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By implementing a process to convert results into standard electronic messages, health careinstitutions have the opportunity to significantly improve their bottom line, physician efficiency,and quality of care.

Introduction

Data drives clinical care, and the timely reporting of data to aid in clinical decisions is critical to both quality and efficiency. Hospitals in general, laboratories, pathology, radiology, and health information management (HIM) departments in particular, struggle to deliver results to providers in a timely and efficient manner. The current process, fragmented and expensive, focuses mainly on paper delivery and typically does not integrate with modern electronic communication and record keeping systems. Providers, in turn, struggle to manage the data that flows to them. Multiple sources have multiple formats and the delivery medium (paper and fax) does not lend itself to clinical or workflow automation.

One of the problems with failing to automate delivery is that clinical data is not homogenous:

• Some data is routine and needs to be accessed only when requested;
• Some data must be delivered as soon as it is available;
• Abnormal data has a different significance from normal data;
• Critically abnormal data requires a unique process;
• Most data items need to be delivered to multiple recipients;
• Data must be available at the time that clinical decisions are made;
• Some data requires confirmation of receipt;
• Some data needs editing or signature;
• Data providers must assure that data has been delivered to the appropriate recipient; and
• HIPAA now requires that access to data is recorded.

This complex maze of data delivery is complicated by varying expectations of providers. Some want paper delivery, others fax; some want delivery directly to local printers. And, an increasing number of physicians want data delivered electronically – to either manage online or deposit into an electronic medical/clinical record (EMR).¹ Electronic data needs to be accessible via the Web and formatted to accommodate PDAs and cell phones. To ultimately complicate the process, some result types (e.g. stat, critical) may need to be delivered by a different method from the final copy.

Hospital departments often have completely different systems for data generation and results distribution. Many hospitals have unique laboratory, radiology, and HIM data management systems. While these systems might link to a common hospital network, the resulting reporting is likely local to the department, which relies on a paper output with subsequent fax, mail, or courier delivery.

This lack of coordinated delivery is not only inefficient but precludes delivering data to physicians in a way that allows the physician to automate or otherwise improve their data management processes. For a physician with a busy clinical practice, the management of the flow of clinical information is time-intensive yet critical to making appropriate clinical decisions. The data should be available in multiple locations: office, ER, home, or hospital; and in multiple media: paper, electronic, PDA, or cell phone.

This paper outlines a solution for automating institutional results delivery, providing an immediate and significant return on investment for the hospital system and its affiliated providers. By centralizing data delivery across multiple hospital departments, an institution is able to reduce paper and mailing costs, assure reliability of data delivery, meet HIPAA requirements, and meet the needs for delivering different types of data (e.g. stat, critical) to providers needing data in different forms (paper, fax, Web lookup, electronic deliver, cell phone, or PDA).

Since the most efficient delivery of data is electronic, provider buy-in to receiving data electronically is critical. Key elements to move physicians to accept data electronically is discussed based on eight years of experience of physicians working with online data management.

Physicians need to know which data has already been reviewed. Since data management doesn’t stop with physicians, data delivery needs to include mechanisms to annotate the data and route to other members of the health care team with appropriate instructions.

In addition, as physicians attempt to automate their offices, they need data in a format that can feed their electronic systems. But, one of the major factors holding back the implementation of ambulatory EMRs is the ability to directly capture clinical data. Encounter-based data represents only about 20 percent of the clinical data that makes up a health record. For EMRs to take hold, laboratory, radiology, and other ancillary data will need to directly feed the ambulatory EMR. This will require ancillary data providers to solve the issue of format standardization and unique patient identification.

The resulting delivery problem isn’t solved with Web viewers linked into hospital-centric databases. Results need to be delivered in a format that allows the physicians to own and manage the data. The provider’s copy, whether electronic or paper, must exist in the physician’s private space and allow modifications by the physician, including annotations, signature, and editing where appropriate. Delivered documents should be routable with new electronic “copies” generated for other providers where appropriate.

The System Broken

In some hospitals, each department delivers their results; in other hospitals, copies of results pass through the HIM department for delivery.

When departments deliver results, the process is complex:

• The result is printed;
• The result is determined to be stat or critical;
• The order is reviewed to determine if copies are requested;
• Depending on the ordering and the nature of the result, a determination of how to deliver that result is made (some departments do this by relying on paper lists, databases, or the memory of staff members);
• Results are then called, faxed, or delivered by paper (courier or mail); and
• Some system generally exists for exceptions (e.g. unknown physician).

