[MUSIC] Hello, I'm Nicolas Genes and today we'll be talking about clinical informatics in the emergency department. I work in an emergency department, I'm an emergency physician, board certified. I find the work very fulfilling. I went into the field because I thought, I could make a difference in patient's lives when they present to the emergency department. But I also understand that for many of my patients, being in the emergency department of course is not where they want to be. And in fact, for many of them, it is the worst day of their life. So try to remain cognizant of that. And informatics, I feel can also make a difference in our patient's lives. It's said that in the emergency department there are more decisions made per hour, than anywhere else in the hospital. And often these are patients that are new to us and they're very sick. And they are facing a lot of important decisions in a very short time frame. So informatics, which is really the field of bringing the best information to the point of care to influence decision making. Informatics is critically important in the emergency department. The emergency department's also fairly special in that we see a broad array of patients. A huge diversity of patients, from infants and neonates to the very old. And we also see, the very severe, near death patients to patients with mild cuts and scrapes or a sore throat or things that are concerning them but things that they can't get care for elsewhere. And this is why it's so critically important that, we have good patient data available to us to help us make our decisions. And we need our electronic systems to really support this decision making as best we can. Finally, the emergency department is special because of it's unique nature, there's a lot of interruptions. We don't have a cap on the number of patients we see, if a lot of patients are sick. A lot of patients will come into the emergency department and we have to stretch to accommodate them. So sometimes we can up staff, if we know in advance it's going to be a bad day. But for the most part, we have to cope with the volume, cope with cognitive load, the number of interruptions that happen and try to manage as best we can while providing good care to our patients. We can be become very crowded and again, I don't envy the patients especially when it is crowded. But as a practice environment, I feel we are providing important service. The specialty of emergency medicine really just began in the 1960s and only became board approved in the late 70s. So, this is one of the newer medical specialties. And really emergency department as it was founded, it was really built on the concept that we would have limited information on patients. These are patients who can't reached their primary care doctor or maybe traveling, maybe tourists, maybe driving out of state and get in the car accident. They need to be taken somewhere but they're almost necessarily taken to a place where they are unknown and where a lot of decisions have to be made quickly. So, in the practice of emergency medicine, typically doctors will see two to four or sometimes many more patients per hour of varying ages of acuities, yes there are sub specialists that focus on pediatrics or geriatrics. But to be board certified in emergency medicine, you have to be able to treat all comers. And yeah, you have little warning about who's coming. Maybe if you're lucky an ambulance will notify, you five or ten minutes before they arrive, so that you can prepare for a mass casualty event or trauma. It's been studied and it seems that emergency physicians get interrupted about every six minutes. Although, I feel that's an underestimate. I find it rare when I go more than a couple minutes with a phone call or a nurse tapping me on my shoulder to remind me to do something or an alert on our electronic health record or an overhead page. So I feel we have to move very quickly. We have a huge cognitive burden and we also have to document a lot. And as patients get older, as the population ages, as complexity increases and sicker patients can live a lot longer. We have increased burdens for coordinating care, documenting the complexity of care that is delivered. And finally, as we discussed elsewhere in the series, there are quality metrics, billing band rates and obligations to down stream providers that we have to tend to. So, a lot of burden to use our electronic health systems and to use informatics but also informatics can be beneficial for us. When we think about what patients want in their emergency department experience, I think the overriding thing that they would prefer not to be in the emergency department, I can understand that. I think that they would also prefer that ED personnel move quickly but safely to deliver care to them. And that the ED providers, I think, patients would want them to be following guidelines and using the best available evidence as they make their decisions about care. I think patients also would want us to access the established information about them. Such as their medication lists, their allergies, their key prior test results, key prior documentation about other hospitalizations. And finally, advanced care directives such as end of life wishes, I think patients would want their doctors in the emergency department to have ready access to all of these things. And finally, I think these patients would want the ED doctors to facilitate prompt follow up. So make the notes and make the records of the ED visit accessible to their primary care doctor for follow up. When you ask an ED clinician what they are hoping for, in an encounter they always want to help their patients and they want to do everything the patient wants to do. I think, provide safe and efficient care, access the relevant records, facilitate follow up, follow evidence based guidelines. This is what every physician wants. However, emergency physicians are faced with many constraints. We have constraints on our time pressure. We want to see everyone that comes into the department, document everything relevant that's happening, coordinate care, which involves a lot of phone calls, messages, sometimes still faxes. And we also have to recognize that, we have limited resources in the emergency department. While we can see anyone who comes in, we just sometimes don't have enough space to see everyone in a comfortable manner. We have consultants that need to come and see the patient and there's a turnaround time associated with that, there's placing the phone calls, receiving the phone calls, scheduling care. And we have a few precious resources the CT scanner, the MRI, the x-rays, that really can only accommodate one patient at a time. And we have