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Using Information Technology to Improve the Quality and Safety of Emergency Care Daniel A. Handel, MD, MPH, Robert L. Wears, MD, MS, Larry A. Nathanson, MD, and Jesse M. Pines, MD, MBA, MSCE

Abstract With the 2010 federal health care reform passage, a renewed focus has emerged for the integration of electronic health records (EHRs) into the U.S. health care system. A consensus conference in October 2009 met to discuss the future research agenda with regard to using information technology (IT) to improve the future quality and safety of emergency department (ED) care. The literature is mixed as to how the use of computerized provider order entry (CPOE), clinical decision support (CDS), EHRs, and patient tracking systems has improved or degraded the safety and quality of ED care. Such mixed findings must be considered in the national push for rapid implementation of health IT. We present a research agenda addressing the major questions that are posed by the introduction of IT into ED care; these questions relate to interoperability, patient flow and integration into clinical work, real-time decision support, handoffs, safety-critical computing, and the interaction between IT systems and clinical workflows. ACADEMIC EMERGENCY MEDICINE 2011; 18:e45–e51 ª 2011 by the Society for Academic Emergency Medicine

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n 2001, the Institute of Medicine advocated the adoption of electronic health records (EHRs) with the goal of improving the quality of care and reducing adverse events.1 This was based on the belief that From the Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University (DAH), Portland, OR; the Department of Emergency Medicine, University of Florida (RLW), Jacksonville, FL; the Clinical Safety Research Unit, Imperial College (RLW), London, UK; the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (LAN), Boston, MA; and the Department of Emergency Medicine, George Washington University School of Medicine, and Department of Health Policy, George Washington School of Public Health (JMP), Washington, DC. Received August 2, 2010; revision received September 21, 2010; accepted October 1, 2010. Funding for this conference was made possible (in part) by 1R13HS018114-01 from the Agency for Healthcare Research and Quality (AHRQ). The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. The authors have no relevant financial information or potential conflicts of interest to disclose. Supervising Editor: Mark Hauswald, MD. Address for correspondence and reprints: Daniel A. Handel, MD, MPH; e-mail: [email protected].

ª 2011 by the Society for Academic Emergency Medicine doi: 10.1111/j.1553-2712.2011.01070.x

elements of EHRs would enhance the parts of clinical practice that were limited by paper charting systems and, in the process, prevent medical misadventures. For example, systems with computerized provider order entry (CPOE) and clinical decision support (CDS) could potentially detect incorrect doses or medication interactions and notify clinicians at the point of care; they might also reduce the misinterpretation of orders and prescriptions due to handwriting.2 EHRs are also more accessible and potentially easier to search, allowing providers to make more informed care decisions by knowing prior medical histories.3,4 CDS has also been used to improve workflow by bringing relevant information or guidelines directly to the clinician, reducing care variability, and encouraging adherence to best practices.5 In addition, in emergency medicine (EM), there is the potential to integrate clinical decision rules,6 to ensure that high-risk clinical factors are addressed, and that unnecessary testing may be avoided. However, despite the potential advantages of EHRs and related technologies (CPOE, CDS), their track record has been mixed and adoption has been slow.7 Barriers to adoption have included financial issues such as costs of acquisition, maintenance, and unclear return on investment, as well as poor integration into workflow, unintended consequences, the uncertainty of success, and lack of expertise with information technology (IT).6,8–12 Smaller hospitals, and nonteaching hospitals outside of larger health systems, have been less likely to overcome these issues and implement EHRs. Similarly, there

