Primary Care

Practice Facilitation
Curriculum
Module 10: Mapping and Redesigning Workflow

Agency for Healthcare Research and Quality

Advancing Excellence in Health Care www.ahrq.gov
Primary Care Practice Facilitation Curriculum
MODULE 10. Mapping and Redesigning Workflow

Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov

Contract No. HHSA2902009000191-Task Order No.6

Prepared by:
Mathematica Policy Research
Princeton, NJ
Project Director: Deborah Peikes
Deputy Project Director: Dana Petersen
Principal Investigators: Deborah Peikes, Erin Fries Taylor, and Jesse Crosson

Primary Author
Lyndee Knox, Ph.D., LA Net Community Health Resource Network

Contributing Author
Cindy Brach, M.P.P., Agency for Healthcare Research & Quality

AHRQ Publication No. 15-0060-EF

September 2015
This document is in the public domain and may be used and reprinted without permission except
those copyrighted materials that are clearly noted in the document. Further reproduction of those
copyrighted materials is prohibited without the specific permission of copyright holders.

The findings and conclusions in this document are those of the authors, who are responsible for
its contents; the findings and conclusions do not necessarily represent the views of AHRQ.
Therefore, no statement in this report should be construed as an official position of AHRQ or of
the U.S. Department of Health and Human Services.

Suggested Citation

Knox L, Brach C. Primary Care Practice Facilitation Curriculum (Module 10). AHRQ
Publication No. 15-0060-EF, Rockville, MD: Agency for Healthcare Research and Quality;
September 2015.

Primary Care Practice Facilitation Curriculum MODULE 10 M10-ii

Contents
Instructor’s Guide ........................................................................................................................... 1
Time ............................................................................................................................................ 1
Objectives ................................................................................................................................... 1
Exercises and Activities To Complete Before and During the Session ...................................... 1
Module 10. ..................................................................................................................................... 3
Workflow Maps .......................................................................................................................... 3
Important Workflows in Primary Care Practices ........................................................................ 6
Reference .................................................................................................................................. 10

Primary Care Practice Facilitation Curriculum MODULE 10 M10-iii

Module 10. Mapping and Redesigning Workflow

Instructor’s Guide
Practice facilitator (PF) competencies addressed in this module:
 General skills in basic quality improvement and coaching

Time
 Pre-session preparation for learners: 45 minutes
 Session: 85 minutes

Objectives
After completing this module, learners will be able to:
1. Describe the purpose and process for mapping workflow.
2. Identify activities that take place in a primary care practice setting that may be important to
map.
3. Create a workflow map of common and complex activities.
4. Use the redesign reflection questions to help a practice redesign a workflow.

Exercises and Activities To Complete Before and During the

Session
Pre-session preparation. Ask the learners to review information in item 1 and access item 2. (45
minutes)
1. The content of this module.
2. AHRQ’s workflow or process mapping tools. Available at:
http://healthit.ahrq.gov/portal/server.pt/community/health_it_tools_and_resources/919/workf
low_assessment_for_health_it_toolkit/27865.

During the session. Presentation (30 minutes)

1. Present key concepts of this module.
2. Guide on Workflow Mapping. L.A. Net Community Health Resource Network; 2013. See
Appendix.

Primary Care Practice Facilitation Curriculum MODULE 10 M10-1

 Activity for learners. (20 minutes)
1. Break into pairs or small groups. Ask learners to assign roles: practice facilitator and
participant(s) (optional).
2. Provide learners with large paper, pencils, and sticky notes for mapping.
3. Exercise 1. Map a simple process. Ask learners to: create a workflow map from memory of
the participant making a call with his or her cell phone.
4. Map the same workflow a second time while the practice facilitator observes the process and
corrects the map.
5. Exercise 2. Create a Swimlane workflow map of a complex process from a practice. Ask
learners to map handling patient calls to clinicians (or another multi-individual, multistage
process with which the learners are familiar).
6. Create a workflow map of handling patient calls to clinicians (or another multistage, multi-
individual process with which the learners are familiar).

Discussion. Ask questions and explore answers with learners. (10 minutes)
1. What did you learn from the mapping exercise?

a. Highlight lessons such as:

i. Mapping the process as it is, rather than what you think it is or think it should be.
ii. Having the person who owns the process map their part of the process.
iii. Understanding the role of the facilitator in supporting the mapping process.

