|Will Freeman, M.D., is associate program director at the Louisiana State University (LSU) Earl K. Long Emergency Medicine Residency Program and CMO for C&M Medical Services. For more on C&M Medical Services: C&M Medical Services|
Emergency departments (EDs) are increasingly being seen as the hospital’s front door, with more than half of all hospitalizations beginning in the ED. Emergency departments now serve as the main source of healthcare for a growing segment of the U.S. population that lacks adequate access to primary care services for a variety of reasons, including inability to pay for healthcare costs, lack of insurance, physician shortages and working households that need after-hour services.
This high rate of use has led to resources being stretched thin and an increased impact from inefficiencies in hospital processes and flow. Many EDs are overcrowded. According to a report in the Annals of Emergency Medicine, the average waiting time for patients to see a physician in the ED is 37 minutes, well above the recommended maximum of 15 minutes (Ann Emerg Med. 2010 Feb.; 55(2): 133-141).
Moreover, much of the backlog of patient flow isn’t necessarily related to ED problems, but instead caused by systemic issues that delay moving patients from the ED to inpatient floors. These in-house delays drive up ED wait times and lead to more patients leaving without being seen (LWBS) by a physician. The sheer volume of patients means more diagnostic work is being done in the ED, and inefficient or inadequately staffed ancillary systems result in prolonging stays.
To combat these issues are the new value-based initiatives and performance incentives, which effectively promote collaborative care for better patient outcomes. Once regarded almost as “entities unto themselves,” EDs are increasingly recognized as partners along the healthcare continuum – partners that can significantly impact access, quality and cost. The advent of models, such as the patient-centered medical home, accountable care organizations and evolving regulations regarding meaningful use and data sharing, means that information exchange between EDs and other providers – primary care physicians (PCPs), specialists, hospitals and ancillary care facilities – is critical.
Effective health information technology (HIT) has become integral to meeting these objectives and elevating healthcare delivery in any setting. EDs, in particular, are challenged when assessing and selecting electronic health record (EHR) systems because their workflow and treatment protocols differ from other providers. Their clinical decisions can also be significantly influenced by access to other patient data. Choosing an ED information system (EDIS) tailored to the specific needs of ED professionals improves patient safety, provides for coordinated care and allows for ongoing patient care management and monitoring of public health issues.
The opportunities for improving patient safety in the digital ED abound. Enhancing communication among care team members, optimizing department workflow and ensuring appropriate reimbursement are just a few examples. The EDIS also helps with meaningful-use attestation by meeting multiple measurement standards, including problem lists, physician order entry, active medication lists, quality measure reporting and medication reconciliation compliance.
In an ED setting, maintaining the proper documentation and efficient flow of information can be difficult when traumas, severe illnesses and other medical emergencies fill the department beyond capacity. An EDIS provides real-time data on volume, acuity, wait time and length of stay. Armed with this data, leaders can adjust clinical and operational processes to streamline workflows and improve patient safety. The system also can help reduce the time patients wait to be seen. Reducing wait time decreases the number of LWBS, which boosts patient satisfaction. The EDIS also helps improve admissions, ensuring that patients are placed in the most appropriate hospital unit, and accelerates discharges.
The most advanced EDIS technologies are also creating a safer environment for patients by providing physicians and nurses with vital data, such as drug and allergy interaction alerts, laboratory and radiological tests results, and best practices information to help these individuals make better clinical decisions at the point of care. The end result for the ED is a seamless flow of patient data enabled by software that does not interfere with clinicians’ patient care.
An EDIS helps improve patient care by allowing EDs, hospitals and PCPs to share information. Coordination of care can occur in the ED through accessing information from previous visits, sharing information from the ED visit with the primary care physician and accessing information from other hospitals with similar systems. Sharing information from other sources enables the ED physician to better care for the patient by reducing the need for unnecessary testing or repeating tests already performed. Cutting redundant tests saves patients and payers money.
In addition to facilitation information sharing, an EDIS improves patient care through the use of an electronic record. The EHR allows the ED to track all patient encounters in real time, documenting activities, such as when patients arrive, when they are first visited by a nurse or physician, when orders are placed and results returned and the time the visit concludes, with either an admission into the hospital or a discharge.
