Despite the potential benefits of electronic information…

mohajer79 Despite the potential benefits of electronic information…Despite the potential benefits of electronic information management, including increased patient safety and more cost-effective health care delivery, few countries report the adoption of electronic systems for managing hospital information. On January 1, 2011, the Valle del Lili Foundation (VLF), a university hospital in Cali, Colombia, switched from paper to electronic documents to manage medical records (MR) and all related clinical and administrative procedures. The VLF, which reported revenues of US$200 million in 2014, is ranked the third best hospital in Latin America and the best in Colombia. The hospital made the ambitious decision to simultaneously implement electronic medical records (EMR), computerized physician order entry (CPOE), and enterprise resource planning (ERP). The new system is now fully operational. Marcela Granados, chief medical director (CMD) at VLF, was t the board of directors with analyzing the IT implementation process and documenting the main reasons for its success. While reflecting on this task, Granados concluded that one thing was certain: SAP implementation was a major turning point in VLF’s history. A brief about the Valle del Lili Foundation (VLF) The Valle del Lili Foundation is a private non-profit organization founded in 1982 to deliver tertiary medical care. The VLF was founded by two cardiologists from Cali who identified the need for a regional healthcare institution to deliver specialized care to medically complex cases and critically ill patients. They were later joined by Vicente Borrero, a public health physician, who has been CEO since 1986. Bringing together regional civic and political leaders and donors, they collected the necessary funds to launch the project. Initially focused on cardiology cases, they gradually expanded their service offerings. Today, VLF offers clinical care in more than sixty medical specialties and serves as a teaching hospital, where ICESI University medical students receive training. In 2006, VLF embarked on an ambitious plan to expand its service offering by constructing new facilities to house additional beds, an emergency room (ER), and ambulatory care services. By December 2010, the number of beds had increased by almost 60%. This growth put tremendous pressure on all patient care delivery procedures. In December 2014, revenues totaled about US$200 million. VLF was ranked the 3 rd best hospital in Latin America and the best in Colombia. Also, the previous year, America Economia magazine had ranked VLF the 4 th best hospital in Latin America and the best in Colombia based on clinical, administrative, and financial indicators. These awards confirmed VLF’s long-standing commitment to delivering excellent health care services in a patient safety-centered environment. A brief about the Structure and Operation of Columbia’s Healthcare Industry The functional and financial structure of Colombia’s health system is complex. Law 100 (1993) launched a major reform of the country’s healthcare industry. This law identified the system’s stakeholders and Strategic Management Track Class 2022/2023 [Mid-Term Exam ] Organization Development & Change Management 2 Case Study Prepared By Prof. Riham Adel established their responsibilities. These included private health insurers, known as Health Promotion Organizations (HPO), which are responsible for enrolling members and managing the system’s available resources. Other important players are the Care Delivery Organizations (CDO), including hospitals, which are responsible for providing services to HPO members. Under this scheme, insurance companies contract services with hospitals (in this case VLF) through managed care agreements and decide which CDO will care for their members. This is an important feature of the Colombian system because it means that HPOs, not doctors, decide where patients are treated. By December 2013, 58% of VLF billing went to HPOs; the rest went to prepaid medical organizations, other companies, and private patients. Law 100 also created the Obligatory Health Plan (OHP), which specifiesthe health-care services, surgeries, procedures, hospital services, and medications that HPO members are entitled to. The OHP also provides a reference price list for the industry, used when negotiating health-care contracts between insurers and CDOs. The VLF Medical Staff Structure VLF is a hierarchical, top-down hospital composed of medical units, each headed by a specialist physician. The CEO, the CMD, the chief nursing officer, the chief administrative officer, and the heads of the medical units form the physicians’ medical council and are responsible for communicating all senior management decisions to their units Although physicians are not directly employed by VLF, they comply with the policies of the medical directorate and the physicians’ executive council regarding quality and patient safety issues, the terms agreed to by VLF and insurers, and standard administrative procedures. Physicians are paid according to the number of patients they see, charging at the rates established by the insurance contracts; VLF takes a 20% cut to cover administrative expenses. Approximately 20% of total VLF billing is for medical fees. Additionally, all doctor-patient contact takes place within VLF facilities; full-time medical staff are not permitted to see patients or deliver clinical services outside VLF. Given