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Emergency Medicine Informatics Section Newsletter - October 2013

circle_arrowThe Chair’s Letter – Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowACEP National Chief Complaint Ontology - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowShare your expertise with Health Information Technology Standards Developers at HL7 - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowEmergency Physicians Take Aim at Patient Safety in Health IT - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowThe ACEP Health IT Forum Emerges - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowThe Impact of the Federal Government’s Meaningful Use Requirements on Emergency Department Physicians - EMI Section Newsletter, October 2013
circle_arrowScottsdale Healthcare Case Study - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowEHR era presents ED documentation obstacles - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowUsability Considerations for EDIS Design - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowFilling in the data gap between EHRs and patient safety - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowBest Practices for Scribes - Emergency Medicine Informatics Section Newsletter, October 2013
circle_arrowAttend the Sections Showcase at ACEP13 in Seattle!

The Chair’s Letter – Emergency Medicine Informatics Section Newsletter, October 2013

Jeffrey A. Nielson, MD, MS, FACEP

Jeff Nielson, MD, MSIt has been an exciting year. I write this from Copenhagen, Denmark at MedInfo 2013, the international informatics conference of the International Medical Informatics Association, which is held every two years. Denmark is showing their national EHR's ED tracking boards which show how the RN chooses a service to which each ED patient is assigned. On arrival the patients are assigned to Ortho, Medicine, Surgery, as appropriate. They typically do not have emergency physicians in their departments it seems. Thirty years of organized EM in the US has phased out the need for that column. It makes me wonder if any system ever had it. Because they deal with so many doctors, an actual photo of the nurse is shown in the nurse assignment column. It is humbling to see the computerization of "old" processes mixed with such innovations. In two years, MedInfo 2015 will be in Sao Paulo, Brazil and I look forward to a group of emergency physicians from the group attending!

For me, this is the end of six years in some capacity in leadership of the section. As chair of the section, I have been able to observe a lot of progress in emergency informatics. Though it has not always been the fastest processes and some of my hopes and stated goals have not gained much traction, we have really come a long way. During my tenure, the section has been awarded several successful section grants. We united Health Information Technology vendors at an ACEP-sponsored HIT Forum in July and initiated the “End-Users Matter” campaign. We collaborated with the Quality Improvement & Patient Safety (QIPS) section to write the Quality and Safety Implications of Emergency Department Information Systems white paper; and Meaningful Use continues to impact our daily work. We have begun the ACEP-funded coded chief complaint ontology. What do we need to do next? Well, that depends on you. It has been the work of the section members that has made us so effective. Decide how you want the world to be and change it!  The section infrastructure will be there to help you.

It has been an honor to work at the helm of the section. It has been an honor to serve you. Our incoming chair, Kevin M. Baumlin, MD, FACEP will bring new ideas and new direction. I am sure you will welcome his efforts and support him as you did me.

Jeffrey A. Nielson, MD, MS, FACEP

ACEP National Chief Complaint Ontology - Emergency Medicine Informatics Section Newsletter, October 2013

Steven Horng, MD, MMSc
Beth Israel Deaconess Medical Center, Harvard Medical School

HorngEmergency Medicine Informatics section was recently awarded an ACEP Section Grant to create a national, standardized chief complaint ontology for the Emergency Department that can be utilized by any emergency department with an ED information system. A standardized chief complaint vocabulary will allow administrators and researchers to accurately and systematically represent the reason for a visit in the emergency department as structured data that will facilitate comparison of patients within an institution and across institutions. A structured chief complaint can then be used to facilitate:

  1. Clinical Care and ED Operations, 
  2. Quality Assurance, Improvement, and Measurement, 
  3. Education, 
  4. Surveillance, and 
  5. Research.

Our section will build a chief complaint ontology using clinical terms from SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms), the largest and most commonly used clinical vocabulary that is freely licensed by the International Health Terminology Standards Development Organisation (IHTDSO), to the National Library of Medicine. This extensible, hierarchal, locally customizable vocabulary is both free to use and consistently maintained. Our section will build this ontology through an iterative, field-based approach with input from multiple emergency departments across the country to ensure completeness and generalizability.

