July 2, 2019

How to Improve Clinical Workflow: 50 Expert Tips

Dave Levin, MD

Chief Medical Officer

Healthcare organizations are embracing innovative technologies at a faster pace than ever before, but clinical workflow management remains a pain point for providers. As providers face pressure to do more in less time, technology tools like EHRs seem like a practical solution, yet implementing new technologies doesn’t always solve workflow issues.

Poorly-integrated solutions can actually hinder clinical workflows by making it necessary for clinicians to duplicate data across multiple applications or log in and out of several systems to find the relevant clinical data they need to inform clinical decision-making. Evaluating a solution’s potential impacts on workflow should be a primary consideration when evaluating any new technology solution. For instance, robust API solutions like Integrate reduce the administrative burden on clinicians and staff by enabling the seamless exchange of data across EHRs and non-clinical applications. Integrate empowers clinicians with real-time, relevant data for clinical decision support and supports bi-directional workflow interaction between EHRs and third-party applications, eliminating the need for data duplication and automating tedious, manual tasks such as chart retrieval and copying and faxing records to other providers.

While solutions like Integrate can eliminate many workflow obstacles, healthcare organizations working with cobbled-together or outdated IT solutions face an uphill battle. Coupled with other challenges, such as inefficient staffing and challenges associated with the transition to value-based care, many providers find their workflows becoming more complex, not less.

Below, we’ve rounded up 50 expert tips and best practices from health innovators and thought leaders to help you recognize common clinical workflow constraints and implement the right solutions to overcome them. From standardizing your clinical processes to adopting automation solutions and leveraging smart staffing strategies, there are many steps healthcare organizations can take to remove barriers and optimize clinical workflows.

Standardizing Clinical Processes

![Jennie Welch Quote]

__ 1. Use value-stream maps to pinpoint opportunities to improve workflows. “Value-stream maps are useful for pinpointing workflow process improvement potential. The concept of value-stream mapping is simple but highly effective: identify the flow of work throughout the ED for various conditions (e.g., stroke). Then evaluate the flow and determine the most effective method (the best practice) for carrying out each step in that process. By standardizing these best practices, you can eliminate waste in your processes.” – __Jennie WelchImproving Clinical Workflow: An Example from the Emergency Department, Health Catalyst; Twitter: @HealthCatalyst

2. Analyze each step in your value stream map to identify waste. “Look at each step on your map and ask yourself whether that step is directly valuable to a patient. (Receiving treatment? Valuable. Waiting in the waiting room? Not valuable.) Mark each step to indicate whether it delivers direct value. Kozlowski puts red and green dot stickers on the steps: green for value-added, and red for non-value-added steps.

“Any step with a ‘wait’ triangle should get a red dot. Hagerty points out that motion (such as the doctor moving out of the exam room to find supplies) and duplication (such as the doctor repeating questions the medical assistant just asked) are other forms of waste, so they’d also get red dots.

“You’re identifying the waste in order to eliminate it. Of course, it won’t be possible to eliminate all waste. Some steps that aren’t directly valuable for patients are necessary to your practice (such as proper coding). ‘Perfection’ isn’t achievable, says Hallett, but it’s the benchmark to work towards.” – Gaby Loria, The Lean Doctor’s Office: Using Value Stream Mapping to Improve Your Workflow, Software Advice; Twitter: @SoftwareAdvice ![AA of Pediatrics]

3. Maximize appointments and minimize downtime resulting from no-shows. “In terms of delivery of care, patient scheduling is one of the most crucial operational systems in a practice. For provider, staff and patient satisfaction, it is important to maximize patient appointments and minimize the downtime that happens when patients fail to show up. The use of an Electronic Health Records (EHR) system can create a smooth and seamless experience for both the patients and providers that can increase operational efficiency.” – Ideas and Examples for Improving Workflow, American Academy of Pediatrics

4. Set aside a specific time each day for communication tasks. “Such tasks may include responding to messages, answering questions that staff members may have about treatments and coordinating tasks such as lab orders, prescription refills, etc. Best practice is in the morning before the first appointment and during the lunch period before starting afternoon appointments. This practice also aids staff members in prioritizing their own workflow and in effectively setting patient expectations as to when they may receive response to their inquiries.” – Quick Tips for Improving Clinical Admin Workflow, __Power 2 Practice; Twitter: __@power2practice ![AHRQ]

5. When redesigning workflows, identify dependencies and peripheral effects. “It is rare that a workflow is completely independent of other processes in the practice. In most cases, workflows for one activity will overlap or depend on the execution of another activity or process. It is important to identify and consider these dependencies when redesigning workflow, as the effects of redesigning a workflow can be positive or negative.