Activity for learners. (15 minutes)

1. Reconvene pairs or small groups. Have learners evaluate and redesign a workflow from
Exercise 1 or 2.

 Use Redesign Reflection questions from Table 10.1 in module to redesign workflow.

Discussion. Ask questions and explore answers with learners (10 minutes)
1. What changes did you make to your workflows and why?
2. What did you learn about working with a group to redesign a workflow?
3. How will you use this with a practice?

Primary Care Practice Facilitation Curriculum MODULE 10 M10-2

 Module 10.

W orkflow is defined as a series of steps, frequently performed by different staff members

and often dependent on related workflows, that accomplishes a particular task.
Workflows represent how work actually gets done, not the protocols that have been established
to do the work.

Clinicians and staff in busy practices suggest that one of the most helpful things a facilitator can
do for them is help them map key workflows. Workflow mapping is a way of making the
invisible “visible” to a practice so they can look for ways to improve their processes to increase
efficiency, reduce errors, and improve outcomes. As a facilitator, you will have the skill, time,
and vantage point to help a practice map its key workflows and then to lead discussions about
improving them.

While many practices will have participated in workflow mapping for implementing electronic
health records, many will not have used these processes with the idea of improving quality and
outcomes. Workflow mapping is the process of documenting the specific steps and actions that
take place in completing a particular task. Creating a workflow map enables you and the practice
to see what is currently happening, identify opportunities for improvement or change, and design
new, more effective processes.

You and the quality improvement (QI) team will need to consider workflows associated with the
following three processes:

 Perceived process (what we think is happening);

 Reality process (what the process actually is); and
 Ideal process (what the process could be).

The perceived process can be obtained by having the group map what they believe the current
process is. The reality process is obtained by having various group members validate the former
through direct observation; the ideal process should reflect the workflow the improvement group
aspires to and wants to implement.

Workflow Maps
Creating a workflow map is not difficult. However, it is very important to map what is actually
happening, not what the practice “thinks” is happening or wants to happen. Figure 10.1 shows an
example of a detailed workflow map. You will need to identify every step of the activity and
who performs it. It is important that each individual involved in a process can describe how a
particular activity takes place. In addition to a traditional form of detailed workflows, Swimlane
workflows are also an option. Swimlane mapping is performed when you want to illustrate a
single process that involves more than two roles simultaneously across time. Figure 10.2 is an
example of a Swimlane workflow. When mapping a workflow, you should not rely on a single
person to describe a process unless that person controls and executes all steps of the process
being mapped.

Primary Care Practice Facilitation Curriculum MODULE 10 M10-3

Figure 10.1. Sample workflow map: lab result follow-up

MA takes lab MA pulls

Lab results
result from patient's
faxed
printer chart

MA gives
chart and lab
result to
RN/LVN

Normal or
RN/LVN RN/LVN writes mildly RN/LVN calls RN/LVN
follows lab normal, mildly Lab result abnormal patients about lab schedules repeat
result abnormal, or very is? results lab for mildly
protocol abnormal
Very abnormal lab per
abnormal standing orders
RN/LVN brings
lab result to
clinician
Implemented
standing lab
order Clinician reviews
lab result

Clinician gives
instructions to
RN/LVN

RN/LVN implements
instructions per standing
orders

Source: Bodenheimer T. Workflow mapping: a tool for achieving meaningful use. University of California San Francisco, Department of Family and Community Medicine,
Center for Excellence in Primary Care. Reprinted with permission. See Appendix 8.

Primary Care Practice Facilitation Curriculum MODULE 10 M10-4

Figure 10.2. Sample Swimlane workflow map: office visit

Adapted from “Physician Assistant (PA) Office Visit,” Health Resources and Services Administration.

Primary Care Practice Facilitation Curriculum MODULE 10 M10-5

To be effective in helping your practice map and redesign workflow, you will need a good
working knowledge of the practice’s electronic health record and information technology
systems so that you can assist them in redesigning workflows that use these systems. A good way
to map complex processes is to observe the process in action. You may find that there is not a
single process for carrying out a particular task, but several variations in how the activity takes
place.

