1. Time to Improve Your ED Throughput - Part I
5 Steps to Select the Right Technology
Maureen Anderson, MD, Physician Executive
1

2. Today‟s Presenter
Maureen Anderson, M.D.
T-System Physician Executive
Dr. Anderson is a practicing physician at
William Beaumont Hospital in Troy,
Michigan and a physician consultant for T-
System. She provides input and strategy
for new services and solutions designed to
enhance the performance of emergency
departments. She also works with clients
to help them leverage our products to
optimize clinical quality and efficiency.
Smarter Emergency Care: everywhere, every

3. Low Throughput Has Negative Implications
for EDs
Patient Patient Revenue
Safety Satisfaction Reduction
• Longer waits increase • Time to provider most • Each LWS costs $300-
morbidity important to patients $500
• EDs on diversion may • Each ambulance
increase mortality for diverted costs >$3000k
MI patients
75/100 dissatisfied Tell 465 potential patients
patients
Smarter Emergency Care: everywhere, every

4. Current Trends Are Further Exacerbating
The Issue
• Healthcare Reform
– More patients in the ED
– MU is promoting EHR
adoption which doesn‟t
promise support of ED
processes
• ICD-10
– Requiring documentation of
more specific information
• ACO / Initiatives to keep
patients in-network
With the right strategy, EDs can provide evidence-based,
efficient and compassionate care
Smarter Emergency Care: everywhere, every

5. Significant Financial Incentives for Improving
Throughput
Metrics Results
• 50,000 APV ED • Reduced LOS by 60 min
• Avg LOS of 200 min – New LOS 140 min
– 50,000 hours of increased ED
• Physician group capacity
– bill $100 per patient – 21,739 in potential new visits
• Facility • Physician group increases
revenue by
– Bill $500 per ED visit
– $2,173,900
– Bill $3,000 - $7,000 per
inpatient admission • Facility increases revenue by
– $8,696,000 for discharged
patients
– $13,041,000 for admitted
patients
Smarter Emergency Care: everywhere, every

6. 5 Steps to Select the Right Technology
1. Build your team
2. Define your needs
3. Look for key attributes
4. Understand requirements
5. Measure the ROI
6

7. 1. Build Your Team
Who needs to be involved?
Supportive and engaged Other key stakeholders
leadership
• CIO • HIM / coding
– How will it fit enterprise system
strategy – How will system support
– Plan for support resources efficient coding and billing
– How will it support key priorities • ED medical director
such as MU, ICD-10, ACO
– How will physician group
• CFO
productivity and
– What financial savings and
growth will result reimbursement be impacted
– Adequate funding for training, • ED nurse director
upgrades
– Own and drive plan for ED
• CNO / CMO
workflow and management
– How will it support quality
initiatives and care coordination • Frontline providers
Smarter Emergency Care: everywhere, every

8. Assess “Readiness” for a Change
• As a facility/organization
 Clear vision/direction/goals
 Strong/committed/engaged leadership
 Resources; financial/IT
• As an ED
 Leadership
 Staff buy-in
 Staffing levels
 ED space/layout
Smarter Emergency Care: everywhere, every 8

9. Working Together
Assess, re-assess, fine-tune and celebrate
1. Define desired outcomes and prioritize
– Understand motivation and communicate benefits for each
member
2. Define potential project barriers and plan to address
– Technology proficiency and adoption
– Conflicting projects
– Travelling clinical staff / high turnover
– Staffing levels
3. Define baseline
Smarter Emergency Care: everywhere, every 9

10. 2. Define Your Needs
Can Technology Help?
• Dictation/Scribe cost
• Illegible or incomplete records
• Lost charts/lost revenue/undercoding
• Prolonged los
• Capacity; volume/space mismatch
• IPD Bed Availability
• Safety/cleanliness of the ED/Waiting Room
• Inadequate staffing
• Patient Satisfaction
• Medication errors
• Medicolegal risk/Quality issues
• Meeting regulatory requirements
• Communication across the continuum of care
• Variability in clinical practice/documentation
Smarter Emergency Care: everywhere, every 10

