HIMSS Daviesenterprise Application Submission Form

HIMSS DaviesEnterprise Application Submission Form

HiloMedicalCenter –End-user EfficiencyMenu Case Study

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Name ofApplicant Organization:Hilo MedicalCenter

Organization’s Address:1190 WaianuenueAvenue, Hilo, HI 96720

Submitter’s Name:Money Atwal

Submitter’s Title:CIOCFO

Submitter’s E-mail:

MenuItem:End-user Efficiency

Executive Summary

Various information systems, applications, and enhancements at Hilo Medical Center (HMC) have led to an increase in end-user efficiencies. The Emergency Department (ED) has decreasedthe length of stayby 39% and increased patient volumesby 13 %. An increase in all Imaging modalities patientvolumesby 11% also occurred. Simultaneously, the hospital’s Press Ganey patient satisfaction scores were maintained during this period of ED and Imaging technology growth.

In2009, HMC went live with a picturearchival andcommunication system (PACS) allowingthe Imaging Department to store, display,and interpret theimagingstudies electronicallyleadingto adecreasein exam to interpretationtimes. The followingyear, the electronic healthrecord (EHR) system wasimplemented. TheEHR provided tools to assistin improved coordination of patient admits and real-time patient trackingthroughout thefacility. In the ED, enhancements madeto the tracking board with links to orders, results and admit status now provide the toolsend-users require to accomplish their day-to-day responsibilities efficiently. In theyears followingthe EHR implementation, additional ancillarysystems(e.g., GE Museand PowerScribe 360) contributed to an increasein patient throughput,as wellas, further decreasingturnaroundtimes between requestedexams and final results reporting.

1. Background Knowledge

Hilo Medical Centerbelongs to theEast Hawai’iRegion of Hawai’i HealthSystemsCorporation(HHSC). It isa276-bedfacilityservicingtheIsland ofHawai’i and boastsoneof thebusiest EmergencyDepartments in the state. HMC’s missionof “improvingtheir community's health through exceptional andcompassionatecare”is aconstantreminderand drivertoward making improvements in ancillarytechnology,as wellas,the EHR to achievetheexceptional care goals.

Patient flow and throughput can haveboth positive or negative effects on patient satisfaction and the level of care.If patient processes are properlycoordinated, waittimes can bedecreased leadingto fastertreatment andbetter outcomes. Inconjunction, decreasedwaittimes will increasepatient throughput allowingthe facilitytotreat morepatients while containingstaffing costs. Thus, institutingchanges in areas likethe Emergency, Admitting,andImaging Departments to optimizepatient flow and throughput is not onlybeneficial forthe patients, but the organization as a whole. In order toattain efficiency, consideration ofthe end-user knowledge flow isinstrumental. A 2014 white paper by Ian Chuang,MD, states, “Knowledgemustbeprovided at the right time, forthe right individual, forthe right decision, and tietogether with other decision points anddecision flow alongtheentire care continuum.”[i]

1. Local Problem Addressed and Intended Improvement

Before2009, Hilo Medical Center employedamanual process of printingimagingstudiestofilm,hangingthefilmsforinterpretation, and providinghandwritten preliminaryreports to the EmergencyDepartment. Generating a preliminary report could requireup to 45 minutes prior to reaching the hands of the ED physician,and 308 minutes for final report creation – only minimalinformation wasavailable for Stat exams.

Priortothe implementation ofHilo Medical Center's EHR in May2010, patients in the EmergencyDepartment weretracked on a hand writtenwhiteboard. This static methodof patient tracking adverselyaffected patient flow. In some cases, patients would bemoved to new rooms without the whiteboard beingupdated causingdelays in testsand treatments as thepatient couldn't be foundin the assigned room.

Patient admits to the acute facilitywerecompletedusingamanual process. This process included numerous phone callsbetween the admittingdepartment, receivingdepartment, and nursingsupervisor. Printed papercensus reportswereused to determine available beds, but only provided astatic view ofbed statuses.

Delays in providing finalreports fortestsand exams toorderingprovidersled to a delayin treatment of diagnosed conditions and patient waittimes. Thesedelays, inturn, had the potential to increasepatient's length of staysrequiringadditional resources to continue care. Decreasing the turnaroundtimes forfinal reports allowedorderingphysicians to morequicklyaddress patient's diagnosed conditions and diminishwaittimes.

