Info System / Health Care

Content

Week 2, Monday, October 28, 2019 - Sunday, November 3, 2019

IFSM 305 7980 Information Systems in Health Care …

The following should be completed in Week 2:

Read:

Read/View all Week 2 Content

Do:

Participate in Discussion(s), as assigned

Submit the Case Study Stage 1 Assignment

0 % 0 of 3 topics complete

Last week’s readings introduced some basic concepts and contexts for

information systems in the health care sector. This week we focus on how health

care IT systems can help improve the quality of health care delivery, and,

ultimately, improve patient outcomes. Then, before a system is acquired for use,

the processes it is expected to support must first be analyzed and optimized. So,

the next step is for you to learn what health care processes are, and how they are

analyzed and improved using process analysis, process mapping and ultimately,

process redesign.

The following table lists the Week 2 outcomes, mapped to the corresponding

course outcome. The course outcome gives you "the big picture," and the weekly

outcomes provide more detailed information that will help you achieve the

course outcome.

Activities

Week 2 Learning Resources Link

Discussion for Week 2 Discussion Topic

Case Study Stage 1 Assignment Assignment

Due November 3 at 11:59 PM

Course Outcome Met in Week 2 Week 2 Outcomes

analyze the flow of data and

information among disparate

health information systems

to support internal and

external business processes

explain the role of Health Information

Technology in advancing the quality of

health care

describe the principles of quality and

safety in health care

describe health care processes

explain health care process analysis an

mapping

explain how process redesign is used t

optimize workflow in health care settin

Working with Health IT Systems is available under a Creative Commons Attribution-NonCommercial- ShareAlike 3.0 Unported license. © Johns Hopkins University. UMUC has modified this work and it is available under the original license.

Welcome to Quality Improvement: Introduction to Quality Improvement and

Health Information Technology. This is Lecture a.

This course has been designed to examine the critical relationship of

healthcare quality and health information technology. We will explore the

concept of healthcare quality and the role of Health Information Technology in

advancing the quality of healthcare.

The Objectives for Introduction to Quality Improvement and Health Information

Technology are to:

•Identify the current challenges in healthcare quality.

•Examine the components of the healthcare system that have an impact on

quality.

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The national mood is reflective of a complex healthcare system that is plagued by exorbitant healthcare spending and quality and safety concerns. The National Coalition on Health Care (NCHC) reported that total healthcare expenditures make up 16 percent of the gross domestic product and are expected to reach $4.2 trillion in 2016. The NCHC also reported that there were more than 47 million uninsured Americans in 2006 and that this number has risen by almost 9 million people since 2000. As a response to these problems the Affordable Care Act was signed into law March 23, 2010. This law has brought Health Information Technology (HIT) to the forefront as an indispensible tool and ensures comprehensive changes to the current healthcare system, placing emphasis on the role of QI and HIT in the system.

Some of these changes include:

•Increased health coverage for children

•Health insurance mandate

•End lifetime and most annual limits on care

•Allows young adults under 26 to stay on their parents’ health insurance

•Give patients access to recommended preventive services without cost

The Act includes other benefits, such as:

•50% discounts on brand-name drugs for seniors in the Medicare “donut hole”

•Tax credits for small businesses that provide insurance to employees

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Dr. Donald Berwick, the former chief of Medicare and Medicaid, is a prominent

leader in healthcare quality and the founder of the Institute of Health Care

Improvement. He has dedicated his career to improving patient outcomes and

providing better healthcare at lower cost. In a speech to the Harvard School of

Public Health, Dr. Berwick said that system performance depends, not only on

the elements of the system, but on the interaction among these elements. He

goes on to say that healthcare improvement depends on systems thinking and

redesign and that healthcare reform without attention to the nature and nurture

of healthcare as a system is doomed. To quote Dr. Berwick, “It will, at best,

simply feed the beast, pouring precious resources into the overdevelopment of

parts and never attending to the whole—that is, care as our patients, their

families and their communities experience it.”

As part of understanding the current healthcare landscape, we are going to

review three programs that have profound impact both in the use of HIT and

the quality of the health care system. The first of this program is Meaningful

Use, in which providers show they're using certified Electronic Health Records

(EHR) technology in ways that can be measured significantly in quality and in

quantity. The second program, the Patient Centered Medical Home, has

providers organize care around patients, working in teams, coordinating care,

and tracking over time. Finally, the Accountable Care Organization component

ties provider reimbursements to quality metrics and reductions in the total cost

of care for an assigned population of patients.

It is generally understood that rarely will organizations be able to become

completely electronic. According to Marc Holland, an expert in HIT and health-

data exchange, “even hospitals with fully functioning EMRs still make

extensive use of digitalized scans of manually completed forms and textual

checklists. With no forms or screens to capture data in a structured way,

hospitals fail to report quality measures as a routine byproduct of the practices,

relying instead on a retrospective chart abstracting process.”

The complexities of quality measure reporting have not been completely

understood and much of your effort as HIT professionals will be directed

toward finding ways to manage this complexity.

The Obama administration has continued to respond to a national call to have

computerized health records by 2014. The American Reinvestment and

Recovery Act of 2009 authorized the Centers for Medicare and Medicaid

Services (CMS) to provide reimbursement incentives for eligible providers and

hospitals who can demonstrate that they use certified electronic health records

in a meaningful way. This act has Health Information Technology for Economic

and Clinical Health (HITECH) provision to establish programs under CMS in

coordination with the Office of the National Coordinator (ONC).

Meaningful use of Electronic Health Records means that use of these records

improves quality, safety, and efficiency of care; engages patients and families

in their care; improves coordination of care, improves population and public

health, and reduces disparities; and ensures privacy and security protections

for all. To qualify for federal incentives, users of certified EHRs must

demonstrate that they meet these criteria.

Meaningful use criteria will be released in three stages. Stage 1 (2011) criteria

are directed toward capturing and sharing data. The objective of stage 2

criteria (2013) is to advance health care processes with decision support, and

in stage 3 (2015), meaningful use criteria will be targeted at improving

outcomes.

Stage 1 criteria address the priority of improving quality, safety, efficiency, and

equity of health care. The goals of stage 1 criteria are four-fold. First, in order

to meet the stage 1 criteria, health information must be electronically captured

in a structured and coded format by both hospitals and eligible providers.

Then, they must be able to demonstrate that they use that information to track

key clinical conditions for quality improvement purposes. Third, providers and

hospitals must be able to communicate that information to other care providers

to ensure coordination of care. Then they need to lay the foundation for

reporting clinical quality measures and public health information. Criteria have

been divided into two sets: a core set that must be met by all eligible providers,

hospitals, and critical access hospitals in order to qualify for incentives, and a

menu of additional criteria from which they must select any five choices to

receive incentives.

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The Patient-Centered Primary Care Collaborative (the PCPCC), is a group that

includes consumer groups, hospitals, providers, large employer groups, and

many others, joined together to focus on the Patient-Centered Medical Home

(PCMH). This group has formed to advance the concept of the PCMH and

puts forth the following definition, “an approach to providing comprehensive

primary care for children, youth, and adults. The PCMH is a healthcare setting

that facilitates partnerships between individual patients, and their personal

physicians, and when appropriate, the patient’s family.”

The American Academy of Family Physicians (AAFP), the American Academy

of Pediatrics (AAP), American College of Physicians (ACP), and the American

Osteopathic Association (AOA) in 2007 created a set of joint principles that

outline the characteristics of the PCMH. These four groups have a total

membership of more than 33,000, and have a vested interest in the PCMH.

The Joint Principles document can be found on the website of the American

Academy of Family Physicians.

There are seven principles that have been put forth by this consortium of four

groups for the PCMH. We will briefly describe these seven principles.

Here are the first four of the seven PCMH principles.

The first principle asserts that each patient has a personal physician who

becomes the captain of the ship, taking total responsibility for a patient’s care.

The second principle is the physician-directed medical practice. This principle

espouses that there is a team of individuals, led by a physician, who take total

responsibility for a patient’s care.

A whole person orientation—the third principle—means what it says. The

person is viewed as a whole, not a collection of systems or illnesses. In the

PCMH, this principle means that all aspects of the patient’s health care needs,

across all stages of life, is the personal responsibility of the primary physician.

The personal physician must also assume responsibility for arranging and

coordinating care for a given patient.

The fourth principle assures that care is coordinated and/or integrated across

all sites of care, including acute care, home care, long-term care, in the

community, and the like. Such care assures smooth, continuous, and

culturally appropriate care. Of course the ability to provide such continuity and

coordination is reliant on Health IT, mechanisms for health information

exchange, and a patient-centered focus that takes into account culturally and

situationally appropriate plans of care.

The final three dimensions start with quality and safety—which are the fundamental and defining characteristics of the PCMH.

The goal of the PCMH is to support and encourage attaining patient-centered outcomes. These are not the outcomes decided by the provider; instead these are commonly derived goals between the care team, the patient, and his family. It requires compassion and strong relationships between all members of the patient-centered team. It also requires that the patient and family expectations for the care process and the outcomes are being met.

Quality and safety measures also include adhering to evidence-based practice and the use of robust clinical decision support tools to guide optimal decision making. Achieving quality and safety also requires that all members of the team, with the feedback from patients and families, participate in continuous quality improvement and voluntarily participate in quality improvement measurement and reporting.

Interestingly and quite relevant for health IT professionals, these guidelines (under the Quality and Safety header) require the use of health IT to facilitate high quality communication, measurement of performance and outcomes, to support superior patient care, and for patient and family education. Finally, demonstration that the practice has the capacity and wherewithal to provide patient-centered care consistent with the PCMH determined by a voluntary recognition process conducted by a non-governmental entity is required.

The sixth principle of enhanced access to care is directed at assuring that patients are able to reach providers and care staff with a minimum of effort. This can be achieved via the use of health IT (such as online scheduling, emailing with providers—much in the way that the Veterans Affairs My Healthe Vet web portal works) or by other methods such as weekend hours, evening hours, and the like.

The seventh and final principle focuses on payment. The payment principle is premised on the acknowledgement of the value that is derived from patients who are participating with the PCMH. A payment structure has been derived as part of this framework and includes aspects such as payment for care coordination, financial incentives for adoption of Health IT (recall, these principles were developed in 2007—long before the HITECH Act), payment for remote monitoring activities and the use of alternative telecommunications with patients and families, attention to case mix, allowance for enhanced cost sharing across providers for cost savings derived from the PCMH, rewards for achievement of high quality and low-cost services, and several other aspects.

The entire payment framework can be found by accessing the reference at the end of this slide deck from the AAFP. In addition, these entire 7 Principles of the PCMH are very clearly outlined in the same reference for student’s to examine in closer detail.

The principles just outlined translate into specific elements that healthcare delivery sites have to put in place to be part of this system. This slide presents an example of elements and their scores necessary for the NCQA certification. This is one of many PCMH certifications, and it presents a good example of the specific elements.

The Enhance Access and Continuity standard accrues 20 points in the following elements: access during office hours (4 points), access after hours (4 points), electronic access (2 points), continuity (2 points), medical home responsibilities (2 points), culturally and linguistically appropriate services (CLAS) (2 points) and practice organization (4 points).

The Identify and Manage Patient Populations standard accrues 16 points in the following elements: patient information (3 points), clinical data (4 points), comprehensive health assessment (4 points) and using data for population management (5 points).

The Plan and Manage Care standard accrues 17 points in the following elements: implement evidence- based guidelines (4 points), identify high-risk patients (3 points), manage care (4 points) manage medications (3 points) and electronic prescribing (3 points).

The Provide Self-Care and Community Support standard accrues 9 points in the following elements: self- care process (6 points) and referrals to community resources (3 points).

The Track and Coordinate Care standard accrues 18 points in the following elements: test tracking and follow-up (6 points), referral tracking and follow-up (6 points) and coordinate with facilities/care transitions (6 points).

The Measure and Improve Performance standard accrues 20 points in the following elements: measures of performance (4 points), patient/family feedback (4 points), implements continuous quality improvement (4 points), demonstrates continuous quality improvement (3 points), performance reporting (3 points) and report data externally (2 points).

The total amount of points is 100.

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PPACA creates accountable care organizations. Accountable Care Organizations (ACOs) refer to physicians, hospitals, other providers and service suppliers that have agreed to work together to coordinate patient care under the original Medicare program. While working to provide these coordinated services for Medicare beneficiaries, the provider groups establish a mechanism for shared governance, and strive to provide high-quality and coordinated care. ACOs are recognized legal entities at the state level and are therefore bound by state law. The Centers for Medicare/Medicaid services (CMS), the entity that administers Medicare, will enter into three-year agreements with an ACO, and the ACO then assumes responsibility for the coordination, cost, quality, and overall care for assigned Medicare beneficiaries. Cost savings are to be shared across the ACO partners.

According to the proposed rule, “Medicare would continue to pay individual providers and suppliers for specific items and services as it currently does under the fee-for-service payment systems. The proposed rule would require CMS to develop ACO specific level of savings which need to be achieved by each ACO if the ACO is to receive shared savings, as well as a level of losses realized by an ACO if it is held liable for losses. Additionally, an ACO would be accountable for meeting or exceeding the quality performance standards to be eligible to receive any shared savings."

Overall, the goal of the ACO is to reduce the cost of care while improving quality and care coordination for Medicare beneficiaries. Care decisions are shared between the providers and the patient in an ACO – thereby in addition

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to improving quality and increasing cost efficiency, an ACO would also

contribute to a patient-centered orientation to care.

This concludes Lecture a of Introduction to Quality Improvement and Health

Information Technology. In summary, in the current healthcare environment

there are a number of initiatives that aim to improve the care for all Americans

through the use of HIT.

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Welcome to Quality Improvement: Introduction to Quality Improvement and Health Information Technology. This is Lecture b.

The Objectives for Introduction to Quality Improvement and Health Information Technology are to:

•Explain healthcare quality and Quality Improvement (QI).

•Describe quality improvement as a goal of meaningful use.

2

According to an Institute of Medicine report, “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.”

So who defines healthcare quality? Lots of people do, and each does so from his own unique perspective. Take healthcare providers, for instance. They are more likely to view quality as the application of evidence-based professional knowledge to the needs of individual patients. Patients and families, on the other hand, may place more importance on how the provider talks with them or how long they have to sit in the waiting room. Payers value patient satisfaction and use of preventive services rather than focusing on clinical outcomes of the patient. And regulatory bodies, like the Joint Commission or the CMS, or professional organizations, such as the American Medical Association, view quality as conforming to their standards.

The image is a composite of four intersecting circles, each containing a category of entities that help define quality healthcare: healthcare providers (application of evidence-based principles), patients and families (communication & timeliness), professional and regulatory bodies (conformity with standards), and payers (cost vs. outcomes).

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These are some of the regulatory bodies and organizations that help define and bring consensus around QI issues.

A non-profit organization, the National Quality Forum (NQF), is charged with improving the quality of healthcare in America.

They have a three-part mission that includes:

•Working in partnership to achieve consensus around performance improvement based on national goals and priorities;

•Supporting standards for publicly measuring and reporting performance based on national consensus; and

•Supporting the use of outreach programs and educational interventions to attain national goals.

The National Committee for Quality Assurance is a private, 501(c)(3) not-for-profit organization dedicated to improving health care quality.

It develops quality standards and performance measures for a broad range of healthcare entities. These measures and standards are the tools that organizations and individuals can use to identify opportunities for improvement.

The American Medical Association’s Physician Consortium for Performance Improvement (the PCPI) is a national, physician- led initiative dedicated to improving patient health and safety.

According to their website they achieve this by:

•“Identifying and developing evidence-based clinical performance measures and measurement resources that enhance quality of patient care and foster accountability;

•Promoting the implementation of effective and relevant clinical performance improvement activities; and

•Advancing the science of clinical performance measurement and improvement”.

The Joint Commission is an independent, not-for-profit organization that accredits and certifies more than 19,000 healthcare organizations and programs in the United States.

The Institute for Healthcare Improvement (IHI) is an independent not-for profit-organization located in Cambridge, Massachusetts. The IHI is concerned with investigating new models of care and how they perform, (while partnering with patients, families and healthcare professionals). In addition, IHI is focused upon encouraging and supporting change while helping to maintain the momentum and commitment to serious and transformational health-system change. Finally, the IHI is committed to innovation and wide-scale adoption of best practices, high-quality care, and cost-efficient services for all.

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Each year, the Agency for Healthcare Research and Quality, or the AHRQ, partners with the  Department of Health and Human Services to report on progress and opportunities for  improving health care quality. In 2009, the report concluded that the US health care system  needs to be improved, especially for the uninsured, and that patient safety and healthcare‐ associated infections warrant urgent attention. Although quality is improving, the pace is  slow, especially in preventive care and management of chronic disease. 

Some Americans receive health care that is worse than other Americans. These disparities  are often due to differences in access to health care, provider biases, poor provider‐patient  communication, and poor health literacy. The AHRQ tracks gaps where some people  receive poor or worse health care than others and looks for improvement over time.  Emphasis is on race, ethnicity, and socioeconomic status, but also includes attention to  broadly defined priority populations (groups with unique health care needs or issues that  require special focus such as recent immigrants or people with limited‐English proficiency,  women, children, older adults, residents of rural areas, and disabled individuals).

