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PDAs Chase Workflow Improvements
Health Data Management Magazine, May 2006
Botz, associate medical director for the intensive care unit, no longer has to make telephone calls to a transcription service or fill out a stack of billing paperwork each day. He has even thrown away the handwritten, three-by-five inch cards he used to carry in his pocket with each patient's problem list. Those lists now are part of the system.
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"It's a great timesaver for me," says Botz, who estimates he now spends up to 40% less time on billing and dictation tasks.
M.D. Anderson has rolled out hand-held dictation and charge capture applications from Boston-based MedAptus Inc. to more than 90 physicians in the last 18 months. It plans to move 108 clinicians to the system in the next six months, a fourth of the approximately 800 physicians on staff at M.D. Anderson, including researchers. The rollout will continue until 450 clinicians are using the system.
Early studies show that physicians are saving time and billing more because of increased accuracy in charges. The cancer center has learned, however, that implementing such a system also comes with many challenges, says John Tietjen, vice president of financial services.
The need to upgrade an existing wireless network and customize the charge capture application for each medical department has added months to the original implementation schedule. Physicians and information technology staff have to work together, for example, to design templates that present the most common billing codes for each department in a way that makes sense to physicians.
"We never anticipated how difficult it would be," Tietjen says.
Mobile technology offers great potential to improve physician workflow-if it works, says Tim Gee, principal at Medical Connectivity Consulting, a Beaverton, Ore.-based health care information technology consulting firm.
To be successful, hospitals have to ensure that mobile applications achieve the promised workflow benefits to physicians and that they are reliable, he says. The medical staff also has to understand and buy into how the system helps the institution as well as them, he adds.
To gain physicians' trust, M.D. Anderson delayed the implementation for about six months to upgrade its wireless network because early users were having trouble maintaining connectivity. Physicians are highly mobile, and the project was the first to tax the network as much as it did, says Lori English, associate director of patient business services and the project manager for the MedAptus implementation. Physicians have seen a great improvement in being able to stay connected, English says.
M.D. Anderson has also tried to remain flexible regarding physician needs, English says. For example, the cancer center is rolling out the charge capture and dictation applications first to the departments that request them. Critical care, cardiology, pulmonary medicine, the emergency center, pain care, general internal medicine and endocrinology are all up and running.
Usage mandatory
Every physician within those departments is required to use the charge capture application, English says. But the cancer center has decided not to require physicians to use the dictation application because some are not comfortable with it and others don't believe it will improve their productivity. About 65% of the physicians using charge capture also use the dictation application, and they each send an average of 250 dictations per month, English says. No one has complained about sound quality, she adds.
Yet physicians in the emergency department, for instance, do all handwritten notes because others need to see them right away, she says. "And some physicians don't have a real high trust level at first that their dictation is going to go where it is supposed to."
Dictation files are transmitted wirelessly as a WAV file-a digital audio file-to a database, where a transcription service accesses them. Many physicians who are reluctant to leave the tried-and-true telephone first test the dictation application by sending through small notes to make sure it works and then switch to using the PDA for all dictations, English says.
Other physicians, especially consulting physicians who visit patients throughout the multi-building facility, immediately appreciate the increased mobility they get by dictating into a PDA, she says. Using the same device for charge capture and for dictating notes also helps physicians better structure their notes because they have the patient's problem list and diagnosis information right in front of them while they are talking, Botz points out.
To dictate a note using the PDA, physicians tap an icon next to the patient's name on their patient list and start speaking. They are able to pause, rewind, review and re-record the voice file if necessary, a feature Botz uses often.
"The ICU is a busy place," he says. "When I was dictating into a telephone and something needed my immediate attention, I would have to hang up and I didn't have a way to start again where I left off. I would have to call in a second time and try to piece the notes together days later when they came back from the transcription service. With the handheld, I can just pause the dictation, turn the PDA off, put it in my pocket, go deal with something, and then start dictating again where I left off."
Once dictations are transcribed, they are sent back to a document management system developed in-house, where physicians access them via a computer rather than the PDA. Physicians edit their notes and sign them electronically, just as they do if they dictate the notes over the telephone, English says.
Customized coding
The biggest obstacle to implementing the charge capture application, and the most important to physician acceptance of the system, has been the design of the templates that present the ICD-9 and CPT codes for physicians to chose, English says.
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