Evaluation of Cetrea Emergency by The PWT Foundation

Final evaluation of project at Emergency Department, Regional Hospital of Horsens & Brædstrup. ABT application no. 59. 2011

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Demonstration project at

Emergency Department,

Regional Hospital of

Horsens & Brædstrup

IT support as a means to improve

efficiency and quality of patient

treatment

“The system provides an overview which makes it easier for me to prioritise. I am not interrupted as often as I was before we started using the system.”


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Report by: Susanne Daugaard Kristensen, Stine Rønsholdt Hansen & Gitte Kjeldsen. Project

group: Ove Gaardboe, Susanne Buch Vinter, Birgitte Bigom Nielsen, Thomas Riisgaard Hansen,

Susanne Daugaard Kristensen & Gitte Kjeldsen. Steering Committee Chairman: Jørgen Schøler Kristensen.


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Contents 1. Executive summary ........................................................................................................................................ 3

2. Report objectives .......................................................................................................................................... 4

3. Method ......................................................................................................................................................... 4

3.1. Risk of bias in observation results ......................................................................................................... 5

3.2. Context-dependency of the results ....................................................................................................... 5

4. Description of Emergency Department’s interaction with patients, and the role of the Emergency Department vis-à-vis other units at the hospital .................................................................................................. 5

4.1. The Emergency Department’s role at the hospital ............................................................................... 6

4.2. Roles as Medical Adviser/Assessor and Coordinator ............................................................................ 7

5. Description of the demonstration project’s IT solution at the Emergency Department ............................. 8

5.1. The patient flow system and how it is connected to other units at the hospital ............................... 10

6. List of existing patient flow systems introduced at the Regional Hospital of Horsens & Brædstrup.......... 12

7. Description of work flows before and after implementation of the patient flow system .......................... 14

7.1. Before Cetrea Emergency ................................................................................................................... 14

7.2. After Cetrea Emergency ....................................................................................................................... 15

8. Results ......................................................................................................................................................... 16

8.1. Labour-saving potential and financial benefits ................................................................................... 16

8.1.1. Project’s financial balance ........................................................................................................... 23

8.1.2. Labour-saving potential at the national level ............................................................................. 24

8.1.3 Other financial benefits (service and quality) .............................................................................. 24

8.2 Qualitative benefits ..................................................................................................................... 25

9. OPI (Public-Private Partnership) - commercial benefits and market penetration ....................................... 29

10. Technological maturity and factors that may impede penetration ............................................................ 32

11. Conclusion .................................................................................................................................................... 35

12. Appendixes ................................................................................................................................................. 36


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1. Executive summary

Support from ABT-fonden (the Danish PWT Foundation) has made it possible to demonstrate

both the quantitative and qualitative effects of introducing a patient flow system at the

Emergency Department at the Regional Hospital of Horsens & Brædstrup.

The quantitative effects amounted to a 19 % increase in production between the first half of 2009

and the second half of 2010. At the same time, an analysis at micro-level indicates that the

improvements to efficiency achieved in 2010 corresponded to the workload of four full-time

positions. The analysis is based on 21 specific assignments for which the patient flow system has

provided a number of benefits. These benefits are those we have used to estimate the hourly or

quality benefits gained. It is important to emphasise that our assessment of the overall

improvement in efficiency is subject to a significant degree of statistical uncertainty as none of the

assignments, on which the assessment is based, is standardised, and there is therefore no

guarantee that they take exactly the same time to complete every time they are performed. The

project group has reached consensus on the preconditions necessary for the estimated savings.

The qualitative benefits materialise in the form of increased security for the patient and

improved patient treatment quality, which is also based on the assessment provided by the

parties involved. Patients were not asked to participate as they have no knowledge of the

patient flow system, as the system is used only by the hospital staff. However, the hospital staff

has assessed the indirect effects and their assessments are concordant.

This means that the patient flow system provides benefits at both productivity and quality levels.

Figure 1 Summary of benefits of and impediments to the introduction

of the patient flow system


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2. Report objectives

Our report is intended to demonstrate the effects of the introduction of a patient flow system at

the Emergency Department at the Regional Hospital of Horsens & Brædstrup, seen from the

perspectives of communications, coordination and overview. The report will describe how the

patient flow systems have:

resulted in improvements to efficiency in the shape of labour savings at assignment level

brought about better utilisation of resources

encouraged more knowledge-sharing

encouraged better cooperation within the Emergency Department and with other units

brought about better quality of treatment and improved security for the patient

the potential for market penetration to other hospitals in Denmark and abroad

resulted in more growth for the private companies, which supplied the IT solutions.

3. Method

To demonstrate the effects of the introduction of IT support at the Emergency Department at

the Regional Hospital of Horsens & Brædstrup (Danish PWT Foundation project application no.

59), we chose to combine several different research methods:

Observations at the unit

Qualitative in-depth interviews with key Emergency Department staff

Brainstorming sessions and group interviews with the unit’s nursing staff

Interviews with Hospital Management (represented by the Medical Director).

In each of the interviews, one of the participants was a person who had not taken part in the

project. This step was taken to minimise the risk of bias, although we realise that this risk cannot

be eliminated entirely.

Based on previous experience, we chose to focus primarily on qualitative in-depth interviews and

observations, as a physical presence at the unit and close two-way communication between

management and staff in the interviews are most beneficial to project evaluation. For those of us

with no clinical background, the observations provide us with a kind of insight that cannot be

achieved by any research method based on data extracted e.g. from financial systems or

questionnaire-based surveys. We have chosen not to carry out a questionnaire-based survey as

part of this final evaluation as we know that a high response rate is difficult to achieve because

hospital staff seldom have the time to spend at a computer or to complete a pen-and-paper

questionnaire. Instead, we collected input from focus group interviews and brainstorming

sessions with the staff.

On the basis of the surveys described above, we created a comprehensive list of assignment types,

which we evaluated as having become faster and easier to complete after the introduction of the

patient flow system. We then examined all the assignments, with the help of e.g. the Emergency

Department management team, who gave their assessment of how much time was thus saved. In

some cases, the task was an impossible one because the range of time spent was either too great

or varied too much, although everyone generally agreed that improvements had been felt. In other

cases, we specifically timed e.g. how long it took to locate a colleague in the unit or how long it

took to type a long name into the patient flow system. In some cases, the improvement was less a

case of having completed a task more quickly but rather of an improvement to the quality of

treatment or to patient security. The Table in Section 8 lists our findings. However, it is important

to underline that our results are not exact science but estimates made by qualified staff and

managers.


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In addition, to supplement the survey, data was collected from the hospital’s financial systems.

Where this project is concerned, as one of our objectives was to become more efficient as a result

of introducing the technology, the production figures in the data are especially interesting. Monthly

production figures are calculated on the basis of the number of patients at the Emergency

Department. Percentage occupancy is also calculated. This is an interesting statistic in relation to

how we utilise capacity. A hospital bed is a finite and also a cost-intensive resource. Finally, the

survey includes an analysis to show the development in staff numbers and distribution of the

different professional skills as these are also factors used in calculating the unit’s efficiency.

3.1. Risk of bias in observation results

It is impossible to eliminate bias in the observation results contained in this survey. For this

reason, we attempted to plan observations sessions so that any disruption that the observers may

have caused (e.g. asking questions to clarify) would not have a significant effect on the validity of

the conclusions drawn from the observations. Furthermore, again with a view to avoiding bias, the

observations were made by people who had no prior knowledge of the project or the unit.

3.2. Context-dependency of the results

Measuring the effects of the introduction of the solution in isolation can be difficult as there are a

number of external conditions and changes that have had an effect on efficiency in the unit. For

example, organisational changes were made, such that the medical advisory/coordinator role in

the department is now divided into two separate roles. Three teams have been amalgamated into

two and this means that the department overall is now physically larger than it was before. These

changes are described in detail in the report. This report focuses on identifying the labour savings at micro-level by comparing working

processes before and after implementation of the solution. The report focuses on specific changes

that are easier to study in isolation and which most clearly demonstrate whether or not the

system has brought about specific labour savings.

