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February 15, 2010

Beat the Odds
By Selena Chavis
For The Record
Vol. 22 No. 3 P. 20

Automating the emergency department is crucial to efficient hospital operations, but successfully implementing and managing an EDIS has proven to be a difficult endeavor.

Consider the following statistics: In the United States, the annual number of emergency department (ED) visits jumped from 90.3 million in 1996 to more than 119 million in 2006, a 32% increase, according to the most recent Centers for Disease Control and Prevention (CDC) National Hospital Ambulatory Medical Care Survey: 2006 Emergency Department Summary.

At the same time, the number of EDs fell from 4,019 to 3,833, and the percentage of nonobstetric hospital admissions that came through EDs climbed from 36% in 1996 to more than 50% in 2006. And according to industry professionals, that trend is not expected to change in the near future, further elevating the need for effectively automating ED systems and workflows to mesh efficiently into providers’ overall success.

“Given the increasing volume of patients seen in the ED and the frequent flow of patients from the ED to the inpatient setting or to an ambulatory clinic for follow-up care, the value of timely sharing of patient information and the role an emergency department information system [EDIS] plays in improving information flow cannot be overstated,” says Marie Gardenier, RHIA, CHPS, enterprise EHR program manager with Albert Einstein Healthcare Network in Philadelphia.

“The reality is that the ED is pretty much the front door of the hospital,” adds Robb White, ED director with Texas-based Tomball Regional Medical Center, a 357-bed facility serving the north Houston region. “We admit upward of 30% of patients, which represents 70% of admissions to the hospital on any given day.”

Alongside EDs’ elevated status as it relates to hospitals’ overall success, there is increased pressure placed on ED personnel. Add to those complexities the inherent need for flexibility and timely response and the process of automating and integrating the department’s workflow into a larger hospital EHR system becomes daunting. Industry professionals say these combined components cause many implementations to be less than successful and some to fail.

“One of the big things is that time is very much of the essence with what we do,” says Dan Handel, MD, MPH, director of clinical operations for the ED at Oregon Health & Science University (OHSU), adding that a system’s reliability as it relates to speed, stress, and number of users presents an inherent challenge. “[Information systems] don’t always work perfectly for EDs. … They are not quite as optimized to fit the workflow. Even with ED-specific systems, there are some inefficiencies.”

The primary question that most organizations grapple with when choosing an EDIS is whether to go with a best-of-breed system designed specifically for ED workflow or to utilize the functionality of an enterprisewide system.

“In many instances, organizations have to make a trade-off between functionality and interoperability when choosing an EDIS application,” explains Gardenier.

The Choice
Integrating the ED into a larger enterprisewide system will provide benefits in the way of interoperability, but many managers are finding these systems don’t have the nuts and bolts to address the department’s specific and timely needs.

In fact, both Albert Einstein and Tomball Regional opted to trade off some of the benefits of interoperability for a system that would address more specific needs. “The best-of-breed systems tend to be better for practitioners,” White notes.

That said, Gardenier acknowledges the EDIS chosen by Albert Einstein did not address all of its needs. “From a medical record perspective, the EDIS chosen for our three ED sites—two suburban, one urban teaching—never made it to our urban teaching site because it could not handle the complexities of documenting the care of physicians-in-training.”

White points out that there tends to be more red tape to fight through when providers that have opted for larger enterprisewide systems decide to make changes on the fly due to the nature of the system. Because any change would affect more than just one department, more managers would have to approve the move.

Conversely, the ability to make localized changes has meant a number of benefits to Tomball Regional. For example, White recalls early in the identification process of H1N1—before the strain had even been named—he received a Twitter alert about an outbreak of “novel” flu in San Antonio. Because the Houston area and San Antonio are connected via interstate traffic, White saw an immediate need to launch an application in the ED that modified nursing triage screening.

“We instantly started gathering data and documenting intervention,” he says, adding that the modification would have taken much longer had the ED been linked to an enterprise system. “We were a solid week ahead of CDC recommendations for screening. That’s the flexibility of a best-of-breed system.”

The Make or Break of Buy-In
Experts agree clinician buy-in is the one component that will either bring success to an implementation or kill it before it even gets off the ground. And often it is the ED physician staff that get bypassed during this process.

“The emergency physician in many cases is the overlooked partner,” White explains, pointing out that because this group is often hired on a contract basis, it makes them appear less a part of the decision-making process. “If you bring them in late, then they feel removed from it, and they are key to the implementation process.”

