(Good) growing pains.: Michigan ED automates patient tracking, nurse documentation and charge capture to maintain excellent customer service, increase efficiencies and boost revenue.

MetroHealth Hospital's emergency department (ED) struggles with the same issues facing EDs across the country. We operate in a challenging fiscal environment and face rising volumes of patients. We also strive to meet high customer expectations for efficiency and exemplary service. Prior to 2001, our customer service was good and sometimes exceeded benchmarks. Busy ED nurses, who were primarily focused on patient care, however, often did not have the time or expertise to capture charges and assign ED levels of service. Our dilemma was how to maintain excellent service with escalating demands and finite resources--and capture charges more effectively.

Forty percent of our admissions to the hospital come directly from the ED. MetroHealth could not underestimate the importance of optimally managing our growing ED. In 2001, we began replacing our cumbersome paper--and white-board based system with an emergency department information system. Today, we have not only maintained our high level of customer service, but also improved our operational efficiencies. And we boosted revenue by capturing charges more effectively.

MetroHealth Hospital is a 238-bed acute care osteopathic hospital located in suburban Grand Rapids, Mich. We provide a wide range of acute, chronic and rehabilitative services and support a large network of primary care physicians. We are also a teaching hospital affiliated with Michigan State University. Our hospital is part of Metropolitan Health Corp. Metropolitan owns 10 neighborhood outpatient centers and a 170-acre health village in Wyoming, Mich., where our hospital will relocate to in 2007.

In 2001, our ED of 42 FTEs and seven physicians saw approximately 33,000 patients. Our average length of stay (LOS) was 2.18 hours for outpatients and 3.98 hours for inpatients. The average time from when the patients arrived to when they saw the physician was greater than 30 minutes. Only about 1 percent of our volume--an average of 20 people a month--left without being seen. Our Press Ganey patient satisfaction ratings, in relation to other hospitals, were in the 85th percentile rank. We were doing well. To continue to provide great service and improve our financial standing, however, we needed to get a better handle on tracking patients, documenting their care and capturing charges.

Ubiquitous White Board

Prior to 2001, we had a white board to track patients in ED. We not only didn't have a real-time view of the patient's location or care process, but worse, we couldn't capture and review tracking information to analyze for improvement. Nurses and physician staff vied for patients' paper charts. It was often difficult to decipher handwritten nursing documentation.

Our manual coding and charge capture system was labor- and time-intensive. At the end of each patient's visit, nurses checked boxes on a charge sheet based on the care provided and resources used. The nurses did their best to accurately capture charges. Audits showed, however, that we left money on the table. Automation would make us more efficient, improve the delivery of patient care and help us build revenue. It would also help us confidently comply with the requirements of regulatory bodies like the Healthcare Facilities Accreditation Program (HFAP) and the Centers for Medicare & Medicaid Services (CMS).

The EDIS (emergency department information system) team spent five months, from January to June of 2000, intensively reviewing and evaluating solutions from various EDIS providers gleaned from Emergency Nurses Association (ENA) contacts and elsewhere. The MetroHealth ED team realized early on that success would hinge on bringing together key players from the entire hospital. This meant full involvement of the finance and IT departments working collaboratively with ED staff and administration.

Our team initially considered more than five vendors ranging from large enterprise software companies to "best-of-breed" vendors focusing solely on emergency department solutions. We quickly narrowed our choices to three top picks. Our IT director led the team through an abbreviated RFP process using a three-page grid listing our expectations and required features and functions. Cost was one of the major factors. Our team assessed the criticality of each feature and scored each proposal. Conference calls and demos were the final steps.

MetroHealth had little experience with electronic documentation and many of our staff were not yet comfortable with computers. When evaluating vendor systems, therefore, we gave ease-of-use high consideration. The concern was that vendor solutions that required a lot of keystrokes, mouse-clicks or movement between screens would be a significant disincentive for nursing staff. We required a product with touch screen technology that made intuitive sense to our staff. We also looked for a product that would allow us to incorporate ENA standards into our documentation, thus enhancing our nursing records. In July of 2000, we signed a contract with MEDHOST Inc. of Addison, Texas, primarily because of the cost of its EDIS and the product's touch screen functionality. Its template reports and workflow tools also were important.

Tracking First

We implemented the EDIS in three phases to gain maximum buy-in from all involved staff, as well as build the costs into our budgets incrementally over several years. Phase 1 included tracking and triage documentation. In Phase 2, we went live with nurse documentation. Phase 3 was the roll out of the charge capture module.

