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About This Guide OntarioMD created this illustrated guide to assist physicians and their practices during the EMR implementation. This guide forms part of OntarioMD s change-management methodology. It describes critical information to help practices select and implement the appropriate EMR. Consultations with physician practices, vendors, and OntarioMD employees have identified and prioritized fourteen major physician-practice processes. These include: Administrative Processes 1. Patient Scheduling 2. Patient Registration 3. Reporting and Results 4. Billing and Revenue 5. Specialists Receipt of Referrals 6. Internal Communications Scanning 7. Internal Communications Messaging 8. Preventative Care Management Clinical Processes 9. Encounter Notes 10. Immunizations 11. Specialist Referrals 12. Diagnostic Referrals 13. Pharmacy and Prescription Management 14. Managing Patients Who Have Chronic Disease Additional blank pages have been inserted to accommodate specialists needs, or variants for particular practices. The first section illustrates each process the workflow at an abstract level. Figure 1 below is an example of a workflow diagram. Figure 1: Sample workflow diagram
About This Guide Illustrated workflows help physicians and their teams understand their practices operating environments as they relate to EMRs. Practices with EMRs report that understanding workflows are a key success factor in their choice of EMR vendors. This guide is organized as follows: 1. Background information and reading sample workflows 2. Illustrating your current state workflows, responsibilities, and needs 3. Identifying your future state requirements 4. Preparing for vendor meetings Your Support from OntarioMD Our experienced team of Peer Leaders, Practice Advisors, and Change-Management Experts work with physician groups to support their transition to an EMR solution. We re here to help you, and look forward to supporting your practice s transformation.
Table of Contents Introduction 1 Current State Workflows 2 How to Use This Tool 3 Tips for Effective Workflow Analysis 4 Current Sample Workflows 6 Considering Future Workflows 11 Preparing for Vendor Discussions about EMR Selection 12 Appendices: Workbook 13
Introduction Congratulations! Your practice is one step closer to having its own EMR. This guide and workbook will help you understand workflows before selecting the EMR that best suits your practice s needs. Implementing an EMR is not just about technology. It reflects how technology supports the way physician practices work how their people, processes, and activities combine to create a distinct set of needs for each practice. Done properly, EMR selection and implementation benefit patient care, office efficiency, and resource management. Four critical success factors enable this: 1. Understanding and prioritizing your practice s needs 2. Appropriately matching its needs to required EMR features 3. Executing an effective implementation process 4. Planning and realizing ways to improve patient care and office efficiency All EMRs effectively reduce paper management and improve various administrative processes. However, some may be customized or designed to support your practice s unique needs. - 1 -
Current State Workflows Workflows refer to the processes, resources, and functions that operate physician practices. They create a view of needs which helps physicians understand what features they require of an EMR ultimately guiding their choice of an appropriate EMR. In our experience, many physicians describe their office processes as informal, undocumented, and yet adequate. However, the structured approach of workflows creates several benefits. Once physicians see their practices workflows, they quickly realize opportunities for improving patient service, their administrative and reporting practices, and their planning. Workflow analysis works best when as many office staff as possible are involved. Assistants and office managers often know idiosyncrasies of particular hospitals, specialists, CCACs, and other stakeholders that affect workflows. They perceive inefficiencies that escape the busy physician. Most important, their involvement in the workflow and selection process creates stronger buy-in and understanding of the system they will use and support. Five of the total thirteen workflows samples are provided to illustrate some of the common processes in a physician practice: 1. Patient Scheduling 2. Billing and Revenue 3. Immunizations 4. Specialist Referrals 5. Pharmacy and Prescription Management Each workflow includes a table which considers two aspects of the workflow: 1. A description of current workflow events 2. Issues to consider - 2 -
