A respiratory therapy director at one of the largest health systems in the nation recently shared a troubling story with me.
With his hospital’s original computerized provider order entry (CPOE) process, physicians would write orders in a paper chart. Each hospital floor had a clerk who would enter those orders into the CPOE system. Notifications of the orders were then sent to printers, where the respiratory therapists (RTs) would pick them up.
For respiratory therapists, who are mobile and working with patients across the hospital, the process wasn’t ideal. It was manual, location-dependent, and subject to printer malfunctions and paper outages. Rudimentary as it was, the RT team had come to rely on it for new orders.
When the hospital launched an electronic health record (EHR), which supported a more streamlined ordering process, the printers were removed. The RT director said it was a disaster for his team. In the first several months, they received only 20% of patient orders, at best. They didn’t notice some orders for eight to ten hours after physicians placed them.
In one case, a physician stopped the RT director in the hall and asked him about an order he’d placed for a patient the day before. The RT director was embarrassed and concerned; he was not aware of the order. (Thankfully this incident did not result in patient harm.)
The director discovered that the RTs were not seeing the orders because this particular EHR didn’t provide a central place to check for them. Instead, an RT would need to log into each individual patient record to check for new orders, sifting through routine information to identify orders requiring more immediate attention. The director estimated that each RT spent more than an hour per shift searching for new orders. This was time his team simply did not have given their busy workloads.
The resulting delays in patient care created safety concerns, and were also leading to extended lengths of stay. For example, if a patient could not receive his or her diagnostic RT treatment quickly, it might mean another night in the hospital – and potentially a reimbursement hit for the hospital.
Push, Not Pull
The hospital solved this issue by linking their EHR to their Vocera solution. The Vocera solution includes software that runs on a variety of mobile devices to enable voice calls, secure texting, and alerts from EHRs and other clinical systems.
Now, order notifications are sent directly to the RTs on their mobile devices. They’ve reversed the paradigm; instead of needing to pull the right information from the EHR and hoping they get it quickly, the Vocera solution proactively pushes an order to the right person at the right time, wherever they are. The RT team and the physicians are now confident that orders are being handled in a timely manner.
Santa Clara Valley Medical Center (SCVMC) took this solution a step further. SCVMC is a public teaching hospital affiliated with Stanford Medical Center. The busiest health care facility in the region, they co-locate five trauma and emergency care services on one campus. They have a very busy emergency department.
Many people who visit the ED need to be admitted to the hospital for further care once they’re stabilized. That means the hospital needs to quickly clean beds after other inpatients are discharged from the hospital, so those beds are available for the ED patients. And, the sooner a patient is admitted to the hospital, the sooner the ED can free up an open exam room for a new patient. It’s a constant cycle.
The environmental services (EVS) team sits at the heart of this cycle. SCVMC had already linked their Epic EHR with Vocera so they could deliver bed cleaning requests to EVS team members on their Vocera badges. As a result, their EVS team knew right away when a bed needed to be cleaned in their area, which made them more efficient.
But management knew they could do better. The EVS supervisors needed real-time visibility into which beds were being cleaned and which ones were complete so they could effectively coordinate new admissions. In order for that to happen, after getting the bed cleaning notification, each EVS team member would have to locate a computer, log into the EHR, locate the bed, and mark the bed cleaning as “in progress.” After cleaning the room, they would need to go through the whole process again to mark the bed cleaning as “complete.”
Because it took so long to complete these administrative steps, the EVS team was not logging these updates. They were focused on their primary job, which was preparing beds for new patients.
Improving Patient Flow
SCVMC worked with Vocera and Epic to develop a solution that would allow the EVS team to focus on their primary job and to provide real-time updates for their supervisors.
Now, the EVS team member receives a bed cleaning request on their Vocera badge, and simply responds by saying “yes” to accept the request. That update is sent immediately to Epic, reflecting the status in real time. After a set period of time, the team member receives another alert, asking if the bed cleaning is complete. Again, they simply respond by saying “yes” to update the status in Epic. All of this is done hands-free. EVS supervisors can now track bed status in real-time.
As a result, SCVMC reduced bed turnaround times by 50%. They reduced patient wait times and improved admission throughput. They streamlined the EVS process, eliminating the need for care teams to rush from floor to floor to find an open bed.
Interestingly, they also boosted team morale. Their EVS team members had always focused on cleaning beds efficiently, but their results weren’t always visible to their supervisors. Now, with timely updates, it is easier for management to recognize their efforts.
The Illusion of Communication
EHRs have transformed health care, improving quality, safety and efficiency. They’ve been shown to improve care coordination, public and population health, patient and family engagement, and quality measurement. And the promise of what they can enable going forward is tremendous, especially as we seek ways to leverage the rich data they contain.
While EHRs offer many benefits, a lot has also been said about the ways in which they have changed the way care providers interact with patients, and the way they communicate with one other.
In its Guide to Reducing Unintended Consequences of Electronic Health Records, RAND Corporation outlines how to understand, identify, avoid, and remediate the unintended consequences of EHRs. Such undesirable outcomes include everything from creating more work for clinicians to the generation of new kinds of errors.
One consequence the guide calls out is “unfavorable changes in communication patterns and practices.” The authors explain that EHRs can create an “illusion of communication … a belief that simply entering an order ensures that others will see it and act upon it.”
Sending proactive alerts to care team members on their mobile devices is one very important part of the solution. The second part is to make it easy for care team members to communicate directly with each other so they can effectively coordinate patient care.
Restoring the Human Connection
In a survey of physicians using commercial EHRs published in the Journal of General Internal Medicine, researchers found that physicians benefitted from features such as email and improved access to patient information in the EHR. But, the asynchronous nature of communication was a problem, especially for complex clinical cases.
One cardiologist said, “If I am implanting a defibrillator, the primary care physician may have some thoughts about the patient’s true life expectancy that might influence our decision making process about whether the device is appropriate for the patient … We need to do a better job of [communicating orally], because we [cardiologists] can’t do it without input from the physicians who understand the patient’s complex chronic conditions.”
In the same study, the CMO for an EHR vendor summed it up in this way: “The best way to ensure good coordination of care is for two physicians to speak with each other directly. You can’t approach any technology solution, in as complex and risky a work environment as the practice of medicine, and have it be a substitute for appropriate human interactions.”
Another thought leader said, “While the EMR cannot replace synchronous communication, it can be a highly effective context-rich collaboration tool … If care coordination is to be done and optimized, it can’t be done without an EMR (albeit a transformed one).”
That’s where Vocera comes in. We are extending the power of the EHR by adding a layer of intelligent communication capabilities to it. We’ve established integrations with EHRs such as Allscripts, Cerner, Epic, McKesson, and MEDITECH, and are actively working with our customers and EHR partners to support new use cases. By proactively delivering the information care team members need – when and where they need it – we are transforming the EHR experience. And by linking team members to one another through intuitive voice and text communication, we’re restoring the human connection to care.