- Email: [email protected]
Information Systems Support for Emergency Med icine
PROCEEDINGS
Information Systems Support for Emergency Medicine From Partners Health Care, Inc, Clinical Systems Research & Development; Department of Emergency Medicine, Brigham & Women’s Hospital; Boston, MA. Presented at the Future of Emergency Medicine Research Conference, Washington DC, March 1997. This article is being copublished in Academic Emergency Medicine. Copyright © 1998 by Hanley & Belfus, Inc.
Jonathan M Teich, MD, PhD
Information needs for emergency medicine research and for practice are closely related. A well-developed information system can serve both, allowing data gathered in one setting to be used for the other. To produce the best environment for emergency medicine research, providers should support data standards, promote education in data analysis, and understand the informational structure of emergency medicine practice. [Teich JM: Information systems support for emergency medicine. Ann Emerg Med March 1998;31:304-307.] In Part I of the proceedings of the Future of Emergency Medicine Research Conference, Cordell et al1 addressed strategies for improving information management in emergency medicine to meet clinical, research, and administrative needs.1 This article expands on those concepts. In particular, it is important to discuss the requirements for an information system suited to emergency medicine, the available strategies of data gathering, and the types of information-related projects in the field of emergency medicine. I N F O R M AT I O N : P R A C T I C E V E R S U S R E S E A R C H
Academic emergency departments need not, and in fact cannot, separate their information needs used in daily practice from their needs for research. The two tasks may seem quite different: for practice, the goal of information gathering is to rapidly assimilate a wide range of information related to one patient; whereas in clinical research, the goal is to cut a long, longitudinal slice to acquire similar data over a narrow informational range from many patients over time. In data and content, however, the two tasks cross often. Most emergency medicine research is practice based, relying on clinical information to study the effectiveness of a new treatment or the typical course of a given presentation. The practice of medicine generates the data that are used for clinical research; the validity of the research depends on the success in getting accurate, complete data entered during
3 0 4
ANNALS OF EMERGENCY MEDICINE
31:3 MARCH 1998
INFORMATION SYSTEMS SUPPORT Teich
practice. A research project that requires data not normally captured in practice will often be unsuccessful, unless a dedicated member of the research team is actually present during the visit or obtains prompt follow-up with the care team and the patient. An advanced information system could even use practice events as a trigger for this process, notifying the research team when a patient with favorable enrollment characteristics is registered in the ED. Similarly, practice is, or certainly should be, research based, with care plans based on clinical evidence wherever possible. As computerized decision support (the provision of alerts, reminders, guidelines, or other supplemental information to help steer the provider’s decisions) becomes more common, it is incumbent on clinical and informatics leaders to make sure that these reminders reflect the most current research findings. The natural conclusion is that an academic ED should try to choose the same information system for practice that it will use for research. Although data can be somewhat translated and shipped from one system to another, the transfer is much more efficient and accurate if the research effort is using the same database as is the practice. If this is true, then the desired system should be one that supports both practice and research information needs. I N F O R M AT I O N N E E D S F O R R E S E A R C H
The desirable features for a research information system include the ability to (1) collect a wide variety of data types, (2) enroll patients/episodes into a study, (3) support regular and ad hoc queries, (4) spot trends in the data as they are being acquired—an advanced feature, and (5) capture data across sites, if multisite collaboration is desired. Taken together, these requirements imply that the research system should be based on a broad, integrated database, featuring standard query capabilities, and ideally with a notifying or altering function to help enroll patients. I N F O R M AT I O N N E E D S F O R P R A C T I C E
On the practice side, the information system characteristics for optimal practice support include the ability to (1) keep track of a large number of patients simultaneously; (2) rapidly assimilate and organize data from many different sources, such as laboratory, radiology, and ED encounter data; (3) distill the information, displaying the key information and alerting the provider when important new data values are filed, such as “panic” laboratory values; (4) facilitate communication: inbound (referrals to the ED), outbound (to
MARCH 1998
31:3
ANNALS OF EMERGENCY MEDICINE
the primary care providers and follow-up clinics), and to the patient (eg, discharge instructions). Given these requirements, a practice system should be one that collects, organizes, and analyzes data, and presents the most important information at all times to the provider. Although there are always choices and trade-offs in the selection of a computer system, it is possible to buy or build a system with many of the features needed for both practice and research. I N F O R M AT I O N S O U R C E S I N A N E D V I S I T
