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.