HIMSS Davies Enterprise Application Submission Form
Hilo Medical Center – End-user Efficiency Menu Case Study
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Hilo Medical Center
1190 Waianuenue Avenue, Hilo, HI 96720
Money Atwal
CIO & CFO
matwal@hhsc.org
End-user Efficiency
Executive Summary
Various information systems, applications, and enhancements at Hilo Medical Center (HMC)
have led to an increase in end-user efficiencies. The Emergency Department (ED) has decreased
the length of stay by 39% and increased patient volumes by 13 %. An increase in all Imaging
modalities patient volumes by 11% also occurred. Simultaneously, the hospital’s Press Ganey
patient satisfaction scores were maintained during this period of ED and Imaging technology
growth.
In 2009, HMC went live with a picture archival and communication system (PACS) allowing the
Imaging Department to store, display, and interpret the imaging studies electronically leading to
a decrease in exam to interpretation times. The following year, the electronic health record
(EHR) system was implemented. The EHR provided tools to assist in improved coordination of
patient admits and real-time patient tracking throughout the facility. In the ED, enhancements
made to the tracking board with links to orders, results and admit status now provide the tools
end-users require to accomplish their day-to-day responsibilities efficiently. In the years
following the EHR implementation, additional ancillary systems (e.g., GE Muse and
PowerScribe 360) contributed to an increase in patient throughput, as well as, further decreasing
turnaround times between requested exams and final results reporting.
1. Background Knowledge
Hilo Medical Center belongs to the East Hawai’i Region of Hawai’i Health Systems Corporation
(HHSC). It is a 276-bed facility servicing the Island of Hawai’i and boasts one of the busiest
Emergency Departments in the state. HMC’s mission of “improving their community's health
through exceptional and compassionate care” is a constant reminder and driver toward making
improvements in ancillary technology, as well as, the EHR to achieve the exceptional care goals.
Patient flow and throughput can have both positive or negative effects on patient satisfaction and
the level of care. If patient processes are properly coordinated, wait times can be decreased
leading to faster treatment and better outcomes. In conjunction, decreased wait times will
increase patient throughput allowing the facility to treat more patients while containing staffing
costs. Thus, instituting changes in areas like the Emergency, Admitting, and Imaging
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Departments to optimize patient flow and throughput is not only beneficial for the patients, but
the organization as a whole. In order to attain efficiency, consideration of the end-user
knowledge flow is instrumental. A 2014 white paper by Ian Chuang, MD, states, “Knowledge
must be provided at the right time, for the right individual, for the right decision, and tie together
with other decision points and decision flow along the entire care continuum.”i
2. Local Problem Addressed and Intended Improvement
Before 2009, Hilo Medical Center employed a manual process of printing imaging studies to
film, hanging the films for interpretation, and providing handwritten preliminary reports to the
Emergency Department. Generating a preliminary report could require up to 45 minutes prior to
reaching the hands of the ED physician, and 308 minutes for final report creation – only minimal
information was available for Stat exams.
Prior to the implementation of Hilo Medical Center's EHR in May 2010, patients in the
Emergency Department were tracked on a hand written white board. This static method of
patient tracking adversely affected patient flow. In some cases, patients would be moved to new
rooms without the white board being updated causing delays in tests and treatments as the patient
couldn't be found in the assigned room.
Patient admits to the acute facility were completed using a manual process. This process included
numerous phone calls between the admitting department, receiving department, and nursing
supervisor. Printed paper census reports were used to determine available beds, but only
provided a static view of bed statuses.
Delays in providing final reports for tests and exams to ordering providers led to a delay in
treatment of diagnosed conditions and patient wait times. These delays, in turn, had the potential
to increase patient's length of stays requiring additional resources to continue care. Decreasing
the turnaround times for final reports allowed ordering physicians to more quickly address
patient's diagnosed conditions and diminish wait times.
In each of the above scenarios, ways to minimize delays were examined and addressed. Also, in
each, a health information system (i.e., PACS, EHR, etc.) was tasked with creating a more
efficient environment that would positively impact patient outcomes.
3. Design and Implementation
Recognizing several areas played a large role in determining patient throughput, HMC focused
on creating more efficient end-user processes to accomplish specific tasks. The Imaging,
Emergency, and Admitting Departments were the most affected by the new workflows.
However, additional ancillary departments like Respiratory Therapy and Housekeeping were also
impacted.
