A poster presented at the American Medical Informatics Association 2008 Annual Symposium. The abstract can be found in "Kijsanayotin B, Du J, Theera-Ampornpunt N, Gurses A, Speedie SM. Improving access to clinical information in an emergency department: a qualitative study [abstract]. In: Suermondt J, Evans RS, Ohno-Machado L, editors. AMIA Annual Symposium Proceedings; 2008 Nov 8-12; Washington, DC. Bethesda (MD): Omnipress; 2008. p. 1003. Cited in: PubMed; PMID 18998882."

1. Improving Access to Clinical Information in an Emergency Department:
a Qualitative Study
Boonchai Kijsanayotin1 MD, PhD, Jing Du2 MPH, Nawanan Theera‐Ampornpunt1 MD, Ayse Gurses2 PhD, Stuart M. Speedie1 PhD
1Institute for Health Informatics, 2Health Policy and Management, University of Minnesota, Minneapolis, MN
Abstract Information Desk Clerk /
Triage Nurse/Paramedic EMS Paramedics Emergency Room
We studied the information flow in an
emergency department (ED) to understand Patient Walks in Start Admit Patient to
Appropriate Room
Start
Nurse Provides
how patient information flows between Complete Short
with Paper Chart
Following Patient EMS Notifies ED of
Nurse/ Physician
Transfers Notes onto
Instructions and End Patient ED
Intake Nurse Educational
providers and how information from a Registration Form Incoming Arrival the Ambulance
Run Sheet
Assesses Patient Materials to Patient Encounter
and Provides Care
computerized ambulatory system, which was Look up Patient Communicate with
ADT Record In-Charge Nurse
not well integrated with the hospital Prepare Room/
Equipment/ Use IT System to
Facilities and Write Prescribe and
information systems at the time, could be Found ?
Generate New EMS Delivers Information about
Document
Information on Provide
Chart is kept
in ER for 24
No Record Provide Patient to ER EMS , Intake
Instructions or
used. The study aimed to identify possible Yes
Procedures / Nurse on
Whiteboard
Paper Forms
Provide Written
hrs and then
Treatment as Admitted Room on Sent to MR
methods that could push information from an Verify Patient
Necessary Create Paper
Chart
Order Lab , X-rays , Prescription /
Instructions
Medications ,
ambulatory EHR system to providers with Name and Address
Need to Follow Yes
Procedures per
Order Lab , X-rays , Quick Registration Specific ED Protocols Yes
EMS Verbally No
minimal interference with the ED’s current Medications ,
Procedures per
Reports Case to
using “Kwik Reg”
and Verify Patient
Protocol(s) and Provide (Hospitalize / HUC and Nurse
ER Providers Treatment as Discharged Transfer) Coordinate with
workflow. The ED’s information flow was Correct ?
No
Edit information Protocols Identity
No Necessary Home ? Inpatient /Referral
Yes Print Sticker Facility
mapped and a strategy for making Yes
Registrar Locates
Labels
Place Chart in
Create Encounter
Create New ADT No
ambulatory encounter information available Encounter
Need to Follow
Specific ED
Protocol(s)
Patient’s ADT
Record
“New Patients”
Holding Rack
Physician Discharges
Discharges Patient
Pt from ED
was identified. Print Sticker EMS Writes Report
Iterative Processes
Labels and Provides a
Document Patient Copy to ER
Yes
History and Triage Providers Found? Create Encounter Physician Reviews Physician Sees Document Notes
Information Order through Yes
Information in Patient /Provides through IT system Monitor Patient
Introduction - Label Blank Physician Order Form
- Collate Documents into Chart Ask for Current
No Chart and /or CIS Treatment
Hospital IT System
Or Dictation
- Send to Triage Nurse/Paramedic
This study focused on understanding the Medications and
Allergies
End for EMS
Generate New Lab/ HUC Coordinates with
ADT Record If Patient Recently Imaging
various sources of patient information that are Arrived ,Registrar What Type Orders
Lab Technician for Lab
Orders or Radiology
Physician Tracks
Lab/Imaging
Attach Wristband Triage Patient to of Orders?
Completes
used for patient care in the target hospital ED Patient Identification Determine
Legend
Registration./
Technician for Imaging
Orders
Results
to Patient Urgency Insurance forms
and how the information is collected and used Darker Boxes Represent
Processes Interacting with A
Nurse/ER Technician
by providers. This knowledge was used to System
End for Acknowledges, Processes
Registrar ,
and Documents Orders in IT
determine if information gaps exist in the ED, Orders for Medications,
Procedures, Labs that Systems and Paper Record
and how information from an existing Providers will Process
Themselves
ambulatory system could be made available
during an ED visit. The ultimate goal is to find ED Information and Activity Flow Diagram
opportunities to better utilize available
information to enhance patient care, with Observations Observations Recommendations
minimal disruption of the current workflow.
Significant variation in how physicians and other Information in the hospital’s clinical information Clerk flags paper chart if patient already in
providers used the available systems. system was occasionally consulted if the patient system.
Methods was hospitalized previously.
We conducted approximately 54 person-hours Providers mostly relied primarily on information Simplify provider access to the ambulatory
of semi-structured ED observations and from patient or family interviews. Ambulatory encounter information from the system.
interviews in the target hospital ED. The ambulatory EHR system was rarely consulted.
patient care process and the information flow Information from sources other than self-report
starting from the registration and triage was infrequently utilized in the ED’s care Many physicians believed that they did not have
through discharge were carefully observed. process. access to the ambulatory system, even though it
These qualitative observations were translated was available.
into the flow diagram above.