Module 17 Appendix

Workflow mapping: a tool for achieving meaningful use

 

Contents

Slide 1. Workflow Mapping: A Tool for Achieving Meaningful Use
Slide 2. Goals
Slide 3. Example 1a: How Not To Provide Lab Results to Your Patients
Slide 4. Example 1b: Lab Result Follow-Up After Workflow Mapping
Slide 5. Example 2a: How Not To Do Rx Refills
Slide 6. Example 2b: Rx Refills After Workflow Mapping
Slide 7. What Is a Workflow Map?
Slide 8. Workflows Before Implementing EHR Are Different From Those After
Slide 9. Workflow Mapping Pre-EHR Reveals Inefficiencies and Waste
Slide 10. Workflow Mapping Pre-EHR: Tailor EHR To Meet Practice Needs
Slide 11. Workflow Mapping Post-EHR: EHR Is a Huge Change
Slide 12. Workflows Post-EHR: Shows Practices How Best To Use EHR
Slide 13. Who’s Involved With Workflow Mapping?
Slide 14. Types of Workflow Maps
Slide 15. Know Your Symbols
Slide 16. Simple Steps for Workflow Mapping
Slide 17. What To Do With Your Workflow Map
Slide 18. How Not To Do Workflow Mapping
Slide 19. Achieving Meaningful Use Requires Workflow Change
Slide 20. Meaningful Use Criteria: Stage 1
Slide 21. Meaningful Use Criteria: Stage 1
Slide 22. Meaningful Use Criteria: Stage 1
Slide 23. Suggested Workflows for Meaningful Use
Slide 24. Example Flowchart: Documenting Vital Signs (Example, Blood Pressure) 
Slide 25. Example Flowchart: Maintaining Active Medication Lists
Slide 26. Example Flowchart: Maintaining Active Allergy Lists
Slide 27. Example Flowchart: Documenting Smoking Status for Patients 13 and Up
Slide 28. Example Flowchart: Providing Clinical Summaries at the Conclusion of Appointments
Slide 29. Example Flowchart: Reporting on Clinical Quality Measures to CMS (Example: % of Diabetes Patients With A1c>9) 
Slide 30. Example Flowchart: Reminders to Patients for Preventive and Follow-Up Care (Example: Outreach to Patients Due for Annual FOBT)
Slide 31. Example Flowchart: How To Change a Job Role Using Lab Result Follow-Up as an Example
Slide 32. Conclusion


 

Slide 1. Workflow Mapping: A Tool for Achieving Meaningful Use

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Center for Excellence in Primary Care
UCSF Department of Family and Community Medicine
Tom Bodenheimer, MD

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Slide 2. Goals

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  • Explain workflow mapping.
  • Discuss why workflow mapping is useful prior to and after EHR implementation.
  • Demonstrate how to create workflow maps.
  • Review some meaningful use workflow examples.

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Slide 3. Example 1a: How Not To Provide Lab Results to Your Patients

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Flowchart of providing lab results to patients:

Here is a process that many practices are familiar with: following up with patients and their lab results. Some of you may be grumbling as you think about how frustrating this process can be sometimes. Many practices will probably rank lab results follow-up as the most or one of the most common problems they deal with on a regular basis.

One practice was very aware of the problems around lab result follow-up. They tried different things ways to fix the problems but encountered many failed attempts at improving something. It wasn’t until they mapped out the process from beginning to end that they actually figured out the main cause of the problem.

At this practice, when a lab result was faxed to the printer, the MA would receive the fax and make three copies of the result. The MA would then give one copy to the RN/LVN, one copy to the Clinician, and keep one for themselves. The MA would then retrieve the patient’s chart and put their copy of the lab result on the chart and place the chart on the Clinician’s desk. The RN/LVN looks at their copy of the lab result and writes normal, abnormal, or urgent on it, then places it on the Clinician’s desk. The Clinician now has all three copies of a lab result. At some point in the day or night, the Clinician has to sort through all the labs and calls patients with abnormal labs. Patients never learn about lab results that come back normal.

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Slide 4. Example 1b: Lab Result Follow-Up After Workflow Mapping

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Flowchart of providing lab results to patients:

The practice changed the way lab results were handled by writing protocols for the RN to handle lab results. This is the same practice’s new improved process. You can visually see the difference between the new process and the former process; look at how many fewer steps are involved in the new process.

