Adoption of Patient Tracking Systems among C A L I FOR N I A Hospital Emergency Rooms in California H EALTH C ARE F OU NDATION Introduction these systems are comprehensive enough to include With the burgeoning of health care technology, everything from the EMR, patient tracking, and more and more systems throughout hospitals computerized provider order entry (CPOE) to are becoming automated, including those in computerized discharge orders and instructions the emergency department (ED). The desire to and billable charges. Others are “home-grown” by Issue Brief streamline care systems in the ED is being driven the hospitals’ own information technology (IT) in no small part by patient demand. Nationwide, staff and simply used for patient tracking. an estimated 41 percent of all hospital admissions originate from the ED, and 48 percent of hospitals The patient-tracking component of an EDIS report that their ED is overcrowded, operating essentially time-stamps patient movement through either at or over capacity.1,2 the system. For example, it might capture the time of arrival to the ED, the time the patient The California HealthCare Foundation is triaged, the time he or she is placed in an ED retained The Abaris Group to conduct a survey treatment station, the time when seen by provider, of California hospitals and their emergency and the time a disposition decision is made — all departments to understand to what extent they are the way to the final disposition. Additionally, the using ED information systems (EDIS), also known systems generally track other variables, such as as ED tracking systems. The research focused on laboratory and radiology orders, from the time determining which features are being used by EDs of order entry to the time results are ready. Many and what barriers hospitals encounter in either systems also allow complete nursing and physician acquiring or using these systems. Additionally, documentation, patient order entry, and business Abaris looked for positive outcomes and best features from start to finish, including registration practices from the adoption of an EDIS. and the record of billable charges as a result of the clinician documentation. The survey found that most hospitals have an EDIS and are taking advantage of many features The need to move these systems to an electronic of the technology; however they are doing so with format is hardly controversial. The literature varying levels of satisfaction and success. overwhelmingly supports the benefits of doing so; however, many of the systems are prohibitively This issue brief examines the survey results and expensive and the personnel resources needed to provides a side-by-side comparison of some of implement them can be overwhelming, especially the most common EDIS and hospital tracking for smaller organizations. Additionally, there is systems. often a resistance to the change from paper to electronic systems, as it can disrupt workflow in Background the busy ED environment. Many hospitals are transitioning to electronic medical records (EMRs) as well as EDIS. Most of J uly 2008 Nationally, the demand for ED treatment has increased demonstrated by a survey conducted by the Healthcare the need to further streamline care systems. In 2005, Information and Management Systems Society (HIMSS).6 there were approximately 115 million patient visits to EDs in the United States, or about 39.6 visits per 100 Figure 1 shows the leading concerns expressed by some U.S. residents. From 1995 to 2005, the number of 750 U.S. hospitals and health care organizations who visits increased from 96.5 million to 115.3 million (up participated in the 2007 Annual HIMSS Leadership 19.5 percent), an average increase of nearly two million Survey. The survey gathers information and opinions visits each year. During the same period there was a regarding the use of IT to improve health care from IT decrease in the number of hospital EDs from 4,176 to executives and various health care providers across the 3,795, meaning a total increase in visits per ED from nation. The survey asks about IT priorities, adoption of 23,119 in 1995 to 30,388 in 2005. technology, application usage, and other issues relating to the use of IT in health care. In California, there were approximately 10.1 million ED visits in 2006, or 27.1 visits per 100 residents. ED Figure 1. Top Health Care Business Concerns visits increased 14.6 percent from about 8.8 million to 10.1 million during the ten-year period from 1997 to Improving quality of care 69% 2006, or about 1.4 percent annually. During the same Patient (customer) satisfaction time period, the number of hospital EDs decreased from 55% 395 to 339; however, the inventory of treatment stations Medicare cutbacks within the remaining