How to Use This Tool This tool has two components: background information and the workflow tools. OntarioMD will provide this tool to physician practices before their workflow sessions. Physician practice members will read the guide before the workflow session, and complete Appendix C. 1. Review the workflow samples provided on page 6 2. Complete Appendix C this will take five minutes per day for five consecutive days 3. Complete Appendix A with your office staff the sections are divided into administrative and clinical processes. Your OntarioMD Practice Advisor will review these materials with you at a subsequent meeting 4. Complete Appendix B with your OntarioMD Practice Advisor 5. Your OntarioMD Practice Advisor will provide you with the OntarioMD EMR Solution Selection Guide And Workbook - 3 -
Tips for Effective Workflow Analysis a. Maintain a high-level view of the process. It s easy to become distracted by the rare exceptions ( Yes but Mrs. Jones is 96 years old, she always walks in to schedule all her appointments and has perfect recollection of her medications, lab test dates and results, and knows her OHIP number and its version code off-by-heart. ). Instead, focus on the majority of patients, specialists, referrals, etc. b. Your current way of doing things may not be the best way. During the workflow analysis, consider what if questions and be prepared to change the way things are done now. For example: i. What if we used voice-recognition software for dictation instead of typing notes into a patient chart? EMR selection implications: the EMR must be compatible with voice-recognition software such as Dragon. ii. What if we started documenting telephone advice provided by our nurse? EMR selection implications: the EMR must allow other users to add notes to a patient chart besides the physician c. Involve as many of your office employees as possible. Their contribution is invaluable. d. The workflows selected for this guide and workbook are designed primarily for family physician practices. Your practice may have patient groups, services, or functions that aren t reflected in these workflows. Other Tips For example, a dermatologist s need for high-resolution image-management is an unlikely priority for a psychiatrist s practice. This guide should allow you to map your own workflows and help you understand your practices distinct needs. Blank workflows are provided in the accompanying workbooks. Keep a copy of this guide on hand for your EMR vendor meeting Don t rely on EMR vendors to complete or interpret your workflows. They understand the workflows for their products not for your needs. Step back from the workflows and ask employees and peers for general input, such as, What could we do better? Then map those possibilities into workflows, or keep a Parking Lot of desired features. Consult OntarioMD your Practice Advisor or Peer Leader for support. Similarly, consult your colleagues and peers for their perspectives, or things they might do differently if they were to implement an EMR again. - 4 -
Sample Workflows - 5 -
Sample Workflows Sample 1: Current State Workflow Patient Scheduling Event A B C D The patient may reach the office Office retrieves messages, and staff immediately and complete checks patient availability with the process. the physician s availability. Patient contacts physician office to schedule, reschedule, or cancel an appointment The office reconciles the schedule, appointment, or cancellation. Or The patient may leave a message via voicemail, an answering service, requiring follow up Issues to Consider Time lag between the patient s call and the office s response. Could the patient self-schedule? What proportion of the patient roster could self-schedule? Time spent by the office to reconcile schedules, remind patients of appointments, or to cancel appointments. How could the scheduling process operate more efficiently? Preventive or prospective scheduling - 6 -
Sample Workflows Sample 2: Current State Workflow Billing and Revenue Event Issues for Consideration Patient visit prompts OHIP, private, or thirdparty insurance invoice. A B C D E Either a nurse or a physician can charge for services. Office staff consolidate invoicing information. Unbillable telephone consultations. How are these documented or captured? Tracking nursing activities for billing. Automated invoice creation. The ability to distinguish clients by payer type Accuracy of captured information Deferred revenue collection (Time for consolidating and reconciling invoices) Transmission of invoice via various channels Rejected invoices from OHIP or insurance companies are returned to practice and resubmitted. - 7 -
Sample Workflows Sample 3: Current State Workflow Immunizations A B C D Event Patient contacts physician practice to schedule immunization date. Office staff screen patients for eligibility and schedule time. Patient arrives at physician office on date of immunization. Nurse administers immunization (intra-muscular or sub-cutaneous), records on patient chart and files. Issues to Consider Pre-screening patients could save time Parents scheduling appointments for entire families could take a lot of time to screen and schedule Patients not seen before or during flu-campaign activities might not be aware of flu schedules, or be notified by their physicians What time-saving opportunities exist in the immunization scheduling, screening, and administration process? How could vaccination schedules improve supply forecasting? Quick report generation to determine total eligible patient roster that has received immunizations. - 8 -