RN/LVNs at the practice now have standing orders for handling lab results. When the results are faxed to the printer, the MA still picks up the lab result, but instead of making 3 copies, the MA hands the lab result to the RN/LVN along with the patient’s chart. The RN/LVN contacts patients for normal or mildly abnormal labs. The RN/LVN brings very abnormal results to the Clinician’s attention. The Clinician instructs the RN on how to handle the lab result and the RN carries out the orders.

After mapping out the process, this practice was able to see where the waste occurred in the old way of doing things. By eliminating steps that did not add value to the process, like making three copies of the lab result, and implementing protocols for RN/LVNs to follow, the practice was able to inform patients of normal lab results, which did not happen previously.

The process on the screen is how the practice envisioned lab result follow-up in a paper chart environment. This workflow will change once this practice goes to EHR.

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Slide 5. Example 2a: How Not To Do Rx Refills

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Flowchart of prescription refills:

Here is another example of a process with a bad workflow.

Prescription refills are another common headache for practices. This example covers incoming phone calls for prescription refills.

At this practice, the receptionist would take the incoming phone call and write down the patient’s request on a tiny slip of paper. The slip of paper would somehow make its way to medical records and a clerk would pull the patient’s chart after an hour had passed.

The medical records clerk then has to figure out which MA is working with which Clinician and give the chart to the correct MA. The MA puts the chart on a stack on the Clinician’s desk. The Clinician is too busy to do anything at the moment.

The same patient calls the clinic 2 hours later asking if the refill has been faxed to the pharmacy. The receptionist takes down another note to put on the chart. The receptionist doesn’t know where the chart is so they have to ask all the MAs who has the chart. The receptionist gives the note to the correct MA, who puts the new note on the chart sitting on the Clinician’s desk 4 hours later; the Clinician approves the refill and puts the chart on the MA’s desk. 2 hours later, that MA calls in the prescription to the pharmacy. No one informs the patient that the refill has been approved.

There is a different but similar workflow for faxes coming from the pharmacy for refills.

A lot of time was wasted spent looking for the chart and there was a huge delay in the patient getting a prescription refilled.

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Slide 6. Example 2b: Rx Refills After Workflow Mapping

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Flowchart of prescription refills. Receptionist uses a refill form, which goes to a medical records clerk. The clerk pulls the patient’s chart, determines the clinician and corresponding MA, and gives the form to the MA. If clinician approval is needed, form goes into the DO NOW pile and clinician approves refill within 1 hour. The chart goes to the MA. The MA calls the pharmacy. If approval is not needed, the MA calls the pharmacy.

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Slide 7. What Is a Workflow Map?

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  • A visual representation of a process:
    • A process is a series of actions, steps, or tasks performed in a certain order to achieve a certain result.
  • Defines the beginning of a process, the end of a process, and all the steps in-between.
  • Defines who does what in the process.
  • A measurement of what IS.

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Slide 8. Workflows Before Implementing EHR Are Different From Those After

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Drawing of practice manager visualizing clinician and medical assistant holding clipboards. Then EHR adoption takes place. The practice manager sees the clinician and medical assistant using computers.

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Slide 9. Workflow Mapping Pre-EHR Reveals Inefficiencies and Waste

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  • Workflow mapping helps practices
    • Identify inefficiencies, waste, and dangers.
    • Eliminate wasteful steps.
    • Streamline complicated workflows.
    • Standardize how work is done.
  • Example 1 (lab results): workflow mapping uncovered unnecessary steps that could easily be eliminated, making life easier for physicians and staff.
  • Example 2 (Rx refills): workflow mapping showed that big changes were needed to eliminate waste and reduce patient delays.

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Slide 10. Workflow Mapping Pre-EHR: Tailor EHR To Meet Practice Needs

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  • Mapping out processes before EHR implementation helps practices decide how to use the EHR.
  • Workflow mapping demonstrates what protocols and standing orders are needed to redistribute work.
  • Workflow maps help practices work with their EHR vendor so that the vendor understands how each person will use the EHR.
  • Examples 1 and 2: protocols and standing orders written pre-EHR adoption delineate who does what, which facilitates implementation of the EHR.

