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Workflow Redesign Is Crucial to Adopting a New Health IT System – Breakaway Thinking

Posted on January 20, 2016 I Written By

The following is a guest blog post by Todd Stansfield, Instructional Writer from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield
Workflow analysis and redesign have long been touted as essential to health IT adoption. Most organizations recognize the importance of modifying current workflows to capitalize on efficiencies created by a new application and identify areas where the system must be customized to support existing workflows. Despite this recognition, there remains room for improvement. In fact, last month the Office of the National Coordinator (ONC) identified the impact of new IT systems on clinical workflows as one of the biggest barriers to interoperability (ouch).

A successful redesign includes both an analysis of current workflows and desired future workflows.

Key stakeholders – direct and indirect – should take part in analyzing existing workflows. An objective third party should also be present to ask the right questions and facilitate the discussion. This team can collaborate to model important workflows, ideally in visual form to stimulate thorough analysis. To ensure an efficient and productive meeting, you should model workflows that are the most common, result in productivity losses, have both upstream and downstream consequences and involve multiple parties. The National Learning Consortium recommends focusing only on what occurs 80 percent of the time.

Once you document current workflows, you can set your sights on the future. Workflow redesign meetings are the next step; you need them to build a roadmap of activities leading up to a go-live event and beyond – from building the application to engaging and educating end users. Individuals from the original workflow analysis sessions should be included, and they should be joined by representatives from your health IT vendor (who can define the system’s capabilities) and members of your leadership team (who can answer questions and provide support).

After the initial go-live, you need to periodically perform workflow analysis and continue adjusting the roadmap to address changes to the application and processes.

Why should you spend all the time and effort to analyze and redesign workflows? Three reasons:

  1. It makes your organization proactive in your upcoming implementation and road to adoption. You’ll anticipate and avoid problems that will otherwise become bigger headaches.
  2. It’s the perfect opportunity to request customizations to adapt your application to desired workflows.
  3. It gives your staff a chance to mentally and emotionally prepare for a change to their daily habits, increasing buy-in and decreasing resistance to the switch.

Thorough and disciplined workflow redesign is an important step to adopting a new health IT application, but of course it’s not the only one. You’ll still need leadership to engage end users in the project, education that teaches learners how to use the new application to perform their workflow, performance metrics to evaluate adoption, and continual reinforcement of adoption initiatives as the application and workflows change over time.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

EHR Swapping: A New Approach for Effective EHR Transitions – Breakaway Thinking

Posted on September 16, 2015 I Written By

The following is a guest blog post by Todd Stansfield, Instructional Writer from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield
The trend to swap electronic health records has been gaining momentum in recent years. A 2014 KLAS report surveyed 277 large US hospitals, half of which indicated plans to replace their current EHR system by 2016. That number marks a significant wide-scale investment, since the cost of an EHR implementation may range from millions of dollars for a standalone hospital to hundreds of millions for a regional health system, according to a Becker’s Healthcare article. Organizations are increasingly swapping systems to gain needed functionality, achieve interoperability, leverage analytics and more. As the EHR market continues to consolidate, this development begs the question: are organizations ever fully adopting their EHR systems and overcoming problems uncovered during the initial go-live?

A new survey may provide insights. The American Academy of Family Physicians (AAFP) surveyed 305 physicians to uncover the challenges and outcomes associated with EHR-to-EHR transitions. While 59 percent agreed their new EHR provided useful functionality, only 39 percent reported being satisfied after transitioning. In fact, 49 percent disagreed that their new system improved productivity, and 41 percent considered their new EHR overly complex to use. These numbers suggest that changing applications does not always improve outcomes related to the EHR, especially since a majority of respondents had been using the application for a year or more.

The challenges being reported around EHR transitions are similar to those we have observed for years when the EHR isn’t fully adopted. Research published in Beyond Implementation: A Prescription for Lasting EMR Adoption identified how often organizations overestimate their adoption of an EHR system, a factor that can have significant consequences as organizations transition between applications. These organizations are likely to overlook problems impeding adoption and underestimate the resources and focus needed for the new system. Disengaged leaders, poor education, inadequate end-user support—all are inevitable if unresolved in the original system. The result is a continuation of an organization’s current headaches—from poor usability, to decreased productivity, to end-user dissatisfaction.

