Dual vs. single computer monitor in a Canadian hospital archiving department: a study of efficiency and satisfaction.
Abstract: This paper describes a comparative study of clinical coding by Archivists (also known as Clinical Coders in some other countries) using single and dual computer monitors. In the present context, processing a record corresponds to checking the available information; searching for the missing physician information; and finally, performing clinical coding. We collected data for each Archivist during her use of the single monitor for 40 hours and during her use of the dual monitor for 20 hours. During the experimental periods, Archivists did not perform other related duties, so we were able to measure the real-time processing of records. To control for the type of records and their impact on the process time required, we categorised the cases as major or minor, based on whether acute care or day surgery was involved. Overall results show that 1,234 records were processed using a single monitor and 647 records using a dual monitor. The time required to process a record was significantly higher (p=.071) with a single monitor compared to a dual monitor (19.83 vs.18.73 minutes). However, the percentage of major cases was significantly higher (p=.000) in the single monitor group compared to the dual monitor group (78% vs. 69%). As a consequence, we adjusted our results, which reduced the difference in time required to process a record between the two systems from 1.1 to 0.61 minutes. Thus, the net real-time difference was only 37 seconds in favour of the dual monitor system. Extrapolated over a 5-year period, this would represent a time savings of 3.1% and generate a net cost savings of $7,729 CAD (Canadian dollars) for each workstation that devoted 35 hours per week to the processing of records. Finally, satisfaction questionnaire responses indicated a high level of satisfaction and support for the dual-monitor system. The implementation of a dual-monitor system in a hospital archiving department is an efficient option in the context of scarce human resources and has the strong support of Archivists.

Keywords (MeSH): Clinical Coding; Efficiency, Organisational; Financial Management, Hospital; Health services research; Cost Savings; International Classification of Diseases; Hospital Information Systems; Informatics; Medical Record Systems, Computerized

Supplementary keyword: Health Information Management
Subject: Video monitors (Usage)
Health care industry (Management)
Medical records (Usage)
Physicians (Practice)
Physicians (Services)
Authors: Poder, Thomas G.
Godbout, Sylvie T.
Bellemare, Christian
Pub Date: 10/01/2011
Publication: Name: Health Information Management Journal Publisher: Health Information Management Association of Australia Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Health Information Management Association of Australia Ltd. ISSN: 1833-3583
Issue: Date: Oct, 2011 Source Volume: 40 Source Issue: 3
Topic: Event Code: 200 Management dynamics; 360 Services information Computer Subject: Monochrome monitor; Health care industry; Company business management
Product: Product Code: 3573255 Computer Display Monitors; 8011000 Physicians & Surgeons NAICS Code: 334119 Other Computer Peripheral Equipment Manufacturing; 621111 Offices of Physicians (except Mental Health Specialists) SIC Code: 3575 Computer terminals
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 271051802
Full Text: Introduction

The productivity of the Archiving Department of the Centre Hospitalier Universitaire de Sherbrooke (CHUS) has been affected by many factors. These include the shortage of staff (a similar experience has been reported by McKenzie et al. [2004]), changing archiving practices (e.g. changes in the sequence of information to check for coding, and the adding and removing of elements to code), and the passage of the codification of the International Classification of Diseases (ICD) 9th edition to ICD-10 (Healthcare Financial Management Association [HFMA] 2009; Owen & McCubbin 2011). These various changes have caused a 22% decline in productivity (defined by the total number of records coded divided by the total number of hours worked) between 2007 and 2008, resulting in a cumulative delay of seven months in the processing of records.

To perform the analysis and codification of records, Archivists must simultaneously consult multiple digital documents, including the electronic patient record ARIANE (the local database of patients' records in our CHUS), the database MED-ECHO (a centralised database at Quebec's Ministry of Health designed to ensure the maintenance and operation of data for the study of hospital clients), data from Microsoft Excel spreadsheets, the Canadian Classification of Interventions (CCI), and the new electronic classification ICD-10, which was previously issued as a hard copy book. In addition, some paper documents must be consulted. Therefore, Archivists must switch between several windows of different software as well as paper documentation to obtain all the information required to process records.

One solution that has been proposed to reduce the backlog is to use dual computer monitors to maximise the simultaneous display of documents. Although no studies were found in the area of the hospital Archiving Department, we found relevant studies in other fields; for example, academic libraries (Russell & Wong 2005), software development (Czerwinski et al. 2003; Hutchings et al. 2004) among others (NEC 2003; Berger 2006), which revealed positive results with an increased productivity.

