Experiences and Metrics for Calculating Return on Investment

September 20, 2013

©2013 HIMSS 2

Experiences and Metrics for Calculating Return on Investment

Contributors

• Ángel Blanco RubioOrganizationandProcessesDirector.Idcsalud.

• Miguel CabrerHIMSS(HealthcareInformationandManagementSystemsSociety)-EuropeGoverningCouncil.

• Julio Díaz OjedaDeputyDirectorofInformationSystemsandTechnologies.HospitalRegionalUniversitarioCarlosHaya(CarlosHayaUniversityRegionalHospital).

• Vicent Moncho MasDirectorofInformationSystems.HospitalMarinaSaluddeDénia(MarinaSaluddeDéniaHospital).

• Manuel Pérez VallinaSeniorAdvisor.HIMSSEurope.

• Carlos Piqueras PicónHealthDirector.Intel.

• Jesús Redrado RedradoDirectorofInformationSystems.ClínicaUniversidaddeNavarra(UniversityHospitalofNavarra).

• Guillermo Vázquez FernándezDeputyDirectorofInformationSystems.ComplexoHospitalarioUniversitarioACoruña(ACoruñaUniversityHospitalComplex).

• David Vidal FernándezDirectorofInformationSystems.HospitalClínicBarcelona(HospitalClinicBarcelona).

Mediapartner

©2013 HIMSS 3

Contents

Introduction 4

Purpose of the document 5

Automation of administrative processes and work in real time 6

Management of requests: Referrals 9

Digital imaging 13

Hospital medication process 15

Management of complex treatments in the day hospital 18

Nursing care management 21

Improves surgical planning 24

Clinical decision support systems 27

Non face-to-face services 30

©2013 HIMSS 4

IntroductionCost,value,return,inshort,measurement.Itisimpossibletoconsidercarryingoutanybusiness-relatedactivityorserviceproperlyiftheseconceptsarenotonthedecision-makingagenda.Beingabletomeasurethevaluegenerated,toplantheenvironmentinwhichthemultipliereffectofaninvestment’svaluewillbeofthegreatestbenefittousers,andtoachievethemaximumreturnoninvestmentwithinitseconomicdimension,hasbeentheobjectiveofhealthmanagersanddecision-makersforyears.

Thereisaneedtoassesstheimpactoftheeconomicsituationonhealthcare.Theenvironmentofstableorgrowingdemandcontainsfactorsthatputpressureonexpensereduction.Thesefactorsmakeitnecessarytogobeyondtheobviousandtosearchfortheperfectsolutiontoincreaseefficiency,withinnovativeproposalsandbravemanagementdecisions.

Inaddition,inhealthcaresystems,costreduction,improvementofprocessesandinnovationortheimplementationofinformationandcommunicationtechnologies(ICT)areamuchhigherprioritythanmaintaininganequilibriuminthebalancesheetorreorganization.Fordecades,healthcareeconomists,healthcareITpersonnel,planners,andclinicalandnursingdirectorshavemadestridesintheestablishmentoftheconceptof“healthcareoutcomes”,inwhichimprovementineconomicindicatorsisalsototheadvantageofpatients,throughamorepersonalizedcare,avoidingunnecessaryactions,orimprovedinformationinthehandsofprofessionalsandthepatientsthemselves.

Withoutadoubtoneofthemostprevalentideasinthisenvironmentisthatthemassivedeploymentofinformationandcommunicationtechnologiesinthehealthcarefieldleadstocostsavings,improvespatientsafetyandintegratescarelevels.Eventhoughitispracticallyadogma,theideaitselfisnotenough:themanagersanddecision-makersneedtomeasureit,andtheallocationofresourcesisnowmoreofastrategictaskthanever.

ThisiswhyROI(ReturnOnInvestment)initsmoreorthodoxeconomicdimension,orwhenitisassociatedwithimprovementsinsatisfactionandpatientprocedures,isaconstantinallinformaloracademicdiscussionsabouthowtomaintainthequalitystandardsforwhichSpanishhealthcareisgloballyrenowned.

TheattentiontocostsandthecalculationoftheseisaregularaccompanimentofICTinvestmentsinhealthcare

institutions.However,themonitoring,measuringandverificationofthesuitabilityoftheseprojectsovertime,onceintroduced,isnotcommonpractice.

AtHIMSSEurope,incollaborationwithIntel,wehaveformedagroupofCIOs(ChiefInformationOfficers)tocarryoutanexercisethatcangivevaluetotheICTs(InformationandCommunicationTechnologies),whicharecurrentlysetupinhealthorganizations,aswellasimplementationplansthroughoutthecontinent.

WhattoolsdoesaCIOhaveinordertoprioritizetheirinvestmentprojects?HowdoyouconvincemanagementthattheICTpathleadstocostreductioninhealthorganizations?HowdoyoumeasureincreasesinpatientsafetyasprovidedbyacomprehensiveandintegratedElectronicMedicalRecord?ArethereobjectivereasonsforgivingpreferencetoICTinvestmentsoverhospitalequipment?Theseandotherquestionsariseintheday-to-dayofhealthorganizationsasanelementofdiscussion,prioritizationanddisputeaboutresourceallocation.

ROI = (Gain from investment - Cost of investment)

Cost of investment

©2013 HIMSS 5

Purpose of the documentTherefore,itisnecessarytomeasurewiththeutmostrigor,keepinginmindthedifficultyofquantifyingsomeoftheresults,andthatitmaynotalwaysbepossibletoestablishaone-to-onerelationshipbetweenanactionanditsresult,especiallyinverycomplexorganizationalecosystemssuchashospitals.

Suchcomplexitymeansthatthedeploymentoftechnologyalonewillnotbeabletoimproveprocessesorresults.Inaddition,theresultsobtainedhaveamulti-factorialorigin.Theyrequirepeople,processesandsystemsanditisnotalwayspossibletodeterminethespecificweightofeach.

Anobjectiveorbusinessneedtocovercostsavings,healthcarequalityandsafetyimprovements,andprocessefficiencyimprovements,etc.,willrequirepeopleandprocessestobedefinedandorganized,aswellastheInformationSystems(ICT),inorderforthemtojointlyrespondtothisobjectiveorneed,providingaddedvaluetotheorganization.

Themarketproposestechnologicalsolutionsfor99%oftheproblemsbutitisimportanttorememberthatpeopleandprocessesarethekeyfactorintheseprojects:thetechnologyismerelyameans.

Thepurposeofthedocumentis,therefore,topresentinterestingcases,whichhavebeensummarizedbuthaveanappropriatelevelofunderstanding,withoutsacrificingthecomplexityoftheideas,orthestringencyoftheconclusions.ThesecasesshouldgeneratewithintheICThealthcarecommunityaninterestinmeasuringandadvancingresultsinprojectplanning.

Therefore,itisnecessarytomeasurewiththeutmostrigor,keepinginmindthedifficultyofquantifyingsomeoftheresults,andthatitmaynotalwaysbepossibletoestablishaone-to-onerelationshipbetweenanactionanditsresult,especiallyinverycomplexorganizationalecosystemssuchashospitals.

Suchcomplexitymeansthatthedeploymentoftechnologyalonewillnotbeabletoimproveprocessesorresults.Inaddition,theresultsobtainedhaveamulti-factorialorigin.Theyrequirepeople,processesandsystemsanditisnotalwayspossibletodeterminethespecificweightofeach.

Anobjectiveorbusinessneedtocovercostsavings,healthcarequalityandsafetyimprovements,andprocessefficiencyimprovements,etc.,willrequirepeopleandprocessestobedefinedandorganized,aswellastheInformationSystems(ICT),inorderforthemtojointlyrespondtothisobjectiveorneed,providingaddedvaluetotheorganization.

Themarketproposestechnologicalsolutionsfor99%oftheproblemsbutitisimportanttorememberthatpeopleandprocessesarethekeyfactorintheseprojects:thetechnologyismerelyameans.

Thepurposeofthedocumentis,therefore,topresentinterestingcases,whichhavebeensummarizedbuthaveanappropriatelevelofunderstanding,withoutsacrificingthecomplexityoftheideas,orthestringencyoftheconclusions.ThesecasesshouldgeneratewithintheICThealthcarecommunityaninterestinmeasuringandadvancingresultsinprojectplanning.

