Preventing Your EHR from Working Against You, Part II: Personal Workflow Analysis

The ultimate purpose of an EHR is to assist in caring for patients.  Analyzing personal workflows aids in gathering the information required to choose the best product. Personal workflow analysis is easier to do than group workflow analysis because the focus is on the activities of only one person. How you choose to document your workflow is up to you. Diagrams are a good idea if others will need to make use of your findings. Otherwise, keep it simple. A writing pad and a few pencils are fine for documenting personal workflows. Focus on creating an accurate, straightforward depiction of the steps in each task. For those who want to create workflow diagrams, I suggest using Microsoft Visio. It offers an array of diagram types and a trial version (good for 60 days) is available.

Once a documentation format has been selected, the next step is deciding which tasks to analyze. It would be a waste of time to attempt to document every single thing you do. Instead, go for the top 10 to 12 things that you do most often. For a primary care physician, a typical list of frequent tasks might include the following:

  • Write a prescription
  • Order labs
  • Request a consultation
  • Review test results
  • Document a visit
  • Review preventive care interventions

For each task selected, focus on three areas: the number of steps required to complete the task; the information required in order to make task-related decisions; and the time required to complete the task. The best way to understand how to perform these steps is by doing them. So let’s get started. We will analyze writing a prescription, a task that every clinician has done hundreds, if not thousands of times. Whether you are moving from paper to an EHR, or from one EHR to another, the analysis steps outlined below work equally well.

Task Steps
Start your analysis by listing each identifiable step beginning with the decision to write a prescription and ending with a written prescription. The hardest part of doing a personal workflow analysis is developing an awareness of things that are done unconsciously. For example, before writing a prescription, the following are usually reviewed: diagnosis, age, co-morbidities, and current medications. If the patient is well known to you, consideration of these items might occur quickly and seemingly without much thought. The workflow example listed below outlines the steps that usually occur when writing a prescription. These steps are generic and should be adjusted for your situation.

Workflow: Writing a Prescription

  1. Review patient information
    1. Confirm main diagnosis for which drug is being prescribed
    2. Co-morbidities, age, insurance type
    3. Medication history, drug allergy history
    4. Lab data
  2. Formulary review
    1. Available drugs by indication, available drugs by chemical class, trade versus generic, cost
  3. Select medication
  4. Determine medication dosage, route, frequency, amount to be dispensed, number of refills.
  5. Write prescription
  6. Determine if additional prescriptions are required
  7. Obtain patient education handout

Do not attempt to accomplish too much in one session. For any task that you scrutinize, try to limit each analysis session to no more than an hour. Short sessions aid in developing task awareness because each time you review a task you will be more conscious of the steps taken to complete it. Longer sessions may become tedious and cause a loss of focus.  In addition, longer sessions may lead you to focus on extraneous details. Three to four one-hour sessions should be sufficient to capture all the detail required for any task.

The Information Requirements Review
The information requirements review (IRR) assures that no critical information needs are overlooked. Depending on the task, you may find that all of the information required for decision-making can be included in the list of task steps. Items 1 and 2 above contain the results of a basic information requirements review for prescription writing. The IRR aids in EHR selection because, among other things, it provides a guide to the information an EHR screen should display while you are performing a task. An EHR that presents the required information at the proper time will make you more efficient. On the other hand, if key information is missing, you will waste time clicking through screens looking for it.  Therefore, the results of the information requirements review are critical for writing a good test script.

Time Requirements
Determining the time requirements for a task is easy–all that you need is a watch. Record the amount of time required to complete each task step (items 1-7 in this example). If you use the PDR or other resource to look up drug information, include the time spent accessing them. If you have to consult a formulary, include that time as well. Capture the time for each step separately, then add them to obtain the total time for the entire task.

Measure the time required to create prescriptions for new medications and refills separately. Pay particular attention to the amount of time required to write a prescription (Step 5) on paper or with your current EHR. This is a common pain-point when moving to an EHR from paper, or from one EHR to another. Most clinicians can write a paper prescription in 20 to 30 seconds. Writing time is particularly important for refills because most clinicians write more refills than new prescriptions. No one is happy to find that a process that requires 30 seconds on paper requires 60 seconds when using an EHR. Once you have collected the requisite time and information requirements data for each task step, your analysis is complete. At this point, you have everything needed to create a test script that can help you to find the EHR that best fits your way of doing things. The final post in this series will demonstrate how one creates a test script using a personal workflow analysis.

I hope this tutorial has been helpful. It represents my approach to incorporating work habits into software evaluation.  Please let me know how it works for you.

Preventing Your EHR from Working Against You, Part I: EHR Workflow and Personal Work Habits

Preventing Your EHR from Working Against You, Part III: Creating a Test Script

See Electronic Health Records, Second Edition (Chapters 16, 17, 22) for additional information concerning workflow analysis, EHR evaluation, and test scripts.



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