According to a recent KLAS survey on emergency department information systems (EDIS), 38 percent of hospitals surveyed are already looking to invest in their second or even third EDIS. Seems high? Not if you consider that for many hospitals, the ED is the first point of entry for a majority of their patients, so it better deliver. The same survey also says that though only 25 percent of hospitals currently have an EDIS, 40 percent plan to implement one in the next two years. The wealth of new or improved products on the market means that CIOs shopping for a system have choices, and many more questions to ask.
“There's no magic bullet for me,” says Jason Hess, research director at KLAS Enterprises, Orem, Utah. “By and large the argument comes down to IT vs clinical.” Best of breed EDIS (typically developed by clinicians) generally garner high satisfaction rates. And yet, according to KLAS, the greater majority of second generation EDIS purchases are sole source enterprise solutions that easily integrate back to a hospital's main HIS. Why? Connectivity, it seems, is key.
Connectivity through effective interfaces to internal and, increasingly, external applications rate high on everyone's wish list for an EDIS, but Hess says functionality is also important. “We look at key modules,” he says. “The first is patient registration, typically captured in the patient ADT (admission/discharge/transfer) system for the hospital and sent over an interface to the EDIS.”
Triage or tracking through an electronic whiteboard is next, Hess says, and allows clinicians to see in real time where the patient is, if labs are back and make room assignments. Next up? Clinical documentation. “Are physicians really documenting electronically in real time at the bedside?” he asks. “Many physicians say if the solution takes 17 mouse clicks, we don't use it when we're busy.” And what ED isn't busy?
Hess says the ordering module of an EDIS is the last key piece, which means tests like CT scans or labs, with results incorporated in the main EMR, and the ability to view PACS images right in the EDIS. If it's not interfaced, he says, nurses may have to print the order and re-key it into the clinical system. “I've seen that a lot,” he says. “Yes, the physician is ordering into the EDIS, but if it's not integrated to the rest of the clinical (systems), it's double the work.”
Though best-of-breed systems are easier to use, Hess says, “With no interface there will be no adoption.”
Best of breed
But if a hospital chooses to go best of breed, are the daunting interfaces a roadblock to implementation? Not for Eastern Connecticut Health Network (ECHN) in Vernon, Conn. ECHN went live last March, and though its primary HIS system is Meditech (Westwood, Mass.) the organization chose Chicago-based Allscripts for the EDIS. “I'm not going to throw away my whole HIS just to get an ED system, yet I needed an ED system with all the management features that Allscripts offered,” says Charles Covin, CIO at ECHN. Allscripts EDIS came from the acquisition of physician-developed Nine Rivers Technology, Raleigh, N.C., and is number one in KLAS.
Why not stay with Meditech as a sole source solution? Covin says at the time Eastern was looking, execs didn't feel the Meditech ED system had the advanced functionality they needed.
“We realized there's no way you can fully interface everything from two foreign vendors,” Covin says. “But there is a core functionality that is important to fully integrate.” ECHN negotiated that interface even before bringing in the system, using Iatric Systems, Boxford, Mass. “It was a very complex interface, which had never been done before between Meditech and Allscripts,” he says. He says ECHN felt it could establish a strong working relationship with Allscripts and Iatric to get the project to work — and that was a key factor in the decision.
Documentation is a shared process. Lab orders placed in the Allscripts EDIS go back to the Meditech system for service, which then sends the results back to Allscripts. “Our intention here was not to have anyone use two systems,” says Covin. Registration is done in Meditech, the registration appears in Allscripts and at that point the patient is on the tracking board. The ED nurses and physicians do all their work in Allscripts and that's interfaced back to the appropriate Meditech module. User departments work in their Meditech module, and the results interface back to Allscripts. At the same time, the results go to the Meditech system too, so when the final ED report comes over, everything now resides in the Meditech system.
“Attending physicians only look at Meditech for a complete record,” Covin says. “And they didn't have to learn a new system. Almost nobody has to know two systems.”
The final ED report is sent to the physican's office in a number of different ways. “If physicians have an EMR, and we've developed an interface for it, we send it directly to their EMR,” Covin says.
“My advice for a hospital considering this system is more to the senior administrative team about committing resources,” he says. “Allscripts was very good about identifying each job function needed for the implementation. If they said we need an ED nurse, fulltime, for six months to be relieved from her duties to effect this implementation, that's what we needed, and that's exactly what it took to get it done. The organization committed to the resources that Allscripts said they needed and it absolutely worked.”
“I would think long and hard about buying a system that's going to be an island,” says Tony Farley, IS director at St. Elizabeth Medical Center in Edgewood, Ky. “There are so many data points in a system like that, to try and integrate in a house-wide system, I would think twice. There is so much value in the integration.”
St. Elizabeth is a McKesson shop, dating back to 1989. The medical center is also on its second EDIS. “Our old tracking board never lived up to its expectations and the vendor yanked it,” Farley says. (St. Elizabeth's previous ED tracking board was through Orca Medical Systems, a provider of medical emergency room software products which was acquired by Issaquah, Wash.-based SpaceLabs Healthcare, which then discontinued the product.) “We have a lot of other McKesson products. We talked to other vendors, and many of them, I don't know where they are today. We paid a fair price for the McKesson EDIS, but some of those niche products cost just as much or more. Integration was very important to us at the time.”
Farley says that so many of the hospitals' patients are admitted through the ED that the goal at the time was to have an integrated application. St. Elizabeth has three hospitals, three types of EDs and 110,000 ED visits annually.
At St. Elizabeth, physician and nurse electronic documentation is currently only in the ED; on the patient floors it's mostly paper. But that doesn't stand in the way of getting the EDIS info into the inpatient chart. “We use McKesson's portal technology and we also have their document imaging system. We have more than 10 years of scanned medical records available through that portal product.” He says his caregivers signing into the portal see what's happening with the ED patient in real time, and the same goes for lab results.
The McKesson Star financial system interfaces with the McKesson Horizon clinical. “The interface is behind the scenes and because it's McKesson it was pretty easy,” Farley says. An account number is generated in the EDIS to get the patient on the board.
According to Covin, for hospitals that still don't have a house-wide EMR, implementing an EDIS before an EMR can make good sense budget-wise. “Cost savings were quickly apparent,” he says. “Previously, our physicians were dictating everything and transcription costs were over $300,000 a year. Those costs went away.” There's also been a big improvement in documentation to support the level of charging. “We've seen an increase of $100,000 a month in physician billing related to better documentation including guidance through the system.”
Hess agrees the charge capture component is very import. “One physician said to me, ‘With this EDIS I'm a more expensive doctor to see today.’ If you're the CEO of a hospital, that's pretty compelling.”
For hospital executives shopping for a system, many EDISs today can functionally meet their needs. Glen Tullman, CEO of Allscripts, believes the next frontier is going to be connectivity to the community, to PHRs like Microsoft's HealthVault platform, and to local ambulatory practices.
“That's going to be the next big frontier in EDIS,” he says. “It's not going to be what feature or function do you have? The first question is going to be ‘is the system connected?’”
He says the other piece becoming increasingly important is information. “Is this system making physicians smarter by giving them best practices and decision support? And does it have management tools for benchmarking across EDs with connections to things like the CDC for bio-surveillance?”
“Most people will only talk to you about functionality, this new bell or whistle and yet it's like giving your kid a new computer,” Tullman says. “They'd be happy, but if you told them it didn't connect to the Internet, they wouldn't. And physicians in the ER are going to be the same pretty quickly. They're going to say, ‘What do you mean I don't have real time records on this patient?’ I think the story is not about functionality. It's about connectivity, about information and where these systems are going.”