1. Maximizing Clinic Efficiency with RelayHealth
Maj Matthew Barnes, MD
Hello everyone, my name is Dr. Matthew Barnes.
I’m a Family Physician and Informaticist, and today, I’ll be talking about maximizing clinic efficiency with relay health.

2. Introduction Novel Workflows Deployment Implementation Sustainment
Now, there’s a lot of opinion on relayhealth: some of them are good, some of them are bad, and most of them are a mix.
In order to speak to this on an intelligent level, I added a picture of a puppy, kitten and bunny rabbit – because it’s here, and in order to make it work, we all have to work together.
But that has nothing to do with my talk.
I’m going to go over deployment or redeployment of relayhealth, implementation of this technology, sustainment strategies and then novel workflows which become a possibility.

3. Streamline Team Based Care
Stop printing things out! Send it by RelayHealth!
Appointments – Direct to Central Appts
Medication Refills – Direct to Pharmacy for refilling
Consult Renewals – Low risk? No intervention on your part? Consider nurse refilling
Clinic has protocols? Use MiCare if possible
So, first off – I want to talk about some quick wins – easy things that relayhealth can do.
First, my personal favorite – during my time in clinic, I never had access to a local printer. If I wanted a copy of a handout, I had to map it to the printer, run over there, and run back – hopefully the printer worked or had paper. Not to mention, I just had to find out where that book was. Now, I just secure message them the document or the link I got it from. No more printing.
Plus, the patient doesn’t lose the document. They always can access it! I can’t even say how many handouts I’ve given that the patient never looked at.
Now, next up – many nurses get appointment requests instead of the appointment line. You can set up a relayhealth box at the appointment line, so that the nurses are completely off-loaded from making appts. They would only be contacted if there were no available appts, or if they elected to make appts for certain individuals.
You also have a lot of patients that need refills of low-risk medications, like allegra, that they’ve had for years. If you have a pharmD, or a refill protocol, you can automatically direct these patient messages to them.
Certain consults, you need to see; certain consults you don’t need to see. If there are consults for conditions that you don’t manage, and that don’t require any intervention on your part – you can send them to your nurse, who can sign them for you.
If your clinic has protocols – your nurse can use micare to help document those protocols before the visit. She has to use automated questions anyway, so micare can help facilitate that.

4. Asynchronous Workflow
Webvisits:
MISNOMER! Webvisits imply no in-person care
Can be used to PRIOR to the visit to ensure standard of care documentation is done
Can be used with templated directions
Not directed – if an early adopter, try it!
I wanted to put forth an exciting option – that of asynchronous workflow.
If you engage your techs with secure messaging, they can literally send out screening documentation prior to the visit.
This can also be used to ensure that standard of care documentation is done – basically, your patients do the medico-legal standard of care documentation prior to the visit for their back pain (like sending out red flags), then the techs cut and paste it in the note – and you don’t have to try it.
When you get back to your base, check on the webvisit section – they have forms on everything from toe pain to ADHD.
Basically, that means your HPI could essentially be done prior to your visit!
That’s a significantly less amount of documentation that you could do.
And you can still modify it based on your visit – but that changes everything; your history is confirmatory, instead of exploratory. Making this helpful. How does it work?

5. Webvisit Workflow Team Based Workflow:
During huddle, “Scrub the list” one week ahead, and send out Webvisits to patients with templated instructions
Consider engaging appointment line
On patient screening, have tech cut and paste into HPI, medication list, etc…
Added benefit – patient is engaged with their record!
Well, make it team-based.
During the huddle, scrub the list for your appt’s one week ahead. Then you can send out webvisits with the attached sheet.
It doesn’t have to be the techs who do this. If you engage the appt line, they can also do this.
On patient screening, you have the tech cut and paste into the HPI, medication, list, or wherever it works – and then you can edit as needed.
So, this is great – because that way, the patient is involved. They’re thinking about what they’re here for before the visit, instead of during – this lessens historical alternans, and engages your patients. It also allows for some more intelligent discussion with your patients – they might even read up on some of the attached information in the library, so they know where you’re coming from.

