Do self-service kiosks leave EDs legally vulnerable?
"Kiosks are only as good a toolor as big a riskas the way they are utilized"
A small but growing number of EDs are implementing self-service computer kiosks to streamline the triage process. Potential benefits may include improved patient flow and satisfaction, but what are the liability risks of this practice?
"Because there are so few places doing this, there is no documented research on patient outcomes good or bad," says Shelley Cohen, RN, BS, CEN, a consultant with Health Resources Unlimited, based in Hohenwald, TN. "But the possibilities for improper use and resulting compliance and liability risks are substantial."
In 2007, Parkland Memorial Hospital in Dallas was struggling with an annual patient volume of 110,000 and long lines at triage, with a 15% leave without being seen (LWBS) rate. "We knew that people were waiting in that line and leaving, but we didn't know how many or if they were leaving with serious complaints," says Jennifer Sharpe, RN, director of nursing for emergency services.
In addition, security had to be called regularly because of increased tension and threats toward ED staff. "Disruptions were occurring regularly, mostly because people were standing up and uncomfortable," says Sharpe. "We also wanted to speed the process up to decrease our liability for patients with a higher acuity."
There was a concern that since the first thing patients saw was a long line, it could be construed as encouraging them not to stay, a potential violation of the Emergency Medical Treatment and Labor Act (EMTALA). "We were certainly not denying anyone treatment, but it put us in a situation where we needed to do something," says Sharpe.
Parkland's ED became the first in the country to use self-service computer kiosks (Galvanon's MediKiosk) Patients use touchscreens to enter their name and date of birth, and choose from a list of ailments and body parts. The information then pops up on a computer screen so nurses have a running list of everyone who has signed in. A greeter is stationed near the kiosk to help patients if needed.
Sharpe acknowledges that the system has limitations. "There are times when the information entered is completely wronga patient will put in chest pain because they think they'll get seen faster," she says. "But you can't build a process around that. You just have to see them based on what they enter."
Previously, the only LWBS patients the ED knew about were individuals who had waited long enough to see the triage nurse. "Now we know how many patients are leaving before they see anyone," says Sharpe. "I can tell you how long they wait with a minor complaint before they leave, on average. The liability was always there, we were just never able to quantify it. Now we have real information so we can improve our processes, to solve some of the things that are causing the liability in the first place."
The ED's data showed that the vast majority of patients leaving within the first hour had minor complaints. "Although that is just based on the information they are giving us, it did make us feel a little more comfortable that we are not losing patients in dire need of medical attention, and gave us some real data to work with," says Sharpe.
As a result of the data obtained from the kiosks, the ED redesigned its triage process. "We needed three or four months of good consistent numbers before we made any decisions," says Sharpe. "We implemented a two-tiered nursing role that pushes patients through the ED a lot faster, and can identify patients who are really sick a lot quicker."
Previously, nurses were in booths, and a technician managed patients in the waiting room. "Now we're going to flip that around so the techs are in the room and the nurses are out front," says Sharpe. "This way, how much of an assessment you get depends on how sick you are."
EMTALA considerations
Kiosks are only as good a toolor as big a riskas the way they are utilized, says Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals.
"Kiosks have the potential for either improving or worsening liability and compliance risks, but they are still unproven in application and in court," he says.
Kiosks so far have been deployed in larger EDs such as Parkland's, where the waits to triage were several hours. "The kiosks are credited with bringing down the wait-to-triage time, but it remains more than an hour according to some reports," says Frew.
Citations have been issued from the Centers for Medicare & Medicaid (CMS) for less than 15 minutes delay in triage. "Mere deployment of kiosks, without other significant system improvements and staffing changes, is not going to bring a facility into EMTALA compliance," says Frew.
Field data and experience will determine whether a given ED's method of using the kiosks is compliant. "Validation of the accuracy between kiosk entries and triage findings through quality assurance monitoring will be prudent for facilities to have on hand for EMTALA investigations," Frew says.
Access to this quality data varies in different jurisdictions, but may be important in a malpractice case if it is discoverable, says Frew.
Clearly, if someone is having a heart attack and chooses the right entries on the kiosk, the system should alert staff and that person should be seen more promptly for triage. "Reliance on the machine, however, is not automatically legally sufficient or EMTALA compliant," says Frew.
Address literacy issues
Use of greeters to assist with the kiosks could make non-computer literate patients reluctant to disclose their condition. "It also raises the issue of how the observations of the greeter are documented or handled in the process, which may have implications for EMTALA compliance or malpractice claims," Frew says.
Since kiosks can question patients in various languages, this should alert the staff to the need for an interpreter, but other literacy issues aren't so easily solved. "Dialect variations can carry different meanings that may cause inaccurate reporting by the patient," says Frew. Also, since ED patients may be unable to read, a reliable and accurate alternative is needed.
