The emergency department of a public hospital is one of the most complex and busiest departments. From the perspective of a HIT product manager, this paper discusses how the emergency business process of public hospitals can be optimized, and what other changes and upgrades can be made to the emergency department information system.
The emergency department of a public hospital is undoubtedly one of the busiest and most complex departments in hospitals. Even when I went to the emergency department of some well-known tertiary hospitals as a patient, I felt that there was a lot to be done in the whole process.
In this article, from the perspective of a HIT product manager, I summarize and discuss how the emergency business process of public hospitals can be optimized, and what other changes and upgrades can be made to the emergency department information system.
1. Relevant basic concepts
First, let's familiarize ourselves with some of the basic concepts in the emergency business process.
Emergency pre-triage: Emergency pre-triage is the first step in the emergency care process, which aims to quickly assess emergency patients and prioritize treatment and appropriate treatment areas based on the urgency and severity of their condition. This link is of great significance to ensure the safety of patients, improve the efficiency of emergency work and optimize the allocation of medical resources.
Emergency clinic visit: refers to the process of queuing up for treatment at the corresponding emergency clinic department after the patient is pre-checked and triaged. Emergency departments include emergency medicine, emergency surgery, emergency pediatrics, etc.
Emergency rescue: refers to the emergency treatment process carried out by the hospital for critically ill patients, which needs to be carried out in a special emergency room. The emergency room is a specially designed area equipped with dedicated medical equipment and professional medical staff to ensure that the rescue can be carried out quickly and accurately in the event of an emergency.
Emergency Observation Ward: A short-term observation ward set up in the emergency department of a hospital for patients who are not yet in stable condition or who need further examination. Emergency observation is not a long-term hospitalization, but a short-term, transitional phase of treatment. During the observation period, once the patient's condition is stable or requires further treatment, the medical staff will arrange for the patient to be transferred or discharged from the hospital in a timely manner, and formulate a follow-up treatment and rehabilitation plan for the patient.
Emergency green channel: refers to a fast and efficient service system provided by hospitals for critically ill patients, aiming to save the lives of critically ill patients and reduce the time delay in the treatment process. The emergency green channel is suitable for a variety of situations, including but not limited to shock, coma, cardiorespiratory arrest, severe arrhythmia, acute vital organ failure, and dying patients, patients who are not accompanied by family members but need emergency treatment, patients whose identity cannot be determined but need emergency treatment, and patients who cannot pay medical expenses in time and need emergency treatment.
2. Pain points of traditional emergency business processes and information systems
Traditional emergency business process diagram
Patients in the emergency department of the hospital can be divided into three categories: patients in the emergency room, patients in the emergency department and under observation, and patients in the emergency green channel. All patients need to go to the emergency pre-examination triage table for pre-examination triage by the nurse, and then go to the registration fee office to hang the corresponding treatment number according to the triage results, and then go to the corresponding treatment area.
The emergency department has the largest proportion of patients, and the process is similar to that of the outpatient clinic. The slight difference is that the emergency department has an infusion area, and patients who need infusion in the hospital can go to the infusion area after paying the fee to pick up the medicine.
Patients who are rescued and kept for observation in the emergency department also need to register at the billing office first, and then enter the emergency room or observation room for treatment. For critically ill patients, rescue will be carried out first, and then the patient or accompanying person will complete the registration. For patients whose identity cannot be determined but require urgent treatment, the patient with the name "Anonymous" will be entered into the system first, and the information will be supplemented or merged with the existing medical records afterwards.
For patients who meet the conditions of the green channel, the system needs to support the user to be able to mark the corresponding patient with the green channel. The green channel mark should be clearly indicated in the business system of doctors, nurses, pharmacies and laboratory departments, and patients in the green channel will be prioritized. Patients marked as green channel can continue to issue medical orders and complete the corresponding tests and examination items even if they are in arrears.
Due to the lack of a special emergency observation system in the early days of hospital informatization, hospitals generally apply the system process of emergency clinics to deal with observation patients. As a result, as long as there is a new doctor's order during the observation period, the patient or family member needs to pay the fee at the billing office before completing the follow-up treatment.
Secondly, the patient or family members also need to go to the emergency pharmacy window to pick up the medicine at the emergency pharmacy window and then take it to the nurse at the observation nurse station. Patients or family members need to run around. Moreover, if the drug is not properly stored during the self-collection process, it may cause the drug to become ineffective or deteriorate, affecting the treatment effect. It may also lead to nurses not being able to access the patient's medication in a timely manner, affecting the patient's treatment.