Share your expertise with Health Information Technology Standards Developers at HL7 - Emergency Medicine Informatics Section Newsletter, October 2013

James McClay, MD, FACEP, Immediate Past Chair EMI Section, Co-Chair of the HL7 Emergency Care Workgroup

McClayOver the past few years the HL7 Emergency Care Workgroup (ECWG) has represented the interests of emergency providers in the development of EDIS certification, meaningful use implementation, and interoperability standards. After the standards are drafted they are circulated for review and voting for approval through a formal process. The ECWG has participated in numerous development and voting cycles for specifications that impact emergency care. Most recently, the ECWG developed a data specification for Emergency Department Information Systems.

Both the previous National Coordinators for Health Information Technology, Farzad Mostashari, MD, ScM and David Blumenthal, MD, MPP, have made it clear that future development of health information technology depends on feedback from specialty societies such as ACEP. Now that we are past the first stage of Meaningful Use, future development of measures, standards, and technology should be driven by the users.

Recognizing the importance of input from clinicians HL7 created a new category of membership for Health Professionals. This membership is significantly discounted from a full membership. In order to qualify for the Health Professional membership you have to be working for a healthcare provider organization and either be directly engaged in patient care or have at least ten years of patient care experience.

Health Professional members have access to specifications in development and an opportunity to directly influence the process. However, in order to be able to vote, a full membership is necessary. ACEP often taps non-members to review relevant standards with the comments pulled together and submitted by a full member. Other benefits of membership include direct access to the latest developments, an opportunity to network with international technology leaders, and insight into the impact of data standards on your practice.

We provided a Health Professional educational session at the annual HL7 Plenary meeting in Cambridge, MA on September 23rd. We strongly encourage more emergency physicians to take advantage of this role. If you would like to participate in HL7 as a Health Professional you can join here.

Emergency Physicians Take Aim at Patient Safety in Health IT - Emergency Medicine Informatics Section Newsletter, October 2013

Kevin Baumlin, MD, FACEP, EMI Section, Chair-ElectTarget

BaumlinRaising awareness to the unique HIT issues in EDs, the American College of Emergency Physicians (ACEP) Quality Improvement & Patient Safety (QIPS) and Emergency Medicine Informatics (EMI) Sections led by Heather Farley, MD, FACEP and Kevin Baumlin, MD, FACEP collaborated on the development of a white paper that studied the quality and safety implications of Emergency Department Information Systems (EDIS) under an ACEP Section grant. The paper, Quality and Safety Implications of Emergency Department Information Systems, was recently published in Annals of Emergency Medicine as an e-pub ahead of print in June and also appears in this month’s issue. The unique characteristics of EDs, including rapid patient turnover, frequent transitions of care, constant interruptions, large variations in patient volumes, and unfamiliar patients, make the ED environment particularly sensitive to the potential hazards of HIT. As described in the white paper, potential EDIS safety concerns can include communication failure, wrong order-wrong patient errors, poor data display, and alert fatigue, among others.  They made seven recommendations directed at the EDIS vendors, hospital administration, and the clinician end-users. These include:

  • appointment of an emergency department “clinician champion,” 
  • creation of a multidisciplinary EDIS performance improvement group, 
  • establishment of an ongoing review process, 
  • timely attention to EDIS-related patient safety concerns raised by the review process, 
  • public dissemination of lessons learned from performance improvement efforts, 
  • timely distribution by EDIS vendors of product updates to all users, and
  • removal of “hold harmless” and “learned intermediary” clauses from all vendor software contracts.

Prior to publication, ACEP shared the white paper recommendations with the Office of the National Coordinator (ONC) for Health IT focusing on shared responsibility between physicians, hospitals and vendors to address patient safety events related to the use of HIT. ACEP called for judicious clinical decision support alerts, improved usability standards, and improved accountability for addressing reported issues. ONC’s Health Information Technology and Patient Safety Action & Surveillance Plan, released in July 2013, took into consideration a number of these recommendations.  In fact, ONC recently contracted with The Joint Commission to investigate health IT-related safety concerns.  ACEP has also urged CMS to modify their Conditions of Participation so that quality and safety events related to the use of HIT and electronic health records (EHRs) be among the matters addressed in a hospital’s QAPI program. QAPI programs are already required to address adverse patient events, and ACEP maintains that CMS should clarify that HIT-related adverse patient events would be included.

