Theera-Ampornpunt N. Informatics in emergency medicine: a brief introduction. In: The International Conference in Emergency Medicine: Challenges in Emergency Medicine: It’s Time for Change!; 2012 Jan 30 - Feb 1; Bangkok, Thailand. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi Hospital; 2012 Feb.

1. Informatics in Emergency Medicine: A Brief Introduction
Nawanan Theera-Ampornpunt, M.D., Ph.D.
Health Informatics Division
Faculty of Medicine Ramathibodi Hospital
Mahidol University, Bangkok, Thailand
Abstract
Patient care in any specialty requires good information, which is the focus of biomedical
and health informatics. Emergency medicine presents challenges for informatics that are distinct
from other specialties. This paper discusses roles informatics can play in emergency medicine
and offers examples of how common informatics solutions will be key toward high-quality
emergency medicine in the future. Technologies introduced include electronic health records,
personal health records, health information exchange, mobile health and social media, and finally
the future of biosurveillance.
Introduction
As in any other medical specialties, emergency medicine provides care to patients in
need, and the quality of care unavoidably hinges on the quality of the information.[1] This is at
the heart of biomedical and health informatics (previously known as “medical informatics”), an
interdisciplinary field that is concerned with “the optimal use of information, often aided by the
use of technology, to improve individual health, health care, public health, and biomedical
research.[2] Unlike other specialties, however, emergency medicine presents unique challenges
for informatics. The urgency of its patients, with limited time and resource constraints,
oftentimes compounded by severely restricted and scattered information makes it difficult for
emergency physicians to make quick and appropriate decisions without errors.[3] The scale and
unpredictability of mass casualties and disasters complicate the matter even further. A
thoughtful, comprehensive, and well-executed informatics approach, therefore, is critical to
emergency medicine. Such an approach must not interfere or slow down the providers in this
setting where every second matters, but instead should aim to improve how providers perform
and allow them to do their job more efficiently.
The purpose of this paper is to introduce emergency medicine providers to the field of
informatics by offering perspectives on how some informatics solutions can help them perform
better. While it is impossible for any single paper to cover the breadth and depth of growing
informatics knowledge bases, I hope that this paper will open the doors for emergency
physicians and “informaticians”[2] to work together in finding the most appropriate solutions
that will maximize values toward our mutual goal—the patients’ health and wellbeing.

2. Roles of Informatics in Emergency Medicine
With the literature noting information gaps prevalent in emergency visits,[4] it is not
difficult to imagine the inherent values of patient’s health information an information system can
bring, especially in the emergency settings where self-reported information is usually unavailable
or unreliable. In fact, there exists literature evidence for the values of such information in the
quality and efficiency gains in the emergency settings, at least for some medical conditions and
in some health care organizations.[5-7] These documented benefits highlight the roles of “health
information exchange” (HIE),[8] an electronic intermediary platform that serves as information
brokers between health care organizations as well as with other parties (including governmental
agencies and patients).
While it is natural to think of informatics as the deliverer of patient information to health
care providers, informatics in fact has much more to offer. Any well-designed information
management approach, paper or electronic, must integrate well with the user’s workflow and
provide tangible values to the care process. An information system that simply digitizes the
existing workflows without adequately considering the workflow implications, therefore, not
only demonstrates the failure to recognize the “transformational” opportunities informatics
solutions can bring, but could also hinder high-quality care because of inherent problems in the
existing care processes. Good information systems, therefore, not only provide information that
are easily accessible by their users, but also seize the opportunity to redesign and add values to
the work processes by leveraging the technologies. This section discusses the potential roles of
informatics in transforming the care processes that will set the stage for other sections that
follow.
The Institute of Medicine, in its “Crossing the quality chasm” landmark report, identifies
six aspects of quality health care—safety, timeliness, effectiveness, efficiency, equity, and
patient-centeredness.[9] This serves as a useful framework in identifying roles informatics can
play in emergency medicine. The availability of patient health information, offered by HIE and
other technologies, provides a clearer picture of the patient’s health status, allowing emergency
physicians to make more effective decisions in a timely manner. Knowledge of the patient’s drug
allergies and current medications also provides patient safety benefits, whereas prior laboratory
results may prevent unnecessary or redundant testing (i.e., making care more efficient).
Apart from these simple information broking roles, health information technology (IT)
can also be leveraged in other ways that further improve care quality. Consider first the safety
aspect. Computerized physician order entry (CPOE) systems, where physicians enter medication
orders directly into the system, prevent medication errors resulting from poor handwriting. They
also enable the use of clinical decision support systems (CDSSs) features such as alerts and
reminders that warn the users about certain drug allergies or potential drug-drug interactions that