A phased approach was utilized to implement the various workflow changes. Initially, the focus
was on decreasing exam and interpretation time within the Imaging Department. The following
year, improvements to Emergency Department processes were put in place to provide real-time
patient tracking, patient status updates, and notifications of results. In 2012, the entire admitting
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process was overhauled to eliminate unnecessary phone calls and streamline workflows. Along
with this work came additional vendor selections to align necessary ancillary services with the
EHR. Today, the improvements made in the ancillary arena resulted in creation of streamlined
interfaces to advance interoperability, not just for HMC, but the East Hawai’i enterprise; see the
architectural diagram of interfaces implemented in Figure 1.
Figure 1: Ancillary Interfaces Implemented to Enhance EHR Processes
4. How Health IT Was Utilized
With the implementation of Fuji PACS, the Imaging Department was able to electronically
display imaging studies for interpretation, as well as, provide typed preliminary reports for the
Emergency Department. Image transmission times from the modality to PACS were completed
in at least half the time taken to print hard copy images. Printing a single image would typically
take a minimum of 30 seconds while the transmission of a single image to PACS is completed in
one second. Extrapolating the data led to a minimum time savings of approximately 483 hours
annually. The impact of the PACS implementation to end-user workflows can be seen in Figure
2. The manual process of hanging studies for Radiologist interpretation was eliminated,
removing a delay in reading images of several hours. The Radiologists' handwritten preliminary
reports were replaced by typed notes, which could be generated within seconds and viewed
within PACS immediately upon saving the documentation. The typed written notes were
supplemented with “canned” text for frequent findings, further decreasing the time required to
generate a preliminary report.
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Figure 2: Pre and Post PACS Implementation Workflows
Within the Emergency Department, the implementation of the EHR allowed staff to use an
electronic tracking board to display patients, rooms, statuses, and result indicators. From a quick
glance at the status board, a staff member determines if the patient was currently in an ED room
and if they had been seen by a physician. Staff are also able to tell if orders have been placed for
laboratory or imaging studies and if these tests have been resulted. The real-time status board
provides staff with additional information regarding whether or not the patient needs to be
admitted and if so, the location and bed number assigned to the patient. The ED Tracker serves
to tie information from disparate systems together and present an overall comprehensive view of
the patient's conditions and status. For example, icons indicating pending or performed orders
display on the tracker. These indicators provide links to specific areas of the EHR which house
additional links to systems like PACS and GE Muse (an electronic storage, viewing, and
interpretation application for EKGs), as seen in Figure 3. Utilizing these links to access
information from the ancillary systems streamline the workflow for clinicians as they are no
longer required to launch another application and log on separately.
Figure 3: Emergency Department Tracker with Indicators for Imaging Status Updates
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During the admitting process optimization, the implementation of the MEDITECH Bed Board
was used to eliminate phone calls and provide a communication mechanism for all staff involved
in the process. A bed request is entered into the EHR for any patient being admitted. This bed
request is processed by the Admitting Department and the patient is assigned a bed. The Bed
Board provides real-time census data and allows staff to view how many available beds are on
each unit. The Housekeeping staff was trained to utilize the EHR’s Bed Board to identify and
track beds/rooms requiring cleaning, as well as, entry of information into the EHR to notify the
nurses of beds ready for new patients.
Implementation of GE Muse in 2012 decreased the time required to receive final EKG
interpretations, i.e., EKGs became immediately available in the EHR once read. Prior to the
implementation of GE Muse, EKG results were not available for extended periods due to manual
scanning into the EHR. IT implemented Nuance PowerScribe 360 in 2013 as a front-end voice
recognition dictation system for the Imaging Department. PowerScribe 360 resolved many of
the same turnaround time issues noted with imaging results, but for EKG results instead.
GE Muse and PowerScribe 360 workflows are presented in Figure 4. The implementation of GE
Muse decreased the reliance on a printed paper EKG strip by allowing them to be stored, viewed,
and interpreted digitally. Turnaround times for final interpretations decreased as this process
was no longer dependent on paper EKGs being hand carried from various locations to the EKG
reading room. In addition, the use of GE Muse enabled the final interpretations to file directly
into the EHR for immediate viewing by clinicians. The use of this system removed the need for
transcription services (equivalent to 3 FTE’s) by allowing Radiologists to generate final reports
using voice recognition. These final reports file directly to the EHR and are immediately
viewable by clinicians.
