When it comes to IT, ED managers lag behind

Only 30%-40% of EDs have IT systems

The Institute of Medicine (IOM) report is all about the future. However, when it comes to information technology and ED managers, "the future really means catching up with the past," says one expert.

That's because only 30%-40% of the EDs in this country have any kind of information system in place, according to Larry Nathanson, MD, director of emergency medicine informatics at Beth Israel Deaconess Medical Center in Boston. "The first place for the rest to start is to get one," he advises.

Nathanson is a co-author of a report on information technology commissioned by the IOM, the findings of which have been incorporated into the larger reports. In it, the authors emphasize the value of technological advantages such as ED dashboards, or tracking systems, in a variety of areas, from safety and quality to prioritizing ED activities.

"Certainly from an ED management standpoint, the [report on] technology reviews the tools one needs to put in place in the ED to ensure high-quality, maximum throughput, so you don't have patients coming in, tests being ordered, yet no one knows where they are or what's being done," says John Halamka, MD, MS, chief information officer of the Beth Israel Deaconess ED, a practicing emergency physician, and Nathanson's co-author. "I am a strong believer in metrics, and unless you put them in place you will never improve the management of the department."

How IT helps

One of the greatest advantages of a dashboard — so named because, as in a car, all your vital information is visible directly in front of you — is that you can react to potential problems before things begin to spiral downward, says Nathanson.

"With an automated tracking system, when things get busy, they are even more effective," he says. "Now you know what's going on, if you're getting into trouble, if there is a bottleneck developing." You can be proactive, he explains.

From an administrative point of view, an automated tracking system allows ED managers to be effective while on the floor — or even do from home, he says. "They can page you at three in the morning, you can log in, and instead of a nurse trying to describe a problem, you can look at the screen and see all the same data the nurse sees," Nathanson observes. "This is an important component in communication and ties in to patient safety as well."

Having such a system in place can be a big help when administration wants to review the ED's performance, adds Halamka. "If someone asks what your length of stay [LOS] is, of how long it takes for a patient to get a bed upstairs, what are you going to tell them? That you don't know?" he poses.

His board members are deeply concerned about LOS in the ED, Halamka says. "They think of it as an incredible proxy for the quality of care we deliver," he says. The lesson they have learned is that by having good management tools based on IT, they can achieve higher levels of patient satisfaction, higher throughput, a better business outcome, and higher quality of care "Everyone wins!" he adds.

In addition, electronic documentation can be "a tremendous tool" for training, education, and simulation, Nathanson says. "Why not run doctors and nurses through simulated codes?" he suggests.

Beth Israel Deaconess launched its system five years ago, and Nathanson admits he was nervous about how well it would be accepted. "We had whiteboards in the background just in case, but they took one look at the system and saw the patient care benefits would be tremendous," he recalls. "When it's done well, it takes off by itself."

So, what are the keys to doing well? "We recommend a priority approach," Nathanson says. First, focus on patient flow, he says. "Then, move to continuity of care across other medical realms, such as getting information on your patients from primary care docs," Nathanson says. "Next, focus on decision support tools and preventing errors."

One of the latest developments involves public health surveillance, he says. "For example, if you can scan all of the area's ED records, you might see you're about to have a big flu outbreak or the Norwalk virus is in town," Nathanson notes. To quantify such a development in nonelectronic EDs would require sifting through stacks of charts, he says. "Now, you can press a key, and there's a bar graph in front of you."

As we move closer to a national electronic information system, EDs will contribute to the creation of Regional Health Information Organization Systems (RHIOS) to allow the exchange of data over large geographic areas, he says.

The bottom line, says Halamka, is this: "In the context of the IOM report, you will have to have both an ED background and technology to run the ED of the future."


For more information on information technology in the ED, contact:

  • John Halamka, MD, MS, Chief Information Officer, Emer-gency Department, Beth Israel Deaconess Medical Center, Boston. Phone: (617) 306-9886. E-mail: jhalamka@caregroup.harvard.edu.
  • Larry Nathanson, MD, Director of Emergency Medicine Informatics, Beth Israel Deaconess Medical Center, Boston. E-mail: lnathans@BIDMC.Harvard.edu.