Ineach of the above scenarios, ways to minimizedelayswere examined and addressed. Also, in each,ahealth information system (i.e., PACS,EHR, etc.)was tasked with creatingamoreefficientenvironment that would positivelyimpact patient outcomes.

1. Design andImplementation

Recognizingseveral areas playedalarge rolein determiningpatientthroughput, HMCfocusedon creatingmore efficientend-userprocesses to accomplish specific tasks. The Imaging, Emergency, and AdmittingDepartmentswerethe most affected bythe new workflows. However, additional ancillarydepartmentslikeRespiratoryTherapyand Housekeepingwere also impacted.

A phased approachwas utilized toimplement the various workflowchanges. Initially, the focus was on decreasing exam and interpretation time within theImagingDepartment. The following year, improvements toEmergencyDepartment processes wereput in placeto provide real-time patient tracking, patient status updates, and notifications of results. In 2012, the entireadmitting process was overhauled toeliminate unnecessaryphone calls andstreamlineworkflows. Along with this work came additional vendorselections toalign necessaryancillaryservices with the EHR. Today, the improvements madein the ancillaryarenaresulted increation ofstreamlined interfaces to advance interoperability,not just forHMC, butthe East Hawai’ienterprise; seethearchitectural diagramofinterfaces implemented in Figure 1.

1. How Health IT Was Utilized

With the implementationof FujiPACS, theImagingDepartment was ableto electronicallydisplayimagingstudies forinterpretation, aswellas, provide typed preliminaryreports for the EmergencyDepartment. Imagetransmission times from the modalityto PACSwerecompleted in at least half thetime taken to print hard copyimages. Printingasingle imagewould typically takeaminimum of 30 seconds whilethe transmission of asingle imageto PACSis completed in onesecond. Extrapolatingthe dataled to a minimumtime savings of approximately483 hours annually. The impact of the PACS implementation to end-user workflows can be seen in Figure 2. Themanual process of hangingstudies for Radiologistinterpretation was eliminated, removing adelayin reading images ofseveralhours. The Radiologists'handwritten preliminaryreports werereplaced bytyped notes, whichcould begenerated within seconds and viewed within PACSimmediatelyupon savingthedocumentation. Thetyped written notes were supplemented with “canned” text for frequent findings, further decreasingthetime required to generateapreliminaryreport.

Figure 2: Pre and Post PACS Implementation Workflows

Within theEmergencyDepartment, theimplementation of theEHRallowedstaff to usean electronictrackingboard to display patients, rooms, statuses, and resultindicators. From a quick glanceat thestatus board, astaff memberdetermines if thepatient was currentlyinan ED room and iftheyhadbeen seen bya physician. Staff are alsoable to tell if orders havebeen placed forlaboratory or imagingstudies andif thesetests havebeen resulted. The real-time status board provides staff withadditional information regarding whetheror notthe patient needs to be admitted andif so, the location and bed number assigned to thepatient. TheED Tracker serves to tie information from disparate systems togetherand present an overallcomprehensiveviewof thepatient's conditions andstatus. For example, icons indicatingpendingorperformed orders displayon the tracker. These indicators provide links to specific areas of theEHR which house additional links to systems like PACSand GEMuse (anelectronicstorage, viewing, and interpretation application for EKGs), as seen in Figure 3. Utilizingtheselinksto access information from theancillarysystems streamline the workflow for clinicians as theyare no longerrequired to launch anotherapplication and logon separately.

Figure 3:Emergency Department Tracker with Indicators for Imaging Status Updates

Duringthe admittingprocess optimization, the implementation of theMEDITECH Bed Board was used to eliminate phone calls andprovideacommunication mechanismfor allstaff involved in theprocess. A bed request is entered into theEHR for anypatient being admitted. This bed request is processed bytheAdmittingDepartment and thepatient is assigned abed. TheBed Board provides real-timecensus dataand allows staff to viewhow manyavailable beds areon each unit. TheHousekeepingstaffwas trained to utilizetheEHR’s Bed Board to identifyand track beds/rooms requiringcleaning, as wellas, entryofinformation into the EHR to notifythe nurses of beds readyfornew patients.

Implementation ofGE Muse in 2012 decreased thetime required to receivefinal EKG interpretations, i.e., EKGs became immediatelyavailable in theEHR once read. Priorto the implementationofGE Muse, EKG resultswerenotavailable forextended periods dueto manual scanninginto the EHR. ITimplemented Nuance PowerScribe 360 in 2013as a front-end voice recognition dictation system fortheImagingDepartment. PowerScribe 360resolved manyofthe same turnaroundtimeissues noted with imaging results, but forEKG results instead.

