Emergency Departments Find Meaningful Use of EHRs Challenging

Ken Terry

February 19, 2015

Physicians in emergency departments (EDs) and hospital outpatient departments (OPDs) have found it difficult to use electronic health records (EHRs) meaningfully, despite the widespread implementation of these systems.

According to a new report from the Centers for Disease Control and Prevention (CDC), the percentage of EDs that use EHRs jumped from 46% in 2006 to 84% in 2011, and OPDs' adoption of EHRs soared from 29% to 73% in those 5 years.

Similarly, EDs' use of "basic" EHRs — which can record patient histories and demographics, problem lists, clinical notes, medications, and allergies and can be used to order prescriptions and view laboratory and imaging results — nearly tripled in that period to 54%, whereas OPDs' adoption of basic EHRs grew sixfold, to 57%.

Yet in 2011, just 14% of EDs had EHRs that were able to support nine of 14 meaningful use Stage 1 objectives, and 16% of the OPDs had technology that were capable of meeting these criteria.

EHRs Missing "Right Targets"

One reason why EDs were slow to bring these capabilities online is that the government "didn't necessarily set the right targets for what's necessary to support patient care in the ED," said James Augustine, MD, a board member of the American College of Emergency Physicians, in an interview with Medscape Medical News. In other words, he said, not all of the meaningful use criteria were relevant to EDs in terms of patient care.

The CDC data also show large variations in the kinds of functions that ED EHRs could perform. In 2011, 87% of EDs said their EHRs could record patient history and demographic information, 65% could list problems, 63% could be used to order prescriptions, 43% could provide warnings of drug interactions or contraindications, and 40% could provide reminders for guideline-based interventions.

While most EHRs allow staff to enter patient demographic data, Dr Augustine said, "The ED modules may not yet have had all of the functions that allow you to order drugs and provide warnings and provide reminders on specific guidelines. An increasing number of EHRs now do allow you to perform those functions, but they might have been added later than what the CDC is picking up."

Dr Augustine, who is also vice president of the Emergency Department Benchmarking Alliance, a group that does statistical work for EDs, noted that there are multiple reasons why so many ED physicians might have had trouble ordering medications in their EHRs. For one thing, he pointed out, it takes hospitals some time to tie together all of their systems. So even if an ED was using an enterprise-wide EHR, its physicians might not have been able to order drugs online from the hospital pharmacy.

In addition, he noted, most EDs in the past decade have adopted electronic drug dispensing systems such as Pyxis. In 2011, a lot of EHR vendors had not yet built interfaces with Pyxis, although more have since then.

In general, he said, enterprise EHRs — which are dominant in large healthcare organizations — do not provide ED modules that are as well suited to the ED as best-of-breed EHRs are. "The fast pace of the ED makes it difficult to use systems that are not specifically designed for that pace of work."

This is not just about documentation, he added. If an emergency physician who has his gloves on and is sewing up a patient has to go through 10 computer screens to order a medication, that presents a serious challenge to workflow and timeliness.

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