For medical staff, the work system of emergency observation and use of the consultation room also brings many inconveniences.
First of all, long-term medical advice on the level of care, diet, oxygen, long-term medication, etc. Since the system does not have the same functions as the issuance of long-term inpatient orders and the regular generation of execution plans and billing, there is also a need for a paper-based process between doctors and nurses to record and reconcile the orders and implementation of the inpatient orders. At the same time, the doctor enters the relevant drug prescriptions through the emergency clinic system, and the nurse enters the nursing level, oxygen and other expenses into the system at one time in the function of cost entry. The workstation system, which originally assisted the efficient work of medical staff, has become a pure expense entry system for emergency observation.
Secondly, the electronic medical record for observation is also different from the electronic medical record requirements for outpatient and emergency clinics. It is necessary to record the first page of the observation record, the observation record, the rescue record, the first course of illness record, the daily course record and the summary of the exit. The medical record writing function needs to support the maintenance of multiple medical record forms and the continuous writing of multi-day medical records. The vast majority of outpatient and emergency clinic physician workstations that have only one medical record form cannot support them. Moreover, during the observation period, there are many nursing documents such as temperature sheets and nursing record sheets that need to be recorded, which is also a function that the traditional outpatient and emergency nurse workstation does not have.
Some hospitals will purchase a special electronic medical record system and an observation care document system to write the electronic medical record for observation. Both doctors and nurses need to operate two systems to get the job done. Or some hospitals simply do not use a special system to record the electronic medical record for observation, and directly use the word template to write, print and file or directly go through the paper process.
3. Optimization of emergency business processes and information systems
Emergency business process reengineering
3.1 Registration can be completed at the triage desk
In the traditional emergency business system process, patients also need to go to the registration and payment office to complete the emergency registration after the nurse's emergency triage. This makes it necessary for patients to queue up again in case of emergency, and it also complicates the movement of patients in the emergency room. In addition, after the nurse triages, the patient verbally tells the department that needs to be registered, such as telling the patient to go to the emergency department of internal medicine, emergency surgery, etc., and the patient is also very easy to make mistakes, resulting in the repetition of the treatment process.
Some hospitals will prepare small notes of different colors at the nurse triage desk, and tell the patient to give the note to the staff at the registration window when registering, and the staff will complete the registration according to the department on the note. Such a small note is both heartwarming and sad, and it is also a helpless move by medical staff in order to deal with the lack of data exchange between various systems.
At the system level, in fact, the function of registration and payment can be integrated in the nurse triage system. When the nurse keeps the triage record, the system completes the registration operation according to the department selected in the triage destination. Patients can scan the QR code directly at the triage desk to complete the registration payment.
Only when you need to pay in cash, open a green channel or return a special operation, you need to go to the registration window to deal with it. In this way, the patient can go directly to the corresponding area after the nurse triage without having to run to the registration window to queue up for registration.
The nurses at the triage desk seem to have done more registration work, but according to the feedback from the nurses in the hospitals that have launched this function, compared with telling the patient which department to hang up or giving the corresponding small note, the direct registration for the patient has reduced the workload. And being able to make the patient run less time is also very worthwhile. And with the popularization of mobile payment and electronic medical insurance card, the operation steps of registration payment are becoming simpler and simpler.
3.2 Prepayment mode for observation patients
At present, another point that makes patients feel very inconvenient in the process of emergency observation business system is that although patients have separate beds in the observation area, the payment process is still in the mode of clinic.
As long as a new project is opened, the patient or family members need to go to the toll office to pay the fee, and then the doctor's order can be implemented by each diagnosis and treatment unit, and even the medicine needs to be paid by the patient and then taken to the observation nurse station. The advantage of this is to a large extent to avoid the occurrence of patients evading fees, but patients need to pay back and forth, which is very inconvenient for patients, especially for patients who are unaccompanied.
This is also largely due to the fact that patients under observation in the emergency department follow the process of the in-office system. The business process in outpatient and emergency clinics is to pay the fee first and then complete the next step of the diagnosis or treatment. This procedure is suitable for patients who are easy to move around and do not need to spend a long time in the hospital at a time. However, for patients who are more severely ill and may need to be treated in an observation room for 72 hours, it can be somewhat difficult to perform.
In fact, this problem can be solved by using the prepayment model for hospitalization. A certain amount of advance payment is charged at the time of registration, and the expenses incurred by the patient during the period of observation will be billed in the same way as hospitalization. If the amount that needs to be paid by the patient exceeds the amount of the advance payment, the patient will be prompted to make up the advance payment. If the amount of the advance payment is reasonable, the patient basically does not need to make a second payment during the observation period. In this way, each process in the treatment process is directly transferred from the doctor's order to the corresponding diagnosis and treatment unit, the patient does not need to run more, and the process is simple and efficient.
