With deadlines fast approaching, some organizations are homing in on the specific capabilities necessary to get incentive checks. Others, however, are trying to think through the process and interject and upgrade technologies that, while not tied into incentives, can significantly improve patient safety.
SSM Health Care of Wisconsin, for example, has put together a closed-loop medication administration for all inpatient areas at its St. Mary's Hospital in Madison, St. Clair Hospital in Baraboo and one affiliate hospital. Two more affiliates will get the technology in October, as will a new SSM Wisconsin facility in Janesville when it opens in January 2012.
A physician places an order in the Epic Systems EHR, and the system then checks the dosage before sending the order to the pharmacy queue, where the pharmacist can apply another check. Then the bedside nurse applies bar-coded medication administration technology, going through the "five rights" before giving the medication. "That piece has huge patient-safety implications," says Annette Fox, R.N., director of clinical systems for the Wisconsin Integrated Information Technology and Telemedicine System, a joint venture of SSM Wisconsin and Madison-based Dean Clinic.
"There's a learning curve, but once [clinicians] get used to it, they love it," Fox says of bar-coded medication administration, so resistance has been minimal. She says St. Mary's has recorded more than 97 percent usage each month the system has been in operation, and some months are close to 100 percent.
This is but one example of high-impact technologies health care providers are employing to boost patient safety. Interjecting the technology takes forethought and planning, which is not necessarily an easy proposition with all the other I.T. projects going on.
But even with budgets stretched by EHR and mandate-related investments, providers are putting dollars into integration of medical devices with EHRs; wireless and mobile technologies, including real-time location systems for tracking staff, patients and valuable assets, as well as improving patient flow; and alerts for reporting of critical test results, among other technologies.
Linking devices
A little more than a year ago, Cooper Health System in Camden, N.J., was planning the nursing documentation part of its EHR implementation, the last piece its Cooper University Hospital was going to need to achieve meaningful use in 2011. "We knew that this would add time, and they would not like this," CTO Paul Shenenberger said of the nursing staff.
At the time, Cooper had about two connected medical devices per inpatient bed. "We expect that to grow to three or four," Shenenberger says, so it would only make nurses' jobs more difficult if they manually had to enter device readings into the Epic Systems EHR.
To ease the transition, the hospital contracted with iSirona, a Panama City, Fla.-based, vendor of medical device connectivity technology to create an electronic bridge between devices and the EHR. "We were able to get this live within 30 days," Shenenberger reports.
iSirona extracts information from patient monitors and other devices every 15 minutes, sending the data to the EHR via HL7 message. The nurse simply clicks to "commit" the reading to the patient's record.
"I've done a lot of projects in I.T. This is the first I.T. project I've ever worked on that has been universally loved and embraced by everyone involved," says. He calls the integration the primary reason why nursing documentation was successful. More importantly, it has made care safer.
"We believe we have significantly reduced transcription errors," Schoenenberg says. Soon, the hospital will be extracting data from devices for research purposes and to help develop best practices.
Safety at the fingertip
In June, NYU Langone Medical Center in New York City turned on a system called PatientSecure, from Tampa-based vendor HT Systems, that scans the veins in the palm with near-infrared light to identify and authenticate patients. Palm vein patterns are said to be 100 times more unique than fingerprints. "It had the highest accuracy and highest usability of any biometric technology we looked at," said NYU Langone Chief of Hospital Operations Bernard A. Birnbaum, M.D.
The ID technology is interfaced with NYU's new Epic EHR that also came online June 5, when the organization activated patient registration, billing and some ambulatory clinical documentation functions.
"All sites have scanners as they come live on Epic," Birnbaum reported. That includes NYU Langone's Tisch Hospital, the Rusk Institute of Rehabilitation Medicine, the Hospital for Joint Diseases and several affiliated medical practices.
"The most important reason why we did this was for patient safety," Birnbaum says. NYU Langone also now takes photos of patients as they register so staff can visually identify patients as another level of security. "If someone forgets to close out my patient account, someone else could come in and look at it," Birnbaum notes. The photos help prevent confusion, potentially stopping a clinician from entering information into the wrong patient's record.
The scanning and photography lengthen the initial registration process, but it saves time on subsequent visits because patients only have to re-scan their palms to bring up all their information, then verify their date of birth. "Repeat registration takes less than a minute," Birnbaum says. There is no more need to keep Social Security numbers to identify patients, Birnbaum added, a safeguard against identity theft and other fraud.
"It's in the sweet spot between patient safety and convenience," Birnbaum says. "It's pretty foolproof."
NYU Langone is taking advantage of the biometric scanning to create more complete records by matching up duplicate files. The organization reports having 125,000 instances where at least two patients have the same first and last names, and much of the overlap is due to patients registering under their full name one time and a nickname on another visit, or perhaps shortcuts by staff. Either way, information gets fragmented.
"You're not only merging hospital records, you're merging your entire health care experience," Birnbaum says. "Your whole medical record is there."
Across the East River in Brooklyn, N.Y., Maimonides Medical Center had problems communicating critical and less-urgent abnormal test results to physicians who ordered diagnostics. So the departments of laboratory medicine, radiology, cardiology and pathology turned to technology called critical test results management, or CTRM, for closed-loop results reporting. Maimonides implemented Nuance Communications' Veriphy, a CTRM reporting system to make sure the proper caregivers are alerted if a diagnostic test returns an abnormal value.
"It's a really nice, clean, effective way to get results to doctors," says Mark Flyer, M.D., vice chair of radiology. "No patient falls through the cracks."