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So how are we doing in terms of healthcare quality? Many of the measures available to us would suggest we are not doing so well. In a national phone survey, McGlynn and colleagues found that participants in the survey received 54.9 percent of recommended care. There was hardly any difference among the proportion of recommended preventive care (54.9%), recommended acute care provided (53.5 %), and recommended care provided for chronic conditions (56.1 percent). The study raised concern for the health of the American public. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure stated that two- thirds of hypertensive individuals were being inadequately treated. Saydah and his colleagues in a review of data from the Third National Health and Nutrition Examination Survey (NHANES III, conducted 1988-1994) and NHANES 1999-2000, cross- sectional surveys of a nationally representative sample of the noninstitutionalized civilian US population described that two- thirds of individuals with diabetes had uncontrolled levels of HgbA1c (a measure of diabetes control). In another study, Afonso and colleagues also described that two-thirds of individuals with elevated cholesterol levels had not reached adequate control. This is not only true in the world of ambulatory care. The same kind of quality concerns are found in the hospital environment. Examples of this include the level of hospital acquired infections. In a recent review, Umscheid and colleagues found that anywhere from 50% to 70% of these infections are preventable. Another measure of quality lapses in the hospital world includes the high rate of readmissions. A fourth of the patients admitted with heart failure in this country will be readmitted within 30 days.

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This lack of quality is not only reflected in the outcomes of care but also in the patient’s experience of care. In a national survey conducted in 2006 by the Commonwealth Fund’s Dr. Beal and colleagues, they found that only 27 percent of adults who actually had a primary-care provider could easily contact their physician over the phone to obtain care or medical advice or get timely office visits.

In another national survey found that only half of the adults receive very good information, find it easy to get an appointment, or do not feel they waste their time when they visit their physician.

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These are just a few examples of the state of health care in the US. Given the current quality of care received by Americans, the introduction of quality improvement initiatives is imperative. As we look at the different ways to improve our healthcare system we should consider the role of HIT could play in this improvement.

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Paul Batalden, MD Director Health Care Improvement Leadership Development famously states, “Every system is perfectly designed to achieve the results it achieves.”

Thus the way to improve our healthcare system is to redesign it.

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There are a number of methodologies used to improve the quality of a system: model for improvement, lean thinking, six sigma, theory of constraints, customer inspired quality … and many others. The detailed review of these multiple methodologies is beyond the scope of this lecture. However, at the core of all these methodologies there are the same basic principles that we will now review.

The quality improvement process starts when you set an aim. You cannot improve a system if you do not have a clear idea of what you need to improve. Subsequently, a continuous cycle of measurement, change, and learning starts. Measurement is an essential component of quality since you must have the ability to measure change to direct change in the appropriate direction. Change is the second essential component of any improvement process. As an old proverb states, “you can’t fatten the cow by weighing it.” Finally, the third essential component of improvement is our ability to learn and better understand the system we are changing. To achieve long- lasting change we need to move away from the project mentality and dive into the system we are trying to change.

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The aim we set needs to be very specific; if at all possible a numeric aim should be set. It is very difficult to improve a system if your aim is vague. “We will improve our infection rate” is a much harder aim to attain than “we will cut our rate of hospital acquired pneumonia by half.” However this aim, although better than the former, could be improved. What is your current rate of infection? Where are the majority of infections happening? Is there any shift or time of year where these infections are worse? The inclusion of all those aspects into your aim denotes an understanding of the system you are working on and assists you in achieving your goal. A better aim would read “we will reduce the number of hospital-acquired pneumonias from the current 35% to 15% in the ICU.” Assigning a timeline is an important component of setting an aim. If you don’t have a timeline to achieve your improvement, it is difficult to see it through or to engage a team that usually is busy with many other responsibilities. Making your aim measureable will assist you in seeing it through. There are very commendable aims that cannot be accomplished because they cannot be measured. An example of an immeasurable goal is, “we will make 90% of our patients happy in 6 months.” Although it is specific and it has a numeric value, we have to choose a variable that can be measured. How will we measure if they are happy? A better option for this aim could be “90% of our patients will rate our services as ‘excellent’ and will state they would recommend our services to a friend or family member.” This captures the essence of the original aim and allows you to measure it. Make sure you challenge your team with the aim you choose. An aim you can achieve in a week may make you look good in the short term, but is unlikely to bring permanent improvement to your system.

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As we mentioned before, measurement is an essential component of quality since you must have the ability to measure change in order to direct change in the appropriate direction.

There are three types of measure we will be focusing on.

•Process measures. These measures look at the steps in the system and determine if the system is performing as it should. Performance measures will improve before the outcome measures do. They assist us in determining if we are on track to get the improvements we want to see in our system.

•Outcome measures. These measures determine the impact of our changes in the system. They measure results from the view of patients about their health and wellbeing. These measures may also look at the impact on other stakeholders such as payers, employees, or the community.

•Balancing measures. These measures are designed to look at the whole system and make sure we are not causing new problems in other parts of the system while trying to fix something. Although these measures tend to be measures of cost or patient experiences, any of the process or outcome measures could be used as balancing measures if they help us look at the whole system.

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We will now present two examples of measures selected for improvement projects. The first is a hospital example. In this example, the staff of the ICU set an aim to reduce the number of ventilator-associated pneumonias (VAP). They set a specific aim with a clear timeline. For process measures, they choose factors that have been chosen to relate to VAP. For example the more days a patient is connected to a ventilator the more likely he will become infected. The outcome measure is actually the number (or rate) of VAP. This measure ties directly to the aim. In this case, staff members have chosen to use cost of care as a balancing measure since there is a chance that by incorporating the changes they must decrease the rate of VAP, and the cost of care will improve. They also included the rate of re-intubation as a balancing measure since it is possible that some of the changes they incorporate may cause patients to be extubated too soon. These are two examples of how balancing measures look at the rest of the system. In our ambulatory example, the team members want to improve their access to care. To do so they will reduce the time it takes patients to get an appointment. In this case, the process measures are the supply (or amount of slots available for practitioners to see their patients), the demand for appointments, and the no-show rate. The staff chose to include the no- show rate in the process measures because they believe that by reducing their no-show rate they will have more space to see patients sooner. If they thought that the changes they wanted to incorporate would increase the number of no-shows in the schedule, they would have added this measure to the balancing measures. The outcome measure is the third next available appointment. It is a good measure of access, since it disregards appointments that are available due to last moment cancelations. Again the outcome measure ties directly to the aim. Finally, the balancing measure the staff chose is a measure of patient satisfaction. As you can see, setting a measurement strategy is not cut and dry. You need to make some assumptions regarding where you envision your system is going.

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After you set your measurement strategy it is time for you to consider the change you want to test. As you consider change you will first need to decide on basic concepts or strategies that you want to focus on. Overall ideas for change will lead you to improvement, but they are not specific enough for testing change.

In our VAP example, our concepts and strategies could be:

•Reduce the number of ventilator days,

•Reduce over-sedation

•And improve oral hygiene.

Once you have established the overall categories, you will design tests to measure change. To accelerate improvement, the tests of change need to be small, fast, and frequent. This way you will be able to build new tests of change on your initial improvement and head toward your aim. Examples of tests of change in our example could be some of the following.

To reduce the number of ventilator days: we could have the respiratory therapist test the settings every two hours to determine when a patient is ready for extubation, the rounds should include discussion of extubation for all patients, trials of spontaneous breathing could be included as part of the routine. As you can see, these are specific tests that can be done fairly fast and of which we could have results in a day or two.

To determine the effect of a test, you may need to include measures and discussion of the test. Continuing with the example we have been using, we could meet with the respiratory therapist to determine at the end of the first day how the tests are going and determine if they need some tweaking.

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In designing your change package you may want to consider using pre-existing change packages. These are built by QI professionals based on scientific evidence.

This is an example of one such change package. The table contains a partial copy of the California Academy of Family Physicians Diabetes Initiative Care Model Change Package. It was originally developed by Lumetra, California’s Quality Improvement Organization, under contract with the Centers for Medicare and Medicaid Services to assist practitioners to improve the care of patients with diabetes.

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The final component of improvement is learning about your system. Intertwined in all aspects of improvement is the concept of the importance of understanding your system in order to be able to improve it. This is based on a system theory proposed by William Deming, a well-known statistician. His theory of profound knowledge is based on the principle that each organization, (department, site) is composed of a system of interrelated processes and people. Improvement of the system depends on the capability to organize the balance of each component to enhance the entire system. Thus understanding and learning about your system is essential to improving it.

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This concludes Lecture b of Introduction to Quality Improvement and Health Information Technology. In summary, quality of healthcare in the US needs improvement. Quality improvement is an ongoing process that includes the setting of an aim, a progressive measurement, change test, and understanding of the system.

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Welcome to Quality Improvement: Introduction to Quality Improvement and Health Information Technology. This is Lecture c.

1

The Objective for Introduction to Quality Improvement and Health Information Technology is to:

•Analyze the ways that HIT can either help or hinder quality improvement.

2

So what needs improvement in our healthcare system? In 2001, the US Institute of Medicine (also referred to as the IOM) produced a report that called for a marked redesign of the American healthcare system. In this report, the IOM called for transformational change that will help to close the quality gap. In addition, the IOM provided far-reaching principles that provide directions for those who purchase healthcare, those who provide healthcare, those who regulate healthcare and those involved with policy-making for healthcare.

This report identified six aims of quality improvement. These aims state that healthcare should be:

•Safe,

•Effective,

•Patient-centered,

•Timely,

•Efficient,

•And equitable.

3

Most of our interest in increasing the use of Health Information Technology is its potential to improve the quality of healthcare as we know it, to increase our ability to achieve the six aims of quality improvement. Not only does Health IT have the potential to improve quality and prevent medical errors, but it also has the ability to increase efficiencies of all kinds, reduce cost, and decrease paperwork. HIT also has the potential to expand access to affordable care and improve population health.

Mr. Smith was prescribed a blood thinner to be taken once a day. He received his daily dose of the drug and was then transferred to another unit. In the receiving unit, the blood thinner order was rewritten and POE interpreted this as a new order and scheduled a dose to start that same day. This resulted in Mr. Smith receiving two doses of the drug during the same day.

Considering this case, how would you address this issue?

5

Safety is defined as freedom from the occurrence or risk of injury, danger, or loss. When applying the term to patients, we are speaking of protecting our patients from unintentional harm from the care that is intended to help them. HIT has the potential to protect patients from unintentional harm. Computerized Provider Order Entry (CPOE) can reduce errors in drug prescribing and dosing by triggering alerts when doses exceed acceptable limits, for example. Medical device interfaces allow for automated capture of vital signs, such as heart rate and blood pressure. This reduces the possibility of error on the part of the human who collects this information by eliminating the transcription step. The electronic medication administration record can reduce errors in drug administration by displaying a record of drugs that have already been administered, and those that are scheduled to be administered.

An electronic allergy list can reduce errors by preventing adverse drug events caused by administering drugs the patient is allergic to.

Knowledge links can reduce errors by providing links to reference materials when there is a lack of knowledge on the part of the prescriber or the patient. Quality metric reporting can identify opportunities for improvement. Reminder prompts and flags can reduce errors in omission by reminding providers of interventions that are scheduled, and structured notes use standardized observations that can reduce errors related to failure to detect subtle changes in status.

6

In response to this event, a decision rule, or medical logic module (MLM), was created that provides the following functionality: When selected drugs are ordered at a frequency of every 24 hours or longer, the prescriber is automatically presented with the last administration time if the drug had been ordered previously.

In this example, the way in which the CPOE was configured was not helpful to prescribers who were trying to order drugs taken once per day. In fact, a patient’s safety was compromised in that he received duplicate medication therapy. This appears to have been, in part, due to the way in which the system interpreted an order. A careful review of reported events such as the event depicted here often results in recommendations for change to the way the IT system is configured. For this reason, it is helpful to appoint an IT professional to sit on incident review committees.

7

Early detection and effective treatment are the cornerstones of treatment for pneumonia. Adults aged 65 and older should receive the influenza and pneumococcal immunization to prevent pneumonia and its complications.

8

Clinical effectiveness can be enhanced by HIT by providing knowledge links to clinical practice guidelines in order to increase use of best practices; quality measure reporting to identify gaps in practice; reminders in the form of practice alerts and flags; and structured notes to guide providers through standardized observations to enhance assessment and diagnosis.

9

There are a number of best practices that are written in the form of protocols or practice guidelines. Protocols provide guidance for care surrounding particular clinical conditions to increase the effectiveness of care. Think about a scenario in which a standard protocol (document specifying best practices for care) and electronic prescriber order sets are used for all adult patients receiving intravenous blood thinners.

Considering this case, how would you address this issue?

10

There are new changes to the protocol due to a switch to new laboratory tests for monitoring drug activity. The team responded to this event by revising the current protocol and electronic-order sets to include orders for the new laboratory tests. The new order sets included changes to the therapeutic goals of nurse-managed therapy.

In this scenario, modifications made to changes in the protocol required changes in the electronic order sets that had been in use in the facility. Keeping up with care standards requires up-to-date order sets and electronic clinical documents. Here it is helpful to have HIT professionals involved in protocol-development work.

11

Telemedicine is the use of telecommunication technology to provide, enhance, or expedite healthcare services. This technology is typically used to increase access to clinical expertise to improve the effectiveness of care.

12

Patient-centered care is supported by HIT as well. Patient-friendly websites provide medical information and access to support groups; patient portals allow patients to access and manage their own health records; clinical decision support can tailor information according to patient characteristics; and customized health education and disease management messaging can enable patient self-management.

13

Mr. Jackson took his mother to a pre-operative evaluation center in preparation for her impending surgery. He was asked to help her complete an information form that included her home medications. Mr. Jackson’s sister manages these medications and he had forgotten to bring the list. He was unable to contact her on her cell phone and became increasingly frustrated since, after all, his mother’s doctors should know what medicines she is taking! In response to this event, the ambulatory care center implemented a web-based patient portal that would allow patients or caregivers to enter much of the history information in advance, from home. Patient satisfaction scores improved with this active role in their care.

Consider how you would address this issue.

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Effective patient-provider communication, where the patient and family perceive themselves as participants in the patient’s care, is essential for quality health care. The scenario depicted in the previous slide highlights a frequent situation encountered surrounding the issue of home medications. Collecting an accurate and current home medication list at each patient encounter is a national patient safety goal. HIT can help to engage the patient and family in the patient’s care to ensure that this goal is met.

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A medical office practice is considering the use of a web-based secure messaging system to improve patient-provider communication and enhance patient satisfaction.

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HIT can support timely care. Telemedicine provides immediate access to medical information through the internet. Task list schedules can remind nurses when treatments are due. Time-sensitive prompts, such as timed draw alerts, can remind nurses when a procedure is due; and patient reminders can let patients know when they need to return for follow-up visits or tests.

17

Timeliness is a quality aim that is especially amenable to HIT solutions. In this scenario, the importance of timely placement and removal of medication patches lends itself well to an HIT solution. Medication patches are small, flesh-colored, and are usually placed in discreet locations, for example, the upper shoulder area or on the back of the upper arm. Some patches are appropriately left on for 2-3 days or longer. It is difficult to track the placement and removal of these patches over time, leading to errors in which medication patches were not removed and the patient received too much medicine.

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In response to this event, a change was made to the Electronic Medication Record (eMAR). After the nurse documents the application of the patch in the eMAR, a follow-up task to remove the patch at the ordered date and time is automatically generated. If the follow-up task is still active during a transfer in care, the receiving nurse will see this task on the eMAR.

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Patient-satisfaction surveys reveal that timeliness of care is a powerful indicator of healthcare quality from the patient’s perspective. Patients and families value their time as much as do health care professionals. HIT can help by ensuring timely access to information. Think about the following case: A health care system saw increases in adverse events in their home care company due to inadequate transfer of clinical information at hospital discharge. An electronic hospital discharge summary with auto-faxing was developed to increase availability of discharge information at the time of follow-up care.

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HIT can enhance efficiency in many ways. Wireless mobile technology allows for vital sign capture and can eliminate the need to write or type vital signs. Character expansion allows for the ability to translate a few characters into phrases, sentences, or paragraphs and can decrease typing time. For example, the provider can type a few letters, such as WNL, which can be converted to within normal limits or an entire paragraph describing the normal assessment parameters. System integration allows for pulling forward of historical information and can reduce data collection time. Clinical decision rules can be written to prompt for duplicate labs to reduce redundant laboratory testing.

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In fast-paced healthcare settings, such as emergency departments and operative suites, a tracking board can help to streamline throughput (or admission, discharge, or transfer activity). Think about a situation in which the Emergency Department (ED) staff at a community hospital used a large whiteboard mounted on the wall that could be quickly updated with felt-tip markers to track patients and treatments. The problem was that staff could not obtain information from the board unless they were physically standing in front of it. In addition, information on the board only reflected what was already known by the ED staff.

