IMPACT OF HOSPITAL INFORMATION SYSTEMS ON EMERGENCY PATIENT PROCESSING

JAMES E. RUSNAK
WASHINGTON HOSPITAL FREMONT, CALIFORNIA
Abstract
The Emergency Department offers the Hospital Information System's designer some unique problems to solve in the operational areas of patient registration, order entry, charge recording, and treatment processing. In a number of instances, Hospital Information Systems implementers have encountered serious difficulties in trying to design system components to support the requirements of the Emergency Services Department's operations. Washington Hospital has developed a very effective system for Emergency Services. The system's features are designed to meet the special requirements of the department and to maximize the use of the data captured by the Hospital Information System. The system supports accurate and timely charging for services. The treatment of the patient has been dramatically improved through the use of a computerized order processing and control. The installed systems resulted in a higher quality of care and cost effective operations.

processing capabilities.
Patient Control (Tracking) Board Prior to the implementation of the Hospital Information System, several manual procedures were introduced to improve the efficiency of the Emergency Services' operations. One such change was the implementation of a Patient Control (Tracking) Board and support procedures. One problem that many emergency departments have is knowing the location of a patient during the period of the diagnostic and treatment process. It is a common practice in many hospitals to have the X-Ray Technician or Lab Phlebotomist ask a nurse "Do you know where patient John Smith is?" and get the response "I don't know, check with Nurse Jones in Minor Treatment Room #3. She may know." At Washington Hospital, a magnetic patient identification label is prepared for each patient when the patient is triaged (the first stage of the patient encounter). The label information contains the patient's last name and first name initial. If the patient is to be seen by a staff physician instead of an Emergency Services Department physician, the staff physician's name is also entered upon the label. The label is attached to the patient chart clipboard, along with the registration form with recorded vital signs, by the Triage Nurse. The patient is then registered, and the registration form with computer printed patient and guarantor information added, and an industrial injury report form when it is required, is attached to the chart clipboard. The patient is next taken to a treatment room from the registration area, when the nurse places the patient's identification magnetic label on the Patient Control Board in the area designated for that treatment room. The board is magnetic and outlines the physical layout of the Emergency Services Department. It also contains separate areas for placing labels to denote patients located in areas other than treatment rooms, including the Waiting Room, Radiology Department, etc. The board is centrally located on a corridor wall in the department, and can be easily viewed by the nurses, physicians, and clerks from the Energency Services Nursing Station and charting work station. Refer to EXHIBIT I for a diagram of the layout of the Patient Control Board, a 3' x 5' magnetic board with a white surface. As the patient is moved from one location to another, the patient's label is moved to denote the new location. The procedure is continued until the patient is admitt-

Background
Washington Hospital's Emergency Services Department treats from 3800 to 4500 patients per month--a significant number for a 265-bed hospital. The Hospital initiated a systems project in 1976, when it began to experience the growth in the volume of emergency patient services, which grew significantly from the current level of activity. At the time of the inception of the project, the Emergency Services Department's physical facilities were being expanded to prepare for the anticipated rapid growth in the population of the community. During the next two years, the new facilities were opened, an online Hospital Information System was installed, and significant changes occurred in the information processing systems, forms, and departmental procedures used in patient processing. At this time, Washington Hospital is recognized as having one of the leading Emergency Services Departments in the San Francisco Bay Area. Its Emergency Services Department systems have served as a model for other hospital system installations. This paper will describe some of the forms, procedures, computerized information and manual system functions, and problem solving techniques, which are used to achieve the current level of patient

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ed to the Hospital or discharged and leaves the department. The Patient Control Board is used by the Hospital staff physicians to locate their patients; by ancillary department personnel; and used by the emergency physician to monitor the department patient workloads. The Patient Control Board is relatively simple to operate, but does require all personnel to maintain its accuracy by moving the patient label when a patient is moved to a different area in the department or to a location outside the department. The Patient Control Board has been highly successful in its continuing operation for over fouryears and has eliminated the problem of department staff and persons outside the department locating the patient for rendering services. A back-up board is maintained, since the board's markings become badly worn after six to eight months of use and requires another board to be in place while the worn markings are being re-touched. The department is so dependent upon the board that one must be available at all times--a testimony to the effectiveness of the Hospital's patient tracking procedure.

