Capital Health project re-engineers patient flow

By Andy Shaw

EDMONTON – It doesn’t have the snappiest name ever, but the Emergency Services & System Capacity (ESSC) patient flow project at Capital Health Authority promises to be a memorable landmark in the evolution of regional healthcare in Canada.

The innovative ESSC project is being designed to remove the bottlenecks restricting patient flow through a region’s resources – from emergency rooms through acute care hospital beds to community care facilities.

Capital Health encompasses 13 integrated hospitals and numerous community care institutions that serve about 2.6 million people in Edmonton and its environs, as well as in northern Alberta. It has recently added 300 hospital beds and nearly 1,000 long-term care spaces. But that additional capacity alone was not enough to ease an increasing pressure felt by just about every health region in Canada.

“Emergency overcrowding and the resultant backups are a longstanding issue in Canada, and not unique to Capital Health,” says project chief Susan Mumme, who is the vice president and chief operating officer of Capital Health’s Regional Clinical Support Services and Integration arm. “We tried a number of approaches in the past, but the ESSC project is a fresh look at the problem. Rather than looking just at our facilities, it focuses more on how patients flow through the entire system, through the in-patient areas and out into the community.”

As they move through the system, patients touch a lot of different bases; consequently the ESSC project does too. It is carrying out 15 different sub-projects to streamline and co-ordinate patient flow through four key areas: Emergency Departments, Bed Management, Care Management, and Community Care Services.

But the ESSC is not starting entirely from scratch. Rather, it is building on an enviable infrastructure that already extends right across Capital Health.

“We have always had a region-wide emergency department system that enabled us to do standardized triage, and know who to send where,” says Capital Health CIO, Donna Strating. “But that didn’t get people out of Emergency any faster. It only told us how big the piles were getting at each site.”

So the ESSC project began instead with a closer look at the roles and responsibilities of those who influence and who could enhance patient flow.

“We’re looking at new ways of our people doing things and standardizing those processes across the region,” says project leader Mumme. “And from there we began to look at what kind of technology we have now, such as our Emergency System and our ADT systems (admission, discharge, transfer) – the ones whose information might help us make better patient-flow decisions.”

What Mumme and her team learned from that information has been translated into 15 ESSC “design solutions” that include new processes, new systems, and new staff doing new kinds of work including:

• The implementation of a Full Capacity Protocol (FCP) – which is triggered when the Emergency Department gets stretched beyond limits. FCP calls for patients to be quickly moved out of Emergency into pre-determined areas in the inpatient units and from inpatient units out into Community Care Services in response.

• Emergency Department Navigators – who work in the Emergency waiting room and talk to patients and families about the Emergency process and who ensure the triage nurse and physician are aware of any changes in the patient’s medical condition while he or she waits.

• Comfort Care Carts – that help make a patient’s wait in Emergency more comfortable.

• A Centralized Bed Hub – that helps place patients in to a clinically appropriate bed.

• Bed Managers – who are available around the clock to decide, using bed management software, who gets what bed and who co-ordinates transfers between sites and facilities.

• Twice-a-day, bed conference calls connecting Capital Health’s four largest acute care sites with community, mental health, and regional transport offices.

These solutions had their origins in the first “needs assessment” phase of the ESSC project last summer and were further refined as the project rolled into the next “design” phase.

“We had a look at best practices around the world as a result of our needs assessment and then we brought in staff and physicians to ask them about the kind of processes we should support, how they would work, and what kind of information and technology we would need to implement them,” says Mumme.

Implementation of the solutions developed began late last fall. Charged with getting them up and running over a 12-18 month roll-out is Jan McGuinness, the director responsible under Mumme for Capital Health’s capacity management.

“We’re using the Emergency Department’s information system to give us a good picture of what the bed situation is at each site in real time, says McGuinness, “and also we’re using the data from the system to help us evaluate the changes we are making. We are really trying to make this a data driven effort.”

One initiative whose success will be determined by the data it spawns in particular, says McGuinness, will be the Full Capacity Protocol. “It’s been shown elsewhere that the FCP has resulted in decreased length of stay for patients who were admitted through the Emergency Department. So we have developed a dashboard of data just to watch that.”

The ESSC also involves a quality of service element that’s being elevated with the help of technology.

