challenges:

• Reimbursement is increasingly linked to both clinical quality and cost performance
• Competitive pressures
• Patient expectations for an easy, yet effective experience
• Incomplete solutions that solve 80% of the problem but leave 20% unresolved

However, practices struggle to find solutions for several reasons:

• Staff shortages
• Rising costs
• An extremely fragmented industry in almost every way
• Data that is non-standard/unstructured and growing exponentially 
• No time to consider or make changes

The question all practices are asking:  in this environment, how can I make improvements that improve the quality of treatment provided, increase capacity to see more patients, and lower operating costs? 

The answer to this question is what we’ll explore.

 

First Though, Why We Do What We Do Must Be Answered?

Before going into more detail, let’s go up thirty-thousand feet and look at the big picture. Whenever we decide to do something, we should think through the reason we want to do it. It’s ok to say “because I want to and it makes me feel good” when deciding to eat ice cream or watch a movie, but when it comes to running a business, it’s necessary to have a vision for the business to guide goals and objectives. 

What is your vision and what are your high-level goals and objectives?

Most healthcare organizations’ vision statement probably goes something like “to provide the highest quality safe care so those we serve achieve the best possible outcomes and can have the healthiest possible lives”.  Like any business, provided services must be of a quality level and price that is competitive and must be done so at a cost that covers expenses and generates a reasonable profit.  

Visions provide a north-star around which decisions about direction and process can be both planned and assessed. With this guidance, we can start a discovery into what an organization does well and where it might need to be improved.

 

What Do We Do with Medical Practice Vision Statements?

One reason to have a vision statement is to help guide the thinking and actions in how to organize people, software, procedures, and policies in ways that strive towards seeing a vision become a reality.

Inside any business, including medical practices, people and things are organized in ways to do the things that are necessary to provide the services that are done.  Sometimes these ways of doing things are very well defined and understood, while others are more ad-hoc and less defined and understood. 

Understanding how things are done is critical because medical practices, as with any business, there are costs associated with provided services and revenues must be at or exceed these costs or the business at some point will not be viable.   

Medical practices want to deliver safe, effective, and high-quality care to all patients, and do it at affordable, competitive, and profitable prices.  Accomplishing this though is a complex balancing act – one that requires reviewing and often adjusting how things are done. 

Healthcare works today because of the dedicated people involved, but they need tools that are easy to use and effective in solving the many complex problems faced when trying to provide optimal care to patients against a growing set of challenges.

What’s needed is an examination – not the one physician’s do, but an examination of practice operations; the aim of this examination is to discover how things are done and how effective they are at providing an effective high-quality solution for a need. To examine how things are done requires a look at workflows – the processes and people that are organized in ways to do the things that are done as a business.

 

What are Workflows?

A workflow contains the steps or tasks that must be done to accomplish or produce something.  Workflows can be defined broadly or narrowly, and in great or with few details. It’s important to keep in mind that the product or service of one workflow could be an input or interact directly or indirectly with other workflows; meaning, workflows frequently interact with other workflows. For example, the output of one workflow could be the input of another workflow or could direct another workflow in what it should do.

Defining and documenting workflows doesn’t require an engineering or data science degree – many times it can be done by talking and listening to someone who does the job or task.  Why would we want to take the time to define and understand workflows? We want to discover how things get done so that they can be analyzed, improved, monitored, and standardized.

Workflows, whether they are defined, ad hoc, standardized, non-standard, manual, or automated, impact the quality of services, and, of course, determine how much things cost:  there’s usually labor, tools, supplies, and overhead associated with all workflows in a business.  

One goal of workflow improvement is to help staff be more productive and effective in what they do.  Workflows of particular importance are ones having high frequency, such as daily and hourly, are critical to the services provided, and since labor is the highest cost in any medical organization, workflows having manual steps where people must do or use things like telephones and faxes, are workflows that should be examined and understood for potential improvement.

Medical practices are often described as having two primary parts: an administrative part and a clinical part (some practices may have more, such as those with in-house labs), and generally these two halves have their own unique workflows.

