Podcast Episode 23: Optimizing Workflows in Clinical Practice and Practice Management

Enlightened Practice Podcast

Dr. Ken Braslow and special guest Dr. Amy Berlin discuss how suitable information systems help organizations manage change while enabling individual clinicians to think creatively within their practices. Our hosts share their experiences to demonstrate how maximizing efficiency can help with clinical care. Sit back and enjoy this enlightening episode.

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Transcript of the podcast

Ken: Hi Everyone. Today we have a special guest on our podcast. I’m really happy to be welcoming friend and colleague, and someone I’ve learned a lot from, Dr. Amy Berlin is joining us. She’s a psychiatrist and she’s passionate about how suitable information systems help organizations manage change while enabling individual physicians to think creatively within their practices. She sees adults of all ages in her psychotherapy and pharmacotherapy practices and she regularly teaches at the Psychotherapy Institute in Berkley, California. She is also a Luminello user and very excited to have her on the podcast today. Welcome Amy, to the podcast! 

Amy: Thank you, excited to be here. 

Ken: Well, thank you so much for joining us. Today we’re going to talk about workflows in practice management and how they help with clinical care. It’s such a broad concept and I thought we’d start off by just setting the stage for, what is a workflow, anyway, and what does that mean for clinicians?

Amy: Yeah, that’s a great question. When I think about workflows, I think of it’s how you work. In my mind, a workflow refers to a process that you might repeat in the course of your workday many times. Something that’s pretty habitual like how you would document an intake, when and how you would bill patients, how you respond to prescription refill requests. For each of these tasks, there’s probably a consistent, habitual way that you complete them and that process is called your workflow. 

Ken: It’s interesting. As you say that I wonder how many workflows per day I have that I don’t even realize that I have. Do you think most of our practice is workflow-based during the day or half of it? What’s it like in your practice?

Amy: Well, one thing that I remember learning when I was doing a lot of work in the healthcare information technology space was there’s an optimal balance between the things that are repetitive. The more those can be streamlined, the more room there is, the more bandwidth there is for the parts of our work that actually require creative problem-solving. When I think about my work, I think, yeah, there’s a decent amount of things that are road to repeated processes that just have to get done and there’s also a fair amount of creative problem solving that happens. That’s what I love about psychiatry. You get to think creatively all the time. I never had to try to quantify like what percentage is what. 

And probably different people like different balances. I think, I probably like a balance where 30 to 40% of the time I’m doing things that are repetitive and just efficiently getting things done. And 60 to 70% of the time I’m getting to think creatively. And that’s probably an optimal balance for me, but I imagine, depending on the type of work that you’re doing and even within psychiatry or mental health that will probably vary. Does that make sense?

Ken: It does. So, let’s say I’m new to practice. Where does the rubber meet the road here? How does this apply to me? What should I be thinking about as I start out on my journey?

Amy: Well, I’ve always been passionate about maximizing efficiency and thinking, is there a way to streamline this, which is where my mind has always gone. I think that anyone that’s new to practice, has come out of residency, I’m talking about psychiatry practice, but anyone who’s new to practice has come out of some training and in that training most likely you were working in some organization where you had to see patients and had to either adapt to the workflows that were there to some degree and also learn how to do your own way of doing things. Everyone has probably more practice ways of taking in initial history or doing a suicide risk assessment. All of these things are things that I think were best if there’s a consistent way that you do them. 

For example, the idea of the right amount of structure to leave room for the right amount of creative problem solving if you think about a suicide risk assessment, every time you do that you’re reinventing the wheel for what questions you ask and how you assess someone’s level of risk. That’s a lot of energy going into creating a process. But if you have your typical way of asking questions about suicidal ideation or a history of self-injurious behavior. Then, as you ask those questions that are available for you to pull from your procedural memories so to speak, and leaves a lot of room for you to be paying attention to the answer that you’re getting and thinking critically about that.

