Technology in the Emergency Department
In the popular media, emergency departments (ED) are usually associated with long wait times and uninsured patients.
But Neal Sikka, M.D., assistant professor of Emergency Medicine at The George Washington University’s School of Medicine and Health Sciences (SMHS), believes a more productive conversation would be about the booming use of technology in ED’s across the country.
So, as a part of a GW series on Emergency Care and Public Health Preparedness in American Society, Sikka started the discussion himself, Feb 22. The seminar, titled “Technology in Emergency Care,” was hosted by five GW schools including SMHS and the Milken Institute School of Public Health (formerly the GW School of Public Health and Health Services).
The event featured five emergency care experts from the federal government, academia, and local hospital systems.The first speaker, Gregg Lord, an emergency medical technician and director of the Emergency Care Coordination Center in the Office of the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human Services, addressed the evolution of technology in the ED.
Lord said that information about a patient should be portable. “When you create an electronic record for a patient, you should be able to see it in real time.” he said. But, the problems with this approach are the same as the problems with the internet —“not the least of which is privacy,” he said.
Real-time patient information is particularly critical to emergency medicine physicians and technicians in terms of clinical decision-making. In an ambulance, for example, providers rarely know anything about the patient’s history. “We end up treating them according to protocol,” rather than in the context of what’s most appropriate for that individual, he said.
Lord said that telemedicine is a promising example of medical technology, particularly for people living in rural areas. He was also optimistic about the newfound ability of hospitals to work together and form coalitions. He introduced the concept of “coopertition” — a combination of competition and cooperation.
Social media, too, has the potential to benefit patient outcomes, Lord said. In fact, a phone application has already reduced the incidence of cardiac arrest by alerting passersby where to assist someone who has collapsed. “This all comes back to connectivity and the speed with which you move data,” he said. “But it also leads to a huge gaping problem: security.”
Rollin J. (Terry) Fairbanks, M.D., director of the National Center for Human Factors Engineering in Healthcare at the MedStar Health Research Institute, attending emergency physician at Washington Hospital Center, and associate professor in the Department of Emergency Medicine at Georgetown University, next spoke about technology in emergency care from a safety and risk perspective.
He began with some startling statistics: In 2000, reports indicated that clinician errors caused 44,000 to 98,000 patient deaths each year. Despite a government mandate to reduce those numbers by 50 percent, Fairbanks said that today, “12 years later, there’s been essentially no change.”
The problem, he said, is in the solution. Rather than focusing on error elimination (or essentially telling providers to “do better next time”), the solution should focus on reducing harm by building a system that anticipates human error, as is the case in other industries.
Pilots and flight technicians, for example, make an average of two errors per hour, he said. And yet, flying is one of the safest things you can do because “the system is engineered to mitigate error,” said Fairbanks. Unfortunately, healthcare technology is not built with the same tolerance for human error in mind.
Fairbanks also described several situations in which adopting technology in the ED did not benefit providers or patients. Swapping a white board for a computer, in some cases, meant losing valuable communication tools used among ED nurses and technicians that seemed negligable to the outsiders who transitioned the data.
“It gets couched as provider resistance” when doctors hesitate to adopt the latest technologies, Fairbanks said. "But the real problem is that we’re not designing our systems to meet the needs of our workers.”
E. Gregory Marchand, M.D., director of informatics in the Department of Emergency Medicine at Washington Hospital Center, next spoke about the importance of breaking down barriers so that patient information can be shared more seamlessly between physician practices, clinics, and hospitals.
Although hospital CEOs would like to retain their patients, the reality is that people aren’t always—and can’t always be—loyal to one practice, he said. There needs to be more incentives to share information so that the patients can be best served no matter where they choose to go. “You want to talk about occupy Wall Street?” he asked. “I think the healthcare consumer ought to ‘occupy healthcare.'”
Marchand imagined a future where all of a patient’s information — including his or her family history, allergies, prior operations, and even what they eat and how much they exercise — is in one place. He admitted he doesn’t have all the answers to achieving his vision. “But here’s what I do know: It has to happen,” he said. “It’s better for the patient.”
Jesse Pines, M.D., associate professor of Emergency Medicine in SMHS and of Health Policy in the MISPH and director of GW’s Center for Health Care Quality, echoed Marchand’s concerns. “What we know is that nine times out of 10, patients come to the emergency department when care coordination fails,” he said.
What’s more, he added, patients with the most serious health problems are often the ones who have the least accessible information and who are subject to the poorest coordination. He called for technology solutions that would help reduce unscheduled return ED visits and improve follow-up communication with primary care providers.
The final speaker, Keith Littlewood, M.D., assistant dean for Clinical Skills Education and medical director of the Clinical Performance Education Center at the University of Virginia Health Sciences System, addressed the role of technology in medical education.
Medical education has improved greatly, said Littlewood, in part thanks to remarkably realistic simulated devices like “task trainers,” which allow students to practice procedures and teamwork before working with patients. The simulated devices have also saved a substantial amount of money for both the system and the hospital, he said.
Littlewood said that simulated patients are better for both students and patients than the old "see one, do one, teach one," medical education mantra. “We’ve had simulators for centuries—they were the disenfranchised patient,” he said. “So even if we don’t have better outcomes [from today’s technologies], I don’t care because we have a moral obligation to use them.”
While technology is no substitution for a strong curriculum and faculty, Littlewood said that “there’s been an astounding jump” in simulation since the mid-1960s, when it was first introduced with little success. “We have really grown up.”