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Incremental approach is best with a new EDIS
Staff need time to be comfortable with applications
An Emergency Department Information System (EDIS) often is referred to as a "suite" because it is an integrated software system, with multiple applications designed to work in concert with each other. Given that design, an ED manager might well be inclined to purchase and implement such a suite in one fell swoop.
But that's not the best way to go, advises Donna Biscamp, RN, the process improvement nurse for the ED at Memorial Hermann Baptist Beaumont Hospital in Beaumont, TX. Her ED, which uses an EDIS from Addison, TX-based MEDHOST, introduced its first applications in 2003 and still is adding modules incrementally.
"We went live in the summer of 2003 with tracking and discharge instructions," Biscamp recalls. "In September the nurses were inserviced on nursing documentation, and that was implemented in October."
However, it wasn't until 2005 that an interface was introduced that allowed lab work to "cross over" into the computer system, says Victor Ho, MD, FACEP, FAAEM, the medical director of the ED. "Then, in March 2006 the physicians added physician documentation and order entry applications," Ho says.
They've also just started ED level charges — nursing documentation that determines the patient's bill, says Biscamp. "What is left in that area is procedure charges," she says. The next step, she says, will be coding. "Everything will be done electronically, based on the documentation," she explains. All of that information will then be automated into the patient's bill. "Right now we have somebody sit behind a screen and manually enter the charges," notes Biscamp, who said at press time the goal is to have this latest process ready to go in a week or two.
One step at a time
What is the rationale for this step-by-step approach?
"The ED works best when it is able to get one aspect working very well, and the nurses are comfortable with it, before moving on to another aspect," explains Biscamp, noting that she and MEDHOST provide separate training for each application.
How does Biscamp know when the nurses are comfortable with a new application? "I do a tremendous amount of training, and then I monitor their documentation," she says. "If we see an area where they need improvement, we step up to the plate right then."
Once the department goes live with an application, she explains, both she and Ho can watch on their computer screen and see how well the staff is using it. "I can see when they are not documenting what they should be," she explains. "I talk to them to see what is wrong."
The nurses often come to Biscamp to explain why they are not comfortable, and what they do not like about the system. Sometimes, they simply have to improve their performance, but often the system can be adapted to better suit their needs. "For example, if they feel certain meds need to be added, or the phrasing of sentences makes them uncomfortable, we can adjust that," she says.
Ho adds that he and Biscamp, as the "most efficient [EDIS] users," also can help staff make better use of the system. "We hopefully can see with our [quality] audits when people are going too slowly, and we ask them to tell us what they are doing," he explains. "Sometimes we can show them how to do a process in one step instead of five."
Doctors, says Ho, are more of a challenge than nurses. "The doctors are strange animals; they're creatures of habit and do not like to change," he says. When the department was about to switch over to physician documentation, Ho visited other hospitals that already were using the system and learned that the key was preparation.
"You really have to pound it into their heads, because a lot of them have big egos," he says. "We had multiple sessions for doctors to learn."
Ho offered to provide one-one-one tutorials, in addition to the four sessions provided by MEDHOST. Still, he did not have much success getting people to show up for the tutorials. "When we went live, you should have heard what came out of people's mouths," he says.
As with the nurses, he was able to respond to some of the negative input and adjust the system to make the doctors more comfortable. Eventually, he says, the system caught on. "Unfortunately, two physicians had to leave," he recalls. "You really need to know how to type to use this system, and one doctor was near retirement and refused to learn."
The department has hired some new, computer-savvy doctors, who realize this gives them a better chart" says Ho. The rest of the staff, he adds, "have learned to embrace the system."
For more information on how to implement an Emergency Department Information System (EDIS), contact:
For more information on the MEDHOST EDIS, contact: