Pennsylvania Chapter - ACEP

1
Pennsylvania Chapter - ACEP
intelligent solutions for Emergency Department
Information Systems
2
The ED Evolution Advancing into the Electronic
Domain with an EDIS

• L. Albert Villarin, Jr MD FACEP
• Director Medical Informatics
• Department Emergency Medicine
• Albert Einstein Medical Center, Philadelphia PA

3
L. Albert Villarin, MD FACEP

• Assistant Professor of Emergency Medicine
• villaria_at_einstein.edu
• Director, Medical Informatics
• Clinical Leader AEMC ED Renovation Project
  Group
• Chair, Communications PaACEP
• Research Development Web Education
• Academic Emergency Medicine Nov 2004
• Member Consensus Conf Informatics Technology
• Webmaster
• PaACEP.org, EDwin
• Aemc-emergency.com
• Em-Arc.org, EMalumni.org

4
EDIS ED Information Survival
5
EDIS ED Information Survival

• BUSINESS Hospitals are laying the groundwork for
  EMRs
• Trends among health systems also point to more
  computerized order entry by physicians
• Doctors need to take a leading role on electronic
  medical records
• With EMRs becoming an inevitability, it's
  essential for the physician's voice to be heard
  in how the technology gets implemented.
• Health IT chief Public-private partnership
  needed for EMRs
• The foundation for a national health information
  technology infrastructure will be laid in
  communities, says David Brailer, MD, PhD.

.
6
EDIS ED Information Survival

• Report details plan for e-prescribing
• A study makes suggestions for doctors looking at
  electronic prescribing systems.
• By Tyler Chin, AMNews staff. July 26, 2004.
• Eliminating the Paper Chase
• When an emergency department goes electronic, a
  lot of inefficiencies vanish.
• by Cindy Sheets
• June 2003 - Healthcare Informatics
• Caregivers Carry Virtual Clipboard
• Students design mobile data-access system for
  health-care workers.
• Thursday, August 12, 2004 Emily C. Kumler, Medill
  News Service
• Health care technology is a promise unfinanced
• Published December 3, 2004, 731 AM PST
• By Steve Lohr - The New York Times

7
EDIS ED Information Survival

• Report Time To Pay Doctors To Adopt E-Records
  July 15, 2004   One of the industry's
  most-influential nonprofit groups says in a new
  report that doctors should be paid to adopt
  electronic records.
• Medical Economics ArchiveMay 9, 2003
• SPECIAL TECHNOLOGY SECTIONThe Connected
  Physician
• EMRs What you need to know
• HHS Awards 139 Million to Drive Adoption of
  Health Information Technology
• Oct 19 2004 0400AM By News Story Government
  Technology

8
EDIS ED Information Survival

• Hospital ER docs welcome wirelessSt. Francis
  project includes a new high tech system

9
in search of EDIS

•  Web Results 1 - 10 of about 188,000 for EDIS

EDIS
10
EDIS A bad system
Physician data entry 0440
11
ED Evolution
12
ED Past Future

• Past
• Swipe boards
• Paper charting
• Patient monitoring
• Radiological
• Multi-tasking
• simple procedures
• Few data loci
• expensive portals

• Future
• Automated location
• Web-based chart
• Mobile receivers
• Digital imagery
• Single-tasking
• complex procedures
• Omniscient data
• electrical data fields

13
EDIS

• Competitive Pressures
• Measurement of improvement
• Return on Investment
• Resource utilization
• Quality enhancement
• Service excellence
• Staff Productivity
• Physicians
• Nursing
• Ancillary

14
EDIS

• Technologic Transparency
• Machines in background away fro patinet care
• Data in Foreground at patient bedside
• Extract data just by being
• infra-red data ports
• portable info-ports

15
Our EDIS world
transform
16
The Challenge for All of Us

• Take the most important steps to move your
  Emergency Department to an integrated paperless
  environment.
• The latest advancements in wireless technology
  and hand-held personal data assistants allow more
  information to flow to the bedside.
• Wireless portability and passive tracking allows
  for more efficient clinical evaluation of the
  patient and less time searching for data.
• Strategies for creating the wireless/paperless
  ED
• Key methods to ensure your ED transformation
  PDAs, mobile laptops
• How to create and deploy web-based interfaces
• Shifting perceptions of informatics as an
  integral part of ED efficiency and patient
  throughput
• Using your passive tracking system to improve
  administrative admission, bed status and patient
  flow

17
EDIS Outline

• Components
• Tracking
• Charting
• Disposition
• Wireless Technology
• Web-based Information

Our Expectations
18
EDIS Controlling Information
Our Reality
19
EDIS Components WHY?

