Using data from hospital information systems to improve emergency department care

ACAD EMERG MED d November 2004, Vol. 11, No. 11 d www.aemj.org 1237

Using Data from Hospital Information Systems to
Improve Emergency Department Care
Gregg Husk, MD, Daniel A. Waxman, MD
Abstract
The ubiquity of computerized hospital information systems, of detail that can be used to educate staff and improve the
and of inexpensive computing power, has led to an un- quality of care emergency physicians offer their patients.
precedented opportunity to use electronic data for quality In this article, the authors describe five such projects that
improvement projects and for research. Although hospitals they have performed and use these examples as a basis for
and emergency departments vary widely in their degree of discussion of some of the methods and logistical chal-
integration of information technology into clinical opera- lenges of undertaking such projects. Key words: hospital in-
tions, most have computer systems that manage emergency formation systems; quality improvement; emergency health
department registration, admission–discharge–transfer in- services. ACADEMIC EMERGENCY MEDICINE 2004;
formation, billing, and laboratory and radiology data. These 11:1237–1244.
systems are designed for specific tasks, but contain a wealth

Over the last two decades, the microcomputer revo- FOLLOW-UP INFORMATION FOR ED
lution has brought processing power and mass storage ADMISSIONS
to the desktop of inexpensive personal computers.
E-mail and Internet access, ensuring scheduled back- Although follow-up of patients admitted from the ED
ups of data, and the need to move data between is a requirement for residents training in emergency
different hospital information systems have catalyzed medicine,1 the logistics of doing so are often cumber-
the networking of hospital computers. Standardiza- some, and, in our experience, residents and attending
tion of formatting of medical information using the physicians do not always follow-up on cases of educa-
Health Level 7 (HL7) standard has facilitated sharing tional value. We have designed a quarterly report that
of information between different hospital information provides follow-up information for each resident and
systems. Middleware formats data and routes the data attending physician on every patient whom they have
to different applications and network destinations. admitted. This report includes the admitting diagnosis,
Data from these ubiquitous information systems are the length of hospital stay, the principal discharge
a rich source for study of a broad range of emergency diagnosis, the principal inpatient procedure, and the
department (ED) issues, both clinical and administra- patient’s discharge status (Figure 1).
tive, for research and quality improvement (QI) For this project, the ED uses two monthly down-
purposes. In this article, we give examples of quality loads. One file contains each ED patient’s demo-
improvement and research projects we have per- graphic and financial information, date and time of
formed using data commonly available in hospital ED arrival and discharge, up to two ED providers, ED
administrative databases. We discuss some of the diagnosis, and the patient’s disposition. The ED also
methods and logistical challenges of implementing receives a monthly file containing all inpatient dis-
such projects. Our facility is a multihospital network; charges, including coded diagnoses, procedures, and
most of the projects described use data from our the patient’s discharge status. These downloads are
primary site, an 894-bed teaching hospital with 65,000 imported into Stata (StataCorp, College Station, TX),
ED visits annually. a data-management language, to manipulate the data.
To combine information from the ED and inpatient
monthly file, the medical record number and admis-
sion date are used to match records.
This approach has limitations. This system is
passive and succeeds only if the individual clinicians
From the Department of Emergency Medicine, Beth Israel Medical read their reports and identify cases of interest. A
Center (GH, DAW), New York, NY. given patient may have more than one ED attending
Address for correspondence and reprints: Gregg Husk, MD, physician or resident involved in his or her care but,
Emergency Medicine, Beth Israel Medical Center, First Avenue
and 16th Street, New York, NY 10003. Fax: 212-420-2863; e-mail:
until recently, we captured only one attending physi-
ghusk@bethisraelny.org. cian and one resident in the data. Data entry person-
doi:10.1197/j.aem.2004.08.019 nel did not always accurately enter the involved ED

1238 Husk and Waxman d HOSPITAL INFORMATION SYSTEMS

Figure 1. Selected cases from one resident’s quarterly report (identifiers redacted).

