C-suite executives in virtually all U.S. hospitals would agree that improving care delivery while simultaneously cutting healthcare costs are the twin goals of every clinical information and documentation solution initiative. Following a 2006 report by The Institute of Medicine (IOM) that concluded there is “a national crisis in emergency care,” we have seen a large number of hospitals make IT investments for their hospital emergency department (ED).
However, to this date, a significant majority of ED physicians refuse to use the electronic charting tools provided and still rely on either manual paper charting or dictation and transcription. In a recent survey of healthcare organizations in New England, for example, physicians in more than 70 percent of the hospital EDs use either paper charting or dictation/transcription rather than rely on any type of charting system.
ELECTRONIC CHARTING ROADBLOCKS
Obstacles to adoption of electronic documentation in the ED are many and varied. The first is the drop in physician productivity that inevitably occurs due to the non-intuitive, rigid charting functionality that is characteristic of today's enterprise hospital information systems and electronic medical records (EMRs). In most cases, too much time is taken away from actual patient care in order to create, maintain, and utilize an electronic chart that does little to help the quality of care administered. Another time-related problem is that due to the non-intuitive design, extensive training is generally needed to master the charting application.
This leads to a scenario where ED physicians are being asked to learn a complex protocol and then add 20 to 30 percent more time to their workload with minimal benefit from their perspective. And while an EMR does help with their professional billing, it does not come close to offsetting the increased workload imposed on them during their shift. Furthermore, in many organizations, the quality of charting and documentation is independent from physician reimbursement. So, it's clear that there is little economic incentive for physicians to adopt electronic documentation.
If we look to improved quality of care as a sufficient motivator for doctors to adopt electronic charting, we run into other real roadblocks. Large vendors have designed electronic physician charting applications that tend to interrupt the ED workflow and force the physician away from the bedside, resulting in unhappy patients. In addition, these clinical charting applications focus on meeting billing and coder requirements but do little in collecting and presenting clinically useful information to help manage the goal of improved quality.
Lastly, hospitals have commonly opted for product selections offered by their preferred vendor rather than listening to ED physicians’ needs. What might be seen as easier selections from the CIO's vantage point lead to failed roll-outs that make care delivery more difficult and result in no discernible improvement in outcomes, efficiency, or profitability. Is it so surprising that healthcare CEOs, CFOs, and CIOs see passive-aggressive resistance from ED physicians to changing the charting process?
DELIVERING SPEED, SAFETY, EFFICIENCY
There is general agreement that speed, safety, and operational efficiency are the critical variables associated with running a successful ED. Patients entering the ED potentially have threats to life and limb and, from a clinical perspective, the faster they are treated, the better the outcome. For those patients without an underlying pathology, fast treatment improves overall satisfaction with care delivery. And, viewing the ED in terms of strict economics, the faster a physician can treat a patient, the higher the physician's hourly billable rate.
THERE IS GENERAL AGREEMENT THAT SPEED, SAFETY, AND OPERATIONAL EFFICIENCY ARE THE CRITICAL VARIABLES ASSOCIATED WITH RUNNING A SUCCESSFUL ED.
Emphasis on speed in the ED must, however, be tempered by a heavy focus on patient safety. The physician must ensure that nothing important-allergies or potential negative drug interactions, for example-is missed while delivering speedy treatment. Otherwise, the potential for creating problems downstream in the care delivery process can grow to unacceptable levels.
Finally, the financial pressures that are a constant presence for healthcare administrators mean that ED physicians must attempt to be as cost-effective as possible in their treatment choices. Speed, safety, and efficiency all pull in different directions and, if forced to prioritize, there is no doubt that medical ethics demand that patient safety is most important. But, the balance among these variables generally determines the treatment approach taken in the ED. It logically follows that clinical information systems for the ED, including electronic charting, must enable and measure these variables in order to ensure successful adoption.
STRIKING A HEALTHY BALANCE
To gain the necessary buy-in by the ED physician team of the proposed clinical information system offered, including electronic charting, one has to offer a solution that allows operational improvements and that ensures that a healthy balance of patient time versus computer time is preserved. Critical components of an optimal solution include:
Simplicity-Minimal number of clicks to learn and document everything that should be known about the patient;
Usability-Non-intrusive options and guiding tools that offer real help in documenting and managing patients;
Speed-Minimized computing time that allows for increased time at the patient's bedside (a major factor driving patient satisfaction).
The choice of providing input via keyboard, dictation, digital pen, or PC tablet should be left to the clinician rather than be pre-specified by technologists. At the Beth Israel Deaconess, we are exploring the Digital Pen technology that takes data collected on a paper form and is then uploaded to the appropriate electronic record. The chart is finished at the computer using keyboard/mouse or dictation, signed and sent to the hospital's electronic medical record repository. This has the benefit of reducing by as much as 70 percent the time that the physician needs to spend at the computer rather than with the patient.
One additional critical success factor is that the patient EMR must be designed for rapid evolution. The healthcare landscape is characterized by ongoing change in regulations, clinical practices, and information requirements. Without the capacity for change built into the EMR design, the ED system will only be optimal for a limited time period. In summary, the ideal ED system, with “ideal” meaning one that will actually be used rather than ignored, is one that is designed by ED physicians for use by ED physicians in an environment where treatment must be delivered rapidly, safely and as efficiently as possible.
A ROADMAP THAT WORKS
No matter how usable, flexible, and efficient the system, it will fail if careful thought isn't applied to ensuring adoption in the real world.
The path to success begins with getting the ED staff involved with the system selection and implementation. There should be open discussion about why change is necessary and what the healthcare organization hopes to achieve with the new system. The next critical step is to ensure that the recognized leaders within the ED are first to test, pilot, and debug the new system. Once buy-in from the leaders is achieved, acceptance by the rest of the staff usually follows fairly quickly. The people using the system must be invested in its ultimate success rather than looking for excuses to abandon it. That motivation to succeed will only happen if the clinicians have the opportunity to work with the new technology and see a positive impact on their productivity and workflow. As a result, the organization's C-level executives will see the benefits of improved productivity, efficiency, and profitability that become possible with the transition to a fully automated ED.
Richard Wolfe, M.D., is the chief of the Department of Emergency Medicine of Harvard Medical Faculty Physicians and directs the emergency department at the Beth Israel Deaconess Medical Center as well as five other emergency departments in Massachusetts and Rhode Island. Dr. Wolfe is a member of the board of Forerun, Inc., a clinically-focused healthcare IT company Healthcare Informatics 2010 October;27(10):43-44
