IT & Health Informatics: How IT Can Help Emergency Department Flow?

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IT & Health Informatics: How IT Can Help Emergency Department Flow?

  1. How IT Can Help Emergency Department Flow?Nawanan Theera-Ampornpunt, M.D., Ph.D.Health Informatics Division, Faculty of Medicine Ramathibodi HospitalJanuary 28, 2013http://www.SlideShare.Net/Nawanan
  2. The Mission
  3. Ideal Process in ED Input Process OutputEmergency Urgent Care Treated Patients Patients
  4. Ideal ED Characteristics• Predictable patient arrivals• All patients are truly emergency patients• Staff & resources match demands• Little or no wait times• Good patient outcomes & satisfaction• Efficient use of resources
  5. The Unfortunate Truth
  6. Real Process in ED Input Process OutputEmergency Urgent & Treated & Non- Non-Urgent PatientsEmergency Care Patients
  7. Real ED Characteristics• Unpredictable patient arrivals• Mixture of urgent & non-urgent patients• Staff & resources don’t match demands• Looooooooong wait times• Poor patient outcomes & satisfaction• Inefficient use of resources
  8. A Closer Look ED Emergency PatientsTriage Investigations Non-Emergency Patients Observation Treatment Disposition
  9. Conceptual Model of ED CrowdingAsplin et al (2003)
  10. Simplified ModelDemand Supply Input Process OutputEmergency Urgent & Treated & Non- Non-Urgent PatientsEmergency Care Patients
  11. Process Improvements• Operations Management – “The science of understanding and improving business processes” (Soremekun et al., 2011)• Close linkage to – Operations Research – Industrial Engineering – Business Process Reengineering/Redesign/ Improvement/Management – Quality Improvement (e.g. Lean Management)
  12. How IT Can Help ED Operations?• Delivers information at point of care – Timely access to useful information – Prevention of potential adverse events – Such as • Past history • Drug allergies • Medication list • Problem list
  13. IT Role: Timely Access to Information E-mail Postal Mail (Snail Mail)
  14. How IT Can Help ED Operations?• Enables improvement of business processes• Changes workflow – More efficient – More effective – Parallel processes (not serial) – Concurrent access• Business process redesign/reengineering (BPR) facilitated by IT
  15. IT Role: Facilitates Workflow Redesign
  16. Key To Leveraging IT for ED• Think of IT as operations management tools• Recognize values of IT in – Facilitating Patient Flow – Controlling Information Flow• How these two flows can be optimized & aligned?
  17. Operations Management Strategies • Increasing Capacity • Eliminating Waste • Reducing Variability • Increasing FlexibilitySoremekun et al. (2011)
  18. Key Operations Management Concepts • Flow Time – Total time spent by a flow unit within process boundaries • Flow Rate – Number of flow units that flow through a specific point in the process per unit of time • Inventory – Total number of flow units present within process boundaries • Throughput or Arrival Rate – Average number of flow units that flow through (into and out of) the process per unit of timeModified from Anupindi et al. (2006)
  19. A Simplified ED Process Process Input Output Flow Time (hours) TimeThroughput = # of Flow Units Per Time Crowded ED = Flow Unit means too much (Patient) inventory
  20. Little’s Law Average Inventory = Arrival Rate x Average Flow Time I = RxTModified from Anupindi et al. (2006)
  21. Little’s Law: Manipulating Process Average Inventory = Arrival Rate x Average Flow Time I = RxT What We What Needs to Be Reduced Want to ReduceModified from Anupindi et al. (2006)
  22. Fixing ED Crowding I = RxT• Reducing inventory through – Reduction in ED arrival rate – Reduction in flow time
  23. Strategies to Reduce ED Arrival Rate• Ambulance diversion – Communications & situational awareness among EDs & dispatch• Non-urgent referrals• Improved primary care access & insurance coverage• Patient education & counseling• Telephone triage
  24. Strategies to Reduce ED Arrival Rate• Preventing repeated ED arrivals – Reducing “Leave Without Being Seen” – Improving post-ED ambulatory follow-up care – Predicting high risk patients and intervene before ED visits
