Vanderbilt University Medical Center (VUMC) is Tennessee’s largest and most prestigious medical facility. A decade ago, its anesthesiologists initiated the development of an easy-to-use, electronic anesthesia documentation solution that has evolved into a comprehensive patient information system specialized for acuity care. Called VPIMS, the solution was developed using Microsoft® software and runs on the Windows Server® 2003 operating system and Microsoft SQL Server® 2005 database software. Using VPIMS, VUMC staff members have been able to improve patient care by having quick access to accurate patient data. The hospital has also improved its bottom line by making staff more efficient, reducing surgery delays, reducing administrative work, and improving billing accuracy. By analyzing data generated by VPIMS, VUMC continues to improve on all metrics.
Throughout its 132-year history, Vanderbilt University Medical Center (VUMC) has been a leader in medical education, research, and patient care across the southeastern United States and the nation. At the heart of the medical center is Vanderbilt University Hospital, a 700-bed, tertiary-care not-for-profit center with 58 operating rooms in eight locations. VUMC also includes medical and nursing schools, a children’s hospital, extensive biomedical research facilities, and a number of specialty clinics. Combined, Vanderbilt University and VUMC employ more than 22,000 people, and they are the largest private employer in middle Tennessee.
||We now have the data to determine best practices for both patient care and operating room efficiency. The information management system has made a revolutionary difference in the way the OR operates.
||Dr. Michael Higgins
Chairman, Department of Anesthesiology, Vanderbilt University Medical Center
About ten years ago, a group of anesthesiologists at VUMC began to address the issue of patient-care consistency; quality of care had just begun to surface as an important issue across the United States. “We were treating thousands of patients in a large, thriving academic practice, but there was a lot of variability in care,” says Dr. Michael Higgins, Chairman of the Department of Anesthesiology at Vanderbilt University Medical Center. “Each physician did things differently, but we had no real data to know which way was best. We wanted to improve care, especially during surgery, but we knew that we had to start collecting data if we were to compare the effects of different medications and anesthetics on different patients.”
By identifying and standardizing best practices for patient care, the anesthesiologists hoped to improve not only patient care but also operating-suite efficiency. In most healthcare institutions, the surgical suite represents the largest source of hospital revenue and costs. Inefficient use of a hospital’s most-expensive staff and facilities has a huge negative impact on the bottom line.
At VUMC, operating-suite inefficiencies began with paper-based documentation methods for preparing patients for surgery, which sometimes led to delays and cancellations. Usually, a patient was sent to a preoperative center, where a nurse took the patient’s past medical and anesthesiology history on a paper-based form. Using this report, the anesthesiologist developed an anesthetic plan, made sure that needed medications were on hand during surgery, and developed a postoperative pain management plan. However, often the paper report wasn’t available on the day of surgery or was incomplete.
“Our anesthesiologist spent 30 minutes re-creating the report—not a good use of a highly paid and busy professional’s time,” explains Dr. Paul St. Jacques, Associate Professor of Anesthesiology at Vanderbilt University Medical Center. “Even if the report did show up, the patient data was sometimes incomplete or illegible, which could result in the surgery being cancelled, resulting in waste of expensive resources.”
At the time of surgery, the anesthesiologists might find that they needed additional testing or equipment that hadn’t been scheduled, which could also delay or cancel the surgery. The worst case was that the surgery would proceed with insufficient patient data, with the possibility of an adverse outcome for the patient.
Once in the operating room (OR), anesthesiologists, nurses, and surgeons wanted better, more convenient access to patient data, which was difficult to obtain when the data was on paper. In addition, anesthesiologists often manage multiple patients in simultaneous surgeries and had to run from OR to OR to monitor them.
“Once we began to think about capturing patient data electronically, we saw opportunities for process and care improvements everywhere,” Higgins says. “The challenge was how to best collect and share patient information in the surgical suite, to provide a real-time view of what was going on with a patient throughout the process, before, during, and after surgery.”
Doctors Higgins and St. Jacques turned to a group of engineers within the anesthesiology department for help. This team, headed by Nimesh Patel—who today is Director of Perioperative IT for Vanderbilt University Medical Center—had been working on a variety of data-collection projects for the anesthesiologists.
Rapidly Developed Surgical Tracking System
The doctors explained their vision of an electronic patient information system that would span the surgical process. Patel’s team started by evaluating commercial healthcare information applications, but found none that could be adapted for use in the OR environment. “We wanted a system that collected data on the entire continuum of care, from patient history to post surgery discharge,” Patel says. “There was nothing on the market that had everything we needed, so we decided to create our own.”
