Accid Emerg Med 1997;14:92-97

Desktop system for accounting, audit, andresearch in A&E

C J Taylor, S G Brain, F Bull, A C Crosby, D G Ferguson

AbstractThe development of a database for audit,research, and accounting in accident andemergency (A&E) is described. The sys-

tem uses a desktop computer, an opticalscanner, sophisticated optical markreader software, and workload manage-

ment data. The system is highly flexible,easy to use, and at a cost ofaround £16 000affordable for larger departments wishingto move towards accounting. For smallerdepartments, it may be an alternative tofull computerisation.(7Accid Emerg Med 1997;14:92-97)

Keywords: accident and emergency department; audit;computer; workload management.

Royal HallamshireHospital, CSUH NHSTrust, Glossop Road,Sheffield S10 2JF,United Kingdom:Accident andEmergencyDepartmentC J TaylorA C CrosbyD G Ferguson

Department ofMedical AuditS G Brain

Workload ManagementCoordinatorF Bull

Correspondence to:C J Taylor, Consultant inA&E, James Paget Hospital,Great Yarmouth, NorfolkNR31 6LA.

Accepted for publication16 July 1996

Most larger computerised accident and emer-

gency (A&E) systems in this country, whetherthey are custom designed or form part of thepatient administration system (PAS), have one

problem in common: once installed, they are

difficult to change.Although it may be easy to add another

computer terminal, updating an existing sys-tem to capture new data usually requires thehelp of a software firm, which is costly and timeconsuming. When the new data are only to beused for a short term project, the expense israrely justified and for one-off studies, likemany audit projects, it is often easier to collectthe data by hand than to write a software mod-ule to do the task. Most notably, most existingA&E computer systems were installed beforethe NHS became cost conscious and none ofthese, as far as we are aware, has software mod-ules capable of producing accurate coatings ofindividual patient episodes.Using the workload management data out-

lined in a previous study,' we developed a sys-tem that solves these problems. It is suitable forall A&E departments, irrespective of size.

The systemThe system uses a desktop computer, an opti-cal scanner, and three commercially availableprograms which can share and exchange data.Data sources are administrative informationdownloaded from PAS, clinical informationcollected at the time of patient attendance, andthe workload management data derived fromthe study described by Taylor et al.' Figure 1represents graphically the steps necessary inthe development and creation of the computer-ised database.

HARDWARE AND SOFTWARE REQUIREMENTSHardwareThose unfamiliar with computer jargon maysimply wish to note that we used a state of theart desktop computer with a little mouse and abig screen (fig 2A). The computer wasconnected to an optical scanner (fig 2B) whichtakes an image of the questionnaire and sendsthis to the Formic' Software (see below) forprocessing. Formic then decides if any of theboxes have been ticked and keeps the images ofany handwritten information for the user toview on-screen and code later.The system runs on a standalone IBM com-

patible PC (dan 486DX2/66, 16 Mb RAM,525 Mb hard disk and built in tape streamer)and a 17' XGA monitor with 1024x768resolution. The optical scanner is a FujitsuM3093E, which reads single sided question-naires and with the use of an ADF (automaticdocument feeder) is capable of scanning up to23 pages/min.

SoftwareThe system requires a database, a spreadsheet,and optical mark reader software. For databaseand spreadsheet, we used the Windows'versions of Access' and Excel' respectively.Both programs are commercially available andcome with their own documentation. Althoughprobably unintelligible for those unused tocomputerised data handling, both are so widelyknown that most hospitals will have an ITtechnician on site who will be able to set up thesystem and customise both programs within afew hours.The heart of the unit is Formic, a sophisti-

cated optical mark reader program that fulfilsthe triple function of designing the scannerreadable forms, driving the scanner andprocessing the data.Formic reliably reads forms filled in biro,

ink, and pencil. It ignores all information

Approximate costfor a middle of the range computer system(including VAT)

Non-recurrentComputer £2 150Tape streamer £55017' XGA monitor £650Database and spreadsheet software £300Optical scanner £4300OMR software £7 100Training and installation £800Total £15 850

Recurrent-Support for OMR £900/yearSupport for scanner £300/yearOn-site maintenance for other hardware £250/yearTotal £1450/year

OMR, optical mark reader.

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outside defined areas of the sheet: smudges,too boldly marked tick boxes, and even doodlesdo not interfere with the scanning process. Theuser only has to keep filling the ADF; all errorsencountered during scanning are stored asimages for later on-screen editing.The table gives a breakdown of the costs of

the whole system.

THE PROCESSThe system was designed for maximumflexibility, and the steps outlined below should

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allow each department to customise it to theirown requirements, including collecting a dif-ferent dataset, using different forms, andextracting different statistics.

