Where there's a will, there's a way; Alabama referral hospital combines scheduling and document imaging systems to create a paperless order-tracking system

Health Management Technology, April, 2004 by Eric Daffron

When it comes to orders for diagnostic or preadmission tests, no hospital can afford to be lax. For one thing, medical necessity checking is a must; for another, JCAHO requires that an order be on file before any diagnostic test is performed on a patient. When hospitals don't have test orders on hand in advance of patients' testing or admission dates, everyone wastes time. That frustrates patients, physicians' offices and hospital staff alike.

Missing in Action

Southeast Alabama Medical Center (SAMC) is a 400-bed regional referral hospital serving Dothan, Ala., and several surrounding communities. We perform many diagnostic tests related to cardiology, neurology, radiology and numerous surgical procedures. We see at least 250 outpatients daily; during fiscal year 2003, we registered 20,181 inpatients, 90,599 outpatients and 37,202 emergency room patients.

Prior to January 2002, SAMC received only 30 percent of scheduled patients' orders before their testing or admission dates. We would receive handwritten, printed or faxed orders for tests from the day the test was scheduled by staff right up to the day of the test, when the patient himself might bring in the order. But patients also arrived without an advance order having been sent to us by the referring physician's office.

Physicians' offices complained when we lost orders they had sent far in advance, which we then asked them to resend. Patients, too, got upset, because they might have to wait more than an hour while their test orders were relaxed to us. In some cases, patients had to complete their tests on subsequent days. Understandably, physician and patient satisfaction was very low.

We relied on a manual filing system, and as we registered a growing number of patients, lost orders became a more prominent issue. In 1994, we instituted a computer log that staff used to sign in or sign out hard copies of physician orders, but this did not prevent orders from being lost due to misfiling or carelessness.

In January 2002, we created a staff group dedicated to order tracking and began using fax software and Microsoft SharePoint for temporary electronic storage of fax orders. When patients arrived for testing, the orders were printed and then deleted from the system. Thus, there was no long-term electronic storage of physician orders.

In time, we realized that we needed a process that would improve both physician and patient satisfaction. We needed to eliminate the rewriting of orders and simultaneously to decrease patient wait times for tests. We realized that SAMC needed a computerized system for tracking orders and making them available from any location within seconds.

Putting the Pieces Together

Unfortunately, computerized physician order entry was still a few years away on our hospital's implementation timeline. In July 2003, we decided to combine the functions of our two existing systems--Pathways Healthcare Scheduling (PHS) and the Horizon Patient Folder (HPF) document imaging system, both from McKesson Information Solutions in Alpharetta, Ga.--to create our own paperless order-tracking system.

The process begins when a physician's office initiates a request for a diagnostic or pre-admission test appointment, either by phone or fax. This request goes into our central scheduling office, which schedules the appointment in PHS and confirms it back to the requesting physician's office by voice or electronic fax. Orders then are faxed from the physician's office to HPF's fax server, which converts the fax to a digital image and places it into an HPF work queue to be indexed to the patient's account by our order-tracking group.

When a patient is scheduled in PHS, a temporary account number is created and sent via HL7 to our McKesson Series hospital information system (HIS) and HPF. When the patient with the temporary account is chosen in the HIS and preregistration is completed, a final account number is generated and sent back to override the temporary account number in both PHS and HPF. The result is that the electronic patient folder follows the patient and remains available from the scheduling process to preregistration and beyond. Technicians use a schedule furnished by PHS that includes the patient's final account number and that gives them easy access to the physician order.

SAMC chose to concentrate on using faxes for obtaining electronic images after doing a survey on the technology in physicians' offices. Very few of the offices had document imaging and e-mail solutions, but every one of them had a fax machine. This presented an opportunity for using an e-fax solution to get the orders into HPF efficiently, while scanning only those orders presented in person by either a patient or a referring physician's staff.

We added additional fax lines to handle the increased volume of orders, and we placed workstations in key clinical areas where technical staff members were trained to view orders online through HPF. The registration department worked extensively with physician office staff and continually updated information to help get patients scheduled for their admissions or tests.