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SPECIAL CONTRIBUTION
Emergency Medicine Can Play a Leadership Role
in Enterprise-wide Clinical Information Systems
From the Department of Emergency
Medicine, Washington Hospital
Center, and the National Center for
Emergency Medicine Informatics,
Washington, DC*; Department of
Emergency Medicine, Northwestern
University School of Medicine,
Chicago, IL‡; and the Department of
Emergency Medicine, Prince George’s
Hospital Center, Cheverly, MD.§
Received for publication
November 9, 1998. Revision
received July 12, 1999. Accepted for
publication September 10, 1999.
Reprints not available from the
authors.
Address for correspondence: Craig
F. Feied, MD, Washington Hospital
Center, Department of Emergency
Medicine, 110 Irving Street NW,
Washington, DC 20010; 202-8777574, fax 202-877-2468; E-mail
[email protected].
Copyright © 2000 by the American
College of Emergency Physicians.
Craig F. Feied, MD*
Mark S. Smith, MD*
Jonathan A. Handler, MD‡
Meera Kanhouwa, MD§
At many institutions, the department of emergency medicine is
uniquely suited to a leadership role in the deployment of new
clinical decision support systems (computer systems that
support clinical practice). Many factors favor such a leadership
role, including institutional politics, organizational structure,
extent of local control, clinician solidarity, openness to change,
departmental size and scale, and willingness to take risks. Such
a role should be undertaken in partnership with the institution’s
information services (IS) department, and a clear understanding
of goals and responsibilities will facilitate such a partnership. A
leadership position with respect to new information systems
entails a certain risk, but the potential benefit to an emergency
department in today’s competitive environment is substantial.
The authors’ experience with one such collaborative
development project is presented.
[Feied CF, Smith MS, Handler JA, Kanhouwa M. Emergency
medicine can play a leadership role in enterprise-wide clinical
information systems. Ann Emerg Med. February 2000;35:162167.]
0196-0644/2000/$12.00 + 0
47/1/103131
INTRODUCTION
One of the most important transformations that will
occur in medicine over the next 10 years is the application of new information technologies to clinical practice.
We believe that at many institutions, the department of
emergency medicine is in a unique position to assume a
leadership position in this transformation through a
partnership with the institution’s information services
(IS) department.
A revolution in the applications of new information
technology is currently under way in medicine. As clinicians become more computer-savvy, health care enterprise IS departments struggle to meet the new needs of
demanding clinical users at the same time that they strug-
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gle to shore up monolithic legacy mainframe systems. The
highly publicized “year 2000 bug” is only one in a long list
of perennial problems that threaten traditional billing,
laboratory, and financial services systems. These missioncritical systems must be kept operational in an increasingly alien and rapidly changing modern computer systems environment. Because of the funds invested in these
legacy systems, they cannot be easily abandoned. Yet clinical users are increasingly dissatisfied with traditional
mainframe interfaces that require extended effort to
deliver small aliquots of information about a single
patient.
Although integrated clinical information systems are
highly desired by clinicians, most clinical departments
will continue to work with manual systems until they can
become passive end users of a generic enterprise-wide
system. Unfortunately, today’s commercially available
enterprise-level clinical information systems are designed
with a “patient-centric” and “problem-centric” approach
in which current and historical information is displayed
about a single patient with well-characterized clinical
problems that are followed over a prolonged period.
These longitudinally organized, single-patient–focused,
problem-oriented data systems are ill-suited to the needs
of emergency departments, where episodic care is delivered simultaneously to many critically ill patients whose
conditions are not yet diagnosed.
Increased competition and declining reimbursement
have made the need for more and better information critical to EDs.1 If integrated hospital-wide systems cannot
immediately meet the information needs of EDs, many
such departments will be forced to operate with standalone emergency medicine computer systems that are
separate from the hospital system. Although this can be
an effective short-term solution, such systems cannot
persist for long. In the information age, connectivity is
king and stand-alone clinical systems are at best a bridging technology, if not an anachronism. Systems that do
not fully participate in standards-based connectivity and
exchange of information will be abandoned as testaments
to the shortsightedness of their developers and their purchasers.
