Electronic Patient Tracking Systems: A Healthy IT Investment for Emergency Departments

Damon Dietrich MD, MHCM FAAEM
AAEM Young Physicians Section Treasurer
AAEM Louisiana State Chapter President

Emergency department visits are on the rise while EDs continue to close at an alarming rate. Effective internal strategies for any hospital must encompass measures to improve operational flow and throughput to meet the demands of increasing volume. In the evolving environment of customer-centric health care, hospitals must implement information technology (IT) products and solutions to improve patient safety, to remain competitive, and to survive financially. Dr. David J. Brailer, who was the National Coordinator for Health Information Technology from 2004 to 2006, was responsible for coordinating the development, maintenance, and oversight of a national strategic plan to promote adoption of health IT in the public and private sectors.¹ This national urgency for implementation of IT products still exists in a healthcare sector that faces awesome challenges. Healthcare spending and health insurance premiums continue to escalate at rates that outpace the Consumer Price Index (CPI) or general inflation. It is estimated that the Medicare trust fund will go bankrupt by 2012. Although US healthcare spending totals over $2.2 trillion annually or 16.2% of the Gross Domestic Product (GDP),² challenges continue, including preventable errors, uneven health care quality, and poor communication among physicians and hospitals. Administrative inefficiencies, high costs, medical errors, variable quality, and lack of coordination are directly linked to the inadequate use of IT as a vital part of the health care delivery system.¹

In 2006, the Institute of Medicine (IOM) released a report titled "Hospital-Based Emergency Care: At the Breaking Point," which identified weaknesses in the nation's ability to respond to large-scale emergency situations, whether disease outbreaks such as pandemic influenza, naturally occurring disasters, or acts of terrorism.³ Partly underlying these weaknesses is the fact that, over the last several decades, the role of EDs has expanded from treating seriously ill and injured patients to also providing urgent unscheduled care to patients unable to gain access to their providers in a timely fashion and to providing primary care to Medicaid beneficiaries and persons without insurance. At least 15% of the population is completely uninsured, and a substantial additional portion of the population is "underinsured", or less than fully insured for medical costs they might incur. Additionally, more money per person is spent on health care in the United States ($7,026 per person annually in 2006) than in any other nation in the world, and a greater percentage of total national income is spent on health care in the U.S. than in any United Nations member state except for Tuvalu.⁴ Medical debt is the principal cause of personal bankruptcy in the United States.

EDs are now also frequently overloaded. ED visits in 2006 rose to 119.2 million, up from 90.3 million in 1996. As ED visits have increased, the number of hospital-based EDs has decreased by almost five percent between 1996 and 2006, resulting in dramatic increases in patient volumes and waiting times.⁵ One of the most common factors related to ED crowding is the inability to transfer ED patients to inpatient beds once a decision has been made to admit them.¹ As the ED begins to "board" patients, the space, staff, and resources available to treat new patients are further reduced. Another consequence of overcrowded EDs is ambulance diversion, in which EDs close their doors to incoming ambulances. The resulting treatment delay can be catastrophic for the patient. Approximately 500,000 ambulances are diverted annually in the United States (about one ambulance diversion per minute).⁶

Over the last 10 years, U.S. emergency departments have experienced a transition from a patient focus to a customer or consumer focus. This customer-centric atmosphere marks a renaissance in the design and function of U.S. emergency departments. Disaster incident preparedness, ED closures, higher acuity patients, rapidly increasing volume, regulatory pressures, and a change in the functional mission of hospitals have all contributed to this transformation.⁷ Hospitals must focus on high quality, cost-effective care to drive their missions in an environment of narrower operating margins. This current challenging and competitive environment dictates that EDs incorporate measures such as electronic patient tracking systems into facility design and process to reduce the operating expenses of a continuously running ED.⁷

To surmount these new challenges, competitive hospitals have incorporated new concepts borrowed from other industries to facilitate superior customer service. Electronic patient tracking systems (EPTS) have been shown to improve operational flow and throughput with multiple benefits. The application of IT support systems, such as an EPTS, is of paramount importance to meeting the needs of patient consumers in the ED. With the ED and labor and delivery unit providing the majority of first impressions about overall hospital operations and service delivery, IT solutions should be designed and implemented in these arenas. The ED is the "front door" or "front line" for over 50% of all patients admitted to most US hospitals, while serving as a central community outreach center, most notably for the indigent and uninsured population. As we all know, EMTALA is not going away. ED encounters average 405 visits per 1000 population each year in the US.⁵ Therefore, for many patients, the ED drives the perception of overall hospital service.⁷

Because the ED drives the majority of overall hospital service perception, ED systems and processes must maintain adequate surge capacity. The hospital must recognize and address the highest community expectations and perceptions of treatment for an emergent condition. In times of increasing volume, the ED is under intense pressure to remain open to avoid triggering a cascade of events that lead to ED diversion. Diversion leads to increased customer dissatisfaction and declining operating margins due to falling revenue generation.⁷ Dissatisfaction can evolve into decreasing market share in a competitive environment where consumers choose other EDs for treatment. In addition, if patients prefer to use other EDs, then they may also choose a different hospital for other non-emergent healthcare needs which contributes to declining market share and revenues in other hospital service lines.