• Patient manipulation
• Registration
• Triage
• Charting
• Order entry
• Results reporting
• User compatibility facilitation
• Nurse
• Physician

20
EDIS Components

• Registration / Pre-Registration
• Human interface meeter greeter
• Computer interface
• Desktop / Laptop
• Thin Client
• Kiosk city / ED

21
EDIS Components

• Triage

22
EDIS Components

• Triage Registration
• Chief Complaint triage category assignment
• Information
• Past ED visits / Healthcare System
• Personal demographics / insurance
• Vital signs - automatic
• Medications past current
• PMHx / Soc Hx / Allergies

23
EDIS Components What?

• Practical Charting
• Requirements
• Multiple View support
• Triage
• Nursing
• Physician Attending / Resident / PA
• Overlapping information
• Customizable via USER Environment
• External Requirement
• Agency HCFA, JCAHO
• Active data determination logic
• Prompt orders / template meds / discharge

24
EDIS Components What?

• Practical Charting (continued)
• Requirements
• User friendly Fields / Templates
• Assessments / Admission Notes
• Discharge Disposition
• CC / PFSHx / HPI
• Allergies / ROS
• Pick list
• Data forwarding past encounters, meds, PCP
• Template driven Free Text
• Chief Complaint / Age / Gender
• Pre-populate Order sets Treatment plans

25
EDIS Components What?

• Practical Charting (continued)
• Requirements
• Input Modalities
• Point of Care Data bedside labs
• Pick Lists / Table Solutions modifiable
• Speech Recognition ...its coming...

Circa 1997
Future?
26
EDIS Components

• Chart

27
EDIS Components Who?

• Registration
• Quick registration
• Minimal and basic patient information
• John or Jane Doe
• Chart Merging
• Merge unknown patient with later information
• Master Patient Index
• Matching duplicate MR / ID for unification
• Pre-Registration
• En-route regs for EMS, PCP Doctors referral

28
EDIS Components

• Rapid Trauma Triage

29
EDIS Components Who?

• Registration
• Point of Care registration
• Services to the patient
• Thin client Palm / COWS
• Wall mounted tablets Ethernet / wireless
• Customizable
• Easy user modification of registration screens

30
EDIS Components
Complete Rapid Access
Point of Care Resources
31
EDIS Components Where?

• Patient Tracking
• White Board Replacement
• Current Conditions
• Patient
• location / condition
• encounter milestone differential times
• alert generation
• Multiple views birds eye / active / static

32
EDIS Components Where?

• Patient Tracking
• Requirements
• Patient Location
• Passive
• No human interaction
• Infrared sensors and/or radio frequencies
• Bracelets badges IR ? RFID
• Active
• Human input of data very unreliable
• More work for overworked staff
• Poor accuracy / Very difficult
• NOT real-time

33
EDIS Components
34
EDIS Components Where?

• Patient Tracking
• Encounter times
• Collect store milestones of patient encounter
• Analyze throughput, workflow, delays
• Admission / Disposition

• Times
• Triage
• Treatment area entry
• Nurse at bedside
• Physician at bedside
• Medications administered / Orders
• Research
• Physician interactions
• Resident education
• Find the bottleneck

35
EDIS Components
36
EDIS Components
37
EDIS Components Where?

• Patient Tracking
• Alerts
• Directly dependent upon tracking system
• Data analysis
• User-determined time phases delays
• Electronic White Board
• Data interface tracker ? user
• Specialized view user dependent
• Patient data- labs, admits, waiting room, etc

38
EDIS Components Where?

• RFID
• Radio Frequency Identification (RFID) is a method
  of identifying unique items using radio frequency
  waves, which allows for better tracking of all
  aspects of patient care

39
EDIS Components Where?

• RFID

40
EDIS Components Where?

• RFID collect data by touch

41
EDIS Components
42
EDIS Disposition How?

• Disposition Discharge
• Rapid Accurate
• Patient specific
• Prescriptions
• legible accurate pharmacy
• Aftercare Instructions
• multiple languages modifiable by user
• Work / school notes
• Automatic via diagnosis / time in ED
• Patient dispo returned to EDIS / Admissions