resident. Most recently, we have changed the ED data for a number of stat ED laboratory tests (tracked tests)
source to our ED information system, EmSTAT (A4 with the laboratory leadership. We drafted a daily
Health Systems, Cary, NC), and each attending report for the laboratory manager, and modified the
physician and resident involved in the patient’s care report in response to her requests. The daily manage-
is now reliably identified. Textual descriptions of ment report highlighted outliers for each of the study
International Classification of Diseases (ICD-9) codes tests, in a single high-acuity ED that cares for 30,000
are not always meaningful to clinicians, e.g., ‘‘Chest patients a year and admits 9,000 patients.
Pain NEC.’’ Nevertheless, we believe that providing We studied intralaboratory TAT from December 1,
some follow-up information on every admitted pa- 2002, to March 1, 2003, the first half being a control
tient seen by emergency physicians is of value—it period preceding the daily report. In the first half of
allows ED clinicians to review the patient’s medical the study, 2,097 ED patients had at least one tracked
record if they find a mismatch between the ED and test performed, and during the intervention period,
inpatient diagnoses. When our medical center imple- 2,049 ED patients had at least one tracked test
ments its clinical information system for its outpatient performed. The percentage of ED study tests that
practices, we will be able to use a similar approach to met the 60-minute TAT standard increased from 88.8%
provide follow-up for patients discharged from the in the preintervention period to 95.3% postinterven-
ED. tion (p , 0.0001, Pearson’s x2 test). The overall
median TAT improved by 14% (5 minutes) and the
90th percentile TAT improved from 59 minutes to 46
LABORATORY TURNAROUND QI PROJECT minutes (21%). During the study, there were no
In an effort to improve the efficiency of ED care, we changes in laboratory staff, procedures, or equipment
undertook a QI project to improve laboratory turn- that would otherwise explain the improvements. One
around time (TAT).2 We requested a daily download individual was responsible for supervising all labora-
of all ED laboratory tests for which results were tory personnel, and she used this report to raise
available the preceding day. We hypothesized that general awareness of time standards and to provide
by providing data to the laboratory leadership for feedback to technologists when particular tests were
patients with prolonged TATs, we could reduce completed later than the time standard.
variability in TAT and improve the average perfor- During the preintervention period, no specific
mance. We negotiated a TAT standard of 60 minutes feedback was provided other than routine supervision


of the technologists. The hospital’s laboratory per- A NEW MEASURE OF ED CROWDING
formed an average of 337 stat tracked tests per day
(for the ED and inpatient units). This report high- Our walkout rate is higher than the national average,
lighted certain problems that had previously gone and the physical space of our ED is small for our
undetected—delays during shift change and when volume. ‘‘ED overcrowding’’ has been much dis-
laboratory staff were busy distributing reports to the cussed, but it remains imprecisely defined. We in-
inpatient units. The ED continues to provide these troduced the hourly ED census as a new measure of
daily management reports to the laboratory, and the crowding3 and demonstrated that the hour-by-hour
improvements in TAT are sustained. ED census could be recreated over a prolonged period
This project was challenging. Initially, our informa- (one year), using patient arrival and departure times
tion technology (IT) services were unable to provide captured in our hospital registration system. A pro-
the necessary data. We obtained laboratory results gram was written in the Stata language to calculate
using the laboratory information system (LIS) directly, the number of patients in the ED at any given hour
and there was no outbound interface that contained over the one-year study period. Hourly census
test results. When the laboratory began performing changed dramatically over the course of the day and
tests for other hospitals and physicians’ offices, an between our busiest and least busy days (Figure 3).
outbound interface that contained test results was To validate hourly census as a measure of crowding,
developed, and we began receiving daily files con- we used logistic regression to show a correlation
taining all laboratory data that originated from the between the hourly census at the time of a patient’s
ED. Stata does not support importing of files where registration and the likelihood of the patient’s leaving
each field is separated by the HL7 field delimiter (a without being seen (LWBS) (Figure 4) and the ED’s
pipe (|) character), so we needed to translate each being on ambulance diversion. The logistic regression
pipe character into a comma, which Stata can use to odds ratio for LWBS was 1.05 (95% confidence interval
identify separate fields. We initially tried this trans- [95% CI] = 1.04 to 1.06), and the odds ratio for ambu-
lation with two different editors (Brief [Solution lance diversion was 1.10 (95% CI = 1.07 to 1.12). We
Systems, Wellesley, MA] and Microsoft Word for believe that our quantitative measure of crowding will
Windows [Microsoft Corp., Redmond, WA]), and prove robust across a wide range of clinical settings,
found that these translations (750,000 to 1,000,000 and will provide a common standard for research
per day) took approximately 10 minutes. We identi- purposes. We are also using our findings to support
fied a stream editor (SED from Microsoft Windows our request for improved access to inpatient beds,
Services for Unix) that performs the substitutions in physical plant modifications, and a facilitated redesign
approximately 15 seconds. In addition, the report for effort of ED work processes to improve the timeliness
a single laboratory test is spread across several seg- of emergency care.
ments (Figure 2), and it took us some time to learn to
combine these data into a single record of interest.
Initially, daily downloads included only testing
EFFECT OF AMBIGUOUS TROPONIN I
performed on ED patients, but we soon discovered CUTOFF ON THE RATE OF POSITIVE TEST
that ED tests performed on patients who remained in RESULTS
the ED after the admission decision were classified by The guidelines of the American College of Cardiology
the LIS as inpatient tests and, therefore, we included (ACC) and European Society of Cardiology (ESC)4 con-
all inpatient testing as well. tain a significant ambiguity in their recommendation

