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April 28, 2008

Take EDIS to the Next Level
By Selena Chavis
For The Record
Vol. 20 No. 9 P. 12

To get the most value out of an emergency department information system, hospitals would be wise to take full advantage of its many capabilities.

For many hospital emergency departments, the days of dry erase boards and paper shuffling to track patients and visits are over. Thanks to advances in HIT and emergency department information systems (EDIS), many departments have automated the basic processes of registering and moving patients through a visit. As a result, they are realizing the benefits associated with streamlined processes.

However, many professionals say there is more to garner from a fully integrated EDIS, leading to the question: Why stop there? While automating the basic functions of an emergency department goes a long way toward creating efficiencies and improving patient care, many healthcare experts suggest that most departments are not capitalizing on these systems’ full potential.

According to Steve Weichert, director of information services at Overlake Hospital Medical Center in Washington state, it’s not due to a lack of system capability but rather a lack of demonstrated ability by emergency departments to take the initiative to the next level.

Part of an overall movement toward fully integrated electronic health systems that share patient data seamlessly with predefined departments and providers, EDIS are, on the most basic level, designed to facilitate health information and patient management within an emergency department. These systems can be single-focus systems, such as discharge instructions and patient tracking modules, or fully integrated ones that manage all patient data from the point of entry to the emergency department to final disposition.

Plus, many vendors tout advanced capabilities for nursing and physician documentation, along with computerized physician order entry (CPOE), with capabilities of sharing data within an entire facility or health network. Hospitals and health systems that are capitalizing on some of these advanced data-sharing capabilities are also finding significant return on investment.

“It’s all the value you get out of provider order entry,” Weichert says, pointing to legible orders, no misinterpretations, minimized errors, and faster turnaround at Overlake, a 337-bed, nonprofit regional medical center with more than 800 active and courtesy physicians on staff. “A lot of it stems from efficiencies we’ve gained. Physicians are now able to see patients more quickly. They are able to do their work as they go.”

The results are much the same at Conway Medical Center, a South Carolina-based hospital that handles more than 43,000 emergency department visits per year. According to Director of Emergency Services Steve Lanning, the department was able to decrease its “through times” for patients by 20 minutes per visit after implementing a fully integrated EDIS. “We wanted to streamline some of our processes,” he recalls, noting that prior to the implementation, everything was a paper process. “Now, there’s no second-guessing about charges. The charts are very neat and organized. … It’s very systematic.” Lanning also notes that his department saw net revenues jump more than 34% following the EDIS implementation.

Besides efficiencies garnered through automated processes, significant cost savings were realized through improved charge capture and the elimination of emergency department transcription at Overlake, netting a savings of approximately $700,000 per year.

The system’s ability to analyze data has allowed Lanning to identify peak times within the emergency department and make necessary staffing adjustments. “It has enabled me to better utilize my staffing levels,” he says. “It allows me to staff better for peak and low times. In fact, the physicians have also started using the data for staffing.”

Weichert says the implementation has also produced an unexpected benefit in the community. “It inspires confidence in those who are seeing an organization operate with this level of technological expertise,” he says. “It looks a whole lot more streamlined. We didn’t anticipate that as being a benefit.”

A Phased Approach
Weichert acknowledges that the ability to integrate Overlake’s EDIS and share data throughout the hospital did not happen overnight. “Much of it came later,” he says, adding that the facility started with the automation and integration of patient demographics, laboratory results, and charges. “We started out with very simple data sharing. Where we really started seeing the value, though, was around the [physician] orders interface.”

Lanning agrees, pointing out that physicians “can spend five to 10 minutes writing medications down alone.”

Overlake’s fully integrated EDIS went live in the fall of 2007, just short of one year from conceptualization, Weichert says. Now, all clinical documentation and physician orders pass directly into the host system.

Conway Medical Center followed a similar phased approach, but the implementation occurred over several months. Phase 1 included patient tracking and nursing documentation, encompassing such areas as triage, discharge instructions, online prescription writing, and work/school excuses.

“It’s an electronic grease board with a lot more bells and whistles,” Lanning says of the patient tracking piece. “It tells you who’s waiting and how long they have been waiting.”

For many EDIS, the clinical documentation piece typically includes nursing assessment, social history, progress notes, physician history and physical exam templates, automatic display of ICD-9 code after selecting a diagnoses, and CPT and Ambulatory Patient Classification codes provided as part of the patient record.

Lanning says as part of the documentation piece, Conway also implemented a discreet data interface allowing patient medical data from the initial emergency department assessment to automatically flow into a chart that transfers into the main Meditech network within the hospital. “They love that upstairs,” he says.

While few hospitals using an EDIS have advanced to this capability, phase 2 of the Conway implementation included the CPOE and results reporting piece. This capability allows real-time order entry at the point of care where the system automatically alerts physicians to related tasks needing completion. Results-reporting capabilities then notify emergency department staff when diagnostic tests and procedures are completed.

Weichert says most emergency departments have not moved much further than what was included as part of phase 1 at Overlake and Conway, and most “probably don’t even have lab results” integrated into the EDIS. Noting that the greatest benefit has been realized through the CPOE capability, he suggests that even putting the lab interface in place will produce immediate results. “Once we had lab results going in the emergency department system, we no longer had physicians and clinicians running around trying to track down information,” he says.

