Electronic patient records result in efficiencies

Case managers spend time with their patients

Since the implementation of a state-of-the-art electronic patient record system, case managers at Evanston Northwestern Healthcare have more time to visit with patients and their families, enabling them to better prepare the patient for going home.

"The case managers have more time to spend face-to-face with their patients and families, and therefore, they’re able to improve throughput and make more appropriate referrals," says Mary Ellen Mitchell, RN, BSN, MA, director of clinical services at Highland Park (IL) Hospital.

"We’re hoping to see enhanced patient satisfaction as well. It’s already at the 90th percentile in the [South Bend, IN-based] Press Ganey [Associates] scoring, but now we know we can be more comfortable in spending time with the patients and families and answering their questions."

Highland Park Hospital rolled out the electronic patient record earlier this year, the third hospital in Evanston Northwestern Healthcare system to adopt the system. Designing and implementing the patient record system was a three-year process.

Within the entire three-hospital system, savings generated by the electronic patient record system are estimated to be $10 million a year, from improvements such as higher copay collection and rising reimbursement. Insurance denials due to lack of information have fallen to nearly zero.

The three hospitals are among only 41 throughout the nation that fully comply with the computerized physician order-entry (CPOE) standards set by the Leapfrog Group, a health care watchdog agency in Washington, DC, dedicated to improving hospital care.

The system integrates CPOE with electronic health records and allows all charting, ordering of tests, procedures and medications, registration, scheduling, and physician billing to be done electronically through one system.

The integrated patient record system creates a record that follows the patient from the physician’s office to the laboratory to the pharmacy to the hospital, rather than being scattered among various providers.

Systemwide, the turnaround time for test results has fallen significantly, and entire categories of medication errors have been eliminated. Delayed administration of patient medications has decreased by 70%, while omitted administration of medication has dropped 20%.

From a case management standpoint, the system has saved time, allowing documentation and concurrent review to be done in real time, and increased the efficiency of the staff.

"The electronic patient record system speeds up all the tasks the case managers undertake to facilitate patient treatment and care. From our perspective, the system has a positive impact on the advancement of patient care, resulting in improved quality," Mitchell says.

Within minutes of a patient’s admission, the case managers are able to make sure the patient’s medical records and admission status coincide. "In real time, we are able to see if we have a patient who does not have an order or a patient whose admission status does not match the actual physician order."

The system is particularly helpful for concurrent review, she adds. "We can avoid the aspect of having a patient who is not admitted in the right status in real time."

The new electronic system helps case managers keep tabs on the documentation required for reimbursement in a timely manner, Mitchell adds. "With this system, there’s no mistaking. Something either is there or it’s not. We have to be very precise about the cause, the coding, and other factors to be reimbursed for treatment, and this system helps improve the clarity of the documentation," she says.

It eliminates questions about exactly what the physician said about the patient’s status, comorbidities, or treatment plan.

"To have a tool this refined gives us a distinct advantage. The documentation is so enhanced that we never have to ponder or call and clarify what a physician has written. We never have to worry about not being able to read an order or about making an error because it isn’t clear what the doctor intended," Mitchell explains.

The system allows for a tremendous amount of flexibility in communication, she points out.

The nurses and case managers are able to communicate with the physicians through an electronic in-basket and receive a rapid response instead of telephoning their offices and being kept on hold or waiting for a reply. The system allows case managers to access patient charts at any time from anywhere in the hospital, rather than standing around in the nursing station, and allows more than one person to access the chart at the same time.

"We all know the limitations of the patient chart. It goes with the patients if they’re having testing, and you have to wait to access it. With automated medical records, we have access from any point, and all individuals who need to can access the chart at the same time," she says.

The electronic system makes it possible for documentation to be mobile and in real time, Mitchell adds. The hospital has about one computer mounted on a wheeled cart for every four patients in each unit.

Case managers and other staff take computers into the patient rooms for documentation when they visit the room if documentation at the bedside is appropriate.

"Not only do we have the advantage of knowing everything we need to know, but we also can document on the spot instead of making notes and then writing it down later when we have time," she says.

Through the electronic system, if a question or concern comes up during the rounds, the case manager can contact the physician by e-mail.

The intensive care unit (ICU) has a case cart with a computer mounted on it, along with other tools the ICU nurses need as they make their rounds.

The hospital system uses 42 clinical pathways, which, on the electronic system, are integrated with the nursing care plan — an innovation that is particularly helpful for case managers, Mitchell points out.

With the electronic system, the case managers no longer are the only clinicians who see each patient’s overall care plan, she adds. "For everybody in the hospital to know where the care they provide fits in the overall plan and where we are headed is a real efficiency tool."

With paper clinical pathways, the physicians sometimes had problems finding the forms or the nursing station was out of the form they needed.

Now that the clinical pathways are computerized, the physicians can just pull up an order set, click off what they want to order, and have it instantly documented.

The result is that the electronic clinical pathways are being used much more frequently than the paper pathways, Mitchell reports. "Now we can be sure that no patient is having less than a minimum of care for that particular diagnosis."

Physicians can enter orders from the hospital, from their offices, or from their homes any time of the day and night. For instance, when attending physicians are notified by a nurse or a case manager that their patients are being admitted, they can enter the orders remotely and get the treatment started.

"The orders are actually entered in real time. This has an effect in the overall time in the case of the patient," she says.

The hospital does 100% utilization review, but only about 25% of the patients need in-depth discharge planning with appropriate referrals.

A referral for case management goes to a central call pool where staff forward the referral to the case manager who is on duty.

"We didn’t want the referrals to go to the unit and identify the case manager by name because someone might be sick, on vacation, or working in another unit," Mitchell adds. That way, whoever is following the patient gets an automatic referral. "This allows flexibility without being concerned about having the referral covered," she adds.

Since the case managers are not on duty 24 hours a day, the system allows the physician to place an order for discharge planning with a mechanism for the referral to go to the proper person for follow-up, she adds.

The case manager, with the assistance of the social worker, creates an interdisciplinary discharge plan for the patients. All clinicians are aware of the plan from the beginning. The system allows all the disciplines to have access to the discharge plan and the case managers to have access to what the other disciplines recommend, she says.

"With an average length of stay of around four days throughout the corporation, time is of the essence, and having the electronic medical record as a support tool helps facilitate the discharge process. It helps to have all the information in a timely basis," she says.

The only paper the hospital uses these days are items that patients actually sign and any other support documentation. Initially, because of the detailed documentation like flow sheets, the patient record could encompass hundreds of pages, but staff quickly identified what items they needed. Printing out what was needed when a patient transferred to another facility was another learning experience, Mitchell recalls.

"The wonderful part of the automated medical record is that you can print summaries. We’re now down to printing five sheets and all summaries, including demographics. It is more efficient and user-friendly, because at a glance, you can see everything about patient care," she adds.

Designing and implementing an electronic patient record system took three years and involved representatives from every department of Evanston Northwestern Health Care.

"The case management and other departments participated in the design of the elements of documentation, and to a lesser degree, reviewed and participated in the building of the other elements," Mitchell says.

Staff members underwent a minimum of 16 hours of training, depending on their computer skills.

At each hospital, the system was rolled out in two parts, starting with the documentation portion, followed by the complete order-entry system. "Rolling out the system in two parts allowed the staff to become more adept at documentation then go to the order-entry portion with expertise to build on," she says.