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End-users: four benefits: countless: Clinical information systems aren't limited to documentation in acute care hospitals. Four end-users of EDIS, bar coding, oncology and patient tracking IT share insights on the benefits and challenges of stretching CIS to its limits.

Technology Streamlines ER

Carol Hendrian, R.N., went out on maternity leave. A month after she returned to her job, she was rolling out the first components of the ibex PulseCheck emergency department information system.

As director of emergency services for the 325-bed Decatur Memorial Hospital in Decatur, III., Hendrian knew that tracking the 40,000 patients who visited the ER every year was an arduous task involving a lot of paper and wasted time. "There was never any emphasis on time," she says. "Charts were left on the doctor's desk in the order we wanted them seen. The doctor would just go from the top of the pile down."

The ibex system allowed the ER to decrease its patient turnaround time 22 percent, from 173 minutes to an average of 135 minutes. Similarly, door-to-doctor time (the time it takes for a patient to be seen by a doctor) has decreased 77 percent, from 70 minutes to about 16 minutes.

Improved Reports

Also, emergency services' monthly reports are now more accurate. "For years, we tracked a large number of measurements and thought we were pretty good at it, but the ibex system has allowed us to see where our reports were wrong. For example, we thought we might have 10 patients a month who were here for six hours or more. The first month we used the system to track this, we learned that we had about 80 patients. The system allows us to see bottlenecks or problems, not just guess at them," Hendrian says. By September 2003, the number of patients in the ER for six hours or longer was down to 20.

Automating the ER also led to better staffing. "We always thought Monday was our busiest day. But we learned that Saturday, Sunday and Monday are collectively our three busiest days, and that Friday is our least busy day. Now we can staff according to those patterns," Hendrian says.

The first phase of the rollout included the triage, patient tracking, physician documentation and discharge instructions modules, while the subsequent phase included the nurse documentation module and interfaces to lab and radiology systems.

Hendrian admits that implementing the system forced the staff to look at how they had done things in the past. "We used the computer system to address process and procedures," she says. "Those have changed, which has resulted in better outcomes. But I can't say it was 100 percent the computer system." Her staff, she says, stopped using a lot of "paper crutches" and eliminated many needless of repetitive steps.

Customized Tracking Board

In time, staff also began focusing on the tracking board, a significant feature of the PulseCheck System that Decatur Memoria] has customized.

Although the tracking board can be viewed on any of the department's computers, moving into a larger space at the end of 2003 allowed for the installation of large plasma screens at either end of the ER, which now can be viewed by all staff members. But because of HIPAA regulations, names of patients are only viewable from the computer.

By using colors, lights and letters ("X" for X-ray, "L" for lab and "E" for EKG), the tracking board tracks a patient from the time he enters the department to the time he is discharged of admitted. It also allows nurses and doctors to order tests and read the results. "Everything is based on your sign-on," Hendrian says. "If I'm a physician and I click on 'L,' it shades the field white, meaning that the physician has viewed the lab work that's back. Everyone will see it white, but only the physician can turn it white."

Another example is the letter "V," which stands for vital signs. If the "V" is black, the vitals are normal for that patient, Hendrian explains. If it's pink, they're borderline, and red means abnormal. "If that 'V' is red and I click on it, it takes me to vital signs and automatically highlights the abnormal vital signs," she says. Similarly, if a patient's name is in bold type, that means he has been to this ER before. With two clicks, Hendrian can pull up the patient's history.

To determine a patient's length of stay in the ER, color is used again. Green means more than two hours, yellow means four hours and red means six hours or longer.

Hendrian says that since the systems as been up and running, both patients and staff have benefited.

"There is always some resistance to change, but if everyone works together, we can provide the best quality care in the most efficient environment."

For more information about PulseCheck from ibex,

Barring Errors

Scanning bar-coded medications when administered should reduce errors at the point of care. That's why NorthEast Medical Center in Concord, N.C., a 380-bed, nonprofit hospital that runs a family medicine residency program, decided to invest in bar coding technologies from Bridge Medical Inc.

"Once the patient, the nurse's badge and the drug are scanned, the system will generate a charge for that transaction. In effect, there will be nothing to audit at billing, since every transaction will be charged automatically when the drug is administered," says Jeffrey Patchett, R.Ph., M.B.A., NorthEast's director of pharmacy services.

Although the rollout of MedPoint began in August 2002 and was completed hospitalwide in March 2003, work actually began in June 2002 with the integration of databases and the hunt for prepackaged, bar-coded units. "We wanted 90 percent to 95 percent of drugs with bar codes," Patchett says. "When we did site visits, many other hospitals only had 50 percent of drugs bar coded." Currently, 90 percent of all doses administered to NorthEast patients are being scanned.

