Anyone who has spent time in a hospital emergency department (ED) or even watched television shows about them realizes that they present a daunting knowledge management challenge. In many EDs, a physician might oversee the treatment of up to 15 patients simultaneously. Triaging and moving those patients through the ED and capturing the necessary clinical and administrative data require speedy communication and cooperation among clinicians, administrative staff members and personnel in other parts of the hospital.
Traditionally staff members have relayed information about patients through verbal communication, paper charts and visual tools such as white boards. But as both hospitalwide clinical information systems and specialized ED information systems (EDIS) have grown more sophisticated, many hospitals are replacing the white boards and paper charts with automated tracking systems and computer displays.
Some systems not only give up-to-the-second information on patient status and location, but also track workflow measures such as time to triage, which EDs can use to provide feedback to clinicians.
Yet, despite the efficiency gains promised by automation, the product testing, choice and implementation can be difficult. Often emergency department officials and hospital CIOs face a tough choice between the emergency department module of the hospitalwide clinical information system already in use and a smaller, best of breed system designed specifically for emergency departments. The first option offers easier integration with other software such as laboratory systems and electronic medical records; the second promises more features designed specifically for EDs and customization options.
A few years ago, several small to midsize vendors began creating clinical documentation software specifically for EDs that spoke to physicians’ needs, explains Dr. Todd Rothenhaus, senior VP and CIO of the Caritas Christi Health Care System in Boston. Larger health information system vendors were typically adapting software code already in place in the intensive care unit for use in the ED, and it wasn’t as appealing to physicians.
Yet Rothenhaus, who is both a CIO and an emergency room physician, says there are considerable challenges to buying a separate system for the ED and integrating it with the hospital’s main software system.
"You have to write a lot of interfaces, and most hospitals don’t have a deep bench to do that," he explains. "You might have nursing notes that include medication history and allergies that you want to become part of a patient’s record for those 20 to 30 percent of ED patients who are admitted. How do you get that to flow into the hospital clinical information system? That’s a hard interface to write now." It’s much easier to use a module from the larger system vendor, and those modules are getting better all the time, he adds.
One CIO who agrees with Rothenhaus on that point is Andrew Fowler, who heads up IT operations for the seven-hospital Methodist Le Bonheur Health System headquartered in Memphis, Tenn. In 2003, Methodist chose to roll out an emergency department module called FirstNet from its clinical information system vendor Cerner. FirstNet facilitates triage, patient tracking and basic emergency department functions.
"We made a strategic decision to go with as integrated a clinical product as we could," explains Fowler. "From the time you appear in the ED to when you are admitted as a patient, we now get that continuity in one database. With niche products, you end up writing interfaces between products, and you run the risk of losing valuable information or entering something improperly. You need one source of the truth."
Fowler stresses that hospitals should be prepared to take advantage of workflow changes the EDIS offers to eliminate manual tasks. "I would say that process engineering is 50 percent of the work, and if you don’t do it right upfront, you end up redoing it," he adds.
Devoting enough resources to training is also key to a successful implementation. "And the training has to be focused on workflows, not technologies. If you focus just on the technology, you’re putting the onus on the user to figure out how it applies in their job," Fowler adds.
No more pulling charts
Planning a move to a much larger space was the impetus for the emergency department at Riverside Regional Medical Center in Newport News, Va., to switch from paper records to an emergency department information system.
"We knew that our old system based on paper was not going to work in this larger space that was going to be more decentralized," says Dr. Gary Kavit, medical director. "We thought we would be in big trouble without an electronic system. Plus, a long-range goal was integrating with a larger electronic medical record for the whole hospital."
Six years ago, he says, there were few promising offerings from clinical information system vendors, and he believed several smaller software companies were making promises they wouldn’t be able to deliver on. "We were skeptical about what several vendors were promising," he says. "We were being overwhelmed by vaporware."