GE Muse and PowerScribe 360 workflows are presented in Figure 4. The implementation of GE Muse decreased the reliance on a printed paper EKG strip by allowing them to be stored, viewed, and interpreted digitally. Turnaround times for final interpretations decreasedas this process was no longer dependent on paper EKGs being hand carried from various locations to the EKG reading room. In addition, the use of GE Muse enabled the final interpretations to file directly into the EHR for immediate viewing by clinicians. The use of this system removed the need for transcription services (equivalent to 3 FTE’s) by allowing Radiologists to generate final reports using voice recognition. These final reports file directly to the EHR and are immediately viewable by clinicians.

Figure 4: Pre and Post GE Muse and PowerScribe 360 Workflows

1. Value Derived/Outcomes

Overthe last fewyears of implementations ofthe various systemsand applications,improvements havebeenmadetoend-user efficiencies. Theuse of real-time status boards like the ED Trackerand BedBoardallow forimproved patient trackingand streamlined coordination ofpatient flow. Thesestatus boards, alongwith additional systems like PACS, GEMuse, and PowerScribe 360 have also led to moreseamlesspatient throughput. This can be evidenced by examining past andcurrent Imaging Department study volumes. Pre-PACS study volumes were approximately 50,000 studies a year. Following thePACSand PowerScribe360 implementations, the annual study volumes wereover 59,000. Despitethe increased volume, Press GaneyPatient Satisfaction scores for “Waiting Time for Radiology Tests” in ED remained essentially the same at an 84-point mean score; see Figure 5. Theseadditional 9,000 studies equate to aminimumincreaseof $2 MMin chargeable services,andwereaccomplished withoutan increasein staff. In the currenteconomic climatewhereeveryoneis tryingto domorewith less, the abilityto increasethenumberofpatient exams performed withoutincreasing staff resourceexpendituresor decreasing patient satisfaction issignificant.

The ability to achieve rapid results was also essential to accomplishing HMC’s efficiency goals. In 2008 with only Dictaphone usage, report turnaround times were at an unacceptable 72 hours. With a new RIS and continuing Dictaphone transcription services, times still remained elevated. The activation of PowerScribe 360 truly accomplished the efficiencies HMC was seeking. The PowerScribe 360 application eliminated the need for reports to be dictated then transcribed prior to being signed and finalized. Turnaround times for final reports decreased from 308 minutes prior to implementation to 5.5 minutes in September 2014; see Figure 6.

Further, during the discovery phase for PowerScribe 360 HMC identified multiple areas of improvement for radiologists, technologists and support staff. These improvements include the optimization of ultrasound paper processes and the creation and implementation of a Critical Test Result Management (CTRM) integrated system.

HMC strived to eliminate the use of transcription or editing services upon PowerScribe 360's implementation, the last processes reliant upon paper was ultrasound worksheets with multiple exam measurements. Historically, transcription services typed these values into the document for the Radiologists. HMC designed templates for the ultrasound exams measurement values to be entered directly into PowerScribe 360 by the technologist during or directly after the exam is performed. Upon opening the study in PowerScribe 360, the Radiologist review the entered values for accuracy prior to completing their interpretation. The optimization of this workflow eliminated the technologist's use of manual paper documentation and the need for Radiologist transcription or editing services.

The CTRM process created by HMC integrated the technologies of PowerScribe 360, EHR, and wireless communication systems. Upon review of an examination, the Radiologist now has the capability to mark an exam "Call and Confirm" within PowerScribe 360 to request a phone call to the ordering physician for confirmation andreceipt of the report. When the "Call and Confirm" field is selected, an alert is sent to a designated Imaging Department wifi telephone and a "CTRM/Call and Confirm" task is created in the EHR. Staff have been trained to log four attempts to call and confirm the report with the referring provider. If the confirmation is not obtained after the fourth attempt, the Radiologist is informed of the failure to confirm the report and determines if further action is necessary. The CTRM process enhances patient safety, increases communication, and improves provider satisfaction.

Other benefits realized due to the implementation of improved efficiencies saw a decrease in the length of stay in the ED, as well as, an increase in ED volumes. From 2011 to 2014, the ED average patient length of stay decreased by 39% while ED volumes rose almost 13% for the same time period; see Figures 7 and 8.The ED Press Ganey Patient Satisfactionscores did not decrease during this period of change and remained in the mid-80 range. This is a testament of doing more with less, and at the same time accomplishing the least disruption to the patient’s hospital experience.

