The way from pen and paper to electronic documentation in a German emergency department

Benjamin Lucas,Dominik Brammen,Gerald Pliske,Wiebke Schirrmeister,Martin Kulla,Peter Schladitz,Felix Walcher

doi:10.1186/s12913-019-4400-y

Benjamin Lucas, Dominik Brammen + Show 5 more

Open Access

https://doi.org/10.1186/s12913-019-4400-y

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Abstract

BackgroundSome of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. However, for multi-center evaluations, standardized documentation is necessary. The AKTIN project (“National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany”) has used the “German Emergency Department Medical Record” (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry.MethodsUntil March 2016 the documentation standard in ED was the pen-and-paper version of the GEDMR. In April 2016 we implemented the GEDMR in a timeline-based EDIS. Related to this, we compared the availability of structured treatment information of traumatological patients between pen-and-paper-based and electronic documentation, with special focus on the treatment time.ResultsAll 796 data fields of the 6 modules (basic data, severe trauma, patient surveillance, anesthesia, council, neurology) were adapted for use with the existing EDIS configuration by a physician working regularly in the ED. Electronic implementation increased availability of structured anamnesis and treatment information. However, treatment time was increased in electronic documentation both immediately (2:12 ± 0:04 h; n = 2907) and 6 months after implementation (2:18 ± 0:03 h; n = 4778) compared to the pen-and-paper group (1:43 ± 0:02 h; n = 2523; p < 0.001).ConclusionsWe successfully implemented standardized documentation in an EDIS. The availability of structured treatment information was improved, but treatment time was also increased. Thus, further work is necessary to improve input time.

Highlights

Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments
The German Emergency Department Medical Record (GEDMR) was utilized in the HL7 Clinical Document Architecture (HL7-CDA), which is used as an interface for a national ED data registry prepared by the joint research project “National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany” (AKTIN) [3, 5, 6]
The original data fields were distributed among 33 dialog windows; the basic module was distributed among 20 dialog windows, supplemented by eight additional dialog windows, six of which contained data fields for documenting standard procedures and examinations carried out in EDs such as wound management, and two containing data fields for nursing documentation (Fig. 1)

Summary

Introduction

Some of the advantages of implementing electronic emergency department information systems (EDIS) are improvements in data availability and simplification of statistical evaluations of emergency department (ED) treatments. The AKTIN project (“National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany”) has used the “German Emergency Department Medical Record” (GEDMR) published by the German Interdisciplinary Association of Intensive and Emergency Care as the documentation standard for its national data registry. The German Emergency Department Medical Record (GEDMR) was utilized in the HL7 Clinical Document Architecture (HL7-CDA), which is used as an interface for a national ED data registry prepared by the joint research project “National Emergency Department Register: Improvement of Health Services Research in Acute Medicine in Germany” (AKTIN) [3, 5, 6]. The main disadvantage of their solution is that it was not connected with patient data management systems (PDMS)

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