Automation may be cost-cutting alternative
Automation may be cost-cutting alternative
Try this step-by-step approach
Developing an automated pathway system for your hospital’s case management department doesn’t have to be a solo project, says Cindy D. Spurr, MBA, RN, corporate manager of clinical systems, who spearheaded an internal pathway automation project at Brigham and Women’s Hospital in Boston. Spurr recently shared her 702-bed hospital’s experiences in automating this pathway, step-by-step, with Hospital Case Management.
Prior to the automation project, the hospital’s Care Improvement Council called for the development of multidisciplinary teams to focus on solutions for improving quality and cutting costs by 15% to 20% on the hospital’s highest volume and highest cost clinical procedures. The cardiac services multidisciplinary team that originally developed the paper version met for an additional six months to determine how to best proceed.
The team first determined key areas that users would need on an automated path to be able to obtain useful data. Staff needed to be able to perform the following functions easily and quickly:
• revisions;
• documentation;
• variance data collection;
• additional pathway day documentation;
• pathway access.
The group’s discussion then turned to the next question to buy or build. After reviewing available vendor products, the team decided to develop the pathway in-house as a pilot Windows application. Developing the product in a Windows application proved to be challenging because Windows-based projects were just beginning in the hospital’s information systems department, Spurr explains.
Clinical requirements
The team next determined what the system should include to make the documentation easy and logical for the case managers. Brigham and Women’s end product consists of four computer workstations and bedside computer terminals where patient documentation is entered. The bedside terminals are linked to the workstations and the hospital’s main computer database.
The cardiac team outlined the following requirements:
• Allow writing of individual pathways.
Case managers structure pathways according to multiple phases of the patient’s care and access several subsections that are categorized by clinical areas. Case managers also can cut and paste if necessary.
• Allow the rapid documentation of patient progress.
Quick identification of patients on paths and easy review of their progress is needed because the system is used in a critical care area.
• Allow all of the activities to be captured in a database.
All pathway documentation activities including checking off specific items, capturing variance data, printing and graphing, documenting progress notes, and removing patients from paths needed to be captured in a database. Capturing of data allows for subsequent reporting and analysis.
• Allow linkage to other clinical systems.
The automated pathway system is integrated with the hospital’s other clinical systems, particularly the order entry application.
Creating the automated pathway design
Once these goals were established, a smaller working team broke out from the multidisciplinary team to fine-tune the application. The director of outcomes management and research and the co-director of the clinical initiatives development program also met with the group regularly.1
The following applications were developed as a result of the working team’s efforts:
• Writing tool.
Allows users to document on the pathway. The automated path reflects the same sequencing of events as the paper version, but the time frames can be developed in any increment of time or phases, Spurr notes.
Each day is then filed with its content and displayed as a file folder, which is created as the pathway is developed. As items are added, they are saved in the dictionary. Subsequent authors can use the same items or phrases rather than re-keying them into the system.
• Documentation portion.
The documentation portion of the automated version significantly mirrors the paper path, notes Donna Rosborough, RN, program manager for cardiac services, who worked closely with Spurr in developing the automated path. Care interventions and outcomes are listed on the left side of the screen, while the staff shift and variance columns are displayed on the right. At the bottom of the screen are the action keys used to access the following functions:
signing;
selecting a patient and/or pathway;
writing additional notes;
printing the pathway;
removing a patient from the pathway;
reviewing variance information;
accessing other portions of the patient’s on-line clinical record;
invoking the patient progression graph.
Documenting on the pathway
Users are first prompted to sign on with their own computer password to document on the pathway. This allows the user’s initials to be documented upon completing each item.
Next, patients are selected through several identification methods including:
the medical record number;
the last and first name;
the unit census;
any one of the last 10 pieces of documentation recorded for that patient;
Path days to be documented in are selected by using the mouse or the arrow and enter keys on the keyboard.
Actual care and outcome documentation is done by clicking in the appropriate cell and column, which also automatically enters the user’s initials. A check mark appears on the tabs of the file folders that have been documented.
Admission, transfer, discharge, and progress notes are written by selecting a ’notes” key. The notes screen contains both write and read-only sections. All of the documentation is saved when the user initials the information and hits the ’enter” key.
Variances at the click of the mouse
To document variances, a variance column appears as part of the pathway that corresponds with a particular intervention or outcome. Users simply click on the variance column on which they are working to prompt a list of variance code choices, which includes room for additional notes and an option to print variance reports. Earlier variances can be read but not altered.
The letter ’V” appears on the file folders where variances are documented and can be accessed by a variance key.
The automated pathway allows for both individual and aggregate data collection. Spurr explains that aggregate data reporting is possible without the lag time of the paper system, allowing the team more analysis time.
Spurr says that more pathways will become automated in the coming months. Variance tracking is perhaps one of the most important aspects but most difficult to fine-tune. ’One of the key things we are looking at doing is ensuring that the [case managers] get the variances tracked the way they want them. It is key that the system tracks their variances instantaneously. We haven’t done that fast enough, and that was the downside of being home-grown, but we’re slowly getting there.”
Reference
1. Spurr C, Flammini S, Fisher D. Automating critical pathways One hospital’s experience. Presented at the annual Healthcare Information and Management Systems Society Conference and Exhibition. Atlanta; March 1996.
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