Figure 2. Format of Health Level 7 (HL7) laboratory data for a single test (identifiers redacted).


offs in clinical laboratories; our laboratory uses the 10%
CV cutoff. We undertook a study9 to determine the
effect of using one level for the diagnostic cutoff (the
99th percentile) versus another (the 10% CV) in our ED
population.
We studied two different assays (one manufactured
by Abbott Diagnostics [Abbott Park, IL] the other by
Ortho-Clinical Diagnostics [Raritan, NJ]) used by our
clinical laboratory during sequential study periods.
The daily laboratory download was used to identify
all unique patient encounters in which troponin level
was measured in an ED patient during each period. In
Figure 3. The distribution of the census of nonpsychiatric accordance with ACC/ESC guidelines, the highest
emergency department (ED) patients who received care in troponin level within 24 hours of the ED visit was
the main ED. The horizontal line identifies the number of used for analysis. The two cutoffs defined three
patient-treatment spaces in the main ED. The census is
reflected in two ways: the number of patients and the percent
patient groups (low, medium, and high) based on
occupancy of the number of main ED treatment spaces. their highest troponin levels: less than 99th percentile,
between the 99th percentile and 10% CV, and greater
than 10% CV. The primary endpoint was the number
for where to place the diagnostic cutoff for the troponin of patients in each group, or the number of positive
I test. They stipulate that the cutoff should be placed at cases at each cutoff. To further characterize patients in
the 99th percentile of a reference population, but also each group, we evaluated the following data from the
say that the coefficient of variation should be less than hospital’s inpatient database: inpatient mortality, re-
10% at that cutoff. Coefficient of variation (CV) is vascularization procedures, and discharge diagnoses.
defined as the standard deviation divided by the Analysis of inpatient procedures and discharge di-
sample mean. In laboratory medicine, it refers to the agnoses was challenging. Each admission had up to
variability of replicate measurements of a single sam- 20 coded procedures and 20 secondary diagnoses.
ple and is a measure of the precision of the assay. Text string searches were developed by manual re-
Most assays have better precision at higher concen- view of all coded procedures and diagnoses, and
trations.5 The 10% CV cutoff is the minimum concen- validation of the algorithm by two physicians. Each
tration at which the CV (of replicate samples at that patient with a cardiac revascularization procedure
concentration) is less than 10%. At present, most had a coded procedural descriptor that included the
commercial troponin assays have a CV significantly text string ‘‘aortcor bypass,’’ ‘‘cor art bypass,’’ ‘‘coro-
greater than 10% at the 99th percentile of the reference nary artery stent,’’ ‘‘aortcor,’’ or ‘‘aortcor,’’ and this
population, and several investigators have advocated algorithm did not erroneously include any noncardiac
the use of the 10% CV cutoff rather than the 99th procedures. Patients with a coronary artery disease
percentile.6–8 There is considerable variability in cut- (CAD) diagnosis had a coded diagnosis descriptor of

Figure 4. The relationship between the emergency department (ED) census and walkout rate. For each ten additional patients in
the main ED, the walkout rate rises 1.8% (95% confidence interval, 1.8%–1.8%).