Figure 4: Pre and Post GE Muse and PowerScribe 360 Workflows
Pre-GE Muse Workflow
EKG performed
and printed
Printed EKGs
delivered to EKG
reading room
Cardiologist
completes Final
Interpretation of
EKG
Post-GE Muse Workflow
EKG sent to
Medical Records
for filing/scanning
in patient chart
EKG performed
and transmitted
to GE Muse
Cardiologist
completes Final
Interpretation in
GE Muse
Final Interpretation
files in Meditech
EHR (immediately
available for
ordering
physicians)
Pre-PowerScribe 360 Workflow
Radiologist
generates
handwritten
Preliminary Report
and Dictates Final
Report
Final Report
transcribed by
Transcriptionist
and sent for
signature
Radiologist signs
final report
Final Reports
printed to Imaging
Department printer
One copy of Final
Report filed into
patient’s imaging
jacket
One copy of Final
Report sent to
Medical Records
to be filed in
patient chart
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Post-PowerScribe 360 Workflow
Radiologist
utilizes
PowerScribe 360
to dictate and
sign Final Report
5. Value Derived/Outcomes
Final Report files
into Meditech EHR
(immediately
available for
ordering
physicians)
Figure 5: Imaging Studies Volume and Pt. Satisfaction Scores
Over the last few years of implementations
of the various systems and applications,
improvements have been made to end-user
efficiencies. The use of real-time status
boards like the ED Tracker and Bed Board
allow for improved patient tracking and
streamlined coordination of patient flow.
These status boards, along with additional
systems like PACS, GE Muse, and
PowerScribe 360 have also led to more
seamless patient throughput. This can be
evidenced by examining past and current Imaging Department study volumes. Pre-PACS study
volumes were approximately 50,000 studies a year. Following the PACS and PowerScribe 360
implementations, the annual study volumes were over 59,000. Despite the increased volume,
Press Ganey Patient Satisfaction scores for “Waiting Time for Radiology Tests” in ED
remained essentially the same at an 84-point mean score; see Figure 5. These additional 9,000
studies equate to a minimum increase of $2 MM in chargeable services, and were accomplished
without an increase in staff. In the current economic climate where everyone is trying to do
more with less, the ability to increase the number of patient exams performed without increasing
staff resource expenditures or decreasing patient satisfaction is significant.
The ability to achieve rapid results was
Figure 6: PowerScribe 360 Final Report Turnaround Times
also essential to accomplishing HMC’s
Pre and Post Implementation
efficiency goals. In 2008 with only
Dictaphone usage, report turnaround
times were at an unacceptable 72 hours.
With a new RIS and continuing
Dictaphone transcription services, times
still remained elevated. The activation of
PowerScribe 360 truly accomplished the
efficiencies HMC was seeking. The
PowerScribe 360 application eliminated
the need for reports to be dictated then
transcribed prior to being signed and
finalized. Turnaround times for final
reports decreased from 308 minutes prior
to implementation to 5.5 minutes in September 2014; see Figure 6.
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Further, during the discovery phase for PowerScribe 360 HMC identified multiple areas of
improvement for radiologists, technologists and support staff. These improvements include
the optimization of ultrasound paper processes and the creation and implementation of a
Critical Test Result Management (CTRM) integrated system.
HMC strived to eliminate the use of transcription or editing services upon PowerScribe 360's
implementation, the last processes reliant upon paper was ultrasound worksheets with
multiple exam measurements. Historically, transcription services typed these values into the
document for the Radiologists. HMC designed templates for the ultrasound exams
measurement values to be entered directly into PowerScribe 360 by the technologist during
or directly after the exam is performed. Upon opening the study in PowerScribe 360, the
Radiologist review the entered values for accuracy prior to completing their interpretation.
The optimization of this workflow eliminated the technologist's use of manual paper
documentation and the need for Radiologist transcription or editing services.
The CTRM process created by HMC integrated the technologies of PowerScribe 360, EHR,
and wireless communication systems. Upon review of an examination, the Radiologist now
has the capability to mark an exam "Call and Confirm" within PowerScribe 360 to request a
phone call to the ordering physician for confirmation and receipt of the report. When the
"Call and Confirm" field is selected, an alert is sent to a designated Imaging Department wifi
telephone and a "CTRM/Call and Confirm" task is created in the EHR. Staff have been
trained to log four attempts to call and confirm the report with the referring provider. If the
confirmation is not obtained after the fourth attempt, the Radiologist is informed of the
failure to confirm the report and determines if further action is necessary. The CTRM
process enhances patient safety, increases communication, and improves provider
satisfaction.