3. busy and overworked clinicians could have missed otherwise. The effects of these technologies
on patient safety have been noted,[10] although the presence and degree of specific benefits still
vary from one study to another.[11,12] As previously noted when discussing HIE, the
importance of timely information can never be overstated in emergency medicine. Apart from
HIE, several other technologies also help deliver timely information or offer timely care to those
in need, including personal health records, telemedicine, and mobile health (mHealth)
technologies. Several of these also make health care more equitable and patient-centered by
reducing barriers to care of disadvantaged populations and empowering patients in their self-
care.
While health IT has great potential to improve health care, it is also important to note, as
informatics experts have rightly pointed out, that health IT is not a panacea to cure all problems
in the health care systems.[13,14] Risks of health IT in facilitating errors and other unintended
consequences have been documented.[15,16] This underscores the need to balance the technical
focus on health IT with the equally important “people and organizational issues” as repeatedly
noted by informatics experts.[17-20] It is important not only to develop a good information
system, but also to manage the IT implementation appropriately, with attention to project
management, change management, communication, training, and workflow implications.[21]
In short, there are several undeniable roles for health IT in improving patient care in
emergency medicine, but in order to maximize benefits and minimize unintended consequences,
it is necessary to view health IT not just as a technological innovation but also as an agent for
organizational and work process transformations. The following sections discuss in more detail
how some health IT solutions of today can transform care in emergency medicine of tomorrow.
Electronic Health Records and Health Information Exchange
Many providers may have heard of “electronic health records” (EHRs) or “electronic
medical records” (EMRs). Among informatics professionals, EHRs often refer to electronic
records of a patient’s health information that are documented by and accessible to health care
providers. EHRs are often housed within the walls of health care organizations, but to maximize
continuity of care across settings, EHRs from one health care organization should ideally be
accessible to other health care organizations through HIE or other mechanisms when providing
care to the patients, with appropriate privacy protections. Since different organizations often use
different EHR solutions, the need to use agreed-upon information standards is paramount to an
interoperable health information infrastructure that shares and processes electronic information
across different technologies.
As discussed in the last section, availability of patient health information can reduce
errors and improve quality of care in the emergency settings. An HIE infrastructure that

4. integrates data from disparate EHR systems provides a more complete picture of a patient
presenting to the emergency department. Consider, for instance, a diabetic patient from Bangkok
who visits Phuket as a tourist and happens to lose his consciousness during one of his tours.
Without additional information, an emergency physician in Phuket may be forced to use her best
judgment uninformed to treat the patient to the best of her ability. With an interoperable HIE, the
physician may be able to access the patient’s history from a Bangkok hospital’s EHR system
(assuming that the patient could be identified, say, based on an identification card in his wallet).
The doctor may notice from the records that the patient has missed an appointment and likely ran
out of his oral hypoglycemic agents. Alternatively, she may realize that the patient has severe
allergies to penicillin, which would be of critical importance if sepsis is suspected. The value of
information in the EHRs to the emergency physician will vary depending on clinical
presentations and the information in the records, but having an access provides potentially
valuable information that might not be available otherwise. For this scenario to become a reality,
there is a need to have a public policy that facilitates widespread adoption of EHRs and an
infrastructure for an interoperable HIE. The United States is moving in this direction, with its
HITECH Act and “Meaningful Use” efforts.[22,23] Several European countries also have a high
adoption rate of ambulatory EHRs as well as facilitative public policies and social contexts,[24]
all of which are key ingredients to a successful HIE.
Although electronic documentation of clinical care provided to patients is a necessary
element of any EHR system, it is not sufficient to bring about quality benefits we endeavor.
Experts have identified other important functionalities that an EHR system should have,
including order entry and electronic viewing of laboratory and radiology results.[25] Recent
studies of EHR adoption in the United States have used these functionalities to assess how much
progress has been made toward widespread adoption.[26-28] This reinforces the point made
earlier that health IT should not be viewed simply as an information provider but instead as an
agent of work process improvements that accompany its implementation. These work process
improvements could include, for example, “meaningful” use of computerized order entry to
reduce medication errors and streamline the entire medication management process; use of
clinical decision support features to alert users to potential errors; and electronic viewing of
laboratory results to provide timely reporting, to bring abnormal results to the clinicians’
attention, and to plot the results on a chart that makes it more easily for clinicians to
comprehend. In short, to delivery substantial benefits, EHR implementation needs to move
beyond electronic documentation of clinical care.
Personal Health Records
A less familiar technology that nevertheless has a potential to improve emergency care is
personal health records (PHRs). While EHR systems target at health care providers as the main
users, PHR systems focus on the individual patients.[29] Patients can access, enter, and update

