Electronic Patient Tracking System Research Articles

Comparing the effects of intraoperative information delivery via electronic patient tracking system and mobile phone on stress and coping ability among the family members of patients under coronary artery bypass graft surgery

Background and aims: Coronary artery bypass graft (CABG) surgery is associated with high levels of stress for patients’ family members. Information delivery to family members is a strategy with potential positive effects on their stress. The aim of the present study was to compare the effects of intraoperative information delivery via electronic patient tracking system (EPTS) and mobile-based communication (MBC) on stress and coping ability among the family members of patients under CABG surgery. Methods: This clinical trial was conducted on 80 family members of patients under CABG surgery. Participants were randomly allocated to an EPTS and an MBC group. Intraoperative information delivery to family members in the EPTS and the MBC groups was performed using EPTS and hourly mobile phone contacts, respectively. Data were collected before and after the intervention using the Perceived Stress Scale and the Coping Response Inventory. The SPSS software (v. 22.0) was used for data analysis through the Fisher’s exact, Chi-square, independent-sample t, and paired-sample t tests. Results: There were no significant differences between the groups in terms of the pretest and the posttest mean scores of stress and coping ability (P>0.05). The mean scores of stress and coping ability did not significantly change in the EPTS group (P>0.05). Moreover, the mean score of coping ability did not significantly change in the MBC group (P=0.429), while the mean score of stress significantly decreased in this group (P=0.009). Conclusion: Intraoperative information delivery to family members through mobile phone contacts is effective in significantly reducing stress among the family members of patients under CABG. Healthcare providers can use the findings of the present study to provide quality care to patients’ family members.

Delayed Antiretroviral Therapy (ART) Initiation among Hospitalized Adults in a Resource-Limited Settings: A Challenge to the Global Target of ART for 90% of HIV-Infected Individuals.

Background Combination antiretroviral therapy (cART) initiation in hospital settings, where individuals often present with undiagnosed, untreated, advanced HIV disease, is not well understood. Methods A cross-sectional study was conducted to determine a period prevalence of cART initiation within two weeks of eligibility, as determined at hospitalization. Using a pretested and precoded data extraction tool, data on cART initiation status and reason for not initiating cART was collected. Phone calls were made to patients that had left the hospital by the end of the two-week period. Delayed cART initiation was defined as failure to initiate cART within two weeks. Sociodemographic characteristics, WHO clinical stage, CD4 count, cART initiation status, and reasons for delayed cART initiation were extracted and analyzed. Results Overall, 386 HIV-infected adults were enrolled, of whom 289/386 (74.9%) had delayed cART initiation, 77/386 (19.9%) initiated cART, and 20/386 (5.2%) were lost-to-follow-up, within two weeks of cART eligibility. Of 289 with delayed ART initiation, 94 (32.5%) died within two weeks of cART eligibility. Patients with a CD4 cell count≥ 50 cells/μl and who resided in ≥8 kilometers from the hospital were more likely to have delayed cART initiation [adjusted odds ratio (AOR) 2.34, 95% CI: 1.33-4.10, p value 0.003; and AOR 1.92, 95% CI: 1.09-3.40, p value 0.025; respectively]. Conclusion Up to 75% of hospitalized HIV-infected, cART-naïve, cART-eligible patients did not initiate cART and had a 33% pre-ART mortality rate within two weeks of eligibility for cART. Hospital based strategies to hasten cART initiation during hospitalization and electronic patient tracking systems could promote active linkage to HIV treatment programs, to prevent HIV/AIDS-associated mortality in resource-limited settings.

Validity of reported retention in antiretroviral therapy after roll-out to peripheral facilities in Mozambique: Results of a retrospective national cohort analysis.