There are other potential pitfalls in transitioning EHR systems. For instance, leaders tend to underestimate the need for strong communication, physician alignment, and governance for upcoming changes. While they may have focused on these areas during their initial implementation, they may perceive them as unnecessary for the new system, a decision that puts adoption at risk over the long-term. Organizations should expect the EHR-to-EHR transition to bring the same, if not more significant, challenges as their original implementation.

Organizations may also struggle to anticipate end-user resistance to the new system, which is greater than the switch from paper. While end users may be dissatisfied with the current system, they are often not willing to face the challenge of learning a new system, requiring them to relearn the workflows and keyboard shortcuts they worked so hard to learn. Additionally, end users might question the value of an electronic-to-electronic switch. This is especially true when the transition is due to a merger or acquisition, as shown by the AAFP survey.

Organizations must rely on the tried-and-true methods to achieve EHR adoption, whether moving off paper or an existing electronic system. Beginning with leadership engagement, organizations must communicate, ensure physician alignment, and create governance to ensure accountability and ownership of the new system. End users should receive consistent and effective education. Education is most effective when it is scenario-based, repeatable, readily-accessible, and provides hands-on experience completing workflows in the EHR system. To understand the education and support needs of end users, organizations must track and measure performance. And lastly, they must sustain adoption efforts over time to ensure they remain relevant despite application upgrades and workflow improvements.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

HIMSS15: Adoption Still a Problem for Organizations Swapping EHRs – Breakaway Thinking

Posted on May 20, 2015 I Written By

The following is a guest blog post by Todd Stansfield, Instructional Writer from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield

Each year the Health Information and Management Systems Society’s (HIMSS) annual conference is the Super Bowl of health IT. No other conference boasts more attendees ranging from health IT innovators and collaborators to pioneers. This year 40,000 plus participants descended on Chicago, all eager to learn about the new direction, trends, and solutions of the industry.

As always, buzzwords were aplenty—interoperability, care coordination, patient experience, and value-based care, to mention a few. During her keynote address on April 16, Karen DeSalvo, National Coordinator for the ONC, called the current state of health IT the “tipping point.” In 2011 the ONC released its four-year strategic plan focused on implementing and adopting electronic health records (EHRs). Now, DeSalvo says the industry is changed and ready to move beyond EHRs to technologies that will create “true interoperability.”

Enlightening conversations were happening among the crowded booths, hallways, and meeting rooms between organizations looking to ‘rip and replace’ their current EHR for a new one. While some organizations are struggling to unlock data across disparate systems, others are looking to upgrade their current system for one compatible with ICD-10, Meaningful Use, analytics solutions, or a combination of these. Still others are looking to replace systems they dislike for lack of functionality, vendor relationships, etc. In many cases, replacing an EHR is needed to ensure interoperability is at the very least viable. This buzz at HIMSS is a strong indicator that EHRs are still an important and essential part of health IT, and perhaps some organizations have not reached the tipping point.

In addition to the many challenges these organizations are facing—from data portability, an issue John Lynn wrote about in August 2012, to the cost of replacing the system—leaders are agonizing over the resistance they are facing from clinician end users. How can these organizations force clinicians to give up systems they once resisted, then embraced and worked so hard to adopt? How can leadership inspire the same level of engagement needed for adoption? The challenge is similar to transitioning from paper to an EHR, only more significant. Whereas the reasons for switching from paper were straightforward—patient safety, efficiency, interoperability, etc.—they are not so clear when switching applications.

Clinicians are also making harsher comparisons between applications—from every drop-down list, to icon, to keyboard shortcut. These comparisons are occurring at drastically different phases in the adoption lifecycle. Consider the example of an end user needing to document a progress note. In the old EHR, this user knew how to copy forward previous documentation, but in the new system she doesn’t know if this functionality even exists. Already the end user is viewing the new system as cumbersome and inefficient compared to the old application. Multiply this comparison by each of the various tasks she completes throughout her day, and the end user is strongly questioning her organization’s decision to make the change.

This highlights an important point: Swapping one EHR for another will take more planning, effort, and strategy than a first-ever implementation. The methods for achieving adoption are the same, but the degree to which they are employed is not. Leadership will not only have to re-engage end users and facilitate buy-in, they will have to address the loss of efficiency and optimization by replacing the old application.

Leadership should start by clearly outlining the reasons for change, a long-term strategy, as well frustrations end users can expect. They should establish a strong governance and support structure to ensure end users adhere to policies, procedures, and best practices for using the application. The organizations that will succeed will provide end users with role-based education complete with hands-on experience completing best practice workflows in the application. Education should include competency tests that assess end users’ ability to complete key components of their workflow. Additionally, organizations must capture and track performance measurements to ensure optimized use of the system and identify areas of need. And because adoption recedes after application upgrades and workflow enhancements, all efforts should be sustained and modified as needed.

