Unique computer system to help patient care in America

Like a chain with many fragile links, the care of every hospital patient in America is made up of dozens, even hundreds, of daily interactions and handoffs between the doctors, nurses, therapists, residents and medical students who care for them. The chain extends out of the hospital, too, into the offices of a patient's primary and specialty care doctors, their pharmacy, their insurance company, and beyond.

And every link, or handoff, takes time, costs money, and poses a risk of problems with information transfer. One weak link can jeopardize a patient's health and safety.

But new research results show that a unique computer system developed and implemented at the University of Michigan Health System can strengthen the entire chain. The system, in turn, reduces risks while saving time and money, and improves the quality and continuity of patient care, and patients' education and satisfaction.

The secure, Web-based system creates a virtual workspace for all members of a patient's in-hospital health care team, and gives information automatically, quickly and accurately to those who will care for the patient when he or she goes home.

At the annual meeting of the Society for General Internal Medicine here on May 15, U-M researchers will demonstrate the system, called the Discharge Navigator, and discuss the randomized, controlled study involving 700 patients that shows its value.

Among their findings: The system reduced by six days the time it took for a patient's personal physician to get a report on the patient's hospital stay; far more information was entered into a patient's record for current and future use; physicians had to dictate 77 percent fewer discharge reports; transcription costs dropped accordingly; and patient satisfaction scores on post-hospitalization surveys jumped substantially.

The four-month trial involved two hospital units where the Discharge Navigator was added to the U-M's existing electronic medical record system, called CareWeb, and two comparison units where it was not. All the hospital units were part of the general medicine service of the U-M Department of Internal Medicine, and treated patients with a variety of medical problems. The two comparison units have since begun using the system, and other areas of the U-M's three hospitals will start this summer.

"The system lets the whole team communicate through a central information space, automates time-consuming and hand-written reports, and means that there are fewer cracks for things to fall into," says lead author J. Michael Kramer, M.D., M.B.A.

Kramer, who will present the results at the SGIM meeting, and who serves as the physician lead for integrating the U-M Health System's clinical systems, adds, "The system allows us to make sure that patients get clear instructions for what they're supposed to do when they go home, makes sure that the referring physicians who will care for them get the right information fast, and in general helps improve the timeliness and the quality of any transfers of health information about a patient."

During his residency and fellowship at U-M, Kramer was part of a massive team of clinicians, information technology specialists, referring physician communicators, and others that developed the Discharge Navigator over the last four years and implemented it last August. The system's development was funded by grants from two UMHS initiatives: the Operations Improvement Council and the Collaborative Health Services Research for Practice Improvement program.

Now a clinical assistant professor of internal medicine and pediatrics, Kramer worked with William Bria, M.D., to apply for and use a grant from the Aetna insurance company to study the Discharge Navigator's effect on patient care and costs as it replaced antiquated documentation systems.

Bria, an assistant professor of internal medicine and medical director of clinical information systems in the Medical Center Information Technology division, says, "When you look at the complex process of the workflow in a modern hospital setting, this shows how automation can improve what we do. With Discharge Navigator, everybody involved in a patient's care has the same accurate information about that patient, and they don't have to guess or ask what others are thinking or planning while a patient is in the hospital and before he or she is discharged. It takes a process that's fraught with potential error and repetitive tasks, and tries to provide something better."

The system provides a way for hospital clinicians to meet four important challenges facing health care today: the increased number of daily handoffs between medical residents caused by new mandatory limits on resident work hours; the insurance-driven mandate to keep hospital stays as short as possible; the need to know all of the medications a patient was taking before he or she came to the hospital; and the push to reduce near-miss incidents and improve patient safety.

"It's a rare situation where the incentives of all the important stakeholders all fall in line – those who pay the bills, the hospital administration, clinicians in and out of the hospital, and the patients themselves," says Mark Fendrick, M.D., a professor of internal medicine and health management & policy who helped champion the system during its development and led the study's design.