Sample Workflows Sample 4: Current State Workflow Specialist Referrals A B C D E Event Physician prepares referral for patient. Physician office contacts specialist office to advise service request Specialist receives referrals request. Specialist contacts patient to schedule appointment Patient visits specialist. Issues to Consider Selection of specialists is often by route or rolodex Additional specialist capacity or service may be available Referring physicians would like confirmation for receipt of referral and specialist follow up. How could the specialist-referral process be more contiguous? How could the specialist-selection process be improved? What items need to be faxed with the referral? - 9 -
Sample Workflows Sample 5: Current State Workflow Pharmacy and Prescription Management A B C D E Event Patient or pharmacy contacts physician s office for renewal, confirmation, or contraindication. Patient or pharmacist contacts physician group via phone or fax. Physician s office confirms the order and returns to the patient and pharmacy. Prescription-status confirmation sent or phoned to pharmacy and/ or patient. If the pharmacy suspects risk, it contacts the physician s office. Issues to Consider Redundant processes for confirmation or clarification Legibility of physician s writing Length of time for confirmation Ease of accessibility for current contraindications Alternative approaches to confirming prescriptions, refills, and contraindications. Improved management of risk, file sharing, and activity reporting throughout practice, or for patients when seen by other physicians in the practice. - 10 -
Considering Future Workflows Future workflow analysis must consider more than the flow of processes. This list of questions explores structural features of your practice as well. Structural / Responsibility Considerations a. Are any computer systems used in the practice for non-clinical purposes, such as payroll, finances, OHIP, scheduling, or inventory management? b. Will these need to be integrated into the EMR? c. How will a physician know which room the patient is in without a paper file? d. Where will the EMR equipment be configured in a way that maintains comfort, privacy, and security? e. Who will be responsible for technical issues? f. How will the EMR equipment be configured in patient rooms so that it is minimally invasive? g. How will the equipment configuration maintain a strong physician-patient relationship? h. Who will need to access various files? i. How will passwords, permissions, and privacy features be created and secured? j. If the practice intends to communicate through email, has it identified appropriate privacy and consent requirements? k. How will your training needs be supported? l. How will you scan and dispose of scanned charts? Who will manage this process? m. How many workstations are there currently? Is this enough to support the EMR? n. Does the EMR support the creation of assignable tasks and work queues? o. How does the EMR support recalls and follow ups? p. Does the EMR enable results, performance, or other data trending? q. How does the EMR ensure consistency in data formats (such as kilo, kg, Kg., etc.)? r. Others? Physician Practice Comments Although the EMR will automate and integrate many of your practice s workflows, you should be prepared for technology mishaps. Power failures, weather, construction, Internet-service provider (ISP), among other factors can affect your EMR. Some backup paper processes and materials should be kept at the practice in case of emergency. - 11 -
Preparing for Vendor Discussions about EMR Selection After completing workflow analyses and identifying and prioritizing your practice s needs, the EMR vendor search should begin. OntarioMD maintains a list of funding-eligible vendors, whose products they have validated. The tests determine whether the EMR meets functional specifications, not how well each vendor-system performs. To qualify for funding, you must select an approved vendor. The OntarioMD EMR Solution Selection Guide And Workbook is available to assist physician groups select the appropriate EMR in a step-by-step process. Vendor Demonstrations After completing your workflows and prioritizing your practice s needs, you can contact vendors to ask them for demonstrations. Be as explicit as possible in describing your needs and priorities. You may find that: In vendor language, can and do mean different things. A product that can automatically prioritize patients may not be able to do so when you buy the product. It