An important rule of thumb when mapping a process is “the person who controls the process
controls the pen.” This means the person who actually carries out a particular process is the one
who maps that step of the process.

Important Workflows in Primary Care Practices

Important processes that you will need to be prepared to help a practice map include:

 Answering phones
 Making appointments
 Scheduling procedures
 Making referrals
 Providing health advice by phone or e-mail
 Assigning patients to panels
 Completing new patient workups
 Educating patients and family
 Managing patient panels
 Planning patient visits
 Coordinating referrals
 Conducting patient outreach
 Checking formularies
 Entering lab results into the information systems
 Making referrals for specialty care and community services
 Consulting with specialists

Many additional activities carried out by a practice will need to be redesigned when it transitions
to team-based care. These include:

 Registration
 Appointment scheduling
 Medical assistant role (pre-visit, vitals, agenda setting, checking chronic and preventive
care needs, ordering)
 Receipt of test results by clinician (lab, x ray, other)
 Receipt of test results by patient (normal, slightly abnormal, very abnormal)
 Internal messaging (which messages go to whom, what action is required)
 Prescription refills (chronic meds, acute meds, secure script meds)

Primary Care Practice Facilitation Curriculum MODULE 10 M10-6

  Billing workflow
 Form completion (clinician role, other team member role)

You should also be prepared to assist in mapping and redesigning clinical care processes for
specific patient groups:

 Preventive care
 Acute problems (major/minor)
 Chronic conditions (diabetes, hypertension, asthma)
 Complex care needs
 Mental health
 Chronic pain
 Women’s health
 Pregnancy
 Well child care
 Palliative/end-of-life care

Many resources available online for free or at a small cost can assist you in preparing polished
maps. Maps can also be handwritten or constructed with sticky notes to allow a practice to move
activities around and redesign workflow. These types of maps are better during the active
mapping stage. Your program may provide these resources or ask that you use them, or you may
want to explore them on your own.

Helping practices redesign workflows. Redesigning workflows has two goals: improving
performance and increasing efficiency. Once you document the reality process, you will need to
assist the QI team and other members of a practice to redesign the workflow to incorporate the
desired improvements and then test these changes using the Plan Do Study Act (PDSA) process.

When redesigning workflow, it is essential to have all key players involved in the process. The
frontline staff who are currently or will be implementing the workflow will have
recommendations and ideas for how to maximize efficiency and effectiveness.

It is rare that a workflow is completely independent of other processes in the practice. In most
cases, workflows for one activity will overlap or depend on the execution of another activity or
process. It is important to identify and consider these dependencies when redesigning workflow,
as the effects of redesigning a workflow can be positive or negative.

It will be important for the team to be able to determine the potential peripheral effects of
redesigning workflows. The Model for Improvement and PDSA can help a practice identify
unanticipated effects of redesigned processes and correct them before taking them to scale.

New workflows will often require realigning jobs, changing staff time allocation, roles, and
responsibilities to fit the redesigned workflows. This in turn will require changes to policies and
procedures, job descriptions, training, and accountability/reporting systems for ensuring tasks are
completed.

Primary Care Practice Facilitation Curriculum MODULE 10 M10-7

When working with a QI team and practice staff on redesigning workflow, you will need to
provide them with a copy of the existing workflow. This should be large enough for everyone on
the team to view together and to mark up as they design new processes. Table 10.1 contains
some questions that can be useful in starting a team on the redesign process. Review the
following questions with the practice:

Table 10.1. Redesign reflection questions

 Is there a problem with current performance? Do you need better results?
 Have you been skipping any critical steps?
 Are all steps necessary? Are there areas of unnecessary duplication or redundancy?
 How often do you have to do each step?
 Are there areas that rely on an individual to remember to do something? Any process that
relies on memory is prone to error.
 What happens if the process breaks down? Do you need a fail-safe mechanism?
 Can some steps be done simultaneously?
 Is there a more logical way to sequence the steps?
 What skills are necessary to perform each step?

o If more skills are required, can current staff be trained or do duties need to be shifted
to more qualified staff?
o Could someone with fewer skills perform this step? Would they need training or
support?
o Could someone be hired to perform this step?
o Could this step be outsourced?

