Case Study #1:
Preventing Errors and Waste
In the operating room (OR), clear communication is supremely important. Extensive time is spent gathering patient information, and ensuring all the appropriate preparations are made. But, miscommunications and mistakes still occur resulting in potential medical mishaps and lost revenues. Within the confines of OR suites, full utilization of information technology (IT) can help prevent such errors and waste. Numerous people, operating on countless systems, are responsible for gathering all the necessary data, and a system that creates centralized storage for medical information can prevent technology gaps that plague many hospitals.
Judy Swanson, RN, joined Texas Children’s Hospital as director of perioperative services in February 2001, and discovered that the department’s existing perioperative information system was full of holes. Texas Children’s Hospital in Houston, located in the Texas Medical Center, is a 697-bed licensed, internationally recognized pediatric hospital, and is the largest children’s hospital in the U.S. The Texas Children’s surgical staff operates 24 hours a day in three different sites, treating patients ranging from newborns to adults. Managing all of the department’s vital data in order to maintain the hospital’s high-standard of safety and keep costs in check is a great challenge. Swanson, who has managed ORs like Texas Children’s for more than 19 years, led the implementation of department-wide automation technology to meet and exceed this challenge.
The Challenge
For years the department had been collecting information in several different applications that required a significant amount of manual data entry and failed to provide comprehensive reports. Surgeon preference cards were stored in Microsoft Word, and could not be tracked or organized in a significant way. Intraoperative nursing documentation and inventory control were done by hand, often with unreadable handwriting. Nurses documented surgical cases and calculated OR charges manually, resulting in numerous clerical errors. Bits and pieces of information were scattered across a group of disconnected systems, and each staff member used a personal method for documenting procedures. The lack of an agreed upon nomenclature and a central location for patient and billing information contributed to an inefficient workflow and inaccurate data. The information the system did gather could not be effectively analyzed, because the system did not generate statistical reports.
Additionally, the department’s unproductive system of data capture resulted in missing or erroneous information in approximately 40 percent of patient records. The billing department returned all errors to the OR for correction. This forced nurses to waste valuable time trying to track down correct information and caused numerous reimbursement problems. The department averaged more than $100,000 per month in late charges, and the staff time lost to manual documentation and backtracking was priceless.
The department was in desperate need of a comprehensive system that would institute an agreed upon language for all procedures being documented, and provide a single, central location for all information, from patient record details to billing codes. After initial research, it was decided that an upgrade to an all-inclusive OR management system would improve the hospital’s clinical documentation and make good sense for the hospital’s bottom line. The hospital launched a wide-ranging search for software that would document all phases of surgical care, from scheduling to preoperative care, through the OR and on to recovery, critical care and billing. Additionally, the system needed to provide a complete electronic record of the surgical event that enabled easy data access to promote patient safety, and allowed for analysis of this data to ensure the best allocation of time and resources.
A Singular Solution
In 2001, after an extensive assessment of all viable software systems on the market, the hospital team selected CareSuite OR Manager, a total perioperative automation solution from Picis, a Wakefield, Mass.-based company that specializes in high-acuity-care automation technology. The hospital chose this system because they felt it met its diverse clinical and administrative needs. OR data management and electronic record keeping from preoperative care through surgery to recovery, were all available as part of the system. Also, it easily interfaced with the hospital’s IDX admissions system and allowed for a multitude of ways for staff to capture and report statistical data without requiring manual entry.
After selecting OR Manager, Swanson and the department staff set out to fully implement the system. An implementation team was established and they examined, in detail, the functionality of the system and then streamlined organizational processes to maximize use of its capabilities. The team standardized surgeon preference cards and implemented online nursing documentation in the system to provide a complete electronic patient record of surgery, thereby erasing the need for the time consuming, often inaccurate, manual methods previously employed. Additionally, they adopted routine accounting principles in the department and focused on getting charges right before transmitting to billing. This included development of accurate and well-tested billing rules in OR Manager that automatically calculate perioperative charges based upon time, procedures, supplies and other factors. The entire staff, from clinicians to accountants, was now speaking the same language, and the focus shifted to accuracy and correctness during input, thereby greatly reducing the need for reconciliation.
