Emergency Department Directors Academy – Phase II The Computerized ED: Components of a Perfect System May 2011 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: [email protected] 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 <[email protected]> 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: [email protected] 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 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 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.) 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: [email protected]. 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: [email protected] 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 © 2008 American College of Emergency Physicians. All rights reserved. American College of Emergency Physicians ● PO Box 619911 ● Dallas, TX 75261-9911 ● 972-550-0911 ● 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: [email protected]. 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 (8½ 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 ¾ Listed below are a few interesting web sites you may want to try ½ 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: [email protected] 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 © 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: [email protected] 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 [email protected] To: ED Directors Academy Class 1 [email protected] 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:[email protected]] 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:[email protected]] 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:[email protected]] 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: [email protected] 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:[email protected]] On Behalf Of Eric Cure Sent: Saturday, April 25, 2009 4:21 PM To: [email protected] 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:[email protected]] 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: [email protected]), 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. Systems must be easy to learn, somewhat akin to a web browser, a word processor, or a spreadsheet. 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‐ defined goals developed from stakeholder input and justifiable potential benefits of the project (Table 1). The objectives should be reviewed by a broad range of stakeholders (management, physicians, nurses, security, pharmacy, etc.) for additional input and revision. Capital allocation funding is critical to the success of the project and should be addressed and committed at an early stage. The manner in which administration is approached will, in large part, determine the success in obtaining appropriate institutional support for an EDIS. [6] 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. Information collection process 3. Assessment tools (e.g. spreadsheet) based on selection criteria 4. Division of labor (e.g. who does what when) 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. Contracting & Scope of Work process 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‐ minute basis. Such systems will only reach their potential when they are fully integrated or interfaced, including legacy systems. Finally, good clinical content and domain knowledge is the key to virtually every aspect of the EDIS. Much of this content is yet to be developed and what is available needs better customization to the EDIS environment. Daunting as it may be, a properly accomplished EDIS implementation will result in better patient care, improved staff productivity, and a satisfying work environment. It is our hope this white paper is another step forward in the maturation of the EDIS knowledge base and will result in more successful EDIS adoption and HIT integration. Your feedback and questions are welcomed. Figure 3: Pearls & Pitfalls for Successful EDIS Selection & Implementation 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. Establish objectives (different for every ED): Asking the right questions will achieve the right solutions. Certain objectives may be mutually exclusive, for example: Eliminating dictation costs with physician computer charting will likely impact ED throughput (decreased throughput = less revenue which may offset savings achieved by eliminating dictation) 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. Budget equal amounts of money for hardware & deployment as the EDIS software purchase 5. Fix other aspects of the ED environment before implementing an EDIS. 6. 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. 7. Downtime: EDIS must accommodate downtime from external systems. Scheduled EDIS downtime (ex. for upgrades) should be less than 5 minutes 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. ACEP Policy Statement: Health Information Technology. Ann Emerg Med. 2008;52:595. 