5. their personal health information in a PHR system, though the architecture of the system can
vary depending on who provides the services and whether the PHRs are standalone or integrated
with provider-managed EHRs. A PHR system can serve as a patient’s personal information
management tool, and it may also offer health care professionals access to the patient’s
information when it is needed to provide care. When a patient presents to the emergency
department, emergency physicians may be able to access a patient’s PHRs which may contain
their underlying conditions, current medications, allergies, laboratory results, among others.
While this sounds similar to accessing the patient’s electronic records residing in other health
care organizations through an EHR system and an HIE platform, the key difference between
PHRs and EHRs is on who primarily manages the information (patient vs. provider). Like EHRs,
quality gains in PHRs lie not only on the information provided, but also on other functions that
help transform the care process. These include reminding diabetic patients about annual eye
examinations or providing personalized access to online resources related to smoking cessation
(improving both the effectiveness and patient-centeredness aspects of care).
The current PHR landscape is still relatively immature, especially after Google Health
closed its services,[30] and more research is needed on various aspects of PHRs.[31]
Nevertheless, with the society increasingly moves toward more consumer empowerment and
online presence, PHRs are expected to play an integral role to the future of health care and its
potential benefits to emergency medicine are obvious.
Mobile Health
While traditional telemedicine technologies that connect providers and patients separated
physically or chronologically have been known for decades, use of mobile technologies for
health-related purposes has received much attention in the past few years. The exponential
increase in mobile device adoption creates a large, enthusiastic consumer base. The rise of social
media in the recent years also offers convenient and appealing platforms for social interactions
and online information seeking. These recent advances in mobile health (mHealth) bring
ubiquitous access to health information and health care resources into the hands of not only
consumers worldwide but also the rural populations where traditional telephone lines and
Internet may still be out of reach. It changes the way consumers communicate about health issues
that undoubtedly will influence how they expect health care services will be delivered in the near
future.[32] A study by the World Health Organization also shows that mHealth is a global
phenomenon that has the potential to benefit not only high-income countries but also low-income
ones.[33]
One area in emergency medicine where mHealth is particularly helpful is disaster
management. From the 2004 Indian Ocean tsunami to the 2010 Haiti earthquake to the 2011
Japan earthquake and tsunami, mobile devices and social media have provided new ways for

6. victims, relief workers, and disaster managers to communicate and coordinate.[33,34] The roles
of mHealth were evident during the 2011 record flooding in Thailand. In that disaster, social
media including Twitter, Facebook, and YouTube were used along with many other public and
private online resources to help assess the situation, spread the words, and coordinate relief
efforts, among others. Mobile devices were predominantly employed to communicate via voice,
text messages, and social media, as well as many more innovative uses of IT tools. The need for
mHealth technologies becomes especially important when traditional telephone lines and
electricity are disrupted by the disasters. Nevertheless, the use of these mHealth technologies
during disasters is still mostly scattered and unorganized, with many lessons to be learned.[35] It
remains a challenge for emergency and disaster management specialists to recognize the full
potential of these technologies and leveraging them to prepare us for future disasters.
Biosurveillance
The last informatics solution to be discussed that has a direct implication on emergency
medicine is biosurveillance. This encompasses a group of technologies used to electronically
monitor the trends in health status of a population so that a timely investigation or intervention
can be made if necesary. The pandemic influenza in the past few years and the rising threat of
bioterrorism are two apparent scenarios where biosurveillance can make a difference. Several
approaches to biosurveillance exist today, from the active use of IT by a group of users to report
the newly identified cases for a disease of interest (e.g., malaria) in a particular location, to the
passive monitoring of the current trends using data from various sources. The timeframe of
reporting also varies depending on the purpose and nature of the surveillance, from days or
months after the case identification to real-time monitoring. The Google Flu Trends,[36] which
uses keywords from the popular online search engine in near real-time to predict with a
considerable degree of accuracy the likely presence of influenza epidemic in a geographic area,
demonstrates the utility of biosurveillance not only to epidemiologists and public health
administrators but also to the general public.[37-39] With EHRs widely adopted and connected
by many emergency departments in a community, one can imagine a powerful biosurveillance
system that monitors the chief complaints (e.g., flu-like symptoms), laboratory results (e.g.,
laboratory-confirmed cases of influenza), and clinical diagnoses of emergency patients visiting
one of such the emergency departments through their interconnected EHR systems and provides
a real-time situational awareness (e.g., a rising trend of possible influenza cases that might
indicate an ongoing epidemic) that would allow governmental agencies responsible for disease
control and prevention to act fast in assessing and controlling the situation. Although this
scenario is currently not achievable in most communities due to a lack of widespread adoption of
interconnected EHR systems, the landscape is changing and such biosurveillance tools are
expected become a reality of emergency patient care in the coming years.

