Information Systems to Improve and Enhance Services Provided by a Healthcare Communications Center

Scott Preston, B.S., Larry Benton,

Cindy Barry, and Claudia Cloutier

Shands HealthCare, Gainesville, FL.

Introduction

The Communication Center is a very important component of the healthcare enterprise. For many customers the Communication Center can be the first interaction with your facility and may produce the first impression of your organization. Once a customer is admitted, friends and family contact their loved one via the Communication Center. After the patient has been discharged and needs additional assistance, they again contact the Communications Center and rely on the staff to guide them through the system for after-hours care.

As the size of the healthcare enterprise grows, the quantity of information required to properly handle all the situations in the Communications Center seems to have exponential growth. The only way to balance the information overload and continue to provide timely service is with expertly crafted systems.

When Shands Communications decided to completely re-engineer the Communications Center in 1992, we had a predominately paper-based system and a vendor-provided message center based on proprietary hardware. The work behind the scenes to keep the paper current and the message center running was arduous. The message center was slow and provided only basic features.

Our goals were to increase the call processing capabilities of the Communications Center, reduce administrative overhead, and to provide data necessary to reduce one-on-one supervision requirements.

Methods

Initially we studied the current operation. Our primary goal was to provide a system to identify and tackle the largest problem in the center and provide the basis for our “killer application.” This would allow us to move in the new computers and begin training the staff on the PC and Windows 3.1 operating system.

After studying the complex environment in the Communications Center we concluded that the application was a Doctor’s On-call system. The center had large books full of “information” about the doctors’ on-call rotation. Each department independently determined the format and content of their schedule. This led to 60 unique call schedules with varying degrees of usability and information. The amount of individual knowledge and training required to master the variety of call schedules and provide first class service was overwhelming.

Next we concentrated our resources on understanding the current schedules. We worked diligently to understand why some of the schedules were considered good and why some were abysmal. Understanding the pitfalls of the current system was key to providing an information system that could conquer the problems.

The on-call problems identified were:

· Schedules not up to date

· Frequent changes

· Last minute changes

· Inconsistent information

· Department procedures not on the schedule

· Times when nobody is on-call, or schedule holes

· Updates phoned in after-hours required that all the books get updated manually by the operators

· Pager numbers not always provided or accurate

· No clear escalation procedure and direction

· Paging and tracking of return calls difficult to mix with continued call processing

· Handwritten paging logs difficult for management to track and review

· Sequence of events in an on-call issue difficult to establish with multiple people and systems

· Inability to determine “Teams” of staff to select appropriate call schedule

· Code Blue and Code Red logs handwritten and mixed with regular paging logs

· Time frame-specific notes had to be manually inserted and removed from multiple on-call books

Once a clear problem definition was created, we proceeded with the design of the system and program. We decided that the environment would be PCs with Windows 3.1 operating using a Novell Netware server. The application would be based on the Netware server and would access shared data on the server. Each department that had an on-call schedule would update and maintain their schedule by accessing the On-call program on our server via the network. We would also allow anyone on the network to view on-call data without contacting the operators. Among the departments using the system to do their own research were Admissions, the Transfer Center, and the Consultation Center.

Our On-call system has many features and provides a wide range of benefits to both the Communications Center and throughout the Shands HealthCare enterprise. Departments are able to maintain their own schedules without intervention of the Communication Center staff. This allows them to make changes immediately to the call schedule, departmental procedures, and staff. A lost or changed pager no longer requires them to contact a multitude of people with paper call schedules. These changes are displayed immediately on the system. If something changes after-hours the staff in the Communications Center can quickly and easily update the schedule. When the schedule is updated the system automatically checks that the schedule has no time without coverage and notifies the user. Log files are kept showing when the schedule was last updated and who performed the edit.

Many features are designed for the Communications Center and other staff using the On-call system to contact doctors. Normally, first-call is the leftmost column of the four columns available and the escalation procedure is toward the right-hand column, but the departmental procedures can be set individually. The department’s procedures are displayed with the call schedule and allow them to direct the user to the appropriate on-call person. Also, each time frame includes its own note field for special events or actions related to that time frame only. When a user checks an on-call schedule they are automatically taken to the current time in time tracking mode so the schedule on the screen is always the current schedule. In the Communications Center, paging is done by the system once an on-call person is selected. The page is logged and a reminder is set to pop up after a period of time if the call has not been cleared. When someone returns a page the operator can select the correct item off the reminder list, handle the call, and clear the reminder. If the page is not returned, the reminder pops up with several options: Re-page, Answered, Reschedule, or Remove. Each option allows the operator to add comments to the log file while performing the selected function. If an operator leaves, either for a break or at the end of a shift, with outstanding pages, another station can retrieve his/her page list to handle the calls. In addition the staff can log Code Blue and Code Red calls with On-call. The log files and historical on-call records, which cannot be changed by the users, allow management to easily reconstruct the sequence of events if there is an issue related to on-call. For the departments, the system makes editing easier by learning the pattern of their call schedule and automatically selecting new time frames based on their history when they add records to the end of the call schedule. The department can easily make phone numbers “unlisted” and keep the general hospital staff from viewing the numbers. Finally, the system will send an e-mail to the department when their schedule has less than 14 days of future data to help them keep track of their own schedule.

