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

1. 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

2. 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

3. Would You Invest

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

5. 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 1992;37(2):170–180.

6. “The complexity of medicine exceeds the inherent limitations of the unaided human mind”

7. 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, Sep;30(9):2038-43

8. “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

9. 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

10. FEDERAL DEPARTMENT OF HEALTH & HUMAN SERVICESCenters for Medicare & Medicaid Services In concert with Secretary Thompson’s 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

11. The Director and RC Department Operations STAFFING PRODUCTIVITY CHARTING BILLING COST MANAGEMENT BUDGET PI and REPORTS JCAHO, HIPPA, … MULTI-DEPT PROTOCOLS

12. 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 2004:47(8):893-897

13. 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

14. 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

15. 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

16. 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”

17. RCMIS and HIS… Seamless to End User • System Connectivity • HIS/CIS • Equipment • Interfaces • ADT • Orders • Results

18. RCMIS Manufacturers Less than 250 Respiratory Care Installations

20. Charting View

21. 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.

22. Cart Mounted Pen-Slate

23. Pocket PC – (MPC Thin Client)

24. 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

25. 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

26. 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

27. 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

29. 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

30. 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

31. 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

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

33. 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

34. 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.

35. 130 120 110 100 90 PRODUCTIVITY % 80 70 60 50 2/5/89 1/7/89 3/1/92 6/1/92 5/8/94 6/26/88 5/28/89 9/17/89 4/29/89 8/19/90 12/9/90 3/31/91 7/21/91 1/31/93 5/23/93 7/17/94 9/11/94 11/6/94 1/15/95 3/26/95 5/21/95 7/16/95 10/16/88 11/10/91 10/11/92 PAY PERIOD Improving Productivity

36. Improving Productivity • 8-10% improvement • Cost savings of $180,000

37. Does it Look Like We Need Help ?

38. 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

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

40. Protocols are Executable Steps- Software is too!

41. Charting

42. Justifying an RCMIS - UCSD • Capture of lost charges - YES • Revenue enhancement - YES • Productivity gains - YES • Manage Patient Driven Protocols YES

43. Convinced…What 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.

44. 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

45. User Groups and Forums

46. 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

47. 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

48. 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

49. 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

50. 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@ucsd.edu www.respcare.ucsd.edu