American Association for Respiratory Care 33rd Respiratory Care Journal Conference Computers in Resp

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American Association for Respiratory Care33rd
Respiratory Care Journal ConferenceComputers in
Respiratory CareApril/May 2004

• Evaluating the Need for a Clinical Information
  System
• Richard M. Ford, BS, RRT, FAARC

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Objectives

• Understand the role and importance of information
  systems in health care
• Discuss the options available to RC departments
• Review features and considerations in choosing an
  information system 
• Identify approaches to justifying the additional
  expense

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Would You Invest
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Hospital Information Systems

• Developed in the late 70s with the proliferation
  of micro computers
• Designed to support ADT, billing, fiscal
  functions
• Not designed for capture and integration of
  clinical information

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Need for Automation

• East identified 236 information categories of
  data that were reviewed at the bedside for
  clinical decision making.
• Eddy stated, it is simply unrealistic to think
  that individuals can synthesize in their head
  scores of evidence, accurately estimate the
  outcomes of different options, and accurately
  judge the desirability of those outcomes.

East TD. Respir Care 199237(2)170180.
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The complexity of medicine exceeds the inherent
limitations of the unaided human mind
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Point of Care Systems-Weaning

• Irigue and colleagues assessed the impact of
  weaning using a handheld computer version. They
  observed patients were identified much earlier
  for spontaneous breathing trials and the length
  of stay in the ICU was significantly shorter.
  Among 352 patients, a total of 264 ICU days for a
  cost savings of 369,600 resulted.

Crit Care Med 2002, Sep30(9)2038-43
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We estimate that universal implementation of
CPOE would avert approximately 567,000 serious
medication errors each year in the United States
The leap requires doctors to use computers for
prescriptions to avoid errors and receive
e-reminders based on medical guidelines.
2003 Report, John D. Birkmeyer, MD
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Health Care Information Technology Strategic
Issues Work Group

• Examine opportunities for JCAHO to contribute to
  the rapid adoption of a health care information
  technology
• IM standards reframed to serve as the primary
  vehicle to facilitate the adoption of clinical
  process redesign, electronic medical records and
  the use of information for clinical decision
  reporting

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FEDERAL DEPARTMENT OF HEALTH HUMAN
SERVICESCenters for Medicare Medicaid Services
In concert with Secretary Thompsons initiative
to increase the use of information technology
(IT) in healthcare, the rule allows hospitals to
implement information technology programs as part
of their QAPI programs.
January 2003 Press Release CMS ISSUES FINAL
QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT
CONDITIONS OF PARTICIPATION FOR HOSPITALS
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The Director and RC Department Operations
STAFFING PRODUCTIVITY CHARTING BILLING COST
MANAGEMENT BUDGET PI and REPORTS JCAHO, HIPPA,
MULTI-DEPT PROTOCOLS
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Savings with Wireless

• Stoller demonstrated wireless mobile workstations
  have several advantages, including a reduction
  between receiving an RT consult response from 7.8
  hours to 2.8 hours, and a decrease in the time
  spent assigning RC work from 81.6 to 43.6
  minutes.

Respir Care 200447(8)893-897
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HIS vs. RCMIS

• RCMIS systems are designed to facilitate the
  essential and unique functions within respiratory
  care, including assessment of work demand, the
  ability to assign and track resources, charting,
  billing, and reporting of results

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Consolidated HIS

• Most Hospital Information Systems are not geared
  towards the unique environment and practices of
  respiratory care
• HIS generic modules which can be used by Lab,
  Radiology, and other requisition-based
  departments do not have the functionality and
  configurability of an RCMIS

Greg Giefer, Via Christi Regional Medical
Center Wichita, Kansas White Paper/Clinivision
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HIS Limitations

• Does the HIS allow customized order and charting
  templates for each respiratory care procedure?
• Can the HIS assign staff to regions, patients, or
  with specific procedures and route new orders?
• Can the HIS accurately capture patient charges,
  and clinical outcomes based on therapist
  charting?
• Does the HIS allow for on-the-fly user
  configured reports and data mining?

Greg Giefer, Via Christi Regional Medical
Center Wichita, Kansas White Paper/Clinivision
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AARC Management List-Serve

• The CIS system leaves a lot to be desired, it
  is not easy to use and is difficult to
  customize.  It is much more convoluted than the
  system it replaced
• The CIS is a great database manager only. It is
  not a user friendly system. It reminds me of
  systems I used in the late 80's early 90's
• It is with considerable regret that I report to
  you that we have used CIS for the past 5 years.
  Our version has no data collection or management
  tools

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RCMIS and HIS Seamless to End User

• System Connectivity
• HIS/CIS
• Equipment
• Interfaces
• ADT
• Orders
• Results

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RCMIS Manufacturers
Less than 250 Respiratory Care Installations
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Charting View
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Mobile Workstation
Fujitsu (Santa Clara, California) P-1120 touch
screen notebook PC with integrated wireless LAN
capability is one example of the many options
available when considering mobile charting
devices for clinicians.
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Cart Mounted Pen-Slate
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Pocket PC (MPC Thin Client)
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Features- Work Assignments

