T-System EHR in an Emergency Department: A System Analysis
This paper examines the implementation and ongoing performance of T-System, an electronic health record (EHR) platform adopted in a Brooklyn teaching hospital's emergency department in 2007. Drawing on staff interviews, direct observation, and institutional data, the paper traces the hospital's transition from paper-based documentation to electronic records, the workforce challenges encountered during and after the go-live period, revenue cycle discrepancies between physician and nursing charge capture, and the integration of a secondary system called Health Bridge. The paper also addresses federal policy context, specifically the HITECH Act's meaningful use requirements, and assesses how those mandates shape both the hospital's technology strategy and the day-to-day experience of frontline nursing staff.
- Introduction: Hospital background, mission, and T-System context
- Basic Needs Assessment: ED layout, hardware inventory, and staff resistance
- Transition: Go-live preparations, training, and super-user roles
- Growth, Challenges, and Drawbacks: Charge capture gaps, Health Bridge integration, and ongoing errors
- Meaningful Use and EMR Implementation: HITECH policy, attestation, and budgetary pressures
- Conclusion: ARRA incentives, nursing adaptation, and future outlook
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What makes this paper effective
- The paper grounds abstract technology policy (HITECH, meaningful use) in concrete, firsthand workplace observation, giving it both analytical and documentary value.
- Multiple primary sources — interviews with a Chief Nursing Officer, a nursing informatics manager, staff nurses, and a finance representative — give the analysis credibility and narrative depth.
- Specific operational details (computer-on-wheels counts, shift coverage ratios, charge-capture discrepancies) make the argument vivid and verifiable rather than generic.
Key academic technique demonstrated
The paper demonstrates insider ethnographic observation combined with structured stakeholder interviewing. Rather than relying solely on published literature, the author uses the workplace as a primary research site, triangulating perspectives from nursing leadership, frontline nurses, and finance staff to build a multi-dimensional picture of EHR adoption. This approach is especially well-suited to health informatics case studies, where implementation experience diverges sharply from vendor or policy claims.
Structure breakdown
The paper opens with organizational context and mission, then moves through a hardware/workflow needs assessment, the go-live transition process, an extended section on ongoing problems and partial solutions, a policy-level discussion of meaningful use and HITECH, and a brief conclusion. Each section builds logically on the previous one, moving from description toward critique and finally toward policy implications. The structure mirrors a standard informatics system-evaluation report, making it a useful model for health administration and nursing informatics courses.
Introduction
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 the University 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. The hospital had to update its system in order to meet state standards and quality core measures. The transition from paper to electronic documentation is significant; while it assures many advantages, it also faces many challenges. This paper uses the emergency department (ED) as the observed unit, and identifies other healthcare professionals — such as fellow nurses assigned to Super User or Preceptor positions and other multidisciplinary care providers — who assist with the system. The discussion covers the system's benefits, contributions, deficiencies, and the challenges it must overcome to achieve its maximum potential.
The organization of interest is the University Hospital of Brooklyn, also known as University 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 eight-story, 376-bed facility in central Brooklyn. The hospital has eight intensive care and step-down units, 12 operating rooms, an emergency services department, a diagnostic and ambulatory surgery facility, an ambulatory care center with approximately 75 clinics, plus five satellite health centers and a nearby dialysis center.
The University Hospital of Brooklyn has three main locations: Central Brooklyn, Long Island College Hospital, and Bay Ridge. Satellite centers are located in Bedford-Stuyvesant, Midwood, Family Health Services (Lefferts Avenue), a Dialysis Center (Parkside), and a Sleep Center (Flatlands and Flatbush). In terms of size and workforce, the Medical Center employs 8,000 people and is the fourth-largest employer in Brooklyn. The hospital's estimated economic impact exceeds $2 billion; for every dollar invested, $12 is returned to the local community (SDMC, Facts at a Glance, 2012).
The hospital aims to become the leader among other hospitals and schools in New York State. It operates a college with 1,751 students studying medicine, graduate studies, nursing, health-related professions, and public health. The hospital also maintains a joint Biomedical Engineering program with Brooklyn Polytech. Its 1,049 residents train in 57 specialties across 23 affiliated hospitals. The institution has become the leader in physician education, with more New York City physicians having trained there than at any other medical school. In some specialties, the hospital has trained more than half of the borough's physicians, and it has ranked first among New York State medical schools in the number of minority students and eighth nationally. It is also the only college in Brooklyn offering an 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 hospital's 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 conducted with the Assistant Vice President and Chief Nursing Officer, she stated: "We 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." She also confirmed that "our objective for meaningful use is to improve quality, safety and efficiency of both doctors and nurses; we want patients 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, the hospital hired a manager of nursing informatics who directs and oversees all technological development at the Medical Center and all its affiliates. She has been with the hospital for seven 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 in 2007 and was initially appointed to the role of project manager, subsequently being promoted to a managerial position throughout the adjustment period (V. Small, personal interview, November 26, 2012).
During the interview, the nursing informatics manager pointed out how challenging it was to get the staff on board, though today she is proud of the progress made. She noted that she was the direct link between the nurses and the T-System team on-site to ensure the system was more nurse-friendly. This "direct link" was important because T-System was designed not by nurses but by emergency room doctors. She also spoke about how most senior nurses found it very difficult to let go of paper records — many hoarded paper forms in their lockers, charted on them, and then placed them in the chart. As she stated, "it was a difficult adjustment period, but we definitely made it."
HITECH Act
The Health Information Technology for Economic and Clinical Health (HITECH) Act, passed in 2009, was enacted to address the issues of meaningful use in healthcare information technology. HITECH has several consequences, both economic and practical. For instance, "the nation's employers can expect a 9% jump in medical costs in 2011" as costs for EMR implementation rise due to HITECH requirements (Monegain, 2010). Hospitals are expected to receive bonuses or penalties depending upon their compliance with HITECH regulations. The implementation and use of health IT has effectively become mandatory in the healthcare field.
HITECH may be viewed as a positive piece of legislation for IT firms, but for the nursing and physician staff at the hospital, it appears to be shouldered as one more burden in the ongoing evolution of healthcare services. From cluttered workstations to complex, electronically bureaucratized documentation systems, staff members feel the effects of HITECH in different ways. Regardless of their overall sentiments, however, T-System is here to stay — at least for as long as the promise of better quality service through information technology enhancements is believed to hold.
Reference List
B., C. (2012, November 19). Personal interview.
B., G. (2012, December 2). Personal interview.
E., G. (2012, November 19). Personal interview.
Fraser, C. (2012, November 19). Personal interview.
Jackson, M. (2012, November 26). Personal interview.
Monegain, B. (2010). HITECH Act 'lit a fire' under health systems. Healthcare IT News. Retrieved from http://www.healthcareitnews.com/news/hitech-act-lit-fire-under-health-systems
SDMC. (2012). Facts at a glance. Retrieved from http://www.downstate.edu/
SDMC. (2012). Mission, vision and values. Retrieved from http://www.downstate.edu/
Small, V. (2012, November 26). Personal interview.
T-SYSTEM. (2012). About us. Retrieved from
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