43
EDIS Components

• Charge Capture / Billing
• Pick lists
• Supply Cabinets
• Bar coding / Patient ID
• Code Generation
• CPT / HCPC / APC
• Facility Charges

44
EDIS Components

• Interfaces
• Bi-directional
• HIS ADT admissions, discharge, transfer
• EMPI assign correct patient ID via registration
• Charge post chart production billing
• Orders results
• EDIS ? LAB (CERNER)
• EDIS ? RAD (PACS)
• EDIS ? HIS (Vendor vs. Custom Interface Engine)

45
EDIS Components

• Special Features
• AUTO
• Paging of patients primary physician
• Faxing of patients results office / admission
• Multiple facilities
• Multiple Emergency Departments
• Patient transfers
• Community to Trauma Center
• Clinical staff nursing, physicians
• Schedules, Information

46
EDIS Technology - phobia
47
EDIS Technology

• System Components
• Server
• data storage, rapid access
• T1, T3 networks
• Backup, upgrades
• Interface Engine
• Thin Clients
• Desktop Computer fixed locations
• COWS mobile laptops
• Handheld Computer PDA, PC Tablets

48
EDIS

• Components

49
EDIS Technology

• Interface Engine

50
EDIS Technology Thin Clients

• Desktops
• Fixed locations
• Multiple per area
• Ratio 1.5 to 1 patients
• Clinicians -gt ED / consults
• Sitting within circular desk
• Standing around
• Ergonomically specific
• Standing functionality
• Secure

51
EDIS Technology Thin Clients

• Flat screen
• 19 inch
• Conformable to user
• Height adjustable
• Swivel for view-ability
• Securely fastened to desk
• HIPPA security screens
• 15 viewable arc

52
EDIS Technology Thin Clients
53
EDIS Technology Thin Clients

• C.O.W.S.

54
EDIS Technology Thin Clients

• C.O.W.S.
• Computers on wheels
• Stability 5 wheels
• Versatility user developed
• Longevity easily upgraded
• Durability 12 hour battery life
• Dos
• Customized Investment big bucks
• Many configurations, takes time!
• Donts
• Deploy a FEW at a time
• Get feedback ASAP
• Baby-sit these babies!

55
EDIS Technology Thin Clients

• PC tablets
• Portable thin screen computer
• Wireless / Bluetooth / Images
• Difficult to carry for hours
• Drop and you own it
• Put it down, someone else owns it
• Needs some improvements
• Tablet PC2
• Mobility approx 3 4 lbs
• Indestructibility
• Cost approx 2200

56
EDIS Technology Thin Clients

• PDA
• Quick reference
• Personal software
• Web-based products
• Interactions
• Healthcare providers / patients
• Transacting orders, results, education
• Productivity
• Improved control of patient outcomes
• Command of information
• Patient confidence improved

57
EDIS Technology Thin Clients

• PDA essentials 1
• Wireless
• Integrated for internet, intranet, databases
• Efficiency
• Portable no bricks
• Usability user upgrade
• 3 levels of user
• A) Tech savvy resident always tests you
• B) Hey Al, what PDA do you have?
• C) No Al, I dont have one yet. Why?
• Buy-in support by Admin, IT, Most clinicians
  / esp. Chairperson!

58
EDIS Technology Thin Clients

• PDA software
• Pharmacopeias
• ePocrates Rx
• www.epocrates.com
• 3,000 drugs
• Adult pediatric dosing
• Drug interactions
• Adverse reactions
• Costs packaging information
• Tarascon Pocket Pharmacopoeia
• www.tarascon.com

59
EDIS Technology Thin Clients

• PDA software
• Infectious Disease Guides
• ePocrates Rx Pro
• www.epocrates.com
• Sanford Guide to Antimicrobial Therapy
• www.sanfordguide.com
• EMRA_Antibiotics Guide
• www.emra.org

60
EDIS Technology Thin Clients

• PDA software
• Arterial Blood Gas Analysis - www.stacworks.com
• Medical Calculator - www.med-ia.ch/medcalc
• Reference skyscape / handheldmed
• Procedure logs www.ddhsoftware.com
• Prescriptions www.allscripts.com /
  www.advancepcs.com
• Voice dictation OPUS www.bostonbar.com
• Electronic charting
• www.digitalassist.com
• www.handheldmed.com

61
EDIS Technology Thin Clients

• PDA essentials 2
• Security
• Encrypt files, prevent unauthorized beaming
• www.trustdigital.com
• Autoscan anti-virus software
• www.symantec.com / www.mcafee.com
• Data backup
• www.bluenomad.com / www.spritesoftware.com
• Wireless HIPPA issues
• Ensure IS developed interfaces w/ 128-bit
  encryption
• Keep patients, families, others from access

62
EDIS Web technology

• EDwin
• ED Web-based Information Network
• PACS
• Picture Archiving and Communications Systems
• EMR
• Electronic Medical Record
• VoIP
• Voice over Internet Protocols
• Voice Interactive processes
• Current research and development
• Manage charting, discharge, consultations, ?