The primary focus of this study was on efficiency in terms of production time, potential monetary gains from the purchase of dual-monitor stations, and satisfaction of Archivists. It was hypothesised that:

1. considering that Archivists must check data from multiple applications to process a record, the use of dual monitors can reduce the loss of time associated with switching between windows

2. doubling the surface display of information could, all other things held equal, increase the number of records processed by the Archiving Department. With regard to these hypotheses, the objective of the assessment was to study the potential benefits related to the introduction of computer stations equipped with dual monitors. Specifically, we looked at the elements of efficiency, cost savings, and Archivists' satisfaction.

To evaluate efficiency, we compared the time required to process records according to the type of computer used: computer with a single monitor or computer with a dual monitor. Two types of cases were considered by the Archivists in this study: cases of acute care (major cases) and cases of day surgery (minor cases). Definitions for these cases are provided by the Canadian Institute for Health Information (2006). Acute care consists of medical, surgical or obstetric services for in-patient treatment and/or care. Day surgery corresponds to interventions or procedures to patients who are admitted and discharged from hospital usually on the same calendar day.

We evaluated the cost savings as a result of using a dual monitor instead of a single monitor for processing records.

Finally, we evaluated the satisfaction of Archivists working with a dual monitor as compared with a single monitor.

Preliminary steps

Ergonomics at work

The first step prior to assessing the effectiveness of using a dual monitor was to verify the ergonomics of the workplace. We consulted with an Occupational Therapist (OT) to verify the ergonomics in the workplace before and after the introduction of the dual-monitor stations. To avoid disturbing the ergonomics of the work environment, the OT suggested that each Archivist should 'have two identical monitors with a profiled contour as thin as possible. Both monitors should be placed on a unique stand to be adjustable in height and angle. The keyboard and mouse should be centered at the junction of the two monitors.' Therefore, we followed these recommendations in the setup used in our assessment. We also considered installing a larger size monitor. However, we did not choose this option because of the price in 2008 and because the OT indicated that an angle in the field of view should be created between the two monitors to ensure an ergonomic position and to avoid musculo-skeletal problems.

Standardization of computer equipments

We listed the technical characteristics of the computer equipment used by the Archivists that were likely to influence the performance of data processing. In fact, we collected the capacity of memory in megabytes, the power of video cards, the speed of central processing in megahertz, disk space available, spatial resolution of the display and the version of the operating system. Subsequently, using the results provided by the software EVEREST Ultimate Edition, which is a comprehensive tool for diagnosis and evaluation of computer hardware, we upgraded and standardised the overall performance of the computer stations by changing their components before the start of the study.

Method

Efficiency

Of all Archivists in the Department, 10 out of 20 participated in this study on a voluntary and anonymous basis. Five Archivists participated in the study in June 2008, and five more participated in September 2008. All Archivists were women, with an average age of 32 years, and their average experience on the job was 119 months (9 years and 11 months).

For the study, all participants processed records on a single-monitor station and a dual-monitor station. According to statistics collected periodically by the Archiving Department, we estimated that an Archivist could process about 2.5 records per hour. For each type of monitor, we calculated that a minimum of 20 hours would be required to obtain data on a minimum of 50 records processed by each Archivist.

Each Archivist in the study processed records over a period of 40 hours using a workstation with a single monitor and over a period of 20 hours using a workstation with a dual monitor. The discrepancy in time spent on each monitor was due to the fact that only one dual monitor computer station was available for the entire assessment. The assessment periods consisted of four consecutive hours per day in each case. During these four hours, Archivists did not perform other related duties, so we were able to measure the real-time processing of records. In addition, we should mention that records were not coded twice; different records were coded before and after the change.

To achieve an acceptable level of proficiency using the dual monitor, each participant trained for a week on a workstation with a dual monitor for four hours per day for a total of 20 hours. For the assessment, we did not include data from this first week of adaptation.

A grid survey was distributed to the Archivists to record the real-time processing for each medical record and the area of medical specialty as well as the type of record considered (major vs. minor). The processing time for each record was measured by the computer clock.

The sample was selected respecting the usual order. This means that all records to be coded were listed in an order where prosthesis and trauma cases were given priority, and then the other cases were listed chronologically by date of patient's departure. This order was not modified for the study.