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Hospital Information System Implementation

There are a number of approaches that one can take in the implementation of a Hospital Information System. Data collection and order entry are important elements in a Hospital Information System. The proper implementation of these functions permit significant improvements to be made in the Emergency Services Department's operations. Perhaps some of the decisions that we made in our implementation strategy would apply to your Hospital Information System implementation as well. When considering the various areas of the hospital in which to implement the Hospital Information System, the Emergency Services Department proves to be one of the most difficult because of the very nature of its operations. Yet, it is one which can benefit the most from the capabilities available in the system. Paperwork and administrative procedures are difficult to maintain, especially during periods when several major trauma patients are in the treatment process. Demand levels for service can vary greatly. Many

be the first area of implementation. If you consider it, the Emergency Services Department is in many regards just another nursing station in the Hospital. As in the regular nursing units, the Emergency Services Departnent does have a nursing station which operates in providing patient services in a manner similar to inpatient nursing stations. From this nursing station are initiated orders for services to be performed by the various ancillary departments in the hospital, such as the Laboratory and Radiology Departments. Because the department deals with emergency cases, most activities are on a high priority basis and must be completed in the shortest possible time. One of the problems in installing a Hospital Information System is to be sure that the system functions in a manner which results in these response times of various ancillary support activities being improved, rather than lengthened. If the latter takes place, of course, it reduces the effectiveness, timeliness, and quality of patient care. By implementing the Emergency Services Department first, we were able to validate some of the aspects for ordering services that would be done at the inpatient nursing units, but at a much larger volume of orders and types of services ordered. However, not all aspects of these automated procedures were tested during our Emergency Services implementation. Some problems did develop with certain types of orders for services when we implemented the system in the inpatient nursing units, but the problems were minor in nature. This is due in part to the fact that in the Emergency Services Department only a limited number of ancillary department services are utilized when compared to those used for inpatients. When the Hospital Information System was installed in the Emergency Services Department, both registration and order functions were implemented at the same time. All ancillary departments' orders for diagnostic and treatment services were implemented concurrently to avoid using dual ordering procedures within the Emrergency Services Departnent. Some of the principal system functions available in our Hospital Information System, which are used in Energency Services, will be discussed now. Forms
Desim

computer systems have not been responsive to the problems found in the department. Many of the patients seen in the departrent are transient, with little or no identification information available on them. For this and other reasons, we find that the Energency Services Department is usually left to the last phase of the Hospital Information System's inplementation because of these complications. Sometimes this department is either not implemented at all or supported by the system in a very 1imited manner. In our particular case, we felt that since there were a nunber of complex issues to be resolved in implementing the Hospital Information System in the Emergency Services Department, that this department ought to, in fact,

In developing the desigi for the customizing of the Hospital Information System programs which are used in the registration of patients in the

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Emergency Services Department, it was decided to use the hand-fed type forms instead of continuous forms for patient registrations and billing documents. It is our opinion that the zip-set type of forms construction, which have the pages and carbon (when present) attached to a stub at the top of the form, are far superior in terms of forms handling than the forms that result from the use of continuous forms construction. In addition, by using the hand-fed forms in the system's remote printers, each of the three registration printers in the Emergency Services Department can be used to print a patient Registration form, to print a Doctor's First Report of Injury form, and to print the patient's bill, utilizing the same printer device at each work station. This obviously reduces the hardware costs associated with such a system installation, as well as providing a high degree of flexibility in the system functions that can be performed at each computer terminal station. This same approach was also made at all Outpatient Registration work stations located in other areas of the Hospital, where only one remote printer is used in each location.

the patient's disposition and any work related instructions, and the physician's signature. This is one example of utilizing the data collected during the patient registration process to be used
to prepare several different types of documents required in the patient treatment, and in reporting the patient's diagnosis and treatment information to the insurance carriers, government programs, health agencies, and to meet other reporting requirements. This particular feature of the system saved about 1 to 1 hours of clerical time per day, and reduced the time to initiate an industrial accident claim by one working day.