The addition of a web-based viewer should help staff throughout the hospital with real-time easy access to the On-call system.

Features of On-call include the following:

·xDepartments maintain their own schedules using the on-call system, including procedures and staff listings

·xUpdates are immediately available throughout the system

·xAutomatic tracking to current time

·Automatic time frame selection based on past patterns to speed editing

·Automatic internet email to departments when the on-call schedule is not set far enough in the future

·xLogging of on-call editing

·xDepartment procedures are always displayed on the on-call screen

·xThe system checks schedules automatically for “holes” or overlapping times during edit and displays a red error message when problems are detected

·xAfter-hours the communications center staff updates the electronic schedule and updates are immediately available to everyone

·xFirst call is generally the left most column and escalation moves across the screen toward the right.

·xOn-call staff for a single “department” and single time-frame is limited to four individuals

·xPaging is done by the system, including logging, reminders, and tracking.

·xSequence of events in an On-call issue is easy to establish with the log files

·Department titles and staff combine to show which teams should handle a call

·xCode Blue/Code Red logs are done within the on-call system.

·xUnlisted phone numbers are hidden from public view

·xOperators can retrieve outstanding pages from other stations

·xIn 1999 we added a web-based on-call viewer

·xNotes attached to individual time frames

·xOnce On-call records are past their end-time they cannot be changed

·Department contact screen

Electronic Phone Listings

When our on-call application approached completion, we began to look ahead for new applications to write. The second application needed was clearly a searchable directory including our departments, employees, and pager numbers. This was second only because the technology was not that difficult. The largest part of this project was converting our paper “Rolodex” to an electronic format. While the basic viewer application was being developed we devoted other resources to converting the paper files to an electronic format and getting data electronically from our Human Resource departments for the employee phone numbers. One of the primary goals was to have the system perform the search rapidly and return the results in less than two seconds, preferably less than one. The electronic phone listings eliminated the following problems:

· Paper lists

· Inconsistent information

· Frequently handwritten

· Data source and update problems

· Age of the data

· Format

· Man-hours required to maintain the data

· Different lists for each dataset

o Paper for UF employees

o Rolodex for department phones

o Paper “pocket” directory

o Pagers numbers stored on our hospital’s mainframe

o Shands employee office phone numbers on the proprietary Astra

o On-call paper for home phones and pager numbers

The original version of our viewer could handle up to 16,384 records and was modified later, based on updated requirements, to handle 65,536 records. We also have a Web based interface to our phone listings available to everyone.

Patient Census

Since the patient census was critical to our operation and it was frequently unavailable, we decided to develop a system to keep the census on our servers. This would eliminate getting paper copies when the mainframe system was scheduled to be down and having very little information available when unscheduled downtimes occurred. The staff was also interested in modifying the display to indicate which patients were confidential. Confidential patients in our system included prisoners, VIPs, and psychiatric patients. Our census application displays confidential patients in red to easily identify their status to the staff so that no information on these individuals is given to callers. Our new application also allowed a search on all of the fields in the census. This is very helpful in labor and delivery areas since mothers could be found by a first name only and a quick list of all newborns could be generated.

Message Center

Once the PCs and network had been installed we decided to get rid of the proprietary message center. This would improve the message center function and reduce the clutter on the desktop caused by having both the PC monitor and the message center terminal. The new message center was designed to interface with the phone switch to identify which service the customer called. The program was developed as a 16-bit Windows application written using Borland C++.

The Message Center allowed us to collect statistics on the calling patterns and volume quickly and easily and featured Internet-capable e-mail for message delivery to the departments. Before we had e-mail addresses for most of the departments we were able to see the high peak of morning traffic in the Center and the impact of manual message delivery. Once we eliminated most of the time-consuming manual delivery of messages we were able to see the direct benefits of message center delivery via e-mail. The new system also has the option of separate “profiles” under each account, which allows us to e-mail a message to the physician or individual staff directly. Benefits of the e-mail based message delivery also include improved accuracy and timeliness of message delivery. This allows all the messages to be delivered to the departments, or individuals, as they are received, and are available as soon as the department opens or immediately via the Web.

Billing was easily handled in the new environment. The system allows billing using almost any criteria. We have recently added a hefty per-call charge for each message center call between 0800 and 1600, hours where we do not have the staff or resources to handle phone calls for over a hundred departments.

Statistics available from the message center provided the data necessary for quality assurance and staff performance review and enhancement. We developed staffing reports that show number of calls per hour per operator. These reports are automatically done each day and placed on the Web. Each operator can review his or her own performance as well as the performance of their co-workers.

This leads to a form of self-management within our Communications Center. The supervisor can review these statistics for an employee’s performance review and to determine how the Center is performing overall. As part of the process to develop performance statistics and monitor employee performance, we developed a system to monitor the Communication Center’s call queue length and wait times (see Queue for details). This allowed us to determine whether our customers were waiting too long and look at “abandon” rates. Recently added to the system is the combination of real-time monitoring of the queue with real-time monitoring of the operators via message center.