4. Description of the Emergency Department’s interaction with patients, and the role of the department vis-à-vis other units at the hospital

To place the study in its correct context, the report describes the Emergency Department and its

connections with the other units at the hospital. The Emergency Department takes care of

patients with acute injuries (e.g. patients who come in with broken bones) and admissions

(patients admitted to the observation unit in the Emergency Department and whose are expected

to be discharged within 48 hours). In addition, the unit also receives patients for admission to

other units at the hospital.

Figure 2. How the Emergency Department is organised


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Figure 3 (below) illustrates the complexity of patient interfaces. There are many parties involved:

some staff are responsible for treating the patient (they are organised as a interdisciplinary patient

team), other members of staff are responsible for patient services (e.g. porters) or perform only

sub-assignments of the patient’s treatment (e.g. specialist physicians who perform examinations

that the Emergency Department needs in order to diagnose the patient’s disorder and determine

the level of severity (triage)). While some of the parties involved are notified, others play an active

role in treatment. If the patient is passed on to an inpatient ward or to the Emergency

Department’s own observation unit, the recipient unit is also involved. Coordination is a major task

which is necessary to optimise treatment quality and ensures that treatment progresses and is

highly efficient. Dissemination of information and making certain that treatment sub-assignments occur in the right

order are both crucial to achieving improvements.

Figure 3. Overview of patient “interfaces” on arrival at the hospital’s Emergency Department.

Figure 3 includes people who are in direct contact with the patient and staff who work together to

provide patient treatment but with whom the patient has no direct contact.


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4.1. The Emergency Department’s role at the hospital

To resolve the complex treatment and logistical task facing the Emergency Department, high-grade

knowledge-sharing, communication, coordination and overview are required in order to achieve

optimum patient flow. In the event of acute illness, it is crucial for patient security that the issue of

how the patient is to be treated is determined quickly, that the relevant partners are involved at

the right time and that patients are transferred without delay to the correct unit within the public

health sector for further treatment or discharged as soon as they are ready.

4.2. Roles as Medical Adviser/Assessor and Coordinator

The medical adviser/assessor and coordinator roles are both crucial in terms of optimising and

improving the efficiency of patient logistics. These roles do not have much direct contact with the

patient as the primary duties of these positions are administrative. In the past, the role of medical

adviser/assessor and coordinator were amalgamated. Today, however, the role is divided into two

separate roles in the Emergency Department. Experienced nurses take turns to fulfil these roles.

They have the skills required to work under great pressure, and to coordinate, make decisions and

communicate.

The Medical Adviser/Assessor in the patient reception/Emergency Room receives incoming

telephone calls - from patients on their way to the hospital, from ambulance crews and from

general practitioners or municipal players (social services or medical health centres). She is the

unit’s point of contact with the outside world. Her telephone rings frequently (sometimes she has

more than one telephone) and she is assigned only “light” patient duties alongside the medical

adviser role.

The Coordinator in the observation team is responsible for contact with other involved units at

the hospital and internal coordination within the observation unit. She coordinates with other

hospital units which perform specialist investigations or to whom patients are to be transferred

(other inpatient wards). In addition to the coordinator role, she has responsibility ideally only for 1-

2 patients who do not require especially intensive care and can therefore be combined with the

coordinator role.


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Figure 4. The objectives of IT support in the Emergency Department

In addition to showing the objectives of IT support, the figure also indicates who is responsible

for sending patients into the system and who receives patients following the initial contact with

the hospital.

5. Description of the demonstration project’s IT solution in the

Emergency Department Large (40-inch) screens provide an overview of a variety of patient data, including treatment tasks

and staff assigned to each sub-assignment in the Emergency Department. These are touch screens

with "drag-and-drop" functions and touch screen-optimised menus (drop-down menus) which make

it easy to move assignments and change status display at only a few clicks. The user can also click

deeper into the system via drop-down menus to access more detailed information. The Cetrea

Emergency software used on the screens is developed and supplied by Cetrea A/S. In this report

the solution in its entirety is termed “the patient flow system” as the Emergency Department

solution is integrated with software developed by other suppliers – e.g. FMK (Fælles Medicin Kort,

or Common Medication Card) developed by Trifork A/S and wireless DECT telephones and software

developed by Ascom A/S. Integration with the Labka 2 and MidtEPJ systems is supplied by

Systematic A/S.


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Figure 5. Overview of patient flow system including system integrations

The Emergency Department’s patient flow system displays the following:

o Overview of number of beds and occupation status (incl. extra beds in corridors). o Overview of staff resources assigned to each patient. (Photos of staff assigned to

each patient).

o Status in treatment process for each patient – incl. triage which provides a priority

category for the severity of the patient’s condition. Indicated by a colour code on the

screen, where e.g. red and orange indicates that the patient is seriously ill and thus

requires extra attention.

o Overview over tests booked and whether the results have arrived (blood tests and X-rays)

o There is integration to the Fælles Medicin Kort (FMK) solution via a fingerprint reader for

fast login without password and user name. You just press on the pad with a finger. Using a

computer screen or a smartphone, via the FMK solution the doctor can access a list of drugs

prescribed to the patient during the last two years, including data from the patient’s own

doctor. The function is particularly crucial if a patient is not well enough to explain or cannot

remember which drugs he/she is taking or has taken within the last two years. o The Job agent solution allows staff to book a porter with just a few clicks on the big

screen, via SMS or via a computer. Relevant patient data is transferred automatically with

the booking (i.e. name, civil registration no. and ward no.). The screen displays status as

to whether the task has been received by the service department, whether it is in progress

or completed – i.e. has the patient been brought from A to B. o Tracking. Using pocket ultrasound technology, doctors’ and nurses’ whereabouts can be

followed on the overview screen. Tracking equipment is installed in most rooms in the


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unit (see Appendix 3). The equipment detects a signal from a chip in the pocket and

sends this via a wireless network to a receiver, which displays the person’s current

location on the big screen. “Dead zones” are planned where it is either not possible or

not relevant to track people (e.g. toilets). o Data from ambulance crews and other data received over the phone by the medical

adviser/assessor are registered in the system under “Incoming Patients”. This means that

all staff in the unit can see the incoming patients with their name, civil registration no.

and a brief description of the symptoms. Planning patient flow, prioritising and assigning

resources starts here. o Staff can quickly form an overview over capacity and patients, and assess resources, e.g.

is there sufficient staff on duty? o The status bar shows how long the patient has been in the unit, how far treatment has

progressed and if the patient is about to be discharged from the unit. o It is possible to view the content of the overview screens remotely via a smartphone or

computer. This feature is called “Cetrea Anywhere” and the display is adapted to show

relevant data for different staff groups, e.g. Unit P4 (organ surgical ward) has a tailor-made

display, which only contains patient data relevant for that particular department. Special

displays adapted for smartphone-size screens are also available. Figure 6. Generic patient process as outlined on the screens.

The colour indicates if the patient's treatment has been scheduled. If it is not, the coordinator will

remind the people responsible. This helps ensure that treatment progresses and increases patient

security.


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Figure 7. Overview of the patient flow system benefits for different staff groups

The figure shows examples of the benefits the patient flow system provides for different groups

of staff. When data is updated, the change is applied to all screens throughout the unit and in the

units which have a special display, e.g. P4 and Therapy. This overview is displayed real-time on

any big screen connected to the system but also on smartphones and computers, on which the

“Anywhere” software is installed.

5.1. The patient flow system and how it is connected to other units at the hospital

A variety of other different patient flow systems have been introduced in several other units at

the hospital (in addition to the system in the Emergency Department). These solutions have been

developed in close partnership with the users to ensure that specific user needs in relation to the

actual patient flow are covered. The following is a brief description of the three different

solutions. All three are outlined in Figure 8 (below).

Cetrea Surgical

The first solution was implemented in 2007 in the Surgical Department and the Same-day

Surgical Centre and the associated wards, and at the Sterilisation Centre. This solution is called

Cetrea Surgical. It was originally a research project which ran as a close partnership between

Aarhus

University and the Regional Hospital of Horsens & Brædstrup. The project developed into a

commercial product and led to the foundation of a commercial company, Cetrea A/S.