 

Administrative v. Clinical Workflow 

When looking at a medical practice from ten-thousand feet, the necessary workflow to see patients for treatment could seem simple, but upon closer inspection, nearly all medical practices have an administrative and a clinical side of the practice – and both must work together to ensure that physicians can see as many patients as possible since physician time is ultimately the primary revenue source.

Before the patient is seen by the treating physician, administrative staff makes sure appointments are coordinated, patient demographic information and consent is obtained from the patient, insurance is verified and financial clearance is understood, and, at some point, just like administrative staff have a check-list of must-do things before the patient can be seen, clinical staff perform a critical task of ensuring that each patient’s clinical history and/or clinical updates are found, reviewed and in place for the physician to have before and while the physician sees the patient. 

The healthcare industry has made improvements administratively.  Most practices now have electronic scheduling and billing systems that have enabled taking advantage of electronic data interchange or “EDI” transactions, like the “270” ANSI standard for eligibility, the “837” for claims and “835” for payment.  These improvements have yielded operational efficiencies that have lowered operational costs and made processes much more effective as well.  Administrative staff who have worked in the industry for a while can attest that processing “EOB” information by hand v. the now standard “EDI” 835 automated way has made them far more productive.  These improvements are seen in modern “Practice Management Software”, or PMS, software systems.

But what about the clinical workflow?

 

The Clinical Workflow

It’s undeniable that Electronic Medical Record, or EMR, software has revolutionized how clinical medical charts are managed.  While there could be a debate over how easy they are to use, most would say EMRs have helped and are a good idea. But how and in what ways exactly have they helped?  

EMRs are now the tool used to manage medical charts and the clinical data associated with each patient who has been treated by the medical practice.  Clinical workflows include check-in, measuring and recording vital signs, a review of clinical details, and ultimately finish when a physician uses his or her clinical decision tools and knowledge to make a diagnosis and to create a treatment plan. EMRs have enabled clinical details to be recorded and stored for the entire span of care for each patient, along with automating heavily recurring tasks like lab and prescription orders. 

Many times, the clinical workflow is thought to begin when the patient checks-in for the appointment and ends when the patient checks-out. However, it could be argued that the clinical workflow starts almost immediately after the appointment is made. This is because clinical staff is involved in making sure the right clinical data about the patient is in place at the right time for physicians to have for clinical decision making before and during the patient encounter.  This could be called the “clinical pre-encounter” workflow.

Improvements to the clinical workflow are not a new idea and are slowly occurring.  For example, in the past, prescription refills and lab and test orders were manual, but today are automated, which frees up clinical staff time.  Leveraging the latest industry advances in clinical data standardization, interoperability, and integration, it’s time to improve the clinical and clinical pre-encounter workflows.

 

What Happens in the Clinical Pre-Encounter Workflow?

The clinical pre-encounter workflow begins when the patient makes an appointment.  Most, if not all, treating physicians need clinical information about each of their patients, and what and how much clinical information is needed can vary greatly from physician to physician.  

Specialists usually need the immediately prior physician’s notes and/or lab results, but when a patient selects a new primary care physician, the new primary care physician wants the patient’s entire clinical history from as many sources as possible.  Each physician is different, so the process and effort associated with finding the right amount of information from the right sources is unique to each practice. One thing all practices experience though is that finding and obtaining medical charts is complex undertaking – mostly because it varies widely among all possible sources – ranging from 100% electronic exchange with affiliated practices to widely varying requirements for non-affiliated practices.  

Those involved in the clinical pre-encounter workflow must determine what clinical data is needed, find out where it’s located, determine how to obtain and get it, and finally prepare it so that it’s available for the treating physician. Obtaining prescriptions, lab results and images are also usually an important part of this workflow depending on the nature of the upcoming encounter and physician preference as well.

The goal of the clinical pre-encounter workflow is to provide the treating physician with enough clinical information so that the physician clinically knows the patient in enough clinical detail to have a clinical baseline to begin clinical assessment and decision making from.

