- Utilizing Lean methodology to redesign inefficient, first-generation EHR systems can help to improve clinical documentation, boost provider satisfaction, and cut provider EHR use by almost one hour per day, according to new research published in AHIMA’s Perspectives in Health Information Management.
Dinkins et al. launched a quality improvement project at the Mayo Clinic Department of Physical Medicine and Rehabilitation in an effort to reduce or eliminate errors and redundancies in clinical documentation for rehabilitation therapists.
The team of researchers first collected baseline data about EHR use among Mayo Clinic therapists using therapist EHR interaction time studies, therapist productivity measurements, and stakeholder surveys. Researchers also evaluated existing documentation templates and health IT in use at the academic medical center, as well as applicable regulatory requirements.
Researchers found therapists were largely dissatisfied with the existing EHR system. While the system had been custom-developed to meet providers’ needs, therapists reported difficulties quickly locating relevant data due to a poorly-designed EHR documentation template.
The template used for EHR documentation included eight form options that varied based on discipline (occupational therapist or physical therapist), as well as location of services (hospital or clinic.)
Researchers also noted that department leadership had failed to solicit feedback from clinicians about template design, or include clinicians in the initial EHR implementation planning phase.
While the hospital documentation template included 29 expanded sections, providers only used 18. Similarly, providers working in the clinic only utilized 13 of the 20 sections included as part of the clinic documentation template. This indicated to researchers that certain aspects of the documentation template and process were wasteful and excessive.
Clinician productivity suffered as a result.
“Department leadership noticed a reduction in staff productivity and a substantial decrease in job satisfaction related to increased documentation time after the initial implementation of the original system,” wrote researchers in the report.
“The number of complaints from external stakeholders related to poor readability of therapy documentation, ineffective communication, and reduced timeliness of therapy documentation being entered into the EHR increased,” the team continued.
Department leadership convened a multidisciplinary team including therapists, nurses, and physicians to participate in Lean methodology training in an effort to improve clinical documentation process efficiency and EHR note templates.
As part of the quality improvement project, the team streamlined EHR note content and used technology to improve documentation flow and design. The team also examined applicable regulatory requirements for Mayo Clinic providers and chose a documentation application available in the EHR system that included a variety of free text and structured template options, as well as speech recognition software.
The team created and implemented the customized notes in three phases.
First, the team identified all relevant regulatory requirements for rehabilitation documentation. Next, the team met with a member of the IT department to create customization templates that factored in user feedback, streamlined content, and regulatory requirements.
For the final implementation stage, the quality improvement team trained 52 therapists on the new template and communicated the changes to external stakeholders.
By implementing the new methodology, researchers aimed to reduce the amount of time therapists devoted to EHR use by 35 percent, increase staff productivity by 10 percent, and achieve an 80 percent overall stakeholder satisfaction rating.
“Analysis of data showed that the project met or nearly met the goals set initially and within the time frame of 60 days after implementation,” noted researchers. “The goal of decreasing the therapists’ time in the EHR was expected to lead to the possibility of therapists having more time available for direct patient care. “
Ultimately, applying Lean methodology to EHR clinical documentation assisted therapists in cutting the average amount of time spent on EHR use from 2.8 hours per day to 1.9 hours. Additionally, therapists using the methodology increased the amount of time they spent interacting with patients face-to-face by 18 percent.
Satisfaction rates among therapists increased from 80 to 97 percent, while satisfaction rates among external stakeholders — including nurses, physicians, and case managers — jumped from 37 to 80 percent.
“This implementation of Lean methodology applied by Mayo Clinic Rehabilitation Services proved to be an effective approach to identify inefficiencies in the first-generation EHR documentation templates and processes,” maintained researchers.
The project highlighted the importance of fostering a collaborative environment in hospitals and clinics that encourages clinician engagement and stakeholder input in EHR content and design.
Researchers also emphasized the importance of EHR note design in influencing clinical efficiency.
“The team learned that it is beneficial to have an efficient and concise note template with the most frequently used fields and an electronic check of compliance with regulatory requirements,” wrote researchers.
Mayo Clinic plans to apply the methodology during its $1.5 billion Epic EHR implementation, which will involve all rehabilitation sites.