CASE STUDY 7 **** WHAT DID YOU LEARN FROM THE CASE STUDY? ( ****basically just summarize what the case study is about)
Transforming the Clinical Process at Farmington Endoscopy Center William C. Kinney
Transforming the clinical work process in healthcare is not going to be a simple task, as many of today’s work solutions are rooted in decades-long and even century-old autonomous and hierarchical structures. As mentioned in the chapter, Paul Starr’s The Social Transformation of American Medicine explained how US healthcare evolved into a system that separates the business side and clinical side of care delivery. Separating the two functions ultimately created two diverging approaches, leaving the patient caught in the middle. Regulations from both the insurance industry and federal government are trying to bring the two sides together in the interest of what is best for the healthcare system as a whole.
The IOM’s reports on medical quality highlighted the inefficiencies and mistakes that resulted from the increased complexity of healthcare. Although IT exists to change the system, it has lacked the leadership and skills needed to bring about a redesign that, in turn, could transform existing processes and structures. The IOM reports and subsequent analyses have highlighted IT as a tool to improve quality and efficiency. Clinical decision support system (CDSS), in particular, has been identified as a priority health IT, as it pushes evidence-based health recommendations that lead not only to better clinical processes, quality, and outcomes but also to lower healthcare costs. The challenge in adopting CDSS is determining where and how to apply the evidence.
This case highlights the use of health IT to transform the clinical and business processes. Readers should take note of who the relevant players are, the information needs in care delivery, and the method of leveraging information to make care delivery more efficient and effective.
Farmington Endoscopy Center
Farmington is a Midwest college town with a population of more than 100,000 and a large and productive medical community supported by a local medical school. The medical community serves not only the residents of Farmington but also the residents of the surrounding rural communities, some of whom drive more than two hours to get to their respective clinic or hospital. The limited number of primary care physicians who work in rural settings, lack of supporting facilities, and varying socioeconomic backgrounds all add to the complexities of rural medicine. Rural communities also have few manufacturers and corporations that hire employees and provide employer-sponsored, private health insurance. This leaves many rural patients no choice but to enroll in government- supported healthcare programs. Farmington Endoscopy Center (FEC) is a freestanding, physician- owned endoscopy facility that serves both adult and pediatric patients. The main procedures—esophagogastroduodenoscopy (EGD) and colonoscopy—are performed by six gastroenterologist (the owners). Last year, it completed almost 5,000 cases, and this year it is anticipating a 5 percent growth in volume by adding a new physician. FEC is owned and managed by the physicians, but a full-time administrator is in charge of day-to-day operations, compliance with state and federal safety/account- ability standards, billing and collections, and staffing. Rounding out the staff are eight nurses, four receptionists, one billing specialist, and one certified registered nurse anesthetist (CRNA).
Patients are referred to FEC for an endoscopy procedure by the six physicians, each of whom runs a separate outpatient clinic, or by independent primary care or specialty physicians. The independent primary or specialty care physician assumes patient-management responsibilities for the results of the endoscopy, so the gastroenterologist who performs the procedure is essentially a technician whose responsibility to the patient ends at the completion of the procedure. Both EGD and colonoscopy are not painful, but they are uncomfortable and thus require sedation. Administered by the CRNA, sedation techniques range from applying topical anesthetic to running an intravenous line of light anesthesia (where the patient stays awake and can communicate) or a heavy dose of anesthesia (where the patient is unconscious and could stop breathing and may need respiratory support). The CRNA is licensed by the state but cannot act as an independent provider and must be under the close supervision of the gastroenterologist. Throughout the procedure, the gastroenterologist is ultimately responsible for the patient’s well being.
Areas of Improvement
Susan Michaels, the FEC administrator, is reviewing last year’s reports to find ways to increase volume. Both private and public insurance have changed their rules, resulting in lower reimbursements. Meanwhile, healthcare costs continue to rise, further cutting into profits. Needless to say, the FEC physician owners are concerned. Susan identifies two problem areas in the reports:
1. The center has a day-of-procedure cancellation rate of 8 to 12 per- cent. These patients show up for their scheduled procedure only to be cancelled by the clinic because of some factors that were not known before their arrival. The top-five factors are blood-thinner usage, unidentified cardiovascular risk, failure to adhere to NPO (latin for “nil per os,” which means no food or drink hours before a procedure), improper guardianship, and lack of bowel prep.
