Beyond E-Health Records: Technologies That Enhance Care Delivery
This article is based on a CSC Leading Edge Forum "2010 CSC Papers Winner". Download the full report.
by Fran Turisco and Jared Rhoads
Hospitals are keenly focused on implementing electronic health record (EHR) systems to capture and share patient information. In the U.S., the implementation of certified EHRs that meet “meaningful use” criteria is the highest priority in the coming years. The incentives are substantial and the long-term benefits to care providers and patients are significant. Beyond EHRs, however, there are a number of technologies that also enhance and improve inpatient care.
This article describes examples of these technologies, all of which have been successfully deployed as part of an overall change initiative that included process workflow redesigns. The information is taken from a larger research report, titled “Equipped for Efficiency,” that CSC Emerging Practices created for the California Healthcare Foundation.
Enhancement/improvement was defined as a change that increased efficiency, safety, care quality, or streamlined communications. In completing the research, it became clear that some technologies provide benefits in multiple areas, as outlined in Table.
To demonstrate the matching of “improvement need” to “technology use” in different situations, two technologies and how they were used in specific hospital settings are profiled for each Improvement Area.
Efficiency improvements include more effective use of resources and redesigned workflows that allow care providers to spend less time on non-care related tasks. In the case of Catholic Health West in Nevada, a three-hospital system, the implementation of a workflow management system allowed them to consolidate management of inpatient flow, staffing, and bed placement to improve overall census (the number of patients staying at a hospital).
- Workflow management systems collect information from multiple sources and integrate it into a single display that highlights key patient and bed management information, such as room availability, patient wait times, rooms ready for cleaning, and key clinical data. All information is displayed using color-coded icons overlaid onto an image of the nursing unit’s floor plan, or a patient or room list.
For Catholic Health, patient census had been very uneven among its facilities, whereby one hospital often experienced many emergency department admissions and long waits for beds, while the other two hospitals had idle capacity. The new enterprise-wide system enabled nurses to offer on-the-spot transportation to other facilities where patients would receive immediate care. Knowing when beds are or will become available helps the staff increase census and bed turns across the three hospitals. The system and change processes took several months to implement and improvements occurred within the first 30 days. Now, more than 260 patients a month are transported to open beds, up from 30, and with better coordination.
At Brigham & Women’s Hospital in Boston, locating medical equipment took time away from patient care and created an environment where equipment hoarding was commonplace. The hospital decided to implement real-time location technology to track equipment so the care team could quickly locate what they needed.
- Real-time location systems (RTLS), also known as indoor positioning systems, are used to locate equipment, patients, and staff. Resources to be tracked are outfitted with small tags that communicate with transmitters and detectors located throughout the facility. The system’s positioning algorithms locate assets and display their location online using a map of the unit to indicate where the closest available resource can be found.
During the RTLS implementation, Brigham & Women’s also redesigned roles and responsibilities for equipment tracking, making unit secretaries responsible for locating equipment. Since they coordinate equipment transfers, they know whether equipment should be leaving the area.
Patient safety and quality of care
An inpatient care team handles multiple patients and care management tasks. The result is a complex web of workflows prone to decision bottlenecks and missed or delayed tasks that can ultimately impact patient safety and care quality.
At Beaumont Hospital in Royal Oak, Mich., the analysis of a close call involving a telemetry patient prompted a rethinking of the communications approach between technologists watching the telemetry monitors and floor nurses. The change team redesigned the workflow and decided to replace its pagers with a wireless hands-free Voice over Internet Protocol (VoIP) communication system.
- Wireless mobile VoIP communication solutions tap into the hospital’s wireless local area network as its infrastructure and can be integrated with monitoring systems, bed management solutions, and clinical information systems. They offer escalation capabilities and group broadcast messaging. There are two types of devices: telephone handsets and wearable badges.
The impact of these process and technology changes on nursing response time to alarms was dramatic at Beaumont, dropping from 9.5 minutes on average to 39 seconds, well under the hospital goal of three minutes. The communication loop is closed 100 percent of the time, compared with the previous 35 percent rate with pagers.
