Improving Access to Clinical Information in an Emergency Department: a Qualitative Study

Boonchai Kijsanayotin1 MD, PhD, Jing Du2 MPH, Nawanan Theera‐Ampornpunt1 MD, Ayse Gurses2 PhD, Stuart M. Speedie1 PhD1Institute for Health Informatics, 2Health Policy and Management, University of Minnesota, Minneapolis, MN

AbstractWe studied the information flow in anemergency department (ED) to understandhow patient information flows betweenproviders and how information from acomputerized ambulatory system, which wasnot well integrated with the hospitalinformation systems at the time, could beused. The study aimed to identify possiblemethods that could push information from anambulatory EHR system to providers withminimal interference with the ED’s currentworkflow. The ED’s information flow wasmapped and a strategy for makingambulatory encounter information availablewas identified.

MethodsWe conducted approximately 54 person-hoursof semi-structured ED observations andinterviews in the target hospital ED. Thepatient care process and the information flowstarting from the registration and triagethrough discharge were carefully observed.These qualitative observations were translatedinto the flow diagram above.

Observations

Information in the hospital’s clinical informationsystem was occasionally consulted if the patientwas hospitalized previously.

Ambulatory encounter information from theambulatory EHR system was rarely consulted.

Many physicians believed that they did not haveaccess to the ambulatory system, even though itwas available.

IntroductionThis study focused on understanding thevarious sources of patient information that areused for patient care in the target hospital EDand how the information is collected and usedby providers. This knowledge was used todetermine if information gaps exist in the ED,and how information from an existingambulatory system could be made availableduring an ED visit. The ultimate goal is to findopportunities to better utilize availableinformation to enhance patient care, withminimal disruption of the current workflow.

Observations

Significant variation in how physicians and otherproviders used the available systems.

Providers mostly relied primarily on informationfrom patient or family interviews.

Information from sources other than self-reportwas infrequently utilized in the ED’s careprocess.

Patient Walks in

Complete Short Registration Form

Look up Patient ADT Record

Verify Patient Name and Address

Found ? Generate New Record

Correct ? Edit information

Create Encounter Create New ADTEncounter

Print Sticker Labels

- Label Blank Physician Order Form- Collate Documents into Chart- Send to Triage Nurse/Paramedic

Attach Wristband Patient Identification

to Patient

Information Desk Clerk /Triage Nurse/Paramedic Emergency Room

Triage Patient to Determine Urgency

Document PatientHistory and Triage

Information

Ask for Current Medications and

Allergies

Need to Follow Specific ED Protocol(s)

, Order Lab , X-raysMedications ,

Procedures per Protocols

Provide Procedures /Treatment as

Necessary

Communicate with In-Charge Nurse

Admit Patient to Appropriate Roomwith Paper Chart Following Patient

Start

EMS Paramedics

EMS Notifies ED of Incoming Arrival

Nurse/ PhysicianTransfers Notes onto

the Ambulance Run Sheet

Admitted Room on

Prepare Room/Equipment/

Facilities and Write Information about

EMS , Intake Nurse on

Whiteboard

EMS Delivers Patient to ER

EMS Verbally Reports Case to

ER Providers

Quick Registration using “Kwik Reg”and Verify Patient

Identity

Registrar LocatesPatient’s ADT

Record

Found?

Generate New ADT Record

Create Encounter

Print Sticker Labels

Create Paper Chart

EMS Writes Report and Provides a Copy to ER Providers

Start

End for EMS

Iterative Processes

, Orders for Medications,Procedures, Labs that Providers will Process Themselves

Imaging Lab/

Orders

Yes No(Hospitalize /

Transfer)

Intake Nurse Assesses Patient

and Provides Care

Document Information on Paper Forms

Place Chart in “New Patients”Holding Rack

Physician Reviews Information in

Chart and /or CIS

Physician Sees Patient /Provides

Treatment

Order through Hospital IT System

YesDocument Notes through IT system

Or Dictation

Physician Tracks Lab/Imaging

Results

Nurse/ER Technician Acknowledges, Processes

and Documents Orders in IT Systems and Paper Record

HUC Coordinates with Lab Technician for Lab

Orders or Radiology Technician for Imaging

Orders

Need to Follow Specific ED Protocol(s)

Order Lab , X-rays, Medications ,

Procedures per Protocols

and ProvideTreatment as

Necessary

What Type of Orders?

,

/

If Patient Recently Arrived Registrar

Completes Registration.

Insurance forms

Discharges Patient Physician DischargesPt from ED

Discharged Home ?

Use IT System to Prescribe and

Provide Instructions or

Provide Written Prescription /Instructions

Nurse Provides Instructions and

Educational Materials to Patient

HUC and Nurse Coordinate with

Inpatient /Referral Facility

Chart is kept in ER for 24 hrs and then Sent to MR

End Patient ED Encounter

End for Registrar

Monitor Patient

Legend

Darker Boxes Represent Processes Interacting with A

System

No

ED Information and Activity Flow Diagram

Yes

Yes

No

No

No

No

Yes

YesYes

Recommendations

Clerk flags paper chart if patient already insystem.

Simplify provider access to the ambulatorysystem.