“For patients and their families, for example, we’re installing plasma screens in waiting rooms that display healthcare news and updates. Or if we had some kind of respiratory outbreak in a hospital, we will put notices up on the screens about the etiquette they should follow,” says McGuinness. “We are also looking at piloting a paging system, similar to what you might have in a restaurant, for patients who are ambulatory and who can go and get a coffee and be given a pager and be called when a physician is available to see them.”

To effect these changes, Capital Health has engaged its Human Resources department to set up ESSC transition teams at each of its sites, as well as to hire new staff (the biggest budget item) for the new Bed Manager and the Emergency Department Navigator positions.

Among the payoffs that McGuinness, Mumme, Strating and others expect from the $10 million invested in ESSC:

• Greater patient and staff satisfaction.

• Throughput of patients to the right, clinically appropriate bed as fast as possible.

• Business intelligence for physicians and managers, accessed through an Oracle database portal that tells them how patient-flow changes are affecting their areas of responsibility. The system will help them determine whether the changes are sustainable.

• A steadier state of coverage by appropriate physicians and staff that does not peak on weekdays and bottom out on weekends.

• A greater capacity in the Emergency Department to handle the rising number of acute and chronic care cases stemming from an aging population (Capital Health’s Nurse Call Centre implemented several years ago has managed to decrease the number of low-acuity cases showing up in Emergency).

• Information about the care provided by Capital Health will flow seamlessly back to the patient’s family physician or primary care provider in order to reduce the rate of re-admissions.

To assess the value of these expected returns on investment, Capital Health has set up an ESSC evaluation team in co-operation with the University of Alberta. The major measure it will evaluate, says Mumme, is how quickly the project freed up high cost acute-care beds and moved patients to lower cost community care beds and beyond.

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Hospitals and companies develop electronic solutions to control and reduce pain

By Andy Shaw

“Pain is a more terrible lord of mankind than even death itself.”
– Dr. Albert Schweitzer

Pain can be a real a pain in the neck. Pain does have its place of course. It serves as a warning sign for disease and injury. But beyond that usefulness, pain doggedly persists where it’s neither wanted nor needed.

None more so than the pain connected with surgery. To keep surgical pain at bay, most surgical procedures involve potent local or general anesthesia, followed often by potentially harmful, pain-numbing drugs after the operation. As a result, surgical pain-control involves careful pre-surgical preparation, then watchful monitoring both during and after the procedure if the patient is to remain not just comfortable but also safe. To that end, virtually every teaching hospital in Canada and many others have instituted an Acute Pain Management Service (APMS) system that is in the hands of the Anesthesiology Department, where pain management expertise traditionally lies.

To guide it, APMS-related information, research and references abound. The World Health Organization has issued pain management standards; there are pain management societies, international conferences, specialized pain medicine training, and even professional trade journals, all devoted to combating pain. Yet it remains an elusive enemy. Managing pain is just so complex. First one must deal with the divergent pulls of cure and comfort. Too readily the physician imperative of “get the X-ray first” can supersede the nurse’s plea for pain relief for the patient. Then in the case of surgical pain, there are all the perioperative clinical decisions to be made about where and when and how much drug and non-drug pain killers, such as physiotherapy, should be administered to the patient.

From the surgical patient perspective, some need more pain relief than others. Worry can increase the pain people feel. So, part of pain management involves patient education – to help them deal with the details of the pills, tablets, liquids, or suppositories they must ingest; the injections they may need; the drug pumps they must operate, or the pain-masking relaxation and mental diversion techniques they should learn.

These complexities are rife with the potential for medical error. Small wonder then there’s a demand for APMS systems that are managed with the risk- and complexity-reducing capacities of computer technology.

In Canada, three notable wielders of technology are vigorously attacking surgical pain. At Kingston General Hospital (KGH) in eastern Ontario, Dr. David Goldstein and acute care nurse practitioner Rosemary Wilson head a multi-disciplinary team; since 1999, they have been developing a wireless-based APMS for the 2,500 surgical patients a year at KGH who require pain care.

Meanwhile, in Flamborough, Ont., near Hamilton, Adjuvant Informatics Corp. is helping their clients both at home and abroad to organize surgical pain management with a suite of anesthesia department software that includes an Acute Pain Service (APS) Manager module.

And in Toronto, Philips Medical Systems is working with anesthesiologist Dr. Steven Chan, at the University Health Network (UHN), on an ultrasound system than can block pain by guiding a needle accurately to a local nerve and freezing it – a system that may significantly change the whole approach to surgical pain management.