In addition to accolades from multiple entities on the efforts of emergency physicians to improve the safety of HIT, both the QIPS and the EMI Sections are being awarded an ACEP “Service to College” Section Award at ACEP13 for their success in addressing member concerns. Over the course of the past few years, the QIPS and EMI sections have hosted multiple discussions between EDIS vendors and emergency physicians, and the conversation will continue this dialogue at ACEP13:

Quality Improvement & Patient Safety (QIPS) Section
Tuesday, October 15, 2013, 1-3pm
Cirrus, Sheraton Seattle Hotel (35th floor)

Emergency Medicine Informatics (EMI) Section
Wednesday, October 16, 2013, 12-1:30pm
Metropolitan B, Sheraton Seattle Hotel (Third Floor)

The ACEP Health IT Forum Emerges - Emergency Medicine Informatics Section Newsletter, October 2013

Jeffrey A. Nielson, MD, MS, FACEP

Jeff Nielson, MD, MSOver the past year, a very exciting group has emerged, the ACEP Health Information Technology (HIT) Forum.  The HIT Forum was organized for a variety of reasons, including facilitating vendor cooperation, using technology to improve safety for emergency patients, enabling better communication between ACEP and the vendors, and helping create a better HIT experience for physicians.  Its membership is limited to IT vendors and developers and ACEP members.

The first meeting took place in Denver, CO on October 10, 2012 during ACEP’s Scientific Assembly.  This inaugural meeting helped set priorities and brought the vendors to the table.  We shared goals and debated the value of a variety of objectives.  This was evidence that the vendors were as interested as ACEP in creating a shared vision.

For the vendors, membership requires a nominal fee which covers conference expenses, and allows them to send representatives to the summer meeting, which will occur annually on the day before ACEP’s Corporate Advisory Council meeting.  The fall meeting at ACEP13 is also open to vendors considering membership. At the ACEP HIT Forum on July 22-23, 2013 a wide range of issues were covered. Many of these issues could not be covered in depth, but some important points of discussion and agreement were made. 

James C. McClay, MD, FACEP spoke on several HL7-related topics.  He spoke on DEEDS 1.1 and he urged all present to be involved in the HL7 Emergency Care Workgroup.  Christopher J. Alban, MD, MBA of EPIC spoke about the HL7 process and suggested the vendors might collaborate on regional awareness, national registries, and integration of the ambulance data in the hospital EHR.

L. Kendall Webb, MD, FACEP discussed the National Quality Strategy priorities and how quality measures are being developed.  Matthew Weintraub, RN, BSN, CEN, PHRN from Wellsoft gave an overview of meaningful use. Mark L. Mackey, MD, MBA, FACEP and Greer Contreras, CPC from T-System then spoke about coding and billing in an EHR era. 

I led a discussion of methods of engaging users and vendors to have closer collaboration.  Participants suggested that separate time be held for vendors to have a group meeting with their users.  This led to the “End-Users Matter” campaign for 2013, and will be further developed in 2014. 

Kevin M. Baumlin, MD FACEP led a discussion on the patient safety monitoring including data display, wrong patient wrong order, communication, and alert fatigue.  Robert Hitchcock, M.D., FACEP from T-System gave talking points on the hold harmless clause and on the importance of clinician involvement in the EDIS. 

KLAS presented the results of their report EDIS 2013 Revealing the Physicians' Voice and discussed their report methodology.  Todd B. Taylor, MD, FACEP discussed the use of scribes in the ED and Marcin Kubiak from Elite Medical Scribes presented suggestions for integrating the scribe role into the EHR. 

The meeting was a great success and has led to a new listserv, a stronger shared vision, and several future project ideas.  All of the participants have already signed on to the “End-Users Matter” campaign which will connect working Emergency Physicians with software designers at ACEP13.  Future steps for the HIT Forum include formalizing ACEP usability guidelines and implementing the recommendations from the Quality and Safety Implications of Emergency Department Information Systems article.

End-Users Matter 2

The Impact of the Federal Government’s Meaningful Use Requirements on Emergency Department Physicians - EMI Section Newsletter, October 2013

Matthew Weintraub, RN, BSN, CEN, PHRN

It has never been more important to ensure that technology and electronic health record systems do not hinder the efficiencies of the clinicians providing care.  This is especially true in light of the vast number of workflow scenarios and requirements currently encountered in the emergency department (ED).