6. Disease Management Create Patient Lists
Can be done by Disease Manager/Nurse
Based on Disease, Demographic, etc…
Can be used to proactively send information to the right people
Send something once a week, over a peak time (i.e. 3 PM)
So, I also wanted to mention something that could be helpful for your disease management staff, or you as the doc.
You can create patient lists by disease, disease manager, nurse, etc…
This is a way we can finally send out information to our patients. We can be proactive! You can have your disease managers send out messages on educational seminars, nutrition – really, anything that you could want.
I would caution – when you send the message is important. Send it in the mid afternoon in the middle of the week. You’d be surprised with what you come up with.

7. Adoption Chances are, you already have RelayHealth!
RelayHealth’s utility hinges on adoption
You may have RelayHealth, but your patients may not be using it!
You might not be either.
What are your numbers? Do you know how many patients signed up?
So… wait? Why am I here? Don’t we already have relayhealth?
Well – yes, but relayhealth’s utility hinges on adoption. And this is the rub – I’m talking about all the awesome things that relayhealth can do, but you have trouble getting a meaningful set of vitals.
I mean, if your team, you or your patients aren’t using relayhealth, then it’s just another thing to check. There’s no value added.
The value added doesn’t stop among your team – once you get patients using the system, new docs reap the benefits. Likewise, the patient brings their “activation” to the next clinic.
So, saying that, I’d give all of you the challenge -- take a look at your numbers in relayhealth! See how many you have! Try and get about 30% -- this can be especially useful if that 30% includes your “high utilizers” – that way, you can use all those time saving measures I mentioned.

8. Key Players Are you the Champion? Are you the Sponsor?
Someone in the field; respected
Their role is to advocate for change among providers
Needs to be given time to do this
Are you the Sponsor?
Back the champion!
You are the “big stick!”
I also wanted to make a nod to the key players for this – since you’ll be benefitting from this talk the most.
Are you the Champion for RelayHealth in the Clinic? If not, is that something you want to do?
Basically, they’re the advocate.
I need to state as an aside – you absolutely have to get devoted time to do this. Being a champion can’t be an afterthought for people with a full clinic schedule. In order for the VA’s secure messaging to work, they literally had to hire full time staff at their facilities. I would give anything to have a similar staffing schedule, but that just won’t happen… So… make sure you do what’s right for both you and the clinic, and ask for time to do this.
Are you the Sponsor for RelayHealth in the Clinic? That’s if you’re leadership – make sure that you back your champion. You’re the enforcer.

9. Change Management Can be done ANYTIME ADKAR Awareness Desire Knowledge
Action
Reinforcement
The reason why I’m identifying “key personnel” is because they usually are engaging in change management. They usually have to do this without getting any training – so that’s part of why I’m here. Having a quick knowledge of change management can help anyone.
There are several models, but I prefer the ADKAR model because it’s quick and easy. ADKAR is an acronym:
A – is for awareness – which, per the army is the WARNO or the preparatory command in the Air Force. That’s your chance to know the change is coming.
D – is for desire – it’s the desire to change that really gets a lot of people stopped. That’s where you talk about how things can add value – how it’s good for them in the long run, and we’ll go through how secure messaging can make everyone’s life easier.
K – is for knowledge – the how-to. In secure messaging, it’s pretty easy. At it’s base, it’s buttonology – when you’re good with buttonology, it’s workflows, and utilization. That’s what this lecture focuses on.
A – is for action – you actually need to do things with secure messaging. After I’m done with this lecture, that’s where it falls on you. If you’re a supervisor, bring this to your clinic; if you’re a clinician, take these things to heart.
R – reinforcement – this is something that again, is outside of my ballcourt; but, if you’re a supervisor, clinician, or anyone who uses this – you’ll want to ensure that you do this. Reward good behavior, consider punishing poor behavior.

