Abu N.G.A. Khan
• Electronic Health Records (EHRs) are evolving as an integral technology for use in medical practice. They have the potential to improve quality and safety in modern health care, and reduce cost.
• “Meaningful use” is the set of standards, defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that must be met by eligible providers and hospitals to earn incentive payments.
• Clinical decision support (CDS) is an important element in improving healthcare delivery. It is also a measure of “meaningful use.”
• The emergency department electronic medical records (ED EMRs) should be integrated with the hospital EHR, preferably as different faces or displays of the same EHR system.
• The ED EMR module must have additional special features to optimally match the workflow of the ED, including a dynamic status board and ability to create a chart quickly.
• ED EMR documentation for teaching physicians must comply with CMS regulations.
• The ED is a 24/7 dynamic service. It is important to have a clear down time policy and procedure in case the system fails partially or completely.
• There is a large gap between the postulated and empirically demonstrated benefits of eHealth technologies. It is vital that future eHealth technologies are evaluated against a comprehensive set of measures.
Implementation of potentially transformative electronic health technologies are underway both nationally and internationally, often with significant impact on national expenditures. The US Federal Government committed to a $38 billion eHealth investment in health care. Similarly, England invested at least £12.8 billion in the National Program for Information Technology (NPfIT) for the National Health Service (NHS).1
Such large-scale expenditures have been justified based on the belief that technology can help address the problems of variable quality and safety in modern health care through the use of electronic health records (EHRs), picture archiving and communication systems (PACS), electronic prescribing (ePrescribing), computerized provider (or physician) order entry (CPOE) systems, and computerized decision support systems (CDSs). However, there is a gap between the postulated and empirically demonstrated benefits of eHealth technologies. Despite being frequently promoted by policymakers and “techno-enthusiasts,” there is little convincing research demonstrating that these technologies are cost effective. To maximize the likelihood of successful implementation and adoption of an electronic system, these assessments should pay careful attention to sociotechnical -factors that occur throughout all stages of a technology’s life cycle.2
ELECTRONIC MEDICAL RECORD VERSUS ELECTRONIC HEALTH RECORD
The electronic medical record (EMR) is an application environment, composed of clinical data repositories, clinical documentation, CDS tools, controlled medical vocabulary order entry, and pharmacy systems. This environment supports the patient’s EMR across both inpatient and outpatient settings and is used by healthcare practitioners to document, monitor, and manage healthcare delivery within a care-delivery organization. The data in the EMR is the legal record of what happened to a patient during his or her encounter at the organization and is owned by the organization.3,4
The EHRs, do everything an EMR does and more. EHRs focus on the total health of the patient—going beyond the standard clinical data collected in the provider’s office. They are inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collects the information. The National Alliance for Health Information Technology stated that EHR data “can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.”5 They are built to share information with other healthcare providers, such as laboratories and specialists, so they contain information from all clinicians involved in the patient’s care.
THE BENEFITS OF EHRS
• With fully functional EHRs, all members of the team have ready access to the latest information, allowing for more coordinated, patient-centered care.
• The information gathered by the primary care provider informs the emergency department (ED) clinician about the patient’s significant medical history, so that care can be adjusted appropriately, even if the patient is unconscious.
• A patient can log on to his own record and look for trends in his laboratory results over the last year. This information can then be used as a source of motivation for the patient to take his medications and keep up with lifestyle changes that have improved laboratory values.
• The clinician’s notes from the patient’s hospital stay can help create discharge instructions and follow-up care, enabling the patient to move from one care setting to another more smoothly.
The Office of the National Coordinator for Health Information Technology (ONC) exclusively uses the term electronic health record or EHR.6
The ED EMRs should be integrated with the hospital EHR, preferably as different faces or displays of the same EHR, so that the ED encounter information flows into the inpatient record, if the patient is hospitalized, or into the primary care office record, if the patient is discharged.
THE PROCESS OF EHR IMPLEMENTATION
The road to EHR implementation is paved with incentives and challenges.4,7–9 Successful EMR implementation requires careful consideration of the following points:
• EMR/EHR system selection is the biggest decision that needs to be made, but most often, this decision is made on an administrative level above the ED. The EHR Report 2012 published by Medscape gives an overview of commonly used EMR systems in the country for different practice sizes.10 Since the ED is a 24/7 service, it is important to consider the cost of system downtime: How often does the system go down (how reliable is it)? Is periodic downtime required for maintenance or upgrades? What kind of back-up options are available?
• Implementation and ongoing governance of the EMR should include input from clinical staff and physician champions.5,11–13
• There are two major strategies to implementing an EMR: the big-bang approach and the phased, or incremental, approach. Each strategy has pros and cons that must be considered.14
• Expect a temporary decline in provider productivity when the EMR is first implemented and develop a plan that addresses concerns about patient throughput. With a good system and good training, pre-EMR throughput should be restored within 2 to 6 weeks depending on the size of the ED.