Consider how you would address this issue.

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In response to this event, the hospital implemented an automated ED patient- tracking system that used business intelligence technology. This technology enabled more efficient patient flow using real-time data.

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Hope Memorial Hospital implemented an electronic Picture Archiving and Communication System (PACS) for requesting radiological examinations and displaying images. They saw a reduction in repeat chest X-ray films at outpatient appointments.

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Finally HIT can enhance equity of healthcare and services. Data capture can allow for monitoring by population characteristics to uncover healthcare disparities. The multi-modal functionality of systems can allow for various ways for patients to get health information to decrease health care disparities. Competency-based patient education can tailor information to the patient’s educational background and developmental status. Decision support can offer drug cost information to assist providers in selecting alternatives for low-income patients.

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This concludes Lecture c of Introduction to Quality Improvement and Health Information Technology. In summary, all healthcare settings can benefit from the assistance of HIT professionals in identifying electronic solutions to quality concerns.

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Welcome to Quality Improvement: Principles of Quality and Safety for HIT. This is Lecture b.

1

The following unit is presented by Dr. Peter Pronovost, a practicing anesthesiologist and critical care physician, teacher,

researcher, and international patient safety leader. Dr. Pronovost is a professor in the Johns Hopkins University and director of

the Armstrong Institute for Patient Safety and Quality at Johns Hopkins. The institute focuses on eliminating preventable harm

for patients.

The Objectives for Principles of Quality and Safety for HIT are to:

•Investigate the fallibility of people and systems.

•Describe the ways that every system is designed to achieve the results it gets.

•Apply the basic principles of safe design.

•Explain the ways that teams make wise decisions with diverse and independent input.

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Now let’s move on to the next idea, and that is you understanding the principles of designing safe systems. And they are

standardized work whenever you could, and, that is, either by eliminating steps, if possible, so that the mistakes cannot even

occur or standardizing work. Second, is to create independent checks, or checklists, for things that are really mission critical;

things that are really important for you to do. And lastly, learn when things go wrong. You see, in health care we’re really, really

good at recovering from mistakes, but pretty poor at learning. That is, actually reducing the risks that future patients won’t be

harmed. To learn we need to answer four questions: What happened? Why did it happen? What did you do to reduce risk? And,

most importantly, how do you know that it actually worked?

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4

So, let me give you an example we were trying to reduce catheter infections You may have read about this in my book, Safe

Patients, Smart Hospitals. There are types of infections that we give patients when they have catheters typically tubes that go

into their neck to deliver medicines or monitor their heart. And what we found is that doctors were supposed to comply with a

checklist when they were placing these catheters that required them to cover themselves to wear a gown, to cover the patient.

In essence, they needed about eight pieces of equipment. But that equipment wasn’t stored together. We made our docs run

around the hospital seeking it. Often times, it wasn’t stocked, and, predictably, they would go without it sometimes. So we could

have just told them to try harder, but we took a systems approach. So what did we do? We got a cart that stored all the

equipment that was needed to comply with this checklist. We standardized the procedure took eight steps down to one, and

compliance went up dramatically.

You may have seen this in your own life with going to an ATM machine, it’s a great example of eliminating steps so that errors

can’t occur. You can see that in many of the older ATM machines, and perhaps a few of the current ones, you used to put your

card in, the machine would keep your card, you’d type in what you want, it would spit out your money and then it would spit out

your card. And many, many people left their cards behind, because once we got our money, predictably we’re human we’d walk

away. And that was a very expensive mistake for banks because they had to go back and correct all the forms and paperwork

and, not to say, very expensive and annoying for consumers.

Now, the banks could have put a sign up on the ATM machine that said “Ok, be careful. Try harder. Be more vigilant,” but they

didn’t. They took a systems approach and what did they do? In most ATM machines now you can’t even make this mistake

because your card never leaves your hand. You swipe it. They eliminated the potential for making this mistake by taking that

step out, and as a result, the error of leaving your card behind went down several hundred times. Great example of how you

could just eliminate a step and make care dramatically safer.

5

Ok lets go into some independent checks. Now the greatest example of this is a seatbelt. As you all probably know, there’s

quite good data that buckling your seats results in improved safety for yourself and your passengers. Because without them we

tend to go flying out of cars, but we’re human. We get busy, we sometimes forget to do it so what do most cars have now? An

independent check where, if you don’t buckle your seat once the car is moving, you get either a beep that might get louder or

you get a rather annoying voice speaking to you, but some independent check, a reminder to say, “Hey buckle your seatbelt, it’s

important to you and you forgot and, lo’ and behold, these things work!” I suspect many of you have had this beep go off in your

cars and have complied and started bucking your car seat. Remarkably effective. We haven’t applied them as much as we

could in health care. Now, we can’t have these things beeping for everything, because it would annoy clinicians and work

wouldn’t be able so we have to be judicious about thinking about what’s most important.

6

These principles of designing safe systems don’t just apply to technical work but they apply to teamwork. And I love this model of communication because it

applies to really any kind of communication you do with your family, with your colleagues, with patients at work. And what it says is that the center of a

message encodes some meaning and that might mean the words are ambiguous so that they don’t have a direct clarity about what they do but they are more

innuendos. There is a most certainly non-verbal communication either through tone or eye and facial movements. And that message passes through an

environment that in health care is often noisy or chaotic and it goes to a receiver who has to get that message and then decode what the meaning was in

what you asked them to do. And that decoding could be corrupted, that is, there can be truly a translation error the more the wording is vague, the more the

receiver is distracted or not paying attention, the noise in their environment.

So let me give you an example. If I came home from work and I say to my wife, “Oh, I had a rough day at work.” She immediately decodes that to say, “So

what your saying is that you want to go take a jog and not give our kids a bath.” And she’s absolutely spot on that’s what I was saying. But we’re familiar with

each other, we have that decoding so we don’t have a translation error. Most people in health care don’t know each other that well. We’re not that familiar,

and so, with that, we’re at enormous risk for decoding errors and we don’t standardize and say explicitly what we mean when the receiver doesn’t read back

and create an independent check to insure that they heard what they said.

Let me give you an example. When we make rounds in the ICU now, we have a tool called “the daily goals.” The sender says explicitly what’s going to

happen for every patient in the intensive care unit. The nurse then reads back and confirms that she heard or he heard what the plan was and the probably is

that about half the times, they decoded it as a mistake. When they check back to confirm, we then say, ”No that’s not exactly what I was talking about. What I

meant was this,” Imagine if you didn’t have that read back, half the time there are errors that wouldn’t get caught. So applying these principles of

standardizing communication, creating independents checks and then when you communicate erroneously learn are critically important. Now, this last idea of

the science of safety is for you to understand the notion that teams make wise decisions with diverse and independent input, diverse and independent input.

And what that means is that the more lenses you get about a problem, the more input you get from consumers, from patients, from parents, from colleagues,

the wiser a decision you’re going to make. Now if you are the decision maker, you ultimately still make the decision. It doesn’t compromise your authority, but

you will make better decisions when you have a broader and richer view.

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Great example of this is this jelly bean test that it was written about in a book by Jim Surowiecki called the Wisdom of Crowds.

In this and you may have done this at your church or at a fair there’s oftentimes groups of people will be asked to guess how

many jelly beans are in a jar and whoever gets closest typically will win the jelly beans. What researchers have found is

something remarkable, that while any individual guess might be off in groups say over thirty or fifty, a large enough group, the

group mean is remarkably close often within a few jelly beans from what the actual number is. What the idea here is that there

is wisdom in this group that on average will get things right, and the more you can tap into that wisdom in designing information

systems, the better off you’re going to be.

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We see so many examples where information systems or code comes down from on high, with little input from clinicians or

diverse or software programmers and we’re poorer for it. I have a little metaphor about this. As you may know, Hopkins is a big

lacrosse school. And, in lacrosse or in soccer, if you get a penalty, you play man down. For the women out there, I tried calling

it woman down or person down, but even many of the women who play lacrosse say we still call it man down. So let’s go with

the phrase “man down.” When you’re in the penalty box, you’re clearly disadvantaged indeed. Several years ago, Johns

Hopkins almost threw away the national lacrosse championship to Duke when they got a penalty with a few minutes left and

Duke scored several goals when they were man down. Luckily Hopkins hung on to win the game. But as I watched that, I sat

there and thought why on earth do we voluntarily play man down every day at work in health care by not listening to our

patients, by not listening to nurses, by not listening to our colleagues. It’s a foolish way to play. Frankly, we’re disadvantaged

and we’re going to lose. So what you need to do is, if you see something or you think there’s a risk, speak up and when others

are speaking up, make sure that you’re giving them their due.

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So what’s your role and how can you apply these principles in your work? Well first if you accept that you’re fallible, assume

that things will go wrong, don’t believe that no matter how expert you are in informatics that you’re going to program or do your

work flawlessly. You’re going to make mistakes as we all will. So assume that things are going to go wrong so you can defend

against them. Secondly, develop lenses to see these systems. When things go wrong, don’t just see yourself or your colleagues

and patients. Think about training, think about teamwork, think about protocols. Third, work to mitigate both the technical and

teamwork risks in your environment. Do that by standardizing your work and that means, for example, limit the number of

choices of drugs that people have so you don’t have to choose from thirty in a drop down list. Create independent checks. If

something is really, really critical, make sure the information system has a fail safe to say, “This is too important. We have to

confirm its right.” And learn from your mistakes. Next is make sure that you apply this knowledge of making wise decisions by

getting input from others whenever you make decisions. You don’t need to make this work in a vacuum.

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And lastly, keep patients as your North Star. This work that you are embarking on is really about them and make sure that the

way we organize our work isn’t geared solely around clinicians. It’s not geared around the information technology people. It’s

geared around patients and their needs, because, at the end of the day, we have to make sure that people like this little girl who

died needlessly of a catheter infection that wasn’t treated appropriately, no longer suffer these kinds of harms. And I’m confident

that with your leadership and with this training you will be able to do so. I thank you and I hope you enjoy the class.

11

This concludes Principles of Quality and Safety for HIT. In summary, in this unit, we’ve learned about the ways that teams

make wise decisions with diverse and independent input. We’ve also learned about the importance of communication and

especially the place of critical listening. We’ve learned about the ways that teams make wise decisions with diverse and

independent input. We’ve also explored the importance of communication and especially the place of critical listening.

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Welcome to Fundamentals of Health Workflow Process Analysis and Redesign, The Concepts of Health Care

Processes and Process Analysis. This is Lecture a.

This component, Fundamentals of health workflow process analysis and redesign is a necessary component of complete

practice automation and includes topics of process validation and change management

This unit, Concepts of Health Care Processes and Process Analysis, covers the need for Health Care Workflow Analysis

and Redesign, the processes common in the health Care setting, and the role of Health Care Workflow Analysis and Redesign

Specialist.

1

The objectives for this unit Concepts of Health Care Processes and Process Analysis are to:

• Describe the purpose for process analysis and redesign in the clinical setting,

• Describe the role of a Practice workflow and information management redesign specialist and contrast it with other roles such as technical support and implementation management,

• Explain how health care process analysis and redesign and meaningful use are related,

• Analyze a health care scenario and identify the components of clinical workflow,

• Given a scenario of health care analysis and redesign, analyze the responsibilities of each participant in the process and how the roles complement or overlap with one another, and finally,

• Describe how the workflow processes used by a health care facility might differ depending on the type of facility.

2

Tom DeMarco, an early pioneer and thought leader in process analysis, said in his 1979 book, Structured Analysis and System

Specification, that “Procedure, like dance, resists description” (Demarco, 1979). One of the workforce roles described by the Office of the National coordinator for Health IT (ONC), is the Health Care Workflow Analysis and Redesign Specialist. Using

this analogy, individuals in process analysis and redesign jobs are experts at both “describing the dance,” and at “choreographing a better one.”

This Curriculum component, over several units, covers the concepts of processes, process analysis, and process redesign, and

provides the information and practice necessary to develop process analysis and redesign skills.

3

Before we start, and in a way, as an introduction, we will cover the following definitions:

• Process,

• Process Analysis,

• Process Redesign,

• Workflow,

• Workflow Analysis, and

• Data and Information Flow.

4

Merriam-Webster (2011) defines process as a series of actions or operations conducing to an end. Similarly, the American

Society for Quality (ASQ) (2011) defines Process as “a set of interrelated work activities characterized by a set of specific inputs and value added tasks that make up a procedure for a set of specific outputs.”

Still another authoritative source, the Business Process Modeling Notation (BPMN™) standard (Miers and White, 2008) defines

a process as, “what an organization does – it’s work – in order to accomplish a specific purpose or objective.” And goes on to say that most processes have input, consume resources, and produce output.

The word Procedure is related to process. The American Society for Quality (ASQ 2011) defines a Procedure as: “The steps in a process and how these steps are to be performed for the process to fulfill a customer’s requirements; usually documented.” Processes can be described at different levels of detail – High level, i.e., not much detail, or a very granular level, i.e., a lot of detail. I think of the latter as a procedure.

Important characteristics of processes for our work are that processes have 1) steps, also called activities, actions, operations,

or tasks, 2) the steps have sequence or order, 3) processes have inputs and outputs, and that 4) processes happen over and

over, i.e., are ongoing. For example, appointment scheduling is a common process in health care facilities.

5

Merriam-Webster (2011) provides several definitions for the word analysis. The one most relevant for our work here is: “an examination of a complex, its elements, and their relations or a statement of.”

So, a Process Analysis is an examination of a process to understand its elements such as the inputs, the process steps, the

outputs; and the relationships between them, including things like:

• the order of steps,

• what things can be done in parallel versus sequentially,

• who or what performs the steps,

• maybe where they are performed, and

• what information is needed or generated.

Because the goal of our “analysis” is to ultimately improve a process, we also look for things like gaps, lack of conformity with best practice such as meaningful use of health IT and health care quality improvement, delays, redundancy, rework, and lack of

efficiency. For us, the combination of 1) understanding process elements and the relationships between them and 2)

identification of opportunities for improvement comprise Process Analysis.

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Merriam-Webster (2011) defines redesign as: “to revise in appearance, function, or content.”

Process Redesign, then, is the revision in appearance, function, or content of a process. The reason why we analyze a process

is to improve it. The improvement is achieved through Process Redesign. A significant amount of process redesign in health

care today involves the introduction of electronic health records (EHR). A report published by the Institute of Medicine (2001),

Crossing the Quality Chasm, offers six key areas in which health care in general can be improved, and ultimately these six

areas, discussed in detail later, are our goal. For now, we will think of “better” as “safer, more efficient, more convenient, less errors, and more cost effective.”

In quality improvement, process redesign, also called process re-engineering, sometimes has the connotation of, drastic and

major changes expected to result in breakthrough improvements. The American Society for Quality (2011) defines Process Re-

engineering as: “A strategy directed toward major rethinking and restructuring of a process; often referred to as the “clean sheet of paper” approach.”

This is in contrast to Process Improvement, which sometimes takes on the connotation of more incremental change, is

defined more specifically by the American Society for Quality (2011) as: “the application of the plan-do-check-act cycle to processes to produce positive improvement and better meet the needs and expectations of customers.” We will cover more

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about both of these different approaches in the unit on Process Redesign.

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The Workflow topic on Wikipedia (2011) defines workflow as: “A workflow consists of a sequence of concatenated (connected) steps.” Another online resource defines workflow as, “the sequence of processes through which a piece of work passes from initiation to completion (Concise Oxford English Dictionary, 2011).”

In everyday use, the terms workflow and process are used interchangeably. Workflow is often more specifically thought of as

the flow or path of the work steps, i.e., the way in which work progresses, including things like order of steps and selection

between alternative steps. Like a process, a workflow has inputs and outputs, i.e., resources (mass, energy, information) and

the people or things that perform the steps or activity that comprise the work are considered. In this component, the words

workflow and process will be used interchangeably.

8

Now that we have defined workflow and processes in general, we can talk more specifically about health care. Clinical Workflow is way in which activities in the health care setting are carried out, by whom, in what order, etc. Examples of clinical workflows include:

Admitting a patient

Submitting a claim

Prescribing a medication

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Think about your last visit to your provider. If you could break the visit up into clinical processes, what would they be?

Pause the slides while you write them down on a piece of scratch paper.

10

You might have listed:

• Patient registration / intake / payment

• Waiting to be seen

• Information checking / gathering

• Checking vital signs

• Visit with the clinician

– Ordering tests

– Diagnosis

– Writing prescriptions

• Drawing blood

• Referral to another provider

• Billing

Or something like them. They are all sets of activities that accomplish a particular goal (a sub-goal) of a patient visit. For

example, checking vital signs measures and records necessary data for patient care. Information checking such as medication

reconciliation, i.e., comparing the medications that the patient is currently taking to those that are listed in the patients chart, is

necessary for quality of care and patient safety. Each of these processes accomplishes a part of a patient visit; each would e

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considered a process or a workflow.

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One person’s data flow may be another person’s information flow … Like process and workflow, the words data and information have specific definitions that are used in certain fields, and are often interchanged on other fields and in everyday

use.