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Slide 11. Workflow Mapping Post-EHR: EHR Is a Huge Change

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  • Going from paper to EHR changes every single thing in a practice.
  • Roles will change:
    • What will medical records clerks do?
    • Medical assistants will enter vital signs electronically and provide more services in the rooming process.
    • Clinicians will type progress notes and use templates.
    • E-prescribing often shifts all refill work to Clinicians’ inboxes.
  • Example 2 (Rx refill): Post-EHR workflow can be set up so that Clinicians do not handle every refill. This depends on pre-EHR workflow redesign.

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Slide 12. Workflows Post-EHR: Shows Practices How Best To Use EHR

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  • EHR implementation tends to push work back onto the Clinician. Workflow mapping can prevent this.
  • Workflow mapping helps staff look at entire process and think how their work fits into a larger system.
  • Workflow maps help practices decide which personnel they need post-EHR.
  • Example 1 (lab results): If a practice does not have an RN or LVN, Clinicians need to review all labs. If the practice wants to delegate lab review to another team member, the practice would need an RN or LVN because MAs cannot review labs. Also, the practice will not need a medical records person.

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Slide 13. Who’s Involved With Workflow Mapping?

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  • One designated person :
    • Oversees the team and keeps tasks on track.
    • Understands all aspects of the process in detail.
    • Drafts the initial workflow map.
  • The team:
    • Decides what processes to map.
    • Everyone involved in a workflow should be part of the mapping process.
    • Discusses accuracy of the workflow map after it’s been drafted.
    • Perfects the process and maps it out.

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Slide 14. Types of Workflow Maps

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High-Level Flowchart: Shows the major steps of a process. A high-level (also called first-level or top-down) flowchart illustrates a “birds-eye view” of a process.

Diagram of high-level flowchart of prenatal care process, showing patient arriving, registering, seeing doctor, paying bill, and making follow-up appointment.

Detailed Flowchart: Provides a detailed picture of a process by mapping all of the steps and activities that occur in the process. This type of flowchart includes such things as decision points, waiting periods, tasks that frequently must be redone (rework), and feedback loops. This type of flowchart is useful for examining areas of the process in detail and for looking for problems or areas of inefficiency.
Diagram of detailed flowchart of registration process. Patient arrives at registration desk. Is there a line for records? Yes means Delay. If No, is record clerk available? No means Delay. If yes, is clinical officer available? No means Delay. If yes, patient seen by clinical officer.

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Slide 15. Know Your Symbols

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Chart showing flowchart symbols and their use:

Before diving in to how to do workflow mapping, we will go over a few basic symbols.

I say a few symbols because there are a lot more symbols that you can use in more complicated workflows. These symbols are the more commonly used ones.

The first four symbols are the most crucial to workflow mapping.

The first symbol is an elongated oval shape that represents the start and end points of a process. All processes have a start and end symbol and some processes may have more than one starting or ending point.

A rectangle is used to represent a step that is performed in the process.

A diamond is used to represent a point in the process where a decision must be made before moving on to the next step. The decision can be a yes/no question or a question with a choice of answers. Not all processes will have a decision point.

An arrow is used to direct the flow of information. Arrows connect different steps in the process.

Elongated semicircles are used to represent delays in the process.

The pentagon shape is used to refer to a separate workflow that is located on another page.

A circle is used to refer back to a step in the process that is located on the same page as your map.

A cloud is used to symbolize a step that you may be unclear about.

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Slide 16. Simple Steps for Workflow Mapping

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  • Step 1. Pick a process to map out, pick which type of workflow to use, and agree on its purpose.
  • Step 2. Determine the beginning and end points.
  • Step 3. Identify each step in the process.
  • Step 4. Put the steps in order.
  • Step 5. Review and edit the first draft.
  • Step 6. After a day or two, review the flowchart with the team for input.

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Slide 17. What To Do With Your Workflow Map

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  • Look at your workflow map and examine it:
    • Beginning and end points.
    • Each activity and wait symbol.
    • Decision points.
    • Hand-offs (where one person finishes his or her part of the process and another person picks it up).
  • Ask questions about the workflow map:
    • Does that step really need to be there?
  • Map out the improved process.

