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Case Studies

Measuring the effectiveness of eMerge Health Solutions is a critical indicator for success. Ongoing documentation helps our team to thoroughly understand the impact of eMerge solutions on the health practices we aim to improve. It also helps to power continued research and development to fuel feature and solution additions and modifications.

Effect of Real-Time Visual Feedback on Adenoma Detection Rate

Measuring the effectiveness of eMerge Health Solutions is a critical indicator for success. Ongoing documentation helps our team to thoroughly understand the impact of eMerge solutions on the health practices we aim to improve. It also helps to power continued research and development to fuel feature and solution additions and modifications.

eMerge is an endoscopic workflow system that allows users to intraoperatively document procedures thus providing quality indicators data in real-time. In this study, endoscopists at the center began using eMerge real-time computer automation to collect, analyze and present data for quality indicators. During colonoscopy, withdrawal time was displayed live in prominent, large bold numbers on the nurses charting record immediately adjacent to the video monitor – giving the edoscopists visual feedback as can be seen in the following chart .



Having previously documented the success of eMerge in decreasing the number of colonoscopies with withdrawal time less than 6 minutes by providing real-time visual feedback, we worked to now evaluate if adenoma detection rate improves with improved withdrawal times. The results were encouraging.

Preliminary data collected over a 5-month period showed that adenoma detection rates improved from 26.6% to 31.8% in men and from 19.8% to 28.7% in women after real-time visual feedback for colonoscopy withdrawal times was provided to the participating group of endoscopists. We continued to collect data over a 9-month period and as a result showed that adenoma detection rates improved from 30.42% to 31.89% in men and from 20.32% to 24.22% in women.

Improvement in adenoma detection rate after providing real – time visual feedback

Time period July 2007 to March 2008 July 2008 to March 2009 p-value
Adenoma detection rate-men 30.42% 31.89% 0.68
Adenoma detection rate-women 20.32% 24.22% 0.26
Total number of male patients 460 322
Total number of female patients 423 351

Our analysis showed that by giving endoscopists access to real-time and visual quality data, there was a trend towards improvement in adenoma detection rate in screening colonoscopies. Having automated tools to present quality indicators results in improved clinical outcomes, thus providing value as pay-for-performance reimbursement is introduced.



Feasibility of measuring quality indicators in real-time for gastrointestinal endoscopic procedures using visual tools and computer automation

Quality indicators are objective measures which are being used to establish competence in performing gastrointestinal endoscopic procedures and to help identify areas for continuous quality improvement in order to provide patients with the best possible care. A task force consisting of expert endoscopists selected by the board
of directors of the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology was formed. This task force created a list of potential quality indicators for the four major endoscopic procedures.
Quality indicators were described for three stages of endoscopy: Pre-procedure, Intra-procedure and Post-procedure. In this particular case we studied the intra-procedure quality indicator for colonoscopy: withdrawal time. Mean withdrawal time should be ≥6 minutes in colonoscopies with normal results performed in patients with an intact anatomy.

In order to implement quality indicators, endoscopists need access to continuous quality data. Using eMerge, it is possible to collect, analyze and present data in an automated fashion with the use of technology. In this study, we’ll show how eMerge is putting its web-based, intra-operative documentation and workflow system to use in endoscopy centers to measure quality indicators in real-time. The eMerge automated workflow system captures data at every step during endoscopic procedures. Some of the intra-procedure quality indicators for colonoscopy implemented by eMerge include procedure time, cecal intubation time and cecal withdrawal time. During the procedure the physician or nurse can interact with the system via patented voice command navigation to document data that is used for quality measures (highlighted area 1 in figure 1). Procedure start time (highlighted area 2 in figure 1), cecum reached time (highlighted area 3 & 4 in figure 1) and procedure end time (highlighted area 6 in figure 1) are documented interactively via voice commands. This data is used to calculate cecal intubation time, cecal withdrawal time and procedure time. In addition, the withdrawal time is displayed live in bold numbers giving endoscopists visual feedback during the procedure (highlighted area 5 in figure 1).


Figure 1

Endoscopists can review this data for any time period, as can be seen in the following system graphics.


Figure 2



Figure 3

Performed at the Ohio Gi and Liver Institute, data was analyzed and collected by eMerge at one center, for cecal withdrawal time, for 15 endoscopists over a 9 month period prior to availability of quality data summary; and for 4months after data was available. 2060 screening colonoscopies with normal results were studied for the period 1/30/08 to 10/31/08. Endoscopists started reviewing their summary data 11/3/08 onwards. 1362 screening colonoscopies with normal results were studied for the period 11/3/08 to 2/27/09.