In Kingston, more than $1 million in research money and support from government and industry have gone into the KGH’s APMS system.

“We are at version 4.1 of the software,” says Dr. Goldstein. “But the software actually is quite uncomplicated. It simply interfaces (via a hospital-wide Cisco 8.0211g wireless backbone) with the registration and ADT (admission, discharge, transfer) system of the hospital, so you know who the patient is, and where the patient is, updating immediately whenever the patient moves. The software also interfaces with the likes of pharmacy, imaging, EKG, and other systems to provide the information about the patient’s condition.”

Anesthetists and other pain management clinicians at KGH can now securely access that information held in an APMS database to also find the patient’s care plan, lab results, notable events, consulting notes, and even billing details from anywhere they are in the hospital. As well, they can switch to an assessment screen on their on their computer tablets, which lists up to 21 patient variables and 18 options for planning patient care, such as reordering or changing medications.

This computerized APMS model has been exclusive to KGH’s anesthesiology department, but other departments such as obstetrics/gynecology are keenly interested in its potential, reports Dr. Goldstein. “It’s applicable to them because it is not about the particular hardware and software we use, it’s about how you get people and patients working together better.”

The software on board the APMS tablet fosters such co-ordination. It generates an alert if physicians have prescribed incompatible drugs or if the lab returns abnormal results. It also allows users to make additional narrative comments. Finally, a built-in research function also captures the data needed from patients participating in studies.

It is the lack of reliable data about patients and their pains that drives the folks at Adjuvant.

Says Douglas McVeigh, Adjuvant’s vice president of sales and marketing: “Among the facets of the problem our APS Manager solves are inconsistent data capture, incomplete clinical documentation and care management plans, missing billing and paperwork, and the lack of data needed to carry out in-depth and accurate quality assurance in a reasonable time.”

In addition, says McVeigh, the APS Manager is uniquely set up to link with important pain management resources outside of hospital walls, including the International Clinical Anesthesia Data Base being established by Adjuvant to aid researchers worldwide. That capacity has helped attract users of Adjuvant systems now operating in hospitals in Canada, Norway, Australia, and the United Kingdom.

“We are marketing to a very receptive audience,” says Adjuvant president Dan Meyer. “Pain has become the fifth vital sign in patient care. Government, administration, physicians and nurses are demanding better tools and processes to ensure that patient pain is minimal and the therapies are safe.”

Adjuvant has made contributing to that research easier and the general use of its products more attractive by moving their software from client-server to a web-based platform.

“The IT department in any hospital has a very difficult task of managing all their client computers. So if you can go into an IT department and give them a solution that is very light weight on their current system, as ours is, they are very happy,” says Meyer.

Other decision-makers take comfort in the software’s round-the-clock reliability, secure user logins, full audit trails, and digital signatures that enable complete compliance with government privacy and security imperatives.

Like the KGH experience, Adjuvant has found that among the biggest boosters of its systems are those on the very front line of pain management, the acute pain nurses.

“These nurses have undergone special training, and generally they are very intelligent and skilled,” says Meyer. “But until now they have had no electronic tool. They walk around with paper reference binders, but often still can’t answer questions that are posed to them. So when they are presented with an opportunity to use a tool that can give them access to all the information they would ever need, they respond very well.”

That also leads to better communication and understanding with physicians and it pleases the hospital’s back office.

“The physicians love it because they can walk in Monday morning and get a complete, up-to-date picture of their patients,” says Meyer. “And hospital administrators like it because with the data the system gathers they can do benchmarking.”

Benchmarking, of course, allows administrators to see the performance of their services in a new, more statistically valid light. Seeing is believing, in other words. In a more literal way, Dr. Steven Chan at UHN is believing what he finally can see.

As head of the Regional Anesthesia and Pain Program in UHN’s Department of Anesthesia, and an anesthesia professor at the University of Toronto, he is an expert in a field which he admits has been seeing ‘blind’ for some time – nerve blocking.

Nerve blocking or “regional anesthesia”, as it is formally known, can obviate the need for general anesthetics that put the patient completely under – resulting in much less risk to the patient and lower costs to the healthcare system. Find the local nerve, freeze it with a needle, and do your surgical business while the patient remains awake and pain free, and in many cases not in hospital at all.

The problem is finding the nerve.