“It will be important for the team to be able to determine the potential peripheral effects of redesigning workflows. The Model for Improvement and PDSA can help a practice identify unanticipated effects of redesigned processes and correct them before taking them to scale.” – Practice Facilitation Handbook, Module 5. Mapping and Redesigning Workflow, AHRQ; Twitter: @AHRQNews

6. Simplify patient check-in and check-out processes. “Major causes of bottlenecks, the patient check-in and check-out processes influence the efficiency of the patient flow. Before even seeing the physician, patients may arrive late or get held up filling out forms with front office staff. After seeing the physician, patients may need to schedule a follow up visit, diagnostic testing, and/or be referred to another physician for specialty care. Simplifying these processes not only frees up staff time and facilitates necessary care, it enables patients to check in easier and leave quicker.

“Check-in tips: When a patient calls to schedule an appointment, verify their insurance information over the phone instead of when they check in to their visit. If possible, use a secure online portal where patients can fill out required forms ahead of time. Keep forms simple and focused to help patients complete them quicker. To make it easier for billing later on, collect co-pays during check in, too.

“Check-out tips: Use a different counter to check patients out so they don’t have to wait on patients checking in. When a follow up or referral visit has been recommended, schedule the appointment with the practice’s provider or provide the patient with necessary information for the referral appointment.” – 4 Patient Flow Strategies That Improve Medical Practice Performance, Conventus; Twitter: @ConventusNJ

7. Standardization should be established at the start of introducing any new information system elements. “Standardization, an essential element of quality improvement, should be established as much as possible at the beginning of implementing any new element of an information system. Workflow needs to be designed to be as lean as possibly by automating routine information flow and eliminating every possible aspect of individualized work.” – Tips to improve efficiency in radiology departments with radiology informatics, Applied Radiology; Twitter: @Applied_Rad

8. Practice new workflows. “Take a lesson from successful professional sports teams that require impeccable cooperation and efficiency to win games.

“Teams don’t just show up to games and expect to click on all cylinders. Coaches walk the team through the gameplan every day until it becomes second nature to the players.

“Treat your pharmacy team in a similar way. Make time to train everyone in their roles individually and within the entire pharmacy workflow. Then, practice it with them. Together, process a prescription from start to finish, stopping along the way to correct mistakes and reinforce successes.

“When your system becomes second nature to your employees, your workflow will whirr like a finely tuned engine. Your team will make fewer errors and boost productivity.” – Improve Pharmacy Workflow in 6 Simple Steps, Elements Magazine; Twitter: @elementsmag

9. Understand the experience from the client’s perspective when designing clinical workflows. “In an integrated system of care, understanding the initial and ongoing experience of the client as s/he moves throughout the organization’s policies, procedures, and activities is key to designing workflow systems that engage and respond to the felt needs of recipients. The best way to understand the effect of a particular policy and procedure on a client is to go through the process yourself. Some organizations have done just that and found the process invaluable. An organization’s workflow that aligns with the aims of the PBHCI initiative involves closely examining the following questions related to key processes and procedures.” – Workflow Design: A Focus on the Experience of the Recipient of Services, SAMHSA-HRSA Center for Integrated Health Solutions; Twitter: @samhsagov