A Nursing Tool

When the system was rolled out, it was never touted asa pharmacy-based system, Patchett says. "The medication administration record is a nursing tool, not a pharmacy tool. Many people think that because it involves drugs, it's owned by the pharmacy, but it isn't. Nurses administer medications."

Patchett says that the medication administration record is a nursing tool that, historically, has been verified by the pharmacy. But when the MedPoint system was installed, nurses were told, "Now we're going to put it on the screen. It's the same tool, but we want it to be user-friendly for you. We want you to be experts at using it."

Although MedPoint features three integrated applications, it is the point-of-care application that uses touchscreen and bar code scanning technologies to provide nurses with information on medication orders, patient allergies, medication administrations and pre- and post-administration clinical observations. Nurses find it easy to use, because it uti]izes a handheld scanner and a cartmounted laptop that can be wheeled into each patent's room.

The system includes a unique reference feature that resulted from a partnership between Bridge Medical and Lexicomp, a publisher of instant reference guides. If a nurse has a question about a certain drug, she scans the drug and then clicks on an icon that takes her directly to the drug in question on the Lexicomp Web site. "We have it set up so even our pharmacy staff can use it," Patchett says.

Challenges to Overcome

But utilization is not without challenges. One example is the split-dose effect. The order might be to administer 500 mgs. of a medication twice daily, but the medication might come only in 250 mg. tablets. The nurse would have to scan two tablets for the first dose and another two tablets for the second dose, but the system will read that as four doses, not two, and will shoot out a warning even though there isn't an error. Patchett says the next version of the software will be even smarter to take this type of issue into account.

A common but preventable problem involves drugs with the same name but with different ingredient strengths. "A lot of oxycodone-related products have multiple strengths of aspirin or acetaminophen," Patchett says. "So, we're going to limit the number we have and supplement them with additional aspirin of acetaminophen."

Other challenges were more procedure-centered. Psychiatric patients, for example, might feel threatened by the scanner, so nurses attached the patients' pictures to wristbands kept on the cart and then scanned them in the hallway.

Some nurses--especially younger ones--initially thought the three-step scanning process slowed them down. When it comes to saying, "this is making me a better nurse," it is the older nurses who have bonded most with the system, Patchett says.

Fore more information about MedPoint from Bridge Medical,

Linking Cancer Theraphies

Running a comprehensive cancer center requires a robust CIS, says Jeff Skjerseth, administrator of the Cancer Treatment Center in Swansea, III. The system not only needs to integrate data pertaining to the medical and radiation oncology departments with data collected from CT scans, MRIs and PET scans; it must also provide a comprehensive scheduling and practice management system, too.

For the Cancer Treatment Center, the challenges were compounded. This free-standing, not-for-profit center is owned by two competing hospitals in nearby Bellville. "They decided not to compete when it came to cancer treatment, and to provide the community with one complete comprehensive cancer center," Skjerseth says. "Because we are a free-standing facility, we bill and operate like any other physician practice. We also have the added responsibility of providing services for the two hospitals."

The Cancer Treatment Center also offers additional staff and services that usually are found in a major university setting, such as a full-time dietitian, a full-time psychosocial counselor, massage therapy, yoga training and support groups for patients. "You can make huge gains in efficiency by having one system that can interact with all the different equipment and technologies in a comprehensive center," says Skjerseth.

Multiple Modules

In 2000, Skjerseth began rolling out an oncology CIS developed by IMPAC Medical Systems Inc., but only after considering products from other vendors. The problem was that other products "were designed just for medical oncology or radiation oncology or practice management. The reason we picked IMPAC was because it provided one solution in a single, comprehensive package. We wanted a system that would handle the complex clinical data collection necessary for cancer treatment, but also one that would link and correlate to administrative requirements and financials," he says.

Included in this suite is eChart, an electronic medical record designed to document patient information throughout the medical assessment and chemotherapy process; PhAST Note, an automated physician documentation system built around customizable, disease-based templates that generates a complete patient note without the need for transcription; eVAL, an assessment tool for documenting patient data, chemo- or radiation-induced side-effects and quality-of-life indicators; and METRIX, a statistical query and report generator.

Skjerseth also had added IMPAC's new clinical trials component, which will help analyze patient data and match those patients who meet the specific criteria for clinical trials being offered. The center, which is filmless, also uses IMPAC's ViewStation product to store and maintain its digital film component.

Skjerseth adds that the center worked with IMPAC to develop an interface to its chemotherapy drug-dispensing unit. The system automatically creates the charges when any drug is removed from the machine and transmits those charges to the system's billing module.

One Piece at a Time

Surprisingly, the rollout of the IMPAC CIS marked the first time personal computers were ever used in the center. That meant many staff members had to be trained in basic computer skills as well as how to use the software.

This challenging style of rollout worked to everyone's benefit, because it allowed them to become part of the process, and they were invited to offer suggestions on how to improve the process.

