SEARCH LEARNING CENTER
Designing with Patient & Provider EHR Workflow in Mind
Every once in a while I get to have a really, really meaty conversation about healthcare workflow. I’m especially interested in so-called “front-end” workflows, the ones most directly affecting (one might actually more accurately say “effecting”) provider and patient experience. So I was especially excited to sit down with Jared Alviso, PMI-ACP, Senior Product Manager at AdvancedMD, to discuss the shift in the company’s mindset toward designing workflow- and process-aware healthcare technology.
By the way, this is a hectic week for AdvancedMD, they’re at three conferences!
- The American College of Obstetricians & Gynecologists Booth 1329 (#ACOG17 on Twitter)
- ASCRS•ASOA Symposium & Congress Booth 337 (#ASCRSASOA2017 on Twitter)
- HEALTHCON 2017 Booth 327 (#hcon17 on Twitter)
(I’m tempted to put an animated GIF referencing the admonishment in Ghost Busters, to not “cross the streams,” but … oh what the heck!)
All in all, this week is an incredible conjunction of opportunities to press that same case I’ve now made for decades. Healthcare needs to dramatically up its game when it comes to improving workflows to improve patient and provider experience!
Let’s find out from Jared about AdvancedMD’s advanced thinking about front-end healthcare workflows.
1. CW: What is “integrated workflow” at AdvancedMD?
JA: Our clients are smaller private practices. In these practices, a medical assistant is also the front-office person taking phone calls and making appointments. One thing we’re doing is putting the practice management features and functionality needed to fully run an office into the EHR. We know that most EMRs/EHRs are all about the clinician side of things, so from an integration perspective, we put some of the key [practice management] workflows and functions into the EHR. A medical assistant can now take care of appointment scheduling and track the charge slips from the EHR itself for visible day-to-day appointment workflows.
The first step we’ve taken is with our new AdvancedEHR dashboard. The dashboard basically allows our clients to see a single column scheduler – a list-view of the patients they’re seeing that day. Additionally, it allows them to see non-appointment workflow items. When they’re not seeing patients, they’re actually looking at messages, pending referral requests, pending lab orders, result orders – in other words, items that need to be addressed that are not necessarily associated with an appointment, and the dashboard allows them to do that.
CW: Is it live in the sense that if you don’t touch it and you just look at it, you see things happening?
JA: Yes, it is live. If you just left the dashboard there, this is what happens: As you check the patient in, you “flow” with the patient; you’re able to see that the dashboard actively updates, as well as any new messages and any new review bin or task items that come across to the user who’s logged in.
CW: Are there some kind of workflow rules behind the dashboard?
JA: That’s the case. The dashboard is customizable based on the workflows for that individual practice. We’ve made it specialty-specific and workflow-specific out of the box. If a user has rights to see certain providers’ schedules, they will in return see the potential review bin or task that needs to be done. We know that an orthopedic doctor is not going to want to see immunizations and growth charts. Donut graphs that we currently have in the dashboard are customizable, and you can drag and drop items in a view that best suits the user.
CW: Is there a sort of an editor mode – just like you would author a report? You’re authoring or editing the dashboard view.
JA: As it relates directly to the dashboard graphs themselves, yes. Enter into an edit mode, then drag and drop things wherever you would like to place them. And the table directly reflects whatever changes you make. To further elaborate on that, we are also adding a filter functionality, which will allow users to see their review bin items, such as results review and prescription renewals. Or, they can filter to see a specific provider information should they have access to do so.
CW: What is a quick list of systems with which you integrate?
JA: Areas we’re integrating into workflow are around patient engagement. We’ve added a rooming integration to be able to track the patient flow. That’s from our practice manager assistant to the EHR and all the way to our mobile application. We also have our patient messaging, communications that will be accessible from the dashboard in all of our platforms. They also have the ability to capture what patient preferences are – if they like to be communicated with via text, email or phone, we can capture that information. We also have patient forms capture so the intake process is another key area that can be monitored throughout our portfolio of applications.