EDs actually increased from 4,900 52% to 6,063. This data supports the findings of a 2003 issue Increasing need for health care services brief published by the California HealthCare Foundation 45% which found that ED capacity has been increasing in Adoption of new technology recent years, despite the fact that there have been a 38% number of hospital closings in the state.3 While visits per Demand for capital ED increased from 22,274 to 29,732, visits per treatment 31% station actually decreased from 1,796 to 1,662.4 Availability of clinical staff 29% With this growing demand, hospitals and their EDs are Decrease in health insurance benefits pursuing numerous measures, including automation, to 28% address the crowding dilemma by accelerating patient Source: Annual HIMSS Leadership Survey, 2007. flow and improving throughput. This is not always a simple undertaking. In fact, a recent survey of over 400 rural hospital EDs showed they continue to use paper- Methodology based medical records.5 Funding is commonly cited as The Abaris Group obtained a list of all hospitals in a barrier, along with uncertainty about which vendor to California licensed for comprehensive, basic, or standby choose and a lack of the personnel resources necessary emergency medical services from the Office of Statewide for implementing complex systems and ensuring that Health Planning and Development’s (OSHPD) Web site. they are compatible with existing systems. Nonetheless, The initial list contained 343 hospitals, of which five that adoption of new technology continues to be a major did not have an ED were later eliminated. concern among hospital leaders across the country as 2  |  California HealthCare Foundation The Abaris Group contacted each of the hospitals and information from survey participants and other hospitals asked the ED manager to participate in a brief survey demonstrated otherwise. The product points described in for the California HealthCare Foundation. A general the marketing materials were not always seen by hospital description of the study was provided and survey staff as being easily integrated with existing hospital participants were asked a series of questions from a systems. What’s more, hospitals usually have the option of scripted survey. In several instances, the ED manager purchasing only a portion of the products, and those that referred the call to someone else in the department do may not understand that full functionality typically who was more knowledgeable about the EDIS selection requires a comprehensive system. process and the expectations for the system. Given the frequent turnover in ED management positions, every Some of the vendors also offer other options such as attempt was made to interview those people who were risk-management features, radiology image viewing, present when the EDIS was implemented and to focus patient photo identification capture, and physician the research on actual users of the systems (e.g. ED scheduling. managers) rather than IT personnel. Survey Results In the end, 47 telephone and four email surveys were The survey responses by question are as follows: completed, for a total of 51. Two surveys were not complete, although any responses provided for individual If you have an ED tracking system, which system do questions were included in the report. you have? Thirty-five (69 percent) of the hospitals interviewed have The survey sample is generally representative of California an EDIS. Figure 2 lists which they use. hospitals in terms of the number of annual ED visits, admissions, treatment stations, and visits per treatment Figure 2. ED Tracking Systems station, with no significant differences observed in any of these areas. This report highlights the pertinent findings Unknown from the study. 6% Vendor Comparison Nine of the most well-known EDIS vendors were chosen Meditech to develop a side-by-side comparison for the purposes 29% of this study. Of the nine vendors, only Medhost and Other Wellsoft are stand-alone EDIS products; Picis offers 43% EDIS, intensive care unit and operating room products. Epic The remaining vendors offer both EDIS and full hospital- 6% McKesson wide patient-tracking and IT systems. StatCom is 6% primarily a patient-tracking system and does not consider Eclipsys itself a “clinical” product for documentation and other 6% Logicare features. 