A GCIMS-ED system would allow clinical staff to create a system as lightweight as needed to do their tasks and tailor it at any time. The Trauma system is a good example where its first design followed exactly the forms they had developed to streamline their process. Once we did a usability test they made a significant re-organisation of their forms. That required no change from our side just a re-jigging of their specifications.

So my answer to the question is that you have to provide for a system designed by the users for the users and changeable at any time by the users, then they will get what they need and the ED will increase productivity and patient care and safety. How we do that – we’re working on it.
cheers
jon

The NSW Case study has amongst, other things, two circumstances relevant to your comments. Firstly, there are EDs with an existing clinical information system and lots of experience in HIT. They found that their data entry costs/time had significantly increased relative to their old system. The only gain they got compared to the old system was better patient tracking (in my report the one of two persons who supported FirstNet did so because he wanted the tracking and he told others they expected too much by trying to use it for patient notes). The losses were: time, which caused them to drop the data entry for patient notes where they reverted to paper records after years of electronic records, (as a researcher who specialises in natural language processing I’m sure you could hear me cry); and 50% decrease in the number of patients seen by a doctor within 20 minutes of arriving at ED.

The second circumstance is the smaller rural hospital with no previous IT. They would seem to fit your scenario precisely, however there are two unexpected components in this case. More than 80% of GPs in Australia have clinical information systems in their private practices, and these are the people who staff rural hospitals. So they are well experienced to assess new systems. The most IT expert of these GPs have built their own systems, which is the situation in question for the most expressive case I quoted in my report. They ran systematic tests on using Firstnet for data entry and found that it cost them 30% more time to do their data capture. They argued that this result had an interesting multiplier effect in that the NSWHealth would have to pay them 30% more for each patient to maintain their income level, but that the department would then have to pay another 30% for the patients they couldn’t now attend to because of their increased time with the other patients. That’s a 60% cost increase. The second element of their problem with Firstnet was that in rural hospitals staffing levels are minimalist and that nurses worked with heavily multi-tasked responsibilities. Their complaint is that these staff could not afford to be used for increased data entry as it would take their attention away from the critical care issues they had to attend to that were all around them – this is a patient safety issue.

Finally my point is that IT has be efficient and applied wisely in health contexts for it to provide the gains people expect of it. We haven’t been shown yet that has been achieved in the NSW case and many believe we will be waiting a long time if at all to hear it.
cheers
jon

At the end of the day, this isn’t going away (HIT) and instead of being a force of resistance, use your knowledge to help better the solutions. I also find it incredibly difficult to understand an un-automated ED works more efficiently all-around than an automated ED. While I don’t have the studies on hand (but have seen them), if anyone would be so kind to link the ample amounts of studies where it has shown that an ED has been able to increase volume, have better reimbursements, cut down on errors, and have had more time to spend with patients & providing care. I think some of the pitfalls is that many EDs are resistant to changing their outdated workflow processes to streamline and take advantage of the systems in which they purchased. Instead, they insist on keeping the redundant processes that were set in place for their paper environment. Remind me again of how long it takes to pull a paper record from Medical Records vs. one within an EMR?

Your essay raises several questions.

When I was a CMIO at a 1400+ bed hospital system a decade ago, a regional center in a state with very few hospitals at all (Delaware), I counseled that the best solution in my opinion for the very, very busy ED was document imaging of paper, supplemented by a nurse/intake triage system to rapidly record and/or confirm basics (e.g., meds/major problems/allergies/vitals) that was interfaced to the main EHR system.

I based this on the assessment that in the ED, a localized and “closed” environment, the incidence of charts getting lost or writing being illegible resulting in adverse outcomes was minimal. Charts also did not get lost when patients moved to the floors and were adequate for quick transfer and acceptance. Therefore we felt images of past ED charts (of paper) would be satisfactory for assisting care in the ED, where time constraints and hectic pace made the type of system you describe disadvantageous (and for exactly the reasons you describe in your essay).

Document imaging is a proven technology that works well even in high volume settings. For example I managed a departmental budget of $13 million, as did an entire pharma company, using an enterprise document imaging system.

I’ve also been startled by the ED EHR installed at the hospital where I take my mother, who unfortunately has needed far too many admissions in recent years than I care to see. Some of the ED staff were my former medical colleagues and even high school classmates. They’ve told me, in no uncertain terms, that the system is terrible, again for many of the reasons you cite. My own views of it (albeit brief) showed what appeared to be a mission hostile environment, including multiple very tiny pulldowns, picklists, and screens. Most recently that system did not prevent busy ED docs from almost giving my mother Levaquin after her telling the triage nurse it had caused tendon rupture in the past – and the data being entered. They actually brought in a bag of it to hang, and if I’d not been there as medical advocate for my mother they might have given it. Then when she got to the floor, the next day they almost gave it to her again, except by this time mom was her own medical
advocate. I trained in that hospital, Abington Memorial, and as Admitting Officer to the ED held the record for the most number of admissions, ever, in one night (New Year’s Eve 1986), when it was beyond crazy, starting out with one of our own physicians being brought in, shot in the chest, and dying after open heart massage just to set the mood. We managed on paper, and despite out gloomy emotional state not a single error occurred, to my knowledge.

With all this in mind:

Do we really need full EHR’s in the ED?

Is there literature that shows that the time, expense, and resources for a full ED EHR are worth it in terms of clinical outcomes, ROI etc.?

Or are we over-computerizing healthcare, even environments where doing so might actuallyube deleterious due to the nature of the environment, just because “we can” (and because there is money to be made by some)?