VUMC already had a large investment in Microsoft® software, so Patel’s team decided to create its new patient-tracking system using the Windows® 2000 Server operating system, Microsoft SQL Server® 6.5, and the Microsoft Access™ 97 database—software in use in the mid-1990s. The first module, created in just a few months, allowed anesthesiologists to digitally record all patient information during the preoperative evaluation. This early system eliminated paper records at patient intake and the associated rework and delays often caused by records being unavailable or incorrect on the day of surgery.
“One of the big advantages of using Microsoft software is the ability to deploy something quickly and iteratively—use it, improve it, and keep the cycle going,” Patel says. “Sometimes, in those early days, we’d have daily releases of the solution.”
The team has since upgraded the information management system to run on the Windows Server® 2003 operating system and Microsoft SQL Server 2005 database software, using Microsoft .NET Framework, Web services, and forms technologies as the development environment. “Moving to SQL Server 2005 gave us big performance improvements, and moving to Windows Server 2003 gave us long-term support for our solution, plus the ability to manage upgrades more easily,” Patel says. “Using the .NET Framework, we are able to create many more reusable components to make ongoing development faster and easier.”
VPIMS, a Multimodule Solution
Over a period of ten years, VUMC has expanded its original patient evaluation solution into a multimodule solution, called VPIMS, that supports the entire continuum of surgical care and patient monitoring, from scheduling to billing. Using Microsoft software in an iterative development environment, Patel and staff have been able to incorporate new ideas and capabilities, test them in a live OR environment, and continue to improve VPIMS at a rapid rate.
“Because this was not an IT-driven but a physician-driven solution, we’ve seen a high degree of adoption among the clinical staff,” Patel says. “Microsoft software has been key to our ability to get new modules out quickly, incorporate changes rapidly, and improve the application in an iterative fashion.”
|Figure 1: The VPIMS patient tracker module shows |
patient status throughout the surgical process.
Today, there are eight VPIMS modules:
- Preoperative Evaluation Module. This module is the initial point of entry for patients’ medical history data. Clinicians use an electronic form to gather data, which is stored in the central database for future reports and queries.
- Patient Tracker. This module (see screenshot below) is the backbone of VPIMS in that it brings together information from all the other modules. It is used to monitor patient status and improve staff management and efficiency by providing real-time information on case progress. Data entry at multiple points in the care path (admitting office, preoperative holding area, OR, postoperative anesthesia care unit), provides a time-stamp and indication of patient status.
- Nurse Charting. An application for recording events, patient information, and notes throughout the surgery. The documentation captured by this module is used to provide comprehensive information to the physicians and nursing staff regarding the patient and the surgical process. It continually provides updated information to the Patient Tracking module for planning and OR scheduling.
- Gas Chart. An application for complete intraoperative anesthesiology charting designed to mimic standard workflow patterns taught to clinicians during their training. Documentation compliance is supported through more than 30 checks for record completeness, with electronic reminders that address potential errors. Decision support for key protocols such as prophylactic antibiotics and beta blockade administration are also included.
- eORBoard. eORBoard displays all pertinent information relating to the surgery schedule in an intuitive, graphical format that replaces the need for white boards, markers, and magnets. The application is integrated with the electronic case information and patient status data entered from other VPIMS modules. Patient-protected data can be masked from unauthorized viewing when the data is displayed in public areas such as family waiting rooms. Estimated case lengths are adjusted as each case progresses, so rooms and personnel can be effectively managed in high-demand situations.
- Continuous Quality Improvement. This module is used after surgery by specially trained staff members who follow up on anesthesia care with the patient. Using customized questions, they collect data that is aggregated for specific reports on patient satisfaction and quality of care for peer review.
- Reporting. The VPIMS reporting module offers a robust set of operational, clinical, and financial reports to track performance across the perioperative enterprise. The reports are designed to capture key billing information as well as all clinical information and use standard clinical terminology and symbols.
- Vigilance. Vigilance evolved out of the need to improve the situational awareness of clinicians managing multiple patients simultaneously. It is a clinical decision-support application that mobile clinicians use to concurrently monitor all stages of care for multiple patients in multiple ORs and within intensive care units. The clinicians have immediate access to vital signs, lab data, and streaming video from the point of care for instant assessment of patient progress. Clinicians can subscribe to a number of alerts in the form of on-screen messages as well as text paging to increase patient safety and respond rapidly in critical situations. A clinician does not need to rely on others to summarize the patient’s situation when time is of critical importance; instead, Vigilance presents pertinent patient data along with clinician configurable alerts that can be displayed on any mobile device (see figure below).
|Figure 2: Mobile device showing Vigilance.|
VUMC runs VPIMS on the OQO model 02 ultra mobile PC, which offers complete Windows functionality in a pocket-size form factor, critical for physician adoption. A sliding display with pen tablet capability and ergonomic thumb keyboard facilitate easy data entry. Additionally, the OQO computer can access data networks with built-in WiFi and mobile broadband, so physicians are always connected to patient information.
