Taking Lean to the screen: Removing waste from the electronic health record

Many physicians and nurses are traveling across desolate EHR wastelands replete with digital detritus, pixel dust and other non-value-add items.
By David Butler, MD
10:10 AM
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Ser Jorah Mormont from Game of Thrones (Photo: HBO)

Say you run into a friend and after catching up for a while, he shares he's recently self-diagnosed a highly contagious skin disease that "looks like what Ser Jorah contracted during the fifth Season of Game of Thrones." You instruct him to make an appointment with his doctor, so he can rest assured that his disease is likely far less serious.

If you're in healthcare, you truly understand what your friend is about to go through to schedule an appointment with his doctor (and probably a dermatologist referral). Your friend may not fully appreciate how similar this journey to the primary care physician may resemble a trek across the fictitious world of Westeros! Just consider all the steps it takes to see your doctor:

  1. Freak out after reading about your symptoms on "Google University"
  2. Call to make the appointment
  3. Drive to the doctor's office
  4. Attempt to park
  5. Check in with registration, provide your insurance information and reason for visit
  6. Wait…you got it, in the "waiting room"
  7. Get seated in a nondescript room where your vitals are taken by the nurse
  8. Wait for the physician or care provider
  9. See your doctor and receive care for possible "Greyscale"

In today's traditional healthcare model, this is exactly what occurs. Estimates from a value stream mapping (VSM) event from a previous healthcare system that I had the opportunity to work with showed that only 10-35 percent of a clinic visit is considered 'value add' for patients. The nurse's preliminary exam and the physician exam are considered to be the only 'value add' steps in the process outlined above. Remember, the patient determines if value is added, not the clinician.

To strive to deliver more value, many traditional healthcare systems have turned to utilizing formal process improvement methodologies such as Lean and Six Sigma, tools derived from the manufacturing industry, to deliver care efficiently and effectively. This trend and its effects have been well-documented by industry leaders like Patricia Gabow, MD, and John Toussaint. Dramatic improvements in cost reduction, quality improvement and patient safety have been seen in health systems like Toussaint's ThedaCare, Seattle Children's, Park Nicollet, and Denver Health. Centers for Medicare and Medicaid Services decreased contract modification cycle time by more than 50 percent and achieved a 95 percent reduction in post-implementation information technology change requests in national quality programs by adopting Lean.

With these success stories and over 300 books about Lean management available on Amazon, Lean is definitely hot in healthcare and not just a fad destined for hospitals' basement boxes within a few years. Many experts describe Lean as "corporate common sense" or metaphorically refer to it as "a diet and exercise routine for companies in order to stay healthy." These process improvement strategies are critical in healthcare because unlike other business models, we cannot just "have a sale" or drive more business strictly through marketing. We must streamline our processes and remove the waste and non-value add steps from the clinical care process. The most successful organizations leverage Lean transformation efforts to drive all business and clinical processes throughout their organization.

The Problem
I've been a part of many process improvement events throughout my career, both as a healthcare provider and more recently as an executive sponsor. After over 15 years of participating at all levels of these processes in four separate healthcare delivery systems, each one seems to have neglected Lean thinking once their doctors, nurses, and ancillary staff log into the rabbit hole that some call the EHR (electronic health record). After discussing the above scenario with colleagues that are experts in Lean, Six Sigma, or other process improvement methodologies, many of them seem a bit intrigued by the thought of this approach: applying Lean to the EHR. They ask, how would our process improvement team remove waste from the EHR? I'm glad they asked, and I hope you can find value, too – pun intended.

To fully grasp a visual of the concept, I can't help but think of the crew from the classic sci-fi hit  Fantastic Voyage (or Mrs. Frizzle's Magic School Bus, if you're a Millennial) as they would shrink themselves down to microscopic levels in order to travel through the human blood stream to cure a clot or fight white bloods cells.

By metaphorically shrinking down to travel through your hospital's EHR system, you'll more than likely find a lot of EHR waste: The No. 1, 2, and 3 complaints I hear from clinicians are 1) There are too many buttons and icons cluttering up the screen, aka "the cockpit effect"; 2) placing orders and documenting the visit takes a long time; and 3) keeping up with the InBasket (secure internal communication tool where labs, med refills, and other notifications are sent to the physician) is impossible.  An American Journal of Emergency Medicine study found that emergency department physicians spent 44 percent of their time entering data into the EHR, clicking up to 4,000 times during a 10-hour shift. They spent less than one-third of their time – 28 percent – with their actual patients.

Or think of it this way: If every computer mouse inside your hospital had a little odometer and "clickometer" inside, how many "mouse miles" are being logged? Many physicians and nurses are traveling across desolate EHR wastelands replete with digital detritus, pixel dust, and other non-value add items such as lab summary reports, non-intuitive icons and drop-down lists, and outdated order sets.

