Electronic Health Records and Process Improvement

Thanks to the American Recovery and Reinvestment Act, or the economic stimulus program as it is better known, billions of dollars are being made available to support computerizing the mostly paper-based medical records system in hospitals. Electronic Health Records (EHR) is viewed by many as a way to save money and improve healthcare quality by streamlining the access to patient information throughout a healthcare system.

But the initiative begs the question whether it is the solution to better healthcare. Clearly, studies of the introduction of computers to the workplace confirm the positive impact on productivity and GDP. Unfortunately, many of the processes in hospitals are too inefficient and complicated, so an EHR system will likely result in doing the same inefficient, complicated activities electronically.

The need to simplify and eliminate wasteful activities in hospital processes is a prerequisite to implementing an EHR system that will produce positive outcomes on patient care quality. The implementation of instantly accessible patient records is merely a piece of the infrastructure necessary for excellent healthcare processes.

Healthcare, as with any other business operation, requires a framework built upon industry’s best practices in process improvement and innovation to improve quality and control costs. The factors that prevent accomplishing these objectives are unnecessary inefficiencies, including those that are associated with the administrative, operational and logistical processes.

Handoff to failure

The reality is that the processes of patient care in healthcare systems do not flow smoothly. Few if any departments in a hospital are linked and services are often delivered in “batch and queue” fashion. The result is a patchwork of handoffs that generate unnecessary costs and variability. An EHR system that incorporates these broken processes will fail to deliver the promise of improved operational efficiencies and patient care.

The solution to this dilemma is the implementation of process improvement programs in advance of implementing EHR. Lean (a rapid and simple approach to drive non-value added activities, or waste, out of processes) and Six Sigma (a rigorous, data-driven, problem-solving method) are gaining greater adoption as the evidence of remarkable successes is reported in hospitals that have employed these proven methodologies.

For example, when a Lean Six Sigma team mapped the inpatient billing process at a hospital during the initial stages of a Lean Six Sigma deployment, they found that the process included 43 unique steps in order to complete one patient’s bill. This took an average of 12 days to complete at this hospital. After streamlining the process by removing the non-value added activities, minimizing handoffs, and correcting for some common delays, the process was regularly turning around bills in less than 6 days.

Inpatient Billing	Before	After
Total Steps	35	12
Value-Added Steps	8	7
Number of Handoffs	42	14
Average Cycle Time	12 days	6 days

Table 1. Improvements to a hospital billing process using Lean Six Sigma.

One important advantage of the Lean Six Sigma approach is that it can be applied throughout a healthcare facility to achieve improvements in ED patient flow, appointment availability, infection rates, purchasing costs, billing cycle time, never events, medical equipment utilization, and other key hospital pains. So, the objectives of controlling costs and improving the quality of care – two goals seemingly at odds with each other – can be achieved simultaneously.

The architecture of success

Lean Six Sigma achieves the best results when it is deployed with sound strategy and a strong understanding of a hospital’s culture. Many organizations have made the mistake of sending a few key individuals out to get training and then expecting them to return with the skills and knowledge to produce immediate results.

The most successful deployments are forged by a strategy that incorporates the necessary infrastructure for Lean Six Sigma to become an intrinsic part of the way the organization operates. The best Lean Six Sigma programs are a synthesis of the components that make the methodology so effective and the elements that make the organization great. Success is fleeting when one of these two things happen (1) the methodology is applied too rigidly at the expense of the company’s culture and identity or (2) the organization strips the methodology down to a point where it lacks the necessary levers for change.

Aiming for the future

The EHR program will not happen easily. Hospital administrators already focus on issues of privacy, security and information accuracy. Mostly, they want interoperability much like the banking system. Accomplishing this wish list will not happen overnight.

In the meantime, eliminating the waste from healthcare processes and understanding the needs of the patient is a key element to overall EHR success. “If you can’t describe what you’re doing as a process, you don’t know what you’re doing,” said the father of the quality revolution, W. Edwards Deming. The implementation of Lean Six Sigma to support EHR will help greatly to assure the long term success of healthcare IT.