 

Improving the Clinical and Clinical Pre-Encounter Workflows

Why look at this workflow?  It’s simple: obtaining a clinical history of the patient prior to the encounter is essential, and it’s an activity that is necessary for each patient encounter.  Workflows with high frequency, ones that are critical and have manual components, are ones that warrant time to review. The clinical pre-encounter workflow checks all these boxes.  Improvements here can:  

• improve staff productivity, reduce labor and operational costs by reducing the number of manual tasks and increasing the amount of automation, 
• lead to improved quality measures and outcomes because physicians consistently have the clinical information necessary for optimal clinical decision making.

The goal is to improve how clinical data about a new patient (or updated clinical data about an established patient) are obtained and made available to treating physicians for more effective and efficient clinical decision making.

Let’s discuss workflow analysis and improvement.

 

Workflow Analysis and Process Improvement

Workflow analysis and improvement doesn’t have to be complicated.  Let’s start by acknowledging that there can be big differences in workflows between large, medium, and small medical practices; however, these differences are generally in how many people or things are involved and perhaps the degrees of specialization where, for example, one person in a smaller practice wears many hats and in larger practices, single tasks could be assigned to a single person or group.  Regardless of size, the fundamental steps are the same. It’s important to remember when thinking about changing medical practice workflows that since medical practices provide clinical services, patient safety and adherence to HIPAA, State and Payer regulations and requirements must be prioritized to ensure corners aren’t cut leaving the practice open to potential revenue, litigation, or reputation risk.  

It’s probably likely that many think about making improvements, but don’t for one reason or another.

Many times, the hardest part of doing something is not knowing where or how to start, and this leads to “anxious inaction” – the knowing something should be done but there seems to be so many ways it’s too hard or impossible to change that it stops us from doing anything.  The reasons why to not consider investigating improvements to workflows can be daunting; many times, they are not for technical reasons, for example: 

• This is just the way we do things.
• Not knowing alternatives exist.
• Finding time.  

The first step is to not wait for time to magically appear but to make time to review business operations with the goal of becoming aware of how critical workflows are performing and then to make improvements.

The second step in any improvement endeavor is to understand how a process or thing works at the present time as a baseline. Before something can be improved, it must be understood. Understanding how a process works provides confidence in where and how to make changes with confidence.

Practice managers must understand their internal processes and workflows in enough detail to understand how they operate, know what’s needed and required for them to work, and be aware of the quality of what they produce, among other details. This is especially the case for workflows directly associated with products and services that are responsible for revenues that keep the business going.  

But, before starting, do it on paper first.

 

Look Before Leaping

The first step is to make time to think, organize and plan.  This could be as simple as blocking or scheduling time on your calendar to think about and categorize to-dos into one of four buckets:

• Important and urgent
• Important, but not urgent
• Not important, but urgent
• Not important, and not urgent.

Important and urgent things are usually front-and-center by their very nature because they have deadlines or could be a crisis requiring immediate attention.

Important but not urgent things don’t need to be done immediately but are important.  If these things are done, they have the potential to improve things for the better in the short and long term.  These are things that could prevent a future crisis, could make workflows and jobs better, and could make employees and patients happier.

Not important things, whether urgent or not, should be where we spend the least amount of time, but still somehow manage to make time for – things like Facebook, which is usually neither important nor urgent to clinical operations.

While it may seem unnatural to stop for a second to think about how to improve business operations, it can yield enormous positive future returns.

During your thinking time, start with a blank Excel or Google spreadsheet so it’s easy to add, delete or modify contents and create a list of all business workflows and processes.  With a list, it’s easier to understand, measure, and monitor processes.

By stopping to think first, you are enabled to act smarter. 

On the spreadsheet list of processes and workflows, document primary inputs and outputs and list all tasks associated with each workflow.

For each task, fill in important details like:

• Who or what does it do?
• What and how is it used?
• How often is it done?
• Is it required, sometimes required or completely optional? 
• What does this process need to work and where does it come from?
• Frequency/timing
• Interface information with other workflows and processes (required, document, etc.).

Workflow task lists can include anything necessary to better understand how things work. A critical part of understanding is knowing where things are done manually, semi-automatically or fully-automatically.   In healthcare, obviously not all tasks can be automated, but many repetitive tasks that are done manually today could be automated because of technological advances and policy changes.

