Dr. Jim Jirjis, left, and StarPanel creator Dario Giuse: “Doctors are hungry for this,” Jirjis said. (photo by Dana Johnson)
Going paperless — Suite IV uses StarPanel to improve efficiency
A vanguard of doctors and staff within the department of Medicine’s division of General Internal Medicine has in recent weeks begun practicing entirely with use of electronic patient records. From office computers and from remote locations, the complete patient record is now available via secure Web server—orders for tests and drugs, clinical notes, test results, letters, phone messages, faxes, etc. The pilot is hailed as a milestone in Vanderbilt’s three-year project to remove paper-based processes from all outpatient areas.
The E3 project (as in electronic by year three) is all the more noteworthy in that only a few institutions of comparable size have committed to attempt a similar transformation. E3 has special interest because of close alignment with Vanderbilt’s clinical improvement program and with a sweeping Vanderbilt Medical Group operations improvement project known as clinic redesign.
“As the project proceeds, the combination of E3 with quality improvement and clinic redesign will take out paper-based processes and old infrastructure in ways not done elsewhere,” said Dr. William W. Stead, associate vice chancellor for Health Affairs and director of the Informatics Center.
In aiming for paperless outpatient processes, Vanderbilt is building on earlier groundbreaking success in bringing information technology to bear in hospital settings. Last summer Vanderbilt University licensed rights for commercial development and marketing of WizOrder, the highly prized hospital electronic order entry and decision support system created and developed at VUMC. E3 continues Vanderbilt’s experimental approach, aimed at more thoroughgoing and reliable application of the best existing clinical knowledge, supporting continuous improvement of clinical outcomes and new levels of efficiency.
“Vanderbilt is on the cusp of a major change in how we manage increasing amounts of medical information,” said Dr. Eric G. Neilson, Hugh Jackson Morgan Professor and chair of the department of Medicine. “Computer literacy and faculty willingness to live on the edge of breakthrough technology is part of the reason why we are on the leading edge. For the first time, the clinic exam room has become a laboratory for innovation.”
E3 in E1
With eight attending physicians and 17 residents, Suite IV is a practice group within the adult general internal medicine clinic, located on the seventh floor of Medical Center East. For patients of this suite the entire Vanderbilt patient record is now electronic. “We’ve all heard about E3. This is E3 in E1,” said Dr. Jim Jirjis, assistant professor of Medicine and medical director of the clinic. The Suite IV project is spearheaded by Jirjis and Dario Giuse, Ph.D., associate professor of Biomedical Informatics. Nancy Lorenzi, Ph.D., professor of Biomedical Informatics and assistant vice chancellor for Health Affairs, is project director for E3.
Lorenzi has focused on communication between users and system developers, making it more likely that people across the organization will accept and value Informatics Center products.
“This project ultimately will be a hit for the same reason that WizOrder became indispensable—because Informatics comes to the practitioners and tailors system to the needs of users,” Jirjis said.
Like the rest of VMG, Suite IV has for years used a Vanderbilt computer application called StarChart (formerly called MARS) for electronic retrieval of test results and doctors’ notes. Suite IV’s first step in going paperless was to pioneer a major new twist on StarChart called StarPanel. Created in collaboration with Giuse, StarPanel allows doctors and their staff to manage patient groups more efficiently, with a new level of clinical quality control. For managing a patient population, StarPanel is to StarChart what a Ferrari is to a donkey. Where StarChart retrieves records one at a time, StarPanel is able to retrieve information on user-defined patients groups (called panels), and this new capability is changing the way patient groups are managed at Vanderbilt.
StarPanel today draws information from three systems: clinical information (StarChart), outpatient scheduling (Epic), and hospital admitting/discharge/transfer (Medipac). A Vanderbilt doctor can instantly create panels that include, say, all patients that he or she has seen in the past two years; patients seen by his or her residents; all patients on the service; all patients with a given diagnosis. Other useful panels would include patients on today’s clinic schedule or patients on a given hospital unit. A user need only define a panel once: as new patients appear in the VUMC system, StarPanel automatically adds them to the appropriate panels and automatically removes any patients who no longer belong.
Doctors especially value being able to instantly call up new results for their patients. In less than two seconds, StarPanel surveys a given panel and gathers the results not yet seen: lab tests, radiology reports, all clinical notes, cardiology tests—anything that appears in StarChart. New results drive clinical decision making and this function alone would make StarPanel indispensable.
StarPanel opens up a new route to creating patient registries for coordinating and measuring practice improvement. Staff can easily find patients who appear due, say, for a mammogram, or flu shot, or colon screening. When a drug in wide use is discovered to be dangerous, this formerly would require getting every available staff member to pore over charts, but with StarPanel it will be easy for one person to get the list of patients for notification without delay.