Results
Texas Children’s Hospital went live with the Picis system in September 2002, and nurses began scheduling cases in OR Manager while tracking supplies and recording exceptions online. The data was then transmitted directly to the hospital’s billing system. Charge capture was improved, and lost time was decreased. Due to increased accuracy, online documentation and data analysis, Texas Children’s was then able to manage an increased number of surgical cases and meet the goal to drop the bill promptly.
Now, dependable and accurate reports allow staff members to continually see what is working and to fix what is not. With reports from OR Manager, the evaluation of staff performance, overall costs, use of supplies and other activities in the department is substantially simplified. All such reports were unavailable with the department’s old surgical information system. Reports also track staff members having clinical documentation issues, and log quality information.
Supply utilization and procedure times of individual surgeons can also be reviewed to improve the accuracy and management of schedules and supplies. By introducing a physician office link, they were able to decentralize scheduling and allow surgeons to schedule cases at their convenience into their block time. Physicians enjoy the increased flexibility, and remote scheduling has saved Texas Children’s Hospital the equivalent of two full-time positions while enabling an increase in the volume of cases. The schedule is more accurate with the offices doing their own scheduling. Additionally, the offices now can provide insurance information through the system directly to the admissions department. This has resulted in fewer delays for insurance hold.
Sweeping change across a department is never easy, and implementation of a new automation technology is no exception. But, it was worth the hard work, and hospital administrators see the effects, so they are happy. Before implementing the Picis system, it took Texas Children at least five days to process the correct patient bill. Now, the hospital captures accurate clinical, financial and statistical data during each phase of surgical care, and within 12 to 24 hours of surgical care the process is complete.
Now, less than 2 percent of OR charges contain errors. Within four months of go-live, the hospital recognized significant benefits of using the system: faster billing; an 80 percent reduction in monthly late fees; a department-wide language for documentation; and centralized data storage and reporting tools for easy access to meaningful reports. The result has been enhanced resource planning, which has physicians and staff praising the system.
Case Study #2:
Achieving a Complete Patient Experience
In March 2007, SourceMedical, a provider of information management solutions to the ambulatory surgery center (ASC), surgical hospital, practice, rehabilitation clinic and diagnostic imaging markets, announced a strategic partnership with InstyMeds. The union establishes SourceMedical as the exclusive provider of the SourcePlus PrescriptionCenter, a fully automated, ATMstyle dispensing system for outpatient prescription medication services to ASCs and surgical hospitals. The complete outpatient prescription medication system is ideal for facilities who want to provide to patients fast, accurate dispensing every time, with the added benefit of safety and the convenience of receiving full prescription medication at the point of discharge. The system provides facilities a “complete patient experience” and differentiates them in the market and allows patients to return to the comfort of their home as quickly as possible. It will also support underserved communities that lack 24/7 pharmacy availability.
Today’s surgical facilities are always looking for distinct advantages over the competition while providing patients with compelling benefits never before seen at the point-of-care. The SourcePlus PrescriptionCenter acts as a new profit center — increasing revenue while reducing medication errors and supporting patient convenience.
Waseca Medical Center, located in Waseca, Minn. and part of Mayo Health System, has become one of the first healthcare providers in the region to offer a unique service that gives patients the option to have their prescriptions filled 24-hours a day, seven days a week. This service targets not only same-day surgery, urgent care and emergency room patients, but is available to all patients.
“Our patients have told us they want to be able to fill their new prescriptions around the clock,” says Michael Milbrath, executive vice president of Waseca Medical Center. “This new system gives our patients access to a pharmacy that never closes. They may no longer have to drive somewhere else to have their prescriptions filled, especially after hours.”
Getting a prescription through SourcePlus PrescriptionCenter works much like getting a prescription through a pharmacy. The patient’s insurance information is gathered and entered into the computer during the admission process.
The healthcare provider enters a prescription and gives the patient a prescription order number. At the SourcePlus PrescriptionCenter dispenser, located near the emergency room at Waseca Medical Center, an automated touch screen walks the user through the ordering process. The patient enters the prescription number and their birth date for verification.
The patient then enters a credit card, debit card or cash to cover the cost of the prescription or co-pay. The medication is automatically labeled and a comprehensive bar code check system ensures that the patient gets the correct medication. In most cases the medication is dispensed in less than five minutes.
“Although many of the most common prescriptions can be filed, not every medication is available from the InstyMeds (SourcePlus PrescriptionCenter) machine,” says Kim Rux, pharmacy director at Waseca Medical Center. “The machine will also carry some over-the-counter medications. InstyMeds (SourcePlus PrescriptionCenter) was added with our patients in mind. They are charged the standard retail price without any added fees or charges.”
