Leveraging Technology to Leveraging Technology to Improve Patient Flow, Improve Patient Flow,

Collections & ProductivityCollections & Productivity

Seth J. Guterman, MD FACEP FAAEM

President, ECPS

How Technology Can Help the How Technology Can Help the Emergency DepartmentEmergency Department

HOWHOW can computers help the ED?The archaic handwritten patient chart is at the crux of the overwhelming obstacles faced by ER staff on a daily basis. Removing this unnecessary evil is the first step toward enhanced efficiency and improved patient outcomes.

WHYWHY help the ED?The ED is the portal through which the most critical patients enter, generating approximately half of all hospital admissions. If the ED fails to receive funding and equipment its staff desperately needs, this will form a negative first impression for patients.

Improving Patient FlowImproving Patient Flow

TriageNurses assess Patient’s condition and categorize seriousness of Chief Complaint

RegistrationRegistration personnel obtain Patient’s demographics (Name, Address, SS#, etc.) and start a medical

record in the hospital’s computer system to order diagnostic tests, medicine, supplies, etc.

Primary Nurse’s Assessment

Patient Placed in an Exam Room

Emergency Medicine Physician Examination(Medical Screening Exam)

Diagnostic Tests and Medicine Ordered

Medical Insurance Information ObtainedBy Registration Personnel

EM Physician, Review of Diagnostic Tests Re-assessment, and Disposition Decided

Nurses Disposition Patient: Admit or Discharge HomeNurse gives discharge instruction and prescription if discharged home

Nurse obtains hospital bed assignment if Patient is admitted

Primary Nurse Executes Physician Orders

ED Patient Flow ChartED Patient Flow Chart

NOTE: All critical patients receive a clinical evaluation and registration at the bedside.

Emergency Department FactorsEmergency Department Factorsthat Impede Patient Flowthat Impede Patient Flow

Ranked from greatest to least impact on patient flow:

1) THE HANDWRITTENHANDWRITTEN CHART

Paper-based charts hobble

patient flow and leave

clinicians open to costly

malpractice cases that could

be avoided by implementing

proper documentation practices.

2) IN-HOSPITAL BEDBED ASSIGNMENT

a. Staffing restraints

• Inadequate staff for Telemetry and ICU beds MORE COMMONMORE COMMON

b. Physical restraints

• Available beds usually Telemetry and ICU

LESS COMMONLESS COMMON

ØWhen there are delays in hospital bed assignment, the ED exam rooms and ED staff are unable to provide medical careunable to provide medical care for those patients in the waiting room.

3) INADEQUATE ED STAFFINGSTAFFING

§ Nurses

§ Medical Assistants

§ Unit Clerks

§ Transporters

Ø Because of sick call, staff breaks, and lunch, the ED is almost constantly understaffedunderstaffedEVERY DAY.

4) NO REALREAL--TIMETIME COMMUNICATION

§ Tracking Board

§ Medical Order Status

§ Disposition

5) SLOW REGISTRATIONREGISTRATION

Ø If patients are

not registerednot registered

in a timely manner

into the hospital

computer system,

ED staff cannotcannot

execute physician orders.

6) ANCILLARY TURNAROUNDTURNAROUND TIME

§ Laboratory

a) Staffing restraints

•• MORE COMMONMORE COMMON

b) Physical restraints

• Location of the Laboratory

LESS COMMONLESS COMMON

§ Radiology

a) Staffing restraints

•• MORE COMMONMORE COMMON

b) Physical restraints

• Location of the Laboratory

LESS COMMONLESS COMMON

7) CLINICIAN PRODUCTIVITY – LEAST IMPACTLEAST IMPACT

Ø IF…

…the ED is adequately staffed with Physicians, Nurses, Medical Assistants, Unit Clerks, Transporters, and Registration personnel,

Ø THEN…

…then the greatest impediment to improving patient flow in the ED is AVAILABILITYAVAILABILITY and ASSIGNMENTASSIGNMENT of in-patient hospital beds.

The 2nd greatest impact on patient flow is having adequate ED staff 24 hours a day to carry out the physician medical orders and provide medical care to patients.

The Results: DocumentedThe Results: DocumentedImprovements in Patient FlowImprovements in Patient Flow

Avg Length of Stay

Before After Before After Before After

# Patients LWOT # Patients LAMA

3 hr/1 min. 2 hr/30 min. 62/month 16/month 36/month 12/month

• Reduced Length of Stay

• Reduced # of patients LWOT

• Reduced # of patients LAMA

Hospital Patient Flow: Before/After ED EMRHospital Patient Flow: Before/After ED EMR

-67% -17% -74%

CONCLUSION: In general, EM physicians and ED nurses are NOTNOT the reason for long increasing patient wait times, and many of these problems can be rectified by implementing the correct technology in the Emergency Department.