Improving Clinical Workflows with Automation & Technology

10. Leverage technology at every opportunity to streamline and automate manual tasks. “The core assets of a hospital are the education and experience of the caregivers. Gone are the days when caregivers would keep making calls to remind patients about their appointments. You can turn things around through the use of communication software. There are a million of ways hospitals can use technology to streamline their processes. For example, adoption of an electronic healthcare record helps reduce the time spent searching for paper files and get rid of paperwork. Electronic health records systems ensure health records are available from any location. Hospitals could also take advantage of enterprise imaging technology to capture, manage, view, and analyze all their clinical multimedia content to enhance their electronic health records. Your outdated software and devices will also require investment. It could be time to upgrade your computer if it is taking ages to load files. That way, it becomes easier to send patient appointment reminders through pre-recorded phone calls or emails.” – Dennis McKonkie, 4 Tips to Improve Hospital Workflow, __PharmaNext; Twitter: __@KNect365

11. Go paperless to automate check-in and check out to remove bottlenecks. “If you want to create a positive patient visit experience, paperless automation is a good place to start. Streamlining administrative tasks associated with a patient’s visit to your facility can make a world of difference for patient happiness and staff productivity. The entire patient visit workflow—from check-in to check-out—can be automated to remove bottlenecks and improve patient flow.” – Abby Nieten, How to Accelerate Your Patient Visit Workflow, Formstack; Twitter: @Formstack

12. Clinician-centered design of EHRs can improve workflow, usability, and patient safety. “Workflow, usability, and patient safety can be enhanced through clinician-centered design of electronic health records. The lessons learned from implementing NIST recommendations to improve workflow in ambulatory care using an EHR provide a first step in moving from a billing-centered perspective on how to maintain accurate, comprehensive, and up-to-date information about a group of patients to a clinician-centered perspective. These recommendations point the way towards a ‘patient visit management system,’ which incorporates broader notions of supporting workload management, supporting flexible flow of patients and tasks, enabling accountable distributed work across members of the clinical team, and supporting dynamic tracking of steps in tasks that have longer time distributions.” – Emily S. Patterson, Svetlana Z. Lowry, Mala Ramaiah, Michael C. Gibbons, David Brick, Robert Calco, Greg Matton, Anne Miller, Ellen Makar, Jorge A. Ferrer, Improving Clinical Workflow in Ambulatory Care: Implemented Recommendations in an Innovation Prototype for the Veteran’s Health Administration, EGEMS (Wash DC) via NCBI; Twitter: @NCBI

13. Implement clinical laboratory information systems to aid in complex decision-making. “By automating and standardizing the decision-making process through implementation of clinical laboratory information systems, the lab can decrease the margin of human error and increase the quality of results. New clinical information systems and state-of-the-art technology have allowed constant monitoring of analyzer functions by alerting the tech the second any aspect of testing could be compromised, simplifying complex decision making to streamline laboratory workflow and the results management process. Data management systems help determine the cost of errors caused by inefficient work practices and aim to minimize opportunities for loss of reimbursement. By tracking both the work and the outcomes, the lab can begin to see a decrease in work duplication, erroneous clinical decisions and inefficient use of resources.” – ADVANCE Staff, 5 Ways to Improve Lab Workflow, Elite Learning; Twitter: @EliteCME

14. Capture data prior to appointments with pre-registration. “There is an opportunity to engage patients in a pre-registration workflow, pre-service before they have even stepped foot on premise, on a personal device, such as a laptop, smartphone or tablet. Several items go into a pre-registration workflow, some of which can include a confirmation/update of a patient’s demographics and insurance information, completion of forms and/or questionnaires, and bill payment. Capturing that information beforehand has a great impact when it comes to anything that needs to be sent to the patient, such as appointment reminders, billing, mail order prescriptions, and lab results.” – Janie Tremlett, Automating Clinical Processes to Improve Value in Healthcare, __The Doctor Weighs In; Twitter: __@docweighsin