Since patients are typically active in multiple departments (e.g., laboratory, radiology, or HIM) the above system generates multiple duplicate deliveries. In some cases, physicians will receive separate mail from multiple departments on the same day.

The central model offers little improvement. One hospital studied had devised a complicated process of delivery and sorting of results. It worked slowly.²

• Results would come printed from the labs to the medical records department;
• Departmental full-time equivalents would then highlight the physician’s name with a marker and staple multiple pages together;
• Mailroom staff would come by at specified intervals to pick up the stack;
• If multiple names were on a result, copies were made for each physician;
• Once received in the mailroom, the mailroom staff was responsible for stamping the reports and sorting them – twice;
• Initially they would roughly sort by first letter; later, they would sort them alphabetically;
• Mailroom staff would then print labels for each report; fold, stuff, and label each envelope; and
• The envelopes would be sorted by weight and be pre-sorted.

With either model, there is no efficient way to electronically deliver the reports. Many hospitals mistakenly believe they have solved this problem by implementing Web-viewing technology for the physicians to access their clinical results. While this technology provides some functionality for the physician to occasionally look up data, it does not solve the problem of data delivery. Such a system provides no incentive for physicians to actually log on and print out their results, nor does it substitute for the institution’s responsibility to deliver a copy of the results to the ordering provider.

The impact of these models on the provider is also important to consider. Physicians have a responsibility to “react” to each piece of data they receive. Current systems deliver data to physicians unreliably and inefficiently. Some data will come multiple times (e.g. preliminary, stat copy, and final copy), some by multiple routes (e.g., stat by fax, final by paper). Despite the fact that the patient has multiple tests on the same day, they often are delivered at different times. In a multiple physician office, the results are delivered unsorted by physician or patient. The physicians’ office must deal with a data delivery process that is insensitive to how it is delivered, where it is delivered, when it is delivered, and how it is sorted.

These delivery problems create further problems for the institutions. The failure of timely and appropriate delivery leads to frequent requests for information. Significant resources are spent on telephone queries of laboratory, pathology, or radiology results.

The Solution

Efficient results delivery involves standardization of format, centralization of delivery, and a progressive move to electronic delivery. This is accomplished by taking HL7 feeds from data generation systems throughout the institution (the same process works equally well across multiple institutions), mapping the data to a standard HL7 map,³ linking the data to a specific patient through a master index, and routing to a central server where through an address book the result can either be printed, faxed, or delivered electronically according to the data type and provider’s wishes.

While physician adoption of clinical automation has been slow, physicians do use the Internet. An increasing number of physicians have desktop Internet access in their office. With the Internet comes connectivity and that connectivity allows institutions to begin to migrate to electronic results delivery. Even if institutions do not want to take advantage of electronic communication, there are going to be an increasing number of physicians who will demand it. So, on top of the current complexity of delivering data by paper and fax, hospitals are going to need to address electronic push technology.

As the institution begins to transfer data to electronic format for Internet delivery, it solves another much bigger problem. Electronic delivery requires standard formatting, an address book with a structured addressing system, and a method for unique patient identification across multiple departments. These are the identical requirements to automate the delivery process independent of the medium. Once a system can capture data from multiple locations electronically, it is possible to automate and centralize the process of delivery whether it be electronic, printed, or faxed.

While delivery costs approach $0 with electronic delivery, there can be tremendous savings simply centralizing the process of delivering by print or fax. As seen in Figure 1, the most significant savings come from the centralization of data delivery even without moving to electronic delivery.⁴

Figure 1. Significant savings results from the centralization of data delivery.

The centralization of paper data delivery eliminates the need for staff involvement in all paper processing functions for report distribution and consolidates all mail functions into one location. The thousands of results received daily are automatically printed out in alphabetical order in the mailroom with preprinted addresses and physician cover sheets. Results can automatically be sorted by physician or group of physicians. Rotating physicians, emergency staff, and residents can be added to the queue or easily removed – saving paper on unnecessary printing. Mailroom staff simply collects the pre-sorted documents from the printer and places them in envelopes with a window showing the address, weighs them, and sends them off. Results can be combined into one envelope, saving on postage costs.

Likewise, centralization of faxing allows direct fax delivery through a centralized fax server. Exceptions, such as persistently busy or disconnected faxes, are reported and managed appropriately. Finally, those physicians who do not wish to receive physical copies can have paper selectively “turned off,” saving significant resources. Some physicians may wish to receive only outpatient data, others outpatient but not ER, etc.

Significant Return on Investment

A hospital system in Cincinnati completed a detailed analysis of the cost of data delivery before and after implementing a centralized process. Their results, not including any savings from physicians accepting electronic delivery and turning off paper, was $200,000 a year (see Figure 2).

