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The Electronic ElixirPrograde Inc. led an 18-month project to help a North Carolina hospital convert 850 paper forms to electronic documents.
March 1999 No one enjoys a trip to the hospital. It can feel like an affront to all your senses—the sound of diagnostic equipment, the sight of bandaged patients, the bitter taste of medication and the jab of needles. The experience is often made worse by long waits in the admitting area and endless streams of forms. One hospital in North Carolina is trying to make the bureaucratic end of a hospital visit less painful. Craven Regional Medical Center, a 252-bed hospital in New Bern, N.C., installed an electronic document system to streamline the process. And it has worked. Two years ago, if a patient entered the hospital for knee replacement surgery, the task of completing forms was arduous. An admissions clerk would enter pages of information about the patient, including name, address, insurance information and next-of-kin data, into the computer. The clerk would then print a multipart continuous admitting form, pull other necessary forms from a cubbyhole stacked with documents, imprint those forms with demographic data and send the patient off to the nursing station on the hospital's orthopedic floor. Once there, the patient would likely repeat some of the forms processing procedure. The method was time-consuming and invited error. The admissions clerk easily could pull the wrong forms out of the cubbyhole, pick up extra forms or include an obsolete form. Using electronic documents helps Craven process patients faster and with more accuracy. Today, a patient entering the hospital for a knee replacement still visits the admissions clerk. If the patient has been to the hospital before, the clerk enters his name into a master patient index on the computer. If several people with the same name pop up, the clerk narrows the search by asking for the patient's birth date and address. Then, the clerk verifies and updates patient information recorded in the system during a previous visit and adds data pertinent to knee replacement surgery. The clerk hits the print key, and the electronic document system prints all forms necessary for the surgery at printers throughout the hospital. Some documents print at the admissions area, some print in the business office and others print at the nursing station on the orthopedic floor. All the forms include basic information about the patient and blank fields specific to each document. Electronic documents have cured many of Craven's ailments. "The staff doesn't waste time putting an admissions packet together. They print forms when they need them, they always get the latest form, and they always get the information they need," says Larry Wallace, the hospital's director of information systems. But implementing an electronic document system isn't easy. It certainly wasn't a task the hospital wanted to undertake on its own, so Craven sought assistance. Officials from Craven visited Mercy Medical Center, a hospital in Ohio that installed an electronic document system in 1996. The officials were impressed and decided to call on Mercy's vendor—Prograde Inc., a Cincinnati distributorship and electronic document management firm. Prograde, a 5-year-old firm, began providing electronic document services in September 1995. Although the firm still offers paper documents, its Healthcare Group sells only forms automation. The group follows a set path when marketing electronic document systems to hospitals, beginning with an analysis. Performing an Analysis Prograde considered several financial factors. First, it examined Craven's materiel management reports detailing which preprinted forms the hospital purchased. Craven was on a forms management contract with Wallace Computer Services and spent about $250,000 a year on forms. Many of these preprinted forms would be eliminated by electronic documents. Prograde also compiled data on the cost of warehousing forms and the price of peripheral items. For instance, Craven used Addressograph7 imprinters and plastic cards. When patients entered the hospital, information such as name and address were embossed on a plastic card. As patients moved to other departments within the hospital, that information was imprinted on various forms via an electric imprinter. Electronic documents would eliminate the need for imprinters and plastic cards. During the final part of the financial assessment, Prograde fully examined one department at Craven. "During an EFMA, we typically don't look at every process, but prioritize processes of key importance and flow chart them," says Jeff Moder, vice president/healthcare for Prograde, who initiated the account with Craven's IS department. Prograde's next step in the EFMA was to analyze Craven's technical infrastructure, including its hardware, software and network. "Electronic document software is a tool," says Moder. "It's like a snap-on product. It must integrate into existing software." For example, Craven already relied on a health information software package to run key clinical and business processes. Its electronic document software would have to convert data from this package into electronic document templates. Prograde recommended that Craven upgrade its network and replace its impact printers with Hewlett-Packard 4000 and HP5si laser printers. The hospital installed about 60 laser printers, with at least one at every nursing station. In addition, Prograde recommended an electronic menu system so hospital staff could gain access to documents. The menu contains a search engine so users can look up forms by name, number or key words, such as "radiology" or "consent forms." During the final component of the analysis, Prograde evaluated Craven's operations. This step involved extensive interviewing with key decision-makers in the hospital, including department heads. First, Prograde held a 2-hour orientation session for 15 directors at Craven, including several nursing managers and staff from medical records, admitting, purchasing, quality assurance, the emergency room and the business office. The session covered basic information about the project—what electronic documents are, what they can do for hospitals and why Prograde was at Craven. Next, Prograde held one-on-one interviews with department heads to answer specific questions. For instance, the nurses had questions about patient assessment forms and progress notes. Moder says it was particularly important to interview representatives from all departments, rather than just the director of information systems or the hospital's chief of staff. "The more input we can get from the breadth of the organization, the better," says Moder. After concluding the interviews, Prograde left surveys with department directors. The results became part of an EFMA report Prograde provided Craven. Moder says the survey was basic. "These people are very busy. We try to boil it down for them," he says. The surveys questioned each director's understanding of electronic documents and their benefits to individual departments and the hospital as a whole.