While HIMSS15 brought to the stage a wealth of new ideas, solutions, and visions for the future of health IT, the struggle to adopt an EHR has not completely gone away. Many organizations are grappling with their current EHR and choosing to replace it in hopes of meeting the triple aim of improving care, costs, and population health. For these organizations to be prepared for true interoperability, they must overcome challenges unseen in paper to electronic implementations. And if done successfully, only then will our industry uniformly reach the tipping point, a point where we can begin to put buzzwords into practice.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

Mobile Health to Transform Care: The Case for Adoption Now – Breakaway Thinking

Posted on February 18, 2015 I Written By

The following is a guest blog post by Todd Stansfield from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield
Mobile health (mHealth) is here to stay, and you don’t have to look far for proof. Patients now use mHealth to comparison shop basic healthcare services and access test results. Providers use it to increase efficiencies and lower costs. And CIOs use it to get more out of an electronic health record (EHR) while juggling new security challenges from the bring your own device (BYOD) movement.

Perhaps one of mHealth’s greatest areas of impact is providers’ bottom line. A new study finds that baby boomers and millennials prefer providers who incorporate mobile technology into their practices. Seven percent of patients responded that they are willing to leave their current provider for one who offers remote care, a move that could have a significant financial impact on independent physician practices. This is especially clear when considering that an overall 20 percent of patients reported seeing the same doctor for less than 2 years and 14 percent reported not having a doctor. Additionally, the Centers for Medicare & Medicaid Services (CMS) is now offering providers roughly $42 a month to manage care for Medicare patients with two or more chronic conditions in its Chronic Care Management program. These patients comprise two-thirds of Medicare beneficiaries. For practices with 20 eligible patients, that figure translates to over $10,000 per provider per year. Providers must use mHealth to meet some requirements of Chronic Care Management, such as offering 24-7 access to consultation, and companies are now creating technologies to help. Just last month, Qualcomm and Walgreens announced a joint venture to pair medical devices with mobile and web apps to provide remote patient monitoring and transitional care support.

And then there’s efficiency. Another study finds that “the average hospital loses $1.7 million per year due to inefficient care coordination,” according to a HealthIT Analytics article. Providers are finding mobile technology valuable for improving health information exchange and communication, areas underserved by current EHR systems. More providers are text messaging care information rather than communicating face-to-face with colleagues, resulting in more informed care teams and fewer avoidable healthcare errors. Providers are also using mobile devices to enhance real-time patient engagement rather than relying on cumbersome computers to document in the EHR. Often the result is improved patient care, shorter appointments, and more time to see more patients. And besides getting in and out of their provider’s office sooner, patients are also welcoming new efficiencies with real-time access to their medical records via smartphone, a selling point among younger generations pursuing an active role in their care. In a recent survey of Americans, millennials indicated a preference for patient portals that they can access via a smartphone or tablet.

Yet providers should plan carefully when implementing mHealth, as there are major costs for failing to set up robust infrastructures that support safe mobile use. Providers should perform security risk analysis to ensure the safety of protected health information (PHI). This includes evaluating the security of all mobile devices—tablets and smartphones—ensuring that each device stores, sends, and receives PHI securely using encryption and other methods. Providers must perform this analysis routinely to receive payments under Meaningful Use (MU) and to prevent the ever-growing number of data breaches. Data security has remained a chief concern for healthcare providers and leaders and has largely stifled the widespread adoption of mHealth. This may change as the Department of Health & Human Services plans to offer more guidance to mHealth developers and users for adhering to HIPAA rules, as it recently announced.

Providers must adopt mHealth to survive in today’s competitive marketplace. Not only will they reap the short-term benefits of higher revenues through Chronic Care Management and attracting new patients, but they will also build the secure infrastructure and tools needed for long-term success. mHealth will be critical to population health and health information exchange, two eventual destinations for the healthcare industry. Providers who adopt mHealth now will be ready for when our industry makes the complete shift toward a population-focused, value-based care model.