Early work done in the 1960’s and 70’s uses the term “data flow,” more people today tend to use “information flow”, for the distinction see (the diaphoric definition of data -DDD and the general definition of information - GDI).

For this component, and because most of the literature that you will see uses the two words interchangeably, in this

component, we will too.

When we use the terms data flow and information flow, we mean the steps or path that the data takes through a work process

or a system or some combination of both, including the order of steps, and operations performed on the data (or information).

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A practice workflow and information management redesign specialist uses knowledge and understanding of two key things 1)

an organization’s objectives, structure and procedures, and 2) information technology for the purpose of improving how the organization operates and achieves its goals.

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The role of practice workflow and information management redesign specialist is one of 12 roles defined as necessary by the

Office of the National Coordinator for Health IT to achieve meaningful use of health information technology using Electronic

Health Records -- a goal for all Americans by 2014. This component covers material critical for the workflow and information

management redesign specialist role. Other roles, such as implementation specialist, will also benefit from this material.

The description, expected background and competencies for the role are provided in a supplemental handout sheet. Workers in

this role assist in reorganizing the work of a provider and facility staff to take full advantage of the features of health IT in

pursuit of meaningful use of health IT to improve health and care. In contrast to other roles, the practice workflow and

information management redesign specialist works with providers to make changes in clinic processes.

14

Tom DeMarco, introduced earlier as a pioneer and thought leader in process analysis, likens process analysis to describing

a dance. He adds further insight to the process analysis part of the role by emphasizing the intensive communication

requirement, and by describing the following three key communications challenges that process analysts face:

• The first is the Natural difficulty in describing any process or procedure.

• The second is the inappropriateness of narrative text for describing procedures, and

• finally there is a lack of common language between the user and analyst.

Practice workflow and information management redesign specialists require very strong written, visual/graphic, and verbal

communication skills to overcome these challenges. Successful Practice Workflow and Information Management Redesign

Specialists are strong listeners, and are able to identify when others are uncomfortable or having difficulty or not in

agreement and are able to constructively work through difficult situations.

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DeMarco further outlines process analysis skills helpful to overcome the challenges inherent in Process Analysis. These are:

• Knowledge of data and data system concepts,

• Knowledge of clinical workflow concepts, and the

• Ability to communicate these concepts.

We added the ability to identify problem areas.

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If Process Analysis is describing the dance, Redesign is choreographing or planning a new dance. For us, the dance is the

interaction between humans, information and computers in the clinical setting. The key skill a Process Redesign Specialist

needs is the ability to combine, analyze and synthesize the organizational knowledge, including knowledge of clinical workflow

and technology to create a “better way.”

John Gall in his 1970’s book Systemantics said, “systems run best when designed to run down hill.” The goal of process re- design is to find the “down hill” design, i.e., the design that takes the least amount of input energy to get the desired output. The “down hill” design is the one that will have the least errors, the highest quality, the happiest staff, and the lowest cost.

A professor at the University of Arkansas, Dr. Elizabeth Pierce, told a story in one of her information quality classes about Penn

State that is a great example of designing systems that run down hill. At Penn State Campus, the foot paths made by students

did not last very long. Whenever the University built a new building or expanded, instead of fencing off new landscaping, they

left it open and waited for students to make paths between the buildings. The architects and landscaping staff waited to see

where the paths were worn. These were usually the shortest distances between the most important places on campus, and the

places where walkways were most needed. Once they were spotted, the foot paths would be replaced by a paved walkway to

make the new route a permanent part of the campus map and with good lighting so they were safe. Or if the foot paths were

considered unsafe or undesirable, the campus planners would find some type of barrier to discourage further use of the foot

path. Less wise institutions are not able to see the signs of a process trying to “run down hill” and fence off areas as soon as

17

new construction is complete. People still make paths, but they are muddy and messy and lack safe lighting.

I recently heard of a similar example in intensive care units. It is important for people on a ventilator to have the head of their bed at a

30o – 45o angel. One creative and early team in health care quality improvement used red tape to mark the bed so that it was easy for

the staff to see whether or not the bead angle was correct. This was much easier than other methods like, a question on a check list, “is the height of the head at least 30 degrees?” A clever person redesigned the process to “run down hill”.

17

Why do we need to analyze and redesign the processes currently used in the health care organization?

Why are we implementing health information technology in the clinical setting at all?

A 2000 Institute of Medicine (2000) report estimated that 98,000 or more people die annually in the US due to medical errors, .

This is more than die from motor vehicle accidents, breast cancer or AIDS, and more than die from Alzheimer's, diabetes or pneumonia.

The 2001 report, Crossing the Quality Chasm, specifically listed five imperatives for increasing quality of health care in the United States. This list included

1. Reengineered care processes,

2. Effective use of information technologies,

3. Knowledge and skills management,

4. Development of effective teams, and

5. Coordination of care across patient conditions, services, and sites of care over time (Institute of Medicine, 2001).

Most of these involve or depend on Health IT. Process Analysis and Redesign is at the heart of increasing the quality of health care.

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As the great thought leader of quality, Edwards Deming stated, “You can only elevate individual performance by elevating that of the entire system” thus, this effort is focused on the entire health care system. (Demming, 1982)

18

Crossing the Quality Chasm provided six aims and simple rules for redesign of health care. They are:

1. Care should be safe, as safe for patients in their health care facilities as in their homes.

2. The science and evidence behind health care should be applied and served as the standard in the delivery of care.

3. Care and service should be cost effective and waste should be removed from the system.

4. Patients should experience no waits or delays in receiving service.

5. The system of care should revolve around the patient, respect patient preferences, and put the patient in control.

6. Unequal treatment should be a fact of the past; disparities in care should be eradicated. (Institute of Medicine,

2001)

Importantly, increasing the quality of care is our goal. Implementing technology is a way to achieve this goal.

19

“Meaningful Use” of EHRs is used to collectively describe those criteria established by the American Recovery and Reinvestment Act or ARRA to qualify health care providers for the electronic health record incentives to be provided. The

purpose of these incentives is to encourage the greater health care community to implement EHRs. The expectation is that the

coordinated adoption of EHR use across health care providers will address the five established national health policy priorities.

The Health Information Technology for Economic and Clinical Health (HITECH) Act incentives and assistance program seeks to

improve . . . the performance of the U.S. health care system through “meaningful use” of EHRs to achieve five national health care goals:

1. Improve quality, safety and efficiency and reduce health disparities,

2. Engage patients and families,

3. Improve health care coordination,

4. Improve population and public health, and

5. Ensure adequate privacy and security protections for personal health information (PHI).

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Meaningful use of Health IT includes the following things (Department of Health and Human Services, 2010):

• Data Capture,

• Data Standards, such as

 - ICD, SNOMED, RxForm, LOINC,

• Effective Clinical Workflows,

• Computer-based Order Entry,

• E-Prescribing,

• Clinical Decision Support,

• Patient Health Information Exchange,

• Privacy and Security, and

• eMAR (Medication Administration Records).

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For providers to meet or successfully claim that they are using Health IT meaningfully, they must achieve the requirements

stated in the meaningful use rule. An example of such a requirement is “More than 30 percent of all unique patients with at least one medication in their medication list seen by the eligible provider have at least one medication order entered using

CPOE” (Eligible Professional Meaningful Use Core Measures Measure 1, 2010).

Another example is “More than 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient recorded as structured data” (Eligible Professional Meaningful Use Core Measures Measure 3, 2010). The full criteria is available on the CMS website at http://www.cms.gov/EHRIncentivePrograms/

22

Meaningful Use (MU) includes both a core set and a menu set of objectives for eligible professionals, eligible hospitals and

CAHs. Meeting 20 of 25 for eligible professionals and 19 of 24 for eligible hospitals and critical access hospitals (CAHs)

qualifies the facility for a government (Centers for Medicaid and Medicare) incentive payment in the early program years and

prevents a penalty there after (Department of Health and Human Services, 2010).

Meaningful Use (MU) requirements get tougher each year. The incentives are a fixed dollar amount for the initial years while

the penalties for not meeting the requirements are in the form of a several percentage point decrease in the reimbursement

payments from the Center for Medicaid and Medicare (CMS) in later years (Department of Health and Human Services, 2010).

To a large hospital, this means millions of dollars. To small and large practices and health care facilities alike, the MU

incentives considerably offset the cost of obtaining and implementing Health IT.

23

A Qualified EHR (Department of Health and Human Services, 2010) is defined as an electronic record of health-related

information on an individual that:

• Includes patient demographic and clinical health information, such as medical history and problem lists; and

• Has the capacity to:

 provide clinical decision support

 support physician order entry

 capture and query information relevant to health care quality and

 exchange electronic health information with, and integrate such information from, other sources

An EHR Module is defined in the Final Rule to mean “any service, component, or combination thereof that can meet the requirements of at least one certification criterion adopted by the Secretary” (Institute of Medicine, 2001).

24

Stage 1 of the Meaningful Use requirements lay the groundwork for what is planned to become a secure nationwide health

information network with the purpose of improving the quality and safety of patient care and increasing the efficiency of the

health care delivery system.

The Final Rule, i.e., 42 CFR Parts 412, 413, 422, and 495, defines Certified EHR Technology (Department of Health and

Human Services, 2010) as:

1. A complete EHR that meets the requirements included in the definition of a Qualified EHR and has been tested and

certified in accordance with the certification program established by the National Coordinator as having met all applicable

certification criteria adopted by the Secretary; or

2. A combination of EHR Modules in which each constituent EHR Module of the combination has been tested and certified in

accordance with the certification program established by the National Coordinator as having met all applicable certification

criteria adopted by the Secretary, and the resultant combination also meets the requirements included in the definition of a

Qualified EHR.

An EHR Module is defined in the Final Rule to mean “any service, component, or combination thereof that can meet the requirements of at least one certification criterion adopted by the Secretary” (Department of Health and Human Services, 2010).

25

A Qualified EHR is defined as an electronic record of health-related information on an individual that includes patient

demographic and clinical health information, such as medical history and problem lists; and has the capacity to provide clinical

decision support, support physician order entry, capture and query information relevant to health care quality, and exchange

electronic health information with, and integrate such information, from other sources.

In order to attain these levels of functionality, and thus achieve meaningful use, eligible professionals and hospitals must adopt

EHR systems which, at a minimum, adhere to the standards, implementation specifications, and certification criteria included in

the Final Rule.

The standards are organized into categories:

• Vocabulary standards (i.e. standardized nomenclatures and code sets used to describe clinical problems and procedures,

medications, and allergies),

• Content exchange standards (i.e. standards used to share clinical information such as clinical summaries, prescriptions, and

structured electronic documents), and

• Transport standards (i.e. standards used to establish a common, predictable, secure communication protocol between

systems).

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This concludes Lecture a of Concepts of Health Care Processes and Process Analysis.

In this lecture, we:

• Defined key terms, including Process, Process Analysis, Process Redesign, Workflow, Workflow Analysis, and Data &

Information Flow.

• Described the practice workflow and information management redesign specialist role and skills. In addition, we worked an

example where we described a patient visit in terms of clinic processes.

• Discussed the patient safety and health care quality reasons why Health IT is a national priority and the Centers for

Medicare & Medicaid.

• Discussed the CMS program to incentivize nation-wide adoption and meaningful use of health IT.

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Working with Health IT Systems is available under a Creative Commons Attribution-NonCommercial- ShareAlike 3.0 Unported license. © Johns Hopkins University. UMUC has modified this work and it is available under the original license.

Welcome to the Fundamentals of Health Workflow Process Analysis and Redesign: Process Mapping Theory and

Rationale. This is Lecture a.

This component, Fundamentals of Health Workflow Process Analysis & Redesign, covers fundamentals of health workflow

process analysis and redesign as a necessary component of complete practice automation. Process validation and change

management are also covered.

In two parts, Fundamentals of Health Workflow Process Analysis and Redesign: Process Mapping Theory and Rationale,

Lecture a and Process Mapping Diagramming Tools, Lecture b, covers the background necessary for graphically representing

processes. It uses flowcharts and basic flowchart symbols to provide an introduction to graphical process representation, also

called process diagramming. Separate units cover complete symbol sets and conventions for different types of process diagrams.

1

The objectives for this unit, Process Mapping Theory and Rationale and Process Mapping Diagramming Tools are to:

• Articulate the value of process mapping.

• Describe standard process mapping symbols and conventions.

• Analyze an existing workflow process chart in terms of the information that could be generated, and the sequence of steps that

are being communicated.

• Choose the correct scope and detail level for a process map.

• Choose an appropriate process mapping methodology.

• Create a process map for a health care system (or system component) using correct symbols and conventions.

2

There are 5 topics covered in this unit including:

• Purpose of graphic process representation,

• Process diagram vocabulary,

• Identifying process steps,

• Basic flowchart symbols, and

• Creating a basic flowchart.

3

Before written language, early humans used symbols to communicate. While we aren’t sure if a picture is really worth a thousand words, we do know that with some graphic representations, humans perceive more information and perceive the information

faster than through verbal and written communication channels. (Wickens, 1999)

4

Humans directly perceive meaning through symbols. For example, the skull and cross-bones is a universal symbol for danger.

United States road signs use images that directly convey meaning, for example, the no U-turn sign. Similarly, a road sign with a

picture of a tipping truck lets drivers know that the road conditions are conducive to rolling vehicles. When it is important to

communicate meaning quickly, we use signs and symbols.

These concepts have been applied to clearly communicate process information. For example, the steps and their order in a work

process. Like signs that communicate messages, process maps are graphical representations of processes. They use standard

symbols to communicate information about a process.

5

Similar to maps of subway routes, process diagrams often are drawn at a level of detail that enables them to fit on one or a few

pages. As such, they provide a way to, in one place, see the whole process. Similar to road signs, process maps convey

information through commonly understood symbols. Similar to subway maps, process diagrams show and focus attention on

different aspects of processes. For example, subway maps posted in the station show the different routes, their location

throughout the city, the stops on each line, and proximity to local landmarks. Subway maps don’t usually show local highways that

would be less relevant to riders.

In contrast to subway maps and road signs, process maps document tasks in a process and sequence of tasks. The act of

documenting a process requires that each step be understood and made explicit. The graphical representation of process steps

and the explicitness makes the knowledge about the process steps and relationships between them easier to share.

While on the surface, this seems simple, most processes are complex systems. They can be examined and viewed from different

perspectives, including static and dynamic aspects, data flow versus workflow, and at different levels of detail. Process

diagramming provides the ability to smoothly progress from abstract to detailed. Additionally, process diagrams are

multidimensional, conveying different types of information about a process. Different types of diagrams are used to make explicit

and document the “who, what, when, where, and how” of processes.

6

Consider the steps that you take to look up a phone number in the yellow pages. You might describe this as “looking up the number,” i.e., you may describe this as one process or task that is at a high-level. Or, you may describe it at a more detailed level and list each of the individual tasks that make up the larger task of “looking up a phone number.”

Processes also involve both physical and mental steps. Some of the physical steps include clicking to open the web browser,

typing the URL for the phone book, and scrolling through the search results. Some of the mental steps are locating the icon to

start the web browser, remembering the URL for the search engine or locating the link to the search engine or going directly to the

yellow pages, and assessing each search result to decide if it is the restaurant that you are looking for.

The information exchange can be described apart from the workflow or process steps. For example, the user requires a data

value such as a phone number for a certain restaurant, the user queries the yellow pages data store through the internet, then a

set of potential data values is returned.

7

In the previous slides and example, we have introduced terms that may be new, or that may be used in a different way. In the

next few slides, we will discuss and define the following terms that are used in workflow and data flow diagramming.

8

First, we will look at the process.

A process is a series of steps and decisions involved in the way work is accomplished. (American Heritage Dictionary, 2009)

Everything we do in our lives involves processes. Some examples are preparing for work in the morning, cooking a meal, and

scheduling an appointment with your doctor.

The health care system is an interconnected web of many processes. John Gall in his book Systemantics, stated that “A complex system that works is made up of simple systems that work” (Gall, 1978).

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A process map is a visual representation of a process that shows:

• The boundaries, i.e. where the process begins and ends,

• The steps or tasks in the process, and

• The sequence or order of the steps.

Process maps use standard symbols so that a process map created by one person can be understood and used by others.

There are different approaches to process diagramming, each with its own symbol set. Process maps are also called process

diagrams and flowcharts. However, there are more precise uses of these terms that we will cover.

10

A task in process lingo means the same as it does in everyday use: a step in a process. We further differentiate physical,

informational (or computational), and mental tasks. Physical tasks are actions that humans or machines perform, e.g., moving

supplies from the loading dock in to a manufacturing facility. Mental tasks are those that are performed by the human mind, e.g.,

reading or reasoning. Computational tasks are those performed by humans or machines that involve manipulations of values or

calculations.

Also, it is helpful to think of tasks in terms of composite or higher-level tasks that are composed of smaller tasks and of the

primitive tasks that cannot be broken down into smaller or sub-tasks.

11

Now, we will look at an example.

