EMERGENCY ROOM OF THE FUTURE LEVERAGING IT AT WELLSTAR HEALTH SYSTEM: KENNESTONE EMERGENCY DEPARTMENT Jon Morris, MD, FACEP, MBA WellStar Health Systems September 18, 2008

Agenda  Introduction  Kennestone Emergency Department  Metrics  More Metrics- Exit Phase  Even More Metrics- Non-ED Physicians  So far…

To Err Is Human  Patient Safety Issues: IOM report Nov  > 44,000 – 96,000 deaths related to preventable medical errors/year  $17B - $29B cost  2000 – Leapfrog Group

Example: 2007 Adverse Drug Events

The Need For Change “The definition of insanity is to continue to do the same thing over and over again and expect different results” Albert Einstein

Kennestone ED

Kennestone Emergency Department AdultFast TrackPediatric Hours24/711A-11P24/7 Levels411 Beds6189 Hall beds902 Total70811 >102,000 Annual patient volume 40% of Kennestone admissions 24.38% admit rate (July 08) October 2007: ED Online

ED Flow “Before”

Paper ED Record

Completed ED Evaluation - Waiting For MD

October 2007: Kennestone ED Live Online Documentation and Order Entry  “Sole Source” strategy- McKesson  18 month build  ED Tracking Board  Online Clinical Documentation (Horizon Emergency Care  – HEC)  Online Order Entry (Horizon Expert Orders  - HEO)

ED Flow “After”

WSKH ED Applications ED Tracking Board

Patients Waiting For MD

ED Patients: Status & Tasks

WSKH ED Applications Documentation

Online Documentation  Always Available  Real-time  Legible  Automated Date & Time  All Clinical Documentation In One Place  More Complete

ED MD Charting

Paper vs. HEC- MD Note

WSKH ED Applications Order Entry

Definition: CPOE  Provider Enters Orders  Clinical Decision Support  Easier to do the right thing  Harder to do the wrong thing  Immediate Order Transmission

Tools: I-Forms

Tools: Order Outlines

“Easier To Do The Right Thing:” Weight-based Dosing

Leveraging CPOE: Automation

“Harder To Do The Wrong Thing”

Allergy Checking

Allergy Alert

CPOE: A Process  Multiple applications  Provider  Nursing  Pharmacy  Ancillary Services, i.e., Laboratory, Medical Imaging  Global process - multiple stakeholders  KLAS: 17.5% US Hospitals > 200 beds in 2007

CPOE- Financial Gains CPOE in Community Hospitals:  ADE cost  Renal dosing errors  Unnecessary / Redundant diagnostic studies  IV to PO conversion  $2.7M Reduction in Cost, 26 month payback* * Feb 08 MA CPOE Initiative Report

The Competition

Goals- WellStar Health System  Improve Care  Lower Costs  CPOE Using HEO  Two Years To First Facility Go-live  100% Physician Adoption Two Years Post-live

WSKH ED Implementation

Challenges in Implementing HEC-HEO  Development  Training  Deployment  Adoption  Reporting

Implementing HEC-HEO

The Good-

The Bad-

And the Ugly Truth.

One solution… “In the middle of every difficulty lies opportunity” - Albert Einstein

A Better Way: Metrics

Throughput Analysis  Neglected value of ED applications  Acquire data from HEC & TB.  Quarantine invalid data  Report data compliance, i.e., reporting efficacy and accuracy.  Select and study throughput intervals.  Identify high-yield opportunities.

WS KH ED - Throughput Intervals Arrival to Triage Arrival to Bed Arrival to EDMD Assigned Arrival to EDMD At Bedside Bed to EDMD at Bedside EDMD at Bedside to EDMD Decision to Disposition EDMD Decision to Disposition to RN Disposition RN Disposition to Exit LOS

ED Metrics

The Good: Reliable ED Metrics ERK - July 2008

The Bad: Delays in Seeing EDMD Admitted Patients: Patient Arrival to MD At Bedside: 61 minutes Patient in Bed to MD At Bedside: 42 minutes

The Ugly: Delays in Exit From ED July 2008 EDMD Decision to Admit to Exit from ED: Exit Phase = EDMD Decision to Admit → Patient Exit From ED = 172 minutes 39-47% Average ED Patient LOS (Jan – July 2008)

Progress: Bed to MDATBED Jul 08: Additional 1P EDMD shift present on 12/31 (38.7%) days 90% August dates have 1P ED MD Coverage

Exit Phase Delays

Admitted ED Patients: 3 Steps 1. Get Into An ED Bed 2. Receive ED Treatment &/Or Evaluation 3. Move to Next Level of Care

Getting Into An ED Bed:  Available ED Bed and Resources  Clinical Staff, i.e., RN, tech, etc.  Open Beds  Patients Must Be Able To Leave  ED MD Must Be Available  Appropriate ED MD Staffing

Treatment &/Or Evaluation:  Treatment  Laboratory Tests  Medical Imaging Studies  Consultation for Admitted Patients ED Process Improvement Committee

Moving to the Next Level:  Receive Admitting Orders, then…  Additional ED Orders  Call For Bed (Next Level Of Care)  Bed Assignment  Inpatient RN Staff Available to Receive Report  ED Staff Available to Move Patient

Moving to the Next Level:  Exit Phase:  Begins With EDMD Decision To Admit  Ends With Patient Exit From ED  minutes January – August 2008  39-47% of LOS

Exit Phase: Study Intervals How long did it take to receive orders?  Consult Interval  [EDMD Decision to Disposition] to Admit Orders Received (AOR)

Exit Phase: Study Intervals How long after AOR did patient leave EDTB?  ED Inpatient Admit Interval  AOR to Exit (ED bed available)

Exit Phase Study: May – September 2008 May 2008June 2008 July 2008Sep 2008 Total # Admissions Admission Rate23.05%23.41%24.42%23.54% Admit Record Compliance 51.67%54.15%53.81%55.32% Total # Compliant Records Average Consult Interval (min.) 86 (1-1360)90 (0-1376)92 (0-2391)110 (0-1467) Averaged minutes just to get admit orders Haven’t even called for a bed. (Practice & provider-specific data available)

Results- Consult Interval

Results- Inpatient Admit Interval (additional studies in progress)

ED Metrics Admitting (Non-ED) physicians

Average ED Consult Intervals May-July 2008 Practice# Admits A696 B245 C202 D105 E92 F72 G63 H50 I49 J41

Selected Average Consult Interval May – July 2008 (EDMD Decision to Disposition to AOR*) *AOR = Admit Orders Received

But… Admitting Strategies

Cardiology- Average Consult Interval May – July 2008 (EDMD Decision to Disposition to AOR)

Cardiology Admissions Significant variation in consult intervals exists between cardiology practices. Two of three cardiology practices, Practices “A” and “C,” account for 22.7% of all ED admissions. These practices almost exclusively admit only following consultation and evaluation in the ED. Practice “B” routinely phones in orders and evaluates the patient on the floor if they left the ED by the time they arrive. This is reflected in patients’ consult intervals and LOS:

Cardiology- Average ED LOS May – July 2008 (EDMD Decision to Disposition to AOR)

In Progress:  Medical Staff Admit Strategies  Staffing Changes and Allied Health Professionals  EDMD Calls For Bed  Admit Holding Area

Summary  Introduction  Kennestone Emergency Department  Metrics  More Metrics- Exit Phase  Even More Metrics- Non-ED Physicians  So far…

Questions? Contact Information: Jon Morris, MD, FACEP, MBA WellStar Health Systems