Keith Conover, M.D.
Information Systems Coordinator
Mercy Hospital of Pittsburgh
Department of Emergency Medicine
This document provides both general and moderately specific specifications for the Department of Emergency Medicine electronic medical record. This version concentrates on the tracking portion of this electronic medical record system and integration with existing electronic applications: Logicare Checkout Level I discharge instructions and Kurzweil VoiceEM voice dictation physician charting.
Interface design for the charting and tracking systems must be a dynamic process with feedback at all stages.
The first phase shall be a system for tracking patients by name, location, diagnosis, and a few important times. Later phases shall implement additional functions.
Regardless of how the system is implemented, it must meet the following general requirements:
Whatever system we set up must not take more time than what we do now, unless there is a great benefit from it. Any decrease in the efficiency of the Emergency Department will require either (1) additional staff, or (2) a decrease in the quality of care offered by the Emergency Department. Times for data entry shall be similar or better to that offered by existing similar systems, and similar to existing times, to be acceptable.
There shall be no duplication of any data entry; nothing shall be entered twice. All computer systems shall connect together. An example applicable to our present system is that we shall not have to enter the name into the Logicare Checkout system when generating discharge instruction. We shall be able to just use the cursor or a mouse or a finger to pick the right patient from those currently registered in the department.
People doing data entry should have benefit from it, so they have a good reason to do it and to do it well. An example is of a PIA (Emergency Department clinical secretary) entering the time of admission and where to. PIAs often must answer calls about patients who have been admitted, and thus they have an investment in having up-to-date information in the computer.
We shall be able to get needed information wherever we are: Emergency Department, office, Emergency Medicine Association of Pittsburgh office down the street (our emergency physician group), or at home. This is primarily for quality management and other administrative information, but occasionally a patient calls with a problem and we need clinical information from these other locations. This incudes modem access (which is already available through the hospital's network server modem pool).
To use a phrase from Bill Gates of Microsoft, we need "information at our fingertips" for research and follow-up. It shall take little effort and little training and little time to find the information right when we need it. Many of our staff rotate in the Emergency Department from other facilities, and sometimes from other countries.
Our tracking system shall be the front end for our ED computer system. It shall tie together our other applications. It must export and import data to other ED applications (Action 2000, Protouch lab reporting system, Logicare Checkout Level I, Kurzweil VoiceEM). Equally important, the tracking system's interface will provide entry to other applications. For instance, selecting a patient from the tracking system, and then picking the "discharge instructions" button shall bring up Logicare Level I with the patient's name and medical record number already entered. When a user exits from generating a discharge instruction from Logicare Level I, the tracking system shall flag that discharge instructions are prepared, as well as sending a copy to the patient's electronic chart.
The Department of Emergency Medicine currently uses two major computer systems in its daily documentation activities, and any tracking system must either (1) interface seamlessly with them, or (2) completely replace them with adequate substitutes.
The first system is Kurzweil Applied Intelligence's Voice-EM voice-dictation charting system. This is currently used by attending physicians for charting. To interface properly, the tracking system shall feed Kurzweil basic demographic information (patient name, medical record number, visit account number) and then take back a completed medical record, along with an appropriate electronic signature, and pass it to the hospital's electronic chart. The tracking system shall pass information about labs ordered to Kurzweil, and the physician shall be shown the labs and prompted by Kurzweil to comment on each lab, as is required.
Voice dictation is not an adequate substitute for the Kurzweil system because (1) it does not prompt the user for pertinent negatives when charting, and (2) the delay in receiving dictated charts is unacceptable for attending notes unless a transcriptionist is sitting in the Emergency Department typing in real time, and we have found such a system prohibitively expensive.
At present, attending physicians in the Pediatric Emergency Center do not use the Kurzweil system. We expect them to start using the system once we obtain funding for a fourth Kurzweil station for the Pediatric Emergency Center, which we have not yet been able to do.
The second system in general use is the Logicare Checkout Level I program for generating discharge instructions. We now mandate that every patient discharged from the Emergency Department receive written discharge instructions, and 99% of our discharge instructions are generated by this program. The discharge instructions form part of the medical record, and so the tracking system must absorb these from the Logicare program. The tracking system shall also export demographic information to Logicare so that the generated discharge instructions can be matched up with the appropriate medical record.
In some Emergency Departments, a status board can be replaced by a single large display board (e.g., a large LCD display). However, in our department, a single large LCD display would not be visible from many parts of the department. It also raises questiona of patient confidentiality. An attractive alternative has been suggested: have a status board display function as a sort of "screen blanker" for all monitors in the department. If no other application or application module has been used for a few minutes, the status-board-screen-blanker appears. Or, users could switch to it on demand, if they wish.
The status board would serve two main functions. First, it would display information about all patients currently registered in (or recently discharged from) the Department of Emergency Medicine: where they are, what their chief complaint is, what their current status is; with colorful flags for conditions requiring attention.
