In an extremely busy orthopedic surgical practice, patient flow is exceptionally important. Such is certainly the case at the Center for Orthopedics, an orthopedic medical group practice with six orthopedic surgeons, one non-surgeon physician, five physician assistants, and a combined staff of about 60 people, with a headquarters medical office in the Cleveland suburb of Sheffield Village and four satellite locations. Affiliated with University Hospitals of Cleveland, the group practice sees about 20,000 patients a year.
Sheila Tonn-Knopf, director of the Center for Orthopedics, has been leading an ongoing performance improvement effort aimed at optimizing patient flow and reducing “traffic jams” of patients and processes, as patients wend their way through a variety of phases in their visits while at the organization’s locations. Back in January 2012, at the same time that her organization implemented its electronic health record (EHR), it partnered with the Nashville-based Shareable Ink to implement a solution that helps to optimize a variety of processes around information-gathering and documentation of patient data. Tonn-Knopf spoke recently with HCI Editor-in-Chief Mark Hagland regarding all these developments. Below are excerpts from that interview.
Tell me about the history of this initiative?
Before our EHR go-live three years ago in January, we used to have lines out the door in the waiting room. And once we had implemented our EHR, it became apparent that with the added layers of data collection, the inputting of data would either bring us to a complete halt at the front desk, or we’d have to interface with the patients in the clinical rooms, which then ties up those rooms. And some of our physicians see upwards of 70 patients in a day; their patient visits are very focused.
There are a lot of process elements to this, because the average patient coming to see their doctor may well interface with three different teams of caregivers. We have an entire radiology team; an entire ortho technician/bracing team (we do a lot of casting and braces); and we have clinician teams composed of two clinical assistants, a physician assistant, and a doctor. So while the patient may only interface directly with the physician for a very short while, they’re getting their prep time with the clinician assistant and their education time with the physician assistant. So the patient self-reports their demographics, a lot of their history, a lot of different things, onto the Shareable Ink form, which involves a special electronic pen writing on digitized gray paper; the information being written goes immediately into the EHR.
As part of the process, the patient is self-reporting information via the form; the clinician assistant is taking down information; the physician assistant is taking down information and also assessing complex clinical information; and then the physician is interpreting all the information all these people have brought to him, and then devising a plan of care.
Do you have a name for the process of process improvement you and your colleagues have been engaging in?
All this really is like an ultimate Lean management project, in which you’re isolating all the different parts of a complex set of processes, and diagnosing the problems. Really, we’re dealing with all of this in a “surgical” fashion—systematically, and based on real, hard evidence, but also dealing with things as they come. Our patient visits involve many different elements and people, so it’s important to get all those elements right.
At the core of the improvement process, it’s about patient flow, correct, because you were experiencing blockages and hold-ups in patient flow?
Yes, and the implementation of an electronic health record actually can exacerbate some of the process problems. Because in the olden days, the patient would get a big packet of paper and would fill out forms, and the front desk would three-hole-punch the information in a binder, and there it was. Now, who’s going to take down the information, and share it? And with meaningful use, you’ve got to be able to capture and report data. For example, MU requires us to capture information on smoking cessation, but doing so does not fall naturally into the flow of our patient-visit processes. So we’re able to capture it through the use of the Shareable Ink solution.
So what this tool did in a unique fashion was to essentially mirror the old intake process. What we do is, Shareable Ink utilizes a pen with a camera in it, and paper, where these sheets of paper are generated out of the system with the patient’s name embedded into the background of the paper, if the patient is registered. It looks like a gray piece of paper with little tiny dots all over it. And there’s data embedded in this pattern. So when the patient takes this fat pen, they’ve got this form and the clipboard, and they write their demographics on the paper, including do you smoke, when did you quit smoking? Any vaccinations? What kind? Etc. Check, check, check, all through. The patient turns in the form and the pen is docked, and the data goes into the EHR. And the paper follows the patient through the visit.
You went live with both that solution and your current EHR, at the same time. Was that difficult?
When we went live with all of this at the same time, we went down to 50-percent productivity for two weeks, 75-percent productivity for a week, but then got back up to 100-percent productivity within a month. If I had just implemented Shareable Ink and the EHR had already been in place, we wouldn’t even have felt a ripple. Because it really replaced a process and created a better process.
What have your and your colleagues’ biggest learnings been so far in all of this?
The biggest thing for me, and it’s related but unrelated, is that the practice continues to grow, and we’re really, really busy. And now, two-and-a-half years later, I’m running into some situations where my technology solutions can no longer keep up with my patient load. So I’ve learned that a technology solution is only as good as understanding an implementation. So I can put x number of people through a process, but if I don’t have a third x-ray machine and hire a couple of more surgeons, I’ll still have a flow process. We all buy tools in our everyday lives, and hope they’ll be silver bullets. But there aren’t those things really. Shareable Ink was a fantastic silver bullet; it brought me a year-and-a-half of streamlined productivity. But any solution can only do so much. So it’s fantastic technology, but still has to be used in the appropriate context.
More broadly, physicians in practice are having to become hyper-efficient and hyper-effective, correct?
Yes. But at some point, when it costs too much to further improve productivity, making further improvements is simply not possible. What’s happening is that we just keep layering more and more processes on top of the physicians, and there are impacts that no one wants to pay attention to. But we’ll just keep chasing that efficiency as far as we can.
And I’ll add a personal note. My parents were professional beekeepers for over 20 years. And they would say, you may not even like bees personally, but you need what they produce, right? And that’s kind of how it is in terms of understanding how doctors function within the healthcare system. They’re irreplaceable and what they do is irreplaceable; so you have to figure out how to make all the processes around physicians work as optimally as possible, so that they can produce optimally as clinicians. I and my colleagues very much do appreciate what doctors do; but in any case, we have to make all these processes work, so that doctors can do what they do best.