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1. Mobile Solutions in Health Care
Case Studies
Reiner Hermanns - Reiner.Hermanns@cgey.com
Theodossia Papawassiliu - Theodossia.Papawassiliu@cgey.com
Managing Consultants, Intelligent Products & Mobile Solutions,
Cap Gemini Ernst & Young Deutschland GmbH
With contributions from:
Lex van der Giessen - Cap Gemini Ernst & Young Nederland B.V.
Ashif Jiwani - Cap Gemini Ernst & Young US LLC
A Changing Environment
A rapidly aging population, empowered consumers, new technologies, new scientific
findings, unrelenting cost pressures, DRG’s are just a few of the many trends affecting
the future of healthcare. To prepare for that future, hospital and board members must
understand the dynamics of these trends and how they are likely to influence each of the
organizations’ key constituencies, including payers, physicians, and consumers.
Until now, hospitals and healthcare systems have had to deploy costly hardware-based
systems for capturing and managing physician dictations. Inefficiencies in the clinical
documentation lifecycle also add significant operational expense to the organization.
Creating, distributing, signing and archiving transcribed patient reports has been a
manual, time-consuming process for healthcare providers. It has been expensive and it
has not been automated.
In the hospital sector, there are numerous changes concerning the format of the
information; in the future, these will have to be eliminated with electronic media. Thus,
for instance, there is no uniform data administration in clinics. Interfaces between digital
and paper-based documents are often not available. [1]
Though many safety advisors have suggested automated functions such as physician
order entry as part of the solution, few have understood the essential importance of
automated clinical documentation, or the need to integrate these two functions to achieve
real interdisciplinary benefits. [2]
Physicians want to be able to look after their patients more intensively and reduce their
administrative activities substantially, as these often constitute fifty percent of their
working time.
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2. Automation offers opportunities for improving the clinical practice
When it comes to clinical documentation, hospitals and healthcare systems require more
than just insular solutions that capture physician dictations and transcribe reports. They
need a comprehensive solution that can manage the entire clinical documentation
lifecycle – from dictation recordal and transcription to physician review/ signing and
chart distribution. The solution must be highly reliable, provide a mechanism to ensure
privacy of the patient data, and offer support for integrating innovative technologies such
as speech recognition. The clinical documentation system allows the clinician to docu-
ment vital signs, intake and output values, assessments, progress notes and nursing tasks
in the electronic patient record. This also allows viewing, graphing and reporting vital
patient information to aid in making important decisions regarding patient care.
Automating clinical documentation in a way that helps improve the quality of care from
a clinician’s perspective is much more than – and completely different from – simply
computerizing an existing paper system. Computerizing a bad paper system only reveals
its shortcomings and exacerbates things. Simply computerizing a good paper system
won’t lead to improvements that make a difference for clinicians and patients.
Automation must take a new path.
Automating clinical documentation in this new way necessitates conceptualizing the role
of clinical documentation in providing care according to a new paradigm. Before any
productive automation can take place, this paradigm must be understood and adopted by
an organization. Well before new software is designed or computers are installed, one
must think in a new way. Some guiding principles are:
Clinical documentation systems must build and present a coherent patient across the
continuum of care received. Documentation must keep the focus on the patient, not on
the forms or the data.
Clinical documentation systems must keep the members of the interdisciplinary clinical
team informed about the care other members are providing. Given that clinicians have
less and less time with patients, documentation must enable clinicians to build on each
other’s contributions and expertise without duplicating efforts or capturing redundant
data.
Clinical documentation must support defined frameworks of practice that clarify the
responsibilities, competencies, and evidence-based knowledge for which each member
of the interdisciplinary team is accountable. Frameworks of practice must be integrated
so that team members understand others’ responsibilities.
Clinical documentation systems should provide clinicians with the latest relevant
evidence-based information at the point of care.
Clinical documentation systems should enable clinicians to capture patient data
concisely at the point of care (for accuracy and time-saving purposes) and to view
relevant data only in the form most useful for them at the point of care.
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3. These guiding principles make up a holistic framework for understanding the role
automated clinical documentation can play within the healing environment.
