Information Technology in the Emergency Department
Introduction
Information is power. Although this concept is not new, its application to the medical field has grown exponentially in recent years. While it is estimated that only 4 percent of physicians in the United States are currently entering orders and obtaining results/reports for patient care electronically, the advent of deregulation and managed competition are changing this paradigm and creating a need for a new business model requiring prompt access to patient data and financial information. Furthermore, a renewed focus on patient care and improved outcomes on a national level has demanded a transition to a computer-based patient record (CPR) with knowledge-based decision support. With rapidly advancing technology, and increasing affordability, many in the health care industry are embracing various technological solutions in order to utilize information to offer their organizations better efficiency, improved clinical care, and increased profitability. Achieving these gains, however, requires far more than technology. In addition to the concrete investments of time and money, it is the abstract cooperation and coordination of the various participants of the organization that are just as critical to the success of any operation. This is especially true in the fast-paced, chaotic yet centralized nature of the emergency department (ED).
How Clinical Systems Improve Delivery of Care in the ED
The overall goal of any clinical information system is to improve the quality and effectiveness of patient care by providing real-time access to comprehensive clinical information wherever and whenever needed. This is especially applicable to the ED, where patient conditions are often life threatening and where paper records are easily lost, threatening ongoing patient care and consequent billing. Centralized computer-based charting capabilities, accessible from multiple locations simultaneously, can directly improve the delivery and quality of care at several levels. For example, a nurse can document updated vital signs, a resident can document a complete history and physical exam, while an attending physician simultaneously reviews laboratory and radiology reports. This centralized charting model clearly offers significant advantages as compared with a paper chart that can only be used by one person at a time.
While several efficiencies can be realized with a CPR, patient safety issues are of paramount concern to any organization. The high-volume, stressful environment in the ED makes this area especially prone to medical errors. With nurses and physicians often multitasking beyond their ability, it can be easy to mistakenly order a potentially contraindicated medication for a patient. The incorporation of decision-support and rules-based systems into a CPR can prevent many of these errors. Alerting a physician to a medication allergy at the time of order entry would immediately prevent any errors and subsequent potential bad outcomes. Screening patients for potentially lethal contraindications prior to ordering magnetic resonance imaging is another example of how incorporating decision-support logic into a CPR can greatly improve patient safety.
On a more general level, a major advantage to implementing a CPR is to gain access to the large data warehouse generated by daily use of the system. This clinical repository is a potential gold mine of data if utilized correctly. Employing various data-mining techniques, one can extract customized data sets that can be used to build a variety of useful models. Analysis of patient demand, for example, supports fact-driven staffing models for both nurses and physicians. This would potentially affect not only patient-care issues, but financial issues for the organization as well. Overall, by applying learning from aggregated data, these second-order effects of system implementation provide great opportunity for improving the dimensions of clinical quality, service quality, and cost effectiveness.
Critical Success Factors
Implementing technological clinical solutions in the health care environment is both complicated and expensive. Achieving "success" really depends on whose definition you are using. Physicians, for example, might define success as any system that helps them improve their efficiency in order to provide better, safer care to their patients. Hospital administrators, on the other hand, might view success more from a financial perspective. While there is no one specific definition, it is important to realize that the formula for achieving success is remarkably universal, applicable to the medical floors, and radiology, as well as the ED. Paying attention to the following will no doubt increase your chances of a successful implementation.
- Establish programs and methodologies aimed at physician participation, buy-in,
and ownership. Different groups, including community/volunteer physicians,
paid attending physicians, residents, medical students, nurse practitioners,
and physician assistants, cannot be treated homogenously, as each has its
own requirements. Community physicians, for example require access to the
system from their home or office, while emergency physicians care more that
the system will save them time as well as help improve patient care.
- Ensure strong leadership and financial commitment from hospital executives
for not only purchasing and installing information technology, but also for
critical elements such as training, help desk, and other change-management
activities.
- Define metrics to examine and value each project in a systematic way. Adopt
a method for the identification of metrics, payback, and how the required
technology is tied to the strategy of the organization as a whole in order
to justify the large allocation of resources placed in these areas as compared
to other competing organizational needs.
- Identify project risks and develop risk-reduction strategies. Implementation
of multiple, small, manageable pieces, or quick hits, following the principle
of "success builds upon success," will help earn implementation credibility
among the users and other staff.
- Provide a command post and help desk to offer support, with super users
and other vendors readily identifiable and available to staff around the clock
for at least the first four to six weeks following deployment.
- System monitoring, support, and evaluation should be continuous along with
the establishment of user and physician feedback committees aimed at identifying
system upgrades, enhancements, and user educational reinforcement.
- Employ "just-in-time" training before any deployment in order to maximize
user competence.
- Ensure that every system conforms to federal, state, HIPAA, and JCAHO regulatory
requirements. The penalties for violations are often operationally and financially
severe.
