5
Technology and Communications

Daniel Conway is a 65-year-old male who has a sudden onset of excruciating back pain. He calls his primary caregiver, Dr. Thompson, who tells him to call an ambulance to bring him to the Eastern Hospital emergency department (ED).

Dr. Thompson clicks on a Web page for the Eastern Hospital Emergency call-in program. He imports his last progress note with Mr. Conway’s history and adds a personal note describing his concerns that the patient’s uncontrolled hypertension could have led to a ruptured abdominal aortic aneurysm.

The ED immediately receives the on-line submission and begins preparations for the patient’s arrival while the ambulance is still en route. Paramedics, using interoperable communications systems that give them equal capability to communicate with fire and police agencies on one hand and hospitals on the other, inform the ED that Mr. Conway’s vital signs are stable but he is in severe pain. The emergency physician advises them to administer a dose of intravenous morphine and carefully monitor his blood pressure, oxygenation, and respiratory rate. Upon arrival, Mr. Conway is rapidly transported to a preassigned room, where the emergency physician, Dr. Hendricks, and his team are waiting. While the nurses take his vital signs and the doctor examines him, a clerk arrives at the bedside with a wireless laptop. After the initial evaluation, she collects the information necessary to register him in the system without delay. The paramedics complete their run report on



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Hospital-Based Emergency Care: At the Breaking Point 5 Technology and Communications Daniel Conway is a 65-year-old male who has a sudden onset of excruciating back pain. He calls his primary caregiver, Dr. Thompson, who tells him to call an ambulance to bring him to the Eastern Hospital emergency department (ED). Dr. Thompson clicks on a Web page for the Eastern Hospital Emergency call-in program. He imports his last progress note with Mr. Conway’s history and adds a personal note describing his concerns that the patient’s uncontrolled hypertension could have led to a ruptured abdominal aortic aneurysm. The ED immediately receives the on-line submission and begins preparations for the patient’s arrival while the ambulance is still en route. Paramedics, using interoperable communications systems that give them equal capability to communicate with fire and police agencies on one hand and hospitals on the other, inform the ED that Mr. Conway’s vital signs are stable but he is in severe pain. The emergency physician advises them to administer a dose of intravenous morphine and carefully monitor his blood pressure, oxygenation, and respiratory rate. Upon arrival, Mr. Conway is rapidly transported to a preassigned room, where the emergency physician, Dr. Hendricks, and his team are waiting. While the nurses take his vital signs and the doctor examines him, a clerk arrives at the bedside with a wireless laptop. After the initial evaluation, she collects the information necessary to register him in the system without delay. The paramedics complete their run report on

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Hospital-Based Emergency Care: At the Breaking Point a tablet computer and use the wireless network to beam it into the hospital databases. Mr. Conway is in too much pain to recall all of his medications accurately. Dr. Hendricks queries a clinical data-sharing network, which compiles a list from the computerized records of local pharmacies. The doctor has a question about which would be the best diagnostic test to order given the specifics of Mr. Conway’s history. He consults the hospital’s digital library, and with several mouse clicks he confirms that a computer-assisted tomography (CAT) scan is still the expert-recommended choice. He orders the study via the computerized physician order entry (CPOE) system and also orders some pain-relieving medication. The program alerts him that his choice could have a dangerous interaction with one of the medications Mr. Conway is taking. The computer suggests an alternative, which the doctor selects instead. A few moments later, Dr. Hendricks sees that the patient is not in his room. He looks at the electronic dashboard, which is tracking the radio frequency identification (RFID) tag on Mr. Conway’s wristband. He learns that the patient was transported to radiology 5 minutes ago and is currently undergoing the scan. Shortly thereafter, an alert on the dashboard warns him that the radiologist has reported an abnormality on the study. Luckily, the pain is being caused by a kidney stone instead of something more serious. With a single click the emergency physician is able to view the digital images and confirm the findings. Looking for assistance in managing Mr. Conway’s kidney stone, Dr. Hendricks pages a urologist. Instead of wasting time waiting by the phone, he immediately goes to see another patient. He knows that whenever his call is returned, it will be routed to the digital communication device he wears on his lapel. Dr. Hendricks generates the documentation for the patient’s ED visit through a wireless dictation or wireless tablet system that allows him to note historical and physical findings, order laboratory tests and radiographs, and submit orders via CPOE with integrated decision support. In either case, he does not have to search for a chart or wait for someone else to finish using it. The dashboard is updated with Mr. Conway’s pending discharge so the housekeeping manager can ensure that the resources required to clean the room will be available when needed. The triage nurse in the ED selects the next patient to use the room when it becomes available. A short time later, Mr. Conway is feeling better and is ready to be discharged home. He receives a computer-generated instruc-