After these instructions, pause the slides. List the process tasks required to schedule an appointment with your physician using an

on-line scheduler.

Pause the slides now.

12

Let’s go through this example step-by-step.

First, you must:

1. Identify the need for an appointment,

2. Sign on to a computer,

3. Open a search engine,

4. Find an electronic scheduler for your physician,

5. Search for acceptable dates and times by

6. Visually inspecting results from the scheduler,

7. Select the date and time, and then

8. Confirm the date and time.

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The distinction between workflow and dataflow is sometimes very blurry. However, the distinction is important because the

underlying things being represented, i.e., tasks versus information, are different. Workflow is usually defined as a sequence of

connected steps or tasks. Dataflow involves the transformations or operations performed on data as it moves within and between

systems. Data and information are often part of workflow, and vice versa – data flow impacts workflow.

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For workflow, we care about the physical, mental, and computational steps that occur. In the phone number example, these

steps are clicking the mouse to open the browser, then clicking to open the search engine, then typing in the search text, then the

results being returned and the scrolling and assessment of each result.

Often, as in the phone number example, processes have both workflow and information components that need to be represented.

15

On the other hand, dataflow is about data and information content. Often the mechanism and steps by which it is moved are

unimportant. In data flow, what we care about are the data points that are being communicated or transferred, where the data are

stored, and how those data are transformed. In the phone number example, we care about where the name of the restaurant is

stored, e.g., was it recalled from memory or from a personal rolodex. We care about the data values returned by the search and

about where the data are stored so we know where to search.

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Adequately representing workflow or tasks and dataflow or information requires clear analysis. Tasks and information are two

intertwined but distinct things. Sometimes, the emphasis on workflow or dataflow is less, and just one representation can be used.

Other times, both are significant and both representations are needed.

17

“Flowchart” is probably the word that has come to mind most often so far in this presentation. The reason that we have not used the word flowchart is that flowcharts, in common use today, blur and muddy the two different concepts of dataflow and workflow.

Often both are shown intertwined on a flowchart, and the chart is an incomplete representation of both the dataflow and the

workflow. We make this distinction between work and dataflow, because it is important for the analyst to be clear and to

deliberately make decisions about what aspects of each (dataflow and workflow) to show on a diagram.

There are several available definitions for Flowchart; some commonly used definitions are displayed on the slide. The Merriam- Webster Online Dictionary defines a flowchart as a “diagram that shows step-by-step progression through a procedure or system especially using connecting lines and a set of conventional symbols” (Merriam-Webster Online Dictionary 2010). The 1985 ISO/ANSI 5807 standard was an early definer of flowchart symbols and defines a flowchart as something that is “used to diagram the logic paths through computer programs”. Each communicates important aspects of flowcharts, e.g.,

• Shows step by step progression through a process

• Uses standard symbols

• Depicts logic or decision points and thus, paths

Flowcharts are the most common type of process map, and are easily understood by most people, thus, they are widely used.

Most of the symbols needed to create flowcharts are included in word processing, drawing, and presentation software packages,

such as the Microsoft Office packages.

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By notation we mean the set of shapes and drawing conventions, e.g., straight lines or curved ones, that are used to create

process diagrams. Shapes are also called symbols.

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The example flowchart on the slide depicts an over simplified version of the troubleshooting process for a lamp that doesn’t work.

The first step in the process, noticing that the lamp doesn’t work, is depicted by a terminal symbol. The second step in the

troubleshooting process denotes a decision, either the lamp is plugged in or not. If the lamp is not plugged in, the next process

step is to plug it in. However, if the lamp is plugged in, the next step is to decide if the bulb is burned out – denoted by a decision

box. If the bulb is burned out, the next task, denoted by a process box, is to replace the bulb. If the bulb is not burned out, the final

step, denoted by a terminal symbol is to buy a new lamp. Note, color is not required in flowcharts. Sometimes it can be helpful if

used carefully and for a purpose. We only use color here to draw attention to multiple uses of the same symbol, e.g., both

terminal symbols are red.

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Correct symbols are used for the decision boxes and the connectors.

Incorrect symbol use is:

• a matter of which notation one is following, and

• how formal or conformant to any one notation one wants to be., i.e., correctness with respect to notation is a relative matter.

Pause the slides now.

Comparing the flowchart on this slide to the symbols on the previous slide, we see that the rounded corner rectangle used as a

terminator should be a different shape, one with parallel lines on the top and bottom and half-circle curvature on the left and right

sides. The arrow heads should be shaded or filled in rather than open.

22

Next we have an example of a defined health care process flow. We will use the scenario on this slide to demonstrate

representing a process in pictorial form, i.e. in a process flow chart.

Pause the slides and read this scenario - list the process steps.

After you restart the slides, we will go over the steps so that you can see how you did.

Pause the slides and list the process steps now.

23

Listing the tasks is essentially breaking the scenario down into discrete steps. Placing them in sequential order will help with drawing the flowchart later.

The discrete steps of the Patient Intake and Clinic Visit that you should have listed are:

1. Patient arrives at the clinic and signs-in and checks-in with the front desk.

2. Receptionist enters the patient into the visit system as present and confirms the contact and insurance information with the patient.

3. The nurse pulls the chart from the filing stacks and calls the patient to the exam area and escorts the patient to the exam room.

4. The nurse interviews the patient regarding symptoms and/or complaints and records into the Nurse’s/Progress notes.

5. Nurse takes and records vital signs in progress notes and alerts the Physician that the patient is ready to be seen.

6. The Physician examines the patient and records findings in the progress notes.

7. The Physician determines if a prescription, procedure, lab work or a referral is required and completes the necessary paperwo rk if applicable.

8. The Physician provides any additional instructions to the patient and concludes the visit.

9. The Physician provides the patient chart to the office staff for refiling.

10. The office staff refiles the patient chart.

11. The patient pays their co-pay and concludes the office visit.

Pause the slides and determine if these steps match the ones you listed.

Next, use the standard symbols and draw a flowchart that depicts the steps. Restart the slides when you are finished.

24

Pause the slides now.

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Compare the flowchart you drew to the one on the next two slides. Remember that connector symbol denotes that this flowchart

is continued on the next slide. The process steps depicted on this slide include:

1. Patient arrives at the clinic.

2. Patient signs-in/checks-in with the front desk.

3. The patient is marked as present, their contact and insurance information are confirmed.

4. The chart is pulled.

5. The patient is escorted to the exam room.

6. Chief complaint and vitals are recorded.

7. Provider is alerted that the patient is ready to be seen.

This flowchart is continued on the next slide.

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Additional process steps depicted on this slide are:

1. Examination of the patient

2. Determining if an order is required

3. If an order is required, write one

4. Educate the patient and dictate their clinic note

5. The patient visit with the physician ends and the patient pays their co-pay and exits

6. The patient’s chart is refiled

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This concludes Fundamentals of Health Workflow Process Analysis and Redesign: Process Mapping Theory and

Rationale, Lecture a.

In this lecture we have

• Described the value of process diagrams,

• Given an example list of the process steps from a healthcare scenario, and

• Described basic flowchart symbols.

At this point you should be able to

• List the information generated or used in the process and the sequence of workflow steps when given a workflow process

chart consisting of basic flow charting symbols, and

• Read a scenario and use basic flowchart symbols to represent the process steps and their sequence.

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Working with Health IT Systems is available under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported license.

© Johns Hopkins University.

Welcome to Fundamentals of Health Workflow Process Analysis and Redesign, Acquiring Clinical Process Knowledge. This is lecture a.

This component, Fundamentals of Health Workflow Process Analysis and Redesign, is a necessary component of complete practice automation and includes topics of process validation and change management.

In three lectures, this unit covers the concepts and methods for Acquiring Clinical Process Knowledge in the Health Care setting needed by the Health Care Workflow Analysis and Redesign Specialist.

1

Objectives for this unit, Acquiring Clinical Process Knowledge, are to:

• Identify how the strategic goals and stakeholders for a given health care facility can influence workflow processes in that facility, • Create an agenda for an opening meeting to discuss workflow processes in a health care facility, in light of that facility’s strategic

goals and stakeholders, • Compare and contrast different types of knowledge and their impact on organizations, • Analyze a health care scenario according to CMMI levels, • Identify the workflow processes that are likely to be used by a healthcare facility, • Identify the workflow processes that are essential to observe in order to determine how best to streamline the operations in a

given health care facility, and • Identify key individuals with whom the Practice Workflow and Information Management Redesign Specialist should meet or

observe in order to gain an understanding of the nature and complexity of their work.

2

Additional learning objectives for this unit, Acquiring Clinical Process Knowledge, are to:

• Given a process observation scenario, formulate the questions that would facilitate a productive discussion of the workflow of information, activities and roles within that facility,

• Suggest ways to successfully respond to common challenges encountered in knowledge acquisition, • Given a practice scenario, choose an appropriate knowledge acquisition method, • Given a process analysis scenario including a list of observations, create an agenda for a visit closing meeting and an initial

meeting report, and • Given a set of diagrams and observations from an information gathering meeting, draft a summary report.

3

“Before you attempt to set things right, make sure you see things right.”

– Blaine Lee

This quote gets at the heart of knowledge acquisition. It means that we must understand a process before we attempt to change it. Knowledge Acquisition is the necessary step of gathering information. In our case, that is gathering information about the processes at a healthcare facility before we change the process. This is particularly important in health care, where errors and process problems can harm people.

This unit is about knowledge acquisition, an early and necessary step in process improvement.

Blaine Lee, Ph.D. was a founding vice president of Covey Leadership Center and a contributing author to books by Stephen R. Covey and Norman Vincent Peale.

4

Lecture a covers background for knowledge acquisition (KA). The topics covered in this lecture include:

• Knowledge Acquisition (KA) goals in healthcare, • Importance of KA, • Categories of knowledge, and • Knowledge and the Capability Maturity Model (CMM).

5

The Goal of Knowledge Acquisition for Health Care Process Analysis and Redesign is to elicit and document workflow information about a clinical practice so that technology can be leveraged and patient care can ultimately be improved.

Knowledge acquisition, also called KA, is the way that we gain a thorough and accurate understanding of the present state. Knowledge acquisition is a necessary step that allows us to identify salient workflow issues, for example:

• Which processes are the most important? • Which are the high volume processes? • Which processes will present the greatest challenge to implementation of HIT? • Which processes will need to be revised? • Which processes will disappear?

6

Clinicians and IT professionals have different expertise. However, in order to make computers and information systems effective in clinical settings, knowledge from these two disciplines must be combined or integrated. The knowledge gap between these disciplines is often filled by a health informaticist or a health IT professional. We’ll call this individual an analyst. Either the analyst can work with clinicians and practice staff to understand their workflow, or the analyst can train and facilitate practice staff in doing part of this work. Methodology for the latter is covered in a separate unit. This unit focuses on methodology for an analyst to gather information and document clinic processes such that appropriate technology can be leveraged to improve clinic processes and ultimately patient care.

7

Knowledge acquisition means what you would think from everyday use of the words: gathering and capturing knowledge.

Knowledge acquisition is a broad term, i.e., it is used in many other disciplines: • Management science, • Computer science, • Artificial intelligence, and • Cognitive psychology.

There is no one definitive method. Further, methods are customized for particular disciplines and for the level of detail needed. As Aristotle wrote, “It is the mark of an instructed mind to rest satisfied with the degree of precision which the nature of the subject admits and not to seek exactness when only an approximation of the truth is possible.”

What he meant was that it is a bad idea to do a more detailed analysis than what is required to accomplish your goal. Simply put, too much detail wastes time and other resources. Therefore, we present here a method that 1. is focused on health care and matching health IT to clinic processes, and 2. is only as detailed as necessary.

8

Brian Gaines, a recognized Knowledge Acquisition expert from the University of Calgary, conducted a research project where he worked with managers involved in an ongoing project on knowledge modeling of manufacturing processes in small companies. This provided us a concept map (reproduced here from Gaines’ research report) of the routine ways in which organizations acquire knowledge, i.e., the universe and scope of Organizational Knowledge Acquisition. (Gaines, n.d.)

Several of these methods are applicable to our work in Health IT adoption and clinic process improvement. For example, the clinics who hire process analysts and redesign specialists or who receive this expertise through their regional extension center are “Recruiting people with expertise” and “Gathering advice from consultants.” Professional process analysts routinely “gather advice from professional literature” through conferences and reading trade and scientific journals. Some of the Regional Extension Centers are establishing local support groups that give clinic leadership and staff the opportunity to “participate in communities of practice.” When clinics approach a Regional Extension Center, they are “contracting with other organizations.” Through working with the Regional Extension Centers, clinics are engaging in “process improvement through experience in use,” “process improvement through process analysis,” and “process improvement through purchase of technology.” This and related units teach methodology for “process improvement through process analysis,” and “process improvement through purchase of technology.” (Gaines, n.d.)

9

Without spending too much time on theory related to Knowledge and Knowledge Acquisition (and there is a lot of it), we present two important concepts in this and the next slides. Seven aspects of knowledge are given. The important thing to understand is that knowledge is what we call a multi-dimensional concept, that is, there are different aspects. Gaines’ work does not provide definitions for each of the dimensions. However, we can explain them by example. Let’s look first at internal versus external knowledge. Some knowledge is internal to us or in our minds while other knowledge is external or in the world. When we use a GPS while driving, it is usually because we do not know the way, or maybe the quickest way, thus we do not have internal knowledge and we rely on the external knowledge that resides in the GPS system. (Gaines, n.d.)

Knowledge can also be classified as coded or tacit. (Gaines, n.d.) Tacit knowledge is knowledge that individuals have that is difficult to transfer. When we hire a senior craftsman or performing artist, they are special because they can do something in a way that no one else can. In cases like this, their knowledge that enables them to such unique and expert performance is innate. It is not written down. There is no step-by-step process that one can follow. In fact, such experts often cannot articulate the knowledge that is the core of their expertise. This is tacit knowledge. Coded, also called explicit, knowledge, on the other hand, is knowledge that is written down in step by step manner such that others can use and apply it. In clinical practices, there is a lot of tacit knowledge and part of the job of an analyst acquiring knowledge is to take in this knowledge, document it in writing or diagrams, i.e., turn it into coded knowledge and thus, make it explicit.

Still, others have made the distinction between active and passive knowledge in the way that knowledge is used by the knower. Active knowledge is something that is used by the knower to do something. For example, Nurses use their knowledge every day to take care of patients. Passive knowledge is different, it is knowledge or experience that is encoded by the knower but not in actual use. In passive knowledge, the knower is not applying the knowledge. (Gaines, n.d.) Another way to look at knowledge is whether the knowledge has been or is best learned through transmission, i.e., taught or read, or whether the knowledge is experiential, i.e., learned by doing.

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Probably the most widely-used dimension is declarative versus procedural knowledge. Declarative knowledge is the knowledge of facts, i.e., properties between things and concepts and the relationships between them. Procedural knowledge, on the other hand, is the knowledge of how to do something. (Milton 2007) A standard operating procedure is an example of coded procedural knowledge. A recipe has aspects of both declarative and procedural knowledge. The ingredients list is declarative knowledge, whereas the statements about the sequence of mixing and procedure for cooking are procedural knowledge. Gaines and others have described other aspects of knowledge that are, for example, properties of an organization’s intent for acquiring the knowledge, or how it will be used, but these are not properties of the actual knowledge and are less important for our work here.

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The two-by-two diagram adapted from Gaines, shows the relationship between passive, active, tacit, coded, sticky , transmittable, and declarative and procedural knowledge. A third dimension was added to this framework, declarative and procedural knowledge. In the left upper quadrant is experience. Experience is both passive and tacit knowledge. Through science or reflective learning, tacit knowledge can be acquired and captured in coded form. Coded knowledge is in the right upper quadrant. Coding tacit knowledge creates information, i.e., facts – declarative knowledge. Creation of coded knowledge adds immense value because then, the knowledge is accessible to others. For example, where an organization has coded knowledge, that knowledge resides with the organization and provides consistency of performance, rather than residing and leaving with individuals. Where knowledge resides with individuals rather than with the organization, organizations are NOT in control of their consistency and ultimately quality and performance. Coded knowledge is transmittable, manageable, and sharable. Importantly, active, coded knowledge, lower right quadrant, is coded knowledge in action, i.e., know-how that can be transmitted to others. Moving back to the left, in the lower left quadrant lies skill. Skill is tacit, active knowledge. It is the alternative to coded knowledge, skill is sticky knowledge, i.e., it comes and leaves with individuals.

