Healthcare has transitioned from a paper-based system to one that relies on information technology to support all facets of healthcare delivery. These include (but are not limited to) the implementation and use of electronic health records (EHRs), picture archiving and communication systems (PACS), electronic prescribing (ePrescribing), computerized provider (or physician) order entry (CPOE) systems, automated clinical decision support (CDS) systems, telemedicine, mobile data capture, disease surveillance, charge capture for professional and facility services, and electronic billing and reimbursement. This transformation moves us closer to the goal of providing patients with the right care at the right time in the right place every time.

The American Recovery and Reimbursement Act (ARRA) of 2009 provided a major incentive for electronic health records, with reimbursement by Medicare and Medicaid for the Meaningful Use of certified EHRs, as well as other programs that supported EHR education and health information exchange. Such large-scale expenditures have been justified based on the belief that technology can help address the problems of variable quality and safety in modern healthcare.¹

However, there is a gap between the postulated and empirically demonstrated benefits of eHealth technologies. There is little convincing research showing that these technologies are cost effective.

ELECTRONIC MEDICAL RECORD VERSUS ELECTRONIC HEALTH RECORD

The electronic medical record (EMR) is an application environment composed of clinical data repositories, clinical documentation, CDS tools, controlled medical vocabulary order entry, and pharmacy systems. This environment supports the patient’s EMR across both inpatient and outpatient settings and is used by healthcare practitioners to document, monitor, and manage healthcare delivery within a care delivery organization. The data in the EMR is the legal record of what happened to a patient during his or her encounter at the agency and is owned by the organization.^2,3

The EHRs do everything an EMR does and more. EHRs focus on the total health of the patient—going beyond the standard clinical data collected in the provider’s office. They are inclusive of a broader view on a patient’s care. EHRs are designed to reach out beyond the health organization that originally collected the information. The National Alliance for Health Information Technology stated that EHR data “could be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.”⁴ They are built to share information with other healthcare providers, such as laboratories and specialists, so they contain information from all clinicians involved in the patient’s care.

The Office of the National Coordinator for Health Information Technology (ONC) exclusively uses the term electronic health record (EHR).⁵

The ED EMRs should be integrated with the hospital EHR, preferably as a different view, face, or display format of the same EHR, so that the ED encounter information flows into the primary care office record and inpatient record if the patient is hospitalized.

THE BENEFITS OF EHRs

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  Improved care coordination:

  
  

  A functional EHR can provide the latest information about a patient’s health status to all members of the healthcare team, leading to coordinated, patient-centered care. It allows access to a patient’s record simultaneously by multiple care providers, regardless of their location, allowing for more efficient collaboration.

  
  
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  Improved quality of care:

  
  

  An EHR can keep accurate and complete patient health information at providers’ fingertips.⁵ The information aggregated by the primary care provider informs the emergency department (ED) clinician about the patient’s significant medical history so that care can be adjusted appropriately, even if the patient is unconscious. EHRs can also help patients better manage their conditions and become more involved in their healthcare. Using a patient portal, patients can view their personal record and look for trends in their laboratory results. This information can then be used as a source of motivation for patients to take their medications and keep up with lifestyle changes that have improved laboratory values. This could lead to better patient experiences and outcomes. Using ePrescription, physicians can communicate directly with the pharmacy, reducing transcription errors, saving pharmacy waiting time, and eliminating lost prescriptions.

  
  
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  Increased efficiency and productivity:

  
  

  EHRs facilitate a faster and trackable communication with multiple clinicians, insurance providers, pharmacies, and diagnostic centers. They also help to streamline the office management through integrated scheduling, automated coding, and insurance claims.

  
  
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  Increased healthcare safety and reduced medical errors:

  
  

  EHRs can help providers make efficient, effective decisions about patient care through improved aggregation, analysis, and communication of patient information, clinical alerts and reminders, support for diagnostic and therapeutic decisions, and built-in safeguards against potential adverse events. Patient safety is also improved, as CPOE and electronic prescribing checks automatically for potentially dangerous drug interactions, drug allergy, drug dosing errors, etc.