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Hospital-Based Emergency Care: At the Breaking Point tion sheet with information about his diagnosis of a kidney stone, including what warning signs to watch for, as well as whom to follow up with and when. Upon discharge, the system sends the patient’s primary care physician, Dr. Thompson, and the consulting urologist a secure e-mail summarizing the ED visit and the patient’s discharge instructions. The e-prescribing module, having screened for potential drug interactions and provided dosage guidance, electronically routes Mr. Conway’s prescriptions to the pharmacy near his home, saving time and reducing the risk of errors associated with legibility problems. Mr. Conway uses his secure doctor–patient messaging application to communicate with Dr. Thompson 2 days later, letting him know he passed the stone and is feeling much better. He also mentions how pleased he was with his emergency visit. Even though the ED seemed to be incredibly busy, everything went smoothly and efficiently, and he feels he got great care. Although the story of Mr. Conway’s visit to the ED sounds futuristic, all of the technology described above exists today as both home-built and commercial products. But the diffusion of these technologies to date has been limited. The average community hospital and even some large medical centers lack basic information technology (IT) enhancements that have been shown to improve the efficiency of care and patient flow, inform clinical decision making, and enhance provider-to-provider and provider-to-patient communications. This chapter describes the current state of the art in health care IT and highlights several specific IT tools that have proven ability to improve emergency care in six key areas: management and coordination of patient flow and hospital patient care, linkage of the ED to the wider health care community, clinical decision support, clinical documentation, training and knowledge enhancement, and population health monitoring. The chapter also considers some of the new clinical technologies that are expected to impact emergency care within the coming decade. This is followed by a discussion of challenges and barriers hospitals may face in adopting these technologies. Finally, the chapter addresses the need for and approaches to prioritizing investments in technologies that can improve emergency care now and in the future. INFORMATION TECHNOLOGY IN THE HEALTH CARE DELIVERY SYSTEM The early application of health care IT was limited almost exclusively to hospital accounting systems. As early as the 1960s, hospitals began to use

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Hospital-Based Emergency Care: At the Breaking Point various computer programs for business operations and financial management (Detmer, 2000; Shortliffe, 2005). By the mid-1970s, a small number of hospitals had equipped their programs to process data with medical content (Henley and Wiederhold, 1975; Hospital Financial Management Association, 1976). During the 1980s and 1990s, many hospitals further enhanced their systems to include electronic health records (EHRs), a trend that was also seen among a small percentage of private physician practices (IOM, 1991, 2003). Despite these early advances, progress toward widespread adoption of health IT has been slow. This is especially true of applications aimed at improving the quality and timeliness of patient care, such as programs that assist with patient flow, clinical decision making, and medical communications. Today, it is estimated that fewer than one-third of hospitals and one-fifth of private physicians use EHRs. Use of CPOE systems is even less common, with only 12 percent of hospitals and 10 percent of private physicians using the technology (Brailer and Teresawa, 2003; Goldsmith et al., 2003; The Lewin Group, 2005; Healthcare Information and Management Systems Society, 2005; Burt and Hing, 2005; Bower, 2005). In comparison, more than one-half of primary care physicians in New Zealand and the United Kingdom have reported using both EHRs and CPOEs in their daily practices (Harris Interactive, 2001). Commonly cited barriers to the adoption of these and other IT tools include prohibitive costs, lack of standardization, and physician resistance to change; additional discussion of these barriers is provided later in this chapter. While usage rates for specific IT applications remain low, data do suggest that American physicians are increasingly reliant on computer-based resources within their offices. According to a recent American Medical Association survey, 99 percent of private practices and 96 percent of physicians use computers in their offices, 84 percent have a computer network in place, and 75 percent have Internet access. At the same time, however, the interconnectedness of these resources with other points in the health care system, such as the ED, has been found to be lagging, with only 35 percent of physicians reporting a connection with a hospital or laboratory (Chin, 2002). The apparent isolation of this emerging IT usage raises significant concerns about the continuity of care, particularly for ED patients, for whom immediate access to medical records can mean the difference between lifesaving intervention and life-threatening medical errors. Data also suggest providers’ growing recognition of the potential of IT to significantly improve the quality of health care in the United States. For example, a majority of respondents to a 2005 survey conducted by the Healthcare Information Management and Systems Society (HIMSS) cited “reducing medical errors and improving patient safety” as their top IT priority. Of these respondents, nearly two-thirds indicated their next IT

