Wednesday, June 14, 2000

The Technology Challenge for Emergency Departments

My recent weeks have been filled with technology. My department is preparing to take the plunge and install an electronic medical record for the emergency department that will be fully integrated into the hospital information system and provide complete ED functions including support of triage, tracking, orders, results, and discharging.

We’ve tried twice before, and both times the niche vendors we contracted with were not up to the challenge in our environment. Each of them has apparently successful installations elsewhere, but they have some failures elsewhere, too. No vendor can ensure success, and even those who have been successful elsewhere may fail if you and your hospital management — particularly, information systems (IS) — are not ready to undertake the installation. Those are the warnings, so how to proceed?

The most important lesson I’ve learned from our past failures is that the leaders of the hospital IS department must be engaged and confident. The leaders of hospital IS are conservative by nature and by their experience with the systems they have in place and maintain. In most hospitals, IS has been asked to do more with less every year — just like emergency medicine — and that demand is only increasing. Many hospitals don’t even support much of an on-site IS presence around the clock. Thus the system must be planned and sized so that the hospital can successfully implement and maintain it.

Exploring what is available in the market can be a never-ending task. Every vendor will tout the benefits of his system, yet most will have fewer than 20 active working installations. Those few that have more up and running do not necessarily have the best track record either. Other vendors will say how many sites they have under contract. This too can be misleading. There may be two vendors still counting my hospital.

Start with Research

A good place to start is by researching what is available at the International Symposium on Emergency Department Information Systems Site and a 2009 ACEP whitepaper (PDF), "ED Information Systems". These sites point to other resources, and are all-around good starting point for exploring computing resources for support of emergency medicine.

All is not lost if your facility has meager resources because vendors are increasingly partnering and creating systems whose price is based on patient volume and even charged on a monthly basis based on how many patients have been entered in the system. As the Internet has become a growing consideration in implementing all information systems, vendors are implementing systems as application service providers. Assuming the proper attention to information security and privacy (required by the Healthcare Insurance Portability and Accountability Act [HIPAA]), it is conceivable that one or more of these nascent vendors may provide what you need for your ED.

I’ve recently examined vendors’ offerings at several meetings. New approaches abound. The vogue for template charting remains unabated, but now several vendors compete in the template chart marketplace. More than a few have either developed their own electronic version of template charts or have partnered with an information system vendor and offer either electronic charting or more commonly, electronic storage of a hand-completed template.

That is, a paper template chart is completed as usual, but the completed chart is then scanned and stored in the computer for later access. Scanned storage does have limitations, but it also sharply reduces the amount of paper that requires handling and integration into a hospital’s permanent medical record. It also can facilitate transmission by fax — with the patient’s permission — of a chart to the patient’s primary physician, thereby enhancing communication. Lastly, with the coming of Outpatient Prospective Payment System for Medicare patients and the attendant Ambulatory Payment Classifications (APCs) and the consequent increased attention the medical record will receive from both hospital and physician practice billers, an electronic record, even one as simple as an image of the scanned ED chart offers significant advantages over a paper record.

Be Wary of Data Use

At the American College of Emergency Physicians Connections meeting in New York City during early April 2000, one vendor offered a prescription-writing kiosk. The kiosk is offered at no charge to the hospital, and the vendor assured me that integration into the hospital’s registration system was part of the no-charge package. I was told that discharge instructions would be included by later this year.

On its face, this is an intriguing offer. It addresses the growing concern about errors in outpatient medication dispensing through poor handwriting on prescriptions, yet it raises a series of questions. When I challenged the vendor about the advertising that would be put in front of the physician at the time of prescription writing, I was told that this was “physician education.” Yet, it was clear to me that certain medication names were prominently and permanently available as one-touch selections for the physician.

Although I failed to ask, you should ask the vendor what will become of the patient information (demographics and prescriptions today with discharge instructions coming soon) captured in the database? Will it remain at the hospital or passed on to the vendor? I see the potential benefit for patients and physicians of this and other advertiser-supported tools, but I fear the consequences. While an advertising model for free Internet connectivity may work, I’m troubled by this apparent parallel in providing computing support for health care.

No Panacea

Installing technology is no panacea to difficulties and barriers in delivering excellent emergency medical care. In fact, improperly selected and implemented systems by paving the goat paths rather than helping reorganize the way the ED staff works as a team may worsen rather than improve the clinical environment.

Technology can be a wonderful tool, but steamrollering over colleagues and co-workers can put painful barriers in the way of effective teamwork. The vendors will say how easy it is to install and operate. Increasingly they are correct, but will it work for your environment? Please remember the hard lesson I’ve learned: Technology is easy; people are hard.

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