2. Barthell EN, Taylor TB: A View of the Emergency Department of the Future. American College of Emergency Physicians. 1992 (revised 2000) Dallas, TX. 3. Smith M, Feied C: The Next Generation Emergency Department. Ann Emerg Med, 1998;32:65. 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. The American Recovery and Reinvestment Act of 2009. (Accessed March 21, 2007 at: http://www.whitehouse.gov/the_press_office/ARRA_public_review/). 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. 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: [email protected]) • 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: [email protected]) • ACEP Section of Emergency Medical Informatics (SEMI) eList (Membership required: http://www.acep.org) • eMed‐L (Subscription: [email protected] Messages: emed‐[email protected]) ‐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 W 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 ⁄ 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: [email protected]. A related commentary appears on page 524. 536 ISSN 1069-6563 PII ISSN 1069-6563583 ª 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 % Missingà 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). Number of EDIS with feature out of total EDIS, calculated using weighted, national estimates. àMissing 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 ACAD EMERG MED • May 2010, Vol. 17, No. 5 • www.aemj.org 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 ⁄ Medicaid payers were no longer statistically significant (Table 4). Fully functional ⁄ 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. ACAD EMERG MED • May 2010, Vol. 17, No. 5 • www.aemj.org 541 Table 3 Unadjusted Analysis of Featured-based EDIS Classification by ED Characteristics Fully Functional ⁄ 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 ⁄ race Hispanic Black or African American Payment type Missing Private pay Medicare ⁄ 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) (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)à 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. 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. àn = 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 ⁄ 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 ⁄ race Hispanic Black or African American Payment type Missing Private pay Medicare ⁄ 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 ⁄ 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. 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 ⁄ 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- ACAD EMERG MED • May 2010, Vol. 17, No. 5 • www.aemj.org 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. References 1. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006; 144:742–52. 2. Shekelle PG, Morton SC, Keeler EB. Costs and benefits of health information technology. Evid Rep Technol Assess (Full Rep). 2006; 132:1–71. 3. Participatory Politics Foundation and Sunlight Foundation. American Recovery and Reinvestment Act of 2009. H.R. 1. Available at: http://www.open congress.org/bill/111-h1/show. Accessed Feb 7, 2010. 4. Blumenthal D. Stimulating the adoption of health information technology. N Engl J Med. 2009; 360:1477–9. 5. Stiell A, Forster AJ, Stiell IG, et al. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003; 169:1023–8. 6. Burt CW, Hing E. Use of computerized clinical support systems in medical settings: United States, 2001–03. Adv Data. 2005; (353):1–8. 7. Burt CW, Sisk JE. Which physicians and practices are using electronic medical records? Health Aff (Millwood). 2005; 24:1334–43. 8. Cutler DM, Feldman NE, Horwitz JR. U.S. adoption of computerized physician order entry systems. Health Aff (Millwood). 2005; 24:1654–63. 9. Jha AK, Ferris TG, Donelan K, et al. How common are electronic health records in the United States? A summary of the evidence. Health Aff (Millwood). 2006; 25:w496–507. 10. California HealthCare Foundation. Adoption of Patient Tracking Systems Among Hospital Emergency Rooms in California. Available at: http://www. chcf.org/documents/hospitals/AdoptionOfPatient TrackingSystems.pdf. Accessed Feb 7, 2010. 544 11. DesRoches CM, Campbell EG, Rao SR, et al. Electronic health records in ambulatory care–a national survey of physicians. N Engl J Med. 2008; 359:50– 60. 12. Jha AK, Desroches CM, Campbell EG, et al. Use of electronic health records in U.S. hospitals. N Engl J Med. 2009; 360:1628–38. 13. Feied CF, Handler JA, Smith MS, et al. Clinical information systems: instant ubiquitous clinical data for error reduction and improved clinical outcomes. Acad Emerg Med. 2004; 11:1162–9. 14. Feied CF, Smith MS, Handler JA. Keynote address: medical informatics and emergency medicine. Acad Emerg Med. 2004; 11:1118–26. 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. 23. Department of Health and Human Services. Meaningful Use: A Definition. Recommendations from the Meaningful Use Workgroup to the Health IT Landman et al. 24. 