StarPanel’s added communication tools mimic systems established in the paper world. As doctors view patient results in StarPanel they can type reminders to themselves; the system automatically attaches the patient information that will later be useful for initiating follow-up. In Suite IV, referral authorization is now handled entirely from within StarPanel. Suite IV nurses also enter clinical notes—injections, patient education, etc.—directly into StarPanel.
“Faculty and staff say this new way of working is great—including the people who just knew they were going to hate it,” said Dan Meredith, assistant manager of the general internal medicine clinic.
“The big change from the staff’s perspective,” Meredith said, “has been the electronic message basket function. It has totally revolutionized how we do things.”
At least in primary care, phone messages are a large part of the outpatient record. While on the phone with a patient, the Suite IV PSC (patient service coordinator) types the patient’s message directly into StarPanel then sends it to the nurse’s electronic message basket. Depending on the issue in question, the nurse can often anticipate a doctor’s need for certain information from the patient record. Without leaving StarPanel the nurse can copy and paste this information into the message then forward it to the doctor’s electronic basket, and the nurse can color-code the message as urgent or requiring a response. After responding, the doctor can turn a message stream into a note in the patient record. Part-time clinicians no longer need to visit the clinic daily to tend to their in-box, and can instead handle the work from any Internet location. As Jirjis points out, if a patient were to call for a new medication in the afternoon and wind up the following morning in the Vanderbilt ED with an adverse drug reaction, the ED immediately would have the vital information from the previous afternoon’s electronic record. The clinic manager can see how many messages are in each nurse’s electronic basket and when work piles up for one nurse, other nurses can pitch in without leaving their own area.
“It used to be a big deal to pull nurses in from other areas,” Meredith said, “but when people don’t have to leave their usual surroundings, help is all around.”
StarPanel communication/documentation tools take the place of several written documents, but this still left roughly 20 percent of the patient record available only on paper. Suite IV’s next step was electronic scanning of existing paper records and scanning of all new documents as they arise. For now, Suite IV is continuously scanning outpatient test ordering forms, faxes sent to pharmacies, physician referral letters, insurance company inquiries, the patient’s completed medical history form and the photocopy of the patient’s insurance card. All scanned pieces are indexed to the patient record through the StarPanel interface. A vendor does the scanning on-site.
Suite IV has stopped delivery of patient charts from Medical Information Services. The suite is discovering which clinics and ancillary services put their work into StarChart, and is shutting off delivery of letters and records from those areas as well.
Removing cost
The elimination of paper removes much of the work, cost and frustration associated with clinical practice. “The opportunity is to use computers to manage patient records, instead of using a complex hierarchy of people,” Jirjis said. “Rather than having to manage pieces of paper, we want to allow our staff to focus directly on helping to manage patients, and with StarPanel we’re making our most accelerated leap toward this new way of working. The only way to get there, however, is to go entirely electronic, because the minute you decide one piece of paper doesn’t have to be electronic, you suddenly need a clerk and a filing system.”
As E3 begins to bear fruit, Vanderbilt will be in a position to begin reducing clinical record-keeping costs. This coming transition poses highly sensitive issues of job loss and staff retention. At Vanderbilt as elsewhere, much effort goes into managing patient records. There are file clerks within all the clinics and there is a large centralized staff responsible for assembly, retrieval and transport of patient records. It’s expected that the eventual cost reduction will be achieved through staff attrition, with some of the remaining staff deployed to assist clinical improvement initiatives. A former filing clerk could be assigned to assist, say, with the diabetes beat—electronically surveying the diabetic population, finding patients due for their next HbA1c test, and contacting these patients to schedule the test. The benefit from such systems include not only improved clinical quality, but also tremendous patient loyalty.
Next steps
The intensive use of scanning technology in Suite IV is a stop-gap only. If Vanderbilt is one day to realize the full potential of its new outpatient systems, information that is today bound within images or within free-text blocks will instead need to fall out in data fields as discrete values and terms, ready for programmed inspection by expert systems. Since late June VMG general cardiologists have been piloting an electronic outpatient order entry system and Jirjis hopes Suite IV will soon be included in this pilot. A physician note writer is also under development as an alternative to the current system of dictation and transcription.
Suite IV has ordered computers in its exam rooms. (Doctors in the suite currently use hallway computers to retrieve each patient’s problem list.) Jirjis doesn’t necessarily foresee doctors entering data while examining and talking with patients, but with outpatient order entry he thinks it likely that doctors will gravitate to ordering tests during the patient exam.
Learn how to use StarPanel
All StarChart users have access to StarPanel. Self-paced materials covering basic StarPanel functions are available through the StarPanel help button; or call the VUMC help desk, 3-4357 (available 24/7); or call Systems Support Services, 6-6778. Classes for advanced StarPanel functionality are available through Systems Support Services; for a schedule of classes please point your Web browser to www.mc.vanderbilt.edu/sss/.