6% While the comparison initially indicated that these Note: Figures do not add up to 100 percent due to rounding. Source: The Abaris Group survey of California hospitals products generally offer similar features, anecdotal Adoption of Patient Tracking Systems among Hospital Emergency Rooms in California  |  3 Table 1. Vendor Comparison Patient RN /MD Charge A n c i l l a ry Or d e rs Re g i s tr ati o n / Tracking Docum entation Ca p t ure T ra cking RX W rit ing CP OE Tr i a g e Cerner 4 4 4 4 4 4 4 Medhost 4 4 4 4 4 4 4 Wellsoft 4 4 4 4 4 4 4 Meditech 4 4 4 4 4 4 4 Picis 4 4 4 4 4 4 4 McKesson 4 4 4 4 4 4 4 Eclipsys 4 4 4 4 4 4 4 Statcom 4 4 4 Epic 4 4 4 4 4 4 4 Note: 4 Indicates system has the feature. Source: The Abaris Group Table 1 shows the standard products offered by these order entry. Of the hospitals that use the patient order- vendors in their most recent versions. entry function, most reported that orders are entered by physicians, nurses, and the unit secretary. About The most common ED tracking system is Meditech, 55 percent use their EDIS for capturing billable charges, which is used by 29 percent of respondents. Another half of them use the nurse documentation feature, and 6 percent each use Epic, McKesson, Logicare, and about 40 percent use the physician documentation Eclipsys. Only two respondents (6 percent) reported that function. Some respondents stated that although they are they did not know the name of the system which they are not now using some of the available functions, they plan using. “Other” responses include one hospital each using to implement them soon. Cerner Firstnet, CPSI, Dairyland, EDIM, EmStat, Health Connect, Ibex, Healthmatics ED, Last Word, Medhost, How was the system selection decision made and who MS4, and Wellsoft. Two hospitals are using home-grown was involved in the implementation? systems. Only 31 percent of respondents said that the ED leaders made an independent decision about which EDIS to Of the hospitals which have an ED tracking system, purchase; the remaining 69 percent said that the decision 51 percent are linked to the hospital’s inpatient tracking was made at a hospital-wide, corporate, or regional level. system. At 34 percent of the hospitals, the two systems do not share data. The remaining 14 percent did not have an At more than half of the hospitals (53 percent) the ED inpatient system. nurse manager was involved with the EDIS development and customization, 47 percent included ED physicians in System Functions the development, and 41 percent included both the ED Survey participants were asked whether they use medical director and ED staff nurses. At 22 percent of their EDIS for a series of common functions. The hospitals, all product development was done at a higher most commonly used function is real-time ancillary level, and did not involve ED input. information, which is used by 84 percent of responding hospitals. The vast majority also reported using their tracking system for both data reporting and patient 4  |  California HealthCare Foundation What kinds of implementation challenges did you face? What would you change about the EDIS? Respondents were asked what challenges they faced with Survey respondents were also asked what they would implementing their EDIS and what they would have like to change about their EDIS, if they could change done differently to make the process smoother. Most anything. Twenty-six percent of respondents stated that (69 percent) said their implementation could have been they would not change anything about their system. better. The top improvements they identified included The most common desired changes were more speed, addressing integration capabilities from the start, more better ability to track patient throughput times, increased thorough training for staff, more research and testing user-friendliness, increased ability to share data with prior to roll out, and customizing the system for the the hospital’s inpatient system, and improved reporting ED rather than simply adopting technology used by the capabilities. rest of the hospital. Other responses included having additional nurses on duty during roll out so that patient What is your satisfaction post implementation? care was not delayed due to the learning process, having Survey respondents were asked to rate how satisfied they better programming support, improved communication are with certain features and outcomes of their EDIS on plans, valuing staff opinions more, and having an a scale of 1 to 5, where 1 indicated “very dissatisfied” employee of the hospital serve as the project manager. and 5 “very satisfied.” On average, participants were Figure 3. Average Satisfaction Rating* of Tracking System, by Feature (n=32) Quality of discharge instructions 4.2 Increases HIPAA compliance 3.9 Ability to enter orders in a single location 3.8 Ability to pull real-time data 3.7 User-friendliness 3.6 Screen aesthetics 3.5 Ability to capture billable charges 3.5 Increases patient/family satisfaction 3.4 Reporting capabilities 3.4 Ability to interface with lab orders/results 3.4 Ability to interface with the inpatient tracking system 3.2 Ability to customize your