Examining Your Workflow for Efficiency

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Examining Your Workflow for Efficiency

• Dana Kraus, MD, Northern Counties Health Care
• Bonnie Walker, Tupelo Group, LLC
• September 24, 2009

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Improving Efficiency Using Your EMR

• Dana Kraus, MD

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Who am I?

• Practicing Family Physician in St Johnsbury
• Employed by NCHC- a group of FQHCs
• 6 clinics, 20 providers, plus dental and HH
• EMR since 2005 (2002 other clinics)
• Involved in Diabetes collaboratives and Blueprint
• Pilot site for Blueprint and Medical Home

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Who Are You?

• POSITION
• IT, Provider, nurse, front staff, admin, other
• EMR USE
• Contemplating, in the market, adopting (lt1 year)
• New (1-3 years)
• Experienced user (gt3years)

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WHAT IS EFFIENCY?

• See more patients per day?

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My Personal Goals of of EMR Use

• IMPROVE PATIENT CARE
• Enter data reliably so it will flow
• Pull relevant data to my fingertips
• Prompts/reminders to address key items
• be more thorough
• Decrease time at end of day finishing
  notes/documentation

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Entering Data

• Identify all pieces of information that needs to
  flow or be tracked
• Demographics, vitals, labs
• Key tests mammo, pap, ECHO
• Disease specific data
• Retinal exam, foot exams
• Peak flows, asthma action plans

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Entering Data

• Move work AWAY from the providers!
• Automatic lab/xray feeds from source
• Tagging items at time of entry
• Scanning templates
• Maximize the use of nurses
• Smoking, depression, exercise, med compliance
• Limit provider-dependent items
• Self management goal, foot exam

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Why even bother entering data?

• Can easily find the data in future
• Allows for population tracking

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Go with the FLOW

• Take advantage of being able to PULL any data
  (once it is entered correctly)
• Pull data into
• Template/note
• Avoid searching for data, ? Increase billing
• Flow chart
• Referral letter
• Letter to patient
• Interval history form

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Prompts/RemindersBuilt into Templates

• Our nurses now ask about smoking, depression,
  alcohol and exercise
• Health Maintenance
• Last APE, mammo
• The case of the disappearing Tdap vaccine
• Disease specific
• Last retinal exam or monofilament exam
• Pertinent Review of Systems
• UTI nausea, fever, flank pain

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Getting Home on Time

• Complete most documentation DURING the visit
• Incorporate the nurses work
• Use a nursing or SHARED note
• Nurses can complete good part of the history
• DM-Basic ROS, home monitoring results, ASA use,
  exercise, medication compliance
• UTI- essentially the whole history

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The Nurses Noteor Shared Note

• Problem List
• Key age/sex relevant Health Maintenance
• Medication list/medication compliance
• Depression and Alcohol screen
• Pulls data from last visit
• ER visits / hospitalizations
• Exercise
• Chief Complaint

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The Key to a Good Provider Template

• It is all in the design
• Needs to work for individual providers
• Logical order/format
• Providers need to use it and tweak it to their
  needs!

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Start with a Few Templates

• Health Maintenance Exams
• Pulls in relevant past information to review
• Lots of counseling and standards
• Chronic Diseases
• Pulls in relevant data to avoid searching chart
• Lots of counseling and standards
• Simple complaints
• Bladder infection, URI, knee pain
• Frequent visits
• Suboxone follow up, Anticoagulation

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Look for REPETITION

• HPI
• Disease specific
• ROS
• Physical Exam
• brief exam normal infant exam
• Counseling
• Tobacco, exercise, lactose intolerance

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TRAINING, TRAINING, oh, did I mention TRAINING?

• Providers need to be aware of what the system can
  do for them!
• Need to use and ADAPT the system to meet their
  needs

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Templates do and do not

• DO
• Pull and push information
• Provide prompts
• Enter canned text
• DO NOT
• Think for themselves
• Enter data by themselves

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My Personal Challenge

• Adopt and use a generic soap note
• Complete HPI and ROS during visit

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Beyond Note Templates

• Referral letters
• Pulls in medications, PMH, canned text
• Letters to patients
• Pulls in labs, canned text
• Pull address to fit into window envelope
• Interval history forms
• Pulls in meds, Social history, tests and
  immunizations for patients to review
• Forms
• Lab, x-ray, PT referral, nutrition referral,
  retinal exam referral

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The Morning Huddle

• Nurse and provider
• Consider BHP, Chronic Care Coordinator
• Relevant data available
• ER/hospital discharge, labs
• Relevant data collected
• PT/INR, U/A, urine drug screen, Hgb
• Relevant treatment given
• Flu shot, Hep A vaccine, B12 shot, DEPO
• CHOOSE A TEMPLATE

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Easy Benefits

• The medication list
• Electronic prescribing
• Messaging system
• Not looking for charts
• Legible notes
• Population tracking

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Skills Tools for Continuous Quality Improvement

• Bonnie Walker
• Tupelo Group, LLC

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So..