Cost savings

We investigated whether there was interest from CHUS to finance the enhancement of the Archiving Department's computers by adding the components needed to install dual monitors. Therefore, we evaluated the costs of changing a conventional workstation with a single monitor to a workstation with a dual monitor. This change required the purchase of two identical monitors (recommended by the OT), a graphics card with the capacity to manage two monitors, and an adjustable monitor stand so as to orient the two monitors as recommended by the OT.

[ILLUSTRATION OMITTED]

We calculated the cost savings in terms of time savings afforded by using a dual monitor instead of using a single monitor. In this study, the annual salary for an Archivist was $58,360 CAD (with fringe benefits, social benefits, and payroll taxes).

Archivists' satisfaction

We evaluated the satisfaction of the Archivists on using a workstation with a dual monitor. To do this, we distributed three questionnaires that focused on ergonomics, efficiency, and general satisfaction. These questionnaires were completed by the Archivists at the end of the study.

Results

A total of 1,881 records in 56 medical specialties were processed. In this study, paediatrics, orthopaedics, plastic surgery, general medicine, external medicine, cardiology, obstetrics and general surgery accounted for 50% of the specialties in the records. Of the 1,881 records, 1,234 records were processed with a single monitor and 647 records were processed with a dual monitor. The chart below shows the breakdown of records processed and the time required for processing based on the type of monitor used as well as the type of case (acute care or day surgery).

For using the single monitor system, we found that for cases of acute care, which are cases that are longer to process because of their complexity, compared to cases of day surgery, which are easier cases to process, there was a difference in processing time of 8.19 minutes per record. For using the dual monitor, this difference was 5.58 minutes per record.

Efficiency

The average time spent on processing a record using a single monitor was 19.83 minutes, while the average time with a dual monitor was 18.73 minutes. The difference was 1.1 minutes (1 minute and 6 seconds). Therefore, Archivists would be more efficient with a dual monitor.

A simple student t-test to compare the difference in means indicated that the difference of 1.1 minutes is statistically significant (p=.0713).

However, a more detailed analysis shows that the statistical significance of the difference in processing time between the two types of monitor use is mainly due to the difference in the distribution of major and minor cases assigned for processing. A total of 78.1% of the records processed using a single monitor were major cases (which corresponds closely to the usual case-mix of major and minor cases in our hospital), compared to 69.2% using the dual-monitor group; this difference of 8.9 points was statistically significant (Table 2). The average time spent processing a major case record was significantly longer than that spent processing a minor case record (Tables 3 and 4); therefore, considering the difference of 8.9 points in the percentage of major cases in the two groups, the average time spent processing a record using the single monitor was mechanically longer than that spent using the dual monitor, regardless of how the monitors are used.

This simple observation was confirmed by an ordinary least squares (OLS) regression (a method for estimating the unknown parameters in a linear regression model), indicating a non-significant effect of the type of monitor (single monitor=1; dual monitor=0) on record processing time when a binary indicating the type of record processed was introduced (acute care=1; day surgery=0).

Thus, to determine whether there was interest for the CHUS to adopt the dual-monitor system, we needed to calculate the real difference in record processing time according to the type of monitor and adjust for the percentage of major cases in each type of monitor usage. This calculation was performed as follows: we artificially increased the number of observations in the dual-monitor group so that the percentage of major cases in this group was the same as in the single monitor group (78.1% instead of 69.2%). As a result of artificially increasing the size of the dual-monitor group with 261.7 records of acute care, the average time to process a record in this group became 19.22 minutes. Therefore, with 78.1% of major case records in both groups, we found a difference of 0.61 minutes (19.83 - 19.22) in favor of the dual-monitor group, which represented a difference of 37 seconds for each record processed. This difference of 37 seconds corresponds with a time savings of about 3.1% that can be applied using the dual-monitor system compared with using the single monitor system currently in the Archiving Department of the CHUS.

Cost savings

For the year 2008-2009, 16,451.24 hours were spent analysing and coding 44,713 records; we calculated that each record was processed, on average, in 22.08 minutes and that each Archivist spent, on average, 822.56 hours per year analysing and coding 2,235.65 records. Considering that each Archivist works a total of 1,594 hours each year (after deducting holidays), it is possible to deduce that each Archivist spends 51.6% of her time analysing and coding records.