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Cetrea Emergency

The second solution was implemented in connection with the Danish PWT Foundation’s

demonstration project in the Emergency Department. During the first phase, patient flow

system screens were set up at the central staff office, from which staff could coordinate the flow

of patients through the hospital.

The Emergency Department was quick to determine that they required big screens in their medical

assessment office, which assesses patients in the patient reception/Emergency Room. The solution

was then extended to include a further series of big screens in another medical assessment office.

In the final phase of implementation in the Emergency Department, a solution was added to

provide the medical secretaries with an extra screen to provide them with an overview and list-

generation function on their own computers.

At the same time, screens were installed in one ward (Organ surgical ward P4) to demonstrate

that ward staff can allocate beds and resources more efficiently if they can see which patients are

on their way to the ward at a very early stage in the process. The same applies to the X-ray

department, where staff can see patients “shared” with other units. Most recently, the Therapy

unit has had a 40” screen installed so that they are now in a position to distribute tasks, chat

with the Emergency Department and maintain an up-to-date daily overview of patients and

workload.

Cetrea Patient Ward

The newest solution was implemented in March 2011. This is adapted to meet a ward’s

overview, coordination and communication requirements. This solution, called Cetrea Patient

Ward, is not included in the present project. In the next version of the product, the Emergency

Department will be able to transfer patients via the patient flow system to the medical ward,

which is expected to ease cooperation between the two units.

Figure 8. Illustration to show development from first patient flow system and next-step

perspectives.


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Figure 9. Overview of patient flow and related systems at the Regional Hospital of Horsens & Brædstrup

Figure 9 shows both solutions implemented and players interacting with departments, which have

patient flow systems. The dark blue boxes are implemented patient flow systems. The primary

solutions are on the Surgical Corridor including the Same-Day Surgical Centre (Cetrea Surgical), the

Emergency Department (Cetrea Emergency) and the most recently implemented solution that is

tailor-made for ward use (Cetrea Patient Ward). The light blue boxes show our ideas and requests

for new solutions. We are already working on these in partnership with local authorities, pre-

hospital agencies and suppliers.

The solutions are integrated with special hospital units, such as the X-ray department and the

Laboratories and with the Services Unit (in connection with booking porters). The Surgical

Department is integrated with the Sterilisation Centre, which is responsible for cleaning and

sterilising instruments. Special screen displays have been configured for individual departments,

adapted to their specific working processes and requirements. This means that specialist units do

not “inherit” a standard screen display from another department. Data is filtered so that only data

that is relevant for a ward or the Sterilisation Centre is displayed on the screen. For example, the

Sterilisation Centre has no need to see Civil Registration numbers. The project has been acutely

aware of the need for data security and compliance with data legislation.

General practitioners are integrated via the FMK (Fælles Medicin Kort, Common Medication Card)

solution. The pre-hospital agencies are integrated via patient data received by the Emergency

Department from the ambulance (before the patient is received at the hospital).

6. List of existing patient flow systems operational at the Regional Hospital of Horsens & Brædstrup

Cetrea Emergency in the Emergency Department

12 screens in all, in the reception and coordination rooms, and secretariat

Ward P4 – 2 screens (in both staff rooms)


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X-ray department – 1 screen in the joint area

Therapy department – 1 screen in the staff room

Cetrea Surgical in the Surgical Department (COP) and at the Same-Day Surgery Centre

(DKC)

4 screens in the Sterilisation Centre (only OP data)

2 screens in P4

DKC – 4 screens

DKC – 5 screens

COP – 4 coordination rooms

COP – 7 operating rooms

Therapy – 1 screen in the staff room

4 screens in wards

Cetrea Patient Ward in ward P7

4 screens are installed in the staff room

1 screen in staff room - gastrology/geriatrics

1 screen in staff room - pneumonology

1 screen in interview room

1 screen in office

1 screen for secretary (in process)


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Figure 10. Overview of selected functions in the solution

7. Description of work flows before and after implementation of the patient flow system

7.1. Before Cetrea Emergency

All patient details were written by hand on whiteboards. There was a significant amount of erasing

and rewriting involved whenever there were changes, e.g. when patients were moved. The

handwritten information was often difficult to read and a hindrance to creating overview. The data

was often unstructured even though there were specific fields for specific data. All the data had to

be transferred from somewhere and written on the board. There was often an intermediate step,

as the data was accessed electronically and jotted down on a notepad and then finally written on

the whiteboard.


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7.2. After Cetrea Emergency

An overview over patients, beds, nurses and doctors is updated in real time. The overview shows

status in the patient’s programme of treatment. The data is displayed on 40” big screens. The data

is validated in the Civil Registration No. register and the data is structured. The data is easy to

read – and easy to understand.


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Figure 11. Part of screen display in the Emergency Department showing test data (for

patient security reasons).

8. Results

8.1. Labour-saving potential and financial benefits

The application to the Danish PWT Foundation prepared during spring 2009 foresaw annual savings

of 11 man-years and DKK 4.2 million (salaries). The majority of the 11 man-years were calculated

as four man-years for doctors and five man-years for nurses. The two remaining man-years were

one secretary and one health care worker.

There have been a great many changes in the interim period, which makes it very difficult to make

a reliable "all-things-being-equal” evaluation. Among these changes is the on-going process of

converting the hospital into a so-called ”Emergency Treatment Hospital”, which means that there

will be a far greater burden on the Emergency Department than has hitherto been the case. We

have therefore elected to evaluate the effects already achieved at both macro and micro level. At

the micro level we demonstrate how the solution has helped resolve specific tasks in the

Emergency Department and associated units, while, at macro level, we describe developments in

staff numbers and production. Our assessment is that there are still more benefits to be achieved

and these will materialise in due course. This applies to the tracking system and the Job Agent,

while important benefits have already been achieved using the basic system.

Macro level

At macro level, we have chosen to concentrate on the number of staff in the department and

production figures. The data is shown in the tables (below).


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No. of staff 30 June 2009 31 January 2011 Doctors 10 16 Care staff 63 54 Secretaries 13 14

Total 86 84

The number of people employed has fallen by 2.33 % during the project period. The hospital has

implemented a major reorganisation of the doctors' workplaces within the hospital, as a result of

process of transforming the hospital into an “Emergency Treatment Unit”. The “Emergency

Treatment Unit” concept entails that patients are treated and remain in the Emergency

Department observation unit for a longer time prior to either discharge or transfer to a ward.

Hitherto the normal practice has been to transfer patients from the Emergency Department as

soon as this was practicable. In the project period more doctors have been assigned to the

department. In the past, they were assigned to wards elsewhere in the hospital. The increase in

the number of doctors is the result of a change in the doctors’ tasks. The same doctors were

previously employed in other units but performed the exactly the same tasks in the Emergency

Department. There is therefore no real increase in physician resources in the department. By

contrast, the reduction in the number of health care workers expresses an actual cut in the

healthcare worker presence in the department.

If then we correct the figures for the increase in the number of doctors (due to an extraneous

factor which can be eliminated from the project), there has been a 9.3 % reduction in the

number of staff during the project period.

Development in no. of patients 1. halvår

2009 2.halvår 2010 Stigning

Injuries 10,567

5,132

11,304

5,443

6.67 %

6.06 % Admissions

Outpatients 203 273 34.48 %

Total 15,902 17,020 7.03 %

The total number of patients treated has increased by 1,118 patients per six-

monthly period, representing a production increase of 7.03 %.

Overall – including the correction for doctors’ resources – staffs was 19 % more efficient

during the period, as patient turnover per staff member increased from 185 to 218

patients.

At the same time, percentage occupancy in the department increased by 1.4 % from the first

half-year of 2009 until the second half of 2010, which means that hospital bed space has been

better exploited, which represents a further efficiency benefit as available beds are saved in

other wards in the hospital.

