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When you talk to an emergency physician about electronic medical records and emergency department information systems, you’re likely to get a strong reaction. While some EPs report stories of great time-saving potential from these technologies many others have seen the same platforms cripple their department. One thing is certain, regardless which side of the fence you’re on, it’s very likely an EDIS is coming to your ED soon. According to Greg Brown, MD, the head of clinical informatics at TeamHealth, EPs basically have two options: Join the EMR discussion with administrators early on or wait until an EMR is implemented without their input. Either way, says Brown, hospitals are moving this direction, and emergency physicians need to be prepared.

The problem is this: current EDIS technology is a mixed bag at best, often creating as many problems as it solves. The Joint Commission released the “Issue 42 Alert” in December, noting that technology is frequently the cause of medical error. In example, 43,372 of 176,409 medication errors were created by technology. Depending on your ED’s situation, more automation may or may not be the answer, and EPs need to know how to ask the right questions and convey the hard truth to administrators.

The impetus to implement an EDIS is obvious. Our EDs are frequently dysfunctional and quite honestly many are in need of substantial operational improvement. As patient complexity and volumes grow and additional regulatory requirements are added to our already overburdened workload, this only compounds and magnifies the inefficiencies of our operational systems and the inability for us to meet surging demands. Our hospitals, and we, are looking for solutions. Enter the savvy EDIS vendor…

For starters, let’s be clear: There are many potential benefits from an EDIS. If you’ve spoken with any of the vendors, they’ll all make many of the same claims. Improved operational efficiency, better coding and billing, improved risk management, patient tracking, computerized physician order entry, better charting, no more transcription costs and the list goes on. I can’t argue with those benefits; if they come to fruition, everyone wins. The physician benefits from less restrictive operations, easier charting, better reimbursement and reduced risk. The hospital benefits by reduced risk and improved financial performance by streamlined operations and reduced cost (e.g. reduced transcription costs). The patients benefit from reduced wait times, expedited care and reduced risk.

Sound too good to be true? Well, you know what they say. If it sounds too good to be true, it probably is. Let’s take a good look at the downsides. First is the cost. These babies are not cheap. Wellsoft, for instance, will run between $400,000 and $500,000 for a department with an annual census of 50,000. Oh, and there is an annual software maintenance fee of 18% on that purchase price. But don’t worry, that’s “industry standard.” Feel better? There is also an initial installation cost of approximately $150,000. The T-System charges an ongoing fee of $4.75 per patient, with an initial set up fee of around $100,000 for the same sized ED.

Vendors often make the argument that these systems pay for themselves. At those price points, that’s a hard line to sell. The devil is in the details. What you gain in improved documentation and data collection you’ll most likely lose in operational inefficiencies. Take the fact that an EDIS puts physicians–the most highly trained and compensated providers in the ED–in front of screens entering patient data, effectively turning them into data entry clerks. Under these systems, EPs order their own tests and meds and can provide countless entries for performance improvement and operational data extraction. Sure, the data is great to have, but at what cost? Anything that slows us down doesn’t fix anything. In absolutely every installation I have witnessed, physician productivity has circled the drain, and in most, it never returns to baseline. So, if the physician is made less efficient, door-to-physician times and length of stay increase, wait times go up, and more patients leave. Lots more. All of this results in less revenue and more risk.

Still, there are those who claim that these systems actually improve operational performance, increase collections and reduce risk. I guess it depends on your frame of reference. The “poster children” for these systems are those in need of substantial operational assistance. In other words, if you have an average length of stay of 6 or 7 hours or a door to physician time of over an hour, etc., you can use almost any tool you want and you’ll be able to make a positive impact. The Hawthorne effect is a wonderful thing. Once you start casting light on the process, things begin to improve. The same is true for charge capture and collections. Sure, if your documentation tools are ineffective, your physician documentation lacks sufficient detail and coding isn’t up to snuff, a prompt-driven, drop down menu charting system will help. But there are a lot more cost-efficient ways to improve documentation and charge capture then an EDIS. The scenario further deteriorates the better your department currently functions. If your average ED length of stay is 2 or 3 hours or your door-to-physician time is only 30 minutes, the benefits from an EDIS will almost invariably be outweighed by the inefficiencies it will create.