15. Seek out the right technology partners. “Seek out vendors who not only have IT experts in house, but also nurses and physicians on staff who can leverage their real-world expertise and assist your hospital’s clinicians. Before selecting a technology, ask prospective vendors to conduct a clinical workflow assessment showing the impact of their solutions or platforms. Mapping gaps in certain processes will shed light on how the technology will actually perform at critical points in patient care delivery. Healthcare technology vendors must also understand the importance of security and be knowledgeable about the latest regulations and privacy protocols. Be sure to check out the vendor’s experience working with hospitals and health systems, and also ask for a list of the security credentials they have earned.” – Benjamin Kanter, MD, CMIO of Vocera Communications, 4 Tips for improving clinician adoption of new healthcare technology, Becker’s Hospital Review; Twitter: @BeckersHR

16. Adopt lean methodologies. “In order to improve workflow in conjunction with an EHR, ‘lean’ methodologies (originally introduced by Toyota) have recently been employed by health care by providers such as Massachusetts General Hospital, Beth Israel Hospital in Boston, and ThedaCare. The basic idea behind lean methodologies is to understand the steps in a process and remove or re-engineer wasted steps while preserving and optimizing steps that add real value. Combined with general best practices for the clinical workflow, these methodologies can enable practices to see more patients and complete documentation by close of business, thereby increasing practice revenue.

“So, what exactly slows down providers working with an EHR? Bear in mind that a patient visit is not a one-onone encounter between the provider and patient. From arrival to check-out, a patient interacts not only with the provider but also with administrators, medical assistants, nurses, and technologists. In addition, various activities during these visits must be documented in the EHR. It’s a delicately coordinated series of hand-offs of information and people that can go poorly without the right tools and strategies to make it run smoothly.” – Getting Lean with Your Practice: Five Tips for Improving Provider Productivity with an EHR, athenahealth, Inc.; Twitter: @athenahealth

17. Reduce no-shows with automatic reminders. “Using an automated notification service to send secure text or email appointment reminders is a good idea even if you are already making reminder phone calls. It provides an additional avenue for reaching patients, and if you have a day when making reminder calls is not feasible, you’ll still have your bases covered if you have automated reminders in place. For example, PCC’s software includes a feature called Notify that lets you automate reminders for appointments (as well as recalls and account balance notifications). These services are so easy, it doesn’t make sense not to use them.” – Courtney Edelson, The Best Ways to Reduce Patient No-Shows in 2019, PCC Pediatric EHR Solutions

18. Adopt digital alternatives to replace analog and paper-based processes. “Interoperability remains a challenge for seamless exchange of medical documentation inside and outside the provider organization. This leads to the persistence of outdated technologies that can be a major drain on productivity. Pagers, fax machines, paper records; all of the critical functions served by these manual and analog processes could be significantly improved with digital equivalents.

“Take fax, for example. One study suggests that fax accounts for 75% of all medical communication, which is a mind-blowing statistic in today’s digital-first world. When a medical practice has a workflow process enabled by fax that has been deemed to comply with HIPAA privacy and security regulations, it is thus resistant to change.” – Brenda Hopkins, Three ways to improve healthcare workflow, eFax Corporate; Twitter: @eFaxCorporate

19. Leverage AI for point-of-care learning. “AI has potential to deliver information to physicians as clinical questions arise. Current efforts to keep physicians up to date on the latest medical developments lack personalization, so doctors waste time reviewing what they already know or scanning through content that is not relevant to their practices.

“In contrast, AI can personalize content that physicians need and desire by analyzing practice data, online search queries and formal and self-completed assessments.

“Similar efforts are underway at Johns Hopkins University School of Medicine, where the use of informatics personalizes what and how students are taught.” – Andis Robeznieks, 3 ways medical AI can improve workflow for physicians, American Medical Association; Twitter: @AndisRobeznieks, @AmerMedicalAssn

20. AI can also reduce physicians’ clinical documentation burden. “One of the most promising applications of AI in medicine is reducing the clinical documentation burden on physicians, which has been exacerbated by the adoption of electronic health records (EHRs). A recent study supported by the American Medical Association (AMA) found that primary care physicians spend almost six hours a day on EHR data entry during a typical 11.4-hour workday. By auto-populating structured data fields (for example, allergies and problem lists) from open-ended physician notes, querying relevant data from prior clinical records, and transcribing recorded patient encounters, AI has enormous potential to free physicians from their computers and dramatically reduce documentation burden. Examples include clinical language understanding applications that analyze physician free-text narratives and extract problems and allergies as structured data.” – Shantanu Nundy Michael L. Hodgkins, The Application Of AI To Augment Physicians And Reduce Burnout, HealthAffairs; Twitter: @Health_Affairs

21. Keep the revenue cycle flowing with digital solutions. “Digital solutions by way of revenue cycle management software and online patient portals is a must for streamlining patient communication and payments. Cloud-based RCM software offers medical providers the unique ability to aggregate claims filing, invoicing and payment transactions, appointment scheduling as well patient data (among other things) all in one single convenient place.