The Federal Government’s Meaningful Use (MU) program is nearing the end of its Stage 1 cycle where “adoption of certified technology” was the primary emphasis. As hospitals embark upon Stage 2 MU, the underlying goal of “utilization and integration” will bring new challenges to ED physicians.

Stage 2 requirements include increased use of electronic clinical notes, computerized physician order entry (CPOE), electronic prescription writing, electronic medication reconciliation, and electronic record exchange with other providers and with patients. All have the potential to significantly impact both the efficiency and quality of care delivered in the ED setting.

As the demand for ED clinicians to collect, aggregate, reconcile, and codify numerous data elements using non-traditional EDIS vocabulary sets increases, there has never been a more critical time for ED Physicians to work with their vendors and hospital information technology staff to ensure that the risks and inefficiencies of generic system implementation, or poorly designed systems, are mitigated as much as possible. As MU progresses through stage 2 and onwards toward stage 3, one thing is clear; the effects of increased requirements faced by EDIS users will be felt, and EDIS vendors will need to work to minimize these effects as much as possible.

Scottsdale Healthcare Case Study - Emergency Medicine Informatics Section Newsletter, October 2013

Scottsdale Healthcare Case Study
Elise DeCourcy
Picis Optum

For most health systems, the ED is the starting point for the care of a large segment of the hospital’s patients, and is often a central point in the delivery of quality care within the community at large. The need for a more “connected ED,” and the ability to efficiently and cost effectively manage patient care cannot be over-emphasized. For Scottsdale Healthcare, Scottsdale, AZ, of particular note was the need to obtain complete and accurate information in order to drive clinical, operational and financial goals.

The transition to Optum’s Picis ED PulseCheck, an ED-focused EMR, and the integrated LYNX ED Charging Application enabled a systemic approach to achieve key patient care priorities in all of Scottsdale Healthcare’s emergency departments. Dramatic improvements in efficiency, productivity and patient access measures enabled clinicians to have the latest medical information to make quick and accurate decisions that improve care measures, as well as patient care and satisfaction. In addition, obtaining objective data helped how physicians and nurses perform on specific metrics in order to identify best practices and try to implement them throughout the ED. From a financial perspective, Optum’s Picis and Lynx solutions have delivered substantial benefits, helping Scottsdale Healthcare reduce costs and generate additional revenue, which included a net gain of $4.2 million in benefits.

EHR era presents ED documentation obstacles - Emergency Medicine Informatics Section Newsletter, October 2013

Greer Contreras, CPC

The rapid adoption of electronic health records (EHRs) poses some concerns for the coding and billing world. We are seeing an increased adoption of enterprise solutions, which can cause documentation setbacks in specialized areas such as the emergency department (ED). 

The role of the ED is crucial for the hospital, with 40-50 percent of inpatient admissions coming from the ED. EHRs that are not designed for the unique workflow and episodic nature of the ED make it difficult for physicians to document the medical necessity and thought process of the encounter – both essential elements for physician reimbursement.

Physician reimbursement is further complicated by a multitude of regulations and guidelines associated with the documentation of the patient’s encounter.  The current regulatory audit environment is also a concern related to documentation – beyond being reimbursed for the service the physicians must also be able to support the services in an audit situation based on their documentation.

High-quality clinical documentation should provide a full account of the clinical assessment, professional judgment and critical thinking to support the “why” behind the treatment and diagnosis.  The documentation for each encounter needs to reflect patient specificity.  Some enterprise EHR features such as macros, copy and paste and automated history population make potentially dangerous assumptions about specific patient encounters that can put both patient care and physician regulatory compliance at risk.  

The ability to easily and efficiently document all the relevant information while meeting regulatory requirements within the EHR environment is critical.  Using systems for specialty areas of care they were designed for leads to higher user adoption, improved patient care and optimized reimbursement.

Usability Considerations for EDIS Design - Emergency Medicine Informatics Section Newsletter, October 2013

David Ernst, MD, FACEP
EPOWERdoc, Inc.

