LAS VEGAS - As emergency room (ER) physicians become increasingly dependent on imaging to rapidly diagnose their patients, radiology departments are under greater pressure to prioritize reads, turn around reports, and keep patients moving in overcrowded conditions.
To accomplish both its patient care and financial goals, Nyack Hospital in Nyack, NY, collaborated with healthcare information systems firm McKesson on the development of the company's Conserus Workflow Intelligence program. Details of the collaboration were shared on Wednesday at the Healthcare Information and Management Systems Society (HIMSS) 2016 annual meeting.
Nyack Hospital is a 375-licensed-bed acute care community hospital in Rockland County. An affiliate of the Montefiore Health System, it staffs approximately 275 beds when at full capacity.
"Like any hospital in the country, our No. 1 mission is to provide quality care to the patients," said Dr. Evan Kaminer, Nyack's chairman of radiology. "We want patients to be treated well, and we want them to have a good experience, but we need to do that in a way that is cost-effective so we can keep the doors open and reinvest in our technology."
Controlling the average length of stay is one way hospitals manage their financial margins in large part because they are reimbursed a fixed amount for their services. And, like other facilities, Nyack's emergency room is overcrowded.
"Any time you go to the emergency room, you will see people lining the halls, stretchers two-deep; and the length of time in the emergency room is a patient dissatisfier," said Kaminer, who also serves as CEO of Hudson Valley Radiology Associates, Nyack's radiology services provider. "So we want to try to do everything we can to reduce the amount of time a patient is in the emergency room and keep that flow going through the emergency room."
Timely evaluations
Because it is a community hospital, most of Nyack's admissions come through the emergency room, where physicians need to evaluate patients in a timely manner for admitting or discharge.
"If [patients] are housed in the emergency department for too long, we will see it in our [Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)] scores," Kaminer said.
Given these challenges, Nyack began beta-testing McKesson's Conserus Workflow Intelligence program about a year ago. The vendor-neutral, workflow rules engine is custom-designed for each healthcare facility to create its own workflow and business rules to enhance a variety of processes across its enterprise.
Tomer Levy, general manager of workflow and infrastructure in McKesson's Imaging and Workflow Solutions unit, cited previous studies estimating that 6% to 17% of adverse events are caused by diagnostic errors, and as many as 10% of patient deaths could be attributed to misdiagnoses.
"If a bad decision was made at the beginning with the diagnosis, everything done after that will be misguided," Levy said. "All downstream procedures at best will be ineffective, and in the worst case it will have a negative impact on patient treatment."
Kaminer said the venture was a "journey for both McKesson and our hospital, because neither the company nor our hospital quite understood the power of what we were dealing with. It took us a while to really hit our stride about how we could use the tools they were giving us."
Radiology in the ER
In recent years, Nyack's radiologists have been deluged by requests from emergency room physicians for reads as soon as possible. In fact, the use of CT, MRI, ultrasound, and nuclear medicine scans in Nyack's ER increased by 30%, from 29,815 total scans in 2011 to 38,819 total scans in 2015.
Using McKesson's workflow engine, Nyack altered its priority read strategy to include the patient's location, the type of scan performed, and the time of the procedure. Thus a scan from a patient in the ER or intensive care unit (ICU) would be a greater priority. In addition, the urgency of a scan read can also be upgraded or downgraded.
"The system will scan the order from the doctor, and if the doctor typed the words 'wet read,' it will automatically be recognized and raise the priority of that case," Kaminer explained. A technologist can also manually increase the priority of a case, such as a CT scan for a brain bleed, or if a patient is waiting for final results before discharge.
The system also offers a notification feature to alert radiologists that a case has not been read in a timely manner. Based on the urgency of the read, alerts pop up at five-minute intervals.
For example, Nyack radiologists are required to read a stroke case within 30 minutes. If the case has not been read within 15 minutes, all neuroradiologists will receive an alert that the case needs evaluation. If that alert receives no response, all hospital administrators receive an alert five minutes later that the case is still pending.
"Rather than waiting to the next day to ask, 'Why didn't we read this stroke case within the 30 minutes?' and point fingers, we can proactively make sure it is read within the time frame as needed," Kaminer said.
Performance benchmarks
To see how well the McKesson system performed, Nyack compared read turnaround time from a four-month period before Conserus was implemented (September to December 2014, weekdays from 8 a.m. to 5 p.m.) with turnaround time after it was implemented, in the same four months of 2015, when radiologists were comfortable with the processes.
McKesson's system did improve performance for Nyack's ER and ICU. For the ER, average turnaround time for CT, MRI, and ultrasound reads decreased 35%, from 20.13 minutes in the 2014 time period to 13.03 minutes in 2015. Average turnaround time for the ICU decreased 50%, from 52.37 minutes in 2014 to 26.06 minutes in 2015.
Interestingly, Nyack discovered that the average turnaround time for stroke reads did not improve. In fact, read time increased by an average of 45 seconds.
"The reason was we already had a high-priority method of having the technologist notify the radiologist by phone that there was a stroke patient waiting for results," Kaminer said. "Adding workflow intelligence into that process did not change [turnaround time] that much."
Hudson Valley Radiology Associates' agreement with Nyack requires that priority radiology reads be completed within 30 minutes. Using the new workflow engine, the radiology group now handles 94% of reads within 30 minutes, compared with 79% before implementation.
"It will be hard to prove that this alone will decrease length of stay, because there are so many parts to a hospital that affect length of stay, but it is every department's job to focus on what they can do better to improve the workflow of a hospital," he said. "Our focus was to see how we, as a radiology department, could improve the way we service the hospital."
McKesson's workflow program is still evolving with Nyack's help. Recently, the hospital noticed that an imaging study will occasionally slip through the cracks and remain unread over the course of a day.
"We found that some of the lower priority cases lingered until the end of the day," Kaminer said. "We knew it was a problem, and we are working with McKesson to create an 'escalation model' that will automatically raise the level of priority for cases that have been sitting too long."