BackgroundRetention in anti-retroviral therapy (ART) presents a challenge in sub-Saharan Africa. In Mozambique, after roll-out to peripheral facilities, the 12-month retention rate was reported mostly from sites with an electronic patient tracking system (EPTS), representing only 65% of patients. We conducted a nationally representative study, compared 12-month retention at EPTS and non-EPTS sites, and its predictors.MethodsApplying a proportionate to population size sampling strategy, we obtained a nationally representative sample of patients who initiated ART between January 2013 and June 2014. We calculated weighted proportions of the patients’ status at 12 months after ART initiation, and 12-month incidence of lost to follow-up (LTFU) and death. We assessed determinants of LTFU and death by calculating adjusted hazard ratios (AHR) through multivariate cox-proportional hazard models.ResultsAmong 19,297 patients sampled, 54.3% were still active, 33.1% LTFU, 2.0% dead, 2.6% transferred-out and 8.0% had unknown status, 12 months after ART initiation. Total attrition rate (LTFU or dead) was 45.5/100PY, higher at facilities without EPTS (51.8/100PY) than with EPTS (37.7/100PY). Clinical stage IV (AHR = 1.7), CD4 count ≤150 (AHR = 1.3) and being pregnant (AHR = 1.6) were significantly associated with LTFU. Clinical stage III or IV (AHR = 2.1 and 3.8), CD4 count ≤150 (AHR = 3.0), not being pregnant (AHR = 3.0), and ART regimens with stavudine (AHR = 4.28) were significantly associated with deaths. Patients enrolled in adherence support groups were 4.6 times less likely to be LTFU, but the number (n = 174) was too small to be significant (p = 0.273).ConclusionRetention in ART was substantially lower at non-EPTS sites. EPTS should be expanded to all ART sites to facilitate comprehensive routine monitoring of retention in care. Retention in Mozambique is low and needs to be improved, especially among pregnant women and patients with advanced disease at ART initiation. The effect of ART adherence support groups needs to be further monitored.

Rapid Patient Discharge Contribution to Bed Surge Capacity During a Mass Casualty Incident: Findings From an Exercise With New York City Hospitals.

Mass casualty incidents may increase patient volume suddenly and dramatically, requiring hospitals to expeditiously manage bed inventories to release acute care beds for disaster victims. Electronic patient tracking systems combined with unit walk-throughs can identify patients for rapid discharge. The New York City (NYC) Department of Health and Mental Hygiene's 2013 Rapid Patient Discharge Assessment (RPDA) aimed to determine the maximum number of beds NYC hospitals could make available through rapid patient discharge and to characterize discharge barriers. Unit representatives identified discharge candidates within normal operations in round 1 and additional discharge candidates during a disaster scenario in round 2. Descriptive statistics were performed. Fifty-five NYC hospitals participated in the RPDA exercise; 45 provided discharge candidate counts in both rounds. Representatives identified 4225 patients through the RPDA: among these, 1138 (26.9%) were already confirmed for discharge; 1854 (43.9%) were round 1 discharge candidates; and 1233 (29.2%) were round 2 discharge candidates. These 4225 patients represented 21.4% of total bed capacity. Frequently reported barriers included missing prescriptions for aftercare or discharge orders. The NYC hospitals could implement rapid patient discharge to clear one-fifth of occupied inpatient beds for disaster victims, given they address barriers affecting patients' safe and efficient discharge.

A5159 - Use of an electronic patient tracking system in an outpatient bariatric surgery setting and patient wait times

A5159 - Use of an electronic patient tracking system in an outpatient bariatric surgery setting and patient wait times

Implementation of an electronic fingerprint-linked data collection system: a feasibility and acceptability study among Zambian female sex workers.