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Through its immense amount of contracting experience, and prompted by contracting for software, the United States government realized the need to be able to assess an organization’s likelihood to consistently deliver a quality product on time. This is described by the Capability Maturity Model, initially developed by the Software Engineering Institute (SEI) at Carnegie Mellon University. The Capability Maturity Model (CMM) was developed through a US Department of Defense-funded research project where data was collected from organizations that contracted with the U.S. Department of Defense. At its heart, the Capability Maturity Model describes five levels of increasing codification and institutional management of knowledge. The uppermost (5th) level is an ideal state where processes are systematically managed by a combination of process optimization and continuous process improvement. The CMM or CMMI model is important to have a feel for, because as an analyst, you will encounter clinics at all levels of process maturity. Your job will differ depending on the CMM level at which the clinic operates. For example, if you find an organization at a lower level, much of your time will be spent eliciting tacit knowledge and helping the clinic leadership and staff codify it. The knowledge acquisition and process analysis phase will take longer where this is the case. Alternatively, when you encounter a clinic at the higher levels, there will be existing documentation of clinic processes that you can use as a source, and your acquisition and analysis phase will be shorter. When you encounter a clinic at level 5, your work as a process analyst may fit into their existing process improvement framework as part of their continuous improvement.

There are five levels of the Capability Maturity Model: Level 1 - Initial (Chaotic)

It is characteristic of processes at this level that they are (typically) undocumented and in a state of dynamic change, tending to be driven in an ad hoc, uncontrolled and reactive manner by users or events. This provides a chaotic or unstable environment for the processes.

Level 2 - Repeatable

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It is characteristic of processes at this level that some processes are repeatable, possibly with consistent results. Process discipline is unlikely to be rigorous, but where it exists it may help to ensure that existing processes are maintained during times of stress.

Level 3 - Defined It is characteristic of processes at this level that there are sets of defined and documented standard processes established and subject to some degree of improvement over time. These standard processes are in place (i.e., they are the As-Is processes) and used to establish consistency of process performance across the organization.

Level 4 - Managed It is characteristic of processes at this level that, using process metrics, management can effectively control the As-Is process (e.g., for software development). In particular, management can identify ways to adjust and adapt the process to particular projects without measurable losses of quality or deviations from specifications. Process Capability is established from this level.

Level 5 - Optimized It is a characteristic of processes at this level that the focus is on continually-improving process performance through both incremental and innovative technological changes/improvements.

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This concludes lecture a of Acquiring Clinical Process Knowledge. Lecture a covered background principles relevant to knowledge acquisition including:

• Knowledge Acquisition goals in healthcare, • Importance of Knowledge Acquisition, • Categories of knowledge, and • Knowledge and the Capability Maturity Model (CMM).

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Welcome to Fundamentals of Health Workflow Process Analysis and Redesign: Process Analysis. This is Lecture a.

This component, Fundamentals of Health Workflow Process Analysis & Redesign, covers fundamentals of health workflow process analysis and redesign as a necessary component of complete practice automation. Process validation and change management are also covered.

In two lectures, Fundamentals of Health Workflow Process Analysis and Redesign: Process Analysis covers the background and methodology for process analysis.

1

The Objectives for this unit, Process Analysis, are to:

• Describe the purpose of process analysis,

• Describe skills and knowledge necessary for process analysis,

• Perform a process analysis for a given clinic scenario,

• Given results of a process analysis draft a summary report, and

• Given results of a process analysis, identify desired EMR functionality.

2

In Lecture a of this unit, Process Analysis, we will focus on common process variations and exceptions in the clinic, including: • Objectives of Process Analysis

• Relevant concepts for process analysis

• Steps for process analysis

• Starting with process inventory and diagrams

• For each process, listing – Variations applicable to the clinic – Exceptions

• And Reporting findings

3

Healthcare is comprised of individuals working in processes. As W. Edwards Deming stated, “You can only elevate individual performance by elevating that of the entire system” (Deming, 1982). Paraphrasing this quote, the way to consistently improve the performance of individuals is to improve the system or process. Process analysis is a way to examine a process and identify these opportunities for improvement.

There are different ways to analyze processes, often the methods concentrate on one or more process aspects. The process analysis methodology covered in this unit focuses on identifying processes in use at a clinic, and translating information about the processes into a list of Electronic Medical Record functions that are needed at that clinic. The purpose of this type of process analysis is to make the best match possible between an EMR and a clinic and to optimally leverage health information technology to improve patient care.

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Before we start, and in a way, as an introduction, we will cover the following definitions: • Process, • Process Analysis, and • Process Improvement.

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Merriam-Webster defines process as a series of actions or operations conducing to an end; especially, a continuous operation or treatment. Similarly, the American Society for Quality defines Process as “a set of interrelated work activities characterized by a set of specific inputs and value added tasks that make up a procedure for a set of specific outputs.” (Process, n.d.)

The word Procedure is related to process. ASQ defines a Procedure as: “The steps in a process and how these steps are to be performed for the process to fulfill a customer’s requirements; usually documented.” (Procedure, n.d.)

Important characteristics of Processes for our work are that processes have 1) sequence or order, 2) steps, also called activities, actions, operations, or tasks, 3) inputs and outputs, and 4) happen over and over, i.e., are ongoing. For example, appointment scheduling is a common process in healthcare facilities.

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Merriam-Webster provides several definitions for the word analysis. The one most relevant for our work here is: “an examination of a complex process, its elements, and their relations or a statement of such an analysis.” (Analysis, n.d.)

So, a Process Analysis is an examination of a process to understand its elements such as steps and actions; and the relationships between them, including:

• the order of steps, • what things can be done in parallel versus sequentially, • who or what performs the steps, and • maybe where they are performed.

However, because the goal of our “analysis” is to ultimately improve a process, we also look for things like gaps, lack of conformity with best practice, undue delays, redundancy, rework, and lack of efficiency. For us, the combination of understanding process elements and the relationships between them and identification of opportunities for improvement comprise Process Analysis.

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If we define a process as a continuous series of actions or operations conducing to an end, then process improvement is making changes to a process to make it better in some way. In health care, the Institute of Medicine listed six areas or goals for health care quality improvement. These are that health care should be: safe, effective, efficient, timely, patient centered, and equitable. We improve processes by analyzing them and identifying things that could be made better.

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DeMarco further outlines process analysis skills helpful to overcome the challenges inherent in process analysis. These are: • Knowledge of data and data system concepts, • Knowledge of clinical workflow concepts, and the • Ability to communicate these concepts

We added the ability to identify problem areas.

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There are many different methods of analyzing processes, and they have been contributed from different fields, including business, quality improvement, industrial engineering, cognitive science, computer science, and informatics. It is impossible to review all of the perspectives and methods in this unit.

We take a very pragmatic approach in the framework presented here. Our approach is based on forming an objective picture of clinic processes, process variations, and exceptions and translating information about the processes into a list of Electronic Medical Record (EMR) functions that are needed at that clinic. The purpose of this type of process analysis is to make the best match possible between an EMR and a clinic, and to optimally leverage health information technology to improve patient care.

The unit on Process Redesign focuses on how to identify areas for improvement, and ways to change clinic processes to improve health care.

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Like process diagrams, process analysis can occur at different levels. A detailed process analysis examines each process, usually using a process diagram, and looks for clues to inefficiency, redundancy or opportunity for error. An analysis at this level might also collect some data about how the process operates, for example, time from patient check-in to time seen by the provider, as well as interview practice providers and staff to understand their perceptions of opportunities for improvement. While this level of detail in process analysis is often necessary to trouble shoot problems, it is not routinely necessary for the task of identifying an EHR that is a good match for a particular clinic. For this, we recommend a less detailed approach. By less detailed, we mean identifying the major things that, based on a clinic’s core functions, the EHR needs to do and understanding how the clinic does each.

We adopt the less detailed approach here:

1) Start with process inventory & process diagrams (covered in units 2 and 3). These should provide a context diagram showing clinic functions and a flowchart for each process.

2) For each process, list the process variations applicable to the clinic as well as exceptions that often occur. For example, for a patient visit, a common exception would be that a patient cancels or does not show up.

The last step in process analysis is 3) report findings. The findings from a process analysis would include: Major observations, a list of EHR functionality necessary to support clinic functions, and opportunities for improvement (technology assisted and otherwise).

11

A separate unit mentioned identification of major processes in use at a health care facility. After the processes are listed, the analyst works with leadership at the health care facility to identify those that are of high priority for analysis and improvement. All of the processes can’t be assessed. Some can’t feasibly be improved with the available resources, for others the gain would be too small to make the effort worthwhile. Still others can be improved, but by means other than use of health IT.

After the processes for analysis have been identified, the analyst, working with people from the clinic creates diagrams of the processes. These graphical representations of the processes are used in the process analysis and redesign. We start with a process inventory and diagrams because sometimes they are all that is needed, and they point to areas where different types of objective information may be needed.

A separate unit covers creating process diagrams. This unit assumes that students are familiar with at least one method of creating a graphical representation of a process, for example, a flow chart.

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Practices have a set of core functions. Some functions are performed by most practices, like billing, prescription writing, office visits, and referrals. Other functions vary according to the type of practice, for example, a small practice may draw blood but may not perform any lab tests, while large practices may have equipment to perform common blood and urine based lab tests. The lab tests, other diagnostic tests, and procedures vary by practice size and by specialty.

The first step in Process Analysis is understanding the main processes that are performed by a practice. A context diagram, like the one on this slide, should always be created to make sure the analyst and clinic staff working with the analyst are aware of the main tasks that a clinic performs. As a context diagram, the depiction is purposely at a very high level, has less than 20 or 30 boxes, and usually fits on one page of paper. The purpose of this diagram is to “understand the whole.” A diagram like this shows areas where data exchange is needed and depicts the main processes at a clinic or other health care facility.

13

Recall from unit 4 that a process inventory is a list of the main processes used by a practice. If there are more than 20 or 30 processes on your inventory for a practice, you may be working at too detailed a level. If the practice consists of multiple specialties, you will have a larger number of processes on the inventory, and the analysis will take longer.

For each process, the main activities, roles, locations, flow, and information needs are identified, either in writing or by process diagrams as described in other units. These steps are preparatory to Process Analysis and are covered in separate units.

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Additional detail that we alluded to in unit 4 is needed for process analysis. An inventory should also specify which of the common process variations are in use at the practice. For example, virtually all practices need to obtain biological samples and have the samples analyzed. However, how and where the lab samples are processed varies among clinics. The common variations are: 1) all lab tests are processed and analyzed at the clinic, 2) blood is drawn at the clinic but samples are sent to a central lab for processing, or 3) some of both 1) and 2) depending on the type of sample and the tests that are needed on the sample.

The workflow, data flow, and information needs for each of these variations differs.

In the following scenario, which of the following process variations are used?

“PA James tells Patient Paul that there is an unusually high number of strep cases in the community over the past month, and that based on the appearance of his throat, he may have strep throat, and that he would like to swab his throat and do a rapid strep test. Patient Paul agrees. PA James swabs his throat with a long cotton tipped swab and does the test. Five minutes later, PA James returns and tells Patient Paul that the test was positive…”

In this scenario for the rapid strep test, the practice is obtaining the sample (a throat swab) and performing the test in the clinic. Importantly, most clinics will use multiple process variations. The occurrence of multiple variations is a signal to the analyst that 1) the EHR must support multiple options, and 2) that there are criteria for making the decision on which variation is used and that the EHR will likely need to show different screens or otherwise facilitate the process variants based on the criterion. Process choices, sometimes called branches, indicate important functionality needed in an EHR.

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Process variations are processes used by the clinic, i.e., the way a particular clinic does something, the clinic’s process. They are called variations because they vary from clinic to clinic. For example, some clinics only schedule appointments by phone while others use online scheduling or both online and phone. There should be a process diagram for the variation or variations used by the clinic.

Process exceptions are errors or common odd things that happen during the clinic’s processes. Things like a lab sample goes bad or a patient has to leave the appointment early. You will most likely not have the time and resources to create process diagrams that include exceptions. They are important to note, because EHR functionality needs to cover expected exceptions and needs to have a generic way to handle the unexpected.

In lecture b, we will list common process variations and exceptions for processes used by most clinics.

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This concludes Lecture a of Process Analysis. At this point, you should be able to:

• Understand relevant concepts and steps for process analysis, starting with process inventory and diagrams • Understand the concepts of variations and exceptions for each process listing and know how to report findings

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Welcome to Fundamentals of Health Workflow Process Analysis and Redesign: Process Analysis. This is Lecture b.

This component, Fundamentals of Health Workflow Process Analysis & Redesign, covers fundamentals of health workflow process analysis and redesign as a necessary component of complete practice automation. Process validation and change management are also covered.

Lecture b is the second of two lectures in this unit, Fundamentals of Health Workflow Process Analysis and Redesign: Process Analysis and covers the background and methodology for process analysis.

1

The Objectives for this unit, Process Analysis, are to:

• Describe the purpose of process analysis,

• Describe skills and knowledge necessary for process analysis,

• Perform a process analysis for a given clinic scenario,

• Given results of a process analysis draft a summary report, and

• Given results of a process analysis, identify desired EMR functionality.

2

In Lecture b of this unit, Process Analysis, we will focus on common process variations and exceptions in the clinic, including: • Patient check-in

• Patient visit

• Prescription

• Received documentation

• Labs & diagnostic tests

• Referral and consults

• Disease management

• Billing

We will assess how they impact process analysis, and how process analysis is used ultimately in identifying electronic health record (EHR) functionality.

3

Remember from Lecture 1 that process variations are processes used by the clinic, i.e., the way a particular clinic does something, i.e., the clinic’s process. They are called variations because they vary from clinic to clinic. There should be a process diagram for the variation or variations used by the clinic.

Remember also that process exceptions are errors or common odd things that occur during the clinic’s processes. They are important to note, because EHR functionality needs to cover expected exceptions, and needs to have a generic way to handle the unexpected.

On the following slides, we will list common process variations and exceptions for processes used by most clinics.

4

Common process variations for patient check-in include: • New patient intake and registration, • Existing patient intake and registration, and • Walk-in intake and registration.

Exceptions for the patient check-in include: • No insurance / non-covered service, and • Change in insurance information.

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There are many variations for patient office visits. A few of them are referral out needed, procedure needed, and diagnostic test needed.

Likewise, there are many possible exceptions that may occur during an office visit. Some of them include emergent reason to stop the visit, a non-covered service needing a separate visit, and the need to be seen by a different provider.

6

The common variations on the prescription process include paper prescriptions provided during the office visit, electronic prescriptions provided during the office visit, a refill call-in prescription needed, and other call-in prescription needed, for example, a patient on an antibiotic is out of town and not getting better; calls their provider, and asks for a different prescription.

Common exceptions or errors that can occur during a prescription process include no insurance or a non-covered service, samples provided, prescriptions need to be sent to multiple pharmacies, and the prescription can’t be filled at a pharmacy.

7

Filing or otherwise associating documents received from external sources, for example, emergency room visits, hospital discharge summaries, reports from procedures and diagnostic tests with a patient’s records can be a lot of work for a primary care clinic. Common process variations include the format of the received document (paper or electronic) and whether or not the information in the document necessitates follow-up with the patient. For example, a discharge summary that lists a discharge prescription for a medication that is redundant with one the patient was taking prior to hospitalization, a hospitalization for a poorly-controlled chronic condition, or a hospital discharge summary that indicates necessary follow-up with the primary care provider.

Common exceptions with external documents include inadequate patient identification, inadequate source identification, and unintelligible or ambiguous information.

8

Common Lab variations include sample taken in clinic and test done in clinic, sample taken in clinic, test done externally, and sample and test done at central lab.

Lab exceptions, on the other hand, include bad sample – need another blood draw, for example; lab results not received, and lab results not physiologically possible.

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Diagnostic tests vary widely depending on the type of practice. Common diagnostic test variations include the following: • Test done in clinic, • Test done externally, • Report expected, and • Image or test result data expected.

Similarly, diagnostic test exceptions include: • No insurance / non-covered service, • Test error / unintelligible results, and • Results from external test not received.

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Generally, but not always, primary care providers refer out to specialists, and specialists receive requests for consults from primary care providers and from other specialists. Referral variations include:

• Paper referral communicated by the patient, • Paper provider to provider, • Electronic referral, and • Referrals for one patient to multiple providers.

Referral exceptions include referee does not accept the referral.

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Variations to the consult prescription can be paper or phone request, as well as electronic.

Exceptions for the consult can be: No insurance or a non-covered service, as well as a consult no-show.

12

Disease management is a process where a provider follows established clinical guidelines to care for a patient with a chronic condition, or conditions. The guidelines describe what tests should be performed to assess how the patient is faring, and the test frequency, as well as the patient treatment. Disease management can be accomplished with paper charts or with electronic decision support. Disease management exceptions include insufficient data, data errors, care fragmentation, and contraindications.

13

Billing is a core process of any practice. Some billing variations are using a paper superbill, i.e., the sheet that providers use to check off tests and write diagnoses on during the visit, as the source, electronic data recorded by providers during the visit as the source, where the coding is done, and whether or not billing and collections are done externally.

Billing exceptions include: No insurance or non-covered service, claim denied, coding errors, and data errors.

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In summary, a main part of process analysis is creating an inventory of processes that a practice uses, and identifying the variations of those processes employed by the practice, and the likely exceptions. These things together help identify the EHR functionality.

Start with the process inventory & diagrams. Include context diagram showing clinic functions and flowcharts for each process.

For each process, list the variations applicable to the clinic and all exceptions.

Finally, report findings such as major observations, EHR functionality necessary to support clinic functions, and opportunities for improvement to the management.

