“Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.”
― H. James Harrington, performance improvement expert
Starting in 2007, emergency departments in the Department of Veterans Affairs began adopting a system called Emergency Department Integration Software (EDIS). An extension of the Computerized Patient Record System (CPRS), EDIS was designed to help manage the delivery of care to patients in an emergency department (ED). The system, easily visible to clinicians on screens throughout the ED, tracks and records information about the status of each patient in the ED, how long they have been there, and the clinicians assigned to their care. The idea was to improve patient flow.
EDIS was the brainchild of Gary Tyndall, M.D., director of the Syracuse, N.Y., VA Emergency Department and now the VA’s national program director for emergency medicine. Use of the program started in Syracuse and quickly grew popular throughout the VA system.
For the last few years, Tyndall has been working with the VA’s CIO Office and consultant Daniel Swedberg, president of Oakton, Va.-based SyntheSys LLC, to use this patient tracking software now widely used across VA’s EDs as a business process management framework to pull data from 150 sites and create metrics and dashboards to help standardize operations across the enterprise and improve performance. Their effort was launched last year and called the Emergency Medicine Management Tool (EMMT) Process Analytics Application. It recently won an award from the American Council for Technology and Industry Advisory Council’s Institute for Innovation. I recently had a chance to speak with Tyndall and Swedberg about their work.
“Initially EDIS was just a tool to help provide situational awareness,” Swedberg said. But now that all this information about how long processes take in EDs is digitized, it can be captured and analyzed.
EMMT tracks a number of metrics associated with the flow of patients through the ED. Four have to do with length of stay. Others track length of time from door to triage or how many patients left without being seen. Others track provider productivity.
“One of the key drivers has been to try to standardize as much as we can across the enterprise,” Tyndall said, with the understanding that there was so much variation that you had to allow a certain amount of leeway to adjust what you want to do to their personal situation. “We want to help EDs figure out where delays are and understand roadblocks,” he said. “This is not about slapping anyone’s wrists. It is about understanding the processes and making problems evident.”
Tyndall said sites do feel peer pressure when they see their data compared to other sites. “No one likes to be the worst,” he said. “When we explain to them how the data is collected and talk about things that can make a difference, they tend to do better. Also, we try to help them understand that we are measuring some things that are outside their control that can then be categorized and documented, such as a shortage of inpatient beds. We have a huge problem with boarding. They can present this data to other folks on the inpatient side where a lot of our roadblocks exist.”
A training effort is under way to help providers get better at using the dashboard tools. “Once that is done, then we have a quality performance improvement plan to help start to look at metrics from every site,” he said.
There are about 30 sites still struggling to use the tool. “Frankly, most of the problem is due to a leadership issue in the department,” Tyndall explained. Most experienced ED leaders in the VA understand the importance of the metrics. “Sites where we have problems are smaller ones where we don’t have a dedicated ED director,” he said. “You tend to have contract folks staffing the department. Without someone taking the lead and getting people to understand the importance of the data and how it can bebeneficial to them, those sites struggle, and those are the ones we have to work on. We expected that to happen. We just had to identify them and provide them with the resources to do better.”
There are other projects being developed around EDIS that will help collect data. The VA is building a mobile product and a pilot pathway to gather stroke data. “We have a lot more coming down the pike in terms of EDIS being used as the primary focus for ED docs,” Tyndall said. “We want them to be able to do their notes and orders right through EDIS so they don’t have to go back and forth from CPRS.”
Swedberg said part of the three-year plan is to move from day-old data to real-time operational dashboards in the ED showing at any point in time how many patients are queued at a summary level instead of just the individual patient level.