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have been technical challenges in the design of emergency department (ED) information systems (EDIS) to meet the complex needs of emergency care. Specifically, poor usability of EDIS has been cited as an issue.13–18 To address the issue of IT utilization in emergency care, the Society for Academic Emergency Medicine convened a consensus conference in 2004 on ‘‘Informatics & Technology in Emergency Care.’’ Three of their recommendations were:19 • 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. • 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 smoothly integrated into all clinical systems. In 2009, the American College of Emergency Physicians released a white paper as a primer for EDIS. They stated that, ‘‘Health Information Technology (HIT) presents ongoing opportunities to improve the quality of emergency care, promote patient safety, reduce medical errors, and enhance the efficiency of emergency departments.’’20 However, if an EDIS reduces the efficiency of patient flow, there may be an increased risk for nonstandard ‘‘workarounds’’ and elopements,20 as well as delays in care and increased mortality.21 It is well established both in health care and in other high-hazard fields that while IT can interrupt some paths to failure, it simultaneously creates new ones; in many instances, those new paths are more difficult to foresee, to understand, and to mitigate. In addition, IT may decrease the incidence of small failures, while increasing the severity of those failures that remain.9,10,22–38 In October 2009, a consensus conference titled ‘‘Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach’’ was held the day before the 2009 ACEP Scientific Assembly in Boston, Massachusetts. The conference participants were charged with developing a research agenda to improve the delivery of care in their respective areas. This paper is the output of the group that focused on IT and its impact on emergency care. The conference was supported by a grant from the Agency for Healthcare Research and Quality. IMPROVING SAFETY Overall, systematic reviews across the entire health care arena have been mixed as to whether or not HIT increases safety by minimizing hazards and adverse events.39,40 In support of increased safety, it has been estimated that EHRs could potentially reduce the number of calls from pharmacies to clarify prescriptions and eliminate 95% of adverse drug reactions.2 In one state survey, a desire to improve patient safety was found to be leading motivation for EHR implementation.41

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However, studies of national data on Medicare patients have reported only a small positive effect and concluded that there was not enough evidence to support a strong link between EHRs and improved safety.42 Workarounds are a common phenomenon in HIT implementations and may pose a risk to patient safety.43 For example, providers still document vital patient information on scrap pieces of paper in EDs while interviewing patients, even with fully integrated EHRs. Larger system failures have been documented as well, such a database corruption leading to loss of service44,45 and mix-ups between patients and their medications46 or their laboratory results.47,48 CPOE is one of the most studied areas of IT in health care. The potential benefits of CPOE, especially when combined with CDS, include better legibility with reduced transcription errors, standardized naming conventions, automatic calculations, alerts, and screening at-risk populations.49 However, with poor design or implementation, CPOE has been shown to increase mortality.50 A 62-hospital study of CPOE and decision support combinations has shown they detect only slightly more than half of potentially fatal medication orders.40 Other studies have demonstrated that CPOE has decreased harmful adverse drug reactions and improved patient safety.51,52 Given this conflicting literature, the relative safety of CPOE may be a local phenomenon related to the interaction between the technology and its context, not the technology itself.8 IMPROVING QUALITY IT has tremendous potential to improve the quality of ED care. The practice of modern EM is a complex, fastpaced, and high-stakes endeavor. Each patient encounter involves unique circumstances, needs, and hazards. Identifying optimal treatment plans while simultaneously eliminating errors in all cases is beyond the capabilities of even the best physicians. However, welldesigned CDS tools can provide necessary information when intelligently integrated into ED workflow. Some techniques include alerts, which interrupt the clinician with critical information, and reminders that passively display useful facts. Order sets group related tests and interventions together and can help reduce omissions and improve efficiency. Contextual information includes clinical calculators that can help guide diagnostic test ordering and therapeutic interventions. Creatively combined, these techniques may reduce and mitigate the effects of errors and omissions. One example is the electronic ‘‘whiteboard’’ or ‘‘dashboard’’ system. These may improve care by enhancing the situational awareness of ED staff, by displaying the state of an individual ED patient’s care and the overall state of the ED. By automatically aggregating the relevant clinical data, these systems may allow clinicians to focus on data interpretation and patient management, rather than hunting for information.33,38,53–55 These systems should assist ED charge nurses in identifying patient flow bottlenecks as well and proactively assist in ways to fix them. However, just as with CPOE and decision support, studies of EDIS have yielded mixed results,16–18,33,56–59 so the

