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Strategies for Improving Information Management in Emergency Medicine to Meet Clinical, Research, and Administrative Needs William H. Cordell, MD, J. Marc Overhage, MD, PhD, Joseph E Waeckerle, MD, for the Information Management Work Group*
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The ED of the future will require the effective integration of information technologies into clinical care. This article proposes strategies for improving information management in emergency medicine to facilitate patient care, public health surveillance, clinical research, medical education, and health care management. Key words: emergency medicine; information; informatics; emergency department; research; epidemiology. Acad. Emerg. Med. 1998; 5162-167,
I Both society and the profession of medicine are being transformed by information. McDonald noted, “During the Industrial Age, we used machines to improve our lives by extending the capacity of our muscles. During the Information Age, we are improving our lives by extending the
capabilities of our minds.”’ Barnett wrote, “The practice of medicine js dominated by how we process information, how we record information, how we retrieve information, and how we communicate information.”* This article proposes strategies for improving information management
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From Methodist Hospital and Clarian Health Partners, Emergency Medicine and Trauma Center; and Indiana University School of Medicine, Indianapolis, IN (WHC); Indiana University School of Medicine, Department of Medicine and Regenstrief Institute for Healthcare, Indianapolis, IN (JMO); and Baptist Medical Center; Department of Emergency Medicine and University of Missouri at Kansas City School of Medicine, Kansas City, MO (JFW). *Other Information Management Work Group Members: Edward N. Barthell. MD. Department of Emergency Medicine, St. Mary’s Hospital and Medical College of Wisconsin, Milwaukee, WI; Craig E Feied, MD, National Center for Emergency Medicine Iilformatics, Washington Hospital Center; Washington, DC; Herbert G.Garrison, MD, MPH. Department of Emergency Medicine. East Carolina University School of Medicine, Greenville, NC; Daniel A. Pollock, MD. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention and Division of Emergency Medicine, Emory University School of Medicine, Atlanta, GA; Robert J. Schwartz. MD. MPH. Department of Emergency Medicine. University of Pinsburgh Medical Center; Pittsburgh. PA; Mark S. Smith. MD, National Center for Emergency Medicine Informatics, Washington Hospital Center; Washington,DC; Todd B. Taylor; MD, Department of Emergency Medicine, Good Samaritan Regional Medical Center and Phoenix Children’s Hospital, Phoenix. AZ; Robert L Wears, MD. PhD; Department of Emergency Medicine. University of Florida Health Sciences Center; Jacksonville, FL; and Andrew D. Zechnich, MD, MPH, Department of Emergency Medicine. Oregon Health Sciences University#Portland, OR. Received: August I3, 1997; accepted: August 29, 1997. Prior presentation: The Future of Emergency Medicine Research Conference, Washington, DC, March 1997. Address for correspondence and reprints: William H. Cordell, MD, Emergency Medicine and Trauma Center; Methodist Hospital of Indiana, Inc.. I701 North Senate Boulevard, Indianapolis, IN 46206. Fax: 31 7-929-2306; e-mail:
[email protected] This article is being copublished in Academic Emergency Medicine and the Annals of Emergency Medicine. 01998 Hanley & Belfus, Inc.
in emergency medicine (EM) to improve emergency medical patient care and public health, research, education, and health care management. Although our discussion inevitably includes the uses of information technology in health care, our main focus is information managementthe capture, storage, sharing, analysis, display, and standardization of information.
THE IMPERATIVES FOR CHANGE Our industrial-based society is transforming into one where knowledge is the central resource. Drucker observed, “The real, controlling resource and the absolutely decisive ‘factor of production’ is now neither capital nor land nor labor. It is knowledge.”3 Numerous cultural, professional, political, financial, and technological forces are driving the need for improved information management in health care. These include a transformation to a knowledge-based society, changes in health care reimbursement and delivery, rapid improvements in information technologies, and increasing volume and complexity of clinical information. In addition, payers are requiring that the ,value of the care being purchased be demonstrated through measurable improvements in patient outcomes.
Information Management in EM, Cordell et al.
At the same time, health care reimbursement is moving toward a capitation-based payment system and away from a charged-based system. In response, there has been a shift to outpatient treatment, shorter hospitalizations, care for people at the lowest appropriate level of intensity, and an emphasis on preventive health care. “We are in a new age, in a world that focuses on the patient and his or her relationships (e.g., family, employer, insurer, provider) and on the multidisciplinary approaches to care across the continuum. This paradigm emphasizes prevention and care management for members of the communit^."^ Managed care is largely predicated on alliances, tightly linked components, and “portable” information. The success of these systems will depend on a seamless delivery system in which patients, as well as information regarding their medical histories, move from point to point in a coordinated fashion.