Integrating the ancillary systems with the EHR has provided readily accessible views of information in one location for our physicians and clinicians across the geographic area. For example, the RIS image can be seen a click away from the EKG tracing and their associated reports; refer back to Figure 3. HMC is also now capable of sharing results across multiple organizations and providers via the Hawai’i Health Information Exchange (HHIE) secure messaging process.

1. Lessons Learned

ContinuousImprovementCannot Stop

Whilethe current state ofthe systems and applicationsusedto improve end-userefficiency, knowledge flow and patientthroughput areworking effectively, the organization continues to look foropportunities forimprovement. In an effort to take advantageof new opportunities, existingprocesses orworkflows maybe revised. System improvements are requestedbyend-users, hospital administration, or clinical analysts. All proposed changes requirechangecontrol approval from the integrated/Operational ReviewForum (iORF) whichconvenesweekly.

In thecaseof theED Tracker, thelayoutand notifications contained havebeen revised numerous times in the attemptto providethe most important information in the most efficient way. Additional status notifications havebeen added tonotifystaff ofresulted exams or tests and columns havebeenrearranged to allow the most pertinent information to be easilyviewable.

TheBed Board hasalso undergoneseveralrevisions in order to provide better communication with affected staff. Bedstatuses havebeen eliminated to streamline theworkflow ofpreparing the room foranew patient and unit descriptions havebeen edited toeliminate confusion.

Driving End-User Adoption

Implementing PowerScribe 360 was not an easy task for the Imaging Department and the project team. In order to address the Radiologists concerns, an initial project kick-off was hosted by the Project Manager to include all stakeholders and in particular the Radiologists. Project goals, workflows, and timelines were presented in the kick-off along with project expectations. Throughout the project "Radiologist Acceptance" was a constant category of attention with an adjusted mitigation plan as the project progressed. Salient themes emerged though evaluating Radiologist acceptance to include elbow-to-elbow training, custom templates, and a strategy to train in the live environment rather than spending time training in the test environment.

Communication with the radiologists and Imaging staff was clear and constant during the PowerScribe 360 project. Timelines and milestones where identified and celebrated when reached. Risk management was also continuous throughout the project lifecycle, as each risk was paired with a mitigation plan and a contingency plan. A final 30-day post live review and transfer to operations was conducted with the Radiologist and stakeholders to formally transfer the product to the operational owners and to evaluate ongoing adoption levels.

End-user EducationandTraining– Ongoing

An extensive amountof end-user education and trainingmaybe requiredto ensure allworkflowimprovements areperformed correctly. In some cases, re-trainingmaybeneeded to assureallstaff members arefollowing the appropriate processes.

HMC is currentlyholdingre-trainingsessions forGE Muse. Itwas found some end-users werenot following the designatedworkflows, which was leadingto delays in ordering physicians' receiptof the final EKG reports.

1. Financial Considerations

Implementinginformation systemscan requiresignificant financial investment. Even so, the

RIS, PACSand other ancillarysystems noted in the casestudy and theEHR was funded with operational dollars. Thereturn on investment(ROI) leadsto substantial cost savings over time and improved patient careoutcomes. As patientand clinical knowledge workflows areoptimizedthrough the utilization oftheinformation systems,the organizationis able to effectivelytreatmorepatients withoutneedingto hire additionalstaff.This allows HMC to keep employeecostsfixed whileincreasingthepotentialrevenue.

Figure 9: Pre and Post PACS Implementation Cost Comparisons

TheHMC PACSprovides an exampleof asystem that contributed to improvedpatient throughput whilealso leadingto cost savings. Film costs associated withprinting hard copyimages hadincreased annuallyuntilthe implementation of the PACS. In 2008, theHMCImaging Departmentsaw its highest expenditure ofover $300,000annuallyforfilm. From2009to2013, the department was able to reduce the amountspent on film creating an overallsavings ofapproximately$390,000 despitethe added annual cost of thePACS; see Figure9. Overall, HMC is on aproductivepath toward accomplishing revenue, and most importantly, patient goals with the efficiencies put into placeto assist its end-user community.

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[i]Chuang,Ian,MD,F.C.F.P.,CMO,October(2014),“TransformingtheEHRintoaKnowledgePlatformtoEnsure

HealthandHealthcare”,a Netsmartwhitepaper