The importance of Usability related to Emergency Department Information Systems (EDIS) is demonstrated by the fact that the average ED physician is interrupted 10.2 times per hour and spends over 60% of their time simultaneously managing 3 or more patients (office based physicians average 3.9 times per hour interruption and less than 1 minute per hour managing over 1 patient).  Additionally, over 50% of the US ED’s are mainly single physician coverage.  The majority of EDIS are not designed around this unique workflow, and these results in dramatic inefficiencies in patient care and a frustrating experience for the user. 

Workarounds that have been created to accommodate for these inefficiencies include increasing nurse and physician staffing, scribes, voice recognition software, chart cloning techniques, and the use of macros.  Unfortunately, these crutches are mainly accessible to the larger facilities with available financial resources.  Two thirds of the hospitals in this country are small to medium sized and do not fall into this category.  Further, the use of chart cloning and macros by EHRs has come under recent scrutiny by CMS.

EDIS design features that have been shown to overcome these inefficiency and frustration challenges without the need for expensive workarounds include the elimination of unnecessary “clicks”, avoidance of subscreens, elimination of redundant documentation by sharing common data amount user categories, single screen chart access as opposed to modular design, ability to quickly mark commonly negative or normal findings, a template based input format over dropdown data capture, and a prose “transcription like” final record.

Filling in the data gap between EHRs and patient safety - Emergency Medicine Informatics Section Newsletter, October 2013

Robert Hitchcock, M.D., FACEP

Patient safety and electronic health records are receiving an increasing amount of attention. We currently face several challenges when defining patient safety issues of EHRs. The most concerning of these are the lack of a substantial and standardized database of patient safety events and an inability to reliably determine a causal relationship between patient safety and EHRs.

Presently, the method of evaluation by the Department of Health and Human Services and the Food and Drug Administration looks primarily at two variables in defining a healthcare IT related patient safety event – the presence of an adverse event and if the hospital has deployed an EHR. This is problematic because it assumes a relationship between the event and technology when there may be no correlation; in fact, the technology deployed may not have even been employed in the care of the patient experiencing the adverse event.

In order to effectively determine and manage the impact of healthcare technology on patient safety, I believe we must develop a method where we can collect real, relevant data related to EHRs and patient safety events that is standardized, allows for a causal analysis and maintains enough anonymity so as to not impede data submission, or inhibit vendor involvement in the process.

Given the visit volume of the emergency department as well as the pressure-filled environment, ED care providers are in a unique position to provide substantial information on HIT related patient safety. Through collaboration with ACEP and its members, a process and data structure to communicate safety concerns could create a robust knowledge base of de-identified data. Clinicians, informaticists, quality experts and vendor experts would then have an adequate foundation to begin developing tools for addressing EHRs and patient safety. An extensive, relevant patient safety database could make ACEP the loudest and most effective advocate for improving healthcare technology and enhancing patient safety.

Best Practices for Scribes - Emergency Medicine Informatics Section Newsletter, October 2013

Marcin J. Kubiak, MBA
Elite Medical Scribes

Working with a scribe is one of the best ways to allow providers to get back to what they went to school for: to practice medicine. However, to fully see the benefits a scribe can bring, it is important to understand the best practices for utilizing a scribe.  As a facility using scribes, having a designated “scribe space” that is located near the providers is key, as well as having laptops for the scribes to use. These allow for increased efficiency and enhanced workflow. As a provider, some best practices include: alerting your scribe when you are going to see a new patient or doing a patient recheck, having a “normal” exam that your scribe is aware of and dictating exam findings while actually examining the patient. Most importantly, let the scribes do all of the scribing functions your facility allows. Be sure to review all notes and always provide the scribes with as much feedback as possible to help your scribe continually improve! From a software standpoint, having the capability for the scribe (in the EMR) to “share” the note with their provider, so the providers can assume ownership of the note, is key. Lastly, having internal programs and software that track scribes’ progress is also beneficial. This allows you to quantitatively and qualitatively measure whether a scribe is progressing and if they are performing at your facility’s standards.

Attend the Sections Showcase at ACEP13 in Seattle!

Find your niche.
Build your network in Emergency Medicine.
Visit the Sections Showcase!  

Exhibit Hall Sky Bridge, Washington State Convention Center
Monday, October 14, 2013
9:30 AM - 11:00 AM 

Funded by
University of Florida, College of Medicine /
Network for Pancreatic Organ Donors with Diabetes (nPOD)
and EPMG


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