An Emergency Department Clinical Information System: Continuing Improvement and Benefits

• 3/31/2010
• Author: Steven Berman
• Category: The Journal Blog
• 13921 Views
• 1 Comments
• 

This week, Kevin M. Baumlin, the lead author of " Clinical Information System and Process Redesign Improves Emergency Department Efficiency ” in the April 2010 issue, guests on the Journal blog. Dr. Baumlin’s article describes how Mount Sinai Medical Center, a hospital in Manhattan, coordinated a variety of efforts—including changes in patient registration, order entry, and results retrieval—with the implementation of a fully integrated emergency department information system, leading to significant decreases in length of stay and door-to-doctor, doctor-to-disposition, and radiology turnaround times. Dr. Baumlin follows up on the article to provide some updates on continued progress—and spread. We welcome your comments.

Since implementing our comprehensive emergency department information system (EDIS), the team at Mount Sinai has enhanced and refined it to better meet the needs of patients and staff. We will publish our recent findings on our financial return¹ and our experience in integrating clinical decision support into the information system² soon.  

Some improvements since we initially implemented EDIS include changing the sequence of the clinical content sections in the “electronic view” so that it is consistent with nurses’ and physicians’ preferences. For example, we have found that nurses prefer to navigate from triage to allergies, past medical history, current medications, nurse assessment, nursing procedures, physician history of present illness (HPI), physician assessment, and plan. The preferred sequence for physicians is as follows: call-in information, triage, allergies, current medications past medical history, MD HPI, review of symptoms (ROS), physical examination, laboratory interpretation, physician assessment and plan, physician procedures, nurse assessment, and nurse procedure. The difference may seem small but the users reported this to be a large improvement. We have also added doses, including units with approved abbreviations (that is, excluding the Joint Commission “Do Not Use" List) to our most commonly used medication order sets. This has led to a marked decrease in free-text medication orders, thus enabling us to disband our free-text oversight committee.

Another benefit of implementing the EDIS has been the use of the data to support multiple projects for reporting in peer-reviewed publications. More importantly, EDIS has given us the ability to gather data so that we can participate in multicenter studies^3,4 and build a consortium of researchers to define and improve care for patients in hospitals across the United States.

In 2007 we were able to reproduce our success in implementing EDIS at our sister institution, Mount Sinai Hospital of Queens. With an ED volume or 50,000 and extreme physical plant restrictions, the site was in dire need of improved efficiency but still needed to meet the needs of its multicultural community. We planned and implemented EDIS in less than six months, with immediate results. We have also been able to advise several other community and academic sites (including George Washington University Hospital ED) in their review and implementation of their own information systems.

The methodology for work-flow documentation, as we described in the article, is .simple and transportable—and, regardless of the specific information system used, requires only a spreadsheet and identification of roles and systems (that is, paper or computer program) used to carry out a function. One enduring lesson, as we described in the article, is that optimization of work flow, reflecting staff members’ input, must go hand in hand with implementation of any information system.

References
1.  Shapiro J.S., et al.: Implementation of an emergency department information system at an urban academic center: Results in rapid return on investment. Acad Emerg Med, in press.
2.  Melnick T., et al.: Translation of the American College of Emergency Physicians Clinical Policy on Syncope using computerized clinical decision support. Int J Emerg Med, in press.
3.  McCarthy M.L., et al.: The emergency department occupancy rate: A simple measure of emergency department crowding? Ann Emerg Med 51:15-24, Oct. 31, 2007, epub Nov. 5, 2007.

4. Hoot N.R, et al.: Forecasting emergency department crowding: An external, multi-center evaluation. Ann Emerg Med 54:514-522, Oct. 2009. Epub Aug. 29, 2009.