This is undoubtedly very satisfactory. Even at this early stage, the solution has brought about

improvements to efficiency, although these improvements cannot reasonably be ascribed to the

patient flow system alone. We expect that the patient flow system will bring about further

improvements to the department’s efficiency when all the functionalities are fully operational.

Moreover, once the system is developed and connects all departments at the hospital, we expect

to see further improvements to efficiency. Finally, we envisage that expansion into the primary

health sector, which would provide medical centres and social services departments access to real-

time data about their patients/citizens, could create optimum transition between the sectors, with

better service and greater patient security as a result.


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Micro level

The table (below) shows specific examples of labour savings at micro-level after the

introduction of the patient flow system. Labour-savings calculations include only morning and

afternoon shifts as activities carried out on the night shift are limited and can be different

from other tasks and there are not as many staff on duty (e.g. less likely to need to locate

each other). The table describes work processes using the whiteboards prior to implementation of the IT

solution and work processes in the period following implementation of the patient flow system.

The table also describes the benefits gained in relation to improved quality of treatment and

increased patient security which cannot be measured in terms of hours, although these factors

do have a derived financial effect. The calculation assumes that that there are ten nurses on the

morning shift and ten on the afternoon shift every day. There are seven doctors on the day shift.

The number of minutes saved is calculated on the basis of observation studies and interviews

with nurses and managers in the department. They are therefore very rough estimates

and our best evaluations of the observations, measurements and interviews carried

out. There will always be a very wide variation in the time spent on the same task,

depending on the person and the specific context.

Task Whiteboards Big screens Hours saved per

year 1) Locate contact

nurse Ask who is assigned to

the patient and

possibly also what

he/she looks like.

There is a rapid

turnover of doctors

(internship system).

Search in wards and

corridors, etc.

Time: 2-4 minutes

each time and

interrupt 2-3 people in

the process.

See staff photo and DECT

no. on big screen. Start

call: 2 secs. Interrupt contact nurse

only. Saving here about 1

min. each time.

2,340

2) Locate the doctor As above. Large

numbers of junior

doctors on

department for a short

period only. Difficult

to recognise them.

As above – photo +

location on screen make it

easier to find the right

doctor.

1,200

3) Register patient’s

name Write name and Civil

Registration no. on

whiteboard. Double

check that the name

is spelled correctly

and number is correct. Time: At least 18

secs. per patient

name

Enter Civil Reg. no. and

patient name. Patient

appears automatically on

screen when validated by

the CPR Register. This

increases patient security.

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4) Making patient

lists at shift end/start

3 x shift changes per

day

Find labels in pigeon

holes, cut and paste

with name and CPR

no. Write diagnosis on

list.

Time: Approx. 5

minutes per list

1-3 clicks on the overview

screen - print list. Time: 2-3 secs. per list

360


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5) Overview of the

patient’s symptoms

Update own memory,

e.g. before ward

round

Changes in e.g.

critical values or

status are not updated

in several places at

the same time and

there is insufficient

space on the board for

so much information.

Note in pocket with

patient info is not

often updated.

Quick glance (2-3 secs.) at

screen provides overview:

why is the patient

admitted, has he/she been

seen by a doctor and are

values critical? 0=normal

values, arrow down=low

values and arrow up =high

values. Department staff can view

updates also from a

distance (remote access).

Time saved cannot

be estimated. Qualitative

improvement.

6) Prioritise patients

in order of severity

Triage and admission

duration.

Difficult to assess

handwritten data on

board. Difficult to read

and insufficient space

to write patient data.

Systematic colour-

coded triage not yet

introduced.

See colour code on screen

for own patients (a few

secs.). Green=to be

attended by a doctor

within 3 hours, yellow=1

hour, orange=15 minutes

red=immediately, blue=

no doctor required but

nurse treatment instead.

Patient security and

treatment quality. Used by

doctors, nurses and

departmental managers

(these last as follow-up

and resource assessment

tool).

Time saved cannot

be estimated. Provides

qualitative

improvement,

better quality of

treatment and

patient security.

Acc. to patient

status/patient flow

and waiting time

Difficult to determine

which patient should

be seen first.

Sometimes just “NB

diagnosis”. No

information available

remotely.

Treat most severe patients

first and those who have

been waiting longest

(System automatically

keeps track of admission

time).

Time saved cannot

be estimated. Benefits are faster

patient flow and

increased patient

security.

8) Transfer patient to

Surgical ward P4. Coordinated over the

phone – oral

transmission of

patient data.

Telephone interruption

eliminated: Patient’s

name, CPR no. and

diagnosis displayed on

screen at P4 when patient

is on his/her way to the P4

from the Emergency

Department. Total

overview in one place - all

patients on their way to

the department. Patient

info cannot get lost in

transit from the

Emergency Department to

P4 and this makes for

increased patient security.

Cannot be

estimated.

9) Chat with P4

about available

beds

Surgical patients (+

2 medical beds in the

department)

Telephone call about

available beds, when

patients are to be

sent on from

reception or

observation unit.

Daily status on beds

available in P4 is sent via

chat function to the

Emergency Department at

08.00, 12.00, 14.00, 17.00

and 21.00. Shows total no. of beds

30


22

and no. of occupied

beds. Chat between

medical assessor

(reception team) and

coordinator (ward team)

in place of telephone call

to transfer patient. Helps

maintain overview and

logistical optimisation of

available beds. Saves time and creates

fewer interruptions:

Saving at least 6

telephone interruptions per coordinator/medical

advisor. Individual calls

about patient are shorter

because some of the

information is already

available before the

patient is physically

transferred to P4. 10) Overview of

available beds in

own department

Walk around wards

to get overview of

available beds and to

find out which

patient is in which

room. No real-time

updates as to which

patient is in which

room. Difficult to

move patients on the

board (see point re

moving a patient)

Overview on all screens

and remotes shows which

beds are available.

Emergency Room and

reception can see

available beds in

observation ward.

Observation ward can see

patients on their way to

the department. =>

opportunity to plan better.

30

11) Find a

patient Find patient on the

whiteboard. Difficult

to read

(handwritten).

View patient beds: 2 secs.

Can also see if patient is

in X-ray. All data about

patient’s whereabouts is

updated real-time on

screens at Reception, in

Observation unit and in

P4.

Doctors, nurses, porters,

laboratory technicians,

etc. can locate the patient

via the screen and can

see at a glance in which

room they can find the

patient and who the

contact person is.

780

12) Give status to

relatives, who call

or visit the hospital.

Find out who is

responsible for the

patient. Find out

where the patient is

right now (no

general overview if

the enquiry comes

from a relative).

Status displayed on board

and call can be

transferred to the nurse

responsible (if required).

The department has

become larger due to

amalgamation. Up-to-

date screen at “both

Cannot be

estimated.


23

E.g. status in

observation dept. is

not known in

Reception once a

patient has been

transferred there.

Coordinator must be

contacted or the

member of staff has

to go to the

department in

question.

ends” of the department

means that callers can be

given up-to-date

information as to the

physical whereabouts of

the patient and how far the patient’s

treatment has

progressed at the

general level.

Improved service and

patient security. If the

patient is approaching

discharge, it is easier to

notify relatives and make

the necessary

arrangements. 13) Find data from

the injury card,

when it is being used

by another member

of staff (e.g. if a

member of staff is

carrying the card

with him/her

during a ward round)

Search for injury card

to obtain data.

Interrupt others to

ask where the injury

card is. Patient

overview and

description of

injury/injuries can

only be seen on the

hard-copy injury card

and only one person can

have this information

at a time. If the

injury card is lost,

staff had to log into

the “Green System”

to print a new one.

View patient data on

screen:

2 secs.

Now also remote access to

view data re volume of

patients and triage.

The data is registered

twice as it has to be

entered both in the Green

System and on the board.

However, some of the

typing is saved in the

observation unit and more

staff has access to the

same data, i.e. a

qualitative improvement.

The data is also

transmitted to the P4

screen.

Cannot be

estimated.