10. Awareness/Desire/Knowledge
Marketing
Posters
Waiting Room
Pharmacy
In-processing
Social Media
DO THIS FOR CLINICIANS! A LOT!
Did I mention this needs to be done for clinicians?
No seriously. Do this for all clinicians.
So, as I mentioned, awareness is the first piece. Secure messaging isn’t going to do anything if patients aren’t on it.
Look at marketing secure messaging – even if you already have secure messaging in the clinic, you may need to push for it. This might benefit if you do it yearly.
Try and devote a month to pushing secure messaging – like making march messaging month or something like that.
Put posters up in the waiting room/pharmacy
Have secure messaging sign-ups part of inprocessing.
Even push it on social media if your clinic uses that!
Think of all the places that you could push things.
Then, do this for clinicians – not just providers, not just nurses, not just techs. Everyone who’s involved -- they need to not only know that it exists, and that there’s no chance it will go away – they need to know what it can do.

11. The Adoptees? Who are your early adopters in clinic?
Who are your late adopters?
Who are your key individuals?
Leveraging key individuals makes change happen
Do NOT ignore risks/weaknesses
Address them – ask for advice!
As you’re going through clinic, you’ll want to engage with your colleagues to find out where they fall on the adoption spectrum.
Some people are early adopters. They want things to change, and they’re willing to do a lot to change it.
Some people are late adopters. They’re either content with their current system or resigned to it – and they’ll take a while to do things.
Being an early or late adopter has nothing to do with attitude to age. It has everything to do with how you react to a change.
Within this spectrum, you’ll notice key individuals. These are leaders within a community – that don’t necessarily have command sanction. Command doesn’t sanction who’s an influencer. They just happen – and they’re very important. These are the people that others look to when a group is looking to form an opinion. You have to deal with them, and you really have to change their opinion to change the groups opinion.
Now, as you discuss the change, and address your stakeholders, just wanted to give some points.
Intelligently explain risks/weaknesses; and discuss how they are outweighed by the benefits.
And address the key individuals – even ask them for advice.

12. Implementation Team Approaches work best. Top Down for Early Adopters
Bottom Up for Late Adopters
Time for Training
Role Based Training is Ideal
Time for Sustainment Training
Establish Secure Messaging
High Performance Teams
I wanted to go into implementation – or how you deploy the system. In general, you can’t view a system deployment as just training it to providers or techs. You have to train it as a system! That means, training amongst the team.
So, I’m using a provider-centric view for secure messaging; but you want your deployment to be based on the provider involved.
With early adopters, you can use a “top-down” approach, meaning the provider can manage the change.
With late adopters, you may want to try a “bottom-up” approach, meaning that the team around that provider does the change first, irons out all the procedural problems, and then the provider can fall in.
Most people require a mix – that’s why TEAM training is important; Just because you have an early adopter; it doesn’t mean he’ll keep going if he has techs that push back on technology. But – a chief way to do this training is through role based training – docs should learn things like applications of relayhealth in clinic; techs should learn how to invite people (and understand a few time-savers that docs can use).
Training is not just buttonology – or showing what buttons do – training really should teach the medicine and the workflow behind it. Hence this lecture.
You need to build in time for sustainmment training as well – where instead of just showing buttons, you can show these advanced workflows.
Establish it, and re-establish workflows.
Then – think about creating a “high performance team” where you have a team who adopts secure messaging, and they pilot the process for others in the clinic.

13. Early Adopter Model
26 yo Male Provider who’s comfortable with Information Technology
Not a champion
He created novel workflows for his team for sign-up for secure messaging
Success was REWARDED by offering a three day pass
Not much intervention required.
I wanted to go through some adopter types:
First the early adopter.
You have a young provider who’s comfortable with IT, he’s not a champion or superuser or anything.
But he’s good with this stuff. He thinks outside the box – he creates a novel workflow that gets people signed up at the front desk.
As a result, he’s rewarded. And I foot-stomp – HE’S REWARDED.
Make sure you reward those that do above and beyond – other people see it, they know and they follow.
In this case, other than reward, not much intervention is required.
Never underestimate the power of rewards as a motivator.

