Add-on Apps Can Supercharge Your Orthopedic EHR

Ira H. Kirschenbaum, MD


April 02, 2014

In This Article

3 Processes Doctors Need to Manage

The important daily goals discussed above can actually be looked at within the framework of a somewhat standard operations concept called "process management." Wikipedia describes process management as "the ensemble of activities of planning and monitoring the performance of a process. The term usually refers to the management of business processes and manufacturing processes."

Process management is managing things not by task or function but by understanding the distinct and separate processes within larger processes and by assuring the flow through these processes. Tracking -- and responding to the information garnered from tracking -- is central to process management.

A classic nonmedical example of process management is the operation of the oil industry. Take a hypothetical oil company, NuCo. NuCo finds, refines, and distributes oil. Using classic process management jargon, the 3 processes can be termed "upstream," "midstream," and "downstream." Oil exploration is an upstream process, oil refining is midstream process, and trucking the oil to gas stations is a downstream process. There are managers overseeing each of the processes, but executive management makes sure that all of these processes are connected.

Physicians play both roles: middle manager and executive. They are at times managing a single process, but they also are intimately connected to the end result of all of the processes in combination. The analogy to a medical/surgical process is easy to see. Finding new patients or marketing a program is an upstream process. The clinic or office is analogous to the refinery. The OR is the downstream target. The Table summarizes the many different ways we can look at upstream, midstream, and downstream management in healthcare.

Table. Management Processes in Healthcare

Upstream Midstream Downstream
OR PACU Discharge to the hospital floor
PACU The hospital floor Discharge to home
New patients calling Clinic or office hours OR

OR = operating room; PACU = postanesthesia care unit

These examples show the concept of process management in surgery. The OR produces patients (upstream) for the postanesthesia care unit (PACU) that needs to process these patients (midstream) for discharge to the hospital floor (downstream).

In this analogy, the PACU is essentially the refinery for the process. If the PACU is not efficient, patients back up in the OR. A second process shows how the concept of the refinery shifts. The PACU produces patients (upstream) for the hospital floor (midstream), which eventually discharges patients home (downstream). If discharges get blocked, the floor gets filled, and the PACU can't unload patients.

So new patients are found through marketing efforts, and they want to make appointments (upstream). The clinic or office processes these patients (midstream), and some of these patients are scheduled for the OR (downstream). The clinic/office (the refinery) can cause a backup in patients getting access and can decrease your surgical volume. Tools to track, manage, and improve these processes are missing in most EHRs, thereby not allowing you to optimize surgical processes.

Every physician is a manager. Physicians were managing care well before a group of insurance business suits decided to call controlling payments "managed care." Physicians manage care; insurance companies manage risk. The goal can be the same -- a healthier public -- but the processes are different. The better physician care managers understand the processes that happen each day. As the volume and complexity of medical processes increase, we need tools to track these processes to give us better medical clinical intelligence and medical business intelligence.

This brings us back to the EHR. An EHR does not have these tools built into it. Most EHRs are wonderful recorders, executive assistants, and time managers, which are critical functions, but they are not process managers. To manage processes, we need to reach into the IT universe for add-on solutions.

Orthopedics From a "Process Management" Perspective

Dr. B is a hypothetical busy surgeon. He performs 150 total joint replacements each year in a large referral-based practice, in addition to performing a variety of general orthopedic procedures. He will tell you that he has a stable practice but would like to do more joint replacements, yet he says that he sees more than enough patients. He smiles when he says that he is so busy it takes 2 months for patients to get their next appointment. He believes that his clinical and business practices are healthy. Are they? Probably not, but we won't know unless we ask some questions. Here are some sample questions that a process management analyst would ask Dr. B:

What is the volume capacity of your OR?

How many joint replacements can you complete in a day?

What is your personnel cost in the OR -- do you pay for assistants out of pocket?

What is your maximum clinic/office capacity per day?

How many patients are you actually able to fit into your office hours?

How many joint replacements do you indicate a week?

How many indicated cases eventually go to surgery?

How many joint replacements are performed in your larger catchment area?

What is your level of patient satisfaction in the process?

What is a patient's in-hospital and outpatient treatment experience?

These are just a few of the questions a process management analyst would ask. To use our NuCo Oil analogy, Dr. B's office is like a refinery. Patients waiting to make appointments in an office without slots for 2 months are like supertankers in the harbor waiting to offload oil to a NuCo refinery. If it took 2 months until the refinery could take the new oil, then the supertankers, like the patients, would have to go elsewhere.

Would NuCo Oil executives be smiling like Dr. B if they were forced to allow incoming oil to go elsewhere? I don't think so. Consider the OR as the refinery -- a midstream process -- with the office visit being an upstream process. If the OR cannot efficiently process the volume of patients being indicated from the office, then indicated cases will need to be "refined" elsewhere. The flow of patients, like the flow of oil, needs to be micro- and macromanaged using real-time data that allow for valuable decision-making.

Currently, EHRs have trouble with this.


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