Collaboration between the ED and IS department in a
joint implementation of solutions based on accepted
standards makes sense for both parties. Much of the data
needed by the ED to serve its patients already exist in the
stewardship of others. To have access to those data, computer systems used by the ED should link to a variety of
disparate legacy systems. The IS department can provide
those critical links to many sources of real-time and his-
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torical data throughout the institution, as well as a pathway by which to reintegrate new information and data
generated within the ED. Conversely, the IS department
of a health care delivery system often is in great need of a
clinical partner, one who is engaged in delivering the
actual service that the health care organization was created to provide (ie, clinical care). In many institutions,
the IS department is pressured to demonstrate clinical
utility and to satisfy a demanding medical staff accustomed to modern Internet interfaces. In a hospital where
essential services depend on legacy mainframe systems in
which a huge investment already has been made, this is
not an easy task.
More than 50 years ago, George Pólya, a brilliant
Hungarian mathematician, set forth guidelines for tackling difficult mathematical problems.2 For the most difficult classes of problems, he proposed first trying to solve a
simpler problem derived by changing the scale of the
problem or by dropping 1 or more constraints.3 This
principle is also applicable outside mathematics.3 The
general health care enterprise clinical information systems problem is very complex, and may be more easily
approached by first solving it in the simplified environment of the ED.
From a clinical information point of view, the ED is a
much simpler system than the entire enterprise. Fewer
people are involved in its operation, the area is geographically compact, most patient visits are of short duration,
and most diagnostic tests are performed only once per
visit. The ED is essentially a self-contained miniature
health care delivery system in terms of the processes of
care and categories of information that exist within its
departmental walls. The menu and complexity of ED processes reflect those of the clinical operation of the whole
clinical enterprise—patients are registered, insurance
information is collected, clinical care is rendered, laboratory, radiology and other diagnostic tests are ordered and
completed, results are returned in real time, diagnoses are
assigned, disposition is made, and billing is performed.
With the implementation of intensive diagnosis and treatment units in many EDs and the growth of observation
medicine, selected ED patients may have an entire 48-hour
hospital admission compressed into an intensive 12-hour
stay. Patients who are admitted as inpatients may go to
virtually any hospital area, and those who are discharged
or transferred may go to almost any receiving facility.
While physicians and nurses play a central role in the ED,
housekeeping, dietary services, materials management,
engineering, plant maintenance, and other personnel also
are involved. From a practical point of view, EDs have
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more political autonomy, smaller and more centralized
leadership and administration, and more unanimity of
purpose among clinicians than many other departments.
Issues that can require months or years of political wrangling in other departments can be decided more quickly
in an ED.
Simplicity of scale in the ED also applies to the physical
installation of a clinical information system. Fewer than
40 computer terminals on a single network segment in a
very small area of the hospital can supply all of the clinical
information needs of a typical ED serving 50,000 patients
a year, whereas more than 10 times as many terminals
may be needed when the same number of patients are distributed throughout the rest of the hospital. A protected
environment in the ED is an added bonus during the vulnerable period of early development and initial installation of a clinical information system. Because of the closed
team structure of the ED, awareness of the inevitable
deployment problems and pains can be confined to a
small number of people. And after successful deployment, no site in the hospital can be made more visible to
more members of the medical staff from more specialties.
A successful system in the ED is an immediate high-visibility win for IS.
Because the ED is a scale model of the totality of a
health care enterprise’s administrative, financial, and
clinical processes of care, it is a natural “best choice” as
the primary site for the introduction and testing of new
information technology that can later be generalized to
meet the needs of the rest of the enterprise. It would be
difficult to find or design a better small-scale test site for
the introduction of information technology innovations.
A systems solution that works in the ED usually is readily
scalable to an entire hospital or health care system. For
example, in most hospitals the total patient volume of the
ED is of the same order of magnitude as the total number
of inpatient admissions. Scaling is further facilitated
because in most hospitals, 25% to 50% of all inpatients
are admitted through the ED. (There are approximately
90 million ED visits in the United States annually, and
approximately 30 million hospital admissions. Roughly
12 million ED visits result in admission each year. Thus
ED admissions account for about 40% of all hospital
admissions.4-6)
To make such a partnership work is not always easy. It
will be necessary for both parties to adapt to new ways
and to make compromises based on poorly understood
needs that must be taken on faith. Leaders of the IS
department should accept their natural role as guardians
and providers of “clinically owned clinical data” rather
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than as owners of those data. Their self-perceived role
must be to ensure that all available data can be made available to the authorized clinical user through secure,
authenticated connections using industry-standard hardware and software protocols. They should accept the need
for different end user tools that query the same data sets to
meet the needs of different clinical users. They should
accept the deployment of dedicated technical resource
personnel whose appointments are entirely within the
clinical departments they serve. They will be required to
accept a pace of change that is faster than may be comfortable.