2. CW: I think a good strategy for companies is to figure out how to use workflow, workflow-esque ideas and workflow thinking to market the advantages of a product. A) Do you agree? B) When and how did AdvancedMD realize that workflow is key?
From that perspective, I do agree. Now, you ask when AdvancedMD really realized the importance of workflow. From a historical perspective, AdvancedMD has been a practice management system. Workflow was obviously the reason for the success of our practice management system. Since then, we’ve added the EHR. Today, we’re really trying to change the conversation at AdvancedMD by indicating that flow is key. In the design phase, we’re going down the path of outright creating “certified workflows,” or we can call them “best practice workflows.” We basically say, “This is how AdvancedMD recommends you write a prescription, how you document a patient visit, how you order labs, and how you preview results and your messages.” Everything we’re doing for the new design of AdvancedEHR is around the workflow definition first, so we can help extract the requirements needed to run a successful practice. Then, we don’t force the requirements into the design, but rather make the design suited to the business requirements and, in this case, the office workflow.
We feel that providing the “best practice workflows” is key, so that’s what we’re focusing on in our software development. We know not every office is the same, but we do know that probably around 80% of practices are the same. We already customize for the other 20%, such as specialty-specific items. It’s a big effort and we’re very much vested in it.
3. CW: Do you have an example or can you paint a mental picture of how two different sub-systems such as the EHR and the practice management system, because of the similar look and feel, are going to give a better or more satisfying or more efficient or more effective user workflow experience?
JA: From the practice management, we’ve made our application browser-agnostic, so it can be used in any browser, Chrome, Safari, Firefox, IE; anything. With that came a design of what we call the “new shell.” This new shell contains a menu structure that allows us to use the latest technologies as we create new software. As it relates, the design, the look, the feel, the functionality and the value that it brings to our clients is the ability to say, “You know what? It’s integrated. You don’t have to switch among multiple terminals or applications open at once. You can actually schedule an appointment from the EHR, based on your ‘persona’.”
The persona base is another big area of focus for us. Based on your persona, what you see when you log into the integrated application is what you’re going to get. If my role and persona in the office is a receptionist, I’m going to get scheduling, I’m going to get access to very minimal patient information because I don’t need to see all the clinical information. Harvesting that information, and being able to do that from one application, to me, the value that it adds is like the alt-tabbing. Customers can now work within the structure that we built in the global shell and be accustomed to the global feel of our practice management and EHR systems.
4. CW: One frequently hears EHRs are not usable because they were designed as billing systems. What does AdvancedMD respond to that?
JA: The way I feel we are responding to the needs of providers is by putting more emphasis on the clinical side. Billing is probably the number one thing that private practices are making sure they can achieve. But next to that, what’s most important to clinicians? It is being able to document/back up claims that they’re making to insurance. So, having a good system that is capable of documenting that and with a good process is key. We think a persona-based system can address the issues that each role has in an ambulatory flow.
CW: Yes, when people think of electronic health records, they tend to have a very data-centric notion. They think, well, an EHR is basically a database with a user interface on it. EHR matches the structure of the data when you really need it to match the structure of the workflow. But if you have a system in which the workflows can be customized by person and role, you can have billing and clinical workflows existing in the same system. I’m giving my opinion here, and there are a lot of EHRs that are designed, like you said, with billing being historically a number-one priority, and then, of course, you have the clinical part. And if you can’t have different workflows for different roles and people – and I think that would be the personas in your case – then you’re going to butt heads. You’re going to have to go with the billing workflow. But if you can have customizable workflows for different people and roles and personas, then you can have your cake and eat it, too.
5. CW: Just how customizable are AdvancedMD’s workflows? What’s the basic workflow customization paradigm?
JA: One of our primary objectives for the integrated workflow project is for products to function fully right out of the box. We deliver the EHR already customized by a specific specialty; we have our core four: family practice, pediatrics, internal medicine and obstetrics. We can also open it up to a broader array of specialties.