14) Legibility and

standardisation of

data

(Observation unit)

Decipher illegible

handwriting on the

whiteboard. Not sure

that it is correctly

understood.

Insufficient space for

the many important

details and

unstructured. No

standard data

display.

Digital and organised

uniformly everywhere

in the department.

Updated and easily

read everywhere.

Increased patient security.

Cannot be

estimated.

15) Inter-sectoral

medical data on

integrated FMK

(Fælles Medicin Kort,

Common Medication

Card)

Either patient or

medical centre

supplied the

patient’s drugs list.

If the patient did

not have the list,

either the patient’s

own doctor, medical

centre or similar,

It now takes only two

clicks to access inter-

sectoral information on

drugs prescriptions in the

last two years. The

member of staff then

activates the fingerprint

reader and the CPR no. is

transmitted automatically

Increased patient

security and time

saved on

obtaining drugs

info and

immediate

treatment start

(fast access to

drugs overview).


24

had to be contacted

by telephone to

provide the

information needed.

Staff had to note

down the name and

CPR no. and register

the drugs list

manually.

to the FMK solution (no

typing required). As the

CPR no. is validated by the

CPR register, high-level IT

security is assured. The

drugs information is fast

and easily accessible, and

the patient data is checked

more quickly. Highly

beneficial if the patient is

either unconscious or

confused and therefore not

able to give any

information about the

drugs they are taking.

Increased patient security.

Faced with a gradually

ageing population in which

drugs pr. patient can be

expected to increase,

there will more than likely

be a need for better drugs

overview in the future.

Qualitative

improvement.

Time saved

cannot be

estimated.

16) Secretaries

have patient

overview on their

own screen

Must call or go to

Emergency Room or

observation unit to

find contact person –

ask several on the

way who is

responsible for a

given patient.

Interrupt medical

adviser/coordinator.

Can give

information/status to

relatives and other

relevant contacts in the

unit - thus reducing the

need to contact nurses

(fewer interruptions).

Saving time and energy

(walking). Do not need to

leave the department –

e.g. to go to Emergency

Room or observation unit.

Able to provide better

service.

167

17) Move a patient

from one bed to

another

(registration)

Manually: 1½ minutes Digitally: 2 secs. 4-5 moves per patient.

623

18) Check X-ray

status Manually access pc to

check status.

Checked by both

nurses and doctors

(especially critically

ill patients).

Time: 1 minute

Digitally: 1

sec. At least 1-2 patients

per day by four

different people (incl.

doctor/ emergency

doctor, contact nurse).

Approx. 85% of

patients are X-rayed = 61 X-ray cases per day.

482

19) Calculate

admission time

(hours) Used e.g. to

calculate reaction

time in connection

Manual calculation: 20

secs. Digital calculation: 1 sec.

The system automatically

calculates admission time

and updates continually.

239


25

with triage. 20) Calculate a

patient’s age Find patient

label in the

pigeon-holes

Time: 10 secs.

Digital calculation:

System calculates age

automatically.

Time: 1 sec.

14

21) Check for

blood test results Staff spend time

fruitlessly opening

LABKA to see if

blood test results are

available.

Time: 1-1½ minutes

per patient who has

had blood samples

taken. Check often to

see if blood test

results are available

if the patient is

critically ill.

Blood samples taken

from nearly all

patients (except

orthopaedic

patients)

Staff can view status in 1

second. When results are

available, the data is

indicated on-screen: A red

field indicates how many

test results are available.

104

Total

improvements

to efficiency

6,398 hours

The table indicates that there is a total improvement to efficiency of 6,398 hours,

corresponding to about four full-time positions (where one full-time position is

calculated as 1,600 hours). The time saved has been converted to higher productivity

and there is more time available to perform core services.

8.1.1. Project’s financial balance

The figures here are based on the original project application budget, viz.:

Balance Actual 2010 (DKK) Budget 2010 (DKK) Labour savings Derived labour-related savings Savings on operating costs

1,368,000 1,100.000 30,000

Total financial benefits 1,368,000 1,130,000

Derived labour-related costs Total project costs Increased operating costs Depreciation

2,738,422

171,000

75,000 3,100,000

410,000

Total costs 2,909,422 3,585,000

Financial balance -1,541,422 -2,455,000


26

The figures indicate that, as early as 2010, improvements to efficiency were greater

than expected. Based on in-depth implementation of some of the functionalities

(including tracking and ordering healthcare worker assistance), it is expected that

further efficiencies will be achieved in 2011, and our assessment is that the

demonstration project is a success.

Increased operating costs in 2010 were due to the fact that double registration was required due

to a lack of integration with the Green System, which is awaiting implementation of a new

Electronic Patient Journal (EPJ) system in the latter part of 2011.

8.1.2. Labour-saving potential at the national level

The demonstration project indicates that implementation of a patient flow system in an

Emergency Department produces positive benefits.

The Danish Regions published a list of indicators for health service IT in 2010, stating: “The

major emergency departments at all Danish hospitals will have electronic boards installed

before the end of 2011”. Many emergency departments have implemented or are in the

process of implementing a patient flow system. The Cetrea solution is sold to four of the five

regional authorities in Denmark. If you multiply efficiencies at the micro level to national level, all other things being equal, the

introduction of a patient flow system would produce an improvement of 136 full-time

positions (assuming that the Regional Hospital of Horsens & Brædstrup performs 1/34 of the

total workload at national level).

Seen from the perspective of disseminating the solution, it is not certain that the introduction of

the same solution in other hospitals will necessarily have the same effect as at the Regional

Hospital of Horsens & Brædstrup. The benefits gained depend to a great extent on how staff are

organised and their capacity and willingness to cope with change and get to grips with new

systems. At the Regional Hospital of Horsens & Brædstrup, the staff is very willing to try out

new ideas and new IT tools in order to improve quality, reduce pressure of work or create an

opportunity to achieve more from the same resources. It may well be that this innovative

culture does not exist elsewhere. We consider that it is crucial for successful implementation

and use of the system. We also believe that the same applies to management style. It is crucial

that management takes the lead, becomes involved, spends time and motivates staff in the

process.

8.1.3 Other financial benefits (service and quality)

It has not been possible to calculate the effects of the solution on absence due to sickness and

the costs budgeted for temporary staff. However, we have shown that available beds, and

therefore the unit’s production apparatus, has been utilised more effectively. These benefits

however do not necessarily have any direct connection with the project. On the other hand, the

possibility cannot entirely be discounted.

It is also interesting to note that the project has brought about not only increased patient

quality but also higher productivity. These benefits cannot be measured as such. However, they

became clear when we reviewed all the tasks listed at micro level and assessed them in relation

to patient quality and trust. This is interesting as, in the health sector, better patient quality is

often achieved at the expense of productivity.


27

Figure 12 shows that the patient flow system provides higher productivity, better

quality and improves patient security.

8.2 Qualitative benefits

Qualitative benefits are described in the table in section 8.1, where it was not possible to trace

the quantitative effect. One example is the fact that data on the big screen is far easier to read

than handwriting on a whiteboard.

Another example is the timing of the coordinator’s telephone calls. It is clear that the length of

these telephone calls is reduced significantly. This may indicate that the accessibility of data on

the screens means that there is less need for telephone calls.

The number of adverse events in the period has increased. This may be due to the fact that, in

the project period, there has been increasing awareness of and incitement to report such

events. None of the adverse events reported was due to the patient flow system.

The following is a description of some of the benefits the system has brought with it and a

number of quotes from the interviews/dialogues with staff substantiating the benefits of the

system at the Regional Hospital of Horsens & Brædstrup.

Centrally updated “here-and-now data” provides an overview, saves energy and causes

fewer interruptions.

Consultant Physician: “Making our whiteboards electronic is hugely beneficial! The key

factor is that the solution provides an electronic overview which is exactly the same on


28

every screen. If we change patient data at one end of the department, it is immediately

changed at the other end. We no longer have to run around updating the data. The update

is made centrally so everyone has an overview wherever they may be.”