If we use an ED visit as a template for the spectrum of research in emergency medicine, we can easily identify specific opportunities for clinical and health services research, which depend on advanced information availability and organization. These examples also show the need for integration of the ED research database with data from the rest of the hospital. 1. Preventive care Effect of vaccinations, screening tests; primary care availability. 2. Referral Referring patterns by provider, patient, problem; time from referral to treatment; effect of direct-admission protocols. 3. Patient arrival and triage Case mix; availability of services; individual care as a function of overall ED activity. 4. Evaluation Effective utilization of tests; diagnostic algorithms; value of laboratory data in a given presentation. 5. Treatment “Door-to-treatment” times; effect of therapies on outcomes; stratification of these by other patient conditions 6. Disposition/release and follow-up Efficiency of hospital admissions process; effectiveness of laboratory follow-up systems; course of disposition to non-ED care; real-time data mining and patient enrollment; outcomes research. Such research projects are unified by the need to screen all data, extract an interesting subset, stratify the subset, and compare the stratified groups with respect to a measurable outcome. Existing computer database systems can aggregate these data and perform stratifications on demand, if the appropriate data have been collected in the first place. Effective ED information systems allow collection of the data as part of the natural operation of the ED practice, without duplication of work to build the research database. The most advanced systems can also do automatic triggering of searches (eg, to check, in real time, whether a patient’s presentation suggests enrollment into a study) and can make practical use of research results by alerting the ED staff when a patient’s data necessitate immediate attention, based on rules derived from prior study.
3 0 5
INFORMATION SYSTEMS SUPPORT Teich
R E C O M M E N D AT I O N S 1
The article by Cordell et al identifies a number of specific recommendations for the effective use of information in emergency medicine research. Several of these deserve further emphasis and annotation. Promote standards for data exchange and communications; integrate information systems across the health care environment The development of effective, usable standards for ED
data is absolutely necessary for several aspects of research. First, standards are necessary within an institution if computer systems from different vendors are to efficiently share data. Most hospitals have different systems for billing, laboratory, admissions, and clinical records. An effective study of diagnostic strategies, such as for chest pain, depends on laboratory and ECG data, diagnosis information, and hospital care. Without effective interchange between a hospital’s diverse systems, such studies require a cumbersome process of combining the data into a third database, and may ultimately fail because the data models used in the two original systems are not compatible. This integration is important for effective practice, as well. Data entered in one clinical encounter should be available to all. If a drug allergy is discovered during an inpatient stay, or if a patient’s primary provider makes a treatment plan with the patient, it should be entered and integrated so that the ED provider has full access to it. Second, standards are necessary for maximum efficiency in multicenter trials. This standardization is required on many layers, some for general use and some specific to a given study: • A raw data-exchange layer to actually move the data • A common vocabulary so that both systems use the same codes, for example, for a serum potassium test • Data normalization, so that local variations (eg, in normal ranges) are reconciled • Agreement on the set of data to be acquired during an ED visit • Reconciliation of practice variations that affect a study, such as different local patterns of test utilization or fluid management. Key standards have been built or are in development in many of these areas. If departments require that their systems and their data acquisition use standards, then regional and national pooling of data (subject to appropriate confidentiality requirements) will become an effective way to build studies with great statistical power. Train health care professionals how to use information Training in general use of computers, office software suites, and the Internet is rapidly becoming part of the standard of general education. This trend is likely to continue by itself,
3 0 6
although specific attention should be given to training persons who did not grow up under these circumstances. Perhaps more important, and less generally taught, is a firm knowledge of information management and data analysis. Formal training not only produces more enlightened and enthusiastic researchers, but also produces analytical thinkers who are better equipped to make decisions about adopting new practice strategies. This training could be offered as a required or elective part of residency education, fellowship training, and faculty development. Study future trends This requires a national effort not only to predict future developments, but to disseminate information about best practices in the present as well. Potential purchasers of medical information technology may not have the experience to know what a system should have. A general source of information on best practices and the most useful features would help these purchasers to make more informed choices, and to know what to request of their vendors. A large single effort to acquire and disseminate this information would be more efficient than many individual processes at local sites. It could encourage vendors to raise the quality of their systems, to account for a more informed group of purchasers. Once the general emergency medicine community is informed about current capabilities, a central organization can also keep the community up-to-date on new capabilities of technology, new applications and features that improve information management, and changes in practice trends that will require new modes of information management. Leverage emergency medicine special strengths The development of an effective medical computing application requires that two key human skills be applied to the task. There must be a medical person who can clearly express the needs of the potential users, and a technical person who understands the general ways in which technology can be useful. The relevant expertise of emergency medicine providers includes use of central knowledge resources and forms of telemedicine. It also includes heavy experience in multitasking, rapid distillation of key data, and efficient communication. Each of these is an information processing task that can be augmented by the use of technology. An emergency medicine provider or group who can understand these processes in a systems model, and who can clearly communicate the information transactions that occur, will be able to specify the truly beneficial information systems of the future; no one else will be as effective in bringing new tools into our workplace. If such a person also carries a working knowledge of effective technology paradigms, the task will be that much easier.