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Hospital-Based Emergency Care: At the Breaking Point development would be the adoption of an EHR system. Other applications identified by respondents included CPOE and clinical decision support systems (CDSSs). The HIMSS survey respondents included hospitals, physician offices, mental/behavioral health facilities, long-term care facilities, and home health agencies with annual gross revenues ranging from $50 million or less to $1 billion or more (Healthcare Information and Management Systems Society, 2005). Given that more providers recognize and are turning to IT as a tool to improve the safety and quality of care, one might expect to find significant IT investments occurring in the health care field. After all, the United States invests approximately $1.7 trillion, or 16 percent of its gross domestic product (GDP), on health care annually. Data reveal, however, that the expected level of investment simply has not occurred. In 2004, just $17–$42 billion, or 10–25 percent of all U.S. health care investments, was applied to health IT. Less than one-third of this amount, or approximately $7 billion, was invested in hospital clinical systems such as EHRs, CPOE, or CDSSs (Goldsmith et al., 2003; Bower, 2005; The Lewin Group, 2005). The health care field has also failed to keep pace with IT investments as a percentage of industry revenue. While spending on health care IT as a percentage of revenue has increased slightly in recent years, rising from 1–2 percent in 1998 to 2–3 percent today, these figures are far below those for the IT and financial services industries, which invested 10 and 7 percent, respectively (The Lewin Group, 2005). This disparity becomes even more striking when one examines IT investment rates on a per worker basis; while most U.S. industries invested approximately $8,000 per worker for IT in 2004, the health care industry invested only about $1,000 (DHHS and ONCHIT, 2005). The paucity of investments in health care IT has ramifications far beyond the financial. Without adequate resources for the coordinated development or implementation of proven IT systems, efforts to enhance safety, optimize workflow, and foster communication among and across health care settings have largely stalled. Further, where improvements have been made, they have occurred in relative isolation, resulting in islands of innovation rather than systemic repairs to a failing system. Progress toward a highly integrated and coordinated emergency care system has been slow even though the value of such integration and coordination has long been recognized (NHTSA, 1996). Instead, multiple systems of varied quality have developed independently of one another. The resulting fragmentation undermines the quality, safety, and timeliness of emergency care; limits the application of proven health care IT; and prevents the aggregation of data for public health surveillance and research purposes (Halamka et al., 2005).

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Hospital-Based Emergency Care: At the Breaking Point The federal government recently assumed a leadership role through the provision of funding and other support to develop a uniform national health information infrastructure capable of supporting integrated health IT (Taylor, 2004; Cunningham, 2005; Hillestad et al., 2005; Shortliffe, 2005). This initiative can lead to significant improvements in emergency care, as well as in other areas. Federal leadership is needed because of failures in the health IT marketplace, including asymmetrical risks and rewards for technological innovation and the inability to offer aggregated data comparisons (Taylor, 2004; Middleton, 2005). Moreover, such leadership is needed today to ensure that IT advances are made in a coordinated way that facilitates the necessary interoperability and communication. The federal government has shown the ability to initiate essential industry innovation when market forces have failed to do so. The Hill-Burton Act, for example, is largely responsible for the nation’s hospital infrastructure (Halvorson, 2005). Adopted in 1946, Hill-Burton provided federal grants to states for the construction of hospitals, requiring states to adopt plans ensuring that constructed facilities would meet a variety of minimum requirements. Over the course of the next 30 years, Hill-Burton subsidized the construction of 40 percent of all U.S. hospital beds. Other examples of federal leadership filling a market void include the Rural Electrification Act of 1936 and the Federal Aid Highway Act of 1956 (Halvorson, 2005). A number of other industrial nations have already embraced the need for national leadership in and funding of health IT innovation. Britain’s National Health Service (NHS), for example, recently embarked on the world’s largest civilian IT project, planning to spend approximately $11 billion on a national system that will replace the existing hodgepodge of local systems and paper medical records (The Lewin Group, 2005). Among the IT tools to be featured in this effort are lifelong EHRs coordinated at the national level, integrated information sharing among all health care settings, and online communications and data access for patients and providers (Detmer, 2000). Using a Regional Health Information Organization (RHIO) model that provides common elements across the full continuum of health care settings, the U.S. government has the potential to significantly improve the quality, safety, and timeliness of emergency care. While the direct costs associated with this effort are estimated at $276 billion over 10 years, a national health information infrastructure would generate direct savings amounting to $613 billion over the same period and $94 billion annually thereafter—this in addition to the many ancillary savings associated with such benefits as improved management of chronic disease (Kleinke, 2005).

