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• W2202552012 abstract "Emergency physicians tend to be the MacGyvers of the medical world. They must think quickly and decisively, maintain a wide variety of medical skills, and under stressful conditions find creative solutions to problems. So it seems natural that an emergency physician would not simply accept using a clunky information system that slows things down. A new breed of emergency informaticists has emerged, and they’re educating themselves about what’s under the hood of their electronic medical record systems so they can be tweaked to do good instead of evil: to access key information about new patients, get tips on the best care, and document the visit, rather than introducing time-wasting and potentially dangerous steps into providers’ work flow. Thus, we have the field of emergency informatics. Emergency physicians interested in a basic grounding in the topic have been taking the online 10×10 course in Biomedical and Health Informatics for Emergency Physicians, sponsored by Oregon Health & Science University. The 10×10 informatics course is designed for physicians and nurses of all backgrounds; an emergency medicine–specific version has been available for the past 5 years, in partnership with the American College of Emergency Physicians (ACEP) (which publishes this journal). The course culminates in an in-person session at the fall ACEP Scientific Assembly. Some physicians are geeking out more intensely by pursuing board certification in clinical informatics, which became available in 2011 and will soon require completion of a 2-year fellowship. As a result, biomedical and clinical informatics fellowships are popping up across the country, with versions sponsored within emergency medicine at universities such as Yale, Stanford, University of California–San Diego, the Icahn School of Medicine at Mt. Sinai Hospital in New York, University of Maryland, Indiana University, and University of Arizona. Emergency physicians are being lured into informatics for a variety of reasons, they say, from being better informed when their hospitals are buying or adjusting their information systems, to potentially pursuing clinical informatics as a career, to simply being ready for whatever the digital future throws at them. Nikhil Goyal, MD, an emergency physician and director of the emergency medicine residency program at Henry Ford Hospital in Detroit, MI, had an information technology (IT) background before going into medicine, so when he heard there would be a board certification available in clinical informatics, he said “[I]t was completely aligned with my interests…. Board certification will be helpful because it will drive me to learn more about data and informatics.” He can also use it as a career booster, a credential that lets others know he has some serious expertise. Yaniv Kerem, MD, an emergency physician and a fellow in clinical informatics at Stanford Medical School, likes the idea of helping patients in the emergency department (ED) while also having a foot in the informatics world, to use digital tools to improve care. He believes information systems, designed well, can make the ED more efficient. “You have [patients with] complex medical conditions come in, acutely presenting, with a number of patients all at once,” he said. Easy access to patient information and decision support “reduces the mental energy needed to make these decisions, which ultimately results in improving patient care.” Although he doesn’t plan on pursuing the board certification in informatics, pediatric emergency specialist Fahd Ahmad, MD, MSCI, took the 10×10 course in 2014 because he sees clinical systems being more relevant to his work as time goes on. “A necessary part of any work anyone does, either clinical or research, is getting a grounding in informatics,” said Dr. Ahmad, who works at Washington University School of Medicine and St. Louis Children’s Hospital in St. Louis, MO. Even a small quality improvement project in the hospital requires information from patient charts, he said, and it helps to be able to communicate with the IT department to extract the right data points. “Even if you have no interest in informatics per se, if you want to improve care you have to rely on the [electronic medical record]…. You have to know what your system does for you, and its limitations.” Nick Genes, MD, an associate professor of emergency medicine, genetics, and genomics at the Icahn School of Medicine at Mt. Sinai, took the 10×10 course about 6 years ago to supplement an ongoing interest in informatics and has gone on to be a leading voice in the field, writing a blog called Blogborygmi that often touches on IT and social media issues in emergency medicine. “There’s never been a better time for emergency physicians to get involved in informatics,” Dr. Genes said, because they depend on it so much to learn about their patients. He is also a fan of the proper display of guidelines and decision support to improve the efficiency of emergency care. “When you think about all the decisions we have to make in the emergency department and all the guidance we could be receiving, informatics is a natural.” At the same time, frustrations with electronic health record (EHR) usability are fairly rampant in medicine, including in the ED. In the June issue of Annals, Robert Wears, MD, PhD, an emergency medicine professor at the University of Florida in Jacksonville, summed up the concerns in an editorial complaining about poor information system design and the workarounds they require, “embarrassing reminders of how much more needs to be done to make health information technology an effective assistance rather than a disruptive burden,…these issues arise because the normative notions of work inscribed in current health information technology systems clash too strongly with the nature of clinical work in the ED.”1Wears R.L. “Just a few seconds of your time…” at least 130 million times a year.Ann Emerg Med. 2015; 65: 687-689Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Informatics geeks argue that rather than letting work flow problems sour physicians on using the computer in patient care, the clunkiness can motivate them to work with vendors and hospital administration to improve usability. It helps to learn enough about how the systems work to get what you want, said Jeff Neilson, MD, emergency physician and director of ED informatics at Summa Akron City Hospital in Ohio. “Look at a simple problem, such as why…my lab tests show up the way they do. Maybe you want to find out why you can’t trend a particular value over time and want to get it fixed. You need to know is this a data interface issue, a systems issue, [or] a standards issue, or do