Monday, August 20, 2007

The Healthcare Enterprise | Making a case for eHealth Investment

Many healthcare executives look at technology as a cost of doing business. However, investment in strategically chosen technology can enhance revenue while lowering operational costs. Labour, as an example, is the most expensive and valuable resource in a hospital. Therefore, any measurable improvement in the use and efficiency of labour can improve a hospital’s bottom line considerably.

Whether business office staff processing claims information, nurses performing patient assessments, or physicians diagnosing and treating patients, with the current disarray of disparate information databases (and wireless and remote technologies;) users are constantly striving to gather the information required in order to perform and optimize their job function. Strategic implementation of new Technology can significantly improve efficiency in:
• Clinical Operations (ex: Nursing, Physicians and ER)
• Financial Operations (ex: Contract Management, Administration and Registration and Accounts Payables and Material Management)
• IT Operations (ex: Training, Help desk, Network, etc.)

1. Nursing:
This is the primary area for patient care improvement and enhanced patient revenue. All aspects of technology must perform smoothly – and be transparent to the end user – or nursing will not use it for patient care. When this area is not supported by IT effectively, nurses and other clinicians will revert to paper as the only reliable way to record information regarding patient interventions and notes on the patient’s status. When this happens it significantly lengthens the process, potentially up to two hours per patient per shift. Furthermore it results in duplicate processes and redundant data capture – so much so the caregiver spends too much time managing the clerical tasks, and the patient care process is inhibited. Accurate and timely charging for patient procedures, tests and supplies do not always occur resulting in lost revenue for the hospital. The key technology elements that must all be operating effectively are:
• Robust Clinical Application System including Case Management and Scheduling
• System reliability (99.9% availability)
• System performance (instant response time)
• Easy to use and accessible system devices (e.g., wireless, PDA’s, tablets, printers, etc.)

2. Physicians:
Physicians’ have two main concerns
• time to see patients and
• the timely availability of accurate patient information.

Therefore, creating a way for physicians – no matter where they may be – to continuously receive updated information on their patients addresses both of their primary concerns. Providing this technology is a key contributor to recruiting and retaining satisfied physicians, as well as providing high-quality patient care. The key technology elements that must all be operating effectively are:
• Physician-oriented presentation of patient results information
• Easy-to-Use computerized physician order entry system
• Online access to patient’s diagnostic x-ray and ultrasound information (PACS)
• System reliability
• System performance
• Support for multiple input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.) from in-hospital as well as remote locations
• Integration to their office practice management and EMR systems

3. EMR:
The ultimate goal of most healthcare organizations is a paperless electronic medical record to improve the efficiency and effectiveness of the enterprise workflow process and enhance the revenue generation process. Healthcare management understands, at a conceptual level, that having an automated digital hospital would improve the entire patient care workflow process, and thus, patient satisfaction and staff productivity. The successful automation of previously paper-based processes requires a robust IT infrastructure, and careful planning among all the affected stakeholders.

4. PACS:
A PACS system not only has proven to produce positive bottom-line results, but also is often considered a necessary precursor to the EMR. A wise investment that often pays for itself within 3-5 years, it allows the “reading” of images from all modalities from a workstation that is either in the hospital, or in a remote office. The biggest benefit however is the ability to transmit and view the image to wherever it is needed, and removes all of the barriers to access that exist with traditional film. To achieve all the available benefits, the network bandwidth must be in place to support very large image files, and again, careful planning among all the affected stakeholders is critical to a successful implementation.

5. ER:
Increasingly hospitals are realizing that their ER is a major entry point for patients and should not be overlooked as a revenue source. Providing comprehensive computerized systems that are optimized for the ER’s workflow are mandatory if the hospital desires to realize the potential benefits available. The key technology elements that must all be operating effectively are:
• Emergency Room Patient Tracking System
• System reliability
• System performance
• Easy to access and use input and output devices (e.g., wireless, PDA’s, tablets, printers, etc.)
• Seamless Integration to a hospital’s Master Patient Index to retrieve patient information and provide billing data
• Integration with the EMR to maintain a comprehensive clinical record.

