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EDIS: Why You Need It How to Succeed

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Emergency Department Information Systems
How Do I Make my EDIS Work?
Presented By Todd B. Taylor, MD, FACEP
PRESENTATION ABSTRACT
Emergency Department Information Systems (EDIS) have been around for more than 20 years.
However, it has been only in the last few years that they have begun to achieve critical mass and real
usability. This presentation will review where EDIS has been, the current state-of-the-art and what we
have to look forward to in the near future. A detailed look at EDIS components and the selection
process will be presented.
For a PDF of this handout or more information about this topic contact: ttaylor@acep.org
LEARNING OBJECTIVES
1.
2.
3.
4.
Identify reasons for past failures in implementing ED patient information systems.
Describe a process by which a successful EDIS strategy can be implemented.
Be able to review strengths and weaknesses of current ED information systems.
Learn how to implement information system strategies and develop an action plan.
ABOUT THE SPEAKER
Todd B. Taylor, MD, FACEP is a computer aficionado and self taught computerist who really only
practiced emergency medicine to support his computer habit. After retiring from clinical practice in 2006,
he joined Microsoft Corporation’s Health Solutions Group as a Physician Executive.
He was a founding member and served as Chair & Newsletter Editor for the American College of
Emergency Physicians’ Section for Emergency Medical Informatics. He authored the first visionary
document for the Section, “A View of the Emergency Department of the Future” and continues as the
principle promoter of the Emergency Department of the Future Project. In the past, he was Chief
Medical Officer for MediServe Information Systems. He frequently lectures on a variety of computer
related topics and serves on several national committees related to medical computing and informatics.
Dr. Taylor received his Doctor of Medicine from Indiana University School of Medicine and completed a
residency in Emergency Medicine at Mount Carmel Mercy Hospital in Detroit, Michigan. He is board
certified by the American Board of Emergency Medicine and serves as a Fellow of the American
College of Emergency Physicians.
He has 20 years experience teaching clinical emergency medicine at Banner Good Samaritan Medical
Center, a 700-bed level one trauma and tertiary referral center and has held a variety of academic and
professional positions. This includes having been Vice-President for Public Affairs for the Arizona
College of Emergency Physicians for 15 years.
These professional and volunteer activities have afforded him the opportunity to gain experience in ED
Crowding & Ambulance Diversion, EMTALA, Healthcare Legislative & Regulatory Advocacy, Healthcare
Policy, Managed Care Issues, Emergency Medicine Management, Coding, & Billing, and many other
issues facing emergency medicine & healthcare.
Page Intentionally Left Blank
Steps for Successful EDIS Selection & Implementation
Todd B. Taylor, MD, FACEP <ttaylor@acep.org>
What to avoid:
The “Holy Grail” Syndrome:
Waiting for the ultimate solution, is no solution
Seek short-term solutions to meet specific definable needs
Don’t purchase systems that tend to automate poor manual processes:
The less human input required the better
ex. Systems that automatically track patients
Systems that automatically capture data already available in hospital HIS or previous EDIS visit
Downtime
EDIS must accommodate external system downtime.
Scheduled EDIS downtime (ex. for upgrades) should be less than 5 minutes
Don’t accept enterprise HIS EDIS offering unless it substantially meets identified needs
While you may ultimately be forced to do so, due diligence in an EDIS search may allow
opportunity to change course if necessary
What to do:
Establish Objectives (different for every ED)
Asking the right questions will achieve the right solutions
e.g. Improve ED throughout to increase functional bed space to reduce LWOT
Improve availability & tracking of lab results
Certain objectives may be mutually exclusive
e.g. Eliminating transcription costs with physician computer charting will likely decrease ED throughput.
Decreased throughput = less revenue which may offset savings achieved by eliminating transcription
Certain challenges can be mitigated, e.g. use of scribes to increase computer charting efficiency
Decide what you need then decide what you want (in that order)
What you end up with should be somewhere in the middle
Obtain a guarantee of milestone implementation
e.g. Money back guarantee if EDIS not ultimately integrate with the hospital HIS or a
particular module not successfully fully implemented
Fix other “broken” aspects of ED environment before implementing an EDIS
EDIS is only a tool, not the solution to an already dysfunctional ED
Adding additional IT overhead to an ED will have both positive & negative impact
Spend as much time selecting hardware & planning deployment as selecting software
Budget as much money for hardware & deployment as the EDIS software purchase
Employ a modular step-wise implementation in a logical order
Minimize “password bloat”
Buy for today - Tomorrow will change
Consider transition systems as a 3-5-yr solution that will likely need to be replaced or upgraded
You are going to make mistakes - Be willing to fail & change course when necessary
Major Components & Subcomponents of an
Emergency Department Information System (EDIS)
Complied by Todd B. Taylor, MD, FACEP
HIS = EDIS is a module of the enterprise-wide hospital information system (+\- integration)
Best-of-Breed (BoB) = Niche EDIS vendor that must interface with the HIS & other systems
NOTE: Information about EDIS product features is most often obtained via a “Request for Information” (RFI). When
investigating an EDIS purchase, it is critical to determine the components you need (and will use) vs. “wanting it
all”. No current EDIS (HIS or BoB) “does it all” very well. BoB systems tend to have better functionality where as
HIS modules tend to have better integration (i.e. interfaces). Prioritizing components for your needs and selecting
an EDIS that best meets them will significantly increase your chances of a successful EDIS implementation.
For a model EDIS RFI, e-mail your request to: ttaylor@acep.org
The following components have been place in order of importance and recommended
implementation order. Certain subcomponents may be installed out of order, but typically
items later in the process are dependent upon properly functioning earlier components.
System Interfaces* (See “EDIS: HIS vs. BoB” – certain interfaces may be unnecessary with HIS vendor product)
Admit-Discharge-Transfer (ADT)-inbound (will need ADT-outbound if EDIS does primary registration)
Results-inbound (from lab, radiology, etc.)
Orders-outbound (may also need orders-inbound if no CPOE in the EDIS)
EMR-outbound (if EDIS will not be the system of record or primary data repository)
EMR-inbound (if EDIS will capture data, example allergies, from external systems)
*NOTE: Most system interfaces are accomplished via the “Health Level Seven Standard” (HL7), but that “standard” varies among HIS
products (even within the same vendor), so custom work is often necessary to achieve data interchange.
Security
Basic user name\password, system time out, Joint Commission\HIPAA compliance
Registration (ADT)
BoB: Usually have “mini-reg” capability so patients can be managed pending the ATD interface info arrival
Matching BoB entered info with ADT info may be manual or partially automated
HIS: Most (but not all) integrate ADT directly into the HIS system
May also have “mini-reg” capability to quickly initiate patient care
Tracking (manual vs automated via RFID)
Usually displayed via a computer tracking view that also serves as the primary system user interface
Patients, staff, assets (i.e. equipment, gurneys, wheelchairs, etc.) may be tracked
Department Metrics: Example – pre-arrival to time of arrival to triage to room to doctor to discharge
Triage Assessment
Although part of nursing documentation, triage assessment is often included as a separate component because
information collected at this point (ex: chief complaint, vital signs, medical & medication history, allergies, etc.)
is critical to downstream patient management within the EDIS. Pay particular attention to this module as it has
the potential to adversely affect ED staff efficiency by increasing triage times significantly.
Information Management
Laboratory results (current & prior +\- ability to graph trended results)
Documents (prior EDIS documents & external text documents, ex. H&P’s, D/C Summary, diagnostic tests, etc.)
Review & bring forward pertinent prior EDIS information (i.e. medical & medication history, allergies, etc.)
Digital radiography (may be achieved via link to external subsystem)
External system data, e.g. Health Information Exchange (may be the “Holy Grail” by adding the ability to view
every piece of patient data regardless of source)
NOTE: Next to “Tracking”, information management has the most potential for improving ED efficiency by placing “information at your
fingertips”. The above subcomponents have been listed in order of importance. Not all of these are necessary or even possible without
other hospital subsystems (ex. digital radiography).
Revised December 2008
Major Components & Subcomponents of an EDIS
_________________________________________________________________
Page 2 of 3
Discharge Planning
Discharge instructions, patient education, prescriptions, work\school release, etc.*
Clinical Impressions (Final Diagnoses)* *NOTE: May be part of physician documentation, but can stand alone.
Follow-up management (ex. nurse call back, pending results like GC\Chlamydia, ED recheck, etc.)
Social Service (shelters, transportation, etc.)
Reportable events (infectious disease, domestic violence, etc.)
Computer Provider Order Entry (CPOE)
Order selection with transmittal to appropriate hospital subsystem (i.e. lab, radiology, etc.)
Order sets & protocols (ex. advance triage orders, standard “cardiac chest pain” orders, etc.)
Order tracking (ex. track & alarm when results return, abnormal or time parameter exceeded)*
*NOTE: “Order Tracking” can be done without CPOE, but requires an orders inbound interface for an automated process.
Adverse Drug Event (ADE) (ex. allergy & drug-drug interaction checking)
Medication Administration Record (MAR) (part of nurse documentation enhanced by CPOE)
Order justification (ex. assures required documentation for billing purposes) & acknowledgment (sign-off)
Tasks Management
Organizes & distributes tasks to the appropriate provider (or group of providers) based on EDIS functions
Ex. CPOE orders for particular patients are directed to the primary nurse, SVN treatment orders are
directed to respiratory therapy team, splinting orders directed to ortho tech, etc.
Appropriate notification & organization of tasks is critical to the success of CPOE.
Ex. On screen notification of provider specific task lists or defined lists sent to a WiFi PDA or text pager.
Alarms & Alerts
Standard metric alarms (ex. room to Dr exceeds threshold) & ad hoc alarms (ex. remind me to recheck in 5 min)
Alerts for various conditions (respiratory isolation, suicide precautions, VIP, at risk for fall\infection, etc.)
Reports, Staff Management, Workload & Productivity
Tracking allows management of resources (beds, staff, etc.) by increasing visibility of entire ED +\- hospital.
Tools integrated into the EDIS that automate this process & provide real time feedback information are ideal.
Post hoc analysis of a variety of ED metrics (ex. census, acuity, staff:patient ratio, throughput, etc.) at
appropriate intervals (daily, weekly, monthly, quarterly, etc) allow for improved budgeting & staffing.
Preferences
Ability to customize work flow, display screens, etc. by individual, based on provider role or log-on
Ability to customize certain documents and processes (ex. discharge instructions, prescriptions, order sets. etc.)
Clinician Documentation (nursing, technician, ancillary department personnel)
Patient assessment & re-assessments (includes narrative & objective data, i.e. vital signs +/- automated entry)
Procedures (ex. respiratory treatment, IV start, wound care, splinting, etc.)
Misc. (ex. I/O bodily fluids, belongings, notifications, etc.)
Medication Administration (see CPOE above)
Physician Documentation
Patient history, ROS, physical examination, procedures, medical decision making, discharge planning, & diagnosis*
*NOTE: Certain aspect of physician documentation may be done without full documentation implementation (see above)
Pay particular attention to the final output as many EDIS “charts”, although readable, are incomprehensible.
Assurance that the sense of the patient visit is easily ascertained is mandatory.
COMMENT: Computer physician documentation is the most difficult component to implement for a variety of reasons.
Efficiency is entirely dependent upon prior successful implementation of other components that “feed” information to
the physician’s chart. Therefore, this component should always be implemented last & only if more than 50% of
necessary information (ex. medical history – including review of systems, medication history, allergies, lab results, etc.)
is efficiently captured & available for easy integration. Planned cost savings on physician documentation by
eliminating dictation (or other forms of documentation) as the primary “return on investment” (ROI) for an EDIS
purchase is folly. For more information on computer physician charting see:
“Electronic Medical Records (EMR): Do the �Write’ Thing” ACEP Scientific Assembly - Monday, October 18, 2004 - (MO-108) by Todd Taylor, MD
“Systems for Charting, Order Entry, Discharge/Prescription Writing” ACEP ED Director’s Academy Series by Richard Bukata, MD
Major Components & Subcomponents of an EDIS
_________________________________________________________________
Page 3 of 3
Optional Components
NOTE: Optional components are not listed in any particular order as utility depends upon the unique needs of an ED.
Forms & Content Management
FORMS: ex. AMA, Consents, EMTALA, Advance Directives, Conditions of Authorization, Medicare ABN, etc.
Print on demand with scan & store vs. electronic forms with signature or biometric acknowledgment
CONTENT: ex. list of local 24-hour pharmacies, dental clinics, free\low cost clinics, etc.
Imaging & Document Management
Capture (i.e. scanning) of paper & external documents (ex. EMS run sheet) with integration into the EMR
Messaging & Communications
Internal Communications (ex. departmental e-mail memo, message to primary nurse by ED physician, etc.)
External Communications (ex. patient information sent to PCP, electronic Rx, etc.)
Positioning & Automated Tracking
Automates the process of patient location assignment via infrared &/or radio frequency tracking devices.
Frees staff from the burden of manually assigning patients to an area & improves accuracy of tracking metrics.
Allows tracking of other things, ex. staff & assets
For more information see: “ED Computer Tracking Systems” ACEP ED Director’s Academy Series by Todd Taylor, MD
Charge Capture
Supplies & materials for billing management
E/M CPT physician documentation scoring & hospital APC determination
Correct Coding Initiative (CCI) edits, Local Medical Review Policies (LMRPs), etc.
Online Resources & References
“Information at Your Fingertips”, ex. online texts, anatomy atlas, prescribing information, etc.
Medical staff, ED staff & general hospital phone lists – Regional physician phone directory
Hospital Policies & Procedures
Device Connectivity & Integration
Keep digital data digital: Vital signs, monitors, EKGs, ventilators, etc. all record digital data often subsequently
transcribed into analog form & then reentered into EDIS creating opportunity for transcription error & data loss.
Clinical Context Object Workgroup (CCOW) standard can allow single sign-on across multiple applications
Scheduling & Enterprise Resource Planning (ERP) Systems
Nursing staff, ED physicians, specialty on-call rosters, etc.
Readily available sophisticated scheduling programs are rarely integrated into EDIS, despite many potential opportunities.
Credentialing\certification management, education\training, human resources, time & atrendance, etc.
Various departmental functions can benefit from integration with EDIS or being provided as a core function.
Risk Management
Another “Holy Grail” of EDIS is the promise to improve the quality of care & reduce medical errors 1 . While
enticing, current EDIS have largely failed to deliver on this promise. Instead, the complexities, and in some
cases the poor design, of such systems have introduced the opportunity for additional errors 2 .
Decision Support: In limited form, this is becoming a reality for EDIS. Yet such functionality is still in its infancy
& this feature should be taken in the context of other aspect of the particular EDIS.
Mobile Computing
This is perhaps the future of EDIS functionality and efficiency offering the ability to work wherever you are.
See: “Mobile Computing: Bringing Real-Time Information to the Bedside” ACEP Scientific Assembly - Wed, Sept 28 - (WE-197) by Todd Taylor, MD
Research & Data Aggregation (export)
Ease of data aggregation & retrieval is an increasingly important aspect of ED management as well as more
traditional clinical research and support of clinical trials.
1
2
Horsky J, Zhang J, Patel V. To err is not entirely human: Complex technology and user cognition. J Biomedical Informatics 2005; In press
Koppel R, et. al. Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors. JAMA 2005;293:1197-1203
“Always consider the total cost, return on investment,
time to deployment, functional consequences,
interface requirements, and cultural implications
of an EDIS when considering a
“Best of Breed” vs. an HIS “single source” solution.
Does it meet the needs of the ED
within the time frame required?”
“Best-of-Breed”
vs
“Single Source” HIS
Enterprise Solutions
for
Emergency Department
Information Systems
By Todd B. Taylor, MD, FACEP
“Best-of-Breed” vs “Single Source” HIS Enterprise
Solutions for ED Information Systems (EDIS)
Hospitals seeking information system solutions to best meet the needs of emergency
departments (EDs) are faced with many choices and a barrage of decisions when selecting an
emergency department information system (EDIS). One of the first decisions may be choosing
to go with the EDIS offering from the hospital�s existing HIS enterprise vendor vs. exploring
alternatives available from so called “Best of Breed” (BoB) vendors. Opinions about the best
strategy abound, but will ultimately depend more on factors unique to the hospital and ED in
question. Each choice has intrinsic advantages and disadvantages.
The search, selection and implementation process for an EDIS is covered in the Additional
Readings listed at the end. But it is important to recognize that in choosing between BoB and
HIS vendors, much of that process will occur during the “sales process”. All too often vendors
over-promise and under-deliver. When you hear “we do that”, make sure they do. When you
hear “we can build that” make sure the delay in delivering that functionality is acceptable and
you are prepared to assist in its development. For the foreseeable future, it appears no single
vendor will meet all of the “wants”, and perhaps not even all the EDs “needs”. Ultimately you
will likely have to select a “best fit” & work with that vendor to address any unmet functionality.
The ability of a vendor to do so may become an overriding criterion in the decision process.
In selecting an EDIS, one must closely examine HIS vendors espousing the “single-source”
solution. They may claim their solution provides the specific department functionality and
workflow desired, when in reality they have simply “leveraged” their current in-patient system
functionality in an attempt to make it fit in the ED. At the same time, one must ask tough
questions from potential Best-of-Breed EDIS vendors regarding interfaces, vendor viability,
support, functionality, efficiency, and return on investment.
There are renewed efforts by enterprise HIS vendors to address the EDIS market, but Best-ofBreed solutions continue to thrive and even expand. Regardless of the type of solution these
three criteria must be considered:
(1) Tangible return on investment
(2) Implementation horizons of a few months
(3) Functionality & workflow that truly meets the needs of ED managers & end-users
EDIS vendors fall into three basic business categories:
(1) Large publicly traded companies (typically enterprise HIS vendors)
(2) Venture capital companies (typically niche single product vendors)
(3) Privately held companies (often multi-product vendors, i.e. ED plus other ancillary depts.)
The advantages and disadvantages of these business models will be discussed.
(2)
Advantages: BoB vs Enterprise HIS Vendors
The top 5 HIS vendors occupy the majority of
hospital IS “shelf-space” & continue to push the
single-source theme, while a passionate group of
BoB systems continue to make inroads.
What is the viability of the BoB vendor?
Are they public or private?
The primary advantage of Best-of-Breed EDIS solutions is their ability to meet the unique
workflow needs of the ED, provide a seamless view data from a variety of external systems and
greatly extend the capabilities through customization.
It can take years to customize HIS
applications that best-of-breed
solutions offer out-of-the-box.
How fast can the EDIS solution be deployed vs. time of
custom coding of HIS software to meet these same needs?
Single-source HIS vendors often appear to have lower Total Cost of Ownership (TCO) by
bundling departmental modules into the facility licensing. However, one must account for the
cost of custom professional services necessary to ultimately meet the needs of the ED. HIS
vendors often have a multi-year horizon on availability of new applications and functionality, so
you may have to wait years for applications to be developed. Waiting equals lost revenue and
productivity, adding to the hidden TCO.
Smaller projects have a
greater chance of success.
Does the HIS vendor have evidence of dept-level success? e.g.
demonstrated end-user acceptance & preference for their EDIS?
The “implementation that never ends” has emerged as a painful reality in the healthcare
industry. Human nature responds to “quick wins” resulting in momentum for a new IT project.
Best-of-Breed vendors are often more adept at matching this business need. With the necessary
functionality already included “out-of-the-box”, more implementation time can be spent on
mapping clinical and business processes to the software. The customer gets more value, hour
for hour, for professional services provided.
Is the HIS vendor able to map business needs
at the department level?
Best-of-breed vendors have complete domain
expertise in the company & in the software.
HIS vendors tend to hire the “right credentials” just for the implementation, but Best-of-Breed
vendors typically have domain expertise integrated into their product management and
development teams. As a result they can be very responsive to changes in the core product
roadmap vs. “one-off” customizations.
Does the HIS vendor have an accessible
product management point-of-contact
in communication with the ED?
Some HIS vendors acquire best-of-breed systems
achieving “integration” into their enterprise product
suite via product acquisition.
HIS vendors that promise a unified architecture across applications may not be the sole
software vendor source in any one hospital-wide installation. Some “single source” vendors
even offer to “private label” their best-of-breed application. Therefore, the same due diligence
regarding integration and data flow must also be considered with regard to HIS vendors, just as
it is for Best-of-Breed vendors.
(3)
Disadvantages: BoB vs HIS “Single Source” Vendors
Although many Best-of-Breed EDIS vendors have been successful for more than a decade, the
fact new vendors continue to enter this market is an indication of their failure to fully meet the
needs of EDIS customers. This has also given the HIS vendors a golden opportunity to enter the
EDIS market with their own offerings.
The demise of a few venture-funded EDIS niche companies and difficulties with integration
standards are the primary challenges for the Best-of-Breed strategy. However, one should not
assume that Best-of-Breed vendors have substandard support, unreliable interfaces or will
abandon the customer after the sale because research show that these issues are no more
common with Best-of-Breed than with enterprise HIS vendors.
Satisfaction studies 1 indicate HIS vendors &
Best-of-Breed vendors are on par regarding
customer support & reliability.
How does the BoB vendor structure its support?
What is the response and escalation model?
In the 2003 Hospital CIO Survey, Bank of America Securities, the top 17 HIS vendors received
an average of 6.57 for global satisfaction (1 to 10 scale). The individual scores for some of the
most recognized vendors may surprise some, but this indicates that both HIS and Best-of-Breed
vendors have a long way to go in the area of customer support and reliability.
How many ED personnel are required
for implementation of the project plan?
HIS single-source proponents claim their strategy will
result in less cost for maintenance and integration.
Before assuming a cost savings for maintenance and integration with an HIS enterprise
solution, look closely at the system administration requirements of the Best-of-Breed application
and interface/integration requirements. While there may be less cost for the HIS EDIS, the price
to be paid may be in less functionality with an enterprise HIS vendor solution.
Is downtime in the ED acceptable?
Down time is “accepted”, but not “acceptable”.
A potential significant adverse impact of an HIS EDIS solution is scheduled and unscheduled
downtime. This forces the ED to use alternate means of operation during downtime and then
to re-input critical data at a later time. Using a Best-of-Breed system insulates the ED from
this HIS vulnerability. In fact, some ED’s choose to use the Best-of-Breed EDIS as a backup
registration system when the HIS is on downtime.
Many CIOs prefer a one vendor relationship, but in the EDIS
market this may not be possible. Even if an EDIS module is
available, it may not meet the needs of a particular ED.
Does the vendor offer standard,
subscription and financed
licensing models?
The hospital’s relationship with an enterprise HIS vendor and close alignment with a Best-ofBreed EDIS vendor does not have to be mutually exclusive. Best-of-Breed vendors often have a
financial incentive to perform after the sale because they can be more easily replaced. Not
always so with an enterprise HIS, that can “hold hostage” an entire hospital due to the cost and
pain associated with a change in HIS vendors.
1
Emergency Department Systems Study – Dec 2004 – KLAS Enterprises – www.healthcomputing.com
(4)
Best-of-Breed vendors focus on the ED. They have to - It’s their specialty. Not necessarily so
with HIS vendors who must manage multiple departments and competing interests both inside
and outside of the company.
While healthcare IT is perhaps the last industry to be fully automated and it has clearly been a
“laggard” in adopting technology, most other industries have already addressed the issue of
“Best-of-Breed” vs. “Single Source” applications. Lessons from other industries indicate that HIS
vendors will be fervent single-source proponents as long as integration & technology standards
in healthcare are still being developed. It is important when considering a Best-of-Breed vendor
that one validate that they have a forward-looking roadmap for adopting these standards. At
the same time, other industries seem to indicate that, “single source” and “the safe choice” may
not always belong in the same sentence.
Evidence shows that Best-of-Breed applications for
Customer Relationship Management (CRM),
Enterprise Resource Planning & Supply Chain
Management (ERP/SCM), and Business Intelligence
(BI), continue to thrive and are now preferred to
those of “single-source” vendors among CIOs
- Bank of America Security ERP User Survey
January 2003
“if the trend continues. . .in a few years
CIOs won’t be buying any more tightly
coupled, multi-million-dollar enterprise
systems from just one vendor.”
- Stephanie Overby
“This Could Be the Start
of Something Small”
CIO, Feb 15, 2003, p.55
It appears in some other industries the pendulum has swung back in favor of Best-of-Breed
systems due to the enterprise vendor’s poor adoption, runaway costs and implementations that
are so complex that they are essentially “never completed.”
Finally, profitable privately held EDIS companies may be the “best of both worlds”. They
essentially have the financial stability of a publicly traded company, yet the flexibility and ability
to focus on the customer of a niche vendor. Such attributes are rare in any industry and the
EDIS market is no exception. At the same time, competing interests within a multi-product
company and integration issues still may be factors.
Return of Investment Comparison
Return on Investment (ROI) analysis is fairly new to many in the healthcare industry and
patient quality, satisfaction, and safety are often overriding objectives with any process
redesign. However, hard financial numbers can assist in driving administrative efforts to
improve patient care across the organization. In calculating ROI, facilities may use a borrowed
cost of capital model to assume a baseline percentage that the project must meet or exceed to
be considered a success, or for the project to be considered in the first place.
Does vendor provide a free in-depth ROI
analysis during the sales process?
Hospitals may use a hurdle rate 2 in ROI analysis,
a more aggressive assumption that compares
Is creating an ROI baseline for
implementation part of the contract?
the investment in the EDIS with a hypothetical
investment of the available capital in securities.
Most hospital IT projects have multi-year ROI and are based on multi-year implementations. In
the overcrowded, inefficient, poorly resourced hospital ED, the allure of an efficient well2
The minimum amount of return required that will get "over the hurdle" to justify an invest.
(5)
designed EDIS becomes clear with an ROI analysis. Implementation in weeks vs. months or
years provides a solid ROI at six to twelve months post-implementation, meeting the highest
project acceptance standards. An assessment of the vendor’s ability to meet this objective and
performance guarantees in the contract is highly desirable.
Given available capital, hospitals may wish to take
advantage of “smart investments” – wherever they occur.
What is the EDIS vendor’s
documented ROI field experience?
Broader organizational imperatives such as error reduction via Computer Provider Order Entry
(CPOE), Leapfrog compliance or Electronic Medical Record (EMR) initiatives also create
administrative ROI opportunities. Data mining this information may be difficult and hospitals
simply may not have the resources to analyze metrics via existing manual processes. However,
consideration of the ED as business unit or cost center, in addition to a patient care area,
should prompt hospitals to investigate ROI. “Tangible” and “intangible” ROI can be assessed
and a baseline established from published ED best practices (e.g. ED Benchmark Alliance3 ).
A recent tend has been for EDs to be forced to accept the existing enterprise HIS vendor’s EDIS
offering with little consideration for usability, functionality or potential productivity loss. An
“apples-to-apples” ROI comparing the actual HIS vs. projected Best-of-Breed ROI after six
months may reveal a compelling argument for one system over the other and convince the
hospital to re-examine their strategy. Also, be careful of the “we can build that” promise that
may cost thousands of professional services hours vs. the total cost of an EDIS solution that
meets the EDs needs out of the box. The cost of time delay of implementation is a major factor
in the “build as you go” strategy.
Forcing “solutions” onto end-users that do not
fit the workflow invariably have an adverse
effect on the ED. Some vendors assume that
all hospital departments have the same
workflow. This clearly shows a lack of
expertise regarding ED processes – not to
mention a disregard for best practices.
“Physicians & other caregivers often have
been the rock that a CIO’s IT dreams have
crashed and broken upon.”
- Greg Gillespie
“CIOs Making Soft Sell When Calculating ROI”
Health Data Management - August 2002
Vendors should take a personalized approach to maximize ROI and understand that you must fix
poor manual processes, not just “computerize” them. So, the staff “efficiency return on time
investment” must be considered in the overall design and implementation of an EDIS. To
achieve true efficiency, the system must adapt to the user with minimal user adaptation to the
system itself. Be careful of solutions that assume what works everywhere else in healthcare, will
also work in the ED. Forcing an inadequate solution onto an ED creates an adverse cultural
impact, that in turn, impacts acceptance of the system.
Workflow tailored to ED processes allows end-users to focus on treating patients. Vendor
supported subject matter expertise to help create familiar reports, content, forms and
templates, along with prepopulated databases can have an immediate impact and get users
excited about using the system. ED managers need to feel like part of the team and get
involved in the product development. End-users involvement is the best way to ensure the
product evolves to meet needs of the department, without custom code development,
professional service resources and core system upgrades.
3
Emergency Department Benchmarking Alliance, 332 Congress Park Drive, Dayton, OH 45459 - www.edbenchmarking.org
(6)
Compared to typical multi-million dollar, multiyear hospital IT projects, an EDIS can drive real
results in a time horizon that demonstrates the
investment of time & money is worthwhile to
managers & end-users alike. Momentum such as
this creates enviable adoption success &
preference for system use vs the prior manual
process, even by those not required to do so.
Does the vendor have evidence of >90%
adoption and end-user preference of their
EDIS vs manual systems at a client site?
Does the vendor have quantitative or
qualitative evidence to support claims of
increasing staff retention and productivity
from use of their system?
Finally, the ED leadership should have direct access to vendor product managers and
implementation specialists before, during and after deployment of the EDIS, benefiting from
years of experience in the ED clinical information systems market. Training, support and usergroup activities with vendor clinicians provides for networking and the ability for users to
consult with peers on the efficient use of the EDIS.
The BoB vs Enterprise HIS Vendor Battle Continues in Healthcare . . .
Hospitals and ED managers that take the time to evaluate EDIS vendors and ask tough
questions will be rewarded with an efficient system and a company that is a true partner, with a
stake in the success of the emergency department.
When vendors claim “we can do that” or “we can build that” for the ED, CIOs and ED managers
should consider total cost, return on investment, time to deployment, functional consequences,
interface requirements, and cultural implications of both promises compared to using a solution
that meets the ED needs today.
Summary
HIS enterprise vendors offer a compelling argument to CIO’s looking for a single source for all
hospital clinical applications. Integration with current clinical applications is all but assured and
reduced vendor relationship management enjoyed. The primary question to be considered:
Does the existing HIS vendor’s EDIS offering substantially meet the needs of the ED? Only an
in-depth analysis, to include a comprehensive installed-base assessment, will answer this
question.
Best-of-Breed systems have been proven to coexist peacefully with HIS systems, often below
the radar screen, hiding in the “all-eggs-in-one-basket” model. Their inherent ability to address
the unique needs of the emergency department often greatly outweighs the institutional desire
for a single source vendor. The primary question to be considered: Can the Best-of-Breed EDIS
successfully interface with all necessary host systems and provide a single access point for
clinical information?
Hospitals are often challenged with reducing costs, maintaining revenue stream, retaining staff,
and enhancing efficiency. An EDIS can be a tool toward that end, if properly selected,
implemented, and maintained. A careful analysis and comparison of an existing enterprise HIS
vendor’s EDIS offering and Best-of-Breed solutions is often required to achieve this goal.
Additional Reading:
Taylor, TB Information Management in the ED. Emerg Med Clinics N Am 2004;22:241-257
Taylor, TB A View of the Emergency Department of the Future. ACEP Section for Emergency Medical Informatics
2000, Dallas, TX
(7)
Page Intentionally Left Blank
Introduction
“If you cannot measure it, you cannot manage it”, trite, but true. Such is the state of many Emergency
Departments (ED) – unmanageable due to a lack of valid measurable metrics of patient care. Even worse,
often the information that is available is inaccurate, too little and too late to impact patient care on a real
time basis. Such are the challenges for ED managers in the current healthcare environment. It would seem
that technology would be a natural tool to fill this information gap. On the other hand, for technology to
help, it must be usable, reliable, appropriate to the task, cost effective, improve efficiency of the ED, and
be effectively implemented - a daunting task. There are perhaps few other initiatives in the ED that have
such potential for good and harm as ED information systems (EDIS). This article will focus on the critical
aspects of EDIS and offer suggestions for successful product selection and implementation.
ED Information System (EDIS): “Garbage in – Genius out?”
One of the more common mistakes when deciding to install an EDIS is assuming it will make a bad
situation better. The best way to assess and implement an EDIS is to design a good process and then
automate it. Otherwise, as has been said, “You do the same wrong things you have always done . . . only
faster”1
Many EDs, even on a good day, are dysfunctional and the reasons for this have been well documented2.
Just like adding a new baby to a dysfunctional marriage always make things worse, one should not
assume that adding an EDIS will solve fundamental inadequacies of an already dysfunctional ED. In fact,
doing so will undoubtedly exacerbate the situation.
Example #1: If identifying, repairing, and maintaining broken equipment in the ED is already a problem,
adding 100’s of additional pieces of computer equipment will exacerbate the problem. When the EDIS
depends upon having a functional “special” printer in each ED area and that printer fails, so will the
EDIS. Planning for equipment redundancy for the EDIS is as important as other ED equipment.
Example #2: If patient throughput is a problem in the ED due to poor staffing or other reasons, adding the
additional work required by an EDIS to already overworked staff will make the situation worse, perhaps
much worse. In a large urban trauma center with 70,000 annual visits, Left Without Treatment (LWOT)
increased by 100% in the first month after installation of a new triage\tracking EDIS3.
Therefore, in preparation for introducing an EDIS, one should first assess and repair the current ED
processes and environment. Once implemented, the EDIS can then assist in refining these fundamental
improvements, rather than merely illuminating, documenting, and exacerbating an already broken system.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
The Interface – Making EDIS Work
EDIS will only reach its potential and offer a real opportunity for efficiency if it is integrated and properly
interfaced with all necessary new and legacy hospital information systems. These interfaces include oftenignored equipment such as cardiac monitors, EKG machines, automated vital sign and pulse oximetry
equipment. For the future, interfaces with community-wide and even nation-wide healthcare information
networks will truly provide all of the information necessary to care for any patient at any time.
Most EDs rely on computer interfaces to hospital systems that are not totally reliable. Anyone who works
the night shift knows how frustrating it is when the hospital system "goes down" for routine maintenance.
During this down time, ED personnel are forced to fall back on archaic manual methods of information
management. As a result, many EDs have acquired stand-alone, proprietary EDIS products that are
difficult, if not impossible, to integrate into hospital-wide systems. At best, these stand-alone systems are
transition technologies that serve limited functionality and will perhaps never meet all of the EDs
information needs.
Efforts to redesign the information environment must go beyond simply automating paper flow in the ED.
Instead, the goal should be to support the department's business plan with a design that combines
productivity and profitability with the delivery of high-quality patient care. This can be best accomplished
in a step-wise approach (Figure 1). This article will help begin that process and provide the tools
necessary to implement a usable, functional, and efficient EDIS. For an expanded view of where EDIS
should be, read “A View of the Emergency Department of the Future”4.
EDIS Functional Considerations
Remote Access
ED managers never really leave work and increasingly that is true of other staff as well. The need to
remotely access data is a new healthcare reality and comes in a variety of forms. Medical records
retrieval, on-line authorization (signature), staff scheduling management, e-mail advisories – the list may
be endless. While perhaps intrusive into ones personal life, the efficiency gained by this functionality is
enormous. The goal is to have the ability to securely access the EDIS from any web enabled computer
worldwide.
Authorization & Identification Systems
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has forced many hospitals to
reassess how Protected Health Information (PHI) is accessed. At the same time, it is an opportunity to
apply new technology to what may seem an onerous mandate. Automated login\logout via infrared badges
is one such solution. Regardless of the technology, the need to access multiple computers and information
systems must be coordinated to avoid “password-bloat”. Using the same technology, access to various
hospital locations can be authorized and restricted for hospital personnel.
Positive identification of patients must also be addressed. The extension of “unsecured healthcare loans”
under the guise of “you don’t have to pay today, we will bill you”, has become a severe financial strain on
EDs. This is often due to inaccurate or even fraudulent information. Integrating demographic verification
software and procedures is an often-missed opportunity for revenue capture in the ED5.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
Patient Centered Automation
The electronic medical record (EMR) should be updated automatically as soon as the information
becomes available.
New patients to a doctor’s office spend the first several minutes completing medical history forms. This is
not only a vital part of the medical database acquisition, but also important for coding and billing. Most
EDs fail to take similar advantage of those patients who are capable of completing this part of their
medical history on their own. Automating the process of registration, chief complaint, history of present
illness, review of systems, family\social histories, medications, and allergies is a ripe opportunity to gain
vital information and efficiency in the ED data collection process. Using a touch-screen computer (no
keyboards) and scanner, most patients would be able, and perhaps be more than willing, to self-register
and feel as if they are actively involved in the process.
Passive patient tracking (via infrared or radio frequency tracking devices) not only automatically tracks
location, but also how long it takes to move through the ED. Such systems can also automatically log
patients into the computer terminal closest to them and avoid misidentification. Tracking of staff using
similar technology is somewhat controversial, but can provide invaluable data for staff management and
productivity.
Computer-assisted triage protocols based on data input can help ancillary personnel to initiate diagnostic
tests and necessary treatment from the moment of arrival. Artificial intelligence protocols have the
potential to further automate the clinical decision-making process and provide enhanced ability for the ED
staff to recognize common and not so common clinical syndromes. Prompting for diagnostic
considerations and providing recommended treatment standards can greatly enhance staff efficiency and
clinical accuracy.
Computerized Physician Order Entry (CPOE)
CPOE is the “latest” buzzword in EDIS. A landmark CPOE study6 from 1993 showed that physicians
using a computerized order-writing system discharged patients on average 1 day earlier and with medical
bills $900 less than physicians using traditional order entry methods. The system also warned of potential
drug interactions, patient allergies, and "expensive" treatments.
CPOE promises to be a key component to increasing patient safety, efficiency, and functionality in patient
care, but research and development in this area is ongoing. While this aspect of EDIS will serve as an
enhancement, it should not necessarily be considered a prerequisite to implementation of an EDIS. For
more information: www.cpoe.org
Consolidated Digitized Environment:
For an EDIS to be truly efficient, information must be in digital format. Any EDIS should keep digital
information digital (CT scans\ultrasound\EKGs\cardiac monitoring\automated vital signs), transition
analog information to digital (digital plain radiography), and digitize everything else (scan all paper).
Prior to implementing the EDIS, every effort should be made to transition the entire ED to a digital
environment. This will allow the Bill Gates concept of “Information at Your Fingertips” to become a
reality in healthcare. The goal should be for all information necessary to manage patient care to be
available at a single computer workstation or mobile terminal.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
Digital radiography in the ED has been demonstrated to be as reliable as hard copy7. The advantage is
widely distributed simultaneous accessibility and opportunities for contemporaneous reading by
radiologists even at a remote site. Picture Archiving and Communication System (PACS) is becoming the
standard in radiology for digital information management. Extending this to the ED is only logical and
perhaps vital to an EDIS. Further, as the PACS can operate over the hospital TCP\IP network, the PCAS
workstation can also be used as the emergency physician primary workstation for all other computer
functions. This concept reduces the number of necessary workstations saving space and capital
investment.
Scanning technology is inexpensive and reliable. Barcoding every piece of paper used in the ED allows
for automatic archiving of digitized material and reduces the need to manage paper. The cost savings by
eliminating NCR (no carbon required) paper alone often pays for such systems in short order.
Other digital opportunities such as digital photographs and video are made possible due to the digital
environment, but not required for implementation of the EDIS.
Patient Safety
The opportunities for patient safety systems in the digital ED abound. Computerized alerts for abnormal
values (symptom recognition, laboratory values, vital signs, wait times, syndromic surveillance, etc.),
drug-drug or drug-syndrome interactions, and patient monitoring (pulse oximetry, CO2 monitoring, etc.)
are but a few of the many opportunities.
Coordination of Care
Automated notification of specialists, primary care physician, ancillary services (respiratory care),
radiology technician, housekeeping, admitting department, insurance plans, etc. are but a few of the
opportunities available with EDIS. Further, exchange of patient data easily becomes HIPAA complaint,
immediate and inexpensive using encrypted or secure internet transmission. Nursing report for admitted
patients can become an automated process. Documentation is completed simultaneously with patient care,
so delays due to documentation completion are eliminated.
Automated alerts can easily be transmitted to staff via pager or cell phone, such that workflow is not
interrupted simply looking for data. For example, ordering a small volume nebulizer (SVN) treatment
automatically notifies the physician for reevaluation 10 minutes after completion. Automatic notification
of laboratory and radiology results, etc. are automatically transmitted to the ordering physician.
Content
Computer systems are of limited value without reliable up-to-date evidence-based clinical content. This
may very well be the greatest future challenge for EDIS. While most currently available EDIS provide
adequate technical infrastructure necessary to manage data, the technical aspect of a comprehensive EDIS
may be the easy part. The real challenge is to provide high quality clinical content that will enhance the
clinical staff’s ability to make better clinical decisions and focus on patient care.
For example, discharge planning. A recent survey8 revealed that there is no currently available peer
reviewed evidence-based discharge instruction content. Further, the content that is available is often
presented to patients in a non-user friendly way (i.e. unformatted plain text).
Clinical content is also often lacking. Web links to emergency medicine web sites such as the National
Center for Emergency Medical Informatics (NCEMI) are helpful, but often require searching for useful
information. Integration of clinical content into the EDIS is essential in order to achieve the full potential
of such systems.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
Regulatory & Liability Considerations: When does an EDIS become a “medical device”?