Future integrations
63
EDIS Web technology

• EDwin
• ED Web-based Information Network
• Intranet based system ED server platform
• Supported and updated 24-7 / VPN accessible from
  anywhere
• Real time mission critical information
• Physician call-ins, admission services, equipment
  training updates
• Clinical Pathways CATH Alert, Stroke, Pneumonia
  Time sensitive issues
• Real-time announcements, Quality Assurance
  Education
• Bioterrorism surveillance integrated regional
  system for immediate alerts
• Web resources to local, state sites /
  educational, reference, clinical 300
• Attending / Residency / PA resources
• Schedules / conferences / CME / EBM / CBT
• Web resources - gt 300 bedside accessible tools
• Procedure log databases US, clinical education

64
EDIS Web technology

• VoIP
• Telephone calls using a computer network, over a
  data network like the Internet.
• VoIP converts the voice signal from your
  telephone into a digital signal that travels over
  the internet
• Disadvantages gt out of the ED
• Some VoIP services dont work during power
  outages and the service provider may not offer
  backup power
• It may be difficult for some VoIP services to
  seamlessly connect with the 911 emergency
  dispatch center or to identify the location of
  VoIP 911 callers
• VoIP providers may or may not offer directory
  assistance/white page listings.

65
EDIS Coalescence
66
EDIS is it here?
67
EDIS _at_ AEMC Emergency Dept.

• Albert Einstein Medical Center
• Philadelphia, PA
• AEMC gt 70,000 visits Level I trauma center
• 48 residents / 20 attending staff
• Completed 10 million renovation / expansion
• Improvements at two local community EDs
• 48 available patient care area 3 trauma
• 3 PODS A,B,C 6 bed Fast Track

68
EDIS _at_ AEMC ED
69
EDIS _at_ AEMC ED
70
EDIS _at_ AEMC ED

• EDIS 4 years to complete
• Paper charting ? TSystem paper currently
• 30 Pentium 4 desktops
• Ergonomically integrated into clinical areas
• 10 wireless COWS
• Passive Tracking Healthcare IT
• Infrared badges , web-based interface for ED
• Nov 2004 PACS radiological implementation
• Jan-Apr 2007 Amelior EMR implementation
• July 2007 - PDA Dashboard

71
EDIS _at_ AEMC ED - tracking
72
EDIS _at_ AEMC ED- tracking
73
EDIS _at_ AEMC ED - tracking
74
EDIS _at_ AEMC ED - computers
75
EDIS _at_ AEMC ED - computers
76
EDIS _at_ AEMC ED - efficiency
77
EDIS _at_ AEMC ED

• Dashboard

78
EDIS _at_ AEMC EDJuly 2007
79
EDIS _at_ AEMC EDJuly 2007
80
EDIS _at_ AEMC EDnear future
81
EDISyour best friend.
82
EDIS Web resources

• www.educ.ahsl.arizona.edu/pda/art.htm
• www.palmgear.com
• www.palm.com
• www.handspring.com
• www.pencomputing.com
• www.skyscape.com
• www.medscape.com
• www.the-gadgeteer.com
• www.iScribe.com

• www.allscritps.com
• www.ephysician.com
• www.healthcare-informatics.com
• www.pdamd.com
• www. handhledmed.com
• www.ncemi.org/
• www.emedicine.com/home/
• www.emergencymedicine.com

83
Questions?

• References
• www.acep.org Reference Resource Guide2004
  Personal Technology
• www.aemc-emergency.com EDIS WMD educational
  resource
• www.emergencydepartment.com MediServe /
  MediLinksED
• www.ePocrates.com palm resources
• www.healthcareIT.com Passive Tracking Systems
• www.paacep.org isEDIS Annual Resource for
  EDIS Intelligentsia
• www.pcts.com Amelior ED
• www.saem.com Annals of Emergency Medicine
• www.tarascon.com palm resources