Therefore, it is possible to calculate the cost savings for a salary with fringe benefits (fixed amount of $2.51 CAD), social benefits (13%) and payroll taxes (11.5%). These cost savings would be $934 CAD (0.031*0.516*58360) per year, per workstation. However, if workstations with dual monitors were dedicated to be used only for the analysis and coding of medical records (i.e. 35 hours per week rather than 18.06 hours per week (35*0.516)), then the cost savings for each workstation using a dual monitor would be $1,810 CAD.

Extrapolated over a period of 5 years, with the cost of installing a dual monitor being about $1,150 CAD for each workstation, the extra annual cost for a dual monitor would be $230 CAD over the cost of a single-monitor system. Therefore, a net gain of $704 CAD per year and per workstation over a period of 5 years by the installation of dual monitors is theoretically feasible. Without discounting the calculation, the annual net gain for 20 workstations would be $14,080 CAD or $70,400 CAD over 5 years. However, considering an annual 4% increase in Archivists' salaries, a discount rate of 5%, and the cash cost of installing dual monitors in the first year, the discounted net gain over 5 years would be reduced to $68,637 CAD ($154,585 CAD if workstations with dual monitors were dedicated to be used only for the analysis and coding of medical records).

Archivists' satisfaction

The results of our satisfaction survey indicate that the vast majority of Archivists (4 out of 5) found the dual-monitor system to be easy to use, more effective for the processing of records, and allowed for easier coding and transcription. In addition, the learning time (between 1 and 5 days) required to work with the dual monitor was considered sufficient.

In terms of ergonomics, we noted that the installation of the dual monitor on the desktop met the requirements for the codification work. The distance and height of the monitors, the size of the characters on the screen, the ease of navigating from one screen to another, the ease of navigating from one software application to another, the workspace, and the reflection of the display were all judged to be more than 85% adequate.

Conclusion

From this assessment, it is possible to detect a 3.1% difference in record processing time between using the dual-monitor system and the single-monitor system, which is much less than in other areas of work (NEC 2003; Berger 2006). Similarly, we find that the Archivists had greater satisfaction and greater ease for the analysis and coding work using the dual-monitor system.

Indeed, Archivists switched less often between applications and were more efficient, especially in regard to cases of acute care, for which the records are complex and time-consuming. Therefore, although the difference in record processing time between the two systems was minimal, the Archivists considered the dual-monitor system to be easy and user-friendly.

Given the productivity gain of 3.1% and the current use of workstations to perform the analysis and codification of records (a task requiring 51.6% of an Archivist's work time), the potential cost savings per workstation would be $704 CAD per year over 5 years. However, if the workstations using dual-monitor systems were used full time (35 hours per week) to process the analysis and coding of records, then the potential discounted cost savings per workstation would be $1,545.8 CAD per year over 5 years. Given the number of records to process, this would generate even more savings due to an overall smaller number of workstations that need to be equipped with the dual-monitor system.

Note: Throughout this paper the Canadian term 'Archivist' is used. In other countries, including Australia, the correct term is 'Clinical Coder'.

Acknowledgements

We acknowledge the Archiving Department of the Sherbrooke University Hospital Centre (CHUS), the participants of this study, and Renald Lemieux, Assistant Director in the DQPEP of the CHUS.

References

Berger, I. (2006). 'The virtues of a second screen'. New York Times, 20 April. Available at: http://www.nytimes.com/2006/04/20/ technology/20basics.html?ei=5090&en=6fc17b9bf54ea2ef&ex =1303185600&adxnnl=1&partner=rssuserland&emc=rss&adx nnlx=1145537733-/Kdyvqpu0/eVBVNBYUcsqg

Canadian Institute for Health Information (2006). CIHI portal analyst training pre-reading. Ottawa, Canadian Institute for Health Information. Available at: http://www.cihi.ca/CIHI-extportal/internet/EN/Home/home/cihi000001

Czerwinski, M., Smith, G., Regan, T., Meyers, B., Robertson, G. and Starkweather, G. (2003). Toward characterizing the productivity benefits of very large displays. Proceedings of Interact 2003. IOS Press. Available at: http://www.idemployee.id.tue.nl/g.w.m.rauterberg/conferences/INTERACT2003/ proceedings.html

Healthcare Financial Management Association [HFMA] (2009). Implementing ICD-10: A Canadian perspective from the front line. Revenue Cycle Strategist (HFMA publication), February 2009. Available at: http://www.hfma.org/Publications/Newsletters/Revenue-Cycle-Strategist/ Archives/2009/February/RevenueCycle-Strategist--February-2009-Issue/

Hutchings, D., Smith, G., Meyers, B., Czerwinski, M. and Robertson, G. (2004). Display space usage and window management operation comparisons between single monitor and multiple monitor users. Proceedings of the working conference on Advanced Visual Interfaces, Gallipoli, Italy, pp. 32-39.ACM Press, New York.