As ED information systems become more sophisticated and take on larger roles in patient monitoring and
care management, they have the potential to create new opportunities for introducing error or fostering
complacency among the ED staff. Reliability testing and perhaps even Food and Drug Administration
(FDA) approval may become necessary. In the short term, these considerations may limit technology
advancement or require frequent human acknowledgment of data input.
Summary
There are many obvious advantages to EDIS. The staff can spend time caring for and talking with patients
instead of shuffling paperwork. Physician support is enhanced by the availability of remote specialists in
real time who directly assist in making diagnoses. The EDIS also aids in diagnosis, so less time is spent
wondering what you may have missed. Patients receive optimal care regardless of time of day. Updated
medical records are distributed to appropriate parties instantly.
There are also some not-so-obvious advantages. Clinical information is captured in local and national
databases would allow real-time CQI/QA and opportunities for national data mining for research. Patient
tracking identifies inefficiencies in department processes and enhances ED management. Staff
productivity can be monitored in real time. Family members can be kept informed even from remote
places.
There are many hurdles yet to overcome and perhaps hurdles not as yet realized. Nevertheless, the
technology necessary to implement basic systems is now available and future enhancements can be added
as they are developed. The possibilities are limited only by our imaginations.
______________________________________________________________________
Strategies for Emergency Department Information Systems Planning9
Establish planning parameters
A management steering committee should be established and charged with overall project oversight. This
oversight should include seeking input from stakeholders, integrating input into strategic objectives, and
implementing the project in accordance with the agreed plan and timeline. The committee should include
clinicians, information systems consultants, local experts in the field of emergency medical informatics,
and information systems personnel. It is important at this stage to develop the emergency department's
strategic objectives supported by well-defined goals and potential benefits of the project (Table 1). The
list of goals should be developed from stakeholder input and may be extensive depending on the scope of
the project. It is the steering committee's duty to develop objectives based on these stated goals and justify
them by identifying benefits. The objectives should be reviewed by a broad range of stakeholders
(management, physicians, nurses, security and pharmacy personnel, etc.) for additional input and
revisions. Capital allocation funding is key to the success of the project and should be addressed and
committed at an early stage.
Assess the current information environment
It is important to define the current information environment; otherwise there is little chance of knowing
where you want to go. Current software, hardware, network, and operating systems need to be
inventoried. Understanding how these systems are currently integrated with the hospital's main computer
is critical. Since many emergency departments have only limited automation in place, this step may be
easier than anticipated.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
A crucial decision at this juncture is whether current systems can be upgraded or whether a completely
new system will be installed. Due to the rapid pace of technological advances, this is often a difficult
decision. The multimillion-dollar system of 5 years ago may be worth only a few thousand dollars today.
A final decision will often be based on whether it is more cost effective to upgrade, adapt the current
system or simply start over. A new system usually provides more flexibility and can integrate the latest
technologies but will be more expensive and often more difficult to implement.
It is also important to decide at this point whether the emergency department system will be a stand-alone
system or be integrated into (or part of) a hospital-wide system. A hospital-wide information system
redesign is a huge project but solves the most frequent cause of failure of stand-alone emergency
department systems—the interface (sharing data between incompatible systems).
A stand-alone system is designed to perform specific functions (e.g., patient triage or tracking) only
within the emergency department. When planning or deciding on a standalone emergency department
system, you should consider how it will interface with the current (and future) hospital system.10,11 The
EDIS must interface with pharmacy, laboratory, radiology, ICU/medical/surgical units,
registration/admitting, general accounting/billing offices, medical records, dictation/transcription, staff
management systems, and facility maintenance, as well as, information sources outside the hospital. The
cost of creating these sometimes-complex interfaces can be prohibitive. But without such interfaces, the
EDIS will ultimately fail to reach its potential and become an island of information cut off from the
outside world.
The analysis at this stage should delineate information flow (what, when, where, and by whom) in the
emergency department and hospital-wide. This will allow identification of current information issues and
areas of potential improvement in terms of quality of care, staff productivity, and cost effectiveness. It is
important that key personnel in each functional area be involved in this analysis to identify the pertinent
activities for their areas and document the flow of information. A case scenario approach that follows the
paper trail may be useful.
Propose a concept for a new information environment
Using the information obtained in the previous steps, a core group will then need to develop a plan for a
new information environment. This may take the form of a flow chart that acts as a blueprint for future
planning. Emphasis should be placed on improving quality of care and productivity, reducing operating
costs, decreasing inefficiency and redundancy, decreasing errors of omission and commission, and
increasing the availability of information necessary for effective decision making. Again, input should be
solicited from all parties involved.
Investigate potential solutions
At this stage a decision must be made whether to develop a proprietary system from the bottom up or
investigate commercially available systems that may meet the identified needs. Proprietary bottom-up
system development requires many more resources and likely a longer development time. Its advantage is
flexibility and an almost guaranteed ability to interface with existing systems. However, depending on the
resources available, such an approach may not necessarily result in the most robust of systems.
Several commercially available products have been developed in recent years and vary considerably in
features, compatibility (ability to interface with existing systems), flexibility (modular versus packaged),
and price. Depending upon the hospitals main computer system, an ED module may be available from the
current enterprise-wide vendor. If so, this vendor should be a major consideration and the possibility of
building upon the current system investigated.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
Resource information on vendors include ACEP's Directory of Software in Emergency Medicine12, MD
Computing's Annual Medical Hardware & Software Buyer's Guide13 and commercial consulting resources
such as the KLAS Enterprise ED Systems Study14. See table 2.
Although software decisions are typically made first, hardware and connectivity infrastructure (e.g.
wiring) are likely to significantly affect the total system cost and should be considered together. How the
final product is selected will depend on the corporate structure. A request for proposal (RFP) is often
formulated and sent to several contractors, but forming a group to simply shop around may be equally
effective. A model RFP is available from the author15.
Regardless of how the vendor is selected, it is important to set performance and milestone parameters in
the final contract to ensure that promises made in the selection process will be honored during installation
and implementation. Payment for the system should be graduated and predicated on the vendor meeting
these criteria. If possible, define critical criteria that if not met would result in a full refund. These might
include a guarantee of a workable hospital-emergency department system interface, system fault tolerance
(i.e., limited downtime), and system support.
The fiscal health of the vendor should be ascertained. Most emergency department system vendors are
venture capital businesses and do not have the fiscal robustness of a publicly traded company. Seeking
information on current installations is critical; do not rely on the vendor-provided referral list alone. The
ACEP Section for Emergency Medical Informatics list server16 can be a valuable tool for finding current
and former installation sites for real user experiences. Telephone contact and/or onsite visits of current
and former clients are valuable in determining vendor reliability.
Software vs. Hardware Selection
Depending upon the vendor, the hardware and software may come as package or may require independent
selection and purchase. Failing to appropriately investigate and plan for hardware is a prescription for
failure. Large CRT monitors that do not fit on a counter; small LCD monitors that are difficult to read and
require constant scrolling to view information; slow printers that frequently run out of paper; slow
computers/networks that delay information access; insufficient number of workstations; non-standard
equipment (i.e. rollerball mice without a scroll wheel or keyboards in atypical layouts); poorly placed
workstations; computers, battery backups, power strips, cords lying of the floor, etc. are all examples of
hardware foibles. Table 3 lists several hardware considerations.
Also, depending upon the current ED space environment, a redesign of work areas may be necessary to
allow for efficient use of the new system. Few EDs have ever been constructed with enough counter space
to accommodate all the typical equipment necessary. Adding an EDIS will complicate the space crunch.
Consolidating work functions into single workstations may help, but significant forethought as to the
location and type of equipment is essential to a successful implementation of an EDIS.
Implementation
Buying something that no one will use accomplishes nothing.
Implementation is the most crucial stage of the process with the most opportunity for failure. Twenty-five
to 50% of the cost of the system may need to be reserved for implementation. Besides initial training
costs, additional on-site clinical and clerical staff may be necessary during the rollout to assure as little
impact on patient care as possible. Additional unplanned expenditure for equipment and infrastructure
will be necessary. Retraining and ongoing training should also be anticipated.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
A phase-in or modular approach to implementing the new system will allow incremental learning and
adaptation with less impact on patient care during the transition. Where to begin will depend upon the
priorities set by the steering committee, but starting with the simplest and most efficient part of the system
is recommended. A sample implementation schedule is outlined in Figure 2.
Physician charting has traditionally been touted as an area with great potential for cost savings (“return on
investment”) and is often implemented first. Unfortunately, physician charting is the most difficult
module to implement because it requires a fundamental change in the way physicians accomplish their
work. In addition, this part of the patient information system has almost infinite variability and makes
charting system design very difficult.
Efficiencies in the physician charting component will only be realized once all of the other components of
the system have been fully implemented. Ideally, in order to gain sufficient efficiency to make physician
computer charting viable, elements of the Chief Complaint, History of Present Illness, Past Medical
History, Social History, Family History, Current Medications, Allergies, Review of System,
laboratory/diagnostic imaging/EKG, and demographic information would be collected for the physician
and automatically integrated into the chart. Only the physical examination, medical decision making,
disposition, and final diagnosis would then be required to be completed by the physician. Even so, one
should expect resistance from the physicians as virtually any system will take more time to accomplish
charting. Gaining early efficiencies (pay back) is crucial to EDIS acceptance.
As an interim short-term charting solution, some facilities have implemented a blend of computer-based
and traditional dictation. Most emergency departments are better served by continuing their current
charting method (e.g., paper-based template or transcription) until more usable computerized solutions are
proven to work efficiently.
Finally, the first and last stages of implementation process are critical. A reliable interface with the
hospital's main computer through an ATD (Admit\Transfer\Discharge) interface is essential. This
interface captures patient demographic information and supplies data to multiple sites throughout the
EDIS. On the back end, "charge capture, coding, and billing," if properly implemented, can reap many
benefits and help offset the initial and ongoing cost of a totally integrated system. As noted in Figure 2,
billing, as well as other processes, may need to continue independently until all the pieces are in place.
Billing is particularly dependent upon the availability of information collected by other subsystems.
EDIS Return on Investment (ROI)
An entire paper or even a novel could be written on this topic. Suffice it to say, ROI is always done in the
EDIS selection process and is nearly always wrong. In EDIS and information technology in general,
computers rarely save time or money. What they do is allow you to do things that were previously not
possible; often taking more time and costing more money. Nevertheless, the advances in medical care
demand better and more available computer systems. Imagine trying to fly a Boeing 737 without a
computer. It was computer technology that allowed such a plane to be designed and to fly. EDs are no
different, but have been slow to adapt computer technology to the work environment. So, when
considering the EDIS ROI, staff efficiency, ability to gather data for ED management, patient safety,
improved data distribution/access/archiving, workflow automation, and the many other benefits discussed
are the true “return” on the EDIS investment. Cost savings on transcription, presumed ability to reduce
staffing, and other “hard” cost savings are probably not realistic.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
How to develop an action plan
The final blueprint should include a step-by-step project management scheme and cost-benefit analysis.
Once this plan has been reviewed and approved by the entire team, it is validated against the business
objectives. A vendor is selected to either develop or supply the system, and final decisions are made
regarding hardware and software. The plan is not static and should be reviewed periodically (perhaps
quarterly initially then annually) even after the immediate project has been completed.
Emergency department automation is challenging and often fraught with pitfalls. EDIS consultants may
bring valuable expertise to the process, but the success of the project will depend greatly on the
commitment of the development team and a willingness to dedicate adequate resources to the goal.
Summary
Information system planning for the emergency department is complex and relatively new to emergency
medicine despite the fact that it has been used in other industries for many years. It has been estimated
that less than 15% of ED have comprehensive EDIS in place17. The manner in which administration is
approached will, in large part, determine the success in obtaining appropriate institutional support for an
EDIS.7 Active physician and nurse involvement is essential in the process if the new system is to be
accepted at the user level.
In the ED, large volumes of information are collected, collated, interpreted, and acted upon immediately.
Therefore, effective information management is key to the successful operation of any ED. Although
computerized information systems have tremendous potential for improving information management,
such systems are often underutilized or implemented in such a way that they increase the workload on
caregivers and staff. This is counterproductive and should be avoided.
In developing and implementing EDIS one should be careful not to automate poorly designed manual
processes. Examples are ED tracking systems that require staff to manually relocate patients in the
system. This task probably will be completed only when the ED volume is low and "worked around"
when the department is busy. Information from such a system is, therefore, flawed, at best useless and at
worst counterproductive. Alternatively, systems are available that can automatically track patients through
the ED via infrared sensors similar to those used in baggage-tracking systems that have been in place in
airports for years.
In the automated (computerized) emergency department, we must have zero-fault-tolerant enterprise-wide
hospital information networked systems that prevent unnecessary duplication of tasks, assist in tracking
and entering data, and ultimately help analyze the information on a minute-to-minute basis. Such systems
will only reach their potential when they are fully integrated, including legacy systems, rather than standalone proprietary EDIS. Further, a modular approach where individual components are connected to a
flexible computer backbone is ideal.
Finally, good clinical content is key to virtually every aspect of the EDIS. Much of this content is yet to
be developed and what is available still needs to be adapted to the EDIS environment.
Daunting as it may be, an EDIS implementation properly accomplished will result in better patient care,
improved staff productivity, and a satisfying work environment.
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
Pearls and Pitfalls
В„
В„
В„
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EDIS to address the enterprise-wide information management problem are only now beginning to
become available.
Consider transition (temporary) systems as a 3-year to 5-year solution that will likely need to be
totally replaced when enterprise-wide hospital systems become readily available in the next few years.
Fix other aspects of the ED environment before implementing an EDIS.
Be careful not to develop or purchase systems that merely automate poor manual processes. The less a
system requires human input the better; consider systems that automatically capture data already
available on the hospital main system and systems that automatically track patients through the ED.
Phase in the installation in a modular approach and be sure to obtain a guarantee of milestone
implementation, (i.e. a money-back guarantee if the EDIS cannot ultimately integrate with the
hospital’s main system.)
Spend as much time selecting hardware as the software and in planning its deployment in an already
crowded work environment.
Decide what it is you need then decide what it is you want. What you end up with should be
somewhere in the middle.
Be willing to fail and change course if necessary. Forcing a square, inadequate system into a round
hole will end in disaster.
Waiting for the ultimate solution is no solution.
Figure 1
Strategic information systems planning overview
Step 1: Establish planning parameters
Step 2: Assess the current information environment
Step 3: Propose a new conceptual information environment
Step 4: Investigate potential solutions
Step 5: Plan implementation strategies
Step 6: Develop action plan
Figure 2
Recommended steps for implementing a modular emergency department automation system*
Phase 1: ED patient log/ATD interface
Phase 2: Patient tracking
Phase 3: Triage
Phase 4: Results-In interfaces (lab, rad, etc)
Phase 5: Computer Provider Order Entry (CPOE)
Phase 6: Clinician documentation
Phase 7: Physician charting
Phase 8: Discharge planning integration *
Phase 9: Charge capture, coding, billing *
* These items refer to a totally integrated system. Some of these items may continue to be used as standalone modules during the integration process but brought online in the proper order. Some early phases
may also be grouped (ex. Phases 1, 2, 3 are often implemented together)
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
Table 1: Example of goals, strategic objectives, & potential benefits of an integrated EDIS
Goal
Objective
Benefit
Minimize redundant input
Improve tracking of
patients, equipment, and
staff
Provide cost-effective
physician charting
Provide digital
("filmless") radiology
Automate ATD input into ED system
Automate laboratory, ECG, radiology, and
ancillary reports into the emergency
department record. Integrate discharge
instructions and prescriptions into chart and
automate output for patient
Obtain a passive tracking system that will
automatically track department assets and
provide regular status reports
Investigate methods of physician charting to
determine if better alternative available
Investigate digital radiography systems
Saves staff time
Saves time and provides information on
productivity and efficiency
Productivity may not provide any additional
benefit over current charting method
Allows immediate access to and archiving of
radiographs, may be cost prohibitive
Table 2: EDIS Vendor Contact Information (Updated December 2008)
Product Name
Niche Vendors
Vendor
Website
Alphabetical by Company Name
ALERT EDIS
ALERT Life Sciences Computing
www.alert-edis.com
HealthMatics ED, EMSTAT
Allscripts (Former A4 Health Systems)
www.allscripts.com/products/edis/default.asp
Codonix ED System
Codonix
www.codonix.com
CMR (Complete Medical Record)
CMR
www.cmr-med.com
ED Information Manager (EDIM)
EDIMS (Alpha Physicians Resources)
www.edims.net/edim.php
EmpOWER Systems
Emergency Care Doc Systems
www.ecds.md
EmergisoftED
Emergisoft
www.emergisoft.com
PulseCheck
IBEX (A Picis Company)
www.picis.com/products/emergency-department/default.cfm
iSOFT Emergency
iSOFT
www.isoftplc.com/AU/products/accidentEmergency.asp
OnTrack, CHECKOUT, PET
LogiCare
www.logicare.com
NWS/EDS
New Wave Software
www.newwavesoft.com
AmeliorED
Patient Care Technology Systems
www.pcts.com/Home/ed_solutions.asp
NavigatorWeb
The Poseidon Group
www.poseidongroup.com
Pro-MED Clinical Info System
Pro-Med Clinical Systems
www.promed-windows.com/products.html
T-SystemEV
T-System
www.tsystem.com/ED-Information-System/features.asp
Wellsoft EDIS
Wellsoft
www.wellsoft.com
Enterprise Vendors
Alphabetical by Company Name
FirstNet
Cerner
www.cerner.com/public/Cerner_3.asp?id=184
Sunrise Emergency Care
Eclipsys
www.eclipsys.com/solutions/emergency_care.asp
ASAP EDIS
EPIC
www.epicsystems.com
Centricity Emergency
GE Healthcare
www.gehealthcare.com/it_solutions/clinical/ed.html
Horizon Emergency Care
McKesson\HBOC
www.mckesson.com
ED Management Application
Meditech
www.meditech.com/ProductBriefs/pages/ProductBriefsCSEDM.htm
Amalga (formerly Azyxxi)
Microsoft Health Solutions Group
www.microsoft.com/amalga
(hospital & cross-enterprise)
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
Table 3: Suggested Minimum EDIS Hardware Standards (Updated December 2008)
Item
File Server
Workstations (CPU)
Mobile\Wireless Workstations
Monitors
Printers
Keyboard
Mice
Battery backup\Surge Protection
Power strips and cords
TCP\IP Network
Workstation Environment
Large Tracking Monitors
Redundancy
Supplies
Specialty Software & Devices
Considerations
Standard configuration sufficient to handle the anticipated network traffic with high fault–tolerant
redundancy. Dual redundant servers ideal.
Faster is better, but also space is a major consideration. Small compact “brick” computers amenable to
attaching to the wall under a desk are ideal. In most EDIS installations, the only functions necessary is
TCP\IP, video, mouse, & keyboard outputs. If a local floppy or even hard drive is not required, it is
better to not have it as a potential hardware failure point.
Certain applications may be amendable to portable wireless workstations. Until recently the hardware
for these devices has been heavy, expensive, not rugged enough, and ill-suited to the task. New
technology has emerged that moves the video & input functions to the mobile device making them
much more usable. [EX: Motion Computing C5 - www.motioncomputing.com/products/index_c5.asp]
LCD monitor 22” wide screen (16:9) diagonal size range is ideal. Anything less than 19” is unusable.
Lightweight and thin is best. Certain applications may benefit from monitors capable of being rotated
to portrait orientation. Unless sound is required, integrated speaker only add to the bulk. CRT monitors
are no longer a viable option.
Minimum 35ppm with 1000-1500 page capacity. Duplex & dual paper trays may add additional
functionality.
No frills, rugged, standard 101 layout keyboards are ideal. Specialty keyboards (ex. Microsoft “Natural
Keyboard”) and non-standard layouts can be problematic for multiple users.
Simple, reliable, optical, no frills, standard mice. [EX: MS Standard USB WheelMouse Optical
Ideal solution to avoid mishaps. Must be mounted off the floor to avoid damage.
If necessary, in lieu of battery backup, must be mounted off the floor to avoid damage & mishaps.
1000 Mbit has become the standard.
Each workstation must be ergonomic & suited to the task. Nothing should be left lying on the floor
including power cords & network cables. Dual monitors can add significant efficiency.
Large plasma screens may be useful in certain environments, but with adequate and well-placed
workstations this money may be better spent elsewhere.
Things break – in EDs they break often. Standardize the workstations to allow for “plug and play”
replacement when failures occur. One redundant printer for every 4 and 1 redundant complete
workstation for every 10 is ideal.
Establish a system for replenishing consumables such as toner cartridges, special safety paper for
prescriptions, etc.
Digital paper\pen [Logitech io digital pen], speech recognition, etc. are often touted as offering
significant functionality\efficiency. Their utility remains to be proven.
Additional Reading
В„
Taylor TB. The emergency department of the future. Topics Emerg Med. 1995;17(4):1-10. (An indepth look into emergency medical informatics and the emergency department of the future.)
В„ Taylor TB. Emergency Department Information Systems for Patient Care. Critical Decision in
Emergency Medicine. April 2000; 14(8):12-16
REFERENCES
1
Roy Simpson
Taylor TB. Threats to the Healthcare Safety Net. Academic EM 2001;8:1080–1087
3
Banner Good Samaritan Medical Center, Phoenix Arizona, July 2003 – Author’s personal data.
4
Taylor TB. A View of the Emergency Department of the Future. ACEP Section for Emergency Medical Informatics 2000, Dallas, TX.
5
Taylor TB. A Solution for the Emergency Medicine Conundrum: Point of Service Revenue Capture Program (aka The “Turnstile” ED & Charity Care
Program). Publication pending. For a pre-publication copy send an e-mail request to: tbtmdaz@cox.net.
6
Tierney WN, Miller ME, Overhage JM, et al. Physician inpatient order writing on microcomputer workstations. Effects on resource utilization. JAMA.
1993;269(3):379-383.
7
Kundel HL, et al. Reliability of soft-copy versus hard-copy interpretation of emergency department radiographs: a prototype study. AJR Am J Roentgenol.
2001 Sep;177(3):525-8
8
Survey conducted by the author summer 2003 via an internet list service – unpublished data.
9
Kulick SK, Barthell EN, Felton CW. Strategic information systems planning in emergency medicine: an introduction. Top Emerg Med. 1995;4:36-40.
10
Ferguson J. I/S interoperability a must in tomorrow's complex healthcare environment. Comput Healthcare. 1993;14:22-28.
11
Bleich HL, Slack WV Designing a hospital information system: a comparison of interfaced and integrated systems. MD Computing. 1992;9(5):293-296.
12
American College of Emergency Physicians, Section for Emergency Medical Informatics. Directory of Software in Emergency Medicine. Dallas, TX:
American College of Emergency Physicians; 1996.
13
Annual Medical Hardware & Software Buyer's Guide. MD Computing
14
Emergency Department Systems Study. July 2003. KLAS Enterprises, 207 E. 860 S., OREM, UT 84058, (801) 226-5120 www.healthcomputing.com
15
Model EDIS RFP – For a copy, send an e-mail request to: tbtmdaz@cox.net
16
American College of Emergency Physicians, Section for Computers in Emergency Medicine, Dallas, TX.
17
Proprietary data from market research known to the author.
2
© Emergency Medicine Clinics of North America z Volume 22 (February 2004) z Pages 241–257
POLICY
STATEMENT
Policy #
Approved August 2008
Health Information Technology
Approved by the ACEP
Board of Directors titled,
"Health Information
Technology" August 2008
ACEP believes that:
1. Health Information Technology (HIT) presents ongoing opportunities to
improve the quality of emergency care, promote patient safety, reduce
medical errors, and enhance the efficiency of emergency departments (ED).
Replaces, "Internet Access"
2. Hospitals have a duty to patients, staff, and the community to provide HIT
rescinded August 2008;
Revised & approved by the
that is suitable for use in the ED. HIT should facilitate the delivery of patient
ACEP Board of Directors
care, conform to relevant data interoperability standards, and comply with
titled, "Internet Access"
applicable privacy and security constructs to ensure the secure availability of
February 2003; Originally
relevant health care information.
approved by the ACEP Board
of Directors titled, "Internet
3. Evaluation, selection, implementation, and ongoing assessment of HIT that
Access" October 1998
impacts emergency care is best accomplished with active involvement of
emergency physicians, nurses, and other emergency care providers.
Emergency physicians should have a role in the selection and approval of
any HIT that impacts the ED or the local emergency medicine community.
4. Emergency Department Information Systems (EDIS) are electronic health
record systems designed specifically to manage data in support of
Emergency Department patient care and operations1. EDIS should be
properly implemented, sufficiently integrated, and well-maintained.
5. Emergency physicians must have a role in the selection of EDIS. Clinical
functionality, usability, efficiency, and interoperability should be the primary
criteria by which systems are evaluated. Preference should be given to
systems that ensure support for ED workflow, clinical accuracy, patient
safety, and operational support. System costs and assessment of return-oninvestment should take into account the impact on physician and staff
productivity.
6. Access to historical patient information, including data in Electronic Health
Records and Personal Health Records, should be available for ED patients.
Connectivity with external systems and participation by hospitals in health
information exchanges should be encouraged. Provisions and policies for
emergency access (i.e. “break-glass”) to critical health information should be
in place for emergency physicians to access protected health information
when necessary to prevent harm or risk to life.
7. Access to on-line tools including the Internet, hospital policies and
procedures, medical reference materials, regional status of hospitals, EMS,
mass casualty, and other pertinent information should be readily available.
Reference 1: Health Level 7 Emergency Care Special Interest Group: Emergency Department Information
Systems Functional Profile. Health Level 7, 2007. http://xreg2.nist.gov:8080/ehrsRegistry/index.js
Copyright В© 2008 American College of Emergency Physicians. All rights reserved.
American College of Emergency Physicians в—Џ PO Box 619911 в—Џ Dallas, TX 75261-9911 в—Џ 972-550-0911 в—Џ 800-798-1822
Intentionally Left Blank
Millennium Special Edition 2000
Membership Section
Emergency Medical Informatics
Newsletter from the American College of Emergency Physicians
A View of the Emergency Department of the Future
Adapted from: Strategic Information Systems Planning for Emergency Medicine
It’s 5pm, you just woke up, and you’re between
night shifts. You go to get your “mail”, but not to
the post office box – to your computer. The computer announces “You have new mail”: several personal messages, a notice that next month’s schedule is now available on your group’s web site, follow-up on patients you admitted last night, and a
list of available shifts for next month at an ED
where you moonlight. After downloading your
schedule you note a conflict. No problem. You go
to the web site, check that day, and note 4 others
are available to work the shift. A click of the mouse
notifies each that you need to trade. The moonlighting hospital has no shifts that you can work, so you
send out a broadcast message to anyone wanting to
give up shifts for next month. Business done, you
have a peaceful meal with family & get ready for
work.
At 7pm your pager notifies you the ED is becoming
very busy and requesting you to come in an hour
early. You check the web site. It reveals several
ambulances are expected from an MVA. The video
option allows you to “look around” the ED from
home. Yup, it’s busy alright! You also check the
city-wide EMS and hospital status system. Looks
like everyone’s busy tonight. Off to work!
As you enter the ED the computer status board lists
8 patients waiting to be seen, 4 in triage, and 3
more expected from an MVA. Each are automatically prioritized and you are directed to an elderly
man in obvious respiratory distress, diaphoretic and
complaining of chest pressure. Classic triage dictates you care for sickest person with chest pain
and the others wait. But this is the future and the
routine has changed. The triage nurse has directed
the other patients to appropriate treatment areas.
Most patients are registered via a national database
that automatically enters demographic and medical
information into the system after authorization via
fingerprint identification. Anyone not already in the
system is "self-registered" using a touch screen
computer and scanner. Use of keyboards are virtually eliminated. Managed care plans, PCP’s, and
specialists are automatically notified when appropriate. Each patient is “tagged” with an automatic
tracking device that not only tracks their location
and how long it took to move through the system,
but also automatically logs the patient into the
computer terminal closest to them. The computerized medical record is completed automatically
from information as it becomes available. Meanwhile those “waiting to be seen” are not waiting.
Advanced computer assisted triage protocols help
initiate diagnostic tests (i.e. x-rays, labs, etc.) and
necessary treatment (i.e. SVN’s, O2, etc.).
Back in the treatment area, the elderly man with
respiratory distress is placed on an oxygen mask
that senses end expiratory CO2 levels, a cardiac
monitor, blood pressure, and pulse oximetry. A
nurse initiates lab work and an IV. As you examine
the patient, you order blood work, an EKG, CXR,
Lasix and nitropaste all at the bedside via a hand
held computer linked to the main system by wireless remote. No one need leave the room to notify
radiology or the EKG technician. The computer
system continuously monitors all inputs (cardiac
monitor, pulse oximetry, etc.) and time stamps each
event. You use the bedside computer to confirm the
automatically recorded readings. You document the
history and physical via a hand held touch screen
computer that helps prompt you for the necessary
items to attain the appropriate coding level. The
CXR & EKG results are digitized and included as
part of the computerized record. A copy of the old
EKG is immediately available from the national database & computerized comparison is automatically
performed. An optional "visual record" (video camera) is also added to the medical record to view patient status and for delayed documentation.
The computer prompts that the patient’s end expiratory CO2 is rising, the oxygen saturation is falling, and asks if you should consider assisted ventilation. The patient is intubated and arrangements
are made for admission to the ICU. A touch of the
computer screen automatically pages the PCP, notifies admitting, and the managed care plan. The
completed medical record (history, exam, & treatment) is immediately available to the ICU staff and
sent to the admitting physician's office &\or home
by e-mail. "Calling report" is simplified and communications are more efficient. Documentation is
completed simultaneously with patient care letting
physicians and nurses move on to care for others.
A young child with a wrist injury has not waited
for treatment. Nurses, using artificial intelligence
protocols, have initiated evaluation and treatment
using bedside computer prompted history and
physical exam items. A digitized radiograph is obtained and sent to a remote radiology site where a
staff radiologist is available 24 hours for real-time
evaluation. He indicates on his screen with an arrow his concern about a subtle fracture. The report
is completed in real time, sent back to the medical
record, and awaits your attention.
Your role as an emergency physician has been
transformed. You are no longer a collector of mundane information. The patient &/or more cost effective workers now collect this with automated information systems . You are the director of care, interpreter of data, and teacher. You are not pressed
for time to obtain unessential information necessary to complete the medical record.
Documentation for the wrist injury is confirmed at
the bedside, printed discharge instructions are produced and a splint is applied. Since the patient lives
in another state, a copy of the record with the digitized radiograph is added the national database for
review by the orthopedic surgeon.
Next, a patient with the persistent cough is examined and note is made from the history already entered by the patient that she has been pale and complained of weakness. A CXR is obtained and read
as "unchanged" by the remote radiologist who
compared it with her old films available by digitized record. A CBC is drawn and tagged with a bar
coded label and is analyzed within minutes by the
ED lab. The hemoglobin, hematocrit, and platelets
are noted to be low. A Giemsa-Wright stain is prepared by the main lab and a digitized microscopic
image is sent to a remote pathologist for interpretation. The printed report is returned within minutes
and available at any terminal. A computer generated differential diagnosis is formulated based on
the available clinical information. A peculiar diagnosis prompts further investigation via the Internet.
The search reveals a short summary and additional
resources. No time to read it all now, but a click of
the mouse and it is forwarded to your home computer for reading later. You can now spend time reviewing the information with the patient instead of
sorting and collecting data. Discharge instructions,
medical records, and referral to a hematologist are
automatically arranged. The national database is
also updated for future reference.
There are obvious advantages to such a system. The
staff can spend time caring and talking with patients instead of shuffling paperwork. Physician
support is enhanced by the availability of remote
specialists in real-time that directly assist in the diagnosis. The computer also aids in the diagnosis so
less time is spent scratching your head wondering
what you may have missed. Patients happily receive the best care regardless of day or night.
Medical records are distributed timely to all parties .
There are also some not so obvious advantages.
Clinical information is captured in a database that
allows real time CQI\QA. Patient tracking identifies the weak links in the system and enhances ED
management. Research possibilities are limitless as
all clinical data is in database format.
This is not a dream. The technologies mentioned
here are all currently available. They are admittedly
not well organized. This is what the Emergency
Department of the Future Project hopes to bring
into reality. For more information read
on . . . . . . . . . .
2 Millennium Edition 2000
ACEP Section for Emergency Medical Informatics
Emergency Department of the Future: Introduction
The Emergency Department of the Future (EDOF) project represents our ideas and wishes for an emergency department that automates as
many tasks as possible without burdening staff with mundane procedures such as data entry and patient tracking. Our goals are not lofty.
While this project has been named Emergency Department of the Future, we do not expect a department that is not achievable with current
technology assuming unlimited financial resources. We are not looking for a Star Trek type of plan, however, some of these ideas have been
born from similar futuristic thinking.
Within this document is a schematic that is a loose representation of patient flow through the EDOF. It does not represent physical space, but
the basic components of each area in the EDOF. In the following paragraphs are more detailed explanations and ideas that correlate with the
numbers on the schematic. Please note that this plan is far from complete. The ideas presented here are a compilation of a few years of
planning primarily by one group. It is now your turn to review and add ideas. We hope you will review this information and send your
written ideas to the ACEP Section for Emergency Medical Informatics. You may mail your comments to ACEP at the usual address or email to: informatics.section@acep.org. Also check out our web site at: http://www.acep.org/about/index.cfm/pid/48htm. Let your
imaginations run wild. We will try to integrate any feasible ideas into the plan.
Communication and distribution of medical and demographic information through national network would be ideal. Confidentiality problems
still need to be addressed and may require government regulation. But with the introduction of Internet “E-commerce” these barriers seem
less problematic. We are all plagued by the ED hoppers that seek multiple evaluation for the same problem or simply go to a different ED
when they do not improve. A significant amount of wasted resources could be saved by immediate availability of distributed medical
information. This would also subvert drug seeking behavior from the midnight marauders. Few other systems seem as plausible (including
“medical ID cards” or fax-back systems) as an Internet Medical Record System.
<1> Main & Ambulance Entrance
Security issues are of great concern.1 ED’s will continue to experience
increasing violence as our society wrestles with the American love
affair with weapons. A classic study done at Henry Ford Hospital 2
using a metal detector shows us the magnitude of the problem. In the
four year study period nearly 17,000 weapons were identified! To
ignore security procedures in the EDOF is to create an environment
that is unsafe and unusable. An airport security model may be ideal
for an EDOF and consultants in this area may be a valuable resource.
1
Goetz RR, Bloom JD, Chenell SL, Moorhead JC: Weapons Possession by Patients in a
University Emergency Department. Ann Emerg Med January 1991;20:8-10
2
Thompson BM, Nunn JC, Kramer TL: Incidence and Type of Hazardous Objects Found
Among Patients and Visitors Screened by Magnetometer in an Urban Emergency Center.
Ann Emerg Med May 1992;21:618-619.
Limited Access: As few entrances to the EDOF as possible.
Preferably ALL (including hospital personnel) would enter through
the Main Entrance and go through security procedures. Acts of
violence are as likely to be committed by current or former employees
as gang members. The only other entrance should be an ambulance
entrance with similar, although modified, security procedures to
permit rapid access. No other outside access should be allowed and
fire doors should be alarmed to prevent unauthorized access. Hospital
access should also be minimized and preferably kept to one corridor
with equal security to the main entrance. If independent access is
necessary, "scanning finger print" or other “biometric identification
technology, if possible, for positive identification. Access patterns
should be monitored for recapitulation should an incident occur.
Access code numbers and card swipe security procedures are easily
flawed and do not represent the desired technology of the EDOF.
Metal Detectors: These are an unfortunate reality in our society.
Bullet proof glass at the registration area is more intrusive and does
not stop the real problem. ALL individuals entering the department
should be screened for weapons. Weapon lockers and checking
procedures should be in place.
Manned Security Posts: Each entrance should be manned with 24
hour security personnel. The issue of arming security is more difficult
and will need to be individualized. ED’s with more than 25,000 visits
and\or those in urban setting should seriously consider armed security.
ACEP has recommended a police substation for ED’s with more than
50,000 visits.3
3
American College of Emergency Physicians: Protection from physical violence in the
emergency department. Ann Emerg Med October 1993;22:1651.
Video Surveillance & Panic Buttons: Locations need individual
attention, but consideration needs to be given for all EDOF.
<2> Triage
This area has the most potential for immediate implementation of
automated procedures. Several systems have already been
developed that address the special needs of the triage process.
Information Exchange: Insurance cards or "medical ID cards"
have the potential for containing at least basic information about
the patient. While "RAM card" technology has the potential to
contain the entire medical record and demographics in a credit
card size package, updating this information and reaching critical
mass to make it effective is problematic. Such technology is better
utilized for security procedures and to “point“ to an internet site
where continually updated information would always be available
since the Internet has already established information exchange
and security protocol standards. Electronic photo ID is also
possible. Such technology would help control healthcare fraud and
at the same time help with insurance "notification" nightmares.
Wouldn’t it be great to simply log onto a national web site,
authorize access via fingerprint identification, download medical
and demographic information and then upload the appropriate
medical information to the insurance carrier via electronic
communication?
Electronic ID Bracelet: Tagging each patient with an
electronic ID badge as they enter the EDOF would allow
automatic tracking by infrared or radio frequency as they make
their way through the EDOF. The system would tell you where
everyone is at any moment. The model is the Federal Express
barcode tracking. If they can tell me where my package is among
the 2 million they deliver each day, why can’t I tell a family where
their loved one is or if they have even been seen? Better yet the
system should be able to look over your shoulder and tell you
when delays at certain stages are excessive. Such systems are
already being used in other industries.
Triage Information: Vitals Signs can automatically be entered
into the system with integration of electronic BP, temperature, HR,
RR, pulse oximetry, and weight. Chief complaint can be entered
via standard template categories that assist in prioritizing patients
and assigning resources and bed space. Examples: “Ankle Injury”
would prompt for a triage order of an X-ray. Fevers noted by the
system would prompt for acetaminophen administration and
calculate the dose by weight.
This process begins the electronic chart and all the information is
immediately available to the system and even outside the system
for "notification" procedures with managed care plans.
3 Millennium Edition 2000
ACEP Section for Emergency Medical Informatics
<3> Waiting Room of the Future:
<4> Self Registration:
The EDOF reminds one of Disney World where you pay
$100 for the privilege to wait in a two hour line for a 10
minute ride. Why do million of Americans enjoy this? They
are entertained every minute of the wait. Granted sickness is
not conducive to entertainment/enjoyment, but we can do a
better job than a blaring TV in a room with 50 people and
screaming children.
Society has accepted banking machines, voice mail routing
systems, and point of sale charging systems. It is time to
introduce "self registration". Level 3 & 4 (non-critical)
patients &\or their families can easily be guided through self
registration via prompted computer questions. The area will
still require a hospital attendant to be available but the vast
majority of information can be obtained through an
appropriate computer interface. This interface is important
and simplicity should be paramount. A touch screen or voice
recognition solution would be ideal.
Segregation of Children: Those with children should
suffer together! If you have ever sat on an airplane with a 5
year old seated behind you, you know the aggravation of the
noise and kicking of the seat. Should ill and injured adults be
subjected to this torture in the EDOF? Somehow parents with
children seem to be immune to this torture. Let them suffer
together. It also allows the ED "entertainment" to be tailored
to the age group.
ED "Edutainment":
Appropriate to age, it can range from toys for children to
individual interactive TVs for adults. This would allow a
variety of programming to be available including a vast array
of medical educational programs. The Disney metaphor lends
great potential in this area.
General Information: A general information video
could play at regular intervals explaining the ED process. A
variety of ways of presenting the same material should be
done to avoid boredom. i.e. The same information would be
presented by a cartoon video, then a comedian, then from "the
eyes of a child", etc. I am reminded of the presentation of
cartooning at MGM studios at Disney World with Robin
Williams & Walter Cronkite.
Specific Information: Various videos on a variety of
medical topics that could be selected from a menu.
Status Board: Either by interactive TV, large monitor, or
high tech board, the status of patients could be monitored by
their loved ones using an ID code. It would keep them
apprised of what stage of the process the patient is in.
Examples: "Waiting to be Seen by Doctor", "Waiting for Lab
Work", "Please Contact the Nurse", etc.
<5> Attended Registration:
Some patients will require the personal attention of "live"
registration personnel. However, this role should be expanded
into obtaining the basic medical information mentioned in the
"Self Registration" section.
Mobile Registration: Hand held units or computer carts
would allow registration to take place at the bedside for more
critically ill patients or all patients anywhere in the ED.
Pre-Registration: An effort should be made to preregister patients. This could be done through a marketing
campaign and would benefit the hospital by attracting patients
already registered when the need arises for emergency care.
Free offers to place medical information on "medical
information cards" would encourage participation.
- The Basics Are Outlined Below Demographics: Access to the system could be initiated
by "card swipe", "RAM card", or fingerprint identification as
mentioned above. If current demographic information is
present (via "RAM card" or prior registration) then only
confirmation would be necessary (Is the information correct?
Yes or No). Truly new patients may require assistance.
Medical Information
Much of this information is amenable to prompted
acquisition and can be retained within the system for future
visits. In addition, pre-registration information could include
much of this and make the process simpler at the time of
need. A series of Yes\No questions (either read off the screen
or spoken by the computer) would be asked to build this
database.
