Ours was once a department like many others – urban, academic, and overwhelmingly busy. Care in our department involved over two dozen different processes supported by separate, disparate systems: from triage and registration through laboratory, radiology, medication orders and review of previous medical records, to bed request or discharge instructions. Patients waited at each step of the process. Documentation was lacking, with many charts lost or insufficiently complete for proper reimbursement.

We looked to redesign ED throughput as an opportunity to fulfill our core mission to provide quality patient care, and also, as an academic institution, to effectively teach residents and promote research.

We settled on an electronic chart because it served so many key functions: documentation of the care delivered, communication to each other and to our colleagues on other services, official legal record for purposes of litigation, generation of facility charges and professional fees, and a source of data for clinical research. Compared to unstructured or template paper charts, or dictation systems, or scribes, only an electronic chart system could provide us with a completely legible record of the care given during the visit, with every data element stored in a searchable database, and the capability to give real-time decision support to improve clinical care and to optimize reimbursement.
We chose to seek a comprehensive EDIS that provided triage, patient tracking, electronic physician and nurse charting, electronic order entry, discharge instructions and prescription writing. While setting up a comprehensive EDIS requires more initial preparation, training and investment, we figured more functionality from the get-go would actually be worth it, and that a single comprehensive implementation and go-live date would ultimately be less disruptive than expanding a limited feature set slowly over many months.

One essential feature we agreed upon early was a single, universal log-in. We’ve witnessed the inefficiency and frustration of doctors carrying around separate passwords to log in to one system for lab results, another for charting, and a third for prescription and discharge documents – often on different, dedicated computers. We wanted every feature of our comprehensive EDIS available to every user on every computer in the ED.

Other essential characteristics included a user-friendly interface that facilitated the work of ED staff physicians and nurses; useful administrative data on throughput times, turn-around times, staff productivity, resource utilization and quality of care; and facilitation of data collection for research in the ED. It was also specified that the system must sufficiently improve documentation and billing to pay for itself within 18 months.

Having chosen this direction, we took a lot of steps to make sure our ED information system was implemented well. Because attempts to automate dysfunctional processes always seem to produce unsatisfactory results, we performed a workflow analysis and mapped out each step in patient flow through our ED, and redesigned our processes for IT optimization.

The emergency department is nothing like an inpatient unit, a doctor’s office or a clinic*. The pace, nature and organization of the work are unique. All activities are time sensitive. ED providers see multiple patients simultaneously and are constantly interrupted. Multiple providers must be able to access the ED chart simultaneously. Orders are often placed singly rather than in sets. An understanding of these workflow issues should be apparent in the design of an EDIS.

So we went to trade shows, reviewed the literature available at the time, and surveyed our colleagues at other institutions.

Then, we had structured vendor site visits. We asked doctors, nurses, registrars and administrators to evaluate the products using standardized scoring sheets, and brought in hospital IT personnel to take a look at our finalists and determine support needed for each. This screening period had the added affect of building consensus and achieving buy-in from our various stakeholders – because so many people had a hand in choosing features and final product, they were invested in making sure it worked. Buy-in was no doubt also helped because our EDIS champions were physicians and nurses, rather than something foisted upon the department by outside administrators or consultants.

Implementation was expensive, and had a steep learning curve. But when it was complete, our process redesign and paperless EDIS implementation enabled a single sign-on capability for access to all system applications and a streamlined, more efficient operation.

The EDIS provides triage, patient tracking, physician and nurse documentation, retrieval of charts from prior ED encounters, one-click access to more extensive historical hospital data from an enterprise data repository, computerized provider order entry, results review, discharge instructions and prescription writing. All data entered into the EDIS are time-stamped. Patient care documents from other departments or facilities are scanned into the patient’s electronic chart and are simultaneously viewable by all personnel caring for the patient.

Switching to a paperless ED has had a tremendous effect on our department – some effects are easy to measure, others less so. Our own data (some of this previously published, some of this in press) about ROI and implementation is, of course, unique to our busy urban academic center.

•When we compared a period over a year post-implementation to the days before our EDIS, the ED Length-Of-Stays for all patients decreased by 29%, from 6.7 hours pre-intervention to 4.8 post-intervention. The ED LOS for admitted patients decreased 35%, from 12.2 hours pre-intervention to 8.0 post-intervention

•Door-to-doctor time for all patients (triage to first doctor-patient contact) decreased 44%, from 1.2 hours to 0.7, while doctor to disposition time for all patients (first doctor-patient contact to disposition decision) also decreased 52%, from 3.6 hours to 1.7 hours. Disposition to discharge for admitted patients (boarding time) decreased 28%, from 6.8 hours to 4.9 hours.

•CT scan turn-around time decreased by 40% from 3.9 hours to 2.3, laboratory report TAT decreased from 2.0 hours to 1.4, and X-ray TAT decreased from 0.9 hours to 0.7.

•On the revenues side, average collections per patient rose 47.5% between pre-implementation and a sustained-effects period over a year later. Total charges rose 69.4% during the same period and total receipts rose 70.1%.

•End-of-month chart completion rates by attending physicians rose from 65% in 2003 to 95% in 2005, while lost or illegible charts decreased from 4,992 in 2003 to zero in 2005. The average professional evaluation and management (EM) levels (the five-point scale used for coding ED charts for billing purposes) rose from 3.17 during the pre-implementation period to 3.73 during the a period more than a year implementation.
•The number of charts meeting professional fee criteria for critical care billing increased from just one chart during the entire 15-month pre-implementation period to 1,614 charts in the more than a year afterward, and from 45 to 974 respectively for facility critical care billing.

•Despite an overall decline in the facility EM level, net facility receipts increased 60.9% between the pre-intervention period and a time over a year later.

As dramatic as our improvement was post-implementation, this data says nothing about improvement in patient safety or satisfaction, or improvements in QA and core measure monitoring, all of which have been noted but not as rigorously reviewed. Furthermore, as an academic institution, the EDIS has made it far easier for residents to review cases for educational or research purposes, which allows us to fulfill an important mission as a teaching hospital.

But perhaps most importantly, if you survey faculty who lived through the transition, they’ll all note that, as challenging as adoption of an EMR was, no one would go back.

*Because the ED is not a unit or a clinic, interpreting the growing literature about EMR adoption in various healthcare settings becomes more problematic. Many of the concerns ED docs have about EMR – more clerical duties in front of a computer, less face-time with patients, expensive and time-consuming training – have been measured and quantified in other settings. So, too, have the benefits in safety, increased revenue, core measure and QA compliance. If someone is waiting for a more precise cost-benefit analysis for EMR implementation for the unique environment of the ED, they’d do well to remember that each ED itself is unique, and what ultimately gets reported from one ED’s experience may not apply well to another.

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