EPTSs have been shown to increase throughput and revenues though improved operational efficiencies and work flow processes. Both of these enhancements lead to decreasing diversion times. With EDs having wide variations in capacity requirements, EPTS increase the bandwidth of an ED. Bandwidth refers to the ability of an operating unit such as an ED to tolerate wide variances in work requirements. Essentially, an EPTS increases ED tolerance and efficiency during volume surges. With length of stay (LOS) increasing in emergency rooms, particularly for admitted patients waiting for inpatient beds, EPTSs serve to decrease LOS thereby increasing volume and throughput.

Due to the potential capacity constraints for most EDs, it is imperative for ED leadership to invest considerable energy in managing spatial and functional relationships. For instance, the timely management of ED patients is critically connected to inpatient bed management, radiology, and laboratory services. An EPTS allows for effective operational oversight of the efficiencies or inefficiencies of all respective departments. All services can be held accountable, as the system tracks workflow processes in all departments allowing for identification, correction, and process improvement of workflow inefficiencies and bottlenecks. The EPTS serves as a highly functional status board to improve inter-connectivity and operational flow.⁷

Goals and Benefits of Electronic Patient Tracking Systems:

Tracking of the physical location of patients after triage
Identification of patients' current status and visit progression
Tracking of ED utilization and specific room status
Indication of specific providers involved with each patient's care
Identification of bottlenecks contributing to decreased operational flow
Maintenance of patient privacy, including HIPAA standards
Ability to interface with existing hospital IT products (interoperability)
Improvement of process flow and throughput
Increased accountability of all interactive departments
Improved patient safety
Streamlining of coding and billing for faster revenue generation

EPTSs can also incorporate evidence-based decision support systems. Doctors are then able to have the most current information about treatment options and new drugs, as well as immediate access to relevant patient information. With an Electronic Health Record connected to an EPTS that stores demographics and billing information, hospital and physician reimbursement increases. The link provides accurate, detailed documentation of care. This helps to avoid denial of payment from managed care companies and to avoid allegations of fraud from Medicare.⁸ A bill can be generated in a more efficient system through linking documentation with billing information. Physician documentation can be linked through the system to CMS documentation audit criterion, which ensures adequate documentation for the nature and severity of each patient encounter. This ensures appropriate reimbursement by eliminating mandatory down coding secondary to insufficient documentation.⁷

Emergency departments must undergo transformation to meet the needs of consumers. As the U.S. hospitality industry is committed to setting progressively higher standards for customer service, the healthcare industry is addressing increasing patient volumes and acuity with a reduction in the total number of EDs, worsening cost pressures, and increasing regulation.⁷ In addition, ED providers need to avoid adverse outcomes and medical errors, while implementing strategies for disaster preparedness and bioterrorism surveillance and detection. IT advances such as an EPTS provide countless benefits through improved patient safety, increased operating margins, increased revenue and throughput, decreased LOS, and improved patient satisfaction. The EPTS also serves to enhance operational process flow through accountability and oversight leading to bottleneck identification and elimination. For U.S. healthcare to improve, a committed and determined focus on IT solutions such as EPTS for EDs must be recognized as vital to the financial solvency and future of any healthcare organization.

References:

1. Thompson TG, Brailer DJ. The Decade of Health Information Technology: Delivering Consumer-Centric and Information-Rich Health Care: Framework for Strategic Action. United States Department of Health and Human Services, 21 July 2004.
2. <http://www.hhs.gov/news/press/2004pres/20040721.html>.
3. "National Health Expenditure Fact Sheet." Centers for Medicare & Medicaid Services. United States Department of Health and Human Services.
4. <http://www.cms.hhs.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp>.
5. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press. 2006.
6. Gollogly, Laragh, ed. World Health Statistics 2009. Geneva: World Health Organization. 2009. World Health Organization Statistical Information System.
7. <http://www.who.int/whosis/whostat/2009/en/index.html>.
8. Pitts SR, Niska RW, Xu J, Burt CW. National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary. National Health Statistics Reports; No. 7. Hyattsville, MD: National Center for Health Statistics. 2008
9. Burt CW, McCaig LF, Valverde RH. Analysis of ambulance transports and diversions among U.S. emergency departments. Ann Emerg Med 2006; 47(4):317-326.
10. Augustine, Jim. ED Design: Form, Function, and a Friendly Front Door. American College of Emergency Physicians News. Aug 2005; 24(8).
11. Landro, Laura. Medical Studies Link Mistakes and the Lack of IT Solutions. Wall Street Journal. Sep 3, 2002.