From choosing the dataset to the scanner readableformOne of the problems of collecting data for A&Eis that the spread of patient conditions varieswidely: to design a form that captures (in tickbox form) all the information that should becollected for a multiply injured patient but

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Figure 1 Flow chart representing the steps necessary in the development and creation of a computerised database for auditand accounting in A&E.

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Figure 2 (A) The desktop computer usedfor development;(B) Optical scanner with ADF (automatic documentfeeder).

which is at the same time still simple enough tocode the much more common complaint of"sprained ankle" is impossible. We solved theproblem by designing three different forms,one for each of the traditional working areas ofan A&E department: resuscitation room, trol-ley bay, and walking wounded. As Formic doesnot require the completed forms to be sortedbefore scanning, this does not represent a

practical problem.Before determining the detail to be asked for

on each sheet, we established the mostcommon conditions, treatments, and outcomesin each of the three areas. With that, we were

able to design forms that allow between 85%and 95% of all necessary information to be

Figure 3 Designing and editing the questionnaires on screen.

coded and only 5-15% need to be writtenlong-hand.Formic allows the forms to be created by

making the screen represent what the page willlook like when printed (fig 3). This enables tickboxes and other data collection types (boxesfor handwriting, horizontal and handwrittennumber grids, code frames, bar codes, etc) tobe placed anywhere on the page. Choosingappropriate data types and grouping logicallylinked questions together (that is, creating asingle or multiple choice question) has allowedus to build error checks directly into the designof the form. This improves data accuracy byeliminating some of the errors that occur dueto faulty coding when the forms are filled in.

Figure 4 shows the finished results. Despitethe high detail, all information relating to anattendance can still be collected on a singlesheet ofA4. The boxed areas on the sheet allowfor additional information to be entered longhand. During scanning, these areas are storedas images and appear on screen where theymay be manually transferred into typed text.This is then stored in the respective data field.For the present study, the master copies werephotocopied, as printing relatively smallbatches would have been more expensive.

From scanning to databaseThe completed forms are collected and may bescanned any time. For our department, whichsees between 150 and 200 patients per day,scanning a daily workload takes approximately20 minutes. At the end of scanning, the opera-tor brings up those stored images onto screento correct errors and transfer handwritteninformation into typed text (fig 5). This takesapproximately 30 minutes per 100 sheets ofdata, even when the degree of accuracy whichthe forms have been filled in is only moderatelyhigh, as is usual for busy doctors.The resulting data files are then sent to

Microsoft Access where they go through aseries of checks to ensure data accuracy.Duplicates are eliminated, missing consecutivenumbers are flagged, and non-consecutivenumbers are checked to ensure that they arereattenders or clinic patients. Any patientdetails that fail on these tests are sent to anerrors section to be checked manually.

From database to accountingBy now, all patient related information re-quired for costing attendance episodes isstored in Access (fig 6); the remainder of theinformation required is held in the form of ref-erence tables within an Excel spreadsheet.The bulk of the data are those derived from

the workload management study we referred topreviously. In brief, this entailed setting stand-ards on management of a given "presentingcomplaint". The standards took the form of alist of "activities" (take history, examine, takeblood, etc) which were further broken downinto their individual components. Each activitywas timed and the sum of times tabled formedical, nursing, and clerical staff respectively

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Figure 5 On screen editing of errors and transfer of handwritten information intorespective data fields.

Figure 6 Computer screen showing appearance ofAccess database record with details ofcosting of individual patient episodes.

(for further details see previous article). Thesetables were entered into Excel and linked totables that hold further information on the costofwages, x rays, laboratory investigation, sterilesupplies, drugs, overheads, and fixed capitalcosts. Updating one item on any one of thetables automatically updates all related infor-mation. Access uses those tables for referenceto automatically calculate the cost of treatmentof an individual attendance.At the end of the process, the data are

merged with patient identification data down-loaded from PAS and then optionally stored onmagnetic tape for safekeeping. Each recordwithin the database now contains all adminis-trative (name, postcode, address, GP, etc),clinical (diagnosis, treatments, outcomes),non-clinical (date and time of attendance,triage category, number and specialty ofdoctors involved, etc) and all cost information(basic, x ray, investigations, etc) for a patientepisode.

All regularly required information is ex-

tracted by running prewritten macros (compu-ter jargon for smaller, user written programs

running within a larger program); non-standard queries may be designed on screenand then run. Access has extensive facilities forinterrogating the database: any data field maybe related to any other and the possibilities ofextracting information is only limited by thetype of data chosen to be kept.