11. 3. Look for Key Attributes
• Intuitive
• Flexible
• Robust, ED-appropriate
content to minimize
typing and clicking
Smarter Emergency Care: everywhere, every

12. • Provides cues without
causing alert fatigue
• Supports communication
between all team
members
• Features that support
rather than impede
workflow
Smarter Emergency Care: everywhere, every 12

13. EDIS Functionality: ED Workflow
Features Objectives
• Registration • Maintain EMTALA compliance
• Tracking • Allow for non-sequential, parallel processes
• Task Management • Provide data and information to identify bottlenecks
• CPOE & • Identify patients and procedures exceeding time thresholds
e-prescribing • Provide visual queues for next steps in workflow
• Discharge planning • Allow for seamless transition of care
• Streamline and standardize order process
Smarter Emergency Care: everywhere, every

14. EDIS Functionality: Clinical Documentation
Features
• Triage, physician/nurse/ancillary
• Clinical decision support
Objectives
• Allow consistency and efficiency
• Reduce or eliminate free text
• Help providers make evidenced-based
decisions faster and easily document their
MDM and ED course
• Present information sequentially and one a
single plane
Smarter Emergency Care: everywhere, every

15. EDIS Functionality: Data / Integration
Features Objective
• ADT / Lab / Radiology • Integrate with clinical and
• Patient monitors business applications to
reduce duplication of
• Medications and allergies
information in disparate
systems
• Reduce re-entry of information
that already exists
• Support current and future ED
and hospital workflow and best
practices
Smarter Emergency Care: everywhere, every

16. EDIS Functionality:
Management & Reporting
Features Objective
• Patient load • Accurate, actionable reports to
• Patient flow (Throughput)
enhance
• Staff productivity
– Throughput
– Patient safety and outcomes
– Patient satisfaction
– Staff efficiency
– Staff satisfaction
– Identify opportunities for
improvement
Smarter Emergency Care: everywhere, every

17. 4. Understand Requirements
• Server needs or remote • In-house or HIS or other • On-site, remote, travel
hosting • Trainer and end-user
• Vendor staged or in-house training
staging resources
Hardware Training
Interface work
needs, staffing resources and
and time line
and time
requirement
expenditure requirements
• Design time and resource • Site specific fields, reports
availability
Customization
Content build
time and
requirements
requirements
Smarter Emergency Care: everywhere, every 17

18. Potential Pitfalls in Selecting an EDIS
Partner
• “Product flexibility”-Total cost of ownership
• “Staged deployments”
• Vaporware
• Make sure to actually try out the product to assess
usability in your clinical environment.
• Consult KLAS and other references
Smarter Emergency Care: everywhere, every 18

19. 5. Measure the ROI
Setting Baseline Performance
Capturing Facility Metrics
Patient Population Charting HIM
• ED annual patient volume • Annual lost charts not billed Facility CPT
Utilization
Code
• Revenue per discharged / admitted • Annual cost to find lost
patient 99281 8%
charts
99282 22%
• LOS for discharged / admitted patients • Annual cost of paper /
(min) dictation 99283 25%
• % patients discharged / admitted • Annual cost of discharge 99284 17%
instructions
Radiology/Lab
99285 23%
• Clerical FTEs required to 99291/99292 5%
manage paper charts
• Infusions down-coded to IV pushes
per month
• % of charts incomplete
Payor Mix
• Coder time to rework
• Infusions not billed per month incomplete charts (minutes • Medicare (% of APV)
• Denied radiology claims per week per chart) • Medicaid
• # of patients with denied lab claims per • Nursing time for follow-up • Insurance
week calls (minutes per call) • Workers
• % of patients that require Compensation/Other
• % of patients that require „Imaging
Only‟, „Labs Only‟, „Imaging and Labs‟ nursing follow-up calls • Self Pay*
Smarter Emergency Care: everywhere, every 19