 Is there any technology that would make this process more efficient or easier to do? Are
you thinking outside the box? Is there an entirely different way to get this done?
 Who do you know that handles this task very well (an exemplar)? Can you study their
workflow?

Implementing and sustaining new workflows. Once the team has developed a new workflow,
it will need to be implemented and evaluated. The PDSA process from the Model for
Improvement can be a good way to test the effectiveness of a new workflow. You will need to be
prepared to assist the QI team in implementing and evaluating the impact of a new workflow as
part of the PDSA cycle. You also need to include them in thinking through the different
administrative changes that will be required to fully implement and sustain newly redesigned
workflows.

Throughout this process, your goal as a facilitator will be to build the team and practice’s
capacity to engage in these processes in the future, as understanding and modifying existing
workflows is an essential component of any improvement process. AHRQ’s Integrating Chronic
Care and Business Strategies in the Safety Net toolkit contains resources from Clinical

Primary Care Practice Facilitation Curriculum MODULE 10 M10-8

Microsystems for training practices in workflow mapping. This toolkit is available at:
http://www.ahrq.gov/populations/businessstrategies/.

Note: this module is based on Module 5 of AHRQ’s 2013 Practice Facilitation Handbook.
Available at: http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/
pfhandbook/

Primary Care Practice Facilitation Curriculum MODULE 10 M10-9

Reference
Sample flowcharts related to primary care services. Available at http://healthit.ahrq.gov/health-it-tools-
and-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/flowchart.

Primary Care Practice Facilitation Curriculum MODULE 10 M10-10

 Module 10. Mapping and Redesigning Workflow

Appendix 10A. A Guide to Workflow Mapping

This is an introductory course on workflow mapping. This session is meant to provide basic 
knowledge in workflow mapping, while demystifying the process.

1
2
3
4
5
Become familiar with the following symbols. Your team will want to construct its workflow 
diagram to include these. The symbols offer an immediate visual representation of: 
start/end, decision point, delay, and direction. 

1) Indicates the start or end of a process
2) A specific task or activity performed
3) A point in the process where a decision needs to be made to determine the path in the
process
4) Indicates a point in the process where there is delay or wait in line
5) Arrows indicate the direction of flow
6) Use this as a cross reference from a process on another page

6
7
8
9
This is an example of what is referred to as a “swim lane map.” A swim lane map displays 
processes that are carried out for multiple roles across multiple stages. 

Each swim lane is representative of a role, in this case: PCP, Clerk, LVN.

The stretch of each lane is marked by the stages in the process. Here they are marked in 
the following order: 1) Appointment list review, 2) Appointment status, 3) scrubbing

10
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After Step 6 Your next step will be to  PDSA one of the identified fixes for 
improvement

Step 1: Agree on a process to map: (HAVE A PLAN) Consider surveying your 
staff, patients, or others on which processes are the biggest problems Process
that are the most time consuming, most labor-intensive, have the most
complaints, etc.

Refer to your “Know Your Processes” assessment template for guidance.

Step 2: Agree on a beginning and end - IMPORTANT when you start high‐level flowchart 

12
Ask each member of the staff to rate the core and supporting processes using this 
worksheet.

Based on these findings, staff members chose what to work on improving.

Rate each process by putting a tic mark under the heading which most closely matches 
your understanding of the process.

13
Give 2 examples from needs assessment to conduct 

DO NOT USE WITH TEAMLET. Only one right answer. The reason we are showing this to 
you, is for you to use it and select low complexity processes. If for some reason, you have a 
highly functional team, then you might consider jumping into a higher complexity process. 
But what you do not want is taking on if not ready. Digest this.  