An automated clinical documentation system enables fast, efficient, accurate data
collection and facilitates information sharing and collaborative processes within and
across clinical documentation systems. [2]
Benefits of automated clinical documentation systems
Advanced automated clinical documentation systems include much more than just
clinical documentation in the traditional sense. There are a number of benefits that an
advanced automated system could provide:
Improved patient safety and timeliness of care through alerts and rules triggered by
documentation;
Increased patient and clinician satisfaction through fewer redundant activities, such as
taking vital signs, asking questions, and documenting;
Streamlined clinician workflows through intentionally designed tools that are directly
linked to documentation, enhancing process and outcomes;
Real-time access to patient data by all authorized personnel;
Enhanced real-time clinical decision making through special data views.
Health care information is inherently dynamic. To do their jobs efficiently and
effectively, health care professionals have a constant need for consolidated and timely
information related to accessing, delivering, and financing care. “Clinical portals” can
provide a dynamic and interactive view of clinical information. For example, the “home
page” of a physician’s portal might show a personal and hospital schedule, a list of
patients, and content sources. When the doctor selects a particular patient, the window
will change to display that patient’s personal health record, recent lab results and next
scheduled appointment. [2]
Mobility
Another key ingredient for improved workflow is mobility. Mobility point-of-care
solutions focus on the extreme fluidity of most health care delivery environments.
Patients, physicians, nurses, administrators, and supporting personnel are in nearly
constant motion. Decisions that shape the course of diagnosis, treatment, medical
outcome, and profit or loss can be made anywhere and anytime. Informing those
decisions and reliably capturing their clinical and business outputs is highly complicated
by the variety and physical distribution of relevant resources.
Mobility is much more than putting a Web site or an application on a PDA or Pocket PC.
Under this new model, users can perform any task on their computing devices without
having to think about whether they are connected or how they are connected to a server.
This means that a user’s computing device and applications communicate with each
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4. other about the kind of connection required for the user’s task and settle competing
priorities for communicating with the server most effectively – without the user ever
having to think about what is happening behind the scenes. Users no longer have to
worry about synchronizing their various devices. Whether ordering a lab test or prescri-
bing medicine, they simply go about doing their work, anywhere and under any circum-
stances. [2]
This results in similar advantages in the healthcare sector as determined in studies [3] for
other industrial areas: higher productivity and lower costs through easily available
information on appointements and online documentation.
Integrated Solution CareMore+
In several countries, solution development has started in parallel – more focused on
either home care or clinical care. In both instances, the main work was the development
of the architecture and the integration of existing products. As shown in the illustration
below, the integrated solution consists of different layers and components. Using
different tools, all existing data can be accessed via one interface.
Cap Gemini Ernst & Young Europe has named this architecture framework CareMore+:
PDA: Personal Digital
Assistant
CMS: Content
Management System
CRM: Customer
Relationship Management
WFM: Workflow
Management
DM: Document
Management
Characteristic for the care market and especially for the home care market are the
isolated IT solutions around the core process automation, a consequence of many
mergers among solution providers and purchases of niche package solutions. The
enormous diversity of information systems will come to an end through replacement and
by integrating applications. As a result, data can be considered in an integrated way and
it is possible to extract management information of high importance for effective and
efficient operational management of the care organization.
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5. Case Study: Automating Patient Records Management Extends
High-Quality Care to More Patients at the Swedish Hospital of
Seattle [4]
Introduction
Swedish Hospital of Seattle’s aim was to get an automated data management platform
that would enable the hospital’s emergency room staff to use tablet PCs connected to a
wireless network to gather patient data and also collaborative workspaces to organize,
share, and manage the data on the hospital intranet. Converting their manual paper-based
recordkeeping system into a streamlined computer documentation and care management
solution would enable the hospital to:
Realize a 74-percent internal rate of return (IRR) with a 13-month payback on its
investment.
Provide high-quality care for 10 percent more patients.
Increase annual per-patient revenue at the hospital’s First Hill facility by 3 percent.
Situation
When patients experience unexpected medical problems, the knowledge and experience
of the emergency department staff and medical technology are the hospital resources the
patient encounters first. However, efficient workflow and accurate recordkeeping are
other less obvious elements of high-quality patient care.
As in most U.S. hospitals, the emergency department staff at Seattle’s Swedish Hospital
First Hill, Ballard, and Providence facilities spend about half their workday caring for
patients and the remaining time filling out forms and performing administrative tasks.