At OHSU, the team began planning in 2006 and didn’t go live until April 2008, leaving a wide window of lead time to create an atmosphere of ownership and to properly train staff. “There were a lot of meetings with key stakeholders,” Handel says. “The more buy-in from providers, the better it will be.”

And the reason it will be better is that physicians will be able to provide insight into what works and what doesn’t within the daily workflow. While an EDIS creates many efficiencies that can cut costs and save lives, Handel notes that there is often more administrative function placed on physicians, making them wary of the system’s benefits.

“One of the big complaints from physicians is that they have to do more clerical work,” he explains.

To be valuable, Gardenier suggests that a system should minimize clinicians’ charting work by creating documentation as a by-product of their treatment activities. “Particularly in the ED, this should include a great deal of structured entries,” she says. “The challenge here is for the system to minimize this effort and still create a legal record that will stand on its own to document the care given.” This means the data are coherent, completely reflect the complexity and intensity of services provided, and are trustworthy by reflecting the uniqueness of each patient’s condition and treatment experience.

When choosing a system, Glen Blaschke, MD, an ED physician at Tomball Regional, suggests that ease of use is important to gaining physician buy-in. “Touch screen is huge,” he says.

Some physicians will request there be several options for how documentation is completed, but Blaschke cautions against this strategy. “How are you going to educate everyone if you have all these options before you go live?” he says.

White agrees, noting that simple is better because of the amount of training typically involved just to get a basic system off the ground. Begin training early, he says, even if it means setting up something basic just to get clinicians used to new technology.

“We brought [technology vendor] MEDHOST in very early, right after the site survey,” he recalls, further explaining that a simple default database was set up for training. “We did this for two reasons: one, to get people used to the concept … and also to start training physicians on some of the basic components early on.”

Keys to Success
Understanding and anticipating the EDIS’ impact on workflow is critical to successful implementation, Handel notes.

White agrees, adding that one of the greatest pitfalls to automating an ED “is not being aware of the amount of energy for implementation milestones and getting them done on time.”

Handel suggests that the initial strategy should be the creation of an implementation timeline that sets a reasonable go-live date. This step makes the implementation process tangible so everyone involved realizes the urgency of their work.

Identifying a physician champion early on is also a good idea. “The role of the physician champion is vital to moving from the vision to implementation, as physician attitude is a critical factor for a successful implementation,” Handel says. “This physician champion is responsible for advocating on behalf of the successful implementation of the [EDIS] and must have a significant vested interest.”

Alongside a physician champion, an oversight committee should be put in place with project teams that will determine the project’s scope and drivers. This group ensures day-to-day implementation chores are on schedule.

Once an EDIS is chosen, Handel recommends mapping out workflow to make certain the system is set up to match department activity. “An important question is to what extent should you use all the capabilities of your new [EDIS] in the ED and whether or not it should be a full or partial implementation. A partial implementation means that the functionality of your new EHR is gradually expanded over time, whereas a full implementation takes more of the ‘big-bang’ approach,” he explains, acknowledging that even with best-of-breed systems, it’s rare that “you can perfectly replicate workflow.”

Understanding the technical, organizational, and political demands that may impact the extent to which a system is used early on is important, White notes, because once the go-live is under way, it’s not a good idea to resort back to any old methods. “Mixed implementations tend to be a point of failure,” he says.

Be prepared to face scheduling difficulties during training periods and allow flexibility in the plan, Handel adds. “Given the 24/7 nature of the ED, enough classes will have to be offered to meet the demands of diverse work schedules,” he says, adding that research suggests financial compensation for training makes staff more accepting of the additional time requirements.

Several training methods should be considered, White says, noting that organizations need to be prepared to staff extra personnel if they want clinicians to train while they are at work. Other methods include online classes, small group gatherings, and one-on-one sessions.

After the go-live, Handel points out that even with extensive training, some clinicians will still be uncomfortable. “People who are less tech savvy will have a harder time adapting to it,” he says, acknowledging there are “certain barriers of user challenges you can overcome [and] some you can’t.”

Also, EDs should be prepared for some functions to slow down and anticipate errors during the early stages. As a result, leaders need to create a process for rapid troubleshooting to avoid losing valuable time that could be better directed elsewhere. Handel says a schedule for follow-up training will likely need to be implemented, as well as further analysis of workflows for refinement.

“A plan should be created for continued improvement not only of the technology itself and its useful features but of the end-user skills as well,” he suggests, adding that improved coordination of hospitalwide systems should also be compared with separate systems and determine what efficiencies can be achieved unilaterally. “Periodic reassessments need to be made to make sure the system is continuing to meet your needs.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.