“It’s well known that nerve blocking has many benefits to our patients, but this technique was under-utilized because we used to perform nerve blocks blind in the old days,” says Dr. Chan. “But by using today’s ultrasound we can now visualize the nerve structure. Nerve blocking procedures are safer today because we can see vessels, pleura and other things we do not want to put the needle into.”

Bill Bevan, the Canadian national sales manager for ultrasound at Philips Medical Systems, says Dr. Chan and others in this burgeoning field can now see even more.

“When they were going in blind, they knew where the nerve was supposed to be structurally but they pretty much had to go in by feel,” explains Bevan. “But now the resolution of ultrasound has become so good they can actually see individual nerves inside a nerve bundle. So then anatomically, they can say, aha, that is the particular nerve bundle that we want. Then as they insert the needle, they can see the needle coming in, see it hit the target, and therefore make it a safer procedure.”

Through Bevan, Philips sponsors, supports, and helps equip Dr. Chan’s 12-member team of developers and researchers and also connects Dr. Chan with Philips’ ultrasound equipment builders and designers in Seattle.

Dr. Chan regularly co-chairs international symposia and workshops for the Association for Ultrasound Imaging in Regional Anesthesia and is editor of the Regional Anesthesia and Pain Medicine Journal.

“We’re pretty proud to be associated with one of the world leaders of this rapidly emerging field,” says Bevan.

As with all emerging fields, though, they come with their challenges.

For Dr. Chan it is overcoming the differing mindsets that separate two medical specialties. “With anesthesiologists, you have the challenge of convincing them to learn a brand new technique.”

For Dr. Goldstein at KGH and Adjuvant Informatics, there are few studies yet which show the return on investment (ROI) likely from APMS systems. Goldstein does point to one study that said the use of hand-held APMS computers in the post-operative acute pain management ward reduced the time required to see each patient by 30 percent.

Elsewhere, an eight-month study of a wireless APMS system in use at three nursing units of the Nebraska Medical Center indicated that it averted 157 medical errors, which translated into a projected cost-avoidance to the hospital of $712,000.

In terms of how much you need to invest in order to gain such potential returns, KGH and Adjuvant Informatics are at different ends of the scale. Goldstein and KGH are offering their APMS software to other hospitals for free – with the buyer picking up the costs of having a KGH-approved third party install, adapt, and maintain the system. Meanwhile, Adjuvant is offering their applications at an up-front cost – but one that includes installation and maintenance and which, says marketing manager McVeigh, will deliver $160,000 to $240,000 in savings and thus pay for itself in less than six months.

However the market responds to these and Dr. Chan’s pain saving techniques, their prospect remains highly promising: no longer will surgical pain, at least, be able to lord it over us.  

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Patient Destiny: Consumers must have access to their health records

By Kevin J. Leonard and David Wiljer

Just as customers accessing their information have reduced banking industry costs, it is a general assumption that the same will hold true in healthcare. As more patients bypass the “hands-on” personal method and obtain information for themselves, it is estimated that great savings will be gained, and consequently, a tremendous amount of strain will be removed from the system.

However, very seldom is patient information (e.g., the specific results of diagnostic tests) ever shared with the patient. As a result, it is very difficult for patients to enter a dialogue with their doctors about treatment, because the healthcare provider is the only one with the information. One truism seems to be constantly ignored: It is impossible for patients to manage their health without the requisite information! This is not just a passing fad or part of a catchy slogan, but rather a conclusion that is based on a number of logical premises, outlined as follows:

Times have changed: This may not appear to be all that insightful, at first glance, but this premise contains very important building blocks. We are no longer in an era where businesses and governments tell people what to do and when. The rise in consumerism has created the demand from the public for better information and better service. The public wants information in the way they want it, when they want it. We have rapidly progressed through the Information Age into a “Knowledge Era”. Information that is meaningless to consumers has no value. In the next 20 years, the industries that will be successful will be the ones that can take advantage of technology and deliver pertinent information, which is “targeted knowledge” channeled down to the individual consumer.

Patients are at the centre of healthcare: We have seen many Hospital Mission statements echoing this same message – changing to patient-centered care. However, this ‘mantra’ has not been firmly understood or appreciated. Without the patient, there is no need for healthcare professionals. The patient is the one constant throughout all of the healthcare system.

What patients do want, and will demand, is better information about the system, about who does what services, and about how well they perform these services. Answers to these questions will allow consumers to make informed decisions surrounding their care.

