Transforming Health Care Through Improved Clinician Workflows

by Barry P. Chaiken, M.D.

Can IT transform health care? As organizations rush to satisfy meaningful use criteria to qualify for electronic health record incentive payments, many organizations are turning their focus to a rapid deployment of EHR systems. Unfortunately, EHR adoption is just one tool used to transform health care, and not the single transformative activity so many believe it to be.

Transformation of health care encompasses enhancing quality of care, improving patient safety, expanding access to care and reducing the cost of care. EHRs deployed to satisfy the criteria for meaningful use can influence these factors, but only within a broad framework that recognizes the role of incentives, clinical decision support and health care IT in facilitating transformation.

Introduction of new technology often distracts us from our primary task. Our fascination with the technology leads us to focus on what the technology can do, rather than what we need the technology to do. This misguided use of technology also occurs in health care delivery. Many EHR implementations focus on the impressive features of the EHR software -- ability to graph results, display images -- rather than the workflow requirements of the clinician users.

Required Vision

Health care transformation requires a comprehensive vision of care delivery that understands the importance of effective workflow in delivering care. Technology expands the options available in designing workflow, allowing forward-thinking clinical leaders to create ever more effective and efficient care delivery processes. Implementing IT using workflows designed for paper-based processes fails to leverage the benefits inherent in the technology. In addition, such approaches can lead to severe inefficiencies and medical errors.

Proper use of IT requires workflow redesign that safely leverages the technology to enhance processes and workflow while delivering higher levels of safe and efficient patient care.

Clinicians faced with technology that is an obstacle to patient care develop workarounds that reduce productivity, expose personal health information to unauthorized access and severely limit the value of the deployed health IT. Failure to recognize and address workflow issues when implementing EHRs greatly threatens the success of an entire health IT initiative.

In addition, failed projects not only waste enormous resources but also severely injure the reputation of the institution. Organizations cannot hope to satisfy the criteria for meaningful use, and in turn qualify for stimulus funds, without deploying effective workflows associated with high levels of clinician adoption.

Make Patient Data Easily Accessible

The first step in unlocking the potential of health IT is to make sure clinicians can access the information and applications they need for a patient at the point of care, within their disjointed workflows. Single-sign on (SSO) and strong authentication in the form of fingerprint biometrics, smart cards, etc., provide the glue that binds together the various health IT applications, improving user workflow and speeding secure access to patient data.

In most health care environments, clinicians need to remember complex passwords for each individual application they access, which can change on a regular basis. The constant entry and re-entry of user credentials and searching for patient data takes time away from actual care delivery. The simple act of opening one application to find a patient and the required information can take two to three minutes per patient. Unfortunately, to find all relevant information that exists across applications means this process may need to be repeated four to six additional times per patient encounter. This is a time-consuming process that takes away from delivering patient care and encourages the workarounds noted above.

SSO and strong authentication remove the burden of remembering multiple passwords by enabling access to the entire health IT infrastructure through one login, or by authenticating the user based on biometric fingerprints or through the swipe of a card. Not only does this remove the need to remember multiple user names and passwords, but it also authenticates the user based on role. 

Regardless of where a clinician might be in their daily workflow, this process ensures they have the access needed to deliver superior care, while complying with federal mandates like HIPAA and HITECH that demand a detailed reporting of data access activity.

Adapting to How We Think

Workflow and process redesign must consider not only the existing patterns of care delivery and the ways to make them better, but also the inherent way human beings process their environment. To make their way through the world, humans generalize their environment, making quick assumptions based upon their experiences.

For example, a glowing bottom light at a traffic signal is green, an octagonal red traffic sign says "STOP" and a yellow triangle sign says "YIELD." In reality, we do not read these signs or process the colors. Our brain infers the meaning of the signs and lights from previous experience. Using inference, our brains function much more efficiently and allow us to process considerably more information than if we fully evaluated every situation. A workflow that does not consider how inference affects human actions can easily lead to medical errors.

Even the simple act of signing on and off a workstation has its risks. For example, let us assume that a physician signs on to a workstation to chart a patient, Mrs. Jones. After a few minutes of using the workstation, the physician walks away to speak with a consulting physician a few feet away.

With the workstation unoccupied, a second physician ends that first physician's session and creates a new session so he can write orders on his patient. This second physician, having finished his work, leaves the workstation without signing off.

The first physician, now finished with his conversation, returns to the workstation to complete his patient orders. He assumes that the workstation was not used during his brief time away from it and infers that the patient order entry screen he sees on the workstation monitor is for the patient under his care, Mrs. Jones. He writes the orders and walks away without signing off. Anyone who has worked in a busy clinic, emergency department or patient ward sees the high probability of this happening on a frequent enough basis to present a measurable risk to patients.

As organizations work to deploy health IT and deliver clinical transformation through redesigned workflows, they need to recognize the basis for many of the errors we, as human beings, make in our everyday lives. Through a deep understanding of the capabilities of health IT tools, clinician leaders with their informaticist partners can design and implement effective workflows that encourage physician adoption while delivering high quality, safe and efficient patient care.

Constance Berg
Dr. Chaiken has effectively nailed these issues and needs and they are of critical importance. His views come from his indepth knowledge of the industry and systems and they are valid. The industry has been quick to place many individuals in front line roles who lack the perspective and experience to go beyond the top layer of the impact of HIT and thus are unable to identify the gaps and layers of an activity. Plus the rush of curriculums that are being developed for the new wave of 6 month trained IT workers are hardly enough to address the totality of an IT project. Given this is a start; the learning curve is immense and the industry cannot expect this bandaid will meet the industry's needs for some time. The new HIT worker will need considerable support and on-going training which will take place on the job. Thank you Barry for keeping the focus on the challenges of transformation and workflows in the forefront.

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