7. Conclusion
The roles of biomedical and health informatics in emergency medicine were reviewed.
Examples of how informatics tools can lead to safe, timely, effective, efficient, equitable, and
patient-centered care have been offered. Important informatics solutions that have great potential
to improve patient care in the emergency settings have been discussed, including the electronic
health records, personal health records, health information exchange, mobile health, and
biosurveillance. it is my hope that these discussions have provided you a brief introduction into
the field of informatics and encouraged you to explore ways informatics can help improve how
emergency medicine functions.
References
1. Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep
15;304(11:1227-8.
2. Hersh W. A stimulus to define informatics and health information technology. BMC Med
Inform Decis Mak. 2009 May 15;9:24.
3. Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, Benjamin E,
Henneman PL. Errors in a busy emergency department. Ann Emerg Med. 2003
Sep;42(3):324-33.
4. Stiell A, Forster AJ, Stiell IG, van Walraven C. Prevalence of information gaps in the
emergency department and the effect on patient outcomes. CMAJ. 2003 Nov
11;169(10):1023-8.
5. Theera-Ampornpunt N, Speedie SM, Du J, Park YT, Kijsanayotin B, Connelly DP.
Impact of prior clinical information in an EHR on care outcomes of emergency patients.
AMIA Annu Symp Proc. 2009 Nov 14;2009:634-8.
6. Overhage JM, Dexter PR, Perkins SM, Cordell WH, McGoff J, McGrath R, McDonald
CJ. A randomized, controlled trial of clinical information shared from another institution.
Ann Emerg Med. 2002 Jan;39(1):14-23.
7. Connelly DP, Park YT, Du J, Theera-Ampornpunt N, Gordon BD, Bershow BA,
Gensinger RA, Shrift M, Routhe DT, Speedie SM. The impact of electronic health
records on care of heart failure patients in the emergency room. J Am Med Inform Assoc.
Forthcoming 2011.
8. Shapiro JS, Kannry J, Lipton M, et al. Approaches to patient health information exchange
and their impact on emergency medicine. Ann Emerg Med. 2006 Oct;48(4):426-32.
9. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the
quality chasm: a new health system for the 21st century. Washington, DC: National
Academy Press; 2001. 337 p.
10. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of
computerized physician order entry and a team intervention on prevention of serious
medication errors. JAMA. 1998 Oct 21;280(15):1311–6.

8. 11. Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does computerized provider order
entry reduce prescribing errors for hospital inpatients? A systematic review. J Am Med
Inform Assoc. 2009 Oct;16(5):613–23.
12. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and
clinical decision support systems on medication safety: a systematic review. Arch. Intern.
Med. 2003 Jun 23;163(12):1409–16.
13. Blumenthal D, Glaser JP. Information technology comes to medicine. N Engl J Med.
2007 Jun 14;356(24):2527-34.
14. Hersh W. Health care information technology: progress and barriers. JAMA. 2004 Nov
10:292(18):2273-4.
15. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. Role of
computerized physician order entry systems in facilitating medication errors. JAMA.
2005 Mar 9;293(10):1197-203.
16. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in
health care: the nature of patient care information system-related errors. J Am Med
Inform Assoc. 2004 Mar-Apr;11(2):104-12.
17. Kaplan B. Evaluating informatics applications--some alternative approaches: theory,
social interactionism, and call for methodological pluralism. Int J Med Inform. 2001
Nov;64(1):39-56.
18. Kaplan B, Harris-Salamone KD. Health IT success and failure: recommendations from
the literature and an AMIA workshop. J Am Med Inform Assoc. 2009 May-
Jun;16(3):291-9.
19. Ash JS, Stavri PZ, Kuperman GJ. A consensus statement on considerations for a
successful CPOE implementation. J Am Med Inform Assoc. 2003 May-Jun;10(3):229-34.
20. Lorenzi NM, Novak LL, Weiss JB, Gadd CS, Unertl KM. Crossing the implementation
chasm: a proposal for bold action. J Am Med Inform Assoc. 2008 May-Jun;15(3):290-6.
21. Theera-Ampornpunt N. Measurement of health information technology adoption: a
review of the literature and instrument development [master’s Plan B
project]. Minneapolis (MN): University of Minnesota; 2009. 165 p.
22. Blumenthal D. Launching HITECH. N Engl J Med. 2010 Feb 4;362(5):
382-5.
23. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health
records. N Engl J Med. 2010 Aug 5;363(6):501-4.
24. Protti D. Comparison of information technology in general practice in 10 countries.
Healthc Q. 2007;10(2):107-16.
25. Institute of Medicine, Board on Health Care Services, Committee on Data Standards for
Patient Safety. Key Capabilities of an electronic health record system: letter report