25. 26. 27. 28. 29. 30. 31. 32. • 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. National Center for Health Statistics. SAS Code to Produce Aggregated Visit Statistics at the Physician or Facility Level. Available at: http://www.cdc.gov/ nchs/data/ahcd/provider-visit-code.pdf. Accessed Mar 13, 2009. Pallin DJ, Sullivan AF, Auerbach BS, Camargo CA Jr. Adoption of Information Technology in Massachusetts Emergency Departments. J Emerg Med. 2009 Feb 18 [Epub ahead of print]. Uscher-Pines L, Farrell CL, Cattani J, et al. A survey of usage protocols of syndromic surveillance systems by state public health departments in the United States. J Public Health Manag Pract. 2009; 15:432–8. Waller AE, Ising AI, Deyneka L. Running the numbers. North Carolina Emergency Department visit data available for public health surveillance. N C Med J. 2007; 68:289–91. Bradley EH, Curry LA, Ramanadhan S, et al. Research in action: using positive deviance to improve quality of health care. Implement Sci. 2009; 4:25. Hripcsak G. Hearing on Meaningful Use Measures Related to Specialists, Smaller Practices and Hospitals, and Providers of Underserved Populations. Available at: http://healthit.hhs.gov/portal/server.pt/ gateway/PTARGS_0_11673_907437_0_0_18/Hripcsak -MUHearing.pdf. Accessed Nov 18, 2009. Emergency Care Coordination Center. Available at: 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 ⁄ 02 and 4R00LM009556-03, which has run from July 16, 2007, to the present. There is ⁄ 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: [email protected]. ª 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 ⁄ 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 (±SD) patient age ranged from 30.28 (±1.38) to 32.3 (±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 ACAD EMERG MED • May 2010, Vol. 17, No. 5 • www.aemj.org 529 Table 1 Revenues and ED Trends (Covariates) Revenues Average professional* E&M level Total professional critical care cases Total professional charges Total professional receipts Professional fee collection rate Average facilityà 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)§ 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 N⁄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. E&M = evaluation and management: the five-point scale used for coding ED charts for billing purposes. àFacility refers to cases assessed a facility charge by the hospital and generally refers to only those treated and released from the ED. §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 530 Shapiro et al. • 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-Sé 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 ⁄ expenses) IT salary for support of preimplementation vendor selection process Total capital costs Operating IT salary (1.25 FTEs ⁄ 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 • www.aemj.org 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 532 Shapiro et al. • 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 ⁄ Peri Professional charges Facility charges Professional receipts Facility receipts 7.06 )1.06 1.21 5.82 · · · · p-value 5 10 105 105 104 <0.0001* 0.6395 0.0216* 0.4830 D Slope Peri ⁄ Post )4.80 3.72 6.84 )3.40 · · · · 3 10 105 104 103 p-value D Slope Post ⁄ Sust 0.9654 0.0447* 0.0982 0.9574 )2.54 )3.29 9.76 2.43 · · · · 4 10 104 103 104 p-value 0.8221 0.852 0.8146 0.7074 D Slope Pre ⁄ Sust 6.76 2.33 1.99 7.91 · · · · 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 · 105 = 0.0000106; 1.21 · 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 • www.aemj.org 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 · 105 (p < 0.0001) and 1.21 · 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 · 105 (p = 0.0026) and 1.99 · 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 · 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 • www.aemj.org 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. References 1. Pallin D, Lahman M, Baumlin K. Information technology in emergency medicine residency-affiliated emergency departments. Acad Emerg Med. 2003; 10:848–52. 2. Taylor TB. Information management in the emergency department. Emerg Med Clin N Am. 2004; 22:241–57. 3. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003; 163:1409–16. 4. Kaushal R, Barker KN, Bates DW. How can information technology improve patient safety and reduce medication errors in children’s health care? Arch Pediatr Adolesc Med. 2001; 155:1002–7. 5. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006; 144:742–52. 6. Horsky J, Gutnik L, Patel VL. Technology for emergency care: cognitive and workflow considerations. AMIA Annu Symp Proc. 2006; 2006:344–8. 7. Boger E. Electronic tracking board reduces ED patient length of stay at Indiana Hospital. J Emerg Nurs. 2003; 29:39–43. 8. Weiner C, Baumlin KM, Shapiro JS. Process redesign and emergency department information system implementation improve efficiency [abstract]. 