to be very careful with how we do utilize this. Our lab can of course, can accommodate more than one sample at a time but there is a turnaround time that's associated with every lab test. Everything that takes time in the emergency department means, the patient is sitting in a stretcher longer. And that's a stretch the patient would probably rather not be in. And sometimes, it means that another patient can't get in to use that stretcher. So, these are some of the constraints that we're facing just in terms of space and time. But we also have regulatory pressures. We've got to document in a consistent manner for our sepsis patients, for our heart attack patients. And, we're facing a variety of quality metrics on a number of fronts. And we have to show that we are following federal and state guidelines. We also under pressure to reduce re-admissions. And facilitate close followup, which means a lot of care coordination, making more phone calls with the community, sometimes holding patients until business hours where we can make some care decisions. And finally, we have technology pressures. Our electronic health records system really has to facilitate care and not impede care, and sometimes I think people would say that that's not happening. There's a debate in emergency medicine between Enterprise electronic health records, which is systems that are used around the whole hospital, including the emergency department, versus Best of Breed electronic health records. These are systems that are much faster and easier to use in the emergency department, but they're much less interoperable. They are not good at sharing records with clinics or with the inpatient services. So, there's always kind of a balance between choosing one or the other, there's always trade-offs. One unique feature of electronic health records in the emergency department is the trackboard. And this is borrowed from the old chalk boards and marker boards that were in use in the 70s, 80s, and 90s. The trackboard is kind of a unique feature of emergency department informatic systems, and really can give you at-a-glance information about a variety of patient details. If you look in an emergency department, you'll see attending physicians constantly scanning the trackboard for the latest information. We can get visit details, just simple things such as patient demographics, what room they're in, who their nurse is, who their primary care doctor is, who else is on their care team in the emergency department. What their chief complaint was, how sick were they, a measure of acuity. And finally, we can see how much documentation has been done on them. What the status is of their medication orders, their lab orders, radiology, consultants, whether consultants have seen the patient, put in the note. We have all kinds of different blinking lights and signals to help us at a glance kind of gauge the status of the patient, and overall the status of the emergency department. As good as the trackboards are, they are really limited to what's going on in the current visit. And they don't do enough to really show us data that exists outside the emergency department. And I feel the next generation of trackboards is going to have to surface details from a variety of databases, not just the emergency department but the clinics, the hospitals, and beyond. For instance, it would be helpful to know if a patient has visit notes or test results from earlier encounters, encounters in the hospital or elsewhere. Increasingly, we are looking for case management notes for patients who have care plans in place or have services at their home. This would be very helpful for us in the emergency department to know about as we're planning disposition for our patients. Even the presence of advanced care directives can often be very meaningful and helpful. Health information exchange which we've talked about in other lectures. This is very helpful in the emergency department to know if a test that we're ordering or considering has been performed recently at another facility on the same patient. This would be something to surface in the patients chart or even in the trackboard. Finally, information from state databases about prescriptions, this is something that we want to be able to surface for our providers. It's important to remember that just because a database exists somewhere, it doesn't mean that a physician or a care team is going to know to access it. We need signals to let us know that there's relevant data in that database, and we need really a safe and efficient pathway to be able to access that data. It's not enough to have a database somewhere on a website that I've got to remember a different password for. And if you make it really burdensome to access the data, then often studies show that the data doesn't get accessed and care can suffer as a consequence. So let's talk for a moment about data that can influence care and how we should implement these workflows and really help providers make the best decisions about patient care. This is patients and providers working together in harmony and hopefully working with the electronic health record. Clinical decision support is that name of the process by which information can be surfaced to help providers make the best decisions. Wouldn't be good to have a provider in the emergency department who's considering ordering medication on a sick patient that just arrived? Wouldn't it be good to have the doctor review the patient's allergies and medication list before placing any orders? I think, objectively, everyone would say, yes. This can prevent unintended events, adverse events, side effects, and so on. So, it seems like a good idea, but the implementation really makes all the difference here. You can imagine doing this in a way where the provider would be forced to answer a pop-up. Deal with a hard stop, as we call them, before placing any medications to just confirm that they've reviewed the patient's allergies and medication list. And that might be satisfactory, but if it's something that the provider can simply ignore and blow by, then it won't serve the intended role. If you force the provider to go into one part of the chart to review the allergies and medications before going into another part of the chart to place the orders, then you're looking at something that could potentially delay care. And in a critically ill patient, that's the last thing you want. Really the best way to implement this is to kind of passively, but helpfully, show the patient's allergies and medications at the same time as a patient is placing orders, or really even thinking about placing orders. And, it's also good to build a fail safe into this, where if a provider is ordering a