©2013 HIMSS 6

Automation of administrative processes and work in real timeMosthospitalshavealreadycomputerizedthebasicadministrativeprocesses,suchaspatientadmission,centralizedappointments,dischargeorregistrationofthemedicalepisodewiththerelevantcodification.Thishasmadeitpossibletoimprovecertainprocessesandstudythecenter’sactivity.

Inthissection,wedealwithsituationsthatincludereal-timemanagementcriteria,andtheautomationandeliminationofadministrativetasks.Thisinvolvesnotonlytheclinicalpracticebutalsothemanagementofandrelationshipwiththepatient.

• Arrangingappointmentsforfuturetestswhennecessary,withthepatientpresent.

• Avoidinglinesandadministrativedelayshelpsthepatienttohaveabetterperceptionofthehealthcaretheyreceive.

Aspartofthehealthcareprocess,whencreatingtheattendancenoteordischargereportthepatientisautomaticallygiven,viaacomputeralgorithm,thedayandtimeofthetests.Itispossibletochangethedetailsatthetimeifnecessaryortosimplyleavethemastheyare,andthesecanbeprintedonthedocument.Ifthepatientdecidestochangethemforanyreason,theycandosoatalaterdatebyanyavailablemeans,eitherinperson,byphoneifthereisacallcenter,byInternetoratspecificserviceterminals.

Ifsubsequentappointmentsareprocessedatthepatient’shomewewillgainanumberofbenefits,notonlyofaneconomicnature,whichhavebeenseenanddemonstratedintheIDC(IberiadeDiagnósticoyCirugía)healthcenters:

• Savingofadministrativestaffforappointment-makingorinformationtasks,beingabletoappointthesestafftomoreproductivetaskswithinthehealthorganization.Theexperiencegainedis1administrativeassistantforevery32,000appointments(assumingthatthereare150appointmentsperpersonperday).

• Improvementinpatientsatisfaction:theyonlyhavetogototheirhealthcenterorhospitaltoreceivehealthcare,ratherthanhavingtogothroughtheadministrativeproceedings.

• Itreinforcestheclinicalact.Aninstructionsuchas“check-upin3months”isaclinicalprocedure,but“check-uponSeptember16at11:00”givesfarmoreimportanceandaccuracy,withouttheneedforanadditionaladministrativeprocedureascarriedoutbyathirdpartywhohastothenrepeattheidentificationtasks,understandwhatneedstobedone,forwhenandthesignificancethereof.

CalculationofROIattheHospitalSurdeAlcorcón(SurdeAlcorcónHospital)

• TotalICTinvestmentproject €17,000

• Administrativehoursavoided 1,232

• Approximatecostavoided €19,000

• Annualcorporatemaintenance € 3,000

ROI = 112%

Contacting the patient when test results arrive

Thepresenceofthepatientisnotnecessaryinallhealthcareprocesses.

Methodology

Definingaresultsmanagementsystemmeansthatcertain“routine”taskscanbecarriedoutwithouttheneedforthepatienttobepresent:

• On-lineresults.Thepatientcanseetheirresultswithouthavingtotraveltotheclinic.

©2013 HIMSS 7

• Incaseswherenecessary,healthcarestaffcangetincontactwiththepatientwhenresultsarriveinordertodecideiftheface-to-faceconsultationneedstogoahead,ifthereisaneedtobringitforwardorpostponeit,maintainorchangethetreatment,explainthediagnosisorsubsequentsteps.

• Asamoreadvancedmechanism,remoteconsultationscanbecarriedoutwithaspecialist:referralsinthecenteritself,fromresidences,primarycarecenters,correctionalinstitutions,etc.

Results

• Adecreaseinunnecessaryface-to-faceconsultations:Thistranslatesintothereductionofwaitinglistsandgreaterpatientsatisfactionbypreventingunnecessarytraveltothehealthcenterorhospital.

• Advancedresultsreview.Whentheseoccurandnotwhenthepatientcomesforacheck-up.

Opensupchannelsofnonface-to-facecommunicationwithpatients:Appointments,administrativeproceedings,clinicalinformation.

Givesthepatientthenecessarytoolssothattheycancarryoutcertainadministrativeproceduresthemselvesandalsobemoreinvolvedinmanagingtheirownhealth.

Thesetoolscanincludemakingon-lineappointments,healtharchiving,sendingappointmentremindersviaSMSoremail.

ContactmechanismssuchastheappointmentremindersystemattheFundaciónJiménezDíazdeMadrid(TheJiménezDíazFoundationofMadrid),haveledtoadecreaseof7%inmissedfirstappointments(about640,000meansthecompletionof44,800moreappointmentsperyearwiththesameresources)and2%forsubsequentappointments(about270,000appointmentsmeansthecompletionof5,400moreappointmentsayear).Morethan1,000,000textmessagesaresentfromthiscentereachyearwithreceiptconfirmationandatacostof€70,000.

Initialconsultations Subsequentconsultations

Arrangedconsultations 640,000 270,000

Consultationsthathavenotbeenmissed 44,800 5,400

Averagetime(minutes) 25 15

Doctorhoursnotlost 18,666 1,350

Totalno.ofhoursnotlost 20,016

Estimatedcostofthesehours €706,000

Table I – Impact of the appointment reminder mechanism at the Fundación Jiménez Díaz de Madrid

ROI = 908.5%

Itshouldbetakenintoconsiderationthatthesefiguresareobtainedwithamaximumagreedwaitingtimeof15days,duringwhichperiodtheprobabilityofattendanceisveryhigh.Thelongerthewaitthemorethelikelihoodofnonattendance(oversight,decisiontogosomewhereelse,etc.)andgreatertheROI.

Anotherexampleistheeliminationofthelaboratoryappointmentandmanagementbasedondemand.

Fromascreeningrequestmadebyaphysician,apatienthasaguidancesystemanddoesnotneedanappointment.Viathesamemeans,thepatientgoestothecenterand,afterintroducingtheirhealthcardintothequeuemanagementkiosks,aworkflowistriggered,whichtransferstherequestdataandcommunicatesthepatient’spresencetothelaboratorysystem.Thepatientiscalledviathescreensputinplaceforthispurpose.

Advantages:

• Improvestheserviceprovidedtothepatient.Thereisnoneedtorequestanappointment;itmanagespatients’time.

©2013 HIMSS 8

• Lesswaitinginline.Thepatientdoesnothavetogetinline;theyarecalledinstead.

ROIcalculationattheFundaciónJiménezDíaz:

• ICTinvestmentindevelopmentandconfiguration €19,000

• ICTinvestmentHW,PCs,printers,labels,kiosksandmonitors €19,400

• Annualplatformmaintenance €5,000

• Hoursavoidedofhavingadministrativeassistantsatreception:3,600h(3administrativeassistantsonweekdaysfrom7to12).

• Approximatecostavoided €57,500

• Waitingtime:previouslynotmeasurable.Currently,15minutesmaximumondayswithapeakactivityof500samples.

ROI = 150%

Eliminate manual systems using informed consent biometric signatures

Theinformedconsentprocessisadoctor-patientprocedurewhichproducesadocumentthatservesasproofofthesameandwhichincludesbothsignatures.Thisdocumentrequiresamanualsignature,collection,archivingandsearchsystemtobemaintainedifnecessary.

Itsautomationisbasedonaperson’shandwrittensignatureascarriedoutonatouchscreencapturedevice,althoughitisnecessarytoreviewthelegalsettingineachcase.

Thecapturedevicerecordsparameterssuchasthespeedandpressuremadeduringthesigningandgeneratesacalligraphicpatternofthesignaturebasedontheseparameters.

Itrequirestheintroductionofdevicesforsigninginallareaswhereapatient’sorphysician’ssignaturemightberequired.

Results

• Economicbenefits:

� IntheHospitalReyJuanCarlosdeMóstoles(ReyJuanCarlosdeMóstolesHospital),aninvestmentof150devicesmeansaninvestmentrecoverytimeoffewerthan8months,assumingadailycollectionof500signatures.Maintainingamanualsystemwouldrequirebetween2-3people/yearforcollecting,archivingorscanning,indexing,retrieval,etc.

� Furthermore,itsavesonthecostswhichthephysicalspaceandpaperworkofamanualconsentfilewouldmean.