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benefits of these systems to frontline caregivers is contested. One of the most valuable resources in the aviation industry is the so-called ‘‘black box’’ recorder, which reveals detailed parameters of the events leading up to a crash. Similarly, clinical information systems include a large amount of potentially valuable raw data for quality assurance reviews following a recognized adverse event. Appropriate and inappropriate use of certain medications or interventions can be comprehensively reviewed at the patient population level. Computerized surveillance systems could even aid in the detection of events and improve the response, serving as an educational tool and helping to mitigate the effects.60 However, to our knowledge, no commercially available systems currently support such applications. BARRIERS TO SUCCESSFUL IT IN THE ED A significant barrier to realizing the benefits of clinical computing is a lack of attention to their fit with clinical work (their usefulness) and human–computer interface issues (their usability). The foundational work to inform IT designs that would truly be useful to clinicians in the ED has not yet been done. As a result, much of the benefit of currently available IT accrues to ‘‘back end’’ processes such as management and billing, while frontline clinicians often find their work made more difficult. Similarly, neglecting the usability of IT systems has led to decreased efficiency,13 increased errors,61 and even increased mortality.50 There are many resources available to aid programmers in developing more usable software (e.g., Jakob Nielsen’s usability web site, http://useit.com), including the one ED-specific site (http://ed-informatics.org/category/series/computers-inthe-ed/). Usability principles can also be applied in hospitals and EDs, especially in informing purchase and acquisition decisions and in investigating hazards and adverse events. It seems unlikely that vendors will invest much in usability until consumers or regulators start to demand it. However, given the relative size of the U.S. health care market, further research and development in novel hardware and software solutions to make health IT both more useful and more usable for clinicians is warranted. The American Recovery and Reinvestment Act of 200962 has incentivized implementation of new EHRs and enhancement of current EHR systems to meet ‘‘meaningful use’’ criteria. The final ruling of the Health Information Technology for Economic and Clinical Health Act was passed in July 2010, with hospitals and eligible professionals able to start registering for the program in January 2011.63 Originally ignored in the initial criteria, the ED was included in the final ruling, which includes required criteria involving CPOE, drug– drug and drug–allergy interaction checks, recording of vital patient demographics, up-to-date patient problem lists and active diagnoses, maintaining an active medication and allergy list, recording of changes in vital signs, assessing smoking status for patients 13 years old and older, the use of at least one CDS rule, reporting of clinical quality measures to the Centers for Medicare & Medicaid Services, providing an electronic copy

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of discharge instructions to patients, being able to electronically exchange patient information among providers, and protecting EHR information.64 In the process, it is important to assure that appropriate steps are taken to create a useable system that supports the safe delivery of care. FUTURE AREAS OF STUDY ⁄ RESEARCH AGENDA We present the following research agenda that aims to resolve some key unanswered questions related to HIT in the ED and potentially identify promising solutions that can be generalized. Interoperability Interoperability is the ability of one EHR to exchange information with another. This can either be between an EDIS and inpatient system or from one hospital to another. Currently, many EHRs in the ED are not interoperable with other EHRs at EDs that serve the same patient population. As a result, ED providers may not have vital information, including the results of previous testing and prior health care encounters. In addition, lack of interoperability can tend to lock provider organizations into one vendor’s suite of products; their data are stored in a proprietary format that cannot be easily moved to another system. With regard to other hospitals, regional health information organizations are usually needed to create an infrastructure for exchanging data from one hospital to another. These require a significant amount of resource investment to implement and sustain over time, and few areas have been successful long-term in this. One research question is to study the effect of interoperability, or lack thereof, on the quality and costs of ED care, specifically as it relates to unnecessary duplicate testing and hospital admissions. Specifically, potential clinical decisions that may be affected by interoperability include 1) decisions to use pulmonary embolism protocol computed tomography scanning and 2) decisions to admit for rule-out acute coronary syndrome. Ensuring interoperability between systems to minimize potential unnecessary costs of care and enhancing patient safety may help in justifying the large federal investment in HIT. Patient Flow and Integration Into Clinical Work Patient flow is a central issue in the ED, due to the major problem of ED crowding and the negative effect on quality and outcomes. While EHRs may enhance some aspects of safety, the often time-consuming requirement of EHR documentation may reduce the timeliness of ED care. The broader research questions on this topic relate to studying the effect of EHRs on patient flow, potentially through large epidemiologic databases or time-motion studies. The used of timedstamped data can be vital in this regard. In addition, identifying promising practices at sites that have both EHRs and good patient flow may provide information that can be generalized to other hospitals to mitigate the effect of EHRs on slowing patient flow. A second research area would be to conduct the foundational work to identify how IT might actually

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Table 1 Proposed Research Agenda Major Area Interoperability Patient flow and work integration Decision support Handoffs Safety-critical computing Technology–health care interactions

Definition How does improved exchange of patient information within and between hospitals improve the quality and safety of patient care? How do EHRs impact patient flow and impact the job providers do in delivering this care? How can decision support positive influence providers to deliver high-quality, cost-effective care within their natural workflows? How do EHRs impact the safety and quality of patient handoffs? Does the use of EHRs promote or hinder the safe delivery of health care? How do the natural workflows of health care delivery interact with EHRs?