To be successful, build hope that they can change something. IC should know that not all 
processes are created equal. Your job as an IC is to help teams 

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 Module 10. Mapping and Redesigning Workflow

Appendix 10B. Workflow Mapping and Meaningful Use

Workflow mapping:
a tool for achieving meaningful use

Center for Excellence in Primary Care

UCSF Department of Family
and Community Medicine

Tom Bodenheimer, MD
 Goals

• Explain workflow mapping

• Discuss why workflow mapping is useful
prior to and after EHR implementation
• Demonstrate how to create workflow maps
• Review some meaningful use workflow
examples
 Example 1a: How not to provide lab results to your patients
MA takes
Lab results
lab result
faxed
from printer

MA makes 3
photocopies
of lab result

MA gives MA gives RN/LVN

MA pulls MA keeps
copy to copy to RN/ looks at lab
patient chart own copy
clinician LVN result

MA places RN/LVN
patient’s lab writes normal,
result on abnormal, or
chart urgent

RN/LVN
MA gives gives lab
Clinician result to
chart to receives all
clinician clinician
3 copies of
lab result

Clinician sorts
lab results by
patient

Clinician writes
Did no Clinician
normal,
RN/LVN write on looks
abnormal,
lab result? at lab result
or urgent

yes

Urgent or
Patient Clinician calls Clinician calls abnormal
informed of patients with patients with Lab result is?
lab result abnormal labs urgent labs

normal

No action
Example 1b: Lab result follow-up after workflow mapping
MA takes MA pulls
Lab results
lab result patient’s
faxed
from printer chart

MA gives
chart and
lab result to
RN/LVN

Normal or
mildly
RN/LVN RN/LVN writes abnormal RN/LVN schedules
RN/LVN calls
follows lab normal, mildly repeat lab for
Lab result is? patients about
result abnormal, or mildly abnormal lab
lab results
protocol very abnormal per standing orders

Very
abnormal

Implemented
standing lab RN/LVN brings
order lab result to
clinician

Clinician reviews
lab result

Clinician gives
instructions to
RN/LVN

RN/LVN implements
instructions per
standing orders
 Example 2a: How not to do Rx refills
Receptionist
Patient calls Receptionist writes down
clinic for Rx answers patient’s Rx
refill phone request on slip of
paper

Medical records
Medical records Medical records
clerk figures
clerk picks up Medical records clerk checks
DELAY note one hour clerk pulls chart name of patient’s
out which MA
is working with
later clinician
which Clinician

Receptionist Patient calls MA puts

Receptionist Receptionist Medical records
takes new clinic asking chart on
searches for
patient’s chart
phone message
answers
phone
about refill two DELAY clinician’s
clerk gives chart
with note to MA
from patient hours later desk

Receptionist MA clips new Clinician

Receptionist Clinician puts
asks each MA note on patient’s approves
where the
gives new
message to MA
chart on DELAY refill four
chart on MAs
desk
chart is clinician’s desk hours later

DELAY

MA calls pharmacy
to refill Rx two
hours later
 Example 2b: Rx refills after workflow mapping
Patient
calls clinic Other workflow changes:
for Rx refill 1) MAs teach patients to contact pharmacy for
refills

Receptionist
Receptionist calls
2) Clinicians give patients with chronic meds lots
Receptionist writes down
answers patient’s Rx
medical records of refills
clerk to pick up Rx
phone request on Rx
refill form
refill form
3) Clinicians implement standing orders for MA
to refill meds for patients with well controlled
diabetes, hypertension, and cholesterol

Medical records Medical

Medical records Medical Medical records
clerk figures records clerk
clerk brings note records clerk checks
out which MA gives chart
to medical clerk pulls name of patient’s
is working with with Rx refill
records chart clinician
which clinician form to MA

implemented “DO NOW” MA puts chart Can MA

pile on “DO NOW” no refill Rx without clinician’s
pile on clinician’s approval per
desk standing orders?

yes
Clinician
Clinician puts
approves refill
chart on MAs
within one hour of
desk
receiving request

MA calls
pharmacy to
refill Rx
 What is a workflow map?

• A visual representation of a process

– A process is a series of actions, steps, or tasks performed
in a certain order to achieve a certain result
• Defines the beginning of a process, the end of a
process, and all the steps in-between
• Defines who does what in the process
• A measurement of what IS
Workflows before implementing EHR are
different from those after

EHR adoption
Practice Practice
Manager Manager
 Workflow mapping pre-EHR
reveals inefficiencies and waste

• Workflow mapping helps practices

– Identify inefficiencies, waste, and dangers
– Eliminate wasteful steps
– Streamline complicated workflows
– Standardize how work is done
• Example 1 (lab results): workflow mapping
uncovered unnecessary steps that could easily be
eliminated, making life easier for physicians and
staff
• Example 2 (rx refills): workflow mapping showed that
big changes were needed to eliminate waste and
reduce patient delays
 Workflow mapping pre-EHR:
Tailor EHR to meet practice needs

