Spotlight on Electronic Medical Records January 20, 2010 / Issue 3
Featured Article
EMR designed for ED improves productivity
Capitalize on ARRA/HITECH by implementing a fully integrated healthcare-technology system.

Gerard Bernales, left, an RN at Clara Maass Medical Center, and Dr. Leonidas Pritsiolas review the “nursing dashboard” as Pritsiolas enters orders for a new patient.

Clara Maass Medical Center in Belleville, N.J., has faced an enormous challenge over the past decade as its emergency-department visits soared from 27,000 to more than 70,000 per year. The community hospital, licensed for 450 beds, was forced to take on this load because four other local hospitals closed their doors. The recession has also raised the number of uninsured patients seeking emergency care. Yet, the Clara Maass emergency department (ED) has handled the increased volume without commensurate staff growth or a facility expansion.

The key to this success, says John Fontanetta, M.D., chairman of the ED, has been an electronic medical record (EMR) that the Saint Barnabas Health Care System, based in nearby Livingston, installed in Clara Maass’ ED when Saint Barnabas took over the hospital 11 years ago. Besides increasing the ED’s productivity, the EMR has also enabled the ED to improve the quality of care it delivers, Fontanetta says.

Today, Clara Maass sits near the top of the rankings of 80 New Jersey hospitals. In addition, its ED, a certified center for stroke and chest pain, has one of the state’s top quality scores for opening coronary arteries after acute myocardial infarction (MI).

When Saint Barnabas acquired Clara Maass, the ED was experiencing all of the usual problems of a paper-based documentation system, Fontanetta recalls. With the electronic record, waiting times were decreased significantly, as were walk outs. The electronic record also captured charges more accurately, he adds, improving corporate compliance.

Saint Barnabas hired Emergency Medical Associates (EMA) to staff the ED. EMA had developed an EMR specifically for ED use, now more than 20-years old and known as EDIMS. That EMR was still in an early stage of development in 1999. Saint Barnabas decided to put EDIMS in Clara Maass to improve the quality of care and increase efficiency.

When the Clara Maass ED adopted the EMR, it included only physician documentation and triage modules. Over the next several years, the ED chose to add the nursing notes, order entry and charge-capture modules as they became available.

Before going live on the initial EMR and with each additional module, Clara Maass had to draw work flow maps to see how various hospital operations would be affected. The changes often touched every area of the hospital – from medical records, finance and management to the medical staff, emergency medical services and registration.

Initial Staff Resistance
Experienced ED personnel from EDIMS supported Clara Maass in developing the work flow maps and conducted training, support Fontanetta says was essential to successful implementation. “You need credibility, so you have to bring in clinicians who are respected by the doctors and nurses,” he points out. “Also, there are always questions that a technician cannot answer.

“There was some initial resistance from the ED staff,” Fontanetta continues. “Many of the nurses did not know how to use computers, and one even threatened to quit. But after being trained, she quickly learned the system, and she loves it now.”

One feature the nurses particularly like about the EMR, he adds, is that entering medications off of their simple pick lists is easier than to handwrite them. In addition, for repeat ED patients, all of the patient’s previous visit data can be copied into a chart. Also, many tasks that used to be burdensome are now automated, such as keeping track of infusion times.

The ED physicians presented a different challenge, Fonanetta says. They could not use the software if it would slow them down, and they also disliked programs “that guided them without giving them options,” he says. “They still wanted to make it their chart.”

The design of the system overcame the first objection, he says, because both physician documentation and order entry were created specifically for EDs. “All the dosing, the way the meds are given and the order sets are specific to the ED. So, with the computerized order entry, a physician can enter a full set of orders on a very sick patient in 20 seconds. Handwriting those orders would take much longer.”

The computerized order entry has many features that prevent errors and recommend the best evidence-based treatments for each clinical condition. The order-entry module has proved to be effective, Fontanetta notes. Although the ED physicians are not required to use it (paper forms are still available), all of them do, he says, because it’s faster and safer.

With the nursing module in EDIMS, red-underlined sections in nursing notes are mandatory, forcing the nurses to document items such as “conditions present on admission.” Nursing is usually frustrated by mandatory fields in an EMR because they slow down work flow. “EDIMS worked closely with administration and nursing staff to achieve the right balance, but it is an ongoing issue that we continually monitor,” says Fontanetta.

Departmental Interfaces Created
The nurses use rolling computer carts in the ED, so they can document their assessments in EDIMS wirelessly. The EMR is also linked to the hospital’s automated medication administration system, which is controlled by the mobile computers.

Interfacing with healthcare information systems and ancillary departments is often a challenging area for an ED EMR, Fontanetta explains, but Clara Maass does not have a single information system or inpatient EHR. Instead, each department has a best-of-breed system. Recently, Clara Maass implemented health information exchange software that allows these systems, including EDIMS, to exchange clinical data with one another.

In the first half of 2009, volume in the ED rose 17 percent, but the facility did not add any beds. Prior to that, it opened up some additional beds in October 2008, Fontanetta says, but that was the first expansion of the ED’s capacity in four years.

The ED has added some staff over the past few years, but the staff has grown far less than the number of visits has, Fontanetta says. “You staff to the size of your department, not to your patient volume. You could add all the doctors and nurses you want, but if you don’t have physical space, they’re just standing around bumping into each other. So the best way to handle increased volume is always with better efficiency rather than with personnel.”

Another way to measure the increased productivity of the ED is the average turnaround time for patients. At Clara Maass, average turnaround time has dropped from four hours to 2.5 hours. The EDIMS charge-capture function also has helped the ED to virtually eliminate lost charges, according to Fontanetta, contributing more to the hospital’s bottom line.

Most important, Fontanetta says, the EMR has improved the quality of care. The standardization of ordering has contributed to the hospital’s high scores on CMS core measures, from choosing the right antibiotics for pneumonia to making sure that heart-attack patients receive aspirins.

Another key indicator, Fontanetta says, is the decreased time from the arrival of patients who have had an acute MI to the opening of their coronary arteries in the catheterization lab. To maximize the chance of survival, this should be done within 90 minutes. Four years ago, when the ED began doing emergency angioplasties, it took 140 minutes. Today, a balloon – and a stent, if appropriate – is inserted into the patient’s artery in an average of 55 minutes and sometimes as little as 40 minutes. Considering the numerous steps involved, Dr. Fontanetta points out this would be “essentially impossible without an EMR.”

From the Catalog

According to For more than 20 years, EDIMS has been providing support for the emergency department care process, from work flow documentation to evidence-based medicine best practices and protocols. EDIMS EMR ensures accurate and complete charge capture to improve compliance, reduce denials and increase revenue so providers get paid for the care they deliver. In use at 39 sites nationwide, EDIMS is installed at every type of hospital, from small rural sites with 12,000 annual patient visits, to large urban hospitals with more than 100,000 visits, including academic and trauma centers. EDIMS is experienced in interfacing with all major hospital systems, ancillary departments and health information exchanges. The EDIMS structure provides flexibility and customization to meet the unique needs of each hospital setting.

Click here for more information on EDIMS solutions.

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