• Itprovidesincreasedsecuritytothemanagementsystemandsafe-keepingoftheconsentmaterial.

• Professionalsatisfaction:thepatient’sconsentcanbetraced.

InitialHardwareandSoftwareInvestment €31,750

Annualadministrativesavings €60,000

Table II – Biometric signature project at the Hospital Rey Juan Carlos de Móstoles

ROI = 89%

©2013 HIMSS 9

Management of requests: ReferralsIncludedinthehealthcareproceduresthatformpartofthedailypracticeofhealthcarepersonnelarefoundrequestsfordiagnosistests,consultationswithotherspecialistclinics,treatment,etc.Thesearecomplexprocessesthatcombineclinicalandadministrativetasks,theimplementationofanelectronicsystemtoreplacethepaper-basedprocessesandwhich,amongotherthings,monitorsthefollowingresults:

Request management objectives

Quality of care

Economic

Savings of time

Increase in patient safety

Recording of compound requests

Reduction in response times

Prevents unnecessary tests

Prevents duplicate tests

Methodology

Tomeasuretheprofitabilityofthistypeofproject,itisproposedtocomparetheestimateofthepaperrequestsmanagementprocesswiththeelectronicprocess.Forexample,intheradiologytestsrequestprocesswecancalculatethetimeusedbyeachparticipantinanenvironmentthatusespaperandinanelectronicenvironmentfromthetimethedoctormakestherequestuntilthetestiscarriedout.

Results

TheHospitalMarinaSaluddeDéniacarefullystudiedthecaseoftherequestforreferraltootherspecialists.Itsresultsinclude,intableIII,anobvioussavingoftime,whichcontributesmoreeffectivelytotheprocess.

©2013 HIMSS 10

Referrals processPaper Digital Worse-casescenario Best-casescenario

Task Participant Cost Unit Participant Cost Unit

CarryOutRequest

IncluderequestinH.C. N/A Administrativeassistant

1 min Administrativeassistant

2 min

Notifythereferralsservice

Managementofthenotification

N/A Administrativeassistant

1 min Administrativeassistant

5 min

Traveloftheconsultanttothepatient’slocation

LendingoftheH.C.totheconsultant

N/A Administrativeassistant

1 min Administrativeassistant

5 min

H.C.Consultation

CarryOutReferral

IncludereferralsheetintheH.C.

N/A Administrativeassistant

1 min Administrativeassistant

2 min

Applicationofactionsrecommendedbytheconsultant

Total 4 min 14 min

No.ofreferralsperyear(2012) 23,767 Referrals 23,767 Referrals

Minutessaved 95,068.00 min 332,738.00 min

Hours/person 1,584.47 hours 5,545.63 hours

Days/person 198.06 days 693.20 days

Months/person 9.90 months 34.66 months

FTE(Full-timeemployee) 0.83 FTE 2.89 FTE

Papersaved 23,767.00 sheets 23,767.00 sheets

Table III. Estimated savings with the digitization of the referrals process

Notallofthebenefitsobservedinthecasestudiedcanbemeasured,althoughitdoesaffectpositivelyalloftheparticipantsinvolvedintheprocessandthehealthorganization:

DoctorPetitioner:

• Improvestraceability:ensuresthattheinquirywillbedealtwithandrecordsboththeinquiryandresponse.

• Improvesthequalityofthedata:reducesoraltransferoftheinformation,preventingtranscriptionerrorsandlossofdocuments.

• Improvestimes:reducestheresponsetimeandapplicationofproceduresrelatedtothisresponse.Inthecaseofhospitalizedpatientstheaveragelengthofstayissignificantlyreduced.

PhysicianConsulted:

• Improvesthequalityofthedata:canstandardizetheminimuminformationtobereceivedbythepetitionerofthereferral(diagnosisorientation,answerstokeyquestions,etc.)byavoidingunnecessarydiscussioninordertocompletetheinformation.

• Improvesworkorganizationandtherecordingofprocedureperformed.

• Improvesthequalityoftheresponsebyhavingaccesstoallnecessaryinformation.

©2013 HIMSS 11

Patient:

• Improvesthequalityofcare.

• Reinforcespatientsafetybydecreasingthechancesofmislaidormissinginformation.

• Improvesresponsetimes.

Organization:

• Byimprovingthequalityandstructureofthedataobtained:

� Opportunitytotracetheprocess.

� Usingtheinformationformeasuringpurposesandcontinuousimprovement.

• Thestructuredinformationservesasasupportinclinicalsessionsandtraining.

• Itpreventsthephysicalrelocationofthepatient’smedicalhistory.

• Promotescollaborationandteamwork.Thedoctorpetitionerhascompleteinformationabouttherequestanditstimesandtheconsultantphysicianhasdetailsofwhentherequestwasmade.

ThefollowingtablesreflecttheaverageresponsetimesattheComplexoHospitalarioUniversitariodeACoruñaandattheHospitalMarinaSaluddeDénia,obtaininganaverageresponsetimewhichimpliesthatvirtuallyallofthereferralsareansweredinthesametimeslotorthesubsequentone.

Thelackoftraceabilityintheoldpaper-basedprocesspreventsusfromcomparingtheseresultswiththetimespriortotheimplementationoftheICTforreferralsmanagement.However,wecanstillsaythattheprocessissubstantiallyimproved.

Service Averageresponsetime

Endocrinology 14:23:00

Table IV – Average response times of Endocrinology referrals at theComplexo Hospitalario Universitario de A Coruña

©2013 HIMSS 12

Service Averageresponsetime

AllergyUnit 3:23:30

AnesthesiaandRecovery 5:18:17

Cardiology 10:05:02

Dermatology 41:46:08

DigestiveMedicine 30:31:30

Ear,NoseandThroat 3:37:18

EmergencyPhysician 0:09:00

Endocrinology 3:26:53

GeneralandGastrointestinalSurgery 11:57:29

GynecologyandObstetrics 23:45:29

HealthCareNetwork 0:40:00

HeartSurgery 17:16:30

Hematology 11:27:43

HomeHospitalCareUnit 5:40:09

InternalMedicine 28:25:41

MaxillofacialSurgeon 38:53:15

Nephrology 1:28:45

Neurology 16:53:44

Neurosurgery 15:17:00

OccupationalHealth 10:51:00

Oncology 5:56:00

Ophthalmology 5:33:58

OrthopedicSurgeryandTrauma 2:21:18

Pediatrics 9:07:20

Pharmacy 48:12:07

PlasticSurgery 18:18:40

Psychiatry 21:42:57

Pulmonology 14:39:57

Rehabilitation 21:36:20

ResidentAnesthetist 8:48:30

ResidentCardiology 3:11:20

Rheumatology 5:15:45

SocialWorker 12:45:49

ThoracicSurgery 12:47:00

Urology 19:10:38

Total 12:23:57

Table V – Average response times for referrals at the Hospital Marina Salud de Dénia

©2013 HIMSS 13

Digital imagingTraditionally,theservicesofradiologyandnuclearmedicinehavebeenthemaindrivingforcebehindmedicalimagingsystemsinhealthorganizations,buttherearemanyotherservicesanddevicesthatalsoproduceimaging.Therefore,itisimportanttoclarifythatwhenwerefertodigitalmedicalimagingwearenotjusttalkingaboutradiologicalimaging.

Methodology

Whenanorganizationconsidersimplementingadigitalimagingsystem,itshouldtakethefollowingfactorsintoaccount:

• Requirementsofthemedicalservicesinvolved.

• Worksystem:

� Imageanalysis.

� Informedprocess.

• Technologicalaspectsforintegratingwiththerestoftheorganization’ssystems.

• Economicfactor:

� Investment.

� Expenditure,includingrecurringspendingforsystemmaintenance.

TableVIshowsthedistributionofstorageforeachtypeattheClínicaUniversidaddeNavarra.