Patient Registration and Chart Form

Doctor's First Report of Injury

The Doctor's First Report of Injury is a form that is utilized in the billing for industrial accident cases. Because the Hospital services an area that has several major manufacturing plants, approximately 25 patients per day are seen in the Emergency Services Department who have incurred industrial-type accident injuries. The Doctor's First Report of Injury form was, prior to the time the system was installed, a one-part form provided by several of the industrial accident insurers. For each report, a three-part set was manually assembled, with carbon paper, and typed. The medical information was handwritten on the form by the attending Emergency Services physician. When completed and after being sent to the Business Office, the form was distributed, as follows: One copy of the form was sent to the Insurance
.

As previously mentioned, the system prepares a Registration form for each patient seen in the Emergency Department. The form contains medical record-type pages and two charge-type sheets. To obtain the best legibility of the handwritten treatment information, paper with carbon coating on the backside was used for the Medical Record copies. Many constructions of various paper, carbons, and carbonless forms were examined, tested, and evaluated before this choice was made. The Registration form is a combination of a patient's chart, consent for treatment, discharge instructions sheet, and a record of departmental

charges.
Patient Registration

The system has many patient registration features which are comnonly found in many Hospital Information Systems, such as the ability to copy certain information that has been previously entered if it applies to a field that is being entered. The system provides the flexibility of using prompted CRT displays to enter in the required information. For example, if the patient is also the guarantor, this entire screen of information can be copied from the previously entered patient information. Such techniques greatly reduce the time required to enter the required registration information--especially critical in the Emergency Services Department. One interesting feature of the system installed at Washington Hospital is that when a patient is seen in Emergency Services for the treatment of a laceration or some other kind of injury that will require more than one visit for the treatment, the patient's demographic and occasion of service information is retained in the system for up to 15 days. This 15 day limitation is due entirely to the physicial limitations of the disk storage space we have currently available in our Hospital Information System hardware configuration. When the patient arrives for his subsequent visit, the Registration Clerk is able to recall all of the information that was previously entered on the case, and only a few items of information need to be changed for the subsequent visit. This feature allows the department to register a patient returning for a revisit and print the patient's Registration form in less than 30 seconds; whereas, in the initial visit it will normally take 3 to 3 minutes for registration. This, of course, is

Carrier. One copy was retained in the patient's account folder. One copy was sent to the State Department of
Labor Statistics.

Subsequent changes to the industrial accident regulations no longer require copies of each Doctor's First Report of Injury form to be sent to the State, except for those cases which have potential impact insofar as exposure to special chemicals, and other special types of accidents which are of immediate concern to the State. In many cases the third copy is now being sent to the patient's employer. The Doctor's First Report of Injury form is normally prepared when a patient is registered. The form is attached to a clipboard and accompanies the patient, along with the Registration form, into the treatment area. The only information that remains to be completed on the computer prepared form is entered by the physician. This information includes the doctor's findings, a description of the patient's treatment,