ANNALS OF EMERGENCY MEDICINE
31:3
MARCH 1998
INFORMATION SYSTEMS SUPPORT Teich
CONCLUSIONS
Information systems offer tremendous value to emergency medicine practice and research. For us to realize this value, we must effectively merge clinical and technical expertise in the design of new applications. Integration and use of standards at many levels are of vital importance, so that data are available where needed, regardless of where the data are entered. Information systems should be selected to support both research and practice use; this will enhance the strength of the research effort, and conversely will improve practice by offering guidance based on solid evidence. National organizations can help the specialty grow around the use of information. Education is needed to develop workers skilled in data management and analysis, who can translate the needs of the clinicians to the skills of the engineers. Education is also needed to ensure that EDs everywhere understand the current state of information systems, the features that can be most useful to them, and the trends of the near future. This education can come as part of residency and fellowship training, continuing education for general knowledge, and through academic journals for communicating new concepts in information management and technology.
Reprint no. 47/1/88188 Address for reprints: Jonathan M Teich, MD, PhD 850 Boylston Street Suite 202 Chestnut Hill, MA 02167 617-732-9072 Fax 617-731-3690 E-mail [email protected]
REFERENCE 1. Cordell WH, Overhage JM, Waeckerle JF, et al: Strategies for improving information management in emergency medicine to meet clinical, research, and administrative needs. Ann Emerg Med 1998;31:172-178.
MARCH 1998
31:3
ANNALS OF EMERGENCY MEDICINE
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Information Systems Support for Emergency Medicine From Partners Health Care, Inc, Clinical Systems Research & Development; Department of Emergency Medicine, Brigham & Women’s Hospital; Boston, MA. Presented at the Future of Emergency Medicine Research Conference, Washington DC, March 1997. This article is being copublished in Academic Emergency Medicine. Copyright © 1998 by Hanley & Belfus, Inc.
Jonathan M Teich, MD, PhD
Information needs for emergency medicine research and for practice are closely related. A well-developed information system can serve both, allowing data gathered in one setting to be used for the other. To produce the best environment for emergency medicine research, providers should support data standards, promote education in data analysis, and understand the informational structure of emergency medicine practice. [Teich JM: Information systems support for emergency medicine. Ann Emerg Med March 1998;31:304-307.] In Part I of the proceedings of the Future of Emergency Medicine Research Conference, Cordell et al1 addressed strategies for improving information management in emergency medicine to meet clinical, research, and administrative needs.1 This article expands on those concepts. In particular, it is important to discuss the requirements for an information system suited to emergency medicine, the available strategies of data gathering, and the types of information-related projects in the field of emergency medicine. I N F O R M AT I O N : P R A C T I C E V E R S U S R E S E A R C H
Academic emergency departments need not, and in fact cannot, separate their information needs used in daily practice from their needs for research. The two tasks may seem quite different: for practice, the goal of information gathering is to rapidly assimilate a wide range of information related to one patient; whereas in clinical research, the goal is to cut a long, longitudinal slice to acquire similar data over a narrow informational range from many patients over time. In data and content, however, the two tasks cross often. Most emergency medicine research is practice based, relying on clinical information to study the effectiveness of a new treatment or the typical course of a given presentation. The practice of medicine generates the data that are used for clinical research; the validity of the research depends on the success in getting accurate, complete data entered during
3 0 4
ANNALS OF EMERGENCY MEDICINE
31:3 MARCH 1998
INFORMATION SYSTEMS SUPPORT Teich