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Slide 18. How Not To Do Workflow Mapping

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  • Map out the processes you wish you had.
  • Interview a few key informants to understand the process instead of shadowing everyone involved in the process.
  • Ignore the opinions of those people who know the process best.
  • Put your workflow map on the shelf and don’t look at it again.

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Slide 19. Achieving Meaningful Use Requires Workflow Change

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  • Meeting meaningful use requires practice staff to perform functions they may not have performed before
    • Example: Practices will need to provide patients with an after visit summary.
  • Meeting meaningful use requires efficient high-quality and patient-centered use, not just any use, of the EHR.

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Slide 20. Meaningful Use Criteria: Stage 1

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Core requirementWorkflow changes needed?Workflow change ideas
Record patient demographicsYesSomeone in the practice needs to enter and update demographics
Record vital signs electronicallyYesMedical assistant adds to rooming tasks: calculating BMI, entering height, weight, BP, growth charts into EHR
Maintain up-to-date problem listYesClinicians often fail to keep problem lists updated. MA reviews problem list during rooming and reminds clinician to update. MA does not make updates in EHR
Maintain active med listYesMA does med-rec during rooming and makes or pends updates in EHR
Maintain active allergy listYesMA has series of questions about allergies and is responsible for this task
Record smoking statusYesMA adds this to rooming task and could do brief counseling (readiness to change, perhaps call state quit line

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Slide 21. Meaningful Use Criteria: Stage 1

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Core requirementWorkflow changes needed?Workflow change ideas
Provide patients with clinical summaries for each office visitYesThe clinician does this and trains MA to carry it out
E-prescribingYesFor initial prescriptions, clinicians do the e-prescribing, but for some chronic refills, MA could do the refill based on standing orders from clinician
Drug-drug and drug-allergy interaction checksNo 
Exchanging electronic information with other sites of careYesCare coordinator (probably RN) can assist clinicians with this, particularly tracking/follow-up. If there is no RN, a workflow map would show which steps could be performed by a non-clinician staff person
Implement a decision support rule and track compliance with the ruleYesTracking compliance could be done by RN care manager
Systems to protect privacy and security of patient dataNo 
Report clinical quality measures to CMS or statesNoSomeone would be responsible, perhaps practice manager. The responsible person would need training in CQI, numerators and denominators, measures, etc.

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Slide 22. Meaningful Use Criteria: Stage 1

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Menu of additional tasks (choose 5 out of 10)Workflow changes needed?Workflow change ideas
Drug formulary check systemNo 
Lab results into EHRNo 
Generate lists of patients for QI or outreach (registry)YesThe generation of the lists is a technical issue, but panel managers will be needed to work the lists to see which patients need which services, and provide outreach or in-reach. MAs could be the panel managers except their workload is becoming excessive. MAs would do in-reach.
Electronic health education resourcesYesHealth educator is responsible (if available), but clinicians/MAs would also provide the information to patients
Med reconciliation between care settingsYesBetween settings is complex, but within the primary care practice, MA can do med-rec as part of rooming
Summary of care record for referrals and transitionsYesThis is mainly a clinician function but it also needs to be tracked and reminders done (MA and/or RN care coordinator)
Immunization data to regional registriesYesSomeone on team responsible
Surveillance data to public health agenciesYesSomeone on team responsible
Patient reminders for prevention/chronic careYesThis is a panel manager task
Patient access to lab results, problem and med lists, allergiesYesCreating a secure patient portal is a technical issue, but actually providing the information would be an MA task

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Slide 23. Suggested Workflows for Meaningful Use

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  • The following workflows are examples.
  • How your practice works may be different.
  • Pilot the EHR workflows with one MA or one receptionist and one clinician and a couple of patients to see if they work.

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Slide 24. Example Flowchart: Documenting Vital Signs (Example, Blood Pressure)

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Diagram of a flowchart: MA calls patient from waiting room, MA takes the patient’s blood pressure, MA enters blood pressure in the EHR, Blood pressure is documented in EHR.

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Slide 25. Example Flowchart: Maintaining Active Medication Lists

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Diagram of a detailed flowchart showing decision points and references to other workflows. Workflow is based on whether patient has a medication list or brought in his or her medications. Medication reconciliation itself is a separate process that will not be discussed here.

