A recently published study finds that one emergency department’s implementation of a custom electronic documentation system reduced patient throughput, and researchers call for new strategies to mitigate the efficiency effects of going paperless.

The study, published in the Annals of Emergency Medicine, found that the use of a custom electronic documentation system resulted in small but consistent increases in overall and discharge length of stay (LOS) in the ED. The study found a 6.3-minute rise in LOS for patients treated and released and a 5.1-minute increase for discharged patients. There was no statistically significant change in time to disposition or LOS for admitted patients.

Even though the increase in LOS was small, it still played a significant role in a high-throughput ED. It was extrapolated to the entire department that an “additional six minutes per patient encounter would add more than 16 hours per day for an ED serving 165 patients per day.” As a result, these increases could lead to decreased patient satisfaction and delays in care for time-sensitive conditions, argued the study’s authors.

“The emergency department is a fluid and highly dynamic environment, with high volume, sick patients and frequent distractions and interruptions,” the study’s lead author, Joshua Feblowitz, MD, told AMA Wire®. “The implementation of EHRs holds great promise in the emergency setting, but the environment is especially susceptible to changes that influence efficiency.”

“A change to ED workflow that has a small effect for each individual patient can easily create a large ripple effect in emergency department flow and efficiency as a whole,” added Dr. Feblowitz, an emergency medicine resident at Brigham and Women's Hospital and Massachusetts General Hospital.

One of the study’s co-authors is Ryan Ribeira, MD, MPH, a newly elected member of the AMA Board of Trustees and chief resident of emergency medicine at Stanford University Medical Center.

Previous studies have been conducted on the use of EHRs in the ED, and findings have been mixed. While some have found improvements within the department, others show negative or neutral results. However, these studies do not isolate the effects of individual EHR features—such as patient tracking and provider documentation—from one another.

Federal government incentives have helped more than double the adoption of electronic health record systems (EHRs) in emergency departments (EDs), according to a National Center for Health Statistics data brief.

Changes to physician workflow can potentially create a large ripple effect in a high-volume department, but it is important to balance this against unmeasured benefits of more complete and high-quality EHRs, the study’s authors wrote. Findings in this study were consistent with research that suggests electronic documentation in the ED can be more time consuming than traditional paper charting.

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Physicians were asked to provide input with design, testing and implementation of the custom electronic documentation system. However, even with a focus on workflow and usability, there was still an influence on long-term operational performance. The design of the electronic documentation system and EHRs in general is constrained by billing and coding requirements, Dr. Feblowitz noted.

“Medical documentation also has strict requirements that are based around medical billing and EMRs often encourage greater compliance with these regulations,” said Dr. Feblowitz. “In fact, this may be one of the goals of implementation—to improve reimbursement. However, some of the requirements of documentation, such as review of systems, are based on a seemingly arbitrary number of elements that do not have a high amount of relevance to patient care.”

“We believe that the health care system as a whole should be open to revising the required elements of documentation to focus on more patient-centric documentation,” he added. 

The study recommends research focused on identifying “interventions to mitigate the effect of electronic provider documentation on ED efficiency.”

“It’s important to be open to adapting new workflow strategies and technologies to improve the efficiency of documentation in the emergency department,” Dr. Feblowitz said. “Two specific interventions that are gaining in prevalence are use of scribes and use of electronic dictation software.”

“Both of these have the potential to improve completeness and efficiency of documentation and we are hoping to study the effects of these strategies in the future,” he added.

To ensure new digital health solutions facilitate effective care and relationships between patients and physicians, the AMA brings the physician voice to innovators and entrepreneurs. By recognizing the key challenges physicians face when implementing health IT—such as EHR usability, interoperability and workflow—and the increase of direct-to-consumer digital health apps, the AMA aims to help physicians navigate and maximize technology for improved patient care.

The AMA s focused on influencing health IT with the goal of enhancing patient-centered care, improving health outcomes and accelerating progress in health care.

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