“It is of paramount importance that the system is so easy to use. The touch system makes

it easy for staff to click in and out - when you want to see or you want to show someone

else how far we have progressed in treating the patient.”

Chief Physician: “We are living in an unsynchronised health sector, where 80 % of our data is

updated with between one and three days’ delay. This system provides us with real-time data

which is essential for efficient patient flow.”

The significance of OPI (public-private partnership)

Chief Physician: “External partners with core competences from a completely different

branch are important partners to have. The world of research is equally important. The

differences between us mean we can produce something outstanding.”

Screens to facilitate conferences

Consultant Physician: “We are also using the Cetrea screens for conferences. We hold many

conferences at the screens. The screens facilitate these meetings very well. The surgeons meet

twice a day with the nurses to review the “red” patients. (Editor’s note: the red code here

denotes surgical patients, not the triage category.) The medical patients are colour-coded blue

and it is easy for them to obtain an overview/find their own patients on the screen and review

them. The individual nurse supplies information about her own patients. She can find them

quickly and explain their status using the screen data as supporting material.”

Optimising patient logistics

Chief Physician: “The system provides an overview of all processes the patient undergoes at the

Emergency Treatment Hospital and a logistical picture of where the patient is, where he or she is

heading, and who will make sure that all this happens. The EPJ does not give us this kind of

overview, as it gives an overview only of the individual patient. Here (patient flow system) we

get an overview of all patient groups.”

Consultant Physician: “We meet at the screen and see the flow through the building and we can

see where we can optimise it. At the moment we are facing real challenges relative to finding

capacity for our many medical patients. We have relatively many patients compared to the space

available. We meet with the senior nurse and take a quick look at the patients on the screen.

Can we discharge this patient? No, he/she has not yet been assessed – on to the next patient.

We gain an overview so that we can optimise the logistics. Without that overview, it would take

us far longer to find/create space.”

Consultant Physician: “Now we have the solution, we save a lot of ringing around. Although it is

difficult to pinpoint exactly how much time we save...But the solution definitely means we have

far fewer interruptions because staff in the department, porters and laboratory technicians get a

lot of the information they need directly from the screen.”

Rapid staff turnover – staff photos save time

Consultant Physician: “We get four new doctors every three months and the junior doctors

are only here for six months at a time. With such rapid turnover, the staff photos are a

major advantage. The photos make it easier to know who is who, without having to interrupt

someone to ask.”


29

Does the system affect quality of treatment?

Chief Physician: “The solution is clearly advantageous in terms of quality as we always know

exactly how far a patient’s treatment has progressed. This means the departments have an

opportunity to prepare, and transfers between units are smoother.”

Consultant Physician: “It (the patient flow system) is an important management tool. We can

always see which patients we have in which categories and rapidly gain an overview of their

condition and whether treatment is progressing. We check on-screen: Is the medical journal

written? Is treatment in progress? Have we completed triage? Is this patient in need of urgent

treatment?”

The system as a management tool

Consultant Physician: “It means a great deal for us consultants. If there are patients who are

assessed in triage as critically ill, we can check if we have everything under control! And we can

start treating the most critical patients first. The system counts admission hours so we can

easily see how long the patient has been in our hands. If a patient has not yet been examined,

we react. This improves patient security.”

“I always go down to the Emergency Room in the morning to check – are any patients

categorised orange in triage? If there are, I can follow them up straight away.”

“I also use it as a management tool in my follow-ups. I still ask my doctors if things are going

according to plan. But I also look at the screen to see if we’re going to have a tough day. Do we

have lots of patients, are they critical, and do they therefore need more care and attention?”

“When I am in Copenhagen, I check my smartphone to see how many patients we have

admitted. If I can see that things are looking hectic, I call to ask if there are sufficient resources

or if I need to call in more staff.”

Importance of the system in the light of the hospital’s status as an Emergency

Treatment Hospital and planned expansion

Consultant Physician: “The fact that we have been designated an Emergency Treatment Hospital

means that the department has grown. And there is more pressure on us. We have more

patients and a faster flow. The flow of patients is much larger. Today we simply cannot work

without the electronic overview. At one end we receive patients, prioritise and triage them. Then

they are transferred to another geographical location, which is of course relatively close by. But

we save a lot of walking from one end to the other. There is electronic overview everywhere, and

we can always see where the patient is. We no longer have to erase the same information in two

or three different places. We only have to erase things once.”

“When the extension is finished, we will have eight more beds and there will be even further

distances between the departments. In future we may have 40 beds, over which we have to

maintain a consistent overview – both the reception team and the observation team. This

would be chaotic without the system – we would have to run around far more.”

Increased patient security as the system improves follow-up and data is transferred

electronically

Coordinator: “It gives better patient security when we can move a patient's data via "drag-and-

drop" and obtain the patient’s name directly from the CPR register. When patients are moved,

we no longer have incorrect Civil Registration numbers and information because the data follows

them automatically. Every time we erase data from the whiteboards and rewrote it, there was a

risk that we might make a mistake. Now we are 100 % sure that we get the same data when the

patient is moved.”


30

Coordinator: “We use triage actively. We check: Who has examined the patient? Have we

taken samples for blood tests? Has the patient been X-rayed? Have the test results come

back? And we check that treatment is progressing and ensure that the patient is examined at

the right time.”

Ward sister: “It is easier to make sure that patients are not left unattended for too long as the

system keeps track of how long the patient has been admitted. And we don’t have to assess

whether the patient must be seen now or if he/she can wait because there is another more

urgent patient.”

Pre-hospital sector and patient security

Consultant Physician: “When we are informed of an incoming patient, the patient’s Civil

Registration number is registered on the screen and even at this early stage we can enter the

patient data to see if we have data in the EPJ system and prepare ourselves. However, we do

not yet have pre-hospital triage. We have the CPR number and symptoms and suspected

diagnosis. We prepare ourselves actively. This is significant for patient security. In time we will

get pre-hospital data in Emergency Ward 1 including triage category and this data will be linked

to the Cetrea solution. This will give patient security a further boost. We use the Cetrea screens

to create overview. The pre-hospital and EPJ data are at a different level of detail so the three

systems have to operate in parallel.”

The significance of the system for pressure of work and the working environment

Consultant Physician: “The system eases pressure of work as it provides an overview. This is

difficult to measure, however, as we have more patients and the same staff resources at our

disposal. There is therefore more pressure on staff now than in the past. My assessment is that

there is better overview and fewer interruptions in our daily work and this frees up more time

for treatment.”

Consultant Physician: “There is less noise in the room when fewer questions are asked! If you

look at how much activity goes on in the rooms (Editor’s comment: staff rooms), things have

actually become very quiet. There can be a lot going on but the activity no longer creates noise

because we get so much information on the electronic screens.”

Coordinator: “We are extremely busy so everything would fall around our ears if we didn’t

have this system.”

Benefits of tracking

Coordinator: “We all spend a great deal of time searching for colleagues. Especially we nurses -

we need to make it easier to find us. The tracking system helps save time and energy spent on

walking. And we avoid interrupting each other unnecessarily to ask where a particular nurse is.

Often you are told she is in a certain ward but by the time you get there, she has already

moved on. We waste a lot of time on this which we could put to better use.”

Wireless telephones relieve the pressure

When the wireless telephones are introduced, the burden of communication on the

coordinators is lessened. For example, it has become easier for the doctor to contact

the responsible nurse directly.

One important feature of the solution is that the overview screen displays the extension

numbers of staff on duty today. This means that staff no longer needs to find a computer to

search for these numbers and the coordinator’s mental resources are also freed up. In the past

the nurses had no personal telephone and it was therefore very difficult to get into contact

with them.


31

One coordinator even estimated that this feature saves two hours of her time every day! She

saves time because staff no longer has to search for one another but can call directly without

involving the coordinator in their “search” and without having to ask the coordinator to pass on

a message. In the past, according to the coordinator, the doctor tended to give the message to

the coordinator if he was unable to find the responsible nurse. According to the coordinator,

there was a major risk that something important might be forgotten.