HPI (history of present illness): This would be driven from
the Chief Complaint obtained at triage by the nurse. Simple
questions would be asked such as when, where, how long
ago, etc. This information would be supplemented by the
physician later.
ROS (review of systems): One screen with fancy icons for
nausea\vomiting, diarrhea, fever, chills, cough, etc. The
patient would select all the appropriate icons for ROS. These
would then be noted on the "History Work Sheet" for the
physician to address during the face to face interview.
Medications: Alphabetical and categorical listing with
icons and possibly pictures of the medication. A barcode on
medication bottle labels allowing scanning would be ideal or
identification by number printed on the medication.
Immunizations: Simple questions about tetanus, etc.
FH (family history) & SOC (social history):
Obtained as mentioned above.
Photo ID: A digitized photo could be recorded on the
"RAM card" or embossed on the ID card. Also a photo could
be obtained for the medical record at the time of registration.
During my residency I recall "one" patient who had 3
different blood types recorded in the medical record. Further
investigation revealed the same Medicaid card had been used
for at least three different individuals over a period of time.
Positive ID via picture (or other biometric means such as
finger print scan) is a needed addition to the medical record.
4 Millennium Edition 2000
ACEP Section for Emergency Medical Informatics
<6> Treatment Area - NonNon-Critical Patients:
<6D> Computer Hardware:
The emphasis should be on "point of service". Patient data is
entered at the bedside through computer wall units or hand
held computers. As much information should be
automatically entered as possible. Vital signs can be captured
by the automatic blood pressure cuff, cardiac\respiratory
monitor, and temperature at set intervals. Data would then be
confirmed by the nurse before being logged into the system.
Tracking of patients is done automatically by the system and
progress through the department is recorded for CQI\QA and
to improve efficiency. In addition, the system should be able
to identify patients in which a particular phase of their
treatment falls outside of set norms. For example, if lab turn
around takes longer than 90 minutes a flag would be sent to
check on the patient. Specifics are outlined below.
A variety of hardware and interface types are needed to meet
the varied needs of all ED personnel. Desk top terminals
currently used in most ED’s will still be needed, but the
majority of work will take place "point of service" at the
bedside (wall mounted touch screen) or mobile (hand held
pen or touch screen). Mobile units can be connected to the
system by a "wireless local area network" and should have
docking bays to allow for recharging. Size of these units will
vary from the small PDA (personal digital assistant) to tablet
size (8ВЅ by 11 inches). Desk top terminals can also be
redesigned to be more ergonomic by mounting them inside
the desk or panel similar to the wall mounted units.
<6A> Discharge Planning & Education:
This should begin when the patient reaches the treatment area
or even sooner. Subject matter would be driven by chief
complaint. Example One: Laceration - A video could be
shown outlining the laceration repair procedure and wound
care for discharge planning. Example Two: Asthma - A video
explaining the causes of asthma and usual treatments.
Discharge instructions could also be included. Written or
computer interactive responses could also be obtained and
retained in the medical record to document patient
understanding. Several methods for conducting this could be
used including regular video, video computer interactive, or
simple written true\false responses.
<6B> History Work Sheet:
This replaces the usual "face sheet" with scrawled C\C, VS,
meds, etc. All of the current information in the system is
either printed on the sheet in an organized manner or
available on a hand held computer. Certain items can be
mandatory entry before you can move on. For example:
"Laceration" would require tetanus status to be entered.
Items included are C\C, HPI, ROS, Meds, Immunizations,
FH, and SOC. Availability of this information will allow the
physician to quickly scan the data sheet and address the
specifics at the face to face interview. The work sheet could
also include physical exam check off boxes & a “notes area”
where written notes could be recorded in "electronic ink".
This work sheet could even become the physician’s medical
record if all details are complete or it could simply be used as
notes for later dictation.
<6C> Treatment Phase:
Treatment, medication, lab\X-ray, & patient education orders
are entered via the bedside terminal or hand held computer.
These orders are tracked by the system for expected
completion time and prompting for re-evaluation. Treatment
protocols are available based on chief complaint to speed
order entry. Artificial intelligence systems can even be
integrated to suggest differential working diagnosis and
treatment strategies. Continuous monitoring by the systems
takes place during the entire treatment phase.
<6E> ReRe-Evaluation:
Ongoing vital signs are logged automatically with parameters
to warn of abnormal or inaccurate findings. Confirmation
should be required before this information is permanently
recorded into the system. Re-checks can be noted with a
simple touch of the screen and prompting for re-evaluation
and lab review is automatic.
<6F> Medical Decision Making:
(a.k.a. Computer Assisted Thinking)
Check lists prompt you with a differential diagnosis based on
all the clinical information in the system and might also
suggest lab tests or treatment protocols. Systems such as
"Chart Checker" can review your transcribed record for
adequate documentation. This one area has a vast amount of
potential and may require more sophistication than the whole
EDOF project combined.
<6G> Discharge:
Many discharge products already exits, but few are integrated
and none can produce publication quality output. As
mentioned above, video will play a major role in discharge
planning. However, the ability to produce publication quality,
patient specific, and multilingual printed instructions are a
necessity. Information on the diagnosis, medication
prescribed, and follow up information is imperative. The
system could also provide map instructions on how to get to a
particular doctor’s office or local pharmacy. With the
prevalence of managed care, information on the patient’s
health plan and pharmacy formulary will also be useful.
Prescription writing should be integrated and trigger the
appropriate discharge medication information. Allergy
checking and routine diagnosis driven prescribing options
should be available.
<6H> Data Transfer:
Once all of the information has been collected it should serve
more than a legal record. It can obviously be retained in a
printed or electronic format for the hospital, but automatic
distribution to the referred physician by fax\modem\Internet,
to the health plan, and coding\billing company is also
important. Data could also be transferred to a national data
bank to allow access by other hospitals, physicians, etc.
5 Millennium Edition 2000
ACEP Section for Emergency Medical Informatics
<7> Treatment Area - Critical Patients:
<8> Computer System:
Many of the same principles apply to this area as in the noncritical area. The difference being most of the activities
(registration, history data base, etc.) will take place at the
bedside and will require personal attention by the staff. Also,
critical patients often do not fit well into a structured system
and therefore allowances will need to be made for this
specialized care.
Affordable computer systems are already available that are
capable of handling the EDOF. The missing technology is
the software innovation and integration.
<7A> History Base:
See <6B>
<7B> Treatment Protocols:
Critically ill patients often fall into general categories and
therefore treatment protocols can be used to save time and be
more efficient. Many hospitals currently use similar protocols
at level one trauma and chest pain centers.
<7C> Level One Patients:
Many trauma centers already use video to critique their
trauma resuscitations. Beyond this, video could also be used
to simply record the events for delayed charting. Medication
administration could be recorded on-line with time stamp, but
other details could be reviewed later by video. How often
have you lost track of the number of times you defibrillated a
patient during a cardiac resuscitation?
<7D> Smart Beds:
Beds:
Why do we place a patient on mobile bed and then hook them
to the wall? When they need to be moved we hook them to a
portable monitor and then back to the wall. Beds should be
designed with monitor wiring and power supply built-in.
Portable units could then be attached when monitoring is
necessary and an RF\telemetry device used to transmit data to
a central monitoring system. Hydraulics should be designed
to allow quick and easy adjustment.
<9> Emergency Department Lab:
80% of the labs done in the ED are those listed. New
technologies are emerging that will finally make a satellite
ED lab possible. The ISTAT is an example. It provides the
same information as an BMP and H&H (Na+, K+, Cl-, CO2,
BUN, Glu, HGB, HCT) in a 2 minute test for a cost of about
$7.50. The unit interfaces directly with the hospital main
frame computer recording the results automatically.
Reliability test at Good Samaritan Hospital in Phoenix,
Arizona (beta test site) have shown it to be as accurate
(excluding CO2 and pH) and more consistent than the BMP
instrument in the main lab. Arterial blood gas modules are
also available with the same and other similar instruments.
This technology also has the potential to provide a number of
drug levels (i.e. theophylline). Monoclonal antibody
technology has provided a rapid and reliable drugs of abuse
urine screen and pregnancy tests. Reduced lab turn around
time equals increased efficiency.
Central File Server:
A graphical object-oriented operating system is a must and
several operating systems are vying for supremacy. Any
system must provide the highest level of security and fault
tolerance. There can be no down time. Large amounts of data
must be available on-line and may require use of multiple
CD-ROM/DVD technology. The most difficult part is often
interfacing with current hospital information systems that
have lagged far behind other industries. The EDOF would fit
best in a hospital that has a vision of the "Hospital of the
Future".
Bedside Wall Units:
Touch screen wall units are readily available and have been
used in other industries for years. The advantage in health
care is that they eliminate the keyboard (a deterrent to use)
and are less of a dirt collector. Bedside computing is not as
practical with a keyboard system. Each patient room needs a
unit dedicated to that patient. The main screen shows the
patient status and tracks movement through the department.
Each terminal should also have the capability to monitor all
other patients and the main system screen.
Hand Held PDA (personal digital assistant):
This technology has finally come of age with the introduction
of Windows CE and the PalmPilot. Lightweight and
connected via RF local area wireless networks, these portable
computers allow you to compute where you work. They are
best suited to check off boxes, but can also be adapted to
written "electronic ink", handwriting recognition, and voice
recording/recognition. Battery life is improving, but docking
stations will be required for recharging.
Hand Held Tab
Tablet:
let:
Registration may find a larger portable tablet computer or
mobile laptop computer workstations more useful for
entering larger amounts of data. These would have the same
functional purpose as the PDA but a larger interface.
Desk Mounted Units:
These could be the same wall mounted touch screen units
inserted into a desk top or desk panel. Others may require a
key board for special purposes.
<10> Patient Rooms:
This box summarizes the additional items needed in the
EDOF for patient’s rooms.
Credits
Ideas presented in this document are credited to:
The ACEP Section for Emergency Medical Informatics
Emergency Department of the Future Committee
This document was written and produced by:
Todd B. Taylor, MD, FACEP
6 Millennium Edition 2000
ACEP Section for Emergency Medical Informatics
Special Section: The Internet & The EDOF
The Internet
The Internet (a.k.a. the Information Superhighway) is transforming
our lives at home and work. It is now becoming clear that the
Internet will be the solution to many of our personal and professional
information problems. Why? Because it simply works and, for the
most part, it is FREE. It has the potential to have a greater effect on
society than the invention of the telephone, the automobile, and the
airplane. The telephone allowed us to speak without going and the
automobile/airplane allowed us to go when necessary. The Internet
eliminates the need to speak and to go! It also allows us to collate
disparate information from multiple sources to a single location
without human interaction. Businesses (including medical businesses
such as information systems vendors, hospitals, and physician
groups) that are not embracing the Internet will have difficulty
surviving in the “Internet Age”. Much of what we will do in the
future will be dependent on this technology and that has never been
more true than in the medical arena.
What is the Internet?
The Internet is like a telephone system optimized for computer-tocomputer interaction rather than for voice communications.
Originally designed for the military, the National Science Foundation
transformed it into a way for scientists to access the few
supercomputers that existed in the 1970's. With the advent of the
personal computer, the Internet evolved into a tool for everyday use.
Quite simply it is a way to access the vast array of digital
information available throughout the world. While this information
remains relatively disorganized, software called Internet browsers
(eg. Netscape’s Navigator and Microsoft’s Explorer) make sense of
this formally archaic system. They make connecting and getting
around the Internet easy and fun.
Getting Connected
Anyone with a modem capable personal computer (PC compatible or
a MacIntosh) and a Internet Service Provider (ISP) can connect to
the Internet. The ISP is your gateway or “on-ramp” to the Internet.
They sell access to subscribers for a flat monthly fee or time based
rate. There are hundreds of commercial ISP’s (CompuServe,
America-On-Line, Prodigy, Juno, PSInet, MSN) and a number of
other sources of connections that may be cheaper or even free.
The World Wide Web (WWW)
The World Wide Web is the information age come to life. Although
computers have been around for more than 50 years with vast
quantities of information, until now there has been no easy way for
the individual to access the information. This has radically changed
with the WWW. The WWW uses “hypertext” to allow graphics,
sounds, and even video to be sent and displayed over regular phone
lines to your computer. Hypertext is a computer language that allows
cross-linking of related information. Key words are highlighted and
by clicking with a mouse you are immediately sent to the
information related to that word within the same document or to
another computer around the world. For example, if you are reading
a description about fractures, there may be a hot link that will display
the corresponding x-ray. The beauty of the WWW is that this is all
transparent and you can move back and forth with ease.
The Future for Internet Medical Computing
There are thousands of medical sites on the WWW although much of
it is still poorly organized. That will certainly change in the near
future and will alter the way we think about continuing medical
education (CME), medical resource material, consultation, medical
periodicals, and every other aspect of our practice.
CME: Instead of paying thousands of dollars to attend a medical
conference, you will be able to enjoy it from the comfort of you own
home and still be able to interact with the speaker by asking
questions over the Internet. In fact, you may get more out of the
experience since your question is more likely to be answered albeit
perhaps after the fact. In addition, you will no long have to choose
between one session or another as all sessions will be available to
you on-line and eliminate the need to listen to audio tapes.
Telemedicine (“Internet Medicine“): The internet may be the thing
that make telemedicine affordable for the masses. Teleconferencing
is already a reality and a short step to telemedicine. HCFA is also
addressing how physicians might get paid for this unique service.
Data Retrieval and Exchange: This is the Internet’s real strength –
a standard for information exchange. Disparate information can be
collated and delivered in a consistent format. Examples include:
Patient Records/Demographics, Business Management Information,
and Professional Communication via E-mail. Software vendors such
as Microsoft are making their products HTML (internet language)
compatible. Physician scheduling programs should be made “webenabled” to allow work schedules to be on your group’s web site.
What Can the Internet Do?
The possibilities of the Internet are expanding every day. It has
become much more than a place to look for information. It is quickly
The Internet is limited only by your time and imagination.
becoming a mechanism for commerce (i.e. shopping,
stock trading, product information, advertising etc.);
personal communication through electronic mail
Вѕ Listed below are a few interesting web sites you may want to try ВЅ
services; video conferencing; and data exchange (i.e.
National Center for Emergency Medical Informatics: http://www.ncemi.org/
transferring a computer file from one place to
another). Traditional forms of Internet
EmedHome: www.EMedHome.com
communication such a “newsgroups” or “chat” (an
Radiology Department at the University of Washington
Internet location for groups of people with similar
http://www.rad.washington.edu/AnatomyModuleList.html
interests to interact) remain prominent and are
The Virtual Hospital at the University of Iowa
probably the best source of medical information. In a
http://indy.radiology.uiowa.edu/VirtualHospital.html
newsgroup, you can post a question and receive
"Dermatology On-Line Atlas"
answers from others with an interest in that topic or
http://www.rrze.uni-erlangen.de/docs/FAU/fakultaet/med/kli/derma/bilddb/db.htm
browse other consolidated information on a particular
"Normal & Abnormal Heart Sounds" collection at the University of Alberta
topic. There are more than 11,000 different
http://synapse.uah.ualberta.ca/synapse/00b10000.htm
newsgroups with more being added every day.
The "Virtual Medical Center" at the University of California-Irvine
E-mail “list servers” allow communication with large
http://www-sci.lib.uci.edu/~martindale/Medical.html
numbers of people with the click of a mouse. You
can also subscribe to “clipping service” that will seek
American College of Emergency Physicians: http://www.acep.org
out information that you want and deliver it at your
Society for Academic Emergency Medicine: http://www.saem.org
convenience. Truly “information at your fingertips”
7 Millennium Edition 2000
ACEP Section for Emergency Medical Informatics
2000 Section Report: Emergency Department of the Future
It seems like only yesterday that the ACEP Computer Section was born, but it has almost been 10 years. The Section has completed
and continues to revise several publication related to computer technology. These are available by request.
♦ A View of the Emergency Department of the Future
♦ Preparing for the Emergency Department of the Future: Strategic Information Systems Planning for Emergency Medicine
♦ Directory of Software for Emergency Medicine
♦ Emergency Department Management Systems - Model Request for Proposal (RFP) & Vendor Information List
The Computer Section’s objective of enhancing computerized technology in emergency medicine continues gain momentum. The
ACEP appointed a “Technology Committee” that produced a report on current technology and how ACEP might best use it (available
for ACEP). The ACEP Web Site continue to grow and take on new roles within the College.
Our dream of an EDOF exhibit was realized at the 1996 Scientific Assembly in New Orleans, but the work continues. The EDOF lecture series outlining the Emergency Department of the Future continues to be presented world-wide including Spain and Israel in in
the last several months. The Section will continue to define our vision of the Emergency Department of the Future by utilizing computerized technologies to improve our delivery of emergency care. The revised description provided in this issue is just a place to
start. Feel free to contact us with your ideas of how our vision can be improved.
Emergency Medical Informatics is the
newsletter of the Section of Emergency
Medical Informatics of the American
College of Emergency Physicians. Opinions
expressed do not necessarily reflect the
College’s point of view.
Editorial Policies
Typed submissions or ASCII text on DOS format disk.
Submitted material may be edited.
Similar submissions are at the discretion of the editor.
Deadline for submissions is 30 days prior to publication.
EDOF Goes International
Excitement about the Emergency
Department of the Future continues
to gro w. In 1999 it went
international and was presented at
the 2nd International EPES Forum in
Magala, Spain on October 28, 1999.
It was also presented in March at the
7th Annual Scientific Assembly of
th e I s ra e li As s o c i ation for
Emergency Medicine along with Todd B. Taylor, MD, FACEP presents the EDOF at the
several other informatics topics.
2nd International EPES Forum in Magala, Spain.
Section Chair:
Jonathan Handler, MD, FACEP
Section ChairChair-Elect:
Michael Gilliam, MD
Section Secretary:
Todd Rothenhaus, MD
Immediate Past Chair:
Kirt Walker, MD, FACEP
Newsletter Editor:
Kirt Walker, MD, FACEP
E-Mail:
informatics.section@acep.org
Web Site:
http://www.acep.org/about/
index.cfm/pid/48htm
Forward submissions
and address changes to:
ACEP Section for Emergency
Medical Informatics
PO Box 619911
Dallas, Texas 75261-9911
ATTN: Stu Allison
В© Copyright 2000 American College of Emergency Physicians
Suggested Reading & References:
1) Preparing for the Emergency Department of the Future: Strategic Information Systems
Planning for Emergency Medicine, ACEP Publication.
2) Directory of Software for Emergency Medicine, ACEP Publication
3) ACEP Section for Computers in Emergency Medicine Newsletter and Software Reviews,
ACEP Publication
4) Personal Medical Computing by William Cordell, MD, FACEP
5) Topics in Emergency Medicine, “Emergency Department Informatics: An Overview (Dec
95) & Management Systems (Mar 96)” editors: Todd Taylor, MD, FACEP; Vickey Bradley,
MS, RN, CEN; Karen Sue Hoyt, MN, RN, CEN.
6) Emergency Medicine: The Core Curriculum: Automation & Informatics by Todd Taylor,
pp. 1317-24, ed. Richard Aghababian, pub. by Lippincott-Raven 1998
7) Smith MS, Feied CF: The Next-Generation Emergency Department. Ann Emerg Med
1998;32:65-77
The Emergency Department of the Future (EDOF) Video
May be purchased from Visual Eyes for $25.00 (includes shipping). The EDOF video was
produced with a grant from the Health Information Network and cosponsored by the Defense
Advanced Research Projects Agency and by the American College of Emergency Physicians.
Make your check payable to: "Visual Eyes - EDOF" for $25.00 (credit cards NOT accepted).
Don't forget to include a ship to name and address.
International: PAL version available upon request. Shipping extra. Call or e-mail for pricing
Visual Eyes - 31320 Via Collinas #118 - Westlake Village, CA, USA 91362
Contact Charla: charla@visualeyes.com Studio: 818-707-9922 Fax: 818-707-2393
Main Entrance 1
Level 3 & 4 Patients
Security & Metal Detector
2
DATA
AQUISTION
Internet Access
Card Swipe
Bar Coded
ID Bracelet
Ambulance
Registration
Many of the same principles
apply to this area depending
on the complexity & critical
nature of the patients.
A
Obtained at bedside by RN or
Tech. & confirm any preregistration information
already in system.
Treatment Protocols
Battery of tests & procedures
driven by C\C & working
B
diagnosis.
Example:Cardiac Chest Pain
Oxygen, Cardiac Monitor, IV,
Draw bloods, BP monitor, VS
q15' until evaluation, EKG.
C
Available use of video\visual
record with time stamp to be
used later to record written
record of events.
Critical Care Area 7
Smart Beds D
Self contained carts with state of
the art hydraulics allowing you
to set various positions with
auto adjust. i.e. Trendelenburg.
All monitoring circuits built in
such that BP, cardiac monitor,
temp, respiratory monitor, pulse
oximeter contained within the
bed. Data is transferred via RF to
central & bedside mounted
monitors.
No matter where the patient goes
in the ED they are monitored and
locations are noted with time
stamp.
Hand Held
Pen or Touch
Portable on WAN
Re-Evaluation E
Interface w\monitor for
VS, Rhythm Strips
Log RN & MD Re-evals
& findings
F
Medical
Decision Making
Templates based
on C\C &\or Dx
Order Entry
Medications
X-Ray
Treatments
Cast\Splinting
D
Entered at bedside or work
area during or after H&P
Status of orders listed as well
as prompts for re-evaluation.
Desktop PC or
in-desk mounted
touch screen
C
Interactive recorded
responses insures
understanding.
5
Bedside
Wall Mounted
Touch Screen
Treatment Phase
1
1
See Non-Critical Area
Level One
Prompted by
working diagnosis
-------------------------Video via
laserdisk or Tape
Multilingual
Only used if not Preregistered &\or can not use
self registration.
Level 1 & 2 patients
registered at bedside via wall
or hand units.
Alias MR# allows care to
proceed w\o registration
Level 1 & 2 Patients
Security Procedures
History Base
Prompted
Hand Held
Pen or Touch Screen
Area for "ink" notes
Will be used for later dictation.
Begins during
the Rx phase
3
Non-Critical Area 6
Physical Findings
General & Specific
2B
ENTER
C\C
VS
2A
or
N\V\D\F\C\C\ST
B ABD Pain\Dys\Freq
CP\SOB\H-A
Mandatory Items for QA
Discharge A
Planning &
Education
Self Registration
HPI
4
ROS
Meds
Immunization
FH
SOC
Photo
History Work Sheet
History Printer
1
Triage
Waiting Room 3
Status Board by ID #
Educational Videos
Discharge G
Diagnosis
Printed Instructions
Video Instructions
Prescriptions &
medication information
Follow Up w\ map
Data Transfer
H
Automatic
PMD by Fax or Internet
Hospital Main Frame
Insurance Company
Billing Company
QCI Checking for
alternative Dx based on
clinical information
present in data base.
Artificial Intelligence
Systems
Internet
Connection
Internet Access
Emergency Department of the Future
Room Patient Name
PMD
C\C
LAB
Computer System
8
A
Polly Uria
B
Abby Normal
Central File Server:
C
Freddy Krugger
Graphical Operating System (i.e. Windows NT)
High Level of Security (RAID & User)
Interface with current hospital systems
D
Fred Flintstone
E
Barney Rubble
F
Tim Allen
G
Judy Jetson
Bedside Wall Units: (each room)
Touch Screen
Shows patient status and VS asking
for confirmation and set intervals.
Automatically track patient movement through
ED via IR or RF ID badge..
H
George Jetson
I
Mr. Spacley
J
Ed Barthell
Hand Held PDA:
K
Jack Brown
L
OPEN
Pen or touch screen
WAN connectivity
Primarily used with check off lists
M
OPEN
N
OPEN
O
OPEN
Hand Held Tablet:
As above, but used when more information
needed to be viewed on screen at once
P
OPEN
Desk Mounted Units:
Q
OPEN
May have keyboards for lengthy input.
Still have touch screen for routine use.
Schematic & Text by Todd B. Taylor, MD, FACEP
Produced with VISIO 2.0 by Shapeware Corporation
ED Lab
9
Available Items: (May need lab tech)
ABG
BMP
CBC
Urine Drugs of Abuse
Serum Pregnancy Test (Quantitative)
Certain Drug Levels
Patient Rooms
Available Items:
Monitor w/ Interactive Video Interface
Video for documentation
Computer Wall Unit
Smart Bed w\ monitoring equipment
Bedside ultrasound
10
Pennsylvania ACEP Emergency Department Information System Requirements - Vendor Score Sheet
S= Standard & in live use at 2 Clients
B= Beta Testing with at least ONE client
C= Customized
EMERGENCY DEPARTMENT INFORMATION SYSTEM VENDOR
Registration
Is there a quick registration?
Is there an anonymous registration?
Are you able to merge a quick / anonymous registration with a final/full registration?
Triage - Documentation
Does the Triage module document the acuity/treatment priority?
How are nursing assessment and charting entered in the module?
Does the software use the triage information to assist with patient flow & practitioner workload?
Patient Status (Status Board) Patient Tracking
Ability to track patients by location?
Ability to track patient-physician relationships?
Can the system show where the patient is?
Can the system show what the patient is waiting for?
Does the system automatically track wait times (for room assignment, diagnostic test) and flag the staff when limits
are reached?
Does system use patient tracking information to deliver alerts & time warnings to assist in patient flow & movement?
Order Entry
Does the system have physician order entry?
Does the system have order sets?
Can the order sets be customized by individual care giver?
Handle free text orders (i.e., strange verbal orders from MD's).
Automatically trigger orders from clinical path in the appropriate path day/date and time.
Notify or page physician based on documentation that addresses specific standards &/or patient-specific call orders.
P= Planned rollout in less than
F= Future > 12 months
NA= Not Available
#1
#2
#3
#4
#5
S= Standard & in live use at 2 Clients
B= Beta Testing with at least ONE client
C= Customized
EMERGENCY DEPARTMENT INFORMATION SYSTEM VENDOR
Correspondence
Document communication between hospital, individuals and external organizations.
Use internet technology to share information (e.g., pulling in a little used procedure from P&P book into the path of the
particular patient).
Supports Advanced directives across continuum
Flag patients with special needs
Order entry and documentation supports academic environments (i.e. unverified orders or documentation of medical
staff or nursing students)
Use alias' or hide patient's identity.
Alerts for practice standards
Send HL/7 formatted information (send/receive ADT, orders and results, documentation) to other systems.
Medications are passed from inpatient to outpatient system
Critical Pathways
Critical Pathways is incorporated into system-user can design and/or modify
Ability to document against the pathway
Medication Administration
Chart medications, including IV's on-line
Calculate medication doses
Flag abnormal or critical information, such as lab values
Alert nursing staff of medications that are due or not charted
Print appropriate order requisitions in all departments, when/if needed
Generate work lists by caregiver, by station, by shift
Produce on-line Medication/IV Administration Guides
On-line access to patient education databases
Document patient education
Print medication information, discharge instructions, etc.
Display and print an individual patient census by physician
Display and print patient demographic data
Documentation of observations/assessments/ treatments
Nursing Quality Assurance
P= Planned rollout in less than 12
F= Future > 12 months
NA= Not Available
#1
#2
#3
#4
#5
S= Standard & in live use at 2 Clients
B= Beta Testing with at least ONE client
C= Customized
EMERGENCY DEPARTMENT INFORMATION SYSTEM VENDOR
Equipment Interfaces
Critical Care monitoring devices
Ventilators
IV rate control device
Pulse oximeters
Fetal monitors
Provides access to national clinical databases such as the Medline database
Grateful Med
on-line drug information
Micromedix
CDC, NCHS, etc.
Automatically generates notification of attending, consulting and interpreting physicians of admit/discharge dates and
final diagnosis
DATA ISSUES
What vocabulary standards are used for drugs, problems, labs, etc.?
Order Communications
Does the system also do order communication to other systems and other departments?
Produce laboratory specimen transmittals for nurse collected specimens
What on-line alerts are provided in the system for the following interactions?
Does your system check dose ranges (based on weight, body surface area, renal and liver function)
How could orders which are considered inappropriate according to hospital-defined protocols be identified?
Results Reporting
Displays results and vital signs in graphical format (trends over time) as well as numeric and textual formats.
System stores impressions and full text results.
System highlights critical/panic values and abnormal results.
How does the system provide the capability for results to be incorporated into letters to referring physicians?
How does the system provide electronic signature capability for approving results, discharge summaries, etc.?
Does the system handle charting of in-dept lab work (i-Stat, Pregnancy, UA)?
P= Planned rollout in less than 12
F= Future > 12 months
NA= Not Available
#1
#2
#3
#4
#5
S= Standard & in live use at 2 Clients
B= Beta Testing with at least ONE client
C= Customized
EMERGENCY DEPARTMENT INFORMATION SYSTEM VENDOR
Physician Charting
Is there a physician charting section?
Does the system import dictation results?
Are there user-defined risk management protocols by chief complaint?
Can a copy of the ED chart be transmitted (fax, modem, etc.) to the patient's physician?
Pre-Hospital Assessment
Interfaces exist for pre-hospital assessment tool?
Is there a method for documentation of pre-hospital severity classification?
Nurse Charting
What is the method of documenting nursing assessment?
What standard flow sheet exist? (trauma, cardiac, minor trauma etc.)
Are standardized Nursing Data Classification supported? (Nursing Diagnosis, Nursing Intervention Classification
System, Nursing Outcomes Classification)
Does interface exist for automated medication dispensing equipment?
Can information be viewed by nurses in other departments such as CCU?
How are supplies documented and orders made for restocking?
Discharge Instructions
How are referral instructions given?
Are 2 copies automatically generated (one for patient, one for chart which is signed)
Can prescriptions be written and printed?
Does the work/school release accompany the release instructions?
Does discharge instructions interface with ADT system for physician name, address, etc.
Can the system coordinate follow-up visits within the hospital? MD offices?
Discharge instructions with multiple languages?
Charge Capture
Can a charge be automatically generated from the clinical data?
Does the charge correlate with documentation? Does it comply with RBRVS standards (Resource Based Relative
Value Scale) or identify associated ICD-9-CM to avoid abstracting efforts?
Real time interface with which physician billing systems?
P= Planned rollout in less than 12
F= Future > 12 months
NA= Not Available
#1
#2
#3
#4
#5
S= Standard & in live use at 2 Clients
B= Beta Testing with at least ONE client
C= Customized
EMERGENCY DEPARTMENT INFORMATION SYSTEM VENDOR
Quality Assurance
Is there a quality assurance component?
Can the ED visit be linked and brought forward to an inpatient visit?
What quality control indicators can be entered into your system?
Describe how your system processes sentinel events to trigger further review.
Risk Management
Describe how the system supports flagging patient who are potentially a high risk for lawsuits. Can the user be
prompted when that patient presents again?
Integration Issues
Integrated with Multi-disciplinary, enterprise-wide networked CIS?
Non-proprietary operating system?
Standards compliant (POSIX, HL7, P1073)?
Links to interface engine?
Links to clinic, office, home (up/downloading)
Links to remote databases (WAN, Internet)
No downtime (redundancy, mirroring, instant rerouting)
Standby off-site disaster recovery
Sub-second response time (1-2 seconds maximum)
Multi-media clinical workstation (GUI, easy to use)
E-mail messaging (non-urgent notes, follow-up, referrals, suggestions)
Mouse, trackball, handheld devices, scanners, penputing
voice recognition
automated data input from invasive and non-invasive hemodynamic monitors
Is there security to prevent unauthorized 'browsing' of patient information?
How can hospital use your IS to track physician profiles, but restrict MD access to any economic credentialing and/or
other physician revenue?
Physician Billing
Is there the capability to interface to third party physician billing systems.
Ability to print clinical information in offices and ambulatory clinics
Allows physicians to communicate electronically (mail message).
P= Planned rollout in less than 12
F= Future > 12 months
NA= Not Available
#1
#2
#3
#4
#5
S= Standard & in live use at 2 Clients
B= Beta Testing with at least ONE client
C= Customized
EMERGENCY DEPARTMENT INFORMATION SYSTEM VENDOR
ED Report Writing
Can reports be generated from the system?
Death reports?
Trauma registry? AMA log? Admission log?
Return visits?
Reportable diseases?
Work flow analysis?
JCAHO reporting for the department? Service indicators?
Continuous quality improvement data collection?
Medication history for patients
Does it provide generic vs. brand name medication cost-comparison alerts?
What tools are provided to satisfy COBRA regulations with respect to patient teaching and counseling? Can these be
modified by the users?
In which languages do you provide patient education?
Are there drug/disease alerts?
Reference Material
How is reference material accessed?
GRAND TOTAL for Emergency Dept.
P= Planned rollout in less than 12
F= Future > 12 months
NA= Not Available
#1
#2
#3
#4
#5
From: John Comis jfcomis@gmail.com
To: ED Directors Academy Class 1 edda1@elist.acep.org
Sent: Sunday, December 21, 2008 1:05:12 PM
Subject: Re: edda1 digest: December 19, 2008
Hi All:
Are you using a laptop for an EDIS?
We are moving to Tev in 5 months.
•
community hosp
•
25k visits
• 1 doc, 1 MLP, and a fast track
I want something sturdy that works at the bedside.
From: Mark Reiter [mailto:mark.reiter@yahoo.com]
Sent: Sunday, December 21, 2008 10:16 AM
To: ED Directors Academy Class 1
Subject: Re: edda1 digest: December 19, 2008
John,
You will find that some members of your group will prefer laptops, tablets, or computers on wheels. However, in most
EDs, after a few weeks, the great majority of physicians will end up documenting on desktops.
I've used T-System EV in the past for 1 1/2 years. Although it is one of the fastest charts to create of the different EDISs,
it's still pretty hard to document accurately and comprehensively while at the patient's bedside. You can certainly do it,
but most docs feel that it compromises their interaction with the patient. I type very fast and am very comfortable using
an EDIS but I now document 100% of the time on a desktop away from the patient.
Mark Reiter, MD MBA
CEO, Emergency Excellence
From: John Henner [mailto:jhenner1@cox.net]
Sent: Sunday, December 21, 2008 11:46 AM
To: ED Directors Academy Class 1
Subject: RE: edda1 digest: December 19, 2008
I would echo the same.
Prior to implementation of TEV 3 years ago we did a great deal of research on tablets with the same goal in mind. We
were adamant that we would continue the bedside documentation as we did on the paper T-System. After the first week
we found that the tablets were just plugged in and used as desktops. As a result we’ve been stuck with the small screens
and keyboards of these make shift desktops as opposed to just purchasing good desk tops initially. The biggest obstacle
was the comments from pateints that were frustrated when the physician was looking at a computer while talking to them.
I would add that we’ve just begun implementation of a scribe program and now the scribes do bedside documentation on
TEV while the physician completes the H&P. This is resulting in increased provider productivity and is the best solution
we have found for this.
My recommendation is that if you don’t anticipate using scribes – stick to a desktop.
John Henner, DO
COO, Fremont Emergency Services
From: Todd B. Taylor, MD, FACEP [mailto:tbtmd@cox.net]
Sent: Sunday, December 21, 2008 12:44 PM
To: 'ED Directors Academy Class 1'
Subject: RE: edda1 digest: December 19, 2008
I agree with Mark. Most that use “structured” computer documentation will gravitate to a “sit down” desktop computer (vs
using even a “Desktop Computer on Wheels” near the bedside). In doing so you often lose the biggest efficiency
opportunity which can be gained by using a paper template at the bedside (i.e. “multi-tasking”). However, I do know some
that use the TEV on a tablet at the bedside.
The reason is more than just the technology and has to do with how we process patient information, i.e. in a “linear”
fashion. We usually receive info in a random way, despite our best efforts to get patients to “follow our script” (or more
accurately the computer documentation outline). Plus, we seldom get all the info we need to document at one time
(asynchronous data collection). That’s also why we tend not to document things, because the “transactional cost” (i.e.
time to find a computer, log on, & execute) is so high with computer documentation (i.e. vs just picking up the paper chart
& pen).
The latest trend is to employ scribes to mitigate the “transactional costs” of EDIS in general, but documentation in
particular. So it depends upon your process as to which might be the “best” hardware.
Our real opportunity with documentation is to automatically capture and process data. For example, why not have the
patient complete a ROS, PFH, PSH, etc. on a kiosk or on a bedside swing arm computer? With the right software, most
could probably even do the HPI. Wouldn’t it be great to walk into the room with 80% of your documentation already
completed? In the meantime, you could just use paper forms, just like every primary care doctor does. Not sure why we
have not done so in the ED.
Below are several observations that may be helpful as you make these EDIS hardware decisions. As always, anyone who
would like my EDIS Compendium (a comprehensive look at EDIS), email me directly at: tbtmd@cox.net
Todd B. Taylor, MD, FACEP
Disclaimer: I now work for Microsoft. We do not sell hardware, but do market enterprise software to assist in data
collection and aggregation.
EDIS Hardware Observations:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Spend as much time planning and selecting the hardware as you do the EDIS. You will also likely need to redesign your work
space to accommodate all the new computers. A hospital architect, Jon Huddy once said, “There has never been an ED with
enough work space. . . there never will be.”
You can never have enough workstations (at a minimum one – plus backups - for each clinician in each area, i.e. each nurse,
doctor, plus clerical)
Remember to accommodate residents (both ER & others coming down from the floors) with their own work stations. If you do not
they will occupy (i.e. screw up) yours.
For desktops, have a dedicated workstation (i.e. once you get it set up no one else should mess with it) for docs & nurses.
Don’t call them “Computers on Wheels” – COWS. It has already happened that larger patients will misinterpret your request to “Get
the �COW’ out of room 3”. Other options include: “Workstation on Wheels” (WOW), or just “computer”, etc.
“WOWs” can create “virtual” desk space. We placed one for each nurse by the 3 rooms they were responsible for. It got them out
of the nurse’s station and closer to the beside (although less time actually at the beside).
Minimum screen size is 22” wide-screen. You may want to have a dual monitor set up (e.g. one for PACS, one for EDIS). Get
monitors without the bells\whistles (i.e. no built-in speakers) that have a thin bezel, have a narrow depth (i.e. space from screen to
the wall) and are light weight. As above, make sure it will fit into your workspaces to include the keyboard & mouse. (ex: our
counters were built for hand writing so the depth of the counter was not enough to have a monitor with a keyboard in front of it. You
would not believe the number of permutations of set up that created. I can send pictures.
For desktops, get the smallest “box” you can. Buying the hospital standard huge CPU box just takes up too much room. You do not
need a lot of horsepower for most EDIS and you may not even need a local hard drive. If you do not need it, don’t include it in the
box. (ex: My hospital bought their standard full size Dell desktops with all the trimmings, external speakers, hard drives (which
eventually died), DVD\CD, floppy, etc. Whenever a piece of the computer fails it can bring down the workstation. Fortunately the
external speakers were repurposed, i.e. stolen, quickly.)
Provide a variety of computer hardware, i.e. right tool for the right task: desktops, “Workstations on Wheels”, tablets, wall mounted,
etc.
Ideally the system would be able to automatically log you on the computer nearest to you and maintain the context of where you
were on the last computer &/or bring up the context for the patient nearest to you. (Note: No EDIS is doing this today as far as I
know.)
Get\keep the computer “crap” off the floor. This includes CPUs, battery backups, power cords, network cables, etc. Attached then
to the wall or up under the desk. If it’s on the floor it will be destroyed. BTW: watch for “knee knockers”.
You may want to trial the system with various hardware before you buy it all. Certain systems lend themselves towards different
types of hardware.
“Consumer” tablets (i.e. those you might get at Best Buy) do not work well or last long in the ED. My hospital bought them and
within a month half had been stolen. Within a year the rest had all broken. BTW: We even had a WOW stolen the first week.
Hand held PDAs may be useful for reference material or perhaps patient information, but few (if any) EDIS have design an
interface for them. They are just too small to do documentation.
There are two products that are reasonable (assuming you afford them & can carry the weight) for mobile use in the ED that I have
seen. There may be others.
a. Motion Computing C5: http://www.motioncomputing.com/products/tablet_pc_c5.asp
b. Fujitsu ESPRIMO MA: http://www.fujitsu-siemens.com/products/mobile/tablet_pcs/esprimo_ma.html
For mobile computers, breakage & loss (stolen) are a real problem. Ex: the screen will break on the C5 if you lay it flat on the desk
and lean on the screen with your elbow. Oops - $2000.
From: EMED-L -- a list for Emergency Medicine practitioners. [mailto:EMED-L@LISTSRV.UCSF.EDU] On Behalf Of Eric Cure
Sent: Saturday, April 25, 2009 4:21 PM To: EMED-L@LISTSRV.UCSF.EDU Subject: EDIS & Physician Productivity
Dear List, Does anyone have any information concerning the effect of computerized data entry (Epic) on RVU performance? The best
information that I can find (from the vendor) is that it will slow the physician down. Thank you. Eric
From: Todd B. Taylor, MD, FACEP [mailto:tbtaz-1@cox.net]
Sent: Saturday, April 25, 2009 To: 'EMED-L -- a list for Emergency Medicine practitioners.' Subject: EDIS & Physician Productivity
NOTE: For anyone interested (email request directly to: tbtmd@cox.net), my EDIS compendium has been updated adding:
•
ACEP White Paper: EDIS Primer For Emergency Physicians, Nurses, & It Professionals - April 15, 2009
•
EMR: State of the Art or Digital Disaster?, Emergency Physician Monthly, April 2009, Vol 16, #4, www.epmonthly.com
There has never been a published study on the general productivity impact of EDIS. An unpublished informal study was done by EMCare over
multiple EDs with various EDIS vendors showing an initial decrease of 20-30% from baseline, with a recovery to a negative 10-15% from preinstall baseline after a few weeks. Only one ED recovered fully.