Leaders of the ED should recognize that an investment
in information technology has the potential to do more to
improve clinical care in the next 10 years than any other
advance in the field of medicine. The clinical department
must be prepared to accept the financial and administrative costs of technical personnel whose appointments are
entirely within the clinical department. These personnel
will need to understand the needs of the clinician, as well
as the technical requirements and constraints of the information system. The administrative structure should permit change to be introduced into the department on a trial
basis rapidly and in a nearly ad hoc manner without the
need for layers of approval.
Because of the rapidly changing and unproven nature
of the field, both parties should have an a priori willingness to accept failure or serious delays in up to 20% of
the leading-edge projects and project components that
are undertaken. Both will need to trust that the other
party is dealing in good faith, with an equal need for success in the project. Both will need to eschew and condemn efforts to divide the partners, and publicly and
privately promote the fact and the perception that successful informatics projects in the ED result from a joint
effort between the 2 departments. Neither IS nor the
clinical department will be accustomed to technical
people posted in (and paid by) a clinical department.
Yet these clinically savvy technical personnel will be
the key to the success of the entire operation. They will
be responsible for the expression of the clinical information system within the clinical department. They will
work closely with IS staff to establish and maintain standards-based departmental access to enterprise-wide
clinical data sets. They will provide a buffer for IS technical staff by bearing the burden of the “typical unreasonable demands” of clinicians who do not fully appreciate the constraints of computer systems project
schedules. They will provide a buffer for clinicians by
bearing the burden of the “typical unreasonable refusals”
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of purely technical staff who do not fully appreciate the
clinical importance of features and timetables that consume precious resources.
To illustrate the deployment of these concepts, we
briefly describe the information flow strategy at one
health care institution. Washington Hospital Center is the
largest hospital in the Washington, DC, metropolitan
region, and the largest single component of MedStar
Health, a not-for-profit health care delivery system with
approximately $1.4 billion in annual gross revenues.
During 1996, a general purpose clinical information system (Active Query) was developed by the department of
emergency medicine in partnership with the IS department of the enterprise. Since 1996, this system has been
refined, expanded, and exported to meet the needs of
clinical and administrative users beyond the walls of the
ED. It has recently been deployed in a second MedStar
Health hospital (Franklin Hospital Center, Baltimore,
MD) and has become a model for systems development
and deployment in the institution.
From the start, responsibility for the project was
divided along clear lines. The IS department is responsible for the acquisition and transport of clinical data from a
variety of legacy systems and for the delivery of the data to
the ED. The ED is responsible for the receipt, parsing,
storage, retrieval, and presentation of the data that have
been delivered. In practice, legacy data are received by IS
through a number of proprietary interfaces in a variety of
proprietary formats, and are then converted to the industry-standard health level 7 (HL7) medical data interchange format or are wrapped in HL7 wrappers. The
HL7-compliant data are then passed from IS through a
“sending” interface engine (a system used to translate
data formats and to manage the process of sending and
receiving data transactions across a network) over a standard Ethernet (IEEE 802.3) network to a “receiving”
interface engine belonging to the department of emergency medicine. Transactions are passed from legacy system to sender to receiver in near–real time; laboratory
results and radiology images appear at the ED interface
engine within a few seconds after they are generated by
laboratory equipment. The dividing line between IS and
the ED is the link between the 2 interface engines, as these
2 devices regulate the flow of data between the 2 parties
according to a series of standard and well-documented
protocols (Figure 1).
After being received from IS, data are handled by a
series of software modules in a system that receives,
parses, and stores each item. The architecture of this system is highly modular and fully object-oriented at every
level, and uses a multitier transaction model in which the
native data reside in an industry-standard structured
query language (SQL) server, while rules governing the
interpretation and presentation of the data are managed
separately. Most clinicians and managers work with the
data using a powerful custom-built Active Query client
Figure 1.
The IS department has responsibility for legacy systems and
the IS interface engine. The ED
has responsibility for all other
data and hardware and software systems. SMS, Shared
Medical Systems; MARS (radiology software application manufactured by Adac Systems);
TCP/IP, Transmission control
protocol/Internet protocol;
NCEMI, National Center for
Emergency Medicine
Informatics.
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that can load and run itself inside any modern Web
browser using active-x or Java technology, but access to
the data is possible using any tool or program that can
form an SQL query (Figure 2). Commonly used tools that
can easily be given access to the database include
Microsoft Excel, Lotus 1-2-3, Microsoft Access, and
Crystal Reports.
