In this talk, I will try to sketch our vision of what the Emergency Department of the year 2005 will be like, with an emphasis on the advances in informatics that will characterize it.
This is exercise in seeing further and thinking laterally.
This is an idea talk, not a technical talk.
Most great ideas can be simply and succinctly stated.
The ideas presented here are not so great, but we will try to state them succinctly anyway. Our fundamental premise is that the next ten years will be an incredibly exciting time to be practicing emergency medicine. We will be privileged to be present at nothing less than a total transformation of our practice environment. This will be a revolutionary transformation, one that is forced by changes in the economics and organization of medicine, and one that will be enabled by the tools of information technology.
Most of the technology that will enable us to do things differently is already here, so it is not a matter of waiting for a new technological breakthrough. We need merely apply what we already have, although along the way, we will continue to see refinements in the form of tools that are faster, smarter, physically smaller, and have larger capacity.
This presentation is divided into ten bite-sized pieces.
There has been a great revolution that has occurred in our specialty in the past fifteen years, but it is extra-clinical-- the professionalization of our specialty, the establishment of training programs, and the respect with which we are held by our peers.
If someone who had worked at The George Washington University Hospital 15 years ago came into the Emergency Department today, they would think they had entered a Twilight Zone time warp and had been transported back to 1980. They would recognize almost everything, because in fact thing look not much different than they did 15 years prior. There is a locator board --a swipe board-- that dominates the department which contains key information about a patient: the patient's last name, location in the department, time in room, nature of complaint, doctor-nurse team, whether or not seen by the resident, whether or not seen by the attending physician, special information (e.g., inpatient room status), orders given and orders taken off, special information such as very abnormal laboratory results, and reminders. This board is only evolutionarily different from the board that existed 15 years ago; it has two additional fields that reflect some of the extra-clinical changes in emergency medicine practice: the patient's insurance plan and the patient's personal medical doctor.
The same thing is true with the paper chart that is being used in the GW Emergency Department. It has an expanded disposition field with space to document the specific conditions which warrant return to the ED, some clever interleaving of pages, and a place for serial observations, but it is not really very different from the chart of 15 years ago.
Of course, there are some very obvious differences in equipment. There are monitors in every room now, along with pulse oximetry which did not exist in the ED fin 1980. The CT scanner is down the hall and CT scans are a routine part of the ED work-up. There is electronic laboratory results reporting and old ECGs are now electronically accessible. An on-line information source (Micromedex) is available to supplement the jumble of textbooks. I expect that soon there will be a terminal to view digitized radiographs.
There have also been some major changes in how we handle specific clinical conditions: emergency physicians perform procedures that previously had been done by someone else (rapid sequence intubations), use new types of medications (inhaled sympathomimetics for asthma), and rely on new diagnostic tests (CK-MB). But most of this is evolutionary. The single most important diagnostic advance in the past fifteen years is probably CT imaging, and the most important therapeutic advance is probably the management of acute myocardial infarction. But in terms of the day to day practice environment, there has not been a sea change.
The next ten years will be transformative.
The driving force behind these transformations is economic.
The practice of medicine in the next ten years will be characterized by four things:
In a way completely different from the way to which we have grown accustomed, we will be held accountable for all aspects of what we do in the emergency department-- how much is our diagnostic and therapeutic management costing, how many patients are we seeing, how good are our results, and how happy are our customers.
To accomplish all this, we need better data and better process controls. The tool that will enable this is information technology.
Fortunately, what we will have is a confluence of interest between hospital administrators who control the purse strings and who recognize that information technology represents their key to the necessary reengineering of the patient care process (and therefore makes good economic sense) and those of us who recognize that new information technology makes good clinical sense, besides being exciting and fun in and of itself. Confluence of interests make for good partners.
Any patient encounter consists of three physician axes of endeavor: thinking, doing, and feeling. We think-- we obtain, filter, analyze, and synthesize information about the patient's condition. We do-- the analyzed information impels actions some of which may require specialized manual skills. We feel-- we tend to the patient's emotional state, for we are treating a person not repairing a machine.
