A Conversation About EMRs, Workflow, Usability, and Productivity

Short Link: http://j.mp/6vyEuD

Frank Martin posted a comment to one of my earlier posts that triggered the following conversation. I am “promoting” this conversation to a full fledged weekly post because I think its content deserves it. (And maybe just a little because this is a holiday weekend.)


Frank: We here at EncounterPRO have become very comfortable with the term “Workflow Management”, but I am not sure that everyone in our market is familiar with the term and its meaning in the context of the practice of medicine. At its most basic, Workflow Management is “organizing the way things get done inside a process to insure all of the goals set for that process are accomplished”.

Chuck: That is a good common sense explanation of the benefit of workflow management. However, the technical means by which this benefit is accomplished is very different between traditional EMRs and EMR workflow systems. Traditional EMRs are structured document management systems. While more and more traditional EMRs are adding task management, this is relatively frozen workflow. Without a workflow engine and associated process definitions (called “workplans” in EncounterPRO), the workflow management benefit cannot be generated as automatically or flexibly.

Frank: Seeing a patient is a pretty complicated process with several sophisticated goals. The first goal is gathering all of the clinical data appropriate to the patient’s condition in a way that paints a complete and accurate picture of that condition. This picture is used to facilitate clinical decision making and problem solving. The second goal is creating a profitable transaction for the practice. The third goal is creating a satisfying experience for children and families. I have not attempted to prioritize these goals, but rather simply list them in no particular order. There may be other goals that people would like to accomplish, but I think these are the big three.

Chuck: The tension that occurs when trying to optimize all three goals, when they sometimes conflict, is what I was trying to capture in this (admittedly enigmatic) diagram. For example, short term profit might be increased by reducing staff, but at the expense of decreased patient satisfaction as their wait times go up. One of the wonderful qualities of workflow management systems is that they can ameliorate these tradeoffs. With a EMR workflow system, fewer staff can see more patients *and* patient wait times can decrease.

Frank: Painting an accurate picture of the patient’s condition requires that all of the people in the practice know exactly what information they have to gather. The role of the EMR workflow system is to present the screens in such a way that none of the required data is missed. Different people collect different kinds of data at different times during the encounter so the system has to present the right screen to the right person at the right time.

Chuck: The usability principles of natural, consistent, and relevant workflow apply here.

Frank: Creating a profitable transaction for the medical practice is really all about the control of time. Each person in the practice has a different rate of pay. This rate of pay can be broken down into minute by minute intervals. Physicians have the highest rate of pay and other people in the practice have lower rates of pay. The practice has a cost of providing the exam rooms. The amount of floor space taken up by clinical exam rooms can be calculated and then divided by the number of minutes these rooms are available for patient use. This can give the practice a personnel cost and a physical plant cost for the exam, if the EMR is capable of measuring the time each person from the practice spends interacting with the patient and the time the patient spends in the facilities provided by the practice. The cost of providing the services of the encounter subtracted from the revenue received for the encounter will equal the profit created by that encounter.

Chuck: One of the great promises of EHR workflow management systems or healthcare BPM in general, and specialty-specific EMR workflow systems in particular, is the pairing of activity-based costs with process definitions. Since each step in a process definition is time stamped as to when it is available to be accomplished, when it starts to be accomplished, and when it is actually accomplished and who (cost per minute) and where (rent per minute) is the resource used during each task, the total cost of each patient encounter can be calculated. In conjunction with the revenue per patient encounter that is available from the practice management system, the profit per each encounter can be calculated.

By comparing encounter profitability across similar medical practices, specific reasons for decreased profitability can be located: (1) a step is more expensive per minute than it should be (that is, it is accomplished by less expensive resources at other practices), (2) a step takes longer to accomplish than it should (compared to other practices), and (3) a step is executed more frequently than it should (compared to other practices). The win-win-win analytic result is to find those too expensive and too long steps that are being executed too frequently and change the workflow so as to increase encounter profitability.

Frank: Creating an encounter that satisfies the patient is another complex phenomenon. There are many factors that could go into this equation: the total amount of time from check in to check out, the procedures preformed, the personnel seen, the diagnosis made, the plan of treatment recommended, the amount of time the patient spent unattended. This is a partial list of the things inside an encounter that might positively or negatively affect the patient’s satisfaction with that encounter.

Chuck: You have expressed (in conversation) some very interesting ideas about associating each encounter with a simple measure of patient satisfaction (”On a scale of one to five, how would you rate this visit”) so as to benchmark, not just cost, but patient satisfaction as well. Since patient satisfaction predicts longer term profitability, it is a nice counter balance to purely cost driven workflow benchmarking.

Frank: A good workflow management system would help the practice by providing data that would give the practice insight into what could be changed in their workflow to optimize performance on each of these strategically important metrics.

Chuck: In other words, a good workflow management system is a business process management system. I discussed this in a post that critiqued the idea of “meaningful use” of EHRs.

Thank you Frank! I think this sort of public conversation about the relationship between pediatric workflow management and business process management systems (workflow engines, process definitions, benchmarking, and costing) on one hand and practice profitability and patient satisfaction is a very useful exercise.

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