The Discharge Navigator team notes that their Web interface "isn't Star Wars," as Bria puts it, but even if the screen appearance is pretty basic, the power of the tool itself is formidable. The Careweb and Clinical Data Repository systems on which U-M's electronic medical record is based already move terabytes of data each day, and the Discharge Navigator will add much more to that.

But Fendrick notes that the new study results show it's worth the computing power. He contrasts the UMHS experience with Discharge Navigator with the approach to commercially available computer systems being taken by other hospitals.

"Too often, people will buy into hardware and software without first seeing any clear evidence of benefit from its implementation," he says. "We tried to show from very beginning that there are benefits to this system, and we have."

As the system is rolled out into the other areas of Internal Medicine, and from there into Surgery, Pediatrics and other areas of the three U-M hospitals, the team looks forward to getting suggestions from those who are using it. And, they look forward to integrating it into the computerized physician order-entry system that UMHS will start bringing online in the next two years. They're also welcoming visitors from other medical centers who want to explore developing their own system.

In all, Discharge Navigator allows the generation of four reports: signout reports that must be completed for each patient every time a resident finishes a shift, a discharge report for the patient's medical record, a discharge summary for the referring physician, and a nursing education report.

As part of collecting information for these reports, the system provides a way for residents to document a patient's progress in online notes that can then be accessed by any other member of the team, even long after the resident has gone home. Templates that can be copied and pasted for routine issues cut down on typing time. Information entered once serves many purposes.

There are 12 categories of tasks that can be filled in and completed by anyone caring for a patient, and members of the team can all see what has been done, and what hasn't. Team members can import prescription lists from a patient's regular doctor if he or she is part of UMHS, and type draft notes that they can return to before finalizing them and entering them officially.

Clinicians can also add to the Problem Summary List, the U-M electronic medical record's ever-growing list of what tests, procedures, diagnoses, medications and underlying conditions the patient has had. The study results show that physicians on the Discharge Navigator units contributed several thousand more entries to patients' PSLs than those on the comparison floors, most likely because the system makes it easy to do so. This resulted in more complete medical records.

The Discharge Navigator system also sends the patient home with everything he or she needs: clearly typewritten instructions about health conditions, medication schedules, and preventive measures, upcoming outpatient appointments, and prescriptions that are printed from a computer, rather than written in a doctor's chicken scratch handwriting. Kramer hopes, but does not yet have data to prove, that this will reduce the high number of calls to physicians from pharmacists trying to interpret and verify prescription information.

These tangible signs of coordinated care, as well as the intangible feeling of having a medical team that's sharing information, may have contributed to the seven-point jump in Press Ganey Patient Satisfaction Scores that was seen on the general medicine service after Discharge Navigator was implemented on two of the four units.

The system also fosters better collaboration among doctors and nurses during a hospital stay, and on discharge day. The system reduces the number of clerical tasks that nurses have to perform, potentially freeing them up for more time with patients. And when it's time for a patient's pre-discharge discussion with the nurse, nurses have easier-to-read typewritten physicians' reports and patient medication lists and education materials, rather than handwritten ones.

Even as patients leave the hospital, Discharge Navigator communicates with the physicians who sent them there, and who will care for them once they get home. Since many post-hospital office visits take place within days of discharge, this handoff must be fast in order to aid patient care.

UMHS has put a major emphasis in recent years on giving referring physicians better, faster information, using the M NET system that faxes reports to their offices as soon as they're available. But often, days or even weeks would pass as hospital nurses and physicians filed the reports and dictations, then the information was transcribed and entered into the patient's medical record by records staff, and then made into a report to be sent out over M NET.

With Discharge Navigator, the hospital discharge report goes immediately into a patient's electronic medical record, with no dictation or transcription. In the study, these a discharge summary arrived in the patient's medical record on average 1.2 days after a patient went home from the hospital, and often on the same day as the discharge. The average on the comparison units was 7.6 days. These documents were then sent to referring physicians in a more rapid fashion.

The reports were designed with input from referring physicians, who want "bottom-line" information: test results, diagnoses and prescription information. The Aetna grant is funding a survey of referring physicians, to see how they feel about the new system. Those results are still being analyzed. https://med.umich.edu/