“Insights into patient trends, i.e., rates of visits, occurrences of chronic illness, payment rates, etc., can help your organization make data-based decisions when it comes to updating technologies and services. And housing all accounts receivable information in one central place can make the patient intake, billing, and payment processes more efficient.” – Joe Fleming, 5 Smart Tips for Improving Revenue Cycle Management, ReferralMD; Twitter: @getreferralmd

22. Consolidate and cut IT costs with virtualization. “Aside from eliminating IT silos across geographic regions and throughout the enterprise to avoid redundancies and/or inefficiencies, virtualization also enables rapid and consistent delivery of core IT services.

“As the business of healthcare continues to transform, application and desktop virtualization increasingly play a central role in supporting clinical workflows, especially in areas such as electronic health records and bring your own device deployments, remote work and connected health.

“Investing in the right technologies and a solid network to run those solutions on is imperative. When the care continuum takes a back seat between multiple clinicians and facilities, it can be tragic.

“To close the gap in the care continuum, hospitals need IT systems that work and are built for the future to stay profitable.” – Dan Dillman, chief executive officer, A2U, How Hospitals Can Leverage IT to Improve Healthcare Business Outcomes, HiMSS; Twitter: @HIMSS

23. Usability is a key consideration in adopting health IT solutions. “Although clinicians have reported a high level of use and satisfaction with certain health IT features, such as electronic prescribing (Makam et al., 2013), a number of challenges with usability remain, and the National Institute of Standards and Technology has indicated that usability is often overlooked in the adoption of EHR systems (NIST, 2015). Health IT that is not designed and implemented to support the diagnostic process can increase vulnerability to diagnostic errors. The American Medical Association (AMA) recently released a statement that health IT is misaligned with the cognitive and workflow requirements of medicine and listed eight priorities for improving the usability of EHRs (AMA, 2014). Future research on health IT usability will be important.” – Committee on Diagnostic Error in Health Care, Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors, Board on Health Care Services, Institute of Medicine, Improving Diagnosis in Health Care (2015): Technology and Tools in the Diagnostic Process, via The National Academies Press; Twitter: @theNASEM

24. Clinical decision support systems work best when integrated into the clinician’s workflow. “On a practical level, our findings imply that clinicians and other healthcare stakeholders should implement clinical decision support systems that (a) provide decision support automatically as part of clinician workflow, (b) deliver decision support at the time and location of decision making, (c) provide actionable recommendations, and (d) use a computer to generate the decision support. In particular, given the close correlation between automatic provision and successful outcomes (P < 0.00001), we believe that this feature should be implemented if at all possible. If a clinical decision support system must depend on clinician initiative for use, we recommend that system use be carefully monitored and steps be taken to ensure that clinicians access the resource as intended.” – Kawamoto Kensaku, Houlihan Caitlin A, Balas E Andrew, Lobach David F., Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success, BMJ; Twitter: @bmj_latest

25. Configure EHRs to suit specialized clinical workflows. “Some EHR vendors are willing to work with healthcare organizations to specialize clinical workflows to meet the unique needs of certain specialties, care settings, hospitals, and health systems.