BackgroundPatient identification within and between health services is an operational challenge in many resource-limited settings. When following HIV risk groups for service provision and in the context of vaccine trials, patient misidentification can harm patient care and bias trial outcomes. Electronic fingerprinting has been proposed to identify patients over time and link patient data between health services. The objective of this study was to determine 1) the feasibility of implementing an electronic-fingerprint linked data capture system in Zambia and 2) the acceptability of this system among a key HIV risk group: female sex workers (FSWs).MethodsWorking with Biometrac, a US-based company providing biometric-linked healthcare platforms, an electronic fingerprint-linked data capture system was developed for use by field recruiters among Zambian FSWs. We evaluated the technical feasibility of the system for use in the field in Zambia and conducted a pilot study to determine the acceptability of the system, as well as barriers to uptake, among FSWs.ResultsWe found that implementation of an electronic fingerprint-linked patient tracking and data collection system was feasible in this relatively resource-limited setting (false fingerprint matching rate of 1/1000 and false rejection rate of <1/10,000) and was acceptable among FSWs in a clinic setting (2 % refusals). However, our data indicate that less than half of FSWs are comfortable providing an electronic fingerprint when recruited while they are working. The most common reasons cited for not providing a fingerprint (lack of privacy/confidentiality issues while at work, typically at bars or lodges) could be addressed by recruiting women during less busy hours, in their own homes, in the presence of “Queen Mothers” (FSW organizers), or in the presence of a FSW that has already been fingerprinted.ConclusionsOur findings have major implications for key population research and improved health services provision. However, more work needs to be done to increase the acceptability of the electronic fingerprint-linked data capture system during field recruitment. This study indicated several potential avenues that will be explored to increase acceptability.

SMSaúde: Design, Development, and Implementation of a Remote/Mobile Patient Management System to Improve Retention in Care for HIV/AIDS and Tuberculosis Patients.

BackgroundThe widespread and low cost of mobile phones and the convenience of short message service (SMS) text messaging suggest potential suitability for use with alternative strategies for supporting retention in care and adherence to the treatment of various chronic diseases, such as HIV and tuberculosis (TB). Despite the growing body of literature reporting positive outcomes of SMS text message-based communication with patients, there is yet very little research about the integration of communication technologies and electronic medical records or electronic patient tracking systems.ObjectiveTo design, develop, and implement an integrated mobile phone text messaging system used to follow up with patients with HIV and TB in treatment in Mozambique.MethodsFollowing the design science research methodology, we developed a Web-based system that provides support to patients. A case study involving three health care sites in Mozambique was a basis for discussing design issues for this kind of system. We used brainstorming techniques to solicit usability requirements, focus group meetings to discuss and define system architecture, and prototyping to test in real environments and to improve the system.ResultsWe found six sets of system requirements that need to be addressed for success: data collection, telecommunication costs, privacy and data security, text message content, connectivity, and system scalability. A text messaging system was designed and implemented in three health facilities. These sites feed data into a central data repository, which can be used for analysis of operations and decision support. Based on the treatment schedule, the system automatically sent SMS text message appointment reminders, medication reminders, as well as motivational and educational messages to patients enrolled in antiretroviral therapy and TB treatment programs.ConclusionsWe successfully defined the requirements for, designed, and implemented a mobile phone text messaging system to support HIV and TB treatments. Implementation of this system could improve patients’ self-management skills and strengthen communication between patients and health care providers.

A Systematic Review of Patient Tracking Systems for Use in the Pediatric Emergency Department

BackgroundPatient safety is of great importance in the pediatric emergency department (PED). The combination of acutely and critically ill patients and high patient volumes creates a need for systems to support physicians in making accurate and timely diagnoses. Electronic patient tracking systems can potentially improve PED safety by reducing overcrowding and enhancing security. ObjectivesTo enhance our understanding of current electronic tracking technologies, how they are implemented in a clinical setting, and resulting effect on patient care outcomes including patient safety. MethodsNine databases were searched. Two independent reviewers identified articles that contained reference to patient tracking technologies in pediatrics or emergency medicine. Quantitative studies were assessed independently for methodological strength by two reviewers using an external assessment tool. ResultsOf 2292 initial articles, 22 were deemed relevant. Seventeen were qualitative, and the remaining five quantitative articles were assessed as being methodologically weak. Existing patient tracking systems in the ED included: infant monitoring/abduction prevention; barcode identification; radiofrequency identification (RFID)- or infrared (IR)-based patient tracking. Twenty articles supported the use of tracking technology to enhance patient safety or improve efficiency. One article failed to support the use of IR patient sensors due to study design flaws. ConclusionsSupport exists for the use of barcode-, IR-, and RFID-based patient tracking systems to improve ED patient safety and efficiency. A lack of methodologically strong studies indicates a need for further evidence-based support for the implementation of patient tracking technology in a clinical or research setting.