15

Let’s work an example. After these instructions, pause the slide show and work this example on your own. We will go over the results on the next few slides. Suburban Family Clinic, like most other clinics today, uses a phone scheduling process to schedule patient office visits. As a process analyst working with Suburban Family Clinic, you have listed appointment scheduling on the process inventory. Read the “By Phone Appointment Scheduling Scenario” in the course materials.

First, draw a role-based flow chart of the process. Second, indicate the process variations used by Suburban Family Clinic. Third, make a list of exceptions likely to occur with this process. Pause the slides now.

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In the scenario, Patient Patty wakes up at 5:30 am feeling awful, and decides to call for an appointment with her primary care provider. She calls Suburban Family Clinic. The important steps to diagram are those that directly interface with the clinic in some way. In this scenario, we do not need to represent anything about what time the patient calls, or why she decided to call; it is just important to diagram the trigger event, i.e., the patient desires an office visit, and the step that interfaces with the clinic, i.e., the patient calls the clinic.

Next in the scenario, Receptionist Ronald answers Patient Patty’s call and Patient Patty asks Receptionist Ronald for the soonest appointment with Doctor Dan. Here, the steps answering the phone and requesting a provider are added to the diagram.

Next in the scenario, Receptionist Ronald states that 9:30 is the earliest possible appointment with Doctor Dan and Patient Patty says that 9:30 is fine. Receptionist Ronald adds her to the schedule for 9:30. Each of these steps, finding and stating the next available time, the patient’s decision that the time is okay, and scheduling the appointment are important interactions and are added to the diagram.

Some questions that you might have are as follows:

1. Why did we leave out the detail of Patient Patty’s symptoms and her deciding whether or not to call for an appointment? These details are not important to the clinic’s process or the interaction between the patient and the clinic, thus, they do not provide any information important to our analysis of the clinic process. 2. Why did we include detail about whether or not the next available time is okay? This information signifies a possible branch point in the process, i.e., that the receptionist needs to look for additional times, and that the times might not be agreeable to the patient. This information also signifies information needs by the receptionist. Note the decisions are necessary to outline the possible ways in which the process concludes.

17

In the scenario, the appointment scheduling variation used by the clinic appears to be “by phone scheduling.” In your interactions with the clinic, the critical thing to discern is “is this the only variation used by the clinic?” and “what other variations occur?”. Importantly, process variations are processes used by the clinic. Process exceptions are errors or common odd things that occur during the process.

Possible exceptions that may occur during the appointment scheduling process include the following: • The receptionist doesn’t answer, patient leaves message, • Someone other than patient calls, • The requested provider is not available, and • The available appointment time slots are not acceptable.

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Some of the information gained from process analysis translates directly into EHR functionality, for example: the process variations, flow control between variations, and handling process exceptions. This is the information that we have covered thus far in this slide set. Often, there are opportunities to make process changes, including leveraging technology. Such changes are decided during process redesign (covered in Unit 6) and also result in identification of necessary EHR functionality.

In-turn, an analyst’s knowledge of available EHR functionality informs process redesign, i.e., the analyst who is familiar with available functions draws on this knowledge to suggest ways in which technology can be leveraged to improve processes. Use of technology in process redesign is covered in Unit 6.

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The end result of a process analysis is a list of 1) clinic processes, i.e., the process variations used by the clinic, and 2) a list of common exceptions. For example, based on the process analysis, by-phone appointment scheduling would be on the list for Suburban Family Clinic, as would the listed exceptions.

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Let’s work through an example of how to make a process and exception list.

After the instructions, pause the slide show and read the following scenarios in your course materials: • By phone appointment scheduling, • New patient intake and registration using paper chart, • Existing patient intake and registration using paper chart, and • Receiving and communicating lab results using paper chart.

Create a Process and Exception List. On the next slide, we will go over the results. Pause the slides now.

21

In the scenario, the appointment scheduling variation used by the clinic appears to be “By phone scheduling.”

Possible exceptions that may occur during the appointment scheduling process include: • Receptionist doesn't answer, patient leaves message, • Someone other than patient calls, • Requested provider not available, and • Available appointment time slots not acceptable.

22

The patient intake scenarios indicate the following processes: • New patient intake and • Existing patient intake.

Process exceptions that might be expected include: • No insurance / non-covered service and • Patient has to leave during the intake process.

23

The receiving and communicating lab results indicate the following processes: • Lab sample processing at external lab, • Lab sample acquisition – unknown from the scenario, • Receiving lab results, and • Communicating lab results.

Lab process exceptions include: • No results received, • Results not matchable to a patient, • Results not matchable to a provider, • Results abnormal and require action, and • Patient not contactable / not responsive to contact attempts.

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The results of this process analysis would be compiled together in one document. This might be called a Process Analysis Report. The list of processes and exceptions correspond directly to needed EHR functionality and ultimately will be included in a request for proposal intended for EHR software vendors.

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A process analysis report should include: • Information about the analysis, for example, the analyst’s name and organization, dates of time on site, individuals from

whom information was received, • Process inventory, • Process variations and exceptions, • Process diagrams, and • List of EHR functionality needed for the practice.

If within the analyst’s scope of work and training, suggested EHRs that are possible matches for the needed functions.

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This concludes Lecture b of Fundamentals of Health Workflow Process Analysis and Redesign: Process Analysis.

In Lecture b, we covered • Process Variations for common clinic processes including:

 Patient check-in

 Patient visit, Disease management

 Prescription

 Received documentation

 Labs & diagnostic tests

 Referral and consults

 Billing

• Process Analysis and EHR functionality

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This concludes Process Analysis.

In Lectures a and b, we covered: • Common clinic processes, • Process variations and exceptions, and • Using process analysis to identify needed EHR functionality and identify opportunities to leverage available EHR functionality for

improving clinic processes. Unit 6, Process Redesign uses the results of process analysis to ultimately improve clinic processes.

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© Johns Hopkins University.

Welcome to the Fundamentals of Health Workflow Process Analysis and Redesign: Process Design. This is Lecture a.

This component, Fundamentals of Health Workflow Process Analysis & Redesign, covers fundamentals of health workflow process analysis and redesign as a necessary component of complete practice automation. Process validation and change management are also covered.

This unit, Process Design, consists of 5 lectures and covers the background and methodology for process redesign in the health care facility.

1

The Objectives for Process Redesign are to:

• Identify the factors that optimize workflow processes in health care settings. • Describe how information technology can be used to increase the efficiency of workflow in health

care settings. • Identify aspects of clinical workflow that are improved by EHR . • Propose ways in which the workflow processes in health care settings can be re-designed to

ensure patient safety and increase efficiency in such settings. • Use knowledge of common software functionality and meaningful use objectives to inform a

process redesign for a given clinic scenario.

2

The topics covered in this Lecture a, Process Design, include:

• Objectives and goals of Process Redesign, • Unproductive work, • Twenty seven strategies for optimizing processes, and • An example of each optimization strategy.

3

Health care is comprised of individuals working in processes. As W. Edwards Deming stated, “You can only elevate individual performance by elevating that of the entire system” (Deming, 1982). Paraphrasing this quote, the way to consistently improve the performance of individuals is to improve the system or process. The goal of Process Analysis is to identify aspects of the process that cause or make process problems more likely. The goal of Process Redesign is to prevent, or mitigate process problems, e.g., delays, errors, wasted resources, or inconsistencies.

4

Process redesign is a strategic initiative to improve the quality, cost, and safety of patient care. Goals of process redesign include:

• Improving quality and safety of care, • Enhancing the patient’s care experience, • Decreasing the cost of care, and • Making clinic processes more efficient.

Achieving these goals often involves replacing manual processes with processes capable of greater accuracy and higher performance and making changes in who performs tasks. An effective approach for doing this leverages Health IT to automate processes, gives patients more control, provides more useful information to providers, practice staff, and patients and shares data between providers.

5

In a presentation about clinic workflow redesign from Clinic Ole in Napa California, (Aviña C., 2010) the QI/EMR Implementation Coordinator, Carlos Aviña , graphically describes the goal of process redesign. His diagram, adapted above, depicts that in a typical clinic, there is a small amount of quality improvement, there is productive work and there is unproductive work. The goal of process redesign is to get rid of unproductive work and focus all effort on productive work, including increasing the amount of effort spent continually improving clinic processes, and ultimately, patient care.

6

In a clinic, unproductive work is effort that does not contribute to patient care, i.e., tasks that are not necessary for providing patient care. Unproductive work includes:

• Waiting, • Transportation and unnecessary motion , • Doing things twice, for example, writing a prescription and then documenting that the

prescription was written, • Errors, • Repetitive tasks performed by humans, and • People with higher level of training than necessary performing tasks.

Unproductive work can be identified during knowledge acquisition, process analysis, or during redesign.

Note: By unproductive work, we are not talking about breaks, mealtime and vacation, i.e., things necessary for humans to be rested. These things contribute in important ways to patient care by making sure that providers and staff are at their best when caring for patients.

7

If we say that unproductive work is the problem, then redesign strategies are the potential solutions. Redesign strategies are applied to fix process problems. There are some natural matches between problems and strategies to fix them. The key to process redesign is identifying process problems (unproductive work), and applying the right redesign strategy.

8

In the words of Blaine Lee, one of the original founders of the Covey Leadership Center, “Before you attempt to set things right, make sure you see things right.” (Lee, n.d.)

9

In a recent case study reported by Mansar and Reijers introduction of technology accounted for 25% improvement in invoicing time (Mansar and Reijers, 2005). Adding process redesign in addition to technology resulted in 80% improvement. Thus, while technology is often necessary, it is seldom sufficient.

10

Mansar and Reijers (Mansar and Reijers, 2005) have synthesized known strategies to decrease the amount of unproductive work. Each is defined and illustrated with an example on the following slides. For the purposes of this unit, we have consolidated closely-related strategies.

A checklist of these redesign strategies can be used on the job to systematically assess clinic processes for redesign opportunities.

Strategies for redesign include automation, buffering, centralization, control addition and relocation, as well as contact reduction and use of customer teams and case managers. Other redesign strategies are empower, exception, extra resources, flexible assignment, integration, interfacing, and knock-outs. Each of these will be discussed in the following slides.

11

Other strategies are given here and include outsourcing, order assignments, and resequencing. It is important to understand that in the clinic setting, application of Health IT can be used to facilitate or outright accomplish many of these strategies.

12

Automation means designing processes so that machines, i.e., computers, can do them rather than humans.

Things that may lend themselves well to automation are those that can be completely defined, performed in identical fashion each time and are sufficiently repetitive that the automation efforts are cost effective.

Design decisions related to this allocation of function determine the extent to which a given job, task, function or responsibility is to be automated or assigned to human performance. The decisions are based on many factors. These include the relative capabilities and limitations of humans versus technology in terms of reliability, speed, accuracy, strength, flexibility of response, financial cost, the importance of successful or timely accomplishment of tasks, safety, and user satisfaction (both short- term, e.g. as comfort and pleasure, and long-term, e.g. as health, well-being and job satisfaction). Basing such decisions solely on those functions the technology is capable of performing and then simply allocating the remaining system functions to users is likely to result in an ineffective design.

13

There are many opportunities to use computer systems to automate clinic processes. Some examples are:

• triggering prescription refills, • alerting clinicians to abnormal lab results, • triggering planned assessments, and • subscribing to automatic information updates rather than waiting and requesting

information when needed. Mansar calls this buffering. (Mansar and Reijers, 2005)

14

Centralization can mean common coordination of activities at multiple locations such that they are done the same way. It can also mean carrying out tasks at one location rather than having them be carried out by multiple organizations or individuals.

15

Using a claims clearing house is often more efficient for a practice than the practice submitting claims to multiple insurance companies. Assigning one person in the clinic to answer the phone or one person to handle prescription refill requests are also examples of centralization that may increase efficiency.

16

Control addition means adding checks in a process. Addition of a control step identifies errors before they have a negative impact. This control can be performed by a human or a computer, i.e., it can be automated.

17

Control Addition examples in health care are numerous. Some examples include:

• checking insurance eligibility of a planned procedure or a co-pay, • checking insurance eligibility of a prescription prior to sending it home with a patient, and • checking for drug-drug interactions or drug allergies prior to writing a prescription.

18

Additional Control Addition examples in health care include:

• counting sponges and instruments before closing a surgery site, • double checking the name on the medication and the patient arm band prior to administration,

and • marking the surgery site and confirming with the patient prior to surgery.

19

Control (or work) relocation is changing the person who performs a task, triggers a task to be done, or approves a task. In principle, control relocation usually means pushing control to the “front line.” Stated differently, it means empowering those closest to the customer to make more decisions or even pushing control to the customer.

20

There are several notable examples of control relocation in health care. These include:

• home monitoring devices, i.e., patients taking their blood pressure daily and entering it into a website or using a device to transmit the data to their provider,

• on-line appointment scheduling, • on-line data entry of patient information before a visit, and • patient portals that enable patients to share their health records with other providers.

21

Contact reduction is straight forward. It involves decreasing the number of contacts, length of contacts, or otherwise decreasing the resources devoted to customer contact.

22

Notable examples of contact reduction in health care include:

• completion of patient information forms before a visit, • automated appointment reminders, and • pushing tasks down to the lowest level of staff with appropriate training.

23

Mansar and Reijers (Mansar and Reijers, 2005) call this category customer teams. In health care, these are known as care teams. Sometimes organizations can be complex for customers to navigate. One way to alleviate customer dissatisfaction and other untoward effects caused by complexity is to assign a case manager, or a group of people involved in providing services to a customer. Case managers and care teams smooth the process and increase customer satisfaction.

Examples include: • a case manager assigned to a patient who needs multiple ancillary services, • a Medicaid case manager, • a case manager for a patient’s interaction and interface with social services, and • a patient advocate.

In health care, often multiple care providers are needed including doctors, nurses, and allied health professionals. These professionals come together to provide a care team that works together to provide for a patient’s needs.

24

An exception is a case that is somehow different from the rest, usually involving incompleteness, errors, special circumstances or special needs.

Exception handling is designing a process to handle the ordinary cases and “shunting” the exceptions into a different work stream.

The practice of separating exceptions frees the process to operate at maximum efficiency, i.e., the process is not gummed up by special cases. Often in process redesign, it is tempting to design for exceptions.

Resist this temptation. Design for the norm and separate out the exceptions. A good example of exception handling is the drive-through at fast food restaurants. If there is something about an order that is not ready when the car gets to the window, the cashier takes the money and asks the driver to pull aside, after which, the other “normal cases” can flow smoothly, i.e., the main designed process isn’t held up because of one guy’s fries, the exception, were not ready. The process is designed so that the exception doesn’t interfere or reduce the efficiency.

25

Exception handling examples in health care include having a special process for contacting no-shows and rescheduling, and when one lab test in a batch is held up, available results are returned per schedule and the lab test that was held up is reported when available.

26

Extra resources means identifying those process steps that are known bottlenecks, i.e., the processes cause downstream delays, and then adding extra resources at those steps to optimize the overall process. An example of extra resources in health care include keeping someone at the front desk to check patients in, and maintaining sufficient medical office assistants and nursing staff so that everything that can be done before the provider sees the patient is done with time to spare so the provider does not have to wait.

27

Flexible assignment is “hedging your bet” and minimizing risk.

In process design, things might not always work out, or may have unintended consequences. Flexible assignment means making changes in staff for instance that don’t lock the practice should things go wrong.

An example would be hiring a medical office assistant who can also do blood draws in case having the nurses draw blood causes an imbalance in workload.

28

Integration is designing clinic processes so that they mesh well with high volume/high interaction organizations. By mesh well, we mean that hand-offs processes are automated and flow smoothly.

Examples include:

• electronic interface with a claims clearinghouse, • electronic interface with a lab or high volume diagnostic service, and • electronic interface with a local hospital.

29

Interfacing means providing common and standard interaction points for high volume interactions.

Some examples include:

• all labs come through a lab interface, • on-line appointment scheduling, and • all documents are received in one place and processed.

30

Knock-out essentially means fail fast.

Decisions that decrease workload should be made as early in the process as possible. For example:

• checking insurance eligibility first thing, • initiating the approval process for a procedures as early as possible, and • screening patients for issues that require urgent or a higher level of care immediately, for

example, practice phone messages say first of all “if this is a life threatening emergency, hang up and call 911.”

31

It is important to design processes to involve as few roles and people as possible. This eliminates unnecessary delays, extra hand-offs, and communication errors. Be careful to avoid splitting responsibilities across departments or organizations.

This is more a design principle than a strategy with examples.

32

If others can do things better or more efficiently than the clinic, consider outsourcing.

Examples where outsourcing may be more efficient include:

• responding to requests for records, • using an external lab or diagnostic testing service, and • hosting the medical record software and IT support.

33

Identifying Process Types is more a principle than a strategy, but the process analysis should have identified the main types of clinic work streams and processes.

34

Queues and batches cause delays and wait time. To avoid long queues and large batches of work, it is best to assign work as it comes in and to a person responsible for seeing the work through to completion.