Future anchorage

Chief Physician: “The system has become a sine qua non for the running of an Emergency

Treatment Hospital. The solution has already become firmly anchored in our daily work. There

are some things we simply could not do without the system.”

Strategic potential

Chief Physician: “The system gives us a fantastic opportunity to move beyond the

boundaries of our own sector because an overarching solution to include the inter-sectoral

perspective and pre-hospital sector would provide a better overall overview both for the

nurses who work as medical assessors and for all the other professional specialists

involved.”

9. OPI (public-private partnership) - commercial benefits and market penetration The demonstration project has been a close cooperation between the hospital and several private

companies, Cetrea having been the primary supplier of the demonstration project to the

Emergency Department.

The figures below support the fact that the company has grown significantly in consequence of

the company’s partnership with the Regional Hospital of Horsens & Brædstrup, including the

demonstration project in the Emergency Department, which has become an important reference

customer in the company’s sales efforts. One example is that many customers visited the hospital

to see the solution. A total of 27 visits have been registered. The typical visit had many

participants, both from Denmark and abroad. Furthermore, Consultant Physician Ove Gaardboe

has held lectures on the project at several conferences and took part in an article in Dagens

Medicin (Danish independent health sector journal).

The solution has been continuously adapted to meet the clinicians' needs in close

dialogue with the hospital and is optimised to accommodate both procedures at the

hospital and new technological opportunities.

Cetrea A/S: Growth in a private company as the result of the project Cetrea has grown strongly in the project period and has ambitious expectations for growth

in 2011.

Growth in the number of staff and turnover

During 2010 the company employed 20 new staff and currently employs a total of 34. There

are 18 developers, six PhD’s and five nurses. In 2011, the number of employees is planned to

increase by 16 to 50.

Growth was 200 % in 2009 (turnover DKK 10 million) and 100 % in 2010 (turnover DKK 20

million).


32

New partnership set-ups in Denmark and abroad

Cetrea has established partnerships in Denmark, Norway, Sweden, Germany, USA and Spain.

o Cetrea has signed a strategic partnership agreement with a company called

Systematic and has seen growth and interdisciplinary development (through

partnership with Systematic in USA, UK and Scandinavia). o Cetrea works with CSC on the Danish market.

Market penetration of Cetrea solutions

o Cetrea’s solutions are now sold to four of the five Danish regional authorities. o Cetrea Emergency is currently in operation at eight hospital locations and a further

seven are scheduled for roll-out during Q2 2011.

o Cetrea Patient Ward is implemented at the Regional Hospital of

Horsens & Brædstrup and will be implemented at Herlev Hospital in

Q2 2011. o Cetrea Emergency will be implemented at Karolinska and Jönköping in

Sweden (roll-out in Q2 2011). o Cetrea Surgical is currently in roll-out at St. Olav in Norway and at Linköping in

Sweden (roll-out in Q2 2011).

Trifork A/S:

According to Trifork A/S, which supplies the integrated FMK (Common Medication Card) solution,

the project in Horsens has created a platform for development of mobile solutions in the welfare

sector.

The demonstration project at the Regional Hospital of Horsens & Brædstrup has functioned as a

reference case for Trifork and, according to the Trifork team manager responsible for the

solution, Trifork has gained a great deal of credibility when the company has approached other

parts of the hospitals sector. The project in Horsens has, for example, opened doors for a

development and evaluation process in partnership with another private company, Medcom,

and Hillerød Hospital, which will be based on the solution implemented in Horsens.

Trifork generally focuses on providing mobile solutions for use e.g. in the finance sector.

Trifork’s participation in Horsens has kick-started efforts to work on mobile solutions for the

healthcare sector. The company calculates with 20 % overall growth in the mobile area in 2011.

This figure includes calculated growth in welfare solutions.

Trifork won Danish Digitalisation Award

On 6 April this year, the FMK (Common Medication Card) won the Danish Digitalisation Award.

According to CEDI (Danish Centre for Digital Government - see www.CEDI.dk), in selecting the

winner of the award, the panel of judges laid particular emphasis on the following: “The FMK

(Common Medication Card) has a broad-based social perspective, significantly improving the

quality of healthcare services because the medication card significantly reduces the risk of errors

and therefore improves patient security. The solution helps increase transparency in drugs use at

the national and international level. Furthermore, the panel was impressed to note that the

solution has been implemented in the Danish health system’s complex system landscape and this

required an incredibly large number of integrations.”

“All the nominees for the welfare award have succeeded in liberating resources for exercising

core welfare services and focusing squarely on the individual citizen's welfare needs and legal

rights”.

http://www.cedi.dk/


33

“It is also interesting to note how linking the nominated solutions to the welfare system will

generally create a far more efficient and cohesive public sector with focus on the needs of the

user,” states a fascinated Louise Gade (one of the judges).

The welfare award is presented to a public institution or authority, which has implemented and

launched a solution/service, which, by using technology, first and foremost has generated a

palpable improvement to services and thus to the day-to-day lives of the general public, and

which, secondly, has contributed to the overall improvement of public-sector efficiency.

The Digitalisation Award 2011 is a joint initiative by the Danish Ministry of Science, Technology

and Innovation, the Danish regional authorities, KL (Local Government Denmark), KMD (large

Danish IT company), Hewlett-Packard, CEDI (Danish Centre for Digital Government) and

Rambøll Management Consulting. The panel of judges was Peter Mogensen (Danish political

commentator and Editor-in-chief of Politiken (Danish national daily newspaper) and Louise

Gade, Deputy Director of Human Resources at Aarhus University.

Ascom A/S

According to the chief consultant responsible at Ascom for the project cooperation with the

Emergency Department at the Regional Hospital of Horsens & Brædstrup, this project has

been significant in several different areas:

The project has paved the way for a Nordic partnership with Cetrea, in which

Ascom has become the distributor of Cetrea’s products in both Norway and

Sweden.

The Ascom-Cetrea partnership aims to expand to include the whole

Nordic region.

At the Nordic level, Ascom is working to a budgeted increase in

turnover of 5 - 10 %.

The project has made it possible for Ascom to offer more complete and

integrated solutions to customers, including more value-adding applications.

The project is an important reference for current and prospective customers in

Denmark specifically and more generally in the Nordic Region.

Reflecting the innovative nature of this project, the partnership has

strengthened the Ascom profile as an innovative company.

In general terms, the project has brought about greater focus on future patient communication

issues at Ascom and thus creates more focus on creating innovation solutions for tomorrow’s

hospitals.

General evaluation of market penetration

Consultant Physician: “All parts of the system can provide benefits for any emergency

department and the system may also be beneficial to many other hospital departments.

The benefits of the system in the form of the reduction in the volume of interruptions and

contacts will be the same everywhere.”

Evaluation of market penetration of the FMK (Common Medication Card) solution

Consultant Physician: “It increases patient security. The solution will be disseminated to seven

senior physicians, 11 junior doctors, and 20 doctors in total at the Emergency Department. And


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to 20 first and second-level back-up medical doctors and 12-14 surgical doctors. To about six

orthopaedic surgeons. In total the system will be disseminated to 60 doctors at the Regional

Hospital of Horsens & Brædstrup alone. And there are also national perspectives for dissemination

of the system.”

10. Technological maturity and factors that may impede penetration

We evaluate that the technology is mature and it is already operational at the Regional Hospital

of Horsens & Brædstrup.

System integration and further development

Consultant Physician: “The technology is generally mature. The biggest challenge we face is in

integrating the different IT systems. And from time to time we have received new features which

need to be adjusted to achieve the optimum benefit. Although, of course, when you are working

with brand-new solutions, the correct solution is not something you can define in advance – this

is, after all, an “experimental environment”. For example, we are hoping to adjust the way blood

test results appear on screen, so that only the most important results are displayed. There are

other systems in use here which cope better with the details – in this system focus is on

maintaining an overview – and many patients’ data simultaneously.”

