Recently, I was in an emergency department working with a group on improving patient flow. I spent some time observing how patients moved through this ED – one was a young woman who had come in with abdominal pain.
“Sally” had come in mid-afternoon complaining that her stomach hurt and she feared she had a UTI. She was quickly triaged and her pain was identified as a 5 out of 10. After getting labs drawn and giving a urine sample, Sally was placed back in the waiting room for two hours being fairly uncomfortable, while she waited on an abdominal x-ray. The x-ray was back and the patient was ready for evaluation by a physician within two hours of her visit, but she was still in the waiting room.
At four hours into her visit, Sally was brought back to a room. A nurse completed her new pain assessment where she still described it as a 5 out of 10. Sally had received no pain management to alleviate her discomfort nor had she received any treatment of her condition.
At more than six hours into her visit the physician came back to assess the patient and told her she was good to go home with a prescription. She stood to walk out and immediately sat down, grabbed her abdomen, and started crying from immense pain. She now had pain that was a 10.
Sally was then treated with heavy narcotics to get her pain under control and was in the ED for another four hours while they waited for her to be ready to depart the facility.
So what was the staff’s response? “Sally was a drug seeker. If she kept Tylenol in her purse she could have treated the pain herself.” We blamed the patient for our bad process!
There were several failures in us meeting Sally’s expectations. How could we have done better? Our emergency department was slammed! There were no beds – what were we supposed to do?
How does this scenario relate to EHR optimization? I have worked on several EHR improvement projects. Most projects are focused on building order sets, views, and documentation that is as efficient as it can be for the staff and providers.
What about the patient? If the EHR is meant to improve care, should it not be focused on the patient’s flow as well as documentation? An effectively designed process utilizing an EHR could have prevented Sally’s pain management problems. Most systems can be designed to have triggers, notifications when something is needed. We build our EHR’s to be functional, but we do not build them around our standard work.
In Lean Led IT, we identify critical patient flows and design our systems to support standard work. Each of these workflows should be designed utilizing the 4 Rules in Use.
By developing standard work first, we can ensure that the EHR supports the sequence, timing, location, and outcome of our processes.
Traditionally, the implementation of an EHR focuses on standard work after the build. In Lean Led IT, identifying critical path workflows and creating current standard work is step one.
Building an EHR with standard work, for example care pathways for pain management, would include all elements of “Activities” from the 4 Rules in Use. We can then establish visual triggers that indicate when timeliness of care has not been achieved and establish standard escalation plans for getting Sally the care she deserves.
Here are some questions that a Lean Led IT approach would focus on:
- What are your critical path workflows? Did you build standard work prior to the build? How quickly are we able to respond to patient safety concerns once we go live?
- How has the implementations adoption been since go live? Are we having quality issues? Where are we having issues in patient flow? Do we have adequate operational training and support past go live?
In short, identify your critical path workflows, design your standard work, and then build your EHR. You’ll be thankful that you did!
Today’s blog was written by Eric Watkins, senior consultant at HPP.
Eric’s process improvement background includes emergency department value stream initiatives, EMR operational preparedness, physician practice patient flow, analytics and reporting process transformation, kaizen facilitation and other work.
Eric received his Master’s in Business Administration from the University of Tennessee in Operations and Supply Chain Management.