‘‘AMI’’ or one that included the text string ‘‘cornry,’’ and foreign bodies represent a significant fraction of
‘‘infrct,’’ ‘‘coronary,’’ ‘‘posterior infarct,’’ ‘‘angina malpractice closed claims. We have observed that the
pec,’’ ‘‘post MI,’’ ‘‘othr acute/subacute,’’ ‘‘ischemic ED and inpatient clinical staff do not always report
heart,’’ or ‘‘myocardial infarct.’’ diagnostic failures to ED leadership on those occa-
During the two five-month study periods (from sions when the patient returns to our hospital, and
June 2002 to April 2003), there were a total of 5,570 this has been reported elsewhere.11
patients (3,149 and 2,421 patients, respectively). We In a chart review of 5,000 inpatient and ED records
found that lowering the diagnostic cutoff from the from a single community hospital, Chellis et al.12
10% CV level to the 99th percentile increased the sought cases with discrepancies between the ED’s
relative number of positive tests by 58% (n = 461 vs. admission diagnosis and the principal discharge di-
728) for the Abbott assay and 133% (n = 352 vs. 832) agnosis. Cases with discordant diagnoses were then
for the Ortho assay. For each assay, inpatient mortality reviewed by two levels of physicians. They identified
was significantly greater for high-troponin cases than a very low rate of diagnostic errors (0.6%), and
for indeterminate- (p , 0.009, Pearson’s x2) or low- concluded that this two-tiered chart audit is a valuable
troponin cases. For the Abbott assay, inpatient mor- instrument for ED quality assurance. We created
tality for the indeterminate group was significantly a merged data file of all patients discharged from
higher than for the low group (1.7% vs. 5%, p , the ED in 2003 who were admitted to the hospital
0.003). For the Ortho assay, this difference was not within 96 hours after ED discharge. We then gener-
significant. For each assay, there were significantly (p ated a report showing the ICD-9-coded ED diagnosis,
, 0.0001) more revascularization procedures for together with a textual inpatient discharge diagnosis.
patients with high troponin levels than indeterminate A total of 1,400 cases met the aforementioned criteria.
or low ones. For the Abbott assay, the difference in This report was then manually reviewed for cases that
revascularization procedures in the indeterminate- appeared to represent failure to diagnose during the
and low-troponin groups was not significant, whereas initial ED visit. A sample of these cases is shown in
it was significant for the Ortho assay (p = 0.017). Table 1. Our approach is consistent with Schenkel’s
Principal or secondary discharge diagnoses in pa- suggestion13 of a two-stage process to identify and
tients with high troponin levels were more likely to quantitate errors using an automated review to
reflect CAD than in patients with indeterminate or efficiently identify cases of potential interest, followed
low troponin levels (p , 0.0001), but there was no by a chart review.
significant difference between indeterminate- and In a small study, the Joint Commission on Accred-
low-troponin groups. itation on Healthcare Organizations found that more
Thus we showed that the ambiguity in the di- than half of reported hospital sentinel events resulting
agnostic cutoff translates into a significant effect on in patient death or permanent injuries resulting from
the number of patients potentially diagnosed as delays in treatment originated in the ED.14 A single
having myocardial infarction. Our evaluation of in- error can identify work processes likely to fail again.
patient mortality, revascularization procedures, and A root-cause analysis of a bad result, or a failure-
discharge diagnoses suggests that patients in the mode effects analysis of high-risk work processes,
indeterminate-troponin group probably fall some- may identify opportunities to improve the quality of
where between the low- and high-troponin groups care we provide. The Institute of Medicine’s bell-
in terms of their likelihood of CAD. An understand- wether report, ‘‘To Err Is Human, Building a Safer
ing of the magnitude of this effect led our laboratory Health System,’’15 emphasized the importance of
to reintroduce an indeterminate range (between the identifying, reporting, and analyzing errors.
99th percentile and the 10% CV), rather than to leave
just a single cutoff at the higher 10% CV level.
DISCUSSION
IDENTIFY INDIVIDUAL CASES THAT MAY Over the last 20 years, the personal computer’s clock
REPRESENT A ‘‘FAILURE TO DIAGNOSE’’ speed, maximal memory, and local hard drive storage
have each increased by more than 300-fold at the same
A HIGH-RISK CLINICAL CONDITION time that its price has dropped. Software that har-
Many of the critical decisions in emergency medicine nesses this processing power has evolved in lockstep
involve diagnostic strategies, and many costly errors with hardware improvements, allowing these types
involve failing to diagnose certain dangerous condi- of projects to be efficiently performed on personal
tions. In a study of nine EDs using trained observers, computers. For example, the computer program for
Perry et al.10 found that diagnostic errors were among the laboratory TAT report processes 750,000 to
the most common ED errors. Missed acute myocardial 1,000,000 separate data elements in less than 1 minute.
infarction, appendicitis, ectopic pregnancy, subarach- Hospitals16 and EDs17 vary widely in their degree of
noid hemorrhage, and aortic dissection can threaten integration of IT into clinical operations. Pallin et al.18
the health or life of a patient, and missed fractures surveyed the primary training sites for emergency