THE INFORMATIONINTENSIVE NATURE OF EM Because health care is one of the most information-intensive professions and service industries, continually improving information management for health care workers, managers, researchers, and policy makers is paramount. Information drives all aspects of clinical care, including decision making, diagnosis, treatment, research, continuous quality improvement, and reimbursement.’ Emergency health care workers (physicians, nurses, nurse practitioners, physician assistants, paramedics, and emergency medical technicians) are among the most information-intensive of health care professionals. Because they must rapidly diagnose and treat patients 24 hours a day whenever the patient chooses or the condition mandates, and because they work as a team, emergency medical professionals require immediate access to information and the ability to effectively
communicate with other team members. Yet at present, in terms of access to information about patients, emergency staff are commonly disadvantaged. Patients often forget key details of their medical histories or are too ill or injured to provide any information at all. Because emergency care is, by its nature, episodic, emergency health care workers as a rule do not know individual patients or know the patient’s “baseline.” Alper wrote that emergency physicians (EPs), who don’t know the patient, practice defensive medicine. “They order extra tests, and, because they may never see the patient again, order them all at once. Many of the tests may have been done before, but the results aren’t handy and so studies are repeated . . . Episodic care starts at the beginning again and again.”6 This “shotgun” approach is reinforced by the demands from both patients and administrators to quickly arrive at a disposition. Even when information is available, it may not be available quickly enough. Either the patient’s condition is so acute as to require action before data are available or the time lost waiting for the data may outweigh the disadvantages of repeating tests or gathering information again. Because many health care information systems are “islands of information,” unconnected to other systems, sharing information between hospitals, private offices, and clinics may be problematic. Further complicating information access, even information within a single institution may be scattered across an “archipelago” of databases. Finally, because most EM information management is currently paper-based, information is typically slow to retrieve, often illegible, and difficult to share even when immediately available. Any emergency medical information solution must meet these unique needs of the emergency department (ED) and out-of-hospital environment. Because emergency services
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are required at all times, these systems must operate 24 hours a day with no downtime. The systems must be usable by different care providers including not only physicians, nurses, and secretaries, but often students and physicians in training, ambulance personnel, and support services such as laboratory and radiology.
THE BENEFITS OF COMPUTERIZED INFORMATION SYSTEMS Until recently, most computers in health care were used for business functions such as billing and ordering supplies. In 1992, Wears wrote, “Today, most hospitals have information systems that can tell administrators when to order lasagna noodles, but can’t tell ED directors the ten most common chief complaints in their department.”’ The imperative is now shifting to managing information when it is most useful-when and where patients are being treated and decisions are being made (i.e., at the “point of care”). The potential for information technology to decrease cost while maintaining or improving quality and care processes is enormous. Potential benefits include reducing health care costs, improving quality, minimizing duplication of effort, and reducing error. One of the most persuasive arguments for proliferating computerized information systems in EM is the expected savings. Wong and Abendroth wrote, “Considerable experience to date has shown that computers can improve physicians’ problem solving and decision making by presenting pertinent data, information, and knowledge when it is needed, where it is needed, and in an appropriate format.”’ Computerized alerting, reminding, and monitoring systems can decrease health care costs.* Tierney et al. assessed the effects of a network of microcomputer workstations used to write all inpatient orders on health care resource use.9 They demonstrated that the network signif-
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icantly lowered patient charges and human intelligence at several key hospital costs, which potentially steps of the research process-colcould amount to savings of tens of lecting and storing data, analyzing data, displaying information, and inbillions of dollars nationwide. Diebold believes that $90 billion terconnectivity and integration. Imis wasted each year because health proved use of information will benefit providers cannot access their patients’ clinical and basic research, public full medical histories. He wrote, health research, and health services “There would be huge savings if a research through the availability of doctor or specialist simply could de- large data sets, establishment of senpress a computer key and access a pa- tinel systems, and electronic networktient’s complete medical history and ing of researchers. This section exhealth records instantly.”” Electronic plores the implications of information information systems hold several in health care research. other advantages over paper-based systems, including ease of data re- Integrating Data: Single EDs fretrieval, legibility, and ability to be ac- quently lack sufficient patients or recessed by more than one person at a sources to collect and analyze data on time.” And because computer sys- many aspects of EM patient care. tems are designed for contemporane- Generalization of research findings ous (“real-time”) data entry, docu- remains an issue in single-ED studies mentation of clinical care may occur because of the idiosyncrasies of praccloser in time and location to the ac- titioners and patient selection. To overcome these difficulties, many tual