20. Setting Baseline Performance
Capturing Physician Metrics
Physician Group Billing Metrics
Operational
• Cost of dictation Professional Fee
Utilization
Billing Level
• Cost of paper documentation Level 1 0%
• Annual cost to find lost charts so Level 2 1%
they can be billed Level 3 29%
• Clerical FTEs required to manage Level 4 31%
paper charts Level 5 36%
Critical Care 3%
Smarter Emergency Care: everywhere, every 20

21. Calculate Expected ROI
One Hospital’s Results with T SystemEV
Anticipated ROI (All Benefits) Payback period: 4.3 months
 8X ROI Investment: $189K Year 1
 Good breadth and distribution 3 Year ROI: 744%
Top Benefits (Annual Value):
 Reduces TAT on radiology and lab results Benefits by Value Driver
(facility benefit) = $651K
31%
 Improves infusion charge capture (facility 59%
benefit) = $529K
 Improves support for facility charge levels
(facility benefit) = $496K 5%
5%
Optimize Revenue Capture
Reduce Cost of Care
Increase Operational Efficiencies
Improve Quality of Care/ Patient Safety
21

22. Key Takeaways
Addressing throughput issues requires a multipronged strategy
Technology is not enough without the right team planning and
processes that make the most of new automation capabilities
Not all technology is equal – must support the unique workflow
of the ED and gain adoption
Smarter Emergency Care: everywhere, every 22

23. Q&A
Join us for Time to Improve Your ED Throughput Part II:
6 Effective Strategies Across the Patient Experience
Thursday, Oct. 11, 2012
9 a.m. PT, 10 a.m. MT, 11 a.m. CT, 12 p.m. ET
Click here to register now

24. Time to Improve Your ED Throughput - Part II
6 effective strategies across the patient experience
Cheryl Ann Graf, ARNP, MSN, MBA – Client Relationship Executive
Maureen Anderson, MD – Physician Executive
24

25. Today’s Presenters
Maureen Anderson, M.D.
T-System Physician Executive
Dr. Anderson is a practicing physician at William
Beaumont Hospital in Troy, Michigan and a
physician consultant for T-System. She provides
input and strategy for new services and solutions
designed to enhance the performance of
emergency departments. She also works with
clients to help them leverage our products to
optimize clinical quality and efficiency.
Cheryl Ann Graf, ARNP, MSN, MBA
Client Relationship Executive
Cheryl is a nurse practitioner that currently
works in 4 client sites, and is a Client
Relationship Executive for the T-System.
She has worked at the T-System for 5 years
and has 25 years of ED practice in WA.
Smarter Emergency Care: everywhere, every

26. Low Throughput Has Negative Implications
for EDs
Patient Patient Revenue
Safety Satisfaction Reduction
• Longer waits increase • Time to provider most • Each LWS costs $300-
morbidity important to patients $500
• EDs on diversion may • Each ambulance
increase mortality for diverted costs >$3000k
MI patients
75/100 dissatisfied Tell 465 potential patients
patients
Smarter Emergency Care: everywhere, every

27. Current Trends Are Further Exacerbating
The Issue
• Healthcare Reform
– More patients in the ED
– MU is promoting EHR adoption
which doesn‟t promise support of
ED processes
• ICD-10
– Requiring documentation of more
information – (stat on negative
impacts to productivity =
throughput)
• ACO / Initiatives to keep
patients in-network
With the right strategy, EDs can provide evidence-based,
efficient and compassionate care
Smarter Emergency Care: everywhere, every

28. Significant Financial Incentives for Improving
Throughput
Metrics Results
• 50,000 APV ED • Reduced LOS by 60 min
• Avg LOS of 200 min – New LOS 140 min
– 50,000 hours of increased ED
• Physician group capacity
– bill $100 per patient – 21,739 in potential new visits
• Facility • Physician group increases
revenue by
– Bill $500 per ED visit
– $2,173,900
– Bill $3,000 - $7,000 per
inpatient admission • Facility increases revenue by
– $8,696,000 for discharged
patients
– $13,041,000 for admitted
patients
Smarter Emergency Care: everywhere, every