• List orders due and detail for practitioners
• Determination of work demand prior to and during
  any shift
• Automated work assignments
• Indications of what was done and what is due
• Routing of new patients/orders to practitioners
• Department/shift/area/practitioner productivity

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Features- Charting

• User configurable patient, order and activity
  templates
• Auto fill designated fields from connectivity
  with other systems and devices
• Option to carry forward field values from orders
  and prior activities
• Auto calculate and default field values

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Features- Charting

• Use of field limits and warnings
• Ability to designate required fields
• Provision change/edit with audit trails
• Custom views of prior information
• Smart Fields
• Decision support
• Branching logic

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Features - Charge Capture

• Automated billing capture configured into the
  clinical charting- Never missing required
  documentation!
• Activity Level (performance of intervention)
• Continuous Trigger
• Record Level (entry of data into a field)
• The ability of the manager to quickly modify
  billing configurations to optimize capture when
  there is a change in regulations or payer
  requirements

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Features- Reports

• Workload assessment (how much)
• Practitioner workday (who, where, when)
• Done vs. not, missed or adverse response
• Charting for the medical record
• Billing per patient, area, procedure, for any
  specified period
• Results, outcome and trends
• Inventory control/equipment management
• Tools to export reports and files

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Features- Interfaces

• Admission, Discharge, and Transfer (ADT)
• Orders (inbound and outbound)
• Results (inbound and outbound)
• Billing (batch or real time)
• Equipment (ventilators, ABG, and monitors)
• Other department CIS

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Affordability?

• Can be as much as 250,000-300,000 for a 400 bed
  institution
• The way to secure approval for department systems
  is to convince decision makers that
  computerization will afford significant savings

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Overcoming Barriers to Purchase

• Recover cost within a 1-year period.
• How?
• Charge recovery
• Revenue enhancement
• Improved productivity
• Manage service utilization (Protocols)

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Charge Recovery - Hillcrest

• UCSD Hillcrest experiences a 10 increase in
  gross charge capture
• 3,000,000 annually
• Users of systems that provide automated billing
  capture and interfaces that electronically
  transfer patient charges to finance, report as
  much as a 10-30 increase in gross revenue

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Charge Recovery- Thornton

• Gross charges from 2.5 million to 19 million
  annually
• 900,000 net revenue the first year after RCMIS
  installation
• The ability to significantly improve charge
  capture justified the total expense of the RCMIS
  at Thornton within 60 days.

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Improving Productivity
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Improving Productivity

• 8-10 improvement
• Cost savings of 180,000

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Does it Look Like We Need Help ?
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Enabling Protocols

• User Configurability to Capture Data
• Bedside Clinical Coach
• Point of Care Data Entry/Access
• Centralized Clinical Surveillance
• Appropriate Allocation of Resources
• Reporting Results and Outcomes
• Decision Support

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Result of RCMIS and PDPs

• The actual year end reduction in RC expenses
  associated with implementation of PDPs at UCSD
  exceeded 500,000.

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Protocols are Executable Steps- Software is too!
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Charting
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Justifying an RCMIS - UCSD

• Capture of lost charges - YES
• Revenue enhancement - YES
• Productivity gains - YES
• Manage Patient Driven Protocols YES

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ConvincedWhat Next?

• RCMIS Advisory Team who can provide expert advice
  during system selection, as well as support
  during system installation.
• The team should include RC department leadership
  and staff, as well as representatives from
  information services, telecommunications,
  finance, patient accounting, administration,
  medical records, nursing, and medical staff.

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Evaluate RCMIS Providers

• The provision of off-site/on-site training and
  24/7 support, and related service contracts
• Participation in system configuration and
  development of user defined reports
• Timeline and cost of updates and upgrades
• Investment in R/D and long term viability
• Expertise of development team
• Ongoing commitment to meet changing needs through
  forums and user groups

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User Groups and Forums
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Seek Outside Advise

• Discussions with other users will not only assist
  in the evaluation of the
• Ability to perform specific functions
• Ease of implementation
• Required training
• Need for a department based specialist
• Reliability and manufacturer support.
• Users groups and forums

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Fiscal Benefit

• Lost charge capture Net gain
• Labor savings from point of care charting
• Labor savings from improved tools to manage
  productivity
• Labor savings from reductions in fixed resources

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Fiscal Benefit

• Reductions in department and hospital cost and
  FTEs secondary to facilitating protocols
• Any cost avoidance that can be linked to HIPAA
  compliance, quality improvement, benchmarking,
  CPOE, e-medical record, in which paper systems
  would require additional time/expenses

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What are We Doing Better

• Determining staffing requirements
• Responding to changing patient needs
• Maximizing RCP time at the bedside
• Staff accountability for activities and
  performance
• Productivity management and reporting
• Managing service utilization
• Identification of opportunities for improvement
• Managing more with less

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Bottom Line

• Acquisition of an RCMIS will allow the
  respiratory care team to do more with less, to
  improve their ability to manage resources, to
  report both clinical and financial outcomes, and
  facilitate the capture of information to support
  ongoing performance improvement

rmford_at_ucsd.edu www.respcare.ucsd.edu