Patient Access
A patient's entry point to a hospital's services can come from one of many functional
areas. One patient's physician's office calls to schedule her for an outpatient
procedure. Another patient arrives at the hospital to be admitted for his previously
scheduled inpatient stay for surgery. A third patient seeks care in the emergency
room and must register for admission and treatment. In each case, different software
applications, sometimes running on separate information systems, handle the collection
and flow of patient registration, authorization processing, insurance verification,
scheduling of services, and other information necessary to access the hospital's
services. Information exchange among these disparate applications is frequently
in one direction only, and nearly always incomplete. As a result of, or sometimes
even causing the data processing problems, operational processes, policies, and
procedures, are often also disjointed and redundant.
Gaining access to healthcare services in the current environment is cumbersome, uncoordinated, based on manual processes, choked with paper documents, and — not least of all — unsatisfying to the patient. Service-oriented businesses have long known the value of integrated and comprehensive customer information — available at every point of contact. Health care organizations, providing the most critical and relationship-intensive of customer services, seem acutely unaware of how to provide a positive experience when a customer seeks access to health care services.
The Current State of Patient Access
Let's follow the progress of our first patient mentioned above. Her physician determines she needs an outpatient procedure. An assistant calls the hospital to schedule the procedure. Since the hospital's surgery department uses an application for scheduling the operating rooms that is not integrated with patient registration, the patient can be scheduled while still in the doctor's office, but she can't yet be registered in the hospital. This is generally true of scheduling applications. Later, someone on the hospital's admitting staff calls the patient to get registration and insurance information, next of kin, and other information required for access to care. A clerk types the information into a database, then calls the insurance company to verify coverage. Several calls between the hospital, the patient, and the insurance company may be necessary to finalize coverage issues. Most likely, authorization documents from the IPA/referring physician, and medical necessity documentation from the ordering physician must be faxed to the hospital and kept in a growing paper file, which eventually moves through the organization along with the patient's clinical record. There's significant opportunity for these documents to be lost or misplaced, and often more than one provider needs physical access to the information; these providers are inevitably in different physical locations.
The patient arrives on the date of service, and finds she must provide additional information, much of which she previously told the registration clerk. She signs a "consent for treatment" form, and moves to the pre-op area to be prepared for her procedure. If complications from the treatment require a brief stay, the patient's information must be transferred electronically from the outpatient system to the inpatient system, if they are different. The important issue here is that frequently the registration and admitting applications, though they may share a common data repository with clinical applications, may be different, non-integrated applications.
Additionally, protocols must be established for the real-time transfer of patient data to the clinical system, sometimes also a disparate system. So, a nurse on the floor or in the operating room (OR) cannot order a lab test or a medication — or a bed — until the patient's registration data are transferred to the clinical system. Moreover, this is often a unidirectional transfer of information. Registration information can be automatically communicated to the clinical system, but not the other way around. This limitation continues to contribute to the inefficiencies of current information systems. For example, when a patient needs to be transferred from a monitored bed to a regular bed, a nurse must call the admitting department to make the transfer or enter the transfer in a different system. It's often necessary to do such odd machinations to locate patients and track their treatment and charges.
Drawbacks of the Current State of Access
A fragmented computer system for patient access adds inefficiencies to the delivery of patient care. Tedious, repetitive clerical tasks are inserted at various times into the care delivery process. Both clerks and nurses spend a significant portion of their work time manually running reports, tracking down misplaced documents, and re-keying data into the registration system. Work is duplicated unnecessarily, and the opportunities for errors increase. There's a considerable workload for the physician's office and, potentially, the physician as well, since it may take multiple phone calls, waiting on hold for considerable periods, to perform the multiple tasks of registering and scheduling the patient.
The same is true for insurance companies, where claims processors spend a lot of time looking up patient information and reciting it over the phone. Often, the patient gets involved in these transactions and begins to wonder if the hospital's left hand knows what its right hand is doing. Fragmentation erodes the patient's confidence in the hospital's ability to ensure a favorable outcome and creates an image of poor service. In addition, these manual interventions or duplicate efforts not only increase administrative costs, but may result in a delay in patients receiving service that also increases costs. For example, if the patient arrives on the day of surgery and must spend time in registration providing information, or the registration clerk cannot locate the authorization for treatment, surgery may be delayed, resulting in downtime in the operating room and late starts for all scheduled surgeries later in the day.
The Case for Better Case Management
Patient access deals not only with entry into the clinical system, but also the patient's eventual discharge from it. In today's environment, frequently a case manager is notified, often manually, of a patient's admission. The case manager evaluates the medical necessity of each patient's admission, and determines an appropriate length of stay. The case manager also evaluates the length of stay of patients who have been in the hospital for a long time. With strictly manual record keeping, there is no reliable process for flagging long-term patients for length-of-stay review. Often, these patients would be better served in an alternative care setting, and in any case, the hospital may not be reimbursed for patients who stay beyond the limits set by their insurance plans. This is one way in which the lack of integration of today's clinical processes and information systems contributes to the possibility of losing revenue.