could be part of a future software release, or dependent on your buying additional features. Ask whether the EMR does what you need it to do from the day you install it. Physician-practice training is an underestimated and essential part of a successful implementation. Some vendors provide training by way of product DVDs. Other vendors provide person-to-person live training, and show step-by-step how to get the most out of their EMRs. Ask the vendor about their training services and what s included for you. Although two EMRs may have the same feature, one could be more user-friendly or efficiently accessed. For this reason, involve all office staff in the vendor demonstrations. Everyone who uses the product should have a sense of how well it suits their needs. Discuss important variants from your general practice. For example, when thinking of patient types, consider how many could not schedule appointments over the Internet, have insurance (whether OHIP or private), Contact your OntarioMD Practice Advisor to learn more about getting the most value from the vendor demonstration. Contact and visit existing users to understand how their EMR supports their practice needs. Ask users about their implementation and training experiences with particular vendors. The EMR vendor or your OntarioMD Practice Advisor can refer you to existing users whose practices are similar to your own. Key Success Factors: Consult the EMR Solution Selection Guide and Workbook from OntarioMD - 12 -
Map the current and future state workflows for the following processes: Administrative Processes 1. Patient Scheduling 2. Patient Registration 3. Reporting and Results 4. Billing and Revenue 5. Specialists Receipt of Referrals 6. Internal Communications: Scanning 7. Internal Communications: Messaging 8. Preventative Care Management Clinical Processes 9. Encounter Notes 10. Immunizations 11. Specialist Referrals 12. Diagnostic Referrals 13. Pharmacy and Prescription Management 14. Managing Patients Who Have Chronic Disease Additional blank pages have been added to accommodate unlisted or highly specialized workflows. - 13 -
Administrative Process: Current Workflow Patient Scheduling A B C D Other Event Issues to Consider - 14 -
Administrative Process: Future Workflow Patient Scheduling Considerations Features A B C Questions to Consider 1. Does the EMR allow patient self-scheduling over the Internet (ASP)? 2. Can it screen patients (for immunizations)? 3. If so, does the EMR prevent patients from double-booking? 4. Can patients enter a reason for an appointment? 5. Can patients change their appointment times within 48 hours of the appointment? 6. How will physicians access the scheduler? 7. Does the EMR manage wait/cancellation lists? 8. Does the EMR support multiple schedules? 9. How does the EMR track patient urgency? 10. Does the EMR allow scheduling for nurses (for immunizations, etc.)? 11. Does the EMR offer schedule viewing rights to multiple users? 12. Does the EMR issue reminders? 13. Does the EMR track current patient status? 14. How many patients can t self-schedule? 15. What scheduling information do specialists need? 16. Does the EMR distinguish appointment locations, such as office or hospital? 17. Does the EMR distinguish between appointment types (consults v. follow ups)? - 15 -
Administrative Process: Current Workflow Patient Registration A B C D Other Event Issues to Consider - 16 -
Administrative Process: Future Workflow Patient Registration A B C D Questions to Consider 1. How could the current process be improved? 2. How long does a registration take to complete? How many registrations are there in a day? 3. Tablet compatibility: could the RN/MD receive registration information by tablet? 4. Does the EMR track alternative contact information (N.O.K.)? Considerations 5. Does the EMR track whether patients are rostered? 6. Does the EMR reconcile OHIP numbers immediately? 7. How are vacant exam rooms identified? Features 8. Does the EMR allow specialists to add referring physicians information? 9. What are the minimum requirements to create patient charts? - 17 -
Administrative Process: Current Workflow Reports and Results A B C D E Event Issues to Consider - 18 -
Administrative Process: Future Workflow Reports and Results A B C D Questions to Consider 1. Does the EMR alert physicians to new results? 2. Does it alert physicians to new results by providing updated patient charts? 3. How will patient follow-up be managed? 4. Does the EMR flag abnormal results? How does it alert the physician to these? Considerations 5. How will the physician review paper-based results? 6. Does the EMR enable trending? 7. Does the EMR allow lab results to be forwarded to another physician in case of absence? Features 8. How will specialists forward results to referring physicians? 9. How will the EMR file images? Is there a cost for storage? - 19 -
Administrative Process: Current Workflow Billing and Revenue Patient/Other Payment A B C D E Event Issues to Consider - 20 -
