January 2009 FEATURE ARTICLES
PHRs/EHRs/EMRs
Riding the Painted Ponies
When good workflow goes bad, healthcare environments feel like carnival rides. Fortunately, there are solutions.
By Theresa Lenz
Being the second oldest hospital in Minnesota, the staff at Lakeview understands the need to evolve
in order to provide the highest possible level of healthcare to
our patients. Over the past few years, Lakeview has progressed
into one of the state’s finest hospitals, assuming a leadership
role in patient satisfaction and procedural advancements.
Lakeview Hospital has been named a Top 100 Hospital by Thomson
Healthcare three times, most recently in 2007. In addition, in
recent local patient surveys, Lakeview Hospital has consistently
ranked in the top two of all metro area hospitals as best in
overall patient satisfaction.
Lakeview is a 97-bed, independent community-controlled facility located in Stillwater, Minn. We provide inpatient medical/surgical, ICU and OB/GYN services, and in 2007, we cared for 5,400 inpatients. Our outpatient services include same-day surgery, endoscopy, cardiology, oncology, chemotherapy and infusion, imaging, lab, cardiac rehab, physical medicine, pain clinic, in addition to a sleep center and emergency services. We had 57,650 and 12,805 patients visit our outpatient areas and emergency department (ED), respectively, in 2007. We also specialize in orthopedic surgery.
Rapid Growth Presents Challenges
Lakeview Hospital experienced rapid growth during the past 10 years and this growth continues yet today. Physical space needs for patient care and business services are continuously evaluated and addressed. The requirements for the Health Information Management (HIM) department’s filing area needed to be addressed annually. We were using a straight numeric filing system that required constant shifting and moving of records. Managing the file area became a "merry-go-round" consisting of two on-site and one off-site storage locations, in addition to records previously scanned to network files and microfilm. Prior to 1999, we were able to store 20-plus years of historical active records on site, which our physicians had become accustomed to accessing. By 2005, we were down to just five years on site and were only able to increase our storage space slightly, so as to continue on-site filing. We estimated that by the end of 2006 we would once again be out of space and would have only six years of active records on site.
Thanks to the new technology, we’ve gone from a department that had multiple processes that varied dramatically depending on the type of service provided, to a department that’s standardized, simplified, efficient and proficient.
In late 2005, we initiated a plan to move the HIM staff to the opposite end of the campus. The new location would be quite a distance away from the main filing area, which was in the hospital’s "attic." Due to the anticipated staff inefficiencies of running charts from one end of the building to the other, I insisted the files from both on-site areas be relocated and consolidated into a space adjacent to the new HIM department. It was clear that the new space would not sustain us into the future at our current growth rate; therefore, while planning the relocation, we began discussing the benefits of an electronic record workflow for the HIM department.
Lakeview’s leadership felt confident that the right legal electronic health record (EHR) would enable us to overcome the challenges we faced, which included dwindling file space, restricted physician/nursing access to the HIM department and decreasing staff productivity. Our cumbersome paper processes and workflows were dependent on individual staff members. For example, due to our facility’s smaller size, our outpatient coders had to take on additional clerical responsibilities. As volumes grew, it became apparent that the coders could no longer perform clerical tasks and maintain coding productivity. We needed a system that would enable us to re-assign those responsibilities to clerical staff. We also believed that by allowing our outpatient coders to focus specifically on coding by removing clerical functions from their workflow, and by letting them work remotely from home, we would increase productivity.
Managing the file area became a “merry-go-round” consisting of two on-site and one off-site storage locations, in addition to records previously scanned to network files and microfilm.
By 2004, Lakeview had implemented an electronic nursing and ancillary services patient charting application for our inpatient services. At that time, we decided to not print documents for filing into the paper record, so we created a hybrid medical record; however, this system did not have a long term storage solution. We anticipated that within three years we would need an alternative storage/access solution. This was yet another factor that led us to explore a legal EHR workflow technology.
The legal EHR would become Lakeview’s documented set of information for each patient encounter — a compartment of the entire patient database — which serves as the legal business record for the organization. The functions of the legal EHR support patient care decisions and payment, as well as document the services provided as legal testimony on the patient’s illness or injury, caregiver decisions and reactions to treatment.
Additional Considerations
Finding the right legal EHR technology was just the first step. We also wanted the solution to offer a host of additional benefits, including the ability to analyze data, maintain secure records, seamless and easy implementation, and have Web access. Moreover, the technology needed to be able to address issues throughout the organization. We resolved to look beyond the HIM department’s immediate needs and examine the impact and potential benefits such a solution would have enterprisewide.
Lakeview’s leadership put themselves in the shoes of the doctors, nurses and staff, which provided valuable insight during the implementation process. They took into account the immediate and future impact that a legal EHR would have on existing HIM systems and processes, and worked hard to communicate this information to all affected groups. This well-considered plan ensured that Lakeview’s sizable financial investment would achieve all of our desired goals. The biggest objective for electronic record access was to lessen the administrative burden of our physicians while enhancing their access to critical information, and in turn optimizing patient care.