Another way of losing revenue is when errors in the registration information cause confusion when a clinician tries to add an order to the patient's record. When charges for ordered services cannot be matched to the correct record, the revenue for the service is lost. Loss of revenue from non-reimbursed or mismatched service charges amounts, industry-wide, to 1 to 3 percent of net revenue, which may be equal to a typical hospital's operating margin.
The Future State of Patient Access
In the future state — as an integral component within an advanced clinical information system (CIS) — patient access is fully integrated with scheduling, billing, and all clinical functions. The experience of our hypothetical patient changes dramatically. In a hospital with a CIS, the physician's office pulls up the operating room schedule onto their local computer. They can either schedule the operating room time themselves, or electronically send a request for the schedule to the hospital. Since the patient has been admitted previously, registration information is already available, and will only need updating upon admission/registration. In real time, in a centralized scheduling environment, the scheduling request is processed. At the same time, an electronic message is sent to the patient's insurance company, verifying coverage. The insurance company responds with information that populates the patient's record with the plan's current benefits and requirements. The system sends a schedule confirmation and other relevant information to the physician's office and/or the patient's home. This information tells the physician and patient such things as what lab tests are needed and when, how to prepare for the surgery, when to arrive at the hospital, exactly what benefits will be paid by the patient's insurance plan, and whether additional requirements such as a second opinion or pre-authorization must be met. The patient can have all of this information before she leaves the physician's office, or she can receive it via her personal email.
Each patient contact with the hospital becomes part of the record, and any information provided once is always accessible. Only changes to existing patient information need to be added.
If, post-surgery, the patient needs to be admitted, the seamless integration of information and systems allows the nurse on the floor to schedule a bed. By the time the patient arrives in her hospital room, her comprehensive electronic record is already there, ready to receive treatment orders, clinical information, and to tabulate charges for services rendered. Throughout her stay, her medical information (such as allergies, diagnostic tests, and lab reports) will be available for clinicians to review, helping to provide the best possible outcome. A case manager will be alerted to monitor her status and evaluate her length of stay for medical necessity.
Critical Success Factors
The access component of a CIS — the process by which the patient gets into the clinical environment and is eventually discharged from it — is fundamental to the system's design and implementation. Comprehensive patient information — including both scheduling and registration information — must be accessible at any point of patient contact. Physicians' offices can key in both scheduling requests and registration information and get a response in minutes. Insurance information is readily obtained by electronic links to payers. The patient can get access to this information and update it either over the phone or over a secure Web site. Services become part of the record as soon as they are rendered, the results are posted, and the charges automatically communicated to the patient billing system.
Such a system requires an enterprise-wide information system that operates in real time and with fully integrated applications and database(s). As the patient-access component of a hospital's CIS grows in capability and sophistication, so must the expertise of the people who use it. In the past, the admitting and other front-end patient interactions were conducted by relatively untrained entry-level people with low motivation to provide quality service and a high rate of turnover. The future state will require better-trained, more versatile employees who will function more as account representatives or customer relationship managers.
As with other aspects of the clinical transformation, it is important to design patient access processes with the future state in mind. Using advanced technologies to improve current methods of data storage or to automate current registration, admitting, or scheduling processes is not going to produce benefits worthy of the investment. Admitting, registration, and scheduling processes, any of which may be the patient's first point of contact with the hospital, should be fully integrated. This can be a difficult challenge. Scheduling is a complex function, often having significant political ramifications in an environment including several providers, organizations, and staff groups. If a common system cannot support all patient access functions, it is at least imperative that information be able to travel seamlessly from one application to the other — in both directions.
Focusing on the Patient
Too often, as we concentrate on improving the hospital's internal policies and processes, or on creating order sets for physicians that help to make leading practices the standard for patient care, we neglect to consider the patient's point of view. Are we designing the CIS to improve the patient experience? Will it simplify access to the patient? Will it help to make communication between the hospital and the patient as complete as possible? Will it provide this information in the manner (phone, Web site, or email) most convenient and desirable for the patient? The future-driven CIS must address these issues.
Patients, occasionally termed "health care consumers," are getting smarter. They're getting more demanding, and with their increasing familiarity with information technology, their demands are becoming more sophisticated. Increasingly, insurance plans allow their members to pick and choose their health care service providers. Patients certainly will want to choose a provider with the best reputation for quality care, but their choice will also be based in part on the total patient experience. For this reason, a CIS must offer a satisfying patient experience, as well as improve financial performance and patient safety.
Patient access — the first and last interactions between patient and hospital — is an excellent place to start.
