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.

Implementing your ED Information System: The Reality

Some of you may recall that back in December I briefly mentioned turning on our ED information system on September 11 and then for obvious reasons, turning it off again. Well, on Tuesday, April 9, 2002 we tried it again and right now I’m sitting here with a large smile. Our ED information system (HealthmaticsED™ from A4HealthSystems) is up and running and working pretty well. The staff is tired but mostly upbeat, proud of themselves and their new skills. Justly so. And I’m sitting here, basking in the sense of accomplishment and achievement that I’ve spent nearly seven years at Maimonides reaching for. All is not perfect, there’s still lots to do, problems yet to solve, but we strike more issues off the top of our list every day than we add at the bottom.

One of our greatest challenges, particularly during the first two days we were up was with the creation of two entries on the tracking board. Our triage nurse would create an entry with the first encounter with the patient. This entry would put up an icon of a computer that would alert our registration clerk to the patient then needing registration. The registrar would start registration, but insert the patient’s medical record number into the triage record and then the interface would combine the formal registration in the hospital’s admission-discharge-transfer (ADT) system with the entry in HMED.

Well, we’ve discovered at least five different ways that this plan can fail. I’m not going to describe them for you, but I do think it is worth characterizing the way systems “fail” or at least have troublesome problems in the early days of “go-live.”

First and most commonly system failures occur during implementation because your staff is climbing the learning curve. People make mistakes and even though our staff has been trained (originally for our September 2001 scheduled go-live) and then retrained for this effort in April, people forget or never learned the proper procedures. Some will not truly learn the new process until they are in the midst of it and only then will they grasp the lessons taught in the classroom.

Next, and somewhat overlapping with our first cause, system failures occur because staff fails to adhere to new procedures or because the new procedures themselves are flawed. Distinguishing between these two causes is important, because staff errors are most likely evidence of need for more training and are remediable thereby. Yet, most people will prefer to displace blame onto process, blaming the procedure and possibly obscuring the best means to remediation.

Lastly, technical failures or software shortcomings produce sometimes subtle and sometimes obvious and potentially catastrophic failures depending upon the extent of the problem and whether its impact is restricted to a single workstation or process or more broadly affecting the use of the system.

The late W. Edwards Deming in point six of his fourteen points stated, “Institute Training and Retraining.” During our first few days of running the new system we have learned and relearned this lesson.

All of us who trained in emergency medicine (or any specialty or profession) trained for a fixed period of time. Deming always asserted that training for a fixed period when learning a skill or process was the wrong way to train: That skills should be taught until mastery is demonstrated. He advised “train and test, train and test.” By this he meant that staff should be trained until they demonstrate no further improvement in testing and that the purpose of testing was to evaluate for mastery, not for a grade. Yet in most cases we train for a fixed period, whether in residency or when learning the use of a new ED information system.

This past week we had MIS staff, vendor support staff and our own super users: emergency physicians and nurses, continuously on duty in the ED. As I’ve already mentioned, errors abounded, but we had staff to help train—on the spot—those who erred or were confused. Some detective work and learning about the system in each instance helped persuade the staff that the problems were related to the user, not the system. Corrections to the database and interface errors were the responsibility of other MIS and vendor staff, some on scene and others connected from A4HealthSystem’s headquarters in Cary, NC. We had the personnel on scene around the clock to support the staff that was delivering patient care. We trained and re-trained on the spot. We supported and encouraged staff, helped them learn how to accomplish the tasks for which they were responsible and praised them for what they did well.

Now after one week our MIS staff tells me that we are exceeding their expectations for our low error rate and success in gaining staff confidence. Many of our nurses are already asking to move on to nurse charting rather than waiting for the three months originally scheduled before we implement the next phase. All staff realizes the benefit for patients and for other staff in the hospital. Their enthusiasm, support for one another and persistence in working through their mistakes and identifying problems for our support team has been outstanding. They have performed magnificently and I am incredibly proud of all of them.

Yes, I am delighted. Thirteen years ago I saw an ED information system in a booth at a professional meeting. I knew the moment I saw it that this was a tool that I had to have in my ED. It has taken me since then to successfully bring my vision to reality. But my real lesson of the past week has once again been the realization that it’s the people who make it happen.

People are valuable. Technology is cheap.

Disclosure: I serve as a member of the medical advisory board to A4HealthSystems HealthMatics ED product. I receive no compensation for this service.

Emergency Medicine and Internet Technology: Here Today, More Coming Tomorrow

Technology has always fascinated me. I built Heathkits in my early teens and received my amateur radio license before I was 14. But I’m not you and many of you tell me that you’ve only just come into using a family computer to browse the web and only rarely do you check your e-mail. At a recent gathering one long-time colleague confided that he had only recently decided that computers were not just a fad and that he was going to have to learn to live with them.

In this space in the June 2000 issue, I presented an overview of some issues relevant to selecting an ED information system. I don’t intend to reprise that here; rather, I thought I’d share some of the sites that I’ve learned from in recent months or used as a clinical reference both in delivering care and in case review. If I’ve not included your favorite site please don’t “flame[1]” me.