Type Matrix No.Img.exam

Studysize(MB)

%studytype

%storagetype

CT-Computerizedtomography 512x512 10-10000 299.93 28.58 65.11

CR-Computerizedradiography 048x2048 1 20.58 22.93 8.29

US-Ultrasounds 640x480 33.15 21.16 9.68

MR-Magneticresonance 256x256 100-10000 100.29 12.49 10.31

NM-Nuclearmedicine(NM) 128x128 30-60 3.82 5 0.24

MG-Digitalmammography 4000x5000 4 46 3.38 2.54

PT-PET 100.93 3 2.83

RF-Radiofrequency 8.85 1.85 0.61

XA-Angiography 28.65 0.96 0.17

OT-Other 7.84 0.66 0.22

Table VI. Storage by type at the Clínica Universidad de Navarra (University Hospital of Navarra)

Results

Withanaverageof110,000studiesayear,ahistoricallogof20terabytesandanestimatedannualgrowthrateof8TBperyearandanewmedicalimagingsystem,itwouldplacethecostofthestudyat €1.9comparedwiththe€8thatananalogchestx-raycancost.

Year1 Year2 Year3 Year4 Year5

Total €529,000 €529,000 €137,000 €140,000 €145,000

Table VII. Estimated costs in 5 years (includes storage, software licenses, communications, maintenance, etc.)

©2013 HIMSS 14

Otherbenefits:

• Thearchitectureandplatformofdigitalimagingallowyoutostoreanyothermultimediainformationthatcomesfrommedicaldevicesinstandardformat(DICOM).

• Improvessatisfactionofhealthcareprofessionals.

• Improvesreportpreparationtimes,particularlyrelevantforcriticalservices,suchas,forexample,theEmergencyDepartment.

• Facilitatesuniversalaccesstoanytypeofmedicalimaging.

• Facilitatesimplementationofsecondmedicalopinionsystemsandsharingofthepatient’scasereport.

• Improvesthesecurityofinformationwhenestablishingaccesscontrolsthroughauser/password.

• Itcanhelptoimprovethebillingcyclebyreducingthereportingtimes.

• Reducespatienttravel(forexample,betweenprimaryandspecializedcare).

• Improveswaitinglistmanagement,allowingthespecialisttoscreenpatientswhohavetobechecked.

©2013 HIMSS 15

Hospital medication processThehospitalmedicationprocess,fromanexclusivelyclinicalstandpoint,isclearlyoneofthemostcriticalareasoftheentirehospitalcaresystem,duetotheimportantimplicationsforqualityofcareandthepotentiallysignificantimpactonclinicalpatientsafety,whichinextremesituations,canposearisktothelifeofthesesameindividuals.

Fromapurelyfinancialpointofview,thisisanenvironmentinwhichhigh-volumeconsumptionandeconomiccostaremanaged,essentiallymedication,masterformularies,parenteralnutrition,etc.

Ourproposalrelatesexclusivelytotheautomationofthemedicationprocess,whichisshownschematicallybelow:

1 – Hospital medication process workflow

Themedicationprocessworkflowhasafewtypicalandstringentrequirementsintermsofdataandinteractionsamongprofessionals,toensureappropriatecommunicationbetweenthem,andeffectivedataexchangeinorderforthemtocorrectlymonitortasks.

AnICTimplementationprojectinthehospitalmedicationprocessshouldincludethefollowingobjectives:

Hospital medication process

Economic

Quality of care

Organizational

Saving on consumption

Time optimization

Prevention of legal costs

More collaborative work

Systems/schedule management

Continuity of care

Ability to use the information

Reduction of adverse events

Increase in the use of appropriate therapies

©2013 HIMSS 16

Results

Wewillalsolookattheproject’sresultindicatorsfromthreekeyreturnareas:

EconomicReturn:

• Totalconsumptionofmedicationinhospital.

• Totalconsumptionofmedicationinhospitalperpatient.

• %Return/Decreaseinmedicationduetoexpiration(Costofreturns/Totalcostofmedication,bothin€/yearor€/month).

• %Adjustmenttomedicationindication“highcost”or“critical”(No.ofprescriptionsadjustedtoindication/Totalno.ofprescriptionsofmedication,inayearormonth).

• %Returnofmedicationfromfactorytopharmacy(No.ofprescriptionsreturnedtopharmacy/Totalno.ofprescriptions,inayearormonth).

• Averagepharmaceuticalwrite-uptime(min/day).

• Averagepharmaceuticalvalidationtime(min/day).

• Averagetimefor“administrative”nursingtasks(min/day).

• Averagetimeforpharmacytechnicianpreparationanddispensing(min/day).

Clinicalreturns(qualityofcareandclinicalsafety):

• %Adverseprescriptionevents(No.ofadverseprescriptionevents/Totalno.ofprescriptions,inayearormonth,totalorbymedication).

• %Prescriptionsbasedonprotocol(No.ofprescriptionsbasedonprotocol/Totalno.ofprescriptions,inayearormonth,totalorbymedication).

• %Adverseadministrationevents(No.ofadverseadministrationevents/Totalno.ofprescriptions,inayearormonth,totalorbymedication).

TheHospitalClinicdeBarcelonaisinvolvedinimplementingthehospitalmedicationprocedure,havingobtainedthefollowingresultssofar:

Before After Savings

Totalconsumptionofmedicationinhospital

€ /dayofstay €73 €62 15.7%

€ /patientdischarge €418 €347 16.99%

Totalconsumptionofanti‐infectivemedicationinhospital

€ /dayofstay €21 €16 28.57%

€ /patientdischarge €118 €97 17.80%

Genericprescriptionmedicationfordischargedpatients

%prescription 45% 57% 26.67%(increase)

Medicationstockmanagement

Daysinstock 27 19 29.63%

Table VIII – Savings achieved at the Hospital Clinic de Barcelona

©2013 HIMSS 17

Thishasalsoledtoanothertypeofsaving:

• Addingtwoextrapeopletothepharmacydepartmentstafftocarryoutthetaskofwritingupprescriptionswasavoided(2FTE€60-80K/year).

• Thetimetakenforpharmacytechnicianstoprepareanddispensemedicationfellby20%onaverage(1FTE,€20-25K/year).

• Thetimetakenfornursestocarryoutadministrativetasksfellonaverageby15%infavorofbedsidepatientcare,duetotherebeingfewertranscriptionerrorsand/orinterpretationofhandwrittennotesbythedoctors,nothavingto“huntdown”thedoctorinorderforhim/hertoconfirmthatatreatmentshouldbecontinued,etc.

Wecanalsofindotherbenefitsthatcannotbemeasured:

• Legalcostsavoided(valuesbasedonprobability).

• Patientsatisfaction.

• Satisfactionofprofessionals.

• Improvesoverallefficiencyofthecollaborativeworkflow(timereduction,improvescommunication).

• Improvesthequalityofinformationinpatients’medicalhistory.

• Completeandguaranteedtraceabilityfromprescriptiontoadministration.

• Facilitatescontinuityofcare(communicationwithAP).

©2013 HIMSS 18

Management of complex treatments in the day hospitalAllthemedicationsincludedinthecomplextreatmentscategoryhaveparticularcharacteristicsintermsoftheprescription,preparationand/oradministrationprocess,suchas,forexample:

• Forseriouspathologies:neurological,cardiovascular,musculoskeletalandchronicdiseasesorcancer,etc.

• Theycontainactivesubstancesthathavebeenrecentlyauthorized(withinthelast5years),sotheyareapriorityforthereportingofsuspectedadversereactions(RD1344/2007,orotherlawsdependingonthecountry).

• Next-generationmedication(geneticengineering).

• Hightreatmentcost.

• Orphandrugs.

• Medicationforrarediseases.

Therefore,takingintoaccountthecharacteristicsofthemedication,thoseofthepatientsandthenormaloperationofthedayhospital,aninformationandalertsystemisneeded,whichallowseffective,efficientandsafeautomationofstorage,queriesandmodificationsofallthedataassociatedwithtraceabilityofthepatientandthemedication.Thesearenecessarytocarryoutthemedicalcareprocessforthepatientwiththeutmostsafety,othinthedayhospitalandinthehealthorganization’spharmacyservice.

2 – Complex medication workflow procedure in the day hospital

Methodology

Toimplementanautomatedtraceabilitysystemforthecomplextreatmentprocess,wirelesslocalizationtechnologiescanbeused.Theinvestmentforthisneedstoberecoupedasdetailedinsubsequentsectionsoftheanalysis.

