Health Assessments in Primary Care: A How-to Guide

Section 3. How Do You Work Health Assessments into Your Office Workflow?

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Now that your practice has identified which health assessments to incorporate into routine patient care, the next step is to consider how the assessment fits into the patient visit workflow. If this still feels overwhelming, start with a small pilot test, then move forward sequentially. This section is organized into five subsections addressing key strategies for implementing health assessments into the workflow of the patient visit: practice-wide involvement, training, patient visit planning, standardization, and EHR integration.

Start small. For instance, have one doctor who is interested in [a new assessment] and owns, and hones it to perfect, and then presents it [to the rest of the staff].

-General internal medicine physician, urban private practice, Colorado

 

Is your whole staff involved in the implementation?

Implementing a new health assessment—like many practice improvement efforts—works best as a team effort. Clinicians, staff, and managers must all be involved in the final decisions about how an assessment will be implemented. To achieve this, engage staff and clinicians throughout the entire process of testing and improving how tools or questions are integrated into the office flow. In a larger practice, it might be more practical to do some of the work in a smaller team, bringing in the whole practice at key decision points. Multidisciplinary teams, regular meetings, plan-do-study-act (PDSA) cycles, and ongoing reviews of office processes will help to:

  • Share the planning, design, execution, and maintenance of implementing health assessments.
  • Spread the effort and responsibility for handling health assessments across the health care team.

Links to PDSA and Workflow tools can be found in Appendix 9.

Our recommendations are: 

  1. Figure out your workflow. 
  2. Assess what you are going to do with the data you get. 
  3. Determine what elements of health you are most interested in and know how to deal with the results most effectively. 
  4. Start small and then expand.

-Family physician, suburban private practice, New Jersey

 

In what areas do you need more training?

Well-trained clinicians and staff will facilitate successful health assessment implementation. Staff might not immediately understand their important role in effectively implementing health assessments; however, training staff, setting expectations, getting buy-in from key leaders, and providing evidence on the value of health assessments may help to overcome resistance. Train on both the completion of health assessments and how to discuss results with patients. Consider providing training on the following:

  • Patient engagement techniques (e.g., how to emphasize the importance of completing the assessment and how to explain how the information is used).
  • Specialized EHR training (e.g., work flows, templates, and reporting).
  • Issues specific to the selected health assessment instruments (e.g., scoring, decision support, patient feedback).
  • Implementation (e.g., work flow, data entry, scheduling).
  • Tracking and reporting (e.g., documenting in and reporting from EHR or registry).
  • How the selected health assessment(s) will improve patient care

How will new health assessments affect patient flow?

To succeed with a sustainable implementation, the workflow for health assessments should aim to streamline the patient visit, improve (or at least not increase) patient cycle times, maximize clinician-patient contact time, and improve the use of patient contact time. With some careful planning, this can be accomplished. Allow a patient enough time to complete the health assessment thoughtfully, whether that means allowing them to complete it at home before the visit (possibly using a family member to help) or having them complete it in the waiting room while they wait to be seen. Here are a few considerations:

  • Best types of visits for patients to complete a health assessment (e.g., well visit, sports physical).
  • Options for completing the survey outside of the office (e.g., mail to patients prior to a visit or complete online).
  • Staff availability to help patients complete health assessments (e.g., MA/RN reviews and asks about unanswered questions).
  • Options for review of the completed health assessment (e.g., MA/RN as part of rooming process or while patients wait; scan completed paper surveys; review EHR template or report).
  • Formatting and ordering of questions to ensure efficient review or data entry (e.g., reorder questions to fit with EHR data entry work flow, organize “positive” responses in the same column for quick visual scanning).
  • Acknowledging to patients that you received and reviewed the information.
  • Working collaboratively with patients to create a care plan (e.g., templates or handouts with health goals, priorities, and action items).
  • Coding appropriately for administration and review of health assessments (e.g., preventive coding “cheat sheet” for staff or clinicians).

Consider developing a process map to visually describe the complete health assessment process in your practice. A sample process map can be found in Appendix 9.

We identify Annual Wellness Visit patients before their visit so the correct materials can be sent. The patient is sent an Annual Wellness Visit questionnaire ahead of time to fill out before they arrive in the clinic. The average patient takes about 10 minutes to complete [the questionnaire]. So far, most patients come back with the questionnaire already filled out.

- Family physician, urban residency practice, Georgia

 

Should you standardize your processes?

Standardization of processes, especially establishing expectations for roles and responsibilities, is important for practices to implement health assessments completely and more routinely. Consistency in processes can be especially important when documentation of health assessment questions is required for incentive programs. Writing a brief protocol, guide, or checklist can help the health care team to learn how to work with health assessments. Here are some ways to think about standardizing your health assessments:

  • Which patients (or groups of patients) should receive the health assessment?
  • Who will make sure the patients get the health assessment? How (checklists; EHR reminders)?
  • How often do patients complete the health assessment (e.g., at all well care or preventive visits; annually for patients with chronic conditions)?
  • Where will the data go (into your EHR; into a database; into a paper chart)?
  • Who on your team will primarily review the information with the patient? When?
  • How will your practice arrange patient follow up?

Special considerations for integrating health assessments into EHR work flows

Health assessment data are more useful when they can be stored in structured fields in the EHR and retrieved through queries or reports. Integration into the EHR allows computerized tools to generate standardized decision support to identify health behavior risks and guide behavior change recommendations. Integration may also include using administrative databases to identify high-risk patients for further assessment or follow-up and support for accurate coding and billing. Consider the questions below to help guide the integration of health assessment into your practice’s EHR:

  • What health assessments (or specific questions) are already in your EHR?
  • Do you already have a template for the health assessment?
  • Does your EHR have a patient portal to collect health assessment data?
  • What can you learn about implementation strategies from other practices using your same EHR?
  • If entering data from paper forms, do your paper forms follow EHR workflows?
  • Are answers to confidential or sensitive questions stored in a way to avoid improper release of this information?
  • Does the EHR allow the data from the health assessment to be easily collected for reporting (e.g., quality improvement or population management)?

In some cases, EHR integration might not be practical. Integration with EHRs is not essential—paper can still work well and be efficient for some assessments. For example, a paper health assessment form can be a quick and effective reminder tool for both clinicians and patients to discuss a particular topic that could be affecting the patient’s health.

Do you have an alternative to the EHR?

While integrating health assessments into your EHR is desirable in the long term, it could be more practical to consider some alternatives:

  • Standalone data repository (e.g., a patient registry).
  • Simple spreadsheet or database.
  • Web-based tools for gathering and storing the health assessment information.

Be sure that any electronic files you create are secure and comply with patient privacy regulations. 

It is not easy to find [information] in the EMR so it is rarely used. Also, since patients cannot input the data directly, it takes time to ask the questions. It is easier to have the patient fill this out on paper and put the final number result in [the EMR] as data.

-Family physician, suburban residency practice, New York

Current as of September 2013
Internet Citation: Health Assessments in Primary Care: A How-to Guide: Section 3. How Do You Work Health Assessments into Your Office Workflow?. September 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/health-assessments/health-assessment3.html