Feature: IT soothes ED pain points
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“Total annual visits to EDs nationwide increased from an estimated 95 million to over 115 million,” Tang said in an interview. “This is an increase of 23 percent, twice the rate of growth of the general population over that same time period, which grew by 12.5 percent.”
ED visits by adults with Medicaid grew from 9.6 million in 1999 to 17.7 million in 2007—an increase that cannot be attributed only to the increase of Medicaid enrollment over the same time period, Tang stated. “By 2007, adults with Medicaid visited the ED at a rate that was five times the rate of adults with private insurance.”
EDs are increasingly serving as the safety net for medically underserved patients, particularly adults with Medicaid, according to the JAMA article. With no end in sight to the rising tide of ED patients, many organizations are harnessing IT to better manage emergency room (ER) care.
“There are limits on organizations in terms of what the ED can do and how they can do it,” said Christopher Nemeth, PhD, principal scientist, and group leader for Cognitive Systems Engineering at Klein Associates Division of Applied Research Associates in an interview. “Healthcare organizations like acute care hospitals operate at or near saturation. One of the most frequent circumstances they have to deal with is not being able to transfer patients easily from the ED into the hospitals, because the hospital is already near or at capacity.”
The e-track
Tracking software can help organizations get a back-end view to their practice, which could help decision-making to alleviate ED overcrowding, according to Nemeth’s research colleague Robert Wears, MD, at the department of emergency medicine at the University of Florida in Jacksonville.
“In general, the functionality that was gained by e-tracking in the implementations we studied largely occurred on the back-end process,” said Wears. “Department managers were able to get more detailed information about the flow through the departments and various stages of the processes of care. Another functionality gained was department-wide information was more readily available.”
With the e-tracking technology, clinicians in the implementations Wears studied could see how many patients were in the waiting room and the ER, and see when ER beds were empty or filled.
“If you can tell where the most time is spent [for the patient], then you know where the rate limiting step is. Addressed in a serial fashion, you could ultimately make some improvements,” Wears said.
Nemeth believes that IT-related research can reveal fracture points in an organization—where departments and services do not agree. “It’s bigger than just a technical issue. You have to start by understanding the organization you’re dealing with,” said Nemeth.
For example, prior to implementing a Medhost EDIS (Emergency Department Information System) in 2005, Good Shepherd Medical Center clinicians had computerized patient tracking, but it was difficult to use because clinicians didn’t have a sense of which patients were in the ED and what their status was, said Ron Short, vice president of operations at Good Shepherd, an acute-care regional referral center in Longview, Texas.
Good Shepherd’s 40-bed ED now sees almost 90,000 patients a year and logged a 37 percent increase in ED volume from 2002 to 2007, Short said in an interview. Good Shepherd implemented EDIS and patient tracking to maximize efficiency in the ED, and within 30 days had identified trouble spots. This enabled Good Shepherd to streamline patient turnaround and throughput time to maximize ED efficiency, he said.
According to Short, the EDIS drilled down to the basics of the throughput process, including the time from patient arrival to triage, triage to in-bed, in-bed to initial physician contact, initial contact to care complete or disposition. “We identified quickly that we had issues for admitted patients on the back end of the process, from care complete to assigning the inpatient bed, and then from assigning the bed to getting them out the door and up to the unit,” said Short.
“Overlaying technology in and of itself doesn’t solve your issues. You have to do something with the information at hand and the tangible actions you put in xare what’s crucial,” he said. Good Shepherd hired a patient placement coordinator, nicknamed a “bed czar,” to identify the bottlenecks on the inpatient side as well as in the ED that preclude the facility from assigning a bed in a timely manner and, once the bed is assigned, getting the patient out of the ED in a timely manner.
By 2008, Good Shepherd had cut the median turnaround time on admitted patients by 20 percent. However, the facility was also seeing an increased volume of patients—up 30 percent from 2005. Short implemented a Code Green, comprised of an ED team, admissions team, length of stay team, discharge team and a mindsets team to make the throughput process more efficient given the data from the EDIS. As a result, in a six-month period, Good Shepherd cut seven-tenths of a day from the average length of stay for ED patients.
Kiosks in the ER
Tackling another IT task, researchers from UCSF, in collaboration with the California Healthcare Foundation, are studying data from kiosks placed in select emergency rooms and urgent care clinics in California to expedite diagnosis and treatment of conditions that could be treated in a primary care environment, according to Tang.
For example, women with symptoms of a urinary tract infection (UTI) answer a series of questions at a kiosk computer to determine if they are a low- or high-risk patients with a high likelihood of having a confirmed UTI (independent of any examination by a provider). Based on their answers, the computer at the kiosk will either ask them to wait for a doctor or, if their answers indicate that they most likely have a UTI, the kiosk will print out a summary of their illness history and a prescription for antibiotics, which they have the doctor sign, and then can leave the ER.
“They basically bypass the entire system just by answering a few questions,” said Tang.
Modules are being developed to provide preventive health services in EDs as well, according to Tang. One module being tested facilitates Chlamydia screening for 18-25 year old women; another enables women who are interested in different family planning options to obtain an oral contraceptive prescription through the kiosk as well, she said. “The researchers are looking at what disease conditions we can take care of for these patients through these kiosks that might speed up the process in ED and reduce some of the burden that the ER physicians are seeing currently.”
Tang said she anticipates the release of the kiosks’ data within the next few months.
Click here to see the April CMIO article about additional IT options for EDs.