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Hospital-Based Emergency Care: At the Breaking Point INFORMATION TECHNOLOGY IN THE EMERGENCY DEPARTMENT The ED is a unique setting in modern medicine—a complex and chaotic environment that presents an increasing number of challenges. ED clinicians are frequently called upon to make crucial decisions under pressure with limited data while maintaining continual readiness for new arrivals, stressing available resources. Because ED providers must often make critical decisions without patient records or histories, it has been said that EDs operate on “information fumes.” EDs are subject to increasing patient volumes and more complex conditions, yet over the last decade they have experienced a diminished capacity caused by decreasing resources. One solution to the serious challenges facing today’s EDs may be found in IT, which can both facilitate analysis of the problems and support solutions. All of the common medical tasks performed by doctors involve information processing: taking a history, examining a patient, ordering and interpreting test results, considering diagnoses, devising a treatment plan, and communicating with other providers about the appropriateness of admission or discharge. All of these are data management tasks. Information is generated when procedures are performed, and simply by the presence and flow of patients. Emergency providers are eager consumers of available past clinical data and are creators of information to be used during followup. The quality of information management determines how well providers manage the care of their patients. Today, there is an especially urgent need to apply IT to the delivery of emergency care. Among other factors, this urgency stems from the life-and-death nature of emergency care, the myriad threats to such care posed by ED crowding, and the increasingly common role of the ED as the public’s portal of choice for medical services. Six key areas of emergency care could immediately benefit from an infusion of IT: Management and coordination of patient flow and hospital patient care—Technologies such as electronic dashboards, radio frequency tracking, and wireless communications systems can help ED staff manage patients and maintain control over department workflow. Linkage of the ED to the wider health care community—Enhanced communications among providers within a community can greatly improve the availability of useful clinical information for emergency care, coordination of care, and allocation of community health care resources. Computerized messaging between patients and doctors can ensure that all providers fully coordinate their care. And telemedicine enables advanced medical knowledge to improve the care of patients in remote areas.

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Hospital-Based Emergency Care: At the Breaking Point Clinical decision support—As stand-alone units or part of a broader system, CDSSs can help guide clinicians in choosing the optimal and most economical therapy and can enhance the safety and efficiency of triage. Clinical alerts and reminders can warn providers if a proposed treatment plan poses unrecognized risks. Clinical documentation—Electronic documentation of emergency services can facilitate the timely, accurate collection and storage of information regarding the course of patient care, serving as proof of services rendered for reimbursement purposes and supporting public health and research functions, among other benefits. Training and knowledge enhancement—Computerized education and training resources can make the most up-to-date medical knowledge rapidly available to clinicians so they can deliver quality care. Population health monitoring—Emerging IT applications can provide real-time population health monitoring, including syndromic surveillance and outbreak detection, necessary for many public health and homeland security priorities. In each of these areas, IT has the potential to significantly enhance the timeliness, safety, and quality of emergency care, improving patient flow and reducing health costs in the process. The challenge for the future is to integrate these technologies effectively so that hospitals can invest in applications that address goals and objectives in all of the above six areas. For example, systems should be able to support clinical decisions as well as operations management. It should also be emphasized that the future development and advancement of IT applications must accommodate the special needs of pediatric patients. Management and Coordination of Patient Flow and Hospital Patient Care The case of Mr. Conway presented above illustrates the need for seamless communications among prehospital IT systems; hospital departmental systems, such as laboratory and radiology; and hospital patient-tracking systems. To meet the complex data needs of an ED clinician, data must be shared easily and securely between clinical and financial systems using widely accepted standards and protocols. Among the IT tools currently available to assist with the management and coordination of emergency care are those described below.