Disaster Mobile Health Technology: Lessons from Haiti

Mobile health (mHealth) technology can play a critical role in improving disaster victim tracking, triage, patient care, facility management, and theater-wide decision-making. To date, no disaster mHealth application provides responders with adequate capabilities to function in an austere environment. The Operational Medicine Institute (OMI) conducted a qualitative trial of a modified version of the off-the-shelf application iChart at the Fond Parisien Disaster Rescue Camp during the large-scale response to the January 12, 2010 earthquake in Haiti. The iChart mHealth system created a patient log of 617 unique entries used by on-the-ground medical providers and field hospital administrators to facilitate provider triage, improve provider handoffs, and track vulnerable populations such as unaccompanied minors, pregnant women, traumatic orthopedic injuries and specified infectious diseases. The trial demonstrated that even a non-disaster specific application with significant programmatic limitations was an improvement over existing patient tracking and facility management systems. A unified electronic medical record and patient tracking system would add significant value to first responder capabilities in the disaster response setting.

An assessment of the accuracy and availability of data in electronic patient tracking systems for patients receiving HIV treatment in central Mozambique

BackgroundSince the rapid scale-up of antiretroviral therapy (ART) programs in sub-Saharan Africa, electronic patient tracking systems (EPTS) have been deployed to respond to the growing demand for program monitoring, evaluation and reporting to governments and donors. These routinely collected data are often used in epidemiologic and operations research studies intended to improve programs. To ensure accurate reporting and good quality for research, the reliability and completeness of data systems need to be assessed and reported. We assessed the completeness and reliability of EPTS used in 16 HIV care and treatment clinics in Manica and Sofala provinces of Mozambique.MethodsWe conducted a cross-sectional study to assess the completeness and reliability of key variables in the electronic data system for patients enrolling in 16 public sector HIV treatment clinics between 1 July 2004 and 30 June 2008. Data from the electronic database was compared with data abstracted from a stratified random sample of 520 patient charts. Percent agreement, kappa scores and concordance correlation coefficients were calculated for specified variables. Percentile bootstrap confidence intervals were calculated to account for the stratified nature of our sampling.ResultsA total of 16,149 patients with a median age of 33 years and a median CD4 count of 151 enrolled in these 16 clinics between 1 July 2004 and 30 June 2008. The level of completeness was high for most variables with height (18.6%) and weight (11.5%) having the highest amount of missing data. The level of agreement for available data was also high with reliability statistics of 0.95 (95% CI: 0.92-0.98) for gender, 0.91 (95% CI: 0.80-1.00) for pre-ART CD4 value and 0.97 (95% CI: 0.95-0.99) for patient retention.ConclusionsElectronic patient tracking systems have been deployed to respond to the growing monitoring, evaluation and reporting requirements. In our cross-sectional study of clinics in Manica and Sofala provinces of Mozambique, we found high levels of completeness and reliability for key variables indicating that these electronic databases provided adequate data not only for monitoring and evaluation but also for research. Routine evaluations of the completeness and reliability of these databases need to occur to ensure high quality data are being used for reporting and research.

Improving Access to Longitudinal Patient Health Information within an Emergency Department

We designed and implemented an electronic patient tracking system with improved user authentication and patient selection. We then measured access to clinical information from previous clinical encounters before and after implementation of the system. Clinicians accessed longitudinal information for 16% of patient encounters before, and 40% of patient encounters after the intervention, indicating such a system can improve clinician access to information. We also attempted to evaluate the impact of providing this access on inpatient admissions from the emergency department, by comparing the odds of inpatient admission from an emergency department before and after the improved access was made available. Patients were 24% less likely to be admitted after the implementation of improved access. However, there were many potential confounders, based on the inherent pre-post design of the evaluation. Our experience has strong implications for current health information exchange initiatives.