• Training is perhaps the most important part of the EMR implementation process.
• Some hardware issues to consider include the use of thin clients, PCs, laptops, tablets, touch screens, screen sizes, printers, voice recognition, wireless networks, wired network port locations.
• Security issues to consider include the location of unit displays, formal login procedures, timed logout after a period of inactivity, number of simultaneous logins permitted, and system access on personal (nonhospital) devices.
MEANINGFUL USE OF EHR
EHRs can provide many benefits for providers and their patients,15–17 but the benefits depend on how they are used. In 2009, the Federal government provided the healthcare community with a transformational opportunity for progress. The Health Information Technology for Economic and Clinical Health Act (HITECH) authorizes incentive payments through Medicare and Medicaid to clinicians and hospitals for using EHRs privately and securely to achieve specific improvements in care delivery. “Meaningful use” is the set of standards, defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs that must be met by eligible providers and hospitals to earn incentive payments. The goal of meaningful use is to promote the spread of EHRs to improve health care in the United States. Meaningful use stages of achieving more advanced EHR functionality. To achieve meaningful use and earn the incentive payments, eligible providers and hospitals must adopt certified EHR technology and use it to achieve specific objectives at each of three stages over 5 years from 2011 to 2016. Details about meaningful use and the incentive programs can be reviewed at the CMS17 and Health IT website.18
EHR AND CLINICAL DECISION SUPPORT
CDS is an important element in improving healthcare delivery. Given the dramatic variation in healthcare cost from one location to another,18 prompting physicians with standard-of-care guidelines at the point of care (an example of CDS implementation), may go a long way to normalizing how health care is delivered across the country. CDS is also a measure of “meaningful use,” and the integration of CDS into EHRs is a certification requirement. CDS tools can take many forms. The simplest form is a pop-up alert informing physicians about drug–drug and drug–allergy interactions as they generate prescriptions or medication orders. CDS can also consist of a dashboard prompt that is tightly linked with clinical quality measures (CQMs). For example, while looking through the record of a woman who presents to the ED for an episode of acute respiratory distress, the clinician is prompted that she is a diabetic and that her most recent glycohemoglobin (HbA1c), performed 10 months ago, was 8.3%. In this case, the visual prompt is the CDS, and it immediately informs the clinician that the patient has poorly controlled diabetes and is past due for follow-up. In addition, efficient use of the CDS would mean that the prompt not only displays the A1C result (a CQM-derived finding), but also the targets and standards of care in this situation.
Furthermore, the presence of clinician resources can offer review-based decision support that can be quite valuable.
QUALITY AND SAFETY OF EHEALTH CARE
There is a growing consensus that widespread adoption of EHRs is essential to achieving many of the healthcare goals set by the United States, including improved care quality and patient safety. The Committee on Quality of Health Care in America of the Institute of Medicine notes that healthcare organizations should expect any new technology to introduce new sources of error and should adopt the custom of automating cautiously and be alert to the possibility of unintended harm.3 As Sir Cyril Chantler of the King’s Fund said, “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”19 There is a lack of robust research on the risks of implementing these technologies. Many of the clinical claims made about the most commonly used eHealth technologies were not substantiated by empirical evidence.20–24
It is vital that future eHealth technologies are evaluated against a comprehensive set of measures. The Institute of Medicine (IOM) recently published a report to address this issue. National EHR-related patient-safety goals need to be created to address the current problems known to occur during the implementation of existing EHR systems and the failure to leverage current EHR capabilities.25
SPECIFICS OF ED EMR SYSTEMS
ABILITY TO CREATE A RECORD FOR THE PATIENT
The ED is unique in that the number of new patient registrations is high, none of the patients are expected, and all of them must be registered quickly. Many EMRs designed for inpatient and primary care use rely on registration occurring first, followed by patient care charting. In the ED, the EHR must be able to initiate patient care before registration is completed (often in high volumes). A compromise is a “Quick Registration” option. This option can be used by a triage nurse, or a registration specialist at the triage desk, who enters the patient’s name, age, and sex to generate a visit ID. Subsequently, if the patient has a previous record, a registration specialist should be able to identify this patient in the hospital record system. The registration is then updated and completed. For new patients who are not in the system, a new registration will need to be created. Registration is a complex process that must be entered by a registration specialist and is not a task that should be allocated to a nurse.
The identification of an existing patient record is not a simple task. Other patients may have similar names, and occasionally, a patient may have multiple names or more than one medical record number in the system. Birthdate and sex may be entered incorrectly in the system. The addition of third-party payer information during the registration process (such as medical insurance, workman’s compensation, automobile collision insurance, travel insurance, etc.) further complicates the financial aspects of registration. Patient consent, parent consent, consent for minors brought in by caretakers other than parents, emancipated minors, etc. make the consent issue complex as well. None of these complexities should delay the triage and emergency care process.
