Can Electronic Health Records (EHR) expose quality opportunities in our current Failure Mode and Effects Analysis (FMEA) mapping process? A recent study shows that EHR information can provide significant opportunities to improve FMEA mapping in the quality process. FMEA mapping simply outlines steps in any given process, then identifies and prioritizes the potential opportunities for failure. By using this systematic and prioritized method, teams can make consistent and continuous improvement. Conversely, when information is left unidentified in the FMEA, can real improvement be made?

Quality Opportunities Missed in FMEA

To understand this potential opportunity, researchers recently conducted a study where actual patient data was utilized and provided to a mock quality committee. As with any other FMEA, the committee put together their FMEA mapping based on the information provided to them. The research team then compared the information in the committee’s FMEA mapping the actual data identified in the EHR. The results were enlightening. The study showed that 35% of the processes completed were not identified in the committees FMEA mapping. More illuminating was the fact that people from 12 different categories or positions were involved in the discharge process, and not in the original FMEA mapping. Further, what the original FMEA mapping identified as one activity in their map, EHR data showed it was actually a multi-stepped process, involving completely different people.

EHR Strengthens FMEA Mapping

This study clearly shows the potential EHR has to strengthen and extend the reach of current FMEA mapping processes. Significant amounts of data previously undiscovered in EHR could have a dramatic effect on the success of FMEA mapping. Lean Six Sigma professionals should look to EHR as an untapped resource that could expose significant opportunities for success in your quality improvement opportunities. Use the EHR to drill down to any quality improvement opportunities that are truly hidden gems of quality.

Want help? You can access a FMEA template for FREE >>>

The post Chasing Quality: EHR Exposed Opportunities with FMEA appeared first on 6sigma.

For decades, professionals in the field of health informatics, which is an advantage of electronic medical records, have sought to improve efficacy of healthcare systems using technology and the growing ability to manipulate data. Today, the prevalence of online platforms and communication has led to a push for electronic databases that will allow practitioners instant access to patient records, clinical guidelines and medical terminology. Informatics proponents believe that widespread use of these web-based resources would greatly enhance the relationship between patients and caregivers while reducing errors and wait times.

The overriding goals of medical informatics are expedient access to vital patient data when a conclusive medical decision is required and effective management of this data to ensure it remains confidential. The sub-field of nursing informatics specializes in data related to patient care, such as medication dosage, lab test results, allergies, and other specific information about the patient. Nursing informatics can also be used to design individual care plans based on biometric patient data and apply immediate changes to these plans when required. In theory, effective nursing informatics benefits patients by providing a streamlined healthcare process and made more effective through practice management software, and allows nurses to perform their duties to the fullest extent at a faster pace.

Nursing informatics has many advantages. A centralized data system ostensibly removes the need for constant (and often redundant) communication between physicians, pharmacists and healthcare providers. An electronic platform also ensures that information is accurate and up-to-date. On the other hand, critics have noted disadvantages of informatics systems. One downside is hidden costs; employees that require specialized (possibly academic) training will be required to create an efficient electronic database. Confidentiality is another concern; many have reservations about databases full of sensitive patient information that thousands of people have access to and could potentially be hacked. The mitigation of these problems is necessary to implementing widespread use of nursing informatics systems.

However, these shortcomings have not hindered employment growth in the informatics field; the US Bureau of Labor Statistics estimates the medical and health services management sector will grow by 22 percent between 2010 and 2020. In recent years, nursing informatics has become a popular academic route as well. Today, many undergraduate-level informatics programs are available to students. For instance, the University of Minnesota’s NI program incorporates computer science, statistical analysis, health policy, medical ethics and leadership; the program also allows students to participate in numerous field exercises. The University of Cincinnati’s Nursing and RN Technology program incorporates humanities and science courses in equal measure, supplementing classroom studies with weekly clinical activities at local facilities. As nursing informatics practices have become more prevalent in recent years, many hospitals and clinics have financed undergraduate informatics degree programs for nursing employees.

Graduate programs are also offered at several prominent institutions. New York University’s MS in Nursing Informatics program included practicum opportunities at Mt. Sinai Medical Center, Memorial Sloan Kettering and other area facilities. And for students who wish to earn a nursing informatics graduate degree online, the University of Maryland School of Nursing (UMSON) offers one such program; students coordinate practicum opportunities with local medical centers and facilities that are approved by UMSON administrators. Duke University also offers a distance-based informatics graduate program, which emphasizes clinical informatics applied in the real world and concludes with a generalist exam administered by the American Nurses’ Credentialing Center.

Today the informatics field is more popular than ever, thanks to the rising number of academic programs and projected growth in related employment sectors. As more hospitals shift to online recordkeeping and nurses are properly trained to manage various electronic data, the efficiency of contemporary healthcare stands to receive a generous boost in the coming years.

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At this person’s family practice, the clinical team had been dealing with unorganized medical records, leading to an unusually high search time for the patient’s medical record.