event. EDs need to join collaborative research networks seeking to identify or IMPLICATIONS FOR develop evidence-based clinical pracHEALTH CARE RESEARCH tices and policies. These efforts will The increasing availability of power- capitalize on the emergence of comful information tools and rich data puter-based ED records in which clinsets challenges us to redefine “re- ical information is readily available in search.” Traditionally, research is de- standardized formats. As information fined as the formal process of hypoth- from ED patient records is more easesis testing conducted to gain new ily transmitted and aggregated, it also knowledge. This view is unquestion- will be used more frequently in idenably essential to the advancement of tifying events that are of public health our specialty. There are, however, importance and in building databases other important research implications to support epidemiological research. Large database research is an imof improved information management. Many health care management portant and growing application of inand policy decisions are being guided formation management in EM reby research that may not be published search. The growing focus on health in scientific journals. Information outcomes studies, cost and clinical efanalysis tools and the availability of fectiveness analyses, and health serstandardized datasets give managers vices research emphasizes the utility and quality and outcomes researchers of population-based studies using the opportunity to “data mine” and large data sets. While these databases uncover links between practice and currently contain primarily adminisoutcomes. Electronic information trative or billing data, health services technologies also offer an unprece- researchers in EM are demonstrating dented opportunity to present relevant greater use of such data, particularly research findings at the point of care by linking information from 2 or more data sources to enhance their to influence practice behavior. Computers and other information utility. Clinical data repositories reptechnologies complement or exceed resent both the cornerstone and the
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fastest-growing component of most medical information systems. These repositories store and aggregate clinical data for quality assurance, outcomes analysis, clinical research: and injury and illness surveillance. A standardized medical vocabulary is essential for aggregating data at an institutional or national level.
Linking Researchers: Information technologies can be useful to EM researchers by networking researchers, allowing access to information about research funding, and improving the dissemination of research findings. One example is the use of the Internet and World Wide Web as a channel of communication between EDs throughout the world and investigators who are interested in facilitating the collection of data from multiple sites.” A nationwide or international network of research expertise would facilitate the development of a community of researchers in EM and allow those with expertise in one area to contribute to the development of researchers in another area, bringing the entire field forward at a more rapid pace. Research for Managing Health Care: Health care research is intimately linked with and insinuated in patient care, public health, health care administration and management, and health care policy design. The uses of information by clinicians, researchers, managers, policy makers, and patients are increasingly intertwined. For example, information collected at the bedside from a single patient can be pooled with information from other patients and used to answer research questions or guide management decisions. Conclusions drawn from this research can be fed back to the point of care to guide subsequent clinical decisions. Increasingly, research is being conducted by health care professionals other than traditional researchers. Quality improvement specialists, outcomes managers, managed care administrators, and even front-line phy-
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sicians need skills relative to merge and analyze databases and using information tools. Emphasizing this point, Ruffin noted, “The distinction often made between information collected for research and information collected for practice is counterproductive and unfortunate. We need to apply the discipline of clinical research to all our patients” (Marshall Ruffin, MD, personal communication, January 27, 1997).
Presenting Research at the Point of Care: Computer networks will allow all types of information, including clinical, demographic, financial, and reference, to be integrated and displayed, often automatically, at the point of care to influence decision making. Electronic information systems may be designed to provide feedback to providers at the time they are making clinical decisions. This approach has been shown to be an effective way of changing clinical beha~ior.’.’~.’~ Furthermore, computerized information systems also have the potential to help minimize errors in health care d e 1 i ~ e r y . I ~ ~ ’ ~ Despite the rapid growth of randomized trials and other rigorous clinical investigations, much of this scientific evidence is not applied in the front-line care of patients. There are numerous barriers to applying new evidence to patient care, including lack of awareness of the information, the sheer volume and disorganization of new information, difficult access to clinically relevant information, time constraints, and poor information-seeking habits. The emergence of electronic information networks, some interconnected worldwide, offers a historical opportunity for health care researchers to help organize the results of rigorous clinical investigations for use by clinicians at the point of care. One such example is the Cochrane Library, a new electronic resource that contains the collected work of the Cochrane Collaboration, an international organization that prepares,
maintains, and disseminates systematic reviews of randomized trials of health care interventions.” Thus, in addition to their traditional role of conducting research, health care researchers may help ensure that rigorous, relevant evidence is organized and accessible enough to be used by clinicians.