For example:

• Guaranteed same-day appointments avoid patient back-ups and • Assigning a person to handle all prescription refills regardless of whether the prescription is

called in by patients or pharmacies.

35

Anything that can be done in parallel rather than waiting for another step to be completed should be done in parallel. Resequence process steps to accomplish tasks as early in the process as possible.

36

Task composition is more something to consider than a redesign strategy. Some things are better done as smaller steps, while other things may be easier to accomplish as a group of steps.

An example is the processing of incoming documents:

Processing incoming documents is more efficient and accurate when broken down into smaller steps. These steps include:

1. opening all the mail, 2. checking for document identifiers on the envelopes, 3. sorting in patient number order, and 4. filing.

This is more efficient and accurate than opening a single piece of mail, checking the envelope for document identifiers, processing and filing before opening the next piece of mail.

37

Task elimination is probably what most people think of first when they hear the words process redesign. Getting rid of steps that do not add value, i.e., the “unproductive work.”

Examples:

• ePrescribing eliminates a significant number of steps, • getting rid of redundant work does too, • automating steps effectively eliminates tasks that humans need to do, and • control relocation also can eliminate tasks that office staff need to do.

38

Specialist-generalist is more of a consideration than a particular strategy that can be applied. Some things are more efficient if a person handles only one type of issue. An example would be in a large practice where one person can devote 100% of his time to scheduling external diagnostic tests or surgeries; whereas in a small practice, people wear many hats. The choice of specialist or generalist depends on the training and skill level required for a task, on how easy a task is to do when it is not the main focus of someone, and on the size of the practice.

39

Triage is related to the specialist – generalist concept. Triage means that there is an initial sorting step where things requiring specialist attention are sent to specialists and others are sent where they are most efficiently handled. For example, a triage nurse in an emergency department ensures that urgent patients get seen first and less serious ones wait longer.

40

Some process changes are large: “breakthroughs” in improving efficient, major shifts in the way work is done, and great improvements in performance. Other changes are small with incremental advances. Many of the strategies discussed above, depending on how they are applied, can be either. The former usually takes more preparation and planning, and of course, innovation.

41

This concludes Lecture a of Process Design. In this lecture, we have covered:

• Goals of process redesign, • Common process problems, • Process redesign strategies to address common process problems, and • Clinic examples of redesign strategies.

Lecture b covers Human Centered Design as applied to process redesign.

42

No audio.

43

Activities

Discussion for Week 2 Discussion Topic

IFSM 305 7980 Information Systems in Health Care …

0 % 0 of 2 topics complete

Topic: Analyze organizational processes to identify information systems requirements

For your Stage 1 assignment, you will analyze the processes at the Midtown Family Clinic

to identify the essential requirements for the EHR system for the Clinic. For this

discussion, you will practice analyzing processes and identifying functional requirements

for a system to improve a process.

First, we need to be sure you can identify a process; many students have difficulty with

that, so refer to the week 2 readings that describe various healthcare processes. Keep in

mind that a process is a set of specified steps to accomplish a task.

Second, requirements for a system need to be clearly written so that the people who are

developing the system or evaluating a system for use can discern whether the

requirements are met or not. One set of criteria for writing clear requirements is referred

to as "SMART" criteria, which means each requirement statement is:

Specific – Clearly and simply stated, and not likely to be mis-interpreted.

Avoid such words as: and, or, but, soon, immediately, somewhat.

Measurable - Can be verified as complete or not. Avoid such words as: best,

fastest, optimally.

Attainable – Able to be achieved; appropriate.

Realistic – Considering the project and other requirements, can this one be

expected to be met.

Case Study Stage 1 Assignment Assignment

Due November 3 at 11:59 PM

Time-bound – If appropriate to the requirement, specifies when or how fast

a requirement needs to be completed.

For a more in-depth discussion and some examples, see:

https://jessica80304.wordpress.com/2008/08/04/smart-requirements/

GROUP 2:

1. Drawing from your own experience, select a health care process used at your place

of work or in your interaction with a health care organization that you would like to

see improved. Explain why you picked that process.

2. Imagine that a system is to be implemented (or an existing system improved) to

make that process better, and identify five (5) requirements that the system would

need to satisfy. Each requirement is one sentence in length and addresses one thing

the system must do. Here we are interested in "functional requirements" – the

activities the system must perform to support the identified process. We are not

including "nonfunctional requirements" that include how the system would perform.

3. Review (and re-write if necessary) the 5 requirements statements to ensure they

meet the "SMART" criteria.

GROUPS 1, 3 and 4: In replying to the postings, you are to critically evaluate all of the

following for at least two main postings:

1. Should the process identified actually be considered a "process"; that is, does it

meet the definition of "a set of specified steps to accomplish a task"?

2. Do the requirements listed support the selected process?

3. Are the requirements clearly stated such that system testers will be able to

ascertain whether or not the requirement has been implemented (have they

followed the "SMART" criteria)?

4. What improvements to the requirements would you suggest? At least one is

required; explain what needs to be corrected and provide your re-wording of the

requirement.

EVERYONE: Review the criteria in the Discussion Grading Rubric, and reply to those who

critique your work or post other points of view. Be sure to demonstrate your

understanding of the topic and analytical thinking.

Attached is the Stage 1 assignment. It uses the Case Study located under Content >

Course Resources > Case Study, and is due as shown in the class schedule/calendar.

When you submit your work, please include your last name in the filename.

IFSM 305 Stage 1: Organizational Analysis and Requirements - 11/17/2017 1

Stage 1: Organizational Analysis and Requirements Overview Before you begin work on this assignment, be sure you have read the Case Study. Refer to the System Recommendation Report - Table of Contents - below to see where you are in the process of developing this report.

As a professional medical consultant, you have been asked to conduct an analysis, develop a set of system requirements and propose an Electronic Health Records (EHR) system to improve the Midtown Family Clinic's processes. This work will be completed in four stages, and each of these four stages will focus on one section of an overall System Recommendation Report to be delivered to the Midtown Family Clinic. The sections of the System Recommendation Report will be developed and submitted as four staged assignments. In stages 2, 3 and 4, you will also incorporate any feedback received when the previous stage is graded to improve the effectiveness of your overall report and then add the new section to your report. At the end of the course, you will submit a complete System Recommendation Report that includes all the sections and changes that resulted from previous feedback. A key to successful business writing is quality and conciseness rather than quantity. The sections are described below and the graphic that follows provides the detailed outline and Table of Contents for this report: Introduction – Provides background and sets the stage for the rest of the document. To be written and submitted as part of Stage 1. Section I: Organizational Analysis and Requirements (Stage 1) - The first step is to look at the organization and explain how an EHR system could benefit the Midtown Family Clinic's processes. Section II: Data Sharing (Stage 2) – Next you will explain, the types of data that need to be shared with other organizations, and what data interchange standards should be used. Section III: Ethical, Legal and Regulatory Policy Issues (Stage 3) – Then you will analyze the ethical, legal and regulatory policy issues that impact the EHR solution for the Midtown Family Clinic. Section IV: System Recommendation (Stage 4) – Finally, you will identify a certified EHR system for the Midtown Family Clinic, and explain what improvements the Clinic can expect, how it meets the requirements, and what needs to be done to implement the system at the Clinic. Conclusion – Summarizes the document. To be written and submitted as part of Stage 4. References – List of references. A separate page developed as part of Stage 1 with references added (in alphabetical order) as other sections are added to the report. Begin by creating a title page to include your name, course information and date; followed by a page break. On a separate page, create the Table of Contents, which you will update as you add the sections of the Report. Note that each section has its own introduction and summary.

IFSM 305 Stage 1: Organizational Analysis and Requirements - 11/17/2017 2

System Recommendation Report

Table of Contents

Introduction (Stage 1) II. Organizational Analysis and Requirements (Stage 1)

A. Introduction B. Strategic Use of Technology C. Components of an Information System D. Functional Requirements E. Summary

II. Data Sharing (Stage 2) A. Introduction B. Need to Share Data C. Types of Data to be Shared D. Data Interchange Standards E. Summary

III. Ethical, Legal and Regulatory Policy Issues (Stage 3) A. Introduction B. Table of Ethical, Legal and Regulatory Policy Issues C. Addressing the Most Difficult Issue D. Summary

IV. System Recommendation (Stage 4) A. Introduction B. Proposed IT solution C. How the Proposed IT Solution Meets the Requirements D. Improvements from Proposed IT Solution E. Implementation Considerations F. Summary

Conclusion (Stage 4) References

System Recommendation Report (SRR), Section I – Organizational Analysis and Requirements Section I of the SRR document contains an organizational analysis and identifies ways in which an Electronic Health Record (EHR) system can help the Midtown Family Clinic to meet its strategic goals. The next step is to identify data and functional requirements for the EHR system. This analysis lays the ground work for the rest of SRR, as the recommendation for an EHR must support the Clinic's strategic goals and meet its functional and data requirements.

IFSM 305 Stage 1: Organizational Analysis and Requirements - 11/17/2017 3

Stage 1 Assignment Instructions Using the case study, the overview above, Course Content readings, and external resources, develop your Introduction and Section I: Organizational Analysis and Requirements. Recommended lengths for each section are provided and you should be sure to include all pertinent information. Introduction– briefly describe (at a high level) the organization in the Case Study; provide a context for the rest of the document. (one to two paragraphs) I. Organizational Analysis and Requirements A. Introduction – Introduction to this section describing what is included. (3-4 sentences) B. Strategic Use of Technology - Using the Strategic Goals section of the Case Study, list three

strategic goals that have been identified by the Midtown Family Clinic, and that can be supported with an EHR system. For each, explain how an EHR system can be used to support the goal. (Introductory sentence and list of three strategic goals with one to two strong sentences that explain how an EHR system would support the strategic goal and justify your position with specifics from the Case Study.)

1. Strategic Goal 1 and explanation: 2. Strategic Goal 2 and explanation: 3. Strategic Goal 3 and explanation:

C. Components of an Information System – An information system is comprised of people,

technology, processes (or organizational components), and data. Explain each of the following in relationship to an EHR system to support the Midtown Family Clinic:

1. People – List the people who would use the new EHR system by name and role, and identify two things that person needs (functions) the system to do to help them with their job. (Provide an introductory sentence for Section C, and a sentence on people followed by a list of the people who will use the system and their roles.) A. Person 1 and role, and two functions B. Person 2 and role, and two functions C. Person 3 and role, and two functions

2. Organizational Processes – list three processes that are used at the Clinic that would be supported by an EHR system and explain how the processes would be improved using an EHR system. (Provide an introductory sentence and list/explanation of three processes.) A. Process 1 and how it would be improved B. Process 1 and how it would be improved C. Process 1 and how it would be improved

3. Data – The new EHR system will need to collect, store and process data. An example of needed data is “Name of Patient.” The case study provides insight into the kinds of data that will be needed. First, insert an introductory opening sentence for this section. Then identify ten (10) critical data items for this EHR system solution. (Provide an introductory sentence and copy the table and insert information within.)

IFSM 305 Stage 1: Organizational Analysis and Requirements - 11/17/2017 4

Data Items Needed for EHR System 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

D. Functional Requirements – The next step is to identify the essential requirements for the EHR system. Review the processes and data items you listed above and create a list of ten (10) requirements. Each requirement is one sentence in length and addresses one thing the system must do. The requirements are documented in a table, as shown below. For a full requirement specification, there will be many requirements statements; you only need to provide ten. The requirements should be derived from the Case Study; an analyst should not "invent" requirements. (Provide an introductory sentence and copy the table and insert information within.)

Functional Requirements 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

E. Summary – briefly summarize the content of this section and tie the information together for the

reader. (3-4 sentences) Formatting Your Assignment For academic writing, the writer is expected to write in the third person. In third person, the writer avoids the pronouns I, we, my, you, your, and ours. The third person is used to make the writing more objective by taking the individual, the “self,” out of the writing. This method is very helpful for academic writing, a form in which facts, not opinion, drive the tone of the text. Writing in the third person allows the writer to come across as unbiased and thus more informed. The Report is to be written for the Midtown Family Clinic, and reference should not be made by name to individuals who own or work in the Clinic. • Write a short concise paper: Use the recommendations provided in each area for length of

response. Content areas should be double spaced; table entries should be single-spaced. It’s

IFSM 305 Stage 1: Organizational Analysis and Requirements - 11/17/2017 5

important to value quality over quantity. The body (Introduction to the report and Section I) of the assignment should not exceed 6 pages.

• Ensure each section has an introductory sentence or two that sets the stage for the information to follow.

• Ensure that each of the tables is preceded by an introductory sentence that explains what is contained in the table, so the reader understands why the table has been included.

• Use at least two resources with APA formatted citation and reference. Use at least one external reference and one from the course content.

• Compare your work to the Assignment Instructions above and the Evaluation Criteria/Grading Rubric below to be sure you have met content and quality criteria. Do not overlook this step. Read your work out loud or have your computer read it to you. Fix the grammar and other areas identified.

• Submit your paper as a Word document, or a document that can be read in Word. • Your submission filename should be as follows: Lastname_firstname_Stage_1 EVALUATION CRITERIA/GRADING RUBRIC:

Criteria

90-100%

Far Above Standards

80-89%

Above Standards

70-79%

Meets Standards

60-69%

Below Standards

< 60%

Well Below Standards

Possible Points

Report Introduction

5 Points

Describes the organization and provides an effective introduction to the Report; is clear, logical, derived from the Case Study; and demonstrates a sophisticated level of writing.

4 Points

Describes the organization and provides an introduction to the Report; is clear, logical, and derived from the Case Study.

3.5 Points

Describes the organization and provides an introduction to the Report; is adequate, and derived from the Case Study.

3 Points

Not clear, logical and/or derived from the Case Study.

0-2 Points

Not included, or demonstrates little effort.

5

Section Introduction and Summary

5 Points

Provides effective introduction and summary to Section I; is clear, logical, derived from the Case Study; and demonstrates a sophisticated level of writing.

4 Points

Provides an introduction and summary to Section I; is clear, logical, and derived from the Case Study.

3.5 Points

Provides an introduction and summary to Section I; is adequate, and derived from the Case Study.

3 Points

Not clear, logical and/or derived from the Case Study. Or, either the introduction or summary is not included.

0-2 Points

Not included, or demonstrates little effort.

5

Strategic Goals

How the system will support three of the

13-15 Points

The explanation is clear, logical and fully supported using a

12 Points

The explanation is clear, logical and supported.

10-11 Points

The explanation is provided and supported.

9 Points

The explanation is not clear, logical and/or supported.

0-8 Points

The explanation is not included or demonstrates little effort.

15

IFSM 305 Stage 1: Organizational Analysis and Requirements - 11/17/2017 6

organization’s strategic goals

sophisticated level of writing.

Components

The 3 people, 3 processes, and 10 data items

31-35 Points

Fully and logically explained, are clearly related to the Case Study, and demonstrate a sophisticated level of analysis and writing.

28-30 Points

Logically explained, are related to the Case Study, and demonstrate analysis and effective writing.

24-27 Points

Explanation provided and relates to the Case Study.

21-23 Points

Not all clearly explained and/or are not related to the Case Study.

0-20 Points

Not all addressed or little effort is demonstrated.

35

Requirements

10 functional requirements

18-20 Points

Correctly identified and sourced; clearly derived from the Case Study; demonstrates sophisticated analysis.

16-17 Points

Identified and sourced; requirements are derived from the Case Study; demonstrates effective analysis.

14-15 Points

Identified and sourced; requirements are related to the Case Study.

12-13 Points

Less than 10 requirements are identified and sourced; and/or information provided is not correct; and/or requirements are not all related to the Case Study.

0-11 Points

Few or no requirements are listed; sources are incorrect; and/or requirements are not related to the Case Study.

20

Research

Two or more sources--one source from within the IFSM 305 course content and one external (other than the course materials)

9-10 Points

Required resources are incorporated and used effectively. Sources used are relevant and timely and contribute strongly to the analysis. References are appropriately incorporated and cited using APA style.

8.5 Points At least two sources are incorporated and are relevant and somewhat support the analysis. References are appropriately incorporated and cited using APA style.

7.5 Points

Only one resource is used and properly incorporated and/or reference(s) lack correct APA style.

6.5 Points

A source may be used, but is not properly incorporated or used, and/or is not effective or appropriate; and/or does not follow APA style for references and citations.

0-5 Points

No course content or external research incorporated; or reference listed is not cited within the text

10

Format 9-10 Points

Well organized and easy to read. Very few or no errors in sentence structure, grammar, and spelling; double- spaced, written in third person and presented in a professional format.

8.5 Points

Effective organization; has few errors in sentence structure, grammar, and spelling; double- spaced, written in third person and presented in a professional format.

7.5 Points

Some organization; may have some errors in sentence structure, grammar and spelling. Report is double spaced and written in third person.

6.5 Points

Not well organized, and/or contains several grammar and/or spelling errors; and/or is not double-spaced and written in third person.

0-5 Points

Extremely poorly written, has many grammar and/or spelling errors, or does not convey the information.

10

TOTAL Points Possible

100