• Mapping out processes before EHR implementation

helps practices decide how to use the EHR
• Workflow mapping demonstrates what protocols and
standing orders are needed to redistribute work
• Workflow maps help practices work with their EHR
vendor so that the vendor understands how each
person will use the EHR
• Examples 1 and 2: protocols and standing orders
written pre-EHR adoption delineate who does what,
which facilitates implementation of the EHR
 Workflow mapping post-EHR:
EHR is a huge change
• Going from paper to EHR changes every single
thing in a practice
• Roles will change
– What will medical records clerks do?
– Medical assistants will enter vital signs electronically and
provide more services in the rooming process
– Clinicians will type progress notes and use templates
– E-prescribing often shifts all refill work to Clinicians’ inboxes
• Example 2 (rx refill): Post-EHR workflow can be
set up so that Clinicians do not handle every refill.
This depends on pre-EHR workflow redesign
 Workflows post-EHR:
shows practices how best to use EHR
• EHR implementation tends to push work back onto the
Clinician. Workflow mapping can prevent this
• Workflow mapping helps staff look at entire process
and think how their work fits into a larger system
• Workflow maps help practices decide which personnel
they need post-EHR
• Example 1 (lab results): If a practice does not have a
RN or LVN, Clinicians need to review all labs. If the
practice wants to delegate lab review to another team
member, the practice would need a RN or LVN because
MAs cannot review labs. Also, the practice will not
need a medical records person.
 Who’s involved with workflow
mapping?
• One designated person
– Oversees the team and keeps tasks on track
– Understands all aspects of the process in detail
– Drafts the initial workflow map
• The team
– Decides what processes to map
– Everyone involved in a workflow should be part of the
mapping process
– Discusses accuracy of the workflow map after it’s been
drafted
– Perfects the process and maps it out
 Types of workflow maps
High-Level Flowchart: Shows the major steps of a process. A high-level (also called first-
level or top-down) flowchart illustrates a "birds-eye view" of a process.

Detailed Flowchart: Provides a detailed picture of a process by mapping all of the steps and
activities that occur in the process. This type of flowchart includes such things as decision
points, waiting periods, tasks that frequently must be redone (rework), and feedback loops.
This type of flowchart is useful for examining areas of the process in detail and for looking for
problems or areas of inefficiency.
 Know your symbols
START/END: Indicates the start and end points of a process  

OPERATION: A specific task or activity that is performed  

DECISION POINT: A point in the process where a yes/no question or a decision

is required before moving on to the next step  

DIRECTION: Arrows connect steps in the process and direct flow of information

DELAY: Indicates the workflow goes into a wait

OFF-PAGE CONNECTOR: Refers to a process located on another page

ON-PAGE REFERENCE: Refers to a step in the process located on the same

page

UNCLEAR: Use this when a step in the process is unknown or not clear

Note: There are many more symbols than those listed, but these are
the most commonly used ones
 Simple steps for workflow mapping

• Step 1. Pick a process to map out, pick which

type of workflow to use, and agree on its
purpose
• Step 2. Determine the beginning and end points
• Step 3. Identify each step in the process
• Step 4. Put the steps in order
• Step 5. Review and edit the first draft
• Step 6. After a day or two, review the flowchart
with the team for input
 What to do with your workflow map

• Look at your workflow map and examine it

– Beginning and end points
– Each activity and wait symbol
– Decision points
– Hand-offs (where one person finishes his or her part of the
process and another person picks it up)
• Ask questions about the workflow map
– Does that step really need to be there?
• Map out the improved process
 How not to do workflow mapping

• Map out the processes you wish you had

• Interview a few key informants to understand the
process instead of shadowing everyone involved
in the process
• Ignore the opinions of those people who know
the process best
• Put your workflow map on the shelf and don’t
look at it again
 Achieving meaningful use requires
workflow change

• Meeting meaningful use requires practice staff to

perform functions they may not have performed
before
– Example: Practices will need to provide patients with an
after visit summary
• Meeting meaningful use requires efficient high-
quality and patient-centered use, not just any
use, of the EHR
 Meaningful use criteria: Stage 1
Core requirement Workflow Workflow change ideas
changes
needed?

