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EXECUTIVE SUMMARY

Emergency Medicine Information Technology Consensus Conference: Executive Summary Information technology (IT) is transforming medicine. Emergency medicine (EM) may be the most dataintensive specialty, and the emergency department (ED) is a highly complex system. Therefore, changes in EM IT can have far-reaching and unpredictable effects. Advances in medical IT have been generally positive, but there are numerous examples of largescale failures. These failures severely impact the ED. For this reason, EDs and hospital information systems managers approach EM IT cautiously, sometimes overly so. Guidance regarding EM IT is scant. Where it exists, it is rarely evidence-based, often reflecting the opinion of a single author or small group. Much of the advice comes from those outside of EM, who base their recommendations on outdated experiences that do not reflect the major advances of the past two decades. The major EM organizations have not served as a guiding force in this area, with the exception of a 1998 American College of Emergency Physicians resolution encouraging all EDs to provide EM clinicians with ‘‘timely and convenient access to the Internet and the World Wide Web.’’1 The journal, Academic Emergency Medicine, organizes a yearly consensus conference on a topic of high significance to the specialty. Based on the increasing importance of EM IT and the clamor for guidance, the Editorial Board selected EM IT as its 2004 consensus topic. The consensus process is outlined in detail elsewhere in this issue.2 A number of unifying themes and some general summary points from that process are discussed in this summary.

UNIFYING THEMES Many outside of EM make technology decisions without recognizing that most ‘‘non-EM software’’ is critically important to an ED (e.g., reporting of laboratory results, the online ‘‘bed board,’’ and patient registration systems). The ED should be included in most major software decisions, even when that software is not specifically for the ED. Identifying a member of the ED staff to direct and guide EMrelevant IT is an important step to technology success throughout the hospital. It is not clear how information should be captured and stored: as free text or in a standardized format. What is clear is that various software applications will need access to the data residing in any one system. For example, the rate of bed cleaning during each

hour of the day may reside in software that is ‘‘owned’’ by housekeeping, yet access to that data may be required by ED operations modeling software trying to assess resource availability (such as clean inpatient beds). Sharing data within a department, between departments, and between institutions is vital to the process of quality care. Regardless of the method used to capture and store data, systems that contain ED-relevant data must be able to format and send it using commonly accepted standards that can be ‘‘understood’’ by other applications. Those charged with ‘‘shepherding’’ data must expect and be willing to send it to other systems, as needed, to facilitate quality ED care and management. The ED is a high-volume, high-acuity, high-complexity area where staff turnover can be high. Floating staff from other departments, traveling nurses, locum tenens physicians, rotating residents, and other temporary workers are common in the ED. IT that requires extensive training for basic use can bring an ED to a grinding halt if placed into the staff workflow. Several working groups noted the importance of a software user interface that does not require training to perform its basic functions. This especially applies to order entry systems, documentation systems, and clinical results reporting systems, all of which sit at the center of the patient care process. Similarly, the importance of system reliability, speed, and uptime increases as our reliance on technology increases. The more that technology improves the quality and efficiency of care, the more ethically difficult it becomes to work without it. As technologies are put into place, their effects must be studied to ensure that a net benefit is achieved. ‘‘Benefit’’ is a multivariate concept, and the analyses should reflect this. For example, a technology may improve reimbursement but also increase medical error. A multivariate analysis will better inform technology decision making. This may be the area of EM IT requiring the most urgent research.

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Every ED clinician should have basic computer literacy, and every ED should have Internetbased access to basic online decision support tools and educational materials. The full-service ED should identify a leader from within the department to guide its informatics efforts.

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Systems that handle ED-relevant data should be capable of the real-time transfer of data to and from other applications and institutions, using commonly accepted standards. The enterprise should expect and be willing to provide the data needed by an ED to support its operations, the needs of public health systems, and the clinical needs of its patients who may require care at other hospitals. To the greatest extent possible, all clinical data should be readily available online, and all clinical systems must have fast response times, high reliability, and a highly usable interface that requires little or no training for basic use. The hardware technologies required for clinical activities should be ubiquitously available throughout the ED, with wireless and portable computing solutions showing promise in achieving this. Technologies for EM education, management, and clinical care should measurably improve (or at least not adversely affect) the overall quality of EM care as demonstrated by a quantitative and qualitative analysis of the many facets of ‘‘quality.’’ Online decision support should be seamlessly and noninterruptively integrated into all clinical systems. EM training programs are encouraged to consider using simulation technology as an educational adjunct to traditional educational methods. All of the broad and ever-changing needs of an ED cannot always be met by a single vendor, so that a data-standard approach rather than a vendor-standard approach will provide the flexibility for the current and future successes of an ED.

Many other important statements, discussions, and future research directions are contained in the consensus proceedings of this issue. Together, these documents form a summary of available data and expert opinion in EM informatics that should inform the future of technology in EM research, education, and clinical care. However, they represent only a first step. This work must be built upon through additional research. This research will require grant funding, publication, and dedicated expertise. As a younger specialty, EM informatics is at a disadvantage in obtaining grant funding. Its researchers may not be adept at navigating the complex waters of applying for grants. Funding agencies must provide a mechanism to support these researchers.

Dedicated funding is needed for EM IT, along with a grant application and review process that is tailored to talented yet inexperienced applicants. The success of EM IT depends on the publication of EM IT research. Much of what ‘‘everyone knows’’ about IT has not been studied in the ED environment. EM journals may have a greater understanding of the importance of the research environment than general informatics journals. This perspective is critical, and the informatics community depends on EM journals to recognize the significance of their work. Important innovations and pilot projects in EM informatics may not fit into the format of a prospective controlled clinical trial, and yet their publication will guide future research and inform the EM community. The overwhelming response to this issue’s call for papers demonstrates the interest and expertise in the EM informatics community. EM journals should actively solicit EM IT research and routinely dedicate part of an issue once or twice a year to that topic. Most importantly, the EM community will benefit by fostering an active interest in EM informatics research and development among its members. Success in EM IT will not happen without dedicated resources. Fellowships in EM informatics should be created, and residents should be encouraged to apply. Academic departments should encourage research in EM IT. EDs should dedicate positions in EM informatics, with adequate protected time and a budget sufficient to accomplish ED IT goals. EM has been a leader in medical IT. The broad-based and pragmatic aspects of our specialty offer a critical perspective to the evolution of the field. Continued dedication to developing EM IT will reap health care dividends for everyone.—Jonathan A. Handler, MD (jah505@ northwestern.edu), James G. Adams, MD, Northwestern University School of Medicine, Chicago, IL; Craig F. Feied, MD, Michael Gillam, MD, Institute for Medical Informatics, Washington, DC; John Vozenilek, MD, EvanstonNorthwestern Healthcare, Evanston, IL; Edward N. Barthell, MD, Infinity Health Care, Mequon, WI; and Steven J. Davidson, MD, Maimonides Medical Center, Brooklyn, NY. doi:10.1197/j.aem.2004.08.005

References 1. American College of Emergency Physicians. Action on 1998 resolutions. Available at: http://www.acep.org/1,5287,0.html. Accessed Jul 2, 2004. 2. Handler JA, Feied CF, Gillam M, et al. Developing consensus in emergency medicine information technology. Acad Emerg Med. 2004; 11:1109–11.