By giving physicians access to real-time and visual quality indicators data, the percentage of colonoscopies with cecal withdrawal time <6 minutes decreased. Using automated systems like eMerge make measuring, analyzing and presenting quality indicators data feasible in real-time. In endoscopy centers where automated systems are not implemented, collection of this data involves extensive manual effort and time. In addition the data cannot be
real-time. As pay-for-performance reimbursement is introduced, having automated tools like eMerge to measure quality indicators provides financial incentive. eMerge is a web-based, intra-operative endoscopic documentationand workflow system which uses a common data repository for multiple practices. This makes eMerge a tool that can be used for continuous quality improvement within and across practices. Future possibilities in capturing, analyzing and presenting quality indicators data with the use of computerized systems is limitless.



Sustained Improvement in Cecal Withdrawal Time as a Result of Real-Time Visual Feedback

Quality indicators are objective measures which are being used to establish competence in performing gastrointestinal endoscopic procedures and to help identify areas for continuous quality improvement in order to provide patients with the best possible care. A task force consisting of expert endoscopists selected by the board of directors of the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology was formed. This task force created a list of potential quality indicators for the four major endoscopic procedures. Quality indicators were described for three stages of endoscopy: Pre-procedure, Intra-procedure and Post-procedure. In this particular case we studied the intra-procedure quality indicator for colonoscopy: withdrawal time. Mean withdrawal time should be ≤6 minutes in colonoscopies with normal results performed in patients with an intact anatomy.

In order to implement quality indicators, endoscopists need access to continuous quality data. Using eMerge, it is possible to collect, analyze and present data in an automated fashion with the use of technology. In this study, we’ll show how eMerge is putting its web-based, intra-operative documentation and workflow system to use in endoscopy centers to measure quality indicators in real-time. The eMerge automated workflow system captures data at every step during endoscopic procedures. Some of the intra-procedure quality indicators for colonoscopy implemented by eMerge include procedure time, cecal intubation time and cecal withdrawal time. During the procedure the physician or nurse can interact with the system via patented voice command navigation to document data that is used for quality measures (highlighted area 1 in figure 1). Procedure start time (highlighted area 2 in figure 1), cecum reached time (highlighted area 3 & 4 in figure 1) and procedure end time (highlighted area 6 in figure 1) are documented interactively via voice commands. This data is used to calculate cecal intubation time, cecal withdrawal time and procedure time. In addition, the withdrawal time is displayed live in bold numbers giving endoscopists visual feedback during the procedure (highlighted area 5 in figure 1).


Figure 1

Performed at the Ohio Gi and Liver Institute, data was analyzed and collected by eMerge at two centers, for cecal withdrawal time for normal screening colonoscopies. At that time we had data for 9 months after real-time visual feedback became available. We analyzed additional data to evaluate if this trend of improved cecal withdrawal time is sustained. We now have data for 19 more months. A total of 5,469 screening colonoscopies with normal results were

studied for the period 1/30/08 to 9/10/10.

As a result of this analysis, it was found that 16.43% of colonoscopies performed between January 2008 and June 2008 had cecal withdrawal time < 6 minutes. 7.38% of colonoscopies performed between July 2008 and February 2009 had withdrawal time less than 6 minutes. (This data was presented in the previous poster). 5.78% of screening colonoscopies performed from March 2009 to May 2010 had cecal withdrawal time < 6 minutes. There is a sustained decrease in the percentage of colonoscopies with cecal withdrawal time <6 minutes after endoscopists had access to real-time visual feedback for withdrawal time.

Period % of colonoscopies with cecal Withdrawal time < 6 minutes Mean cecal withdrawal time
1/30/08 to 6/30/08 16.43 8:22 minutes
7/1/08 to 2/27/09 7.38 8:53 minutes
1/30/08 to 6/30/08 5.78 9:18 minutes

Improvement in cecal withdrawal time after continuous access to quality data

Graph 1(presented in DDW 2009): Continuous decrease in % of colonoscopies with withdrawal time < 6minutes after display of withdrawal time during procedure and after access to quality data in real-time.

Graph 2: Sustained decrease in colonoscopies with withdrawal time < 6minutes after display of withdrawal time during procedure

By giving physicians access to real-time and visual quality indicators data, there is a persistent trend towards improvement in cecal withdrawal time in screening colonoscopies. Using automated systems like eMerge make measuring, analyzing and presenting quality indicators data feasible in real-time. In endoscopy centers where automated systems are not implemented, collection of this data involves extensive manual effort and time. In addition the data cannot be real-time. As pay-for-performance reimbursement is introduced, having automated tools like eMerge to measure quality indicators provides financial incentive. eMerge is a web-based, intra-operative endoscopic documentation and workflow system which uses a common data repository for multiple practices. This makes eMerge a tool that can be used for continuous quality improvement within and across practices. Future possibilities in capturing, analyzing and presenting quality indicators data with the use of computerized systems is limitless.