Emergency department patient-tracking system evaluation

Information technology is rapidly being developed and implemented for health care environments, often as a replacement for paper based or other manual tools. One example of this transition is the replacement of large dry-erase boards, used in emergency departments (ED) for tracking patient locations and clinical care, with computerized patient-tracking systems. The design of such systems has important implications for aspects of ED work, including changes to workload and situation awareness of ED staff. In this study, we used a newly developed electronic patient-tracking system simulator which combined a realistic model of ED and patient events with a configurable patient-tracking system display. Situation awareness regarding patient data, workload, responses to system failures, and performance on secondary tasks was measured for two groups of experienced ED staff (nurses, and clerks) across two display conditions and two patient volume conditions. We found that nurses had higher situation awareness than clerks, and that increased patient volume increased some aspects of workload. Additionally there were some indications that color coding information made it easier for participants to remember information in the event of system failures and that the choice of display size may depend on users’ primary tasks. As demonstrated by these important findings, the simulator was considered to be viable in adequately representing emergency department processes in a controlled lab setting for helping assess situation awareness and workload. Relevance to industry Healthcare technology design industry and healthcare systems planning to implement new information technologies would significantly benefit from the methodology and findings.

Supplemented Triage and Rapid Treatment (START) Improves Performance Measures in the Emergency Department

Background: Emergency Department (ED) crowding is well recognized, and multiple studies have demonstrated its negative effect on patient care. Study Objectives: This study aimed to assess the effect of an intervention, Supplemented Triage and Rapid Treatment (START), on standard ED performance measures. The START program complemented standard ED triage with a team of clinicians who initiated the diagnostic work-up and selectively accelerated disposition in a subset of patients. Methods: This retrospective before–after study compared performance measures over two 3-month periods (September–November 2007 and 2008) in an urban, academic tertiary care ED. Data from an electronic patient tracking system were queried over 12,936 patients pre-intervention, and 14,220 patients post-intervention. Primary outcomes included: 1) overall length of stay (LOS), 2) LOS for discharged and admitted patients, and 3) the percentage of patients who left without complete assessment (LWCA). Results: In the post-intervention period, patient volume increased 9% and boarder hours decreased by 1.3%. Median overall ED LOS decreased by 29 min (8%, 361 min pre-intervention, 332 min post-intervention; p < 0.001). Median LOS for discharged patients decreased by 23 min (7%, 318 min pre-intervention, 295 min post-intervention; p < 0.001), and by 31 min (7%, 431 min pre-intervention, 400 min post-intervention) for admitted patients. LWCA was decreased by 1.7% (4.1% pre-intervention, 2.4% post-intervention; p < 0.001). Conclusions: In this study, a comprehensive screening and clinical care program was associated with a significant decrease in overall ED LOS, LOS for discharged and admitted patients, and rate of LWCA, despite an increase in ED patient volume.

Development of a Simulation Environment to Study Emergency Department Information Technology

This article presents a simulation architecture for a patient tracking system simulator to study caregiver performance in emergency departments (EDs). The architecture integrates discrete event simulation modeling with clinical patient information. Evaluation components for electronic patient tracking system displays are also described. A simulation of an ED electronic whiteboard was developed to study situation awareness metrics. Dynamic process data from an actual ED was used to generate simulation parameters including patient arrivals at various hours, distribution of severities, times required to treat the ED patients, and ancillary turnaround times (laboratory and radiology). A team of industrial engineers and ED physicians contributed demographic and clinical information for simulator patients. ED simulation parameters were combined with clinical information resulting in an event timeline database. Event timelines were used to populate a front-end patient-tracking system display simulation. The resulting patient-tracking system display simulation consists of underlying software, desktop and large-screen displays, a phone call/pager system, and typical tasks that enhance the realism of the simulation experience. The system can evaluate the impact of display parameters and ED operations on user performance. Modular design of the patient-tracking system display simulation helps adaptation for different studies to support various interface features and interaction types. The methodology described in this work exploits the benefits of discrete event simulation to iteratively design and test technologies such as electronic patient tracking systems and allows assessment of human performance measures.