MEANINGFUL USE OF EHRs

EHRs can provide many benefits for providers and their patients,⁶ depending on how they are used. In 2009, the federal government provided the healthcare community with a transformational opportunity for progress. The Health Information Technology for Economic and Clinical Health Act (HITECH) authorizes incentive payments through Medicare and Medicaid to clinicians and hospitals for using EHRs privately and securely to achieve specific improvements in care delivery. “Meaningful use” is the set of standards, defined by the Centers for Medicare & Medicaid Services (CMS) Incentive Programs, that must be met by eligible providers and hospitals to earn incentive payments and avoid penalties. The goals of meaningful use are to promote the spread of EHRs and improve their meaningful functionality to improve healthcare in the United States. To achieve meaningful use and earn the incentive payments, eligible providers and hospitals must adopt certified EHR technology and use it to reach specific objectives at each of three stages over 5 years from 2011 to 2016.

In October 2015, CMS released a final rule that specifies criteria that eligible professionals and hospitals must meet to participate in the EHR Incentive Programs in 2015 through 2017 (Modified Stage 2) and in Stage 3 in 2017 and beyond.⁷

Details about meaningful use and the incentive programs can be reviewed at the CMS⁸ and Health IT websites.⁹

THE PROCESS OF EHR IMPLEMENTATION

The road to EHR implementation is paved with incentives and challenges.^3,10–12 Successful EMR implementation requires careful consideration of the following points:

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  EMR/EHR system selection is the biggest decision that needs to be made, but most often this decision is made on an administrative level above the ED. The EHR Report 2016 published by Medscape gives an overview of commonly used EMR systems in the country for different practice sizes.¹³ Since the ED is a 24/7 service, it is important to consider the cost of system downtime: How often does the system go down (how reliable is it)? Is periodic downtime required for maintenance or upgrades? What kind of backup options are available?

  
  
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  Implementation and ongoing governance of the EMR should include input from clinical staff and physician champions.^3,14–16

  
  
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  The two major strategies to implementing an EMR are the big-bang approach and the phased, or incremental, approach. Each strategy has pros and cons that must be considered.¹⁷

  
  
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  Expect a temporary decline in provider productivity when the EMR is first implemented, and develop a plan that addresses concerns about patient throughput. With a good system and proper training, pre-EMR throughput should be restored within 2 to 6 weeks depending on the size of the ED.

  
  
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  Training is perhaps the most important part of the EMR implementation process.

  
  
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  Some hardware issues to consider are the use of thin clients, PCs, laptops, tablets, touch screens, screen sizes, printers, voice recognition, wireless networks, and wired network port locations.

  
  
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  Security issues to consider include the location of unit displays, formal login procedures, timed logout after a period of inactivity, number of simultaneous logins permitted, and system access on personal (nonhospital) devices.

EHR AND CLINICAL DECISION SUPPORT

Clinical decision support is still in its infancy and will likely improve in the future with artificial intelligence. Integration of an alert for suspected sepsis or a communicable disease could expedite appropriate care. Given the dramatic variation in healthcare costs from one location to another,¹⁸ prompting physicians with standard-of-care guidelines at the point of care (an example of CDS implementation) may go a long way to improving healthcare delivery across the country.¹⁹ CDS is also a measure of “meaningful use,” and the integration of CDS into EHRs is a certification requirement. CDS tools can take many forms. The simplest form is a pop-up alert informing physicians about drug–drug and drug–allergy interactions as they generate prescriptions or medication orders. CDS can also consist of a dashboard prompt that is linked with clinical quality measures (CQMs). For example, while looking through the record of a woman who presents to the ED for an episode of acute respiratory distress, the clinician is prompted that she has diabetes and that her most recent glycohemoglobin (HbA1c), performed 10 months ago, was 8.3%. In this case, the visual prompt is the CDS, and it immediately informs the clinician that the patient has poorly controlled diabetes and is past due for a follow-up.²⁰ In addition, efficient use of the CDS would mean that the prompt displays not only the A1C result (a CQM-derived finding) but also the targets and standards of care in this situation. Furthermore, the presence of clinician resources can offer review-based decision support that can be quite valuable.