Strong Leadership Prevails
Throughout the selection and implementation processes, flexibility, respectful questioning, collaboration, open communication, brainstorming and problem-solving consistently turned challenges into opportunities. For example, early in the implementation process during one of our weekly scheduled CME conferences, the physicians suggested that five years of historical dictations be imported into the new system. We had not considered this; however, because we were already planning on uploading historical data from another system, we could easy accommodate the physicians’ request. This turned out to be a very positive selling point for our physicians.
Time for a Decision
For more information
on eWebHealth
Like most hospitals our size, cost and maintenance are key factors when we examine new systems. We considered two applications, both from vendors with whom we already had relationships. Since this was considered an "upgrade" to an existing system, it came down to which one met the financial requirements as well as the vision.
One vendor required substantial hardware investment, per user licensing, time-consuming set up and ongoing maintenance. We ultimately chose eWebHealth because it’s a software-as-a-service model with virtually no hardware to purchase and minimal-to-no ongoing internal IT support. We also found the system to be end-user friendly for physicians, nursing and staff.
Implementation
We had weekly status calls with eWebHealth that included a project plan with dates and timelines. Working closely with our project manager, we evaluated the current paper processes to identify areas for improved efficiencies. Involving our staff to better understand the daily tasks they perform enabled us to create a better workflow process.
We brought many stakeholders into the process, including IT network administrators, interface specialists, nursing staff and HIM personnel. In the beginning, we met to discuss the implementation and communication plans. We performed a risk assessment to identify "risks/barriers" early on in the project, which enable us to address them as we went along. During the entire process, we left nothing to the last minute.
From Paper to Digital
Transitioning from paper records to digital has greatly impacted coder workflow at Lakeview. For example, we had a clerical staff member that assembled and analyzed ED records. With the paper process, she had five baskets through which the ED records flowed. Our coder performed both the facility ICD-9 coding as well as the physician pro-fee coding. To keep her thought process clear, she would look at the records twice — once for the ICD-9 and once for the pro-fee. The five baskets helped her organize what was ready for coding, what had been coded and what was coded but still waiting for something else. A year after going digital, the clerical staff member who manually performed this task can barely remember how she completed the job using the old method.
Tangible Results
Lakeview has achieved great results thus far with the new technology, which has been most gratifying. HIM DNFB (Discharged Not Final Billed) has improved by approximately five days. We were averaging about eight days last year, and with eWebHealth, we are at three days. We continue to evaluate ways to enhance our workflows and systems for continued improvement in this area.
We also eliminated the need for two casual file clerks that added up to one FTE. Within six months from go-live, these staff members were re-assigned to another department. We have re-allocated FTEs from the clerical functions to increase hours in coding and most recently created a "Data Analyst" position that will assist me with managing the eWebHealth system, producing data reports requested of HIM, as well as maintain our departmental performance data. Over the past several years, we attempted to track phone calls to HIM as well as the time associated with them. This time-consuming process often did not reflect the true staff time associated with the calls. Within a few short months of go-live the phone calls practically stopped.
We seldom need to run an "old chart" to the nursing units since the available electronic information is quite sufficient. Moreover, since go-live, there have been no misfiles and zero backlogs in filing and scanning. In fact, everyone knows where everything is at all times. It’s truly amazing. Plus, the time we spent tracking down reports or charts that had not been properly checked out has been completely eliminated.
The eWebHealth system also has had a positive effect on Lakeview’s case mix, including Medicare. In June 2007, Lakeview’s overall case mix was 1.2401 (year-to-date). Then, in just one year, it rose to 1.33025 — that’s a 7.3 percent increase. As for our Medicare case mix, it went from 1.5171 in June 2007 to 1.5769 in June 2008 — a 3.95 percent increase. For a hospital our size, the 3.95 percent Medicare increase alone means an additional $1.6 million annually in net revenue.
Perhaps the most pleasing outcome has been the improved satisfaction of physicians, nurses and other staff at the hospital. As the leadership at Lakeview had always hoped, this improvement has had a beneficial effect on patient care. The most important benefit is the time factor. For example, when a patient presents to the ED, staff can immediately locate the patient’s most recent visit to Lakeview. There’s no more calling HIM or waiting while the information is located, no more nursing visits to the HIM department in the middle of the night trying to find a chart.
The Future Looks Bright
Currently, Lakeview uses the full suite of applications from eWebHealth. We also have our system interfacing with ADT, Dictaphone’s EXText and QuadraMed’s Affinity. We are currently developing interfaces with GE-Centricity Perioperative Surgical System and Orchard Lab System. In addition, we plan to research interfaces with RMS (Swearingen) and the GE Centricity Perinatal Clinical Information System.
In the near future, I envision the system assisting us with "concurrent" communications with physicians (i.e., physician query process). I think we also will add a more robust reporting functionality, along with the ability to print reports directly from the work queues. I also expect to store DX and procedure codes, facilitating an even smoother reviewer process.
Thanks to the new technology, we’ve gone from a department that had multiple processes that varied dramatically depending on the type of service provided, to a department that’s standardized, simplified, efficient and proficient. Lakeview clinical managers, physicians and nursing staff continue to be impressed with the technology and the impact it has had on our organization.
Theresa Lenz, director of health information management and compliance, Lakeview Hospital, Stillwater, Minn. Contact her at
theresal@lakeview.org .