Healthcare's under-the-radar obstacle

Becker's connected with Nathan Merriman, MD, medical director of gastroenterology and digestive health at Salt Lake City-based Intermountain Health, to explain why a lesser-discussed issue in healthcare — friction — is one of the industry's most important — and insidious — issues.

Note: Responses have been lightly edited for length and clarity. 

Question: Can you expand on why you previously said workflow friction is the most insidious issue in healthcare?

Dr. Nathan Merriman: I think people miss the fact that friction really adds up over time for all of us as care team members and patients as well. One example occurs in endoscopy care, when you're talking about 20 to 25 procedures in a day, when I hear things like, "Oh, it's just one more click in the EHR", I think that's one click for me, could be one more click for our nurses, one more click for our technicians doing procedures and, and then multiply that by 20, and consider the aggregate clicks for three to five days a week in endoscopy care for all of us, it's a massive amount of quiet friction that is built up in healthcare over time for all of us as care team members just with aggregate click counts as one example. Another example of increased friction for our care team members are multiple excess steps in workflows that add little to no value at times. On the patient experience side of friction, there can be multiple steps and phone calls and wait times to get care visits scheduled or completed, so friction builds up for patients as well. Sometimes the friction for patients is so severe that they choose to delay or completely forgo the care. I think we should all have a shared goal of simplification of the human experience of healthcare for patients as well as for all of us as care team members.

Q: How do you combat that friction in your own practice, whether it be more on the leadership or clinical side of things? 

NM: In addressing both, the important things are to help identify the pain points and the friction points in workflows for our nurses, our techs, our front desk staff, our physicians and APPs as well as our patients. In clinical practice and in leadership, we need to be good stewards of others' time and friction fixers. To combat bad friction, the goal should be simplification of the workflow with unnecessary step and click reduction — which I think should also be mandatory for EHR designers. Vendors should be saying, "this workflow takes 10 clicks. How can we get it down to six?", in order to decrease the total number of electronic clicks or touches in a process, ideally implementing the most simplified version of that process. That goes for helping care teams with their electronic workflows as well as their handoffs in the hospital or handoffs in the outpatient setting. Generally, the fewer the steps, the better with an understanding that every step, every click adds time and potential friction. Granted, there are some instances where we need to slow down and introduce good friction in workflows for safety, and a great example of that is popups in workflows. As an example, if we were about to order a medication that a patient is allergic to and a pop up helps to prevent that, I would say, is positive friction, because then you help the clinician slow down and prevent a bad event from happening. So there are examples of both good friction and bad friction in healthcare."

Q: Is there necessary friction in ways that aren't in an EMR or another virtual space for care teams, such as in patient contact or direct care?

NM: We've tried to come up with several programs within our Intermountain gastroenterology team to simplify workflows and simplify experiences for patients, but with caution, because we have found that some workflows can create issues by moving too quickly. A good example of that would be our GI rapid access program that we started a couple years ago with the goal of helping to get patients from the emergency department faster for outpatient GI care, if clinically indicated urgent outpatient GI care. What we found, though, we needed to slow down (insert friction) to work together with our ED team, to clearly define what our teams and our patients were defining as clinically indicated urgent outpatient GI care. We needed to co-design the plan with rapid flow focused on patients with new, active GI symptoms like stable GI bleeding or a passed food bolus with trouble swallowing. This rapid add on outpatient GI access program was not designed for chronic abdominal pain GI visits. We learned and improved the program quickly together and learned as we went as we studied and adjusted program friction and flow.

I think every new care model in health systems and other care providers is a continuous learning process. You need to add tweaks over time to really help continue to improve, with the assumption of imperfection — that no program I've ever seen is perfect to start. The goal is to continue to learn and improve.

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