6. Laboratory:
Laboratory orders are processed promptly because of the need of the patient. However, in a paper-based environment, charges can be overlooked because of the multiple steps required to process a patient chart and the extra work involved in capturing charges. A comprehensive Laboratory Information System (LIS) that is fully integrated with the HIS will alleviate this problem, as well as improve the overall efficiency and effectiveness of the Laboratory staff. The key technology elements that must all be operating effectively are:
• Robust Laboratory Information System including integration with all laboratory instruments
• Integration with hospital’s EMR and/or order entry system
• Integration with any external reference laboratory used to enable a complete view of patient’s lab results
• System reliability
• System performance

The key to strategic gains in the Financial/Administrative area is to invest in the newest technology that enables business processes to function more efficiently, and ensures the most accurate billing practices for the organization. Even small procedural changes can create more effective billing and substantially improve the bottom line. Likewise, the implementation of comprehensive scheduling systems can improve turnaround times and help ensure the optimal use of expensive fixed assets throughout the hospital. Other areas suitable for increased investment are described below.

1. Contract Management:
Many hospital billing operations submit claims based upon the personal knowledge of staff billers. Billers often overlook minute and incremental charge optimization opportunities simply because of the volume of bills and claims that must be generated and submitted. The computerization of code optimization and the underpayment analysis of payer reimbursement will have an ongoing and profound impact on a hospital’s bottom line. Whereas these billers are very knowledgeable, their true value is in the management and adjudication of claims denials. The loss of revenue per claim may be small, yet the total volume of claims equates to a substantial loss. Computerization of the claims submission and denial process quickly pays for itself and can immediately increase the hospital’s cash. The key technology elements that must all be operating seamlessly:
• Contract Management Application System
• System reliability (minimal downtime)
• System performance (immediate response time)
• Adequate storage (retrieve discharged patient’s complete information)
• Electronic interface to primary payors
• Integration with hospital’s patient accounting system

Hospitals will vary on the impact of automating these areas of operation. The cumulative effect can be quite surprising. As PriceWaterhouseCoopers and HIMSS analytics reported in their study of cardiac care in 36 hospitals in March 2005, there was an “85% reduction in medical errors and a 65% reduction in inappropriate denials from payors…” in the hospitals studied.

2. Admissions and registration:
This area requires system speed and a reduction in the complexity of screen layouts. There is typically a lot of turnover in this area. Yet Admissions is the first location for revenue enhancement and the primary source of errors and inaccurate data for billers to deal with claims denials. The key technology elements that must all be operating effectively are:
• Comprehensive admission-discharge-transfer system
• Integration with payors to confirm patient coverage
• Integration with patient scheduling system
• System reliability (no downtime)
• System performance (immediate response time)
• Easy to access and use input and output devices

3. Accounts Payable/Materials Management:
The goal of automating the replenishment of the hospital supplies (using just-in-time processes), while taking maximum advantage of the hospital’s contracts, in an effective and efficient process, has a significant impact on the hospital’s profitability. Accurate, ongoing, and continuous inventory, minimal loss of stock, and maximum chargeability are the key components. Taking advantage of discounts by being able to pay vendor’s invoices within the discount can benefit the hospital’s bottom line. The key technology elements that must all be operating
effectively are:
• Comprehensive Accounts Payable System
• Comprehensive Materials Management System
• Integration between Accounts Payable and Materials Management
• System performance (immediate response time)
• Easy to access and use
• Adequate storage

4. Barcoding:
It has been shown that barcoding data at the bedside, from the pharmacy, and through materials management reduces medical errors tremendously, as well as, improves the automation of input of data into the patient chart. It holds the ability to speed and integrate the purchasing, distribution, administration, charting, and billing for pharmaceutical and other supplies. An effective barcoding strategy not only provides more accurate and timely information, but also saves time and improves the work lives of clinicians, managers, and staffers by making things run more smoothly and simply. To realize the full benefits of a barcoding implementation, attention must be paid to the workflow changes necessary to get maximum returns. When combined with supply chain automation, the entire process of acquiring the correct supplies, packaged and correctly prepared for patient delivery, are made available to the care-giver when needed – and the documentation for billing, inventory reordering, and the patient chart, is captured as a by-product of the patient care process.