In my experience at The Breakaway Group, A Xerox Company, effective adoption begins when leaders engage their workforce in the vision and mission of the project; when education is focused, accessible, and targeted; when performance is measured, collected, and analyzed; and when adoption is sustained amid changing technologies and process improvements. For providers to make the transition successfully healthcare leaders must find and implement technologies that patients and providers want to use. They must provide education that is convenient, focused, and practical for providers, education that spans not only how to optimize the technology but also how to use it safely and in accordance with government regulations. Healthcare leaders must also track performance in quality and efficiency, and highlight areas for improvement. And lastly, they must ensure all efforts are sustained, reinforced, and tailored to changing needs.

mHealth is poised to transform healthcare. It’s no wonder that mHealth raised $1.2 billion in venture capital last year, or more than triple what it raised in 2013. I’d venture to say that a significant share of new patients, new revenues, and new efficiencies will be earned by providers who are going “mobile.”

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

EHR Adoption: Step One to Successful Population Health Management – Breakaway Thinking

Posted on June 18, 2014 I Written By

The following is a guest blog post by Todd Stansfield from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield

The Managed Care movement dramatically transformed healthcare in the 1990s. For the first time, our industry discovered increased margins by conserving the services we provided. Now, Population Health Management (PHM) is on the brink of transforming healthcare yet again—and perhaps in a more dramatic fashion. The transformation is already underway, with industry-wide consolidations between hospital networks, physician practices, and even insurance companies; government reforms targeting cost and quality controls; and new breeds of health organizations, professionals, and technologies.

Today’s PHM movement presents the same cost benefit as healthcare’s traditional models with a greater focus on health outcomes. The philosophy behind PHM is that healthcare providers and organizations will save money and improve care by identifying and stratifying patients with high, medium, and low risk for developing chronic conditions. Once patients are assigned a level of risk, care plans are then developed and deployed to treat them appropriately. For high-risk patients, strategic interventions are provided that reduce hospital admissions, readmissions, and complications. For low-risk patients, preventative care is offered to maintain health and avoid costly conditions. The PHM model requires broad-scale data collection, analysis, and transmission between healthcare entities—the latter not yet possible with the lack of integration between electronic health record (EHR) systems. PHM also calls for redesigning processes, discovering gaps in care, and extending patient-provider interactions beyond clinical events to encourage healthy life behaviors.

In order to reach the level of data collection needed for successful PHM, healthcare organizations must first adopt their EHR. Doing so makes it possible to intercept data, analyze it, and transform it into useful clinical information delivered to the point of care. Without EHR adoption, the most foundational elements of PHM cannot be supported: We cannot efficiently discover gaps in our current care, identify and stratify at-risk patients treated by an organization, or improve our processes to lessen the new financial risks of value-based care. EHRs are so central to PHM that overlapping incentives for both initiatives were proposed in November 2011 by the Centers for Medicare & Medicaid Services (CMS). The technology is also a necessary tool for Accountable Care Organizations (ACOs), which are a form of PHM. The Agency for Healthcare Research and Quality (AHRQ) published an interview with Dr. Stephen Shortell, a Distinguished Professor of Health Policy and Management at the University of California, who outlined aspects of EHR adoption as being essential to the success of ACOs.[“The State of Accountable Care Organizations.”The Agency for Healthcare Research and Quality. http://www.innovations.ahrq.gov/]

Our research at The Breakaway Group (TBG) points to four crucial components needed to adopt an EHR for PHM. Strong leadership must inspire continual engagement from users to embrace the EHR as a tool for positive change. Targeted and effective education—creating system proficiency in role-based tasks—must also be established before and after the EHR go-live event. Performance must be gauged, measured, and analyzed to enhance EHR use and establish governance measures. And with the evolutionary nature of the EHR, all optimization efforts must be sustained and refreshed to meet new challenges, such as application upgrades and process changes.

Although the PHM movement is relatively new, there are numerous examples of the model’s success. ACOs enrolled in CMS’s Shared Savings and Pioneer ACO programs have generated $380 million in savings.[“Medicare’s delivery system reform initiatives achieve significant savings and quality improvements – off to a strong start.” US Department of Health and Human Services. www.hhs.gov.] One Pioneer ACO, Partners HealthCare, has established patient-centered medical homes that employ Care Managers specializing in customizing patient care plans.[“Patient-centered Medical Home: Role of the Care Manager.” Partners HealthCare. www.partners.org.] While Partners HealthCare is not employing true PHM in the sense of sharing information with other healthcare entities, it is large enough in size to perform broad-scale data collection that can help better manage health populations. This example demonstrates the potential effect of PHM on our industry when data becomes transferrable.

