Thursday, November 14, 2002

Computer-based Patient Records in the ED and me . . . or how I learned to stop worrying and love the machine.

Regular readers know of my appreciation for information technology’s power as a facilitator of useful change; but, the recent successful implementation of physician charting and order entry into our ED information system made me smile and enjoy a sense of accomplishment—if just for a moment. Then too, last week brought news of Maimonides’ recognition with the Nicholas E. Davies CPR Award of Excellence from the Healthcare Information and Management Systems Society.[1]

Over the years I’ve extolled the virtues of both measurement and interdisciplinary teams in these columns. These recent information system accomplishments at Maimonides Medical Center came to mind when I was thinking about “leadership” in the context of a column for this month because the accomplishments underscore the importance and effectiveness of both measurement and interdisciplinary teams, albeit on different scales.

When I was hired into my current position in 1995 I set only two conditions: unified management of the entire ED and support for an ED computer-based patient record. Readers know that our ED operates with a unified management model. Now we have a fully implemented computer-based patient record.

Ann Sullivan, our CIO joined Maimonides Medical Center shortly after I did and I talked to her during the hiring process. She questioned my resolve for the work required for implementation of an ED Information System as I described it then. She questioned how the work would be divided between information system professionals and clinicians. She asked if we in the Department of Emergency Medicine would support information system personnel in our department. She challenged me to participate fully in the effort. We did and went beyond her expectations by also supporting the capital acquisition expense through practice earnings. We justified the support because we believed that the practice was sure to benefit from a successful implementation of a computer-based patient record.

In submitting our application to the Nicholas E. Davies award committee, we wrote:

“Many elements have contributed significantly to the success of the project and, if omitted or poorly executed, could have derailed it. Foremost among these was establishing programs and methodologies aimed at physician participation, buy-in, and ownership. Other key factors included building a clinically-focused MIS staff, selecting appropriate vendor partners, conducting training to meet the needs of all user constituencies, and winning the support of key leaders and advocates. The result is an information system environment that has brought dramatic improvements in the delivery of patient care while positioning Maimonides to continue to fulfill its mission as a world-class medical institution in the years ahead.”

Note how in this document excerpt—directed to a committee of a healthcare MIS organization: “physician participation, buy-in and ownership” is emphasized. The paramount clinical focus is evident and the technology is subservient to that focus. The outcome of “improvements in the delivery of patient care” is noted and supported elsewhere in the document with an array of numbers obtained both before and after CPR implementation. Ann Sullivan led the writing team though she included 11 others as authors of the document, seven of them full-time clinicians in the hospital and only four others based in MIS. Of those four, three are nurses.

Is this interdisciplinary teamwork, or what?

The work accomplished by these nurses and pharmacists has been invaluable in our departmental system implementation because they understand the process of delivering patient care and they understand the work process encompassed by the computer system so that they have helped us anticipate challenges and plan alternate approaches for using the system, particularly because of the important interfaces and combinations of our ED system with the hospital registration, laboratory and radiology systems and the inpatient order-entry and results reporting system. As to measurement—just one example—our compliance with pain assessment improved from 65% to over 95% because of the prompting of the CPR.

The Davies Award surveyors’ visit had been scheduled for a day that happened to coincide with the third day of our ED CPR go-live. They first visited two different MIS sites; the ED was the first clinical site where they stopped. They later told us that they noticed specifically the dedication and drive of everyone they met throughout the walk through, but especially the ease of physician use in the ED on the third day of our “go-live.” The surveyors asked me to stop a physician at random. They asked that physician to perform several functions at the computer. The physician was so proficient on the third day of use that in the surveyors’ minds, that physician’s capability attested to the hospital’s training and implementation approach. Yet another example of interdisciplinary teamwork observed as a result.

I’ll end this short column with another smile. It’s not truly a measurement, but even Deming acknowledged, “Not all improvements can be measured.” Just a few hours ago, our pediatric emergency medicine chief, Giora Winnik, MD, called me to say that instead of needing a day to prepare for the child safety and protection taskforce, he had needed only an hour because everything he needed he was able to get from the system. You don’t know our history together, but suffice it to say that Giora is the senior physician in the department and has been at Maimonides Medical Center for more than 20 years. He had been skeptical of implementing the CPR, but he called me to make me feel good. He succeeded.

[1]The Nicholas E. Davies C[omputer-based] P[atient] R[ecord] Recognition Program was established to encourage and recognize excellence in CPR development by recognizing health care provider organizations that successfully use CPR systems to improve health care delivery.

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