29. Opportunities for Performance Improvement
at Each Stage
Registration MD Discharge / Call
& Triage for Bed
Pre ED Placement Patient Handoff
Disposition
EMS or Door to Doctor to Decision to
or
Walk-in Doctor Decision Dispo
Discharge
Room
Utilization
29

30. Smarter Emergency Care: everywhere, every 30

31. #1 – Pre ED: Redirect Patients To Most
Appropriate Settings
• EMS pre-triage and transport to
appropriate healthcare provider
• Mobile units provide regional care
• Provider at triage performs MSE
and directs patient accordingly
Smarter Emergency Care: everywhere, every

32. Using Technology to Direct Patients and
Provide Pre-notification of Their Arrival

33. 33

34. #2 – Registration & Triage: Creating a No
Wait ED
• Patient pre-notification
• Quick registration
• Rapid triage
• Provider at triage
• Patients pulled to open beds
• Vertical patients remain
vertical
• Order sets/protocols
Smarter Emergency Care: everywhere, every

35. Fast Track System at
Grady Health System, Atlanta, Ga
How they did it Outcomes
• Patients with acute but non- • 2 hour reduction in Fast Track
life-threatening conditions to throughput
be treated more quickly and • 1/3 increased productivity
then released
• 50% decrease in avg time from
• Sort patients by status and arrival to bed placement
indicate services required
• 19% decrease in avg time from
• Mid-level or nurse more active bed placement to initial exam
to make sure patients receive
needed tests.
Source: http://www.rwjf.org/qualityequality/product.jsp?id=29978
Smarter Emergency Care: everywhere, every 35

36. #3 Door to Doctor: Rapid Medical Evaluation
The What The Vision
• Treatment process • Metrics can improve and you
begins immediately
can make the difference
– Initial assessment
– Ordering of labs, DI • Sites have reduced TTP from
• Some cases have 10-80 minutes
rapid discharge • Increased patient/family
without using a bed
satisfaction scores
• Patients placed
immediately in a bed • Increased revenues both
and provider
examination hospital and provider
completed
• Every dept must own the
• ED culture change
process
Smarter Emergency Care: everywhere, every

37. RME: Case Studies
This 99-bed, acute care facility decreased its TTP
After reengineering its front-end process, this
to 8 minutes and increased its Press Ganey
ED experienced a 75% decrease in TTP from 100
Patient Satisfaction Percentile Ranking from the
to 25 minutes.
25th to the 85th percentile.
By creating an RME team consisting of a
Through a number of modifications, including physician provider, triage nurse and an ED
the addition of wireless bedside registration, Technician, this ED team found its TTP
this ED reduced its TTP from 100 to less than 40 decreased more than 70%, its LWBS percentage
minutes. reduced by 55%, and its diversion hours per
month diminished by 75%.
Smarter Emergency Care: everywhere, every

38. #4 – Doctor to Decision:
Bedside Documentation/CPOE
38

39. #5 – Patient Hand-off:
Active Management of Processes
Reduce readmissions and improve efficiency at
hand-off
• Physician outreach process – Optimize for admitted
and discharged patients
• Case management process – identify and flag
patients at highest risk of re-admission
Transferred
Admitted Medical Home
Registration Triage Treatment Discharged
(in-patient) Hand-off
ED Discharge
Smarter Emergency Care: everywhere, every 39

40. Workflow Automation Technology to Improve
Hand-off and Reduce Avoidable Readmissions
40

41. #6 - Realigning Staffing to Peak Times
41

42. Throughput Technology to Calculate ED
Statistics and Trends
42

43. 43

44. Key Takeaways
Throughput can be addressed at every stage
Addressing throughput issues requires a
multipronged strategy
Specialized technology can help identify
bottlenecks and streamline processes
Smarter Emergency Care: everywhere, every 44