Pennsylvania ACEP -- ED Computer Conference

Tracking Component: The "Hard Question Checklist"

Here is a complete compilation of all the relevant questions I could think of related to tracking systems. I thought about doing it as a grid so you could compare systems. But then I realized that such a checksheet would be very clumsy because it would be so big, and no matter how many columns I put in, it would be one less than you needed. So you'll have to use this for now. When you really need to compare features, I think you'll find the table function of a word processor, or a spreadsheet, the best way to compare systems in detail. Get a laptop and carry it with you to each vendor, making entries as you go. On the computer, you can add or delete rows or columns as needed.

Efficiency/Data Entry/Charting

• Can one "move" patients from one area to another by a mouse drag and drop?
• If so, how many additional keystrokes or menu selections are needed?
• If not, how many keystrokes or menu selections does it take to "move" a patient, and how difficult is it to remember this procedure?
• How long does it take to find out if a patient is in the Emergency Department or nearby: how many keystrokes or menu selections does it take?
• Have you measured the time for a trained nurse to use the system, for the triage function, and for charting patient movements? If so, how much more time does using the system take than making written notes?
• Are there standardized "templates" for nurse entry of labs and studies for common situations such as cardiac arrests and major trauma situations? If so, can they be easily customized by the Emergency Department staff?
• How much staff time should be allotted for system maintenance? (e.g., 10 hours/week, 20 hours/week)
• How does the system deal with occasional users who are unfamiliar with the system, but must interact with it? (e.g., a nuclear medicine technician who brings a patient back to the Emergency Department and must log a patient back in as he returns the patient to the Emergency Department) Does the system allow anonymous logins for such use? If "returning" a patient must be performed by the nurse, and that nurse is not available when the patient is returned to a busy Emergency Department, how can that information be logged in later?
• Does the system print out relevant data, including times for all logged activity, for inclusion in the patient's permanent chart?
• How is data validated? Do users have some sort of electronic signature?
• How long can patient data stored in the system? (A month, a year, ten years?) (I.e., can you find information about a patient who was in the ED 12 months ago.) How long does it take to recall this information to the screen? How is this data protected against destruction?

Flexibility

• How easy is it for users make changes to the system? Can users only modify the data sets, or can they make changes in the program's appearance and menus?
• Who can add, delete or modify information on nurses, ED physicians, and staff physicians?
• Can staff dial in via modem to access the system if needed?
• Can the system identify patients who are covered under specific workers' compensation contracts, and provide users with specific information relevant to that contract?
• Can the system store information about hospital or department specific clinical pathways or clinical guidelines, and provide this information for patients qualifying for inclusion?

Ease of Use/Help System

• For untrained users, how hard is the system to learn?
• How many keystrokes must be memorized to use the system?
• Does the system feature context-sensitive help?
• How extensive is the help?
  • Does the help system include:
  • hypertext links?
  • a search capability?
  • an index?
  • an online tutorial?
• does the system provide popup or balloon help if a cursor is held over an icon or button for a second or so?
• Do user logins expire? If so, how long does it take, and can this expiration time be reset by a selected member of the Emergency Department staff?

User Interface

• Is the system based on text mode or does it use a standard GUI (graphical user interface)? If it uses a GUI:
• does the cursor change when one is performing different functions (e.g., dragging a patient to another location shows a wheelchair, applying a physician to a patient shows a staff of Asclepius, applying a nurse to a patient shows a large R.N.).
• Does the system provide a status bar with hints as the cursor passes over a button?
• Are the icons similar to those used in mainstream Windows or Macintosh programs?
• Does the system use color in a consistent way to indicate patient status?
• Does the system use sound in a consistent way to indicate patient status?
• What is the maximum depth of menus? (E.g., when one selects an item from a menu, how many more submenus "deep" can one get?)
• Is the user interface user-configurable (e.g., can users select between menus or toolbar icons)?
• How can one select from long lists (e.g., nurse's names, diagnoses)? Known options include typing in the name each time (unacceptable), arrow-keys+Enter (most primitive), typing the first character to move to that part of the list, typing several characters until one selects a unique entry or gets near (variants used in Logicare products and in the Quicken Windows finance program), or a standard Windows list-box control.

Status Board

• Can a glance at the predominant colors of the status board display provide an overall impression of the status of the Emergency Department? If there is a view of the entire Emergency Department as well of different parts of it, does this overall color assessment hold even if one is viewing the entire Emergency Department, rather than just a subset of it?
• Does the system require a special device for use as a "tracking board" or does it use standard (albeit large) PC monitors for this function?
• Does the system provide for a user-fill-in "notations" or "comments" field that appears next to the patient's name on the status board? If so, can this easily be edited at any point from the main status board display (e.g., a single mouse click for GUI systems)?
• Can the system provide different default screens for different parts of a large Emergency Department? If so, can one easily switch between them?
• Can the system serve as a patient-based interface to other vendor's programs, even if the tracking system includes these as options? Examples:
  • physician charting
  • nurse charting
  • discharge instructions
  • lab ordering
  • data retrieval
• How does the system help enforce patient confidentiality while still making status information readily available to staff?
• Does the default status display show the following, and if so does it show it by number or letter (text) or by changing-color or multiple icons (graphics)?
  • how many patients are waiting to be seen
  • how many are in a room waiting to be seen by a physician
  • which patients have labs that need to be performed
  • which patients have x-rays that need to be performed
  • which patients have nursing procedures that need to be performed
• During initial implementation, how does the system ensure buy-in (commitment to use) from all concerned staff?
• Is there any easy way to "turn over" all of a particular doctor's or nurse's patients to a replacement? If one is only turning over a subset of these patients, is there any shortcut to make subsequent transfers easier than the first one (e.g., selecting "same as last doctor" rather than selecting from a list?)
• How does the system deal with a "two-fer" or "three-fer" (e.g., mom and two small kids, all with the sniffles and a fever, all in the same room). Cascaded windows? A flag for a room indicating multiple entries, with a "shadow room" in one corner of the screen, that can indicate an additional patient in any room? If so, how are the extra entries for a room accessed? Can all rooms be "two-fers" or "three-fers"? How does the system deal with more than two or three patients in a single room?
• For busy Emergency Departments, how does the system deal with patients who are on stretchers in the hall during busy times?
• Some Emergency Departments have nurses assigned to patients based on the part of the Emergency Department they're in rather than following a particular patient. Can the system offer to change the patient's primary nurse, based on such area assignment, when the patient is transferred from one room to another?
• How does the system display patients "in X-ray" or "in nuclear medicine" or "in ultrasound" or "in waiting room"? Are these patients somehow noted on the main ED display, or on the displays of sub-areas from which the patient was transferred (e.g., an icon or a number)?
• If the monitor is showing a view of one sub-area of the Emergency Department, are there any colored (or other) indications of the overall status of other parts of the Emergency Department?
• Does the system display, or can it be easily configured by users, to display continuously-incremented length of stay?
• Does the system alert users when user-specified time limits are exceeded (e.g., all labs and x-rays completed but patient still awaiting disposition 30 minutes later)?