I know what you’re thinking: why not just buy an Electronic Medical Records System? That’s a topic for another conversation. But here’s the gist: it is wise to create a well-formed and efficient manual process first; then, it makes sense to automate it. Companies get into trouble when they force their processes to match their systems, when process should come first, then design the system to support process.

That’s what this team did. They decided to improve their current manual process and the results they obtained helped the patient and the clinic staff tremendously.

Before the Kaizen Event

The team did the following prior to the actual Kaizen event:

• Team gathered time study data on patient encounters
• Team documented back office medical records process to understand process steps, distances traveled and opportunities for improvement, including a value stream map and identifying value add and non value added steps.

Even though the goal of this clinic was to transition to an electronic medical records system, documenting and improving the current process was really the first step they needed to do.

Here was one astounding result from the Pre Kaizen work the team did:

• The staff spend at an average of 8.5 hours of time searching across 39 potential locations for missing charts that were not in the file room.

The Kaizen Event

After some preliminary 3 hour training of the clinical staff, the clinic staff immediately went to work with 5S of the file room, front desk area, physician and also the resident mailboxes. This was done to create a condition of visual management so the staff could more easily identify a problem and create a point-of-use environment so that things are located where they are used. According to my source, this clinic had apparently accumulated years of stuff just sitting in the clinic.

Then, the team split into several sub-teams to brainstorm ideas with the goal of:

• decreasing the number of chart locations and creating a process for staff to easily identify chart locations without generating additional work.

For this team, they generated some great ideas that ultimately led to the following practical countermeasures:

• The team created colored out guides to track charts that were being pulled for
  • physician messages or refills
  • triage nurses
  • irregular labs
  • etc.

And, of course, the goal is to decrease the time spent searching for files and enable a tracking process for charts pulled for reasons other than for standard appointments.

A process change immediately was implemented and the results of the after Kaizen time study were the following:

• time spent looking for a chart decreased on average from six minutes to two minutes.

But the team didn’t stop there. They also moved the nurses triage station from the library office down the hall from the front desk area to a more convenient location right next to the file room. This simple change decreased non-value-added activities due to travel time by 0.2 miles per day for refill calls (over 100 refills per day) and created a line of sight between the staff and triage nurse, improving communication for response to patient calls. Ultimately, the library was also relocated to the other end of the practice to move it closer to the preceptors and resident workspaces.

According to my source, the biggest impact wasn’t necessarily the quantifiable measures that were apparent in the before-kaizen and after-kaizen, but the culture change that happened to each of the participants was the biggest positive and long-lasting change. This last benefit is often the most long-term benefit – because the change happened internally in the participants, they can apply what they had learned to other clinical processes in the future.

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Apparently, most children outgrow their bone cysts or something like this happens. Thankfully, the surgery was a success and, 6 weeks later, he’s walking just fine. In about 9 months he’ll get his plate and 6 screws removed. Until then, he’ll be setting off metal detectors at the airport.

I’m so proud of my son: in adversity he responded with courage and a great attitude. It goes to show that a great attitude can really carry you through some difficult situations.

I bring this up we just returned from his 6 week check at the orthopedic surgeon. At the hospital where our appointment was at, they are in the middle of an Electronic Medical Records Implementation. The way the nurse described the effort to me was this:

“We’re turning a bazzillion paper based records into bits and bytes and finally I’ll be able to read doctors’ handwriting. Electronic Medical Records Software will help us a ton!”

This got me thinking about a few things:

• The benefits from having Electronic Medical Records
• The apparent tension between Lean and Technology

Electronic Medical Records Benefits

Just off the top of my head, I can think of a few benefits and advantages that come from having electronic medical records:

1. Less Paperwork: But not just paper, but less physical space that the file folders occupy. Also, I can envision search time is reduced as well as redundancies that come with not having to complete paper forms over and over again.
2. Reduced Medical Errors: Since, theoretically, information and medical history about a patient can be conjured in less time and with more accuracy, there will likely be less medical errors that come from poor or incomplete information.
3. Coordinated Medical Care: In situations where serialized workflow is important, such as (1) a visit to the primary care physician, (2) take lab tests, and (3) follow-up with primary care physician regarding the lab tests, then coordination between care is very important. In fact, I can’t think of an instance where coordination for medical care is not important.
4. For those with chronic medical conditions and co-morbid conditions such as diabetes with heart disease or diabetes with lupus or diabetes with obesity, or diabetes with diabetic retinopathy, it’s very important that the primary care physician, in the case of a diabetic, coordinates the care with the optometrist for diabetic retinopathy.

I’m sure there are more and these are just a few.

Tension Between Lean and Technology

In some circles, there is an apparent tension between technologist and the practitioners of lean manufacturing. On the one hand, the lean practitioner is looking at process and how to improve it; technology may or may not play a role as a solution to the problem. On the other hand, most technologist, generally, immediately default to technology as a solution with little regard for the underlying process.