For tracking and triage documentation, the MEDHOST team and our EDIS committee spent four months before go-live analyzing our workflow, customizing the software and developing interfaces with our McKesson HIS. During this time, we also bought a new server, eight wall-mounted flat screen monitors and seven standard PCs for our ED, and we added another printer to the two already used by the ED. Staff received eight hours of classroom training and physicians were invited to a two-hour training session. Everyone was proficient on the tracking and triage documentation system in two days.

On March 27, 2001, we retired the white board and went live with automated tracking and triage. Today, ED clinicians can instantly see all the beds available and view the status of all patients at a glance. We can quickly assign patients to an available room, thereby reducing the wait time for seeing the physician. By giving the triage nurse access to the EDIS, patients are entered into it--and the hospital system--the moment they arrive. Key steps of the care process are recorded and "time stamped" throughout the patient's visit. This data generates a variety of reports we can use for analysis and quality improvement initiatives. Plus, instead of handwriting discharge instructions and prescriptions, the physicians use the tracking module to match electronic folders of instructions to patients' diagnoses and generate discharge instructions. They also can choose prewritten standard electronic prescriptions, which they can modify and print out with the patient's name. No more handwritten instructions and prescriptions for us.

Charge Capture Eliminates Bias

We went live with nurse charting on May 5, 2003. In preparation, we spent the previous four months customizing the automated fields and templates, developing our training plan and purchasing additional hardware. Training for nurse charting was minimal because staff were already familiar with the system and how to move around in it.

The transition from paper to electronic charting was smooth and fairly painless for our staff. Now, instead of hunting for the paper chart and walking to the nurses' station between seeing patients to document, nurses can document patient care directly via a wall monitor with touch screen technology. Nurses spend more time on patient care and less time on documentation.

The following year, we went live with the charge capture module on May 28, 2004. Again, training was minimal because the nurses just continued to document their care as they had done previously. Prior to go-live, we built our charge capture system by tying charges to key nursing tasks and documentation. To study the financial impact, MEDHOST activated the automatic charge capture module but our nurses continued their manual process without access to the electronic data. Then, we compared three months of manual charges to the automated charge capture. A separate analysis by our finance department concurred with MEDHOST's conclusion--the financial impact would be significant.

Now that it's automated, charge capture by clinical personnel no longer has the potential for user bias and subjectivity. Automating the charge capture process allows us to build charges consistently and accurately as the nurses document care. We did not interface the charge capture module with our McKesson STAR billing system because it could not directly accept the charges. ED staff still were required to "touch" or audit the charges to ensure that we sent correct bills. Therefore, we continue to have nurses audit the charge sheet generated at the end of each encounter for accuracy and manually enter the charges into our billing system.

Building on Success

Implementing the EDIS system resulted in MetroHealth achieving our clinical, administrative and financial objectives. Our average LOS for discharged patients is 1.86 hours compared to 2.18 in 2001. This reduction is more remarkable when you multiply the average time savings of 19 minutes by our current outpatient volume of 98 outpatients discharged per day.

The average LOS for the 8 percent of ED patients admitted to the hospital is now 3.55 hours, compared to 3.98 hours in 2001. On average, patients can see a physician within 19 minutes of arriving in the emergency department, compared to a more than 30-minute wait in 2001. Now, only an average of four people a month--significantly less than 1 percent of volume--leave without being seen, compared to an average of 20 a month before we implemented the EDIS. Because we electronically document every patient encounter, it is easy for administrators to run reports and evaluate the performance and efficiency of the ED on a daily, hourly or immediate basis.

The EDIS implementation has produced dramatic financial results. Since going live with the charge capture feature in May 2004, we have generated an additional $50 in net revenue per outpatient. With more than 35,700 annual ED outpatient visits today, this translates into $1.8 million in annual incremental revenue for our hospital. It also helps us comply more easily with HFAP and CMS regulations and maintain continuous readiness for accreditation.

Today, approximately 100 nurses, physicians and staff members use the EDIS. We are currently evaluating a proposal to rollout physician documentation for our resident physicians. Within the next six to 12 months, we anticipate implementing computerized physician order entry at MetroHealth. Beyond that, our next challenge will be transitioning from our 21-bed ED in 1970s facilities to our new 32-bed emergency department in 2007. The EDIS will be a welcome addition to our new emergency department designed to optimize patient flow and operational efficiency.

Helen Berghoef is director of emergency and ambulatory services at MetroHealth Hospital in Grand Rapids, Mich. Contact her at [e-mail].