Posted: January 24th, 2017

Variation in electronic prescribing implementation among twelve ambulatory practices

discussion response- Nursing

DDDCOLLAPSE

NURS 6051-1: Transforming Nursing and Healthcare Through Information Technology

Week 7- Main Question Post

The first section I looked at was under the educational presentations tab, and it contained three power point files: What is Workflow, Why Care About Workflow, and How Do I Evaluate Workflow. The first power point described in detail what workflow actually meant; inputs are transformed into outputs, or the processes needed to produce services. It is a sequence of physical and/or mental tasks performed by various people over time and through space. There are also examples of different types of workflow: inter-organizational, clinic-level, intra-visit, and cognitive. Using this power point can help in redesigning a workflow in my organization because it describes what it is and which types there are; this information is needed when considering specific healthcare information technology (HIT) to support our workflow. For example, if I needed a way for a medication order to get to my patient’s pharmacy, I would need to know the workflow involved in that. It would be inter-organizational, because it is a workflow between one point in the organization to another, and it would involve the patient, the physician, the nurse, and the pharmacist.

The second power point discusses why workflow is important in regards to using HIT. It gives four answers: 1) to avoid pain and suffering; 2) it will assist in vendor selection; 3) to better prepare and train staff; and 4) to plan ahead. It is important to understand that HIT will change workflows, so I must be prepared for change, otherwise it can cause emotional suffering to staff and patients, as well as financial suffering. If I am aware of what workflows are already in place at my organization, it will assist me in correctly choosing a vendor whose product will improve workflows we want to keep, and make the ones we don’t more efficient. Because implementing HIT will cause a change to workflows, it is crucial that I know who participates in the workflow that will change. This will help me to prepare and train the staff affected, making the transition easier. Knowing who is involved will help me prepare for any complex challenges I anticipate down the road after the HIT is implemented. Building from the example given above (a medication order to my patient’s pharmacy): I know that there will be multiple people involved in this process. The patient will have to provide the physician and nurse with information. The nurse will have to input information regarding which pharmacy the patient uses and which medications the patient is currently taking. The physician will have to input a medication order. The pharmacists will have to verify these medications. A system that coincides with this workflow will be chosen, and all parties that participate will be trained on how to use the system for this process. All parties will have to anticipate issues arising when first using this system, and openly communicate to overcome such issues.

The third power point describes how to evaluate a workflow using a flowchart, which helps me to see how a process happens, what contributes to different types of flows for this process, how HIT affects this process, and ways to improve flows. The workflow for ordering medications would start with attaining information from the patient by the nurse (what pharmacy do you use? What medications do you take?) This information would be documented in a specific spot in the EHR. The doctor would order a specific medication in the HIT after assessing the patient’s current medications and health record. This order would populate to the facility’s pharmacy for another safety check (right medication, dose, no contraindications to current medications or duplications), as well as the patient’s pharmacy (another safety check, insurance coverage check, medication availability). The nurse then prints off the medication order and information about the medication, and presents it to the patient while providing education upon discharge. There could be many different flows to this process; the patient might not have a normal pharmacy, the nurse might put the order in for the physician, the patient’s pharmacy might not carry that medication and the physician would be called for a new order, etc.

In Crosson et al.’s (2008) study, twelve practices were observed before and after e-scribing implementation. The five practices that fully implemented it had positive attitudes about the implementation and future use, had training on how to use it, and had previous knowledge on their current workflow relating to prescriptions. The other seven practices installed it and used it unevenly, discontinued it, or didn’t even install and use it at all. All had mixed feelings and apprehensions about introducing change even with knowing the benefits, did not get any training on how to use it, and were not aware of the workflows they used prior to implementation. Some practices didn’t even know that e-scribing was being implemented beforehand, and many complained of poor IT support when problems arose. This study supports the importance of knowing your practice’s current workflow, picking the right vendor to coincide with that workflow that provides strong support services, identifying who is involved in the workflow, providing adequate training on the new HIT system, and preparing staff for any anticipated problems that can arise.

It is crucial to monitor the effects of technology on workflow. When implementing an HIT, workflows will change and can affect any participant that is involved with the workflow. If workflow is not considered before this change occurs, it can have negative effects on the patient, the staff, and finances. Workflow information should be gathered ahead of time so that all parties to be involved are listed, the right vendor is chosen that coincides with the workflow, and that staff are prepared for any anticipated issues that might arise. It is also important to continually assess workflow during and after HIT implementation.