Administrative Process: Future Workflow Billing and Revenue Questions to Consider A B C D 1. Does the EMR allow direct billing at the patient visit? 2. Does the EMR consolidate OHIP invoices for billing? 3. How will the patient collect a receipt for third-party payment or reimbursement? 4. Does the EMR integrate with current accounting practices? Considerations 5. Does the EMR support accounting functions, such as monthly billing and revenue? 6. Does the EMR produce consolidated billing and revenue reports? 7. Does the EMR track payment? Features 8. Does the EMR have a specialist code inventory? 9. Does the EMR offer inventory management? 10. Is the EMR WSIB friendly? - 21 -
Administrative Process: Current Workflow Specialists Receipt of Referrals ( Specialist Practices Only) A B C D E Event Issues to Consider - 22 -
Administrative Process: Future Workflow Specialists Receipt of Referrals ( Specialist Practices Only) A B C D Questions to Consider 1. What patient information does your specialist practice require? 2. How will referral sources interface with the EMR? Considerations 3. How are a patient s medications documented by the referring physician? 4. How will referring physicians be notified of appointments and follow ups? Features - 23 -
Administrative Process: Current Workflow Internal Communications: Scanning, General Data Inflow For each of the following data sources, identify the primary channel of input, and the approximate volume (# of faxes or phone calls, for example) of data (links with Appendix C). Channel Patient Pharmacist Specialist Labs Diagnostics Hospital Clinic CCAC OHIP Insurance Fax Mail / Courier Email Questions for Consideration 1. What is the approximate total number of data pieces received by the practice every week? 2. What is the approximate total number of data pieces sent by the practice every week? 3. Approximately how much time is spent every day using the fax machine to receive and transmit? Hours - 24 -
Administrative Process: Future Workflow Internal Communications: Scanning, General Data Inflow A B C D Questions to Consider 1. Who will be primarily responsible for scanning received or created documents? 2. What type of scan is produced by the device (OCR or other)? Considerations Features 3. What are the steps involved between scanning to document and getting the document readable or searchable? 4. What is your practice s standard for turnaround the time lapse from the receipt of the document (by fax, etc.) to its entry into the EMR? 5. How will the scanned documents be validated for numerical and content accuracy? Who will do this? - 25 -
Administrative Process: Current Workflow Internal Communications: Messaging A B C Other Other Event Issues to Consider - 26 -
Administrative Process: Future Workflow Internal Communications: Messaging A B C D Questions to Consider Considerations 1. How will the EMR improve internal communications for Office Staff? 2. How will the EMR improve messaging from Office Staff to Clinicians? 3. How will the EMR improve messaging from Clinicians to Office Staff, or amongst other Clinicians? 4. What current gaps are there in the messaging process? Features - 27 -
Administrative Process: Current Workflow Preventative Care Management A B C Other Other Event Issues to Consider - 28 -
Administrative Process: Future Workflow Preventative Care Management A B C D Questions to Consider 1. How could the EMR be used to support preventative care management? 2. What objectives could the practice set to support preventative care? Considerations 3. Does the EMR issue prompts to support / flag opportunities for preventative care? 4. Who would be responsible for these reports? How often would they be created? Features - 29 -
Clinical Process: Current Workflow Encounter Notes A B C Other Other Event Issues to Consider - 30 -
Clinical Process: Future Workflow Encounter Notes A B C D Questions to Consider 1. Does the EMR update from SOAP notes automatically? 2. Does the EMR display a single integrated history and ongoing health conditions? 3. How can chart information be entered? (Voice, image, etc.) Are these standard features, or do they come at a cost? Considerations 4. How are past lab results / reports entered into the chart? 5. Do EMR templates suit your needs? 6. How will the EMR affect the environment with the patient? Features 7. How does the chart support multiple workstations? 8. Does the EMR allow notes highlighting? - 31 -
Clinical Process: Current Workflow Immunizations A B C D Other Event Issues to Consider - 32 -
Clinical Process: Future Workflow Immunizations Considerations Features A B C D Questions to Consider 1. How does the EMR track patients who have received immunizations? 2. Does the EMR have any screening criteria for scheduling (such as for immunizations)? 3. Does the EMR track the inventory of vaccinations? 4. Does the EMR provide scheduling for nurses? (They would administer vaccine and need to be linked to scheduler). 5. Does the EMR provide a reporting tool for physicians to measure how many immunization-eligible patients have received immunizations? 6. Does the EMR track where the immunization was administered? - 33 -