VUMC has deployed VPIMS in three hospitals, where it’s running on more than 1,000 workstations and used by more than 500 people, including anesthesiologists, nurses, surgeons, and administrators. VUMC has also recently made VPIMS available to other hospitals as a commercial product through a third-party reseller, Acuitec.
Vanderbilt University Medical Center has improved the workflow for surgeons and anesthesiologists using a multimodule surgical-suite application developed with and running on Microsoft software. VPIMS provides instant access to digital patient information and clinical systems, reduces surgery delays, and improves patient care.
“VPIMS provides real-time information related to the performance of the ORs, and can also track key performance, safety, and efficiency metrics for individual surgeons, procedural areas, and departments,” explains Dr. Naji Abumrad, Chairman of the Department of Surgery at VUMC. “This information is extremely powerful in enabling us to review historical performance while, more importantly, improving our processes, clinical outcomes, and overall patient care and satisfaction. This is accomplished without inconveniencing the surgeon or placing any additional tasks into their already-full daily workload.” Because of its continued investment in Microsoft software, VUMC has been able to create innovative solutions faster and less expensively.
Improved Patient Care
Using VPIMS, the medical center has been able to make preoperative evaluation forms instantly available to attending physicians so they can deliver the best possible care. “Less time doing paperwork translates into more time for patient care,” Higgins says. “Clinicians can complete tasks faster and more accurately electronically, while following the same processes they already know.”
With digital data on patients and each surgery’s progress, physicians are able to engage in more proactive, timely decision making. “When doctors have all the information they need at the point of care, they don’t waste time walking around looking for patient files or other medical staff,” St. Jacques adds. With the ability to monitor patients remotely, using mobile computers, physicians and clinicians can provide better care for more patients.
Including reminders in the software has also increased patient safety. “When we programmed the information management system with prompts such as, ‘Administer antibiotics before incision,’ we saw infections decrease by 67 percent,” Higgins says. “The magnitude of outcome improvements as a result of simple process improvements was a surprise to us.”
Improved Bottom Line
By using VPIMS, Vanderbilt University Medical Center has been able to maximize surgical-suite throughput while maintaining quality, which is critical to maintaining financial viability. “VPIMS improves OR profitability by allowing us to improve surgical case volume and resource utilization,” St. Jacques says. “This also helps us alleviate staffing shortages and overtime charges.”
As a result of using VPIMS, the medical center has realized multiple critical operational improvements. For starters, the annual caseload has grown 10 percent annually for several years without the need to hire additional staff. The number of on-time first-case starts has increased by 100 percent since 2002. VUMC hospitals have seen a 65 percent decrease in day-of-surgery delays. They have also seen a 67 percent reduction in the average time to complete and submit an anesthesia chart to billing and a 69 percent decrease in the number of anesthesia charts that need correction or resubmission.
Additionally, the anesthesiology department has realized a 75 percent decrease in the amount of insurance write-offs and a 96 percent reduction in missed and/or under-billing. Due to improved documentation made possible by VPIMS, VUMC has reduced its third-party write-offs to less than 0.1 percent and is driving billing and collection costs to less than 1 percent of operations. “These changes have helped to dramatically improve our bottom line,” Higgins notes.
“Comparable solutions are typically associated with hardware purchases or enterprise solutions and are significantly more expensive,” St. Jacques adds. “Additionally, configuration and support for off-the-shelf packages add significant expenses to the original purchase price.”
Data for Payer Initiatives and Continued Improvement
VUMC is now able to gather deep, qualitative patient data that it can analyze for signs of continuous improvement. VPIMS produces a wealth of data that helps VUMC hospitals support pay-for-quality (P4Q) and pay-for-performance (P4P) initiatives that many health plans have adopted. The depth and richness of the reporting module not only supports P4Q and P4P initiatives, but also in-depth research and analysis, operational evaluation and improvement, clinical outcomes and tracking, and financial management.
“We now have the data to determine best practices for both patient care and operating room efficiency,” Higgins says. “The information management system has made a revolutionary difference in the way the OR operates.”
Microsoft Solutions for the Healthcare Industry
Healthcare and life sciences organizations are under tremendous pressure to meet regulatory requirements, improve patient care, and reduce the time it takes to develop drugs and take them to market. To meet this challenge, Microsoft and its partners have developed cost-effective solutions that enable healthcare organizations to streamline and automate daily processes that improve productivity and deliver information whenever and wherever it is needed. The result is enhanced productivity, safety, and quality.
For more information about Microsoft solutions for the healthcare industry, go to:
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