So, for folks who are starting out in practice they probably already have a lot of built-in styles and workflows that they’ve accumulated along the way. And if by new to practice you mean launching your own private practice, that’s a really good opportunity to evaluate, okay, is this way of writing up a new intake what I got when I was working at X, Y organization or hospital? Does it really work for me? It’s a good way to reexamine what’s become your practice or your learned way of doing things is going to work in your new setting or if you need to refine things a little bit.

Ken: I like how you personal it out in terms of clinical workflows, also, then there’s the practice management workflows.

Amy: Right.

Ken: What do you think are some workflows that would be useful to think through the practice management side as you’re thinking about starting a practice?

Amy: So, the first thing that comes to mind is bringing a new patient into your practice. How do they make contact with you, how do you have an initial screening triage in conversation with them, is that something that’s done by phone? Is that something that’s done by secure email, how you get them to the point where they revere all the paperwork, whether it’s practice policies, I also have them signup a Telehealth consent, getting what you need to get from them in terms of payment, some patients pay by credit card, so for me, that means getting their credit card information, getting their insurance information. 

So, there’s all this information that you need from your patients and there are steps that you need them to take in order to get them all the boxes checked in terms of being ready to receive care in your practice. So, that’s an example of the practice management workflow that comes to mind for that which works for me in practice. 

Ken: I’m just wondering about how overwhelming it can feel to have to think about all these different kinds of workflows. 

Amy: Yeah.

Ken: New patient, follow-up patient, medication patient, versus….  

Amy: Versus psychotherapy patient.

Ken: Yeah, and maybe depending on referral source or type of evaluation, forensic versus clinical. I can see how it gets overwhelming potentially pretty quickly going through all of these different workflows and then just adding to our matrix here, I guess, billing versus scheduling, versus getting clinical feedback outside of sessions and then breaking that down to if you’re working with families, feedback from the parents, feedback from teachers, just so many different pathways here. 

Amy: Right.

Ken: How do you recommend clinicians from not getting overwhelmed thinking about all these different permutations? 

Amy: As you were saying getting overwhelmed, I know this is not how many people feel about it. I actually get excited when I think about, how can we craft a new workflow that’s going to be really streamlined? But then also, I’m always optimizing. The way that I did it 5 years ago is not how I do it today. This is always a work in progress. I think, I will try to buy off all of those potential new workflows. If you’re getting started in practice, get comfortable with one clinical scenario. And the workflows that are required to take on adult patients for medication management before you try to figure out how you’re going to bring families into your practice. And you’re going to learn things about how you work best from that experience. And those things are going to be translated to the additional workflows that you take on. So, that’s a very long way of saying take it slow and let it enter its process. 

Ken: What are some things that were doing earlier in your career that you’ve modified or are doing better now?

Amy: Well, earlier in my career I didn’t have as sophisticated electronic health workers as I have now. So, there are a lot of things that I can do now that just wasn’t possible then. I think that’s a big differentiator. I remember when I was first setting out and I was meeting with the person that I was going to sub-let from and she said something to me about how she can usually tell from the first voicemail that she gets from a patient whether or not she’s going to want to work with them. And I was in awe. I was like, really? That’s something you can figure out? And fast forward a number of years, these days I get most inquiries via email, so I don’t get the voicemails anymore, but it got to the point where I could pretty quickly tell from the voicemail also. 

One of the things that changed is that I used to spend a lot more time on the phone talking to people and even doing the initial risk assessment to make sure that I wasn’t bringing someone on that was going to require a lot of in between session contact or a lot of acuity. And I both got more confident about in between session contact and acuity as I got further advanced in my practice. So I’m not as worried about that. And I also feel like I can really tell when I listen to someone what’s going to be required and I’m much better at saying, here’s the sort of availability I can offer and I have a feeling that’s not going to work for you.