Every swoop to the opposite side of the screen and every click adds up, and the mouse miles and clicks are continuously mounting. A large percentage of these poorly configured and kludgy designed workflows contributes to the current physician burnout that we are encountering across the U.S. A 2015 survey conducted by the American Medical Association and AmericanEHR Partners found that just 34 percent of respondents said they were satisfied or very satisfied with their EHR systems. This is down dramatically from the 61 percent in a similar survey conducted five years earlier. Our docs need some help!

The Solution: 5S - Sort, Set, Shine, Standardize, and Sustain (not Scream!)
So what is the solution? How do we decrease clutter, engage clinicians, and ensure that critical issues are addressed? While there are many solutions, I will focus on how we can leverage Lean to assist in our journey to optimize the EHR and end-user experience. I posit that not only does Lean work in the physical world, but that this process improvement methodology may have more applicability to the virtual world of the EHR.

Let's consider the following scenario: A group of primary care physicians say they are spending extensive time outside regular business hours managing their EHR inbox – messages from patients, new lab results, medication refill requests, and other auto-generated notifications are filling their evenings.

Okay Mrs. Frizzle, let's get to work with a tool called "5S". For the purpose of this article, we will not use the Japanese terms (which all begin with the S sound). Instead, we will use the terms Sort, Set, Shine, which creates Standard (work) and allows us to Sustain (the process). On to our Lean optimization:

1. Sort: The process of removing unnecessary items, simplifying to keep value-add items only.

  • Establish a project team of physicians, nurses, and other key individuals to ask the "5 Why's" about the EHR inbox in order to identify the root cause of why the users are spending additional time in the inbox. Pulling hard data from the EHR (average time spent, total messages received, etc.) is a key step to overlay with user feedback to identify the true cause(s).
  • After digging and speaking with the EHR vendor and local IS experts, we discover that not only can we delegate certain messages to appropriate care team members, but we are able to automatically configure specific result types to route to certain staff, or not at all if no value was found in the message by the physician.
  • We determine that our EHR was configured to automatically send particular messages to the physician based on the initial EHR configuration agreed upon a decade earlier. Some examples were change provider messages, overdue annual exams, patients over 65 that are due for yearly flu and pneumovax shots, etc. Through healthy debate and Lean prioritization tools, the project team was able to conclude that the communication from many of these messages were important, but the EHR inbox was not necessarily the right venue to receive that information.
  • A variety of messages can be eliminated and new workflows established for clinic managers to follow up on patients not seen in a specified time frame. Sorting the messages and communication in the inbox down to the essential pieces will provide clarity for the users as they create a new process to streamline their time spent in the EHR after hours.

2. Set: Organize items in the right order to maximize efficiency and minimize wasted time. Does the layout of the chart and the screen make sense for how the visit flows?

  • Now that the workflow has been established, the screen can be streamlined to a clean layout to best optimize user time in the inbox. If MAs are to review patient call messages prior to forwarding on to the physician or nurse, position this item at the top of the inbox.  An entire field of study is dedicated to this called human factors engineering.

3. Shine: Make the workspace clean and pretty. Is this section of the EHR pleasing to look at? Could anyone jump in and easily understand the section?

  • Ask the project team to determine consistent verbiage for all users and locations, naming folders cleanly and placing in an identical order for all areas where appropriate. Leveraging consistent color schemes for similar message types is a form of visual management.

4. Standardize: Implement best practices for all individuals, maintain standards, and consistency.

  • During our discovery work (5 Why's), we identified that a significant number of messages in the physicians' inbox can be handled by other more appropriate staff. The IS team partners identified a forwarding/delegation feature that the team was previously not aware of, and a new workflow is developed to have each physician delegate portions of their inboxes to the most appropriate licensed person in their office. This will assist in expediting message triaging and responses to non-urgent requests.
  • From this new workflow, we quickly observe a 20 percent decrease in the number of messages reaching the physician. The physician is now able to spend more quality time with their families or add an additional patient if so desired.

5. Sustain: Develop a workflow and practice that is ongoing, with regular training sessions that encourage compliance.

  • This new workflow and streamlined inbox setup should be incorporated into operations moving forward and adopted as the new standard. This entails incorporating the updates into training materials, considering for future impacts from version upgrades or enhancements, and establishing a routine monitoring process to ensure the improvements continue to benefit users.

As you can see from walking through the scenario above with me, the EHR and other technology tools must not be excluded from your organization's rapid improvement events, even if some may feel that "it's too hard to get changes through!" Approaching all EHR changes through the microscopic lens of Lean will reveal "micro-tons" of technical wastes, which cause increased cognitive friction and physician burnout.

We may never know if your friend truly has Greyscale; however, rest assured that in the near future, he will be able to rapidly see a care provider to find out. We just need to board that Magic School Bus to expedite the process for him and for his provider. Seatbelts, everyone!