Patients want access to their own patient information – and they want to be able to understand what it is that they are reading. In particular, they want to know more about their illness or disease, and they want information on treatment options and success rates. Often, they would like to get in touch with other patients to exchange experiences and to get advice. After all, it is only when they interact with other patients that they get real information about what they are going, or will go, through.

Ultimately, patients are the decision makers: When patients are faced with difficult healthcare questions, they seek advice – from their doctors, other health professionals, and their own personal network. Even though the physician will provide the best medical support, ultimately, it is the patient who has to decide whether they want this drug treatment or that surgery.

It is understood that not all patients may have the maturity or cognitive ability to comprehend the decisions that they have to make. Many caregivers have used this argument to withhold information; but, in actuality, this rebuttal only applies to a small percentage – perhaps, to 20 percent of our population. The remaining 80 percent have the ability and the right to make their own decisions. What they lack is the medical background in order to facilitate all the information and to process it in order to make an informed choice.

It is our belief that in the healthcare system of the future, we will see physicians (and other professionals) act as advisors to patients, rather than the old model, where patients are told what to do. Gone will be the day where patients will feel that they are not free to question facts or to seek options.

Decision-makers need information: It is well understood in information theory, and in the decision analysis literature, that decision-makers need information to assist in making any decision. It then becomes clear that we must get the critical information to the patient in order for them to make informed decisions. This means that the focal point of the healthcare system of the future must be on the patient record, since that is the only point where all the data reside. In order to move the data and information around efficiently, it is obvious as well that this record will have to be in an electronic form.

Conclusion: Patients must be able to access their health records and other patient information if they are to make informed and effective decisions about their health management. Consequently, it is impossible for patients to manage their health without this requisite information!

Access to records improves satisfaction for lung transplant patients

Over 40 percent of patients have at least one chronic illness, accounting for nearly two thirds of all medical expenditures. Because of their long timeframe and high attendant costs over time, chronic illnesses lend themselves to electronically mediated self-management tools. Prototypes of web-based, patient-centered Information and Decision Support Tools have been demonstrated to improve self-management of illness and enhance understanding of the complications of poorly controlled disease. Patients living with chronic illness are also more likely to use health information than their healthier counterparts, although each chronic illness has specific, recognizable challenges for affected patients in symptom comprehension, information management, task fulfillment and social interaction.

It is our hypothesis that leadership will come from these chronically ill patients (either individually or within a group) by demanding better access to health system and service information. In recent research, we interviewed patients on a number of “access to information” issues. Unfortunately, asking patients (or computer end-users or stakeholders) what information they would like to receive is not efficacious due to the fact that end-users are normally not well versed in “system options”.

What stakeholders are very good at, however, is identifying functionality they would “like to have” at the moment that they experience it. As a result, we have engaged different groups of patients suffering from a chronic condition. In this instance, we present results on post-lung transplant patients in both passive (survey interview) and active (simulation) environments to elicit their needs and wants. (This group was analyzed due to accessibility, however, it is believed that many of the findings are applicable across a number of illnesses or chronic conditions.)

Almost two-thirds of these lung transplant patients (63 percent) had seen some portion of their medical record (most commonly blood work or X-ray results) and a similar percentage believed a personal medical record would help them manage their personal healthcare. The most common reason respondents wanted access to their medical chart was to enhance their understanding of their medical condition. This desire to have further access to personal medical information was expressed despite a comprehensive patient education program provided by the transplant program, and despite the fact a high degree of patients felt they were provided with an adequate degree of information upon discharge from hospital. As a whole, this group appears to have a high level of interest in their medical information and can be described as active participants in their care.

The patients were then asked what they believe would be the most valuable aspect of having access to their medical information. Respondents were encouraged to check all that apply:

• 57 percent of patients believe that access to their medical information would help enhance their understanding of their medical condition.

• 13 percent of patients indicated that access to their medical information would help ensure the information was available to their family doctor.

• 13 percent of patients felt access to this information was important in case of an emergency.

Further, over 60 percent of patients believe that having access to information about the medical care that they receive would help in managing their healthcare while at home. The difference in the phrasing of each question may illustrate the importance patients’ place on information necessary for self-management over information about their hospital stay. Sixty percent of patients believe that if they were provided with their medical record, they themselves and their family physician would use it the most. Related to the use of the patient’s medical record, 73 percent of respondents did not have any concerns about a family physician, family members or other medical specialists having access to their record.

