Boarding, diversion, long wait times and lengths of stay (LOS) are among many challenges facing overcrowded emergency departments (ED) throughout the country, and their impact on emergency patient care is well documented. There are many factors contributing to the increasing frequency and severity of these challenges; a practical solution for all of them may not exist. But teamwork, careful planning and a foundation-building approach for the implementation of an EDIS can — and do — make a difference.

Community Medical Center Healthcare System in Scranton, Pa. is already increasing the efficiency and quality of care its ED delivers. Implementing an EDIS and training staff to take the most advantage of its extensive capabilities was part of the plan.

Identifying Needs

Community Medical Center (CMC) is a 399-bed full-service hospital offering quality medical care in northeastern Pennsylvania with an accredited Level 2 Trauma Center, family and specialty practices, outpatient facilities, and long-term care and community education programs.

Prior to September 2008, CMC expanded its ED, increasing capacity from 20 beds to 45 beds. The ED currently averages 39,000 visits annually and manages close to 1,000 traumas per year. With the increase in patient volumes, CMC needed a solution to better manage ED patient flow and maximize reimbursement. Throughout last year, CMC experienced a decrease in overall LOS, improved compliance with core measure orders and a 20 percent increase in revenue capture.

In 1998, CMC improved patient flow and tracking by implementing an early version of Wellsoft Corporation’s EDIS. However, senior leadership within the ED, IT and hospital administration groups recognized afterwards that it could further enhance ED processes by adding electronic nursing documentation and computerized order entry processes and by tying wireless technology and computers on wheels (COWs) to the workflow. They predicted these additional features would increase efficiencies, improve quality of care and provide more complete clinical documentation for nurses.

Joe Fisne, CIO for CMC Health System, says, “In addition to having a solid IT infrastructure, successful projects at CMC require teamwork and coordination across many departments. Because the overall goal for any IT project is to improve efficiencies and quality of care, we’re sharing the lessons we’ve learned from the ED with our entire organization, including the rest of our acute care environment.”

System Selection

CMC maintains a foundational systems-priority philosophy, which Fisne explains is about focusing on core systems that feed an enterprisewide electronic medical record (EMR). Their goal, he says, “is to automate processes underneath the EMR before laying the platform for the system itself.” The organization is making progress toward that goal with the Wellsoft EDIS, and the patient tracking, nursing documentation and physician order entry systems it provides. In addition, its HL7-based standards-compliant order entry functionality for laboratory and radiology orders and results ensures integration with other hospital systems. “We established the need to use a standards-based platform, compliant with state standards, The Joint Commission and others, and determined we would automate in the ED first,” says Fisne. “Our next step is to ensure ED patient information is available and integrated into a hospitalwide EMR.”

Gina McCabe, RN, director, Patient Safety and Logistics, says CMC added Nurse and Physician documentation modules to their Patient Tracking system. “The ability to easily add new features and functionality, as well as the vendor’s technical expertise and project planning support, made our choice easier. In addition to improving patient care, which we accomplished by adding documentation features, we also had the goals of improved charge capture, one-stop chart review and improved patient and family satisfaction.”

Tracking regulatory requirements, eliminating patient care delays and improving overall organization and management were additional objectives for the new system. “A grease board doesn’t adequately allow the ED to prioritize patients appropriately,” says McCabe. “This EDIS product, with its patient tracking, nursing documentation and computerized order entry functions, allows us to get realtime data and makes it possible to know what’s happening across the entire ED.”

Implementation

Fisne says that building the EDIS interfaces was critical for clearly defining the nursing documentation processes as well as for identifying order entry turnaround times. “Using the vendor’s HL7-compliant interfaces, we interfaced directly to our Siemens/NOVIUS laboratory information system and our Siemens radiology information system.”

When lab and radiology results return quickly through the EDIS, the ED benefits because clinicians no longer have to log into and access two disparate systems — a process users found frustrating. “Now, everything is right there in front of the care providers while they’re giving care to the patients,” says Fisne.

Deb Clark, RN, ED nurse manager, says much effort ensured lab and radiology data interfaced properly with the system before they could go live with the nursing documentation functions. “It was just a matter of getting all our interfaces in working condition,” says Clark. “We didn’t want to start it and then have issues.”

Jim Pettinato, director of Critical Care, focused on data flow with respect to patients’ movement through the ED and identified process improvements utilizing the software.

“We worked with the vendor to marry our flow of the patient with the capabilities of the software,” says Pettinato. “We identified information gathered at different points in the process, such as when patients arrive or when they’re moved to rooms, and ensured the documentation reflected their progress through the ED.”

Pettinato, along with the vendor, examined the physician-ordering mechanisms; including how and when tests and studies are ordered as patients move through the ED. This resulted in developing role-defined prompts and data collection material at key points. “Once we determined a process and how our patients moved through the system, the vendor customized the documentation and order entry tool around the process,” says Pettinato.

A manual process of charting and physician order entry, which Pettinato calls the “racking system,” was vastly improved by automation, clearly demonstrating the efficiency of an electronic order entry system. Before using the EDIS to enter orders, physicians manually entered them one at a time into the system. Now, they are electronically transmitted from the bedside without the inherent delays of manual ordering and transcribing into disparate systems. “It may be one study or it may be a batch of tests, but having clinicians themselves do the ordering clearly cuts out the middle man and greatly improves some of our turnaround times,” says Pettinato.