“Specializing clinical workflows to prominently display the information or functionality most commonly used by providers part of certain specialties or care settings can help users more easily navigate EHRs.” – Kate Monica, 5 EHR Optimization Activities for Improving Clinical Efficiency, EHR Intelligence; Twitter: @EHRIntel

26. Measure performance around strategic priorities, then talk to stakeholders to identify pain points and opportunities. “Examining your current enhancement request list for the next optimization project is unlikely to generate a strategic optimization list. Start by measuring performance around those areas that are strategic priorities for the organization. The quadruple aim can be a great starting point, as it accounts for quality and cost as well as both patient and provider satisfaction. Talk to stakeholders to understand where the key pain points reside and understand readiness for change. Spend time observing in high impact areas like perioperative areas to understand primary barriers. Compile your results and assign a tangible financial or other value to the optimization opportunity. Then prioritize your findings. The result is a strategic optimization list that as implemented is highly likely to help your system realize benefits.” – Focus on High Value, High Impact Optimization Areas to Drive Benefits Realization, Impact Advisors; Twitter: @ImpactAdvisors

27. Combining clinical and business intelligence can have a positive impact on care delivery, health outcomes, and operations. “Clinical and business intelligence (C&BI) is the aggregation, analysis, and use of clinical, financial, operational, and non-traditional data captured inside and out of the healthcare setting to directly inform decision-making. It has the power to positively impact patient care delivery, health outcomes, and business operations. Leveraging the power of C&BI will improve our nation’s entire healthcare system as well as the medical and economic wellness of patients.

“C&BI solutions aggregate data from IT systems and other non-traditional data sources into secure repositories or federated databases for the purpose of analysis. Combining the best of both business intelligence and clinical intelligence, it provides historical and predictive views of the organization’s operations – and a similar view of clinical care – in order to enable better business decisions and improve patient care delivery, all while improving the organization’s fiscal sustainability.” – Clinical & Business Intelligence, HiMSS; Twitter: @HIMSS

28. Reduce toil to improve care coordination and workflows. “When a patient moves to a different level of care, a nurse will need to coordinate with a variety of potential support services, including pharmacy, transportation, nutrition, housekeeping and others. At the same time, the nurse will need to update the patient’s medical record, communicate with the patient’s family, and ensure that other staff is informed about the patient’s transition.

“Clinical communication and collaboration tools can empower nursing staff to manage these tasks from any location, rather than remaining stuck behind a desk. A nurse can send individual and mass notifications that will reach the appropriate recipients wherever they are located. No need to track them down or wait for each person to answer the phone.” – Terry Zysk, Reduce Toil to Improve Care Coordination and Clinical Workflow, LiveProcess; Twitter: @LiveProcess

29. Embrace healthcare data analytics. “More data is being pulled from the electronic health records, where core clinical data lives. The number of respondents pulling data from health information exchanges more than doubled in just a year, from 3.8 percent in 2017 to 9.1 percent in 2018. That jump is an encouraging sign that this mode of data exchange has gained a foothold.

“Rising integration of information from patient health surveys with EHR data indicates that stakeholders are focusing on individual patients, not just population health. Lagging are fundamentals like real-time data on hospital admissions and discharges. Improvement in these measures would bode well for coordination of care across providers, the survey noted.” – Fred Donovan, Healthcare Data Analytics Having Big Effect on Clinical Workflows, HIT Infrastructure; Twitter: @HITinfrastruct

30. Use EHR audit logs to determine how clinicians are spending time in EHRs. “Knowing how long providers are spending on administrative tasks in the EHR is valuable information for a number of reasons. First and foremost, this information can be used as a benchmark to measure the impact of future software updates or optimization projects. Any significant changes to provider workflow should be retrospectively reviewed to understand how it impacts the average time providers spend in the EHR. First, do no harm.

“Analyzing user activity logs at the individual level also helps identify highly efficient EHR users within each specialty. The EHR workflow patterns of these EHR champions can be modeled. Peers can be educated on how to adjust their own workflows to mirror specialty-specific champions, reducing their own daily EHR burden. These ‘quick win’ workflow adjustments are changes that can be adopted by clinical staff immediately, before extensive EHR optimization efforts are undertaken.” – Justin Campbell, Vice President, Strategy, at Galen Healthcare Solutions, Physician Burnout, a Healthcare Issue Unique to Our Healthcare Providers, Healthcare IT Today; Twitter: @HealthcareScene

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