The Viral Workflow: The Bug That Spreads Within Your Organization’s EHR


Viral Workflow

You’re at your desk minding your business when Suzie Sneezer walks in, coughing, sneezing, and blowing her germs all over the office. She’s come to help you with a project and wants to show you something. So it begins, within two days everyone in your office is also sick with the sneezing and coughing. Suzie Sneezer, though well-intentioned, has spread her virus throughout the office like wildfire. This can also happen with incorrect workflows, bad data entry habits, or unapproved workarounds which can be highly contagious. We’re talking about a viral workflow.

With the best intentions users often share “short cuts” or “tips” amongst themselves, and these can spread like a virus from user to user throughout an organization and infect the healthiest of EHRs. Some of these “Viral Workflows” might be just a case of the sniffles. On the other hand some viruses, if not treated aggressively, could lead to wide spread issues and have systemic effects throughout the entire organization.

As consultants we are constantly vigilant, always concerned with the health of our clients’ EHR systems and the well-being of the entire organization. While engaged with a single client, consultants may work with numerous members spanning the spectrum of roles within an organization, as well as other hired resources and vendors. This variance in role relations often allows us to witness firsthand the processes and/or workflows of many of the organization’s users, and are in a sense indirectly exposed to these “viruses”.

Below are some examples of “Viral Workflows” my colleagues and I have diagnosed and eradicated recently.

  • While managing an upgrade project for a client, our consultants discovered that 80% of their EHR users were logged onto webserver #1. Upon further research, they found that several months prior, webserver #2 began having issues but it had gone unreported. Instead of reporting the problem with webserver #2 to the proper department so it could be resolved, a user had concocted a “work around” to bypass the load balancer altogether. The provider showed a few users how to edit the URL to hit a specific server (clearly webserver #1), and before long the viral workflow had spread. To the provider this seemed benign so he shared his shortcut with everyone around him, though on a large scale it proved detrimental to the health of the EHR.
  • Optimization assessments often uncover chronic “viral workflows”. A clinical staff person was observed clicking the “reconcile” button during a patient work up in preparation for a provider appointment. Other than allergies, medications were not discussed during the time with the patient. When questioned by the consultant the user stated, “I was told in training if it is yellow, click it”. This user was not aware that reconciling the patient medications actually meant reviewing each medication with the patient. The clinical staff had been doing this for several years.
  • This viral workflow is very common and has been discovered by several consultants: in Allscripts TouchWorksTM, clinical staff who are pressed for time will search for a patient by name or MR# instead of selecting a patient from a provider’s schedule as prescribed by the best practice workflows. When saving any data changes, the application presents the user with an Encounter Selector, forcing the user to choose an existing encounter or create a new one. In haste a new encounter is often created. This virus has a trickledown effect that spreads to billing and coding, causing reporting issues that providers may eventually have to deal with as well.
  • While optimizing in preparation for an EpicTM conversion, consultants uncovered an issue while dissecting preliminary reports. They discovered that many providers were “removing” tasks or messages from the message basket rather than actually completing them according to the best practices. While seemingly harmless to the providers, they found that this fragmented process of “removing” instead of resolving was very cumbersome and was spreading like an infection throughout the system. Order cycles were not completing correctly, reports were not accurately capturing data, and a large number of results and un-signed notes would not have converted as desired by the organization.

Okay, I have some good news and some bad news. Why don’t we go with the good new first? There is a treatment and prevention for these viruses. That treatment is knowledge. Knowledge is the antidote that should be administered to eradicate many viruses within your organization’s EHR system.

As with the human body, some viruses are easily prevented with the proper inoculation. In this case, the vaccine would be proper initial training coupled with ongoing reinforcement, along with policies and procedures to keep users informed and up to date. This could prevent the majority of diseases from spreading throughout the EHR.

Just as with the health of humans, some viral workflows are hard to diagnose and have symptoms that are subtle or go unnoticed for lengths of time.  Until a secondary diagnosis becomes acute and causes severe symptoms or widespread problems throughout the EHR, users and administrators would never even know the system was “sick”.

Now for the bad news. It may take some cognitive effort to resolve the symptoms and cure your organization of the virus. Sometimes the treatment plan can be as simple as retraining users on a certain workflow or process, but that is not always the case. Evaluating and treating one “virus” can often lead to discovering another. Having an “if it ain’t broke don’t fix it” attitude can be detrimental to your system. With this mindset, organizations are most likely addressing one symptom at a time, nescient to the fact that eventually every group needs to consider a full system optimization.

Every organization should treat their system proactively and have a plan to maintain the health and wellbeing of their EHR. A full system optimization is the panacea for your organization’s EHR and its “viral workflows”. Think about it, your EHR is a like a living being, constantly growing, changing, and evolving. With upgrades, new versions, employee turnover, changes in government requirements, etc., your system is bound to need a checkup. Like a hacking cough, your organization may only be treating the “viral workflow” symptoms that become bothersome. The best plan of care for every organization’s EHR is to have a full top to bottom health evaluation (aka System Optimization) that eventually leads to a treatment plan to achieve a healthy system. Furthermore, a plan should be put in place to maintain the optimum level of health for your organization’s EHR.

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