The Active Query client offers an optimized interface
that can handle the large majority of clinical and administrative information needs and is preferred by nearly all
users. To meet the clinical needs of emergency physicians,
the Active Query client was designed to display information for a cohort of patients all at one time, such as all
patients currently in the ED, all patients belonging to a
particular physician, or all patients admitted within the
past year with a diagnosis of tuberculosis. By clicking on
“filter” and “sort” options, in 30 seconds or less any clinician can answer an ad hoc question such as, “How many
patients did I see last year with elevated cardiac enzymes,
and which of them received a fibrinolytic agent in the
emergency department?” Because of the power of such a
cohort-oriented display, a more limited (Web-based) single-patient lookup system also has been deployed for use
in areas where full-system access is considered too risky.
The system is able to support a variety of strong and weak
security schemata, ranging from login passwords (for
access from “secure” clinical sites such as the clinical ED)
to biometric authentication using fingerprint recognition
or iris scanning technology (for access to the cohort-oriented display from unsecured or remote sites).
Before 1996, Washington Hospital Center did not
maintain any long-term storage of clinical data, with the
exception of radiographic interpretations, which were
stored in a proprietary radiology system. At deployment,
the ED Active Query system became the institution’s only
comprehensive source of historical clinical data. This
data resource now includes detailed laboratory results,
radiology results, radiographic images, historical diagnoses, procedures, medications, clinical photographs,
scanned paper charts, financial account information, and
a number of other types of clinical and administrative
information. Because it provided rapid, intuitively easy
access to a variety of information that was otherwise hard
to find, the system quickly became indispensable to the
clinical, administrative, and research functions of the ED.
Although initially limited to ED patients, the system now
receives and can display information on all inpatients and
outpatients at Washington Hospital Center and has been
adopted for use in a number of areas outside that institution’s ED. In addition to being fully deployed in the ED at
a second hospital in the MedStar Health group, the Active
Query system also has been targeted for spot deployment
to meet critical information needs in selected areas at several other hospitals in the group.
In this collaboration, a clinical department had wellrecognized specific information needs and the resources
and ability to develop and deploy a clinical information
system within the department in a very short time frame
(13 months). The IS department had control of the flow of
data from legacy systems, and the ability to translate and
Figure 2.
After the data are received by
the ED interface engine, they
are parsed and stored in an
open, industry-standard
database. Off-the-shelf and
custom-built client software
uses the data as needed for
clinical decision support, departmental management, teaching,
and research. Hct, Hematocrit;
ODBC, open database connectivity.
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repackage those data to deliver them in an industry-standard format according to standard protocols. The collaboration produced a highly successful outcome that has
improved clinical care both inside and outside the ED and
has become a highly visible success with benefits for both
departments.
Emergency physicians regularly make split-second
life-or-death decisions and take decisive action on the
basis of incomplete information. Culture clash can make
it frustrating to work with a department such as IS that
depends on lengthy, detailed project planning. The problem is compounded by the reality that new information
systems development must always take a “back seat” to the
support of mission-critical legacy systems. Nonetheless,
EDs will find many tangible benefits that outweigh the
inherent frustrations of this collaboration. When the specific benefits of new information technologies accrue first
to the ED, the department gains a competitive advantage
over other departments in the hospital, because accurate
financial and clinical analyses lead to a stronger showing
in the competition for scarce institutional resources. With
better information, the ED can enhance its operations to
obtain a competitive advantage over other EDs in the
region. Perhaps equally importantly, the ED’s long-term
leadership role in the enterprise can be enhanced through
a successful partnership with the IS department to pursue
what will be recognized as one of the most important
future directions of the entire enterprise.
Over the past quarter century, emergency medicine has
gained expertise and skills that can be of great value to the
changing health care system. EDs are well positioned to
serve as test beds for enterprise-wide clinical information
systems because they are important care delivery nodes in
the overall system, because they are to a great degree selfcontained in their clinical and ancillary operations, and
because they are at the crossroads of information flow
in the enterprise. A successful test project will require a
partnership with IS departments and a commitment to
use ED talent and resources to help improve clinical
information management beyond the walls of the ED.
At this pivotal time in the reformation of health care,
emergency medicine has a singular and wonderful
opportunity to assume a leadership role in the development and deployment of enterprise-wide clinical information systems.
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