We now have the ability to manage staff problems in the center as they occur.

·Morning message delivery staff intensive and disruptive to the center

·Free format messages without predefined comments and fields

·Inability to select messages in a variety of ways

·Billing

·Individual profiles within a department required a separate “account” rather than being a subset of the department

·Message center screens popped up after the call was answered and being processed

·Center staff could not edit the profiles

·No provision for “special” events

·Unable to handle additional calls with a message screen still open

·Generating statistics was time consuming and resource intensive

·Statistics could not be broken down finer than hourly

Opstats on the web

Supervisor Opstats

Message Center real-time monitoring

Queue

Once we began to collect statistics on the calls answered we noticed a need for the queuing statistics and customer wait times. The phone switch vendor could not provide us with a system to collect this information. We developed a system to generate this information with a custom-designed hardware and software solution. Once we had a complete picture of the call statistics and queuing, we had an opportunity to analyze the staffing and service levels.

We used queuing theory to establish customer service goals and verified the accuracy using a General Purpose Simulation Software (GPSS) model. The additional data helped us justify additional staff in the center and study incoming call spikes during brief windows of time, as short as a few minutes.

·Call counts and wait times unavailable from switch

·Abandon rates unavailable

·Needed info for staffing

·Message Center

Communications Center Operator-assisted Long Distance Logging

Another problem in the Communications Center was tracking operator-assisted long distance and overseas calls. The problems with the process were:

· Paper log sheets

· Accuracy

· Billing

· Reporting

· Staff’s inability to quickly review entries and redial when necessary

Solving this was relatively easy with a small application to log the all the call data in a single location on the network server. Originally a DOS-based application, this was recently upgraded to a Windows-based application.

Electronic Message Board

The Communications Center used a “white” board to show room phone blocks, special patient notes, and other information to share among the group. When the Center needed a seventh workstation, the new position would have a blocked view of the common board. Also, if the Center expanded and/or moved into a different location, the board would certainly become more problematic. To allow the staff to sit in physically different locations or larger overall spaces, we developed an electronic version of the white board. This application used a shared data file displayed in a large window. Everyone can add, delete, or modify data on the electronic board. The information is instantly available on each workstation.

Dictaphone Recording System

Just prior to the software and network development, the Communications department installed a dual deck, reel-to-reel 10-track recording system. The tapes are used for quality assurance and to help track problems and issues in the center. This recording system allows closer supervision of the staff without the need for the management to be in the Center at all times. Each deck could record 24 hours on a 10.5 inch reel tape (1/2” 3600’).

The new Communications Center uses a dual 4mm DAT (dds-2) with 24 recording channels. This system uses approximately one DAT tape per week to record activity in the center.

Results

The systems we have developed have allowed us to provide better and faster service without a comparable increase in staff. Our operators are capable of handing a peak of nearly 200 calls per hour and consistently 100 calls per hour. This is a significant improvement over our original peak of 90 calls per hour and 60 consistent calls per hour.

The systems have proven to be very successful, validating the time and effort spent in the design phase prior to any program development and we were able to reduce the number of “terminals” at the workstation to one, accessible with a single password.

In April 1999 we moved to a new location with new computers. The workstations were replaced with Pentium II 350Mhz machines running Windows NT. The Novell server was migrated to new hardware and we added an NT server. The only application that changed was Message Center. It was moved to a 32-bit platform, and a new Message Center telephone switch interface was designed using IP to transfer call data to the workstations instead of a serial connection. The move was done without any interruption in service, and many people are still unaware the move took place.

Conclusion

The basic information systems needed in a communications center vary, depending on the duties performed by the center’s staff. Minimally, each center will need applications to quickly and efficiently direct customers to the appropriate resources and no center should be without an electronic directory. A proper selection of quality information systems can dramatically improve the performance of the communications center while reducing training requirements, stress, supervision, and errors. The communication center is a great place to develop and deploy systems, since the performance improvements can be great and the staff can provide feedback quickly to close the development loop. There are always additional things that can be done or would be nice, but our current systems are economically providing the features we need and we will continue to use them for the foreseeable future.

Future

We are adding more resources to the Web to allow both customers and staff system-wide access to the information we have collected and condensed from the enterprise. Systems currently being developed are a

Web-based human resource system that would allow each employee to update much of their personal information including address, phone and pager numbers. This system will include features for locating language translators and submitting facility repair work orders.

More information on our systems, including screen shots, and current projects can be viewed at http://communications.shands.ufl.edu/papers.

If you have questions or comments we will have forms on the Web site to facilitate that process.

Copies of this paper and presentation, including corrections, will also be available on our Web site.

Acknowledgments

This work was supported by Shands HealthCare and senior management including Don Glaser, Director Facility Operations, Ralph Swain, Ph.D., and William Montgomery, Senior VP and CIO.

Tom Kisko, M.S. ISE, P.E., was also involved in the system planning and development.