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Slide 26. Example Flowchart: Maintaining Active Allergy Lists

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Diagram of a detailed flowchart. Workflow is based on whether patient has an active allergy list.

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Slide 27. Example Flowchart: Documenting Smoking Status for Patients 13 and Up

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Diagram of a detailed flowchart. MA checks patient’s age and then checks and documents smoking status.

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Slide 28. Example Flowchart: Providing Clinical Summaries at the Conclusion of Appointments

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Diagram of a detailed flowchart showing how the clinician documents patient progress, identifies additional procedures needed, and provides clinical summary.

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Slide 29. Example Flowchart: Reporting on Clinical Quality Measures to CMS (Example: % of Diabetes Patients With A1c>9)

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Diagram of a detailed flowchart showing how patient registry is created and updated:

Another meaningful use objective that practices will need to meet is they will need to use their EHR to report clinical quality measures to CMS or states.

In the paper chart world, performance on clinical quality measures was accomplished through chart audit. Some practices may remember CMS representatives coming to your office, and then someone would pull x amount of charts for the representatives to review and these people would lock themselves in a room somewhere combing through all of the charts.

Needless to say, gathering data on clinical quality was very time consuming and may have potentially been biased if the charts that happened to be pulled belonged to patients who were in good control of their respective conditions.

One advantage of having computerized records is that the EHR can provide a more accurate picture of how your practice is performing on its selected quality measures.

This flowchart is an example of how reporting could look, using the example of % of patients with diabetes with an A1c greater than 9.

The process begins on a certain date; we chose arbitrarily that this process would begin 7 days before the reporting deadline to give the practice plenty of time to figure out how to do it. This means that the practice should be well aware of when CMS or your state requires the report.

The main decision point in this process is whether or not your practice has a registry. For those of you unfamiliar with what a registry is, it is a database that contains patient health information. If your practice does not have a registry, speak to your EHR vendor about the reporting capabilities of your EHR because some come with registry functions like building queries.

If your practice does have a registry, is someone on your staff data savvy or familiar with data reporting? A practice manager may most likely take this function on, but that is completely up to your practice. If there is not a person familiar with data reporting, your local extension center or your regional extension center may be available to provide training, although this may delay reporting. Your practice may consider training a staff member on data before the EHR arrives.

Registries can run queries or searches for a list of patients that fit certain criteria or registries can create reports, which provide statistical information about the patients. Having premade reports in your registry bypasses the steps of running queries individually to find numerators or denominators. Using a concrete example here of calculating the percentage of diabetes patients with A1c greater than 9, if your practice does not have premade reports in the registry, the data reporter would first run a search for the number of patients who had diabetes, the denominator, then run a search for the number of diabetes patients with an A1c greater than 9, the numerator. A report would be able to give you the numerator and denominator at the same time.

After finding the numerator and denominator, the data reporter can plug these numbers into an Excel sheet and can calculate the percentage of diabetes patients with A1c greater than 9 by dividing the raw number of patients with A1c greater than 9 by the total number of diabetes patients.

The data reporter would then send the report to CMS.

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Slide 30. Example Flowchart: Reminders to Patients for Preventive and Follow-Up Care (Example: Outreach to Patients Due for Annual FOBT)

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Diagram of a detailed flowchart showing how the practice determines need for reminders and generates them:

This workflow demonstrates how a practice can send patients reminders for preventive care or follow-up care. This is something practices may not be used to as it asks practices to take a proactive approach to care.

This is an example of how a practice can provide reminders to patients who are due for their annual FOBT. This meaningful use requirement is again dependent on whether your practice has the ability to generate a list of patients using a registry or EHR. Without this list of patients who are overdue or about to be due for services, meeting this objective may require tracking the dates of when patients receive certain services on an Excel sheet, more work than needed.

Contact your EHR vendor about query functions or consider getting a registry or contact your REC or LEC on ideas for how to generate this list.

In this example, this process takes place on the first Friday of odd numbered months. The frequency of when your practice sends out reminders is arbitrary but determining a concrete schedule of when your practice performs these tasks is helpful because it normalizes the behavior of performing a new function like outreach and it makes performing the outreach more manageable because there will be fewer patients to contact at one time.