14. Late Adopter Model
63 yo Male Contract Provider who is very uncomfortable with computers, much less Health IT
Has a strong, early adopting technician who understands, and champions RelayHealth among patients
Provider gets assistance when he needs it
Requires ADKAR – must have Awareness, Desire, Knowledge, Action, and Reinforcement
Pitfall: DON’T PUNISH YOUR EARLY ADOPTERS BY RUINING THEIR TEAM.
Every change to a PCMH team has to be RARE
I wanted to contract this with a late adopter model.
Here you have a provider that doesn’t really like computers all that much. He is paired with a strong early adopting technician, and that tech helps walk him through the process.
But, all the way through, this doc requires adkar – meaning, he’s being taught the workflows that can save time (so he’s motivated), he’s being taught how to use the system, and he’s given incentives to use the system.
Now, I wanted to mention a pitfall, having lived through this. DON’T PUNISH your early adopters. They may do really well and succeed – but don’t make them have to compensate for the late adopters. Otherwise, they’re just going to get bitter and leave. Especially don’t change a PCMH team unless you REALLY, really, Absolutely have to.

15. What About Failures ADKAR? Where did it go wrong?
Key Personnel were negative
Need to address them up front, and often
Unanticipated Obstacles
Failure to Address Potential Obstacles/Conflict
What about when things just don’t work?
Take a look at ADKAR. 9/10, I guarantee it’s the desire piece. People don’t understand what relayhealth can do – that’s where, you have to find out what people need, and figure out uses to relayhealth to address them.
Key personnel could be negative; and that’s why you should address the key personnel up front and often – if you’re climbing out of a PR hole, it’s hard. Again, you need to make sure people in your clinic want this.
Otherwise, there are unanticipated obstacles – everything from not planning sustainment training to not reinforcing good behavior.
And again, make sure you deal with obstacles up front – just leaving them be will only cause problems.

16. Sign-up
Air Force gives the option to increase registration rates via face-to-face registration, e- Registration, and telephone registration
Army/Navy have flexible registration processes too
SEAL THE DEAL!!!
By Cell Phone, By Kiosk (if available), By Non- network computers
Those signing up: ~ 8% without; ~ 90% with
Went from lowest in clinic to highest in Air Force
So, as I talk about implementation, what’s the first barrier?
Sign-up!
As a full FTE clinician in Lackland Air Force base with 4 Pas, and 1 tech, I was able to get 100% of the patients who went through my team’s clinic at least invited. Of those, 80% signed up because I “sealed the deal”. Within 6 months, I went from one of the last in the clinic, to one of the highest in the Air Force. My nurse was primarily the one that benefitted – she went from a 100 t-con backlog to being able to help another nurse.
That’s where it started. Towards the end, I was experimenting with the webvisits I mentioned. My techs were very motivated because my mailouts for results became purely electronic.
That’s right – success stories happen. I actually became one of them.
All I did was get my techs to buy-in on the process, and have them complete the process. But I think the main thing was “sealing the deal.” We didn’t just send out invites – my techs played tech support until they logged in.
And yes, it slowed me down for the first month, but I ended up really making up time in the long run.

17. Sustainment Create workflows for on-boarding
Create periodic sustainment training
After Action Reports
On-record: finding good things can lead to more resources
Off-record: make them BRUTAL
Reinforcement, Reinforcement, Reinforcement
Avoid “punishing” those that do well
I wanted to parallel sign-up with sustainment.
This is where you make things shine.
As people join your shop, get them on-boarded; put it in their in-processing workflow.
Then, create sustainment training; do it periodically. I already mentioned how important it is.
As you keep going, do after action reports; I encourage two kinds: internal and external.
External facing reports – you’ll want to keep them fairly benign; they can lead to more resources and time.
Internal facing reports – make them brutal. Look to see how you can change things.
And again, reinforcement is name of the game. If you inadvertently punish the people that do well with more work, you’re only going to lose your people.