the hospital’s high occupancy rates, doctors don’t need to go elsewhere to find patients. Marcela Granados, a critical care physician, who has been head of the intensive care unit (ICU) since it opened at VLF in 1992 and CMD since 2012, explained: “This type of relationship – with full-time doctors – is a cornerstone of the integrated medical care offered round the clock at VLF. Given the nature of the patients we serve, there are always medical specialists scheduled to be either on hand or on call. At VLF, doctors find everything they need to practice good medicine: technical resources, high standards, a group of highly skilled specialist physicians, nursing and assistive personnel, and many patients. They find it all here; there is no need to go anywhere else.” Strategic Management Track Class 2022/2023 [Mid-Term Exam ] Organization Development & Change Management 3 Case Study Prepared By Prof. Riham Adel This governance structure is not common in Colombia, where physicians usually work as independent contractors at hospitals – often at several institutions simultaneously. This limits the influence that hospital administration can have over medical staff since it has no official authority over them. Patient Care Delivery before IT Implementation A patient can enter VLF in one of four ways: ER, outpatient services, ambulatory procedures (diagnostic or other), or surgery. A patient may be admitted through the ER, be referred for surgery, be sent to recovery, be transferred to the ICU, be sent to a hospital floor unit, and finally be discharged. While in the hospital, the patient may have been treated by a group of specialists in medicine or other disciplines such as nursing, respiratory therapy, nutrition, physiotherapy, and pharmacy. The patient may have been given various diagnostic tests and received specialized medical treatment such as chemotherapy, radiation therapy, and cardiac rehabilitation. Patients generally pass through many hands during their stay at VLF, requiring close coordination between administrative and patient care personnel. This coordination is based on medical records (MR) containing the record of every medical and clinical procedure performed and all supplies and medicines used. Example of Patient Journey: By December 2010, there was an average of 1,000 surgical cases per month. Each case required the coordination of many steps prior to, during, and after surgery with a schedule made up of three shifts. High quality standards were met at all times, but it was not easy to coordinate the work of everyone involved: surgeons, anesthesiologists, medical equipment preparers, assistants, operating room (OR) supply store staff, and clerical staff such as those in charge of detailed billing reports. First, the surgeon issued a medical order with a specific surgical procedure to be approved by the patient’s insurer and another medical order to schedule an appointment for the pre-anesthesia evaluation. Once the insurer had authorized the procedure, the patient met with an anesthesiologist, whose consent for the surgery was required. The surgeon then asked the operating rooms to schedule the surgery and drew up a list of the instruments and supplies required for that specific procedure. These requests were handwritten on a form sent to the chief OR nurse, who added the case to an Excel spreadsheet and informed the OR supply store and sterilization center of the items needed to prepare the case cart. On the day of the surgery, the operating room clerk would admit the patient, ensuring that all administrative documents were in order, especially the insurer authorization. A nurse would then assist the patient and check their paper chart, particularly the signed informed consent form and the preanesthesia evaluation. When the patient was ready, they would be sent to the operating room with the results of diagnostic tests attached to their chart. Once the surgical procedure was over, in addition to the notes made by the surgeon, four forms had to be completed and attached to the patient’s chart. One was the anesthesiologist’s report sheet: on one side was the pre-anesthesia evaluation and, on the other, the Strategic Management Track Class 2022/2023 [Mid-Term Exam ] Organization Development & Change Management 4 Case Study Prepared By Prof. Riham Adel patient’s vital signs during surgery. Another was the report of the case cart technician, recording the equipment and supplies used. Third was the report of the instrument technician. Fourth was the log of supplies and medicines used, which was sent to the operating room supply store to be entered in the inventory system and charged to the patient’s bill. Supplies and medicines that were not used during the surgery had to be restocked by operating room clerks. After surgery, the patient was taken to a recovery room and nurses began reviewing the relevant information. Another form was then completed, recording the patient’s progress during recovery. This was also attached to the paper chart. When authorized by the surgeon, the patient was either hospitalized or discharged. This system worked in the surgical wards, but with so many forms to be completed and so many preliminary steps, confusion sometimes led to delays, making it necessary to reschedule cases. Inefficient procedures created extra work, and delays negatively impacted efficient room turnover and the surgeons’ schedule. María del Carmen Valencia, chief OR nurse, who has worked at VLF since 1994, explained: “In some cases, the