Clinical Information Systems: An Essential Tool in a Managed Care Environment
Clinical Information Systems: An Essential Tool in a Managed Care Environment
Touted as an ED cure-all for everything from high documentation costs to communication glitches, clinical information systems are now being recognized across the country as the essential component in a managed care ED.
"We have just started moving into a managed care environment, but the system has helped us prepare by enabling us to look at the way we do things," says Trini Juarez, RN, Director of Emergency Services at Kaweah Delta District Hospital in Visalia, CA. "It tracks everything."
The system in use at Kaweah Delta, Medi-Mouse, was implemented almost four years ago to help the department save money on dictation costs. Since then, it has proven an invaluable tool for standardizing care in the department, tracking costs and utilization, and improving wait times and patient satisfaction.
"They are a challenge to implement, but once you have a clinical information system you’ll never look to anything else," Juarez notes.
Clinical information systems serve such a varied and useful purpose because they collect data from the minute a patient walks in the door, continue collecting it throughout the ED visit, store the data together, and allow it to be easily linked and sorted to quickly obtain different reports, says Jackie Hjelm, RN, MSN, Clinical Consultant with Logicare Corp., a clinical information software company based in Eau Claire, WI.
"You have lots of associated data," she says. "When the patient comes through the door we gather a lot of information on them, all the triage information and demographic information: pay type, acuity, what ZIP code the patient lives in . . . As we pass through the process we also know the names of all the caregivers associated to the case, all the orders a physician has given for the patient, and the diagnosis."
Tracking costs in the department
Knowing the actual cost to treat certain conditions is one of the essential components in contracting with managed care, says Molly Ciliberti, RN, Clinical Specialist and Co-founder of Orca Medical Systems, a clinical information system vendor in Bothel, WA..
"How much does it cost to treat a Grade 3 ankle sprain in your department?" she asks. "When you ask people that they can usually find out for you, but they don’t know. I find it amazing that people can bid for [managed care] contracts, when they really don’t know a profile of all of their patients and what it costs to provide their care."
This information is easily obtained by computerizing the information and tracking it over a period of time, she says.
Because all of the documentation is online, information can be sorted in various forms to generate almost any kind of report necessary for getting an overall picture of the department: what kinds of conditions and acuity the department sees and when, what payer type the patients are, and what tests are ordered and medications prescribed most often, says Juarez.
Implementing treatment protocols
In addition to simply tracking the performance of the department, clinical information systems can actually be used to guide care and enforce practice standards set up at a given facility.
At Kaweah Delta, Juarez sets up databases that list the standard tests and procedures for each specific complaint.
During triage, the nurse will enter the chief complaint, the system then links to the database containing the list of tests in the protocol for that complaint, instead of linking to a menu with thousands of tests on it, he explains. "For example, the triage nurse will pick the category of hip pain. When the physician goes into it, different things are linked in, the appropriate x-rays, the appropriate medications."
The system also contains "triggers" that compel the nurses and physicians to comply with treatment standards.
"When the physician goes in to input the history and physical, it tells them, Hey, these are the things you need to address,’" says Juarez. "It won’t allow you to discharge the patient if you don’t address them. The managers can put in all kinds of flags to say you can’t discharge the patient without giving the tetanus shot, or addressing the ECG, or that the vital signs have been addressed."
Using diagnosis reports, ED managers also track resource utilization and determine which physicians are complying with practice standards and which are not.
"If we wanted to look at otitis media or strep throat . . . We are able to just look at those diagnoses and pull the charts for auditing," says Juarez. "Doctor X is always ordering the strep culture or the urine culture, when, really, the signs and symptoms show that you can forget the test and treat the patient. We can say, Doctor X, you are out of compliance and we need you to follow the standard of practice the department has set up."
Improved efficiency improves patient satisfaction
More managed care plans are paying attention to how their members perceive treatment in the ED and the computer allows them to track more closely the time it takes for patients to be seen by a physician and how much time they spend in the department, notes Juarez.
"One of the things we’ve done is track the time the physician enters the room," he says. "We can add a flag that asks the physician to enter time of initial contact with the patient."
A good clinical information system can also track the intervals between different points in the ED visit, says Hjelm.
Logicare’s Level III system tracks the time from the time of arrival, to the time to triage, to time of registration, time in the room, and what room, Hjelm says.
"It holds on to the information retrospectively so we can see how long it took the patient to go from one interval to the next, and it lets you know where you need to improve," she says.
With a clinical information system, anyone in the department can check on a particular patient’s status from any one of the computer terminals set up around the department, which can make a huge difference in patient perception of care and in patient flow.
A nurse in a back room with a sick child and parents who haven’t slept all night still needs to make sure the physician sees one of her patients in another room, Ciliberti explains. With the information system, the nurse can check the patient’s status without leaving the room and walking up to the nurses’ desk to look at the tracking board.
Improved communication between the charge nurse and triage nurse allows patients to be moved through the department faster as well, says Ciliberti.
"The charge nurse and the triage nurse move patients through the department, but often the triage nurse is behind a closed door, totally separate from the emergency department," she says. "She has to call on the phone or get up and leave to find out what is going on. With the computer, she looks up the locator board and sees.
Customizing services for managed care
Clinical information systems can also be used to improve compliance with managed health plan requirements by both the department and the patients, and can even be used to find hidden needs some health plans may have for ED services.
Orca’s program is set up to store information about providers in the system. If a patient presents in the ED and is a member of X health plan, then needs a referral to the cardiologist, the system can filter a list of cardiologists for just those who participate in the patient’s health plan and are in the patient’s area.
Logicare’s Level III program also allows the department to incorporate payer-specific information in the discharge instructions, notes Hjelm. "We can put special information to the HMO patient that it is their responsibility to follow-up with the [PCP] appointment . . . In managed care environments, we can put special statements in there just for them. We can customize them."
The system also works to enhance communication between ED physicians and private practice physicians who will see the patients for follow-up.
A spin-off to the Logicare discharge instructions, a follow-up letter to the referral provider, can be generated automatically by the computer and automatically faxed to the provider, Hjelm says. "Once that’s done, it closes a big gap between the ED visit and the outside provider."
Such closure plays an important role in ensuring compliance with follow up care, she says.
"I think, number one, a need for a managed care population would be [to ensure] compliance," Hjelm explains. "Was the appointment made? Did the patient follow through? Did they return to the ED?"
"We store data from every department, lab, x-ray, ED, counseling services, everybody stores their data in the same box," he says. "The physician can call and access a record and pull it up on screen, without it having to be printed out and faxed."
On a larger scale, the clinical information system can help a department locate needs in a certain population or area that a payer might not be aware of, says Hjelm.
"We encourage people to look at what elements they can associate together," she says. "For example, for managed care plan X you can go back and see how many of their patients were seen in the ED, what the typical acuity of these patients is, and what hours of the day they come in."
"Maybe all of the plan’s patients on the east side of the city are coming in after hours," she continues. "Should we have an after-hours clinic? Maybe the plan has a clinic but it is on the west side of town and those patients don’t find it accessible."
This kind of information can help the ED move from just coping with managed care efficiently, to getting ahead in an increasingly competitive environment.
"You have to think about what it is managed care systems need to know in order to get some ideas about how their patients are doing and how their money is being spent in the ED," says Hjelm.
[Editor’s Note: As this article went to press, the editors learned that Orca Medical Systems has ceased operation. According to Ciliberti, the owners are negotiating a sale of the company and expect it to resume operation in the near future.]
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