So, all these things just need more practice and gets easier. So, a lot less time triaging than I do now is one thing that’s changed. There’s a lot of things that I did at the beginning in terms of getting forms signed and getting payment information, when I first started out I can say what I was doing was a lot more clinic care, but now I can just ask my patient to go on their portal and put that information in and I don’t have to be a part of that process, where I used to have to get that information from them, have them transcribe it, scan it, save it as a PDF. The way it happens is different but the principle of the information I’m trying to get is largely the same. 

Ken: What do you think about groups and clinics? How do they think about workflows differently or similarly compared to clinicians and solo-practice?

Amy: Right. So, a few things come to my mind when I think about comparing contrasting. I mean, certainly there are similar principles that the more streamlined a workflow is the more bandwidth the people completing the work have to problem solve other things. The biggest difference is, being a solo-practitioner it’s just me, I don’t have any support staff. So, I get to decide how I want to deploy workflow and I get to practice it and I get to refine it. 

And in group practices, there are workflows that involve more than one person, so there are hand-offs of tasks, hand-offs of information. So there is a lot more coordination that has to happen. There is a lot more education that has to happen. I think this is the most important thing, there is a lot more input that has to be gathered from the people doing the workflow. What I mean by that is, if I’m deciding how I want to design a workflow, for example, the new Love nor Surprises Act, that’s a new workflow. Now, I have to come up with a way to generate a good faith estimate for my new patients or for my existing patients. I have to talk to them about the fact that I’m doing this and I have to send that to them. But that’s between me and myself how I want to do that. A group practice ideally is going to sit down and anyone who is going to be implicated by this new responsibility is going to get to participate in designing that workflow. 

So, if there’s going to be an administrative staff function that gets deployed in providing good faith estimates to patients’ ideally good practices, including those administrative staff people in making decisions about how this is going to go down. So, thinking about the fact that the workflow relies on multiple people and the touch points between steps in the workflow that occur also between different people. And also about how feedback gets given about how smoothly workflow is given so that it can be optimized. When you’re just one person you get to have that feedback conversation with yourself and get to change things. So that’s one difference that comes to mind. 

Ken: I’m just thinking about groups that we meet with when we’re giving a demo and sometimes it becomes more of a conversation about workflows than it is about the demo itself because most groups already have their own workflows. They may not be thrilled with them. They may not be very efficient, but they’re the workflows they know. 

Amy: Right.

Ken: What kind of advice would you give to group owners or the folks who are responsible for controlling workflows when they have to shift from old workflows to new ones, even if in the long run they’re more efficient. Change is really challenging. What would you say to them?

Amy: Right. Change is so hard.

Ken: What would you say to them?

Amy: I’m going to answer that question but you reminded me of another thought I have about a difference that I think is related to this. I’m going to insert that. 

Ken: Sure. 

Amy: A lot of groups I imagine, because this isn’t so much the case in solo practice, but the good faith estimate is an example of this because groups tend to have a lot more regulatory responsibilities to comply with. So, whenever I’m thinking about workflows for a larger organization, what I find to be a really orienting way to think about that, so this helps with the changed management, what’s the end product? What do you need at the end of the day? For example, is there a particular regulatory compliance goal that needs to be met? Is there some answer around the volumes of patients coming in every month that you want to have a benchmark around? Is there some larger organization that requires certain benchmarks to be met one way or another? Is there some sort of accrediting agency that requires things be documented a certain way? 

So, whenever there are requirements that need to be met by a process I start with those requirements and try them backwards in designing a workflow that’s going to best land the organization at the place where they’ve met those requirements. I don’t know if this sounds too abstract. That’s not something that individual practitioners have to think about as much. I don’t have to submit any reports to anybody at the end of the month describing my productivity and that sort of thing. But I take that lens to the changed management piece because the question is, how painful is that. 

With the current workflows free to meet these requirements, how painful is it for you to answer these questions about productivity or volume of patients seen, or revenue in your organization every month? So, sometimes it helps with pivoting the workflows if you will and the pain of change to notice that there’s already a lot of pain embedded in the current workflow. Does that make sense? 