pre-anesthesia evaluation or informed consent was not attached to the patient’s chart, or necessary supplies were not provided, sometimes because the surgeon’s or anesthesiologist’s instruments and supplies list was incomplete. This was a drain on everyone, because surgery could not begin until everything was in order.” Medical Records (MR) and Medical Orders (MO) MR are clinical documents containing information about patients and their clinical course; they are created by healthcare staff while patients are under their care. MR thus contain information essential to both patient care and administrative procedures and must be managed and stored in such a way as to ensure the confidentiality of information and the physical integrity of the records. In Colombia, medical records are legal documents. In the case of VLF, all professionals who dealt with a patient made a note of the procedures done. All these notes were made on paper or, in the case of the epicrisis, dictated by the attending physician into a recording machine and then transcribed by one of a pool of secretaries. The transcription was then printed out and attached to the patient’s chart. This procedure had several implications for the quality and availability of the information contained in the MR. Doctors aren’t known for their legible handwriting, secretaries can make transcription errors, and documents can be lost, mislaid, or filed with the wrong MR. Sometimes a patient’s chart is required by different departments at the same time, affecting its availability. A critical care physician who has worked in the adult ICU since 2007 explained this situation: “In the ICU, there was this paper form on which different team members of the unit worked – doctors, anesthesiologists, nurses, physiotherapists; and sometimes we all needed that paper form at the same time. In addition, it was possible that the chart was in another unit, or that it was being audited by the insurance company.” An ER physician who has worked at VLF for five years added: “Sometimes a Strategic Management Track Class 2022/2023 [Mid-Term Exam ] Organization Development & Change Management 5 Case Study Prepared By Prof. Riham Adel patient arriving in the ER could not remember what their physician had said, or what medications he was taking. In the case of a VLF patient, all of that was written on the patient’s MR, but it took some time for us to get the patient’s chart and review the necessary information.” Medical orders provide additional information to that found in medical records. These are the instructions from attending or consulting physicians on the course of action to be taken. Physicians use medical orders to request diagnostic tests, specify outpatient procedures, prescribe drugs, order surgery or hospitalization, and terminate the treatment and discharge the patient. Various health professionals then carry out the physician’s orders. Doctors would handwrite orders either directly on the patient’s chart or on a separate form, and the professionals who carried them out needed to see the physical chart. An order could involve several people, as in the case of medicines, for example, which involved the pharmacy that dispensed the drugs, the nurses who administered them, and the billing clerk who invoiced customers. Betty Gomez, nurse and chief nursing officer, has worked for VLF since 1987. She explained: “When a nurse administered the medications ordered by an attending physician, she would make a note on the pink nursing form. In the case of inpatients, they would use blue ink in the morning, green ink in the afternoon, and red ink on the night shift. These sheets were then attached to the charts. We wanted traceability of pharmacy-related procedures, but this was time consuming and not always reliable.” Although there are no official statistics on preventable medical errors in Colombia, studies of this subject have been conducted in the United States. The results are disturbing: a 2000 study by the Institute of Medicine concluded that, in the United States, more people die from human error in hospitals than in car accidents. Among the problems that commonly occur during the course of providing healthcare are adverse drug events: preventable injuries resulting from improper order processing, dispensing, or administration of drugs. Jaime Garcia, a physician who has worked at VLF since 2010, explained: “illegible handwriting on medical orders was one cause of adverse drug events, but it was not the only one. The person transmitting the order might confuse the names of similar medications, or trailing zeros might make the dosage unclear. But one of the biggest risks was drug-drug interactions. With the kind of patients, we handle, and the involvement of several specialists, unforeseen or unwanted reactions could take place between the drugs prescribed by different specialists.” There was also the possibility of duplicate orders for diagnostic tests, which could impact patient safety, in addition to the needless discomfort of undergoing them and the extra costs for insurers. Back – Office Procedures Parallel to medical care are administrative procedures, which are governed by regulations. Insurance contract guidelines and billing. Under Colombia’s health funding system, insurers have agreements with CDOs (such as VLF) for the healthcare of their members. The hospital’s Insurance contract department4. Identify the key steps and activities VLF had undertaken in its change management process BusinessBusiness – Other