Crosson, J. C., Isaacson, N., Lancaster, D., McDonald, E. A., Schueth, A. J., DiCicco-Bloom, B., … Bell, D.S. (2008). Variation in electronic prescribing implementation among twelve ambulatory practices. Journal of General Internal Medicine, 23(4), 364-371. doi: 10.1007/s11606-007-0494-8

U.S. Department of Health & Human Services. (n.d.). Workflow assessment for health IT toolkit. Retrieved October 10, 2016 fromhttps://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/presentations

Week 7 Discussion System Design and Workflow

As I completed the assignment this past week, I am learning and finding more interest in the topic of Health Information Technology (HIT). According to the Agency for Healthcare Research and Quality (AHRQ) a successful implementation of HIT balances both the clinical and administrative workflow (U.S. Department of Health & Human Services, n.d.b). The three different concepts I would use to help in redesigning workflow at my organization would be benchmarking, using a flowchart, and usability evaluation.

At St. Joe’s, our Short Stay Unit(SSU) currently utilizes paper for all post-procedural patients, specifically, post cardiac catheterization patients. All documentation pre and intra-procedure is completed in the Electronic Health Record (EHR). Upon admission to SSU, the nurse takes report on the post-procedure paper form and all charting from admission to discharge from SSU is completed on paper. Beginning any new process or redesign requires research on what are the best practices used at other organizations and then looking at how to apply them to our redesign (U.S. Department of Health & Human Services, n.d.b). My first task would be to reach out to our “sister” hospitals and find out what their current practice is. I would also refer to iVantage Health Analytics, an online company. Our organization uses this company for benchmarking purposes. The company utilizes strategic data to provide guidance to healthcare industries regarding policy, research and leadership.

After completing benchmarking, a visual diagram or flowchart would be created to map our current practice (U.S. Department of Health & Human Services, n.d.b). The flowchart would represent our current state and what we would like our future state to look like. Clinical nursing involvement would be key as a flowchart is created and would include both our procedural and short stay nursing staff to ensure all steps are mapped out. As Page (2011) identified, nursing involvement at all stages is needed for redesign to be transformational and sustaining.

In preparation for this redesign, I used the research link on the AHRQ workflow website and reviewed a study that was done to determine how “ambulatory leaders differentiate implementation approaches between practices that are currently paper-based and those with a legacy EHR system (EHR-based)” (Zandieh et al., 2008). The study compared and contrasted implementing an EHR system in an ambulatory care setting, with a system that had already implemented an EHR system. The study found that priorities differed in both practices but that both worried about workflow changes and efficiency. The paper based system worried regarding the staff’s ability to learn and change versus the EHR system’s expression of resistance met by staff. Overall, moving toward implementation of an EHR system for documentation was recognized as a must and the researchers found the new EHR would improve patient care by improving communication among practitioners (Zandieh et al., 2008).

The importance of monitoring the effect of technology on workflow cannot be overstated. Completion of benchmarking and identification of a process by using a flowchart are early phases of redesign, but a successful implementation requires continual reassessment. A usability evaluation will be conducted to determine the extent the system is easy to use (U.S. Department of Health & Human Services, n.d.b). As the researchers identified, ongoing technical support and leader support via communication were needed for success (Zandieh et al., 2008). The implementation of technology must serve to enhance workflow and allow nursing to provide quality care to patients. Nurses must feel that this change is beneficial and not adding to their workflow. Staff feedback will be vital as part of the evaluation phase.

References

Page, D. (2011). Turning nurses into health IT superusers. H&HN:Hospitals & Health Networks

85(4), 27-28.

U.S Department of Health & Human Services. (n.d.b). Workflow assessment for health IT toolkit. Retrieved October 4, 2016, from https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/checklist

Zandieh, S. O., Yoon-Flannery, K., Kuperman, G. J., Langsam, D. J., Hyman, D., & Kaushal, R. (2008, June). Challenges to EHR Implementation in Electronic- Versus Paper-based Office Practices. Journal of General Internal Medicine, 23(6), 755-761

Discussion 2