TheComplexoHospitalarioUniversitariodeACoruñainstalledanRFID+WIFIsystemforthemanagementofadayhospitalwithavolumeof1,000patients/yearwhoreceive6,380doses.Thefirst-yearexpenditureinconsumablesis€44,759.48,whichaddedtothecostsforhardwareandsoftwareinfrastructuregivesusatotalamount,includingthecostofthefirstyear,of€99,959.48.InformationindetailcanbeseenintablesIXandX

©2013 HIMSS 19

Infrastructure € /u Units Total

WIFIAntennas €300 6 €1,800

Drives €400 8 €3,200

Proximitycard €300 2 €600

RFIDPrinterorSoftware €2,000or€2,500 1 €2,500

Softwarelocalization €30,000 1 €30,000

Medicationcart+software €7,900+€2,000 1 €9,900

Traymedication+software €7,900+€2,000 1 €4,500

TotalInfrastructure €52,500

Table IX. Spending on infrastructure (RFID project for complex treatment management) at The Complexo Hospitalario Universitario de A Coruña

Consumables € /u Units Total

Medicationpassivelabel €0.336 6,380 €2,143.68

Patientpassivelabel €0.28 6,380 €1,789.40

Bracelets €0.13 6,380 €829.40

Activepatienttags 40 1,000 €40,000.00

Totalothercosts €44,762.00

Table X. Consumables (RFID project for complex treatments management) at The Complexo Hospitalario Universitario de A Coruña

Results

Thetraceabilitysystembasedonwirelesstechnologiesprovidessignificantbenefitsthatcanbemeasuredusingthefollowingindicators,eitherwithanimprovementinvaluesorusinginformationthatwasnotavailableinamanualsystem.

PatientTraceabilityIndicators:

• Correct/incorrectidentificationofthepatient.

• Alertingthephysicianandpharmacyserviceofthepatient’sarrivalatthedayhospital.Recordingthetime.

• Patientwhohasleftwithoutthemedicationhavingbeenadministered.

• Numberofmedicationorderssentbythedayhospitaltothepharmacyservice.

Traceabilityindicatorsofthemedication:

• Day/timetheprescriptionwasreceived.

• Timeofnoticeofthepatient’sarrivalatthedayhospital.

• Thetimethatthemedicationwaspreparedbythepharmacyservice.

• Thetimemedicationleavesthepharmacyservice.

• Thetimemedicationisdeliveredtothedayhospital.

• Componentsofthemedication(quantity,batchandexpiration).

• Thetimethatmedicationwasadministered.

• Thepersonwhoadministeredthemedication.

• Dischargetimeofthepatient.

©2013 HIMSS 20

CostIndicators:

• Patientwhohasleftwithoutthemedicationhavingbeenadministered.

• Medicationthatexpiresbeforebeingadministeredtothepatient.

• Costoftheunusedmedication:doselostornotused.

• Amountofmedicationreturnedbythedayhospital.

SafetyIndicators:

• Misidentificationofthepatient.

• Patientwhohasleftwithoutthemedicationhavingbeenadministered.

• Medicationthatexpiresbeforebeingadministeredtothepatient.

• Conditionsfortheprescriptionanduseofthemedication.

• Adverse/secondarypharmacologicaleffects:allergy,interaction,intoxication.

• Numberofadverseeventsprevented.

• Batchofthemedication.

• Expirationdate.

In2012thetotalcostofmedicationadministeredintheHospitaldeDíadelComplexoHospitalarioUniversitariodeACoruña,cameto€9,724,179.17.Althoughthereisnodefinitivedataatthetimeofwritingthisdocument,itisestimatedthattheimplementationofthesystemwillmeanasavingof15%(€1,458,626.88)ofthemedicationadministeredinthedayhospital.

ROI = 1,399%

Otherbenefitsobtained:

• Adeclineinadditionaldosepreparation.

• Animprovementinstockmanagement.

• Anincreaseinservicequalitythroughthedecreaseinorders.

• Significantimprovementsinthequalityandefficiencyofpatientcareandservicethroughautomationofprocessesand,therefore,adecreaseinthenumberofhumanerrorsasaresultofthedevelopmentoftheseprocesses.

• Contributestosustainabilityduetoincreasedefficiencyoftheprocesses,reducingthenumberofunuseddoses.

• Anincreaseinstaffsatisfactionthroughtheimplementationofimprovementactionsthroughouttheprocessprescription-validation-preparation/dosage-dispensing-administeringofmedicationtopatientsinthedayhospital.

• Anincreaseinpatientsafetyduringtheprescription-preparation-dispensingandadministeringprocess.And,therefore,areductionintheoccurrenceofadverseevents:

� Animprovementinthetraceabilityofthemedicinesadministered(batchandexpirationdate).

� Animprovementinpatientidentification,medicationandpatient/prescribedmedicationmatching.

� Availabilityinrealtimeandinauniqueinformationlabelrelevanttothepatient’ssafety:thepatient’sclinicaldata,composition,timeofpreparation,pharmacistresponsible,deliverytime,whoitwaspreparedby,stability,specialconditionsofuse,previousmedication,infusionrate,etc.

©2013 HIMSS 21

Nursing care managementThenursingcaremanagementprocess,fromanexclusivelyclinicalstandpoint,isclearlyoneoftheareasinthehospitalcareprocesswiththeheaviestworkloadsandvolumesofdocumentation.Thishasimportantimplicationsforthequalityofcareandwell-beingofpatientsduringtheirstayinhospital,aswellasfortheirclinicalsafety.

Fromafinancialpointofview,intermsofhumanresources,thisisthelargestareaofexpenditureforahospital,anditsplanningandcontrolareextremelycomplicated,duetothehighvolumeandthenecessityofmanagingteamsin24x7x365shifts.

Ourproposalrelatesexclusivelytotheautomationofthenursingtreatmentmanagementprocess,whichisshownschematicallybelow:

3 – Nursing care process workflow

Thisprocessisamethodthathasbeenimplementedwiththeuseofcriticalthinking(reasoning)andseekstheattainmentofspecificobjectives(expectedresults)basedonscientificprinciplesandthescientificmethod.Therefore,itisasystemthatprovidesthemechanismthroughwhichthehealthcareprofessionalcanusehis/heropinions,knowledgeandskillstoidentify,diagnoseandmanagetheresponsetoactualproblems,potentialproblemsoranyhealth-relatedsituationspresentedbythepatient.Itconstitutesapatient‐orientedplantobeusedthroughouthis/herstayinhospital.

Thenursingtreatmentmanagementprocessworkflowhasafewtypicalandstringentrequirementsintermsofdataandinteractionsamongprofessionals,toensureappropriatecommunicationbetweenthem(doctor,nurseandotherhealthcareprofessionals),andeffectivedataexchangeinorderforthemtocorrectlymonitortasks.

©2013 HIMSS 22

Nursing care

Economic

Quality of care

Organizational

Saving of time spent on adminstrative work

Prevention of legal costs

More collaborative work

Improvements in costs/results monitoring

Facilitates research activity

Continuity of care

Ability to use the information

Reduction of adverse events

Increase in the use of appropriate therapies

Increased record-keeping

AnICTimplementationprojectinthenursingdepartmentshouldseekthefollowingobjectives:

Results

Inanycase,itisofutmostimportancetohavepreviousmeasurementsavailableofalloftheindicatorsproposedinthisdocument,beforeintroducinganykindofinformationsystemandmakingchangestotheworkprocess,inordertobeabletomeasure“aposteriori”theimprovementsachieved,andconfirmtheactualreturnobtainedasaresultoftheseimprovements.

Wewillalsolookattheproject’sresultindicatorsfromthreekeyreturnareas:

Economicreturn:

• Averagetimespentbynurseson“administrative”tasks.

• Averagetimespentbynursesonpatientcaretasks.

• Averagetimespentbynursesonpatientassessment.

• %Averagetimespentbynursesonpatientcaretasks.

• %Profitabilityofcomplementary“structural”teams–substitutions.

• %Adjustmentoftheaveragetimethatnursesspendcaringforthepatient,totheintensityofthetreatmentrequired.

©2013 HIMSS 23

Clinicalreturns(qualityofcareandclinicalsafety):

• %Careplansbasedonprotocol.

• Indicators.

• %Adverseeventsofcareplans.

Non-quantifiableresults:

• Legalcostsavoided(valuecouldbecalculatedbasedonprobability).