So, out of the box functionality is priority number one. Number two is customizing specifically around how customers use the software. If there’s a tweak or two they want to make, they can actually do it on the fly. We have a huge matrix that allows them to pick—for example if a user changes the layout of the [AdvancedEHR dashboard] donuts, the next time they log in, the donuts retain the new view. This is because they changed the look for a reason and we want the system to remember the preference. For example, AdvancedEHR today is very customizable. Users can create templates for specific visits. They can create specific chart flows. If they feel like they’re not getting what they need to see in the summary, they can say, okay, I need to pull in, let’s say, an allergies card. They can pull in a specific, new view element that allows them to see a patient’s allergy and they can do that on the fly.
To sum up, these are a few different approaches that we’re taking. One, we want the systems to be easily used by anybody out of the box. Two, somebody in the administrative role can create custom views and then disperse them to users; and three, on an individual basis, a user can change and customize the views at will.
CW: I heard you mention the phrase ‘chart flow’ earlier. What do you mean by chart flow?
JA: The chart flow is different. There’re two main things that we’re focusing on. We have 1) non-appointment workflows and 2) appointment workflows. The chart flow is essentially going through and during the appointment workflow: from when a patient checks in, the nurse puts them in an exam room and gets all the subjective information and the provider wants to be able to access [the “rooming” information before the visit]. We are determining such flows; the age-old conflict of somebody being in the chart while somebody else is in the chart. It can create potential data conflicts. We’ve addressed this chart flow concern; not only from a data conflict point of view, but we’ve made it possible to access a patient’s chart from basically anywhere.
A good example is, again, the AdvancedEHR dashboard. We have the ability to perform multiple things on the single column scheduler. Customers can click through to where it opens up a patient chart, change the rooming status [showing details of a patient waiting in the exam room], check them in, check them out and put notes on the patient’s chart – all from a single column scheduler. That represents a small fraction of the chart flow. Because we put information on a scheduler card, it allows that data to flow to the chart.
6. CW: How “transparent” are AdvancedMD’s workflows? How easily can task status (pending, completed, escalating, etc.) be tracked?
JA: As far as tracking workflows, it goes back to our earlier discussion about seeing changes happen on the dashboard. For example, with the rooming module, a user can not only see the patient status and the exam room they’re in, but also that they are waiting for a nurse, or a provider, or a lab tech for a blood draw. We also track the time it takes so that the clinic and the office manager, someone from an administrator perspective, can identify bottlenecks in the workflows. If a patient is “sitting in a status” for a certain amount of time, visually, on the dashboard, the task item will turn red, indicating the threshold has been crossed. That would mean that the patient has been waiting for the nurse for 15 mins.
The value here is to allow our clinics, our practices, to identify day-to-day workflow bottlenecks, and that’s just one example. Another example is receiving labs results or sending lab requests to be processed. As users navigate through AdvancedEHR, the dashboard is going to refresh every time they log back in. We also use automated pop-up messages indicating items like priority messages. This is a new feature that we’ve enabled for all of our chart items within AdvancedEHR: users can set chart items as high priority. When interfacing with labs to receive results and send orders, we’re designing automatic flags that mark them as a priority. Based on the way we have the dashboard configured, we have a priority bucket, we have a help bucket, and we have all other unsigned items. There are different drill-down capabilities for them to be notified quickly when something high-priority comes in.
7. CW: How smart are automated workflows? Does some new data, something that gets downloaded into the system, trigger a workflow to end up in the right place, to catch someone’s attention?
JA: Yes, that is something that exists today and we refer to as HealthWatcher [within the EHR]. There are rules that can be customized for specific practices and specialties. What HealthWatcher allows them to do is to set up specific rules based on, just as a quick example, a yearly physical. Users can set up lab orders and appointments based on gender, age or other criteria to automatically notify the physician or clinical staff that a particular person that they’ve selected, or scheduling an appointment for, is in need of these lab draws or a physical. These items are included as part of our customizable donut graphs or data that is displayed on the dashboard. Users can access the feature from the dashboard, which makes it automated.