The staff’s efforts at working more productively were hampered by a complex manual
paper-based data collection and distribution process. The staff collected patients’
personal and medical data on paper forms, organized on clipboards that were color-
coded to indicate treatment priority. The status and location of each patient was listed on
a white board hung in a nurse’s station of the hospital’s emergency care facilities.
Getting patient information from the hospital laboratory, imaging units, and medical
database to doctors and patients in the emergency department often created bottlenecks
in the examining rooms, where patients waited until the staff received the needed
diagnostic information.
Developing ways to help the emergency department staff spending more time with
patient care is one of the concerns of the Chief of Emergency Services at Swedish
Hospital. For many years he kept his eye on ways to use IT to help his staff spending
more time caring for patients. But the available technology at that time was not up to the
task.
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6. The development of tablet PCs, wireless networking, and an easy method of recreating
electronic versions of the departments’ many paper forms completely changed the
situation. The solution was able to help caregivers to reallocate part of their
administrative time to patient care, reduce recordkeeping errors, and ensure that
organizational and regulatory requirements were met.
Solution
The clinical forms and collaboration solution integrated mobile PCs, wireless
networking, and XML-based Web services with the hospital’s mainframe-based clinical
and financial database applications. The solution consisted of three major components.
Effortless Data Access, Entry, and Validation
The solution’s front end consisted of tablet PCs, electronic forms, and a customized user
interface.
The emergency department staff collects patient data by using tablet PCs running
Microsoft® Windows® XP Tablet PC Edition connected to an in-house wireless
network. The unfettered mobility of using the tablet PCs provided doctors, triage nurses,
and treatment nurses a discreet way to collect data from patients during examinations
and treatments.
Data Input and Validation
Microsoft Office InfoPath™ 2003 enabled department caregivers to capture structured
data in a flexible, user-friendly way. Additional functionality was employed: drag-and-
drop controls and other easy-to-use InfoPath 2003 development tools to create XML-
based, electronic versions of the paper forms that the staff used to document patient care
and personal information. The user interface enabled doctors, nurses, and administrators
to access form templates, update patient data, and manage patient documents.
Framework
The key components of the clinical portal Framework for the Swedish Hospital as a
special implementation of CareMore+ are shown below:
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7. Major components used for implementation:
The Microsoft .NET Framework
Microsoft Windows 2003 SharePoint Services
Microsoft Windows SharePoint Portal Server 2003
Collaboration, Communication, and Process Coordination
Microsoft Windows® SharePoint™ Services provide the Swedish Hospital emergency
department staff with a dedicated intranet-based team collaboration site that serves as a
hub for vital communication and document management functions. On the Windows
SharePoint Services team site, SharePoint lists provide the caregivers with an electronic
version of their whiteboard, which staff members on duty review constantly for patient
status information. Indexing and intranet-wide search capabilities enable the emergency
services staff to organize all patient-related forms by patient name. The portal also serves
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8. as a document library from which caregivers check out, modify, and check in patient
forms at each step of the ED care process.
Comprehensive process coordination
Microsoft Office BizTalk® Server 2004 automates the processes needed to collect and
report personal and clinical data for each patient, check documents in and out of the
project document library, and forward the data to the hospital’s medical and financial
databases. The solution accomplishes this by exchanging information contained in
patient forms across the solution’s data access, entry, and storage applications.
The BizTalk Server Adapter for HL7 add-on provides specialized functionality designed
for healthcare environments.
The Microsoft .NET Framework that supports all of the solution’s functionality enables
developers to set up communication and document management tasks as a series of
XML-based Web services. By clicking on the solution’s custom user interface, staff
members call Web services that move data and documents into and out of the SharePoint
portal and team site and into the hospital’s databases.
Powerful Data Storage and Analysis
The solution’s back-end resources include databases that store completed emergency
department patient forms, clinical data, and billing information. Microsoft SQL Server™
2000 provides the hospital with a local repository of completed emergency department
patient documents.
The Swedish Hospital clinical forms and collaboration pilot program began in mid-
October 2003. Rollout to the hospital’s downtown location is scheduled to begin in
February 2004.
Benefits
Deploying the clinical forms and
collaboration solution will enable the
Hospital Domain
Swedish Hospital emergency services
HIS LIS MEDS
staff to reallocate administrative time
to more patient care, reduce errors in
patient recordkeeping, and perform
IWSG POC Domain
Physician trend analysis on their emergency care
processes. As a result, Swedish
SQL
Databas Hospital expects to realize a 74-percent
internal rate of return (IRR) with a 13-
e
IWSG POC Server
Triage Nurse
Treatment
Nurse month payback on their investment.