Overcoming Obstacles
Emergency department professionals agree that the CPOE piece is by far the biggest integration challenge, since multiple interfaces must be constructed among the emergency department, health information, and lab/radiology systems.

Weichert recalls that each interface took four to six weeks for implementation, and working with multiple vendors can be a challenge. “Vendors tend to be competitive. They don’t want to work together,” he notes, further suggesting that finding a vendor with a lot of experience interfacing with Meditech was crucial to the process. “It’s never going to work the first time. … There is always going to be a lot of testing. The more untypical [the interface], the harder it’s going to be to get done.”

Weichert cautions facilities to consider more than the emergency department when looking to implement an integrated EDIS. “For us, most of the issues [during rollout] were around the siloed mentality that we took toward this,” he says. “Everything was very emergency department-centric instead of looking at everybody who was touched by this.”

Offering an example, Weichert recalls that even simple pieces such as changes in the emergency department report wreaked havoc throughout the hospital. “The emergency department docs liked it,” he says. “When we turned that thing live, though, [other hospital staff] were livid. They couldn’t find anything. It wasn’t very useable to them.”

In regard to physician buy-in, officials from both facilities note that their staffs were forward thinking, and Weichert points to the value of having a medical director champion the effort. “Our current CMO [chief medical officer] broke down all those barriers,” he says.

While some dug in their heels at the beginning of the effort, Lanning says the system’s ease of use proved beneficial, and “Now, if the system is going to be down, there is an uproar.”

— 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.

EDIS Essentials
In a recent article, “Recommendations for the Selection and Implementation of an Emergency Department Information System,” Paul Postuma, BSc, MD, CCFP(EM), FCFP, of Ars Informatica, an IT consulting firm, outlined recommendations by the Society of Academic Emergency Medicine (SAEM) for the essential components of an effective emergency department information system (EDIS). An overview of his analysis appears below.

1. EDIS Database Structure: Open database standards for any information system should be the rule of thumb to allow all data to be retrieved and exported. Postuma cautions that many EDIS vendors frequently use proprietary database formats.

2. Data Standards: The SAEM report suggests a number of data formats that are becoming standard for EDIS, including the following:

• Data Elements for Emergency Department Systems sponsored by the Centers for Disease Control and Prevention;

• XML formatted per Health Level Seven (HL7) Clinical Document Architecture, with data structures derived from the HL7 Reference Information Model;

• coding for billing to include a minimum ICD-9 (diagnoses) and CPT-4 (procedures), with ICD-10 recommended;

• coding for vital signs and laboratory results that integrates Logical Observation Identifiers, Names, and Codes;

• recommended nomenclature for expressing clinical observations: SNOMED CT; and

• systems should support XML-based messaging. Message formatting should be HL7 version 2.x or HL7 version 2.x-XML; version 3.0 recommended when completed.

3. Minimum Required Data Fields for an EDIS: According to the SAEM recommendations, minimum required patient data should include admission/discharge/transfer information, performance metrics, laboratory data, medication administration data, archived medical records, billing data, and on-staff physician contact information.

4. User Interface: Recommendations stress the importance of choosing an EDIS that provides ease of use for clinical staff and minimal training needs.

5. Computerized Physician Order Entry (CPOE): CPOE developed for the “enterprise” often will not meet the needs of the emergency department but should be specific to them. It must also be widely available at the patient bedside and other strategic points throughout the ED.

6. CPOE, Clinical Decision Support, and Evidence-Based Medicine: Recommendations are made for the seamless integration of comprehensive decision support into all aspects of workflow.

7. CPOE and Medication Checking: Postuma suggests that EDIS systems should seamlessly provide drug interaction, allergy, and clinical-context checking (eg, pregnancy, acute renal failure) and adjust as necessary for age, weight, renal and hepatic function, etc.

8. Clinical Decision Support and Corporate Intranet/Internet Access: An EDIS should provide full Internet access to all major medical and emergency medicine Web sites throughout the clinical area.

9. Physician Medical Record: Regardless of the format, all clinical documents should be converted into an electronically retrievable format.

10. Integration of Emergency Department Equipment: According to Postuma, emergency department equipment should output data that is automatically time stamped and stored to the appropriate database fields in the EDIS. Because many devices do not export data in standard format, interfaces must be written to integrate device output into the EDIS. He suggests selecting an EDIS that has as many interfaces as possible already implemented.

11. Critical Event Warnings: An EDIS should be able to monitor patient data from clinical and nonclinical software systems and automatically trigger appropriate alarms to attending physicians via pager, PDA, or other system.

12. Syndromic Surveillance: An EDIS should allow for the real-time delivery of data to support biosurveillance and public health needs, as well as automate the reporting of diseases.

13. Communication of the Electronic Medical Record: An EDIS should allow the sharing of patient records with primary care physicians, as well as summary reports of emergency department physicians.

14. Research Support: Used effectively, an EDIS can make emergency departments more conducive to research by automating the process of identifying appropriate patients.

15. Data Analysis: Emergency department personnel should be able to choose from a variety of visual analytical tools.

16. Fault Tolerance: Backup systems should be built into the EDIS so clinical systems are always functioning.