1. Workflow and Process Redesign
Health Information Technology Toolkit for Chiropractic Offices

2. Presenter Margret Amatayakul
RHIA, CHPS, CPHIT, CPEHR, FHIMSS
President, Margret\A Consulting, LLC
Schaumburg, IL
Independent consultant, who focuses on achieving value from electronic health records, HIPAA/HITECH, and health information exchange. Developer of tools in Toolkit
Adjunct faculty College of St. Scholastica, Duluth, MN, masters program in health informatics
Founder and former executive director Computer-based Patient Record Institute, associate executive director AHIMA, associate professor University of Illinois
Active participant in standards development, former HIMSS BOD, and co-founder of and faculty for Health IT Certification 2 2

3. Stratis Health
Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities
Stratis Health works toward its mission through initiatives funded by federal and state government contracts, and community and foundation grants, including serving as Minnesota’s Medicare Quality Improvement Organization (QIO)
Stratis Health operates the Health Information Technology Services Center for health care organizations seeking to use health information technology in support of their clinical transformation

4. Agenda Purpose of workflow and process redesign
Steps in workflow and process redesign
Workflows and processes to map
Performing workflow and process mapping
Critical success factors in workflow and process mapping

5. Purpose: Create Ah Ha! Moments
Workflow and process redesign
Starts the process of identifying improvement opportunities with HIT
Helps users identify solutions for current problems and today’s workarounds that will form the functional requirements for your HIT
Aids in setting expectations for achieving HIT goals because users will now expect to see improvements
Ensures that critical controls built into current processes are retained or enhanced
Software
that directs
computer
devices
People
to support
and use
systems
Policy
that drives
adoption of
Hardware
that enables
system use
Process
that helps
achieve
results
Copyright © 2009, Margret\A Consulting, LLC. Used with permission of author.

6. Workflow and Process
Process is the manner in which work to be completed to achieve a particular result is performed
Example: Do you always verify the timeliness of medication administration?
Work flow is the sequence of steps and hand-offs taken within a process
Example: Is information available to schedule patients for labs in advance of a clinic visit?
Workflow and process mapping depicts the detailed nature of the processes and workflow to enable improvements
Five Rights for Right EHR
Right clinical data
Right presentation
Right decision
Right work processes
Right outcomes
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

7. EHR is Not about Automating Charts
“Only automating form, content, and procedures of current patient records will perpetuate their deficiencies and be insufficient to meet emerging user needs”
EHR is about automating & using
information to improve health care
EHRs “encompass a broader view of the record than today, moving from notion of location for keeping track of patient care events to a resource with much enhanced utility” Institute of Medicine, 1991

8. Steps in Mapping Current Processes
Identify processes to be mapped; e.g., those that will be impacted by the HIT being acquired
Use individuals who actually perform the process; they know it best and need to own the impending change
Instruct persons on process mapping – why it is being done and how it is done
Map current processes. Avoid identifying opportunities for improvement now, or critical controls built into current processes may be overlooked
Validate maps to ensure they reflect current processes, all variations, and the information payload
Collect all forms and reports that are part of processes to be automated through HIT
Obtain benchmark data to define expectations for change and for use in benefits realization studies 8

9. Steps in Redesign
Identify potential problems in current workflows and processes and determine their root cause
Identify changes that may resolve problems today
Educate about HIT and EHR and identify further changes that will be possible
Document changes by creating improved map
Use new processes to create use case scenarios to identify HIT functional specifications, and later to build out the HIT application to achieve improvements
Test new workflows and processes
Train all on new workflows and processes
Incorporate changes into policy and procedure
Conduct benefits realization and celebrate successful change/correct course as necessary 9

10. What to Map in Hospitals in Clinics
Admission
Medications reconciliation
H&P/results review/differential diagnosis
Patient assessment
Care planning/pathways
Provider orders
Consultation management
Patient monitoring and charting
Medication administration
Surgery/recovery
Transfer of care/care coordination
Discharge/patient instructions
Charge capture/coding
Reporting/quality improvement
Departmental operations
Scheduling/check-in and check-out
Patient intake
Results review
H&P/encounter notes
Care planning/guidelines
Medication management: medication list maintenance/ prescribing/refills
Provider orders
E&M coding
Charge capture
Patient instructions/education
Patient follow up/health maintenance
Reporting/quality improvement

11. One size does not fit all
Select Tools
One size does not fit all
Process diagram
Swim lane process chart
Flow process chart
Systems flow chart
Software is available to aid in drawing charts, if desired
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

12. Basic Systems Flow Chart
Ovals – start and end
Rectangles – process
Diamonds – decision
Used with permission from P. S. Rudie Associates, Duluth, MN
Robert McDonald, MD and Mary Rapps
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

13. Annotating Processes
It may be helpful to capture components of processes and workflows by simply making a list of all processes, or
Use post-it notes to record processes as they are performed and then arrange them on a wall or large piece of (e.g., examining room) paper
Process mapping is not new, and not even new to health care, but process mapping is foreign to clinicians
Engaging clinicians, however, is critical because EHRs are designed for their use. It may be necessary to start a map for them and have them validate it – Real clinicians really do map!
Courtesy of Dr. Hinck, Bloomington Lake Clinic,
Minneapolis, MN
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

14. Getting Started
Identify one complete process – neither too large or too small
Identify all potential starting points
Follow each to its natural conclusion
Significant delays can be annotated to the side if desired
Refill Processing No
Yes
Place in
MD Box
Patient
Calls
Ask Pt to Call
Pharmacy
End
Chart
Reviewed
Write Rx &
Give to Pt
Document in
chart
Ave
1 hr
2 hr
Request chart
Review chart
Nurse
OK?
Call Pharmacy
Document
In chart
Speak to

15. Reflect Variations
Medication administration in a critical access hospital with five nurses administering medications
Some processes can be corrected immediately; others will depend on acquiring an EMAR
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

16. Validate Process Maps
Initial pass at a swim lane map (clinic example):
Map after validation:
Document
RFV on Post-it
Throw Post-it
away
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

17. Identify (Potential) Problems
Review current maps to identify:
Bottlenecks
Sources of delay
Rework due to errors
Role ambiguity
Duplications
Unnecessary steps
Cycle time
Flow process charts help identify
Nature of tasks
Key questions
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

18. Determine Root Cause Use complementary tools as needed B A
Statistical charts
Radar
Pareto
Relations diagrams
Tree diagram
Affinity diagram
Force field analysis
Cause and effect diagrams
Physical Layouts A B
Copyright © , Margret\A Consulting, LLC. Used with permission of the author.

19. Critical Success Factors
Map processes that will be impacted by HIT, unless other reason for process improvement
Engage persons actually performing the process. Leave bias and blame at the door – reward those who find the most warts!
Avoid getting ahead of mapping current processes, but make sure they are complete and address the information flow – remember, information is being automated, not the staff member or the patient
Get to the root cause of problems when looking for improvements. Address immediate opportunities; use others as key functional requirements for your HIT
Use workflow and process mapping to create Ah ha! moments that initiate the change process. Follow up that changes are adopted and celebrate success once change is implemented

20. For More Support Contact: Stratis Health 2901 Metro Dr., Suite 400
Bloomington, MN 55425
(toll free)
Copyright © 2011 Stratis Health. Funded by Chiropractic Care of Minnesota, Inc. (ChiroCare),
_________________________________________________________________________________________
Adapted from Stratis Health’s Doctor’s Office Quality – Information Technology Toolkit, © 2005, developed by Margret\A Consulting, LLC, and produced under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
For support using the toolkit­­
Stratis Health  Health Information Technology Services 