"If the survey responses are positive," says Moder, "the hospital can move forward with confidence that it has organizational consensus." The answers also helped Prograde establish a migration path for implementing electronic documents. Using data gathered during the analysis, Prograde outlined steps that Craven needed to take to automate its documents. "The migration path is basically building a recipe for doing this," says Moder. It serves as a broad plan that includes suggestions for setting up a forms automation committee, upgrading computer equipment, selecting the first department to automate and so on. Negotiating a Contract This component of the proposal was what gained Prograde the account. "One of the things that was unique about Prograde was that they were willing to accept some of the risk," says Wallace, Craven's director of information systems, who adds that the hospital did not have the budget to pay for an electronic document implementation. "This [project] was not a capital expenditure. We're strictly paying Prograde through cost savings." Craven's forms vendor, Wallace Computer Services, asked for the electronic document business, but the hospital declined. "When Wallace Computer Services found out what we were doing, they suggested alternatives, but they were not geared up to do this type of project," says Wallace. "Prograde is a consulting vendor, and they made us such an attractive offer." Moder says Craven made a "small capital investment" when the project began, then Prograde targeted costly, high-volume forms to convert first. It began implementing electronic documents in Craven's emergency department, and it yielded an immediate return. One of the first forms Prograde converted was a patient admitting form that was a continuous multipart label/form combination. Elimination of that form saved the hospital $25,000 a year, says Wallace. He says Craven was able to pay Prograde $100,000 during the first year of its electronic document project. Implementing Electronic Documents Before any forms were converted, Prograde helped the hospital establish a forms automation committee. "A lot of decision-making in hospitals is done by consensus, and everybody uses documents," says Moder. Each department within the hospital needed to have input in the project. Craven already had a forms standardization committee, so it modified this group. The forms automation committee consisted of a core group, including nurses, doctors and staff from the information systems, materiel management, admissions and medical records departments. Ad hoc members from other departments joined the committee as their areas were automated. "It's essential to have the right people at the right meetings," says Bayliss. Wallace distributed a memo to all hospital staff announcing the project's kickoff. Prograde encourages its clients to keep employees informed about electronic document implementation and offers sample communication packets to help them. Contracts are often made at high levels, not with the users, says Bayliss. It's important to keep the users informed so the project remains on schedule. Bayliss traveled to North Carolina for a kickoff meeting with the forms automation committee. Its role was to determine policies related to electronic documents, serve as project liaison with the hospital at large, resolve conflicts and motivate hospital staff so a smooth installation would ensue. One of the committee's most important tasks was agreeing on a form template. "At the end of this project, independent of the department you go into at Craven, all the documents look the same," says Bayliss. The committee decided how the forms should look, what font they should print in and what bar code specifications to use. (All documents include bar codes to assist with the eventual storage of medical records via document imaging.) The committee also developed standards for naming and numbering electronic documents. Prograde also established a project management plan to help organize the installation. This was no easy task—Craven converted hundreds of documents in 18 departments. Prograde relied on Microsoft Project software to plan and manage the implementation. It identified details of each task required to convert paper forms to electronic documents throughout the hospital. These tasks included collecting and cataloging all preprinted forms. "Each element, as repetitive as it may have been, was laid out for each department," says Bayliss. With the committee and project plan in place, Prograde began automating the first department at Craven—the emergency room. The company collected, analyzed and converted about 200 forms to electronic documents using OptioMedForms electronic document software. The conversion took about eight weeks. Before completing implementation of the emergency room's documents, Prograde began working on the next department—the in-patient and out-patient registration unit. Schmiesing, the project manager, held training sessions at Craven when each new department began implementation and after the installation. But the majority of the programming and design was done via remote computer access. Prograde and Craven relied on two software programs: IBM's Client Access software and PC Anywhere software for file transfer protocol. Using Client Access, Prograde dialed into Craven's AS/400 system and acted as a remote workstation. "It gave us the same capabilities as if we were in North Carolina," says Bayliss. Prograde transferred files containing electronic documents to the hospital's system using PC Anywhere. Craven then uploaded the files from a PC to its AS/400 mainframe. When a department "went live" with its electronic documents, Schmiesing trained the users. She taught