RECOMMENDATIONS We propose 4 strategies to accelerate the incorporation of information management in EM patient care, research, education, and health care management. 1. The evolution of standards and uniform data sets should be funded and promoted. The promulgation of standards facilitates the linking of information technologies and sharing of information. Support should extend to developing a national health care information infrastructure, of which EM is an important link. Creating a national health care information infrastructure requires standards for coding data, messaging standards, a telecommunication infrastructure for sharing the data, appropriate security and confidentiality measures, and statutory authority to exchange the information. National organizations and federal agencies can foster this development by supporting the establishment of standards and uniform data sets. Support for initiatives such as the National Information InfrastructureHealth Information Network (NIIHIN) consortium’s Essential Emergency Data Set (EEDS) and the Department of Health and Human Services/Centers for Disease Control and Prevention and Data Elements for Emergency Department Systems (DEEDS) projectst should be continued. Support.must be ongoing since standards are never static and must evolve with changing technologies and needs. EM organizations could ?The DEEDS report appears on page 185.
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promote improved information management in several ways, including funding emergency medical informatics and large data set research projects, showcasing information technology and management at meetings and symposia, substituting electronic for paper-based correspondence, and serving as a clearinghouse for evaluating new technologies.
2. Health care information systems should be integrated to meet clinical, management, and research needs. The ED can no longer be an “island of information.” In the evolving health care delivery system, individual components of the system must be integrated, interconnected, and networked. EDs must be integrated with local and regional health care delivery systems. In actual practice. this means that patient information is portable. Stand-alone, unconnected information systems are an anachronism. Health care rendered before the ED visit should immediately be available to EM professionals to help guide decision making and appropriate treatment. Likewise, information generated during an ED encounter should be available to the patient’s private physician or clinic, health care managers, and other persons authorized to access and analyze it. Fully realizing the value of information collected in such large data systems requires that comprehensive linkages be achieved. Patient identities must be tracked across encounters, providers must be correctly identified when they render care in different settings, and clinical data must be aggregated no matter where they originate. In addition, clinical records must be linked with financial records to provide the comprehensive data required for decision making in the evolving health care climate. Once data systems are integrated, data must be transformed into useful information and knowledge to guide clinical decision making, continuous quality improvement, and reduce the cost of health care delivery.
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ogies should be systematically stud- patients, telemedicine, and regional ied. Anticipating likely future trends care. In 1995, ED visits increased to in technology, health care, and soci- nearly 100 million in the United ety can guide current information States. EM health care providers have management and planning for the fu- for decades directed mid-level proture. Technologic trends include arti- viders using telecommunication deficial intelligence, transmission of in- vices. Paramedics and emergency formation without regard to distance, medical technicians, in electronic evolution of the Internet, miniaturi- contact with physicians, are trained to zation, and ubiquitous rather than deliver care outside the hospital-in “intrusive” computing. Information the home, on the street, or wherever management in EM over the next it is needed. And poison control cendecade will be typified by uniform ters, typically directed by EPs trained rather than individualized care pro- in clinical toxicology, care for pacesses, noninvasive rather than inva- tients over large geographic areas sive monitoring, and automated rather from a central location. EDs also than manual retrieval of information. serve as a central site for triage, treatThese advances will result in the pro- ment, admission, and referral to beliferation of the electronic medical come an integral component of the records, clinical decision support sys- new health care environment. EM tems, and the evolution of standards should leverage this expertise to betfor clinical data. ter serve health care delivery systems Anticipating information manage- and transform into “knowledge 3. Health care professionals should be trained to use information tech- ment in the future of health care is hubs.” For EM to accomplish this, nologies to transform data into infor- exemplified by 2 projects, the De- the above strategies, including intemation. Funding infrastructure, the partment of Defense’s MHSS 2020 gration with all health care system software, hardware, networks, and and the American College of Emer- components, centralized knowledge standards, is by itself not enough. gency Physicians’ Emergency De- resources, sophisticated databases, Health care workers require formal partment of the Future. The MHSS and a regional or nationwide infortraining in using information systems 2020 project has involved both mili- mation infrastructure, must