Other important safety concerns are failure-to-rescue cases, which account for 60,000 deaths annually among less-than- 75-year-old Medicare patients, and patient falls, a leading cause of death among people 65 and older. Such patients need to be connected to monitoring equipment or be under close supervision of nurses, which is not possible in a general medical/surgical unit. In response to these needs, a new generation of wireless patient monitors has emerged.
- Wireless patient monitor technologies use sensors that can be integrated into the patient’s bed or mattress pad to provide continuous bed-level vigilance. Some bed-based solutions, for example, feature electronic weight scales, blood pressure monitors, and sensors that measure heart rate, respiration, and body movement during sleep.
At the James A. Haley Veterans’ Administration Hospital in Tampa, Fla., a wireless monitoring bed pad enables continuous patient observation. With this solution, patients received care more rapidly. Timely alerts prompted nurses to adjust care parameters to match surveillance needs in at least 10 percent of the cases. In addition, about 2 percent of patients were transferred to a higher level of care due to an alert, often several hours before they were scheduled to be reevaluated.
At St. Joseph’s/Candler Hospital in Savannah, Ga, fall rates decreased from five falls to 1.4 falls per 1,000 patient days after the hospital integrated wireless patient monitoring with nurse communication technologies.
Care delivery assistance
Technology can be used to empower patients and others to assume new care delivery roles, thereby making nurses and other care providers more efficient and effective. For example, Washington Hospital Center in Washington, D.C., introduced robots to take over some delivery tasks previously undertaken by skilled resources.
- Delivery robots can handle a number of fetch-and-deliver tasks. They are more flexible than older solutions, such as pneumatic tube systems, and do not require any structural changes to hospital interiors. Using laser sensors and preloaded electronic drawings of hospital floor plans, and guided by an onboard computer, robots detect beds, water fountains, people, and obstacles, and adjust their route to avoid collisions. They can even call elevators.
At Washington Hospital, two robots deliver routine medication carts to the units, freeing up pharmacy technicians to join the care team, and enabling them to spend more time on new orders, one-time orders, answering medication questions, locating missing doses, and stocking the individual nurses’ workstations-on-wheels. The change also freed nurses from locating and retrieving all medications except for controlled substances.
Patient education is often an inefficient time-consuming task for nurses who need to coordinate equipment, educational materials, and patient availability. At Winchester Hospital in Winchester, Va., the implementation of an interactive patient system reduced this burden.
- An interactive patient system provides two-way communication and delivers multimedia content at the bedside. The system delivers patient education videos, enables communication with the nurse and support personnel, handles patient requests, and provides a range of entertainment and Internet services.
Winchester Hospital’s system prompts patients to view videos on topics such as hand-washing and fall prevention at preset intervals after admission and records completion. Other videos can be added or deleted from the queue based on their relevance to particular patients and their diagnoses. Within the first month of system implementation, patient use of educational videos increased 15 percent, freeing up nurses’ time for patient care.
Collaboration and communication
Inpatient care is provided by a team of professionals and support staff that rarely meets as a group, but needs to be in constant communication. They also respond to requests for information and assistance from patients, family members, physicians, and ancillary services. Wireless communications as described above has been used successfully to streamline both direct communications and group collaboration.
At Children’s National Medical Center in Washington, D.C., wireless communication improvements were significant. Response to patient calls dropped from 4 minutes 45 seconds to 1 minute 22 seconds. The mean response time for alarms dropped from 3 minutes 10 seconds to 34 seconds. In addition, nurses reported fewer interruptions, better continuity of care, and improved workflow.
Hospitals have found that regularly checking online workflow management system displays eliminates the need for direct one-on-one communications. At Oakwood Hospital in Detroit, the solution decreased the number of calls for bed management by 35 percent within weeks of implementation. It also eliminated the need for the twice daily bed meetings with the nursing staff. Housekeeping at Monongalia General Hospital in Morgantown, W. Va., checks the system displays to determine which rooms are ready to be cleaned, reducing calls to housekeeping by 50 percent and calls back to the bed manager by 20 percent.
Technology solutions have the potential to create a better working environment for nurses and other care providers. While not an exhaustive list, the selected technologies mentioned above are in use, have demonstrated their value, and represent both leading-edge technologies that offer great potential as well as advances in mainstream solutions.
Fran Turisco is a research principal and Jared Rhoads is a senior research analyst for Emerging Practices in CSC’s Healthcare Group.