Patient status boards are electronic tracking boards used to assess multiple patients simultaneously. By updating patient tracking information automatically from the clinician documentation system and through interfaces with other ancillary departments, status boards play an important role in coordinating and communicating about patient care in the ED. They allow for comprehensive real-time views of the ED. The latest patient information (status, acuity, length of stay, chief complaints, etc.) is displayed for ED staff to view. The status board allows for easy navigation to other modules: documentation: reviewing and updating orders, accessing work lists, obtaining laboratory and radiology results, etc. The status board should be the first window that opens after logging in to an ED EHR. Customizable views for users and the ability to write communication or handoff notes are extremely helpful for complicated patients and patients who remain in the ED for a longer period of time.
Ideally an ED should have multiple password protected status boards targeted to the practice and needs of different levels of staffs. A physician status board should display the charted data and relevant information needed for patient care by the physician. A charge nurse view should display patient flow information for managing ED bed status with flags for patient acuity level and orders that require action. A clinical nurse view can show all the new orders, prompts for reassessments, and repeat doses of medication. This view needs to be integrated with the nursing worklist and flow sheets, so that there is no need for a duplicated data entry. A vital signs (VS) status board can display VS data of all patients to be viewed and updated. A radiology status board can alert the technician when a new order is placed and contain information on the location of the patient and type of the study, etc.
ED status boards can be used as a means for improving care by providing timely reminders for checking VS, reassessing pain, administrating medication, and performing other interventions. They can also flag isolation status, return of laboratory results, critical laboratory values, status of bed request for admitted patient, etc. Research assistants can also use the ED status board to identify potential patients for enrollment in various ED studies.
Notably, the ED status boards should not be confused with the ED display board. The ED display board is often displayed in the middle of the ED on large screen display viewable from a distance and is used primarily for ED flow. In comparison to the ED status board, the ED display board information can potentially be viewed by patients walking by; thus, the information displayed must not breach patient privacy.
STRUCTURED NOTE: A SINGLE WINDOW VIEW OF MOST (PREFERABLY ALL) OF THE INFORMATION
This is necessary, so that physicians have the opportunity to read entries from nurses, students, residents, and other staff. It should ideally proceed in a top-to-bottom vertical sequence. The triage note is at the top, followed by other notes. The physician scrolls down to the next open point in the note at which point the physician begins to chart. If the physician opens the record again, the notes entered since the last physician notes are arranged vertically, so that all notes can be reviewed. EMRs are developed for inpatient medicine (i.e., prolonged hospital stays), which require the record to split into sections such as VS, nurse notes, physician notes, orders, laboratory tests, imaging, respiratory therapy notes, physical therapy notes, etc. Such an arrangement does not facilitate optimal emergency care. A structured note should include the nurses triage note, residents/student/NP notes, VS, POC test results, pain score, outpatient medications, allergies, immunization status, orders entered, laboratory and radiology findings, reportable conditions, and current working diagnoses. In addition, the note should allow the clinician to enter orders, write a prescription, access patient education materials, and write excuse notes, etc. without having to close the note and open another window. To expedite the data entry, a single note should incorporate the flexibility to use one or multiple means of data entry (i.e., checkboxes, free text boxes with acronym expansion, and advanced templates with tokens to run scripts to import relevant clinical data such as past medical history, VS, chief complaints, health issues, allergies, current medications, etc.). The use of voice dictation for rapid data entry, medical dictionaries with autocorrect support, using software clipboard features, ability to find previous notes, previous laboratory results, consult notes written by other providers during documentation, can help improve quality and efficiency of documentation. All documents created in an EHR must be signed off using a password to prevent inadvertent documentation in another person’s log in. To avoid the documenting in wrong patient, it is also important to restrict data entry to one patient at a time.
VIEWING LABORATORY INFORMATION
The ability to see laboratory results in the main window or via a single click or keystroke to a different window is useful in permitting the emergency physician to view laboratory results rapidly and conveniently. All critical laboratory values must be reviewed before making a disposition plan of an ED patient. Using a hard stop in discharge or disposition order if there is a nonreviewed critical laboratory or radiology value in the chart can ensure this. However, for the chronic patient, similar to inpatient systems, it is also important to be able to view laboratory results in a flow sheet format, to see trends. It may require multiple clicks to explore and review results in these chronic patients.