Patients were also given the chance to choose what type of information from the hospital they would find useful to help manage their care at home The most popular choice was the lab test and results (67 percent) followed by a summary of their medical history, medication information (history and current), contact information (specialists and emergency contacts) and blood pressure/ temperature charts. Family and personal history and height/weight charts were not strongly endorsed. Only 17 percent of all respondents felt the inclusion of an allergy history was necessary in their personal health record. Given a choice, 63 percent of patients would want this information as a paper copy. Other preferences included CD (13 percent), secure Internet (13 percent), and other storage device (10 percent). Forty-seven percent of respondents indicated that they would find it useful to have the entire lung transplant manual in an electronic format.

The survey indicates that lung transplant patients are interested in accessing their personal health information to support their health management. At the time of the survey, well over half of the sample group was connected to the Internet and according to the literature, it can be expected they are accessing health information through that medium. This desire stems from increased self-reliance in the management of personal health and the desire to take a more active role in the medical decision-making process. While the effect that this information may have on patient health outcomes is not clear, access to personal health information is associated with improved patient satisfaction. As patients move to a more self-reliant role in the management of their health, the demand for personalized information will only increase.

Conclusions: We must begin to put pressure on the system to support patients in gaining access to their own health information. As presented herein, this is needed and soon will be demanded. Ultimately, this inevitability has been framed by the term Patient Destiny, where patients are actively involved in all healthcare decision-making. This is an infeasible proposition in a paper-based system, which means we must move to more Electronic Health Records or EHRs. Since patient access to individual healthcare provider organizations’ health record systems appears to be almost as unviable, due to limitations in data format, unique patient identifiers and system constraints, one appealing approach is to follow the path whereby patients interface with their health-related information across the many providers in a Web 2.0 environment.

A web-based patient interface between consumers and the health system could help patients search for quality information and link them to resources that address their needs. In detail, the benefits for the consumers could be as follows:

• Obtain quality health information, quickly and efficiently, based on personal and contextual needs;

• Access an up-to-date consumer health directory with listings and satisfaction ratings of trusted healthcare providers in Canada and elsewhere;

• Connect with like-minded users to share health experiences, knowledge and resources;

• Allow consumers to use monitoring tools to manage active lifestyles and primary healthcare conditions such as blood pressure, weight and high sugars;

• Provide a pathway to their own health information and expectations; and

• Design a reward system for their investment in health, well-being and where health-conscience behaviour is rewarded within a ‘point collection’ system.

In essence, a health sector-wide strategy of patient awareness and education is now required. All consumers of healthcare – the healthy and the ill – need to be presented with a forum for a comprehensive discussion on healthcare, one that deals with the trends of rising consumerism and greater expectations relating to information access and delivery. We must promote an “effective and coordinated consumerism” perspective within healthcare. Hopefully, this will provide an incentive to all consumers to become more involved in their own care and health management and to demand more from health providers.

Kevin J. Leonard is Associate Professor in the Dept of Health Policy, Management & Evaluation, University of Toronto. David Wiljer is Director, Knowledge Management and Innovation, at Princess Margaret Hospital, University Health Network, Toronto.

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Hospitals use computerized strategies to improve document workflow

By Dianne Daniel

If you were to measure the number of paper-based patient charts that get distributed throughout Kingston General Hospital (KGH) and Hotel Dieu Hospital (HDH) each day, you might be surprised to learn just how much paper there is.

“People conceptually understand that there’s some activity, but even those in the hospital don’t quite grasp the order of magnitude,” says Eldon Dutcher, project manager, patient records improvements, at Kingston, Ont.-based KGH. “We estimate that 78.7 feet of (stacked) paper is handled every morning.”

Over the course of a year, that amounts to nearly 1,700 feet of paper – almost the height of the CN Tower in Toronto – despite the fact that both hospitals are currently using an integrated electronic patient chart. “We’re in a hybrid situation,” notes Dutcher. “We have an electronic chart… but unfortunately there’s also a lot of paper.”

Some of that paper stems from emergency room visits, or ambulatory and outpatient clinic appointments, while the rest consists of handwritten nurse or physician notes, as well as reports generated by existing clinical information systems.