hospital staff how to use the computerized menu system and how to select and retrieve documents. In addition, because most of the documents are printed, she taught staff how to use the printers and fill the paper trays. Schmiesing also trained Craven's IS department on OptioMedForms applications, because it will handle maintenance of the electronic documents and design future applications. Moder says this was training in "how to do the guts of Optio work," rather than how to use the final documents. Weighing the Results Wallace says hospital staff had to overcome a reluctance to change systems. "We were challenged to become more efficient, but that meant change," says Wallace. "And the only person that enjoys change is a wet baby!" While the IS department and some directors in the hospital looked forward to electronic documents, many of the day-to-day users of the documents were hesitant to embrace the system. "The users that had been doing things the same way for so many years—getting them to accept it wasn't easy," says Wallace. "We had a tough time with the physicians." Ironically, many of the complaints were about seemingly small things. For instance, some doctors grumbled about their progress notes, which were previously printed on blue paper. Now all documents are white. However, the on-site training provided by Prograde helped smooth the transition for most users. These challenges, though, don't outweigh the benefits. Aside from streamlining operations at Craven, electronic documents have other advantages. Foremost, the system enables document imaging. "We're putting in a document imaging system to store medical records, and we realized how valuable electronic documents would be," says Wallace. "They prepare us for imaging." All Craven's electronic documents conform to the same template and include two Code 3 of 9 bar codes—one indicating the type of form and the other identifying the patient. After the documents are printed and filled out by hospital staff, they are scanned into the imaging system for storage. The bar codes ensure that documents are indexed in the correct electronic file. Without standard forms and bar codes, hospital staff would manually indicate where the records should be stored, a time-consuming task given the number of documents generated by Craven. The emergency room, for example, sees about 32,000 patients a year, each with records between eight and 15 pages. Electronic documents also speed up pre-certification of patient insurance. "Within minutes of registration, hospital staff can call up the insurance company and find out what it will cover," says Schmiesing. When paper documents were handled manually, it sometimes took a day for the forms to reach the reviewer who called the insurance company. Often, costly tests were performed before the hospital discovered the insurance company wouldn't pay for them. Now the documents print out immediately upon patient registration in the insurance reviewer's office. In addition, Wallace says the hospital's electronic documents appear uniform and more professional and help the facility maintain a higher standard of care. This helps Craven adhere to compliance laws. Every three years, the hospital is accredited by the Joint Commission of Accreditation for Health Care Organizations. Electronic documents should help Craven receive its accreditation, according to Wallace. Electronic documents have created a win-win situation for Craven and Prograde. The hospital, while becoming more efficient, has saved up to 70 percent of its cost for paper forms. Prograde earned that money without the hospital spending a nickel extra from its operating budget. That's a healthy outlook for both organizations. Susan Keen Flynn is managing editor of FORM Magazine. Company Capsule The Right Staff Prograde carefully selects employees for its Healthcare Group, which sells only forms automation. "There's so much academia in the medical industry. Almost all the people we deal with have accreditations," says Moder. "It's important for us to step up to the plate with employees who also have accreditations in their fields." Prograde assigned Denise Schmiesing as project manager of the Craven Regional Medical Center account. Schmiesing, who handles day-to-day management of the account, is a registered nurse. The 18 years she spent working as a nurse helped Prograde as it converted hundreds of clinical documents. "The language of health care is just as intimidating as the language of technology," says Moder. Schmiesing's background is an asset not only in dealing with clinical documents, but also with hospital staff, who view her as a peer. For instance, Schmiesing worked closely with a nursing liaison to compile about 17 admission packets, each unique to hospital departments such as labor and delivery, pediatrics and intensive care. Schmiesing is assisted by an integration engineer with a background in IBM AS/400 systems, the platform used by Craven. Prograde matches employees with clients based on what computer platforms and software customers have. It employs integration engineers with experience in AS/400, UNIX, Windows NT and Novell operating systems. Prograde also is a Microsoft Solution Provider with Microsoft-certified engineers on staff. Finally, Prograde relied on a database administrator to oversee a forms management database, and about six document designers to create forms templates using OptioMedForms electronic document software. Moder says most of the staff, aside from Schmiesing, worked on the Craven account part time in addition to other projects. "You pull people in over an 18-month project as necessary," he says. Anatomy of an Electronic Document Project
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