Ken: It does make sense. I’m thinking about when we do our demos and we have one eye on the product but we’re also looking at the folks who are on the screen share with us to see their reaction.

Amy: Right.

Ken: And sometimes, I can see if I’m on a demo it’s with a very large group typically and we can see the cognitive dissonance in real-time. And sadly, many first generation EMRs things were not designed with workflows in mind, certainly not, because I’m from the clinician’s perspective, for the clinicians benefit. 

Amy: Right. 

Ken: And they’re so used to having ten steps for the most routine of workflows and we show them something that can be done in a step or two, and maybe even something that’s automated. And sometimes they’re just like crickets. I can tell they’re like trying to process like, but what about the other nine steps? We don’t try and talk them into anything. It’s really for them to metabolize and then hopefully realize that there’s a lot of value here. At that moment of cognitive dissonance what do you think they should be thinking or how should groups or clinics approach that? 

Amy: Well, this is a place where I actually think my clinical skills are more relevant than my workflow billing skills because it’s true. It’s really disorienting to see something that you’ve been doing this way for so long be done this other way. It can really take a minute to wrap your mind around it. There can be all sorts of feelings that come up. This maybe doesn’t sound like an apt analogy but just because I assume that many of the people listening to this podcast are in the mental health space so they have this experience where you sit with someone and they tell you they’re suffering and you’re able to tell them, I know what that is. We have a clinical concept that describe what that is. There is a way to help that and it can be a really bittersweet moment for people. 

On the one hand they feel really understood and there is relief. And then there can be a lot of grief for all the time that they’ve spent suffering, and lost, and confused around their suffering. So, I think, appreciating that transformation is often bittersweet, like, that is what it feels like. There has to be some willingness to let go of the known and embrace the new, but then a lot of times, I’m not talking about when there’s a lot of grief and that happens over a couple of workflows. I’m talking about an analogy here, but that can feel really disorienting. And if you think about it, whatever they had in place is what’s trusted. And now this is like a new, if you will, object to distinguish that clinical terminology that isn’t trusted yet. And so what do we do to earn trust? We’re patient, and we’re attuned, and we hold steady with the reactions that are happening for people. Maybe I don’t trust your process because it looks too easy. I only trust a process that looks as onerous as the one that I’ve been doing. Maybe it’s anger, who knows what it is, right? It can be any number of things. 

Ken: The five stages of grief. 

Amy: Right, exactly. I think in some ways that’s an apt motto for making sense of it. I try to stay with people, like if you stay with the affect of it, yeah, this is probably a lot to take in and say what’s happening for you as you see this. Is this confusing? Is this disorienting? 

Ken: So you say groups should be thinking these things amongst themselves? 

Amy: I think I’m saying if I were in the room or on the Zoom for this, my style would be a pause and check the temperature of the room and give people an opportunity if you’ve been registering these responses, to speak to them. 

Ken: I think that’s fantastic. And on the other side of the Zoom, what would you say to the group clinicians themselves, how should they approach handling change that they know in the long run is probably for the best, but right now they have a hard time. 

Amy: Totally. I tend to really relate to that. I remember like getting a new piece of furniture in my office and my chair being in a slightly different angle and feeling like I couldn’t think clinically as clearly as in my old chair. It’s really disruptive. At this point I think most people have had the experience of getting a new computer, of getting a new phone, of getting some new device, of getting a new TV that they’ve had to adjust to. I imagine that’s a familiar place and I would want to talk to people, like what has helped you? It’s a normal transitional period to go through when it’s not yet familiar. And really what’s happening as you’re learning to use new technology is you’re developing new procedural memory. Some would also refer to it as muscle memory. But procedural memories are all the things we can do on automatic pilot. And so whenever we get a new piece of technology, or like we move to a new home, or we move to a new office, or we get a new car, all the procedural learning that we did in the prior instance of what we’ve just changed, doesn’t necessarily translate or apply. So there is this period where there’s a lot more bandwidth that’s getting expanded, basically laying down that new procedural memory. Once that procedural memory gets laid down, this is going to feel as familiar and automatic pilot and second nature to you as that prior instance did. So, I would talk to people about what they had learned about themselves and how they navigate those periods of laying down the procedural memory.

