As U.S. hospital emergency departments struggle under the weight of overcrowding, lack of staff and ever-increasing government health-care regulations, many are finding relief through IT systems.
After The Mount Sinai Hospital in New York implemented an emergency department information system, it went from 5,000 lost or illegible charts in 2003 to none in 2005, a year after it moved from paper to electronic charts. Across the country at the Daughters of Charity Health System in California, revenue rose US$40 million across six emergency departments because of better billing processes after an electronic system was put in place.
Such impressive returns on investment can be found at hospitals nationwide at the same time that the federal government is pushing health-care providers to move to electronic records and various agencies and industry groups release report after report about emergency department overcrowding and other issues. The U.S. has almost 4,000 hospital emergency departments, or EDs, and many of those are at “critical capacity” with patient visits overall in excess of 107 million per year, according to the American College of Emergency Physicians. Add to that the emphasis on disaster response by emergency departments and the need to track biohazards and threats from epidemics and automation becomes all the more imperative.
“By automating processes, the time a physician spends looking for charts, tracking down laboratory results, mobilizing staff, and repeatedly recording information that someone else already recorded can be dramatically reduced,” ACEP says on its Web site. “Information technology is changing the way today’s emergency departments operate by speeding the flow of patients through bottlenecks, eliminating redundant patient records, sharing complete medical records, and allowing laboratory tests and films to be viewed instantly and simultaneously at multiple sites.”
Computerizing an emergency department can further decrease costs while increasing revenue and improving care and efficiency, ACEP says. Legal liability can be decreased, labor costs might drop and far fewer patients might give up and leave without being seen because wait times are too long or because they simply get lost in the paper trail.
“I think that our patients get better care,” says Dr. Kevin Baumlin, the director of informatics for the department of emergency medicine at Mount Sinai. “That’s the real point of all of this. It’s about taking care of patients, not about making money.” The Mount Sinai ED sees anywhere from 180 to 320 patients on any given day.
Initially, getting the funding for an automated emergency department system was a challenge, Baumlin says. The hospital spent $150,000 on workstations and spends $28,000 per year on maintenance. A little less than $300,000 a year goes for application lease payments support and actual upkeep. The hospital went with a software system from Picis Inc., based in Wakefield, Massachusetts. It signed its contract for that system in August 2003 and then went live with triage tracking and discharge instructions components of the software system in November of that year. A measured rollout of other software tools followed until the last phase for scanning and an interface to the billing application went live in June 2004.
Getting the staff to accept the new system was a hard sell, but Baumlin set about doing that in a “fairly methodical way,” with all 28 ED doctors and 80 nurses invited to participate in evaluating vendors. He found the “rule of thirds” was in force, with one-third liking the idea of a thorough IT system, one-third ambivalent to it and one-third not keen on it.
One goal Baumlin set, and achieved, was making sure there were enough computers to go around so that even at peak times staff who need a workstation have access to one. The ED has 143 computers, amounting to one for each doctor, nurse, support staffer, and consultant — plus 10. “I did not want any provider who needed a workstation waiting for a workstation. In my world if you have to wait more than three seconds you’re done, you’re on to another task,” he says. During peak times, the emergency department will triage up to 20 patients an hour.
Another benefit has been the ability to work with other sites using Picis software to share data sets and study information on crowding, how rapidly patients who say they are in pain are cared for when they arrive at an ED during a crowded time, as well as to design and share research. “It’s a wonderful research tool,” Baumlin says.
He can also better respond to the needs of regulators and federal mandates that require chart analyses and metric tracking. Without the electronic system, “you’d have to actually hire FTEs [full-time equivalent employees] to do chart reviews and pull them out in real time. That’s just nuts. … I can sit here and pull up the number of pneumonia diagnoses we had last month. In two minutes.”
Besides working with the software, he continues to evaluate hardware, asking if laptops or handhelds will work better, for instance. Laptops don’t work so well in small spaces and handhelds have small screens. And patients, particularly those in emergency care, “want to talk to us — they don’t want to talk to the computer in between us. … The patients really want that three-minute encounter to just be you and them. As a physician, I’d rather just go touch the patient, hold their hand, say hello, find out what it is I need to do and then do the documentation later.”
Doctors at Daughters of Charity’s five hospitals and one skilled nursing facility are engaged in the same balancing act. At the health-care system’s St. Francis Medical Center in Lynwood, California, 70 percent to 80 percent of the ED staff document patient care on laptops that they roll on carts or carry to bedsides, says Dr. Mike Stephen, the medical director of emergency services. He does about half of his documentation at the bedside and the other half after he has finished talking to the patient.
The 14 ED doctors and other staff at St. Francis needed about six to eight months to get comfortable with the new system, also from Picis, with deployment beginning in January 2004.
“From the corporate perspective, we were looking at really improving patient satisfaction and being able to document and show improved patient care,” says Richard Hutsell, vice president and chief information officer of the health system, based in Los Altos Hills. “The vast majority of our hospitals are located in some of the more economically challenged areas” of the state.
The decision was made to implement the automated system first in the emergency departments and then roll it out through the rest of the hospitals. “My view is that the ED is the window to the community and I wanted to make that as efficient as possible,” he says.
The system also lets staff track bed capacity, so they know when they’re full up and also allows for keeping tabs on peak times, which helps EDs to make better decisions about when to have more staff on hand. The total cost to implement the system to date has been about $4 million for all facilities, but that has already been recouped because of the improved billing process.
An average hospital will find the implementation of such a system pays off in five to eight months after installation because of such revenue increases, said Todd Cozzens,CEO, president and vice chairman of Picis. He turns around the question of the expense of implementing an automated system of software tools and applications to ask, “What’s it cost to