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9. Less Time Translates into More Time for Patient Care
At Swedish Hospital, emergency patients progress through a four-step process of triage
and registration, assessment, treatment, and discharge or transfer to a bed in the in-
patient portion of the hospital.
During triage and registration, the triage nurse checks for an existing patient record in
the HIS database. If none exists, the nurse opens an empty Emergency Department
Assessment form template stored in the SharePoint Document Library. A request for a
new form calls a Web service that makes a blank InfoPath-based form available on the
user’s tablet PC. Finally, the nurse fills out the patient’s personal information and
assigns the patient a treatment priority.
If the information entered is incomplete or does not satisfy pre-established data entry
rules, the solution alerts the nurse, who can make the correction immediately.
When the nurse closes the file, the solution timestamps the form, checks the form back
into the SharePoint patient document library, and transfers the patient name onto the
Active Patients list on the SharePoint collaboration site.
The basic workflow is the same during the medical assessment, treatment, and discharge
phases of the ED process:
• Check for existing records
• Check out the appropriate form
• Fill in relevant information during each task
• Correct errors identified during validation
• Check the form back into the document library
At each stage of emergency care, the solution’s communication, collaboration, or
document management capabilities can reduce several common problems that beset
Swedish Hospital’s legacy document management system.
The ability to create, display, share, and manage information in a shared work
environment will enable Swedish Hospital to provide high-quality care to 10 percent
more patients per year, generate 3 percent additional revenue per patient each year at the
hospital’s First Hill facility, and spend 80 percent less time tracking information for
audits.
How Benefits Were Measured
An independent consulting organization performed a cost and benefit analysis to
determine business and financial metrics associated with the investment in the Microsoft
Office System solution.
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10. Using established cash flow analysis standard financial data was measured including:
payback – the time it takes a company to recoup its investment in the solution; net
present value (NPV) – the total value to the customer from investing in the solution,
expressed in today’s dollars; NPV per user – the NPV divided by the number of users
affected by the solution; and internal rate of return – the rate of return that the customer
expects from investing in the solution.
While every organization has unique considerations for economic analysis, this case
study highlights key areas where potential economic value from the Microsoft Office
System can be realized. A Value Impact Analysis (VIA) practice strongly recommends
that all significant IT investments undergo a rigorous economic justification to
comprehensively identify the full business impact of those investments.
Software and Services Used
Microsoft® Office System
Microsoft Office InfoPath™ 2003
Microsoft BizTalk® Server 2004
Microsoft BizTalk Server Adapter for HL7
Microsoft Windows® SharePoint™ Services
Microsoft Windows Server™ 2003 Enterprise Edition
Microsoft Windows XP Tablet PC Edition
Microsoft Data Access Components (MDAC) 2.71
Microsoft XML Core Services (MSXML) 4.0 Service Pack 1
Microsoft Internet Information Services (IIS) 6.0
Microsoft SQL Server™ 2000 Enterprise Edition with Service Pack Microsoft .NET
Framework1.1
References
[1] Elektronische Kommunikationsmedien im Gesundheitswesen: Eine
Zukunftsherausforderung für alle Beteiligten [Electronic Communication Media in
Healthcare: A Future Challenge for All Participants], Manfred Beeres. In: Jäckel
(Hrsg.) Telemedizinführer Deutschland, Ober-Mörlen, Ausgabe 2004, [Guide to
Telemedicine, 2004 edition] ISBN 3-9808837-1-X
[2] Sections “Achieving Success” and “Future Landscape”. In: Health Care Technology,
Innovating Clinical Care Through Technology, Volume 1, 2003, ISBN 1-932178-03-
1, www.HCTProject.com
[3] Studie IT-Trends 2004: Neue Einsichten und Aussichten [Study IT Trends 2004:
New Insights and Prospects], Cap Gemini Ernst & Young, www.de.cgey.com
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11. [4] Automating Patient Records Management Extends High-Quality Care to More
Patients at the Swedish Hospital of Seattle,
www.microsoft.com/resources/casestudies/CaseStudy.asp?CaseStudyID=14772
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