Figure 2. A detailed analysis of the cost of data delivery before and after implementing a centralized process.

Centralized Results Delivery Management

The centralization of results delivery not only reduced staff, mail, and paper costs but it provides critical administrative tools. HIPAA requirements are met:

• By tracking every access to electronic data;
• Actively managing a fax address book to assure appropriate delivery;
• Assuring that recipients are appropriate through address book management; and
• Minimizing the number of support staff with access to sensitive patient data.

The Joint Commission on Accreditation of Healthcare Organizations requirements are met:

• Assuring that results reach the ordering physician through tools to manage exceptions, failed facsimiles, etc.;
• Providing tools to track and deliver critical results; and
• Providing data access to key areas of the hospital, including pharmacy.

Results Delivery – Electronic

Obviously, EMR adoption will push the need for electronic results delivery; however, institutions do not need to wait for physicians to adopt EMRs to begin the electronic delivery process. Using the Web today, results can be delivered to physicians electronically with secure clinical messaging technology. Just as physicians would manage email, they can manage the flow of new information electronically. Implementing a clinical message system not only saves the institution money but will build a loyal group of physician “customers” who will become dependent on the technology provided by the institution.

Clinical Messaging and Physician Workflow

Email communication has superseded paper memos in almost all businesses. Just as email improves the efficiency of data delivery in businesses, clinical messaging facilitates a physician’s processes.

Paper result management for a physician has similar complexity to the institution’s process to deliver that result. This process typically involves:

• A staff person opens the mail or collects the faxes;
• The data is sorted by physician;
• Periodically the papers are delivered to a physician’s inbox;
• The physician does something with each piece of data. Typically this involves writing on the document, adding an instruction, and giving it back to the staff;
• A staff member picks up the reviewed document and delivers it to the appropriate place for action; and
• The staff performs the action and, unless it is a final action (e.g. “file”), the process starts over again.

Adding further complexity to this process are results that are stat, critical, preliminary, and duplicates.

The physician is presented with an inbox full of results unsorted by patient or by need for action. Old results are mixed with new, preliminaries with final, stats with routine, inpatient with outpatient, etc.

Electronic delivery provides the physician with an organized work queue of documents needing action. With a mouse click, they can be marked to file or be printed, sent to a staff to report to the patient, or forwarded to another provider.

Even physicians who ultimately print out all relevant results save considerable time managing an electronic inbox. In 2000, physicians involved in a communitywide implementation of clinical messaging reported, on average, a 30-minute-a-day savings using an electronic inbox to manage results delivery. An independent analysis showed that a typical physician’s office could save as much as $46,000 a year by moving to electronic data management.

However, electronic inbox management is simply the beginning of workflow improvements physicians can realize with electronic data delivery. Electronic data is available by staff and providers streamlining responses to patient queries, forwarding of data, and medical record management. Data grouped by patient from multiple sources provides the foundation for an electronic medical record.

Summary

Hospitals and other health care institutions have the opportunity to significantly improve their bottom line while better serving their providers by implementing a process to convert results into standard electronic messages and using those messages to drive a centralized process of results delivery. This centralization significantly improves the process for delivery by paper and fax and allows for the progressive conversion of physicians to accept data electronically. Physicians and their health care institutions can immediately realize improvement in efficiency with electronic results management and be ready for the more complete automation of their practices.⁵

Through the digitization of results with central distribution management, a hospital can build on its existing IT investment to reduce its costs while extending automation to their physicians.

Endnotes

1 Electronic delivery can include a simple Web-based lookup, a packet of data delivered into a workspace (e.g., an email), a structured data file, or a synchronous or asynchronous link to other electronic systems (e.g., EMRs).

2 Data from HealthBridge, a not-for-profit health care organization serving the greater Cincinnati health care community.

3 Within the HL7 standard, there is enough variability that a mapping to a common HL7 standard across systems is necessary.

4 Based on analysis of a hospital group processing 4,000 reports per day.

5 The term “EMR” is intentionally avoided as it is both misused and misunderstood. Electronic data delivery does in large part create an “EMR.” It provides a repository of patient data and tools to manage that data. By adding data “feeds” from the physician’s office including transcription, encounter forms, prescriptions, orders, and memos, the “EMR” is largely complete. However, to achieve care improvements associated with clinical automation, it might be best to drop the term and focus on the specific functions that enhance clinical delivery. These functions include data lookup, data management, data generation (encounter recording, prescription writing), clinical registries, and decision support tools.