Record patient demographics Yes Someone in the practice needs to enter and
update demographics
Record vital signs electronically Yes Medical assistant adds to rooming tasks:
calculating BMI, entering height, weight, BP,
growth charts into EHR

Maintain up-to-date problem list Yes Clinicians often fail to keep problem lists updated.
MA reviews problem list during rooming and
reminds clinician to update. MA does not make
updates in EHR

Maintain active med list Yes MA does med-rec during rooming and makes or
pends updates in EHR

Maintain active allergy list Yes MA has series of questions about allergies and is
responsible for this task

Record smoking status Yes MA adds this to rooming task and could do brief
counseling (readiness to change, perhaps call
state quit line)
Core requirement Workflow Workflow change ideas
changes
needed?

Provide patients with clinical Yes The clinician does this and trains MA to carry it out
summaries for each office visit

E-prescribing Yes For initial prescriptions, clinicians do the e-

prescribing, but for some chronic refills, MA could do
the refill based on standing orders from clinician

Drug-drug and drug-allergy No

interaction checks

Exchanging electronic Yes Care coordinator (probably RN) can assist clinicians
information with other sites of with this, particularly tracking/follow-up. If there is no
care RN, a workflow map would show which steps could be
performed by a non-clinician staff person

Implement a decision support Yes Tracking compliance could be done by RN care

rule and track compliance with manager
the rule
Systems to protect privacy and No
security of patient data

Report clinical quality measures Yes Someone would be responsible, perhaps practice
to CMS or states manager. The responsible person would need training
in CQI, numerators and denominators, measures, etc.
Menu of additional tasks (choose 5 Workflow Workflow change ideas
out of 10) changes
needed?
Drug formulary check system No
Lab results into EHR No
Generate lists of patients for QI or Yes The generation of the lists is a technical issues, but
outreach (registry) panel managers will be needed to work the lists to see
which patients need which services, and provide out-
reach or in-reach. MAs could be the panel managers
except their workload is becoming excessive. MAs would
do in-reach.
Electronic health education Yes Health educator is responsible (if available), but
resources clinicians/MAs would also provide the information to
patients
Med reconciliation between care Yes Between settings is complex, but within the primary care
settings practice, MA can do med-rec as part of rooming

Summary of care record for referrals Yes This is mainly a clinician function but it also needs to be
and transitions tracked and reminders done (MA and/or RN care
coordinator)
Immunization data to regional Yes Someone on team responsible
registries

Surveillance data to public health Yes Someone on team responsible

agencies

Patient reminders for prevention/ Yes This is a panel manager task

chronic care

Patient access to lab results, Yes Creating a secure patient portal is technical issue, but
problem and med lists, allergies actually providing the information would be an MA task
Suggested workflows for meaningful use

• The following workflow are examples

• How your practice works may be different

• Pilot the EHR workflows with one MA or one

receptionist and one clinician and a couple of
patients to see if they work
 Example flowchart: documenting vital signs
(example, blood pressure)

MA  calls  pa+ent   MA  takes  the   MA  enters  blood   Blood  pressure  is    

from  wai+ng     pa+ent’s  blood   pressure  in  the   documented    
room   pressure   EHR     in  EHR  
 Example flowchart: maintaining active medication lists
MA performs See med
MA opens patient’s Does yes medication rec
MA rooms patients active medication patient have an active reconciliation (med workflow
list in the EHR medication list? rec) with patient
using med list

no

MA performs yes MA inputs

Did medication See med medication name,
yes rec
the patient bring reconciliation dose, and MA updates list as
in all their (med rec) with workflow instructions in needed
medications? patient patient’s
using bottles medication list
no

Obtain patient’s
medication history Clinician updates
yes Does clinician
from former primary patient’s Patient sees
change
care clinic medication list in clinician
medications?
EHR

no

MA/clinician prints
out after visit
summary with
updated medication
list

Medication reconciliation itself is a separate MA checks for

patient
End visit
process that will not be discussed here understanding of
medications
 Example flowchart: maintaining active allergy lists

MA confirms Does patient no

allergy list with have any new
MA rooms patients patient allergies?