Other benefits realized due to the implementation of improved efficiencies saw a decrease in
the length of stay in the ED, as well as, an increase in ED volumes. From 2011 to 2014, the
ED average patient length of stay decreased by 39% while ED volumes rose almost 13% for
the same time period; see Figures 7 and 8. The ED Press Ganey Patient Satisfaction scores
did not decrease during this period of change and remained in the mid-80 range. This is a
testament of doing more with less, and at the same time accomplishing the least disruption to
the patient’s hospital experience.
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Figure 7: ED Average Length of Stay in Minutes
Figure 8: ED Visits Volume
Integrating the ancillary systems with the EHR has provided readily accessible views of
information in one location for our physicians and clinicians across the geographic area. For
example, the RIS image can be seen a click away from the EKG tracing and their associated
reports; refer back to Figure 3. HMC is also now capable of sharing results across multiple
organizations and providers via the Hawai’i Health Information Exchange (HHIE) secure
messaging process.
6. Lessons Learned
Continuous Improvement Cannot Stop
While the current state of the systems and applications used to improve end-user efficiency,
knowledge flow and patient throughput are working effectively, the organization continues to
look for opportunities for improvement. In an effort to take advantage of new opportunities,
existing processes or workflows may be revised. System improvements are requested by endusers, hospital administration, or clinical analysts. All proposed changes require change control
approval from the integrated / Operational Review Forum (iORF) which convenes weekly.
In the case of the ED Tracker, the layout and notifications contained have been revised numerous
times in the attempt to provide the most important information in the most efficient way.
Additional status notifications have been added to notify staff of resulted exams or tests and
columns have been rearranged to allow the most pertinent information to be easily viewable.
The Bed Board has also undergone several revisions in order to provide better communication
with affected staff. Bed statuses have been eliminated to streamline the workflow of preparing
the room for a new patient and unit descriptions have been edited to eliminate confusion.
Driving End-User Adoption
Implementing PowerScribe 360 was not an easy task for the Imaging Department and the project
team. In order to address the Radiologists concerns, an initial project kick-off was hosted by the
Project Manager to include all stakeholders and in particular the Radiologists. Project goals,
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workflows, and timelines were presented in the kick-off along with project expectations.
Throughout the project "Radiologist Acceptance" was a constant category of attention with an
adjusted mitigation plan as the project progressed. Salient themes emerged though evaluating
Radiologist acceptance to include elbow-to-elbow training, custom templates, and a strategy to
train in the live environment rather than spending time training in the test environment.
Communication with the radiologists and Imaging staff was clear and constant during the
PowerScribe 360 project. Timelines and milestones where identified and celebrated when
reached. Risk management was also continuous throughout the project lifecycle, as each risk
was paired with a mitigation plan and a contingency plan. A final 30-day post live review and
transfer to operations was conducted with the Radiologist and stakeholders to formally transfer
the product to the operational owners and to evaluate ongoing adoption levels.
End-user Education and Training – Ongoing
An extensive amount of end-user education and training may be required to ensure all workflow
improvements are performed correctly. In some cases, re-training may be needed to assure all
staff members are following the appropriate processes.
HMC is currently holding re-training sessions for GE Muse. It was found some end-users were
not following the designated workflows, which was leading to delays in ordering physicians'
receipt of the final EKG reports.
7. Financial Considerations
Implementing information systems can require significant financial investment. Even so, the
RIS, PACS and other ancillary systems noted in the case study and the EHR was funded with
operational dollars. The return on investment (ROI) leads to substantial cost savings over time
and improved patient care outcomes. As patient and clinical knowledge workflows are optimized
through the utilization of the information systems, the organization is able to effectively treat
more patients without needing to hire additional staff. This allows HMC to keep employee costs
fixed while increasing the potential revenue.
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Figure 9: Pre and Post PACS Implementation Cost Comparisons
The HMC PACS provides an example of a system that contributed to improved patient
throughput while also leading to cost savings. Film costs associated with printing hard copy
images had increased annually until the implementation of the PACS. In 2008, the HMC
Imaging Department saw its highest expenditure of over $300,000 annually for film. From 2009
to 2013, the department was able to reduce the amount spent on film creating an overall savings
of approximately $390,000 despite the added annual cost of the PACS; see Figure 9. Overall,
HMC is on a productive path toward accomplishing revenue, and most importantly, patient goals
with the efficiencies put into place to assist its end-user community.
i
Chuang, Ian, MD, F.C.F.P., CMO, October (2014), “Transforming the EHR into a Knowledge Platform to Ensure
Health and Healthcare”, a Netsmart white paper
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