With a list of the major processes and their component tasks, it’s possible to pinpoint which activities are the most critical and make assessments on how they are performing. Having this information can inform decision makers of where bottlenecks are at, what doesn’t perform well, is the least liked by staff, and ultimately highlights places for potential improvements.  Workflow and process task documentation provides a framework for assessing how much actual time tasks take, which is important for a better understanding of cost and of practice capacity to provide additional services or see more patients.

As an example, a list of details associated with the clinical pre-encounter workflow will have tasks such as:

The clinical pre-encounter workflow begins when the appointment is made and is therefore dependent upon the appointment process.

The appointment triggers staff to take the following abbreviated list of steps: 

• Determine whether the patient is new or already affiliated with our health system.
  • If new, the patient will need to be entered.
  • If already affiliated, the patient information will need to be reviewed to be sure it’s up to date.
• Determine whether some or all the required clinical information about the patient is available internally.
  • If not available, determine whether it’s known how to ask for and obtain medical charts from the patient’s prior provider.
    • If not known, find out how to contact and obtain information.
    • Follow the steps the other physician requires, which is likely to make a request using FAX.
    • Watch for information to be returned via FAX.
    • When the information is obtained, it’s generally necessary to print and/or scan the FAX pages, search, and copy and paste the desired information from the Faxed information into a new document.  How this is done and what is included is highly specific to practices and physicians.
    • Import the medical record information into the patient chart so that it’s available to the treating physician.
  • This must be repeated for each place information may be at, or when the other practice doesn’t respond to a request.

While this is an abbreviated list, it illustrates the many moving parts associated with the process of obtaining and preparing medical charts prior to the patient’s encounter with the treating physician.

Some practices may want to dive even further.

 

Data!

Just as physicians need clinical data about patients they treat, practice managers need operational data about their business operations.

Involve those who are involved in doing identified tasks. Ask them: 

• Does this list and the information on it look correct?
• Can you guesstimate how much time each of these tasks takes and how often you must do it?
• How often do things “not work” or need to be repeated?

Some practices may need – or want – to take measurements of how long some tasks take because it could be the first time these tasks have been reviewed and questions have been asked.

With information about workflows, processes, and possibly data about them, it’s time to identify where to make changes.

 

Identifying Where to Making Improvements

Certain workflows or tasks will jump out as wow(!) that takes a lot of time, doesn’t work much of the time, and it can be eye opening to practice management.

Reasons for poor performance are many, for example: 

• Processes/software/system perform incorrectly.
• People lack understanding of a process, procedure, software, input, or result.
• Interfaces lack integration with other processes and there is loss of accuracy or data (note that as the number of different software, people and external entities increases, so do the chances that problems exist).
• Many repetitive, unstructured, varying manual tasks.

 

Building Better Workflows

When building new or improving existing workflows, keep the practice vision in mind: processes should be designed with the goals and objectives that advance the practice’s vision.  

Here are common objectives for workflows that advance vision of medical practices:

• Improve the bottom line through increased productivity and reduced operational costs.
• Identify and implement best and standardized practices.
• Build in reporting, monitoring, auding, and an ongoing assessment of the process.

• Design easy and effective communication and data flows – among people, processes inside and outside of your practice.
• Select technology and vendors that solve the problem and work well with others so that interfaces between workflows, software, and people inside and outside of your practice work seamlessly.
• Instill and encourage a culture of continuous improvement.

 

How, specifically, could the clinical pre-encounter workflow be improved? Two things stand out:

• Reduce or eliminate manual steps.
• Use technology and solutions that work easily, that is interface, with other components of the workflow. Transitioning inputs, data, and results from different systems and vendors, whether internal or external, should be easy, accurate, and affordable.  

An improved clinical pre-encounter workflow can eliminate the need to manually find clinical medical records about patients, and it helps clinical staff manage the data that was found so they’re more productive in getting this information in front of treating physicians.  Interoperability is the industry jargon for describing how clinical data from thousands of medical organizations can be shared among treating physicians, regardless of affiliation and EMR vendor used.

Tools that support comprehensive interoperability, or the ability to search all the national and local data exchanges, can by themselves dramatically reduce the number of manual steps associated with obtaining medical records, but there is a way to do this even better: integration. 

