Customer Spotlight: Emergency Situation

Best of breed, or enterprise integration? That is the vexing question facing emergency departments looking to automate.

Source: Health Data Management, March 1, 2010, Elizabeth Gardner

Hospitals looking at emergency department software face a vexing dilemma: should they deploy a best-of-breed system carefully tailored to the department's needs? Or should they turn to their enterprise vendor for a system that's completely integrated-at least according to the vendor's marketing staff-with the rest of the hospital? The niche systems are designed specifically for (and often by) ED physicians, and their intended users sometimes advocate passionately for them. But more and more hospitals have their eye on an enterprise electronic health record, complete with clinical decision support, where a piece of data entered in any department is immediately and automatically available to all others. An interface to a separate ED system rarely behaves with equal seamlessness, and may not be enough to achieve the benefits promised by an EHR.

"The availability of previous records and information in real time is invaluable," says Reid Conant, M.D., who is both chief medical information officer at Tri-City Medical Center in Oceanside, Calif., and a consultant on emergency department information systems. For example, ED physicians can often either rule out or confirm a heart attack in a patient with chest pain if they can access past electrocardiogram records.

The past information can also affect the orders an ED physician gives, Conant says. "If I'm ordering a contrast agent for a CT scan, I need to know whether the patient has any kidney damage," he says. "An isolated system can't grab that creatinine measurement from three months ago and tell me as I put in the order."

In Conant's view, enterprise software will ultimately win the day over best-of-breed in the ED, despite that department's unique information needs and a workflow that moves very differently from other areas in a hospital. The vast majority of hospitals over 100 beds have ED software installed already, according to figures from HIMSS Analytics, a Chicago-based research firm. (See chart this page). However, a study released in December by KLAS Research supports Conant; it shows that among providers who are shopping for a new or replacement ED information system, 72 percent are planning to leave a best-of-breed product in favor of an enterprise system. That percentage is two and a half times higher than it was in a similar study done in 2005.

"Integration is a lot more important than people might think," says Jason Cecil, chief information officer at 114-bed Capital Region Medical Center in Jefferson City, Mo., which is a Stage 6 hospital, as measured by HIMSS Analytics. Measuring progress along the I.T. adoption continuum, the HIMSS scale reaches 7 at the top rung. "Being able to have a single EHR for every unit is key to everything that we're doing."

The hospital has about 28,000 ED visits per year. It has had an enterprise system from Meditech, Westwood, Mass., since 2006, and added Meditech's ED software in 2007. The physician documentation piece of the ED system didn't go live until April 2009. The selection of Meditech occasioned some pushback from the department's physicians. They work at the hospital under contract as employees of TeamHealth, an emergency services outsourcing company that staffs more than 550 hospitals across the country.

"TeamHealth had suggestions about systems they had worked with, and our ED physicians had ideas about what they thought they wanted," says Cyndi Hake, R.N., a clinical analyst on the ED software project. "We talked to them a lot about intercommunication between different applications, and what they would lose if we had silos of information."

The group's medical director embraced the project and helped Cecil and Hake sell it to the rest of the group. "Now that they've been using it awhile, they like the integration and have discovered the benefits," Hake says. "When they order lab work, the results drop right in." Not only does information generated in the ED go directly to the patient's electronic record, but the emergency physicians have ready access to that record for things like allergy information and current medication lists.

Though most of the hospital's departments use Meditech software, the few that don't serve as a reminder of how painful interfaces can be, Hake says. "They're the thing we struggle with," she says. The transcription system, bought shortly before the Meditech decision was made, sends reports to the electronic health record. However, they're just text documents and not associated with specific fields in the EHR, which makes it difficult to pull the information back out again. "Sales people are good about saying they can interface with anything, but making systems talk to each other in a meaningful way is different," Hake says.

Another Kind of Integration

Hospitals tackling ED automation have learned that there is more than one way to approach system integration.

NorthCrest Medical Center in Springfield, Tenn., has a stand-alone ED system from Allscripts, Chicago. It's only interfaced to the hospital's enterprise system, provided by Healthcare Management Systems, Nashville, but it's integrated with the Allscripts systems that are in use (or being installed) at many of the primary care offices affiliated with the hospital. Strane says that while across-the-board integration would be great, good integration with physician offices is more useful to ED physicians than integration with the rest of the hospital.

"One of the challenges in the ED is that you treat people you haven't seen for awhile, and we may just have their med list from their last visit," says Nick Strane, M.D., ED medical director for the 81-bed hospital. It logs about 35,000 ED visits a year. "Allscripts Connect enables us to look at the records of their primary care office visits and make sure we're current on studies, surgeries, pathology reports and current allergies. It lets us extend our scope of practice."

Fighting for Best of Breed

Peter Cridge, M.D., fought hard to get his favorite best-of-breed system installed at the 392-bed University Medical Center at Princeton, where he's the hospital liaison for the emergency department and former ED chairman. He started with a department that operated entirely with paper (along with a system of colored clothespins to indicate a patient's status). From selection to implementation took almost six years, starting in 2001. Within the first two years his committee had decided on a niche ED system from Wellsoft, Somerset, N.J. A final decision was then put on hold while the hospital pondered the replacement of its enterprise software-a prospect that filled Cridge with dread because he was afraid that an integrated ED product would be imposed on his department.

"The problem with an integrated system is that it treats the ED like every other place, and it's different from just about every other place," Cridge says. "We have rapid turnover and widely varied patient needs-it's just a whole different world. We liked Wellsoft because it was designed by an ED doc who designed the system the way an ED doc thinks."

Cridge visited a reference site for one of the integrated systems that the hospital was considering, and got a demonstration from the ED physician champion. "He was going to show me how to do a chart," Cridge recalls. "I grabbed my watch and started timing him. He was four minutes in and he hadn't finished yet. There's no way that was going to work. It would have been a disaster."

Cridge says he can complete a complex chart in Wellsoft in under a minute.

In the end, to Cridge's great relief, the hospital decided to stick with its enterprise vendor, QuadraMed, Reston, Va., which didn't offer a system for emergency departments. That cleared the field for Wellsoft, which was finally implemented in November 2007 to the general happiness of the ED staff. The department quickly went from 100 percent paper to 100 percent computer order entry and documentation. "We got all the curmudgeons to do it without much of a whimper," Cridge says. "There's not a doc here who'd ever want to go back to the way it used to be."

As expected, the interfacing situation isn't as smooth as true integration would be. Currently the ED record is sent to the hospital's EHR as a PDF file. The caregivers can read it, but if they want the information from it to go into analyzable fields in the patient's chart, someone has to enter it in manually. However, the Wellsoft system is also interfaced to the lab and radiology systems, and the results of tests ordered in the ED automatically flow to the other systems in the hospital, as well as back to the ED.

"Is the rest of the hospital in love with it?" says Susan Sunyak, R.N., a clinical analyst for the ED. "No, they'd very much like it if everything we entered flowed over. But before Wellsoft, it wasn't there either. It was in the chart - if you could read the handwriting."