• If youve implemented your EHR it is perfect,
  everyone loves it!
• All the information you need is right at your
  finger tips every single time
• All the paper has gone away
• Patients never call for prescription refills any
  more
• All your providers love the the templates
• You leave the office at 500 every night

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Well..

• If this were true, I wouldnt be here to talk
  about continuous improvement
• And you wouldnt look like this.

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The Fact Is.It Takes Time

• Many still dictate much of the visit
• Patients still call for prescription refills
• We miss information at the time of the visit
• Providers are not using templates
• We still work late
• Etc, etc, etc.

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If Youre Just Getting Started A Few Hints

• Preparation time is key to success
• Plan for lots of testing time
• Slow and steady is often better than speeding up
• Think carefully about what information/data you
  will want to improve patient care and office
  efficiency in your future
• Garbage In Garbage Out!

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If Youre Underway and Improving A Few Hints

• Survey your team
• Prioritize are you improving an existing
  process or starting a new module, new providers,
  new templates
• Stop the Grumbling!
• Consider Big Bang or Incremental Approach to
  improvements
• Build a forum for sharing new information, tips
  tricks
• Keep on, keeping on with your training

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BIG BANGIMPROVEMENTSPROS
CONS

• Shorter Implementation
• Great when great buy-in
• Less confusion
• Less chance of getting stuck halfway through

• More chance of blow-up
• Fixes more difficult
• All staff stressed at the same time
• Glitches more difficult to fix
• Productivity loss

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INCREMENTAL IMPROVEMENTSPROS
CONS

• Time to build consensus
• Time to build confidence
• In-house training
• Possibly less productivity loss
• Less shock

• Very easy to get stuck between EHR paper
  systems
• Longer training period, possibly less support and
  more cost
• More confusion

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Our Approach to Continuous Improvement

• Clinical Microsystems
• Form an Improvement Team
• Short meetings to discuss changes to test
• Short meetings to discuss progress
• Assess, diagnose and treat
• Model for Improvement (PDSA Cycles)
• Small rapid testing cycles (plan, do, study, act)
• Test with volunteers, innovators
• Understand what you are trying to accomplish
• Know where you are today
• Set goals to help you define future success

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Model for Improvement
1. What are we trying to accomplish?
AIM
2. How will we know that a change is an
improvement?
MEASURES
3. What changes can we make that will result in
an improvement?
TESTS
Plan
Act
Study
Do
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PDSA Cycles
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Lets Take an Example

• What are we trying to accomplish?
• Increase the number of providers using the
  chronic visit template by 80 in the next 3
  months
• What is our baseline data?
• 3 of our 10 providers currently use the template
• How will we measure success?
• Track the number of providers using the template
  successfully and routinely
• What tests will we run to accomplish our goal?
• ..Sounds like time for a team working session!

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Team Working Session

• Get agreement on your aim goal
• Clarify where are we today? Baseline?
• How do we do it today? - Flowchart
• What additional data do you need to collect?
• Discuss Things to Consider What are your
  options?
• Big Bang vs. Incremental
• Who is willing to test?
• What will we test?
• Brainstorm ideas for change
• Create a plan to solicit ideas from others

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Example Flowchart Bennington Family Practice
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Run Multiple PDSA Cycles
Changes That Result in Improvement
Learning from Data
Tweak!
Tweak!
Tweak!
Tweak!
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Pitfalls to Avoid

• Dont avoid trying
• Dont assume it wont work
• Dont generalize
• All my patients are complicated templates will
  never work
• Dont quit

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Do

• Ask what would make it better
• Solicit ideas from others
• Give it a try
• Be willing to test more than one change
• Stay positive
• Be patient

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Training

• Understand the Different Learning Styles
• Visual Learners
• Auditory
• Kinesthetic
• Prepare for
• Reflection/Observation
• Try/Do

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Coming together is a beginning, keeping
together is progress, working together is
success. - Henry Ford