Because of its ability to improve the quality and delivery of health care services, the Electronic Health Record is becoming a necessity in almost every healthcare organization. The purpose of this paper is to explain the impact of having an electronic health record system in an emergency department. The current computerized system used at Suny Downstate Hospital in Brooklyn is called T-SYSTEM, and has been in operation since 2007. Documentation prior to its implementation was achieved through handwritten notes on various forms as well as through dictation by doctors. Suny Downstate Hospital had to update its system in order to meet state standards and quality core measures. The transition from paper to electronic documentation is major; while it assures many advantages, it also faces many challenges. As the author of this paper, I will be using my workplace as the unit (ED) project observed. I will also identify other healthcare professionals, such as fellow nurses who are assigned to Super User or to Preceptor positions and other multidisciplinary care providers, who assist with the system. I will also discuss the system, its benefits, contributions, deficiencies, and the challenges that the system must overcome in order to achieve its maximum potential.
The organization of interest is the University Hospital of Brooklyn, also known as Suny Downstate Medical Center. This is a teaching hospital and is the only academic medical center providing patient care, education, research and community services for the nearly 5 million people living in Brooklyn, Queens and Staten Island. Opened in 1966, the University Hospital of Brooklyn is an 8-story, 376-bed facility in central Brooklyn. The hospital has 8 intensive care and step-down units, 12 operating rooms, an emergency services department, a diagnostic and ambulatory surgery facility, an ambulatory care center with some 75 clinics, plus 5 satellite Health Centers and a nearby dialysis center.
As stated above, the University Hospital of Brooklyn has 3 main locations in Central Brooklyn, Long Island College Hospital and in Bay Ridge. Satellite Centers in Bedford-Stuyvesant, Midwood, Family Health Services (Lefferts Avenue), Dialysis Center (Parkside) and a Sleep Center (Flatlands and Flatbush). In terms of size and manpower, Suny Downstate Medical Center has 8,000 employees on board and is the fourth largest employer in Brooklyn. Downstate's estimated economic impact is over $2 billion. For every dollar invested in Downstate, $12 is returned to the local community (SDMC, Facts at a Glance, 2012).
The hospital aims to become the leader among many other hospitals and schools in New York State. The hospital also has a college with 1,751 students studying Medicine, Grad Studies, Nursing, Health Related Professions and Public Health. In addition, the hospital operates a joint Biomedical Engineering program with Brooklyn Polytech. The school has 1,049 residents training in 57 specialties that are assigned to 23 affiliated hospitals. Downstate has already become the leader in physician education, where more New York City Physicians have trained than at any other medical school. In some specialties, Downstate has trained more than half the borough's physicians. Downstate has ranked first among New York State medical schools in the number of minority students and eighth nationally. Downstate is also the only college in Brooklyn offering the MS degree in Medical Informatics. Its mission is "to provide outstanding education of physicians, scientists, nurses and other healthcare professionals, to advance knowledge of cutting edge research and translate it into practice, to care for and improve the lives of our globally diverse communities and to foster an environment that embraces cultural diversity" (SDMC, Mission, Vision and Values, 2012).
The Suny Downstate mission is to be nationally recognized for improving people's lives by providing excellent education for healthcare professionals, advancing research in biomedical science, healthcare and public health, and delivering the highest quality patient-centered care. The hospital values pride, professionalism, respect, innovation, diversity and excellence. With the implementation of the Electronic Medical Record system, the goal is to connect caregivers and patients in order to continue the delivery of quality care (SDMC, Mission, Vision and Values, 2012).
In an interview I conducted with Ms. Margaret G. Jackson (MA, RN, and Assistant Vice President and Chief Nursing Officer at Suny Downstate), she stated: "We at Suny Downstate are pushing aggressively towards 'Meaningful Use.' We would like to have the system interconnect with the other units, to make it more user friendly for other physicians to put their orders in, instead of coming down to the emergency room." Jackson also confirmed that "our objective for meaningful use is to improve quality, safety and efficiency of both doctors and nurses; we want patient and families engaged in the care given. We hope that this will improve care coordination and most importantly, ensure privacy and security for personal health information" (M. Jackson, personal interview, November 26, 2012).
To this end, Suny Downstate has hired Vickie Small, MS, RN, as the manager of nursing informatics who directs and oversees all technological development at Suny Downstate and all its affiliates. She has been with the hospital for 7 years and began her nursing career in the emergency room. She was also one of the key persons involved with the implementation of T-SYSTEM back in 2007, and was initially appointed to the role of project manager. Since that time she has been promoted to the managerial position throughout the adjustment period (V. Small, personal interview, November 26, 2012).
Throughout the interview with Ms. Small, she pointed out how challenging it was to get the staff on board, though today she is proud to see how far they have come. She noted that she was the direct link between the nurses and the T-SYSTEM team on-site to make sure the system was more nurse friendly. This "direct link" was important, as Ms. Small knew it was a system designed not by nurses but by emergency room doctors. Ms. Small also spoke about how most of the senior nurses found it very difficult to "let go" the papers and would hoard them in their lockers and chart on them and then put them in the chart. As stated by Ms. Small, "it was a difficult adjustment period, but we definitely made it."
Basic Needs Assessment
T-SYSTEM has been utilized at Suny Downstate Medical emergency department since 2007. The aim of its implementation is to facilitate better, safer patient care, boost workflow efficiencies and maximize revenues (T-SYSTEM, About Us, 2012). Since its implementation, the system has been upgraded three times to enhance communication and effective coordinated care among all multidisciplinary members involved. Members involved are nurse manager, assistant nurse manager, registered nurses, nursing assistants, physician assistants, nurse practitioners, unit clerks, pharmacy and the radiology department that includes X-ray, CT and MRI personnel.
The emergency room layout starts with one nurse tech/nurse assistant who is stationed outside in the waiting room just to take the vital signs of the patients before they enter the actual triage area. This nursing assistant has one Computer on Wheels (COW) assigned to him/her. Inside the triage area the nurse is assigned a desk top. The registrars have 3 desk tops and 1 desk top for the Pediatric registration personnel. The Fast track area holds a capacity of 11 patients, and has 2 desk tops for the doctors and 2 COWS for the physician assistants and 1 COW for the nurse.
Inside the Pediatric area which holds 11 patients, has 5 desk tops for the doctors, 3 COWS for nurses and 1 desk top for the pediatric triage nurse. In the adult section of the emergency room, which holds a capacity of 37 patients, and 45 on an extremely busy day, has two nursing stations. In Nursing Station B, there are 3 desk tops for physicians, 4 laptops (affixed to the counter tops to prevent theft) that are also for the doctors, 2 desk tops for the clerks, and 2 COWS for the charge nurse and the ambulance triage nurse. Furthermore, there is 1 COW for the resuscitation room nurse, 1 COW for the admitting nurse, and 5 more COWS for the rest of the nurses working in the assigned area of the emergency room. On the ramp of the ambulance bay area, there are also 5 other non-working COWS, which are, however, tested by the IT department frequently.
Initially, when the system was implemented, it was met with a lot of resistance from the nursing staff. Of course, with any new technology, it is typically the novice users that will emphasize stress and anxiety. At the time of implementation, many of the staff, especially the senior nurses, were not computer literate and were reluctant to use the computer as their primary mode of documentation. There were many questions and some nurses would become upset or angry as a result of not knowing where to find a certain piece of information to complete their documentation.
T-SYSTEM uses its own software and is PC based. Citrix is also used along with the system which is a software solution that enables the safety…