TABLE 1. Selected Cases of ED and Inpatient Final Diagnoses for Patients Who Were Discharged
from the ED and Admitted within Four Days in 2003 (Identiﬁers Redacted)
ED to ED
admit Disposition
MR # Adm gap (days) ED Diagnosis Principal Inpatient Diagnosis (1st visit)
Pt MR # Adm date 2 Cellulitis of foot Gangrene T&R
Pt MR # Adm date 3 Acute uri nos Parox ventric tachycard T&R
Pt MR # Adm date 2 Abdmnal pain oth spcf st Abscess of appendix T&R
Pt MR # Adm date 1 Alcohol abuse-unspec Diab ketoacidosis adult nsau T&R
Pt MR # Adm date 1 Abdmnal pain oth spcf st Torsion of ovary or tube T&R
Pt MR # Adm date 1 CVA Cerebral occ unspec w infarct AMA
Pt MR # Adm date 1 Appendicitis nos Acute appendicitis nos AMA
Pt MR # Adm date 2 Nausea alone Gastrointest hemorr nos T&R
Pt MR # Adm date 2 Asthma Othr pulmonary emb/infarction T&R
Pt MR # Adm date 2 Headache Pseudotumor cerebri T&R
Pt MR # Adm date 1 Pyrexia unknown origin Salmonella septicemia T&R
Pt MR # Adm date 1 Dyspnea Diab ketoacidosis juven nsau T&R
Pt MR # Adm date 3 Postsurgical states nec Orbital cellulitis T&R
Pt MR # Adm date 3 Abdmnal pain unspcf site Acute cholecystitis AMA
Pt MR # Adm date 4 Headache Meningitis nos T&R
Pt MR # Adm date 1 Atten to cystostomy Atherosclerosis w/ gangrene T&R
Pt MR # Adm date 2 Abdmnal pain rt upr quad Cornry atheroscelersis native T&R
Pt MR # Adm date 1 Heartburn Intestinl/perteal adhes w/obst T&R
Pt MR # Adm date 1 Gastritis/duodenitis nos Ac append w peritonitis T&R
Pt MR # Adm date 3 Malfunc vasc device/graf Staphylococc meningitis T&R
Pt MR # Adm date 1 Posttraum wnd infec nec Cardiac device/implant/graft T&R
Pt MR # Adm date 2 Constipation Acute appendicitis nos T&R
Pt MR # Adm date 2 Skin sensation disturb Cerebral occ unspec w infarct T&R
Pt MR # Adm date 4 Backache nos Pulm embol nos-antepart T&R
Pt MR # Adm date 2 Viral infections nos Ac append w peritonitis T&R
Pt MR # Adm date 3 Postop oth specfd aftrcr Osteomyelitis nos-ankle T&R
Pt MR # Adm date 1 No proc/patient decision Viral meningitis nos T&R
Pt MR # Adm date 3 Popliteal synovial cyst Othr pulmonary emb/infarction T&R
Pt MR # Adm date 2 Abdmnal pain unspcf site Duodenitis w/ hemorrhage T&R
Pt MR # Adm date 3 Abdmnal pain rt upr quad Acute cholecystitis T&R
Pt MR # Adm date 2 Headache Pituitary disorder nec AMA