A telephone located near the dispenser provides a direct line to a support center staffed by pharmacists and pharmacy technicians 24-hours a day, seven days a week. This is especially helpful for patients who may have questions about their medications, including when they should be taken, how they should be stored and possible side effects, if any.
“With the nationwide shortage of pharmacists, this is one way Waseca Medical Center can truly meet the needs of our patients,” says Milbrath. “We believe this is a good step toward reducing the amount of time patients have to wait to get their prescriptions filled, as well as reducing the number of medication errors.”
Case Study #3:
PNDS, Electronic Medical Record Systems and Data
The Perioperative Nursing Data Set (PNDS) is an American Nurses Association (ANA)-recognized nursing vocabulary developed by the Association of periOperative Registered Nurses (AORN) to describe nursing care for patients undergoing a surgical or other invasive procedure from preadmission to discharge. As a controlled vocabulary, PNDS enables nursing care to be documented in a standardized manner. This will allow for collection of reliable and valid clinical data on perioperative nurse sensitive outcomes resulting from nursing interventions during a surgical or invasive procedure. PNDS is applicable in various perioperative practice settings including both inpatient and ambulatory surgery environments. Standardized documentation allows nurses to evaluate care across caregivers and practice settings.
While PNDS can be used in both paper and electronic documentation, the real advantage comes when it is implemented in the electronic health record (EHR). The manner in which data is documented, captured and mined is a critical factor for improving healthcare. PNDS is designed for the EHR as it contains the framework of uniquely coded clinical terms and knowledge that describe patient care provided during a surgical or invasive procedure regardless of the setting.
Using standardized nomenclature such as PNDS in electronic documentation provides the vehicle for gathering and aggregating data for analysis. The impact of using and mining the PNDS data is on several levels:
- The immediate impact is for the clinical perioperative nurse in terms of enhanced communication and the linkage to clinical support
- Healthcare organizations benefit from effective standardized outcome reporting and quality improvement activities
- PNDS provides reliable and valid clinical data that can be used by researchers to uncover new clinical relationships
Electronic Medical Record Systems
As described above, the electronic medical record is much more than just the replacement of your paper charts. Early attempts at solving the problem of storage space and access gave way to a misconception that simply scanning paper records or moving your paper forms to electronic copies of those forms was an electronic medical record. What advantage would one of those formats have over a paper record in making the use of PNDS any more practical or efficient? The answer is, none whatsoever because the image of an electronically stored document is still just an image and not useable data.
If a facility has decided to standardize the terminology and nursing diagnosis information contained in the PNDS, an EMR is the most efficient way to implement the system. Before selecting an EMR you must ensure that the required functionality is present and that the developer of the EMR has acquired the proper licensing from AORN.
Functionality is a key to the efficient use by the nursing staff. A few of the major points to look for are:
- Does the EMR contain all the required structured data elements (SDAs)?
- Can you obtain the detailed explanations of the SDAs easily?
- Can you easily access information on interventions and recommended activities?
- Does the EMR allow for recording of nursing diagnosis codes?
- Are there standard reports in the EMR for reporting on outcomes and nursing diagnosis codes?
Some of the benefits resulting from integrating PNDS with an EMR are as follows:
- Nursing as a profession benefits from documentation of outcomes and comparisons to procedures completed with a reduced amount of nurse participation.
- The integration of PNDS into an EMR will permit the measurement of nursing full-time employees (FTEs) involved in a procedure directly to a CPT code. This will further support their value in a clinical setting.
- Direct access to PNDS within the EMR (the recommended practice) will help support real-time nursing decisions.
- Facilities will be able to provide more detailed outcome studies with less cost. Comparative studies using paper charts could take as much as one, possibly two additional FTEs.
- Patient safety is a top priority among any healthcare organization. This type of solution would help determine if the correct steps were followed should a negative outcome occur. It provides risk mitigation without sacrificing productivity.
- Submission of outcomes data supported by PNDS to AORN’s national database will assist in enhancing and supporting changing or modifying practices on a national level.
- Electronic access to intervention and recommended activities improves actual utilization and reduces FTE’s when compared to information stored in paper or book format.
- Electronic maintain of nursing diagnoses and other information allows for a more current data set than a once-a-year hardcopy update.
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