Of course, to achieve this model, on the one hand, doctors, nurses and medical technology systems need to increase the billing logic. On the other hand, it is also necessary to develop a separate settlement system for patients who are under observation. Because the vast majority of medical insurance settlements still classify patients under observation as outpatient settlements, this requires separate settlement of daily expenses. If all the expenses of the patients are settled on the last day, it is very likely that the rules of medical insurance for the use of outpatients will not be met, and the deduction for the hospital will be incurred. From the functional level of the system, we can try to settle once a day, but fundamentally, it is still necessary for the medical insurance interface to be able to optimize the settlement of patients under observation.
3.3 The observation system supports long-term medical advice
In the process of issuing and executing medical orders, the observation doctor and nurse workstation needs to support the issuance and implementation of long-term medical orders. If the in-clinic system is used, all prescriptions and application forms are temporary and single-time valid, and there is no way to issue long-term medical orders for patients under observation, such as nursing registration, diet, oxygen inhalation, etc., on the system, and there is no way to avoid using the paper process to transcribe medical orders.
If the observation workstation supports long-term medical orders, the doctor only needs to open a long-term medical order for the patient once, and then set it to stop when it needs to be stopped. Nurses can also see all long-term orders that are currently in use and execute them directly at the frequency set by the order. The system can complete the billing of doctor's orders in the background, and there is no need for nurses to supplement the expenses in the system one by one. This eliminates the need for paper-based order transcription and reconciliation, and the system can also print out the patient's long-term and temporary orders and quickly file them together with the electronic medical record.
In addition, whether or not to support long-term drug orders needs to be determined in conjunction with the execution of hospital nurses and the delivery process of medicines. In the past, some hospitals have been concerned about the risk of nurses missing out on long-term medication orders for patients under observation. At the same time, it is not easy to grasp the delivery time of the pharmacy, so the long-term drug orders are still limited in the observation system.
3.4 Pharmacy for observation patients dispenses drugs uniformly
In the process of taking medicines, whether from the convenience of the patient's treatment process or the requirements of closed-loop drug management, it is necessary to avoid the patient's medication in the hospital being contacted by non-medical staff. Moreover, emergency patients are often in urgent and complex conditions, and the correct and timely use of drugs is crucial to the treatment and recovery of patients.
At the level of system design, the drug dispensing function of patients under observation should support the dispensing of drugs in batches like inpatients, and support pharmacy personnel to send them to the observation area on a regular basis according to the batches of medicines. If the prescription is still issued according to the logic of outpatient dispensing, it will require a lot of manpower to support such a process. For commonly used and first-aid medicines, the observation nurse station can also set up a backup pharmacy, and in case of emergency, you can use the medicine from the backup pharmacy in the observation area first.
At the same time, the process of unified dispensing of drugs by emergency pharmacies for patients under observation not only needs to be upgraded accordingly, but also requires the nursing staff, pharmacy and the team responsible for drug delivery to develop a complete work process. Patients in emergency rescue and observation areas often have temporary and urgent medication needs, so it is even more necessary to establish a set of fast, efficient and safe emergency medication procedures to ensure that patients can get the drugs they need in a timely manner when they need them.
3.5 Emergency Specialist Medical Workstations
The traditional outpatient and emergency clinic doctor workstation is limited to the "one complaint and five histories" of the visit, which can no longer meet the writing needs of the electronic medical record. At the same time, the old outpatient and emergency nurse workstation also lacked a complete observation nursing record function. If a separate electronic medical record system for the observation doctor and the nursing staff were purchased, the medical staff would need to learn and operate two systems, and the patient information could not be fully viewed in one system.
Considering that the same medical team is responsible for the emergency room and the emergency observation area, they need to be able to flexibly switch between the emergency room and the observation area to view patient information, and complete various system operations efficiently. Moreover, the emergency consultation process, blood transfusion, surgery and card reporting are all unique. Therefore, in the design of the system, we should not just take the outpatient and emergency clinic workstation to patch continuously, but should take the emergency department as a core specialty, and tailor a set of integrated workstation system that can efficiently assist the emergency medical staff to complete the diagnosis and treatment of all patients in the emergency clinic and the retention area.
Columnist
Wu Zhimao, WeChat public account: I don't know, everyone is a product manager columnist. Health management Xiaoshuo, medical and health products Wang + literary cat.
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