WebCIS Discharge Summaries

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WebCIS Discharge Summaries

• Automation of discharge summary creation and
  storage at NYP

December 10, 2004 Columbia DBMI G4061 Alla
Kesselman Daniel Rappaport Tielman Van Vleck
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WebCIS Discharge Summaries

• A quality improvement project by Peter Stetson
• Goal improve availability of summaries to
  provide concise and accurate histories at the
  point of care by enabling online entry and
  circumventing bottlenecks

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Project Objectives

• Facilitate d-sum entry within WebCIS
• Reduce transcription costs
• Reduce latency of d-sum
• Simplify d-sum entry to increase completion
• Increase JCAHO compliance
• Improve continuity of care

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Our Objectives

• Identify benefits of implementing online
  discharge summary entry
• Financial benefits
• Intangible benefits
• Justify costs of implementing Dr. Stetsons
  project

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Discharge Summaries

• Full summary of patient visit
• Reason for hospitalization
• Significant findings
• Procedures performed, treatment, services
  provided
• Patients condition at discharge
• Instruction to patient and family
• Created by resident or attending physician
• Signed by attending
• Supports continuity of care with next physician
• Required by JCAHO, ACGME

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JCAHO Accreditation

• Joint Commission on Accreditation of Healthcare
  Organizations
• On-site visit at least every three years
• Substitutes federal certification for Medicare/
  Medicaid
• JCAHO D-sum requirements
• 7 days to complete, 30 days to sign
• 33 compliance rate, 3-months delinquency measure
• Consequences of non-compliance
• Shorter accreditation term - extra survey cost
• Provisional accreditation
• Losing Medicare / Medicaid certification

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Current D-Sum Workflow
2.5 business days before available on WebCIS
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Transcription Costs

• Outsourced
• 14 cents per line of a summary
• Average summary length 80 lines
• Total d-sums per year 26,556
• 297,427 per year

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Workflow Using WebCIS D-Sum
Available on WebCIS shortly after appointment as
physician may complete from anywhere.
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Incentives for Physicians to Use

• Time savings if
• Currently creating electronic discharge note
• Surgery currently does this
• Faster to type than go to HIM to dictate
• Dependant on typing ability
• Convenience
• May be done anywhere, any time
• No walking to HIM encourages timely entry, as
  opposed to batch entry at end of day
• Cultural pressure to improve quality of care

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Costs of Implementation

• Development
• Beta-testing
• Training
• Release
• Support
• Ongoing maintainence

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Development
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Beta-testing

• Initial users
• 10 Hospitalists
• 5-10 Psychiatrists
• 40-50 Surgeons
• 1 hr training session and support by Dr. Stetson

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Release

• Announced on WebCIS login page
• Limited training
• Planning two 30 minute training sessions

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Post-Release

• Limited email support by Dr. Stetson
• 30-60 minutes/week

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Cost Savings

• Reduced Transcription
• Reduced Errors for HIM to process
• Reduced Dictation Support

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Transcription

• If we assume 50 compliance with WebCIS
  (projected by the project lead)
• Savings 145,418 / year
• If we assume 20 compliance with WebCIS
• Savings 58,167 / year
• If we assume 10 compliance
• Savings 29,084 / year

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HIM Error Queue

• 21 of D-Sums have errors requiring manual
  correction
• Missing date, physician/patient name/id,
  transcription errors
• 5,576 summaries per year
• Assume 5 min. to resolve one summary
• 9 hours week
• Assume WebCIS will resolve 75 of these
• Resulting reduction of 4,182 or 7 hrs/wk
• Now, 2 hrs/wk
• Savings 10,455 / year

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HIM Error Queue Savings

• If 50 compliance savings 5,227/year
• If 20 compliance savings 2,091/year
• If 10 compliance savings 1,045/year

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HIM Dictation Support

• Currently 1 FTEs _at_ 70K
• If 50 compliance
• Savings 0.5 FTE, 35K/year
• If 20 compliance
• Savings 0.2 FTE, 14K
• If 10 compliance
• Savings 0.1 FTE, 7K

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Indirect Benefits

• Saving physician time
• Reduce time to generate D-Sum
• May increase patient load
• More information for coding
• May allow coding to higher revenue codes
• Improve Compliance
• Avoid losing JCAHO accreditation

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D-Sums Create Intangible Benefits

• Improved Quality at the Point of Care
• Doctors feel supported
• Good Teaching Tool, sets good example for
  residents
• Cultural Change

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Quantify the added quality of DSums

• The DSum is an asset that generates intangible
  benefits.
• Assign a TRUE VALUE that includes these
  intangible benefits in the price of the DSum
• Calculate the Opportunity Cost of Not Creating a
  quality DSum
• 30 / DSum vs 10-15 (the cost of transcription)

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Concerns

• Transcription Costs vs Physician Time
• Effects on the Quality of the Discharge Summary?

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Transcription Costs vs Physician Time

• Wasting doctor time is very expensive.
• 150/hr
• 6 minutes extra offsets the savings from
  transcription.

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Effects on the Quality of the Discharge Summary?

• Will the quality suffer?
• Balance between speed and quality
• Is dictation intrinsically a more effective
  method of recording a DSUM?
• Expert typists vs clinicians.

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Expected Problems during

• Older physicians reticent 
• Solution No-force policy
• Old and new systems run in parallel
• Technical Hick-ups or Absence of needed features
• Solution Factored into post-release development
  expenses
• Under-used (general inertia)
• Motivation Strong departmental Support
• Motivation Timely posting to WebCIS
• Motivation Other Doctors will appreciate your
  work
• Doesn't fit into workflow as smoothly as expected
• Based in WebCIS, so the workflow changes are
  minor.
• Not everyone is required use it.

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Conversion Effectiveness

• Deployed within a familiar environment
• Little training necessary
• Few additional support costs
• No additional technical requirements
• No forced workflow changes
• Low risk

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Financial Analysis

• Assumptions
• Simple ROI
• IT Investment Equation
• Break-even Conversion

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Assumptions

• Project lifecycle 2 years
• January 2005 January 2007
• Discount Rate 9
• Employee Cost to NYP 150 Salary
• Salaried Employees work 50 weeks/year
• High level employees work 10 hours/day

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ROI Calcs
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IT Investment Equation

• Conversion Effectiveness
• Type of Investment
• Closely resembles Indirect Benefit Model

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Break-even Compliance
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Conclusions

• Low risk
• Probability of break-even very high
• Probability of return high
• Intangible value high
• Recommendation cost-effective, implement