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Emergency Room Of The Future Leveraging IT At WellStar Health System: Kennestone Emergency Department. September 18, 2008. Jon Morris, MD, FACEP, MBA WellStar Health Systems. Agenda. Introduction Kennestone Emergency Department Metrics More Metrics- Exit Phase

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Emergency Room Of The FutureLeveraging IT At WellStar Health System:Kennestone Emergency Department

September 18, 2008

Jon Morris, MD, FACEP, MBA

WellStar Health Systems


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Agenda

  • Introduction

  • Kennestone Emergency Department

  • Metrics

  • More Metrics- Exit Phase

  • Even More Metrics- Non-ED Physicians

  • So far…


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To Err Is Human

  • Patient Safety Issues: IOM report Nov. 1999

  • > 44,000 – 96,000 deaths related to preventable medical errors/year

  • $17B - $29B cost

  • 2000 – Leapfrog Group



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The Need For Change

“The definition of insanity is to continue to do the same thing over and over again and expect different results”

Albert Einstein



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Kennestone Emergency Department

>102,000 Annual patient volume

40% of Kennestone admissions

24.38% admit rate (July 08)

October 2007: ED Online





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October 2007: Kennestone ED Live Online Documentation and Order Entry

  • “Sole Source” strategy- McKesson

  • 18 month build

  • ED Tracking Board

  • Online Clinical Documentation (Horizon Emergency Care – HEC)

  • Online Order Entry (Horizon Expert Orders - HEO)



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ED Tracking Board

WSKH ED Applications




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Documentation

WSKH ED Applications


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Online Documentation

  • Always Available

  • Real-time

  • Legible

  • Automated Date & Time

  • All Clinical Documentation In One Place

  • More Complete




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Order Entry

WSKH ED Applications


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Definition: CPOE

  • Provider Enters Orders

  • Clinical Decision Support

    • Easier to do the right thing

    • Harder to do the wrong thing

  • Immediate Order Transmission










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CPOE: A Process

  • Multiple applications

    • Provider

    • Nursing

    • Pharmacy

    • Ancillary Services, i.e., Laboratory, Medical Imaging

  • Global process - multiple stakeholders

  • KLAS: 17.5% US Hospitals > 200 beds in 2007


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CPOE- Financial Gains

CPOE in Community Hospitals:

  • ADE cost

  • Renal dosing errors

  • Unnecessary / Redundant diagnostic studies

  • IV to PO conversion

  • $2.7M Reduction in Cost, 26 month payback*

* Feb 08 MA CPOE Initiative Report



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Goals- WellStar Health System

  • Improve Care

  • Lower Costs

  • CPOE Using HEO

    • Two Years To First Facility Go-live

    • 100% Physician Adoption Two Years Post-live



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Challenges in Implementing HEC-HEO

  • Development

  • Training

  • Deployment

  • Adoption

  • Reporting






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One solution…

“In the middle of every difficulty lies opportunity”

- Albert Einstein



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Throughput Analysis

  • Neglected value of ED applications

  • Acquire data from HEC & TB.

  • Quarantine invalid data

  • Report data compliance, i.e., reporting efficacy and accuracy.

  • Select and study throughput intervals.

  • Identify high-yield opportunities.


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WS KH ED - Throughput Intervals

  • Arrival to Triage

  • Arrival to Bed

  • Arrival to EDMD Assigned

  • Arrival to EDMD At Bedside

  • Bed to EDMD at Bedside

  • EDMD at Bedside to EDMD Decision to Disposition

  • EDMD Decision to Disposition to RN Disposition

  • RN Disposition to Exit

  • LOS



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The Good: Reliable ED Metrics

ERK - July 2008


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The Bad: Delays in Seeing EDMD

Admitted Patients:

Patient Arrival to MD At Bedside: 61 minutes

Patient in Bed to MD At Bedside: 42 minutes


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The Ugly: Delays in Exit From ED

July 2008 EDMD Decision to Admit to Exit from ED:

Exit Phase = EDMD Decision to Admit → Patient Exit From ED

162 + 10 = 172 minutes

39-47% Average ED Patient LOS (Jan – July 2008)


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Progress: Bed to MDATBED

Jul 08: Additional 1P EDMD shift present on 12/31 (38.7%) days

90% August dates have 1P ED MD Coverage



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Admitted ED Patients: 3 Steps

  • Get Into An ED Bed

  • Receive ED Treatment &/Or Evaluation

  • Move to Next Level of Care


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Getting Into An ED Bed:

  • Available ED Bed and Resources

    • Clinical Staff, i.e., RN, tech, etc.

    • Open Beds

    • Patients Must Be Able To Leave

  • ED MD Must Be Available

    • Appropriate ED MD Staffing


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Treatment &/Or Evaluation:

  • Treatment

  • Laboratory Tests

  • Medical Imaging Studies

  • Consultation for Admitted Patients

    ED Process Improvement Committee


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Moving to the Next Level:

  • Receive Admitting Orders, then…

  • Additional ED Orders

  • Call For Bed (Next Level Of Care)

  • Bed Assignment

  • Inpatient RN Staff Available to Receive Report

  • ED Staff Available to Move Patient


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Moving to the Next Level:

  • Exit Phase:

    • Begins With EDMD Decision To Admit

    • Ends With Patient Exit From ED

  • 158-251 minutes January – August 2008

  • 39-47% of LOS


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Exit Phase: Study Intervals

How long did it take to receive orders?

  • Consult Interval

  • [EDMD Decision to Disposition] to Admit Orders Received (AOR)


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Exit Phase: Study Intervals

How long after AOR did patient leave EDTB?

  • ED Inpatient Admit Interval

  • AOR to Exit (ED bed available)


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Exit Phase Study: May – September 2008

Averaged 86-110 minutes just to get admit orders

Haven’t even called for a bed.

(Practice & provider-specific data available)



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Results- Inpatient Admit Interval(additional studies in progress)




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Selected Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR*)

*AOR = Admit Orders Received



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Cardiology- Average Consult IntervalMay – July 2008(EDMD Decision to Disposition to AOR)


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Cardiology Admissions

Significant variation in consult intervals exists between cardiology practices.

  • Two of three cardiology practices, Practices “A” and “C,” account for 22.7% of all ED admissions. These practices almost exclusively admit only following consultation and evaluation in the ED.

  • Practice “B” routinely phones in orders and evaluates the patient on the floor if they left the ED by the time they arrive.

  • This is reflected in patients’ consult intervals and LOS:


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Cardiology- Average ED LOSMay – July 2008(EDMD Decision to Disposition to AOR)


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In Progress:

  • Medical Staff Admit Strategies

  • Staffing Changes and Allied Health Professionals

  • EDMD Calls For Bed

  • Admit Holding Area


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Summary

  • Introduction

  • Kennestone Emergency Department

  • Metrics

  • More Metrics- Exit Phase

  • Even More Metrics- Non-ED Physicians

  • So far…


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Questions?

Contact Information:

Jon Morris, MD, FACEP, MBA

WellStar Health Systems

[email protected]


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