Ken: It’s a really interesting point. I was thinking back to the chair analogy.

Amy: Yeah.

Ken: Whenever I have moved offices, I don’t know if any clinician is like this, but I need just the right amount of space between my chair and the couch.

Amy: Yeah. 

Ken: I can instantly tell if it’s an inch too far or an inch too close.  

Amy: Right. 

Ken: And that is disorienting. Fortunately, I can just move the chair a smidge. 

Amy: Right.

Ken: But I can apply that to advanced billing workflows.

Amy: Sure. 

Ken: You get a feeling that’s just right.

Amy: Right.

Ken: So you’re saying over time as you lay down that procedural memory, that feeling will come back in just a different way. 

Amy: Totally. And I would argue that if that chair that you moved is bolted to the floor and you couldn’t move it, then it would only be a matter of time and you would adjust to that new distance. If we can’t tweak it back to what’s known comfortable, that’s what we do. But I think that’s really hard with new technology because we can’t do that. And so we’re stuck in that change management literature they talk about, that transitional space, that place where you don’t have the old anymore that was known. And the new isn’t yet familiar. And so you’re in this transitional space and it can be really uncomfortable and it can stop a lot for people, thinking clinically. Depending on how major transitions have gone in your lifetime, and how separations have gone in your lifetime, how it went for you early on in life, losing something that’s known and familiar can really trigger a lot of feelings, and so being mindful about that and trying to keep as many things that can stay constant and familiar and the same as possible while the new thing is being navigated, I think can be really grounding. 

Ken: Well, this is very grounding for me. It gives me some ideas for how we can make the process even smoother.

Amy: Yeah.

Ken: And hopefully it does for clinicians and group and clinical nurses as well.

Amy: Yeah.

Ken: Okay. Any parting wisdom for new grads or even mid career, even late-stage career folks, what’s the one thing they can do to start improving their workflows or their efficiency, or their satisfaction, right, because all these things, it’s a little bit about the technology but ultimately it’s an emotional feeling when things are humming and you’re in a good flow space.

Amy: I’m thinking if this is something probably all folks have done throughout their career is compare notes with colleagues, if there’s a particular task in your practice that you just find really onerous and annoying, or it feels way too time consuming, or way too labor intensive, ask colleagues, “How do you handle this?” because you’ll probably get some good ideas and that’s how we all learn. Like in medical school residency, you would watch the students or the residents a year or two ahead of you and what their note card system was and what they were using to look up drug interactions. And we always learn from our colleagues so I think in any stage in your career there are people that you know who maybe are more interested in thinking about optimizing workflow than others then pick their brains. 

Ken: That’s such a compliant. I was thinking about the feature of classes we get, and we get a ton of them frequently, and there are multiple ways of addressing a pain point or a workflow, and if you ask ten different clinicians you’ll get ten different opinions about the right way it should be done. 

Amy: Right.

Ken: But it’s probably just everyone has stumbled upon their preferred way and it just happens to work well with their systems and how their brain is wired.

Amy: Right.

Ken: So it is interesting to see when we get multiple feature work classes around the same workflow how different they are. And I think that goes to show that there is a lot of power in a crowd for coming up with optimal ideas. Well, thank you Dr. Berlin. This was fantastic. I feel like I learned a lot I’m going to go talk with my team about some of these ideas. But this was great and hopefully we’ll have you on again soon. I know we have some other topics that could be really interesting for clinicians, and I look forward to continuing the conversation soon. 

Amy: Sounds great. It was great to talk to you again.

Ken: Likewise. All right, take care. 

Amy: Thanks.

Ken: Bye.

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