We don’t like to have to constantly repeat ourselves when we speak, and it’s no different when trying to accomplish a work task: we don’t like having to retype and reenter the same information repeatedly because we need to use different software systems or because we need to work with an unaffiliated organization.  There is a solution to this problem.

 

If Banks and Airlines Can Do It, So Can Healthcare

Interoperability refers to the capability of electronically requesting and obtaining medical information about patients.  However, most of the time, it’s necessary to retype the patient demographic information to find the desired information. Wouldn’t it be nice if the information entered in the EMR could automatically transfer to the request to find information about the patient that is available in the national, state, and local health information exchanges, or HIEs? 

Most EMRs have the capability of sharing patient demographic information with other systems and have basic functionality to interact with other systems using Application Programming Interfaces, or APIs; APIs are part of how the internet works.  Working with a solution that can connect and work directly with your EMR software can eliminate manual rekeying of information and could even transfer clinical data back to the EMR!

With interoperability and data integration in place, manual steps are eliminated, time is saved, productivity rises, and the effectiveness or quality of results improves – dramatically. 

By implementing a single tool that connects to all national, state and local HIEs and is integrated with the EMR so that patient demographics doesn’t need to reentered, one practice demonstrated that dramatic positive results can be achieved; by implementing a single tool capable both interoperability and integration, they saw a 75% decrease in necessary staff time, a 50% decrease in new patient prep time, a 56% improvement in the amount of times the right data about the patient was found on the  first try.  This resulted in an increased capability to see at least one new patient per day.  These results were just in the first month!

However, not everything is necessarily a good candidate to be replaced with technology.

 

To Automate or Not to Automate … Is a Good Question

It’s important to have all who are involved in any tasks where changes are to be considered or made involved in deciding when and how to make those changes. Their concerns, desires and needs are important.  For example, a 2023 survey of nurses reports that nurses feel fulfilled in their jobs the more they are interacting with patients. Nurses want technology to be “an enhancement to the care but not a replacement for the [patient] connection”.  Many nurses support a desire for help with charting, documentation, tracking down equipment, medications and, not surprisingly, administrative tasks, including easier ways to obtain medical records.  Listening to staff involved in the various parts of the care delivery process is essential to long-term success. 

Healthcare interactions are an intimate and personal experience between patients and their caregivers that requires, to a large extent, carefully considering where to use technology and to automate so it’s done in ways to enhance the personal experience and not distract from the human interaction.

 

Good news!  Making changes for better results may be easier to make than you thought.

Industry efforts to make clinical data safely and securely available to treating physicians in a trusted environment has advanced significantly in the last few years and is possible because of healthcare entities’ implementation of EMRs and the creation of policies that allowed for the creation of clinical data exchanges. 

Most practice administrators and staff can quickly attest that the processes necessary to obtain medical charts and clinical data about each patient prior to treatment is cumbersome, doesn’t work all the time and impacts the amount of time they have available to ensure the treating physician has all the information needed for optimal clinical decision-making. It is cumbersome today mostly because it’s not a single process but is one that is highly manual and consists of several methods and contact details when working with external physicians and healthcare facilities.  

The good news is that, while the external physician and healthcare facility network is different among different medical practices, the process to find clinical information for treatment is the same, and some practices have gone where no practice has gone before and tried a new approach by replacing their costly, manual, and somewhat unreliable process(es) with one that implements all the latest advances in clinical interoperability and integration.  All practices benefit because this new approach has been real-world tested for effectiveness.  

Implementing change in or replacement of critical, existing workflows can perhaps be intimidating – especially for workflows that have been in place for decades, but the industry itself has changed in stakeholder expectations, regulatory demands, and what’s available to help – like clinical data exchanges and EMR integration. 

Vivlio Health is the tool that implements a single on-ramp to all the national, state, and regional clinical data exchanges to find all electronic data available, integrates with EMRs to eliminate the need for retyping and manual uploading, and assists clinicians in managing the clinical data that was obtained so that the clinical data the treating physician needs is provided in a timely and efficient manner. 

Act and don’t let the only thing stopping you from having better operational processes and higher quality services be you.

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