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5 ways to transform ambulatory workflow

An Epic implementation has many moving parts and organizations are often breathing sighs of relief if their offices are live and above water.

But there are common areas of frustration that stick around after the initial go-live that rear their confusing heads months or years after and receive little attention. Is it because certain issues are too daunting to think about? Is it because there is confusion about what the best workflow should be? Is it because the inconsistency doesn’t seem to be stopping workflow, just making it frustrating?

During a recent engagement with one of our clients, we worked closely with operations, clinicians, clinic managers, quality representatives, coding team members, and IT to address these issues and come up with leading practice workflows that fit their needs and culture.

Common trouble areas we’ve seen at Epic organizations

We’ll focus on these five common trouble areas that we prioritized at the client:

  • Problem List Management
  • MA/LPN/RN ordering policies
  • Refresher training processes
  • External document scanning
  • Prior authorizations

Problem List Management

The Challenge

Providers simply don’t understand the value of the Problem List. Though problem-oriented charting is a well-known and widely used charting method, the problem list is a new concept with the advent of EMRs. Providers rarely understand what diagnoses should be tracked as problems and how to manage them over time. They also rarely understand who “owns” which problems and are reticent or overeager to edit another providers’ entries.

Problem lists are often bloated with inappropriate diagnoses due to the issues above, leading providers to throw their hands up and proclaim the list pointless and would take too much time to clean up.

The Solution

  • We developed a multi-specialty team of physicians to agree on benefits and best practices to clean up the list and define ownership: PCP owns the problem list holistically, and specialists own managing problems associated with their specialty during their office visits
  • The training team developed an interactive training video, narrated by physicians, that was rolled out to the offices in scope
  • We strongly encouraged problem-oriented charting for specialists
  • We built a routine batch job to automatically resolve self-limited diagnoses to prevent problem lists from getting bloated with unnecessary entries and to clean them up from the initial go-live
  • We rolled out “Problem List Mark as Reviewed” statistics onto every physician Radar dashboard

Lesson Learned

While we had solid participation from physician representatives in our task force meetings, we didn't engage the section chiefs early enough to get their buy-in and validate that our work with the Problem List was important. If you are looking to change workflow, ensure you get buy-in from the physician leadership at the top to help drive adoption, not just an identified subject matter expert.

MA/LPN/RN ordering policies

The Problem

Although the EMR has been around for a long time and organizations have been live for years, the responsibility and liability concerns around placing orders can hold organizations back from making providers happier and more efficient. State laws permitting, however, it is critical to provider happiness to allow clinical support staff to place orders per protocol with or without a physician co-signature.

The Solution

  • The clinical task force (which is composed of physicians, clinic managers, operational leadership, quality staff and has legal counsel and inpatient leadership input) decided on a policy for all the medical group outpatient practices, allowing MA, LPN, and RN staff to sign standing orders (such as influenza vaccines) without a physician co-signature. It also allowed RN staff to sign orders per protocol, including medication refills, with a physician co-signature.
  • This policy change also included a system change implementing the “order mode” dropdown menu for orders on the outpatient side, and split up security between MA, LPN, and RN staff. This allows clinical support staff to select how they are placing the orders, improving accountability for the end user to select why they are moving forward on their own. This also makes the outpatient system build consistent with the inpatient build.

Lesson Learned

Make sure operations takes ownership of training when it comes to new policies. While the Epic training teams can help develop materials showing how to order correctly in the system, the details of the policy should be trained by operational leadership so users understand the bigger picture.

Refresher training processes

The Problem

When a new provider joins the organization or after an initial go-live, refresher training is critical to the user’s success. Learning a new EMR, even if a user has prior Epic experience, is daunting and overwhelming. Rounding back with users after their first week is critical to their ongoing success, as users themselves are often unaware of their own inefficient habits or problematic workflows that could be causing inefficiencies or communication breakdowns downstream.

The responsibility of ensuring users receive refresher training is often overlooked and forgotten. Training teams are left frustrated because their services are budgeted for, but underutilized, and users and managers are left frustrated because they don’t have time to prioritize activities that aren’t critical to their day-to-day.

The Solution

  • We improved an existing 30/60/90-day refresher training process and assigned the practice manager to be the accountable owner to ensure the refresher training was scheduled and prioritized for the provider. The scheduling of the sessions is now incorporated into new provider orientation checklists.
  • We developed a standard assessment tool for existing and new providers to assess their proficiency level and understanding of client-specific leading practice workflows.

Lesson Learned

It is critical to define clear ownership of who is responsible for coordinating and scheduling the new physician's time. Ensure someone has the time and organizational skills to set reminders to schedule sessions at the right intervals and follow up to ensure the meetings happen and gather feedback from both the physician and the trainer.

External document scanning

The Problem

If scanning is decentralized, it’s easy for inconsistent scanning workflows to develop and it becomes difficult to hold scanning users accountable to the same standard practices. The different “levels” of scanning documents to satisfy orders, health maintenance topics, and ensure they are filed as outside notes can be confusing for both scanning users and providers to locate external documents. This is often critical to understanding patients referred into the organization.

The Solution

  • We improved the labeling of the columns in the Chart Review Media Tab and re-arranged them so that the encounter date column is first. This allows the patient’s information to be as close to reverse chronological order as possible.
  • We re-trained scanning users on a new workflow to create encounters for every order-level scan. This allows for the user to backdate the encounter date to equal the date of service, which improves the quality of documentation in the EMR and helps physicians locate documents easier.

Lesson Learned

If you have decentralized scanning (each department has their own users who scan) it can be difficult to train consistent workflows. Ensure you have a forum for communicating standard scanning practices and reinforce training multiple times so users get the message.

Prior authorization

The Problem

It can be difficult to ensure procedures that require prior authorization are properly recorded so authorization numbers end up on the claim. Prior authorization workflows are highly integrated between clinicals, patient access, and revenue cycle teams. Greater integration means greater complexity and greater difficulty for IT to recommend best practices end-to-end.

 The Solution

  • We rolled out a series of new orders that providers were not placing as orders, but rather entering in the Follow Up section to be scheduled for their next visit. This led to downstream inefficiencies for the prior authorization staff who didn’t have an ideal place to house the authorization number. This meant the authorization numbers populated onto the claim, which led to unnecessary denials.
  • Our client was able to quickly adopt the simple addition of new orders for physicians. We configured the Epic system to automatically generate a new referral from each order to populate a workqueue to ensure nothing was missed. The referral record in Epic allowed the authorization experts to enter the authorization numbers in the right place, link the referral to the future appointment, and therefore ensure the authorization number populates the claim. This change will reduce denials in the long run and improve efficiency for staff members.

Lesson Learned

Ensure the orders are built with intuitive names so that both the physicians and the authorization staff understand what is being requested and what needs to be authorized. Make sure to validate the list of orders multiple times with physicians and authorization staff and make sure they understand that when an order is placed, a referral will be placed in the workqueue automatically. It is important to demo both workflows so each role knows how their work affects the other.

Duplicates can present initial confusion in training. Service-level authorizations can be used to note multiple authorizations for a single referral/visit, and the duplicate referral can be closed with a reason "duplicate."

I hope this gives you an idea of some initiatives that can transform your ambulatory workflow efficiency and provider happiness!

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