At the level of obtaining, filtering, and analyzing information, the average emergency physician spends more of his or her time on overhead than on content. Much of what we do in the emergency department on a minute-to-minute basis is searching for data ("is the potassium back?"), moving patients into places where specialized data can be obtained ("take the patient down to CT"), recording and transcribing data ("if you didn't write it down you didn't do it"), and looking for things ("where is the chart?" "where is the patient?"). The informaticization of the emergency department will change all that.
Modern information technology is producing a revolution every bit as profound as the pringitng press. The informaticized medical record advances at multiple levels over the paper chart.
An informaticized clinical operation will provide information that is:
The practice changes engendered both by managed care and by the competitive pressures of declining reimbursement--- the increased emphasis on both resource utilization and productivity enhancement, the move towards "evidence-based medicine", and the push for a better quality product at a lower cost-- will all be built on a foundation of new information technology.
The power of available information technology is spectacular
We are starting from way back: medicine is in the veritable Dark Ages of the application of information technology compared to other industries. They are in 1995 whereas we are in 1975 with respect to the use of information technology. We will compress 30 years of change into the next ten.
Even if all that we did is to implement what other industries such as banking or the airlines have done without even applying any "new" technology, we will see vast improvements.
We are fortunate in that there exists enormous room for us to reengineer what we do to produce change for the better. It is usually the final 10% of improvements that take 90% of the time. We are still early on in the first 90% and so there is plenty of room at the top.
The core mission of emergency medicine will be the same in 2005 as it is now-- to care for patients' unsecheduled and episodic medical emergencies and urgencies on a 24 hour basis with no limitations as to severity, patient age, type of problem, ability to pay, or existing patient load.
The Emergency Department is a temple to the unpredictable and time-exigent, and because the untoward and unpredictable will always happen to people, there will always be Emergency Departments. The new information technology that we have at our disposal is enormously enabling and we will be using that technology in the service of our patients. That is the High Tech.
If the information about a patient's Emergency Department encounter is accurate, legible, up-to-date, clearly presented, if the diagnosis is accurate, the treatment correct, and the disposition approriate, and if all of this has been communicated to the patient and to the patient's physician, we will still have failed in our core mission if we have missed the human encounter that is the base on which all of this has to occur. That is the High Touch.
Technologic jumps can obviate the enormous cost of incrementally changing processes. That cost consists of of the extra-process cost of retraining and, monitoring, added to the additional intra-process cost of performing the process. Permit me two examples.
(Being cut off used to happen very frequently, but has decreased as a problem because of another technologic solution-- changing the extension to which a telephone "homes" when it is picked up from an extension that is currently "ringing" [if one is] to an unpublished and therefore "call-only" home number of the telephone set. This prevents the following sequence from happening-- Dr. A wants to make a call; he picks up an available telephone; the telephone jumps to a currently ringing incoming line; Dr. A realizes he does not have a dial tone, has no interest in talking to the person on the other end of the line, and is concerned about one and only one thing-- making his telephone call; so Dr. A. punches up a free line and in so doing cuts off the incoming call.)
Low-tech/high-tech solution: music on hold. Now the caller knows that the line is still active. We chose classical music, very pleasant and soothing. Now when the station secretary gets back on the telephone after five minutes and apologizes for how long the person waited, she often receives a "I could listen for five more".
Of course, the other half of the problem has not been solved-- how do we prevent callers from dangling on hold for minutes at a time. We tried modifying the behavior of the station secretaries. We had meeting after meeting with the station secretaries about the importance of letting no blinking light go on blinking for more than a minute. All to little avail. I am convinced the solution to this is also a technologic one-- a device which displays in a graphical manner how long somone has been placed on hold and automatically rings back after x seconds.
Our off-the-shelf technological solution -- we placed a televsion camera on the locator board and beamed the picture onto a television monitor in the triage booth. Although the resolution of the monitor was such that nurse could not read any of the information written on the locator board (including patient names), she could see if a room was empty or occupied by whether or not there was writing on the line corresponding to that room. Obviously, with a computerized patient tracking system, information about which room is free is available to everyone.