medication that may interact with the patient's medication list or maybe triggering an allergic reaction. That's when you want to see a hard stop or a pop-up that at least warns the provider about this. So, implementation matters and working with the provider to kind of fit into the provider's workflow turns out to be a lot more safe and effective than simply instituting a bunch of rules. And in fact, this has been studied and there are some notable findings when decision support is implemented without much regard to workflows. This particular study by Strom is relatively famous. I think I've cited it elsewhere because of the unintended consequences. When a particularly dangerous reaction when a pop-up appeared warning providers about a particularly dangerous interaction and advising them to call a pharmacist before continuing. The providers had no choice but to call a pharmacist or to just not order the important medication. And in fact, what the provider did was often nothing. They made a note to call the pharmacist later, but they failed to. The patients often didn't get the medications that they needed, so something that was well intentioned ended up having unintended consequences. And this again is because Doctors get interrupted a lot, they have a high cognitive load in the emergency department and other parts of the hospital, and this can lead to disruptive work flows, and then delays in care. So what is a good way to implement decision support. We have these ten commandments to fall back on and a group of distinguished clinical informaticists came up with this list now more than ten years ago. And it's funny because as someone who trained in science, it's hard to read a paper that is called the ten commandments of effective clinical decision support but the truth is when this was written there wasn't a whole lot of evidence behind it. These just seemed like best practices that should be involved, and they do make a lot of sense such as anticipate needs and deliver decision support in real time. Fit the decision support into a provider's work flow. Recognize that physicians will strongly resist stopping, changing direction is easier than stopping. Little things can make a big difference and of course monitor solicit feedback and iterate. We have a lot of other industries that have implemented effective decision support and made their systems usable and user friendly, such as the airline industry. And every time a plane crashes or every time there's a near miss, the records are reviewed. The machines are reviewed and the pilot's actions are evaluated. And sometimes there is a pilot error, but sometimes they find that the pilot error was facilitated by bad instrument layout or readouts that were confusing. And so, over the years, the airline industry has really improved how their systems work and how their pilots can interact with those systems. This is done in a very public forum. This is not done in medicine with as much openness and if we have a bad outcome at one hospital that is often reviewed at one hospital and a change is implemented. Maybe a change in policy or maybe a change in the electronic health record but it stays within that one hospital. Our findings are not shared with other hospitals and this has been identified as a potential limitation of the process and really it might be better to simply share our findings with other hospitals so that everyone can benefit from what we learn and how we move. There are also usability tools, software and procedures that can be used to evaluate work flows and evaluate clinical decision support. Shown here is a setup where someone is watching a provider navigate through screens in the electronic health record, and they are looking at how the provider, how their mouse has to travel across the screen. The provider is encouraged to speak out and think aloud about the processes that they're going through, and even things like eye movements can be tracked, and distracting pop ups and so forth can be analyzed and hopefully minimized. The other key aspect of usability is that even the most thoughtful alerts and most thoughtful workflows don't often survive long in the real world. We have to constantly get feedback from our users about how things are working, assess workflows and iterate, change the work flow to better match with the users need. That's how the emergency department will be more efficient. This is true in any care area but I think in the emergency department efficiency is premium. And finally, usability testing as I showed before implementing do this usability testing to really guarantee that you're not launching with a product or software that's potentially inefficient or even worse dangerous. Finally, I wanted to talk a little bit about ED throughput. When I first learned about this I was a little, well, I thought it was a little off-putting because I went into medicine to help people, and a lot of these models of ED throughput assume that people are almost interchangeable. And really this is a field of informatics that borrows a lot from factories. And the processes that are put in place there. So turns out though, that despite the variety of patients and their diverse presentations, movement through an emergency department can be described and modeled mathematically. And analyzing throughput is becoming an increasingly important way to allocate resources, to budget, and to actually make improvements. So it's becoming an interesting field for me, and it can be very confusing. Every potential interaction can be modeled and has an associated turnaround time, and even an associated cost. So we can model the arrival of a typical patient or the arrival of a diverse array of patients or even a mass casualty incident we can model how these patients will move through triage to the main ED. We can average out how many of them will need x-rays or CT scans or blood testing. And then, we can look at each of those steps and say, how can we improve the turn around time for our CT scanner or for our blood testing? How can we move patients through the ED faster? And models can actually predict the impact of changes in staffing, or upgrades in lab equipment, or even just changing the layout of the emergency department can be modeled. And we can sometimes show how one layout is more efficient or expeditious than another. So I feel like throughput models, while somewhat distasteful, I think, are a new field for informatics and there's a lot of opportunity there to hopefully make patients', emergency department stays as fast and painless as possible. And in general, I feel informatics has a key role to play in emergency medicine, I hope I've explained some of that for you today. Thank you. [MUSIC]
