Patient Flow Enewsletter
Volume 2, Issue 4
Thursday, August 11, 2005
On paper, Peninsula Regional Medical Center reads like a fairly typical hospital. It's a 106-year-old tertiary care facility with 352 beds. More than 300 physicians and 2,400 other healthcare professionals are affiliated with Peninsula, and approximately 500,000 patients come through its doors each year.
It's not the numbers, however, but its location on the Delmarva Peninsula that makes Peninsula Regional Medical Center unique. The Delmarva Peninsula - made up of the entire state of Delaware and parts of both Maryland and Virginia - is a 180 by 60-mile stretch of land nearly surrounded by water. The Chesapeake Bay lies to its west. The Delaware River, Delaware Bay and Atlantic Ocean lie to its east. Its northern isthmus is cut by the Chesapeake and Delaware Canal. With bridges and tunnels connecting the area to the mainland, the Peninsula remains somewhat isolated.
In part, what this means for us is that we don't have the luxury of ambulance diversions to fall back on when the emergency department (ED) crowding that is so common today becomes a problem. We're more than 30 miles away from our closest neighboring hospital, and it doesn't provide the same high level of acuity and trauma care. The closest facilities that do are more than three hours away in Baltimore and Washington, D.C.
Consequently, we are forced to be as efficient as possible - with lessons any hospital, no matter its location, can learn. To achieve this, we determined that we had to be considerably more efficient about sharing, exchanging and compiling data. For two years in a row, we've been rated the "most wired" of all rural hospitals in the U.S.
How did we get there? It began with a 10-year vision to have a completely integrated medical tracking system. The goal was that from the moment the patient comes through any door, his / her care is documented - whether it is medications, direct nursing care, instructions, tests, physician orders - and that the documentation would follow the patient until he / she is discharged. We wanted it to be remotely accessible and viewable and to have some pertinent items (i.e., past medical history, allergies, medications) flowing forward into the chart to eliminate redundancies and better care for the patient in future visits. Essentially, we were striving for an integrated paperless record, easily accessible by all of the customers of the traditional paper chart.
The overall goal was to provide better clinical interface, which we believed would ultimately translate into better patient care. It's a tremendous undertaking, so we began by creating a pilot system for the ED. By helping us identify what works efficiently and what processes are inefficient, the pilot would serve as our guide for creating a facility-wide system.
The process of designing and implementing the pilot was enlightening. From the start, we used the opportunity to evaluate our workflow - looking at every chart, every order, every piece of paper. The last thing we wanted to do was transfer bad paper processes into the new electronic system.
One of our greatest challenges was enlisting a vendor that could work hand-in-hand with us to develop a fully integrated system tailored to Peninsula's needs. Accomplishing this goal required that we enlist a vendor that not only had an integrated application, but enlisting one that was willing to see our vision and to work with us. In the past, there were stand-alone tracking boards, stand-alone lab systems, etc., but the technology needed to create an integrated facility-wide system is just now becoming available.
An emergency department - where everything is done in "stat" mode - works differently than inpatient areas. We needed a system that was going to meet our needs, not one that would require we change our processes to match the system's applications.
We soon appreciated that a pilot truly is a process of trial and error. At first, our ED system was like a circus show with far too many blinking lights. We learned that you have to be careful about what all you ask for, because you just may get it. Before you approach a vendor to design a system, you have to determine what you actually need.
For the first time ever, we now share information in real-time. Nurses receive physician orders in real-time. Secretaries receive consulting alerts in real-time. Lab reports come back to the emergency department in real-time.
The time saved is considerably better utilized. Senior ED nursing managers who have years of experience and considerable skills used to devote some of their shift to running around the hospital with a clipboard looking for an inpatient bed. Anyone could recognize that it was not a good use of their knowledge and skill set, but it had to be done. With our new system in place, they can devote more time to educating other nurses, improving management techniques and providing leadership.
Patients appreciate the efficiency of information exchange, too. Think about what it's traditionally like when a patient walks into an ED. First he or she is seen by a pre-triage nurse, followed by a triage nurse. Let's assume the person needs to be admitted. He or she is then approached by an inpatient nurse. Next a physician will come speak with him or her, followed perhaps by a consulting physician. The patient relays information to a minimum of five people, then a shift change takes place. Suddenly, he or she needs to begin relaying information all over again.
We no longer ask each other, "Where's so-and-so's chart?" Every piece of available data is in the system.
Of course, not everything you learn through implementing such a sophisticated system is necessarily positive. One of our most surprising findings in tracking all data electronically was that the number of patients who left without treatment (LWOTs) increased. It's doubtful the LWOT number actually went up - especially since we were operating more efficiently and reducing ED wait times. Instead, we were just tracking these individuals better. Before, we never really knew how many people were out in the waiting room.
We continue to learn from the ED pilot, which will eventually be integrated into the institutional tracking system that is in development. The systems will be able to communicate with each other, which will further increase our efficiency.
The future of medicine is going to be facilitated by systems like the ones we are creating. To provide the highest quality of patient care possible, we need to reduce the paper flow, eliminate the need for people to run around with chart clipboards and minimize the telephone tag.
It's important to remember, however, that the tools themselves are not the solutions. An institutional tracking system like we're creating is merely a tool that will help Peninsula's staff find the solutions to some of our community's healthcare challenges. That's the real goal, and we're looking forward to meeting it.
-------------------------------
Katherine Ball, M.D.
Medical Informatics Specialist
Peninsula Regional Medical Center
Salisbury, MD