This is consistent with observed impact noted by multiple experts in this field over many years. Impact varies depending upon features installed.
Certain features (e.g. ED tracking only & discharge planning, including eRx) may be neutral to minimal increase\decrease. Physician computer
documentation typically has the most dramatic negative impact, followed by nurse documentation, and CPOE. If properly integrated, other
aspects (e.g. results reporting & imaging review) often have positive impact. My own personal experience with an EDIS implementation showed
a negative sustained (at least 5 years) impact of 25% on average physician productivity (2.4 to 1.8 ave pts/phys hr). This despite eventual (2-3
years after initial implementation) integration of results reporting. This group recently initiated a scribe program.
This is known as “IT transactional cost” or IT overhead. The recent trend is to use scribes (i.e. human capital) to mitigate this impact and has
been shown to be effective and even result in a positive impact more than offsetting the cost such a program. Scribes were recently discussed
on this list, but I had an opportunity visit Harris Medical Center in Ft Worth last week where they have been using scribes across the Texas
Health Resources system (14 hospitals) some for more than 12 years. They claim they fully installed an HIS’s EDIS module 2-3 years ago with
little or no impact on productivity, presumably due to scribes. New scribes get 100 hours of training, including EDIS training.
When evaluating EDIS impact, it is important to consider not only the historical baseline, but just how bad that baseline is. EDIS vendors love to
cite dramatic improvements, but when you consider just how bad they were before, almost anything would make it better (see Mt. Sinai example
below). Despite dramatic improvements, their throughput measures are still below an acceptable level for most EDs. There is not enough info in
the story to comment on the financial impact. But I particularly noted that pre-install they had ZERO pro fee critical care billing. That is not an IT
issue, although implementation of an EDIS can be an “agent for change”.
An ACEP task force on Healthcare IT recently completed a comprehensive (30 page) White Paper on EDIS (reference noted above). This is the
first consensus comprehensive look specifically at EDIS. It will soon be available on the ACEP members-only web site, but I have added it to my
EDIS Compendium if you want it sooner.
There was an editorial in the April 2009 issue of Emergency Physician Monthly (see reference above) discussing EDIS in general based on a
survey of about 60 EDs. While productivity was not directly addressed, the overall impact is discussed.
In the same issue, there is a case study from Mt Sinai which shows the following results on an EDIS implementation:
Throughput
• ED Length-of-Stays for all patients decreased by 29% (from 6.7 hours pre-intervention to 4.8 post-intervention)
• ED LOS for admitted patients decreased 35% (from 12.2 hours pre-intervention to 8.0 post-intervention)
• Door-to-doctor time for all patients (triage to first doctor-patient contact) decreased 44%(from 1.2 hours to 0.7)
• Doctor to disposition time for all patients (first doctor patient contact to disposition decision) decreased 52% (from 3.6 hours to 1.7 hours)
• Disposition to discharge for admitted patients (boarding time) decreased 28%(from 6.8 hours to 4.9 hours)
• CT scan turn-around time decreased by 40% (from 3.9 hours to 2.3)
• Laboratory report TAT decreased from 2.0 hours to 1.4
• X-ray TAT decreased from 0.9 hours to 0.7
Revenues
• Average collections per patient rose 47.5% with a sustained-effects period over a year later
• Total charges rose 69.4% and total receipts rose 70.1% during the same period
• End-of-month chart completion rates by attending physicians rose from 65% in 2003 to 95% in 2005
• Lost or illegible charts decreased from 4,992 in 2003 to zero in 2005
• Average professional E&M LOS rose from 3.17 to 3.73
• Critical care billing:
o Prof Fee: increased from just one chart during the entire 15-month pre-implementation to 1,614 charts in the year afterward
o Facility: from 45 to 974 charts
• Despite an overall decline in the facility EM level, net facility receipts increased 60.9% over following year
• “[T]his data says nothing about improvement in patient safety or satisfaction, or improvements in QA and core measure monitoring, all of
which have been noted but not as rigorously reviewed. Furthermore, as an academic institution, the EDIS has made it far easier for residents
to review cases for educational or research purposes, which allows us to fulfill an important mission as a teaching hospital.”
• “But perhaps most importantly, if you survey faculty who lived through the transition, they’ll all note that, as challenging as adoption of an EMR
was, no one would go back.”
  RESOLUTION 22(07) TASK FORCE WHITE PAPER RESOLUTION 22(07): INFORMATION SYSTEMS FOR EMERGENCY CARE RESOLVED, That the ACEP develop a comprehensive policy on Information Systems for Emergency Care; and be it further RESOLVED, That the ACEP convene a task force, or other suitable group, to produce within the next 12 months a “white paper” outlining the state of the art and needs assessment of information systems for emergency care and a formal plan to educate the membership on the evaluation and implementation of emergency department information systems. EMERGENCY DEPARTMENT INFORMATION SYSTEMS P RIMER FOR E MERGENCY P HYSICIANS ,  N URSES ,  AND IT  P ROFESSIONALS  April 15, 2009  TODD ROTHENHAUS, MD, FACEP, TASK FORCE CHAIR & PAST SEMI‡ CHAIR DONALD KAMENS, MD, FACEP, SEMI MEMBER, EHR STANDARDS LIAISON BRIAN F. KEATON, MD, FACEP, ACEP BOARD LIAISON TO THE TASK FORCE & SEMI  LARRY NATHANSON, MD, FACEP JEFFREY NIELSON, MD, MS, WHITE PAPER EDITOR & SEMI SECRETARY­TREASURER  JAMES C. MCCLAY, MD, MS, FACEP, SEMI CHAIR­ELECT TODD B. TAYLOR, MD, FACEP, FOUNDING SEMI MEMBER & PAST SEMI CHAIR  AL VILLARIN, MD, FACEP  ‡
ACEP Section for Emergency Medical Informatics Copyright 2009 © American College of Emergency Physicians EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS Table of Contents Table of Contents......................................................................................................................................................2 Introduction................................................................................................................................................................3 What is an EDIS? .......................................................................................................................................................5 EDIS Functions...........................................................................................................................................................6 Clinical Functionality..........................................................................................................................................6 Administrative Functions.................................................................................................................................9 Other Considerations .........................................................................................................................................9 System Evaluation & Selection......................................................................................................................... 13 Assessment Process......................................................................................................................................... 15 The EDIS Market & Trends ........................................................................................................................... 16 EDIS Certification.............................................................................................................................................. 16 Return on Investment ..................................................................................................................................... 17 Market Analysis ................................................................................................................................................. 17 EDIS Assessment............................................................................................................................................... 18 Final Due Diligence .......................................................................................................................................... 19 Implementation...................................................................................................................................................... 20 Organization........................................................................................................................................................ 20 Process Change Planning............................................................................................................................... 21 Technical Design and Implementation .................................................................................................... 21 Training................................................................................................................................................................. 21 Parallel Testing .................................................................................................................................................. 22 Go‐Live .................................................................................................................................................................. 22 Barriers to Adoption........................................................................................................................................ 23 Buy‐In .................................................................................................................................................................... 23 The Future of Emergency Care Information Systems ............................................................................ 24 Conclusion ................................................................................................................................................................ 25 Contributions .......................................................................................................................................................... 26 Disclosures ............................................................................................................................................................... 26 Acronyms .................................................................................................................................................................. 27 References ................................................................................................................................................................ 28 ‐2‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS Purpose Given the national attention on information technology (IT) in all areas of healthcare, including emergency departments, there is a need for physicians, nurses, hospital administrators, and IT professionals to better understand the basics of emergency department information systems, including functional requirements, system selection, implementation, and ongoing support. In 2007, the ACEP Council noted that although health IT adoption has been expanding, information systems have largely failed to adequately support the needs of the ED. A task force was created to formulate an ACEP policy on Health Information Technology and produce this white paper‐‐outlining the state of the art and needs‐assessment for information systems in emergency care—and simultaneously instituted a formal plan to educate the membership on how to best evaluate and implement an EDIS.  This primer on Emergency Department Information Systems (EDIS) represents the consensus of leading ED IT experts and the ACEP Section of Emergency Medical Informatics. We begin with a definition of EDIS, including descriptions of high‐level functionalities important for success. We then describe a process for system selection and the implementation process, including integration, staffing, training, and preparation for go‐live. We conclude with a discussion of future directions. Throughout this text, statements from the ACEP policy statement on Health Information Technology [1] are highlighted in italics. INTRODUCTION In 1992, members of the ACEP Section of Emergency Medical Informatics initiated the Emergency Department of the Future [2] project. They envisioned a collection of highly integrated computer systems delivering information to providers in support of quality patient care and efficient operations. In 1998, a paper proposing the “Next‐
Generation Emergency Department” described the practice of emergency medicine as the most “information‐
intensive” domain in clinical medicine, and likened emergency physicians to “hunter‐gatherers” in search of important information to guide care. [3] In 2004, President George W. Bush established the Office of the National Coordinator within the Department of Health and Human Services to accelerate the adoption of health IT. [4] Since then, significant funds and attention have been paid to increasing the quality, interoperability, and implementation of IT in all care settings. The American Recovery and Reinvestment act of 2009 includes $19 billion in direct funds and incentives for the adoption of hospital and ambulatory electronic health record systems (EHR). [5] Five years ago, the Society for Academic Emergency Medicine sponsored a consensus conference on “Informatics & Technology in Emergency Care” with the proceedings published in a special issue of the Academic Emergency Medicine. [6] This remains one of the most definitive works on ED Information Systems and, its content as relevant today as five years ago. However, reflecting the unique character of emergency departments themselves within the house of medicine, emergency department information systems (EDIS) are similarly unique within the house of health information technology, having distinctive tasks, requirements, and challenges. While the vision for EDIS has been grand, in actual practice they are not as “robust”, i.e. “strongly suited to the task”—as those found in some other industries and even other healthcare IT sectors. For decades, clinicians, payers, administrators, and consumers have decried the slow pace of adoption of information technology in healthcare. Electronic health record (EHR) systems, computerized provider order entry (CPOE), and clinical decision support have each been touted as solutions for rising healthcare costs and for improving quality. [7] While some studies on health IT involving physicians have been promising, these have come from academic medical centers, where systems are commonly developed in‐house and deployed primarily to ‐3‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS house staff. [8] Implementation of commercial EHR systems have been more sobering, with some studies reporting increased or new types of errors, [9] little benefit from decision support, [10] and even increased mortality. [11] It has become clear that success in any health IT project is predicated on careful system design, deliberate implementation, and attention to clinician needs. [12] Further, the complicated nature of health IT and formal evaluations can obfuscate significant conflicts of interest. It is clear that Health Information Technology (HIT) presents ongoing opportunities to improve the quality of emergency care, promote patient safety, reduce medical errors, and enhance the efficiency of emergency departments. However, the ED is an exceptional environment, where visits are unscheduled, patients undifferentiated, and care decentralized. Workflows vary from ED to ED and even patient to patient. While few studies have documented a positive impact of EHR systems on ED patient outcomes, the adoption of EDISs has grown steadily. [13] Most early systems deployed in the ED focused predominantly on one of four principal modules: physician clinical documentation, patient tracking, electronic discharge instructions, and prescription support/printing. Although early systems combined only two or three of these functions, over time they have become more comprehensive, with added functionality, and achieved more internal cohesion. Most now offer results reporting, order entry, and the ability to integrate with the extant enterprise HIS. In addition, nearly all enterprise hospital information system (HIS) vendors now have modules intended for use in the ED. Few ED‐related initiatives wield the kind of double‐edge sword as does the deployment of an EDIS. On the one edge is great hope, the promise of significant benefits for patients, patient safety, and the ED work environment. On the other lies apprehension of non‐trivial harm to those same precious commodities. To this end, The Joint Commission in December 2008 issued a Sentinel Event Alert targeting “safety risks and preventable adverse events that can be perpetuated by implementing a HIT solution that does not adapt well to the local clinical environment.”[14] While The Joint Commission’s alert is intended for the broader HIT space and does not single out EDIS, it includes elements to be considered in any EDIS implementation.  Indeed, actual experiences vary widely. EDs are necessarily complex systems with an inherent need to improve process and efficiency. [15] Obvious anticipated benefits of EDIS include improved throughput, reduced costs, support of workflow, reduced reliance on paper, increased provider productivity, thorough integration with other hospital systems, better clinical documentation, decision support, and increased revenues. The expectation is better safer patient care through immediate data availability and decision support. There are also some less obvious advantages including opportunities to capture health‐related information in regional and national databases, expanded opportunities in data mining for research, population management, and surveillance. At the local level, facilitating real‐time CQI/QA, tracking patients and staff in real time to identify departmental inefficiencies, and enhancing provider communication can all improve ED management.  Unfortunately, a significant number of implementations either fail to meet expectations or aggravate already dysfunctional EDs with decreased throughput resulting in increasing wait times and crowding. Although many reasons have been postulated for this phenomenon, none have been well studied. Some of these include abandoning time‐tested and quite functional non‐IT solutions, inserting new and untested workflows into an already chaotic environment, failing to account for the actual needs of clinicians, and increasing IT‐work overhead. Moreover, the evolution of underlying technology commonly outpaces the capacity of individuals and organizations to adjust. Thus, there is an increased need for adaptation and re‐learning that not only adds overhead, but also tends to throw proverbial monkey‐wrenches into tried and true solutions, workflows, and artifacts. With any new EDIS implementation there is nearly always decreased provider productivity in the short term. Moreover, only a minority of EDs ever become as productive as pre‐implementation. EDs are fueled by productivity so this is a major issue. Physicians, nurses, and administrators dealing with critical issues such as ‐4‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS crowding, throughput, and performance, develop understandable angst when anything threatens to make difficult matters worse. Consequently, much of the hope held for EDIS, still remains unrealized. Hospitals have a duty to patients, staff, and the community to provide HIT that is suitable for use in the ED. Most hospitals seeking to acquire new IT rely solely upon the information systems department (IS) for selection and implementation. System vendors are often queried for information and demonstrations via a request for information (RFI) or proposal (RFP) amongst a bewildering array of systems and implementation strategies. Further, vendors tend to claim that they can deliver on every RFI\RFP requirement even when their particular system is ill‐suited. Compounding matters has been a lack of consensus, until recently, on objective criteria to evaluate systems.  Although ED physicians and other emergency care providers are frequently part of the process, this practice is not universal. It is clear to these authors that the evaluation, selection, implementation, and ongoing assessment of HIT that impacts emergency care should be undertaken only with the active involvement of emergency physicians, nurses, and other emergency care providers. Furthermore, Emergency physicians should have a role in the selection and approval of any HIT that impacts the ED or the local emergency medicine community. We hope this primer will enable emergency physicians to begin a dialog with hospital administration and IS departments on the implementation of health IT in the ED.  WHAT IS AN EDIS? Outside of emergency medicine, the term Electronic Health Record (EHR) System has been used to describe computer systems or applications used to support patient care. The term Emergency Department Information System (EDIS) was documented in 1975 to describe a computer system to track emergency department patients and support other aspects of ED workflow. [16] Since that time, the definition of an EDIS has expanded significantly.  The primary purpose of an EHR is to support direct patient care and to serve as the document of record. While other uses are common, such as billing and administrative support, these uses are typically termed “secondary”, albeit equally important. [17] We prefer to label these uses as “clinical” and “administrative” to avoid terms that may be misinterpreted as judgmental. Differences between inpatient EHRs, outpatient EHRs, and EDISs abound. For instance, EHRs used in ambulatory practices tend to concentrate on longitudinal care, where supporting an ever‐changing “active problem list” is paramount. By contrast, in the ED where care is episodic, EDISs tend to concentrate on individual encounters and complex workflow.  The following EDIS definition embodied in ACEP’s Policy on Health Information Technology [1] is derived from international standards definition, the HL7 Emergency Care Workgroup[18], the work of the Emergency Informatics Association and the ACEP Emergency Medicine Informatics Section. Emergency Department Information Systems (EDISs) are electronic health record systems designed specifically to manage data and workflow in support of Emergency Department patient care and operations. ‐5‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS EDIS FUNCTIONS Fundamentally, an EDIS should facilitate the delivery of patient care, conform to relevant data interoperability standards, and comply with applicable privacy and security constructs to ensure the secure availability of relevant healthcare information. EDISs consist of several core functions to support the clinical care in the Emergency Department, such as patient entry, triage, clinical (i.e., physician, nurse, and ancillary) documentation, results reporting, document management, order entry, decision support and risk management, patient and resource tracking, and discharge management (prescriptions and discharge instructions). [18] Core administrative EDIS functions include hospital and departmental statistical metrics management; coding and billing (including interaction with insurance carriers and provision of information to third parties); integration with public health and other registries; disaster management; disease surveillance; and integration of patient satisfaction data. There are also additional core functions such as data analysis and uses that share characteristics with enterprise EHR systems. However, there are several functions unique to the ED that deserve special consideration. CLINICAL FUNCTIONALITY  The following is an overview of relevant clinical EDIS functionality, beginning with patient arrival and proceeding linearly through a typical ED encounter. The ED environment is characterized by unanticipated events, multiple events, and the need to synthesize order out of chaos. Therefore, EDIS systems must be designed to allow constant adaptation and care delivery in an asynchronous and parallel fashion in order to deliver the safest and most efficient patient care Patient entry is the process of uniquely identifying a patient in the EDIS. This is distinct from formal registration which can be done at any time in the care process and usually in a separate hospital registration system. Patient entry may occur at triage or during a “greet” process whereby arriving patients are entered into the EDIS prior to a formal triage assessment. This process may enhance the identification of patients waiting to be seen and track the interval between arrival and triage. Anonymous pre‐hospital identification, “quick registration” (a term used to describe a process for assigning a medical record and account billing number absent full registration), and “John Doe” registrations must also be supported. All of these processes must allow for the initial “temporary” unique identification of patients in such a way that the record can later be merged with the permanent (fully registered) record. This process is unique to the ED given the need for rapid assessment, collection of data and the need to initiate care before full‐registration is practical.  Patient tracking is essential to ED workflow and has unique challenges. A good tracking system provides substantial decision support by assisting hurried staff in managing the ED visit and in deciding next actions for best patient care. There are two primary tracking orientations‐‐patient‐centered and department‐centered.  Patient‐centered tracking has two dimensions: clinical course and location. Clinical course tracking follows the patient’s care throughout the ED process. It provides visit context such as patient status, completed and anticipated events, order status, vital signs, etc. These elements are typically summarized in an electronic grid format with patients in rows so that outstanding tasks can be easily recognized. Patient location tracking follows the patient in physical space through all phases of visit, from pre‐arrival through disposition. It can be accomplished by manually entering patient location or automatically using radio‐frequency ID (RFID) or other ‐6‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS technologies. At times patient tracking may require multiple data points. For example, a patient sent to radiology may need their room “saved” to avoid having a new patient placed in that room. Tracking features vary considerably between vendors and are worthy of careful consideration as a selection differentiator. Department‐centered tracking also has a number of dimensions. On the simplest level, as a byproduct of patient tracking is information on ED bed use and availability. This may be used to organize patient flow and staff distribution. Some EDISs also use automated tracking for equipment such as physical charts, infusion pumps, monitors, and gurneys. The technology has great potential but the software and hardware are still maturing. Advanced EDISs have helpful administrative tracking views such as retrospective (i.e. at point in time) or for forecasting. Diversion status and disease surveillance information can also be communicated via the EDIS. Department dashboards are administrative views of key performance indicators derived from various tracking metrics. These typically include the number of patients: waiting to be seen, in waiting room, awaiting inpatient bed assignment, etc. Relevant dashboards should be viewable on the main EDIS screen to communicate the status of patient flow. Dashboard may be configured to changes color to indicate changes in department or patient status. Clinical Documentation by physicians, nurses, and other ED staff is an essential EDIS function, but can also be a challenge when systems do not allow for quick, accurate, and complete documentation. The system should permit documentation of observations, medical decision‐making and reflect exactly what the user wishes to convey.  Much of routine data gathering in the ED is redundant. For example, a medication list may be present from a previous encounter, verified and updated in triage. This process is frequently repeated by the physician as part of the history documentation. Therefore, key documentation features include the ability to leverage previous documentation (e.g. past medical history, current triage, administrative data) and review, harmonize or incorporate existing data related to the current visit (e.g. nursing notes, medication administration/reconciliation, discrepancy resolution) and provide a summary of pertinent findings.  While documentation is ideally completed contemporaneously, this is not always possible. Clinicians may wait until the end of their shift to complete records. Moreover, ED events are documented in stages (asynchronously). Therefore, systems should provide a means to view the state of completion for each chart individually as well as all charts in the clinician’s custody. Documentation should be able to move from patient to patient without loss of work. It should also be able to be abandoned quickly if necessary, and then returned to where the clinician was previously working, even if someone else has used the workstation or device in the interim, or another workstation or device is used. Unfinished items should be plainly seen in a view that displays the status of all charts for each clinician. Further, systems must support the process of multiple authorship, as two or more providers may need to document on the same patient at the same time.  Ease and efficiency of documentation is a significant issue. If a record cannot be completed in near‐real‐time, much may be lost. Recall hours after an event is questionable in creating a credible ED record and clinical alerts post‐visit are of little value. Unless computer documentation does not slow ED workflow, documentation speed will continue to be an implementation barrier. If anticipating that physicians will document in the EDIS, one should consider the capacity of the system to match a high‐quality ED physician’s ability to work swiftly, directly, accurately, and fully.  Finally, although considered a secondary function, the correlation between documentation and coding\billing is unavoidable. A failure to achieve an appropriate coding level as supported by documentation has serious financial consequences, including difficulty maintaining qualified physicians and placing the ED physician contract in jeopardy.  Computer Provider Order Entry (CPOE) allows for selection, entry, and transmittal of orders. The EDIS should provide the means to order laboratory, radiology, medications, nursing tasks, and even durable medical equipment. The goal of CPOE is not to turn the clinical staff into “expensive data entry clerks”—the goal is to ‐7‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS provide decision support directly to the provider at the time decisions are made. For success, orders must be highly specific and customizable by personnel role, physical location, and patient‐specific factors, as well as institutional variations and preferences. For instance, one ED may determine that clinicians may customize their own order sets and another require that they conform with a consensus standard. The EDIS must support both.  Communication between the EDIS and ancillary department computer systems (such as radiology or laboratory) is vital to CPOE success. Task management systems and order acknowledgment rely upon CPOE to organize and direct ED staff to prioritize tasks and facilitate accurate completion of orders. Thus an ideal EDIS‐CPOE module will facilitate the rapid and safe treatment of ED patients, be interoperable with other EDIS modules (tracking, charting, etc) and smoothly integrate with the hospital‐wide CPOE. A common variant is using the inpatient HIS CPOE along side the EDIS. This can introduce opportunities for error and workflow overhead. However, this can be mitigated with the use of specific workstation tools that automatically log users into multiple systems, and pass patient context between them. Clinical Context Object Workgroup (CCOW) is an HL7 standard designed to enable disparate applications to synchronize in real‐time at the user‐interface level. [19].  CPOE is a key component of patient safety and efficiency in patient care, yet research and development in this area is ongoing. Poorly implemented CPOE has been shown to increase mortality [10], while well implemented CPOE using order sets may assist physician compliance without facilitating errors. Result Reporting can be accomplished in several ways and some EDISs are better than others. Key features are easy access and review within the context of each EDs particular workflow. In most cases this means displays should be easily customizable either locally or by the end‐user  vs. requiring vendor support. Examples of how results displays might be configured include: •
Results from the current visit are displayed in a single view noting which results are still pending.  •
Results less pertinent to the ED visit (e.g. red cell distribution width) should be less prominently displayed than more germane results (e.g. white blood cell count).  •
Abnormal values should be highlighted with ready access to prior values for comparison.  •
Availability of summarized laboratory data in one view (to reduce the amount of searching). •
Accessibility of prior results in both detail and summary form. (Summaries may simply be collections of all prior laboratory and diagnostic data in a single view, but should also extend to a full range of data including visit history, historical diagnoses, existing problems list, medication history, significant testing or procedures, advance directives, and others.) •
Where available, historical data from hospital or regional health information exchange should be integrated with the EDIS.  Discharge Management functions include the following: prescription writing (preferably electronically written and transmitted, even though they may frequently be printed); discharge education (information about the patient’s condition) and instructions (how to care for the condition, as well as precautions, including what signs and symptoms should prompt a return); follow‐up information, including referrals to specialists or back to PCPs; and detailed visit information (e.g. medications that were prescribed and administered in the ED and related precautions). Some systems integrate this content into the EDIS by predicting the instruction set and orders you may want; others allow for easy customization. Good discharge instructions are important and should be evaluated for inappropriate, infrequently updated, or non‐customizable content. ‐8‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS The prescription‐writing module must be evaluated carefully. Some do not accommodate weight based dosing, may be too complicated, or fail to follow a reasonable workflow. For printed prescriptions, some states have strict security paper requirements. In this event specific printers and secure tamper‐resistant paper must be used, often with numbered sets of prescriptions. Be sure that your intended system meets all such local requirements.  A signed acknowledgment of discharge instructions receipt may be required by hospital policy or local standards of care. If necessary, ideally the EDIS will accommodate an electronic signature or else create a paper acknowledgement form.  ADMINISTRATIVE FUNCTIONS Administrative functions typically are post‐hoc data analysis, with the ability to do patient or complaint specific reviews when necessary. All vendors include standard reports, which may or may not meet an EDs needs. Billing and financial management is a key administrative use of clinical data and reports tend to focus on these.  EDISs may facilitate coding by providing feedback at the point of care for clinical documentation. The EDIS should transmit an accurate representation of the care delivered in the ED, so that billing can be done expeditiously. For an ED physician group, the system should be able to help analyze key performance indicators.  Mandated public health disease reporting may be an additional supported function. Others include reporting for hospital administration, clinician profiling, staffing projections, and patient satisfaction. Disaster management and community‐wide resource management can also be enhanced with EDIS.  OTHER CONSIDERATIONS System Interfaces communicate data between disparate computer systems such as the EDIS, enterprise HIS, pharmacy, CPOE, PACS, and laboratory. These interfaces are vital to proper data ecology in the ED environment. Interfaces can be one‐way or two‐way, and usually comply with one of several versions of “HL7”, a messaging standard developed by a not‐for‐profit healthcare standards development organization Health Level Seven.  A simple example of an interface is ADT (Admit/Discharge/Transfer), which communicates demographic information, medical record number, and visit account number from the registration system to the EDIS. An account number is nearly always required for other hospital systems to order radiological studies, laboratory tests, and other departmental services. A two way ADT interface, for example, would allow a discharge or bed transfer within the EDIS to be communicated back to the registration system.  Each system integrated requires one or more separate interfaces, including orders, laboratory results, radiology results, electronic prescribing, etc. Each interface carries a cost to develop, implement, and maintain. An integrated HIS ED module typically communicates directly with the hospital enterprise system and therefore does not rely on as many external interfaces. But this is not always the case, so ask if contemplating an HIS module approach. Also, an integrated HIS ED module may sequester ED data along with other hospital data making it more difficult to access.  Nevertheless, the ability to exchange data continues to improve. ED documents are frequently sent electronically to the HIS, hospital clinical data repository, billing company and others. Electronic exchange of information between inpatient and ambulatory EHR systems and Regional Health Information Systems (RHIO) are increasingly common. Standards to facilitate this exchange continue to evolve. Access to historical patient information, including data in Electronic Health Records and Personal Health Records, should be available for ED patients. Connectivity with external systems and participation by hospitals in health information exchanges should be encouraged. ‐9‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS The User Interface (UI) is the sum of all interactions between the person and the EDIS, including all screens, input devices (e.g. keyboards, mice, touch screens, ePens, etc.), and output devices (e.g. printers, CDs, etc). A well optimized GUI (graphical user interface) is essential for the fast paced error prone ED environment. The design of a GUI may suffer from poor design such as burying frequently used functions deep in hidden menus while unused functions may be easily chosen accidently. Some systems can be used with little training, while others require significant effort and repeated reference to a manual. Whereas pure functionality of software is either present or not, usability is related to the number of click counts, mouse to keyboard transitions, and effort required to complete task. It is imperative that EDIS developers employ usability experts who understand human factors to design the user interface rather than software engineers. Here are some key points to consider when assessing usability: 1.
SystemsВ mustВ beВ easyВ toВ learn,В somewhatВ akinВ toВ aВ webВ browser,В aВ wordВ processor,В orВ aВ spreadsheet.В 2.
Some systems have more “walk‐up‐usability” than others. For example, EDs with either frequent physician changeover, substitutes in staff, house staff, or otherwise inconsistent staffing might consider walk‐up‐usability a must have. 3.
Functionality and usability should be natural and use common‐sense. Human‐computer interaction methods in the public domain (e.g. those used by Google, Microsoft Internet Explorer, and Microsoft Office) are more easily understood. For example, a “back arrow” in the upper left corner and an “X” in the upper right corner are now common standards. Unfortunately, not all EDIS (or HIT software in general) follow even such basic standards. 4.
The user interface should be consistent across modules. For example, a similar‐appearing button should do the same thing in the prescription module as it does in the documentation module. This is especially a challenge for the HIS vendors where modules may have been acquired from various sources and “stitched” together. 5.
System updates should be done carefully and with explicit attention to the psychology and workflow of ED staff. Installing a new version with many changes all at once can severely impact users if not done properly. Options include incremental upgrades that are easily adopted in the course of care or a planned major upgrade with training and a period of practice and testing before being brought online. Clinical Decision Support (CDS) is an often misunderstood concept. Yesterday’s decision support was simple document retrieval and highlighting abnormal labs; today it is order sets, drug‐drug interactions and allergy checking; and tomorrow perhaps it will be assisted diagnosis, real‐time surveillance and artificial intelligence.  CDS should be considered “umbrella functionality” rather than a distinct module. Whether EDIS modules function together to provide CDS (e.g. drug interactions checked against a pharmaceutical database) or separately, their integration into the EDIS should not distract the user. A common type of CDS is related to prescribing and includes dose, allergy, and drug interaction checking. The ideal system offers features such as age and weight‐based dosing; alarms and alerts (e.g. unobtrusive reminder that the patient had a CT scan yesterday); computer‐assisted triage protocols that can help ancillary personnel initiate diagnostic tests; and prompting for diagnostic considerations and recommended treatment standards that can greatly enhance staff efficiency and clinical accuracy. In the future, advanced artificial intelligence has the potential to further automate clinical decision‐making and enhance the ability to recognize common and perhaps not‐so‐
common clinical syndromes.  A Consolidated Digitized Environment describes a “system of systems” where all information is ultimately recorded in digital format. Some have argued that this is the only way for an EDIS to truly be efficient. Nevertheless, an EDIS should keep digital information digital (e.g. CT scans, ultrasound, EKGs, cardiac monitoring, ‐10‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS automated vital signs, etc.) and transition analog information to digital (i.e. scan all paper). Therefore, prior to implementing an EDIS, every effort should be made to transition the entire ED to a digital environment. Scanning technology is inexpensive and reliable but can be obtrusive when performed at the bedside. Bar‐coding every piece of paper (e.g. with a label for external documents) allows for automatic archiving of digitized paper and reduced paper shuffling. The cost savings by eliminating paper alone can justify the cost for an EDIS in short order. The goal is that all necessary information for patient care should be available at every computer or mobile device. Systems that require frequent printing of documents are not only wasteful, but inefficient.  Picture Archiving and Communication System (PACS) is now the standard in radiology for digital information management and commonplace in EDs. Web‐based PACS viewers tend to have fewer features and slower performance, but are more easily deployed to multiple workstations. If practical, PACS viewers should be on all ED workstations and ideally integrated directly with the EDIS. Other images such as digital photographs and video are also available but not as common. Newer tablet devices now have this capability built in, but it must still be supported by the EDIS. Patient Safety has long been touted as a major benefit of EDIS and opportunities abound. Clinical decision support such as alarms and alerts for abnormal values (symptom recognition, laboratory results, vital signs, wait times, syndromic surveillance, etc.); drug‐drug or drug‐syndrome interactions; and patient monitoring (pulse‐oximetry, CO2 monitoring, etc.) are but a few opportunities. At the same time, the EDIS must avoid creating increased risk of errors or inefficiencies. For example, an EDIS that reduces throughput and increases the elopement rate is contributing to potential risk. [18] Coordination of Care should be well‐facilitated with a good EDIS. Automated notification (e.g. of specialists, primary care physician, ancillary services such as respiratory care, radiology technician, housekeeping, admitting department, insurance plans, etc.) is but one example. Remote exchange of patient data must be compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) using encrypted or secured Internet transmission. Transmission of nursing reports for admitted patients can also be automated such that documentation is completed simultaneously with patient care and delays due to documentation completion eliminated. Automated Alerts can easily be transmitted via pager or cell phone, such that workflow is not interrupted. For example, ordering a nebulizer treatment might automatically notify the physician for reevaluation 10 minutes after completion. Automatic notifications of laboratory and radiology results can be automatically transmitted to the ordering physician. Nevertheless, the balance between interruption‐driven processes (“push” alerts) and data lookup (data “pull” requests) remains a challenge. Medical Content and Domain Knowledge varies considerably among EDISs. Well designed systems understand ED flow, but are flexible enough to be customized to adapt to a variety of departments. Good systems understand medical decision‐making so that the next click is what you would do in 80% of cases (while the other 20% is still easy enough to do). Poorly designed systems do not understand that the ED domain can vary in process from one patient to the next and force the user into the system’s way of doing things. Other systems are very flexible but have little domain knowledge, such that they might just as easily be customized to an Obstetrics floor as an ED.  Computer systems have enhanced value when they are augmented with reliable, up‐to‐date, evidence‐based clinical content. This is the greatest future challenge for EDIS. Most currently available EDISs provide adequate technical infrastructure necessary to manage data at a basic level. But the real challenge is to provide high‐quality clinical content that enhances the ability to make better decisions and focus on direct patient care. With regard to patient education, the content available in discharge instructions is often presented in a way that is not user‐
friendly such as unformatted plain text or content well above patient reading level. ‐11‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS Reference Material content should also be assessed. Web links to emergency medicine websites are helpful, but often require searching for useful information. The integration of clinical content into the EDIS is very helpful to achieve the full EDIS potential. Access to on‐line tools including the Internet, hospital policies and procedures, medical reference materials, regional status of hospitals, EMS, mass casualty, and other pertinent information should be readily available. Authentication and Authorization Processes confirm user identity and manage user permission to view data or perform a function. HIPAA mandated improved security for covered entities, including hospitals, for how Protected Health Information (PHI) is accessed. Unfortunately, the initial response for most hospitals resulted in policies stricter than necessary. While the use of strong passwords (requiring letters, numbers, and other characters) may have been beneficial, others like short automatic logoffs have had a negative impact on care.  The implementation of any new system should be an opportunity to apply new technology to the challenge of user authentication. Automated login and logout via infrared (IR), radio frequency identification, or proximity sensors tracking devices (RFID) badges is one such solution. Regardless of the technology, the need to readily access multiple computers and systems must be coordinated to enable user acceptance. Provisions and policies for emergency access (i.e., “break‐glass”) to critical health information should be in place for emergency physicians to access protected health information when necessary to prevent harm or risk to life. Positive identification of patients must also be addressed due to inaccurate or even fraudulent information. Integrating demographic verification software and procedures is an oft‐missed opportunity for fraud prevention and revenue capture in the ED. Using Patient‐Centered Automation, a patient’s location in the department can be updated automatically in near real time. Automated patient tracking via IR, RFID, or similar technologies not only automatically tracks location, but also how long it takes to move through the ED and proximate associations with others. Such systems can also automatically log patients to the computer closest to them and help avoid misidentification. The tracking of staff using similar technology can be controversial, but provides invaluable data for staff management and productivity. Risk Management features are available with some systems. These usually consist of rules that check for deficiencies or risk triggers in documentation. These rules might assure that vital signs are not significantly abnormal prior to discharge or prevent charting of certain high‐risk information without a clear explanation. These can be helpful if properly employed but can also be obtrusive. Remote EDIS Access can be valuable. Examples include medical records retrieval, electronic signature, staff schedule management, email advisories, and others. While perhaps intrusive into one’s personal life, the efficiency gained by this functionality is enormous. The ultimate goal is to have the ability to securely access the EDIS from any Internet‐enabled computer worldwide. ‐12‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS SYSTEM EVALUATION & SELECTION STRATEGIES FOR EDIS PLANNING [Figure 1] Establish planning parameters [See Table 1] Selection of an EDIS should be interdisciplinary and include physicians, nurses, other ED care providers, as well as members from hospital administration and information services. Emergency physicians must have a role in the selection of EDIS. Clinical functionality, usability, efficiency, and interoperability should be the primary criteria by which systems are evaluated. Preference should be given to systems that ensure support for ED workflow, clinical accuracy, patient safety, and operational support.  Figure 1: Strategic EDIS Planning Overview Step 1: Establish planning parameters Step 2: Assess your current information environment Step 3: Propose a new conceptual information environment Step 4: Investigate potential solutions Step 5: Plan implementation strategies Step 6: Develop action plan An interdisciplinary steering committee charged with overall project oversight should be established. This includes seeking input from stakeholders, integrating input into strategic objectives and implementing the project in accordance with the agreed upon plan and timeline. The committee should include clinicians, information systems consultants, local experts in the field of emergency medical informatics, and information systems personnel.  It is important at this initial stage to develop the EDs strategic objectives. They should be supported by well‐
definedВ goalsВ developedВ fromВ stakeholderВ inputВ andВ justifiableВ potentialВ benefitsВ ofВ theВ projectВ (TableВ 1).В TheВ objectivesВ shouldВ beВ reviewedВ byВ aВ broadВ rangeВ ofВ stakeholdersВ (management,В physicians,В nurses,В security,В pharmacy,В etc.)В forВ additionalВ inputВ andВ revision.В CapitalВ allocationВ fundingВ isВ criticalВ toВ theВ successВ ofВ theВ projectВ andВ shouldВ beВ addressedВ andВ committedВ atВ anВ earlyВ stage.В TheВ mannerВ inВ whichВ administrationВ isВ approachedВ will,В inВ largeВ part,В determineВ theВ successВ inВ obtainingВ appropriateВ institutionalВ supportВ forВ anВ EDIS.В [6]В Table 1: Example of goals, strategic objectives, & potential benefits of an integrated EDIS
Goal
Objective
Benefit
Minimize redundant input
Automate ATD input into EDIS
Saves staff time
Automate laboratory, ECG, radiology, &
ancillary reports into the ED record.