medicine residencies regarding availability of IT tools. veillance to detect bioterrorism,19 discharge informa-
Order entry, clinical documentation, and medication tion to state authorities, or claims data to payers.
error checking were each found in fewer than 25% of Combining information from disparate systems
these teaching EDs. Old electrocardiogram retrieval, generally requires that the applications are capable
laboratory, and radiology results reporting, cardiology of sending and receiving information over a network
reports, pathology reports, and electronic reference using standardized protocols and a means of match-
materials were each found in more than 50% of ing appropriate records from the two systems. For
teaching EDs. Most hospitals have computer systems example, when the ADT system processes a transfer of
that manage ED registration, admission–discharge– a patient from one inpatient unit to another, this
transfer (ADT) information, billing, laboratory, and updates the ‘‘current location’’ data element in the
radiology data. If an inpatient is transferred to a dif- pharmacy, laboratory, patient-tracking, and radiology
ferent unit, information about his or her visitors, information systems records for that patient. Middle-
meals, and medications and the ﬁnal reports of his or ware, computers, and software to format and route
her electrocardiograms, laboratory, and radiographic information between different systems is playing an
results need to be sent to the correct inpatient location. increasingly important role in moving information
The hospital’s ADT system commonly provides up- between different systems. If the hospital replaces its
dates to the pharmacy, laboratory, patient tracking, ADT system, it need not design and test separate
and radiology information systems, supporting the interfaces to the laboratory information system, the
proper routing of visitors, medications, and reports. radiology information system, the pharmacy system,
The use of supplies or pharmaceuticals for individual the bed-tracking software, etc. Rather, it ensures that
patients may be sent to billing and inventory manage- the new ADT system’s interface with its middleware
ment systems. In many hospitals, some information is functions as did the old ADT system’s, and middle-
sent to external destinations, providing ED patient ware continues to properly route and format infor-
data to public health authorities for syndromic sur- mation to those systems that require this information.


Health Level 7 (HL7)20 is the most widely adopted errors by more than half, and to reduce unnecessary
standard for many types of clinical and administrative laboratory test ordering.26,27 As hospitals move to-
medical information, including data involving patient ward additional computerization, we will have op-
registration, admission, discharge and transfers, in- portunities for additional quality initiatives to
surance, charges and payers, laboratory tests, imaging improve quality and education by implementing
studies, nursing and physician observations, and phar- these systems and using the data that originate from
macy orders.21 A sample of a laboratory transaction the ED, inpatient units, and outpatient practices.
reflecting one test result (obscuring data that identify
the patients and providers) is shown in Figure 2. Each
segment of a record contains a three-character prefix, LIMITATIONS
and ends with a carriage return character (ASCII This article is derived from the authors’ experiences at
character 13). For example, a given laboratory test two urban medical centers with five EDs in one
result will begin with a Medical Subject Heading geographical area. It is designed to demonstrate the
(MeSH) prefix, and the patient’s medical record num- ease and limitations of using existing databases to
ber will be found in the fourth field of the ‘‘PID’’ address a variety of quality issues. The particular
segment, and the normal range for a particular labora- projects that we undertook were selected based on our
tory test will be found in the eighth field of the ‘‘OBX’’ ability to obtain data from the specific hospital in-
segment. Note that additional information (in the NTE formation systems available in our hospitals. The
segment) can be incorporated into the test result. This ability to carry out these projects may not generalize
standard is evolving and is available from http:// to other institutions.
www.hl7.org.
Data designed to meet one need (to capture in-
formation on inpatient admissions) may not meet all CONCLUSION
potential needs. Coding of inpatient discharges drives
hospital financials, and the accuracy of these data Data from existing hospital systems can be used to
should not be assumed.22 Inpatient coding of second- measure and manage the quality of emergency care.
ary diagnoses may not always distinguish comorbid- As clinical information systems mature and more data
ities from complications. In our troponin study, we sources become available, there will be additional
found that coronary revascularization is consistently opportunities to analyze and improve the quality of
coded, but other procedures that are less likely to care that we provide.
influence reimbursement, e.g., an exercise stress test,
are not always coded. Using data from hospital in- References
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