In our example, the care team member uses the registry to generate a query of patients who have not completed an FOBT in the last 11 months. Although the U.S. Preventive Services Task Force recommends that FOBT is performed once every 12 months, if you run a search for patients who have not had an FOBT in the last 11 months, this allows your practice to catch those patients before they are due instead of just screening patients who are perpetually late!. This gives patients a one month window to complete the FOBT.

How to generate a workflow is another process so we will make a reference to it here rather than explain it.

After the care team member generates the list, they must decide how to contact patients. The two options would be to call patients or mail out a letter. Mailings are generally less time intensive because letters can be printed all at once. Whether your practice decides to make calls or mail out letters, it is necessary to track in the patient’s record that correspondence was made. In a future step one month later, the care team member will be running another query on patients who have received contact but have not completed an FOBT. This allows practices to focus efforts on patients who may have received a phone call or a letter but for some reason may not have come in to complete their care service. Ask your EHR vendor if this is something that can be tracked.

After running the query of patients who have been contacted but have not completed an FOBT, the care team member will call those patients to remind them to complete the FOBT.

One month after the follow-up phone calls, the care team member can run the same query (the patients who have received a letter but not completed FOBT query) again. If there are still patients remaining on this list, that means these people will be outreached again the next time the process starts. Patients no longer on this list have completed their FOBT for their year. If there are still patients remaining, they have yet to complete their FOBT and will be outreached again during next quarter’s FOBT outreach.

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Slide 31. Example Flowchart: How To Change a Job Role Using Lab Result Follow-Up as an Example

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Diagram of a detailed flowchart showing how the team maps workflow and identifies possible changes in roles and implements changes.This is not a meaningful use requirement but will be needed to achieve meaningful use:

The last workflow map that we will discuss is how to change a job role. This is not a meaningful use objective, but as we have shown in the previous workflow examples, a lot of the meaningful use objectives will require practice staff to take on new or different roles to help the practice achieve high-quality use of the EHR.

This example discusses one possible way of redefining the job duties of existing staff members using the previous example 1 of the lab result follow-up process.

Before any job roles can be changed, the EHR implementation team will need to map out the current workflow. After mapping out the workflow, the team will need to analyze the workflow map for inefficiencies and wastes and then the team discusses potential changes to improve the process, which will likely involve changing job functions. In the lab result follow-up workflow from example 1, the workflow team got rid of the MA making 3 copies of the lab result and implemented a protocol for the RN to handle lab results.

After the team agrees on a proposed future workflow, the team leader or another representative will need to bring the new proposed workflow map to an all clinic staff meeting so that all staff members of the practice are aware of the new changes that are being implemented in the clinic. If only half of the MAs and RNs attended the all staff meeting, half of them would operate using the old bad workflow while the other half would do the new better workflow. You could see how this situation could potentially lead to more chaos.

After the new job roles are presented at an all staff meeting, the team leader or representative will then have to clearly explain to RNs and MAs (or whomever it is whose job role has changed) and to their supervisor or supervisors what exactly is expected of them in the new workflow. The purpose of educating the staff’s supervisor is to create a method for accountability.

Then the process goes into a decision point, does the staff person perform their function; if it’s a yes, then you have successfully changed the job role. If the answer is no, the reason that staff member did not perform the new task must be addressed. If the RN still handed the lab result to the Clinician is it because they forgot that there is now a protocol? Is it because the RN doesn’t know how to follow the protocol? Or is it because the RN doesn’t want to perform the function? If it is the former two reasons (forgot or don’t know how), more training is needed. If the staff member doesn’t want to perform the function, their supervisor would need to address the staff member’s concern as to why they don’t want to perform the new function. In the improved lab result follow-up example, the RN is now in charge of calling patients about normal and mildly abnormal labs. Maybe the RNs can’t make the phone calls because they aren’t given enough time.

The supervisor can then bring this concern to the workflow team to propose a new workflow that satisfies everyone.

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Slide 32. Conclusion

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  • Workflow mapping is a great tool to help implement EHR and achieve meaningful use.
  • EHR adoption does not equal meaningful use.
  • Workflow maps are a tool to improve care for patients, improve efficiency in practice, and redistribute work and job roles.

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Return to Module 17

Page last reviewed June 2013
Internet Citation: Module 17 Appendix: Workflow mapping: a tool for achieving meaningful use. June 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod17appendix.html