• Patientsatisfaction.

• Satisfactionofprofessionals.

• Quantificationofthecostofcare(€,allowssubsequentmanagementandcostoptimization).

• Improvestheoverallefficiencyofthecollaborativeworkflow(reducedtimes,improvedcommunication).

• Improvescommunicationbetweenprofessionals(writtenrecord,relevance,acumen).

• Improvesthequalityofinformationinpatients’medicalhistory.

• Facilitates“continuity”ofcare(communicationwithAP).

• Facilitatesresearchactivities(forcontinuousimprovement).

©2013 HIMSS 24

Improves surgical planningSurgicalactivityplaysaveryimportantrolewithinthehealthcareecosystem.Manyactivitiesderivefromthis,anditsdecisivenaturemeansthatitisacarefunctionofthehighestorder,whichcreatessignificantdemand.Therefore,controlandsupervisionofthesurgerywaitinglistsandperformanceoftheoperatingtheatersarekeycomponentsinthemanagementofthehealthorganization.

Surgeryisoneoftheareasthatgeneratesthemostcostsinhospitals;wearetalkingaboutbetween10%and15%ofthebudget.Becauseofthis,andtheincreaseinthedemandforcare,thereisnodoubtthatitisnecessarytomanagethesurgicalareaeffectivelyandachieveabettermanagementofitsresources.

Wefoundstudiesthatclaimthattheoptimalrateofoccupationofanoperatingtheatershouldbearound85%,andthateach1%belowthispercentagerepresentsacostofbetween€7,500and€12,000peryear,peroperatingtheater.

Therefore,theinactivityofthesurgicalarearecordedbyhospitalsinmanycasesapproximates30%,whichisbothagreatfinancialandsocialcost.Forthisreasonitisessentialtoknowtheactualtimesthattheoperatingtheaterisinuseaswellasitsshortcomingsinordertoensureaneffectivemanagementthatimprovestheperformanceofthisarea.

Methodology

Consideringoptimizingtheefficiencyofthesurgicalarea,andwhilecorporatesystemscontinuetobedeveloped,theimplementationofacomputingtoolwasproposedattheHospitalRegionalUniversitarioCarlosHayadeMálagatomakeiteasierforclinicalstafftoproperlyallocatetimesandsessionsbetweentheservices.Thissystem,whichimprovestheoperatingtheaterprogrammingprocessandhelpstogenerateprocedureswithstandardizedcriteriatopreventdelays,lossesoftimeandavoidabledeprogramming,hasbeeninplaceinthehospitalsince2009.

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Figure 1. Typical distribution of the occupancy rate for operating theaters per hour

Infigure1wecanseeatypicaldistributionofsurgicalperformancebyhour.From11:15hoursonwardsthereisagradualdeclineintheoccupancyrateoftheoperatingtheaters,inwhichtheuseofthesystemhadagreaterimpact.

©2013 HIMSS 25

Results

Infigure2improvementsareshownintheperformanceofoperatingtheatersbetweentheintroductionofthetoolin2009and2012.

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Figure 2. Improvements in surgical performance since introduction of the system

Theseperformanceimprovementsbringwiththemsignificantfinancialsavings,obtainingahighreturnoninvestmentinthefirstyearafterintroductionofthesystem.

Toperformthiscalculationthedataonspendingandsavingisdividedintotwo,tablesXIandXII.

Descriptionofexpense Amount

Staff(softwaredevelopment,workinggroups,support) €75,000

Clinicalstafftraining €28,500

Softwarelicenses €6,500

Hardware(PCs,washablekeyboardsandmice,...) €216,000

Othermaterials(cartsforPCsupportinoperatingtheaters,...) €47,500

Total €373,500

Table XI. System implementation costs

Savings Amount

Improvedperformanceofoperatingtheatersfirstyear(+5.87%for38operatingtheaters) €2,689,893

Table XII. Savings in the first year

ROI = 617%

©2013 HIMSS 26

Thenumbersspeakforthemselves:theROIobtainedduringthefirstyearofimplementationattheHospitalRegionalUniversitarioCarlosHayaisveryhigh;however,otherbenefitsthatmaynotbeaseasytoquantifyshouldalsobenoted:

• Reductionofwaitinglists:

� Improveshealthcaresystemuseraccessibility.

� Improvespatientsatisfaction.

• Improvespatientsafety.

• Higherqualityofdata:

� Improvesqualityandcontinuityofcare.

� Hasapositiveimpactonthemanagementofthehealthorganization.

Finally,itisimportanttohighlightinparticularthewayinwhichtheWorldHealthOrganization’ssurgicalchecklisthasbeencomputerized,convertingitintoausefultoolwhichisveryeasytomanageinsidetheoperatingtheaters.ThedesignedsolutionhasbeenintegratedwiththeHospitalInformationSystem(HIS)toreceivepatientandproceduredatafromthis,andtosendtheresultsofthechecklisttotheElectronicMedicalRecord.Suchcomputerizationalsopreventstherequireditemsfrombeingaffectedasaresultofsometypeoferrororsimplyduetoanoversight,anditispossibletohaveanautomaticrecordofwhotheconfirmationwascarriedoutbyandwhen.

Theliteratureconsultedonsimilarimplementationsshowsomespectacularresults.Inparticular,thecenterswheretheresultsarecomparedbeforeestablishingthesurgicalchecklistandafteritsintroduction,confirmtheusefulnessofthesurgicalchecklistsasthenumberofcomplicationsfromsurgeryfellfrom27.3%to16.7%,andthemortalityratedeclinedfrom1.5%to0.8%.Theyalsoshowthatinthemajorityofcases,theresponsibilityusuallylieswiththeentireteam(surgeon,nurseandanesthetist),andthat,hadtherebeenachecklist,themajorityoftheseerrorswouldnothaveoccurred.

©2013 HIMSS 27

Clinical decision support systemsAhealthorganization’sinformationsystemsarelargerepositoriesofunstructureddataamongwhichtherearereports,diagnosticimagingorlaboratoryresults,allergyinformation,etc.AclinicaldecisionsupportsystemsshouldensurethattheElectronicHealthRecord(EHR)evolvesfrombeingapassivetooltobecomeaproactivetoolforhealthprofessionalsandthatitautomaticallyanalyzesinrealtimethenewlygenerateddatafromanyinformationsource.

Theclinicaldecisionsupportsystemsshouldbringapatient’sconditiontotheattentionofheadcliniciansthroughthemostappropriatemeansineachcase(EHR,caregiver,e-mail,‘phone,...),aswellastherecommendedactions.Thereisnoclosedsetofsupportsystemsprojectsforclinicaldecision-making:almostanyprocessiscapableofworkingwithadecision-makingsupportsystem.

Itisnecessarytokeepinmind,amongotheraspects,thefollowingobjectives.

Clinical decision support system

Quality of care

Patient safety

Improves the quality of the information

Reduction of workload through process automation

Reduction of adverse events

Decrease in theoccurance of certain diseases

The case of clinical alerts at the Complexo Hospitalario Universitario de A Coruña

Theoveralleconomicassessmentofaprojectlikethisiscomplicatedandcanonlybedonebycomparisonwithperiodspriortointroductionofthesystem.Thisisduetothefactthatachangeisbeingmadefromageneralserviceprovisionmodel:i.e.,themovefromareactivetoaproactivemodel,andthiswillbeaslowtransition,whichrequiresalloftheprofessionalstoadapttothisnewmodel.

However,partialassessmentscanbemade,whicharemuchmoreobjectiveforanyoneofthestrategicobjectives,primarilywithregardtotheautomationofroutinetasks:

Automation of gynecological pap smear results:

Forbestresults,itisnecessaryfortheAnatomicalPathologyServicetouseacodingsystem,SNOMEDCT.Thisensuresthattheautomaticassessmentofresultsisalwayseffective.

Objectives

• Topreventresultsreviewbythepetitioner.

• Toavoidunnecessaryinquiriesofresultsreview.

Results

Forthetimebeing,attheComplexoHospitalarioUniversitariodeACoruña,itisthespecialistwhodecidesifappointmentsaremadeforreviewsofnon-pathologicalresults.IntableXIIwecanseewhatthesavingswouldbeifnoneoftheseconsultationstookplace.