9. [Internet]. Washington, DC: National Academy of Sciences; 2003 [cited 2011 Sep 14].
31 p. Available from: http://www.nap.edu/catalog.php?record_id=10781
26. Jha AK, Ferris TG, Donelan K, DesRoches C, Shields A, Rosenbaum S, Blumenthal D.
How common are electronic health records in the United States? A summary of the
evidence. Health Aff (Millwood). 2006 Nov-Dec;25(6):w496-507.
27. Jha AK, DesRoches CM, Campbell EG, Donelan K, Rao SR, Ferris TG, Shields A,
Rosenbaum S, Blumenthal D. Use of electronic health records in U.S. hospitals. N Engl J
Med. 2009 Apr 16;360(16):1628-38.
28. Jha AK, DesRoches CM, Kralovec PD, Joshi MS. A progress report on electronic health
records in U.S. hospitals. Health Aff (Millwood). 2010 Oct;29(10):1951-7.
29. Tang PC, Ash JS, Bates DW, Overhage JM, Sands DZ. Personal health records:
definitions, benefits, and strategies for overcoming barriers to adoption. J Am Med
Inform Assoc. 2006 Mar-Apr;13(2):121-6.
30. Brown A, Weihl B. An update on Google Health and google PowerMeter [Internet].
Mountain View (CA): Google Inc.; 2011 Jun 24 [updated 2011 Jul 15; cited 2011 Oct
18]. Available from: http://googleblog.blogspot.com/2011/06/update-on-google-health-
and-google.html
31. Kaelber DC, Jha AK, Johnston D, Middleton B, Bates DW. A research agenda for
personal health records (PHRs). J Am Med Inform Assoc. 2008 Nov-Dec;15(6):729-36.
32. Chou WY, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social media use in the
United States: implications for health communication. J Med Internet Res. 2009 Nov
27;1194):e48.
33. mHealth: new horizons for health through mobile technologies: global observatory for
eHealth series - Volume 3 [Internet]. Geneva (Switzerland): World Health Organization;
2011 [cited 2011 Oct 18]. Available from: http://www.who.int/goe/publications/
goe_mhealth_web.pdf
34. Keim ME, Noji E. Emergent use of social media: a new age of opportunity for disaster
resilience. Am J Disaster Med. 2011 Jan-Feb;6(1):47-54.
35. Doarn CR, Barrigan CR, Poropatich RK. Application of health technology in
humanitarian response: U.S. Military deployed health technology summit--a summary.
Telemed J E Health. 2011 Jul-Aug;17(6):501-6.

10. 36. Google Flu Trends [Internet]. Mountain View (CA): Google Inc.; c2011 [cited 2011 Oct
18]. Available from: http://www.google.org/flutrends/.
37. Carneiro HA, Mylonakis E. Google trends: a web-based tool for real-time surveillance of
disease outbreaks. Clin Infect Dis. 2009 Nov 15;49(10):1557-64.
38. Corley CD, Cook DJ, Mikler AR, Singh KP. Using Web and social media for influenza
surveillance. Adv Exp Med Biol. 2010;680:559-64.
39. Cook S, Conrad C, Fowlkes AL, Mohebbi MH. Assessing Google Flu Trends
performance in the United States during the 2009 influenza virus A (H1N1) pandemic.
PLoS One. 2011;6(8):e23610.