EHR adoption is an essential feat we are capable of achieving now. Doing so is the first step toward learning more about the populations we serve, how we’re not serving them, and how we can adjust our processes to succeed in a value-based model. Yet to manage populations effectively, more is required from us, including being willing to work together in our pursuit of a better, brighter healthcare system. If we can overcome these hurdles now, then we will arrive ready for when our industry is capable of embracing true care coordination.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

Learning by Doing: A Model that Works in EHR Training – Breakaway Thinking

Posted on March 19, 2014 I Written By

The following is a guest blog post by Todd Stansfield from The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
Todd Stansfield
I didn’t learn to change the oil in my car until I changed it. My father instructed me a dozen times, and I watched him a dozen more, but it wouldn’t resonate until I got my hands dirty. I can count an endless number of other tasks that never stuck with me after reading about them in a textbook or hearing about them in a classroom. Some things I need to learn by doing; and I’m not alone.

Why is changing oil different from learning about the Roman Empire? Even years after taking history in college, I still know the story of Romulus and Remus. I can tell that story with the help of a knowledgeable friend, someone to nudge me along as I weave through a non-linear narrative. But when you’re changing oil, you can’t begin at the end, jump to the start, and then fill in the middle details. It’s a linear task with a clear beginning and end, and the workflow impacts the outcome. Changing the oil in a car isn’t life-or-death, but placing an order in an electronic health record (EHR) does impact the lives of patients.

For decades, healthcare has relied on Instructor-Led Training, or ILT, as its answer to education. More hours in the classroom equals a more informed and prepared workforce. It’s the same model supported by our nation’s education system. This would be fine, except that the learning outcomes are vastly different. Where a history class, for instance, aims to teach learners to know something, a hospital class aims to teach learners to know how to do something. Clinicians enrolled in a three-day training session must emerge with the ability to place a medication order using the EHR—a single task that may require upwards of 30 clicks on the computer.

Because actions in an EHR impact the lives of patients, an education model with hands-on, simulator-based training is better suited for teaching health professionals the proper use of an EHR. Perhaps this need is best described by Charles Fred, Group President of Xerox’s Healthcare Provider Solutions division. Mr. Fred is the founder and former CEO of The Breakaway Group, a company providing simulation based training to prominent healthcare organizations across the United States and internationally.

“Consider the value of teaching caregivers to use EHRs through role-based simulators,” he wrote in an article for the American Society of Training and Development. “Simulation provides an opportunity to practice in a real-life environment without real-life risks and consequences. Caregivers learn inside their actual EHR application, which is critical for learning workflow and gaining new knowledge about the system. They only learn tasks that are applicable to their role.” (Source: Fred, Charles. “Driving the Transition to Electronic Health Records.” Training + Development. American Society for Training & Development. Alexandria: 2012, Print.)

Simulation-based education solves many of ILT’s limitations. For starters, the simulations are based online and allow the learner, rather than the trainer, to perform the task. Providers and clinicians can learn to place an order by performing the task directly in a simulated EHR. They may do so at their leisure, from their computer at home, at work, or even at a local coffee shop if they prefer. As long as there’s an Internet connection, they may train until they’re proficient. Simulation-based training also saves money spent on the herculean effort to jam too many professionals into too few classrooms. Another benefit is that it’s more accessible. The simulations exist as long as they are needed and can be upgraded to reflect changes in workflows. Where ILT provides a training event, simulation-based education provides a sustainable solution for ensuring the EHR provides clinical value to the organization. Simulation-based education shortens the learning curve for healthcare providers and allows staff members to train more quickly so they can focus on their core responsibility – their patients.

A combination of simulation-based education followed by ILT can be used to achieve better results. The chief benefit of classroom training is that it provides a venue for social interaction and the exchange of ideas, but this is best leveraged when participants have confidence and knowledge in using an EHR. Simulation-based education makes this possible. After completing role-specific simulations, participants arrive to the classroom already proficient in using the EHR. They are engaged before class even begins. What could have been banter about the next break is now a meaningful conversation about best practices and ways to improve processes. Social interaction can now be leveraged to improve education. What’s more, because participants already have a foundation of knowledge and ability in the system, the training can now focus on teaching participants to complete more complex tasks and workflows. It can also devote more time to independent practice (the most conducive form of learning).

While healthcare’s focus on training hasn’t changed, the industry itself has experienced a whirlwind of evolution. Why then, amidst all the evolution, must providers and clinicians rely on an outdated education model?

Xerox is a sponsor of the Breakaway Thinking series of blog posts.