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Flow and Efficiency in an Electronic Health Records Environment

Elizabeth Holloway, COE, PHR, CPSS

The purpose of this article is to identify EHR issues that can prevent proper flow and efficiency in the clinic and to provide suggestions to alleviate the problems.

As more and more practices adopt electronic health records (EHR), practice administrators face the challenge of helping their practices return to efficient patient flow. The adoption of such integrated technology systems is a new concept for the majority of eye care practices, and benchmarks and best practices are still evolving in this arena. The purpose of this article is to identify EHR issues that can prevent proper flow and efficiency in the clinic and to provide suggestions to alleviate the problems.

EHR software implementation affects many more processes and departments than most anticipate. Full and effective integration typically requires a careful review of all processes in the practice across all departments, including check-in, billing, optical, checkout, scheduling, task management, etc. Paying special attention to “sub-processes” or discrete actions that may ordinarily be taken for granted can help scope the project. It may also be helpful to shadow multiple patient types through the practice visit to identify issues or inefficiencies.

Efficiency Considerations

The following considerations and tips can help administrators in the throes of implementing EHR avoid flow and efficiency issues, ensuring a seamless transition for the entire practice and minimal, if any, disruption to patient services and care.

Make sure sufficient computer terminals or tablets are available and accessible to staff and providers. As data is now electronic, a sufficient number of computer terminals and/or tablets should be available to practice staff as needed, and should be easily accessible throughout the patient visit. This may mean making computers available in more places to personnel who might not have needed their own computers in the past and may require physical changes to the exam rooms and lanes to accommodate monitors and terminals.

Before, during, and after implementation, ensure that the EHR exam templates have been modified by the practice to fit specific needs. Though most vendors provide very good exam templates for eye care practices, these templates may not have the flow or organization preferred by any given practice or provider. Most vendors allow some amount of customization. Working with the vendor to understand what can be changed and evaluating those options for possible adaptation may help meet the practice’s specific needs or preferences. Template customization may also help the clinical staff adapt more easily to the software implementation. After implementation, practice administrators and their teams will need to re-evaluate the EHR templates, particularly with the frequent updates required to meet Meaningful Use requirements.

Make certain that any specific set of data or information is entered into the EHR system only once. One of the goals of implementing a successful and efficient EHR is to input data into the system only once. If data entry is being duplicated at any point, consider seeking out a solution for single-entry, which may include changes to current process, and/or the use of additional functionality or options in the EHR software.

Assist staff and providers to gain comfort with the system software. Implementing an EHR system likely will require the practice to do things differently, and the changes will be more difficult for some to adapt to than others. Try to work through mistakes and be as patient as possible with those learning. Make sure to provide regular and consistent system training as necessary, and work individually with those who need additional attention. Encourage constructive feedback and teamwork to help streamline the new processes, but discourage negativity and resistance to the software by reminding staff of the importance of making the change and of the perceived benefits (or future benefits) of system utilization.

Utilize patient flow management tools. Patient flow management is critical to efficient clinical flow. Consider implementing clear and documented processes that out- line how techs will know when a patient is ready, how techs will know which exam room is open, and how the physician will know which room to go to next. These are processes that may have been managed through the use of paper documents before. Many EHR vendors include patient flow management tools to assist with these aspects of the patient visit.

Transition to electronic patient registration via online portal and/or in-office kiosk. Many EHR systems have electronic registration tools and functions, generally hosted for the practice and accessed via a link on the practice’s website. Patients can enter in demo- graphic information, insurance information, and even health history, which can save significant time during the in-office check- in process. These tools are often designed to work as a kiosk in the waiting room/check-in area as well.

Use electronic check-in processes, including real-time benefit and eligibility verification. Many EHR systems include electronic check-in and benefit verification tools, and various third-party vendors offer these to interface with EHR software. These functions may increase the efficiency of the check-in process by confirming the accuracy of patient demographics, performing real-time benefit and eligibility checks, and transferring appropriate data to the practice management system. When deciding between EHR vendor products and third-party providers, consider talking to other practices that have experience with the system(s).

Take advantage of patient portal functionality. All EHR vendors are required to offer some type of patient portal, either built and maintained by the vendor themselves, or contracted with a third party. Some patient portals offer only basic functionality for exchanging clinical information with patients, but others offer robust features such as appointment scheduling and bill payments. Exploring the full scope of patient portal options may increase efficiency as well as patient satisfaction.

Utilize the efficiency tools and reports that can be generated by the EHR system. Many EHR systems include tools that allow practices to monitor the status of patient wait times, identify problem areas in patient flow, and generate time study reports. Though specific options vary by vendor, these tools can help the practice identify, and ultimately correct, flow and efficiency issues.

Develop an efficient process to code and post exams, tests, and procedures into the financial system. With most EHR systems, exams can be coded by the EHR, and the charges for the exam (along with charges for other services) can be electronically posted to the patient’s ledger (may vary by software system). However, there is often more than one way to use the EHR’s coding and posting tools. For example, the clinical team can code and the check-out team can post, instead of the clinical team performing both functions. Consider the clinical team’s comfort coding exams and adding modifiers when identifying  what works for the practice.

Develop process to transfer data from existing paper charts to electronic health records. Many practices tend toward one extreme or the other when considering the transfer of paper chart data, choosing to transfer everything from the paper record—or nothing at all. Consider trying to find a middle ground, working with the physician(s) to determine what data should be scanned or pre-loaded (entered into data fields) to promote efficiency. Routing the paper chart with the patient on the first few electronically documented visits can help providers identify necessary data to be scanned/in-put. Remember that scanned documents are just images, whereas preloaded data can be modified or used in reports, letters, graphs, etc. If the practice decides to scan documents into electronic records, consider the speed and functionality of the current office scanner. It may be worth investing in a high-speed, duplex scanner with a multipage feed option. Additionally, give careful consideration to the resolution of the scanned documents. Providers and staff will need a high enough resolution to ensure the data will be legible, but not so high that the files are unnecessarily large, requiring extensive electronic storage capacity.

Discuss efficiency issues with other practices. If the practice is struggling with efficient processes, it may be beneficial to talk to (or visit) other practices that are using the same EHR software. Remember that what works for one practice may not work for another, but exposure to different adaptation methods and processes may help correct various issues.

After implementation, focus on restoring office and provider productivity. Reaching pre-implementation productivity levels can be challenging within a few months of the transition. If the practice is struggling to reach a specific threshold, this may indicate the need for a scribe, additional staff training on EHR use, re-engineering of additional processes, modifications to the exam templates, the addition of data entry terminals, or a more general scheduling issue.

Integral Role

Practice administrators play an integral role in helping their practices with the transition into EHR systems. Teams can focus on how the practice utilizes the EHR system, and changes can be made to increase the office’s flow and efficiency. By analyzing the changes that need to be made and implementing new protocols, the clinical experience for the patient, provider, and staff can be improved.

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