Integrated ED: a Mississippi area medical center streamlines critical patient care through EDIS.

Time is a formidable foe in an emergency department (ED). Likewise, a few seconds in the trauma room can mean the difference between life and death. On the administrative side, we are constantly watching the clock as we monitor how long patients have been sitting in the waiting room and when a bed will open in the hospital. All of this is in addition to the normal difficulties involved in organizing and sharing paper charts.

These obstacles are not unique to our ED at North Mississippi Medical Center (NMMC). However, as a Level II trauma center serving 24 counties across Mississippi and Alabama, we often found ourselves overwhelmed by patient loads, excessive wait times and paperwork. We soon realized that our ED operations had reached a critical level and several changes were necessary for smoother operation and maximized care.

Solution Search and Implementation

As an initial step in addressing these problems, we looked for a more efficient way to manage our records and improve the quality of care for the increasing number of patients coming through our ED. The obvious solution based on our needs was an emergency department information system (EDIS).

Before choosing the new system, multiple vendors demonstrated their products to a team of leaders from the Emergency Service and IT departments, as well as other key users. Though many of the vendors had excellent EDIS products, we needed and chose a solution which offered patient information management for triage, tracking, order entry, nurse and physician documentation and disposition. An additionally important aspect of the HealthMatics EDIS was the tracking board capabilities and granular time study reports, which, we felt, were superior to the other products available at that time.

Before implementation of the system, Allscripts assisted us by training super users, which would be critical to the success of the go-live phase. The IS staff held intensive training sessions for all users, supplied around-the-clock support for more than a month and maintained on-call support.

At the request of our Emergency Services Department (ESD) director, we decided to take a "big bang" approach, implementing the EDIS system all at once rather than phasing the system in over time. This shortened the transition period and ensured that everyone was on the same page moving forward.

We started by inputting all of our organization-specific tables and files. The ESD staff documented every conceivable workflow scenario, as well as some that may never be presented. The next step from a system design standpoint was creation of documentation screens, assessment questions and order sets by a combination of staff from the ESD and IT departments.

As this was going on, specific bilateral interfaces were being developed between the programming staff at Allscripts and at NMMC. All of this merged into a robust test environment where nursing and physician analysts in IT spent extensive time ensuring that everything worked according to specification. Once an area was deemed ready, it was presented to the ED project team for final approval and tweaking if indicated. With all development complete and signed off by the project team, training began for the general ED staff. This was completed over a period of two months, after which, the system went live.

Immediate Results

With all of our ED caregivers at North Mississippi Medical Center using the system, it has truly streamlined our workflow. Patient visits now begin with a quick registration process at the bedside. Afterward, we record detailed background data during a nurse assessment at the patient's bedside. This includes a common set of questions developed by our Patient Intake Committee known as the Assessment Clearing House Enterprise database (ACHE). Small footprint computer interfaces in each room allow nurses to key in information, orders and bedside test results. When physicians arrive, they use the system to enter orders, medical information and document the case.

While our ED was able to share critically important information before, the new system reduces the many inefficiencies of operating in a paper-based environment, such as complex patient tracking systems, excessive wait times and the critical challenge of organizing and sharing cumbersome paper charts. With the new system, everyone on the team is kept up to date on each case in real time, without the risk of error. No matter where a user is located in the department, electronic tracking boards with patient records are available at everyone's fingertips. Each PC has a HIPAA-compliant screen saver of the tracking board view. Detailed patient information is only accessed when the user signs on the system.

In addition, with mobile computers in the ED, desktop PCs in the central nursing station, and a computer located in each patient room on a maneuverable arm, the results of this newfound efficiency include a 50 percent reduction in average patient wait times, a 5 percent increase in patient volume, a 15 percent increase in charge capture capabilities, and a 50 percent reduction in time required to identify billable charges.

Although the patients may not be aware that the HealthMatics ED exists, they do see benefits from the system. The staff is able to quickly maneuver in the system, and therefore can devote more time to patient care. The use of colorful, easy-to-read icons simplifies management of the patients' care and ultimate disposition. For instance, icons are used to manage orders and results. Also, the ED recently instituted a pain management program, and added a new icon that lets everyone know immediately if a patient qualifies for treatment. Discharge instructions are customizable and legible. Through the use of reports, time studies are used to monitor turn around times.

Additional Benefits

The ED system can also be configured to meet our changing needs. As new services became available at our hospital, we have customized our system by adding new and easily identifiable icons to ensure the most appropriate patient care. For instance, the new icon for the pain management program mentioned earlier lets everyone know immediately if a patient qualifies for higher priority treatment. Before we had the tracking board, the ED functioned with a simple grease board updated by staff members.

With the icon management provided on the tracking board, we have real time notification of orders, results, patient location, pain indicators, consults to other MDs and disciplines, completion of orders, caregivers involved with the patient, current wait times for each patient, and many other criteria based upon the complexity of the patient and the desires of the leadership of the ESD and organization. These gains were only possible because of the highly configurable icon management provided by the new system.

Adopting this new emergency department information technology system is also improving our billing procedures and turning one-time ED system pessimists into advocates. Work is done twice as fast and is much more accurate. By providing consistent, easily accessible documentation, it is actually increasing our ability to charge for work completed. The flexible reporting features also help administrators better manage scheduling and staff assignments to enhance ED performance. Tools like drug interaction and allergy alerts also improve risk management at the hospital.

Beyond the ED Doors

The influence of the new, automated ED system also extends far beyond the ED's doors. The ED system connects to an in-house database of frequently asked clinical questions, making it easier for staff to enter and retrieve patient information. This information can be accessed by our five affiliated hospitals and 30 clinics, and is also available to individual practitioners outside of NMMC's healthcare family.

Once a patient enters our system, regardless of point of entry, five essential questions are addressed and are then stored in the ACHE in-house custom database. The data elements housed within ACHE include hometown, referring M.D., home medications, food and drug allergies, past patient and family history, past surgical procedures, special devices, tobacco/alcohol usage, religious/cultural practices and advanced directives. These elements basically act like a baseball in a baseball game, in that they are pitched in the direction of the patient, wherever he might be.

With any subsequent readmission, whether at our home care agency, family medical clinic, nursing home, or affiliate hospital, the previous data set is presented to the new user. The user must verify that the data is still accurate, and update any changes or new criteria. Instead of asking a patient if they are allergic to anything numerous times throughout the course of their stay with us, we can simply state, "I see you are allergic to penicillin, are there any other allergies that we need to be aware of?." Every update is then sent back to the core database so that our elements are consistently updated and ready to be "pitched" out to the next admission.

As we have added clinical systems to our network, each vendor must be able to send and accept each of these elements. It is a complex piece of programming backed by NMMC's interface analysts and programming analysts. Allscripts stepped up to the plate and was the first vendor to successfully "play ball" with our custom ACHE database.

The ED is the gateway to our hospital, and a high percentage of inpatients get their first impression of the medical center from the care they receive here.

We are proud of the initiative our hospital has taken to provide a safe, efficient healthcare technology solution for our staff providers and patients not only in the emergency department, but also throughout the entire medical center. Implementing HealthMatics ED has had a big impact on our use of time, workflow and our bottom line. Furthermore, it has significantly improved the quality and level of care we provide our patients.

For more information on Allscripts HealthMatics ED, www.rsleads.com/708ht-203

Karen Hatfield is an RN at North Mississippi Medical Center. Reach her at [e-mail].