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4 Keys to a Better Emergency Department

Joe Cantlupe, for HealthLeaders Media, June 8, 2012

Success key No. 2: EMR in the ED
Hospitals are using electronic health systems to improve coordination and care in the ED, but first they have to recognize one caveat: These systems may not be more efficient, at least initially, than paper records.

The 265-licensed-bed MidMichigan Medical Center in Midland, Mich., turned to an EMR system primarily due to federal mandate, but the transition has become a slow process that involves working with physicians to improve their handling of the records. Hospital officials found that it was important not to just wait for everyone to adapt to the EMR, but to introduce other changes in the ED, as well.

"When the EMR was rolled out at our institution in March 2011, it led to a marked increase in our wait times and throughput times," says Danny Greig, MD, emergency physician at MidMichigan Medical Center. "We were the first people to switch to EMR before the rest of the hospital came on board. It was a huge struggle, just the learning curve, and initially that cut our productivity at least 40%. Initially, a lot of docs were fighting it and wanted to do paper."

As the hospital physicians struggled to deal with the EMR, there were other ramifications, such as a decrease in patient satisfaction, "as waiting times are the major complaint from patients who visit the ED," he adds.

The hospital leaders didn't wait for everyone to come around on EMR.

Because of those early difficulties with the EMR, the hospital could not simply rely on electronic innovation to improve its throughput. Instead, hospital administration and Midland ER Corp. relied on other strategies, such as adding overlap physician shift coverage for afternoons and evenings on a rotational basis, he adds. Essentially, the hospital increased physician coverage from having four to five 10-hour shifts each day.

In addition, the hospital instituted an expedited care model, leaving rooms open for patients with more minor complaints and a nurse staffed to focus on them to move them quickly through the department.  From adding the extra shift and expedited care, overall ED wait times were reduced from 236 minutes to 215 minutes, Greig says.

"I think we're putting all the pieces together," he says. "The hospital is getting patients out of the ED, up to the floors when they need to be admitted, and not boarding them in the ED for six or eight hours or occupying beds that can be used. In the meantime, they are beefing up x-ray, EKG, and lab services to use with the ED. Patients aren't waiting a half hour or 45 minutes to get an ankle x-ray or blood drawn."

More of the doctors are seeing improvements in working with EMR.

"Becoming facile with the EMR is almost completely a function of time," Greig says. "We saw a great improvement at about 2 months, and by 6 months physicians have generally become as good as they are going to get with the technology—again never getting quite as efficient as before it was instituted.

"I embraced it, and it's no question that EMR is the way to go," Greig adds, citing the potential of "improved patient outcomes, the reduced drug errors, the completeness of discharge instructions, in the long run."

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1 comments on "4 Keys to a Better Emergency Department"


Matthew Shafiroff, MD (6/8/2012 at 12:51 PM)
All great ideas. Tremendous focus on the front end problems in the ED. Diverting patients to other resources will be a necessary strategy if the individual mandate clause of the PPACA is upheld. A great follow up article would examine the process (work-up) and back end problems in emergency departments. For example, Many EDs are being superb at managing front end problems only to be failed on the back end where admitted patients languish in the EDs for hours after being admitted. This effectively decreases the number of 'active' beds in the ED, contributing considerably to longer wait times in the late afternoon and evening.