18. Workflow Design Two main areas need workflow: Invitations Patient Care
High up front work
Low back-end work
Ensure patients are given
enrollment opportunities at every point of service (i.e. PHA Clinics, Front Desk...)
Patient Care
Low up-front work
High back-end work
Could consider doing this for Sustainment
I wanted to touch on a primer of “workflow” – this is my current job.
There are two main areas that could use workflow design.
First, invitations, and second, patient care.
Invitations involve a lot of work on the front end, and less on the back-end; and patient care is the opposite.
You could also consider designing workflows for sustainment, but I just want to throw this out as a potential tool.

19. Invitation Workflow
Get help if you can: GPM, Disease Managers, Case Managers
Draw it out!
Use a Swiss Cheese Model v. Process Diagram
Who
Level of Effort/Risk
Yield
Potential Return
So, as you’re doing the invitation workflow, take a look at every place a patient touches.
You’ll need help, so get it from anyone you can – GPMs, Disease Managers, and Case Managers.
Just draw it out!
You can do a quick process diagram.

20. EXAMPLE Workflow Design for Invitations
Front Desk:
Low Effort, High Yield
100%
Appointment Line:
High Effort, High Yield
70%
Med Tech:
High Effort, Med Yield
30%
This is an example of a bubble diagram – it’s patient oriented, meaning each bubble is a patient touch point.
It goes through all of the different people involved.
It’s color coded based on how high a yield it is estimated to be in each setting.
Something like this can be really helpful in terms of where you want to put your time/resources in making changes.
Pharmacy:
High Effort, Medium Yield
50%
Provider:
High Effort, Low Yield
20%

21. Patient Care Workflow
Get help if you can: GPM, Nursing, Medical Technicians
Draw it out!
Use a Layered Model
Who
Purpose
Level of Effort
Potential Return
The next is a patient care workflow, it’s a layered model, and it simply lists out the order of actions, and potential return on what’s done.

22. EXAMPLE Workflow Design for Patient Care
Patient request
RelayHealth:
Appointment Line fulfills Appointment Box
Pharmacist fulfills Refill Requests
Nurse fulfills Lab Requests
Nurse fulfills Consult Requests
Nurse triages Patient Care Questions
Webvisit
And here it is – now this is SUPER-simplified; you can do what’s called OV6’s, which details out duties, decision points and more, but this goes through the different decision points involved. To get a tentative workflow diagram, you can use powerpoint.

23. Tips Enrollment is your first barrier
Use processes which already occur (i.e. base orientation, TAPS)
Engagement is your second barrier
Use processes which already occur (i.e. appointment line, pharmacy)
Put as little on the care team as possible
Contracting
Do not forget about sustainment/reinforcement
Get top cover – and keep it!
So with that, I wanted to go over some final tips.
First, enrollment is your first barrier. Just use processes that already occur – like inprocessing and TAPS, and your numbers will raise regardless.
Engagement is your second barrier. Again, use processes that already occur, and put them on the web! I guarantee that they’ll also raise.
When you diagram everything, put as little on the care team as possible.
Make sure that you also engage your contractors to learn how to do it.
DO NOT FORGET ABOUT SUSTAINMENT AND REINFORCEMENT – train often, on new emerging prcoesses, and REWARD THOSE THAT DO WELL.
And finally, if you aren’t a sponsor/commander, get top cover, and keep it.

24. Conclusion Novel workflows Change management Workflow Diagrams
So, with that, I went over a couple novel workflows, change management and workflow diagrams.

25. Any Questions?
Any questions?