practice. A research project that requires data not normally captured in practice will often be unsuccessful, unless a dedicated member of the research team is actually present during the visit or obtains prompt follow-up with the care team and the patient. An advanced information system could even use practice events as a trigger for this process, notifying the research team when a patient with favorable enrollment characteristics is registered in the ED. Similarly, practice is, or certainly should be, research based, with care plans based on clinical evidence wherever possible. As computerized decision support (the provision of alerts, reminders, guidelines, or other supplemental information to help steer the provider’s decisions) becomes more common, it is incumbent on clinical and informatics leaders to make sure that these reminders reflect the most current research findings. The natural conclusion is that an academic ED should try to choose the same information system for practice that it will use for research. Although data can be somewhat translated and shipped from one system to another, the transfer is much more efficient and accurate if the research effort is using the same database as is the practice. If this is true, then the desired system should be one that supports both practice and research information needs. I N F O R M AT I O N N E E D S F O R R E S E A R C H
The desirable features for a research information system include the ability to (1) collect a wide variety of data types, (2) enroll patients/episodes into a study, (3) support regular and ad hoc queries, (4) spot trends in the data as they are being acquired—an advanced feature, and (5) capture data across sites, if multisite collaboration is desired. Taken together, these requirements imply that the research system should be based on a broad, integrated database, featuring standard query capabilities, and ideally with a notifying or altering function to help enroll patients. I N F O R M AT I O N N E E D S F O R P R A C T I C E
On the practice side, the information system characteristics for optimal practice support include the ability to (1) keep track of a large number of patients simultaneously; (2) rapidly assimilate and organize data from many different sources, such as laboratory, radiology, and ED encounter data; (3) distill the information, displaying the key information and alerting the provider when important new data values are filed, such as “panic” laboratory values; (4) facilitate communication: inbound (referrals to the ED), outbound (to
MARCH 1998
31:3
ANNALS OF EMERGENCY MEDICINE
the primary care providers and follow-up clinics), and to the patient (eg, discharge instructions). Given these requirements, a practice system should be one that collects, organizes, and analyzes data, and presents the most important information at all times to the provider. Although there are always choices and trade-offs in the selection of a computer system, it is possible to buy or build a system with many of the features needed for both practice and research. I N F O R M AT I O N S O U R C E S I N A N E D V I S I T
If we use an ED visit as a template for the spectrum of research in emergency medicine, we can easily identify specific opportunities for clinical and health services research, which depend on advanced information availability and organization. These examples also show the need for integration of the ED research database with data from the rest of the hospital. 1. Preventive care Effect of vaccinations, screening tests; primary care availability. 2. Referral Referring patterns by provider, patient, problem; time from referral to treatment; effect of direct-admission protocols. 3. Patient arrival and triage Case mix; availability of services; individual care as a function of overall ED activity. 4. Evaluation Effective utilization of tests; diagnostic algorithms; value of laboratory data in a given presentation. 5. Treatment “Door-to-treatment” times; effect of therapies on outcomes; stratification of these by other patient conditions 6. Disposition/release and follow-up Efficiency of hospital admissions process; effectiveness of laboratory follow-up systems; course of disposition to non-ED care; real-time data mining and patient enrollment; outcomes research. Such research projects are unified by the need to screen all data, extract an interesting subset, stratify the subset, and compare the stratified groups with respect to a measurable outcome. Existing computer database systems can aggregate these data and perform stratifications on demand, if the appropriate data have been collected in the first place. Effective ED information systems allow collection of the data as part of the natural operation of the ED practice, without duplication of work to build the research database. The most advanced systems can also do automatic triggering of searches (eg, to check, in real time, whether a patient’s presentation suggests enrollment into a study) and can make practical use of research results by alerting the ED staff when a patient’s data necessitate immediate attention, based on rules derived from prior study.
