Comprehensive management, clinical software produce ‘paperless’ office
Comprehensive management, clinical software produce paperless’ office
Cuts report turnaround time from weeks to minutes
When the directors of the speech pathology and occupational and physical therapy departments at Children’s Hospital Medical Center in Cincinnati set out to computerize patient documentation, they just wanted to increase the time clinicians spend in direct patient care. They never dreamed the initiative would win the International Beacon Award from IBM/Lotus for the Best Industry Specific Solution in 1995. The comprehensive application, now available through Chart Links in New Haven, CT, uses Lotus Notes as its platform for more than 20 databases to handle clinical, administrative, scheduling, and referral functions.
"After beginning to work with the computer consultants, we realized the great potential for computerizing all aspects of our business," explains Ann Kummer, PhD, director of the speech pathology department. "We set out to put every piece of paper we had on a computer."
Eighteen programmers, two software companies, and four years later, the two departments have come about as close as possible to a paperless office. In the process, they also discovered many inefficiencies in the old documentation system that caused them to implement redesign efforts along with computerization.
"Early on, we realized we had to step back and look at the work flow," says Kummer, who performed the work analysis with Rebecca Reder, OTR/L, occupational and physical therapy director. "We analyzed every step — from the time we receive the patient referral until we’re completely finished with the patient. We charted everything we do that requires a piece of paper on a work flow diagram."
Many inefficiencies soon became obvious. For example, when the departments received a referral from a physician, they first sent a patient questionnaire in one mailing and an appointment reminder in a second. "When we looked at the work flow chart, we asked ourselves, Why are we doing two mailings?’"
After redesigning the process on paper, they were ready to work with programmers to computerize it. The ultimate result was the following four category databases that contained a variety of forms where material is entered as well as views where information from the forms is sorted and displayed:
1. Patient documentation databases.
The directory of patients contains demographic information for all patients within the practice. The referrals database stores all patient referrals. Each entry contains the name of the referring physician, the diagnosis, reason for referral, and insurance authorization, appointment, and follow-up information.
"Many of the views automatically generate quality assurance reports and provide reminders for follow-up," she says.
But the heart of the documentation system is the evaluations database that contains predetermined evaluation sets such as those for oral-motor/feeding, resonance, and early language and more than 150 individual evaluation sections such as treatment history, articulation/phonology, voice-objective analysis, and oral structure. "Teams of experienced clinicians from each specialty developed the sections," she says.
Clinicians no longer take evaluation notes on legal pads, but enter observations directly into a computer in the exam room or take a laptop with them to clinics. By clicking on various lists under each evaluation section, therapists can compose an evaluation report quickly. If the words or phrases they need aren’t on one of the lists, they can use an open field to type in information.
"Not only do these standardized evaluation sets and sections provide faster, more consistent documentation, but they also serve as guides for less experienced clinicians," Kummer says.
After completing the pertinent selections, the application automatically reformats the information to a professionally formatted text document.
In addition to speeding up the evaluation documentation process itself, the automatic fax capability has cut report turnaround time to almost nil. Under the old system, it could have taken as much as a month for reports to reach physicians.
"Therapists first had to find a block of time to dictate information from handwritten notes. The tapes were then transcribed by an outside dictation firm," she explains. "When the report came back, the therapists had to review the report and return it to transcriptionists for correction. Finally, the secretary had to copy and mail the report to the physician."
Now, therapists can generate the report immediately when the patient leaves. "It takes 10 to 15 minutes to generate a diagnostic report from beginning to end. The other advantage is that if you have two minutes, you can get something done, whereas with dictation you had to have a chunk of time," she says. With computerized documentation, it’s also much easier to revise and edit, she adds. (See sample of databases, p. 31.)
"The physician can receive the report before the patient arrives home from the appointment!" she says.
Quick treatment plans and discharge reports
With the treatment database, therapists don’t have to spend time copying redundant information. "Information from the evaluation report and referral documents automatically fills in the treatment plan," she explains.
Clinicians also select goals from a large data-base. By clicking on a "select" button, they can update the status of each goal. When the patient has met the goal, another click causes the date to appear automatically on the treatment plan.
"When a progress or discharge report is needed, the report almost writes itself by inheriting information from the evaluation report, the progress notes, and the treatment plan," she says.
After selecting from a list of recommendations, the report is done. "Insurance companies really like the fact that we can get progress reports to them within 10 minutes time."
Also in the progress notes and charges database is a built-in mechanism for coping with managed care demands. Clinicians post charges for each patient visit by clicking on the procedure and the number of units. The charge, which is calculated automatically, goes to a billing log that can be printed or sent to the hospital’s billing system.
"Each time a charge is generated, it is counted against authorized visits," Kummer explains. "Insurance authorization views keep track of the number of visits left as well as the insurance expiration date.
To compose letters to insurance companies, physicians, or families, clinicians use the letters database, which contains a directory of template letters.
2. Scheduling databases.
Another important management application is the provider’s calendar/mailbox database, which clinicians use for scheduling appointments and meetings. The current appointments database contains all appointments — sorted by date, location, and provider — that have been scheduled for all clinicians. "There is also a view for all open evaluation slots," Kummer says. The appointment history database, which maintains a record of attendance for all appointments, sorts by patient, date, clinician, and shows whether the appointment was met, canceled by the patient or department, or a no-show.
3. Reference databases.
In addition to databases for ICD-9 codes, information about insurance companies, physicians, and community resources, the reference databases also include a home programs database for more than 150 standardized patient education handouts.
"Before computerization, we maintained a filing cabinet [with patient education materials] at each of our locations, but often the master was inadvertently used," Kummer says. "Now with this database, we not only print each document as we need it, but we can personalize it for that particular patient and family."
4. Administrative databases.
As a clinician, Kummer says she appreciates the way the application expedites documentation of patient care. As a manager, she "loves" its administrative capabilities. The employee database, for instance, tracks all employee information such as status, pay rates, years of service, licensure status, continuing education records, FTE complements, and schedules. It also contains forms and views for students and job applicants.
The budget database tracks budgets and all expenditures against the budget. "It provides a picture of what has been spent and what remains under each budget category," she says. "It also tracks the status of each purchase and current inventory."
In the policies and procedures database, managers sort policies by date, title, category, or accreditation codes. "Clinicians at all locations can access policy changes and updates immediately."
Likewise, a discussion database facilitates communication between the satellite locations and the main campus. "Much like a community bulletin board, this database allows discussion between staff at various locations. Staff can post messages and topics for feedback and discussion, and committee meetings can be conducted electronically," she says.
Even though the application represents sev- eral years of investment of time and resources, Kummer says it’s more than paid for itself in creating a more efficient work process as well as a work force. "Because of the computerization, we now can accept referrals at one location and do billing at one location, so we were able to reduce secretarial support. We are able to serve more patients from our waiting list, generate more patient revenue, and the clinicians are able to do more of what they do best — treat the patients."
When Kummer fields calls from other managers who want tips on how to create their own application, she offers this advice: Don’t develop it; buy it. "When I hear people say, We’ll do what you did,’ I tell them that in today’s market, you can’t afford to start from scratch," she says, explaining that although her facility paid about $150,000 for computer consultants, the two companies assumed hundreds of thousands of dollars in development costs.
Chart Links’ cost for the shared electronic chart is $1,495 per client, and the scheduling program costs $4,995 for the first site. The documentation library is $995 per clinical user. There also are charges for third-party software, maintenance support, and modifications.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.