Clinical Process: Current Workflow Specialist Referrals A B C D E Event Issues to Consider - 34 -
Clinical Process: Future Workflow Specialist Referrals A B C D Questions to Consider 1. Does the EMR have and maintain a current roster of specialists and their contact information? 2. How can the specialist-referral process be improved? Considerations 3. Does the EMR track referrals for follow up? 4. Do specialists require referrals in a particular format? Features 5. How does the physician attach pertinent patient information to a referral? a. How many steps does it involve? - 35 -
Clinical Process: Current Workflow Diagnostic Referrals A B C D E Event Issues to Consider - 36 -
Clinical Process: Future Workflow Diagnostic Referrals A B C D Questions to Consider 1. How are diagnostic referrals tracked and followed up? 2. How many diagnostic referrals are issued per day? Considerations 3. Does the EMR alert physician or the practice to outstanding / unreported diagnostic tests? 4. Does the EMR enable report-creation for lab orders without results? Features - 37 -
Clinical Process: Current Workflow Pharmacy and Prescription Management A B C D E Event Issues to Consider - 38 -
Clinical Process: Future Workflow Pharmacy and Prescription Management A B C D Questions to Consider Considerations Features 1. How will the EMR change and improve the current process? 2. Does the EMR signal drug interaction, allergies, or alerts? 3. Does the EMR produce online prescriptions? 4. How do office staff document Rx renewals? 5. How many prescriptions does the practice generate daily? 6. Does the EMR create a daily or on-demand reminder of which patients need renewals? 7. How does the EMR manage compound medications and variable dosing? 8. Does the EMR store pharmacy information at the patient or practice level? - 39 -
Clinical Process: Current Workflow Managing Patients Who Have Chronic Disease A B C D Event Issues to Consider - 40 -
Clinical Process: Future Workflow Managing Patients Who Have Chronic Disease A B C D Questions to Consider 1. How could the current process be improved? 2. What are the current challenges with chronic disease management? 3. How frequently is clinical content updated? 4. Does the EMR have customizable care plans? Considerations 5. Does the EMR have a feature to let patients interface with their care plans? 6. Does the EMR allow patients to update their own care plans? 7. Is clinical content coded using standardized terminology? Features 8. What proportion of the patient roster has a chronic illness? 9. How would EMR-based care planning support patients? - 41 -
Additional Process: Current Workflow For A B C D Event Issues to Consider - 42 -
Additional Process: Future Workflow For A B C D Questions to Consider Considerations Features - 43 -
Additional Process: Current Workflow For A B C D Event Issues to Consider - 44 -
Additional Process: Future Workflow For A B C D Questions to Consider Considerations Features - 45 -
Additional Process: Current Workflow For A B C D Event Issues to Consider - 46 -
Additional Process: Future Workflow For A B C D Questions to Consider Considerations Features - 47 -
Appendix B: Required EMR Features and Priorities Major Feature 1 Major Feature 2 Major Feature 3 1. Patient Scheduling 2. Patient Registration 3. Reporting and Results 4. Billing and Revenue 5. Specialists Receipt of Referrals 6. Internal Communications: Scanning 7. Internal Communications: Messaging Workflow 8. Encounter Notes 9. Immunizations 10. Specialist Referrals 11. Diagnostic Referrals 12. Pharmacy and Rx Management 13. Chronic Disease Management 14. Additional: 15. Additional: 16. Additional: - 48 -
Appendix C: Data Inflows by Source and Channel Using the following table, enter the number of communications you receive each day for a single five-day week. This assists your practice, the OntarioMD practice advisor, and vendors better understand your needs. In our experience, this recording is done most effectively when designated to one person, and when tally counting is used. Fax Phone Mail/Courier E-mail Walk-In TOTAL Fax Phone Mail/Courier E-mail Walk-In TOTAL MONDAY Patient Hospital Pharmacy CCAC Specialist Lab Diagnostics OHIP Other TOTAL TUESDAY Patient Hospital Pharmacy CCAC Specialist Lab Diagnostics OHIP Other TOTAL - 49 -
Appendix C: Data Inflows by Source and Channel Fax WEDNESDAY Patient Hospital Pharmacy CCAC Specialist Lab Diagnostics OHIP Other TOTAL Phone Mail/Courier E-mail Walk-In TOTAL Fax THURSDAY Patient Hospital Pharmacy CCAC Specialist Lab Diagnostics OHIP Other TOTAL Phone Mail/Courier E-mail Walk-In TOTAL Fax FRIDAY Patient Hospital Pharmacy CCAC Specialist Lab Diagnostics OHIP Other TOTAL Phone Mail/Courier E-mail Walk-In TOTAL - 50 -