2007; 14(5 Suppl 1):S72. 9. Baumlin KM, Shapiro JS, Weiner C, Gottleib B, Chawla N, Richardson LD. Process redesign and emergency department information system implementation improve efficiency. Joint Comm J Qual Patient Saf. 2010; 36:179–85. 10. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med. 2003; 348:2526–34. 11. Kuperman GJ, Teich JM, Gandhi TK, Bates DW. Patient safety and computerized medication ordering at Brigham and Women’s Hospital. Jt Comm J Qual Improv. 2001; 27:509–21. 12. Davidson SJ, Zwemer FL Jr, Nathanson LA, Sable KN, Khan AN. Where’s the beef? The promise and the reality of clinical documentation. Acad Emerg Med. 2004; 11:1127–34. 13. Anonymous. Paperless System Solves Problem of Lost Chart Costs. Emerg Dep Manag. 2005; 17:20–1. 14. Buller-Close K, Schriger DL, Baraff LJ. Heterogeneous effect of an emergency department expert charting system. Ann Emerg Med. 2003; 41:644–52. 535 15. Harris AD, McGregor JC, Perencevich EN, et al. The use and interpretation of quasi-experimental studies in medical informatics. J Am Med Inform Assoc. 2006; 13:16–23. 16. Box GE, Jenkins GM. Time Series Analysis: Forecasting and Control. San Francisco, CA: HoldenDay, 1970. 17. Dickey DA, Fuller WA. Distribution of the estimators for autoregressive time series with a unit root. J Am Stat Assoc. 1979; 74:427–31. 18. Ljung GM, Box GE. On a measure of lack of fit in time series models. Biometrika. 1978; 65:297–303. 19. Khan N, Davidson S, Sable K, Murphy DG. The impact of an electronic medical record on emergency department work relative value unit productivity [abstract]. Acad Emerg Med. 2005; 12:104–5. 20. Irvin CB, Fox JM, Pothoven K. Financial impact on emergency physicians for nonreimbursed care for the uninsured. Ann Emerg Med. 2003; 42:571–6. 21. Kaushal R, Jha AK, Franz C, et al. Return on investment for a computerized physician order entry system. J Am Med Inform Assoc. 2006; 13:261–6. 22. Fung KW, Vogel LH. Will decision support in medications order entry save money? A return on investment analysis of the case of the Hong Kong hospital authority. AMIA Annu Symp Proc. 2003; 2003:244–8. 23. Neal K. ROI in the ED. Installation of EDIS helps Georgia hospital handle population boom. Health Manag Technol. 2003; 24:46, 49. 24. Rosenstein AH. Inpatient clinical decision-support systems: determining the ROI. Healthc Financ Manage. 1999; 53:51–5. 25. Hutsell R, Day M. Managing emergencies. Rapid return on investment highlights ED automation at Daughters of Charity Health System. Healthc Inform. 2007; 24:104–5. 26. Piasecki JK, Calhoun E, Engelberg J, et al. Computerized provider order entry in the emergency department: pilot evaluation of a return on investment analysis instrument. AMIA Annu Symp Proc. 2005; 2005:1081. 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 ⁄ 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: [email protected] 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 ⁄ 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 ª 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 • www.aemj.org 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 ⁄ hr), relative value units generated per hour (RVU ⁄ 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 ⁄ hr, RVU ⁄ 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 ⁄ 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 ⁄ 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 ⁄ hr, Pt ⁄ 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 ⁄ 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 ⁄ hr and Pt ⁄ hr. All models were applied to TAT to discharge. Percentage of patients with scribes was significant for RVU ⁄ hr and for Pt ⁄ hr. The RVU ⁄ 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 ±16.8 0.23 63.3 ±14.1 0.44 25.3 ±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 ⁄ hr TAT to Discharge (Minutes) Pt ⁄ hr 6.9 ±1.7 0.22 256 ±71.9 0.14 2.5 ±0.5 0.09 ICC = intracluster correlations; Pt ⁄ 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 ⁄ 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 ⁄ 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 ⁄ hr and RVU ⁄ 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 ⁄ 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 ⁄ hr Pt ⁄ hr TAT to discharge Effect Estimate %Scribes* %PAs* %Scribes (random slope) %Scribes* %PAs* %Scribes (random slope) %Scribes Pt ⁄ 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 ⁄ 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 ⁄ 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. 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 ⁄ hr and Pt ⁄ 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 ⁄ hr or Pt ⁄ 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 ■ 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 [email protected]. 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
© Copyright 2024