Utilizing an Electronic Health Record System to Improve Vaccination Coverage in Children

Electronic Health Records (EHR) are widely believed to improve quality of care and effectiveness of service delivery. Use of EHR to improve childhood immunization rates has not been fully explored in an ambulatory setting. To describe a pediatric practice's use of Electronic Health Records (EHR) in improving childhood immunization. A multi-faceted EHR-based quality improvement initiative used electronic templates with pre-loaded immunization records, automatic diagnosis coding, and EHR alerts of missing or delayed vaccinations. An electronic patient tracking system was created to identify patients with missing vaccines. Barcode scanning technology was introduced to aid speed and accuracy of documentation of administered vaccines. Electronic reporting to a local health department immunization registry facilitated ordering of vaccines. Immunization completion rates captured in monthly patient reports showed a rise in the percentage of children receiving the recommended series of vaccination (65% to 76%) (p<0.000). Barcode technology reduced the time of immunization documentation (86 seconds to 26 seconds) (p<0.000). Use of barcode scanning showed increased accuracy of documentation of vaccine lot numbers (from 95% to 100%) (p<0.000). EHR-based quality improvement interventions were successfully implemented at a community health center. EHR systems have versatility in their ability to track patients in need of vaccines, identify patients who are delayed, facilitate ordering and coding of multiple vaccines and promote interdisciplinary communication among personnel involved in the vaccination process. EHR systems can be used to improve childhood vaccination rates.

Evaluating Emergency Department Information Technology Using a Simulation-based Approach

Manual status boards, which are used in many emergency departments to track patient and ED status information, are being replaced with electronic patient tracking systems. Such technology transitions can be challenging for the users and can produce undesirable consequences if the new technologies are not properly designed and tested. Understanding the impact of technologies such as electronic patient tracking systems before implementation in a real ED can help avert adverse safety consequences and promote user adoption. However, it is challenging to test technologies in real-world domains such as an ED, due to time pressures and safety critical tasks. A more feasible alternative is to employ simulation in a lab-based environment. This paper describes research measuring situation awareness and workload during user interaction with a simulated electronic patient tracking system. The impact of technology design on situation awareness and workload, and insights on design improvement are discussed.

Cognitive Artifacts in Transition: An Analysis of Information Content Changes between Manual and Electronic Patient Tracking Systems

Today's emergency departments (ED) could not function without a patient tracking system of some kind, manual or electronic. Manual patient tracking systems such as “whiteboards” are large, dry erase, manually updated status boards used as information tracking devices in most EDs. Although it is expected that manual whiteboard systems will completely transition to electronic patient tracking systems with increasing availability of technological solutions, it is not clear if these technological solutions will sufficiently address the information tracking needs of providers. This study documents the changes in the use of a manual whiteboard versus an electronic patient tracking system in an ED to compare types of information and meanings of the represented information. Results show that both systems were used to represent information serving a variety of functional roles. In addition, an analysis of patient chief complaint entries indicates that manual whiteboards are used more dynamically than electronic systems. Differences in functional uses of the systems and the consequences of these changes are discussed.

ED Whiteboard: An Electronic Patient Tracking and Communication System

Slow registration processes, long wait times, manual whiteboard procedures, and fragmented interdepartmental communication are common issues in emergency departments that may lead to less than optimal patient care and decreased staff and patient satisfaction. To address these issues, the electronic ED Whiteboard was developed to facilitate patient tracking, improve communication, and monitor patient flow through the emergency department (ED).

Potentially modifiable metabolic factors and the risk of cardiovascular disease hospitalizations in urban African Americans with diabetes.

