Automating Healthcare
Solving business problems with savvy automation
 


ADT Event Alerting

Business problem
When a patient is admitted to a hospital, the patient's attending physician must be correctly identified in the registration system. Getting this wrong creates rework, which has an adverse effect on both quality and cost of care. But our registration staff had no way to confirm that they were being given the correct attending when the patient was admitted. We needed a feedback loop to immediately correct any mistakes.

Who knows?
Most of the errors occurred with patients admitted through the emergency department (ED). This is predictable, because it can be difficult for the ED to verify who should be the attending for a particular patient, and ED physicians are under tremendous time pressure.

The first question was: "Who really knows whether the attending who was identified for a patient is actually the correct physician?" The answer was easy. Whomever is currently listed as attending will always know if they are NOT the attending for that patient, even if they don't know who IS the correct attending. So we needed a way for that person to confirm whether they were correctly assigned.

Getting the data
The first step was to get the data about admissions as they occurred. We were already assembling data on a daily basis in the data warehouse, but we needed to know about admissions as near to real-time as possible.

Bill began working on an automated process to pull all Admission / Discharge / Transfer (ADT) events from the Meditech system on a continuous basis:

  • An NPR report (Meditech's proprietary reporting system) extracts all recent ADT events to a file. These include:
    • inpatient admission
    • surgical day care (SDC) admission
    • ED admission
    • transfer between rooms, units, clinical services, or attending physicians
    • discharges (inpatient, SDC, ED)
  • The contents of the file are used to update a database, where any new or updated records are flagged for action.

This process runs in a continuous loop, with a cycle time of 10-15 minutes. This means that we know about any ADT event within 10-15 minutes of its being input to Meditech by the registration staff.

Alerting physicians
Using the ADT data, we created an automated process to send e-mail alerts to the attending physician and the patient's primary care provider (PCP). This automated process serves as a supplement to the regular clinician-to-clinician communication when patients:

  • are admitted into or discharged from an emergency department;
  • are admitted to an inpatient service;
  • are transferred from one location to another;
  • are transferred from one service to another;
  • are transferred from one attending or PCP to another; or,
  • are discharged.

This process also provides an opportunity to quickly correct erroneous PCP and Attending assignments, and to gather information to help improve sign-out processes.

How does ADT Event Notification work?

1. E-mail alerts

  • All clinicians receive e-mail notification via Outlook for any ED visit or inpatient admission, transfer or discharge when they are listed in Meditech as the PCP or the attending physician for that patient.
  • These e-mails are sent within 10 minutes of the event being recorded in Meditech.
  • The e-mails will have a subject line beginning with "ADT Alert" for easy sorting and filing within Outlook (sample below).

2. Pager alerts

  • Clinicians may "opt in"to be notified by pager of any or all of the above events.
  • Pager options may be set differently for any combination of event type, role, and paging option (shown below).

  • Pager options may be changed for a specified period of time, and will automatically revert to that clinician's "normal" settings at the end of the period.
  • Because this service uses the Xtend paging system, if a pager is forwarded or set to "Not Pageable" in Xtend, any ADT Event notification pages will also be forwarded or blocked, per the settings in Xtend.

3. Attending/PCP assignment corrections

  • Each alert includes e-mail link to notify relevant admitting department of corrections.
  • The newly-assigned attending or PCP will receive alerts as described above.

4. Reports
Each physician can view, in the intranet data portal, a list of all ED visits and inpatient admissions and discharges for which that physician was listed as attending or PCP during the past 30 days. These reports are currently as follows:

  • ED Visits Month to date
  • ED Visits Last Month
  • Discharges Month to date - attending
  • Discharges Last Month - attending
  • Discharges Month to date - PCP
  • Discharges Last Month - PCP
  • Detail ADT data month to date - attending
  • Detail ADT data last month - attending
  • Detail ADT data month to date - PCP
  • Detail ADT data last month - PCP
  • Current inpatient list (e-mailed daily, shown below)

An Acrobat document containing samples of all e-mailed alerts is available for download (1MB download).

Outcomes
Physicians loved this process. It has some huge benefits for them, including:

  • They know immediately when a patient for whom they are responsible has been admitted or transferred, and can ensure that care is coordinated appropriately.
  • They can immediately correct any mistakes with assignments as attending or PCP, and help ensure that the correct physician is assigned. Again, this helps ensure coordination of care.
  • They have a daily list of patients for rounding or follow-up.
  • PCPs know about ED visits immediately, and can follow up as appropriate with the ED physician or the patient.
  • They have direct, granular control of paged alerts, so they can decide whether and when to receive alerts via pager.

Although the initial blizzard of e-mails with corrections created some initial extra work for the admitting staff, immediate feedback about errors helped the ED and admitting staff improve the initial assignment process, resulting in far fewer errors and less rework.

This process was a major win for everyone — patients, physicians, admitting staff, and nurses (better information about who really is responsible for the patient). With the exception of the programming time, the process had no cost; it simply leveraged existing infrastructure to create a rapid, self-correcting, feedback loop. This process has been running continuously for several years without problems.

Lessons learned

  • Immediate feedback is much more effective in helping improve a process, because the person who makes a mistake is immediately made aware and learns how to avoid it in the future.
  • Engaging physicians in creative use of technology has powerful effects; this solution was the brainstorm of a physician who had been frustrated for years with this problem, knew of our work, and suggested the concept.


Posted 4 April 2008

   


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