Understanding Workflow: The Key to Effective Clinic Management

1. What is Workflow?

2. Defining workflow • Definitions of workflow vary. Here are a couple: • The flow of work through space and time, where work is comprised of three components: inputs are transformed into outputs.[1] • The activities, tools, and processes needed to produce or modify work, products, or services. More specifically, clinical workflow encompasses all of the 1) activities, 2) technologies, 3) environments, 4) people, and 5) organizations engaged in providing and promoting health care.[2]

3. What does that really mean? • That means that workflow is the who, what, where, when and how things get done in your clinic. This includes both clinical and administrative work. • Doing a poor job analyzing your workflows can lead to misleading conclusions.

4. Answering Phones* Flows for different types of phone calls Appointment System* Flows for new vs. existing vs. continuity vs. non-continuity patients Messaging* To different types of staff and for different reasons Scheduling Procedures* Flows for new vs. existing vs. continuity vs. non-continuity patients Order Diagnostic Testing* Flows for different kinds of tests Reporting Diagnostic Test Results* Flows for different kinds of tests or normal vs. abnormal Ordering medications, including Prescription Renewal* Making Referrals* Billing/Coding* New Patient Work-ups* Chronic Disease Management* Receiving and processing patient information from outside providers Confirming insurance or pay status Examples of clinic workflowsThose with * come from: http://healthit.ahrq.gov/portal/server.pt/document/897942/tool_-_know_your_processes_pdf

5. Here are two flow charts showing the workflow of “patient check-in”. Both figures are accurate descriptions of the same process at a particular clinic. But, only the figure on the right (2) shows the details of what the workflow really is. It is the details that will change when you implement health IT. If you don’t understand the details, you cannot plan for the changes that will come. 2 1 Detailed flowcharts

6. Is workflow just the sequence of steps of a process? • Not exactly. • Workflow is the sequence of: • physical and/or • mental tasks performed by various people • over time and through space. • It can occur at different and/or multiple levels (e.g., one person, between people, across organizations) • It can occur sequentially and/or simultaneously

7. Work flows in different ways • Inter-organizational workflow: • Workflow between a primary care physician and a community pharmacy, or • between an emergency department physician and a primary care physician to share information about a patient. • Clinic-level workflow: • Flow of a physician, nurse or patient through physical space, and • the flow of information, in paper or electronic formats, among people at a practice or clinic.

8. Work flows in different ways • Intra-visit workflow: • Workflow during a patient visit, which involves the workflow of the visit (e.g. start by asking for a problem list, then do history and physical, then prescribe treatment) • Cognitive workflow – the workflow in the mind: • Sensation, perception, decisionmaking, and response execution • A clinician might be thinking: “listen for any significant acute problems and deal with those first. Also, investigate my concern about spousal abuse. If I don’t hear any, focus on the chronic problems.” • This is unlikely to be observable.

9. A more detailed example:Medication orders • Consider the workflow of ordering a medication. • Without e-prescribing, the workflow might involve a provider with prescribing privileges writing a prescription on a prescription pad, signing it, and handing it to the patient.

10. Implementing e-prescribing changes the mental and physical steps of the process, as well as the order of steps and the organizations involved. Providers have to log into the system, remembering a password. They have to access the record of the particular patient, which involves a series of physical steps using the mouse and/or keyboard. Medication orders: e-Prescribing • They have to execute mental steps of searching for the correct information and locating the correct medications and pharmacy. • Both the provider and patient need to know the pharmacy where the patient will pick up the medication.

11. Workflow: simple and complex • As you can see, what seems like a simple workflow for “ordering a medication,” in fact involves • multiple physical and mental steps, and • several people working in different locations. • These are the details you will need to consider when implementing health IT.

12. To summarize: • Workflow is • People flowing through space and time. • Information flowing through space and time in paper and electronic formats. • Objects, such as medications, flowing through space and time. • The flow of all of these information, people, and products are necessary to consider when designing health IT to support workflow.

13. References • Carayon P, Karsh, BT. Workflow toolkit and lessons in user-centered design. Paper presented at the AHRQ Annual Health IT Grantee and Contractor Meeting; 2010 June 2-4; Washington, DC. • Niazkhani Z, van der Sijs H, Pirnejad H, Redekop W, Aarts J. Same system, different outcomes: Comparing the transitions from two paper-based systems to the same computerized physician order entry system. International Journal of Medical Informatics 2009; 78(3): 170-181.