EHR and Process Improvement

Electronic Health Records are Only Part of the Solution

Billions of Dollars. Greater Inefficiencies?

Spending billions on electronic patient records without first tackling our inefficient healthcare processes will likely prevent the ambitious healthcare program from living up to expectations.

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 and digital images in hospitals. Electronic Health Records (EHR) is viewed by many as a way to save money and improve healthcare quality, make clinical processes safe and optimize operational efficiencies 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 without radical process changes.

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 across the continuum of care.

Healthcare, as with any other business operation, requires a framework built upon industry’s best practices in process improvement and innovation to improve quality, safety 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. Access to care starts with the admission, then you can have multiple transfers. Adding the complications of the discharge process becomes very challenging, especially when you consider the size of the facility and geographical locations. Today we have a 30 day readmission measure that impacts reimbursements. 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 among care providers. 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 customized 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. Change management techniques and methodologies area a must, as changes are designed, you must manage the resistance and acceptance throughout the entire engagement.

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



Total Steps



Value-Added Steps



Number of Handoffs



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 organizational strategy aligned with the goals, objectives, and has 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. The facilitator of the improvements must have the ability to communicate among the ranks and possess the experience necessary to manage large volumes of project management activities.

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. Organizations are implementing EHR systems at a rapid pace to be in compliance, but taking the time to do the necessary process redesign of old ways of working is what will truly makes the providers efficient in delivering the highest clinical best practice. Providers want to provide care and EHR is another tool to allow them to practice medicine.

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