Integrate discharge instructions &
prescriptions into chart & automate output
for patient
Saves staff time
Improve tracking of patients, equipment, &
staff
Obtain a passive tracking system that will
automatically track department assets &
provide regular status reports
Saves time & provides information on
productivity and efficiency
Provide cost-effective physician charting
Investigate methods of physician charting
to determine if better alternative available
Productivity may not provide any additional
benefit over current charting method
Provide digital ("filmless") radiology
Investigate digital radiography systems
Allows immediate access to & archiving of
radiographs, may be cost prohibitive
Assess the current information environment Defining the current information environment is the first step toward determining the ultimate goal. Current software, hardware, network, and operating systems need to be inventoried. The department must determine if full utilization of the current system would meet its needs. If there are gaps identified, they need to be listed along side existing features. The list of existing and new features should be categorized as wants and needs since one cannot assume a new EDIS will have all these features. Understanding how these systems are currently integrated with the Hospital Information System (HIS) is critical. ‐13‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS The steering committee must decide whether current systems can be upgraded and enhanced or whether a completely new system will be required. The multimillion‐dollar system of 5 years ago may be outdated today, but the ultimate decision will often be based on whether it is more cost effective to upgrade, adapt the current system, or simply start over. A new system usually provides more flexibility and integrates the latest technologies, but may be more expensive and difficult to implement due to changes in workflow.  It is also important at this point to assess whether the HIS has an ED module. The advantages and disadvantages of using an HIS ED module or a “Best‐of‐Breed” (BoB) EDIS must be weighed carefully.  Best‐of‐Breed EDISs are designed specifically for EDs and usually offer better workflow, content, and functionality. However, a BoB EDIS requires interfacing with the HIS and registration system to function properly. An HIS ED module typically is better integrated with other HIS modules, but at times in not as fully developed as a BoB EDIS. Although most of the technical interface issues that have plagued such systems in the past have been resolved, the cost of creating these complex interfaces and their reliability need to be included in the analysis. Without such interfaces, the EDIS will never reach its potential and will become an island of information that cannot communicate with other systems. At this stage, the analysis should delineate information flow (what, when, where, and by whom) in the ED and hospital‐wide. This will allow identification of current information issues and areas of potential improvement in terms of quality of care, staff productivity, and cost effectiveness. It is important that key personnel among physicians, nursing, ED staff, and ancillary departments be involved in this analysis to identify the pertinent activities for their areas and document the flow of information. A case scenario approach that follows the paper trail may be useful. Propose a concept for a new information environment Using information obtained in the previous step, a core group should develop a plan for a new information environment. This may take the form of a flow chart that acts as a blueprint for future planning. Emphasis should be placed on improving quality of care and productivity; reducing operating costs; decreasing inefficiency and redundancy; decreasing errors of omission and commission; and increasing the availability of information necessary for effective decision making. Again, input should be solicited from multiple parties. Investigate potential solutions Commercially available EDIS products vary considerably in features, interoperability, compatibility, flexibility (modular versus packaged), reliability, and price. The current hospital HIS vendor may have an available ED module or a “preferred” EDIS vendor. If so, these should be a major consideration in the evaluation process. Furthermore, a handful of hospital systems are notoriously difficult to interface to with, hence a track record of successfully integrating with these systems is important.  Although software decisions are typically made first, hardware and IT infrastructure (e.g. servers, routers, wiring, etc.) will significantly impact the total system cost and should be considered together.  How the final product is selected will depend on the corporate structure. A request for information (RFI) can be used, but having the steering committee simply shop around may be equally effective. After narrowing choices to no more than 3‐5 vendors, a request for proposal may be used for the final decision process. The committee must consider that no single vendor can provide all the features and functions desired today. Be careful not to buy based on promises of future development unless you have agreed to be part of that development process with the vendor. Identify what you need, consider what you want, and what you get should be somewhere in the middle.  The fiscal viability of the vendor should be considered. Many EDIS vendors are privately held entities and do not have the fiscal robustness of a publicly traded company. On the other hand, large HIS vendors cannot always be as ‐14‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS nimble in meeting unique or advancing needs. HIS vendors are considered by some to be 2‐5 years behind the BoB EDIS vendors. [20] Regardless of which vendor is selected, it is important to set performance and milestone parameters in the final contract to ensure that promises made in the selection process will be honored during implementation. Payment for the system should be graduated and predicated on the vendor meeting these criteria. If possible, define critical criteria that if not met would result in a full refund. These might include a guarantee of a workable hospital‐EDIS interface, system fault tolerance (i.e. limited downtime) and system support. Seeking independent information on current installations is critical and evaluators should not rely on the vendor‐
provided referral list alone. Discussion with other sites that use the same HIS, registration system, billing company, and other systems that will integrate with the EDIS will help you understand what level of integration is possible in your environment. The ACEP Section for Emergency Medical Informatics list server (available only to Section Members) can be a valuable tool for finding current and former installation sites for real user experiences. Telephone contact and/or onsite visits of current and former clients are valuable in determining vendor reliability. In seeking “unwashed” comments from others, one must take into account that there are many factors in the success or failure of an EDIS. Such information is not all created equal and time should also be spent in determining the success and failure factors involved. Most EDIS implementation failures are the result of poor planning, implementation, adequate resources and funding, not the underlying system itself. [12] [21] Another option worthy of mention is the “build your own” (BYO) approach. BYO system development requires many more IT resources and likely a longer development time, but there have been several very successful examples. In fact, many of the BoB EDISs were originally created in this way. Advantages include flexibility and customization, and they are much more likely to interface well with existing systems. However, depending on the resources available, this approach may result in a less robust system.  Software and Hardware Selection Depending upon the current ED workspace environment, a redesign of work areas may be necessary to allow for efficient use of the new system. Few EDs have ever been constructed with enough counter space to accommodate all necessary equipment. Adding an EDIS will likely increase space required for computers used for data entry. Consolidating work functions into single workstations may help, but significant forethought as to the location and type of equipment is essential to a successful implementation of an EDIS. Increasingly, dual monitor workstations for physicians are being employed to allow simultaneous viewing of data, images and completion of documentation.  ASSESSMENT PROCESS How to develop an EDIS selection action plan The EDIS selection process should include: 1.
Step‐by‐step process outline, including time parameters 2.
InformationВ collectionВ processВ 3.
AssessmentВ toolsВ (e.g.В spreadsheet)В basedВ onВ selectionВ criteriaВ 4.
DivisionВ ofВ laborВ (e.g.В whoВ doesВ whatВ when)В 5.
A cost‐benefit analysis 6.
Final decision process (e.g. democratic vote of the team or a recommendation to CIO or other decision‐
maker) ‐15‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS 7.
ContractingВ &В ScopeВ ofВ WorkВ processВ В 8.
A budget to support these activities Once this plan has been reviewed and approved by the team, it is validated against the business objectives. The plan is not static and should be reviewed periodically (perhaps quarterly initially then annually) even after the initial phases have been completed. Once a vendor is selected to either develop or supply the system and decisions are made regarding hardware, you will move to the implementation phase. THE EDIS MARKET & TRENDS The EDIS market continues to evolve with new entries into the market each year. Despite this, there has been relatively little attrition. The more recent entries have been the HIS vendors which appear to be significantly altering the market. Consolidation may eventually follow. All but two of the HIS vendors are publicly traded whereas most of the BoB vendors are privately held.  In recent years, hospital administrators and CIOs have tended toward implementing their current HIS vendor’s EDIS module vs. a best‐of‐breed system. This “business decision” is frequently made despite physician’s impressions that functionality and usability of these systems may not be on‐par with BoB vendors who specifically target the ED. There are many reasons for this trend, the primary factors being cost, interoperability, maintenance, and “vision” of the vendors. Making such a decision early in the process certainly makes the selection easier, but denies the organization the opportunity to build personal investment and “buy‐in”. Therefore, a longer and broader selection process may be worthwhile even if the ultimate decision is to go with the HIS vendor’s offering.  EDIS CERTIFICATION The Certification Commission for Healthcare Information Technology (CCHIT) [www.cchit.org] was founded in 2005 as an independent, voluntary, private‐sector initiative to accelerate the adoption of robust, interoperable health information technology by creating a credible, efficient certification process. CCHIT is currently the only certifying body of its kind in the United States.  CCHIT began with the certification of inpatient and ambulatory systems and in 2006 began pursuing the expansion of certification to other EHR systems and care domains. In 2006, ACEP endorsed the concept of certification and promoted EDIS certification. On the basis of ACEP’s support, CCHIT announced the expansion of certification to EDIS systems in February of 2007 and certification commenced in 2008. As of January 2009 only three vendors had received certification.  These authors collectively agree that published initial‐year certification criteria are neither necessary nor sufficient to drive EDIS selection. Furthermore, we believe that in the future CCHIT certification alone represents only a minimum standard and will never replace a comprehensive evaluation of EDIS.  Certification is an area that should be watched closely since momentum suggests it will play a much greater role in the future. Whether certification should ever be considered a requirement for system selection remains to be determined. However, certified products qualify under a special exemption to the Stark and anti‐kickback laws in healthcare. Furthermore, some professional liability insurers are offering premium discounts for use of certified systems. ‐16‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS RETURN ON INVESTMENT Return on Investment (ROI) is nearly always done in the EDIS selection process and is often based on false premises. Information technology in general rarely saves time or money. But IT does allow things that are otherwise not possible. Rather than a monetary value, the true “return” on the EDIS investment can be in staff efficiency, gathering of data for ED management, patient safety, improved data management, workflow automation, and other benefits. Therefore, a total cost of ownership rather than ROI is the best measure of true value assuming equal system functionality. The traditionally touted cost savings on transcription, presumed ability to reduce staffing, and other “hard” cost savings are in some cases not realistic. For example, physician documentation has traditionally been touted as an area with great potential for cost savings and is often implemented first. Unfortunately, computer physician charting can be the most difficult to implement because it requires a fundamental change in the way physicians work. In addition, physician documentation has very wide variability and makes charting system design very difficult. The decrease in physician productivity due to computer documentation often offsets any cost savings and shifts data entry costs to the physicians themselves, ultimately costing the hospital lost revenue. System costs and assessment of return‐on‐investment should take into account the impact on physician and staff productivity.   MARKET ANALYSIS There has never been a comprehensive Consumer Reports‐type analysis of the EDIS market primarily because this market continues to change rapidly. Most seeking an EDIS will find it necessary to collect information from a variety of source including the internet, an RFI or simple information request. Unfortunately, simply reviewing printed marketing materials will seldom help narrow the choices. There are commercial sources of comparative information. For example, KLAS [www.klasresearch.com] has been collecting end‐user satisfaction information on the EDIS market for the last several years and is arguably the best source for head‐to‐head comparisons. But, it is limited by several factors including the requirement for a minimum number of installs to include a vendor (i.e. several smaller vendors are omitted) and the data is based on interviews of current customers (i.e. more of a user‐satisfaction survey than product analysis). For example, end‐
users may be unhappy for reasons totally unrelated to the vendor or product itself. A poor implementation of a great product may look the same as a good implementation of a not so good product.  The journal “Healthcare Informatics” [healthcare‐informatics.com] maintains a description of the functionality of HIS vendor software. Internet‐based electronic lists can be valuable, “unwashed” sources of information, but one must be careful to consider the source. Disgruntled users tend to be more vocal, vendors (or their proxies) will comment, and opinions can be dated. But despite these limitations, these free lists are perhaps the most current and easily available information.  Consultants can bring value to the entire process from the beginning through post implementation. Diligence in selecting a consultant is perhaps as important as the EDIS selection itself. One should not assume they have any special knowledge of this fast changing market, any special expertise in selection or implementation, and that they are free of bias. It is perhaps best to use them to help you arrive at your own decision instead of telling you what you should do.  The American College of Emergency Physicians (ACEP) Annual Scientific Assembly [www.acep.org] is a general emergency medicine meeting where many of the EDIS vendors have exhibits and there are lectures on EDIS topics.  The Pennsylvania ACEP Annual EDIS Symposium [www.isedis.com] occurs during late fall each year, is the only meeting of its kind and is a good place to learn, network and shop for an EDIS. All major BoB vendors and many HIS ‐17‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS vendors exhibit and showcase their products. It is also an opportunity to hear from industry experts and network with current and former EDIS users.  Request for Information (RFI) remains the industry standard mechanism to formally obtain system information in a standardized way. This is sometimes combined with an RFP, but a shorter RFI may help to narrow the choices before the typically more comprehensive RFP process is begun. However, even a well‐designed RFI may not garner all the necessary information or even guarantee receiving accurate information.  The Request for Proposal (RFP) is often confused with the RFI. The RFP is an opportunity to narrow the choices to 2‐3 vendors and is perhaps the first opportunity to consider the real cost of the system. As with an RFI, it is not a perfect process. The steering committee must do further due diligence with the finalists as noted below.   EDIS ASSESSMENT One reason there are more than 20 EDIS vendors is that no ED is alike and clinicians are particular about managing workflow. In addition, the heritage of EDIS is varied. HIS ED modules tend to be reworked inpatient modules or a BoB that was acquired and integrated. Most BoBs began as tracking systems or documentation systems that grew in functionality over time. Only a few were originally designed for full EDIS functionality. Further complicating this mix is the battle between EDISs using client/server architecture which typically have better performance and those using a web‐based architecture which tends to have easier deployment and maintenance. To follow are several suggestions to help sort through the selection. When investigating an EDIS purchase, it is critical to determine the components that you will need and use. No current EDIS (HIS or BoB) has all features. Generally speaking, BoB systems tend to have better functionality and usability where as HIS modules tend to have better integration (e.g. system interfaces, API). Prioritizing components for your needs and selecting an EDIS that best meets them will significantly increase your chances of a successful EDIS implementation.  Determining Semi‐Finalists By the time you fully evaluate more than 20 EDISs, those you evaluated first may be onto their next product version. Therefore, narrowing your choices to 5‐8 for an in‐depth evaluation is recommended. You may be able to quickly eliminate all of the other HIS enterprise vendors except your own. You may be able to narrow the BoB vendors on gross criteria such as reputation, number of installs, corporate structure, or critical functionality. For example, if IT decides the application must be web‐based it may narrow your choices to only 3 or so vendors. Attending the PA ACEP EDIS meeting is a good way to rapidly consider all of the vendors and arrive at a semi‐final slate. Remember, if you do the “planning parameter” work up front, this process will be relatively straightforward and you will have a much better chance of getting what you need.  Assessing Semi‐Finalists Even if you narrow this group to 5‐8 vendors, a full assessment of each will be challenging. You may wish to use an RFP process at this stage to allow you to begin to consider cost in the analysis. Again, the PA ACEP meeting allows face‐to‐face interaction with multiple vendors in a short time frame. Hospitals often bring their entire assessment team to the meeting just for this purpose. Another option is to schedule regular assessment team meetings and schedule vendors to do onsite or remote demonstrations. Regardless of how you do this, it is critical to have objective criteria upon which to evaluate each vendor. Finalists After narrowing further to 2‐3 vendors, you may wish to update the RFPs as several weeks to months may have elapsed. Options on how to proceed depends on several factors. You may already have enough information to know which system you want and all you need to do is do the final due diligence (i.e., verifying what you know is true) before entering into contact negotiations. Or, you may have identified 3 relatively equal systems and need to explore final differentiators. The final assessment process is the same and only the number of vendors being fully assessed will vary.  ‐18‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS FINAL DUE DILIGENCE There are many methods to evaluate the full functionality of an EDIS, each with varying degrees of costs and benefits. The cost and risk of failure is high enough that some degree of formal evaluation prior to the final decision is warranted. The full steering committee needs to be involved in this step of the decision making. Any of the following could be used at any point in the assessment process to differentiate systems, but it is usually cost prohibitive to do it for more than a few. Usability Assessment A typical vendor demo used in the semi‐finalist process will demonstrate workflow, functionality and usability, but usually follows a vendor’s predefined script. Real usability assessment must determine if it will work in your specific ED. To do so, you should create 2‐3 use case scripts (e.g. urgent care, major work up, and critical care patients) that will demonstrate your workflow and fully assess usability from the front door to disposition. Use cases should also include multiple users such as doctor, nurse, tech, ancillary, private attending, house staff, sign‐out physician, hospital bed control, etc.. Also assess how the system would interact with other departments. For example, how does an aerosol treatment order get to the respiratory technician? How are nursing medication orders implemented?  Site Visits Even under the best of circumstances a demo is still just a demo. Real, well‐planned site visits are critical to the process. While often better than a demo, site visits can also be artificial and misleading. There are conflicts of interest that you may not recognize. Develop assessment criteria in advance to the site visit so that you will be sure to consider all important aspects in an objective way.  Vendors with fewer installs may not have a comparable site. For example, going to a small suburban ED may not give you a true understanding of how the system will work in a large urban trauma center. Ask for a list of all installed sites and choose the site you wish to visit. Be careful to choose the best match, not simply a convenient one.  Be creative. Arrange to visit on various shifts. Call the ED at 2 A.M. and ask staff how they like the EDIS.  Take a stopwatch. Time how long it takes for a typical triage, for a physician to chart a typical encounter, etc. Then, compare these with the length of your current processes. In doing so you can do rough calculations on the transactional overhead cost of the system (Figure 2).  Figure 2 Assess where the staff has created workarounds. For example, one EDIS vendor touts its risk management capabilities, but compliance takes 3‐
4 times longer to document. To mitigate this, some physicians workaround that functionality and use macros to populate a standard non‐
codified ED record, then document “by deletion”. But this workaround eliminates the risk management benefits. Virtual Opinion Poll Using the vendor’s list of their installed base, call colleagues at those sites to see what they say, especially if they are not on the reference site list.  Vendors will seldom provide sites where their system has been de‐installed. But you can often find this information using the ACEP SEMI or eMed‐L list servers. Remember, not all de‐installs are the fault of the vendor.  ‐19‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS Scope of Work This is the “devil is in the details” part of the contract. Vendors put to paper exactly what they will do, what and when they will deliver it and what that process will look like. All the functional details determined up to this point should be incorporated into this document.  Contract Negotiations While you may do your best to find the right EDIS, final selection may be impacted by hospital lawyers. System cost should have been addressed and any system that is too expensive already eliminated. Sticking points often revolve around indemnification, success criteria, and other legal issues. IMPLEMENTATION EDIS should be properly implemented, sufficiently integrated, and well‐maintained. Perhaps one of the greatest EDIS misconceptions is that system selection is the most important part of the process. In fact, there have been reasonable successes and implementation disasters – with exactly the same product. So while system selection often requires significant time and resources, even more time and effort should be dedicated to planning and executing implementation and system maintenance. Further, selection of hardware (both IT infrastructure and end‐user workstations) must be carefully considered and budgeted appropriately. Success may also require ED workspace redesign as most were not built with the use of an EDIS in mind.  Efforts to redesign the information environment must go beyond simply automating paper flow in the ED. Instead, the goal should be to support the department's business plan with a design that combines productivity and profitability with the delivery of high‐quality patient care. This can be best accomplished in a step‐wise approach (Figure 1). This section will help begin that process and provide some of the tools necessary to implement a usable, functional and efficient EDIS. “Garbage in – Genius out?” A common error when deciding to adopt an EDIS is assuming it will make the current bad situation better. The best way to assess and implement an EDIS is to design good processes and then automate them. Otherwise, you do the same wrong things you have always done . . . only faster. One should not assume adding an EDIS will solve fundamental inadequacies of an already dysfunctional ED. In fact, doing so will undoubtedly exacerbate the situation. For example, if maintaining broken equipment in the ED is already a problem, adding more computers will make it worse. When the EDIS depends upon having a functional “special” printer in each ED area and that printer fails, so will the EDIS. Planning for equipment redundancy for the EDIS is as important as other ED equipment. If patient throughput is a problem due to poor staffing or other reasons, adding the additional work overhead often required by EDISs will exacerbate that situation. It is common for “Left Without Treatment" and other throughput measures to worsen significantly during the early implementation process, even under the best of circumstances (Figure 2). Therefore, in preparation for introduction of an EDIS, one should first assess and repair the current ED processes and environment. Once implemented, the EDIS can then assist in refining these fundamental improvements, rather than merely illuminating, documenting, and exacerbating an already broken system. Team Organization There are four main areas of focus when implementing a new system into the ED: Process Analysis, Training, Technology Implementation and Go‐Live Planning. For large departments, these may be managed by individual groups reporting to a steering team that coordinates overall efforts. In smaller departments each of these responsibilities may be delegated to an individual. The executive team of the ED and hospital must actively participate in the steering team. Vendors and hospital staff who have experience with the installation of new technology should be engaged early on in the process to provide guidance and assist with the process.  ‐20‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS PROCESS CHANGE PLANNING  Investing up front in planning and testing to reduce the surprises that arise during “Go‐Live” is critical to successful implementation. Major tasks include careful workflow mapping, local customization of the system, careful resources planning, and a comprehensive education program.  Every department operates differently including staffing models, processes, hospital relationships, and technology. There is no single formula, so a process team will need to determine how workflow will be accomplished with the new system. Based on that analysis the new system will need to be customized for use onsite. This analysis will help determine the impact on departmental productivity and how best to organize the implementation process.  Communication is a key part of change management. Provide regular updates and reminders to the staff to keep them engaged. In communications plans, consider all users that may be impacted by changes in the system, including consultants, patients’ personal care providers, and inpatient staff. TECHNICAL DESIGN AND IMPLEMENTATION The EDIS is not isolated from the hospital information systems environment. During the selection process the fit between the proposed EDIS and other hospital systems should be considered. During implementation, system interfaces will need to be created and tested and the software customized for local use. Although primarily a technical IT function, collaboration with the implementation team is necessary to assure appropriate localization of the software.  RESOURCES AND SUPPORT During the design and customization phase, the team must have adequate resources to complete all the necessary tasks to prepare for “Go‐Live”. The vendor must also have adequate technical support to work with local IT staff to create system interfaces and manage the overall process. Finally, the team must have sufficient expertise to understand local business rules and processes in order to install, customize, and test the system.  At the time of “Go‐Live” extra clinical and technical staff must be available to address inevitable glitches and lost productivity. It is better to be overstaffed than to find out at the time of roll‐out that you are understaffed. TRAINING Resource Requirements for training are often grossly underestimated and poorly provisioned. For major IT projects, nearly twice as many resources are needed for ongoing support, network installation/upgrades, outside consulting and hospital staff time as are necessary for software licenses, installation, and initial basic training [22]. Therefore, beyond system selection, equal attention should be paid to this critical aspect of EDIS success. Further, a decision as to who (i.e. vendor, consultant, or hospital) will do the training needs to be made. Certain vendors are better at training than others, so using an outside independent consultant or inside training may be warranted. Timing of training is also important and should be conducted in close proximity to the true “Go Live”, i.e. technical issues delaying the “Go Live” may require re‐training  Super Users are drawn from current staff (often from the steering committee) who have a deep understating of the product, at least for their particular role, i.e. nurse, doctor, clerk, etc. They will have completed “train the ‐21‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS trainer” education and are added as extra staff during the “Go Live” and available for additional ad hoc point of service training thereafter. One advantage of using super users is that they also have a deep understanding of your ED and immediate credibility with other staff. The qualities for a super user include: a willingness to commit the time necessary (with or perhaps without extra pay); ability to not only grasp a “user level” understanding of the product, but able to teach it in an effective way; understands their own role(s) in the ED well; and most importantly has credibility with the other ED staff.  Training Process As noted, some vendors are better at the training process than others, but all should have a well defined plan and materials available. Increasingly, online training is being utilized especially for industries that function 24/7. If there will be onsite classroom training, multiple sessions at various times of day need to be offered to accommodate both work and personal schedules. Expecting the night shift to sit through a morning session after working a night shift is not reasonable. Another training technique gaining favor is “viral peer‐to‐
peer” training. This process includes multiple short (less than 10 minute) sessions conducted by trainers or super users during the usual course of the work day.  Training as a Selection Criteria The amount of training required to learn the basics of a system is a rough indication of likelihood of success. Training that requires 50 hours of classroom education (an actual case) indicates either a poorly designed training course or an EDIS too complicated to use, or both. Ideally, there should be minimal (less than one hour) of classroom training or better yet online training supplemented with point‐of‐service mentoring.  PARALLEL TESTING An often overlooked phase in implementation is parallel testing, whereby a select group of front‐line users, generally noted for their comfort with technology and knowledge of ED processes and workflow, use the system in parallel with their day‐to‐day activities. Parallel testing affords the opportunity to test the production system “in‐
situ” during real patient encounters. And often reveals design needs or workflow issues which have been overlooked. It can also reveal issues with system access, workspace design, hardware placement, and device compatibility. Parallel testing is essential in EDIS implementations involving multiple interfaces or interactions with other hospital systems.  GO‐LIVE PLANNING At some point changeover to the new system must occur, often termed “Go‐Live”. While anticipation leading up to this date may create angst & stress, it is important to have such a date to drive system implementation, training, and staffing. Good planning, preparation, and training are vital to smooth the transition. Be sure this date does not conflict with other initiatives and fits well with the flow of the department. The days surrounding the “Go‐Live” will require extra support for all phases of clinical and administrative operation. You will know when you are ready for “Go Live” when the dread of a new system becomes anticipatory excitement. In the “Go‐Live” planning, a fundamental decision must be made if all the functionality of the new system will be implemented at the same time (“Big‐Bang”) or if implementation will use a more incremental phased‐in approach.  The “Big‐Bang” approach is just what it implies. At some moment in time, everyone shifts from current processes to the new one. With proper planning and parallel testing as previously noted, some have been successful at using such an approach. Some have postulated it is just better to “get all the pain over at once”, like pulling off a Band‐
‐22‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS Aid. However, the risk of failure may over shadow these benefits. Also, certain EDIS may be more amenable to a “Big‐Bang” vs. other approaches. You do not want to be the first to try this with whatever system is selected.  The incremental phased‐in approach is possible with EDIS because functionality tends to be grouped into modules where each module or group of modules can function on their own. Doing so may minimize workflow disruption. For example, ADT, tracking, and discharge modules could be implemented first followed by CPOE, results reporting, and medication administration. Finally, clinical documentation can be implemented for nurses, then physicians. Recognize that this requires multiple “Go‐Live” dates, but allows for planning to be more incremental. Also, if one “Go‐Live” should fail, it does not bring down the entire initiative.  Another option is a pilot installation to fully test system functionality, but with a limited user group. All or part of the system is turned on for a limited time to a limited group. At the end of the pilot, the system is turned off and changes made based on what was learned. Additional pilots may be necessary depending on the extent of the changes. BUY IN It has been said, "Culture eats strategy for breakfast" which means you may need to change the culture in order to succeed when making major changes to department operations. [23] Full support from decision makers and leaders is critical to the success of the implementation process. The leadership must communicate their enthusiasm for the project and their full support. Specifically the medical director, the nursing director and members of the hospital executive team must be committed to the success of the project and constantly communicate with staff on progress and successes. Finally, do not forget “social factors”. Noted emergency physician Robert L. Wears, MD, MS, FACEP said, “A vision of organizational change has to precede IT systems implementation” recognizing that “clinical IT projects are incredibly complex social endeavors in unforgiving environments that happen to involve computers, as opposed to IT projects that happen to involve physicians.”[11] Bringing in food during “Go‐Live” to acknowledge that staff may not have time to eat; giving awards to acknowledge user adoption and milestones; creating camaraderie and esprit de corp around the task; and simply thanking everyone for their hard work are all vital success factors.  BARRIERS TO ADOPTION Information systems offer many potential benefits for the increasingly stressful and resource constrained environment of the ED. Tracking systems "sunshine the data" and improve the situational awareness for the staff, helping them to work more efficiently. Electronic documentation systems encourage more complete charting, which may improve reimbursement and medico‐legal protection. CPOE systems have the potential to facilitate safer and more effective care by bringing clinical decision support directly to the provider making the decisions at the point of care. Networked computer systems are capable of efficiently storing and moving large volumes of information and are very well suited to repetitive tasks such as maintaining vigilance for both common and uncommon events. With such clear benefits, one might expect that EDIS adoption would be widespread and effortless, however significant barriers remain.  •
The capital required to purchase an EDIS can be significant and such an effort also requires investment in skilled personnel and infrastructure. The federal government estimates an annual savings of $140 billion through improved use of IT (DHHS and ONC, 2005); however such savings may not translate directly to the ‐23‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS ED, nor directly benefit the staff. Making the return on investment (ROI) case for EDIS remains a challenge.  •
The ED is dependent on exchanging information with a number of external departments such as laboratory, radiology, admissions, inpatient, and outpatient offices with disparate computer systems. While there are data exchange standards, they are plentiful and not always consistently implemented. The Healthcare Information Technology Standards Panel (HITSP) was formed to harmonize these standards. Ultimately, improved standards will facilitate the interchange of healthcare information between hospital departments and between different healthcare entities. But in the meantime, EDIS and other HIT systems must accommodate the increasing need for data.  •
High‐risk industries such as aviation and nuclear power have used human factors techniques to improve safety and decrease errors. However there are currently no standards for human‐computer interaction for medical applications and it is an often under appreciated part of the software development process. Poor usability can reduce the usefulness of an application and even cause harm. For example, Cedars Sinai hospital was forced to withdraw its CPOE system after 6 months due to significant resistance from the medical staff who found it difficult to use. •
There remains a relative dearth of research on EDIS as compared to other settings, perhaps because the ED is highly variable and difficult to compare one to another. Also, the sheer number of EDIS products in a rapidly changing industry makes comparison impossible.  THE FUTURE OF EMERGENCY CARE INFORMATION SYSTEMS Health IT is a rapidly changing field so predictions can be difficult. We continue to progress with a lack of objective data and research, mostly complicated by the fact that evaluations of EDIS implementations have so many confounding variables.   Historically, computer solutions that solve problems often constrain or limit users in new ways. Although we remain optimistic that a significant change will occur, we anticipate this paradigm will continue. Closer scrutiny of new technology with cost‐benefit analysis can allow us to choose a future clinical environment without significant feature gaps. Nevertheless, we believe the future will include better data exchange, likely via regional health information exchanges (HIE) initially then perhaps via consumer‐oriented “personal health records” (PHR). Similarly data captured via patient kiosks for registration, chief complaint, history of present illness, review of systems, family/social histories, medications, and allergies are being used to automate data exchange. More importantly, recent political discussion regarding Health IT cost saving initiatives from President Obama and funding from the economic stimulus bill are significant. Although we believe the estimated savings to be inflated, the changes will no doubt be dramatic. Although, it is unlikely to be cost or time saving for physicians themselves, government intervention has historically led to more rapid, more significant, and longer lasting change in healthcare. Data integration has been one of the key items on this agenda and hopefully successes within the government funded National Health Information Network can be reproduced. ‐24‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS Conclusion Emergency department automation is challenging and often fraught with pitfalls [Figure 3]. The success of the project will depend greatly on the commitment of the development team and a willingness to dedicate adequate resources to the goal. Information system planning for the emergency department is complex and relatively new to emergency medicine. Active physician and nurse involvement is essential in the process if the new system is to be accepted at the user level. In choosing and implementing EDISs, one should be careful not to automate poorly designed manual processes. In the automated emergency department, we must have zero‐fault‐tolerant enterprise‐
wide hospital information networked systems that prevent unnecessary duplication of tasks, assist in tracking and entering data, and ultimately help analyze the information on a minute‐to‐
minuteВ basis.В SuchВ systemsВ willВ onlyВ reachВ theirВ potentialВ whenВ theyВ areВ fullyВ integratedВ orВ interfaced,В includingВ legacyВ systems.В В Finally,В goodВ clinicalВ contentВ andВ domainВ knowledgeВ isВ theВ keyВ toВ virtuallyВ everyВ aspectВ ofВ theВ EDIS.В MuchВ ofВ thisВ contentВ isВ yetВ toВ beВ developedВ andВ whatВ isВ availableВ needsВ betterВ customizationВ toВ theВ EDISВ environment.В DauntingВ asВ itВ mayВ be,В aВ properlyВ accomplishedВ EDISВ implementationВ willВ resultВ inВ betterВ patientВ care,В improvedВ staffВ productivity,В andВ aВ satisfyingВ workВ environment.В ItВ isВ ourВ hopeВ thisВ whiteВ paperВ isВ anotherВ stepВ forwardВ inВ theВ maturationВ ofВ theВ EDISВ knowledgeВ baseВ andВ willВ resultВ inВ moreВ successfulВ EDISВ adoptionВ andВ HITВ integration.В YourВ feedbackВ andВ questionsВ areВ welcomed.В В FigureВ 3:В PearlsВ &В PitfallsВ forВ SuccessfulВ EDISВ SelectionВ &В ImplementationВ 1.
EDIS to address enterprise‐wide information management challenges are only now becoming available. Consider transition (temporary) systems as a 3‐year to 5‐year solution that will likely need to be totally replaced when enterprise‐wide hospital systems become readily available in the next few years. 2.
EstablishВ objectivesВ (differentВ forВ everyВ ED):В AskingВ theВ rightВ questionsВ willВ achieveВ theВ rightВ solutions.В CertainВ objectivesВ mayВ beВ mutuallyВ exclusive,В forВ example:В EliminatingВ dictationВ costsВ withВ physicianВ computerВ chartingВ willВ likelyВ impactВ EDВ throughputВ (decreasedВ throughputВ =В lessВ revenueВ whichВ mayВ offsetВ savingsВ achievedВ byВ eliminatingВ dictation)В 3.
Don’t accept the enterprise HIS EDIS offering today unless it substantially meets EDs needs. You may ultimately be forced to do so, but due diligence in EDIS search process may allow opportunity to change course if necessary. 4.
BudgetВ equalВ amountsВ ofВ moneyВ forВ hardwareВ &В deploymentВ asВ theВ EDISВ softwareВ purchaseВ 5.
FixВ otherВ aspectsВ ofВ theВ EDВ environmentВ beforeВ implementingВ anВ EDIS.В 6.
BeВ carefulВ notВ toВ developВ orВ purchaseВ systemsВ thatВ merelyВ automateВ poorВ manualВ processes.В TheВ lessВ aВ systemВ requiresВ humanВ inputВ theВ better;В considerВ systemsВ thatВ automaticallyВ captureВ dataВ alreadyВ availableВ onВ theВ hospitalВ mainВ systemВ andВ systemsВ thatВ automaticallyВ trackВ patientsВ throughВ theВ ED.В 7.
Downtime:В EDISВ mustВ accommodateВ downtimeВ fromВ externalВ systems.В ScheduledВ EDISВ downtimeВ (ex.В forВ upgrades)В shouldВ beВ lessВ thanВ 5В minutesВ 8.
Phase in the installation in a modular approach or be very confident that a “Big‐Bang” implementation has been successful with the same product at similar EDs. 9.
Spend as much time selecting hardware as the software and in planning its deployment in an already crowded work environment. 10. Decide what it is you need then decide what it is you want (in that order). What you end up with should be somewhere in the middle. 11. Obtain a guarantee of milestone implementation (i.e. money back guarantee if EDIS not ultimately integrate with the hospital HIS or a particular module not successfully fully implemented) 12. Be willing to fail and change course if necessary. Forcing a square, inadequate system into a round hole will end in disaster. 13. Waiting for the ultimate solution is no solution. Seek short‐term solutions to meet specific definable needs, e.g. a simple automated RFID tracking system may offer significant value with less cost.  ‐25‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS CONTRIBUTIONS: The EDIS Task Force resulted from ACEP Council Resolution 22(07). All members of the Task Force contributed sections to this paper, which were revised, edited, and agreed upon by all members. While ED informatics remains a relatively young discipline with little formal research available, we did our best to reference statements made herein. Perceived conflicts of interest are inevitable, but every effort was made to prevent bias and to offer an honest appraisal of the current state of Emergency Department Information Systems.  DISCLOSURES: Todd Rothenhaus, MD, FACEP [None] Donald Kamens, MD, FACEP [Former CEO, Founder, Standards Advisor, and Consultant to Xpress Technologies] Brian F. Keaton, MD, FACEP [None] Larry Nathanson, MD, FACEP [None] Jeffrey Nielson, MD, FACEP [None] James McClay, MD, FACEP [Co‐chair HL7 Emergency Care Work Group] Todd B. Taylor, MD, FACEP [Physician Executive, Microsoft Corp. Health Solutions Group] Al Villarin, MD, FACEP [None]  ‐26‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS ACRONYMS USED ADT‐ Admit/Discharge/Transfer Data  BoB – Best of breed BYO – Build your own CCD‐ Continuity of Care Document CCHIT ‐ Certification Commission for Healthcare Information Technology CPOE – Computerized Provider Order Entry DHHS – Department of Health and Human Services EDIS – Emergency Department Information System GUI‐ Graphical User Interface HER – Electronic Health Record HIPAA – Health Insurance Portability and Accountability Act HIS – Health Information System HIT – Health Information Technology HITSP – Healthcare Information Technology Standards Panel IR ‐ Infrared IT – Information Technology ONC (ONCHIT) – Office of the National Coordinator for Health Information Technology PACS – Picture Archiving and Communication System PHI – Personal Health Information RFI – Request for Information RFID – Radio Frequency Identification RFP – Request for Proposal UI – User Interface ‐27‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS REFERENCES  1.
ACEPВ PolicyВ Statement:В HealthВ InformationВ Technology.В AnnВ EmergВ Med.В 2008;52:595.В 2.
BarthellВ EN,В TaylorВ TB:В AВ ViewВ ofВ theВ EmergencyВ DepartmentВ ofВ theВ Future.В AmericanВ CollegeВ ofВ EmergencyВ Physicians.В 1992В (revisedВ 2000)В Dallas,В TX.В 3.
SmithВ M,В FeiedВ C:В TheВ NextВ GenerationВ EmergencyВ Department.В AnnВ EmergВ Med,В 1998;32:65.В В 4.
Executive Order: Incentives for the use of health information technology and establishing the position of the National Health Information Technology Coordinator. Washington, DC: The White House, April 27, 2004. (Accessed August 8, 2007 at http://www.whitehouse.gov/news/releases/2004/04/20040427‐4.html) 5.
TheВ AmericanВ RecoveryВ andВ ReinvestmentВ ActВ ofВ 2009.В (AccessedВ MarchВ 21,В 2007В at:В http://www.whitehouse.gov/the_press_office/ARRA_public_review/).В 6.
Feied CF, Handler JA, Smith MS, Gillam M, Kanhouwa M, Rothenhaus T, et. al: Clinical information systems: instant ubiquitous clinical data for error reduction and improved clinical outcomes. Acad Emerg Med. 2004 Nov;11(11):1162‐9. 7.
Blumenthal D, Glaser JP: Information technology comes to medicine. N Engl J Med. 2007 Jun 14;356(24):2527‐
34.В 8.
Garg AX, Adhikari NK, McDonald H, Rosas‐Arellano MP, Devereaux PJ, Beyene J, Sam J, Haynes RB: Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005 Mar 9;293(10):1223‐38. 9.
Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, Morton SC, Shekelle PG: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006 May 16;144(10):742‐52. 10. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL: Role of computerized physician order entry systems in facilitating medication errors. JAMA. 2005 Mar 9;293(10):1197‐203.  11. Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA: Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005 Dec;116(6):1506‐12. 12. Wears RL, Berg M: Computer technology and clinical work: still waiting for Godot. JAMA. 2005 Mar 9;293(10):1261‐3. 13. Joint Commission, Sentinel Event Alert: (Accessed January 15, 2009 at : http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm). 14. Burt CW, Hing , E: Use of computerized clinical support systems in medical settings: United States, 2001‐03. Adv Data. 2005 Mar 2;(353):1‐8. 15. Smith M, Feied C: The Emergency Department as a Complex System. New England Complex Systems Institute, 1999. (Available at: http://www.necsi.edu/projects/yaneer/emergencydeptcx.pdf).  16. Anonymous: CPHA developing emergency department information system. Bull Am Coll. Physicians. 1975 Feb;16(2):5. 17. ISO/TR 20514: Health informatics ‐‐ Electronic health record ‐‐ Definition, scope and context. 2005‐10‐17 (Available at: http://www.iso.org). ‐28‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS 18. Health Level 7 Emergency Care Special Interest Group: Emergency Department Information Systems Functional Profile. Health Level 7, 2007. (Available at: http://xreg2.nist.gov:8080/ehrsRegistry/index.jsp.). 19. Clinical Context Object Workgroup: http://www.hl7.org/special/Committees/ccow_sigvi.htm. 20. Runyon, B: Hype Cycle for Healthcare Provider Applications and Systems, 2008. Gartner 27 June 2008. 21. TEPR 2007 Survey. The Medical Records Institute, Boston, MA. 22. Navigating the New Frontier of Connectivity. 2008 The Advisory Board Company. 23. Teasdale S: Culture eats strategy for breakfast! Informatics in Primary Care. 2002 Nov 1; 10(4):1,195‐196(2).
‐29‐ EDIS: PRIMER FOR EMERGENCY PHYSICIANS, NURSES, AND IT PROFESSIONALS Additional Resources • HL7 EHR‐S Functional Model, Release 1. February 2007. (Available at: http://www.hl7.org/ehr) • Gillam M, Rothenhaus T, Smith V, Kanhouwa M: Information technology principles for management, reporting, and research. Acad Emerg Med. 2004 Nov;11(11):1155‐61. • Welch S, Augustine J, Camargo CA Jr, Reese C: Emergency department performance measures and benchmarking summit. Acad Emerg Med. 2006 13(10):1074‐80. • Nathanson LA: Information Technology in Emergency Care. In. Hospital‐Based Emergency Care: At the Breaking Point. Institute of Medicine, 2007. • Leavitt M, Gallagher L: The EHR seal of approval: CCHIT introduces product certification to spur EHR adoption. J AHIMA. 2006 May;77(5):26‐30.  • Executive Order: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. Washington, DC: The White House, August 22nd, 2006. (Accessed August 8, 2007, at: http://www.whitehouse.gov/news/releases/2006/08/20060822‐2.html.) • Hagland M: Guaranteed certified. CCHIT announces its first wave of certifications in the outpatient arena. Healthc Inform. 2006 Sep;23(9):14, 16. • Health Level 7 Electronic Health Record Technical Committee: How‐To Guide for Creating Functional Profiles ‐ Electronic Health Record‐System Functional Model, Release 1, February 2007. • Internet Engineering Task Force: RFC 2119 Key words for use in RFCs to Indicate Requirement Levels. March 1997. (Accessed August 8th, 2007, at: http://www.ietf.org/rfc/rfc2119.txt.) • ISO/TR 20514: Health informatics ‐‐ Electronic health record ‐‐ Definition, scope and context. 2005‐10‐17 (Available at: http://www.iso.org) • Aylett RS: Emergent Narrative, Social Immersion and Storification. Proceedings, Narrative Interaction for Learning Environments, Edinburgh, 2000. • Grey M: Emergencies first. HL7 develops the first unique clinical profile for the ED, based on its EHR umbrella standard. Healthc Inform. 2007 Jul;24(7):12, 14. • Emergency Department Work Group: Environmental Scan. Certification Commission for Health Information Technology. Sept 2007. (Available at: http://www.cchit.org) • Taylor, T: EDIS Compendium. (Available via personal contact: ttaylor@acep.org) • Pennsylvania ACEP Annual EDIS Symposium. (http:// www.isedis.com) • KLAS Emergency Department Systems Study, July 2008 (www.klasresearch.com) • Taylor, T: “Best‐of‐Breed” vs “Single Source” HIS Enterprise Solutions for EDIS (available at: ttaylor@acep.org) • ACEP Section of Emergency Medical Informatics (SEMI) eList (Membership required: http://www.acep.org) • eMed‐L (Subscription: listserv@itssrv1.ucsf.edu  Messages: emed‐l@itssrv1.ucsf.edu) ‐30‐ >> T h e I n d e p e n d e n t V o i c e
for
Emergency Physicians, Online
at w w w . e p m o n t h ly . c o m
April 2009 | Volume 16, Number 4 | www.epmonthly.com
NightShift
with Guest Columnist
Joe DeLucia, DO
I
“I Love My Job”
have a confession to make. I
love my job. I’m often afraid
to admit this out loud. I look forward to going to work in the ER
and miss it when I’m away.