Charting for teaching physicians must comply with regulations. Although a teaching physician could simply confirm most of the things that were done by the trainee, it is often not clear exactly what was done by the trainee versus the teaching physician, and when these actions were performed. Electronic audit trails can identify which physician entered information, but these audit trails are not visible to most users of the EHR, such as billers, coders, and peer-review personnel. One suggestion has been to create a separate note section in a structured physician note where the trainee physician writes his history of present illness (HPI), physical examination (PE), and decision-making thoughts. Subsequently the attending physician should review them and write an attestation statement and his assessment and plan (Fig. 153-1). As per the 2011 CMS guideline,26,27 the teaching physician may use a macro as the required personal documentation if he or she personally adds it in a secured or password protected system. In addition to the teaching physician’s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the EMR must sufficiently describe the specific services furnished to the specific patient on the specific date. If both the resident and the teaching physician use only macros, this is considered insufficient documentation.
FIGURE 153-1. Sections of a structured Resident/Attending note: Note: The separate section for attending after the resident’s note, protected by document security rights to prevent editing the attending sections by the resident and vice versa. Attending can review resident’s note and then either just agree with resident’s note using a script or write his free text note or both.
MEDICAL STUDENT CHARTING
Any contribution and participation of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements. As per CMS guideline,27,28 a medical student may document services in the medical record; however, the teaching physician may only refer to a student’s documentation of an Evaluation and -management (E/M) service that is related to the ROS (review of systems) and/or PFSH (past, family, social history). If a student documents E/M services, the teaching physician must verify and redocument the history of present illness and perform and redocument the physical examination and medical decision-making activities of the service. One suggestion to overcome the obstacles to medical student documentation has been to create a separate structured note with duplicate sections of HPI, PE, and decision-making with password protected security rights in each section, so that a student cannot document in the attending section and vice versa (Fig. 153-2). This gives the medical student the opportunity to learn proper documentation and the attending can use the ROS and PFSH sections as a part of his own note to create a billable service note.
FIGURE 153-2. Sections of a structured Medical Student/Attending note: Note: There are duplicate sections in HPI, Physical Examination, and Medical Decision Making (assessment and plan) for the medical student and the attending, protected by document security rights to prevent editing the attending sections by the student and vice versa.
COMPUTERIZED PHYSICIAN ORDER ENTRY AND ORDER SETS
A key component to adaptation of EHRs and achieving meaningful use is CPOE. CPOEs depend on robust order sets that are arduous to develop and need continual revisions to keep abreast of newer pharmacological agents and evolving standards of care in respective specialties. Creating evidence-based order sets for common ED problems could significantly improve speed of care in the ED and can help promote evidence-based practice. For the pediatric population a built-in Pediatric Dosing Table (PTD) has a tremendous role in safe practice. If built properly, PDTs have the potential to reduce common medical errors in drug dosing. PDTs can help to reduce the cognitive load experienced by an ordering physician during an acute and stressful situation in the ED. Physicians no longer need to remember, or search for, the dose of a medication and calculate it manually. Since some of the drug doses could be very different in the ED than the inpatient and outpatient services, in a hospital-wide EHR system, it is crucial to have a customized PDT table for ED-only use.
THE DISCHARGE INSTRUCTIONS SHEET
The discharge prescription should be created and documented in the EMR and printed (physically or electronically) for the patient. The documentation of discharge instructions is essential to provide good patient care and to reduce medical–legal risk. An instruction sheet with medication administration instructions, laboratory and imaging results, and recommendations for follow-up with a patient’s primary care physician could improve compliance with healthcare instructions. In addition, it can substantially reduce medical–legal risk if the patient or parent fails to start the medication or follow-up with their physician. Ideally, this form should be handed to the primary care physician during follow-up to fully inform the primary care physician of the ED encounter details. Although in a system-wide EHR, the ED encounter details will be available for review by the primary care physician, a single page review of the printed sheet is often easier to digest the details of the ED encounter. Sometimes, paper is better.
DOWNTIME POLICY AND PROCEDURE
The ED is a 24/7 service. It is important to have a clear down time policy and procedure in case the system fails partially or completely. It is always wise to have more than one server running the system. This way, if there is a problem with one, it does not disable the entire ED EHR, and users can continue to use the system with limited functions. Stocking all the relevant paper documents in a single location (i.e., a downtime box or cabinet) to be used during downtime should include paper charts, lab radiology order forms, and preprinted discharge instructions. Make sure you have an alternate means to maintain patient care and access other hospital resources (e.g., registration database, lab, pharmacy, radiology, etc.).
Some EMR/EHR systems require periodic downtime for maintenance and upgrades while other systems can perform these tasks while the system is still operational. These scheduled downtime requirements will also affect the ED’s operations. The frequency, duration, and cost of downtime should be an important consideration during EHR selection.
In summary, ED EMRs have special needs to optimize emergency care. Ideally the ED EMR should be built into the hospital-wide EHR system as a separate module while serving the dynamic processes in the ED. The ED EMR module must have additional special features to optimally match the workflow of the ED and other specialties as well.
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