While there are projects under way to transition to electronic documents, Dutcher expects it will take anywhere from five to 10 years before a completely electronic chart is implemented.

In the meantime, the hospitals are launching a short-term strategy to reduce paper by using the Computerized Patient Record (CPR) and Media Manager products from Raleigh, N.C.-based Misys Healthcare Systems, along with Synergize, a document imaging and indexing system from Richmond, Hill, Ont.-based Microdea Inc.

The goal, explains Dutcher, is to capture any paper documents deemed “likely to be referred to in future visits.” The information is then scanned and indexed, and associated with the appropriate “event” in the Patient Care System (Kingston’s implementation of the Misys CPR), using Media Manager and barcodes to ensure a perfect match. Remaining paper documents will continue to be stored with the paper charts.

“This is an interim step, a means to drive immediate benefit so clinicians can more readily have access to information without waiting,” says Dutcher. “Capturing an image is less than optimal, but it’s a rational next step.”

As part of its workflow analysis, KGH and HDH have uncovered close to 900 unique document types that are potential candidates for scanning.

When they go live with their scanning effort in June, physicians will be able to access scanned images from the same chart review screen they’re currently using in PCS, with the added advantage of being able to zoom in on any text or handwriting that may be unclear.

In addition to an anticipated reduction in paper consumption and printing costs, Dutcher is also expecting a 30 percent reduction in labour costs. Having more information readily available at the point of care will also improve patient outcomes, he says.

“What if you were to arrive at Emergency, unconscious, with no visible signs of trauma? The doctor’s essentially working in the blind,” he says. “It can take up to 20 minutes to get that paper chart to a physician. Time is life; if we had that information on-line, perhaps we would know of some pre-existing condition.” That, of course, could make a significant difference in the patient’s medical outcome.

It’s all about creating intelligent workflow, says Avril Cardoso, manager of application services, information systems, at Credit Valley Hospital in Mississauga, Ont. As part of a project called EDDIE, short for Electronic Data and Documentation Integrated Everywhere, the hospital has set a standard that any patient-centric documents must have a barcode and will be centrally managed using electronic forms software from Alpharetta, Ga.-based Optio Software Inc.

“Physicians really like having the bar-coded form because they have more confidence that the correct documents will be attached to the right patient,” she says.

Like KGH and HDH, Credit Valley is using scanning and indexing to improve productivity in its health information management department. But the current focus is on patient registration.

“Registration is a very hot topic because it’s the first touch point with patients,” says Cardoso, noting that as more information flows throughout the hospital electronically, the more important it is to ensure accuracy.

According to Cardoso, the hospital was encountering many issues with workflow management in its registration areas, primarily because registration takes place in over 40 different locations, including six off-site areas. Moreover, registration is staffed by a mix of full-time and part-time employees who don’t always follow the right procedures.

In particular, bills were occasionally being sent to the wrong address, health card information was incorrect, and patient demographics were sometimes inaccurate.

Using the Boston Workstation from Boston Software Systems Inc. of Sherborn, Mass., Credit Valley Hospital has found a way to automate its registration workflow using rules-based scripting. The Windows-based tool is embedded into the hospital’s registration system where it serves as a sort of “electronic manager,” intervening with pop-up messages whenever a particular process isn’t being followed.

To date the hospital has programmed 35 rules into the Boston Workstation system and it plans to include 10 to 15 more.

Examples include rules that ensure a patient’s provincial health card is swiped to verify name, date of birth, gender and health card number; that the address entered matches the listing in a Canada Post database; and that certain fields are not bypassed as a patient is registering.

“At first (administrators) were a little nervous about ‘big brother is watching,’” notes Cardoso. “However, we tried to give back a little by filling in information automatically that they would normally have had to do manually.”

“I think more and more hospitals are seeing this as a real opportunity,” notes Margaret Mayer, director of marketing at Boston Software Systems. “It really goes to patient safety for them.”

At Credit Valley Hospital, for example, the Boston Workstation allows the hospital to be more “intelligent” by capturing data, such as allergic reactions and religious beliefs, at the time of registration and feeding that information to other on-line systems.

As Cardoso explains, certain religions don’t allow the use of blood products, so having that information available as part of an electronic chart helps to prevent someone from receiving an unwanted treatment inadvertently.

The patient menu system is also fully automated so that any patient food allergies are automatically fed to the kitchen, where every ingredient is monitored to prevent the wrong food being served.

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