The National Center for Emergency Medicine Informatics is the one site I suggest everyone in emergency medicine explore first. This site is a wonderful “home page”[2] for your favorite workstation in your ED if you don’t already have a standardized home page. Among the many fine tools on the page, “MedBot” a search tool focused on a dozen or so medicine sites pops up a friendly window for your search terms while keeping the main page visible. Another area of page offers “Medical E-tools and Calculators” including algorithms to compute GI bleed complication risk, hypernatremia treatment, and hyponatremia treatment along with a bradycardia treatment algorithm and a rash diagnosis algorithm.

When away from the ED and direct clinical care the NCEMI site still holds my interest for both its daily and weekly educational and amusing nuggets including aphorisms, eponyms, cartoons, phobias and questions. The overview of the current literature relevant to emergency medicine through the “Daily Sample” column frequently prompts me to start reading an article that I then finish in the journal that had been sitting on the pile by my desk. Many other features may appeal to individual users including the ability to customize the NCEMI homepage with your most used links.

Jeff Mann in his “Site Philosophy” describes his EM guidemaps as “quick-to-read” references that can help neophyte emergency physicians optimize their clinical practice of emergency medicine. Doctor Mann explains that, “My EM guidemaps should be seen as a supplementary informational tool – specifically designed to help you manage acute clinical problems in the ED setting. They are based on a combination of my evidence-based medical knowledge and my personal experience, and they reflect my problem-solving approach to acute medical emergencies. These ready references provide a pared down how to get through the night quick hit of practical wisdom. Don’t confuse these few dozen screens that cover selected ACLS, medical, toxicological, neuro-opthalmological and trauma topics with a comprehensive text, but when you find yourself with a hole in your brain for the evaluation of a patient with for example, diplopia, Jeff Mann ’s guidemap will help you care for the patient with just a quick read of his site.

One of the external sites that we in the Maimonides Medical Center ED use extensively is the emergency medicine on-line text, Emedicine. This commercially supported site (multi-million dollar investments by pharmaceutical and health-care advertising firms) is the home of multiple texts in many areas in medicine, but the emergency medicine text was the first one. The text chapters are well organized with a front-page folder screen allowing easy selection of top-level topic (Allergy and Immunology, Cardiovascular, Dermatology, etc.) and a frame down the left had side of the screen for sub-topic: Aneurysm, Angina, Aortic Regurgitation, etc. The chapters include prominent notice of date and time last updated. Many of the chapters I recently browsed had been updated within 8 weeks of the time I am writing this column.

Another site, EMedHome offers regularly updated content, free CME and has recently implemented a relatively inexpensive CME program in support of the ABEM Life-Long Learning and Self-Assessment program of the Emergency Medicine Continuous Certification program now required of all diplomates. The longstanding, regularly updated “database” of Adobe Acrobat documents described as Protocols, Algorithms, Sample Orders, and Guidelines remains available for download, printing, and distribution. This site has some advertiser support but explicitly asserts its editorial independence.

What if you don’t have Internet access in your ED? While wireless alternatives are available, your hospital should be importuned to support Internet connectivity from your ED as a matter of patient care. Looking up references in the hospital library, no matter how nearby is not the same thing as pondering the advice from any of these sites with the chart in your hand and the patient visible across the ED. Almost certainly you have one or more computers in the ED that could have a web browser installed and a network connection upgraded to include Internet access for negligible expense. Build a coalition of your colleagues, including nursing staff, before you approach hospital administration with your request. Point to this article as describing current practice and request basic Internet connectivity as a tool for patient care.

Today, access to clinical references over the web as described above is the routine in many emergency departments. As hospitals, even small hospitals, implement electronic medical records through the web the Internet and the web browser will likely become important tools for organizing, tracking and documenting care delivered.[3] Applications supporting scheduling and tracking of residents’ hours and demographic, education, evaluation and procedure databases have already come to the web at for example GME Toolkit from Dataharbor.

The Internet and computers are not a fad. Those of us in leadership positions who’ve yet to embrace the web, should begin exploring it at once. I’m proud of my colleagues at Maimonides who have bought home computers and typing tutor programs and have begun learning their way around the web. Just as they learned to read head CT scans long after residency, so too are they learning to navigate the web. When will you?

1 To send an offensive email message or newsgroup posting, especially one containing strong language and personal insults. Compact American Dictionary of Computer Words. Copyright © 1995, 1998 by Houghton Mifflin Company.

2 For a Web user, the home page is the first Web page that is displayed after starting a Web browser like Netscape’s Navigator or Microsoft’s Internet Explorer. The browser is usually preset so that the home page is the first page of the browser manufacturer. However, you can set it to open to any Web site. For example, you can specify that “” or “” is your home page. You can also specify that there be no home page (a blank space will be displayed) in which case you choose the first page from your bookmark list or enter a Web address. Compact American Dictionary of Computer Words. Copyright © 1995, 1998 by Houghton Mifflin Company.

3 An application service provider (ASP) is a company that offers individuals or enterprises access over the Internet to application programs and related services that would otherwise have to be located in their own personal or enterprise computers. Sometimes referred to as “apps-on-tap,” ASP services are expected to become an important alternative, especially for smaller companies with low budgets for information technology. Definition copyright © 1996-99 by Inc.

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 National Center for Emergency Medicine Informatics Library. This site points to many other resources, and is an 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.