Category Archives: Technology

Trauma Patient Stay In The ED After Implementing an Electronic Health Record

So as we discovered, we may spend less time and see fewer patients if we use an EHR. One would think that ED length of stay (LOS) would then increase. But does it?

A 2 year observational study from Greece looked at ED throughput before and after implementation of an electronic trauma documentation system. A total of 101 trauma patients were processed under the paper charting system, and 99 were handled after implementation of the electronic system.

Here are the factoids:

  • Injury severity was high overall, with half going for emergent surgery and an overall mortality rate of about 12%
  • Total ED LOS decreased from 206 to 127 minutes with the EHR
  • This was accomplished by decreasing time between arrival and completion of care from 149 to 100 minutes, and from completion of care to leaving the ED from 47 to 26 minutes

Bottom line: Looks great! Badly hurt patients, moving through the ED at breakneck speed after implementation of an EHR. The problem is that it was not really an EHR, but an “electronic documentation system.” Upon close inspection, this is a homegrown system with very specific functionality for monitoring care, providing checklists, and offering case-specific guidance. This is not the type of complex documentation system one usually thinks of when visualizing an EHR. But it does go to show that well-designed and focused software can be beneficial.

Tomorrow, I’ll start to focus specifically on the electronic trauma flow sheet (eTFS).

Reference: The effect of an electronic documentation system on the trauma patient’s length of stay in an emergency department. J Emerg Nursing 40(5)469-475, 2014.

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The Electronic Health Record And Productivity In The ED

In 2009, the Health Information Technology for Economic and Clinical Health (HITECH) act was passed. This provided an incentive for all US hospitals to demonstrate “meaningful use” of the EHR. For those of you interested in the details, check out the related post link at the end of this article.

Hospitals rushed to comply, shelling out lots of money to try to recoup some of it through these incentives. In theory, using an EHR should allow better record sharing, increase patient satisfaction, reduce unnecessary testing and medical errors, and ideally, improve billing. But does it work?

A community hospital with a medium-sized ED looked at physician productivity in the ED while using an EHR. In this case, the software product was McKesson, and 16 clinicians were monitored prospectively over a 30 hour period.

Here are the factoids:

  • The group consisted of attending physicians, residents, and nurse practitioners / physician assistants
  • The distribution of how they spent their time is shown below:
    ehr-ed-time-study
  • In order to complete an assessment in the EMR, it took an average of 160 mouse clicks
  • On average, clinicians saw 2.12 patients per hour, requiring nearly 4000 mouse clicks to complete their charting

Bottom line: Overall, this is not a very good or coherent or even well-designed study. But it does show us one thing. Clinicians spent only 28% percent of their time seeing patients, and 56% of their time reviewing or entering data into the EHR! Note the blue and green wedges in the pie chart. How can they possibly earn their salaries? Other studies have confirmed that using an EHR does decrease throughput slightly, yet reimbursements increase anyway.

How can this be? EHRs were originally designed to facilitate billing, and it looks like they still do, making up for the fact that fewer patients can be seen. But this seems like a perverse incentive to me. Adopt the EHR, see fewer patients, get paid more!?

Related posts:

Reference: 4000 Clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J E Med 31:1591-1594, 2013.

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A Brief History of the Electronic Health Record

The EHR has been around longer than you think. Even before the current desktop style microcomputers existed, a few hospitals implemented early versions of this product. One of the first was the Latter Day Saints Hospital in Salt Lake City. It installed what it called the HELP system, an acronym for Health Evaluation through Logical Programming.

As computing power increased and the size of the computer box and its cost decreased, a series of advances in medical software systems began to occur. In 1983, a software product geared toward resource scheduling was introduced, and became one of the leading applications of its kind. Most people recognize the name Cadence, but few realize that this was one of the earliest product releases from Epic Systems Corporation.

In 1988, the US government contracted out to develop an electronic record system for the military, much of which is still in use today. On a smaller scale, PC type computers were almost 10 years old in 1990 when Microsoft introduced what I consider the first real version of Windows, version 3.0. Epic was once again an innovator, and it released a product called EpicCare for Windows.

Beginning in 2004, there was a move within the government to emphasize implementation of EHRs across the US, spearheaded by President George W. Bush. And as expected, this led to a number of products developed by a variety of software makers. The push to roll out an EHR universally continues to this day, with no end in sight.

Is this a good thing or a bad one? Although much maligned, the EHR can certainly offer benefits. However, like anything touted as a miracle drug or device, there are always downsides. I’ll review both over the course of the week, but my focus will be on one very specific trauma problem: use of the EHR during trauma resuscitation. Many trauma programs either voluntarily adopted the use of an electronic trauma flow sheet (eTFS), or were forced into it by their hospital administration or IT department. Good idea or not?

We shall see…

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How I Keep Up With The Trauma Literature

Medicine advances quickly. How can one keep up with new developments in their field? Well, there’s an app for that! You can also do it without a handheld device, but it’s not quite as convenient. Let me show you how I do it.

Most regularly updated online content is syndicated for RSS (Rich Site Summary). You know, those cute little  icons on web pages. There are loads of RSS readers available, both online and for handheld devices, that allow you to organize and browse content from RSS feeds. I use Google Reader on desktops or laptops, and the River of News app on my iPad.

I visited the home page of each of the journals I was interested in “following” and snagged the RSS web address from each. I then added it to my Google Reader collection of feeds. Now, at some point every day I can quickly browse through new abstracts in each journal. For most journals, abstracts are released once a month. A few publish early release abstracts more regularly.

When you click an abstract of interest, a web page opens that shows the full abstract. If it looks interesting, I save it using Instapaper, a clipping service that helps you organize web pages of interest. I just click a link at the top of the browser and the page is instantly saved for later reference.

As you probably already know, much of what is published is junk. Class III or worse data. Concluding that “additional research is necessary.” So why didn’t you do the study right in the first place? Therefore, it is vitally important that you read the whole article for the abstracts that you have saved. For this, you need access to a biomedical library, either online or brick and mortar. If you’re not lucky enough to have this, you’ll need to rely on others who do. I just run through my list of saved pages on Instapaper and pull up the full article via an online library connection through work.

Here’s a screen shot of my River of News app. I currently monitor 18 journals that publish trauma articles to a greater or lesser degree. I’m also a firm believer that some of the best ideas come from cross-pollinating your own field with ideas from others. To that end, I also scan another 22 feeds in technology, publishing, cooking, aviation and many others. I’m interested in hearing how others do this as well. Please feel free to comment below.

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Trauma Triage Guidelines: There’s An App For That!

The CDC released an iPhone app covering the Field Triage Guidelines for Injured Patients a few months ago. It’s not received much attention, but could be helpful for some trauma professionals.

The app consists of 2 components: a copy of the triage guidelines pocket card, and a quiz about the use and impact of the guidelines. The app is pretty bare-bones, but is a convenient way to keep the guidelines available for immediate reference. It doesn’t look like it’s available for Android yet.

Click the link below to go to the Apple App Store for more information or to download.

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