As with Cybermedix Inc's "Cliniplex" system, specific distinctive graphics icons could represent status: Waiting for nurse, Waiting for doctor, Waiting for lab tests, Waiting for X-rays or in X-ray, Waiting for Consultation, etc.
Our status board interface shall provide the following:
Sometimes, data elements (described below) combine, in real-time, to indicate an urgent or emergency condition that should be addressed immediately. The tracking system shall, in real-time, alert Department of Emergency Medicine staff to these conditions. The tracking system will let us know when all labs and X-rays are back, and a patient is just waiting for disposition. Dangerous levels on laboratory tests shall immediately show a striking visual indicator on the status board. When labs are overdue, another type of visual display shall notify us so we can check with the lab and see why it is delayed.
For certain data elements, a continuously-updated report is central to efficient Emergency Department function. At present, the location of the paper chart indicates a variety of conditions. The number of charts in the "need a room" box tells us how meny patients are in the waiting room waiting to be seen (assuming the triage nurse is keeping up).. The number of charts on the counter shows how many are in a room waiting to be seen by a physician. The number of charts in the "secretary to enter" and "nurse to do" boxes indicate how many patients have labs that need to be entered by the PIA (clinical secretary), and which and how many patients have physician orders the nurse needs to complete. To be equivalent to the present system, the system must permit a single glance from anywhere in the Emergency Department to give this information.
The following data elements must be captured by the system, and become part of the medical record. All are vital parts of the record for both medical and legal reasons. Items with an asterisk* shall be implemented in the initial phase.
We need to be able to determine DEM volume on different bases: hourly, by numbers and percentages of admissions to different units, by type of discharge, by acuity, by type of diagnosis. In particular, we must compare of our care to practice standards, such as the ACEP clinical policy on chest pain. We need to be able to easily select visits for QA purposes, e.g., "list all patients with chest pain from last month." We must be able to do this with no assistance from MIS, and using untrained personnel.
We need to be able to identify: all Internal Alert patient records; whether the Internal Alert was for a trauma or for something else; whether the Internal Trauma alert turned into a full trauma-team trauma; and any Internal Alert trauma patients readmitted soon after discharge.
The Department of Emergency Medicine is doing more and more bedside testing: urinalyses, pregnancy tests and strep tests at present, and more planned for the future. As with the clinical lab, these tests need to be entered into the tracking system and available electronically.
This will allow us to review these tests for quality improvement programs. For instance, we are now sending every fifth urine to the lab to check against our Department of Emergency Medicine urinalysis. The tracking system shall make this easy for us. We will be able to painlessly identify all urinalyses or other tests done in the Department of Emergency Medicine by day, week, or month.
Department of Emergency Medicine attendings must enter a wet reading of every X-ray. This shall be entered electronically, at the X-ray reading board, with an alternate entry point in the X-ray tech's room for when the X-rays on the board are being read by the radiologist. The radiologist shall be able to immediately review all clinical information for any X-rays, and shall be able to electronically flag X-ray discrepancies for immediate attention by Department of Emergency Medicine staff. Eventually, the DEM attendings' wet reading shall be entered only one time, which attaches to the chart as well as being available to the radiologist. The attending shall be able to review the X-ray readings of resident, intern, and medical student charts, and add an attending note or correction if needed.
The same applies to cardiologists reading Department of Emergency Medicine EKGs. Unlike X-rays, DEM attendings do not enter a separate "wet reading" for an EKG; the EKG reading merely appears on the chart. Cardiologists shall have immediate access to the chart, and shall be able to flag discrepancies.
Times are vital parts of Department of Emergency Medicine charting. And time is vitally important in the care of patients in the Department of Emergency Medicine. However times are captured, it must not slow down the care of patients. Doctors and nurses shall not have to seek out a fixed terminal to enter the time of every intervention; yet, they will not be able to "save up" times and enter them later because memory is fallible and the Emergency Department environment chaotic.
Alternatives for such time entry include personal terminals (Personal Digital Assistants or "workslate" computers with radio modems, such as the new Zenith product), enough terminals throughout the Department of Emergency Medicine that access is not a problem, simple dumb pushbutton terminals in rooms and on carts in the hall, bar-code reader systems, and many others. Whatever system is implemented must be tested with good engineering technique, including stress-testing to destruction using a Saturday night with multiple cardiac arrests and drunken trauma patients as stressors.
An important part of the chart is the report turned in by prehospital providers. We must have some way to integrate this into the patient record. Standard trip sheets are used by all ambulance services, and certain demographic information is entered in machine-readable form, but the copies we get are from the back of a multi-part form and may be unreadable by scanners. The city of Pittsburgh is moving to an electronic EMS trip sheet, which should ease this process.
