December 10 , 2007

Electronic Case Management: Improving Patient Care and Efficiency
By Laura Gater
For The Record
Vol. 19 No. 25 P. 18

Healthcare organizations are finding that doing away with paper systems places patient information in a framework that’s accessible and convenient.

Electronic case management (ECM) systems are enabling patient care to become a more collaborative process by making all patient information readily available and accessible at the touch of a button. In many cases, ECM has helped improve data collection and reporting, allowing hospitals to track different variables and have a baseline for improvement.

Handwritten notes and documents in a patient’s file often require checking and rechecking to verify that everything is complete. Insurance paperwork sometimes requires extra time to sort through, and the status of discharge planning and claims is often unclear. With ECM, all key insurance, discharge planning, and patient care documents are centrally located and easily available to those involved in patient care.

“Case management has become a critical service to ensure timely and effective coordination of care across the continuum,” explains Mari Finley, RN, MBA, director of medical management at Harris Methodist Fort Worth (Tex.) Hospital.

A Typical Scenario
Jane Brown, aged 62, is brought to the local hospital emergency department (ED) by ambulance and is eventually admitted with a stroke diagnosis. The hospital’s admitting department obtains her demographic and insurance information and enters it into the ECM system. When the unit nurse reviews Brown’s data on the computer, she notices that her marital status is incorrect and electronically flags the admitting department to make the correction. Someone in the admitting office immediately makes the change. The date and time of the change is automatically logged and noted in Brown’s electronic file.

The next time the nurse opens the electronic file, she sees that the error has been corrected without making a single phone call or sending an e-mail. Although Brown’s prescriptions are not in the ECM system, they are in a separate system that her care management team can access at any time. Radiology and laboratory tests are also electronic and easily accessed via Brown’s case management file. Her physician receives a daily summary of the care management team’s actions featuring all entries in reverse chronological order, making it easy to review and monitor her process.

Several days later, a discharge coordinator is preparing for Brown’s upcoming release. The coordinator has made arrangements for Brown to be transferred to a local rehabilitation center. The insurance company has given its approval, and the case manager notes this electronically. However, Brown is adamant that she can take care of herself at home and refuses to go to a rehab center. This conversation is also noted in the ECM.

Three days after her discharge, Brown returns to the ED where the social worker pulls up her file and notes that the patient was recently discharged from the hospital and refused to be admitted to a rehab center. The social worker can review Brown’s progress and the care plan, as well as the diagnostic tests and medications. After speaking with the rehab center and Brown, she arranges for the patient to be transferred directly to the rehab center, bypassing another hospital stay.

Without ECM, the ED social worker would have needed to locate Brown’s paper file, call discharge planners and case managers to determine what arrangements had been made for Brown’s release, and find out why she was back in the ED. She also would have had to call the insurance company to see if it would approve the patient’s transfer to a rehab center.

Since all this information was readily available, there was no need to make calls, except to the rehab center to see if a bed was available. As a result, Brown is transported to the rehab facility in a timely, efficient manner because the social worker had immediate access to her medical records.

Going Paperless
Harris Methodist’s goals for going paperless, according to Finley, were to improve throughput management, reduce patients’ overall length of stay, improve the discharge process, and increase staff productivity through information management tools offered by the Canopy Care Management Solution, an Allscripts solution installed at the hospital in 2006. Finley notes that Harris Methodist is still refining and enhancing the system as it applies to all the available tools to maximize capabilities and use.

Middle Tennessee Medical Center in Murfreesboro and Nashville’s Baptist Hospital, both part of St. Thomas Health Services, chose ECM to improve their efficiency and the ability to communicate with staff members. Both hospitals simultaneously redesigned their care management departments and implemented ECM in 2005.

“When you deal with a 100% paper system, it’s hard to track everything; it’s very time-consuming and not cost-efficient, nor is it very productive,” explains Lisa Flamm, Middle Tennessee Medical Center’s director of care management. “We wanted a system with a database to maintain information so we could instantly research what we did for a patient on a previous visit.”