8. CW: From a historical timeline, first, it was practice management system, then EHR, then patient engagement and telemedicine. What comes next? How will the new tools be integrated into existing, seamless, streamlined workflows?
JA: Many enhancements, as well as integrations, are problem-based. We’re allowing the data that’s captured from a patient visit to be used to benefit the clinic. It isn’t about data telling the provider how they should be practicing medicine, but rather guiding them. It’s basically saying, “Based on how you diagnosed a patient with hypertension and diabetes in the past, here are the prescriptions that you’ve written, here are the notes that you used, here are the images that you used, the labs that you ordered, and the plans that you’ve associated with these particular types of cases.” From a high-level design perspective, this is how we’re looking to make that data work for us and for our clients. That’s probably one of the biggest things that’s come from our integrated workflow project.
CW: How about wearables and things like that?
JA: With wearables and health records like HealthVault, we hear from our existing clients that they want this data to be integrated with electronic health records. AdvancedMD currently has a huge initiative where we focus on patient engagement, patient portal and patient-facing mobile applications. That gives patients the ability to leverage various health apps available on their devices and upload data to their portal, which in turn will integrate with our EHR and practice management systems.
That initiative is huge for us because our clients really want to interface with these applications and apps. It’s important to the patient, it’s important to our clients, and I think that’s where the industry is going. In addition to that, we also need to integrate with [other devices’] hardware; for example, an automatic blood pressure cuff that a patient is using or other medical devices the practice wants to interface with to capture data. So, the wearables initiative is in the forefront for us and we’ve been planning and designing our execution in that area.
CW: Are you starting to look at or already have a common workflow engine capability or is it still peer-to-peer?
To me, a part of what makes a successful EHR is being able to integrate with whatever technology the industry introduces. Our interface and interoperability teams specifically focus on doing lab and order interfaces, work on integrations with other PM systems and with other EHRs. Added to this effort is our work to integrate with wearables and medical devices. We are using a lot of in-house, peer-to-peer at this point in time, but we’re currently exploring the integration with a couple of third-party vendors that allow us to quickly integrate. Eventually, we can leverage the third-party to become that one specific integration engine for us.
9. CW: Do you offer any workflow improvement consulting services? Any workflow analytics? (Cycle time, thru-put, activity based costs, bottlenecks spotting, etc.)
JA: To answer the first question, we have a professional services partner that helps clients who need some post-implementation support. The partner will help with things like documenting their patients inside of a note, writing prescriptions, or understanding the flow for ordering labs.
With workflow analytics, the good thing is that we audit everything we do which allows us to put the data that we’re capturing to work. The way we extend this data to help our clients of smaller practices, two to four providers, is by allowing them to pull reports. Let’s say, we’re going to create a new report and it’s going to be called “patient check-in report.” It provides value by letting the office manager, or practice manager, know that our nurses are being kept up. Why? Is it the vital taking? Is it the note opening? Not only do we capture that data for reporting, we can also display it in the EHR dashboard to help with the clinical side.
CW: Well that’s truly impressive. You are moving away from what I call workflow-oblivious health IT, to process-aware. The idea is that IT needs to have some kind of awareness that there is such a thing as a workflow. Because if you don’t represent it, if it’s not a direct, explicit, intended workflow related behavior, you’re not going to get the various efficiencies and effectiveness and usability that a lot of people think is missing from a lot of health IT today.
Jared, do you have any words of wisdom or philosophizing you care to share as a closing remark?
JA: I have a passion for the new approach truly based on workflows. If we can’t expose the bottlenecks, the issues, the aches and pains that our clients and practices have on a day-to-day basis and make it easier for them to do their jobs, then we’re really missing the bus here. I agree wholeheartedly that being process-oriented and workflow-oriented is key. This mindset helps in all different avenues of business, not just software development.
CW: Viva la workflow and onward workflow-istas!