Why do I feel so alone? Is there
something wrong with me? Whenever I’m with a group of colleagues,
all I ever hear is complaining. Last
week, one of my colleagues was
actually banging his head on the
counter top and repeatedly hollering, “I hate my job, I hate my job!”
Of course after ranting and raving
about how miserable it is to work
4continued on page 13
8In
This Issue
Fentanyl Abuse Increasing
Brush up on the signs,
symptoms and street names
of this deadly drug and earn
an hour of CME >8
Is it just the flu?
We posed the scenario, you
submitted the verdict. Now
read the final analysis >10
Wet Reading
What can the X-ray and CT
tell you about this elderly
man’s abdominal pain >4
EMR: State of the Art
or Digital Disaster?
Oh Henry
Can Sebelius Say
the “R” Word?
by Kevin Klauer, DO
Whether it’s rationing or
retirement, the Sec. of Health
must lead on hard questions
by Greg Henry, MD
В­W
hen you talk to an emergency
physician about electronic medical records and emergency department
information systems, you’re likely to get
a strong reaction. While some EPs report stories of great time-saving potential from these technologies many others have seen the same platforms cripple
their department.
One thing is cer- INSIDE
questions
tain, regardless
to ask
which side of the
before
your ED
fence you’re on,
goes
digital
it’s very likely an
8
4continued on page 14
CMS Shuts Down
Retroactive Billing
Have you filed your Medicare provider application? If not, better read the fine print.
by David Packo, MD
O
{
PLUS
}
The Mt. Sinai Experience
The Problem of Interface
EMR Poll Results
Knees, Backs
and Stonehenge
Part II in a series on the art of doctorpatient communication
By David H. Newman, MD
E
ne useless
person is a
depressing sight.
Two
useless
people are a law
firm and three or more useless
people constitute a congress. As we
watch the Obama administration
back away from “change you can
believe in,” there is no place where
it is greater illustrated than in the
question of health care. He was
smart enough to appoint a Nobel
Prize-winning physicist to deal
with energy issues. Why in the
world would he pick mere politi4continued on page 27
Mel Herbert presents
The Best of EM:RAP
Trauma Updates
edited by Veronica Vasquez, MD
ach year Medicare publishes changes to its fees
and rules via the Federal Register. This typically
occurs in the November or December edition for the
following year. For 2009, the November 19, 2008
edition of the Federal Register included changes to
the conversion factor, and some other rules, along
with Medicare “adjusting” the time period for which
a “provider is allowed to (retrospectively) bill for
services...” CMS 2009 Final Rule p.245.
Up until this ruling, once you had your medical license and were credentialed by the hospital,
you could start seeing patients, and in the case of
Medicare, take several months to apply and receive
a provider number. After you received your provider
number you could go back as many as 27 months to
bill for those patients you saw.
But now, all that has changed. Thanks to the edict,
n medicine, we have many mysteries, and in September, 2008 the New England Journal of Medicine delivered another. In the largest and best study of its kind,
investigators found that subjects with knee pain and
those without knee pain had nearly the same prevalence of meniscal tears on magnetic resonance imaging
(MRI).
For some, the findings may strike a familiar chord.
Multiple spinal MRI studies have reported a similar
phenomenon, in which herniated discs are found as
commonly on the MRI’s of healthy individuals without back pain as on the MRI’s of back pain sufferers.
Contrary to standard medical teaching for decades, this
means that for the great majority of patients, both herniated discs and meniscal tears are probably asymptomatic, or even normal. What, then, causes back and knee
4continued on page 3
4see Broca’s Area, page 7
I
A
t a recent All L.A. Conference, a panel of guest speakers from several emergency departments throughout Southern
California discussed a few current
updates and controversies in the
management of trauma patients:
Permissive Hypotension
Does the use of permissive hypotension in trauma patients with
likely hemorrhagic shock represent
the current state of the art for the
hypotensive trauma patient?
The goals of permissive hypotension in trauma are to limit hemor-
8Practical
Emergency Physicians Monthly
5 College Avenue
Annapolis, MD 21401
7
4continued on page 4
Pediatrics
An 8-year-old girl is experiencing
mysterious bruising on her left
shoulder. A thorough H&P reveals
nothing remarkable, so you head to
the computer...
8epmonthly.com Going Beyond the News
Cover Story//The Electronic ED
Electronic Medical Records: More Questions Than Answers
3from cover
EDIS is coming to your ED soon. According to Greg Brown, MD, the head of clinical informatics at TeamHealth, EPs basically
have two options: Join the EMR discussion
with administrators early on or wait until an
EMR is implemented without their input.
Either way, says Brown, hospitals are moving this direction, and emergency physicians
need to be prepared.
The problem is this: current EDIS technology is a mixed bag at best, often creating as many problems as it solves. The Joint
Commission released the “Issue 42 Alert”
in December, noting that technology is
frequently the cause of medical error. In example, 43,372 of 176,409 medication errors
were created by technology. Depending on
your ED’s situation, more automation may
or may not be the answer, and EPs need to
know how to ask the right questions and
convey the hard truth to administrators.
The impetus to implement an EDIS is obvious. Our EDs are frequently dysfunctional
and quite honestly many are in need of substantial operational improvement. As patient
complexity and volumes grow and additional regulatory requirements are added to our
already overburdened workload, this only
compounds and magnifies the inefficiencies
of our operational systems and the inability
for us to meet surging demands. Our hospitals, and we, are looking for solutions. Enter
the savvy EDIS vendor…
For starters, let’s be clear: There are many
potential benefits from an EDIS. If you’ve
spoken with any of the vendors, they’ll all
make many of the same claims. Improved
operational efficiency, better coding and
billing, improved risk management, patient
tracking, computerized physician order entry, better charting, no more transcription
costs and the list goes on. I can’t argue with
those benefits; if they come to fruition, everyone wins. The physician benefits from less
restrictive operations, easier charting, better
reimbursement and reduced risk. The hospital benefits by reduced risk and improved
financial performance by streamlined operations and reduced cost (e.g. reduced transcription costs). The patients benefit from
reduced wait times, expedited care and reduced risk.
Sound too good to be true? Well, you
know what they say. If it sounds too good to
be true, it probably is. Let’s take a good look
at the downsides. First is the cost. These babies are not cheap. Wellsoft, for instance, will
run between $400,000 and $500,000 for a
department with an annual census of 50,000.
Oh, and there is an annual software maintenance fee of 18% on that purchase price.
But don’t worry, that’s “industry standard.”
Feel better? There is also an initial installation cost of approximately $150,000. The TSystem charges an ongoing fee of $4.75 per
patient, with an initial set up fee of around
$100,000 for the same sized ED.
Vendors often make the argument that
these systems pay for themselves. At those
price points, that’s a hard line to sell. The
devil is in the details. What you gain in improved documentation and data collection
you’ll most likely lose in operational inefficiencies. Take the fact that an EDIS puts
physicians–the most highly trained and
compensated providers in the ED–in front
of screens entering patient data, effectively
turning them into data entry clerks. Under
these systems, EPs order their own tests and
meds and can provide countless entries for
performance improvement and operational
data extraction. Sure, the data is great to
have, but at what cost? Anything that slows
us down doesn’t fix anything. In absolutely
every installation I have witnessed, physician productivity has circled the drain, and
in most, it never returns to baseline. So, if
the physician is made less efficient, door-tophysician times and length of stay increase,
wait times go up, and more patients leave.
Lots more. All of this results in less revenue
and more risk.
Still, there are those who claim that these
systems actually improve operational performance, increase collections and reduce risk.
I guess it depends on your frame of reference.
The “poster children” for these systems are
those in need of substantial operational assistance. In other words, if you have an average length of stay of 6 or 7 hours or a door
to physician time of over an hour, etc., you
can use almost any tool you want and you’ll
be able to make a positive impact. The Hawthorne effect is a wonderful thing. Once you
start casting light on the process, things begin to improve. The same is true for charge
capture and collections. Sure, if your documentation tools are ineffective, your physi-
Any More Questions?
If you find your hospital purchasing a system without your input, it’s better to
join the process then be left on the sideline. Here are some critical questions
that may help guide you through the selection and implementation process.
What problems are you trying to fix?
How much does the system cost?
Can you only buy the components you need?
Are there any less expensive solutions that meet your needs, EDIS or otherwise?
How many successful installs does each particular EDIS have?
What issues or problems are encountered with the EDIS?
How many customers have they lost or how many de-installs have they had?
If patients per hour declined with implementation, did they rebound?
cian documentation lacks sufficient detail
and coding isn’t up to snuff, a prompt-driven, drop down menu charting system will
help. But there are a lot more cost-efficient
ways to improve documentation and charge
capture then an EDIS. The scenario further
deteriorates the better your department currently functions. If your average ED length of
stay is 2 or 3 hours or your door-to-physician
time is only 30 minutes, the benefits from an
EDIS will almost invariably be outweighed
by the inefficiencies it will create.
If the physician is the rate-limiting step for
many processes in the ED, why ask them to
do more? We need to put the physician in
front of the patient, not in front of a computer. If an EDIS-driven medical record
requires too many drop downs and mouse
clicks to efficiently document – if it takes six
mouse clicks to order a dose of Tylenol – it
just isn’t worth it. Furthermore, the medical
records generated from these systems can
be very difficult to follow and often read as
though they were dictated by a cyborg. They
don’t flow well and have syntax issues. In
many systems, it is very difficult to personalize the record, only allowing the canned
selections available in the system.
There are a couple things to consider from
a risk management perspective. It’s true that
risk will be reduced by improving wait times,
length of stay, etc. It will also be reduced by
better documentation. The fewer number
of patients who walk out without being
treated, the quicker patients can be seen and
dispositioned and the better you document
your medical record, the less likely you are to
be named in a lawsuit, and the more likely
you are to successfully defend your actions. If
you don’t have a risk management program
in place, these systems may help. That said,
point-and-click documentation tools often
create new opportunities for items to be inappropriately entered in the medical record
such as physical examination items that were
never performed. Such records create risk
management nightmares and coding and
billing compliance issues.
Create a system that is cost-effective, improves patient care, operational efficiency,
reduces risk and improves collections without strapping it to the backs of the physicians and I’m all in. I just don’t think we’re
there yet. So let’s face the ED’s operational
problems head on, engaging in an active
dialogue of both hi- and lo-tech solutions
at the hospital level. Maybe that will mean
using scribes to perform the data entry, or
perhaps merely waiting until EDIS vendors
have made critical improvements. No matter
what, if we leave these decisions entirely up
to others, the 800-lb EDIS gorilla is sure to
break our backs.
Kevin M. Klauer, DO is the editor-in-chief of
Emergency Physicians Monthly and is the
Director of the Center for Emergency Medical Education (CEME).
STAT! EM By The Numbers | We polled 60 EPs about their EDIS usage. Here’s what you said.
Which elements of electronic medical
records has your ED implemented?
We Use Paper Charts
What EMR Vendor Do Your Use?
font size indicates answer prevalence
27%
Electronic Documentation CPOE 72%
50%
Patient Tracking CERNER
EPIC PICIS
ALLSCRIPTS T-SYSTEM
72%
MCKESSON
WELLSOFT MEDITECH
CARECAST EMPOWER SUNRISE CLINICAL MANAGER
Electronic Discharge Instructions 14
April 2009 | Emergency Physicians Monthly
75%
PROMED EMERGISOFT CPRS
Percent of
respondents
who felt
neutral, somewhat positive,
or very positive about their
experience working with an EMR
platform.
12.3% felt very negative – that
EMRs did more harm than good.
Cover Story//The Electronic ED
The Problem
of Interface
The Mount Sinai Experience
Will EMR integration come from the
top-down, or from the bottom up?
How One Urban Academic Center Successfully Implementing a Comprehensive ED Information System
O
n multiple occasions the Obama administration has
made it clear that it aims to see “meaningful” adoption
of electronic medical records in the near future. The
terms might be vague (how much is “meaningful”?), but what
is clear is that electronic record systems can no longer fly
solo. Soon, in order to qualify for stimulus funds, EMR vendors
will have to comply with federal standards and be able to
communicate data not only to the hospital system across the
street, but across state lines.
“We believe the [stimulus] plan will accelerate the standards
adoption and adherence necessary to bring interoperability
between systems,” said Mike Hansen, CEO of T-System.
Therein lies one of the largest looming problems in the
field of healthcare informatics: Interface. In many ways the
current system is antithetical to this goal of system-to-system
integration. Proprietary EMR vendors sell their wares to
hospitals with the specific knowledge that the technology
won’t be shared with the competing hospital across the
street. Even worse, even within a hospital EMR interface is
complicated. A niche system designed specifically for the ED
(such Wellsoft or T-System) may or may not communicate
seamlessly with a previously-established hospital-wide EMR.
So we know that “point B,” is total integration, but how do
we get there? According to Greg Brown, the head of clinical
informatics at TeamHealth, there are two options. Which one
wins out will likely determine the future of EDIS, both at the
emergency department operational level and at the technology
level. Hospital administrators – who will ultimately be making
these decisions and signing the checks – can either focus on
finding the perfect one-size-fits-all system or work to develop
sophisticated mechanisms for creating interfaces between
disparate systems.
With the first option, niche vendors designed for the ED
will lose out to larger, “enterprise solutions,” that market
themselves as the full informatics package. These vendors
will promise to bring hospitals into the next generation of
health record communication while complying with a new
administration’s demands. This option allows hospitals a more
hands-off solution to the complicated informatics quandary.  Option two would be to embrace “best-of-breed” systems
currently in development and capitalize on the fact that
different hospital departments have very different informatics
needs. This option would require hospitals to invest in more
robust hospital I.T. services designed specifically to interface
disparate EMRs seamlessly. Ideally, what a hospital spent
for increased I.T. services it could save through increased
departmental efficiency thanks to more targeted systems.
It’s too early to tell which direction medical informatics will
go under the Obama administration. But one thing is for sure,
there will be a winner and there will be a loser. Let’s just hope
the loser isn’t the emergency department itself.
n Logan Plaster
By Nicholas Genes, MD and Kevin Baumlin, MD
O
urs was once a department like many others – urban,
academic, and overwhelmingly busy. Care in our department involved over two dozen different processes supported
by separate, disparate systems: from triage and registration
through laboratory, radiology, medication orders and review
of previous medical records, to bed request or discharge instructions. Patients waited at each step of the process. Documentation was lacking, with many charts lost or insufficiently
complete for proper reimbursement.
We looked to redesign ED throughput as an opportunity
to fulfill our core mission to provide quality patient care, and
also, as an academic institution, to effectively teach residents
and promote research.
We settled on an electronic chart because it served so many
key functions: documentation of the care delivered, communication to each other and to our colleagues on other services,
official legal record for purposes of litigation, generation of
facility charges and professional fees, and a source of data for
clinical research. Compared to unstructured or template paper
charts, or dictation systems, or scribes, only an electronic chart
system could provide us with a completely legible record of
the care given during the visit, with every data element stored
in a searchable database, and the capability to give real-time
decision support to improve clinical care and to optimize reimbursement.
We chose to seek a comprehensive EDIS that provided triage, patient tracking, electronic physician and nurse charting,
electronic order entry, discharge instructions and prescription
writing. While setting up a comprehensive EDIS requires
more initial preparation, training and investment, we figured
more functionality from the get-go would actually be worth it,
and that a single comprehensive implementation and go-live
date would ultimately be less disruptive than expanding a limited feature set slowly over many months.
One essential feature we agreed upon early was a single,
universal log-in. We’ve witnessed the inefficiency and frustration of doctors carrying around separate passwords to log in
to one system for lab results, another for charting, and a third
for prescription and discharge documents – often on different,
dedicated computers. We wanted every feature of our comprehensive EDIS available to every user on every computer in the
ED.
Other essential characteristics included a user-friendly interface that facilitated the work of ED staff physicians and nurses;
useful administrative data on throughput times, turn-around
times, staff productivity, resource utilization and quality of
care; and facilitation of data collection for research in the ED.
It was also specified that the system must sufficiently improve
documentation and billing to pay for itself within 18 months.
Having chosen this direction, we took a lot of steps to make
sure our ED information system was implemented well. Be-
Q. Regarding EMR, how would you improve patient care and throughput at your facility?
cause attempts to automate dysfunctional processes always
seem to produce unsatisfactory results, we performed a workflow analysis and mapped out each step in patient flow through
our ED, and redesigned our processes for IT optimization.
The emergency department is nothing like an inpatient
unit, a doctor’s office or a clinic*. The pace, nature and organization of the work are unique. All activities are time sensitive. ED providers see multiple patients simultaneously and
are constantly interrupted. Multiple providers must be able to
access the ED chart simultaneously. Orders are often placed
singly rather than in sets. An understanding of these workflow
issues should be apparent in the design of an EDIS.
So we went to trade shows, reviewed the literature available
at the time, and surveyed our colleagues at other institutions.
Then, we had structured vendor site visits. We asked doctors,
nurses, registrars and administrators to evaluate the products
using standardized scoring sheets, and brought in hospital IT
personnel to take a look at our finalists and determine support
needed for each. This screening period had the added affect
of building consensus and achieving buy-in from our various
stakeholders – because so many people had a hand in choosing
features and final product, they were invested in making sure
it worked. Buy-in was no doubt also helped because our EDIS
champions were physicians and nurses, rather than something
foisted upon the department by outside administrators or consultants.
Implementation was expensive, and had a steep learning
curve. But when it was complete, our process redesign and paperless EDIS implementation enabled a single sign-on capability for access to all system applications and a streamlined, more
efficient operation.
The EDIS provides triage, patient tracking, physician and
nurse documentation, retrieval of charts from prior ED encounters, one-click access to more extensive historical hospital
data from an enterprise data repository, computerized provider
order entry, results review, discharge instructions and prescription writing. All data entered into the EDIS are time-stamped.
Patient care documents from other departments or facilities
are scanned into the patient’s electronic chart and are simultaneously viewable by all personnel caring for the patient.
Switching to a paperless ED has had a tremendous effect
on our department – some effects are easy to measure, others
less so. Our own data (some of this previously published, some
of this in press) about ROI and implementation is, of course,
unique to our busy urban academic center.
•When we compared a period over a year post-implementation to the days before our EDIS, the ED Length-Of-Stays for
all patients decreased by 29%, from 6.7 hours pre-intervention
to 4.8 post-intervention. The ED LOS for admitted patients
decreased 35%, from 12.2 hours pre-intervention to 8.0 post4continued on page 27
How well does your EMR interface
with other systems in the region?
“Voice recognition software to dictate H&P to speed throughput and remove onus of typing notes from MD”
“Link best-evidence practice tools with the ED EMR to facilitate knowledge translation.”
“Separate the names in the active list. When ordering meds, it’s too easy to click the wrong name in haste.”
Somewhat
Successfully
Very Successfully
Establish “an electronic patient flow system [that] alerts nurses to give meds, fluids, etc...”
Q. How would you spend the stimulus funds that have been allocated for health care?
“More regional communication between healthcare systems. Perhaps integrate pharmacies as well.”
Average
Very
Poorly
67%
“I would not like to see these funds spent for this purpose. This is a hospital responsibility not a government one.”
“We need to unify the very effective human systems of communication (writing and speech) with the input demands
of EMRs. Speech and handwriting recognition are one mechanism, but they are not quite ready for use in my
experience.”
“Develop one EHR for all caregivers and facilities that is better, faster, and cheaper than paper.”
Somewhat
Poorly
www.epmonthly.com
15
Oh Henry // with Greg Henry, MD
Can a career politician lead the discussion on health care?
3from cover
cians to deal with health care, which is the
single largest business and expenditure in
the United States? We’ve moved from Tom
Daschle – who didn’t know how to pay his
income taxes – to a governor from Kansas.
What exactly does she bring to the table?
I have no idea what makes this person able
to comment on health care in the United
States.
The principle task of anyone who leads the
discussion on health care is that they must
LEAD THE DISCUSSION ON HEALTH
CARE! They have to talk about issues that
are not comfortable or politically correct.
Somebody has to be the stalking horse who
will get out there and talk about the things we
need to discuss. What are those issues? Number one: The shift in the dependency ratio.
How many people are sitting in the wagon
and how many people are pulling the wagon?
The huge shift in this ratio means that this is
an aging country and we are no longer going
to be able to retire at 67 or 68. The number
may have to go up to 72. We are no longer
going to be able to supply certain services to
everybody through insurance programs. The
real question is, who has the courage to carry
on the discussion about the limitations of
health care. Nobody in Washington minds
if you use the “F” word; nobody wants you
using the “R” word. Rationing frightens the
living daylights out of everyone in this country. If you think we’re held hostage by the
National Rifle Association, think again. It’s
the American Association of Retired Persons
(AARP) that is going to closely monitor any
real change in health care.
This is the only country of the 17 western democracies which cannot carry out an
intelligent discussion on end-of-life issues.
What emergency physician has not watched
an 89-year-old with terminal Alzheimer’s
brought in for the treatment of their pneumonia? What are we doing? Why have we
decided that ministering to dying flesh is
better than helping the young?
There is no reasonable way to spend your
way out of this situation. The current stimulus package is probably a misnomer and a
mistake. To think that we are not going to
have pain and suffering while pulling ourselves back into line is a joke. And that pain is
going to fall – to a great degree – upon how
and what we give out as health care. You can’t
avoid it. It’s the largest single expenditure in
the United States government. The only
way that is will be resolved will be through
catastrophic inflation. There are two things
everyone should do when they go home tonight. Number one, rethink how health care
needs to be given. Number two, teach your
children to bow politely to their Chinese
masters. If the Chinese are no longer willing to fund the debt, we are, as a country,
screwed.
The time for small, itsy bitsy band-aid solutions is over. Someone is going to have to
lead. Someone is going to have to make real
suggestions. Someone is going to have to ask
why the Singaporeans are able to have better
health stats for one-quarter the money. Someone will have to ask why the Germans can
figure out what therapies they will and will
not give for breast cancer and we can’t. This is
a politically-driven agenda, not a scientifically-driven agenda. We are encountering forces
that are so entrenched it’s beyond belief. To
think that there will be respect commanded
in the medical community by an ex-governor
of Kansas is a joke. We need to bring people
to the table who can talk about the history,
the worldwide activity, and the future of
what’s actually happening in health care. It is
almost an affront to tax-paying citizens of the
United States (and to our children who will
inherit this mess) that we allow someone appointed to that job who, quite frankly, can’t
articulate the real issues involved.
If not the governor from Kansas, and if
not a former senator who can’t figure out
how to pay his taxes, who should sit in the
seat as secretary of Health and Human Services? There are plenty with health care policy experience and real ideas who ought to
be leading this discussion. I don’t agree with
everything Uwe Reinhardt from Princeton
has to say, but I respect Uwe Reinhardt as a
mind. This is a man who has devoted his life
to health care policy. He is, by birth, a German. He understands hard decision-making.
And Mr. Reinhardt represents only one of
at least a dozen major figures who are well
known in the United States, have at least
reasonable respect from the American Medical Association, and could at least present a
series of discussions which we could all relate
to. God save me from this compulsive need
to appoint people who can’t get honest jobs
to positions where they’ll lead major discussions in this country.
Greg Henry, MD, is the founder and
CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president
of ACEP and directed an ED for 21
years.
How to Sell an Admission
The Mount Sinai Experience
3from page 8
3from page 15
the doctor a reason to turf your patient to
internal medicine when they clearly need a
surgeon.
Anticipate your roadblocks. Admitting physicians get a lot of pushback from
insurers for certain kinds of admits. Find a
diagnosis on the patient that is admittable.
For instance, don’t ask to admit your elderly
patient with dementia because she can’t go
home. Admit her for dehydration or failure
to thrive. Try to find something that the admitting physician can work with.
Be confident: if you don’t sound confident, they will exploit your weakness and
bully you into backing down. How you
phrase your diagnosis is key. For instance,
don’t say, “The patient has abdominal pain
with normal labs and CT, I’m not sure what
is going on, please admit.” Instead say, “Based
on my exam, this patient has appendicitis,
and while the quantitative tests are thus far
negative, you and I both know that some
patients are negative, and I would like this
patient admitted for observation.”
And if they give you trouble with that,
again say confidently, “You are more than
welcome to come in to consult on the patient and discharge them yourself from the
emergency department.” At that point, most
doctors will simply admit the patient over
the phone.
A key point to mention is to have really
good documentation. Do not be accusatory
towards the admitting physician, however,
for your own legal protection you must list
the times you called the physician, the times
you spoke with them, and the result of the
conversation. It is imperative that you do the
best you can for your patient. However, it is
also important to protect yourself from possible liability as well.
Dr. Brenner is the author of the forthcoming
book How to Survive a Medical Malpractice
Lawsuit: A Physician’s Roadmap For Success
(Wiley-Blackwell BMJ, Fall 2009)
Standard of Care: Final Analysis
3from page 11
medications. My belief is that it is reasonable
for a physician to treat this patient symptomatically without any testing at all. However,
it would be important to inform the patient
that influenza is likely, that rapid influenza
testing is both expensive and lacks sensitivity, and that pneumonia, if present on chest
X-ray, would likely be viral in etiology and
would not respond to antibiotic treatment
anyway. If further diagnostics won’t be performed, it is wise to document you have
informed the patient about signs and symptoms suggesting a more serious or worsening
medical condition. Allowing the patient to
take part in decision making presents a winwin situation for providing evidence based
medical care.
intervention
•Door-to-doctor time for all patients (triage to first doctor-patient contact) decreased
44%, from 1.2 hours to 0.7, while doctor to
disposition time for all patients (first doctorpatient contact to disposition decision) also
decreased 52%, from 3.6 hours to 1.7 hours.
Disposition to discharge for admitted patients
(boarding time) decreased 28%, from 6.8
hours to 4.9 hours.
•CT scan turn-around time decreased by 40%
from 3.9 hours to 2.3, laboratory report TAT
decreased from 2.0 hours to 1.4, and X-ray
TAT decreased from 0.9 hours to 0.7.
•On the revenues side, average collections per
patient rose 47.5% between pre-implementation and a sustained-effects period over a year
later. Total charges rose 69.4% during the same
period and total receipts rose 70.1%.
•End-of-month chart completion rates by
attending physicians rose from 65% in 2003
to 95% in 2005, while lost or illegible charts
decreased from 4,992 in 2003 to zero in 2005.
The average professional evaluation and management (EM) levels (the five-point scale used
for coding ED charts for billing purposes) rose
from 3.17 during the pre-implementation period to 3.73 during the a period more than a
year implementation.
•The number of charts meeting professional
fee criteria for critical care billing increased
from just one chart during the entire 15-month
pre-implementation period to 1,614 charts in
the more than a year afterward, and from 45
to 974 respectively for facility critical care billing.
•Despite an overall decline in the facility EM
level, net facility receipts increased 60.9% between the pre-intervention period and a time
over a year later.
As dramatic as our improvement was postimplementation, this data says nothing about
improvement in patient safety or satisfaction,
or improvements in QA and core measure
monitoring, all of which have been noted but
not as rigorously reviewed. Furthermore, as an
academic institution, the EDIS has made it far
easier for residents to review cases for educational or research purposes, which allows us
to fulfill an important mission as a teaching
hospital.
But perhaps most importantly, if you survey faculty who lived through the transition,
they’ll all note that, as challenging as adoption
of an EMR was, no one would go back.
*Because the ED is not a unit or a clinic, interpreting the growing literature about EMR adoption in various healthcare settings becomes
more problematic. Many of the concerns ED
docs have about EMR – more clerical duties in
front of a computer, less face-time with patients,
expensive and time-consuming training – have
been measured and quantified in other settings.
So, too, have the benefits in safety, increased
revenue, core measure and QA compliance.
If someone is waiting for a more precise costbenefit analysis for EMR implementation for the
unique environment of the ED, they’d do well
to remember that each ED itself is unique, and
what ultimately gets reported from one ED’s experience may not apply well to another.
www.epmonthly.com
27
Emergency Department Information System
Adoption in the United States
Adam B. Landman, MD, MS, MIS, Steven L. Bernstein, MD, Allen L. Hsiao, MD, and
Rani A. Desai, PhD, MPH
Abstract
Objectives: The American Recovery and Reinvestment Act of 2009 incentivizes adoption of health care
information technology (HIT) based on support for specific standards, policies, and features. Limited
data have been published on national emergency department information systems (EDIS) adoption, and
to our knowledge, no prior studies have considered functionality measures. This study determined current national estimates of EDIS adoption using both single-response rates of EDIS adoption and a novel
feature-based definition and also identified emergency department (ED) characteristics associated with
EDIS use.
Methods: The 2006 National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits that also surveyed participating EDs on EDIS, was used to estimate EDIS adoption. EDIS
adoption rates were calculated using two definitions: 1) single-response—response to a single survey
question as to whether the EDIS was complete, partial, or none; and 2) feature-based—based on the
reported features supported by the EDIS, systems were categorized as fully functional, basic, other, or
none. The relationship of EDIS adoption to specific ED characteristics such as facility type and location
was also examined.
Results: Using the single-response classification, 16.1% of EDs had a complete EDIS, while 30.4% had a
partial EDIS, and 53.5% had none. In contrast, using a feature-based categorization, 1.7% EDs had a
fully functional EDIS, 12.3% had basic, 32.1% had other, and 53.9% had none. In multivariable analysis,
urban EDs were significantly more likely to have a fully functional or basic EDIS than were rural EDs.
Pediatric EDs were significantly more likely than general EDs to have other EDIS.
Conclusions: Despite more optimistic single-response estimates, fewer than 2% of our nation’s EDs have
a fully functional EDIS. EDs in urban areas and those specializing in the care of pediatric patients are more
likely to support EDIS. Accurate and consistent EDIS adoption estimates are dependent on whether there
are standardized EDIS definitions and classifications of features. To realize the potential value of EDIS for
improved emergency care, we need to better understand the extent and correlates of the diffusion of this
technology and increase emergency medicine engagement in national HIT policy-making.
ACADEMIC EMERGENCY MEDICINE 2010; 17:536–544 ª 2010 by the Society for Academic Emergency
Medicine
Keywords: Financing, government вЃ„ legislation and jurisprudence; United States; medical informatics; medical records systems; computerized; emergency service, hospital
H
ealth information technology (HIT) has the
potential to improve health care.1,2 The American Recovery and Reinvestment Act (ARRA) of
2009 prioritizes and incentivizes the development of a
national, interoperable health information system.3,4
HIT may be particularly beneficial in the emergency
From the Robert Wood Johnson Foundation Clinical Scholars Program (ABL, RAD), Department of Emergency Medicine (ABL,
SLB), Department of Pediatric Emergency Medicine (ALH), and School of Public Health (RAD), Yale University, New Haven, CT;
and the U.S. Department of Veterans Affairs (ABL, RAD), West Haven, CT.
Received September 27, 2009; revision received November 19, 2009; accepted November 30, 2009.
Presented as an abstract at the American College of Emergency Physicians (ACEP) Scientific Assembly, Boston, MA, October 6,
2009; and the Connecticut College of Emergency Physicians (CCEP) Scientific Assembly, Rocky Hill, CT, November 4, 2009.
Dr. Landman is a Robert Wood Johnson Foundation Clinical Scholar at Yale University, supported by the U.S. Department of Veterans Affairs and the Robert Wood Johnson Foundation.
None of the authors have conflicts of interest to report.
Address for correspondence and reprints: Adam Landman, MD, MS, MIS; e-mail: adam.landman@yale.edu.
A related commentary appears on page 524.
536
ISSN 1069-6563
PII ISSN 1069-6563583
ВЄ 2010 by the Society for Academic Emergency Medicine
doi: 10.1111/j.1553-2712.2010.00722.x
ACAD EMERG MED • May 2010, Vol. 17, No. 5
•
www.aemj.org
department (ED), where clinicians continuously care for
new patients, many with complicated medical histories
or information gaps in their history.5 Recent studies have
shown only 17% of physicians and 10% of hospitals have
basic electronic medical records (EMRs); however, limited data have been published on national emergency
department information system (EDIS) adoption.6–12
Emergency department information systems may
help provide ED clinicians with accurate and complete
patient histories, automate patient flow, provide physician computerized order entry, and enable sophisticated clinical decision support systems.13–16 In their
2007 report, Hospital-based Emergency Care: At the
Breaking Point, the Institute of Medicine recommended
that ��hospitals adopt robust information and communications systems to improve the safety and quality of
emergency care and enhance hospital efficiency.’’17 To
realize the potential gains in efficiency, cost savings,
and improved quality of care with EDIS, widespread
adoption of EDIS is required. Accurate EDIS adoption
measurement is needed to understand our emergency
care system’s current EDIS capacity and future needs,
as a baseline to evaluate ARRA programs, and as a possible future measure of quality and performance-related
payments.9
In 2002, the National Hospital Ambulatory Medical
Care Survey (NHAMCS) estimated that 31% of U.S.
EDs had some kind of EDIS.6 However, this estimate
was not sensitive to the specific features supported in
the systems. Because the ARRA will base incentive payments for HIT adoption on ��meaningful use’’ of HIT,
such as support for specific standards, policies, and features, it is important to understand the features supported by EDIS.3 In this article we provide current and
more precise national estimates of EDIS adoption using
both single-response rates of EDIS adoption and a
novel feature-based definition. We also determine ED
characteristics associated with feature-based EDIS use.
METHODS
Study Design
This was a secondary analysis of the NHAMCS, a
national sample of visits to EDs, conducted by the
National Center for Health Statistics (NCHS), Centers
for Disease Control and Prevention (CDC). The Yale
Human Investigation Committee exempted this study
from review because data are de-identified and publicly
available.
Study Setting and Population
We combined patient-level data with ED-level data on
EDIS use obtained during hospital interviews. Crosssectional survey data were analyzed from the 2006 NHAMCS, the most recent available. The NHAMCS used a
four-stage probability sampling strategy to identify a
nationally representative sample of U.S. EDs located in
the 50 states and District of Columbia, excluding federal,
military, and Veterans Administration hospitals.18
Study Protocol
During randomly assigned 4-week periods, ED
staff abstracted patient visit data to a standardized
537
NHAMCS patient record form. Data were then processed and coded by the Constella Group (Durham,
NC). The NCHS calculated sampling weights that can
be used to produce unbiased, national estimates.
Prior to participating in NHAMCS, an introductory
letter was sent and a screening telephone call were
made to each hospital’s administrator to verify eligibility. If the hospital agreed to participate, an in-person
induction meeting was arranged, where NHAMCS
interviewers further verified eligibility, explained the
survey, and collected basic hospital information. EDIS
usage data were collected during these induction interviews.6 Because the hospital administrator was the initial contact, he or she was given the option of
completing the survey or delegating to one or more
persons to complete the survey. NHAMCS recorded
the position of the hospital administrator contact, but
not other individuals who may have responded to the
EDIS questions, and this information was not publicly
available. The administrator and survey respondents
did not have access to the questions ahead of time (personal communication with Esther S. Hing from the
CDC NCHS to clarify the methodology for EDIS data
collection, 2009).
Survey respondents were initially asked whether or
not their ED uses EMRs. If they responded yes, they
were asked whether or not their EDIS supported a set
of features, including demographics, computerized physician order entry, laboratory and imaging, and clinical
documentation. Table 1 lists all EDIS features surveyed
in NHAMCS. Hospitals that did not respond or
responded unknown to the EDIS use question were
excluded from the analysis. In addition, a single ED had
missing data for length of visit and was therefore
excluded from unadjusted length of visit statistics as
well as the adjusted analysis.
Measures
Prior estimates of EDIS adoption using NHAMCS were
based on the hospital representative’s response to the
question: ��Does your ED use electronic medical records
(not including billing records)?’’6,19 Respondents classified EDIS as 1) complete, if they used all electronic systems; 2) partial, if they used part electronic and part
paper; or 3) none, if they did not use an electronic system. To compare our results with prior estimates and
illustrate the limitations of this measurement, we also
calculated the single-response EDIS prevalence question as complete, partial, or none based on response to
this survey question.
Health information technology adoption estimates
based on the response to a single question are limited
because they do not consider specific functionality of
the systems. As a refinement of the response to a single
survey question, we classified EDIS systems as: 1) fully
functional, 2) basic, 3) other, or 4) none based on the
features supported (Table 1). (Italics are used here to
differentiate the feature-based system from the singlequestion system.) EDIS were classified as other if they
had one or more features but did not meet the criteria
for basic or fully functional systems indicated below.
Systems with no EDIS features were classified as not
having an EDIS (none).
538
Landman et al.
•
EDIS ADOPTION IN THE U.S.
Table 1
Feature-based Classification of EDIS and Support for Features
Featur
General
Patient demographics§
Medication order entry§
Test order entry§
Laboratory results§
Imaging results
Clinical notes
Public health reports§
Interoperability
Electronic transmission to pharmacy
Electronic transmission of test orders
Direct access to electronic images
Medical history and follow-up notes included
Electronic transmission of public health notifications§
Decision support
Warnings for medication interactions ⁄ contraindications§
Abnormal laboratory results highlighted
Reminders for guideline based interventions
Fully
Functional
EDIS
Systems
With
Feature*
Weighted %В MissingГ 212
126
181
203
173
147
71
95.20
49.02
82.17
89.29
73.37
63.78
25.42
3
8
10
12
24
16
48
X
X
X
X
38
141
111
120
35
15.22
60.34
42.09
49.67
10.29
20
27
40
15
16
X
X
X
78
149
69
32.96
66.20
31.84
24
39
30
X
X
X
X
X
X
Basic
EDIS
X
X
X
X
X
EDIS = emergency department information system.
*Number of systems supporting feature (unweighted).
В Number of EDIS with feature out of total EDIS, calculated using weighted, national estimates.
Г Missing data are assumed to not support that feature.
§Proposed features for ��meaningful use’’ of electronic health record by 2011.25
Emergency department information systems have
been defined broadly as ��electronic health record systems designed specifically to manage data and workflow in support of ED patient care and operations.’’20
A detailed functional profile for EDIS outlines hundreds
of essential functions of an EDIS, including registration,
patient tracking, clinical workflow, orders, clinical documentation, discharge management, and administrative
support.21 However, no standardized definitions or
required features have been established for EDIS. Given
lack of current consensus, we created the feature-based
classification above based on our own experience, combined with a literature review that identified important
features of EDIS from perspective articles, white
papers, other EMR adoption studies, and draft guidelines for ��meaningful use’’ of HIT.11,12,15,21–25 We were
ultimately limited by the features assessed in NHAMCS.
As described in Figure 1, fully functional EDIS systems
included all features surveyed in NHAMCS with the
exception of public health reporting, because this feature was supported by a small percentage of EDIS in
this survey (Table 1). Basic EDIS systems included five
core features of EDIS: patient demographics, medication order entry, laboratory results, imaging results,
and clinical notes. Our feature-based classifications are
similar to feature sets that other HIT researchers have
determined are important in basic and comprehensive
EMR systems in outpatient and hospital settings.11,12,24
Independent Variables. We also explored the influence
of ED characteristics on adoption of EDIS. These characteristics included ownership type, geographic region,
urban location, teaching status, pediatric ED, patient
race and ethnicity, payment type, immediacy of care,
Figure 1. EDIS adoption estimates based on single-response
and feature-based EDIS classifications. EDIS = emergency
department information system.
percentage of patients admitted, and average length of
visit.
The NHAMCS includes data on ownership type, geographic region, and location in a metropolitan statistical
area (MSA) at the ED level. All other variables were
aggregated from patient-level visit data to characterize
EDs.26 For instance, the length of visit for each patient
in a particular ED was averaged to produce the mean
length of visit for each ED. Continuous variables at the
patient level remain continuous variables at the ED
level, but reflect the average value across all patients at
that ED. Categorical variables at the patient level were
transformed to multiple continuous variables at the ED
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level and reflect the percentage of patients with that
characteristic.
Because NHAMCS does not make teaching status or
pediatric ED publicly available, we classified EDs as
teaching hospitals if more than 10% of patients were
seen by an intern or resident. Similarly, EDs were classified as pediatric EDs if the average age of patients
was less than 18 years old. EDs in an MSA were considered urban, while those not in an MSA were classified as rural.
Data Analysis
We determined adoption rates of EDIS in 2006 using
single-response EDIS classification of complete, partial,
or none. We then looked more closely at the features
supported by single-response system type. We calculated the number and percentage of EDIS supporting
each feature as well as the total number of numbers of
features (range 0 to 15) supported by complete and partial systems. The mean numbers of features in complete
and partial systems were compared using a t-test. Missing responses for specific features were assumed not to
support that feature.
We subsequently calculated the prevalence of EDIS
adoption using our feature-based classification of fully
functional, basic, other, or none. We compared categorization differences between the single-response and
feature-based EDIS classifications using a matrix.
