Throughout the United States, emergency department information systems (EDISs) have been developed in an effort to reduce medical errors. These systems are becoming a significant focus of both federal legislation and healthcare reform. “EDISs are an important component of the movement toward improving quality and outcomes with electronic health records,” explains Kevin M. Baumlin, MD, FACEP.
Many types of electronic systems perform various functions for EDs throughout the country, but variations in EDISs can impact physician decision making, clinician workflow, communication, and the overall quality of care and patient safety. The common perception is that EDISs may ultimately improve the quality of medical care delivered in hospitals. Unfortunately, as they are currently configured, these systems also present important threats to healthcare quality and patient safety.
The Pros & Cons
The purpose of EDISs is to decrease practice variability and improve system reliability. “These systems are designed to enhance communication among healthcare providers, facilitate the retrieval of past information, and assist in clinical decision-making,” Dr. Baumlin says. They can help make medical references easily accessible, assist with important calculations, and monitor for potential adverse events. Some have the potential to share medical information across health systems and may help identify epidemics early. The perceived advantages of EDISs are so significant that Congress allocated nearly $30 billion to build incentives for EDs to universally adopt them through the American Recovery and Reinvestment Act.
The rush to capitalize on the government’s investment for EDISs, however, led to some unfortunate and unintended consequences. Vendors for EDISs are making efforts to meet new demands by clinicians, healthcare administrators, and government, but the uniqueness of the ED environment presents significant challenges. “EDs must deal with rapid turnover, frequent transitions of care, constant interruptions, and variations in patient volumes,” says Dr. Baumlin. If EDISs are poorly designed or implemented, it can be difficult to communicate effectively within the system (Table 1). These factors (and others) make EDs particularly error prone and should be considered carefully when selecting and implementing an EDIS.”
According to Dr. Baumlin, EDISs should be designed to match perceptions and decision making as well as task- and user-specific properties of work. Dr. Baumlin was a co-author of an analysis in Annals of Emergency Medicine, in which two physician work groups in
the American College of Emergency Physicians assessed the potential harms that can result from implemen-ting EDISs. The authors also made recommendations for users and vendors on how to improve patient safety (Table 2).
“Several common pitfalls have emerged in studies with regard to EDIS implementation,” says Dr. Baumlin. “These include communication failure, poor data display, wrong order/wrong patient errors, and alert fatigue. We developed seven recommendations for EDs using any type of EDIS with these pitfalls in mind. Some recommendations were directed specifically at EDIS vendors, whereas others were aimed more toward users. By following these recommendations, it’s hoped that both patient care and safety will improve with EDIS use.”
One of the most important recommendations in the analysis by Dr. Baumlin and colleagues is the need for emergency providers to actively participate in decisions about EDIS selection. “Providers in the ED should be involved in processes relating to how these systems are implemented and in monitoring their successes and failures,” says Dr. Baumlin. “Clinicians with a stake in the EDIS should dedicate a sufficient amount of time to the cause.”
Each ED should appoint a department clinician champion who will oversee efforts to improve EDISs, encourage widespread collaboration, and disseminate information from lessons learned along the way. The EDIS clinician champion serves as a liaison between ED clinicians, vendors, information systems staff, and ED or hospital leadership. “These clinicians should also be instrumental in developing a multidisciplinary EDIS performance improvement group,” adds Dr. Baumlin. “This group should meet and communicate regularly with ED and hospital leadership.” In addition, prospective risk assessments should be conducted regularly.
The Long Haul
No EDIS is perfect, says Dr. Baumlin, and adopting these systems is difficult. “Despite the chal-lenges, there are many ways to optimize the implementation of EDISs. The recommendations developed by our work groups should be paired with those issued recently by the Institute of Medicine (IOM). The drive toward EDIS implementation will be ongoing and must be accompanied by a constant focus on improvements and hazard prevention. Our analysis and the recommendations previously released by the IOM can help create a framework for maintaining this focus. They should be studied by EDs nationwide to ensure patient safety with regard to EDISs.”
Readings & Resources (click to view)
Farley HL, Baumlin KM, Hamedani AG, et al. Quality and safety implications of emergency department information systems. Ann Emerg Med. 2013 Jun 21 [Epub ahead of print]. Available at: http://www.annemergmed.com/webfiles/images/journals/ymem/FA-5534.pdf.
Strom B, Schinnar R, Aberra F, et al. Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial. Arch Intern Med. 2010;170:1578-1583.
Handel DA, Wears RL, Nathanson LA, et al. Using information technology to improve the quality and safety of emergency care. Acad Emerg Med. 2011;18:e45-e51.
Kellermann AL, Jones SS. What it will take to achieve the as-yet unfulfilled promises of health information technology. Health Aff (Millwood). 2013;32:63-68.
Yackel TR, Embi PJ. Unintended errors with EHR-based result management: a case series. J Am Med Inform Assoc. 2010;17:104-107.