Managing Workflow

Workflow: it's one of the hot new words in healthcare technology. During product demos, in seminar rooms, and on vendor Web sites, promises of improved workflow management abound.

"In the past six months, workflow has become a big part of demos. I'm seeing more and more of it all the time," observes Gerry Schultz, vice president of sales and marketing for NextGen, a Tustin, Calif.-based vendor. NextGen's advertising promises that the company's EMR "streamlines workflow."

"There is something of a buzz," concurs Richard Yonis, CEO of AcerMed; his company calls its product line a "complete workflow solution."

While it's clear that workflow solutions are becoming more popular, what's less clear is what workflow improvement actually means -- especially to a practice's bottom line.

Without a doubt, good solutions can cut overhead and eliminate errors and redundancies. However, some practices could benefit simply by reviewing their existing processes with an eye toward improving efficiency --  no purchase required.

What does it mean?

"Most folks don't understand what [workflow management] really means. It's a phrase that's just used across the board," complains Sam Brandt, vice president of clinical informatics for Siemens Medical Solutions.

One definition? Any product -- be it electronic medical records (EMR) or a personal digital assistant (PDA) reminder program -- that reduces redundancies, eliminates "dropped balls," and fine-tunes rough-edged work processes. The idea is that if everyone in the practice can effortlessly do what needs to be done, when it needs to be done, without forgetting key steps, the whole practice will be more relaxed and more profitable. The goal is to avoid waiting for someone else to do their job so you can do yours. Think about how many times you've had to delay a procedure because the supplies weren't stocked up, for example.

To illustrate the concept of workflow management, Brandt suggests imagining a McDonald's restaurant. When an order comes in, the fry guy drops a basket in the fryer, the burger girl flips a patty, and the clerk rings up the sale and fills a soda, while the customer fumbles for change. They don't need to coordinate. No one forgets the pickles. Everything is ready when it needs to be.

Compare that to the medical experience Deborah Walker, of practice management consulting firm Boehm Walker Associates, had during a physician visit with her mother. First, she says, they signed in at the front desk and sat down. Two minutes later, the receptionist called them back with a question. They sat back down -- eventually, several more times, as the staff needed other bits of information. The intake process alone took three or four steps on the part of both the staff and the patient. Nothing was ready when it needed to be.

In most physician offices, "workflow is a continuously interrupted pattern," according to Frank Rhie, MD, chief medical officer of Alteer, a software company in Irvine, Calif. His example: Paper medical charts force everyone in the office to take tasks only to a point before they have to stop, because someone else has the medical record they need.

To be sure, the daily procedural lapses in any average physician office are numerous: A service at the hospital never gets billed. Patients needing a check-up are not called. Insurance is not verified. Anything that helps iron out these wrinkles can go right to a practice's bottom line, and help everyone get home in time for dinner.

"Today's physicians are faced with decreasing profit. Improving workflow makes nonrevenue-producing processes happen much more efficiently," says Schultz.

Another plus: Some workflow management systems collect metrics showing where existing systems fall apart and how fast each process goes, says Brandt. "You can see where the roadblocks are. It gives you what you need to do quality analysis."

Making workflow work

So while workflow management technology sounds like a winner, it has to be implemented well.

Vendors try to make their products very flexible -- and highly integrated among work functions -- so that physicians and others in the practice can use them without too much interruption. The lesson learned is that technologies that are too disruptive tend to fail. "They serve some purpose for a little while, but after some time, people realize it doesn't fit into the physician's workflow, and they stop using it," explains Ahmad Hashem, MD, global industry manager for healthcare at Microsoft. In fact, healthcare technology vendors have a less-than-stellar history when it comes to working with physicians. "The focus had been controlling or changing physicians' behavior, not helping physicians become more productive," Hashem says.

Unfortunately, a product that is meant to improve workflow management can't simply fit into the existing workflow. It needs to change it for the better. Otherwise, "there is a risk of paving the cow path," as Brandt puts it. If a process was bumpy and cumbersome in a paper-based scheme, reproducing it in an electronic format isn't necessarily going to help. Workflow management systems have to ride a thin line between being usable enough to be adopted and innovative enough to be effective.

Physicians looking into workflow management software need to be ready to change -- and so do staff. If your billing manager has spent the past five years creating systems and forms and permission slips, it will be hard to get him to change, warns Walker. In fact, some staff might feel a better workflow makes their paper-shuffling jobs redundant. "The resistance comes more from the office staff members who are worried about their jobs, not from the physicians," Yonis says.

Or, do it yourself

The truth is, no technology will help if poor processes are in place. Often, practices believe that they a have problem with technology, when the real culprit turns out to be related to manual workflow, explains Rosemarie Nelson, market development manager with medical technology developer and manufacturer Welch Allyn in Syracuse, N.Y. For example, a practice with a pile of denied claims may blame their billing system -- even though the problem is that insurance coverage isn't being verified before the claim goes out the door.

Technology can't do it all, so some consultants advise that physicians interested in improving workflow should first take a do-it-yourself approach. Forget technology for now; look at your processes -- every single one.

Create a culture of change, urges Walker. "Let people know there are no sacred cows, [that] we are not going to stick with the status quo. Ask questions about the current structure, about the piece of paper you are filling out. Ask, 'Why did we start doing it this way?'"

Such inquiry and reflection can be exhausting. Walker suggests taking it one step at a time. "Pick one critical function each quarter to ask if there is a better way." Measure how long, or how many steps, or how much cost or staff time the process takes in its current form, then measure later to see if you improved it, she adds. Visiting other practices and reading journals is a good way to pick up new ideas.

Even do-it-yourselfers can benefit from eventually adopting technology, Nelson points out. "Technology will often force change," she says. If improvements don't happen manually, a technological kickstart might help.

Pamela L. Moore, senior editor of practice management for Physicians Practice, can be reached at pmoore@physicianspractice.com.

This article originally appeared in the July/August 2002 issue of Physicians Practice.