preferences 3.2 Increases effectiveness of care 3.2 Increases staff/physician satisfaction 3.2 Increases efficiency of care/productivity 3.2 Ability to completely download the patient encounter 3.2 Decreases medical errors 3.1 Decreases patient throughput times 3.1 Ability to interact with other systems in general 2.3 Ability to interact with physiological/vital signs equipment 2.3 *Rated on a scale of 1 to 5, where 1 indicates “very dissatisfied” and 5 “very satisfied.” Source: The Abaris Group survey of California hospitals Adoption of Patient Tracking Systems among Hospital Emergency Rooms in California  |  5 most satisfied with the quality of discharge instructions productivity, quality of care, and patient safety. However, provided by their tracking system (Figure 3). This feature some of these expectations differed from the actual received an average satisfaction score of 4.2, which fell outcomes realized by those hospitals which do have between “satisfied” and “very satisfied.” The second and computerized patient tracking systems. Specifically, while third highest satisfaction scores were increased compliance 67 percent of hospitals with no EDIS believe that it with the Health Insurance Portability and Accountability would lead to a decrease in medical errors, none of the Act (HIPAA) and ability to enter orders in a single hospitals that have an EDIS reported being very satisfied location, respectively. The systems’ ability to interact with with their system’s ability to do so. other systems in general and ability to communicate with physiological/vital signs equipment in particular received Hospital Characteristics the lowest average satisfaction scores: 2.3 (falling between Table 2 shows the breakdown of various hospital “dissatisfied” and “moderate”). characteristics in relationship to ownership of an EDIS. What three best practices has the EDIS brought to Table 2. Hospital Characteristics H as No the ED? T ra cking Syst e m T ra cki n g S y s tem Survey respondents were asked what three best practices Part of Health System 69% 31% their EDIS has brought to their ED. The top responses Individual Organization 68% 32% were improved patient tracking, improved patient Licensed Beds throughput, and better tracking of laboratory/radiology <50 71% 29% status and results. “Other” responses included streamlined 50 – 99 50% 50% access to existing EMRs, improved communication 100 – 199 69% 31% among different areas of the ED, improved patient 200 – 299 67% 33% safety, guaranteed documentation in a timely manner, 300 – 399 100% 0% and guaranteed compliance with job expectations. Ten 400+ 71% 29% hospitals said that they did not know of any best practices ED Volume produced by their tracking system because it was too new <10,000 50% 50% to evaluate at the time of the survey. 10,000 – 19,999 73% 27% 20,000 – 29,999 56% 44% Hospitals with No EDIS 30,000 – 39,999 80% 20% Thirty-one percent of responding hospitals reported that 40,000 – 49,999 70% 30% they do not have an electronic patient tracking system 50,000+ 88% 13% in the ED. The top reason given was that such a system ED Treatment Stations would be too expensive and they lacked funding. This <10 62% 39% response was given by 75 percent of respondents. No 10 – 19 63% 37% hospital said that they did not have an EDIS because they 20 – 29 75% 25% were not convinced that an EDIS would be better than a 30 – 39 80% 20% paper system. 40+ 83% 17% Inpatient Tracking System All of the hospitals without an EDIS felt that they could Yes 91% 9% benefit from one, and expected that such a system could No 28% 72% lead to a number of improvements related to efficiency, Source: The Abaris Group survey of California hospitals 6  |  California HealthCare Foundation The percentage of hospitals that have an ED tracking with lower volumes. Only half of hospitals with less than system is nearly identical among those that are part of a 10,000 annual ED visits have an ED tracking system. The larger health system and those that operate as individual greater the number of ED treatment stations, the more organizations (69 and 68 percent, respectively). likely it is that the hospital has an EDIS. There does not appear to be any correlation between the The vast majority of hospitals that have an inpatient number of licensed beds a hospital has and whether or tracking system also have an ED tracking system. Only not the hospital has an ED tracking system. 