2. Regulations have doubled the amount of required paperwork to be completed for each patient. Explanation of patient rights and privacy policies, medication-reconciliation process, deep venous thrombosis evaluation, and complication reporting are just some of the tasks or forms that must be completed before a case can be closed. The planned addition of another physician to the practice would increase the number of cases, exacerbating the paperwork problem. Susan is considering hiring another nurse to help the existing staff with the workload, a move that would enable the FEC to accommodate more patients and complete the paperwork quicker. Fortunately, Susan just returned
Fortunately, Susan just returned from a health IT workshop that presented a new logic and tools for how to define the dimensions of a problem and derive workable solutions.
Information Needs
Evaluating and managing patient health needs is about acquiring information and making a decision based on that information. A wise physician once stated that 90 percent of the information a physician consults to arrive at a diagnosis is contained in the patient’s medical history. Much of today’s health IT efforts pay attention to the physician’s information needs for two reasons: (1) The doctor is ultimately responsible for health- care evaluation and management, and (2) the doctor gets paid based on a certain level of information she gathers. A careful review of current EMRs shows that information is maintained in vertical silos or “buckets” and based on billing and collection needs. Information is compartmentalized and cannot be shared easily among all players in the care delivery process. Compartmentalization also hinders the use of the information and masks the time-sensitive value of that information. Time, in this case, is chronologic and pertains to information that must be gathered and acted upon before an event.
In the case of scheduled procedures, decisions need to be made days before the encounter. Anticoagulation therapy, for example, is information that must be relayed before a patient’s appointed surgery or intervention. Appropriately managing anticoagulation is not necessarily straightforward, and a new healthcare player (e.g., a cardiologist) may need more information or guidance. CDSS can ensure that relevant patient information, research evidence, and best practice are available at the right time, a system that is infinitely valuable to a freestanding endoscopy center or ambulatory surgery center.
Information Gathering Process for an Integrated IT
Susan decides to use IT to address FEC’s two problems. She identifies the information needs of each player (i.e., physicians, CRNA, and nurses), and then she breaks down the problems into components to better under- stand the clinical processes and find ways to integrate them to improve efficiencies and patient satisfaction. The ultimate goal is to create a sophisticated data-capture and management IT with an integrated CDSS. The steps she takes are as follows:
1. List each team member involved in an endoscopy procedure. Does the team composition change according to who initiated the patient referral? What steps do the physicians follow to refer patients to FEC? The referring physicians’ information needs must be considered so that a better request-for-procedure ordering process can be developed.
2. List the information needs of each team member, including the supporting players who perform billing, collections, and other administrative tasks. Here are a few examples of these needs:
- The gastroenterologist needs to know why the patient is there. Is this a screening colonoscopy because of a family history of colon cancer? Is this a patient with anemia and guaiac-positive stools?
- The nurse needs to know if the patient had surgery in the last 30 days, as this increases the patient’s risk of deep venous thrombosis. The nurse also needs a current list of medications to complete the medication-reconciliation process.
The CRNA needs to know if the patient is taking an angiotensin- converting enzyme inhibitor. Current recommendations are for patients to not take this medication on the morning of a procedure. The CRNA must know the patient’s cardiac history and be able to identify potential risk factors that would affect the patient’s choice of sedation.
The referring physician needs a system for telling the FEC gastroenterologist, nurses, and CRNA information on the patient, including tests, medications, and risk factors, that could affect the patient’s ability to receive the procedure on the day it is scheduled.
Scheduling needs to know which patients are scheduled for what procedure and how long the procedure is estimated to take. Scheduling staff is responsible for reminding the patient of the appointment time, date, and any preparation (such as the NPO).
Registration needs to know the patient’s demographic and social status. Is the patient a minor? Who will be present to sign the consent? If the child is in foster care, does FEC need to obtain a court order to do the procedure? If the patient is an adult, is he of sound mind and body, or does he have a legal guardian?
Procedure room nurses need to know the capability of supplies and equipment to meet the needs of the patient. Is the patient wheelchair bound, and if so, should more time be added to the schedule? Does the patient have an artificial joint, as this will affect where the electrocautery-grounding pad is placed?
Construct a timeline of the information needs across the encounter. Identify overlapping information needs between players.
As a final step, Susan determines the time component of each information need to ensure that it is available at the appropriate time, which could reduce cancellations. Susan considers available consumer technology, such as the Internet, smart phones, and apps, to enhance the IT option. Susan also looks into outsourcing.
A successful health IT solution for FEC results in a significant reduction in cancellation rates and in a faster or same-day completion of the administrative, regulatory, and nursing paperwork. Such improvements enable FEC to schedule more patients and complete more procedures.