We then performed an exploratory analysis of the
association between feature-based EDIS adoption and
ED characteristics using both bivariate and multivariable analyses. Since there were only ten EDs with fully
functional EDIS, we combined the fully functional and
basic categories, resulting in a three level feature-based
classification for these analyses: 1) fully functional/basic;
2) other; or 3) none (no EDIS).
We determined bivariate (unadjusted) relationships
of feature-based system adoption with ED characteristics, including ownership, geographic region, urban
location, teaching hospital, pediatric ED, race/ethnicity,
payment type, immediacy of care, admitted patients,
and length of visit. EDs with fully functional/basic
systems were compared to EDs with other and no
EDIS. For these unadjusted analyses comparing three
groups, we used chi-square tests for categorical variables and analysis of variance (ANOVA) for continuous
variables.
We subsequently built a multinomial regression
model to evaluate the association between adoption of
EDIS system type and ED characteristics. A direct
regression approach was taken, including all independent variables in the model. Two comparisons were
made in this multinomial analysis: 1) EDs with fully
functional/basic EDIS were compared to EDs with no
EDIS; and 2) EDs with other EDIS were compared to
EDs with no EDIS. Odds ratios (ORs) and associated
95% confidence intervals (CIs) were calculated.
Data management was performed using SAS version
9.1 (SAS Institute, Cary, NC). To account for the complex survey sampling methodology and national estimation weights, all statistical analyses used SUDAAN 9.03
(Research Triangle Institute, Research Triangle Park,
NC). Sample sizes and counts are presented unweight-
539
ed, while percentages represent weighted national estimates. Type I error rate was set at 0.05 for all analyses.
RESULTS
In the 2006 NHAMCS, 364 EDs participated in the
study, representing 4,654 EDs nationwide. The single
ED that did not respond to the EDIS use question,
along with the seven EDs that responded unknown to
the EDIS use question, were excluded from this analysis, yielding a total sample of 356 EDs representing
4,622 U.S. EDs. A single ED did not provide length of
visit data and was therefore excluded from calculations
involving length of visit.
Single-response EDIS adoption
Using the single-response EDIS classification, 62 of the
EDs (16.1%) had a complete EDIS, 160 had a partial
EDIS (30.4%), and 134 EDs had no EDIS (53.5%; Figure 1).
Overall, more than 80% of EDIS supported patient
demographics, test order entry, and laboratory results
(Table 1). Interoperable electronic transmission was not
well supported, with fewer than half of the systems able
to share images or history and follow-up notes or
transmit prescriptions to pharmacies. The majority of
systems highlighted abnormal laboratory results, but
few systems supported more advanced decision support, such as medication interaction or contraindication
warnings or guideline-based reminders.
The limitations of a single-response EDIS classification become apparent when the number of features
supported by each EDIS is plotted by system type
(Figure 2). Possible misclassifications include one complete system with zero features and four partial systems
with the maximum of 15 features. On average, complete
systems had 9.05 (95% CI = 8.11 to 9.99) features, and
partial systems had 7.24 (95% CI = 6.55 to 7.94) features
(t = 3.1, p = 0.0026).
Feature-based EDIS Adoption
Using the feature-based EDIS classification, 10 of the
EDs (1.7%) had a fully functional EDIS, 69 had a basic
EDIS (12.3%), 140 EDs had an other EDIS (32.1%), and
137 had none (53.9%) (Figure 1).
The matrix in Table 2 compares the categorization of
EDIS systems by single-response and feature-based
classifications. Only four (2.6%) of the 62 singleresponse complete systems were found to be fully functional systems. The majority of complete systems did
not meet the feature requirements for fully functional
systems and were classified as basic (46%) or other
(51.2%) systems. Similarly, 16% of single-response partial systems met the feature requirements for basic
EDIS, while the majority (78%) did not meet these
requirements and were classified as other EDIS. Two
systems that were classified as partial and one system
that was classified as complete had no features and
were therefore reclassified as none.
ED Characteristics Associated With EDIS Adoption
We identified differences in EDIS adoption based on
ED ownership type, urban location, pediatric ED, and
540
Landman et al.
•
EDIS ADOPTION IN THE U.S.
Figure 2. Number of features supported by single-response EDIS classification (complete or partial EDIS). Mean features (complete) = 9.05 (95% CI = 8.11 to 9.99). Mean features (partial) = 7.24 (95% CI = 6.55 to 7.94). EDIS = emergency department information system.
Table 2
Comparison of Single-response and Feature-based EDIS Classifications
Feature-based Classification
Single-response Classification
None (n = 134)
Partial (n = 160)
Complete (n = 62)
No EDIS (n = 137)
Other (n = 140)
Basic (n = 69)
Fully Functional (n = 10)
134 (100%)
2 (1.2%)
1 (0.3%)
0 (0%)
116 (78.5%)
24 (51.2%)
0 (0%)
36 (16%)
33 (46%)
0 (0%)
6 (4.3%)
4 (2.6%)
Numbers are based on unweighted sample size; % is row percentage calculated using weighted national estimates.
EDIS = emergency department information system.
percentage of private pay and Medicare or Medicaid
payers (Table 3). Nonprofit, urban, and pediatric EDs,
as well as EDs with a higher percentage of private pay
and lower percentage of Medicare or Medicaid
patients, were significantly associated with adoption of
fully functional or basic EDIS. EDIS system adoption
did not differ based on the ED’s geographic
region, teaching status, percentage of black or African
American patients, percentage of Hispanic patients,
percentage of admitted patients, immediacy of care, or
percentage of patients with other insurance or no
insurance. However, after adjustment in multivariable
analyses, ED ownership type, and percentage of private
pay and Medicare вЃ„ Medicaid payers were no longer statistically significant (Table 4). Fully functional вЃ„ basic
EDIS were more prevalent in urban EDs than rural
EDs. Other EDIS were more prevalent in pediatric EDs
than general EDs.
DISCUSSION
To the best of our knowledge, this is the first study to
examine national rates of EDIS adoption using functionality measures and the first to examine correlates of
EDIS adoption. We found a great deal of disagreement
between rates of EDIS adoption using the two mea-
sures, with significantly fewer fully functional or even
basic EDIS systems than would have been suggested by
the single-response EDIS adoption rates question. In
addition, we found that EDs in urban areas were most
likely to have a fully functional or basic EDIS, and pediatric EDs were more likely to have other EDIS.
When using single-response EDIS estimates, 46.1%
of U.S. EDs had either a complete or a partial EDIS system in 2006. This seemingly high market penetration
increased from 31% in 2002.6 However, these estimates
were based on the survey respondent interpretation of
complete or partial EDIS, with no standard definitions
of these system types. Misclassifications of systems that
had no features as partial or complete systems suggest
respondents were unable to make clear distinctions
using a single-response question for EDIS system definitions.
When specific features of EDIS were analyzed, most
were found to support patient demographics, test order
entry, and viewing of laboratory results. High support
for laboratory results and imaging results was also
found in a recent Massachusetts ED survey.27 As support for the general features of EDIS improves, additional systems will begin to support interoperability
between departments and outside health care providers, as well as advanced decision support.
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541
Table 3
Unadjusted Analysis of Featured-based EDIS Classification by ED Characteristics
Fully Functional вЃ„ Basic
Bivariate Analysis
Ownership
Voluntary, nonprofit
Government, nonfederal
Proprietary
Geographic region
Northeast
Midwest
South
West
MSA
Urban
Rural
Teaching hospital
Yes
No
Pediatric ED
Yes
No
Ethnicity вЃ„ raceВ Hispanic
Black or African American
Payment typeВ Missing
Private pay
Medicare вЃ„ Medicaid
Other pay
No insurance
Immediacy of careВ Missing
<15 min
15 min–59 min
60 min–2 hr
>2 hr
Admitted patientsВ Average length of visit (min)В (n = 79), % (SE)
Other EDIS
(n = 140), % (SE)
No EDIS
(n = 137), % (SE)
p-value*
0.048
17 (3.2)
9 (4.6)
7 (3.8)
35 (5.1)
18 (5.7)
40 (12.1)
48 (5.6)
73 (7.4)
52 (12)
21
7
12
23
40
29
27
41
39
63
61
36
0.077
(5.3)
(3.6)
(3.9)
(7.2)
(7.6)
(9)
(5.7)
(10.1)
(6.4)
(9.8)
(6.7)
(10.6)
0.0017
20 (3.3)
2 (1.8)
37 (4.4)
23 (7.5)
43 (4.3)
75 (7.7)
22 (5.9)
13 (2.7)
35 (8.9)
32 (4.4)
43 (10.7)
55 (5.1)
29 (10.9)
14 (2.5)
54 (11.8)
32 (4.4)
18 (9.4)
55 (5.1)
13 (0.02)
19 (0.03)
12 (0.02)
17 (0.02)
9 (0.02)
18 (0.03)
0.27
0.88
4
40
35
4
17
(0.01)
(0.02)
(0.02)
(0.01)
(0.02)
4
35
42
4
16
(0.01)
(0.02)
(0.01)
(0.01)
(0.01)
4
32
44
4
15
(0.01)
(0.01)
(0.02)
(0.01)
(0.01)
0.91
0.01
0.0013
0.85
0.75
15
16
33
25
10
14
183.34
(0.05)
(0.03)
(0.03)
(0.04)
(0.02)
(0.01)
(8.2)
15
16
35
21
13
14
179.23
(0.04)
(0.02)
(0.03)
(0.03)
(0.03)
(0.01)
(7.7)Г 20
17
35
17
11
11
150.34
(0.05)
(0.02)
(0.03)
(0.02)
(0.02)
(0.01)
(14)
0.74
0.96
0.85
0.22
0.81
0.26
0.11
0.32
0.022
ANOVA = analysis of variance; EDIS = emergency department information system; MSA = metropolitan statistical area.
*p-values are reported for chi-square test and ANOVA, respectively.
В Mean % (SE): patient level variables averaged to ED level and then averaged across feature-based EDIS classification. ANOVA
used to test for differences among these continuous variables.
Г n = 139 for this cell. Missing one observation for average length of visit for an other EDIS.
The 2009 H1N1 influenza pandemic has led to
renewed attention to ED electronic public health
reporting, which is also a proposed requirement for
2011 meaningful use of HIT. In this study, we found
that 25% of EDIS support public health reporting, and
10% of EDIS support electronic reporting and transmission of public health reports. A recent survey of state
epidemiologists reported that 33 вЃ„ 41 states (80%) had at
least one syndromic surveillance system; however, the
study did not report on the representativeness or sampling strategies of these systems within the states and
whether or not the system was entirely electronic or
required manually data entry.28 Some states, like North
Carolina, have a very comprehensive system of public
health surveillance, collecting data from 93% of their
EDs electronically.29 Our results suggest there may be
heterogeneity in support for electronic public health
reporting within states at the individual ED level.
Future versions of NHAMCS have the potential to add
even more to our understanding of ED public health
reporting if survey questions are added on 1) type of
public health data reported (ranging from dog bites to
influenza-like illness surveillance); 2) mechanism of data
reporting (fax, Web-based data entry, direct electronic
transmission); and 3) frequency of data reporting.
After reclassifying systems based on the features they
supported, we found only 1.7% of EDs had fully functional systems and another 12.3% had basic systems.
These adoption rates are comparable to a recent
national survey showing that 17% of physicians had an
EMR available, but only 4% had a fully functional
EMR.11 A recent survey of EDs suggested barriers to
adoption and implementation of EDIS include expense,
difficulty of use, lack of staff acceptance, and fear of
investing in equipment that becomes outdated rapidly.27
There may also be debate over who should pay for
EDIS adoption and implementation: the hospital or the
emergency physician group, which are often different
entities. Fully integrated EDIS may be hindered by slow
support for interoperability standards and high cost for
developing interfaces for the exchange of information
between other hospital information systems (e.g., labo-
542
Landman et al.
Table 4
Multinomial Logistic Regression With Two Comparisons: 1) Fully
Functional/Basic EDIS Compared With No EDIS; and 2) Other
EDIS Compared With No EDIS
Multinomial Logistic
Regression
Ownership
Voluntary,
nonprofit
Government,
nonfederal
Proprietary
Geographic region
Northeast
Midwest
South
West
MSA
Urban
Rural
Teaching hospital
Yes
No
Pediatric ED
Yes
No
Ethnicity вЃ„ race
Hispanic
Black or African
American
Payment type
Missing
Private pay
Medicare вЃ„ Medicaid
Other pay
No insurance
Immediacy of care
Missing
<15 min
15 min–59 min
60 min–2 hr
>2 hr
Admitted patients
Average length of
visit (min)
Fully Functional вЃ„
Basic (n = 79),
OR (95% CI)
Other EDIS
(n = 139)*,
OR (95% CI)
3.98 (0.79–19.96)
1.04 (0.29–3.78)
1.76 (0.24–13.07)
0.45 (0.11–1.93)
1 (Ref)
0.78
0.39
0.57
1
(0.26–2.35)
(0.09–1.75)
(0.16–2.02)
(Ref)
9.84 (1.15–83.85) 1 (Ref)
1 (Ref)
0.69
0.49
0.36
1
(0.19–2.59)
(0.11–2.12)
(0.10–1.33)
(Ref)
1.8 (0.62–5.20)
1 (Ref)
1.44 (0.44–4.71)
1 (Ref)
0.64 (0.24–1.73)
1 (Ref)
4.32 (0.62–30.34)
1 (Ref)
6.61 (1.59–27.52) 1 (Ref)
3.43 (0.12–99.39)
0.77 (0.14–4.16)
1.06 (0.11–10.25)
0.66 (0.13–3.20)
0.16
2.7
0.02
0.46
1
(0–12.42)
(0.03–255.18)
(0–3.15)
(0–279.23)
(Ref)
0.12
0.23
0.13
0.03
1
(0–6.63)
(0–13.8)
(0–7.74)
(0–48.21)
(Ref)
1.29
1.87
0.77
3.49
1
5.93
1
(0.12–13.94)
(0.10–34.99)
(0.07–8.34)
(0.13–93)
(Ref)
(0.04–997.26)
(0.99–1.01)
0.46
0.67
0.66
0.62
1
9.73
1
(0.03–6.74)
(0.04–11.08)
(0.06–6.97)
(0.04–10.69)
(Ref)
(0.10–919.67)
(1.00–1.01)
EDIS = emergency department information system; MSA =
metropolitan statistical area.
*Missing one observation for average length of visit for an
other EDIS. Total n = 355 for multinomial regression.
В Statistically significant at a = 0.05.
ratory, imaging, pharmacy) and EDIS. EDIS implementation may be further complicated because EDIS may
be implemented as a stand-alone system or part of a
larger systemwide electronic health record.
EDIS adoption estimates are dependent on the definitions used. This study is a step forward in obtaining
more precise estimates of national EDIS adoption,
beyond single-question estimates. The results cast
doubt on prior estimates of widespread EDIS adoption
and suggest that the majority of EDIS systems in use
do not have fully functional capabilities. Although likely
to represent a more accurate estimate of EDIS adoption, our feature-based EDIS classification was limited
to the features assessed in NHAMCS. Additional features are important in an EDIS and should be considered in future assessments of EDIS functionality,
•
EDIS ADOPTION IN THE U.S.
including patient tracking, integration with internal and
external hospital and outpatient EMRs, integration of
emergency medical services reports, and an electrocardiogram (ECG) repository.
Researchers studying adoption of outpatient and hospital EMR systems have already developed standard
system definitions and survey questions using modified
Delphi processes with a wide range of experts.11 A similar process could be used to develop standard EDIS
definitions, including specific feature sets to measure
the unique features of EDIS through a multidisciplinary
expert panel of emergency physicians, nurses, staff, informaticians, technologists, and industry representatives. Survey instruments, like NHAMCS, could then be
redesigned and customized to more accurately measure
EDIS adoption so that adoption rates can be tracked
over time. Furthermore, consensus on important features of EDIS would inform vendor product development as well as national HIT policy.
A recent national study found that hospital EMR
adoption was more likely in major teaching hospitals,
hospitals that are part of larger health systems, and
urban areas.12 In multivariable analysis, we found that
the most significant factor associated with fully functional or basic EDIS adoption was location in an urban
area. Although performed on a relatively small sample
of EDs and risking overinterpretation, the multivariable
analysis shows that hospital location explains the unadjusted associations between EDIS adoption and ED
ownership and payment type, because these associations become nonsignificant in the multivariable model.
Pediatric EDs remain significantly associated with
increased prevalence of other EDIS after adjustment for
ownership type, geographic location, teaching status,
and payer mix. This association needs additional investigation, but may be related to children’s hospitals often
having large endowments enabling investment in quality tools like an EDIS.
It is interesting that ED ownership, geographic
region, teaching status, racial вЃ„ ethnic patient composition, payer mix, patient acuity, admission rate, and
average length of visit were not associated with EDIS
adoption. Because most hospitals in this country currently have limited adoption of EDIS, there may be few
characteristics that can predict EDIS adoption. ED
characteristics associated with EDIS adoption should
be reassessed in the future. High adopters could be
studied to identify best practices, while additional
resources could be provided for low adopters.30
Policy Implications
In response to the 2009 ARRA, the Office of the
National Coordinator for Healthcare Information Technology (ONCHIT) released draft guidelines for ��meaningful use’’ of electronic health records in June and
August 2009.23,25 This draft guidance provides details
on what features electronic health record systems must
possess (and in what time frame) as well as the associated outcomes in patient engagement, care coordination, and population health that will be required for
hospitals to qualify for ARRA incentive payments.
While this is a major step forward toward providing an
interoperable EMR to improve health for every Ameri-
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can, these proposed guidelines do not offer EDISspecific recommendations, such as when or how EDIS
must support patient tracking or integration of ECG
tracings. More broadly, this initial draft does not provide guidance for specialty areas of the hospital, except
to note that ��new measures under development, by
NQF [National Quality Forum], and other recognized
organizations will also address the work of specialists.’’23 ONCHIT has recognized that initial meaningful
use guidelines focus on primary care providers, and a
Health IT Policy Committee hearing was held in October 2009 seeking input from specific groups that may
not have been adequately addressed by the proposed
measures, including emergency physicians.31
Current national HIT policy strongly encourages hospitals and physicians offices to prioritize adoption of
inpatient and outpatient electronic health records. However, there may be limited incentive for adoption of
EDIS, since emergency physicians are not eligible for
ARRA incentive payments as ��hospital-based physicians
who substantially furnish their services in a hospital setting.’’3 Emergency medicine leaders should become
more engaged in national HIT policy-making before
meaningful use guidelines are finalized. In addition, the
recently established Emergency Care Coordination Center in the Office of the Assistant Secretary for Preparedness and Response of the Department of Health and
Human Services32 could liaison with ONCHIT to help
ensure emergency services information technology
needs are met in national HIT policy initiatives.
LIMITATIONS
Accurate answers to technical EDIS survey questions
require specialized information technology knowledge
from appropriately qualified individuals. NHAMCS
allows hospital administrators to respond to the EDIS
survey questions or delegate this responsibility to other
individuals. However, no publicly available information
was provided on the individuals who completed the
survey questions on EDIS use, their experience with
these systems, or their technical knowledge of EDIS.
Single-response EDIS adoption rates as well as feature
support may also have been biased by lack of standard
definitions, lack of homogeneity of responses, or overreport. In addition, survey respondents who judged
that they did not have an EDIS were not asked questions about specific EDIS features. This skip pattern
likely caused us to miss some EDs with basic or fully
functional EDIS, leading to misclassification. It is unlikely that an ED in 2006 would not have computer systems at least for demographics or laboratory results;
however, many EDs in this study reported a lack of
these features, suggesting underreporting. Missing values may also contribute to underrepresented feature
support. We were unable to adjust for ED size (or number of beds) because this information is not publicly
available in NHAMCS. While these data are the latest
available, they are from 2006. EDIS have been on the
market for over 10 years, so there has been ample time
for adoption. These results therefore provide baseline
adoption benchmarks prior to enactment of government incentives.
543
CONCLUSIONS
Our results suggest that ED information systems adoption is less widespread than previously reported.6 U.S.
EDs have low rates of ED information systems adoption, except those in urban areas and those specializing
in the care of children. Consensus definitions of what
constitutes an ED information system and features
required for meaningful ED information system use
need to be established. In addition, more specific mechanisms for incentivizing the adoption and implementation of ED information systems should be formulated.
Future work should also study the impact of ED information systems on ED costs, quality, and outcomes.
The first step to realizing the potential value of ED
information systems for improved emergency care is to
better define, understand, and promote ED information
system use.
The authors thank Esther Hing of the CDC National Center for
Health Statistics for her assistance clarifying the survey methodology used in the National Hospital Ambulatory Medical Care
Survey.
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15. Taylor TB. Information management in the emergency department. Emerg Med Clin North Am.
2004; 22:241–57.
16. Smith MS, Feied CF. The next-generation emergency department. Ann Emerg Med. 1998; 32:65–74.
17. Institute of Medicine. Hospital-Based Emergency
Care: At the Breaking Point. Washington, DC:
National Academies Press, 2007.
18. Pitts SR, Niska RW, Xu J, et al. National Hospital
Ambulatory Medical Care Survey: 2006 emergency
department summary. Natl Health Stat Report.
2008; 7:1–38.
19. NHAMCS. Micro-Data File Documentation. Available at: ftp://ftp.cdc.gov/pub/Health_Statistics/NCH
S/Dataset_Documentation/NHAMCS/doc06.pdf. Accessed Feb 7, 2010.
20. Rothenhaus T, Kamens D, Keaton B, et al. Emergency department information systems: primer for
emergency physicians, nurses and IT professionals.
Available at: http://www.acep.org/WorkArea/Down
loadAsset.aspx?id=45756. Accessed Feb 7, 2010.
21. National Institute of Standards and Technology.
Emergency Department Information Systems Functional Profile. Health Level 7 Emergency Care Special
Interest Group. Available at: http://xreg2.nist.gov:
8080/ehrsRegistry/faces/view/detailFunctionalProfile
.jsp?id=urn:uuid:de55973d-63a9-46c5-bc29-8f3a0fdf8
d9a. Accessed Feb 7, 2010.
22. Department of Health and Human Services. Meaningful Use Matrix. Available at: http://healthit.hhs.
gov/portal/server.pt/gateway/PTARGS_0_11113_872
719_0_0_18/Meaningful%20Use%20Matrix.pdf. Accessed Feb 7, 2010.
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the Meaningful Use Workgroup to the Health IT
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•
EDIS ADOPTION IN THE U.S.
Policy Committee. Available at: http://healthit.hhs.
gov/portal/server.pt/gateway/PTARGS_0_11113_872
720_0_0_18/Meaningful%20Use%20Preamble.pdf.
Accessed Feb 7, 2010.
Robert Wood Johnson Foundation, George Washington University Medical Center, Institute for
Health Policy. Health Information Technology in the
United States: The Information Base for Progress.
Princeton, NJ: Robert Wood Johnson Foundation,
2006.
Department of Health and Human Services. ��FINAL
Meaningful Use Objectives and Measures: 20112013-2015’’ from the Meaningful Use Workgroup to
the Health IT Policy Committee. Available at: http://
healthit.hhs.gov/portal/server.pt/gateway/PTARGS_
0_10741_888532_0_0_18/FINAL%20MU%20RECOMMENDATIONS%20TABLE.pdf. Accessed Nov 18,
2009.
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or Facility Level. Available at: http://www.cdc.gov/
nchs/data/ahcd/provider-visit-code.pdf. Accessed
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Pallin DJ, Sullivan AF, Auerbach BS, Camargo CA
Jr. Adoption of Information Technology in Massachusetts Emergency Departments. J Emerg Med.
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of usage protocols of syndromic surveillance systems by state public health departments in the United States. J Public Health Manag Pract. 2009;
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http://www.hhs.gov/aspr/opeo/eccc/index.html. Accessed
Nov 18, 2009.
SPECIAL CONTRIBUTION
Emergency Department Information System
Implementation and Process Redesign Result
in Rapid and Sustained Financial
Enhancement at a Large Academic Center
Jason S. Shapiro, MD, MA, Kevin M. Baumlin, MD, Neal Chawla, MD, Nicholas Genes, MD,
James Godbold, PhD, Fen Ye, MS, and Lynne D. Richardson, MD
Abstract
Objectives: The objectives were to measure the financial impact of implementing a fully integrated
emergency department information system (EDIS) and determine the length of time to ��break even’’ on
the initial investment.
Methods: A before-and-after study design was performed using a framework of analysis consisting of
four 15-month phases: 1) preimplementation, 2) peri-implementation, 3) postimplementation, and 4) sustained effects. Registration and financial data were reviewed. Costs and rates of professional and facility
charges and receipts were calculated for the phases in question and compared against monthly averages
for covariates such as volume, collections rates, acuity, age, admission rate, and insurance status with an
autoregressive time series analysis using a segmented model. The break-even point was calculated by
measuring cumulative monthly receipts for the last three study phases in excess of the average monthly
receipts from the preimplementation phase, corrected for change in volume, and then plotting this
against cumulative overall cost.
Results: Time to break even on the initial EDIS investment was less than 8 months. Total revenue
enhancement at the end of the 5-year study period was $16,138,953 with an increase of 69.40% in
charges and 70.06% in receipts. This corresponds to an increase in receipts per patient from $50 to $90
for professional services and $131 to $183 for facilities charges. Other than volume, there were no significant changes in trends for covariates between the preimplementation and sustained-effects periods.
Conclusions: A comprehensive EDIS implementation with process redesign resulted in sustained
increases in professional and facility revenues and a rapid initial break-even point.
ACADEMIC EMERGENCY MEDICINE 2010; 17:527–535 ª 2010 by the Society for Academic Emergency
Medicine
Keywords: informatics, computerized medical record systems, emergency medicine, hospital
financial management, cost and cost analysis
From the Department of Biomedical Informatics, Columbia University (JSS), New York, NY; and the Department of Emergency
Medicine (KMB, CH, LDR), the Department of Community Medicine (JG), and the Departments of General Medicine (FY)
and Emergency Medicine (JSS), Mount Sinai School of Medicine, New York, NY. Dr. Shapiro is currently with the Department of
Emergency Medicine, Mount Sinai School of Medicine, New York, NY. Dr. Chawla is currently with the Department of
Emergency Medicine, Inova Fairfax Hospital, Falls Church, VA.
Received August 28, 2009; revision received November 4, 2009; accepted November 10, 2009.
Presented at the Society for Academic Emergency Medicine annual meeting, San Francisco, CA, May 18–21, 2006.
Dr. Shapiro is supported in part by NLM 1K99LM009556-01 вЃ„ 02 and 4R00LM009556-03, which has run from July 16, 2007, to the
present. There is вЃ„ was no direct support for work on this project.
In 2006 Dr. Baumlin became President and CEO of SunriseSolutions Group (SSG) Inc. During late 2007 and 2008, PICIS contracted
SSG to perform services related to assessing processes and performing application training for physicians and other staff members.
PICIS in no way sponsored nor offered financial or other support for this research and the consulting engagement ended by late
2008.
Address for correspondence and reprints: Jason S. Shapiro, MD, MA; e-mail: jason.shapiro@mssm.edu.
ВЄ 2010 by the Society for Academic Emergency Medicine
doi: 10.1111/j.1553-2712.2010.00720.x
ISSN 1069-6563
PII ISSN 1069-6563583
527
528
Shapiro et al.
E
mergency department (ED) adoption of comprehensive information systems has been slow1,2
despite perceived advantages in the efficiency
and safety for health information technology (IT) in other
areas of the hospital.3–5 Unclear costs and concerns
about workflow disruption during the transition are reasons frequently ascribed to this reluctance to adopt new
technology.3,6
The adoption of IT solutions may be of particular
benefit to EDs due to the pressures of increasing volumes, crowding, and patient acuity and the difficulty of
obtaining complete histories from patients at presentation. ED tracking systems alone have been shown to
improve patient throughput times,7 and comprehensive
ED information systems (EDISs) have been shown to
improve retrieval of medical and radiology records, laboratory turnaround times, and patient throughput
times.8,9 EDISs also represent an opportunity to
improve patient safety10,11 and clinical documentation12,13 and, through the use of decision support, to
improve compliance with standard medical guidelines.5,14 EDIS implementation at Mount Sinai Medical
Center has led to markedly decreased turnaround times
for test results and improved ED throughput times8,9
and has facilitated research initiatives, quality assurance
activities, and teaching. To the best of our knowledge,
no comprehensive financial analysis of an EDIS implementation has previously been described. Authors and
working groups have called for more data regarding
the financial impact of implementing an EDIS.12
This article describes the implementation of an EDIS
in a large academic ED and the process redesign that
was undertaken to optimize the implementation. The
study presents a financial analysis calculating the time
it took to break even on the initial investment for the
EDIS implementation and the total revenue enhancement at the end of a 5-year study period in a large academic ED.
METHODS
Study Design
This was a pre- and postimplementation study conducted using monthly averages of aggregate financial
data to perform a time series analysis.15 A time series
analysis examines the change in a measure over time
and, through calculation of a slope, whether there is a
change in the rate of change of that measure at the
time that an intervention takes place. This investigation
was deemed exempt from human subjects review by
the Mount Sinai Institutional Review Board.
Study Setting and Population
The Mount Sinai Medical Center (New York, NY) is an
1,171-bed tertiary care academic medical center located
in Manhattan, bordering on the Upper East Side (an
affluent New York neighborhood) and East Harlem (a
working class and underserved area). The facility is
known for cardiac care and transplant services, has a
world-renowned geriatrics program, and is a designated heart hospital and primary stroke center.
Mount Sinai has 45 licensed ED beds, which
increased from 41 in 2005, and includes separate pedi-
•
EDIS IMPLEMENTATION RESULTS IN FINANCIAL ENHANCEMENT
atric, fast-track, and observation areas with an annual
combined volume of 88,140 visits in 2007. There is a 4year emergency medicine residency program that
includes 60 residents, and there are house staff rotating
through the ED from other departments, including
internal medicine, psychiatry, and obstetrics and gynecology. There are also fellowship tracks in pediatrics,
emergency ultrasound, clinical research, and informatics. During the study period, the total number of fulltime-equivalent (FTE) hours decreased slightly for
attending and resident coverage, while the hours of
nursing, technician, and clerical staff support remained
unchanged. The patient population has changed little
over the years, with a payer mix that includes 25%
commercial (with 12% health maintenance organization вЃ„ preferred provider option), 30% Medicaid, 25%
Medicare, and 20% self-pay or uninsured. The admission rate during the study period ranged from 23.5% to
25.9%, and the mean (В±SD) patient age ranged from
30.28 (В±1.38) to 32.3 (В±1.10) years (Table 1). Our prenegotiated rates with payers did not vary significantly
over the 5-year study period, with the exception of
New York State Medicaid, which increased professional
reimbursement from $17 to $25 in 2006 and underwent
a transition to Medicaid managed care programs for a
portion of those who had been on traditional Medicaid.
Study Protocol
Theoretical Model. Evaluations of health IT implementations are often conducted using some variation of
preand
postimplementation
quasi-experimental
design.15 Because this implementation had a prolonged
roll-out with multiple phases that took place over
approximately 15 months, a framework of analysis was
adopted using the following four 15-month time frames
that extended prior to and following the implementation: 1) preimplementation July 2002–September 2003
when the vast majority of ED processes were still on
paper; 2) peri-implementation October 2003–December
2004 while the phases of implementation were taking
place; 3) postimplementation January 2005–March 2006,
which was a period of adjustment immediately following the completion of EDIS implementation; and 4) sustained effects April 2006–June 2007, which was
included to examine the lasting financial impact of EDIS
implementation.
Interventions. Beginning in November 2003, The
Mount Sinai Hospital implemented a comprehensive
EDIS (Picis, ED Pulsecheck, Wakefield, MA, formerly
IBEX). Prior to this, patient care in the ED involved
numerous processes supported by disparate systems,
requiring multiple logins and passwords by users. The
EDIS provides triage, patient tracking, physician and
nurse documentation, retrieval of charts from prior ED
encounters, one-click access to more extensive historical hospital data from an enterprise data repository,
computerized provider order entry, results review, discharge instructions, and prescription writing. Physician
and nurse documentation within the system are template-driven. History of present illness, procedure,
nursing assessment, results interpretation, and followup care templates are chosen by the user, which in turn
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529
Table 1
Revenues and ED Trends (Covariates)
Revenues
Average professional* E&MВ level
Total professional critical care cases
Total professional charges
Total professional receipts
Professional fee collection rate
Average facilityГ E&M level
Total facility critical care cases
Total facility charges
Total facility receipts
Facility fee collection rate
Total charges (professional + facility)
Total receipts (professional + facility)
Average collections per patient
(professional)
Average collections per patient (facility)
Average collections per patient
(professional + facility)
Total excess receipts compared to
preimplementation (unadjusted)
Total excess receipts compared to
preimplementation (adjusted
for volume)
Trends
Total volume of billed visits
Total collection rate
Average acuity (as ESI score)В§
Average age
Average admission rate
Average rate of uninsured patients
Preimplementation
07 ⁄ 02–09 ⁄ 03
Peri-implementation
10 ⁄ 03–12 ⁄ 04
Postimplementation
01 ⁄ 05–03 ⁄ 06
Sustained Effect
04 ⁄ 06–06 ⁄ 07
3.17
1
$21,104,013
$4,445,221
21.06%
2.85
45
$46,590,732
$10,776,247
23.13%
$67,694,745
$15,221,468
$54
3.43
480
$28,496,273
$5,006,412
17.57%
2.47
193
$52,061,306
$12,164,834
23.37%
$80,557,579
$17,171,246
$62
3.66
934
$33,853,661
$7,171,488
21.18%
2.14
1,046
$65,705,669
$15,540,093
23.65%
$99,559,330
$22,711,581
$82
3.73
1,614
$41,610,935
$8,545,243
20.54%
2.24
974
$73,063,284
$17,339,872
23.73%
$114,674,219
$25,885,115
$90
$131
$186
$151
$214
$177
$259
$183
$274
NвЃ„A
$1,949,778
$7,490,114
$10,663,647
$1,860,730
$7,011,804
$9,202,975
81,976
22.56%
N ⁄ A§
30.18
25.47%
20.47%
80,355
21.33%
3.30
30.66
25.90%
18.25%
87,746
22.90%
3.22
31.84
24.19%
18.17%
94,527
22.56%
3.17
32.34
23.53%
18.98%
*Professional refers to cases assessed a professional or physician’s fee and generally applies to all patients including those
admitted and those treated and released from the ED.
В E&M = evaluation and management: the five-point scale used for coding ED charts for billing purposes.
Г Facility refers to cases assessed a facility charge by the hospital and generally refers to only those treated and released from
the ED.
В§ESI = Emergency Severity Index; data not collected until November 2003.
drive the workflow within the documentation system.
All data entered into the EDIS are time-stamped. There
was a phased EDIS implementation beginning with
nursing documentation in the fourth quarter of 2003
(Q4 2003), followed by physician documentation in Q1
2004. Computerized order entry and integration with
other hospital systems (including registration, laboratory, and hospital electronic data repository) proceeded
through Q4 2004. Patient care documents from other
departments or facilities are scanned into the patient’s
electronic chart and are simultaneously viewable by all
personnel caring for the patient. To create a single
sign-on application for users, and to maximize the
EDIS’s efficiency, multiple electronic interfaces were
built to other hospital systems such as admission, discharge, and tracking; radiology; pharmacy; laboratory;
bed management; and the hospital’s data repository
(Table 2). These interfaces and single sign-on capability
obviated the need for personnel to train on multiple
systems and radically reduced the number of steps
required to perform common functions.
Process redesign, which involved detailed process
mapping and changes to clinical and administrative
workflows to maximize efficiency and synergy with the
EDIS, took place throughout the peri-implementation
phase and included 1) the initiation of a ��quick-reg’’
process that allows patients to be entered into the EDIS
and given a visit and medical record number in a much
more timely fashion than had been done previously,
thereby allowing the initiation of orders much sooner;
2) changes in the way that laboratory orders and results
are processed, which previously required paper orders
and several steps of human transcription with various
electronic systems and now is done by bar-coded labels
generated by the EDIS, time-stamped orders sent
directly to the laboratory system, and results returned
directly back into the EDIS via a bidirectional interface;
3) changes in the way that radiology orders are processed, which previously required faxing a hand-written request, and now an electronic order is routed to
printers in the various radiology areas depending on
the type of test ordered, and transcribed results are
routed directly back into the EDIS via an interface;
and 4) changes in the way that facility charges are
captured for nursing procedures, which previously
required the nurse to fill out and submit a paper
charge slip for each procedure separately from their
documentation workflow in the medical record and
now are automatically captured by the EDIS when the
nurse documents the procedure within it through a
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Shapiro et al.
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EDIS IMPLEMENTATION RESULTS IN FINANCIAL ENHANCEMENT
Table 2
Interfaces Built as Part of the EDIS Implementation
Interface
Admission discharge and tracking
Physician master contact database
Laboratory system
Radiology system
Hospital data repository
Hospital bed management system
Professional billing company
Facility billing system
Department of health
Description
Inbound
Inbound
Outbound order entry; inbound results
Outbound order entry; inbound status update for orders and report
(preliminary and final)
Context-specific pass-through (historical data); real-time display of ED report for
non-EDIS users
Outbound request; inbound bed location assignment with status updates
Outbound report (flat file)
Outbound interface
Outbound surveillance data
EDIS = emergency department information system.
��charge-by-documentation’’
feature.
Flow
charts
describing the before and after states in the Mount
Sinai ED are depicted in Data Supplements S1 and S2
(available as supporting information in the online version of this paper).
Methods of Measurement. Cost data were provided
by the Mount Sinai Department of Information Technology. Financial revenues data were provided by the
ED’s professional services billing agency (McKesson,
Grand Rapids, MI; formerly Per-SГ© Technologies,
Alpharetta, MI) and The Mount Sinai Hospital finance
department.
Data Collection and Processing (Cost). Cost data
were divided into two categories—capital and operating
(Table 3). Capital costs include all items incurred as a
Table 3
Total Capital and Operating Costs Over the Five-year Study
Period
Capital
One-time implementation expenses
Training
Travel during vendor selection process
Other capital expenses
Contract execution payment
Sequel server license
Workstations
Plasma displays
Plasma wall mounts
Document scanners
Contingency (other hardware вЃ„ expenses)
IT salary for support of
preimplementation vendor
selection process
Total capital costs
Operating
IT salary (1.25 FTEs вЃ„ year to
support implementation)
Software lease
Server maintenance
Data storage
Total operating
Total cost (capital + operating)
$86,869
$36,242
$144,786
$11,741
$76,453
$52,082
$849
$4,005
$14,889
$31,500
$336,305
$409,500
$962,970
$49,500
$86,670
$1,508,640
$1,936,556
FTE = full-time equivalent; IT = information technology.
one-time charge, such as contracting, training, certain
licensing fees, and hardware. Operating costs include
items such as salaries plus fringe for staff supporting
the EDIS, ongoing software licensing fees, and ongoing
hardware fees for server hosting and data storage.
Because cost data were available as monthly fees or
one-time charges during a particular calendar year, all
costs were added together for each year, divided by 12
to calculate a monthly average, and then the corresponding monthly amounts were added for each of the
15-month periods of the four study phases. This number, the period total, was then divided by 15 and used
to determine the straight-line depreciation for costs
during each of the four study phases.
Data Collection and Processing (Revenue). Revenue
data were provided as both charges and receipts in two
categories—professional and facility. Professional revenue derives from patients both discharged home and
those admitted to the hospital from the ED, because
both receive a professional bill for physicians’ services.
Facility revenue derives from patients treated and discharged from the ED, because admitted patients do not
incur a separate facility charge from the ED. Total
charges and receipts were calculated by adding the values for professional and facility together for a corresponding month, and then sums were tallied for each
study phase. Since December 2003, professional billing
and coding services have been provided by McKesson.
They, along with the ED administration, provide ongoing biannual training and feedback to all faculty members on billing and coding issues. This training began
in the peri-implementation phase and includes chart
reviews with specific deficiencies and potential remedies and individualized remediation for some practitioners who lag behind their peers on specific measures.
Similar training had been conducted internally prior
to the EDIS implementation. Facility coding was outsourced in 2004, with the same vendor in place since.
Outcomes Measures
The primary outcomes measures were 1) time to an initial ��break-even point’’ and 2) total revenue enhancement at the end of the sustained-effects period.
Secondary outcome measures included changes in
ACAD EMERG MED • May 2010, Vol. 17, No. 5
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chart completion rates, the evaluation and management
(E&M) levels (the five-point scale used for coding ED
charts for billing purposes), the number of charts billed
for critical care, professional charges, professional collections, facility charges, and facility collections.
Data Analysis
Data were analyzed by calculating simple averages and
percentages from aggregate monthly data using Microsoft Excel (Microsoft Corp., Redmond, WA). The breakeven point was calculated by determining the difference
between the monthly receipts for each month in the
later three phases of the study and the average monthly
receipts from the preimplementation phase. Excess
cumulative monthly receipts were then plotted against
cumulative monthly EDIS costs for each of the later
three phases in the study. To determine total revenue
enhancement at the end of the study period, the total
cumulative cost of the implementation was subtracted
from the amount of the total cumulative receipts from
the later three phases of the study that exceeded the
cumulative average monthly receipts from the preimplementation period.