yes
yes

MA asks MA inputs
MA opens Does patient no patient if they allergies into
patient’s allergy have an active
have any patient’s allergy
list allergy list?
allergies list

Allergy list
updated
 Example flowchart: documenting smoking status for patients 13 and up

Is the patient no Not required

MA rooms patient 13 years old to document
and up? smoking status

yes
no

MA checks EHR Is the

to see smoking smoking status
status of patient date older than
one year?

yes

MA asks patient if
they smoke

MA documents Smoking status

smoking status in documented
EHR in EHR
 Example flowchart: providing clinical summaries
at the conclusion of appointments

Does Does patient

yes no MA/nurse prints MA/nurse hands
Clinician finishes clinician finish require further
out clinical clinical summary
visit with patient documenting patient’s procedures from
summary to patient
progress note? MA/nurse?

yes
no

Patient receives
MA/nurse summary
Clinician finishes performs task
writing progress and documents
note within 3 appropriately
business days

MA/nurse prints MA/nurse mails

out clinical clinical summary
summary to patient

mail

MA/nurse sends
Clinician informs How does electronically clinical summary
MA/nurse that patient receive clinical
via secure
note is complete summary?
patient portal
 Example flowchart: reporting on clinical quality measures to CMS
(example: % of diabetes patients with A1c>9)
no
Data manager
queries number of
patients in
denominator
(denominator=#
diabetes patients)
Reporting
deadline
Within 7 days
Are reports pre-made?

yes Data manager

queries number of
yes yes patients in
Data manager
Does your Is your numerator
opens registry or
practice have a data manager familiar (numerator=# of DM
data reporting
registry? with data reporting? patients with A1c>9)
program
Data manager
no generates pre-
made report

Practice should talk

to EHR vendor about
reporting functions DELAY
Contact REC
Data manager
or LEC Data manager
inputs numerator
finds numerator
and denominator
and denominator
into excel
from report
spreadsheet

Data manager
calculates % by dividing
numerator by the
denominator
(%DM pts with
A1c>9=#DM pts with
A1c>9/# DM pts)

Data manager sends

report to CMS
 Example flowchart: reminders to patients for preventive and follow up
care (example: outreach to patients due for annual FOBT)

See how to
First Friday of Care team member generate a Care team member
the quarter generates list of prints reminder Care team member
query (list of
patients who have patients) letters and labels mails out letters
not completed FOBT for all patients on with FOBT cards
workflow
in the last 11 months query list

yes
Does practice Do Care team member
have a registry? patients on the list have no
indicates in registry
visits scheduled? that patient
received FOBT
cards
no
yes

yes
Does EHR
have query function? 1 month later, care
Care team member See in-reach team members runs
performs in-reach workflow query of patients who
to patients received FOBT cards
but have not
no completed FOBT in
the last 11 months

Contact EHR vendor

about query function or
talk to REC/LEC
Care team member
calls patients on query
list to follow-up on why
Patient completes patient has not
FOBT completed FOBT

no

1 month later, care

team member runs
Care team member yes query for patients who
Are there
repeats outreach have received FOBT
patients still on this list?
next quarter cards but have not
completed FOBT
again
 Example flowchart: how to change a job role using lab result
follow up as an example
Team or team leader
Team analyzes the
Team discusses brings new proposed
Workflow team workflow for Team agrees on new
changing job roles to workflow (with job
maps current workflow inefficiencies and improved workflow
improve the workflow role changes) to the
wastes
all clinic staff meeting
A

Team or team leader

explains and provides
Staff member yes Does staff member All staff members
training to staff
performs new perform new learn of new
members whose role
function job function changes to job role
has changed and to
their supervisor

no
Doesn’t
want to
Supervisor
perform addresses staff Supervisor brings
Forgot Why is staff member function concern to team
not performing member’s concern
new function? over new job role

Supervisor does
additional training
Doesn’t
know
how

This is not a meaningful use requirement but will be needed to achieve meaningful use
 Conclusion

• Workflow mapping is a great tool to help

implement EHR and achieve meaningful use
• EHR adoption does not equal meaningful use
• Workflow maps are a tool to improve care for
patients, improve efficiency in practice, and
redistribute work and job roles