In this case study, Dani Nordin and Janna Dupree, of athenahealth and Nuance, discuss how they used cross-product research and experience mapping to bring alignment to teams across two flagship product lines.

1. Mapping complex workflows to get
cross-product alignment
Janna Dupree, Nuance
Dani Nordin, athenahealth

2. Dani Nordin
Senior Manager, XD
athenahealth
Janna Dupree
Principal Designer
Nuance
About us

3. Shameless plug:
Come work with us!
https://www.athenahealth.com/careers/design
https://jobs.nuance.com/

4. A tale of two
products

5. athenaCollector Software and services to help medical
practices manage the revenue cycle,
from billing to posting remittance and
dealing with denials.
Cloud-based Electronic Medical
Records software to help clinicians
and their staff record and document
patient care.
athenaClinicals

6. athenaOne for
Hospitals
An end-to-end solution for small hospitals,
which includes:
1. Revenue cycle management
2. Electronic Health Record
3. Integration with lab/radiology
systems
4. Medication management,
administration and dispensing

7. The path from care delivery to billing consists
of 4 distinct jobs.
Register/Check in
patient
Document care
Enter/confirm
billing information
Submit claim
to payer

8. In hospital billing, the tasks subdivide a bit.
Register/Check in
patient
Document care
Enter/confirm
billing information
Submit claim
to payer
Capture charges
Make sure
chart is
complete
Enter billing
codes

9. Lack of automatic charge capture
for many medications led to extra
work for pharmacy technicians.
Problem 1
Capture charges

10. Reconciling medication
charges was labor-
intensive and frustrating.
Pharmacy techs are responsible for dispensing and
keeping inventory on medications in the hospital, as
well as reviewing all the charges that come in over the
course of the day.
Our old system [EDIS] captured our charges... in
ER, you would put in that you started an IV and it
would capture the charges for it.
– Medication Nurse, Holton Community Hospital

11. Coding staff need a read-only
view of the chart to do their jobs.
Our solution made it hard to find
the information they needed.
Problem 2
Make sure
chart is
complete
Enter billing
codes

12. Documents in the chart
were poorly formatted,
disorganized, and lacked
key information.
To code a patient’s chart, users had to hunt and peck
through dozens of documents to get basic
information to do their jobs.
The [Medication Administration Report], to me, is
totally... I don't like it. The only way I really know
to go into it is Coding View, and there's time and
dates that are totally worthless... I don't know if it's
a scanning error, or if the nurses are doing it
inconsistently, or what.
- Coder, Holton Community Hospital
A lot of times we won't see the stop time [for an IV
medication]... that stop time is when they're
discharged, which is not the same as a stop time.
- HIM Director, Greenwood Community Hospital

14. Grabbing clinical information
required creating a hack on top
of already fragile code
Chart documents could only be pulled
into Collector as raw HTML, limiting
customization options.
But it was hard for the Collector teams to make
an impact on these issues.
Cross-functional partners across
the two products were talking past
each other
Conversations about the issues often
focused on explicit technical asks that
zeroed in on narrow slices of the problem.

15. Our clients buy athenaOne for
Hospitals...
The Big Problem:

16. ...But we sat SO FAR AWAY from each other

17. How do we get
these teams to start
working together?
We had three main goals:
Give teams on both sides visibility into the
end-to-end workflow as users experienced it
Map the Medication Management
experience from ordering > preparation >
administration > billing
Pinpoint the problems within those
workflows that create the negative
outcomes we’re trying to fix

18. Experience Map of
current state
Mapping the end-to-end steps within
the workflow as understood via:
● Product walkthroughs
● Tutorial videos
https://blog.practicalservicedesign.com/its-a-new-era-of-practicality-service-
blueprinting-with-mural-d147674641e2

19. Cross-product site
visits with 2 clients
● Identify communication
gaps/breakdowns between providers,
pharmacy and HIM
● Experience and guide each other
through Clinicals and Collector
worlds/users

20. Insights
● Multiple areas in the medication ordering and fulfillment cycle created negative
downstream impacts if a mistake was made
● Reliance on paper and multiple sources of information caused rework and confusion
● Incomplete workflows result in distributed responsibility and lower adoption - Nurses, Rad
Lab and Pharm techs adopting billing/coding work

21. Action
● Pivoted release plans to focus on medication ordering and fulfillment accuracy
● Increased efforts to automate charge capture
● Made dramatic improvements to a key document – the Medication Administration Report
– to benefit both coders and hospital nurses/pharmacy techs.

22. Cross-product understanding

23. Applying the approach to
other problem spaces

25. Goals of this research
1. Understand the modes and workflows by
which charge entry happens
2. Learn more about the breakdown of roles,
responsibilities and tools required to do this
work across different practices
3. Understand how the different paths used to
create claims might impact financial
performance
We conducted 8 site visits in January-February 2019
in a variety of geographies, specialties, and sizes. The
sample included both Visit Beta and non-beta clients.
We also mined previous research and analytics to find
additional context for what we saw on site.
This provided an opportunity to better understand
the workflows across a representative sample of
clients, and explore the impact of differences between
Beta and Legacy workflows.

29. “I need you to make one of your
things… that visual thing that’s
hanging up in 5200, for this other
team.” - Product Management Lead

30. Okay... So how do we do this?

31. Map the current
state of things
Use a tool like Mural or Miro to capture
each step in the workflow inside and
outside the system. Include:
• Screenshots of UI
• Non-computer steps as applicable
• Observations from research
• Known problems
Get information from:
• Product walkthroughs and tutorials
• User research reports

32. Flesh it out with
research
Validate the map with all the information
you can find from:
● Internal SMEs
● User interviews
● Client site visits
Add additional observations and pain
points as the elements of the map become
more clear.

33. Bring people along
for the ride
● Provide regular touchpoints with
cross-functional and cross-product
colleagues.
● Share what you’re learning, and the
various artifacts you’re creating to
support the story.
● Make the work visible around your
organization – put it on the walls,
bring it to meetings.

34. Takeaways
● Silos don’t break down overnight – it requires time and patience
● Designers are powerful when we work together
● Taking people step by step through the process helps drive alignment

35. Thank you!