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a tremendous benefit in avoiding any delay in moving the patient into the treatment area for services. The Registration Offices of the Emergency Services Department are not in close proximity to the nursing station where the Control Register is maintained and where most telephone communications are received. The Control Register is designed to meet the State's requirement. Whenever a patient is registered in one of the department's Registration Offices, a Notice of Registration is printed on the nursing station's remote printer. The printer uses a specially designed continuous form to support the printing of several types of documents. This capability allows the clerk working at the nursing station to receive a record of the patient's registration immediately upon entry into the system and to record the information in the State required Emergency Control Register in a timely manner. The Control Register, by State requirement, has to be a bound document and as of this time we have not allocated the time to develop a more fully automated approach to this record keeping function. Any change may require some sort of change to the current provisions of the State law or in its interpretation. We are not highly motivated to do this, since the current system works reasonably well. The important point is that the patient information is recorded at the earliest possible time so that the nursing station, which receives most of the telephone calls on patients, is aware that a patient is in the facility. During the time the patient is being treated, the Patient Control Board is used for this purpose, and to some degree denotes the progress of the patient's treatment. The Emergency Department also has the capability of admitting patients to the Hospital from its CRT terminals in the registration and nurse station areas. The Emergency Services Department enters in all of the additional required patient information, with the exception of the actual room and bed a patient is to be assigned. The actual bed assignment for the patient is made by the Admitting Clerk in another area of the building, following a message from the Emergency Services Department requesting completion of the patient admission.

entered into the system, the person entering the charge must identify themself. A notice is printed at the nursing station which provides a printed record of each and every physician charge entered into the system. A copy of these printed notices is retained by the emergency physician group, providing a detailed record of the physician services of each group's member in the Emergency Services Department. These notices are used as key documents in the reconciliation of Hospital payments to the emergency physician's group for physician services provided at the Hospital. A special daily report is also provided to the emergency physician's group, listing the patients seen by each physician, and the treatment and charges for those services. One of the charge sheets attached to the Registration form is used for recording physician charges and the other to record department charges. These charges are subsequently entered into the Hospital Information System when the patient is discharged or a short time thereafter. When the decision is made to prepare a patient bill, then the charges would be keyed into the system at the time of the patient's discharge from the department and a bill for service can be presented before the patient leaves the facility. The Hospital Information System provides several types of reports on the entry of patient charges (as well as other types of information

entered):

A special notice is printed on the nursing station printer whenever a physician charge is entered, as previously described. A copy of this notice is given to the Emergency Services Physician, one copy is given to the group under contract to provide the service (as noted above), and one copy is retained by the Hospital to substantiate the payments for services to the emergency physician's group. All Emergency Services charges result in a record of the charge being printed in a system Log Printer, located in the Hospital's Computer Room. A daily report is prepared for each service department, including Emergency Services, which provides detailed information on all

Patient Charges
As with most Hospital Information Systems, many of the charges actually result from the entry of patient orders for ancillary services. However, charges do have to be entered into the system for

such items as Emergency Room charge, special nursing procedures, pharmaceuticals dispensed, supplies used, and professional services. Charges of this nature do not directly relate to an order for service. One essential element in such a system is a commitment by all of the staff members
in the Emergency Services Department to enter all

patient charges as the service is performed. In the case of Respiratory Therapy Services performed on emergency patients, the charges are entered into the system immediately after the service is performed, using one of the Emergency Services CRT units. Whenever a physician's charge is

patient charges. A daily report is prepared which contains all of the charges for each patient seen and treated at the Hospital that day. These reports are routinely reviewed by the department management to insure that the patient charges are entered correctly. Sample audits are performed periodically, using the two patient charge sheets as the base documents. The patient charge records are sent to the Business Office on the following day for inclusion in the Patient Accounting audit files. The main objective in implementing automatic charging when a service is ordered is to minimize those cases when orders are not charged. In the case of outside Laboratory tests, the service fees are so structured so that almost all tests are charged at time of order. Those few cases where a variance may occur are not worth reverting from this method of charging to the previous method of charging after the tests are completed.

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This philosophy has to be administratively supported and encouraged. This policy of charging at time of order is essential if a bill at time of service is to become a reality. Summary
This paper has presented several systemderived methodologies in use at Washington Hospital in the Emergency Services Department. The systems in use in the department have allowed the department to support a significant growth in services without increases in clerical staff, provide accurate and timely charges for services, and improved some areas of patient care. As we look for future growth in Hospital Information Systems and other support systems, attention must be paid to the Emergency Services Department. In many hsopitals, this department plays a significant role in the hospital's overall operations, and must be an integral part of any Hospital Information System.

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