Can $20 Billion Solve this Problem?

Frank Poggio                                                        
The Kelzon Group
March 30, 2009
All rights reserved

There was a poignant opinion piece in the Chicago Tribune Sunday March 29, 2009 that got my attention,
written by Candy Schulman entitled “There is a human in that bed”. It caught my eye and my empathy
because I lived that same experience about a year ago. There were however, two major differences. First
it happened in a different hospital in a different state. Second, since I have worked in the hospital world as
an administrator, systems supplier, and consultant for thirty-five years, I had a better understanding of the
hurdles and therefore was able to force a faster resolution. As I read Candy Shulman’s article I kept
asking myself, as I did a year ago, what is really wrong with this ‘system’ and what can be done about it?
Also, I kept thinking will $20 billion that the government is throwing at health providers really solve this
problem? Let me tell you a little about both stories before I give you my assessment and prognosis.

Candy’s Story - Dumped in the driveway.
Candy tells about her frustration in caring for her elderly mother while an inpatient at a local hospital. Two
of her biggest problems came in simply getting her mother discharged at a reasonable time, and the lack
of coordination with hospice care. The statement I reacted to was, “After her month long hospitalization
and three weeks in rehab, I tried all day to get her discharged, but ran into a hospital quagmire when I
could not get anyone to sign the discharge papers. Finally, at 6 p.m., I left, believing I'd repeat the
arduous process the next day”.

“Two hours later the rehab facility sent a bedridden, demented old woman home in an ambulance—alone.
I wasn't called to accompany her home, nor was her devoted live-in aide, Nellie (I was taking her out for a
bite to eat after a long, tiring day). My poor confused mother was suddenly dumped into an ambulance. In
the driveway of her apartment building, the driver seemed surprised that no one was there to take care of
her.”

Candy Schulman’s complete article can be found at: http://www.chicagotribune.com/news/chi-
oped0329humanmar29,0,552996.story

My story – Who’s on First?
In February of last year I lived through a similar experience. My 88 year old mother after years of
struggling with CHF and COPD, was admitted to a Florida hospital. After a few days of hospitalization we
were told there was nothing that could be done and death was only a month or two away. My family
decided the best course was to move her home and get the local hospice involved to supplement the
efforts of me and my sister. I had spoken at length with her cardiologist, internist, and case worker and
agreed this was the best course. Needing a day to work things out with a local Hospice program, the
hospital agreed she would be discharged in two days.  I lined up the Hospice services to come to her
home to set up the medical equipment, complete their assessment and explain to her their plan and what
would transpire. Although my mother was severely physically impaired she was of sound mind and fully
cognizant of her surroundings to the day she died.

On the agreed to day of discharge I went to the facility to get her at 9am, thinking that by 10am or 10:
30am we’d be on our way. The day before I told the Hospice staff we would be at her house by 12 noon
and they then could commence their process.

To make a long story short, I did not leave that hospital until 1:30pm that day, and then it was only
because having worked in a hospital earlier in my career I knew how disjointed things can get. I personally
tracked down the admitting doctor (not her cardiologist or internist) and brought him to the room to write
the discharge orders and sign it. That was at 12:30pm and still a number of other nursing and related
tasks had to be completed. All the while I was running around the hospital, and in and out of her room, my
mother kept asking ‘Don’t these people know what they are doing and when can I go home”? I kept
answering “No they don’t, and if we’re not out by 2pm we will leave AMA!”

What went wrong?
Everything involved with communication, coordination, and follow-up. No one knew who was on first, who
had primary responsibility, or what needed to be done next. As best I can tell everyone involved was
waiting for the next person to do his/her task, when in fact many of the tasks could have been done
concurrently. Meanwhile this hospital has been using one of the leading HIS packages in the country for
more than a decade.

So let’s spend $20 billion on new HIT/EMR systems like Cerner, or Epic, McKesson, GE, Siemens, or
Meditech…whatever flavor you like. It won’t matter. Although they may help a little, in my opinion, none of
them can solve this problem. Here’s why.