Middle Tennessee and Baptist already had Midas software in use in their quality review departments. After reviewing other ECM systems, they chose the Midas case management module based on its performance and applicability in quality review. Shortly thereafter, an IT team at each hospital followed the care management team members and mapped their processes.

“They took each step of our process and analyzed how to keep the process flowing electronically rather than on paper,” says Flamm. “Then the IT team worked that step into the system to make sure it would give us what we wanted. That took six months.”

Since Middle Tennessee was unit-based, IT had to program unit names and room numbers into the system to populate the program for case managers so they could pull up a list of all patients in each unit.

“It truly was building the program from the ground up,” says Flamm. “The beauty of the system is that as we developed it, we created our communication system. We have a way to track and know that communication took place and that changes are made to a patient’s record when something is incorrect.”

Jeff Marvel, director of care management at Baptist Hospital, notes that Midas has enabled the facility to legibly document notes for the treatment team and collect core measures information by documenting and tracking core measures patients and ensuring that they receive the care they need. ECM also allows them to ensure that patient treatment criteria are being met and they are billing properly according to Medicare.

Improvements in Care
Looking back on the implementation of ECM at Middle Tennessee, Flamm recalls that it went better than she expected. Some of her 12 staff members had been there for more than 25 years, so they had to become comfortable with using the computer and then taught the basics before training could begin on the Midas system. Today, some of those staff members are Flamm’s best Midas users. The business office and admitting office staff were also taught to use Midas.

One of the biggest improvements resulting from the new system at Harris Methodist is in managing patient flow. The automated case management tool helps the case management team identify and prioritize activities. It also identifies high-risk, high-cost patients who will benefit the most from focused case management and discharge planning activities. These patients can be placed into specific episode tracks for optimal care coordination. Also, the system enables case managers and social workers to manage multiple patients and priorities, says Finley.

“We can review information quickly and discuss the most likely discharge plan for each patient. We know in the first 24 hours if a patient needs more care planning,” explains Finley. “We can pull information from Canopy by unit, case manager, or discharge planner to evaluate clinical information, level of care criteria, and projected discharge plans. Canopy helps us organize and manage all the important information we need to coordinate patient care safely and effectively. Additionally, there are tools to help us track and trend the types of patients we serve, demographics, and diagnosis by working DRGs [diagnosis-related groups], the number of patient days, discharges, referral patterns, and avoidable patient days. Alerts can be customized to patients with high-risk triggers.”

The goal at Harris Methodist is to try to manage resources efficiently while ensuring patient outcomes, according to Finley.

At Middle Tennessee, Flamm agrees that ECM benefits are invaluable. “We had no clue of the benefits that would come from electronic case management,” she says. “We can now effect change and connect the dots between admission and discharge. We can see our successes, and we can see our areas for opportunity. The patients benefit. They don’t have to answer a lot of questions because we can see what arrangements were made for their discharge.”

Marvel explains that ECM has affected other levels of patient care by simply providing his care management team with a single place to input all information about each patient. Case managers, nurses, social workers, discharge workers, and utilization review staff can all access staff notes on activities with the patient without having to wade through paper pages of information that are irrelevant to them. Because information is immediately accessible, decision making is faster, which in turn expedites patient care.

“Midas helps us continue to improve our internal efficiency,” he explains, “mainly in the ability to have a reservoir of information to provide communication to our patients and physicians and print information for charts. It enables us to have report structures that allow us as an organization to review what we have done and what we could improve on. One of the most noticeable areas of change that Midas has brought about is its ability to have an effect on our do not final bill process, to expedite the throughput of claims, which has a positive effect on our revenue cycle.”

“I think anytime that you can improve communication and improve the efficiency of a process, impact the length of stay and improve throughput in a hospital, you can affect the bottom line,” says Flamm. “With Midas, we are able to provide better quality outcomes for patients.”

— Laura Gater’s medical and business trade articles have been published in Healthcare Traveler, Radiology Today, Corrections Forum, Credit Union BUSINESS, and other national and online publications.