DDHA 8601 Week 2 Workflow Assessment Example

Three Doors for One Refill: A Workflow Assessment of How Prescription Renewal Requests Move Through Two Primary Care Clinics Before Anyone Proposes a Product

Student Name

Walden University

DDHA 8601: Technology and Innovation in Healthcare

Instructor Name

Month Day, Year

Three Doors for One Refill: A Workflow Assessment of How Prescription Renewal Requests Move Through Two Primary Care Clinics Before Anyone Proposes a Product

What Was Examined

This assessment describes one task, renewing a patient's prescription, at Hollis Creek Family Physicians, a composite group of six primary care clinics. It covers the three ways a renewal request arrives: an electronic renewal request sent by the patient's pharmacy, a request entered by the patient in the portal and a telephone call to the clinic. Observation took place at two of the six clinics over ten weekdays, from 8:00 to 17:00, and covered 412 requests from arrival to the moment the prescription was sent or the request was declined. Requests that arrived after hours were followed from their first touch the next morning.

The assessment proposes nothing. Its purpose is to record how the work happens now, so that any later proposal for technology can be measured against something accurate. Zheng et al. (2011), reviewing time and motion studies of clinical work, found that such studies often fail to report how observations were defined and collected, which makes them hard to compare or trust. The boundaries, hours and counts above are given for that reason.

Pharmacy Electronic Requests

Pharmacy requests were the largest channel, 221 of the 412. They arrive in a shared clinic inbox in the record system. A medical assistant opens each request and looks up four things: the date of the patient's last visit, whether any laboratory test the medication requires is overdue, whether the medication on the request matches the current medication list and whether the drug falls under the clinic's renewal protocol. If all four checks pass and the drug is on the protocol, the medical assistant prepares the renewal and sends it to the clinician's inbox for signature. If any check fails, the medical assistant writes a note and routes the request to a nurse or the clinician.

The request waits in two places: in the shared inbox before a medical assistant opens it, and in the clinician's inbox before signature. Over the observation period, the first wait ranged from under an hour to most of a working day, longer on Mondays. The second ranged from minutes to two days, depending on the clinician's schedule. A request could therefore spend most of its life waiting for signature after all the checking was done.

Portal Requests

Portal requests numbered 97. They arrive in the same shared inbox but in a free-text format, so the medical assistant first has to work out which medication the patient means, which pharmacy to send it to and sometimes whether the patient is asking for a renewal or about a side effect. About one in five portal requests required a message back to the patient before anything else could happen. After that, the four checks and the routing were the same as for pharmacy requests. Waits followed the same pattern, with an added wait for the patient's reply that ranged from hours to several days.

Telephone Requests

Telephone requests numbered 94. A front desk staff member answers the call or, more often, the caller leaves a voicemail on the refill line. Voicemails are retrieved in batches, twice a day, and a staff member types each one into a telephone encounter in the record, which then enters the shared inbox and follows the portal path. This channel could not be timed reliably: the voicemail system records when a message is retrieved, not when it was left, so the wait before transcription is unknown. The assessment reports only the waits after transcription, which resembled the portal channel. This is a real gap, because the telephone channel is used disproportionately by older patients and by patients without portal accounts.

Exceptions Staff Described

Staff described several exceptions that do not follow the main path, and these are recorded because exceptions are where later products usually fail. Controlled substances cannot be renewed by protocol; the clinician must check the state prescription monitoring database and sign with a second authentication step, so these requests always go straight to the clinician and often wait longest. Medications prescribed by a specialist, such as a cardiologist's anticoagulant, require a judgment about whether the primary care clinic should renew at all. Patients overdue for a visit by more than a year are given a short supply and asked to book, which creates a later follow-up task. And requests for a medication the patient has never received from the clinic, often arriving from a new pharmacy, are treated as new prescriptions.

Touches by Channel

Table 1

People and Steps Touching a Typical Renewal, by Channel

Counts are from ten weekdays at two clinics; controlled-substance requests are counted within the channel totals above.

What the Description Shows

Three features stand out. First, the checking work is the same across channels, but the work before checking differs: pharmacy requests arrive structured, portal requests need interpretation and telephone requests need transcription. Second, the largest waits come after the checking is done, while the request sits for signature. Arndt et al. (2017) found that inbox work takes a large share of primary care physicians' time in the record, which helps explain why a renewal ready for signature can sit for two days. Third, one channel cannot be timed with the systems in place, and it serves the patients least able to use the others. Sinsky et al. (2013), describing high-functioning primary care practices, reported that many had reorganized prescription management, for example by synchronizing renewals annually, which shows that the volume of this work is partly a design choice. Any technology proposed later should be judged against these three features and against the exceptions above.

References

Arndt, B. G., Beasley, J. W., Watkinson, M. D., Temte, J. L., Tuan, W.-J., Sinsky, C. A., & Gilchrist, V. J. (2017). Tethered to the EHR: Primary care physician workload assessment using EHR event log data and time-motion observations. Annals of Family Medicine, 15(5), 419-426. https://doi.org/10.1370/afm.2121

Sinsky, C. A., Willard-Grace, R., Schutzbank, A. M., Sinsky, T. A., Margolius, D., & Bodenheimer, T. (2013). In search of joy in practice: A report of 23 high-functioning primary care practices. Annals of Family Medicine, 11(3), 272-278. https://doi.org/10.1370/afm.1531

Zheng, K., Guo, M. H., & Hanauer, D. A. (2011). Using the time and motion method to study clinical work processes and workflow: Methodological inconsistencies and a call for standardized research. Journal of the American Medical Informatics Association, 18(5), 704-710. https://doi.org/10.1136/amiajnl-2011-000083