The fingerprint solution

Consultant Physician: “The Regional IT body has expressed the view that fingerprint technology

does not always work optimally when there are many concomitant users. We have not

experienced problems of this kind here in Horsens. We have had no reason to feel that the

technology is immature. The stationary FMK solution with fingerprint reader works very well and

it is a great tool. We have had some issues with remote access due to the challenges of using

the Digital Signature system in conjunction with the mobile display. The Regional IT body is

currently working to resolve the problem and for this reason not all doctors are using the

solution at present. We have had up to six or seven doctors working with the FMK solution and it

worked really well. Once the Digital Signature issues are resolved, we will be able to reap the full

benefit of FMK.”

Tracking

Some of the wireless units fail from time to time. This is assessed as being due to a

combination of technological immaturity and an underdimensioned wireless LAN.

Technical and IT-specific support

Consultant Physician: “The system must work perfectly all the time. We are entirely dependent

on downtime being close to zero. This is an issue we have to contend with when, for example,

the Technical Department wants to cut the mains power supply during the daytime. Such things

should only take place at, for example, five o‘clock in the morning, when we have fewest

patients and minimum activity. We also have a running battle with suppliers who want to make

upgrades during the day. If the suppliers cannot make upgrades during the night, then they are

unsuited to being our suppliers.”

We find generally that communication via the IT Service Desk is heavy-going. When we carry

out demonstration projects, which are short-term, we have to make contact with a designated

team. We cannot wait for help from a help-desk because our solutions are not standard, because

they are new and not yet fully operational.”


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Integration with the electronic patient journal – EPJ

EPJ is not currently integrated with the patient flow system in the Emergency Department

because we are awaiting a political decision on the choice of EPJ system.

In the long term, the EPJ system will be integrated directly with the screens. When you change

data in EPJ, it will change immediately on the screen. We are not prepared to fund the

implementation of something that we know will be temporary – i.e. integration to our "old" EPJ,

when we know a new EPJ is on the cards. It makes no sense financially. We also opted against

integration with the Green System as this system will be phased out to become part of MidtEPJ.

There will be double registration of data in the reception unit for a time, although there will be a

positive “payback” as less registration will be required in other departments.

Cultural differences and the use of wireless telephones

Coordinator: “We do not actively respond to unanswered calls reaching us via the wireless

telephone and we do not yet use SMS. This is a cultural issue, as we have no previous

experience of using this kind of media in hospitals although we do in the private sphere.”

Figure 13. Extraneous factors that have affected the project


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Summary of barriers

The Regional and Central IT departments may have a strategy, plan or

agenda that creates hurdles and delays

Other major projects, such as DDKM, may deflect focus from the project, and thus cause

delays

Operational departments who believe that new solutions should be given lowest priority as

they make work difficult

We need a person on site to manage the technical set-up and ensure daily support

service to help resolve minor difficulties The Central IT organisation is not organised to

accommodate this as their focus is on standard solutions. This is not compatible with

demonstration projects.

There are differences between the systems and their capacity to interact with regional

and national solutions.

Lessons learned

It would be an advantage to take a step-by-step approach to the implementation of the many

different component elements of the solution in preference to implementing all features at once.

This would mean that there would be more time to adjust all the parts of the solution before they

are implemented and to split user-training of this otherwise very user-friendly system into

phases. It would also be an advantage to make test versions of features in a smaller set-up (with

only one or two users) until adaptation of the individual feature is completed.

11. Conclusion

The idea for the project at the Emergency Department at the Regional Hospital of Horsens &

Brædstrup was conceived when the hospital management team and Cetrea witnessed the great

improvements to efficiency and working conditions achieved after a patient flow system was

introduced in the Surgical Department. The departmental management team was willing to

initiate the project as it was expected that the patient flow system would help increase

production with unchanged resources. This was in fact necessary in order to process the

increasing volume of patients in a period during which costs were pegged.

The process has been disrupted from many sides: centralisation of the local IT department,

new members in the management team, other new time-consuming projects and increased

pressure on staff due to the increasing volume of patients. Even so, the department and the

suppliers have succeeded in maintaining focus on the task in hand and have also taken

necessary steps to accommodate other initiatives. And, at the same time, the project has

progressed in a positive direction. The staff has demonstrated a willingness to accept change

and have welcomed the new initiatives to the extent that today they feel they cannot work

without the patient flow system which is an indispensible tool for everyone in the department.

It is therefore to a great extent thanks to the staff that the system has now become

everyone's tool. We are grateful that they continue incessantly to suggest new functionalities

to the suppliers, who are regular visitors to the department, picking up lessons learned and

bright ideas for future development. This close cooperation between the hospital and supplier

has been decisive for the project’s success.


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The hospital management team has paid adequate attention to and lent active support to the

project and this has been decisive for practical execution of several of the sub-projects. En

route, speedy decisions and actions have been required, without which we would never have

reached our goals.

There is no doubt that the patient flow system has brought about increased efficiency, even

though the analysis at micro-level is not conclusive. Staff and management applaud the user-

friendliness of the system. It provides them with a better overview, and facilitates knowledge-

sharing and better cooperation with other hospital departments. At the same time, everyone

agrees that the introduction of the patient flow system has improved the quality of patient

treatment and security.

That there has been appreciable interest in the patient flow system is reflected in the many

foreign and Danish visitors to the Emergency Department. The media too have demonstrated a

great interest in the system. Cetrea has also sold the solution to four of the five Danish Regional

authorities and initiated international sales too. Furthermore, we have registered an interest

from students, wishing to write papers on the demonstration project.


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12. Appendixes

Appendix 1: Photo of the result of a brainstorming process with nurses (incl. coordinators and medical assessors). Appendix 2: Input form from the brainstorming session with nurses in the Emergency Department Appendix 3: Overview of location of tracking equipment in the Emergency Department.


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Appendix 1: Photo of the result of a brainstorming process with nurses (incl. coordinators and medical assessors).


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Appendix 2. Input form from the brainstorming session shown in Appendix 1.

Post-it notes from the patient logistics

system brainstorming session with

nurses from the Emergency Department

Advantage, disadvantage or idea for new development

You forget fewer patients Advantage Overview of where the patient really is Advantage Rapid overview Advantage Good overview of severity/triage/patient security

Good overview of patient treatment process/time - how long since the patient was admitted

Advantage

Overview of no. of patients Advantage Overview of patient’s disorder Advantage Rapid overview Advantage Rapid patient overview Advantage Gives a very good overview Advantage Increased patient security due to better overview

Advantage

Can see when the doctor has seen the patient Advantage Can see which doctor will examine the patient Advantage Can see when X-rays have been taken Advantage Lose fewer patients Advantage Unsure if anyone has seen the message on the chat function

Disadvantage

When using chat, others cannot view the data Disadvantage Can see if the patient has been to X-ray Advantage See earlier if X-rays have been taken Advantage Good to know how far the patient has

progressed in X-ray (booked and taken) Advantage

Can see when blood test results are ready Advantage Lack of integration to EPJ Disadvantage Lack of integration to GS (Green System) Disadvantage Terrific with telephone number to staff => less walking and less need to interrupt colleagues

Advantage

That you can see staff telephone no. Advantage Blood test results: Opportunity to prioritise and select the most important/relevant

Idea

Chat: Faster communication between medical adviser in Emergency Room and coordinator

in ward unit.

Advantage

CPR number validation – patient security Advantage CPR number generates name automatically => increases patient security

Advantage

When there are many patients in the waiting room, the scroll function is too slow for waiting patients

Disadvantage

Less walking for nurses Advantage Saves staff a lot of walking Advantage Several people can view patient data at the same time (contrast to before when there was only one injury card for each patient)

Advantage

Can prioritise patient sequence Advantage Major difficulties if the screens “go black” Disadvantage Patient data is not lost during transfer to a ward unit => save telephone calls and increase security

Advantage

Write text – not used often enough Disadvantage Good to know how far the patient has progressed in X-ray (booked and taken)

Advantage


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Appendix 3: Overview of Emergency Department and tracking equipment


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Evaluation of Cetrea Emergency by The PWT Foundation

Documents

Transcript of Evaluation of Cetrea Emergency by The PWT Foundation