Statistical Methods. Time series data for the months
encompassing the preintervention, peri-intervention,
postintervention, and sustained-effects periods were
analyzed using autoregressive integrated moving average (ARIMA) models as implemented in SAS software
(SAS Institute, Cary, NC).16 The first stage in the analysis was to see if each observed series was a stationary
series and, if not, to detrend the observed series to
obtain a stationary series. In all instances detrending
was required, and simple differences (between response at time ��t’’ and response at time ��t – 1’’) were
calculated for each variable to obtain a stationary series. The four response series of interest were modeled
as functions of the intervention periods, yielding
adjustments to the intercept for each period. In these
models other covariates, including average age, average collection rate, average rate of uninsured patients,
and total volume of billed charts were forced into the
model regardless of the p-values. After fitting the models to the data, tests were done to examine how well
the models fit the data. This was done using the
Dickey-Fuller unit root test,17 which examines the
residuals to see if they are a stationary series—the first
underlying assumption of the model. The p-value for
the Dickey-Fuller test was p > 0.05, indicating that the
residuals were stationary. The Ljung-Box portmanteau
test18 was carried out to see if the residuals were
uncorrelated, i.e., if they represented white noise. The
p-value of >0.05 indicated that the data were consistent
with the white noise assumption required by the
model.
RESULTS
Costs
Up-front capital costs, involving one-time charges such
as training and hardware, totaled $427,916, with over
90% of this cost incurred in the peri-implementation
period (Table 3). All initial training was rolled into the
531
capital budget and kept at a minimum by training a set
of ��super users’’ and then ensuring that there were one
or two of them in the ED during every shift. Two-hour
training classes for faculty, residents, and staff were
included. Operating costs, covering items such as salaries, ongoing software licensing fees, and hosting and
storage fees, totaled $1,508,640 across the latter three
15-month periods. Although EDIS software is often
purchased outright, in this implementation the software
was financed, and therefore the associate expenses
were categorized as operating costs, causing operating
costs to be relatively higher compared to capital costs
than what might be expected.
Revenue
Gross charges and receipts rose significantly beginning
in the peri-implementation phase. The discrepancy
between charges and receipts allows the calculation of
collection rates and average collections per patient, a
convenient indicator of ED financial health18 (Table 1).
These rates are multifactorial and are affected by the
percentage of uninsured patients and negotiated contracts with and collections from a number of large commercial payers. There was a transient 16.59% drop in
the professional collection rate during peri-implementation, but both professional and facility collection rates
otherwise remained stable through all four study periods. Average collections per patient rose 47.48% (from
$186 to $274) between preimplementation and sustained
effects, total charges rose 69.40% during the same period (from $67,694,745 to $114,674,219), and total
receipts rose 70.06% (from $15,221,468 to $25,885,115).
Costs Versus Revenue
By calculating the amount by which monthly receipts in
the later three study phases exceeded the preimplementation monthly receipt average, correcting for actual
monthly volume and comparing this to the monthly
total cumulative costs (capital + operating), the breakeven point for the initial EDIS investment was determined to have taken place in August 2004. This was
within 8 months of the beginning of the peri-implementation phase and only 5 months after physician documentation went live (Figure 1). After implementation
was completed, costs remained relatively fixed while
revenues continued to rise. Comparing the increased
amount of total excess receipts at the end of the sustained-effects phase with overall EDIS costs through all
four phases, the total revenue enhancement at the end
of the study period was $16,138,953.
Our secondary outcome, physician documentation,
improved with the implementation of the EDIS. End-ofmonth chart completion rates by attending physicians
rose from 65% in 2003 to 95% in 2005, while lost or
illegible charts decreased from 4,992 in 2003 to zero in
2005. The average professional E&M level rose from
3.17 during the preimplementation period to 3.73 during the sustained-effects period. The number of charts
meeting professional fee criteria for critical care billing
increased from just one chart during the entire 15month preimplementation period to 1,614 charts in the
sustained-effects period and from 45 to 974, respectively, for facility critical care billing. Although the
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Shapiro et al.
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EDIS IMPLEMENTATION RESULTS IN FINANCIAL ENHANCEMENT
Figure 1. A comparison of cumulative monthly receipts and costs from the latter three phases of the study to the average monthly
receipts and costs from the preimplementation period. The circles represent the cumulative amount by which receipts from the corresponding month exceeded the average monthly receipts from the preimplantation period. The triangles represent the same thing
after adjustment for changes in ED volume. The diamonds represent the average total cumulative monthly cost, which began with
the up-front capital costs and was then calculated using straight-line depreciation for the cumulative operational costs from each of
the four study phases.
22.56%, respectively. Average monthly acuity, using a
five-point scale (1 = most acute) employed by the ED
triage nurses (Emergency Severity Index [ESI]
increased from 3.30 during peri-implementation, to 3.22
during postimplementation, to 3.17 during sustained
effects). The ESI was not used in the ED prior to the
peri-implementation phase; therefore, the outcomes
could not be adjusted for ESI use. There were no significant changes in trends for the average monthly age of
patients, admission rates, or rate of uninsured patients
over the study period.
mean E&M level for facility billing actually decreased
from 2.85 during preimplementation to 2.14 during
postimplementation, it was trending back up with an
average of 2.24 during the sustained-effects period.
Despite this overall decline in the facility E&M level,
net facility receipts increased 60.91%, from $10,776,247
to $17,339,872, between the preintervention and sustained-effects phases. Table 1 describes the professional
and facility billings and collections for each phase of
the study.
ED Trends and Analysis of Covariates
During the four phases of the study period, the volume
of billed ED visits initially dropped 1.98%, from 81,976
during preimplementation to 80,355 during peri-implementation, but then rose 15.31%, to 94,527 by the sustained-effects period (Table 1). Total collection rates
remained relatively flat, with rates over the course of
the four study phases of 22.56, 21.33, 22.90, and
Time Series Analysis
A change in the slope between study phases was calculated for all measures, which corresponds to the
amount and direction of change in the measured trend
for that variable when comparing one phase of the
study to the other, while adjusting for ED volume,
collection rates, patient age, admission rates, and
Table 4
Results of Time Series Analysis
D Slope
Pre вЃ„ Peri
Professional charges
Facility charges
Professional receipts
Facility receipts
7.06
)1.06
1.21
5.82
В·
В·
В·
В·
p-value
5
10
105
105
104
<0.0001*
0.6395
0.0216*
0.4830
D Slope
Peri вЃ„ Post
)4.80
3.72
6.84
)3.40
В·
В·
В·
В·
3
10
105
104
103
p-value
D Slope
Post вЃ„ Sust
0.9654
0.0447*
0.0982
0.9574
)2.54
)3.29
9.76
2.43
В·
В·
В·
В·
4
10
104
103
104
p-value
0.8221
0.852
0.8146
0.7074
D Slope
Pre вЃ„ Sust
6.76
2.33
1.99
7.91
В·
В·
В·
В·
5
10
105
105
104
p-value
0.0026*
0.5495
0.0144*
0.5532
Slope is the change in the stated measure as a function of time and is adjusted for the covariates volume, age, rate of self-pay,
and total collection rate.
Explanation of notation: )1.06 В· 105 = 0.0000106; 1.21 В· 105 = 121,000.
Pre = preimplementation; Peri = peri-implementation; Post = postimplementation; Sust = sustained effects.
*p < 0.05.
ACAD EMERG MED • May 2010, Vol. 17, No. 5
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percentage of uninsured patients (Table 4). Significant
results from this analysis include the change in slope
between the pre- and peri-implementation phases for
professional charges and receipts of 7.06 В· 105
(p < 0.0001) and 1.21 В· 105 (p = 0.0216), respectively,
and the change in slope between the preimplementation phase and sustained-effects phases for professional
charges and receipts of 6.76 В· 105 (p = 0.0026) and
1.99 В· 105 (p = 0.0144). Additionally, there was a significant change in the slope for facility charges between
the peri- and postimplementation phases of 3.72 В· 105
(p = 0.0447). Figure 2 represents the change in slopes
for professional charges between each time period and
shows that the slope in the preintervention phase is virtually flat with a sharp up-turn in the peri-intervention
phase that is maintained across the two subsequent
study phases, with minor changes from period to period once the upturn takes place. Although the slopes
for some measures yielded a negative result as they
transitioned from one study phase to another, none
were significant (all results are listed in Table 4).
DISCUSSION
Although total ED volume increased by 15.31% over
the study period, and acuity increased by 3.9% from
the peri-implementation to sustained-effects phases, the
significance of the increases in professional charges
and collections, while adjusting for volume, demonstrated that these changes alone would not have
resulted in the observed increases in revenue. Furthermore, an increase in total ED volume while maintaining
a flat collections rate could not, on its own, have produced an increase in the collections per patient as was
seen. It is the increased collections per patient that led
to the actual increase in revenue, and this coincides
Figure 2. The changes in slopes for professional charges
between each time period. This graph shows that the slope in
the preintervention phase was virtually flat with a sharp up-turn
in the peri-intervention phase that was maintained across the
subsequent study phases. Following the initial up-turn, changes
in slope from period to period are visually imperceptible due to
the scale of the graph, but are presented in Table 4.
533
with the implementation of the EDIS and consequent
improvements in charting and billing. Improved chart
completion rates may account for some of the net
financial enhancement and could have been increased
through process redesign alone without EDIS implementation. Other factors, such as increased number of
critical care cases and increased professional E&M levels, are also major contributors to the effect seen. Figure 3 depicts the change in E&M level distribution over
the 5-year study period and shows a clear ��shift to the
right’’ phenomenon, with an increase in Level 5 and
critical care charges and a corresponding decrease in
Levels 1–3. Because fee schedules are nonlinear (i.e., a
charge for a Level 5 visit can be two to four times that
for a Level 3), this shift represents a sizable increase in
charges. In this case, the average professional E&M
level rose from 3.17 to 3.73, corresponding with a 36%
increase in charges based on the department’s fee schedule. Prior to EDIS implementation, concerted training
efforts to improve revenue capture through physician
documentation failed to produce this shift to the right.
One of the reasons that charting likely improved is
that the physician and nurse documentation components, which come bundled with the EDIS system, contain templates for the completion of various chart
elements such as history of present illness, review of
systems, physical exam, and procedure notes. There is
also a score feature that shows the current E&M level
on the tracking board and allows the clinicians to see
which components of the chart are deficient. These
EDIS features prompt clinicians to more completely
document the services that they provide, which in turn
leads to enhanced billing, charges, and receipts.
Although there was an overall decline in the facility
E&M billing level during the study period, the net facility receipts increased 60.91%, from $10,776,247 to
$17,339,872. It is possible that the decreased E&M level
was due, in part, to poorer overall documentation by
nurses in the EDIS as a result of increased ED volume
Figure 3. The change in professional E&M level distribution
over the 5-year study period. This shows a clear ��shift to the
right’’ phenomenon, with an increase in Level 5 and critical care
charges and a corresponding decrease in Levels 1–3. This distribution shift accounts for the reported increase in average professional E&M level from 3.17 to 3.73. E&M = evaluation and
management.
534
Shapiro et al.
without any increases in nurse staffing levels. Although
several contracts for global fees were negotiated with
large managed care organizations during the study period, and this may have helped offset some of the potential decline in receipts due to the decline in E&M level,
most of the increase in receipts is likely due to the
charge-by-documentation feature that automatically
sends a charge to the billing system each time a billable
procedure (such as placing an intravenous line or giving a medication) is documented. Prior to the implementation of the EDIS, charge capture for these routine
nursing procedures on the facility side required the
nurse to fill out and submit a separate paper charge slip
on top of their procedure documentation, which was a
significant workflow impediment and often did not
occur. Although a change in the rate at which these
procedures were being documented was not measured
as part of this study, an increase in billable procedures
combined with the increase in the number of cases
billed for critical care time under the facility charges
could certainly account for the increase in overall facility receipts despite the decline in E&M level.
The time series analysis allowed us to examine the
revenue increases with adjustment for changes in the
covariates over time using statistical methods. In general, although not all of the transitions from one
study phase to the next yielded a significant p-value,
there was an increase in charges and receipts
between preimplementation phases, with a subsequent
decrease during the peri- to postimplementation transition and a resumption of increases during the transition from postimplementation to sustained-effects
phases (Figure 2 and Table 4). This initial increase is
likely due to effects of the process redesign during
peri-implementation, in which workflow problems
were fixed through the implementation, followed by a
period of adjustment and a series of enhancements to
the EDIS that likely caused a transient decrease in
charges and receipts. The transition to the sustainedeffects period, however, shows a clear trend toward
continued financial benefit due to the implementation
when correction is made for the covariates.
The data presented here demonstrate that implementation of a comprehensive EDIS with process redesign
resulted in rapid break even on the initial investment
and a significant total revenue enhancement. Examination of potential confounders, such as acuity, collection
rates, age, and rate of uninsured patient visits, suggests
that the effects measured are likely due to the EDIS
implementation and not other secular trends that may
have affected the results.
•
EDIS IMPLEMENTATION RESULTS IN FINANCIAL ENHANCEMENT
tion to the quantified 1.25 FTEs in the study, including
activities such as pulling network cable, installing new
network jacks, server refresh, and some of the in-house
work done by the institution’s interface team. These
undocumented potential costs, however, must be balanced by other unmeasured potential benefits, such as
decreased cost of paper charts, decreased adverse drug
events, decreased time spent on record retrieval, and
improved ED throughput times.
There are some data that could have been helpful in
performing a more granular analysis, such as the number of billed procedures on the facility side, which were
not available in our data set. Other data could not be
shared because they represent proprietary business
information, such as the details of the institution’s
negotiated fee schedules. Although using relative value
units (RVUs) as a measure of the change in physician
productivity, as was done by Kahn et al.,19 could have
been used, and would have accounted for changes in
the fee schedule or billable procedures, RVUs were not
available in the study data set, represent a measure of
productivity, and would not have allowed measurement
of the direct financial outcomes presented in this study.
Initially the cost analyses included formal accounting
techniques for the determination of the opportunity
cost of noncapital hardware expenses and the net present value of capital hardware using a 5% discount rate.
The total cost using these methods was only $77,796
(4.02%) higher than the total cost using the simple
straight-line depreciation method ($2,014,352 vs.
$1,936,556). Because the reporting of results using these
more formal methods would have been much more
cumbersome and of little added value due to the negligible difference on the overall effect size of $16,138,953,
the decision was made to use the simpler, straight-line
depreciation method.
There were some changes in Medicaid and Medicare
reimbursement over the 5-year course of the study,
including the conversion of regular Medicaid patients
to Medicaid managed care beginning in 2005, but the
data from these changes could not be segregated for
analysis. Furthermore, these changes took place after
the initial break-even point and did not affect charges,
and the impact on collections per patient and receipts
would have been small in light of the overall effect size.
In this single-institution study, there were certain
local events, such as interruptions in billing due to
changes in vendors, which may have affected some of
the measured outcomes. However, since such interruptions would tend to decrease enhanced revenues, they
are likely not responsible for the strongly positive study
results.
LIMITATIONS
This analysis includes those costs directly related to the
EDIS implementation. There are other costs that may
have had affected the results presented in this article,
but were too difficult to measure and financially quantify. These other costs included disruptions to workflow
from physically installing the system; in-kind time contributed to the implementation by various members of
the ED faculty, staff, and residents; and in-kind time
contributed by members of the IT department in addi-
CONCLUSIONS
The Mount Sinai ED information system experience
echoes similar findings from previous studies of a variety of electronic systems in other clinical settings,
including smaller EDs.19–26 This is the first detailed published study to show a rapid break-even point and large
overall revenue enhancement for an ED information
system implementation at a major urban academic ED
of this size. This successful implementation included an
ACAD EMERG MED • May 2010, Vol. 17, No. 5
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extensive number of interfaces to other hospital systems that were built with a concurrent and complimentary process redesign to optimize ED workflow. These
results should help support the decision for other large
EDs to adopt comprehensive information systems.
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Supporting Information
The following supporting information is available in the
online version of this paper:
Data Supplement S1. Pre-EDIS work flow diagram.
Data Supplement S2. Post-EDIS work flow diagram.
The documents are in PDF format.
Please note: Wiley Periodicals Inc. is not responsible
for the content or functionality of any supporting information supplied by the authors. Any queries (other than
missing material) should be directed to the corresponding author for the article.
CLINICAL PRACTICE
Impact of Scribes on Performance Indicators
in the Emergency Department
Rajiv Arya, MD, Danielle M. Salovich, Pamela Ohman-Strickland, PhD, and
Mark A. Merlin, DO
Abstract
Objectives: The objective was to quantify the effect of scribes on three measures of emergency physician (EP) productivity in an adult emergency department (ED).
Methods: For this retrospective study, 243 clinical shifts (of either 10 or 12 hours) worked by 13 EPs
during an 18-month period were selected for evaluation. Payroll data sheets were examined to determine whether these shifts were covered, uncovered, or partially covered (for less than 4 hours) by a
scribe; partially covered shifts were grouped with uncovered shifts for analysis. Covered shifts were
compared to uncovered shifts in a clustered design, by physician. Hierarchical linear models were used
to study the association between percentage of patients with which a scribe was used during a shift and
EP productivity as measured by patients per hour, relative value units (RVUs) per hour, and turnaround
time (TAT) to discharge.
Results: RVUs per hour increased by 0.24 units (95% confidence interval [CI] = 0.10 to 0.38, p = 0.0011)
for every 10% increment in scribe usage during a shift. The number of patients per hour increased by
0.08 (95% CI = 0.04 to 0.12, p = 0.0024) for every 10% increment of scribe usage during a shift. TAT was
not significantly associated with scribe use. These associations did not lose significance after accounting
for physician assistant (PA) use.
Conclusions: In this retrospective study, EP use of a scribe was associated with improved overall productivity as measured by patients treated per hour (Pt вЃ„ hr) and RVU generated per hour by EPs, but not
as measured by TAT to discharge.
ACADEMIC EMERGENCY MEDICINE 2010; 17:490–494 ª 2010 by the Society for Academic Emergency
Medicine
Keywords: performance indicators, scribes, relative value units
I
n emergency departments (EDs), scribes have been
touted as an efficient way to increase physician productivity.1 Scribes are often students working while
From the Department of Emergency Medicine (RA, MAM), the
Department of Pediatrics (MAM), and the Department of Medical Education (DMS), University of Medicine and Dentistry of
New Jersey–Robert Wood Johnson Medical School, New
Brunswick, NJ; and the Department of Biostatistics, University
of Medicine and Dentistry of New Jersey–School of Public
Health (PO), Piscataway, NJ.
Received April 24, 2009; revisions received June 26, July 23, September 20, October 13, and October 24, 2009; accepted October
27, 2009.
Address for correspondence and reprints: Mark A. Merlin,
DO; e-mail: Merlinma@umdnj.edu.Presented at the Society for
Academic Emergency Medicine regional meeting in Newark,
DE, March 27, 2009, where it won the overall best abstract at the
plenary session.
This study received no grants or financial support, and the
authors report no conflicts of interest. Dr. Merlin has grant
support from the American Heart Association.
490
ISSN 1069-6563
PII ISSN 1069-6563583
in school toward an eventual career in the field of medicine. Scribes assist physicians with the clerical aspects of
patient care with the intent of improving physician productivity. Their roles are diverse, but may include
recording patient histories, documenting details of the
physical examination, documenting procedures, following up on lab reports, and assisting with discharges. In a
recent editorial, Dr. Richard Bukata stated, ��(The time
spent performing) Charting prevents a physician from
seeing new patients, the true costs of charting are very
high ... scribes can chaperone вЃ„ assist exams, get labs,
make calls and do other tasks to facilitate physician productivity.’’1 Certain physicians attest to the benefits of
implementing a scribe program, but there are very limited published data specifically examining physician productivity indicators.2–5
Identification of factors that might enhance emergency physician (EP) productivity would be beneficial,
as society’s demand for emergency services continues
to grow. Without published data, many emergency
medicine groups have been forced to rely upon anecdotal evidence or promotional material from scribe
ВЄ 2010 by the Society for Academic Emergency Medicine
doi: 10.1111/j.1553-2712.2010.00718.x
ACAD EMERG MED • May 2010, Vol. 17, No. 5
•
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staffing services to justify a decision to initiate a scribe
program.
The hypothesis tested was that use of scribes during
an ED shift increases EP productivity, as measured by
the endpoints of patients treated per hour (Pt вЃ„ hr), relative value units generated per hour (RVU вЃ„ hr), and turnaround time (TAT) to discharge.
METHODS
Study Design
This was an observational, nonrandomized, comparative study. The university’s institutional review board
approved the protocol.
Study Setting and Population
This study was carried out from July 2006 through
December 2007 in the adult ED at a university-based
academic medical center, treating 59,000 adult patients
per year. The ED is an urban Level 1 trauma center and
a tertiary care center for multiple specialties. Only
board-certified or board-eligible EPs evaluated and
treated patients. Physician assistants (PAs) also see
patients in the adult ED, and all patients evaluated by
PAs are seen by a physician as well.
Scribes are assigned, when available, to specific areas
of our ED, and each scribe provides dedicated service
to only one physician during the scribe’s work shift.
Scribe service is limited to the adult ED; scribes do not
work in our fast-track area.
Study Protocol
Researchers evaluated shifts of 13 EPs working 243
clinical shifts (10 hours during the weekdays, 12 hours
on weekends) over 3,562 clinical hours. Payroll data
sheets were examined for physician shifts that were
uncovered or partially covered for less than 4 hours by
a scribe, due to sickness or absence. Physician shifts
with full scribe staffing were matched against shifts
worked by the same physician during the same shift
time period, but without full coverage by a scribe, as
detailed below under Measures. The main unit of analysis for this clustered study design was physician work
shifts, nested by physician. The main comparison was
that of intraphysician productivity data (Pt вЃ„ hr, RVU вЃ„ hr,
and TAT), compared between shifts with, versus without, full scribe coverage.
Training and Duties of Scribes. The scribe facilitates
and expedites the throughput of ED patients by creating, transcribing, and completing documentation of the
patients’ medical record. The scribe communicates all
laboratory and x-ray results in a timely manner to the
EP.
To apply for the scribe program at our institution,
applicants must have 2 years of clerical experience,
including familiarity with common software packages.
Knowledge of medical terminology and coding is preferred. The scribe training program is 60 hours in
length.
In our facility, scribes complete medical documentation as instructed by a physician. They accurately document time of procedures, calls from physicians, and
491
timelines of events. Chart narratives are added by
scribes, such as the course of events within the ED.
Measures
Physician productivity was compared between shifts
during which physicians had full availability of a scribe,
versus shifts when they did not. Shifts with scribes for
less than 4 hours were considered ��without’’ scribes.
We did not require 0 hours of scribe coverage to qualify a shift as being without a scribe, due to a lack of sufficient numbers of shift that were completely uncovered
by a scribe. Data points were collected on all adult
(‡21 years) patients within each of the selected shifts.
For each patient, the electronic medical record was
examined to determine whether a scribe was used.
Each physician shift is designed to have an assigned
scribe, but scribe availability falls short of this ideal.
During each shift for which scribe services were available, the primary independent variable was the percentage of patient documentation done by a scribe.
Another independent variable was the percentage of
patients seen by a PA.
Investigators extracted patient-specific time stamps
and emergency management (E&M) codes from departmental electronic medical records into Microsoft
Access (Microsoft Inc., Redmond, WA). Pt вЃ„ hr was calculated as the number of patients initially evaluated
over the entire shift, divided by the length of the shift.
Patients ��turned over’’ to an incoming physician at
change of shift were not counted toward the receiving
physician’s Pt ⁄ hr.
Dependent variables indicative of physician productivity were: mean Pt вЃ„ hr (averaged for the full 10 or
12 hours of each shift); RVUs generated per hour, as
assigned by a certified medical coder credited to the
physician who evaluated the patient initially, regardless
of any turnover of care; and TAT (minutes) for discharge, calculated as the difference between the electronically generated arrival and discharge times.
Data Analysis
Means and standard deviations (SDs) of dependent and
independent variables were calculated for each individual physician, as well as across physicians. Intracluster
correlations (ICCs) were calculated for each variable,
describing the percentage of variation in each variable
that could be attributed to differences between physicians. These ICCs, which theoretically could range from
0 to 1.00, quantify the degree of similarity of these measurements within, versus between, physicians.6 Because
these ICCs represent nonnegligible similarities of measures within physicians, statistical models that account
for this correlation are warranted.
Because shifts are nested within physicians, a mixed
linear model was used to evaluate the mean effect of
percentage of patients with scribes (%scribes) on each
of the outcomes variables (RVU вЃ„ hr, Pt вЃ„ hr, and TAT to
discharge). These mixed models have been identified as
correctly handling data in which there are unequally
sized clusters (number of patients per physician). The
initial model included %scribes as a fixed effect and
included random intercepts for each physician, thereby
allowing shifts to be more similar within physicians
492
Arya et al.
than across physicians. F-tests were used to evaluate
the effect of %scribes. Sensitivity analyses examined
whether Pt вЃ„ hr or percentage of patients for whom a PA
was assigned (PPA) were confounders for the effect of
%scribes. Additionally, we examined whether %scribes
was inversely related to PPA. The latter two analyses
were used to assess whether use of scribes was associated with decreased use of PAs.
Exploratory analyses examined the potential for variation among physicians in the association between
%scribes and the performance indicators through addition of a random component for the slope related to
%scribes in the mixed models described above. Wald
z-tests of the random component of the %scribes slopes
formally tested whether the effect of %scribes varies
significantly across physicians. SAS software (SAS for
Windows, version 9.1.3, SAS Institute Inc., Cary, NC)
was used for all analyses.
RESULTS
The sample included shifts from 13 physicians, with the
number of shifts per physician ranging from to 4 to 68.
Table 1 includes the overall summaries of the independent variables, and Table 2 includes the overall summaries of the outcome variables. Table 3 presents results
from the mixed linear models examining the degree of
association between percentage of patients over a physician shift seen with a scribe (%scribes) on the three
outcome variables. Three models were used to examine
the unadjusted and adjusted effects of scribe use.
Model 1 only looked at the percentage of scribe utilization (unadjusted). Model 2 looked at percentage of
scribe adjusted for percentage of PA (%PA) utilization.
Model 3 is similar to Model 2, but additionally adjusts
for patients seen per hour. Models 1 and 2 were
applied to RVUs вЃ„ hr and Pt вЃ„ hr. All models were applied
to TAT to discharge.
Percentage of patients with scribes was significant
for RVU вЃ„ hr and for Pt вЃ„ hr. The RVU вЃ„ hr increased by
0.18 (95% confidence interval [CI] = 0.04 to 0.32,
p = 0.0067) units when the percentage of a shift for
which a scribe was utilized increases by 10%. This
effect persisted even after adjusting for the percentage
of patients during a shift seen with a PA. After control-
Table 1
Descriptives of Independent Variables
Physician
(n = 243 shifts)
Mean
SD
ICC*
%Scribes
%PAs
Total No.
of Patients
30.6
В±16.8
0.23
63.3
В±14.1
0.44
25.3
В±5.7
0.17
Note: 6.1% of patients were seen by physicians with neither
scribes nor PAs.
ICC = intracluster correlations; %PAs = percentage of physician assistants; %scribes = percentage of patients with
scribes.
*Intraphysician correlation coefficient represents the percent
of variation in a variable that can be attributed to physician
differences.
•
IMPACT OF SCRIBES ON PERFORMANCE INDICATORS
Table 2
Descriptives of Performance Indicators
Physician
(n = 243 Shifts)
Mean
SD
ICC*
RVUs вЃ„ hr
TAT to Discharge
(Minutes)
Pt вЃ„ hr
6.9
В±1.7
0.22
256
В±71.9
0.14
2.5
В±0.5
0.09
ICC = intracluster correlations; Pt вЃ„ hr = number of patients
treated per hour; RVUs = relative value units; TAT = turnaround time.
*Intraphysician correlation coefficient represents the percent
of variation in a variable that can be attributed to physician
differences.
ling for PA use, the RVU вЃ„ hr increased by 0.24 (95%
CI = 0.10 to 0.38, p = 0.0011) units when %scribe
increased by 10%. The number of patients per hour
increased by 0.05 per hour (95% CI = 0.01 to 0.09,
p = 0.0399) when %scribe use increases by 10%. For
constant %PA, Pt вЃ„ hr increased by 0.08 per hour (95%
CI = 0.04 to 0.12, p = 0.0024) when %scribe use
increased by 10%. TATs were not significantly affected
by use of scribes (Table 3).
DISCUSSION
To the best of our knowledge, this is the first study to
demonstrate improvement in primary endpoints of
Pt вЃ„ hr and RVU вЃ„ hr with the utilization of scribes in the
ED. If a physician in our department changed from
0% to 100% of the patients seen with a scribe, 0.8 additional patients per hour can be evaluated in a 10-hour
shift, and 24 (2.4/hr) additional RVUs would be generated. This was obtained after controlling for the effect
of PAs on EP productivity.
In our department, there are varying physician practice styles and efficiencies, and there was a variable
influence of the effect of scribes on each individual physician’s RVUs ⁄ hr and Pt ⁄ hr. Assigning specific scribes
to specific physicians might be expected to augment
physician productivity, but this would be difficult to
accomplish, because it would be impossible to exactly
match physicians’ and scribes’ schedules. Nonetheless,
this study demonstrated overall improvement in EP
productivity with use of ED scribes. We did not attempt
to study the potentially variable influence of scribes on
the productivity of highly productive EPs versus less
productive EPs.
As hospitals continue to cut back services to meet
increased financial burdens, individual services deserve
increased scrutiny as to their cost-effectiveness. The
cost of implementing and maintaining a scribe program
may be less than the potential increase in revenue (and
improved patient throughput) that scribes are likely to
generate. Based on the 2008 Medicare RVU reimbursement rate of $38 for one RVU,7 a scribe being utilized
to full capacity, resulting in an additional 2.4 RVUs вЃ„ hr
generated, could result in an additional 91 billed dollars
per hour. Scribes at our institution are salaried
at approximately $16–$19 per hour, so unless an
ACAD EMERG MED • May 2010, Vol. 17, No. 5
•
www.aemj.org
493
Table 3
Results From Mixed Linear Models
Outcome Variable
RVUs вЃ„ hr
Pt вЃ„ hr
TAT to
discharge
Effect Estimate
%Scribes*
%PAs*
%ScribesВ (random slope)
%Scribes*
%PAs*
%Scribes
(random slope)
%Scribes
Pt вЃ„ hr
%PAs
%Scribes
(random slope)
Model 1
Model 2
Model 3
0.18 (0.04 to 0.32) 0.0067
—
0.2108
0.24 (0.10 to 0.38) 0.0011
0.20 (0.00 to 0.40) 0.0418
0.4447
—
—
0.05 (0.01 to 0.09) 0.0399
—
0.2216
0.08 (0.04 to 0.12) 0.0024
0.09 (0.03 to 0.15) 0.0056
0.3082
—
—
—
1.1 ()4.6 to 6.8) 0.7118
—
—
0.4512
0.4 ()5.3 to 6.1) 0.8815
14.3 ()2.4 to 31.0) 0.0918
—
0.4033
1.4 ()5.1 to 7.9) 0.6694
13.5 ()3.4 to 30.4) 0.1179
2.6 ()5.8 to 11.0) 0.5487
0.3784
Each cell includes an effect estimate (95% CI) and a p-value. Cells for random slope for %scribes includes only a p-value.
RVUs = relative value units; %PAs = percentage of physician assistants; Pt вЃ„ hr = number of patients treated per hour; %scribes =
percentage of patients with scribes; TAT = turnaround time.
*The effect estimates for %scribes may be interpreted as the increase in the outcome attributable to a 10% increase in number
of patients with which a scribe was used; for Pt вЃ„ hr, the increase in the outcome attributable to an increase of one patient per
hour; for % PAs, the increase in the outcome attributable to a 10% increase in number of patients seen by a PA.
В p-value given for testing whether the association between %scribes and outcome varies among physicians, with p-value based
on z-test of the variance component for random slope for %scribes.
institution collects less than 30% of their billed revenue, scribes may be expected to improve the financial
��bottom line.’’ A complete cost analysis should of
course take into consideration the fixed costs of training, as well as the variable costs of salary and nonsalary
benefits.
LIMITATIONS
This study is a single institutional evaluation of scribes.
Further research needs to be conducted to explore if
our findings can be generalized to other institutions
with various academic and nonacademic models. Our
method of deploying and utilizing scribes may differ
from the methods of others, and this may change the
effect of scribes on physician productivity at different
sites. Also, facilities that do not have such a high percentage of patients seen by PAs (nearly two-thirds in
our sample) may find different results.
Two of the outcome variables (RVU вЃ„ hr and Pt вЃ„ hr) are
highly interrelated. Our specific model controlled for
the impact of PAs in our department. These data support the assertion that PAs provide not only patient
evaluations, but also assist with other operational
issues. Furthermore, the retrospective nature of the
study limits the ability to determine causality.
Most shifts that lacked scribe coverage occurred on
nights and over weekends. However, day shifts, during
which scribe coverage was more common, tended to
be the busiest shifts in terms of patient volume. The
benefit of scribes may be influenced by such circadian
variation.
We were unable to control for some variables. We
selected physician shifts with and without scribes that
were the same time of day. We chose to utilize less than
4 hours as a cutoff for ��no scribe available,’’ since several ��uncovered’’ shifts occurred because scribes were
present less than one-third of the 12-hour weekend
shift. When scribes were utilized between 0 and
4 hours, the impact of complete lack of a scribe is likely
to be understated. If we had a sufficient number of
shifts for analysis during which scribes were completely
unavailable to work, it is possible that our estimate of
the impact of scribes upon physician productivity measures would have been numerically greater.
It is also possible that certain scribes have variable
performance indicators when paired with different physicians, due to nonquantifiable influences of interpersonal interactions between scribes and physicians. In
addition, we did not evaluate years of experience of
each scribe as a variable. Whether physicians benefit
from scribes could also be a question of utility, as well
as the extent that physicians maximized scribes as a
resource during their shifts. No control for the influence of specific PAs was attempted, and it is acknowledged that this could have changed the RVUs вЃ„ hr or
Pt вЃ„ hr generated by the physicians.
CONCLUSIONS
This retrospective data analysis suggests that at our
institution, ED scribes are associated with an increase
of 2.4 billed relative value units per hour, which is primarily gained from the additional 0.8 patients per hour
who are seen, but not with changes in turnaround time
to discharge.
References
1. Scheck A. The era of the scribe: lightening the EP’s
load. Emerg Med News. 2004; 26:1–6.
2. Allred RJ. Improved emergency department patient
flow: five years of experience with a scribe system.
Ann Emerg Med. 1983; 12:162–3.
494
3. Witt RC, Haedther DR. Nurse-scribe system saves
time in the ED. J Emerg Nurs. 1975; 1:23–4.
4. Hixson JR. Scribe system works like a charm in Sarasota ED. Emerg Dep News. 1981; 2:4.
5. Scheck A. The next big thing: medical scribes. Emerg
Med News. 2009; 2:13–16.
6. Preisser JS, Reboussin BA, Song EY, Wolfsen M.
The importance and role of intracluster correlations
Arya et al.
•
IMPACT OF SCRIBES ON PERFORMANCE INDICATORS
in planning cluter trials. Epidemiology. 2007; 18:552–
60.
7. Medical Reimbursement Systems, Inc. 2009 Physician
Reimbursement. Available at: http://www.mrsiinc.
com/PDFs/2009%20MRSI%20PHYSICIAN%20UPDATE.
pdf.Accessed Jan 29, 2010.
4 EMN
в– January 2010
Quality
Matters
Beyond Scribes: A Better Idea
on the Horizon
By Shari J. Welch, MD
lot of chatter is going on within our
specialty about the use of scribes,
but a better idea is on the horizon. Small
wonder: Physician productivity is down
across the country (VHA Database, August 2009), and the documentation burden keeps growing. ACEP’s Quality and
Performance Committee has seen more
than 140 suggested “quality measures”
proposed for our practice. Imagine trying to comply and document that number of parameters!
Emergency physicians want more
than a clerical assistant to do documentation. Most EDs are fraught with operations that are clumsy, redundant, and
inefficient, and they often require the
most highly trained and skilled person
on the health care team (the physician)
to chase data. “Where is the urinalysis?”
“Why is that CT not back?” “Has anyone
seen that EKG?” Physician productivity
would increase if they could offload not
only documentation tasks but that datachasing and coordination of the ED
workup and care plan.
Interestingly, the difficulties associated with implementing an electronic
health record can lead departments to
discover this newest addition to the
health care team. Sometimes dubbed
the PAL, the physician assistant liaison
or personal assistant liaison helps run
interference for the physician in documentation, data retrieval, and care
coordination.
The leadership at Parkview Medical
Center in Pueblo, CO, was convinced it
could increase patient safety by implementing electronic medical records,
and particularly improve turnaround
time for patient records. They went live
in 2004 with a high-tech EMR that included desktops and portable laptops,
and all charting had to be done on the
computerized system.
What followed was a surprise. Efficiency suffered, patient satisfaction
fell, and walkaways (which had been
remarkably low) rose to 2.5 percent.
Why? The physicians were spending
so much time interacting with the
computer system that overall patient
flow and processes suffered. Even
worse, the EMR was so cumbersome
that physician productivity had fallen
to an unsustainable 0.5 patients an
hour!
Rather than throw out the EMR system, they implemented their physician
assistant liaison program. While they initially tried using emergency medical
technicians and paramedics, they subsequently established a program with local
colleges to use second- and third-year
A
nursing school interns. These PALs follow physicians around doing documentation, order entry, and data retrieval.
The PAL maximizes the efficiency of the
physician, freeing him for clinical tasks.
With the help of the PAL program,
physicians are seeing a respectable 2.5
patients per hour, and ED patients are
being seen 15 minutes faster. In addition, because the scribe pool draws
from students at the nearby nursing
school, this program has proven to be
a built-in recruitment vehicle for hiring
ED nurses! (Urgent Matters 2006;3[4];
http://urgentmatters.org/346834/31874
9/328750/318752.)
Similarly, Mahmood Vahedian, MD,
an emergency physician with the Banner Health System in Arizona, wanted
to improve working conditions for the
physicians in his group. Struggling under staggering clerical duties during
each shift, physician satisfaction was
at an all-time low. Dr. Vahedian, who
worked as a scribe before medical
school, had an insider’s view of the
work. Beginning with five scribes, he
launched a training program. Scribes
are paid by the 35-member physician
group. He had some groundwork to
lay because the job description, credentialing, and security issues had to
be worked out from scratch.
According to data from professional
scribe companies, the majority of
homegrown scribe programs fail. This
is likely due to lack of experience with
job description and credentialing issues
as well as inadequate training. Since Dr.
Vahedian had experience as a scribe, he
was able to incorporate the necessary
elements in launching his program. One
clever strategy he used was to partner
the scribes in-training with
the most productive physicians in his group. As most
readers will intuitively understand, all emergency departments have process
idiosyncrasies, and experienced, efficient physicians
learn the workarounds and
techniques to get workups
done expeditiously. This is
one way homegrown programs may outperform the
outsourced programs. In
turn, these “super scribes”
(who really function as
physician assistant liaisons)
expose each physician in the
group to the tricks of the
trade they have learned
from the most efficient
physicians. It becomes an iterative process with benefits all around.
Dr. Vahedian tries to partner the
same scribe with the same physician as
much as possible in the schedule so
the scribe learns the style and nuances
of how that physician practices and
documents. Over time the efficiency
grows as the scribe and physician
work as a team. Though no physician
has been required to use the scribe
program, over time the group has
unanimously requested scribe services, and even the physician assistants working in the fast track want to
use them. His program now has 40
trained scribes, and he fills their ranks
with pre-med or pre-nursing students.
Many are looking for hospital experience to put on their professional
school applications, and he offers
them great front-line experience for
Quick
Consult
By Jennifer L. Wiler, MD, MBA
42-year-old man, intoxicated
while riding his bike, strikes
a parked car, and lands on his
right shoulder. In the ED, he
complains of right shoulder pain,
but denies loss of consciousness, focal deficits, paresthesias,
or neck, chest, or back pain.
What is the likely diagnosis,
and how would you evaluate his
shoulder injury? See p. 7.
A
which they are paid a small hourly
wage. The program now populates itself by referrals from other scribes,
and turnover is low but expected as
the students advance their education
and careers.
Each scribe currently works fewer
than a thousand hours a year, which allows the physician group to pay the
hourly wage but not provide benefits.
Since its earliest days, Dr. Vahedian’s
program demonstrated an increase of
$28 per chart through better documentation, along with physician and patient satisfaction gains. One physician
who was slated to retire asked to stay
on because he finds the work environment so much less frustrating. Physicians are freed up to spend time with
patients and families, and the frenetic
game of chasing data and paper has
been mitigated. For more information
on how he did it, email Dr. Vahedian at
mvahedian@scribes4doctors.com.
Dr. Welch is a
fellow with Intermountain Institute for Health
Care Delivery
Research,
an
emergency physician with Utah
Emergency Physicians, and a
member of the board of the Emergency Department Benchmarking
Alliance. She has written two books
on ED operational improvement;
the latest, Quality Matters: Solutions for the Efficient ED, is available from Joint Commission
Resources Publishing.
Symptom: Right
Shoulder Pain
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