New Orleans ED saves $200,000 each year with electronic charting
August 1, 1998
New Orleans ED saves $200,000 each year with electronic charting
When ED managers at Alton Ochsner Medical Foundation in New Orleans set out to reduce costs of transcribing physician notes, a decision was made to switch to electronic charting. "We were spending nearly $200,000 a year on transcription," says Joseph Guarisco, MD, the hospital's chairman of the department of emergency medicine.
An extensive evaluation was performed to choose the best electronic charting software, which could interface with the ED's existing electronic patient record. "Physicians were involved in the process of choosing software," says Guarisco. "They narrowed the selection down to two or three vendors. From there, we asked for input from our IS department as to which software was most compatible with our existing system." The DataMedec system was chosen.
Once the system was installed, a four-hour training session was held with each ED physician, but the process was done gradually. "We didn't make it mandatory on day one, because we didn't think it was good to go with a completely new charting system with a flip of a switch," says Guarisco. "There was a great deal of resistance during the first 90 days of use, because of the steep learning curve for electronic charting."
For the first month, physicians were asked to do 30% of their charts electronically. "If they were really jammed with patients, they could pick up the phone to dictate and do manual transcription," says Guarisco. "Having that flexibility took the pressure off the physicians. They felt more comfortable knowing they had a backup system."
For many ED physicians, the learning process took two to three months, but it paid off. "You can't just sit down and go with this system. You need to learn all the menus and how to select the phrases and terminology you need," says William Troxler, MD, an ED physician at the hospital. "I was not very computer literate, so that added to my learning curve. But the more you do it, the faster you get."
The physicians have overcome resistance to the system. "They like seeing their notes constructed immediately. When they sign the notes, there is no need to review them again in six hours. They can be viewed and edited onscreen, which is a big benefit to them," says Guarisco. "They can also do their notes from home if it's toward the end of their shift and they still have a few notes to do. They are able to dial in to the network and complete them from home, or use a laptop in a hotel room if they need to."
Targets were set to increase the percentage of notes done electronically every three months, with the goal of 100% compliance at 12 months. A portion of the savings was paid back to physicians who met their targets as an incentive. "Once it was up and running, we realized that this was a tremendous benefit to the institution. So, we lobbied for some ownership of the system," explains Guarisco. "Getting the distribution from the savings was a nice reward to physicians for mastering a complex task."
In some cases, the chart can be generated more quickly than with dictation, notes Trexlor. "There are certain illnesses that you can actually do faster with the computer than if you were dictating, because charts can be developed for common illnesses, such as migraine headaches, that fit into a preprinted format," he says.
The chart is generated instantaneously. "We don't have to wait for the registration folks to put the patient into the computer-we can do it ourselves," says Trexlor. "Patients can actually leave with a copy of their own record in their hands, which is helpful if they are going to see another physician. This way, they know what was done to the patient in the ED."
The software was customized for the ED. "We looked at our top 40 diagnoses to make it extremely efficient," Guarisco explains. "During any given shift, we found we had two or three patients with ankle sprains or neck injuries. So, we customized it so we used a lot of default settings for those diagnoses. That way, the amount of interaction with the software is minimal."
Overall, the electronic system saves time. "There may be one out of 10 patients who are complex and that takes longer, but others are extremely fast," says Guarisco. "Globally, we spend less time charting."
Electronic charting also eliminated the six- to 24-hour delay in getting notes back from a transcriptionist. "Previously, a full-time person typed out the handwritten charting and faxed it to where the patient was making an appointment, for example, to one of our eight satellite clinics," says Guarisco. "Now, notes are immediately uploaded to the system, so the clinic physicians can read it immediately without involving anybody else."
Instant access to the charts saves time in other ways. "When our risk management department e-mails us with QA issues or patient complaints, I can bring up the patient's visit to review, respond, and e-mail back without ever leaving my chair, which is an incredible time saver for me as a manager," says Guarisco.
The extra time spent by physicians more than makes up for itself in other efficiencies, stresses Guarisco. "Some people say it's inappropriate to have a physician doing stenography work," he notes. "But, the few minutes physicians invest provide efficiencies for medical records, QA, and private physicians. The rewards downstream are tremendous."
Lab, X-ray, and EKG results are all uploaded electronically. "An'ED packet' of information is printed and a hard copy placed in notes, because medical records is still a paper process," says Guarisco. "This is a neat package, rather than having various notes and labs in different places."
Previously, if the patient returned to the ED within 12 hours, the paper record would be difficult to retrieve. "At that point, it would be between ED billing and medical records," says Guarisco. "If the clinical notes had not been transcribed yet, the digital recording of that was not easily obtained. You would have to go into system and listen to the recording."
Interns and residents have also learned to do charting electronically. "In the old system when they dictated, we really couldn't review the chart for 24 hours. At that point, the physician may be gone, and it may be two or three days before they work another shift, adding to the delay," says Guarisco. "Now, we can review it in real time, edit it or add to it, and it's done."
The billing process is also streamlined. "Because there is a readable record of patients visit within moments of discharge, the billing process is initiated within hours," says Guarisco. "This reduces the billing cycle by two or three days for each ED visit."
Voice recognition software is currently being tested, allowing users to add small pieces of text to the notes if needed. "Most of history and physical lend themselves to computer entry very well. But for the history of the illness, when the patient speaks ad lib, you really can't build the software to cover every type of situation a patient might relate to you," says Guarisco. "So if you want to add more details, like the patient was walking down the street and slipped on a banana peel and fell, you can use voice recognition to embed that information in the notes."
The system cost approximately $200,000 for the hardware and $100,000 for the software. "But for the hardware cost, that included printers and PCs, thing we use for a multitude of other purposes," Guarisco notes. "In six months, we paid for the software, and we paid for the hardware in a year. Payback is very fast and continues to generate net savings."
For the first three months, length of stay increased approximately 30 minutes. "But as staff got better and faster and we customized, those delays evaporated. Now, our length of stay is back down to historic lows," says Guarisco. "About 75% of our staff are now faster with computer than any other input, so our system is not a hindrance to patient care."
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