There is universal agreement that in the implementation of an EHR – or any other new application(s) - the workflow design and decisions are often the most challenging component of the project.   There are other factors involved in the implementation such as project planning/management, application build, interface builds, hardware deployment and communication but these seem to pale in comparison to workflow.  The industry talks about workflow in each project but workflow is rarely understood by those who will be most impacted – the end users of “the” system.
When you use the term workflow – what do you mean? 

Workflow consists of a sequence of connected steps.   The steps are not necessarily done by the same individual or even the same department in a hospital or in a physician practice office setting.  An example is seen in the Emergency Departments of every hospital.   For a patient to be efficiently transferred from Emergency Department Care to in hospital care a series of steps are required:

1.    ED provider makes decision that admission is required
2.    Decision is documented via a written order on patient ED chart
3.    ED clerk searches for the chart
4.    Chart found ED clerk calls to the Admitting Department to request a bed
5.    Admitting Department reviews available beds
6.    Admitting Department calls Unit where patient will be placed
7.    Admitting Department calls ED to notify of the bed placement
8.    ED clerk calls to ascertain when the patient can be transferred
9.    ED nurse documents on transfer note all the patient data necessary for transfer
10.  Etc, etc, etc …

Each of these steps is connected by the steps before and after – no one step stands alone to attain the desired result – a newly admitted patient in the correct inpatient bed. 

Well – you get the idea – if the steps happen out of sequence or a step is omitted then smooth execution of the patient transfer is going to fail.  How important is the workflow?  Now, imagine a project to implement CPOM (Computerized Provider Order Management) where Step #2 is going to be altered by the ED physician entering a computerized order for hospital admission. Whoops!  A step not identified earlier – the facility requires the ED physician to have discussed acceptance of this patient with a physician with attending privileges.  The design of the admission order has failed to include this step not identified in the current state workflow step sequence.  If a step is omitted – it should be done by design only – not from the failure to identify the required step.  Step #3 above will truly be omitted by the CPOM admission order.  If we proceed to implementation of the system and the ED provider has not agreed to this new workflow step and we have failed to correctly identify and plan for the subsequent workflow steps -our implementation will fail as well. 

Why does new workflow most frequently fail?  How many projects have you personally seen where the application is stated to be “working as designed” and the workflow is identified as the underlying issue?  The underlying reason is generally failure to understand the end user needs and resistance to change.  How can this resistance to change be overcome?   Next week’s blog will provide some ideas for meeting this resistance in a proactive way through project structure and management techniques that have been tested and proven.  Stay tuned....