DiscussionThere is little doubt that a system like the onedescribed above is useful: an extensive data-base containing accurate administrative, clini-cal, and financial information is an invaluabletool for clinicians and business managers alike.Its remarkable flexibility makes it suitable forthe ever changing environment of the newNHS and its ease of use and its speed makes itattractive for use by less computer literate staffwho may require information for research,audit, or costing exercises. Although most A&Edepartments will still be block contracted,those who can provide their purchasers withaccurate coatings of individual treatment epi-sodes will have the edge when negotiatingfunding. But the system does cost around£16 000 (plus cost of carrying out theworkload management studies and recurrentcosts for maintenance) and the question is: Is itworth the investment in time and money?We described the hardware and software we

used, all of which were chosen because theywere "right" rather than "cheap". The hard-ware specifications are way above minimumrequirement to run the programs. This makesprovision for expansion without having toupgrade; we assumed that purchasers will con-tinue to demand increasing amounts of data asproof of quality of service. A tape streamer isthe lazy computerist's way of creating backupcopies, but its cost is negligible compared tothe cost of losing an irreplaceable database.Admittedly, the 17' VGA screen is a luxury, butit does make designing new queries to interro-gate the database quicker, easier, and morefun. One of the aims of the project was to cre-ate a system that is attractive to those who stillview computers with suspicion. We hope that itwill provide the incentive for them to realisetheir ideas for audit and research.The most expensive items are the scanner

and the optical mark reader software, whichtogether account for 75% of the total cost.Again, despite the high investment, it was thebetter choice.The advantages of a scanner over hand

entering information are obvious: human erroris minimised and it is quicker. The workloadmanagement study carried out in our depart-ment showed that it takes 27 hours a week ofclerical staff time to enter the clinical infor-mation into our existing system' and withsingle operator entry we fall way short of thedesirable 99% mark of data accuracy (thiswould require double entry of all data by a sec-ond clerk with flagging of non-concordantentries). We estimate that once the system isimplemented, this will fall to less than 10 hoursper week while simultaneously storing moredetailed information at the required accuracy.

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With that, the system fulfils two of the mostnotable criteria for an automated data entrysystem: above 99% data accuracy and cost sav-ings after 6-12 months of use.2The second major cost item is the invest-

ment in staff time over and above the timespent on data entry: the time required to createand maintain the database. However, enablingdepartments to design their own data collec-tion forms on-site has distinct advantages.During the design stage, a small team ofin-house staff working close to the shop floorwill be able to progress using the smallsteps/frequent corrections approach: regularfeedback on intermediate results allows themto arrive relatively quickly at a final design thataccurately reflects patient flow and case mixspecific to the particular unit. This in turnmakes it easy for staff to fill in the completeddesigns: despite the apparent complexity of ourthree data collection forms, the acceptanceamong medical staff was high and conse-quently the forms were filled with a surprisingdegree of accuracy and care. Although staff arerequired to give more information than for ourexisting PAS module, it does not take longer togather it.

Furthermore, requirements vary not onlybetween departments, but over time they arelikely to vary within the same department. Thesystem allows end users to alter the databasethemselves using resident expertise; this makesthem independent from software companies,thus saving time and money. Theoretically it isnow possible to decide upon examining the

relation between blue eyes, postcode, and Lankle injury and start collecting the new data"eye colour blue" a few hours later as part ofthe routine data collection. Although the prac-tical value of such a project is doubtful, thesame could be said for the previously unthink-able, but now nationwide, effort to stopwatchthe minutes from arrival to triage.The idea of the project was derived from the

need to develop an accurate and flexible data-base for accounting, but much of the infor-mation required to prepare accounts is clinical,which is now also available for audit andresearch. Microsoft Access is a general purposedatabase and data manipulation requires littleeffort. Its scope is almost unlimited and itsremarkable speed encourages asking questions,if for no better reason than curiosity: none ofuswould have thought that we spend the equiva-lent of two F grade sister's posts per year to payfor staff to do nothing else but communicateinformation about patients from one toanother-that is not counting the time theyspend talking to patients. The reasons are asyet unclear, but we're working on it.

We wish to thank the long suffering staff in Medical Audit fortheir patience when we insisted that ninety nine point nine per-cent perfect was just not perfect enough.

1 Taylor CJ, Bull F, Burdis C, Ferguson DG. Workload man-agement in A&E: counting the uncountable and predictingthe unpredictable. J Accid Emerg Med 1997;14:88-91.

2 Emberton M, Rockall T, Meredith P. Scanning for audit. BrJ Hosp Comput Inform Manage 1993;1O:32-4.

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