What if the study had shown the emergency department (ED) was implementing a lab Information system rather than an EMR, How would that impact patient flow? Explain.
It must be understood when interacting with health information systems that most patient flow structures interface with them. However, laboratory information systems and emergency department systems interface differently. Since this is so definitely it would impact patient flow.
For example, the methods of implementation; software structure and maintenance processes are not the same. Precisely, features that would impact patient flow will be contained in the system hardware and network. These consist of servers, workstations and label printers. Networking refers to the type of IP address installed in the information system. The in wall wiring plays a very import role in the networking feature also (Orchard Software, 2013).
The type of software used during the installation process in a laboratory information system is designed for executing patient flow related to interpreting test values; transmitting them within the system and control patient flow from that level. An emergency department information system may reflect admissions, discharges and services offered during the stay. With reference to the case study being reviewed the emergency department information system was designed to show ‘nursing and physician documentation, computerized physician order entry, tracking, registration with a niche EHR system (EMSTAT) for approximately 1.5 years’ (Kennebeck et.al, 2011, p. 1) from the time of implementation of a system wide EHR-Epic 2008 (Kennebeck et.al, 2011).
The process was phased for a period of over 2 years. Subsequently, the emergency department portion completion was set for 11 November 2009. However, during this phase H1N1 ﬂu pandemic started requiring additional information infrastructure to cater for the increase in patient flow (Kennebeck et.al, 2011).
Had there been a laboratory information system, which could not cater for all the organizations’ information dispersion needs; during the installation phase software designed to account for this category of patient flow data would have been installed. Copia Laboratory Outreach and Integration System software is often installed when organizations are faced with this dilemma. Importantly, the timeline for the software installation dependents on whether the predisposing infrastructure hardware and networking components ready. This would offer a positive patient flow impact, which would have been more manageable. Precisely, the issue of off-loading from one system to the other creating a backup would have greatly reduced patient flow issues (Orchard Software, 2013).
What would have changed if the implementation was planned for the early summer or late spring?
No one can predict when an epidemic or pandemic would emerge. Had the implementation been planned for early summer or late spring it would not have been caught in the heavy patient flow experienced during the implementation process due to the HINI flu pandemic, which began late summer. During the discussion authors admitted that patient visit metrics seemed to have been influenced adversely in the emergency department (ED) during implementation of the Electronic Health Record (HER) system phases (Kennebeck et.al, 2011).
Attempts at increasing stafﬁng to address patient overflow in the clinic seemed unsuccessful. ‘Time to physician, left without being seen numbers, and overall length of stay (LOS) for both admitted and discharged patients were signiﬁcantly higher during the initial EHR implementation phase’(Kennebeck et.al, 2011, p 1). Importantly, this irregularity was temporary. Length of stay (LOS) returned to ‘pre-implementation baselines within 3 months of implementation, after corrected for patient volumes’ (Kennebeck et.al, 2011, p 1).
This supports the theory that if implementation was planned for the early summer or late spring there would have been changes in length of stay (LOS) for both patients admitted and discharged as well as the overall patient flow. Precisely, authors confirmed from case study results that the overﬂow clinic during H1N1 flu pandemic did impact reduction in overall length (LOS) before the implementation ‘(95% CI showed decreased length of stay (LOS) 24 to 53 min for admissions, and by 9 to 19 min for discharges with the clinic in place, comparing time 1 with time 20’ (Kennebeck et.al, 2011, p 1).
It was discovered, though, during the electronic health record (EHR) implementation process that the length of stay (LOS) for admissions and discharges were higher during ‘the H1N1 pre-overﬂow clinic block as well as the H1N1 overﬂow clinic block (95% CI showed increased LOS 32 to 62 min for admissions and by 35 to 44 min for discharges compared with the clinic in place before rollout)’ (Kennebeck et.al, 2011, p 1). Again, it was confirmed admission and discharge length of stay (LOS) rates returned to pre-H1N1 average LOS after 3 months post implementation process (Kennebeck et.al, 2011).
What elements are needed in order to ensure patient safety?
Nancy Staggers, Charlene Weir and Shobha Phansalkar ( 2008) have researched ‘Patient Safety and Health Information Technology: Role of the Electronic Health Record’ and discovered that the key element needed in order to ensure patient safety when utilizing electronic health record systems is the order management interface. The researchers have described this feature as being the connective tissue (Staggers et.al, 2008, p.1) in any electronic health record system (EHR) (Staggers et.al, 2008, p. 1)
Importantly, questions related to who owns the data often surface. Hense, computerized provider (physician) order entry (CPOE) has been under scrutiny as it pertains to patient data safety. However, electronic health records (EHR) providers must comply with HIPPA regulations as it pertains to the software used for ensuring patient records safety within the system. Staggers (2008) and team have advanced that since the implementation of electronic health record system is new patient safety is still a huge challenge adequate orders management software along with staff training in management of the system to avoid common errors in medication and procedure execution can be minimized (Staggers et.al, 2008).
As a nurse manager, what would you like to have seen done differently with the implementation?
It would appear that even though the implementation was planned staff was not fully prepared to embrace the transition rigors such as increases in length of stay (LOS) issues and patient overflow, which was compounded by the HINI flu pandemic. Therefore, as a nurse manager in my opinion more staff training could have been conducted. It seemed as though training was focused on understanding and working the system. However, staff needed transition training coping training also, which encompassed offloading of data and alternations in length of stay (LOS). It was clear that increasing staff and using an overflow clinic did not help during the HINI flu pandemic. Pre-training to cope was the key to resolving this issue quickly or limiting its escalation.
The next phase of the EMR implementation plan involves the ICU and NICU. What recommendations would you make to modify the implementation plan based on the ED experience? Explain.
My recommendation is to conduct a staff readiness seminar prior to implementation using the services of a subject matter expert (SME). Data retrieved from this emergency department (ED) experience could be used as a guide into identifying strengths and weakness as well as planning the content for the seminar. It is my perspective that when a staff is adequately prepare for a transition such as moving into a complex electronic health record system (EHR) appropriate preparation is mandatory for a smooth transition with least. More importantly, Intensive Care Units (ICUs) are more delicate to manage. Increases in length of stay (LOS) is not an option here (Habib, 2010). .
After reading this case, how will you use the lessons learned to implement your group project?
Two lessons learnt from this case study are that increasing staff is not the answer to an electronic health record (EHR) implementation crisis. Secondly, a pandemic/epidemic can significantly alter the implementation process by creating chaos if inadequately managed. As such, this case study is a research project in itself expressing to the group that adequate preparation of staff is vital for smooth transition due to the complexity of the process. Also, in planning always anticipate increase patient overflow issues and manage them promptly (Habib, 2010).
Kennebeck, S. Timm, N. Farrell, M., & Spooner, A. (2011). Impact of electronic health record implementation on patient ﬂow metrics in a pediatric emergency department. J Am Med Inform Assoc. Retrieved September 25th 2013 from http://jamia.bmj.com/content/early/2011/11/03/amiajnl-2011-000462.full.pdf+html)
Habib, J. (2010). EHRs, meaningful use, and a model EMR. Drug Benefit Trends 22, (4): 99–101.
Orchard Software (2013). Harvest the Power of an Orchard Laboratory Information system. Retrieved September 25th 2013 from http://www.orchardsoft.com/product/h_implementation.html
Staggers, N.Weir, C., & Phansalkar, S (2008). Patient Safety and Health Information Technology: Role of the Electronic Health Record in Rhonda Hughes. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency form Health care Research and Quality.