Considerations

When CMC installed wireless networking at the gigabit level to transmit information it also integrated a system of COWs for medication administration. “We leveraged that infrastructure by incorporating it into our ED,” says Fisne. If the network is transmitting at the appropriate speed and the proper diagnostic checks are being performed, it’s just a matter of selecting the hardware that the ED prefers to use. “We discussed handhelds and related technologies but felt that COWs were our best fit.”

Enabling caregivers to upload or receive data from the EDIS when they weren’t near a COW became a matter of observing their workflows and identifying frequent travel paths through the department. “Many organizations invest substantial capital, time and effort into hardware but don’t observe the staff,” says Pettinato. “After implementation, we modified the hardware placement because the usage patterns that we had predicted proved to be inaccurate.” Re-evaluating hardware placement after an implementation is an important step, says Pettinato.

Training

Project planning for the EDIS expansion at CMC began in January 2008. “We could have done it a little sooner, before the ED expansion was complete, but we felt that training the staff first was key to a successful implementation,” says Fisne. “Any system you install is only as good as the training you provide your end users. If everybody’s running on all cylinders, you’re going to implement this product fairly quickly.”

Vendor-supported training sessions produced approximately 12 to 16 “Super Users” (system-trained frontline staff). Four-hour staff training sessions ran practically around the clock in a computer lab set up to train 10 users simultaneously. Training lasted about three weeks and finished just prior to go-live.

Clinician Input and Customization

Vendor support staff remained on site around the clock for several days during the September 2008, big-bang go-live, while the organization continued to elicit buy-in from key physician leaders. “We kept the physicians informed and they assisted us throughout the planning, implementation and go-live,” says Fisne. “Physician support, as well as the leadership of the organization, was critical to the project’s success.”

Physicians and nurses throughout the ED were encouraged to provide input and feedback. In addition to suggesting ways to customize the system, users were asked to identify information needed for the Medication Reconciliation form and to develop “needed orders” pick lists. Clark says this included building the order sets for easier order entry and adding drop-down menus for nurses to decrease typing. “The drop-downs allow nurses to press one key to add an entire narrative, which makes it more user-friendly. The system enables that kind of on-going customization.”

Pettinato says customized elements become effective immediately and are available for the next patient to arrive. Physicians contributed to customization during go-live and afterward, once they learned the system, many provided suggestions for particular circumstances and made recommendations for building items in that were not initially considered. “Once they got the hang of it, the physicians began creating their own improvements,” says Pettinato.

McCabe says post-implementation action plans were developed for trending the influx of new data. “After customizing data collection elements, we focused on the back end of the ED visit and identified the lengthiest delay, which was between the disposition inpatient and hospital admission points,” says McCabe. “From this, hospital administration re-evaluated many inpatient issues, which resulted in many changes.”

Results

Clark finds the EDIS easy to use and likes that it enables COW usage inside patient rooms. While nurses talk to the patients, they drop in data such as patient medications, allergies and past medical history details. “If the patient returns, we can import that data directly into a new chart with a single click, and verify other information,” says Clark. “With standing orders, I press a key while I’m assessing the patient and their orders go where they’re needed. It saves time retrieving charts and writing narratives.”

According to Fisne, CMC is not experiencing the records coding delays that they had been prior to implementing the Wellsoft EDIS documentation features. “With the efficiency gains of these new features we’re dealing with real-time data and quickly turning around our medical records coding. With this increased documentation accuracy, we can pull up any record and ensure that we followed the proper processes. We’ve minimized the risk of human error as much as possible.”

Prior to implementing electronic documentation, CMC used an external billing company to help improve its documentation by teaching good documentation practices to small groups of nurses. Nurse abstractors were added to scrub records for missing data before it went to billers and to ensure that all of the documentation that should be captured was there.

CMC analyzed the data from the abstractors to determine what was frequently missed or poorly documented and established a “best practice” standard for nursing documentation in the ED. This best practice approach ensures more complete documentation with fewer omissions, leading to maximized reimbursement.

“Fewer omissions, time savings and increased accuracy have contributed to an increase in billable services. As a result, CMC’s overall level of service improved,” says Pettinato. “We saw a big shift in acuity levels from our level 3 patients to our level 4s, and even an increase in our level 5 patients, post-go live, and our patient mix number changed as well.”

Support Is Crucial

Clark says buy-in from everyone involved is a must to make the implementation successful, especially buy-in of the end users. “We weren’t just going to hand it to them and say, ‘This is the way it is.’ End users had a lot of input, which made the go-live as well as all the transitions we’ve made since then, successful, because their input drove much of it.”

“Senior management must support the project because while there are the hard costs of hardware and software, installation and getting things up and running, there are also soft costs involved and resources needed that typically aren’t included in the project plan,” says Pettinato.

“Senior management has to support those. The last thing you want is to commit these resources and have the plug pulled in the end because these things weren’t considered. It’s about keeping the project on target.”

“Any implementation like this is done to support the entire institution,” says Fisne. “There has to be a relationship established between the Information Technology group, the leadership of the departments, as well as with the vendor — a 3-way partnership. Now that we have the EDIS in place, our goal is to implement other departmental systems, including in the operating room.

“Then, we’ll begin vendor selection for the EMR, with the plan that the information captured in departmental systems, such as the EDIS, will integrate into the EMR solution.”

February 2009