you just need to go and make friends with the right person in IT?” In many hospital EDs, the challenges of using the EHR are actually getting more complicated as hospitals move away from “best-of-breed” systems designed specifically for ED workflow. Hospitals may find themselves in new partnerships with other providers to better coordinate care—or are just fed up with trying to maintain interfaces among several different vendors’ systems for various departments. As a result, they are increasingly ditching those disparate systems and buying a single enterprise-wide electronic medical record, such as those sold by Epic or Cerner. Some EDs are losing their beloved Emergency Department Information Systems (such as Wellsoft or Medhost) and enduring a painful transition to a more generic EHR that may be more cumbersome to use. Dr. Genes said Mount Sinai’s ED had developed its own system, optimizing it with a developer to meet the ED’s needs. “We were very proud of our system and had won awards,” said Dr. Genes. “We lost all that when the hospital forced us to move to an enterprise-wide system.” Although the switch was painful, it wasn’t without value, he said. “It was a setback but an opportunity to reimagine all our work flows. We were able to salvage some of the work we had done before such as the track board and order sets.” And he sees benefits for emergency care when providers have access to a wider range of patient records from both inpatient and outpatient settings. “We can see past clinic visits, and it’s nice to admit to the ICU and log in the next day and see how that patient is doing. Yes, we lost something, and things got a little slower, but we gained as well.” Given the trend away from ED-specific information systems, emergency physicians will have to work harder to get the tools they need, said Nielson. “The emergency physician is not the customer for these information systems; it’s the hospital’s IT department. That’s why we have to be good partners [with IT staff] so our requests can be submitted and submitted accurately.” Keith Conover, MD, an emergency physician in Pittsburgh, helped run the Emergency Department Information Systems International Symposia from 1995 to 2008. He said the work done on information systems in the ED can also help other hospital departments that face the same issues, but without the same time pressures that the ED has. “The emergency department is the right place to look for solutions for usability and efficacy for medical software,” argued Conover. “We have more pressure to do it and do it right, and can tolerate less BS.” The 10×10 course was created in 2005 with a goal of adding 10,000 informatics-educated physicians and nurses by 2010; the original idea was to have 1 physician and 1 nurse at every hospital in the country go through the course. About 2,000 people have completed it, several dozen of them having taken the emergency medicine–specific version. It is a broad survey course that provides an introductory grounding in the technology and policy issues around information systems in medicine, including such topics as technical standards, interoperability with other systems, meaningful use, electronic practice guidelines and decision support, data analytics, bioinformatics, and precision medicine. Bill Hersh, MD, the Oregon Health & Science University informatics professor who designed and runs the course, said it’s meant for the IT novice who might want to become the physician champion for an EHR rollout in his or her hospital, or sit on a committee that is evaluating a new system. “Installing an EHR is not like buying a new smartphone,” Dr. Hersh said. “It involves the whole institution, and re-engineering your processes and work flows. Physicians are involved in those decisions.” Physicians who have taken the course say they appreciate getting a broad grounding in these issues but also valued the online forum that connected them with other emergency physicians with an interest in information systems and data analysis. “Many people had been through an Epic transition, and our hospital was just about to decide about going to” a new system, said Dr. Ahmad. It was helpful to chat with people who had been through it, he said. Course participants must design a project that could be used in their daily work. Dr. Goyal designed a system that could track the 227 milestones for evaluating an emergency medicine resident to make it easy for faculty to carry out the twice-yearly evaluations; his hospital has used the system for 3 years, and it is evolving to a 2.0 version. Dr. Ahmad just received grant funding for his 10×10 course project to create an electronic questionnaire to screen adolescents for sexually transmitted disease testing during an ED visit. Conover maintains a blog called ed-informatics.org, in which he opines on informatics and medicine issues. It is also a repository for information collected during the years at the international ED information systems symposia, and a place where physicians with an interest in technology can get caught up on the topic. ACEP sponsors an informatics section that sponsors a monthly online grand rounds lecture that is usually attended by 50 to 100 people; the videos remain online and cover topics such as clinical informatics board certification and improving work flows. The section has also recently received grant funding to write an emergency medicine–specific informatics text, and members recently published an article in Annals with recommendations for health information exchange from an emergency medicine perspective.2Shapiro J.S. Crowley D. Hoxhaj S. et al.Health information exchange in emergency medicine.Ann Emerg Med. 2015; http://dx.doi.org/10.1016/j.annemergmed.2015.06.018Google Scholar They are working on a project to improve the reporting of patient safety issues related to information systems.3Farley H.L. et al.Quality and safety implications of emergency department information systems.Ann Emerg Med. 2013; 62: 399-405Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar Maximizing information systems in the ED is central to many big-picture hospital strategies, argued Conover, including accountable care and other reimbursement arrangements that rely on minimizing unnecessary tests, procedures, admissions, and readmissions. “Certainly the emergency department is in the middle of that,” he said, noting that emergency physicians will need to know more about the histories of patients and their care in other settings, and will rely on a better-designed EHR for that information. “The average emergency physician needs to know enough about informatics and particularly usability to be an intelligent consumer of technology.”" @default.
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