A Custom-Developed Emergency Department Provider Electronic Documentation System Reduces Operational Efficiency - 01/11/17

Doi : 10.1016/j.annemergmed.2017.05.032

Joshua Feblowitz, MD, MS ^a, Sukhjit S. Takhar, MD, MS ^a, Michael J. Ward, MD, PhD ^b, Ryan Ribeira, MD, MPH ^c, Adam B. Landman, MD, MS ^a,^d,^⁎
^a Harvard Medical School and the Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA
^b Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
^c Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA
^d Information Systems, Partners HealthCare, Somerville, MA

^∗Corresponding Author.

Abstract

Study objective

Electronic health record implementation can improve care, but may also adversely affect emergency department (ED) efficiency. We examine how a custom, ED provider, electronic documentation system (eDoc), which replaced paper documentation, affects operational performance.

Methods

We analyzed retrospective operational data for 1-year periods before and after eDoc implementation in a single ED. We computed daily operational statistics, reflecting 60,870 pre- and 59,337 postimplementation patient encounters. The prespecified primary outcome was daily mean length of stay; secondary outcomes were daily mean length of stay for admitted and discharged patients and daily mean arrival time to disposition for admitted patients. We used a prespecified multiple regression model to identify differences in outcomes while controlling for prespecified confounding variables.

Results

The unadjusted change in length of stay was 8.4 minutes; unadjusted changes in secondary outcomes were length of stay for admitted patients 11.4 minutes, length of stay for discharged patients 1.8 minutes, and time to disposition 1.8 minutes. With a prespecified regression analysis to control for variations in operational characteristics, there were significant increases in length of stay (6.3 minutes [95% confidence interval 3.5 to 9.1 minutes]) and length of stay for discharged patients (5.1 minutes [95% confidence interval 1.9 to 8.3 minutes]). There was no statistically significant change in length of stay for admitted patients or time to disposition.

Conclusion

In our single-center study, the isolated implementation of eDoc was associated with increases in overall and discharge length of stay. Our findings suggest that a custom-designed electronic provider documentation may negatively affect ED throughput. Strategies to mitigate these effects, such as reducing documentation requirements or adding clinical staff, scribes, or voice recognition, would be a valuable area of future research.

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Plan

Introduction

Background

Importance

Goals of This Investigation

Materials and Methods

Study Design and Setting

Methods of Measurement

Outcome Measures

Primary Data Analysis

Results

Characteristics of Study Subjects

Main Results

Limitations

Discussion

	Please see page 675 for the Editor’s Capsule Summary of this article.
	Supervising editors: Stephen Schenkel, MD, MPP; Robert L. Wears, MD, PhD
	Author contributions: JF, SST, and ABL conceived and designed the study and supervised the conduct of the study and data collection and management. SST and MJW provided statistical advice on study design and analyses. JF and SST conducted the analyses. JF drafted the article, and all authors contributed substantially to its revision. All authors provided feedback on the study design, had full access to all the data in the study, and had final responsibility for the decision to submit for publication. ABL takes responsibility for the paper as a whole.
	All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org/). The authors have stated that no such relationships exist. Dr. Ward is supported in part by National Institutes of Health (NIH) grant K23 HL127130.
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