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Hospital-Based Emergency Care: At the Breaking Point Electronic Dashboards The pre-IT solution for managing ED flow was for staff to track patients on a centrally visible whiteboard. Commonly arranged in the form of a grid, this whiteboard contained a list of patients and their locations, current providers, the status of the visit, and orders to be completed. The information was updated manually when the staff noticed a change and had the time to update the board. Such a system provides a useful central source of individual data points. However, many management decisions are based on aggregate information that needs to be assembled in real time. Since information on whiteboards is updated only when someone notices a change and has time to enter the update, this manual process breaks down during the ED’s busiest times, when the accuracy and timeliness of information are most critical. This problem tends to self-propagate: outdated data cause inefficiencies, further taxing a harried staff that then does not have time to update the whiteboard with further changes. Computer technology transforms the manual whiteboard into an electronic “dashboard” that continuously displays updated information and integrates multiple data sources, such as laboratory, radiology, and admitting databases. Using a combination of colors or symbols to represent ongoing tasks and processes, many dashboards can present information in a tabular, grid-like format (similar to the manual whiteboard), while others arrange the screen as a graphical representation of the ED. Sometimes, the dashboard tracking function is used as a central point of an ED information system, providing links to other systems discussed in this chapter. At other times, the system is a stand-alone tool that can be modified to interface with other components of the hospital information system. However they are configured, electronic dashboards allow providers to see the most recent information without the need for manual input. Computerized systems provide an excellent overview of the ED and patient flow for both clinicians in the ED and administrators in their offices. Bottlenecks become readily apparent, staff members are able to see developing problems, and action can be taken before operations are affected. Long-term storage of the data tracked by a dashboard system, as with several other systems discussed in this chapter, is another useful tool that can aid in resource planning and error identification, analysis, and prevention. Given accurate models of patient flow and information on past bottlenecks, it becomes possible to anticipate future demands on staff and maximize the efficient deployment of resources (Cone et al., 2002). The complexity of the ED makes error identification a difficult process, and sole reliance on clinician reporting will likely be inadequate to effect change (Handler et al., 2000). Readily accessible data on all ED visits facilitates analysis of standard quality assurance measures, such as unplanned revisits, as well as the formu-

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Hospital-Based Emergency Care: At the Breaking Point lation of new metrics for quality care. In the case of an adverse event, analysis of stored dashboard parameters can allow reconstruction of the event, similar to the capability provided by an airplane’s “black box” after a crash. Further, allowing clinicians (especially trainees) to access stored tracking data to follow up on their patients encourages self-monitoring for errors and helps mitigate a key deficiency of the feedback system of the ED: that an unknown result of treatment has the same reinforcing effect as a positive outcome (Croskerry, 2000). Often, errors and near misses are caught during follow-up care but not reported back to the original treating clinician. Storage of visit data makes it easy for ED providers to review a list of patients they have seen in the past. That list could integrate data from the ED course with other information from the hospital system, allowing providers to follow up on whether their diagnoses were correct and their treatments appropriate. While there have been only a few effectiveness studies concerning comprehensive ED dashboard systems, preliminary findings appear to support the benefits of their use. Among these benefits, hospitals with ED dashboards have reported reductions in lengths of stay, fewer patients leaving prior to treatment, and less time spent on diversion (Jensen, 2004). Providing emergency physicians with an updated display of the status of laboratory tests has been shown to improve their perceptions of efficiency and communication with patients (Marinakis and Zwemer, 2003). And the ability to better communicate estimated wait times to patients using dashboard technology has been found to improve patient satisfaction with emergency care (Thompson et al., 1996). Radio Frequency Identification Tracking Effective workflow in the ED requires knowledge of the locations of patients, caregivers, and equipment. New tracking technologies, such as radio frequency identification (RFID), can show the exact locations of people and resources, enabling caregivers to optimize workflow and empowering administrators to understand how people move through the department. Such tracking systems are available in two basic forms: (1) passive systems that require the use of RFID scanners to read unpowered RFID tags and (2) active systems that use existing hospital wireless networks to track battery-operated RFID transmitters. Using hardware and software, active RFID systems then track the position of these transmitters with enough accuracy to identify the room in which they are located. Several pilot studies of RFID tracking in the ED offer insight regarding the potential of this technology to improve the quality, timeliness, and efficiency of emergency care. At Beth Israel Deaconess Medical Center in Boston, for example, RFID is being used to track equipment and key staff