McKenzie, K., Walker, S., Dixon-Lee, C., Dear, G. and Moran-Fuke, J. (2004). Clinical coding internationally: a comparison of the coding workforce in Australia, America, Canada and England. Proceedings of the 14th International Federation of Health Records Congress, Washington, D.C. Available at: http://eprints.qut.edu.au/575/

NEC (2003). Productivity and multi-screen displays. NEC Display Solutions. University of Utah and ATI Technologies.

Owen, G. and McClubbin, T. (2011). ICD-10 ready: planning for clinical, financial and operational improvement. ANI Healthcare Finance Conference, June 2011, Orlando, Florida. Healthcare Financial Management Association [HFMA]. Available from: itsonlytechnology.com/hfma2011/Joe/ER1.pdf (accessed 21 July 2011).

Russell, S.E. and Wong, K. (2005). Dual-screen monitors: a qualitative analysis of their use in an academic library. The Journal of Academic Librarianship 31(6): 574-577.

Corresponding author:

Thomas G Poder PhD

Executive Advisor

Health Technology Assessment Unit

Sherbrooke University Hospital Centre UETMIS-CHUS

3001, 12e Av. Nord

Sherbrooke QC J1H 5N4

Visiting Professor

GREDI--Un'wers'ite de Sherbrooke

2500, Bd. de l'Universite, Sherbrooke QC J1K 2RI

CANADA

Email: tpoder.chus@ssss.gouv.qc.ca

Sylvie T Godbout BSc

Health Technology Assessment and Informatics Advisor

UETMIS--CHUS, 3001, 12e Av. Nord

Sherbrooke Qc J1H 5N4

CANADA

Christian Bellemare MSc

Executive Coordinator UETMIS--CHUS

3001, 12e Av. Nord, Sherbrooke QC J1H 5N4

CANADA
Table 1: Student t-test for the difference in record
processing time (in minutes) between single and dual
monitors

GROUP        NO. OBS.     M      SD       [CI 95%]        p

Single-M       1234     19.83   16.48   18.91   20.75
Dual-M          647     18.73   13.32   17.70   19.76
Overall        1881     19.45   15.47   18.75   20.15
Difference              -1.10           -2.57     .37   .0713

Note: Single-M = single monitor, Dual-M = dual monitor

Table 2: Pearson's chi-square test for the difference
in major case record proportions between single and
dual monitors

GROUP        NO. OBS.     M      SD       [CI 95%]       p

Single-M       1234      .781    .41    0.76    0.80
Dual-M          647      .692    .46    0.66    0.73
Overall        1881      .751    .43    0.73    0.77
Difference              -.089          -0.13   -0.05   .0000

Note: Single-M = single monitor, Dual-M = dual monitor

Table 3: Student t-test for the difference in record
processing time using a single monitor (in minutes)
between major and minor cases

   GROUP      NO. OBS.     M        SD     [CI 95%]            p

Acute care      964      21.62    17.51    20.52    22.73
Day surgery     270      13.43     9.69    12.27    14.59
Overall         1234     19.83    16.48    18.91    20.75
Difference               -8.20             -10.38   -6.02    .0000

Table 4: Student t-test for the difference in record
processing time using a dual monitor (in minutes)
between major and minor cases

GROUP         NO. OBS.     M        SD        [CI 95%]          p

Acute care      448      20.44    14.03    19.14    21.75
Day surgery     199      14.86    10.63    13.38    16.35
Overall         647      18.73    13.32    17.70    19.76
Difference               -5.58             -7.77    -3.39    .0000

Table 5: Ordinary Least Square (OLS) regression on
record processing time

VARIABLE         COEFFICIENT    p         [CI 95%]

Single monitor       .465      .529    -.985    1.915
Acute care          7.163      .000    5.570    8.755
Constant           13.768      .000   12.162   15.375
No. Obs.         1881
R2                   .04

Table 6: Costs of components required to change each
workstation (prices estimated as of 1 January 2009)

COMPONENT                    UNIT COST    TOTAL
                                 $          $

Monitor                       350.00      700.00
Dual-monitor graphics card    150.00      150.00
Monitor stand                 300.00      300.00
TOTAL                                    1150.00
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