I know this tension exist when it comes to ERP and MRP implementations. Lean practitioners would rather opt for a simple Kanban than some fancy automated and expensive monolith that often doesn’t work.

There is a growing field of Lean Electronic Medical Records, which aims to improve process first, then implement the Electronic Medical Records Software. This is an interesting and growing area.

The post Why Lean Practitioners Hate Electronic Medical Records Software appeared first on 6sigma.

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The medical billing process and  processing and revenue stream in health care is particularly problematic, complex and expensive. More than a decade ago, a New England Journal of Medicine[2. content.nejm.org/cgi/content/short/349/8/768] article estimated administrative costs of health care to be as much as $294 billion (Campbell, et al.), and it has only increased since then.

The process begins when a patient makes an appointment and ends when a medical claim is paid by the insurance company. Countless staff and departments contribute to the flow of information and work to achieve payment for patient care provided. Every step in this lengthy process has the potential for administrative waste: excessive paperwork, back-and-forth interactions between provider and payor, nuanced contracts unique to each insurance company, and different forms and ways each payor wants to exchange information. It’s not surprising the hassle has led some doctors to refuse to accept certain forms of insurance payment at all.

Virginia Mason Medical Center’s Patient Financial Services has done extensive work to evaluate the revenue stream and diligently remove waste from the system. Below are some of the common revenue stream wastes in most medical settings today, and many which the Virginia Mason team has helped reduce or eliminate through its continuous improvement work.

Transportation

Movement of product that does not add value

• Using electronic clearinghouses to transmit medical claims to different insurance groups.
• Faxing and mailing additional medical or insurance documentation between the patient, payor and provider.
• Mailing claims in paper format, using courier services.

Inventory

More material information than the customer needs

• Claims held in data systems pending queue transmission.
• Mail correspondence from insurance companies notifying or requesting information.
• Specialized staff who only work with specific payors.

Motion

Bodily or mental motion that does not add value

• Claims channeled through redundant layers of system edits and checks at the provider source, clearinghouse and payor.
• Emailing questions to multiple people with claim-specific or insurance-specific questions

Waiting

Idle time when people, material, information, or equipment is not ready

• Waiting for forms, reviews, approvals and signatures.
• Waiting for receipt of funds for claims aging beyond their original service date.
• Waiting for payor review of a medical claim appeal.
• Waiting for system upgrades and changes to be implemented due to new medical procedures.
• Waiting for payors to amend or update payment routines for the patient or provider based on pending contract renewals.
• Waiting on hold for customer services to obtain insurance information

Overprocessing

Effort that does not add value from the customer’s perspective

• Checking the claim status for every patient balance outstanding via phone, mail and internet portal.
• Receiving overpayment/underpayment, reprocessing the bill and re-pricing claim information for the payor.
• Sending a claim multiple times when no response is received from the payor.
• New medical procedure codes, retesting software and claim checks.
• Asking the patient for existing information: insurance cards, address, relatives.

Overproduction

Producing more than the customer needs or wants

• Generating multiple invoices/statements for the patient’s health care services.
• Creating duplicate files in multiple folders within workstations and filing cabinets.
• Recoupment efforts on low balance claims (e.g. $2 lab fees, $7 diagnostics).

Defects

• Billing complaints for any reason from a patient are indicative of a defect.
• System errors, such as corrupted data, miscoded system logic, data stream interruptions, create claim denials or halt flow.
• Transcription errors where clinical information was not input correctly resulting in denial.
• Registration errors when inaccurate demographic information was not received from the patient resulting in denial.
• Unauthorized procedures, such as surgeries, procedures or inpatient stays requiring authorization with the insurance company prior or during medical services, or denial will occur.

Medical Billing Facts

What is Medical Billing, Medical Coding, and Medical Transcription

Medical Billing, Coding, and Transcription are all inter-related and one can’t talk about one without discussing the other. These three processes and functions are needed in our currently overly-complex healthcare system.

It’s also big business, According to the Occupational Outlook Handbook

medical billers and coders can earn anywhere from $26,210 to $42,760. As of 2008, there were 172,500 medical billing jobs, and the number is expected to grow by 20 percent by the year 2018.

And for an occupation that requires little training, medical billing and coding salary is good. Also, most medical billing can be done from home, also known as medical billing from home.

To become a Medical Billing specialist, one needs the following medical billing training and medical coding certification:

The current standard for medical billers and coders is an associate’s degree in the field. While this is the typical request, if a person already has the necessary job skills and experience, a degree may not be required.

The American Health Information Management Association (AHIMA), the American Academy of Professional Coders (AAPC), the Board of Medical Specialty Coding (BMSC), and the Professional Association of Health care Coding Specialists (PAHCS) all offer credentials. In order to obtain these credentials, candidates must have a 2-year associates degree from a school accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).

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