EHR = electronic health record.

help ED workers do their jobs better. Such work would involve engineering methods not commonly known in health care, primarily work domain analysis and cognitive task analysis.65 A work domain analysis is a technique to identify the integral properties of an environment, with the cognitive task analysis a subset of this, that delineates the thought processes involved to accomplish the intended goal. But, by identifying clearly how clinical work is actually performed (rather than how physicians envision it being performed), a set of design constraints for clinically useful IT could be developed to guide future IT development. Real-time Decision Support One of the major elements of EHRs that may improve care is the ability to deliver evidence-based information on relevant clinical decisions at the point of care. Research questions related to this would include the study of real-time decision support systems in promoting evidence-based ED care and potentially improving the cost-effectiveness of emergency care by eliminating unnecessary testing. Specific research questions include 1) the integration of clinical decision rules at the point of test ordering in the ED; 2) the automated presentation of evidence-based guidelines at the point of ED testing ordering or treatment decisions; 3) development of noninterruptive, nonintrusive methods of decision support that decrease the development of alert fatigue; and 4) the development of better ways of presenting information to clinicians so that problems and potential solutions are more easily recognized. Decision support should also encourage providers to complete actions in a timely fashion, whether it is to send a patient for an abdominal computed tomography after completing oral contrast or renewing other time-sensitive orders such as seclusion and restraint orders. Prompts for appropriate and consistent documentation should also be instilled into EHRs that support the best practices of appropriate charting. Handoffs Improving handoffs between emergency physicians is an understudied topic in emergency care research and one that may be amenable to interventions using EHRs. An important research question on this topic would be to test interventions to improve the quality and safety of emergency care handoffs.66,67 For example, research-

ers could compare differences between templated and less formalized approaches to such handoffs. Another type of handoff that needs to be explored is between the patient in the ED and the primary care provider (PCP). This includes both referring the patient to the ED and the ED communicating back to the PCP once the visit is complete. In addition, the use of personal health records helps communicate with the patient after the visit what was done and what they need to do to be informed consumers and advocates in their health care. This includes the importance of providing patients with legible discharge instructions in their native language. Conversely, emergency physicians need to be able to follow up on the outcomes of their patients in the inpatient and outpatient arenas for feedback on their ED care, thereby necessitating the linkage of EDIS to inpatient and ambulatory EHRs. Computing That Promotes Safe Practices Health IT began with financial and billing systems, which are important but pose few health risks to patients. Clinical IT functionality has been layered on top of these systems, but has been little informed by the engineering field of safety-critical computing.68,69 As clinical systems become more integrated (e.g., a CPOE system linking directly to an electronic medication administration record system linked directly to a bar code medication administration system), the potential for unidentified interactions to pose hazards to patients in ways that cannot be easily intercepted or mitigated increases. One fundamental area of research should be focused on the adaptation and adoption of safety-critical computing techniques and principles into the development, implementation, maintenance, and operation of IT systems in health care.36,70,71 The Interaction Problem The heterogeneity of the existing data on the effects of IT in health care and some direct observations8,72,73 suggest that success or failure of IT is less a property of either the technology or the setting, but rather a matter of the interaction between technology and the clinical arena. In other words, if the technology cannot meet the demands of the inherent workflows, it is doomed to fail. In epidemiologic terms, this is roughly analogous to effect modification, and it is important to note that when effect modification is present, the main

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effects are uninterpretable. This problem suggests that a fundamental re-orientation of the research approach is needed, away from simple comparative studies (is A better than B), to a more nuanced, sociotechnical approach (in what circumstances does A work? In what circumstances does B?).74 This suggests that research on new, effective, and informative research methodologies capable of elucidating these complexities in reliable and informative ways is also needed.

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13. CONCLUSIONS In this article, we present a background and overview of issues related to the relationship between electronic health records and the quality of ED care. While the potential for improvement seems clear, the available experience is much more mixed. With the federal mandate to implement electronic health records broadly, future research efforts (see Table 1) need to focus on the effects of these electronic health records will have on quality and the testing of interventions to improve the delivery of patient care in the ED.

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