be impleand analyzing data as well as learning tary personnel and civilians in envi- mented. to use information tools to manage in- sioning the future of military mediThe goal of information manageformation and create knowledge. This cine for the next quarter century. The ment in EM is to quickly and conmandates that they receive the edu- ED of the Future project has pooled veniently present current, valid, and cation and training to use these tools the futuristic designs and products relevant data of all types in an approfor knowledge navigation and crea- from numerous companies for a walk- priate format when and where they tion. Basic topics include an introduc- through demonstration. These and are needed for those authorized to use tion to informatics and computers and similar projects should be encouraged them. Improved information manageusing productivity software, elec- and financed to continually refine our ment will benefit EM patient care and tronic mail, and the Internet. Ad- vision of the future so that we may research in important ways. Informavanced topics include merging data- begin implementing many of the an- tion can be presented at the time clinbases, analysis of databases, research ticipated changes now. EM orga- ical decisions are being made-at the methods for quality improvement and nizations should consider retaining point of care-to influence practice outcomes management, and present- futures research consultants to track behavior and provide quality, cost-efing information to change clinical be- trends, identify future opportunities fective patient care. And already-colhavior. Although informatics courses and risks, and train EM leaders in the lected information can be “reused” and fellowships are currently offered skill set of futures research. to conduct clinical and public health by universities, federal organizations research, manage patient populations, such as the National Library of Med- CONCLUSION develop health care guidelines and icine, and private institutes, these top- Over the past quarter century, EM has policies, and educate emergency ics need to be adapted to meet the gained considerable expertise in health care workers. unique needs of EM professionals. Thinking strategically about ways health care delivery, which is of great to improve EM information systems value in the current health care envirequires consideration of the major 4. Future trends, opportunities, and ronment. These skills include the triuser groups that these systems curage and treatment of large numbers of risks regarding information technolThe use of information must also be integrated to accommodate the needs of clinicians, researchers, educators, and health care managers. In 1925, Abraham Flexner wrote, “The ward and the laboratory are logically, from the standpoints of investigation, treatment and education, inextricably intertwined.”” In 1998, especially from an information perspective, the same holds true. In addition, effective management requires access to information and fiscal, clinical, and research information needs to be coordinated.” Addressing clinical, research, education, and management information needs depends on integrating disparate information systems, bridging “islands of information,” and merging “database archipelagos.”
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rently or potentially serve.’’ By translating various user needs into functional specifications, the future health care information infrastructure will provide more timely, comprehensive, and accurate information for patient care, education, research, health care administration and finance, and disease and injury prevention. Physicians, nurses, and other health care professionals will remain the highestpriority users, but with proper system design, shared databases and com-, puter networks will accommodate the needs of nonclinical users to an extent not currently possible. As we near the end of the decade, century, and millennium, we are witnessing profound changes in health care delivery and accelerating improvements in information technology. Ironically, in a world where data and information technology are proliferating, health care is often starving for information when it is most needed and useful. To remedy this and to improve patient care, health care research, and public health, we have recommended strategies to improve information management. Many of these are not unique to EM, but could apply to our health care system as a whole. Nevertheless, the
need for rapid access to information in EM patient care is particularly acute. We believe improvements in the management of information-the entry, retrieval, organization, display, interpretation, analysis, and sharing of information-will be one of the major advances in EM patient care, health care management, and medical research over the next decade. REFERENCES 1. McDonald MD. Health in the age of telecognition. In: Bezold C, Halperin JA, Eng JL (eds). 2020 Visions: Health Care Information Standards and Technologies. Rockville, MD: United States Pharmacopeial Convention, Inc., 1993, p. 61. 2. Barnett 0.Computers in medicine. JAMA. 1990; 26312631-3.
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17. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine: How to Practice & Teach Evidence Based Medicine. New York: Churchill Livingstone, 1997, p. 49. 18. Flexner A. Medical Education: A Comparative Study. New York: Macmillan, 1925, p. 6. 19. Gallin JI, Smits HL. Managing the interface between medical schools, hospitals, and clinical research. JAMA. 1997; 277:651-4. 20. Dick RS, Steen EB (eds). The ComputerBased Patient Record: An Essential Technology for Patient Care. Washington, DC: National Academy Press, 1991.
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