Diabetes and cardiovascular disease (CVD) are frequent causes of hospitalization in African Americans but have rarely been studied as coexisting diagnoses. We analyzed data from an urban African American diabetes patient population to identify variables associated with CVD hospitalizations. Demographic, disease, and metabolic characteristics of patients seen from 1991 to 1997 were extracted from an electronic patient tracking system. Data were linked to a statewide hospital discharge dataset to establish who was hospitalized between 1998 and 2001. Patients with a CVD hospitalization were compared to patients without a CVD hospitalization. 3397 diabetes patients (average age, 56 years; 65% women; 92% African American) were included in the analysis; 24% had hospitalizations primarily due to CVD. Persons with CVD hospitalizations were older and had diabetes longer, and fewer were women. Mean systolic blood pressure (SBP), low-density lipoprotein (LDL) cholesterol, triglyceride, and total cholesterol levels and urinary albumin/creatinine ratio were all higher among persons with CVD hospitalizations. In adjusted analyses, women had lower odds of experiencing a CVD hospitalization, but advancing age, diabetes duration, SBP, and LDL cholesterol were all associated with greater odds. In this predominantly African American patient sample with diabetes, specific factors (age, sex, diabetes duration, LDL cholesterol, SBP) were associated with CVD hospitalizations. Additional studies are needed to determine whether management of metabolic risk factors in outpatient settings will translate into lower hospitalization rates due to CVD in this population.

Effects of implementing a modified electronic medical record and comprehensive patient tracking system on the patient care activities of emergency department staff

Study objectives: Many hospital emergency departments (EDs) are converting from paper to comprehensive computerized medical record systems. The impact of this change on ED patient care activities has not been well described. Our own hospital ED converted from a largely paper system to a comprehensive patient tracking and modified electronic medical record system (MEMR) in December 2002. Our research goal is to determine how the increase in computer activities will change physician and nursing patient care activities. Specifically, we examined whether increases in computer use would result in decreases in direct patient care. Our secondary research goal is to measure whether the increased computer time will result in decreased communications between attending and resident physicians that include clinical teaching and supervisory activities. Methods: This was a prospective observational study conducted at an urban public teaching hospital ED with more than 120,000 annual patient visits. Activity analysis using the work-sample method was used to measure work activities of resident and attending physicians and nurses before and after the institution of a new MEMR and electronic patient tracking system. The activities were categorized as direct patient care (bedside), indirect patient care (paperwork, computer use, telephone or face-to-face communications, administration), or idle time (eg, nonclinical discussions, lunch breaks). Data were collected in real time on standardized forms by a trained team of observers. All days of the week and shifts in a day were sampled. Physician and nursing activities were observed and recorded as a snapshot once every minute during 2-hour time blocks. The resulting observation counts for each provider type in each activity category are totaled and reported as a proportion of the total number of observations. The result is the proportion of total time spent performing each activity type for the entire staff. The z test was used to test for statistical differences between the pre- and post-MEMR change periods, with an α of 0.05. Results: There were 9,400 individual staff observations; 4,503 were pre-MEMR change and 4,897 were postchange. Attending and resident physicians were observed 4,176 and nurses 5,144 times in total. There was no statistical difference in the proportion of time physicians devoted to direct patient care after MEMR change. The attending physicians spent 25.4% (95% confidence interval [CI] 22% to 29%) of their time before and 26% (95% CI 22% to 30%) after MEMR change. Residents spent 31.9% (95% CI 30% to 34%) of their time before and 30.1% (95% CI 30% to 34%) after. For nurses, there was a modest increase in direct patient care time from 25.7% (95% CI 23% to 27%) to 32.3% (95% CI 30% to 34%; P P =not significant). Conclusion: The research team expected that increased time spent entering and retrieving clinical data using a computer system might compromise the amount of effort spent in direct patient care or resident education and supervision. It was conceivable that the new system might even necessitate the addition of new staff. This was not the case. In addition, the MEMR and electronic patient tracking system provided more comprehensive, easily retrievable, and legible clinical and administrative data for use in real-time and continuous quality improvement activities.