©2013 HIMSS 28

Pathological NonPathological Total

Numberoftests 12,783 14,348 27,131

Minutes(10min/consultation) 143.480min 271.310min Savingof53%

Hours 2,391H

Specialist 1.45gynecological/year

Table XIII. Savings in pap smears based on 2012 data at the Complexo Hospitalario Universitario de A Coruña

Otherbenefitsobtainedwiththisprojectinclude:

• Substantialimprovementinthehandlingofpositiveresults.

• Improvementsinthewaitinglist.

• Improvementinpatientsatisfaction.

� Decreasedanxietyaboutresults/reviews.

� Reducedtravelexpensestothesurgery.

� Nolossofworkhoursinordertoattendunnecessaryconsultations.

Otherexamplesthatalreadyworkaredermatologicalbiopsies.Withinthisserviceitwasdecidedtocommunicatenegativeresultsbytelephone,whichhasmeantthedisappearanceofallreviewsfornon‐pathologicalresults,therebysignificantlyimprovingthewaitinglistbytheamountofconsultationreviewtimethatisfreedupforthespecialists.

The case of prevention of thromboembolism at the Clínica Universidad de Navarra

Theaimistoidentifythosepatientsadmittedwhohaveasignificantriskofdevelopingvenousthromboembolism(VTE)sothattheappropriatemeasuresaretakenatthemedicalandnursingcarelevels.Inaddition,itallowsthemonitoringofprophylacticmeasurescarriedoutonpatients,dependingonthedegreeofcalculatedrisk.

AccordingtoastudyconductedbyspecialistsfromtheClínicaUniversidaddeNavarra,theintroductionofacomputerizedalertsystemtopreventtheoccurrenceofvenousthromboembolisminallSpanishhospitalswouldmeananannualsavingofnearly30millioneuros,byavoidingthecostsderivedfromthisdisease.

Thedirectcostsofvenousthromboembolismwerereducedfrom21.6eurosto11.8eurosperhospitalizedpatient,comparedtothecostsgeneratedbytheincreaseinprophylaxisandintheestablishmentandmaintenanceofthealerts,whichwere3eurosand0.35eurosperpatient,respectively.Therefore,thesavingsforeachhospitalizedpatientis6.5euros.

Theriskofapatientsufferingfromvenousthromboembolismdependsonseveralfactors:somerelatetothepatienthimself/herselfandothersdependonthesituationinwhichthepatientfindshimself/herself.Thetypeofinformationthatiscollectedincludes:

• Thesurgicalprocedurescarriedoutonthepatientonadmission,whichposeahighriskofcausingVTElateron.

• Othersurgicalproceduresperformedonthepatientduringadmission.Thedeterminingfactorinthiscaseisthedurationoftheprocedureandthepatient’sage.

• Personalhistoryandthereasonforthepatient’sadmission:i.e.,thepredispositionthatthepatientmayhavefordevelopingvenousthromboembolism.

• Anotherfactorinvolvedisthepatient’sage;ifthepatientisnotadmittedforsurgicalreasons.

• Certainmedicationadministeredtothepatientcanincreasetherisk.

• If,duringadmission,aportacathhasbeenplacedinthepatient,viacentralorHickmanline,theriskincreases.

• Theriskishigherinobesepatients(BMI>30).

• Theriskincreaseswhilethepatientisinabsoluterest.

©2013 HIMSS 29

Alloftheabovefactorsareinvolvedinthecalculationoftheriskofsufferingfromathromboembolism.Allofthisdataiscollectedfromthevariousinformationsystemmodules:nursingcare,doctor’sorders,nursingrecordofvitalsignsandprocedurescarriedout.

The case of the Sepsis clinical pathway at the Hospital Marina Salud de Dénia

FourteenSpanishscientificcompaniessignedtheDeclarationofMajorcainNovember2012topromotethecreationofCodeSepsis,bothatthelocallevelaswellasattheinstitutionallevelsupportedbynationalhealthauthoritiesandthedifferentAutonomousCommunities.Theaimof“CodeSepsis”istheearlydetectionofpatientswithsevereSepsis(inthedifferentlevelsofcare),thestructuredapplicationofthesetofrecommendedmeasuresinordertodiagnose,monitorandtreatthesepatients,andthedefinitionofafewcareindicatorsforassessingcompliancewiththerecommendationsandtheresultsoftheapplicationofthecodeatthelocalandnationallevel.

TheoptimizationofSepsismanagementisassociatedwithareductioninhealthcarecosts,whicharecurrentlyquantifiedataround€17,000percase.

Methodology

TheSepsisprotocolisbasedonthefollowingkeypoints:

1. TheSepsisRule:“Acontinuousandongoingradarorguard”ofthedatastoredinthepatient’sEHR,whichwillalertuswhenapatientmeetsthepredefinedSepsiscriteria,andwhosefunctionistheearlydetectionofSepsis.

2. Aclinicalpathwayof“SevereSepsisandSepticShock,first6hours,”whichconstitutesaremindersystemthatdisplaysadiagnosticandtherapeuticroadmap,activatingtheSepsisteamandcollectinginastandardizedmannerthediagnosticandtherapeuticmeasurestobecarriedoutinthefirst6hours,associatedwithdecreasedmortality,andrangingfromtheparameterstobemonitored,relevantparametersforthemicrobiologicaldiagnosisandsourcecontrol,theoptimalempiricalantibiotictreatmentforeachclinicalsituationandhemodynamicresuscitation.Allofthis,assupportforthephysician,withoutlimitingthemodificationsthattheymaywanttomakeaccordingtotheirbestjudgment.

Objectives

• ToreducethenumberofcasesofSepsisperyearineachofthe3stages(septicshock,SepsisandsevereSepsis).

Thecasuistrystudywasstartedin2013,withtheaimofcarryingoutacomparativestudybetweenthefinancialyears2009-2013.AttheHospitaldeDénia,intheperiodfromApril25toJune7,thefollowingresultswereobtained:

Casesinwhichthealertwasactivated 207

CaseswithpreliminaryassessmentofSepsisrecordedbythephysicianontheform 49

Septicshock 5

Sepsis 22

SevereSepsis 22

CasesconfirmedbythephysicianbyincludingadiagnosisofSepsiswhenthepatientisdischarged 28

785.52Septicshock 2

995.91Sepsis 10

995.92SevereSepsis 16

Total 28

Numberofcasesinwhich“SepsisTeam”wasactivated 18

Table XIIV – Data from digital Code Sepsis at the Hospital Marina Salud de Dénia

TherewillbesavingsasaresultofthedeclineincasesofshockandSepsisduetoearlyintervention.

©2013 HIMSS 30

Non face-to-face servicesWhenwetalkaboutnonface-to-faceserviceswerefertothoseserviceswhichduetoICThelpimprovecareservicesortheclinicalcoordinationbetweenprofessionalsand/orpatientssuchastelemedicine,telecareorcollaborativeworkplatforms.TheseprojectsaremadepossibleasaresultofICTandenablethetransformationofclinicalprocesses,systemrestructuringandtheconnectionofprofessionalsandhospitalswithotherhealthcentersinremotelocations.

Asynchronous Telemedicine

Foryearsasynchronousandsynchronoustelemedicinehasbeenusedfordifferentprocessesandspecialties.Inseveralspecialtiesithasbeenconfirmedthatasynchronoustelemedicineprojectsproducethefollowingresults:

• Eliminationofunnecessarytravelofthepatienttothehospital.

• Reductioninthediagnosistimeincasesoflowandmediumcomplexity.

• Sharingofknowledgebetweenspecialistsandfamilyphysicians.

• Providestheopportunitytoworkwithexpertsfromoutsidetheorganization.

• Acceptanceonalargescaleofthetechnologicalsolutionbyphysiciansandspecialists.

• Reductioninwaitingliststoseeamedicalspecialist.

• Preventsduplicationofdiagnostictests.

However,ithasalwayscostalottosetupthetelemedicineprocessasamoreacceptedsystemwithinthehealthorganization.Whilethetechnologyisreadyandvalidated,itinvolvesachangeintheprocessandinthecoordinationofcarethataffectsdifferentclinicalunitsbothinsideandoutsidethehospital.However,technologyadvancesanditallowsyoutotakeanotherstepforward,notonlybyfacilitatingtheexchangeofimagesbutalsobyprocessingtheseimages.

