ed-informatics.org

Let’s suppose it is 1980. Suppose someone shows up in your ED with a fever, and a history of travel to an area with a new plague characterized by fever. The nurse has heard about this on the news, asks the patient about travel to the area, and gets a “yes.” The nurse not only writes this on the paper chart, but tells one of the ED doctors about it. The patient is correctly identified as a possible plague carrier, and admitted into an isolation room.

Mid-20th-Century Emergency Room

Let’s now suppose it is 2014. There is a shortage of primary care physicians. Primary care physicians no longer see emergencies, even minor emergencies, in their offices. EDs are much, much busier, and overcrowded. As a way to make things better (and, let’s be honest, to make money), vendors have developed electronic medical record systems (EMRs). Physicians, nurses and other ED staff give these hospital-wide EMRs low grades for usability, but the Federal government has been dangling big bags of money in front of hospital administrators as an incentive to buy an EMR. The government succeeded in persuading hospitals to go ahead full-bore with hospital-wide EMRs irrespective of their poor usability.

Suppose further that someone shows up in your 2014 ED with a fever, and a history of travel to an area known to have a new plague characterized by fever. The nurse has heard about this on the news, asks the patient about travel to the area, and gets a “yes.” She clicks a button on her computer screen. Being proactive, the hospital had put a checkbox for this on the nurse’s computer screen.

But, compared with the two doctors in the ED in 1980, there are now fifteen doctors on duty. She would like to tell all the doctors about what she found out, but she’d have to spend half an hour wandering around the (now 450% bigger) ED, trying to locate them all. And the EMR is supposed to take care of this, right?

Wrong.

Strictly speaking, an EMR is just that: an electronic medical record. In the hospital in general, but particularly in the ED, hospital omputer software these days is much more than an EMR. Indeed, we refer to ED software as an Emergency Department Information system (EDIS). An EDIS does many things, for example, generates discharge instructions and prescriptions and allow electronic medication ordering. But there are two big parts of an EDIS. One big part is the EMR, and the other is the ED Tracking System.

This site has a series of seven essays on ED tracking systems, but we can summarize: ED Tracking Systems keep track of currently-important bits of information and make them easily available to the people who need them.

Note: easily available. (As opposed to “Doctor, you mean you didn’t read all 300 pages of the medical record before treating the patient’s cold on an emergency basis in the ED?”)

This includes answers to such questions as:

• which labs and xrays were ordered?
• what do the labs show?
• where is the patient right now?
• which nurse is taking care of the patient?
• which doctor is taking care of the patient?
• and, newly-critical information such as “Just came from western Africa.”

But something goes wrong. The doctor somehow doesn’t get the information that the nurse entered. He sends the patient home with active Ebola. Multiple people have to be quarantined as a result.

(Suggestion: search the web for “Dallas Ebola electronic.”)

Dueling Whiteboards courtesy Dr. R.L. Wears

Do we blame the EMR/ED Tracking System vendor?

That’s what the hospital administration initially did. It was the EMR or the “workflow.” (Though KLAS rates this particular EMR vendor, Epic, as one of the best.)  Though, later, they retracted this (under threat of possible legal action from the EMR vendor, some opined in public). Certainly there seems to be plenty of blame for the EMR vendor in the blogosphere, but also those who want to shift blame away from the EMR vendor, which I think may be soemwhat misguided, as discussed below: “ … how fair is it to blame technology for what appears to have been a breakdown in basic communication?” Forbes Magazine chastises those who blame the EMR or the EMR vendor.

Do we blame the nurse?

Do we blame the doctor?

Do we blame the Federal government for forcing the hospital to adopt an EMR/ED Tracking System that has poor usability? (Even the best-selling and top-rated EPIC hospital information system gets low grades for usability on an absolute scale compared with an iPhone or Android phone.)

Do we blame the incentives of the US medical system that has produced so few primary care physicians and emergency physicians compared to the needs, resulting in overcrowded and under-staffed EDs?

Do we blame the incentives of the US medical system that have closed many small hospitals, and forced patients to go to the EDs of large hospitals that then are overcrowded?

But in a case such as recently in Dallas, perhaps blame is the wrong response, despite the way Epic is taking it on the chin. Perhaps we simply need to accept the realities of emergency medicine in 2014 and move on to make things better.

Seeing larger numbers of patients in larger EDs arguably can make emergency medicine more efficient and safer for patients. But communications between nurse and doctor (and nurse and nurse, and nurse and technician, and so on) is exponentially more complicated as an ED gets bigger. The ED I work in has now grown so big that I can be there for a full shift and only meet maybe half of the staff who are working during that same shift.

We have developed ED Tracking Systems to facilitate this communication, but these are a new thing on this earth, and are still shaking the eggshell fragments off their wings, getting ready to fly. The “best of breed” or “niche” ED tracking systems have much better usability than the tracking modules of hospital-wide EMR systems such as Epic, but we’re talking B- instead of D+ in absolute terms.

We should look at how we can improve tracking systems to improve communications in the ED.

We know that, people being people, we tend to do things that are easy, but when we are very busy, tired, stressed, dealing with multiple serious problems and frequently interrupted, we tend to not do things that are hard and slow us down. Like drilling down through multiple menus to view a nurse screening report. Tracking systems should make important information easily accessible. This means the flexibility to make newly-important things (travel to western Africa, fever) stand out. That is, without having to request that the EMR vendor make a change and wait six weeks (or six months) for the change to occur.

If you are interested in the role of ED software on the spread of Ebola, I would recommend reading those seven essays on tracking systems, focusing on their utility and their usability. And maybe ask the CEOs of companies like Epic and Cerner to read them, too. In busy places like the ED, poor usability kills.

Tags: EHR, Ebola, ED Systems, Dallas, Emergency Department, EMR, Computers, ED, Usability, Tracking System, Human Error