  25. Fixing ED Crowding I = RxT• Reducing inventory through – Reduction in ED arrival rate – Reduction in flow time
  26. Critical Path• “The longest path in the process flowchart” (Anupindi et al., 2006) B E Start A G Finish 80% C D F 20% A C D F G Time A B E G Critical Path’s Time
  27. Reducing Flow Time • Shorten length of critical paths (bottlenecks) by – Eliminate work of critical activities • Eliminate non-value added work (“work smarter”) • Reduce repetitions of activity (“do it right the first time”) • Increase speed (“work faster”) – Work in parallelAnupindi et al. (2006)
  28. Reducing Flow TimeA C BF D GF F E G G C D G Total Time Eliminate Non-Value Added Work (Work Smarter) B E Work In Parallel Start A D G Finish Work Faster 80% 97% CC D F Do It Right The First Time 20% 3% Time
  29. Strategies to Reduce ED Flow Time• Work Smarter – Provider in Triage/Team Triage – RFID Location Tracking • Patients • Equipment • Charts • Personnel
  30. Strategies to Reduce ED Flow Time• Work In Parallel – Bedside registration • Role of mobile devices – Bedside triage • Role of mobile devices – Prehospital data transmission – Self-registration kiosk
  31. Strategies to Reduce ED Flow Time• Work Faster – Fast access to patient information • Electronic Health Records (from hospitals) • Personal Health Records (from patients) • Well-designed user interface – Advanced order sets • Paper or Computerized – Effective provider communications (mobile, pager, etc.) – Reducing lab/imaging turnaround time • LIS/PACS • Point of care testing of certain lab tests – Tracking/Monitoring of Patient Status (Online Dashboards)
  32. Strategies to Increase Capacity• Indirectly reduce flow time through increase in throughput or capacity of bottleneck activities – Add more resources (e.g. staff, space, equipment) – Increase availability of bottleneck resources (e.g. 24-hr. MRI, reducing equipment breakdowns through preventive maintenance) – Reducing wasting setup time
  33. Strategies to Increase Capacity• Dealing with ED Boarding of Inpatients – “Full-capacity Protocol” – Better inpatient discharge planning – Faster discharge procedures – More efficient use of beds (e.g. bed pooling) – Comprehensive bed occupancy status monitoring – “Bed Czars”
  34. Strategies to Reduce ED Variability• Dedicated fast-track non-urgent care• Standardized protocols – Practice guidelines – Order sets – Clinical Decision Support Systems (CDSS)• Surgical schedule smoothing• Ambulance diversion
  35. Strategies to Increase Flexibility• Avoid high utilization rates (degree to which a resource is working, not idle, compared to full capacity)• Predictive modeling & forecasting• Full-capacity protocols• Cancellation of elective cases• Flow flexibility (e.g. dynamic bed management & treatment location depending on needs)
  36. Summary• Operations management approach is critical to solving ED crowding problems• IT can play various roles in improving ED patient flow, but key is in process redesign and finding operations management solutions• Success will depend on context• Be careful of “unintended consequences” of poor implementation
  37. References• Anupindi R, Chopra S, Deshmukh SD, Van Mieghem JA, Zemel E. Managing business process flows: principles of operations management. 2nd ed. Upper Saddle River (NJ): Pearson Prentice Hall; c2006. 340 p.• Asplin BR, Magid DJ, Rhodes KV, Solberg LI, Lurie N, Camargo CA Jr. A conceptual model of emergency department crowding. Ann Emerg Med. 2003 Aug;42(2):173-80.• Handle D, Epstein S, Khare R, Abernethy D, Klauer K, Pilgrim R, Soremekun O, Sayan O. Interventions to improve the timeliness of emergency care. Acad Emerg Med. 2011 Dec;18(12):1295-302.• Hoot NR, Aronsky D. Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008 Aug;52(2):126-36.• Pines JM, McCarthy ML. Executive summary: interventions to improve quality in the crowded emergency department. Acad Emerg Med. 2011 Dec;18(12):1229-33.• Soremekun OA, Terwiesch C, Pines JM. Emergency medicine: an operations management view. Acad Emerg Med. 2011 Dec;18(12):1262-8.• Wiler JL, Gentle C, Halfpenny JM, Heins A, Mehrotra A, Mikhail MG, Fite D. Optimizing emergency department front-end operations. Ann Emerg Med. 2010 Feb;55(2):142-160.

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