If the physician is the rate-limiting step for many processes in the ED, why ask them to do more? We need to put the physician in front of the patient, not in front of a computer. If an EDIS-driven medical record requires too many drop downs and mouse clicks to efficiently document – if it takes six mouse clicks to order a dose of Tylenol – it just isn’t worth it. Furthermore, the medical records generated from these systems can be very difficult to follow and often read as though they were dictated by a cyborg. They don’t flow well and have syntax issues. In many systems, it is very difficult to personalize the record, only allowing the canned selections available in the system.

There are a couple things to consider from a risk management perspective. It’s true that risk will be reduced by improving wait times, length of stay, etc. It will also be reduced by better documentation. The fewer number of patients who walk out without being treated, the quicker patients can be seen and dispositioned and the better you document your medical record, the less likely you are to be named in a lawsuit, and the more likely you are to successfully defend your actions. If you don’t have a risk management program in place, these systems may help. That said, point-and-click documentation tools often create new opportunities for items to be inappropriately entered in the medical record such as physical examination items that were never performed. Such records create risk management nightmares and coding and billing compliance issues.
Create a system that is cost-effective, improves patient care, operational efficiency, reduces risk and improves collections without strapping it to the backs of the physicians and I’m all in. I just don’t think we’re there yet. So let’s face the ED’s operational problems head on, engaging in an active dialogue of both hi- and lo-tech solutions at the hospital level. Maybe that will mean using scribes to perform the data entry, or perhaps merely waiting until EDIS vendors have made critical improvements. No matter what, if we leave these decisions entirely up to others, the 800-lb EDIS gorilla is sure to break our backs.

Any More Questions?
If you find your hospital purchasing a system without your input, it’s better to join the process then be left on the sideline. Here are some critical questions that may help guide you through the selection and implementation process.

  • What problems are you trying to fix?
  • How much does the system cost?
  • Can you only buy the components you need?
  • Are there any less expensive solutions that meet your needs, EDIS or otherwise?
  • How many successful installs does each particular EDIS have?
  • What issues or problems are encountered with the EDIS?
  • How many customers have they lost or how many de-installs have they had?
  • If patients per hour declined with implementation, did they rebound?

Kevin M. Klauer, DO is the editor-in-chief of Emergency Physicians Monthly and is the  Director of the Center for Emergency Medical Education (CEME).
 

Comments   

# EMR growing painsSteve Chabala 2009-05-17 03:59
I was interested to read your article in Emergency Physicians Monthly. Our department has been completely computerized in the last few years. For most of us, it has been a wrenching and difficult experience. The introduction of the electronic medical record and physician order entry was soon followed by the elimination of dictation and initiation of a point and click template documentation system that has blown our computer time through the roof. After three years in our paperless emergency department, an administration time study concluded that emergency department physicians were spending nearly nearly 5 hours of every 10 hour shift on the computer. I did some informal poling at our most recent Scientific Assembly in Chicago. Does any group in the country spend 50 percent of a shift in front of a computer? I think we get the prize.

It has been a struggle. We are constantly choosing between taking care of patients and our duties in front of the computer. What are the benefits? Lots of data and data points to track and better billing based on our new template documentation system. Unfortunately, physician productivity and satisfaction have fallen off a cliff and it's not clear patient care has improved. Patient length of stay is about the same or longer and our patient satisfaction scores are mired in the red zone ie under the 50th percentile. I think most of us understand that the electronic medical record is here to stay and we are experiencing the growing pains of a new technology. As a hospital employee with no significant input regarding our software product (First Net/Power note), the primary issue for us has been about integration. How do we layer this new technology on top of our department in a way that works for the staff and improves patient care? That's the $64,000.00 question.

Thanks for the excellent article and keep up the good work.

Steve Chabala
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# Clinical Nurse Manager, Banner Estrella Emergency DepartmentCynthia Oberg 2009-06-09 23:45
In our organization, physicians have begun a new program that helps to alleviate their 'computer time' problems. They are utilizing scribes, basically computer assistants, that follow them around and help with their documentation tasks. The scribes are not providers, they do not diagnose or treat. For some of our faster docs, the addition of scribes has helped them to improve patient care by being able to focus on the patient, and not the dictation.
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