Improving CollectionsImproving Collections

How Technology CanHow Technology CanImprove CollectionsImprove Collections

• Automatically charge supplies & medicines

• Nurse spends more time administering bedside clinical care

• Capture ALLALL and LOSTLOST hospital charges

Technology’s Impact on Technology’s Impact on

Reimbursement/CollectionsReimbursement/Collections

Average reimbursement in two hospitals:

Handwritten ChartsHandwritten Charts vs. ED EMRED EMR

Before ECDS$210/hour,3.3 LOS

After ECDS$277/hour,

3.7 LOS

Physicians

+24% $s & 0.4 pt. LOS

Before ECDS

$3,749,899

After ECDS

$4,085,711

Hospital

+9% $s

Improving ProductivityImproving Productivity

How Technology Can How Technology Can Improve ProductivityImprove Productivity

Need real-time communications system that will eliminate…– Walking past rooms to see which ones are open

– Searching for each other or standing outside rooms waiting

– Searching for paper charts to do further documentation

– Only one staff member having access to a chart at a time

An average of 30-40% of time is lost to activities unrelated to patient care, leading to reducedreduced

staff productivity & impededimpeded patient flow.

Need realNeed real--time operational time operational & quality analysis tools& quality analysis tools

To determine staffing needs…To determine staffing needs…

SMNHC ED

Facility Arrivals by Hour of Day

0

2

4

6

1 3 5 7 9

11

13

15

17

19

21

23

Hour of the Day

MTD

YTD

Need realNeed real--time operational time operational & quality analysis tools& quality analysis tools

To reduce patient Length of Stay…To reduce patient Length of Stay…

2.1 Hrs

3.3 Hrs

0

1

2

3

4

Hours

SMNHC and SEH

Emergency Department ALOS

SMNHC SEHALOS-Exam Rm to Disposition Time

Need realNeed real--time operational time operational & quality analysis tools& quality analysis tools

To remove human error.To remove human error.

SMNHC and SEH

Human vs Computer Coding

0

2000

4000

6000

8000

10000

Hospitals

Nu

mb

er

of

RN

LO

S

SEH

SMNHC

9928 9928 9928 9928 9928 9929

July 1st to Dec 31st 2002

APC 610

APC 611

APC 12

APC 620

SMNHC Billed 2,521 RN 4 > then SEH

SMNHC Billed 1,109 RN 6 > then SEH

7 Critical Issues7 Critical IssuesFacing EmergencyFacing EmergencyDepartments TodayDepartments Today

The Handwritten Chart:The Handwritten Chart:Hindering Productivity & Patient FlowHindering Productivity & Patient Flow

7 Critical Problems Related to the 7 Critical Problems Related to the Handwritten ChartHandwritten Chart

1) Illegible & incomplete documentation

2) Inefficient communication & delayed patient flow

3) Down-coding of charts & reduced reimbursement

4) Poor government compliance

5) Increased risk of error & malpractice liability

6) Tedious operational & quality analysis

7) Inefficient/error-prone prescriptions & discharge

1) PROBLEM: Illegible & incomplete documentation

SOLUTION: 100% electronic, user-friendly documentation system

• Rapid-fire charting from

triage to discharge or

admission

• Easy to learn, intuitive

(1 hour of training time)

• 100%, 24/7 usage by

physicians and nurses

• Interfaces with all hospital

systems and billing

companies

2) PROBLEM: Inefficient communication & delayed patient flow

SOLUTION: Staff communication, teamwork & patient flow enhancement system

• Instantaneously informs & empowers medical team

• Reduces patient’s length of stay & leaving without treatment

3) PROBLEM: Down-coding & reduced reimbursement

SOLUTION: Coding system for more appropriate reimbursement

• Automatic coding, eliminating costs & variability

• Improves documentation, eliminating non-billable & down-coded charts

• Captures all ED hospital charges

4) PROBLEM: Poor government compliance

SOLUTION: Mandatory government compliance in documentation system

• Automatic prompts requiring minimum level of documentation needed for full reimbursement

5) PROBLEM: Risk of error & malpractice liability

SOLUTION: Risk management system at point of care

• No more malpractice losses due to poor documentation: “Not documented, not done”

• Risk-reducing alerts for error-free care, especially high-risk or critical situations

• Mandates that highest standard of care is provided & documented

6) PROBLEM: Tedious operational & quality analysis

SOLUTION: Fast, insightful operational and quality improvement tools

• Real-time productivity tools for

department & by caregiver

• Quality assurance analyses of

any procedure or outcome with

next-day delivery

7) PROBLEM: Inefficient & error-prone prescriptions & discharge

SOLUTION: Prescription, discharge & follow-up systems

• Complete RX database with allergy detection

• Discharge instructions in

patient’s native language

• Medical record automatically

faxed to PCP/specialist

SummarySummary

• Hospital Administrators need to look at healthcare as a businessbusiness by implementing hospital policy and procedures that:

• View the patient as the customer, not the problem

• Embrace technology & improve hospital staff efficiency

• Create employees incentives that promote work ethic and stability