- Any solution should utilize an open design strategy as well as be both scalable and adaptable to incorporate future emerging technologies. For example, advancements in handheld technology can allow for subsets of an individual CPR to be displayed on a wireless handheld device, as well as deliver a complete solution integrating multiple CPR systems on a single handheld.
Common Pitfalls and How to Avoid Them
When change occurs in an organization, both expected and unexpected hurdles are bound to arise. Careful planning and consideration ahead of time will help reduce subsequent frustrations and further ensure maximal compliance and system acceptance. Although many of the following Do's and Don'ts appear to be common sense, the failure to follow these guidelines can result in disastrous consequences.
Do's:
- Always remember: Patients come first! No matter how wonderful a system appears to be, the common denominator for any health care organization must be patient care. Any process that impedes this critical component will always fail.
- Employ rigid testing of all system and interface components in a production or staging environment prior to going live. Make every attempt to simulate a real-time, real-world working environment to confirm system usability under maximal load and stresses.
- System monitoring should be done continuously. Triggers for excessive system responsiveness and lag time should be defined along with policies and procedures for addressing these issues.
- Revisit downtime procedures both after implementation and at fixed intervals to make sure they are effective, realistic, and functional.
- Always listen to your end users. Success depends on their confidence and commitment.
Don'ts:
- Resist the urge to achieve a "big bang." Use a systematic approach when implementing change. A piece wise, phased-in method will not only ensure a more manageable deployment, but will also help build gradual confidence in a new system. In the ED, for example, implement nursing documentation of triage information and vital signs before incorporating physician documentation capabilities.
- Never try to implement more than one clinical system simultaneously. This will consume too many resources, as well as create confusion for the users and other staff.
- Never go live during peak census. In the ED, occupancy significantly increases during the cold, winter months. Therefore, every effort should be made to deploy outside of this period.
- Never underestimate the support needs during implementation. Always be generous in support staffing, realizing that in this area too many is much better than too few.
- Never underestimate timelines and financial appropriations. Take a lesson from the airline industry that routinely allows four hours for a two-hour trip and then praises itself for incredible punctuality!
Case Study
Maimonides Medical Center is a 705-bed hospital in Brooklyn, New York, that is academically affiliated with the Mt. Sinai School of Medicine. It is the third largest independent teaching hospital in the nation. In 2001, Maimonides recorded 36,861 discharges, 76,500 emergency admissions, and 253,316 ambulatory care visits.
Today, Maimonides' integrated CPR solution is used by all employed and community physicians and residents, who enter orders online, review drug interactions, ancillary results, and digital images, as well as fully document and chart clinical information. Utilizing concurrent decision-support and embedded capabilities, intelligent rules engines provide clinical staff with treatment recommendations, diagnostic guidelines, and suggested medical dosages. Ancillary departments view the status of tests, while nurses use the system to document clinical information, dispense medication, and select charge information. All users can retrieve appropriate clinical data and results, including users in remote hospital locations and community physician offices.
Benefits have been remarkable. The medical center has seen a 68 percent decrease in medication processing time, a 55 percent decrease in medication discrepancies, and a 58 percent reduction in problem medication orders. Duplication of ancillary orders has decreased by 20 percent overall, including a 48 percent reduction in duplicate laboratory/chemistry tests. Over a seven-year period, accessibility of clinical data has improved time of diagnosis and treatment, contributing to a 2.21-day (30.4 percent) reduction in average length of patient stay. These improvements have enabled 32,168 additional inpatients to be served by the medical center, representing over $140 million in increased patient revenue, one-quarter of which is attributable to the CPR.
The emergency department CPR has been fully operational since August 2002. Features such as the electronic patient tracking board are not only used by ED staff, but also by other caregivers including voluntary physicians, consulting physicians, radiology technicians, and patient representatives seeking the status and location of patients. Increased efficiency and improved patient satisfaction are achieved by relieving the clinical staff of manual, tedious work that was present with the old system. However, because the ED CPR is relatively new, the extent of its actual impact on both the clinical and financial operations of the organization have yet to be fully realized.
Summary
The pressure to be more efficient, more profitable, and deliver the highest quality health care while maintaining a competitive advantage demands that organizations incorporate information technology into their strategic priorities. Choosing the right CPR for an organization depends on a variety of factors including cost, time to deployment, ability to integrate with existing systems and architecture, as well as whether a product actually exists that fully meets all requirements. Adhering to some of the critical success factors while avoiding the common pitfalls discussed above, will increase the chance of building, integrating, and deploying a successful solution. Recognizing value from using technology is also critical. It is important to keep in mind, however, that although traditional metrics can and should be used to assess value, it is impossible to place a value on certain intangibles. How is the value of reduced medical errors or, most importantly, of satisfied patients, measured? Clearly, CPR's are justified — and by more than strictly quantified financial benefits. Consequently, organizations that adopt and embrace these principles will be more likely to be successful in the health care industry.