The patient locator board and its projection onto a television screen is a wonderful example of the multiple levels at which information is converyed. Information is written on the patient locator board with a blue erasable marker. At the most detailed level, there is content information specific to a given patient-- his or her complaint, orders, time in, etc. Move one level up (which is the level that the triage nurse views the locator board), and the individual words on the board cannot be read (because of screen resolution limitations), but that is not what the triage nurse is interected in. She wants to know whether a room is free or occupied, which is conveyed by whether there is or is not wiriting on a given line of the board (one room per line). At the most general level of information conveyance, with one glance at the locator board, one can get a gestalt of how busy is the emergency department by "seeing" how much "blue" there is on the board.
Consider the recording of the time that a physician sees a patient. Right now, it has to be hand written onto the chart. If the chart is "electronic", then the time that the note is written is automatically recorded, although that time does not necessarily correspond to the time the physician saw the patient. With ubiquitous computing, we will have automatic tracking of personnel, either with infrared emitters or labels or biometric recognition, and will automatically record when a physician is in the presence of a patient.
noninvasive rather than invasive monitoring
If we can assay the sodium content of interstellar gas millions
of light years away, we should be able to non-invasively assess
a patient's serum sodium. Consider how much for granted we take
pulse oximetry and the non-invasive measurement of a patient's
oxygen saturation. Ten years ago, it did not exist in most EDs.
automated rather than manual obtaining of information
Consider how the manual taking of blood pressure has been replaced
by "automatic" blood pressure measurement. This will
become the standard manner of obtianing any physiologic parameter.
With respect to a patient's "demographic" information, it already exists in some system in electronic form, and we will not need phalanxes of registration clerks asking the patient's name, address, insurance, next of kin, employer, etc. Safeway has equivalent "shopping" information on their "Safeway Card." Demographic and insurance information will already be in our system or it will be on a card that the patient has with them.
Consider the evolution from a patient writing all of his or her demographic onto a clipboard which a clerk then laboriously types into the hospital's information system to the clerk's primarily interviewing the patient and entering the information directly into the main hospital information system, to the information being already in the system or on the patient.
multiple rather than single representation of information
Much time is wasted looking for the single source of information
in the Emergency Department. "Where's the chart?"
With an informaticized operation, a patient's clinical information
can be accessed simultaneously by multiple cardgivers (with no
lag time in availability once it is generated).
fewer people involved in the chain of information generation
Consider what happens when a physician wants to know the serum
potassium of a patient. He/she writes an order. The station
secretary (ward clerk) inputs the order into the computer system
and generates a label. The nurse draws the blood. The nurse or
ward clerk puts it in the pneumatic tube system or hands it to
an orderly who runs it to the laboratory. The accessioning clerk
processes the specimen. The laboratory technician runs the specimen.
Hopefully, the result is automatically input from the laboratory
assay machine into the clinical information system. The Emergency
Department of 2005 will have point-of-service laboratory testing
(either noninvasively or invasively) with a nurse or laboratory
technician handling the whole transaction.
single rather than redundant entry of information
Because all personnel involved in caring for a patient will be
working from the same distributed electronic medical record, the
inputs of one will be automatically available to all. We will
have only one "allergy" field on the chart-- not two
or three. We will likely only have one history field on the chart--
contributed to by both nurse and physician.