3 0 5
INFORMATION SYSTEMS SUPPORT Teich
R E C O M M E N D AT I O N S 1
The article by Cordell et al identifies a number of specific recommendations for the effective use of information in emergency medicine research. Several of these deserve further emphasis and annotation. Promote standards for data exchange and communications; integrate information systems across the health care environment The development of effective, usable standards for ED
data is absolutely necessary for several aspects of research. First, standards are necessary within an institution if computer systems from different vendors are to efficiently share data. Most hospitals have different systems for billing, laboratory, admissions, and clinical records. An effective study of diagnostic strategies, such as for chest pain, depends on laboratory and ECG data, diagnosis information, and hospital care. Without effective interchange between a hospital’s diverse systems, such studies require a cumbersome process of combining the data into a third database, and may ultimately fail because the data models used in the two original systems are not compatible. This integration is important for effective practice, as well. Data entered in one clinical encounter should be available to all. If a drug allergy is discovered during an inpatient stay, or if a patient’s primary provider makes a treatment plan with the patient, it should be entered and integrated so that the ED provider has full access to it. Second, standards are necessary for maximum efficiency in multicenter trials. This standardization is required on many layers, some for general use and some specific to a given study: • A raw data-exchange layer to actually move the data • A common vocabulary so that both systems use the same codes, for example, for a serum potassium test • Data normalization, so that local variations (eg, in normal ranges) are reconciled • Agreement on the set of data to be acquired during an ED visit • Reconciliation of practice variations that affect a study, such as different local patterns of test utilization or fluid management. Key standards have been built or are in development in many of these areas. If departments require that their systems and their data acquisition use standards, then regional and national pooling of data (subject to appropriate confidentiality requirements) will become an effective way to build studies with great statistical power. Train health care professionals how to use information Training in general use of computers, office software suites, and the Internet is rapidly becoming part of the standard of general education. This trend is likely to continue by itself,
3 0 6
although specific attention should be given to training persons who did not grow up under these circumstances. Perhaps more important, and less generally taught, is a firm knowledge of information management and data analysis. Formal training not only produces more enlightened and enthusiastic researchers, but also produces analytical thinkers who are better equipped to make decisions about adopting new practice strategies. This training could be offered as a required or elective part of residency education, fellowship training, and faculty development. Study future trends This requires a national effort not only to predict future developments, but to disseminate information about best practices in the present as well. Potential purchasers of medical information technology may not have the experience to know what a system should have. A general source of information on best practices and the most useful features would help these purchasers to make more informed choices, and to know what to request of their vendors. A large single effort to acquire and disseminate this information would be more efficient than many individual processes at local sites. It could encourage vendors to raise the quality of their systems, to account for a more informed group of purchasers. Once the general emergency medicine community is informed about current capabilities, a central organization can also keep the community up-to-date on new capabilities of technology, new applications and features that improve information management, and changes in practice trends that will require new modes of information management. Leverage emergency medicine special strengths The development of an effective medical computing application requires that two key human skills be applied to the task. There must be a medical person who can clearly express the needs of the potential users, and a technical person who understands the general ways in which technology can be useful. The relevant expertise of emergency medicine providers includes use of central knowledge resources and forms of telemedicine. It also includes heavy experience in multitasking, rapid distillation of key data, and efficient communication. Each of these is an information processing task that can be augmented by the use of technology. An emergency medicine provider or group who can understand these processes in a systems model, and who can clearly communicate the information transactions that occur, will be able to specify the truly beneficial information systems of the future; no one else will be as effective in bringing new tools into our workplace. If such a person also carries a working knowledge of effective technology paradigms, the task will be that much easier.
ANNALS OF EMERGENCY MEDICINE
31:3
MARCH 1998
INFORMATION SYSTEMS SUPPORT Teich
CONCLUSIONS
Information systems offer tremendous value to emergency medicine practice and research. For us to realize this value, we must effectively merge clinical and technical expertise in the design of new applications. Integration and use of standards at many levels are of vital importance, so that data are available where needed, regardless of where the data are entered. Information systems should be selected to support both research and practice use; this will enhance the strength of the research effort, and conversely will improve practice by offering guidance based on solid evidence. National organizations can help the specialty grow around the use of information. Education is needed to develop workers skilled in data management and analysis, who can translate the needs of the clinicians to the skills of the engineers. Education is also needed to ensure that EDs everywhere understand the current state of information systems, the features that can be most useful to them, and the trends of the near future. This education can come as part of residency and fellowship training, continuing education for general knowledge, and through academic journals for communicating new concepts in information management and technology.
Reprint no. 47/1/88188 Address for reprints: Jonathan M Teich, MD, PhD 850 Boylston Street Suite 202 Chestnut Hill, MA 02167 617-732-9072 Fax 617-731-3690 E-mail [email protected]
REFERENCE 1. Cordell WH, Overhage JM, Waeckerle JF, et al: Strategies for improving information management in emergency medicine to meet clinical, research, and administrative needs. Ann Emerg Med 1998;31:172-178.
MARCH 1998
31:3
ANNALS OF EMERGENCY MEDICINE
3 0 7