Forexample,thedevelopmentofasoftwaresystemfortheautomaticscreeningofdiabeticretinopathyimagesenablesearlydetectionofthediseaseinthediabeticpopulation.Automaticprocessingisshowntobeareliablemeansofobtainingafirstleveldiagnosiswithoutrequiringspecialistintervention.

DiabetesisthesecondcauseofblindnessinSpainandtheprimarycauseoftotallossofvisionintheworkingagepopulation.Itisestimatedthatbetween15%and30%ofpeoplewithdiabetessufferfromdiabeticretinopathy.Thebestprotectionagainsttheprogressionofthisdisease,inadditiontocontrollingdiabetes,istheearlydetectionoftheretinopathythroughperiodicchecksinwhichFundusphotographyiscarriedoutinbotheyesofchronicpatients.

Afterthetakingofimages,eachFundusphotographshouldbecheckedanaverageoftwotimesbyqualifiedspecialists,throughaslowprocess,whichistediousandexpensive,withtheaimofissuinganaccuratediagnosis.

Todaytherearenonface-to-facecapture,transmissionandimaginganalysissystems.

TheimagesobtainedbytheFundusphotographsaresentsecurelytoacentralizedrepository(thecloud),fromwhereanautomaticscreeningalgorithm(alsointhecloud)evaluatesanddetectsthepresenceorabsenceofretinallesions.Ophthalmologistscanconsultthescreeningresultsdirectly,beingabletofilterthosepatientswithlesionsforasubsequentexaminationandtheissuingofanewdiagnosis.

Trialswiththefollowingresultshavebeencarriedout:

• 15,000patientsexaminedinoneyear.

• 20%diagnosedwithdiabeticretinopathy.

• 95%sensitivityandspecificityof70%.

• Theworkloadofdoctorswasreducedby45%anditallowsthespecialisttofocusonthepatients’pathologies.

©2013 HIMSS 31

Inaddition,otherformsoftelemedicinewhosemainobjectiveistofacilitatecollaborationbetweentheprimarycarecenterandthespecialistobservedthefollowingbenefits:

• Eliminationofunnecessarytravelofthepatienttothehospital.

• Reductioninthediagnosistimeincasesoflowandmediumcomplexity.

• Sharingofknowledgebetweenspecialistsandfamilyphysicians.

• Creationofwebknowledgerepositories.

• Providestheopportunitytoworkwithexpertsfromoutsidetheorganization.

• Acceptanceonalargescaleofthetechnologicalsolutionbyphysiciansandspecialists.

• Reductioninwaitingliststoseeamedicalspecialist.

• Preventsduplicationofdiagnostictests.

2012 2013(upto06/22)

Service No.ofremoteconsultations

Service No.ofremoteconsultations

Dermatology 3,245 Dermatology 1,535

Ophthalmology 867 Ophthalmology 523

AngiologyandVascularSurgery 68

Endocrinology 38

Table XV – Telemedicine at the Complexo Hospitalario Universitario de A Coruña

©2013 HIMSS 32

Health 2.0: Collaborative environments

Socialnetworks,collaborativetoolsandweb2.0haveledtoarevolutionintheformationofnewvirtualcommunitiesthatcommunicate,shareandcollaborateonaglobalanduniversalbasis.Theysharephotos,personalcomments,messagesandprofessionalinformation.Anyonecanhaveanonlineprofileonanyofthereferencedsites(LinkedIn,Facebook,Twitter,etc.).

Inhealthcare,theuseofthistypeoftoolcreatesnewandinterestingscenarioswherethesharingandcollaborationofknowledgecanhelpfostertheobtainingofafasterandmoreaccuratediagnosisaswellastoconnectpatientswithpatients,doctorswithdoctorsanddoctorswithpatients.

TherearemanyinitiativesfortheuseofspecificorstandardtoolsforHealth2.0projects.Manyaredangerous,oldordisruptive.Someareconsolidatingandallowthetraditionalformsofclinicalcollaborationtobechanged.Werefertoprojectsthatenablecollaborationbetweenclinicalprofessionalsforthediscussionandsharingofclinicalcaseswheretherisktoprivacyisminimal(anonymousclinicalcase)andtheresultingcareisimprovedthankstothecollaborativecare.Projectsthatprovideasecondmedicalopinionbyspecialistslocatedremotely;collaborationwithlessdevelopedcountries(Spain-Africa);knowledgesharingformedicaltraining;accesstospecialistsinanypartoftheworldorvirtualtumorcommittees.

Itallowsyoutoorganizevirtualtumorcommitteeswithprofessionalsfromdifferenthospitals.

Theworkflowisbasedonthecreationandsharingofclinicalcasesthatarepresentedattumorcommitteemeetings.Thiscaseissharedprivatelyamongagroupofprofessionalstoencouragethemultidisciplinaryapproach.Itgeneratesadiscussionthroughcommentsontheclinicalcaseinordertomakedecisionsaboutthetreatment,diagnosisormonitoringofthesame.

Afterthesurveywasconductedontherelevantusers,itwasconcluded:

Thatthethreebasicreasonsforacceptingandusingaprofessionalcollaborativeplatformare:

• Rapiddecision-making,predictionofdecisionsandpreparationofcases.

• Inclusionofalltheclinicalelementsnecessaryfordiagnosis(casesummary,images,documents,reports).

• Whenthebindingdecision,madeinthetumorcommittee,isrecorded,thatitsimplementationispromotedinpractice.

• Thepossibilityofdevelopingnonface-to-facecommittees,helpindecision-makingandencouragingparticipationbetweenhospitals.

Benefitsobserved:

• Facilitateshomogeneityintheinformationforpresentationofclinicalcases.

• Compactstherelevantinformationonclinicalcases,whichcentersthedecision-makingprocessfirmlywithintheTumorsCommittee.

• Predictsanddocumentstheopinionsofdifferentspecialties/specialistsinvolvedintheTumorCommittee.

• Standardizescommunicationbetweenhospitalsthatreferclinicalcases.

• RecordsthecasestreatedintheTumorCommitteesasanimportantsourceofteachingandresearchmaterial.

• Improvesthequalityofhealthcaregiventothepatient:multidisciplinaryapproach.

• User(clinical)assessmentisverypositive.

• Preventsrepetitionofcomplementarytestsinpatientscomingfromotherservicesorhospitals.

• Helpstoreducewaitingtimes.Additionalguidanceonearlytreatmentbysharingthesameinformationfromapatientinrealtime.

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• Facilitatestheselectionofpatientsforinclusioninclinicaltrials(costsavingsforthehospital).

• Enhancesandpromotescollaborationwithintheindustry:powerfultoolwithwhichtopromoteclinicalresearchinthehospital.

• Improvessystemmanagement.FacilitatestheTumorCommittee’sselfmanagement.

• Supportsthedisseminationofpublications.

• StandardizationofclinicalpracticeinnewproceduressuchasIORT(intraoperativeradiationtherapy).

• Teaching:Repositoryofmedicalknowledgethatisusedinthetrainingofmedicalstudentsandresidents.

SomecentersarerethinkingtheworkingsofthecommitteesbothinsidethehospitalandattheAutonomousCommunitylevel.Thereorganizingofhealthcareservicescanevenbecontemplatedthroughaconcentrationofspecializedkeyservices(oncology,dermatology,ophthalmology).

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[8]. DouglasGoldstein,PeterGroen–18/7/2006–“ValuemeasurementandreturnoninvestmentforEHRs”–VirtualMedicalworlds.http://www.hoise.com/vmw/06/articles/vmw/LV-VM-08-06-19.html

[9]. BobHerman–3/10/2012–“6wayshospitalscananalyzetechnology’sreturnoninvestment”–Becker’sHospitalreviewhttp://www.beckershospitalreview.com/healthcare-information-technology/6-ways-hospitals-can-analyze-technologys-return-on-investment.html

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[11]. P.J.Murray,M.Cabrer,M.Hansen,C.Paton,P.L.Elkin,W.S.ErdleyTowardsAddressingtheOpportunitiesandChallengesofWeb2.0forHealthandInformaticsIMIAYearbookofMedicalInformatics200831:44-51.

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