28 percent of hospitals that do not have an inpatient tracking system have an ED tracking system. Hospitals with the highest annual patient visits to the ED are more likely to have an ED tracking system than those Participating Hospitals Alameda County Medial Center, Lancaster Community Hospital Presbyterian Intercommunity Hospital Highland Campus (Universal Health System) Redlands Community Hospital Arrowhead Regional Medical Center Los Angeles Community Hospital Ridgecrest Regional Hospital (Alta Healthcare System) Coast Plaza Doctors Hospital Riverside Community Hospital Madera Community Hospital Coastal Communities Hospital (HCA) (IHHI) Mammoth Hospital San Joaquin General Hospital Community Medical Center, Clovis Marshall Hospital San Leandro Hospital (Community Medical Centers) Mendocino Coast District Hospital (Sutter Health) Community Memorial Hospital Mercy Medical Center Sharp Chula Vista Medical Center Corcoran District Hospital (Catholic Healthcare West) (Sharp Healthcare) Encino – Tarzana Regional Medical Mercy Southwest Hospital Sonora Regional Medical Center Center, Encino (Tenet) (Catholic Healthcare West) (Adventist) Enloe Medical Center Methodist Hospital of Southern St. Agnes Medical Center California (Trinity) Foothill Presbyterian Hospital, Johnson Memorial Modoc Medical Center St. Jude Medical Center (Citrus Valley Health Partners) (Sisters of St. Joseph of Orange) Monterey Park Hospital Garfield Medical Center (AHMC, Inc.) Stanford Hospital (AHMC, Inc.) Northern Inyo Hospital Sutter Delta Medical Center Hanford Community Medical Center (Sutter Health) Oak Valley District Hospital (Adventist) (association of Catholic Healthcare West) Sutter Lakeside Hospital Hemet Valley Medical Center (Sutter Health) Ojai Valley Community Hospital (Valley Health System) (Community Memorial) Trinity Hospital Hi-Desert Medical Center Peninsula Medical Center UC Davis Medical Center Kaiser Foundation Hospital, Hayward (Sutter Health) (University of California) (Kaiser) Petaluma Valley Hospital UCLA Medical Center Kaiser Foundation Hospital, West L.A. (St. Joseph Health System) (UCLA Health System) (Kaiser) Pomona Valley Hospital Valley Care Medical Center Kern Medical Center Medical Center Adoption of Patient Tracking Systems among Hospital Emergency Rooms in California  |  7 Summary Authors This survey showed that the majority of California The Abaris Group hospitals are using both inpatient and ED tracking Mike Williams, MPA/HSA, president and IT systems, with Meditech being the most popular Maggie Borders, RN, MHA, CEN, consultant vendor. About half of the respondents were generally Kathleen Hurley, research associate satisfied with the inpatient product, and there were a variety of levels of satisfaction with the EDIS features. Endnotes Just over half of the hospitals have integrated their inpatient information systems with an EDIS, and the 1. Centers for Disease Control, National Center for Health inability to share data with other systems was one of the Statistics, National Hospital Discharge Survey: 2004 Annual most common complaints among respondents. Summary with Detailed Diagnosis and Procedure Data. Series 13, No. 162 (www.cdc.gov/nchs/data/series/sr_13/ sr13_162.pdf ). Most of the respondents were satisfied with the user-friendliness of their EDIS, and users reported 2. American Hospital Association, 2007 AHA Survey of being most satisfied with discharge orders in the ED. Hospital Leaders, July 2007. Interestingly, while those respondents who did not have 3. California HealthCare Foundation, Emergency Departments an EDIS believe having one could potentially decrease in the Health Care System: Use of Services in California medical errors, none of those with an EDIS reported Counties. March 2003 (www.chcf.org/topics/hospitals/ being very satisfied that it had done so. Of those who index.cfm?itemID=20502). did not have an EDIS, funding was clearly the greatest 4. California Office of Statewide Health Planning and barrier; at the same time many best practices that could Development, Hospital Annual Utilization Data, enhance revenue were cited by those with an EDIS. (www.oshpd.ca.gov/HID/Products/Hospitals/Utilization/ Results included improved patient tracking, improved Hospital_Utilization.html). patient throughput, and improved documentation —  5. Upper Midwest Rural Health Research Center all of which can lead to improved recording of billable (UMRHRC), August 2007 report. charges. 6. Healthcare Information and Management Systems Society, One additional conclusion from the survey is that 2007 HIMSS Leadership Survey, April 2007 tracking systems could be beneficial not only from (www.himss.org). a revenue perspective, but also a risk management standpoint. Improved patient safety was cited as a best practice, coupled with the enhanced clinical documentation and options for error reporting. It was evident that to achieve such outcomes, a multi- disciplinary team approach to implementation should be undertaken in order to maximize the results and return on investment from EDIS adoption. 8  |  California HealthCare Foundation