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Computer-Savvy Emergency Department
Patient volumes and a complex organization mean that the ED’s electronic records were a long time coming but worth the wait.

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  Nurses Heather Gardner, Jackqueline Holmes and Maryellen Wilson review the new electronic patient record.

It was a stunning change that Hopkins Hospital Emergency Department administrators launched with what they called a “big bang,” but it barely caused a ripple as it revolutionized procedures in the EDs—literally overnight.

By adopting a custom-designed, comprehensive computer information system, the ED switched from paper-and-pencil records to nearly paperless files in one fell swoop. Both the adult and pediatric EDs made the change this past spring.

What they created is far more than just a patient entry registration system. Not only does it monitor the patient’s arrival and wait times, it provides a real-time tracking board indicating the patient’s location, chief complaint, provider, nurse, allergies, status of lab or pharmacy orders and results. All this information is available simultaneously to physicians throughout Hopkins. Clinical notes and forms, such as consent forms, are recorded electronically, along with the patient or provider’s signature. Discharge notes are generated with patient instructions in several languages and type sizes. Patient documents are automatically faxed to referring physicians.

The new system signals not only a massive change in the way the EDs handle cases but a remarkable collaboration between Hopkins Medicine’s clinical and technical components that made the switch surprisingly seamless. It is a change that already is improving patient safety and saving money, and likely will increase revenues, too.

For example, by using hand-held devices to read bar-coded patient wristbands and test tubes, the EDs have cut the error rate for mislabeled or unlabeled blood samples in half, going from 0.37 percent under the old system to just 0.14 percent now. That’s seven points better than the hospital goal of 0.21 percent, says Heather Gardner, nursing informatics coordinator in the ED.

Furthermore, the elimination of paper forms and the need to store them has saved money, says Greta Kotwani, assistant administrator of the adult ED.

And, adds James Scheulen, ED administrator, “better documentation, better billing, certainly is going to increase revenue.” 

Before the change-over, the EDs did not use the electronic patient record (EPR) like other clinical departments do, largely because of the daily flow of patients into the EDs—approximately 165 in the adult ED and 70 in pediatrics. Handling the influx of so many patients simultaneously requires entirely different documentation procedures, explains Scheulen.

The design of the new $2 million system, called AllscriptsED, was a year-and-a-half collaborative effort between administrators and personnel in the EDs and other clinical departments, the Johns Hopkins Medicine Center for Information Services (JHMCIS), and the North Carolina-based computer software firm Allscripts.

Although hospitals elsewhere have purchased the Allscripts program, the Hopkins version “is more complete with a wider range of technology than probably any academic center in the country,” says Steve Mandell, senior director of clinical information systems.

The comprehensiveness of the new system is due largely to the exceptional—and generous—cooperation of other departments, say Peter Hill, clinical director of the adult ED, and Mitchell Goldstein, assistant professor of pediatric emergency medicine.

Pharmacy, laboratory and pathology services, radiology services, JHMCIS, medical records, compliance and billing all stepped up to the plate, says Hill. “They spent countless hours of time that they didn’t have, but they gave it to us.”

For example, the laboratory and radiology departments compiled long lists of items from which the ED now can order electronically. Goldstein estimates that the pediatric pharmacy alone spent more than 650 hours “to build a spreadsheet that was several hundred thousand line items long.”

In turn, the other departments are happy with AllscriptsED, says Goldstein, because by logging onto the system “from wherever they are located, they now have access to ED records that are legible and complete.” The ED “used to be a black hole,” says Mandell.

“This is a system that’s been designed so that a doctor in the medicine department who is expecting to receive a patient can actually see what’s going on with this patient at every moment, as if they were down in the ED. This is a profound difference.”

AllscriptsED was deployed quickly “to contain the trauma,” says Hill. “We know that change here can sometimes be painful.”

“We took a big risk, but we feel like we got a big reward, both in terms of what it’s accomplished and the lack of long-term pain,” Scheulen says.

Up to 250 nurses and more than 50 physicians in the adult and pediatric EDs underwent training on the new system, and despite a few glitches that were quickly resolved, the overnight switch caused little turmoil. In part that may have been due to the technological savvy of the younger physicians who tend to work in the EDs, Scheulen says. “They just are very facile with computers. We not only didn’t hear any squawks, it was as if it was just another day. Interacting with a computer to do their work was a natural sort of thing.”

 


— Neil A. Grauer

 

 

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