The common thread in improving IT Operations in healthcare is to achieve maximum leverage of the staff resources to implement and support an ever-increasing array of emerging hardware and applications. Through continual centralization of the environment, more ROI is squeezed out of fixed assets and the staff becomes more efficient by giving them the tools to do their job more effectively. Whether it’s server administration, network management, application support, or user provisioning, the innovative investment in the IT infrastructure can improve service levels and ensure optimum utilization of expensive staff resources. Practical examples include:

1. Training:
As the general workflow process is automated, the need for personnel to understand how to use the tools at hand becomes paramount. Training is needed in two distinct areas; the IT staff and the users:
• The IT staff must be trained to understand how to use the servers, switches, software and network to maximize the users’ capabilities. Each IT staff member has a “multiplier effect” upon the user community’s effectiveness. Most should therefore be certified in their area of expertise.
• The automation process is for the benefit of the user and the organization. Therefore, the user must be trained in the optimal usage of the system and the tasks they perform. This means that an ongoing training program should be implemented to ensure employees are accomplished on the system(s) they use and fully understand the implication of their actions when using automated systems to perform their jobs.

2. Help Desk/ Service Level Management:
IT departments may have a phone number for users to call in case of need, however most facilities do not have an automated structured process to monitor
technology, diagnose problems, administer support, and measure performance by automated reporting. It is imperative to be able to understand the source of help desk calls in order to properly plan for the improvements needed to improve customer service.

3. Network:
The network is the nervous system of an organization’s information flow. There are a number of components of a network that must be able to transport data at a guaranteed minimum volume.

4. Switches, bridges, and routers:
The switches, bridges and routers are the devices that route data from one part of the network to another. Considering that a fully automated healthcare workflow process will have a minimum of 25 major applications that will route data for 30 departments, the switches need to be configured to handle the volume of traffic anticipated.

5. Backplane:
A backplane acts as a “traffic cop” for the data that comes from all of the different switches within the network. Therefore, it must handle the accumulated burstable volume of the network. For a fully integrated and automated workflow process, a backplane may need to burst to 4 Gigabytes/sec. of volume.

6. Network Management Software:
Many of the major network vendors have the ability to continuously “ping” the network through a technology called SNMP. This allows IT to proactively monitor the “health” status of switches, PCs and servers. The same software now also keeps an inventory of hardware and software, as well as version control, so that the network can now distribute patches, updates, and fixes to the users quickly. Finally, most of these network vendors now have integrated help desk and service level management automation into their support process. Therefore, IT can now receive a request for assistance, log it, prioritize it, and escalate it automatically. They can then diagnose and fix (either remotely or by the system dispatching a person) user’s hardware and software. Finally, the IT tools can then print out a report that shows the amount of time systems were up for the month, how many service calls were responded to by prioritized need, who was serviced and when, as well as the outcome of that service call.

7. Wireless and Remote Capabilities:
Wireless PDAs, tablet PCs, smartphones and laptops are transforming the way information is gathered and processed. Systems can now be structured so that physicians may plug their device into the hospital system and be uploaded with what happened to their patients overnight. Additionally, caregivers and hospital staff can now work from home.

8. VoIP:
Currently the dual networks and dual support staffs to run a network and a PBX system are costly. Time and again, the return on investment (ROI) to move the phone system onto the network, department by department over a period of time, has shown to be a good investment. There is no charge for moves, adds and changes (MACs) now, the administration of two systems can be handled internally by one group, and future cabling costs are minimized.

9. Cabling:
Cabling is an infrastructure issue and often its importance is overlooked. But, it is foundation of the information highway for a hospital. In addition, as hospitals are adding increasing computerization, cabling installed two years ago may soon be outdated. Cabling should be an integral part of a hospital’s computer plan.

10. Standardization:
Standardization means that the technical components of servers, switches, and PCs should have the same memory, cache, and storage. The reason for this is that servicing a few standards reduces the complexity of support, which has shown time and again to be the best way to reduce the cost of operations.

11. Servers:
Most servers are currently purchased as individual standalone machines. This creates two problems: first, it means that each server is a single point of failure for its own data and there is no failover capability from one server to another; and second, the storage usage of each machine is usually less than 50% of capability. Therefore, the architecture of servers should be configured into a storage array network (SAN) of blade servers configured to backup each other.

The implementation and continued automation of the healthcare workflow process is analogous to building a house. All departments run their own operation, but are interconnected and dependent upon each other to provide a complete workflow environment. The foundation of said “digital house” however, is the technological infrastructure. Any weak points in the infrastructure will create bottlenecks in the workflow process. The demand for quick and accurate patient information in hospitals is continuously on the increase. Hospitals have to improve their technological infrastructure in order to meet the needs of caregivers and to enhance their revenue. Healthcare workflow process improvement will take time to accomplish in a coordinated, synergistic manner that will improve patient care and hospital revenue.

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