The problem Candy and I described is not a data storage (EMR) or transactional (HIS) problem. It is a
communication, coordination, trans-departmental workflow and management problem. Yes, HIT vendor
systems can do communication, but they do very little, if nothing, for work flow coordination and
communication and almost nothing outside of ancillary medical services. These systems are great at
ordering an x-ray and making sure radiology does the prep work, then delivering the results to clinicians
and placing an image in the EMR. But what if that patient needs a dietary consult and the dietician comes
to the room while the patient is still sitting in x-ray, one hour late for a test that was to be done at 1PM?
These million dollar plus systems almost totally ignore non-medical support services such as social work
consults, dietary reviews, transportation needs, patient location or education, timely discharge orders,
and more. Such tasks typically fall to nursing to ‘manage’. Inevitably one task or more falls through the
cracks, and when one fails the whole process collapses and the patient suffers.

Unfortunately this problem is pervasive across health institutions as identified by a recent report issued by
the National Academy of Sciences – Institute of Medicine (IOM) entitled "Computational Technology for
Effective Health Care: Immediate Steps and Strategic Direction". The report states: “
Health care decisions
often require reasoning under high degrees of uncertainty about the patient’s medical state and the
effectiveness of past and future treatments for the particular patient. In addition, medical workflows are
often complex and non-transparent and are characterized by many interruptions, inadequately defined
roles and responsibilities, poorly kept and managed schedules, and little documentation of steps,
expectations, and outcomes.”

If you are a provider CEO or CIO and still do not believe it is pervasive, then answer these simple
questions. Does your facility have a time of discharge policy? Most would answer 'yes'. Then what
percentage of the your discharges hit that time within 15 or 30 minutes? Of course if you can’t answer  
that’s proof enough.

During my years as a hospital CIO /CFO and as a system’s developer I believed that the ever expanding
HIS tools and developing EMR’s would someday address this problem. Today after many years of hands
on experience at all levels I am convinced the new million dollar plus systems cannot and will not. In a
nutshell, I have come to the conclusion this in not an information technology problem. It is a work flow
process problem, a communication problem and lastly a management problem. It is not a department
problem, but an inter-department or enterprise problem. An HIS /EMR can help solve it, but using those
tools alone you are doomed to fail.

What is needed?
The seemingly simple goal of implementing a set discharge time and meeting it has many challenges such
as poor inter department coordination and poor integrated work flow. Inter department resource
coordination founded on solid work flow documentation and monitoring tools is critical to successful
patient flow and meeting discharge targets. Fortunately there are many sophisticated work flow tools
developed outside of health care that can be used to help achieve better patient flow and control. Private
industry has used tools such as optimization, production coordination, queuing analysis and sophisticated
enterprise scheduling for decades. Some of these are finding their way into health care now, but very
slowly.

These tools go beyond electronic bed boards and digitized paper forms, both of which are needed but
only address the symptoms. Hospitals need to know real time where they stand for any given patient. In
effect, a Gant chart or patient critical path for all activities is needed to meet a specific goal or target
discharge time. Remember, a delayed discharge costs the hospital money and it’s the primary reason for
ED diversions, which typically lead to large ED capital expenditures.

Proper coordination of all services (ancillary and non-ancillary) can help hospitals get through these
tough times. It's not easy, but by better utilizing your current resources, (staff, equipment and technology),
through better work flow coordination, you can significantly improve patient throughput to drive improved
productivity, reduced costs, enhanced revenues and most importantly increased patient satisfaction.    

While in the hospital my mom, and I would believe Candy’s, received excellent medical care from some
very dedicated and over worked people. But what we remember most clearly was the bungled discharge
process which colored their entire stay. Medicare starts this year to measure patient satisfaction to set
quality care payments. Today bungled discharges are bad public relations, tomorrow they will be a costly
mistake.