Flyer says that the hospital has its own defined criteria for what is critical, plus a longer list of "unexpected" results that need to be acted upon, though not necessarily right away.
When a test comes back in the critical or unexpected range, the Veriphy system sends an electronic alert to the ordering physician indicating the level of urgency. Notifications are escalated if the physician doesn't respond within a set period of time.
Setting up embargoes
Users can set up alerts so unexpected but non-urgent results are embargoed until a certain time, for example, 8 a.m. Critical alerts get sent right away.
The hospital does not use Veriphy if the findings are normal or insignificant, and the I.T. department has responded to the handful of outliers who don't like constant pages by changing the escalation protocols so physicians aren't pinged at inopportune times, such as when "gowned up," Flyer says.
The physician has to acknowledge receipt, triggering a verification message to the reporting clinician. The file gets stamped with the time of the response, and all the communication is documented. "Yes, it does hold up in court," Flyer says of this reporting audit trail, but the chief purpose is not for protection against liability.
Flyer says that alert compliance averages 99 percent compliance, and some months reaches 100 percent. "It's a protocol that's mandated by the administration of the hospital," he says.
"The real efficiency is getting the result to the M.D. as soon as possible," Flyer adds. "The patient overall is the winner."
Southeast Alabama Medical Center, a 420-bed facility in Dothan, Ala., has had wireless coverage since the late 1990s, before the average person had heard of Wi-Fi or Internet hot spots.
The earliest incarnation was a proprietary network, though several upgrades over the years have brought 802.11(g) coverage to the entire campus via more than 500 access points. "We're constantly having to test it, tweak it," CIO Eric Daffron says.
Today, the wireless infrastructure supports wireless handsets for medication verification, point-of-care cardiac testing machines and Ascom VoIP phones, medical-grade communication devices that look like cell phones.
It also is part of a real-time location system for tracking high-dollar medical equipment and easily misplaced-or hoarded-items such as infusion pumps and wheelchairs.
Southeast Alabama Medical System ran wireless telemetry monitors over the old proprietary network, which mostly covered nursing floors, so the technology was unreliable in ancillary departments, some procedure areas and while the patient was in motion. "Previously, you were restricted to wherever the proprietary network was," Daffron says.
A couple years ago, Daffron thought it was time to start upgrading wireless access points. "We realized there was going to be a big growth in the number of wireless devices," he says. The decision coincided with the hospital's replacement of old telemetry monitors with what is believed to be the world's largest single deployment of the Draeger Infinity M300 wireless telemetry system.
With Wi-Fi, patients can be monitored anywhere in the building, even while being transferred. This continuous coverage is part of the reason why Southeast Alabama Medical Center won a 2011 HealthGrades Patient Safety Excellence Award for ranking among the top 5 percent in the country.
The emergency department at Albert Einstein Medical Center also is putting wireless technology to good use, turning to RTLS to make the busiest ED in Philadelphia-100,000 annual visits, double the volume of eight years ago-one of the most efficient.
Carl Chudnofsky, M.D., chairman of the Department of Emergency Medicine, came to Einstein from the University of Michigan in 2000. "One of the things I noticed was that we had a small, old, and poorly laid out emergency department," he recalls.
Chudnofsky took the job with the promise that the hospital would renovate the ED. The department was expanded and transformed in 2003-04 into a system of four "pods," each with nearly the same capabilities, to create a feeling of openness.
"But it created other issues," Chudnofsky says. "We now had four separate areas that had to be connected." One charge nurse oversees all four sections to maintain patient flow.
Getting real
The response to those connectivity issues was a real-time location system to track visitors and staff, plus some significant physical assets.
A first-generation ED tracking system relied on infrared technology, meaning each badge had to be within clear sight of an infrared beam. It required a number of workarounds, such as mounting patient tags on beds or IV poles rather than the patient's wristband. The software worked fine, but if the patient left the bed, the tag was pretty much useless.
About three years ago, Chudnofsky decided to upgrade. An ultrasound tracking system never quite worked properly, so Einstein turned to a second-generation infrared system from CenTrak, Newtown, Pa. Chudnofsky says this technology works well even when the tag is covered since it also incorporates radio-frequency identification.
This enables the ED to create a "virtual room" around each patient, even if the ED is overcrowded and patients have to be seen in hallways. "It's enabled us to see more patients in a shorter period of time," Chudnofsky says. The hospital is able to identify patient-flow inefficiencies, reduce waiting and shorten bed turnover time because multiple departments, including housekeeping, knows the status of every patient and every bed in the ED.
If the patient has a communicable disease, the system warns hospital staff to take necessary precautions. "The ED staff has a much greater situational awareness," Chudnofsky says. They know the presenting symptoms of each patient in the waiting room, which helps improve triage. "Triage was a bottleneck for us," according to Chudnofsky.
"The system has dramatically improved our admissions process," he adds. This means more physician time at the bedside and less at the computer entering or reviewing data.
The tracking system also provides alerts, based on standardized criteria, such as when there is no disposition decision within 2.5 hours. "We are able to identify problems before they happen," Chudnofsky says. Leaders can call in more staff or reassign personnel when one pod gets crowded. "The charge nurse knows what's going on everywhere."
Even with the sharply higher traffic, throughput is much better. Einstein's ED used to average 160 diversion hours per month, the highest in the city, but that mark is now down to less than 10 hours a month, according to the department chair. For more than 90 percent of stroke patients, door-to-balloon time is less than 90 minutes. "We take every stroke patient directly to the cath lab," Chudnofsky reports.
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Autor(en)/Author(s): Neil Versel
Quelle/Source: Health Data Management, 01.08.2011
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