Furthermore, we will need to record/document/write anything only once. No more writing out on the chart the names of the medicine we are prescribing to a discharged patient and then writing the prescription. The amount of duplicate, redundant, and "macroable" recording that we do is quite large.
uniform rather than "individualized" care processes
Emergency medicine is ideally suited to clinical practice guidelines
because our interaction with a patient is time-limited and (usually)
single problem-focused. As informatics tools become more readily
available, patients will be "pluuged into" pathways
that will handle 60-70% of the patient encounters.
parallel rather than serial processing of patients
The traditional Emergency Department has a "railroad track
apartment" feel to it. Patients are processed serially through
registration, triage (or triage, registration), clinical area,
x-ray. The system works fine for a steady stream of some optimal
number of patients when all components of the system are working
at maximal capacity and no one is in the queue. What happens
when the stream is not steady or the numbers not optimal is that
some personnel are not productive ("sitting around doing
nothing") while others (eg. registration or triage) have
a long line of patients waiting to be processed. The system has
no give in it. There is neither polyvalency of personnel nor the
sense that there can be multiple entries for a patient into the
care system and that the things that must be done to a patient
(registration, intial nursing assessment, physician evaluation)
need not be done in a rigid order nor in only one specific physical
place.
Modern information technology will free us from the physical locus constraint of where processes are done. The process of registration can occur in the "clinical arena", i.e. at the bedside; the process of physician care can occur in the "triage/registration" area.
Consider how you spend your time during a busy shift: looking for charts, tracking down laboratory results, looking for someone (patient, staff), rewriting information.
Or consider the process of clinical research with its laborious manual extraction of data from paper charts. One half of the minifellowship projects in last year's residency program at GW were 90% data collection and 10% data analysis. The data collection part could/should have been done in one hour.
If we keep our core mission in the forefront of our consciousness, we can measure everything we do by whether or not it is in the service of that mission. This will require an exercise in lateral thinking; unfortuntely we are all prisoners of current paradigms. Much of what we do is because "that's the way it was done", processes designed long ago to solve a problem that either no longer exists or whose solution is much easier and cheaper with new tools that are available.
One way of beginning to construct the ED of 2005 is to imagine that all the information that is needed to take care of a patient is available instantaneously. Everything we currently do in order to obtain, look for, transmit, acquire, and process information is eliminated. This frees us to focus on the core processes of care-- the interpretation and analysis of data, the decision of what to do for the patient, the doing of it, and the tending to the patient's emotional and human needs-- and design our processes to accomplish that. Then we add back those processes that are necessary today for us to obtain information on a patient which of course are not instantaneous (at least not now), although will be moving in that direction in the future (consider the how much time and effort was expended to obtain information about a patient's oxygenation prior to pulse oximetry).
In the current paper system, medical record privacy is protected both by the inefficiencies of the system and by locality constraints. Electronic medical records will change that. This is not to say that someone who is not authorized could not currently gain access to a medical record, but the current system relying on voice, person, or place recognition and the secret knowledge of how to access that record makes it difficult. And although it is now very easy to fraudulently access one paper medical record, it would be impossible to access millions. This privacy/security/access problem is a very real one but it is soluble given combinations of security and password protecction (something you know, something you have, something you are).
Another example. Many times, a patient's clinical condition declares itself at hour four or five in his or her Emergency Department stay. The reason that the patient is present in the ED for five hours is not because of any conscious physician desire to observe the patient, but rather becuse the inefficiencies of the system prevented an earlier discharge. As we become more efficient, we will need to more explicitly request "observation" time of a patient, lest something untoward happen after a premature discharge.
Consider the lesson from the airline industry on progress from a person and paper system to an informaticized computer reservation system.
In the old days, ticketing was manual. You called your travel agent for a reservation and your travel agent called the airline who then reported whether or not a seat was available and assigned you one if requested.
Now that airline seat registration has become computerized, the paper that it generates has become the new bottleneck. You may have a reservation, but you must stand on line to obtain your ticket. This is in effect a fractal of the previous problem of getting a seat.
Its solution-- paperless ticketing. You are now assigned a pin # which when combined with your identification (i.e.something you know plus something you have) gets you onto the airplane.
This topic always generates a lot of heat and smoke from those who fear the threat to privacy and to security, but when the smoke clouds are blown away, there is very little fire to worry about. Unfortunately, there is not time today for an adequate discussion of the problems and the solutions, but suffice it to say that we believe the distributed electronic medical record is already a reality, and that it will become natural and ubiquitous over the next few years.
Mark Smith
Craig Feied
January, 1996