We shall be able to E-mail or fax selections or complete ED medical records to another facility. This could be for emergency use by the other facility, or to provide information to private physicians' offices or clinics who will be seeing Emergency Department patients in follow up. Primary physicians shall know, the next morning, that their patients were in the Department of Emergency Medicine, or that their patients were admitted. We don't necessarily call an internist when his or her patient is in the Emergency Department with a wrist fracture, but it's something the physician should know about at some point, especially if the patient is admitted. The tracking system shall automate as much of this as technology permits (including automatic faxing and email)
Likewise, we often get records from other hospitals or doctors' offices by fax (e.g., EKGs), or handed directly to us by office staff. If we are using this information clinically, it shall become part of the medical record, and we shall be able to integrate it into the record. Fax transmissions could go directly into the system, as could e-mail; photocopy records from doctors' offices or other hospitals would have to be scanned into the record.
Whatever emergency clinical documentation system we install must have provisions for disasters, including various levels of backup.
The most obvious disaster is when (not if) the computer system goes down. Despite RAID disks, fault-tolerant networks, and UPSes, systems go down. When lives depend on documentation, an alternative must be available.
What if, as happened during last winter's ice storm, we get a hundred patients in an hour or two? Our clinical documentation system must have a way to deal with the load, especially if the computer system goes down. A paper backup system is essential.
As with when the system goes down, we perhaps can switch back to paper charts and scribbled notes. We could then have transcriptionists later review all these charts and try to transcribe them, keeping scanned originals on file for reference. Or, perhaps some other system would suffice.
Regardless, the system must provide explicit procedures for such disasters, and these must be developed in concert with any tracking system vendor.
(N.B.: the following is not part of the tracking system we expect from a vendor, but a separate charting system to be developed by Mercy Hospital. Nonetheless is is described for completeness.)
Third year residents from the University of Pittsburgh Affiliated Residency in Emergency Medicine provide a significant portion of the staffing for the Emergency Department. These residents are eager to begin using the Kurzweil system. The Department of Emergency Medicine is committed to letting these residents using Kurzweil. This will not only help meet the hospital's commitment to an all-electronic medical record, but it will improve medical documentation completeness and legibility, and will serve important educational needs for the residents.
Attending physicians and third-year emergency medicine residents will have enough training and experience to use the Kurzweil system. By adding a sixth station and providing training to residents we could include second-year emergency medicine residents in the Kurzweil system. However, we have many first-year residents (interns) and medical and Physician Assistant students rotating in the Department of Emergency Medicine.
Interns and medical students are responsible for documentation on all patients that they see. Charts must have an attending note added.
We cannot change the system to make an attending responsible for charting for patients seen by interns and medical student. Doing so would require a large increase in attending staff coverage, and would cost roughly one or two million dollars a year.
Unlike emergency medicine residents who spend considerable time in the Mercy Emergency Department, most interns and students rotate in the Department of Emergency Medicine for only four weeks. This is not enough time to allow them to learn how to use the Kurzweil system and begin to use it effectively.
An alternative is to use rapid-turnaround voice dictation with transcriptionists typing the dictations and returning them electronically to the Emergency Department. However, unlike on the floor, the current system is that an attending physician reviews the intern or medical student chart for accuracy and completeness prior to the patient's discharge. This allows the attending physician to review the workup for completeness. The attending can then direct the intern or medical student to perform studies or physical exam items to complete the workup. This must occur prior to the patient's discharge. You can't go back and do another physical exam item on someone who isn't there any more. Therefore, any such transcription system must have a short turnaround time.
Time from arrival to patient discharge is one of the most critical measures for how many patients the Emergency Department can see. Delaying patient discharge to wait for a transcriptionist to complete a chart will slow down the number of patients the Department of Emergency Medicine can see in a given time. An average delay of even a half an hour for intern/medical student charts would probably require an expansion of the Department of Emergency Medicine physical facility, at a large cost.
Having enough transcriptionists to assure rapid turnaround of Department of Emergency Medicine charts will also be expensive. However, if such a transcription system is already in use in for progress notes on the floor, a large part of the cost is already accounted for, and the incremental cost for extra staffing to cover peak hours in the Department of Emergency Medicine will be less. One option that might be explored is the idea of home distributed processing for peak-hour transcription. Transcriptionists could have a PC at home, and be on call for emergency transcription needs. When the on-call transcriptionist gets an emergency call, he or she could download the voice dictation via a high-speed modem, type the report, and upload it via modem.
Even if we were to accept a certain delay in the transcription of Emergency Department charts, and expand the Emergency Department to account for the delay in moving patients, a quality assurance issue will arise. Time to discharge of Emergency Department patients is one of the most critical factors for patient satisfaction. (If you go to the Emergency Department for a badly sprained ankle, and you're all ready to go home at 1·AM, do you want to wait until 2·AM for the chart to be typed?)