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Hospital-Based Emergency Care: At the Breaking Point members. At Summa Health System in Akron, Ohio, RFID is being used to optimize patient flow and track patient location. Finally, an ED in Memphis is using RFID as a means to reduce patient waiting times by providing realtime notification of bed availability. Digital Voice Communications While the ED dashboard provides complete integration of all hospital data in a single location, there is still a need for real-time discussion of patient care issues among caregivers. Cellular technologies appear to be an obvious answer to this real-time need given the ubiquity of such devices, but pose a number of challenges for hospitals, including electronic interference, varied reception, and germ transfer (Tri et al., 2001; Shaw et al., 2004). One means of addressing these issues is hands-free Voice over Internet Protocol (VoIP) devices for voice communications over existing hospital wireless data networks. Newer VoIP devices provide dual capability—automatic use of the hospital network when indoors and automatic use of the standard cellular network when outdoors. Of note, users of such technology must remain cognizant of their surroundings to ensure that patient confidentiality is protected and that ambient noise does not degrade voice recognition. Wireless Registration In a typical ED, several components of emergency care occur simultaneously. A patient having a heart attack, for example, may require a physician performing an exam, a nurse inserting an intravenous tube, and a medical technician performing an electrocardiogram (EKG). At the same time, the laboratory will be processing blood tests, while radiology is developing an x-ray and the catheterization laboratory is being instructed to prepare for a new arrival. In most EDs, however, there is a critical point of failure in the simultaneous nature of this response: the ED registration clerk. Currently at most facilities, ED registration represents a significant bottleneck in what should be a serial process. For patients who have been triaged with a high severity of illness, one strategy for improvement is to move the formal registration process to the bedside via a wireless network. Such an approach would make the registration process more flexible as it would remove the need to tie the registration process to a single physical space (Smith and Feied, 1998). Mobile Computing Mobile computing (MC) technology, such as specialized wireless laptop carts equipped with 24-hour batteries or specialized tablet PCs, are being

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Hospital-Based Emergency Care: At the Breaking Point BOX 5-2 Veterans Health Information Systems and Technology Architecture (VistA) The Veterans Health Administration (VHA) is the nation’s largest integrated health care system. With a staff of nearly 200,000, VHA provides care to more than 5.1 million veterans and other enrollees annually. It operates over 1,300 facilities nationwide, including 157 medical centers, with one in every state, Puerto Rico, and Washington, DC. It also oversees the nation’s largest medical education and health professions training program, turning out approximately 83,000 health professionals each year. A critical component of VHA operations is the Veterans Health Information Systems and Technology Architecture (VistA). Key aspects of VistA include the Computerized Patient Record System (CPRS), which offers providers a single interface through which they can review and update patients’ medical records, as well as place orders for medications, laboratory tests, and other services. In its next-generation system, HealtheVet, VistA also implements standard functions for health data repository systems, registration systems, provider systems, management and financial systems, and information and educational systems. VHA has shared both its health information and health IT resources—including software and staff expertise—with other federal agencies through the Health Information Technology Sharing (HITS) program since the late 1990s. The HITS program was expanded to include some non-governmental and international organizations in 2001. Through the recent HealthyPeople Initiative, VistA software and expertise are now available as well at minimal or no cost to public- and private-sector organizations that serve the poor and near-poor. SOURCE: Department of Veterans Affairs, 2005. Human Factors Some of the most challenging barriers to the adoption of IT in health care involve human factors. Currently there are more than 780,000 physicians and 2.2 million nurses, as well as many other health care providers, involved in the delivery of patient care in the United States (HRSA, 2003). These individuals possess highly varied levels of IT-related knowledge and experience. Further, clinicians tend to be conservative and reluctant to adopt new automated approaches, especially if previous attempts at IT solutions failed to prove useful in solving diagnostic, therapeutic, or workflow problems (Kassirer, 2000; IOM, 2001).