Skjerseth admits there was some resistance from physicians, but notes, "You can't throw it at a doctor all at once. The key is to let the physician master one piece of the electronic puzzle at a time. It should follow a logical process: scheduling, dictation, electronic orders. By following this strategy, physicians are able to see the full benefits of an electronic chart and make it easier to integrate the technology in their clinical process."

Putting Patients to Bed

Finding beds for all patients admitted each day to a major university medical center takes a team effort and a CIS capable of minute-to-minute tracking of both patients and beds.

In a strategic move to improve efficiency, the University of Wisconsin Hospital in Madison, Wis., formed the PREP (Patient Referral, Evaluation and Placement) Center. "There were multiple ways a physician could have their patients admitted, but there wasn't a centralized process," says Heidi Norwick, R.N., M.S.N., the PREP Center's director. "We don't openly call it a command center, but it functions like that. We do centralized evaluation, admission and acceptance of all patients coming into our system from referring hospitals, transfers within our own hospital, referring clinics and our own ED."

That's no small task. The University of Wisconsin Hospital is a tertiary regional academic medical center that has a Level 1 trauma center, a large transplant center, comprehensive cancer center, clinical cardiac center, neurosciences center, children's hospital and a full array of tertiary services available to citizens of Wisconsin, the upper peninsula of Michigan, Iowa and lllinois.

Unplanned Admissions

Although the hospital has 560 licensed beds, Norwick says, "A bed is not just a bed." There are beds for children, security beds for prison inmates needing medical care, psychiatric beds, beds in the cancer center, cardiac beds and ICU beds, to name a few. When the PREP Center is notified that an adult patient will be admitted, Norwick and her staff need to know why that patient is being admitted and where he can be accommodated.

"Our role is to have appropriate, accurate information on every patient," Norwick says. "For example, a patient in a rural hospital may be in that hospital's ICU, but won't require ICU care in our hospital. At the PREP Center, we need to have staff who can appropriately evaluate the need, and then use the technology to smoothly schedule the admission."

But only 28 percent of admissions are scheduled; 72 percent are unplanned, and most patients have emergent medical needs.

"Years ago, we would have several hours to plan for an admission, but that's no longer true. Now, we need all services and all personnel to be onboard with realtime knowledge of who is in our beds, who is coming in, who is going out and when," says Norwick.

Two years ago, the hospital began rolling out all components of the Bed Management Suite of software from Tele-Tracking Technologies Inc. Fully installed in December 2002, this workflow automation solution integrates the Bed-Tracking and PreAdmitTracking modules with an electronic bed board so that environmental services, admissions and patient placement staff know the status of any patient, as well as which beds are occupied, currently available of needing to be cleaned. The TransportTracking module uses the hospital's existing telephone network to allow the staff to log a patient transport request and to be alerted if a specific request has not been addressed within a predetermined length of time.

Norwick says the PREP Center had been using a "homegrown bed board" developed in conjunction with the medical center's IT department, but it lacked an ADT (Admission Discharge Transfer) interface and required the double-entry of data, which increased the probability of errors.

With Tele-Tracking's color-coded electronic bed board, data entered once is immediately available throughout the institution. This information can be accessed from any computer and can be seen on the large, wall-mounted plasma screen in the PREP Center. Viewable data is determined by specific "view rights': Nursing stations can see information pertaining only to their units, while the ED and postanesthesia care unit have whole institution views, she says.

Cleaning and Repairing

The system has streamlined the critical process of getting rooms cleaned before a new patient is checked in. Norwick recalls that a couple of years ago, 80 percent of room-cleaning requests from nursing stations were "stat," or clean immediately. Today, because PREP staff can accurately track patients and bed availability, cleaning assignments are prioritized. "Routine dirty" means clean in 90 minutes; "clean next" means environmental services will get to it in 60 minutes or less; "stat" means the room must be cleaned in 30 minutes because the patient is in the system of in an ambulance. The only person who can change a request is a member of the PREP staff.

Like hotels, hospital rooms periodically need repairs or refurbishment. In the past, it was hard to know when a particular room could be taken out of service for a length of time. Now, rooms can be "blocked," and the information about what is being repaired and when repairs will be complete can be displayed on the bed board. Also, repairs are prioritized as either emergent or elective. Decisions concerning emergency repairs are made by both the nursing and plant engineering staff, but all elective repairs must be approved by the PREP Center based on patient needs and room availability.

For more information about patient, bed and trasport tracking from Tele-Tracking Technologies,

Richard R. Rogoski is a free-lance writer and contributing editor to HMT. Contact him at rogoski@aol. com.
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Title Annotation:Clinical Information Systems
Author:Rogoski, Richard R.
Publication:Health Management Technology
Geographic Code:1USA
Date:Jan 1, 2004
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