The EDIS also helps determine and coordinate adequate staffing needs. The technology’s analytical capabilities can compare historical information and census data to determine appropriate staffing levels to meet and predict periods of high volume. It can also alert staff if capacity is exceeding the available number of beds.
Workflow efficiency is another critical element to improving patient care. Workflow processes can get backed up when there is no clear, immediate way to notify physicians that lab and test results have come back. With an EDIS, lab results are immediately uploaded into the patient’s record. Automated alerts can also notify clinicians when orders need to be filled, when lab values are abnormal, when patients need to be transferred to a different department or when ambulance patients need to be registered – all of which decrease overall turnaround time.
The technology further helps EDs meet meaningful-use standards by automating and printing discharge instruction forms. EDs can also make discharge instructions available via email to the patient. Prescriptions can be written electronically, reducing errors and drug interaction. Similarly, hospital transfer information can be part of the patient’s electronic record that follows them from the ED to the hospital or primary-care setting.
The automated system provides patient-information management for a variety of ED procedures, including patient tracking, order entry, prescribing, data retrieval, charting and nursing functions. In addition, a facility-wide documentation system promotes patient safety outside of the ED by helping the staff identify people who have multiple visits (ED and primary care) and may need specialized help in managing their care. The right EDIS can also be used to identify patients who are using the ED inappropriately – for example, for non-emergent needs such as suture removal and follow-up care – and help navigate them to the right venue, such as a PCP or urgent clinic.
With the advent of uniform data-collection systems and ED-based surveillance systems, emergency medicine also has the potential to play a powerful role in measuring and improving the health of the population. EDs can provide information on the healthcare needs of a diverse population and serve as a unique research lab for studying the functionality of the healthcare system.
This information can be used to identify, track and trend outbreaks of disease, for surveillance of bioterrorism or for collecting data for regular disease management such as diabetes, hypertension, myocardial infarction, pneumonia and congestive heart failure. Many of the systems are able to aggregate and collect the information needed to report quality measures to CMS and other healthcare organizations. The effective EDIS can help suggest care to the clinician to provide the highest quality care to the patient.
An ED environment is very different from specialty clinics, primary-care sites or even the hospital floor, because ED physicians are typically treating patients with multiple conflicting complaints instead of a singular condition, such as a cough, cold or hypertension. As a result, when it comes to the medical record, there must be a means for addressing these various conditions so that the information can be quickly and easily captured, coded and submitted for reimbursement. Similarly, procedures common to the ED, such as restraints, sedations and intubations, are often missing from clinical EMRs.
A robust EDIS should generate reports on clinical, financial and operational efficiencies. The system should be equipped with real-time tracking or location technology to provide valuable information on throughput, length of stay, door-to-provider time, x-ray and diagnostic-turnaround time. In addition, it should have the ability to integrate across the system by capturing the ED record and combining the information into the inpatient record, which includes imaging, diagnostic physician order entry and e-prescribing; it also provides a transition-of-care summary for the PCP.
Many vendors claim they provide a turn-key service, but what they might not reveal is how much time, money and add-ons you’ll need to invest in the product. Consider, for example, that many records that integrate data will pull in only certain pieces of information and leave other templates, such as the order sets, to be built by the client. Training costs need to be considered as well.
These are just some of the reasons why it’s critical to consider how much time is required for training, installation and deployment. The more specialized the system, such as a best-of-breed EDIS, the faster the implementation (on average three months compared to six or more months for an system-wide EMR) and the easier the flow between clinical, financial and operational components.
One of the most critical steps in implementing any EDIS is building collaboration across and between departments. This includes defining roles and responsibilities, fostering teamwork and helping staff and leadership manage their expectations. Likewise, it’s important to know the strengths and limitations of the technology, of what a record can and cannot do. Addressing those with department and team members will make the transition smoother and promote adaptation to the new processes.
Improving care quality across the continuum continues to be central to healthcare reform and a condition of provider funding. The ED is an integral partner in care delivery and, as such, relies on HIT to facilitate data integration and information exchange within and beyond its organization as it advances toward new care models.