Even if patients are skilled readers, they may be unaware of medical terminology and important issues in their own symptoms. "This may result in a miscommunication that could critically delay 'eyes-on' medical evaluation," says Frew.
Kiosks also may contribute to patients leaving before triage or a medical screening examination. Waiting patients are more likely to become frustrated with delays and leave without completing care when a computer kiosk is their only service contact, says Frew.
"It certainly is easier to walk out on a machine than to walk up and tell a human that you are leaving," says Frew. "LWBS patients and patients who leave against medical advice are primary cases for CMS EMTALA reviews. They generally produce high numbers of citations for inappropriate delays and failures to periodically reassess the patient's condition in the waiting areas," he says.
Delays in ED waiting areas are increasingly linked to adverse outcomes and malpractice claims, warns Frew. "At the very least, increased departures without care have a negative effect on patient satisfaction scores, which in turn are predictive of risk exposure," he says.
Kiosks trigger an electronic, timed record very close to the actual physical entry of the patient, which could help EDs to improve triage processes. "But it could cause the hospital to miss logging and caring for a physically presenting patient who fails to use the kiosk," says Frew. "This could have the effect of documenting delays in triage that previously were escaping investigator recognition."
The ED's record could become a "two-edged sword" by documenting patient arrival times and actual complaints, resulting in either vindication or fault in malpractice lawsuits, says Frew.
A major risk of kiosks is their potential misuse to try to divert lower acuity patients out of the ED, says Frew. "All patients presenting must receive triage and a medical screening examination, regardless of the perceived acuity of their complaint," says Frew. "Busy EDs that are tempted to use the kiosks to expedite processes may also be tempted to rely on kiosk data to 'greet-and-street' the patients with low perceived acuity."
Answer these questions
EDs such as Parkland's should be commended for looking at all possibilities to improve patient flow, says Cohen. "We need to embrace new technologies that improve care, minimize risk, and result in better patient outcomes," she says. "But the bottom line will be: Are you fixing the right problem?"
If the problem is wait time to see a physician, then the kiosk will not improve thatbut if the problem is wait time for registration, then it can be of great advantage, says Cohen.
When considering implementing a kiosk, answer these questions, says Cohen: How is this going to benefit patient care? Will it expedite the registration process? Will it facilitate patient flow for patients who would have to wait for triage anyway? Will it help the triage nurse sort through large volumes to try and reach those most in need? Will it really impact the overall waiting time, or just registration time?
Consider the following when making the decision of whether or not to implement the kiosk, Cohen recommends:
- If patients enter information into the system and still have to wait to see a triage nurse, they may elect to leave.
"Who are they supposed to tell this to, the machine?" asks Cohen.
- Lack of interpersonal communication may lead to wrong assumptions.
What patients enter into the computer may not be a true representation of the problem; this is something the machine cannot assess. It could leave some patients waiting for triage who should have been flagged as high-risk.
"Patients share information with a triage nurse from their perspective," says Cohen. "It is the skill of the triage nurse that assesses the potential for demise of each patient."
- Information must be clearly posted on the kiosk about the patient's right to a medical screening examination.
"Obtaining registration information to initiate a medical record is not triage," says Cohen. "It needs to be clear to the patient using the kiosk that the machine is not replacing nursing judgment."
- A designated nurse must be responsible for reviewing all entries to identify those in greatest need.
"If patients are putting symptoms into a machine and a qualified person is not constantly reviewing the stream of information, this does not improve patient outcomes," says Cohen.
Above all, EDs must be vigilant in determining whether new technology is really in the best interest of the patient, says Cohen.
"If it takes another nurse to constantly review the details on the kiosk, patients might be better served by having that person simply act as another triage nurse," she says. "In addition, if staff are making nursing assessment decisions from information patients input without seeing the patient, that certainly does not meet a standard of nursing care."
Sources
For more information, contact:
- Shelley Cohen, RN, BS, CEN, Health Resources Unlimited, 522 Seiber Ridge Road, Hohenwald, TN 38462. Phone: (931) 722-7206. Fax: (931) 722-7495. E-mail: [email protected]. Web: www.hru.net
- Stephen A. Frew, JD, Vice President-Risk Consultant, Johnson Insurance Services LLC, 525 Junction Road, Suite 2000, Madison, WI 53717. Telephone: (608) 245-6560. Fax: (608) 245-6585. Email: [email protected]
- Jennifer Sharpe, RN, Director of Nursing, Emergency Services Department, Parkland Health & Hospital System, 5201 Harry Hines Blvd., Dallas, TX 75235. Phone: (214) 590-4801. E-mail: [email protected]
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