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Hospital-Based Emergency Care: At the Breaking Point An important potential hurdle for institutions planning major IT enhancements is the 6- to 12-month learning curve for physicians. Implementation of such systems must be carefully executed and supported, and products must be tailored to each institution through use and modification over time. No system is fully applicable directly off the shelf. Unless the system brings demonstrable value to its users, the potential for physician dissatisfaction and indirect patient dissatisfaction is substantial. Human factors research deals with human–computer interaction and has developed methods for testing and improving the usability of software. Used by the aviation industry for more than a decade, human factors research is largely credited with minimizing pilot error and improving the safety of air travel (Vincente, 2004). Many of the actual and perceived problems with health care IT in the ED could be overcome by employing human factors techniques (Helmreich, 2000; Wears and Perry, 2002). For example, the “usability” of software is based on its perceived usefulness as well as its perceived ease of use. A useful program enhances the performance of its users; it makes them more efficient or improves the quality of their work. A program’s ease of use is judged by the amount of effort required to accomplish tasks. Studied barriers to program use include accessibility (whether there are enough computers for all users), availability (whether the system crashes when people wish to use it), start–stop times (whether it takes too long to begin/resume a task or save work to be continued later), system dynamics (whether the response time is too slow), training barriers (whether it takes too many hours to learn to use the program effectively), and lack of consistency (whether various components of a system work together in the same way). Several examples can be found to demonstrate the inefficiencies and reductions in patient safety that accompany poor implementation of health care IT (Ash et al., 2004). As noted earlier, for example, Cedars-Sinai Medical Center removed its CPOE system after less than 6 months as a result of significant resistance by doctors and nurses who claimed the system was difficult to use. Such resistance may be less pronounced among emergency clinicians as IT adoption typically occurs more rapidly in ED than other settings (Healthcare Information and Management Systems Society, 2005). While the barriers to IT adoption are significant, research demonstrates that they are hardly insurmountable. In fact, as was so clearly stated in Crossing the Quality Chasm: A New Health System for the 21st Century, “solutions to these barriers can and must be found given the critical importance of the judicious application of IT to addressing the nation’s health care quality concerns” (IOM, 2001, p. 166). An essential step in realizing the potential of health care IT to improve patient flow and enhance the quality, safety, and timeliness of patient care is the creation of a national health information infrastructure, discussed earlier.

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Hospital-Based Emergency Care: At the Breaking Point Confidentiality One of the biggest challenges to the development of electronic systems for tracking patients, documenting care, and communicating among clinicians is protecting the confidentiality of patient information. As quickly as systems are developed, protections against security breaches and new methods of attack are devised. While technical solutions exist, there must also be trade-offs between the capabilities of systems and the requirements for confidentiality. PRIORITIZING INVESTMENTS IN EMERGENCY CARE INFORMATION TECHNOLOGY The specific costs and benefits of many of the technologies described above to individual hospitals are largely unknown, and can be expected to vary according to the individual circumstances and the technology infra- BOX 5-3 Roadmap for the Implementation of Health Information Technologies In an ideal world, where all hospitals and health care systems were equally flush with capital and similarly motivated to invest in new health care information technologies, the IT tools known to improve the quality, safety, and timeliness of emergency care would be immediately adopted and embraced by staff and patients alike. In the real world, however, financial and other limitations temper the pace at which IT improvements can be implemented. This is particularly true among the nation’s small, rural, and safety net hospitals, which typically have less revenue and more limited IT systems at their disposal. Given these real-world constraints, it is important that IT investments in the ED be made strategically, with close attention paid to such issues as total costs, staff education and training requirements, and the time needed to complete workplace transitions. For example, automated discharge systems represent a relatively inexpensive, easy-to-use technology that many hospitals could turn to as a first step in modernizing their care delivery. While significantly more expensive than automated discharge systems, electronic dashboards are also a priority because they have the potential to improve so many aspects of patient care management. Dashboards also can serve as a launching pad for future IT investments, such as clinical decision support systems (CDSSs) and computerized physician order entry (CPOE).