TELEMEDICINE AND ED TELE-CONSULT

Telehealth medicine is constantly growing to provide healthcare worldwide. It is an avenue to assess, diagnose, plan, implement, and evaluate data over time or distances at a fraction of the cost. Having the remote capability to offer specialty care and access to rapid assessment and treatments can be an answer to a shortage of experts in community hospitals and underserved locations.²¹ A recent survey of healthcare executives found that 90% had already begun developing or implementing a telemedicine program into their organizations.²²

Tele-consult in the ED has been evolving over the last decade. It has been studied for stroke management,²³ psychiatric consultation,²⁴ trauma management,²⁵ and pediatric emergency medicine consultation.²⁶ Telemedicine has a potential role in pediatric emergency medicine for real-time decision making to improve the quality of care for children.

Although there are many advantages to using information technology, there are disadvantages and ethical issues as well. Before implementing new telehealth technology, questions need to be answered such as: Who will benefit? Is it more useful for the client, healthcare providers, or the stakeholders? What is the liability? What is the endpoint? Will it reduce mortality or increase the quality of life? Will it be cost effective? Who will be installing and monitoring the devices? How will consent be obtained? Are surveillance and tracking intruding on a person’s privacy if used as a safety measure?²¹

MOBILE DEVICES AND DATA IN HEALTHCARE

Over the past several years, EDs have become increasingly computerized. Tablet computers and smartphones are increasingly common in daily use. As part of the computerization trend, we have seen the introduction of handheld computers, tablets, and smartphones into practice as a way of providing health professionals (e.g., physicians, nurses) with access to patient information and decision support in the ED. Numerous apps are now available to assist healthcare providers with many important tasks, such as information and time management, health record maintenance and access, communications among the care teams and consulting, reference and information gathering, patient management and monitoring, point-of-care clinical decision support, and medical education and training.^27–31

Despite the widespread adoption of this new generation of mobile devices by healthcare consumers and health professionals, research is needed to better understand the impacts of these new mobile devices on work, workload, and patient outcomes. The security of handheld devices should also be considered when evaluating the new technology. Safeguards must exist to protect any potential breach of patient data.³²

There is a growing consensus that widespread adoption of EHRs is essential to achieving many of the healthcare goals set by the United States, including improved care quality and patient safety. The Committee on Quality of Health Care in America of the Institute of Medicine notes that healthcare organizations should expect any new technology to introduce new sources of error and should adopt the custom of automating cautiously and be alert to the possibility of unintended harm.¹ As Sir Cyril Chantler of the King’s Fund said, “Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous.”³³ There is a lack of vigorous research on the risks of implementing these technologies and their cost-effectiveness. The empirical evidence did not substantiate many of the clinical claims made about the most commonly used eHealth technologies.^34–36

It is vital that future eHealth technologies are evaluated against a comprehensive set of measures. The Institute of Medicine (IOM) recently published a report to address this issue. National EHR-related patient safety goals need to be created to address the current problems known to occur during the implementation of existing EHR systems and the failure to leverage current EHR capabilities.³⁷

EMERGENCY DEPARTMENT EHR DATA FOR DISEASE SURVEILLANCE

Public Health Syndromic Surveillance (PHSS) is a widely adopted and rapidly evolving approach for monitoring and assessing public health. The majority of PHSS systems currently use de-identified patient encounter data from hospital EDs. Epidemiologists find these data valuable because ED data are widely captured using EHR technology, and are available in a timely manner. Moreover, as access points for people in urgent need of medical care, EDs are more likely to care for vulnerable populations during public health emergencies. PHSS is also a part of Meaningful Use.³⁸