Data Collection

• Which of the following time and place data are collected by the system? How many seconds does it take to capture each piece of data.
  • Time of arrival
  • Time of registration (even if patient goes immediately back for emergency treatment and is registered after already in a critical care bed; admissions staff should be able to register patients using terminal in the critical care areas, or with portable terminals with radio modems)
  • Time placed in room and room number (and time and room number for any changes in room or location, e.g., to X-ray or nuclear medicine for tests)
  • Time of vital signs, and the vital signs themselves; abnormal vital signs, at least on admission, should be flagged in a visibly distinctive way, e.g., showing up in red on the screen
  • Time seen by physician
  • Time labs, X-rays, EKGs ordered (and that they were ordered)
  • Time labs expected back (standard time frames for these available from Laboratory Medicine)
  • Time labs back, time patient back from X-rays, and time EKG shown to attending emergency physician
  • Time consults ordered
  • Time consultants paged, and time they answered (having the computer system handle the paging would be ideal; one could just select from a menu of options such as "on-call orthopedic resident", and the computer would show the name of the on-call resident as it pages him or her, as well as stamping the time on the medical record.)
  • Time IVs, drugs, and other treatments administered
  • Time consultants responded (by phone or in person)
  • Time patient disposition decided (discharge, admit, AMA, etc.) and disposition
  • Time patient completes disposition and condition on disposition
  • Time of consult to admitting resident or private attending coming to see the patient, and time seen by resident or private staff attending and name.

Triage

• Can the system input automated vital signs data, e.g., from an automated thermometer and BP cuff? If so, can spurious automated data be deleted and replaced by manual vital signs when indicated?
• Can the system provide a continuously-modifiable set of on-screen algorithms for triage nurses to use in ordering labs, x-rays, and procedures by protocol?
• How long does a triage entry take compared to writing, for a nurse with no typing skills?
• Does the system provide a JCAHO-acceptable triage log?
• How easy is it to enter subjective information, even for very unusual presenting complaints?
• Is there a way to shortcut triage entries when the triage nurse is overwhelmed with presenting patients, allowing some of the triage assessment to be done later?
• Is there any easy way to enter "see and call" or similar messages from admitting staff physicians, and to connect these at the time the patient presents, even if it is a new patient?
• Can the system print hospital-acceptable labels for blood tubes as soon as the patient is entered into the system?
• Does the system have a rapid-entry (lookup/list) system for entering drug names and dosages?

QI Features

• Does the system offer the following QI information?
  • number of patients in Emergency Department hourly,
  • numbers and percentages of admissions to different units,
  • type of discharge,
  • acuity,
  • type of diagnosis
• Can one obtain information such as "what are the names of all patients with chest pain from last month" and "how many patients did Dr. X see last month" and "which patients returned within seven days of a Emergency Department visit and were admitted to the hospital"?
• How easy is it to ferret out information such as above? Can any user do this, or is it limited to those with special training? (I.e., some systems require C or COBOL programming to obtain such information; others have a menu-based or a sophisticated database reporting feature.)
• Does the system allow an English-like query of the database?
• Does the system track EKGs and X-rays?
• Does the system track Emergency Department EKG and radiology readings and match them with the official cardiologist/radiologist readings for QI review? If so, is there a provision for tracking "wet readings"?
• Is there a provision for entering lab data for labs performed in the Emergency Department (e.g., rapid strep tests, urine dip tests, urine pregnancy tests)?

Disaster Management

• Has the system been real-life stress-tested to destruction using a Saturday night with multiple cardiac arrests and drunken trauma patients as a stressor?
• What happens when things are happening too fast for people to keep using the tracking system (i.e., a major disaster)?
• What happens when (not if) the system crashes (e.g., a lightning strike on the Emergency Department, or a rabid computerphobe attacking the monitors with a fire axe)?
• What is the MTBF (mean time between failures) for the system in actual implementations?

Interface with Other Systems

• Who can order labs via the system:
  • physician?
  • nurse?
  • secretary?
• How many keystrokes to order a lab or x-ray?
• Is there a visible flag for labs completed?
• Is there a flag for nurse orders that need to be done?
• Does the system pass lab and demographic information to other vendors' physician charting systems?
• Does the system take information from established hospital information systems?
• Does the system send information to billing systems?
• Can hospital MIS staff make changes to the interface modules to reflect changes in the other systems?