Fix pro­cesses first

Add an EHR only af­ter free­ing clin­i­cians through efficient care pro­to­cols

Modern Healthcare - - Opinions Commentary - Dr. Tim Jahn Dr. Tim Jahn is chief qual­ity of­fi­cer of the east­ern Wis­con­sin divi­sion of Hos­pi­tal Sis­ters Health Sys­tem, Spring­field, Ill.

It’s no great in­sight that im­ple­ment­ing an elec­tronic health record in­volves sig­nif­i­cant ex­pen­di­tures of time and re­sources as well as tem­po­rary dis­rup­tions to the care en­vi­ron­ment. Six months af­ter the fi­nal rule on mean­ing­ful use was pub­lished, many hos­pi­tals are in the fi­nal dis­cus­sions with ven­dors about crit­i­cal needs and out­comes. Prior to choos­ing an EHR, it is im­per­a­tive that providers and ven­dors dis­cuss the EHR’s ca­pa­bil­i­ties and how the sys­tem will sup­port the hos­pi­tal’s ef­forts to achieve to­tal hos­pi­tal ef­fi­ciency.

While this seems ob­vi­ous, part of that dis­cov­ery process is an ex­am­i­na­tion of the care co­or­di­na­tion pro­to­cols that af­fect each hos­pi­tal’s ef­fi­ciency. The chal­lenge for providers is mak­ing sure they have laid the ground­work to im­ple­ment the process smoothly so the EHR’s ben­e­fits ac­crue as quickly as pos­si­ble. With the ex­cep­tion of a few in­dus­try lead­ers, most hos­pi­tals will make the mis­take of in­te­grat­ing an EHR into a sys­tem of pro­to­cols, lo­gis­tics and method­olo­gies that have not been de­signed to max­i­mize a hos­pi­tal’s to­tal ef­fi­ciency.

Avoid­ing this sce­nario re­quires look­ing be­yond the emer­gency depart­ment or in­ten­sive-care unit where a hos­pi­tal has im­ple­mented ad­vanced-care man­age­ment pro­to­cols. Hos­pi­tals must con­sider how the EHR will af­fect the broader in­sti­tu­tion, in­clud­ing its ad­vanced-care prac­tices and those yet to be op­ti­mized. If they do not, the EHR will be­come “dig­i­tal ce­ment” that pre­vents the fa­cil­ity from re­al­iz­ing the full ben­e­fits of an EHR and po­ten­tially hin­ders fu­ture ef­fi­ciency ef­forts. When cou­pled with the on­go­ing de­bate over whether EHRs will ac­tu­ally im­prove ef­fi­ciency, it is clear that hos­pi­tals should first op­ti­mize the care co­or­di­na­tion pro­to­cols that gov­ern efficient care de­liv­ery.

Us­ing ad­vanced process re-en­gi­neer­ing method­olo­gies is an im­por­tant pre­req­ui­site for EHR suc­cess. Ev­ery C-level ex­ec­u­tive should con­sider this when chore­ograph­ing pa­tient flow and max­i­miz­ing through­put. Op­er­a­tional method­olo­gies most of­ten associated with man­u­fac­tur­ing pro­cesses, such as Lean, Six Sigma and Toy­ota Pro­duc­tion Sys­tem, are rapidly gain­ing fa­vor as the best means to in­crease ef­fi­ciency. Be­sides lower re­source uti­liza­tion, in­creased ca­pac­ity, im­proved prof­itabil­ity and greater qual­ity, syn­chro­nized pa­tient flow will re­move many of the lo­gis­ti­cal prob­lems that re­duce the time clin­i­cians have to spend with pa­tients.

Too of­ten, front-line care­givers are bur­dened with non-clin­i­cal ac­tiv­i­ties that in­volve board­ing, sched­ul­ing and trans­port in­stead of pro­vid­ing care. These ac­tiv­i­ties cre­ate waste in a process for which ef­fi­ciency is crit­i­cally im­por­tant. Adding an EHR to this dy­namic will not im­prove care; in­stead it may par­a­lyze al­ready over­bur­dened care­givers. By im­prov­ing pa­tient flow and lo­gis­tics across the en­tire hos­pi­tal, nurses and doc­tors will be freed to spend more time with pa­tients.

Clin­i­cians can use this ad­di­tional time to achieve an op­ti­mal bal­ance of pa­tient care and doc­u­men­ta­tion. In­cor­po­rat­ing an EHR in a hec­tic en­vi­ron­ment buf­feted by in­con­sis­tent pa­tient flow and de­mands will not es­tab­lish a solid foun­da­tion for suc­cess. The ef­fects of hav­ing more time at the bed­side for clin­i­cians will be en­hanced by the EHR’s in­clu­sion of de­ci­sion-sup­port pro­to­cols, com­put­er­ized physi­cian or­der en­try, test re­sults and other func­tion­al­i­ties that are an­tic­i­pated to transform care.

In­creas­ing ef­fi­ciency through ad­vanced­care co­or­di­na­tion method­olo­gies be­gins with de­vel­op­ing a con­sen­sus that the hos­pi­tal is com­mit­ted to trans­form­ing its op­er­a­tions. Once that mind­set is ac­cepted, it is im­por­tant to un­der­stand how pro­cesses are com­pleted. This can be done through map­ping work­flow to ac­com­plish key pa­tient flow tasks. A re­view of the work­flows will iden­tify op­por­tu­ni­ties for im­prove­ment (such as waste, no value added and re­work).

Once the op­por­tu­ni­ties are iden­ti­fied, an op­ti­mal fu­ture-state process de­sign leads to the elim­i­na­tion of un­nec­es­sary steps in the work­flow process. Upon im­ple­men­ta­tion, pro­cesses are stan­dard­ized and key met­rics and milestones are es­tab­lished, re­sult­ing in: op­ti­mized pa­tient flow for all pa­tients; re­duced non-value-added ac­tiv­i­ties and waits; and in­creased hos­pi­tal ef­fi­ciency.

The fi­nal com­po­nent to max­i­miz­ing ef­fi­ciency and re­al­iz­ing the at­ten­dant gains is us­ing adap­tive sys­tems soft­ware and tech­nol­ogy that au­to­mates the process, pro­vides vis­i­bil­ity to and man­age­ment of key met­rics and milestones, and ensures op­ti­mal pa­tient flow. By us­ing a soft­ware plat­form that maps to the new care model and in­te­grates with other re­lated hos­pi­tal sys­tems such as EHRs, re­al­time per­for­mance in­for­ma­tion is avail­able for the en­tire hos­pi­tal as well as spe­cific pa­tients. Not only will this en­sure on-time, com­plete and cor­rect ac­tions re­gard­ing hos­pi­tal op­er­a­tions, but it also will pro­vide clin­i­cal lead­ers with valu­able data about pa­tient care, treat­ment and out­comes.

EHRs are an im­por­tant piece in de­vel­op­ing a high-qual­ity, low-cost health sys­tem. If the foun­da­tion upon which they are built is dis­or­ga­nized, in­ef­fi­cient and over­bur­dened, how­ever, they will fail to live up to their po­ten­tial. The coun­try is spend­ing too much money on EHR im­ple­men­ta­tions to ig­nore the need to first com­mit to greater hos­pi­tal ef­fi­ciency. Designing pro­cesses fo­cused on value-added pa­tient care will rad­i­cally change the care en­vi­ron­ment for clin­i­cians and pro­vide an ideal en­vi­ron­ment for in­te­grat­ing EHRs.

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