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Hospital-Based Emergency Care: At the Breaking Point Clinical documentation programs are the next logical choice for many hospitals and health care systems seeking to improve patient flow and enhance quality and safety. Wireless registration, radio frequency identification (RFID) tracking, and digital hands-free Voice over Internet Protocol (VoIP) communications can facilitate more seamless care with fewer interruptions and more time for direct patient care. These programs also can capitalize on existing hospital wireless networks or dashboard programs, further reducing costs and encouraging coordination. Finally, hospitals may look to CPOE systems to reduce errors, improve safety, and save time in the ED. Efforts should be made to ensure that applied CPOE systems are customized for use in the ED, a task that will require additional expenditures. Further, the impact of such systems on the quality, timeliness, and safety of emergency care should be carefully monitored. Several organizations are moving to make their IT tools more widely available through resource sharing and discounted pricing. For example, the Veterans Health Administration routinely shares its health information and health IT resources—including software and staff expertise—through the Health Information Technology Sharing Program at no or minimal cost. Further, through its Center for Healthcare Information Technology, the American Academy of Family Physicians is making low-cost, standards-based IT more available to family physicians nationwide. In many rural hospitals, it is family physicians who represent the bulk of ED staff. structure and readiness of each institution. For example, adopting advanced systems in a hospital that has a limited existing IT platform would probably not be cost-effective; on the other hand, in a hospital with a sophisticated platform, adoption of such systems could be highly cost-effective as the marginal costs associated with their addition would be very small. Given these inherent variations, it would be difficult to prioritize the many technologies in a way that could be generalized to all hospitals. However, the committee identified categories of technologies that would have a substantial impact on emergency care and that could feasibly be adopted by many institutions within 3–5 years: Technologies that facilitate patient flow management, such as electronic dashboards and tracking systems Technologies that improve the continuity of care across the continuum of care, particularly EMS–hospital system linkages and RHIOs that enhance the information available to clinicians across settings

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Hospital-Based Emergency Care: At the Breaking Point Decision-support tools, such as automated triage, that facilitate optimal use of resources Systems that reduce the likelihood of errors in the ED, such as CPOE Systems that facilitate public health surveillance Some specific strategies for the cost-effective adoption of these technologies are described in Box 5-3. The committee also believes the ED should be a priority site for the early development of enterprisewide IT systems. For example, the development of EHRs is important throughout the hospital and across the health care delivery system. The ED has a particular need for this technology, especially since 43 percent of inpatients are admitted to the hospital through the ED (Merrill and Elixhauser, 2005). SUMMARY OF RECOMMENDATIONS 5.1: Hospitals should adopt robust information and communications systems to improve the safety and quality of emergency care and enhance hospital efficiency. REFERENCES ACP, ASIM (American College of Physicians, American Society of Internal Medicine). ACP-ASIM Survey Finds Nearly Half of U.S. Members Use Handheld Computers. [Online]. Available: http://www.acponline.org/college/pressroom/handheld_survey.htm [accessed July 1, 2005]. Ash JS, Berg M, Coiera E. 2004. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Informatics Association 11(2):104–112. Balas EA, Weingarten S, Garb CT, Blumenthal D, Boren SA, Brown GD. 2000. Improving preventive care by prompting physicians. Archives of Internal Medicine 160(3):301–308. Bates DW, Gawande AA. 2003. Improving safety with information technology. New England Journal of Medicine 348(25):2526–2534. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, Burdick E, Hickey M, Kleefield S, Shea B, Vander Vliet M, Seger DL. 1998. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Journal of the American Medical Association 280(15):1311–1316. Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma’Luf N, Boyle D, Leape L. 1999. The impact of computerized physician order entry on medication error prevention. Journal of the American Medical Informatics Association 6(4):313–321. Baumann MR, Strout TD. 2005. Evaluation of the emergency severity index (version 3) triage algorithm in pediatric patients. Academic Emergency Medicine 12(3):219–224. Bertling CJ, Simpson DE, Hayes AM, Torre D, Brown DL, Schubot DB. 2003. Personal digital assistants herald new approaches to teaching and evaluation in medical education. WMJ: Official Publication of the State Medical Society of Wisconsin 102(2):46–50. Bird SB, Zarum RS, Renzi FP. 2001. Emergency medicine resident patient care documentation using a hand-held computerized device. Academic Emergency Medicine 8(12):1200–1203.

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